COMPREHENSIVE OSTEOPATHIC MEDICAL SELF-ASSESSMENT EXAMINATION
(COMSAE) PHASE 2 FORM 108 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 108
2026/2027 EDITION
━━━━━━━━━━━━━━━━━━━━━━━━━━━━
COMPLETE PRACTICE EXAM
100 MULTIPLE-CHOICE QUESTIONS
EXACT OFFICIAL COUNT: 100 QUESTIONS
PASSING SCORE: 70%
TESTING TIME: 120 MINUTES
━━━━━━━━━━━━━━━━━━━━━━━━━━━━
NBOME-COMPATIBLE CLINICAL SCIENCE ASSESSMENT || ALIGNED WITH CURRENT
COMLEX-USA LEVEL 2 BLUEPRINTS || INTERNAL MEDICINE || FAMILY MEDICINE ||
PEDIATRICS || OBSTETRICS & GYNECOLOGY || SURGERY || EMERGENCY MEDICINE ||
OSTEOPATHIC PRINCIPLES & PRACTICE || CLINICAL DECISION-MAKING ||
DIFFERENTIAL DIAGNOSIS || PATIENT MANAGEMENT || 100% ORIGINAL VERIFIED
STUDY MATERIAL || COMPREHENSIVE BOARD PREPARATION || PROFESSIONAL
EXAMINATION USE ONLY
━━━━━━━━━━━━━━━━━━━━━━━━━━━━
ACADEMIC REVIEW COPY
PROFESSIONAL PRACTICE EXAMINATION MATERIAL
,━━━━━━━━━━━━━━━━━━━━━━━━━━━━
Internal Medicine & Clinical Decision-Making (Questions 1–10)
Q1. A 67-year-old man with a history of hypertension and type 2 diabetes mellitus
presents with progressive dyspnea, orthopnea, and bilateral lower-extremity edema.
Physical examination reveals jugular venous distention, bibasilar crackles, and an S3
gallop. Echocardiography demonstrates a left ventricular ejection fraction of 30%.
Which medication has been shown to reduce mortality most significantly in this
patient population?
A. Furosemide
B. Digoxin
C. Lisinopril
D. Hydrochlorothiazide
Correct Answer: 🔴 C. Lisinopril
Explanation: 🔹 ACE inhibitors such as lisinopril significantly reduce mortality in patients
with heart failure with reduced ejection fraction (HFrEF) by decreasing afterload, limiting
ventricular remodeling, and improving cardiac output. Furosemide improves symptoms
but has not demonstrated mortality benefit. Digoxin may reduce hospitalization
frequency but does not reduce mortality. Hydrochlorothiazide is less effective in
symptomatic HFrEF management. The patient’s presentation is classic for systolic
congestive heart failure requiring guideline-directed medical therapy including ACE
inhibitors, beta-blockers, and mineralocorticoid receptor antagonists.
Q2. A 54-year-old woman presents with fatigue, pruritus, and dark urine. Laboratory
studies reveal elevated alkaline phosphatase and positive antimitochondrial antibodies.
Which diagnosis is most likely?
A. Primary sclerosing cholangitis
B. Autoimmune hepatitis
C. Primary biliary cholangitis
D. Acute viral hepatitis
Correct Answer: 🔴 C. Primary biliary cholangitis
,Explanation: 🔹 Primary biliary cholangitis is an autoimmune destruction of intrahepatic
bile ducts commonly occurring in middle-aged women. Positive antimitochondrial
antibodies are highly specific. Patients present with cholestatic symptoms such as
pruritus and fatigue. Primary sclerosing cholangitis is more common in men and
associated with ulcerative colitis. Autoimmune hepatitis is associated with anti-smooth
muscle antibodies and hepatocellular injury. Viral hepatitis generally causes markedly
elevated transaminases rather than isolated cholestatic patterns.
Q3. A hospitalized patient develops sudden pleuritic chest pain and shortness of
breath three days after hip replacement surgery. Oxygen saturation is 88% on room
air. Which is the most appropriate initial diagnostic test?
A. D-dimer assay
B. CT pulmonary angiography
C. Ventilation-perfusion scan
D. Echocardiography
Correct Answer: 🔴 B. CT pulmonary angiography
Explanation: 🔹 This patient has a high pretest probability for pulmonary embolism due
to recent orthopedic surgery, hypoxemia, and pleuritic chest pain. CT pulmonary
angiography is the preferred initial diagnostic modality in hemodynamically stable
patients. D-dimer testing is more useful in low-risk patients because postoperative states
commonly elevate D-dimer levels nonspecifically. Ventilation-perfusion scanning is
reserved for patients with contraindications to contrast exposure. Echocardiography may
demonstrate right heart strain but is not the primary diagnostic test.
Q4. A 42-year-old man with chronic alcohol use presents with confusion,
ophthalmoplegia, and ataxia. Which vitamin deficiency is responsible for his condition?
A. Vitamin B12
B. Vitamin B6
C. Thiamine
D. Folate
, Correct Answer: 🔴 C. Thiamine
Explanation: 🔹 Wernicke encephalopathy results from thiamine (vitamin B1) deficiency,
classically presenting with confusion, ophthalmoplegia, and ataxia. Chronic alcoholism
predisposes patients due to poor nutrition and impaired absorption. Immediate
intravenous thiamine administration is critical before glucose administration to prevent
worsening neurologic injury. Vitamin B12 deficiency causes subacute combined
degeneration and megaloblastic anemia. Folate deficiency causes macrocytic anemia
without the classic triad.
Q5. A 63-year-old woman reports temporal headaches, jaw claudication, and transient
visual disturbances. ESR is markedly elevated. What is the most appropriate next step
in management?
A. Start high-dose corticosteroids immediately
B. Begin aspirin therapy alone
C. Order carotid Doppler ultrasonography
D. Schedule outpatient ophthalmology follow-up
Correct Answer: 🔴 A. Start high-dose corticosteroids immediately
Explanation: 🔹 Giant cell arteritis is a medical emergency because delayed treatment
can lead to irreversible blindness. High-dose corticosteroids should be initiated
immediately when clinical suspicion is high, even before temporal artery biopsy
confirmation. Aspirin alone is insufficient. Carotid ultrasonography does not evaluate the
vasculitis responsible for symptoms. Outpatient delay risks permanent vision loss.
Q6. A 45-year-old woman with obesity and type 2 diabetes presents with right upper
quadrant pain after meals. Ultrasound demonstrates gallstones without ductal dilation.
Which mechanism most likely contributed to stone formation?
A. Increased unconjugated bilirubin production
B. Cholesterol supersaturation of bile
C. Autoimmune bile duct destruction
D. Pancreatic enzyme reflux
(COMSAE) PHASE 2 FORM 108 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 108
2026/2027 EDITION
━━━━━━━━━━━━━━━━━━━━━━━━━━━━
COMPLETE PRACTICE EXAM
100 MULTIPLE-CHOICE QUESTIONS
EXACT OFFICIAL COUNT: 100 QUESTIONS
PASSING SCORE: 70%
TESTING TIME: 120 MINUTES
━━━━━━━━━━━━━━━━━━━━━━━━━━━━
NBOME-COMPATIBLE CLINICAL SCIENCE ASSESSMENT || ALIGNED WITH CURRENT
COMLEX-USA LEVEL 2 BLUEPRINTS || INTERNAL MEDICINE || FAMILY MEDICINE ||
PEDIATRICS || OBSTETRICS & GYNECOLOGY || SURGERY || EMERGENCY MEDICINE ||
OSTEOPATHIC PRINCIPLES & PRACTICE || CLINICAL DECISION-MAKING ||
DIFFERENTIAL DIAGNOSIS || PATIENT MANAGEMENT || 100% ORIGINAL VERIFIED
STUDY MATERIAL || COMPREHENSIVE BOARD PREPARATION || PROFESSIONAL
EXAMINATION USE ONLY
━━━━━━━━━━━━━━━━━━━━━━━━━━━━
ACADEMIC REVIEW COPY
PROFESSIONAL PRACTICE EXAMINATION MATERIAL
,━━━━━━━━━━━━━━━━━━━━━━━━━━━━
Internal Medicine & Clinical Decision-Making (Questions 1–10)
Q1. A 67-year-old man with a history of hypertension and type 2 diabetes mellitus
presents with progressive dyspnea, orthopnea, and bilateral lower-extremity edema.
Physical examination reveals jugular venous distention, bibasilar crackles, and an S3
gallop. Echocardiography demonstrates a left ventricular ejection fraction of 30%.
Which medication has been shown to reduce mortality most significantly in this
patient population?
A. Furosemide
B. Digoxin
C. Lisinopril
D. Hydrochlorothiazide
Correct Answer: 🔴 C. Lisinopril
Explanation: 🔹 ACE inhibitors such as lisinopril significantly reduce mortality in patients
with heart failure with reduced ejection fraction (HFrEF) by decreasing afterload, limiting
ventricular remodeling, and improving cardiac output. Furosemide improves symptoms
but has not demonstrated mortality benefit. Digoxin may reduce hospitalization
frequency but does not reduce mortality. Hydrochlorothiazide is less effective in
symptomatic HFrEF management. The patient’s presentation is classic for systolic
congestive heart failure requiring guideline-directed medical therapy including ACE
inhibitors, beta-blockers, and mineralocorticoid receptor antagonists.
Q2. A 54-year-old woman presents with fatigue, pruritus, and dark urine. Laboratory
studies reveal elevated alkaline phosphatase and positive antimitochondrial antibodies.
Which diagnosis is most likely?
A. Primary sclerosing cholangitis
B. Autoimmune hepatitis
C. Primary biliary cholangitis
D. Acute viral hepatitis
Correct Answer: 🔴 C. Primary biliary cholangitis
,Explanation: 🔹 Primary biliary cholangitis is an autoimmune destruction of intrahepatic
bile ducts commonly occurring in middle-aged women. Positive antimitochondrial
antibodies are highly specific. Patients present with cholestatic symptoms such as
pruritus and fatigue. Primary sclerosing cholangitis is more common in men and
associated with ulcerative colitis. Autoimmune hepatitis is associated with anti-smooth
muscle antibodies and hepatocellular injury. Viral hepatitis generally causes markedly
elevated transaminases rather than isolated cholestatic patterns.
Q3. A hospitalized patient develops sudden pleuritic chest pain and shortness of
breath three days after hip replacement surgery. Oxygen saturation is 88% on room
air. Which is the most appropriate initial diagnostic test?
A. D-dimer assay
B. CT pulmonary angiography
C. Ventilation-perfusion scan
D. Echocardiography
Correct Answer: 🔴 B. CT pulmonary angiography
Explanation: 🔹 This patient has a high pretest probability for pulmonary embolism due
to recent orthopedic surgery, hypoxemia, and pleuritic chest pain. CT pulmonary
angiography is the preferred initial diagnostic modality in hemodynamically stable
patients. D-dimer testing is more useful in low-risk patients because postoperative states
commonly elevate D-dimer levels nonspecifically. Ventilation-perfusion scanning is
reserved for patients with contraindications to contrast exposure. Echocardiography may
demonstrate right heart strain but is not the primary diagnostic test.
Q4. A 42-year-old man with chronic alcohol use presents with confusion,
ophthalmoplegia, and ataxia. Which vitamin deficiency is responsible for his condition?
A. Vitamin B12
B. Vitamin B6
C. Thiamine
D. Folate
, Correct Answer: 🔴 C. Thiamine
Explanation: 🔹 Wernicke encephalopathy results from thiamine (vitamin B1) deficiency,
classically presenting with confusion, ophthalmoplegia, and ataxia. Chronic alcoholism
predisposes patients due to poor nutrition and impaired absorption. Immediate
intravenous thiamine administration is critical before glucose administration to prevent
worsening neurologic injury. Vitamin B12 deficiency causes subacute combined
degeneration and megaloblastic anemia. Folate deficiency causes macrocytic anemia
without the classic triad.
Q5. A 63-year-old woman reports temporal headaches, jaw claudication, and transient
visual disturbances. ESR is markedly elevated. What is the most appropriate next step
in management?
A. Start high-dose corticosteroids immediately
B. Begin aspirin therapy alone
C. Order carotid Doppler ultrasonography
D. Schedule outpatient ophthalmology follow-up
Correct Answer: 🔴 A. Start high-dose corticosteroids immediately
Explanation: 🔹 Giant cell arteritis is a medical emergency because delayed treatment
can lead to irreversible blindness. High-dose corticosteroids should be initiated
immediately when clinical suspicion is high, even before temporal artery biopsy
confirmation. Aspirin alone is insufficient. Carotid ultrasonography does not evaluate the
vasculitis responsible for symptoms. Outpatient delay risks permanent vision loss.
Q6. A 45-year-old woman with obesity and type 2 diabetes presents with right upper
quadrant pain after meals. Ultrasound demonstrates gallstones without ductal dilation.
Which mechanism most likely contributed to stone formation?
A. Increased unconjugated bilirubin production
B. Cholesterol supersaturation of bile
C. Autoimmune bile duct destruction
D. Pancreatic enzyme reflux
