COMSAE Phase 2 Level 2 BSA 117 – 150 Practice
Questions with Answers in Bold Italic & Detailed Italicized
Rationales – COMLEX Level 2-CE Prep – Osteopathic
Medical Students – 2026 Updated
Short Intro
This comprehensive resource contains 150 original practice questions for the COMSAE Phase 2 Level 2
BSA 117 exam and COMLEX Level 2-CE preparation. Covers internal medicine (cardiology, pulmonology,
neurology, gastroenterology, endocrinology, renal), obstetrics & gynecology, pediatrics, emergency
medicine, psychiatry, surgery, and osteopathic principles (OMM, TART, viscerosomatic reflexes, HVLA,
counterstrain, Chapman points) . Answers in bold italic with detailed italicized rationales.
Perfect for osteopathic medical students preparing for COMSAE Phase 2 BSA 117 and COMLEX Level 2-
CE.
INTERNAL MEDICINE – CARDIOVASCULAR
1. A 62-year-old man with a 40-pack-year smoking history presents with worsening dyspnea and a
chronic cough productive of mucoid sputum. Spirometry shows FEV1/FVC of 0.55 and FEV1 45% of
predicted. Which medication has been shown to reduce mortality in this condition when hypoxemia is
present?
A) Inhaled corticosteroid
B) Long-acting beta agonist
C) Long-term oxygen therapy
D) Tiotropium
Long-term oxygen therapy reduces mortality in COPD patients with resting PaO₂ ≤55 mmHg or evidence
of cor pulmonale . The patient has severe COPD (FEV1 45%) and likely meets criteria for LTOT. Inhaled
corticosteroids reduce exacerbations but do not improve mortality. Tiotropium improves symptoms and
reduces exacerbations.
2. A 58-year-old man with hypertension and type 2 diabetes presents with acute substernal chest pain
radiating to the left arm. ECG shows ST elevations in leads II, III, and aVF. Which is the most
appropriate next step?
A) Aspirin and IV tPA
B) Aspirin and immediate percutaneous coronary intervention
C) Aspirin and clopidogrel with medical management
D) Aspirin and urgent CABG
,Inferior wall STEMI (leads II, III, aVF) requires immediate reperfusion with PCI within 90 minutes if
available . Fibrinolysis is indicated only if PCI delay exceeds 90-120 minutes. CABG is not first-line for
acute STEMI.
3. A 72-year-old woman with atrial fibrillation on warfarin presents with sudden onset of right arm
weakness and aphasia. Last known well 90 minutes ago. INR is 1.8. CT head shows no hemorrhage.
Which is the most appropriate next step?
A) IV tPA
B) Aspirin 325 mg
C) Mechanical thrombectomy alone
D) Heparin infusion
INR ≤1.7 is acceptable for IV tPA in patients on warfarin; this patient qualifies within the 3-hour window .
Aspirin alone is insufficient for acute ischemic stroke. Mechanical thrombectomy may be considered but
does not replace tPA when indicated.
4. A 67-year-old man develops sudden right-sided weakness and aphasia. CT scan shows no
hemorrhage, and symptoms began 1 hour ago. What is the most appropriate treatment?
A) Aspirin only
B) Heparin infusion
C) Intravenous alteplase
D) Carotid endarterectomy
The patient has an acute ischemic stroke within the therapeutic window. Intravenous alteplase (tPA) is
indicated if no contraindications exist. Early reperfusion improves neurologic outcomes .
5. A 65-year-old man presents with acute-onset left-sided weakness and neglect. Last known well 4
hours ago. CT head shows no hemorrhage. CT perfusion shows a small ischemic core with a large
penumbra. Which is the most appropriate treatment?
A) IV tPA alone
B) Mechanical thrombectomy alone
C) IV tPA followed by mechanical thrombectomy
D) Aspirin 325 mg
Large vessel occlusion within 4.5 hours: IV tPA plus mechanical thrombectomy if eligible and salvageable
tissue is present . The large penumbra indicates potentially viable tissue that can be salvaged with
intervention.
6. A 55-year-old man with a 45-pack-year smoking history presents with painless hematuria. CT
urogram reveals a bladder mass. Which histologic type is most likely?
A) Adenocarcinoma
,B) Squamous cell carcinoma
C) Urothelial (transitional cell) carcinoma
D) Small cell carcinoma
Urothelial carcinoma is the most common bladder cancer in the United States. Cigarette smoking is the
strongest risk factor. Squamous cell carcinoma is more common in regions endemic for Schistosoma
haematobium infection .
7. A 72-year-old man with atrial fibrillation on warfarin presents with sudden onset of right arm
weakness and aphasia. Last known well 90 minutes ago. INR is 1.8. CT head shows no hemorrhage.
Which is the most appropriate next step?
A) IV tPA
B) Aspirin 325 mg
C) Mechanical thrombectomy alone
D) Heparin infusion
Answer: A
INR ≤1.7 is acceptable for IV tPA in patients on warfarin; this patient qualifies within 3-hour window .
8. A 45-year-old man presents with a 2-week history of palpitations and lightheadedness. ECG shows
an irregularly irregular rhythm with no discernible P waves. Which is the most appropriate next step?
A) Anticoagulation and rate control
B) Antiarrhythmic therapy only
C) Cardioversion
D) Pacemaker placement
Atrial fibrillation (irregularly irregular rhythm, no P waves) requires anticoagulation based on CHA₂DS₂-
VASc score. Rate or rhythm control is guided by symptoms and hemodynamic stability. Immediate
cardioversion is indicated if unstable.
9. A patient with acute chest pain has a troponin of 0.04 ng/mL (normal <0.04) and a normal ECG.
Which is the most appropriate next step?
A) Discharge with aspirin
B) Admit for serial troponins and ECG
C) Exercise stress test immediately
D) CT angiogram of the chest
A normal initial troponin does not rule out acute coronary syndrome. Serial troponins and ECGs are
necessary to detect evolving myocardial injury. Stress testing should not be performed during the acute
phase.
, 10. A patient develops severe chest pain 48 hours after an acute myocardial infarction. A scratchy
sound is heard on auscultation. Which complication has occurred?
A) Ventricular free-wall rupture
B) Papillary muscle rupture
C) Dressler syndrome
D) Acute fibrinous pericarditis
Acute fibrinous pericarditis typically occurs 1–3 days after transmural MI due to inflammation overlying
necrotic myocardium. Dressler syndrome occurs weeks later and is autoimmune-mediated .
11. Which medication is first-line for acute anaphylaxis?
A) Diphenhydramine
B) Epinephrine
C) Albuterol
D) Prednisone
Epinephrine reverses bronchoconstriction, vasodilation, and mucosal edema via alpha and beta receptor
activity . It is the only first-line treatment for anaphylaxis; antihistamines and corticosteroids are
adjunctive.
12. A patient with atrial fibrillation has a CHA₂DS₂-VASc score of 4. Which anticoagulant is
recommended?
A) Aspirin 81 mg daily
B) Clopidogrel 75 mg daily
C) Direct oral anticoagulant (apixaban, rivaroxaban)
D) No anticoagulation needed
DOACs are preferred over warfarin for non-valvular atrial fibrillation when CHA₂DS₂-VASc score is ≥2 in
men or ≥3 in women. Aspirin is no longer recommended for stroke prevention in AF.
13. Which ECG change is most characteristic of hyperkalemia?
A) U waves
B) Peaked T waves
C) Prolonged PR interval
D) ST depression
Peaked (tall, tented) T waves are the earliest ECG manifestation of hyperkalemia. As potassium
continues to rise, widened QRS and ventricular fibrillation can occur .
14. Which heart sound is associated with heart failure due to volume overload?
A) S1
B) S2
Questions with Answers in Bold Italic & Detailed Italicized
Rationales – COMLEX Level 2-CE Prep – Osteopathic
Medical Students – 2026 Updated
Short Intro
This comprehensive resource contains 150 original practice questions for the COMSAE Phase 2 Level 2
BSA 117 exam and COMLEX Level 2-CE preparation. Covers internal medicine (cardiology, pulmonology,
neurology, gastroenterology, endocrinology, renal), obstetrics & gynecology, pediatrics, emergency
medicine, psychiatry, surgery, and osteopathic principles (OMM, TART, viscerosomatic reflexes, HVLA,
counterstrain, Chapman points) . Answers in bold italic with detailed italicized rationales.
Perfect for osteopathic medical students preparing for COMSAE Phase 2 BSA 117 and COMLEX Level 2-
CE.
INTERNAL MEDICINE – CARDIOVASCULAR
1. A 62-year-old man with a 40-pack-year smoking history presents with worsening dyspnea and a
chronic cough productive of mucoid sputum. Spirometry shows FEV1/FVC of 0.55 and FEV1 45% of
predicted. Which medication has been shown to reduce mortality in this condition when hypoxemia is
present?
A) Inhaled corticosteroid
B) Long-acting beta agonist
C) Long-term oxygen therapy
D) Tiotropium
Long-term oxygen therapy reduces mortality in COPD patients with resting PaO₂ ≤55 mmHg or evidence
of cor pulmonale . The patient has severe COPD (FEV1 45%) and likely meets criteria for LTOT. Inhaled
corticosteroids reduce exacerbations but do not improve mortality. Tiotropium improves symptoms and
reduces exacerbations.
2. A 58-year-old man with hypertension and type 2 diabetes presents with acute substernal chest pain
radiating to the left arm. ECG shows ST elevations in leads II, III, and aVF. Which is the most
appropriate next step?
A) Aspirin and IV tPA
B) Aspirin and immediate percutaneous coronary intervention
C) Aspirin and clopidogrel with medical management
D) Aspirin and urgent CABG
,Inferior wall STEMI (leads II, III, aVF) requires immediate reperfusion with PCI within 90 minutes if
available . Fibrinolysis is indicated only if PCI delay exceeds 90-120 minutes. CABG is not first-line for
acute STEMI.
3. A 72-year-old woman with atrial fibrillation on warfarin presents with sudden onset of right arm
weakness and aphasia. Last known well 90 minutes ago. INR is 1.8. CT head shows no hemorrhage.
Which is the most appropriate next step?
A) IV tPA
B) Aspirin 325 mg
C) Mechanical thrombectomy alone
D) Heparin infusion
INR ≤1.7 is acceptable for IV tPA in patients on warfarin; this patient qualifies within the 3-hour window .
Aspirin alone is insufficient for acute ischemic stroke. Mechanical thrombectomy may be considered but
does not replace tPA when indicated.
4. A 67-year-old man develops sudden right-sided weakness and aphasia. CT scan shows no
hemorrhage, and symptoms began 1 hour ago. What is the most appropriate treatment?
A) Aspirin only
B) Heparin infusion
C) Intravenous alteplase
D) Carotid endarterectomy
The patient has an acute ischemic stroke within the therapeutic window. Intravenous alteplase (tPA) is
indicated if no contraindications exist. Early reperfusion improves neurologic outcomes .
5. A 65-year-old man presents with acute-onset left-sided weakness and neglect. Last known well 4
hours ago. CT head shows no hemorrhage. CT perfusion shows a small ischemic core with a large
penumbra. Which is the most appropriate treatment?
A) IV tPA alone
B) Mechanical thrombectomy alone
C) IV tPA followed by mechanical thrombectomy
D) Aspirin 325 mg
Large vessel occlusion within 4.5 hours: IV tPA plus mechanical thrombectomy if eligible and salvageable
tissue is present . The large penumbra indicates potentially viable tissue that can be salvaged with
intervention.
6. A 55-year-old man with a 45-pack-year smoking history presents with painless hematuria. CT
urogram reveals a bladder mass. Which histologic type is most likely?
A) Adenocarcinoma
,B) Squamous cell carcinoma
C) Urothelial (transitional cell) carcinoma
D) Small cell carcinoma
Urothelial carcinoma is the most common bladder cancer in the United States. Cigarette smoking is the
strongest risk factor. Squamous cell carcinoma is more common in regions endemic for Schistosoma
haematobium infection .
7. A 72-year-old man with atrial fibrillation on warfarin presents with sudden onset of right arm
weakness and aphasia. Last known well 90 minutes ago. INR is 1.8. CT head shows no hemorrhage.
Which is the most appropriate next step?
A) IV tPA
B) Aspirin 325 mg
C) Mechanical thrombectomy alone
D) Heparin infusion
Answer: A
INR ≤1.7 is acceptable for IV tPA in patients on warfarin; this patient qualifies within 3-hour window .
8. A 45-year-old man presents with a 2-week history of palpitations and lightheadedness. ECG shows
an irregularly irregular rhythm with no discernible P waves. Which is the most appropriate next step?
A) Anticoagulation and rate control
B) Antiarrhythmic therapy only
C) Cardioversion
D) Pacemaker placement
Atrial fibrillation (irregularly irregular rhythm, no P waves) requires anticoagulation based on CHA₂DS₂-
VASc score. Rate or rhythm control is guided by symptoms and hemodynamic stability. Immediate
cardioversion is indicated if unstable.
9. A patient with acute chest pain has a troponin of 0.04 ng/mL (normal <0.04) and a normal ECG.
Which is the most appropriate next step?
A) Discharge with aspirin
B) Admit for serial troponins and ECG
C) Exercise stress test immediately
D) CT angiogram of the chest
A normal initial troponin does not rule out acute coronary syndrome. Serial troponins and ECGs are
necessary to detect evolving myocardial injury. Stress testing should not be performed during the acute
phase.
, 10. A patient develops severe chest pain 48 hours after an acute myocardial infarction. A scratchy
sound is heard on auscultation. Which complication has occurred?
A) Ventricular free-wall rupture
B) Papillary muscle rupture
C) Dressler syndrome
D) Acute fibrinous pericarditis
Acute fibrinous pericarditis typically occurs 1–3 days after transmural MI due to inflammation overlying
necrotic myocardium. Dressler syndrome occurs weeks later and is autoimmune-mediated .
11. Which medication is first-line for acute anaphylaxis?
A) Diphenhydramine
B) Epinephrine
C) Albuterol
D) Prednisone
Epinephrine reverses bronchoconstriction, vasodilation, and mucosal edema via alpha and beta receptor
activity . It is the only first-line treatment for anaphylaxis; antihistamines and corticosteroids are
adjunctive.
12. A patient with atrial fibrillation has a CHA₂DS₂-VASc score of 4. Which anticoagulant is
recommended?
A) Aspirin 81 mg daily
B) Clopidogrel 75 mg daily
C) Direct oral anticoagulant (apixaban, rivaroxaban)
D) No anticoagulation needed
DOACs are preferred over warfarin for non-valvular atrial fibrillation when CHA₂DS₂-VASc score is ≥2 in
men or ≥3 in women. Aspirin is no longer recommended for stroke prevention in AF.
13. Which ECG change is most characteristic of hyperkalemia?
A) U waves
B) Peaked T waves
C) Prolonged PR interval
D) ST depression
Peaked (tall, tented) T waves are the earliest ECG manifestation of hyperkalemia. As potassium
continues to rise, widened QRS and ventricular fibrillation can occur .
14. Which heart sound is associated with heart failure due to volume overload?
A) S1
B) S2
