COMSAE Phase 2 Form 114 Exam Prep 2026
Questions and Answers | 275+ Practice
Questions with Explanations, NBOME
Osteopathic Study Guide, COMLEX Level 2
Readiness & Clinical Medicine Review
• This 275-question practice exam mirrors the COMSAE Phase 2 Form 114 blueprint,
covering all high-yield clinical medicine domains tested on COMLEX Level 2, with
board-style stems, five answer choices, and instant EXPERT RATIONALE to
reinforce understanding.
• Study by attempting each question independently before reading the correct
answer and EXPERT RATIONALE, focusing on pattern recognition across systems
and osteopathic principles integrated throughout.
Question 1
A 58-year-old male with a history of hypertension presents with sudden-onset
tearing chest pain radiating to the back. BP is 180/100 mmHg in the right arm
and 160/90 mmHg in the left arm. CT angiography is the next best step. What
is the most likely diagnosis?
A. Acute myocardial infarction
B. Pulmonary embolism
C. Esophageal rupture
D. Pericarditis
E. Aortic dissection ✓
Aortic dissection classically presents with sudden-onset tearing or ripping chest
pain radiating to the back, with a blood pressure differential between arms greater
than 20 mmHg. The hypertension history is a major risk factor. CT angiography of
the chest is the gold standard for diagnosis.
Question 2
,A 45-year-old woman presents with fatigue, weight gain, cold intolerance, and
constipation. TSH is elevated and free T4 is low. Which is the most appropriate
initial treatment?
A. Methimazole
B. Radioactive iodine ablation
C. Propylthiouracil
D. Levothyroxine plus liothyronine
E. Levothyroxine monotherapy ✓
Primary hypothyroidism is confirmed by elevated TSH and low free T4.
Levothyroxine monotherapy is the standard of care. The dose is titrated based on
TSH levels. Combination T3/T4 therapy is not routinely recommended.
Question 3
A 70-year-old male smoker presents with a chronic productive cough for at
least 3 months per year for the past 2 years. Spirometry shows FEV1/FVC less
than 0.70. What is the most likely diagnosis?
A. Asthma
B. Pulmonary fibrosis
C. Bronchiectasis
D. Sarcoidosis
E. Chronic obstructive pulmonary disease ✓
Chronic bronchitis, a form of COPD, is defined as productive cough for at least 3
months per year for 2 consecutive years. Obstructive pattern on spirometry
(FEV1/FVC less than 0.70) confirms COPD. Smoking is the leading risk factor.
Question 4
,A 32-year-old woman at 10 weeks gestation presents with severe nausea,
vomiting, and a uterus larger than expected for gestational age. Beta-hCG is
markedly elevated. Ultrasound shows a snowstorm pattern. What is the
diagnosis?
A. Ectopic pregnancy
B. Threatened abortion
C. Twin gestation
D. Placenta previa
E. Hydatidiform mole ✓
Complete hydatidiform mole presents with markedly elevated beta-hCG, uterus
large for dates, hyperemesis, and a snowstorm pattern on ultrasound. There is no
fetal cardiac activity. Treatment is suction curettage followed by serial beta-hCG
monitoring.
Question 5
A 55-year-old male with diabetes presents with a painless, punched-out ulcer
on the plantar surface of his foot. Peripheral pulses are intact. What is the
most likely etiology?
A. Arterial insufficiency
B. Venous stasis
C. Pressure ulcer
D. Vasculitis
E. Diabetic neuropathic ulcer ✓
Neuropathic ulcers in diabetics occur at pressure points on the plantar surface, are
painless due to sensory neuropathy, and have intact pulses distinguishing them
from arterial ulcers. Management includes offloading, wound care, and glycemic
control.
, Question 6
A 28-year-old male presents with sudden severe headache described as the
worst headache of his life. CT head is negative. What is the next best step?
A. MRI brain with contrast
B. Empiric antibiotics
C. Neurology consultation
D. Discharge with analgesics
E. Lumbar puncture ✓
A thunderclap headache with a negative CT head requires lumbar puncture to rule
out subarachnoid hemorrhage. CT misses up to 5% of SAH, especially after 6 hours.
LP will show xanthochromia or elevated RBCs that do not clear in tubes 1 through
4.
Question 7
A 6-year-old boy presents with a barking cough, inspiratory stridor, and low-
grade fever. Neck X-ray shows a steeple sign. What is the most likely
diagnosis?
A. Epiglottitis
B. Foreign body aspiration
C. Bacterial tracheitis
D. Peritonsillar abscess
E. Croup (laryngotracheobronchitis) ✓
Croup is caused most commonly by parainfluenza virus and presents with a barking
cough, inspiratory stridor, and the steeple sign on AP neck X-ray due to subglottic
narrowing. Treatment includes cool mist, dexamethasone, and nebulized racemic
epinephrine in severe cases.
Questions and Answers | 275+ Practice
Questions with Explanations, NBOME
Osteopathic Study Guide, COMLEX Level 2
Readiness & Clinical Medicine Review
• This 275-question practice exam mirrors the COMSAE Phase 2 Form 114 blueprint,
covering all high-yield clinical medicine domains tested on COMLEX Level 2, with
board-style stems, five answer choices, and instant EXPERT RATIONALE to
reinforce understanding.
• Study by attempting each question independently before reading the correct
answer and EXPERT RATIONALE, focusing on pattern recognition across systems
and osteopathic principles integrated throughout.
Question 1
A 58-year-old male with a history of hypertension presents with sudden-onset
tearing chest pain radiating to the back. BP is 180/100 mmHg in the right arm
and 160/90 mmHg in the left arm. CT angiography is the next best step. What
is the most likely diagnosis?
A. Acute myocardial infarction
B. Pulmonary embolism
C. Esophageal rupture
D. Pericarditis
E. Aortic dissection ✓
Aortic dissection classically presents with sudden-onset tearing or ripping chest
pain radiating to the back, with a blood pressure differential between arms greater
than 20 mmHg. The hypertension history is a major risk factor. CT angiography of
the chest is the gold standard for diagnosis.
Question 2
,A 45-year-old woman presents with fatigue, weight gain, cold intolerance, and
constipation. TSH is elevated and free T4 is low. Which is the most appropriate
initial treatment?
A. Methimazole
B. Radioactive iodine ablation
C. Propylthiouracil
D. Levothyroxine plus liothyronine
E. Levothyroxine monotherapy ✓
Primary hypothyroidism is confirmed by elevated TSH and low free T4.
Levothyroxine monotherapy is the standard of care. The dose is titrated based on
TSH levels. Combination T3/T4 therapy is not routinely recommended.
Question 3
A 70-year-old male smoker presents with a chronic productive cough for at
least 3 months per year for the past 2 years. Spirometry shows FEV1/FVC less
than 0.70. What is the most likely diagnosis?
A. Asthma
B. Pulmonary fibrosis
C. Bronchiectasis
D. Sarcoidosis
E. Chronic obstructive pulmonary disease ✓
Chronic bronchitis, a form of COPD, is defined as productive cough for at least 3
months per year for 2 consecutive years. Obstructive pattern on spirometry
(FEV1/FVC less than 0.70) confirms COPD. Smoking is the leading risk factor.
Question 4
,A 32-year-old woman at 10 weeks gestation presents with severe nausea,
vomiting, and a uterus larger than expected for gestational age. Beta-hCG is
markedly elevated. Ultrasound shows a snowstorm pattern. What is the
diagnosis?
A. Ectopic pregnancy
B. Threatened abortion
C. Twin gestation
D. Placenta previa
E. Hydatidiform mole ✓
Complete hydatidiform mole presents with markedly elevated beta-hCG, uterus
large for dates, hyperemesis, and a snowstorm pattern on ultrasound. There is no
fetal cardiac activity. Treatment is suction curettage followed by serial beta-hCG
monitoring.
Question 5
A 55-year-old male with diabetes presents with a painless, punched-out ulcer
on the plantar surface of his foot. Peripheral pulses are intact. What is the
most likely etiology?
A. Arterial insufficiency
B. Venous stasis
C. Pressure ulcer
D. Vasculitis
E. Diabetic neuropathic ulcer ✓
Neuropathic ulcers in diabetics occur at pressure points on the plantar surface, are
painless due to sensory neuropathy, and have intact pulses distinguishing them
from arterial ulcers. Management includes offloading, wound care, and glycemic
control.
, Question 6
A 28-year-old male presents with sudden severe headache described as the
worst headache of his life. CT head is negative. What is the next best step?
A. MRI brain with contrast
B. Empiric antibiotics
C. Neurology consultation
D. Discharge with analgesics
E. Lumbar puncture ✓
A thunderclap headache with a negative CT head requires lumbar puncture to rule
out subarachnoid hemorrhage. CT misses up to 5% of SAH, especially after 6 hours.
LP will show xanthochromia or elevated RBCs that do not clear in tubes 1 through
4.
Question 7
A 6-year-old boy presents with a barking cough, inspiratory stridor, and low-
grade fever. Neck X-ray shows a steeple sign. What is the most likely
diagnosis?
A. Epiglottitis
B. Foreign body aspiration
C. Bacterial tracheitis
D. Peritonsillar abscess
E. Croup (laryngotracheobronchitis) ✓
Croup is caused most commonly by parainfluenza virus and presents with a barking
cough, inspiratory stridor, and the steeple sign on AP neck X-ray due to subglottic
narrowing. Treatment includes cool mist, dexamethasone, and nebulized racemic
epinephrine in severe cases.
