COMSAE Phase 2 Test Bank | 200 Questions & Answers for Form
109 | COMLEX-USA Level 2-CE Prep | Osteopathic Medical Board
Exam Review
About the COMSAE Phase 2 Exam
The COMSAE Phase 2 is a self-assessment examination designed to gauge a candidate's
knowledge base in advance of taking the COMLEX-USA Level 2-CE . The exam aligns with
the test specifications of COMLEX-USA Level 2-CE and is based on the same content
outline, which consists of seven Competency Domain categories and ten Clinical
Presentation categories . Starting in February 2026, the COMSAE Phase 2 consists of 160
questions (reduced from the previous 176 questions), divided into four sections of 40
questions each . All questions are single-best-answer, multiple-choice format with select
items supported by images or visual exhibits . The timed version remains 4 hours in
length .
Section 1: Internal Medicine & Emergency Medicine (Questions 1-60)
1. A 72-year-old man with hypertension and type 2 diabetes presents with acute onset
of severe, tearing chest pain radiating to the back. Blood pressure is 100/60 mmHg in
the right arm and 140/80 mmHg in the left arm. Which diagnostic study should be
ordered first?
A) Transthoracic echocardiogram
B) CT angiography of the chest
C) Electrocardiogram
D) Chest X-ray
Answer: B
Rationale: The presentation of tearing chest pain with unequal blood pressures suggests
acute aortic dissection. CT angiography is the initial test of choice due to high sensitivity and
rapid availability .
2. A 45-year-old man presents with sudden-onset chest pain radiating to his left arm.
He is diaphoretic and nauseated. ECG shows ST-segment elevation in leads II, III, and
aVF. Which is the most likely diagnosis?
,A) Pulmonary embolism
B) Acute inferior myocardial infarction
C) Aortic dissection
D) Pericarditis
Answer: B
Rationale: ST elevation in leads II, III, and aVF indicates an inferior wall myocardial
infarction. The right coronary artery (RCA) typically supplies this territory. The symptoms of
chest pain radiating to the arm, diaphoresis, and nausea support an acute coronary
syndrome .
3. A 60-year-old man with a history of hypertension presents with sudden severe
headache, neck stiffness, and photophobia. What is the next best step?
A) MRI of the brain
B) Non-contrast CT of the head
C) Lumbar puncture immediately
D) Start empiric antibiotics
Answer: B
Rationale: Sudden severe headache ("thunderclap headache") suggests subarachnoid
hemorrhage; non-contrast CT is the initial test. Lumbar puncture is next if CT is negative .
4. A 55-year-old man with hypertension presents with severe headache and vomiting.
BP is 220/120 mmHg. Fundoscopy shows papilledema. What is the most appropriate
next step?
A) Oral clonidine
B) IV antihypertensive therapy (e.g., nicardipine, labetalol)
C) Captopril 25 mg PO
D) Observation with repeat BP in 1 hour
Answer: B
Rationale: Hypertensive emergency with end-organ damage (papilledema) requires
immediate IV blood pressure reduction, not oral agents .
5. A 60-year-old man presents with progressive difficulty swallowing solids more
than liquids, regurgitation of undigested food, and weight loss. Most likely
diagnosis?
,A) Achalasia
B) Esophageal cancer
C) Peptic stricture
D) Diffuse esophageal spasm
Answer: A
Rationale: Progressive dysphagia to solids and liquids with regurgitation suggests
achalasia. Esophageal cancer can cause rapidly progressive dysphagia, but achalasia is a
motility disorder with a characteristic "bird-beak" appearance on barium swallow .
6. A 55-year-old woman with type 2 diabetes presents with bilateral foot numbness
and burning pain that worsens at night. Which is the most appropriate initial
pharmacotherapy?
A) Aspirin
B) Gabapentin
C) Hydrocodone
D) Metformin
Answer: B
Rationale: Diabetic peripheral neuropathy is initially treated with gabapentin or pregabalin,
which are first-line agents for neuropathic pain .
7. A 65-year-old man presents with progressive dyspnea on exertion, orthopnea, and
peripheral edema. An echocardiogram shows a reduced ejection fraction of 30%.
Which is the most likely diagnosis?
A) Heart failure with reduced ejection fraction (HFrEF)
B) Heart failure with preserved ejection fraction
C) Constrictive pericarditis
D) Restrictive cardiomyopathy
Answer: A
Rationale: HFrEF is characterized by an EF of <40%, typically with left ventricular dilation.
Clinical symptoms include dyspnea, orthopnea, and peripheral edema. First-line treatment
includes ACE inhibitors, beta-blockers, and diuretics .
8. A 30-year-old woman with Graves' disease is being treated with methimazole. She
reports fever, sore throat, and malaise. Complete blood count shows absolute
neutrophil count of 300/μL. What is the most appropriate immediate action?
, A) Continue methimazole and add antibiotics
B) Discontinue methimazole and start propylthiouracil
C) Discontinue methimazole and obtain blood cultures
D) Administer granulocyte colony-stimulating factor
Answer: C
Rationale: Agranulocytosis is a complication of methimazole. Drug should be stopped
immediately. Blood cultures and broad-spectrum antibiotics are critical; G-CSF may be
considered later. Switching to PTU does not resolve neutropenia .
9. A 24-year-old man has 3 days of watery diarrhea, vomiting, and abdominal cramps
after eating at a picnic. No blood or fever. Which pathogen is most likely?
A) Shigella sonnei
B) Norovirus
C) Salmonella enteritidis
D) Vibrio cholerae
Answer: B
Rationale: Norovirus causes acute non-bloody watery diarrhea, vomiting, and cramps
without fever, often foodborne. Shigella and Salmonella typically cause fever and bloody
diarrhea .
10. A 35-year-old woman presents with fatigue, joint pain, and a malar rash.
Laboratory studies reveal positive antinuclear antibodies (ANA) and anti-double-
stranded DNA antibodies. What is the most likely diagnosis?
A) Rheumatoid arthritis
B) Systemic lupus erythematosus
C) Sjögren's syndrome
D) Scleroderma
Answer: B
Rationale: The combination of malar rash, arthralgias, positive ANA, and positive anti-
dsDNA antibodies is classic for SLE .
11. A 65-year-old man with benign prostatic hyperplasia has a serum PSA of 6.2
ng/mL. Digital rectal exam reveals a nodule in the right lobe. What is the most
appropriate next step?
109 | COMLEX-USA Level 2-CE Prep | Osteopathic Medical Board
Exam Review
About the COMSAE Phase 2 Exam
The COMSAE Phase 2 is a self-assessment examination designed to gauge a candidate's
knowledge base in advance of taking the COMLEX-USA Level 2-CE . The exam aligns with
the test specifications of COMLEX-USA Level 2-CE and is based on the same content
outline, which consists of seven Competency Domain categories and ten Clinical
Presentation categories . Starting in February 2026, the COMSAE Phase 2 consists of 160
questions (reduced from the previous 176 questions), divided into four sections of 40
questions each . All questions are single-best-answer, multiple-choice format with select
items supported by images or visual exhibits . The timed version remains 4 hours in
length .
Section 1: Internal Medicine & Emergency Medicine (Questions 1-60)
1. A 72-year-old man with hypertension and type 2 diabetes presents with acute onset
of severe, tearing chest pain radiating to the back. Blood pressure is 100/60 mmHg in
the right arm and 140/80 mmHg in the left arm. Which diagnostic study should be
ordered first?
A) Transthoracic echocardiogram
B) CT angiography of the chest
C) Electrocardiogram
D) Chest X-ray
Answer: B
Rationale: The presentation of tearing chest pain with unequal blood pressures suggests
acute aortic dissection. CT angiography is the initial test of choice due to high sensitivity and
rapid availability .
2. A 45-year-old man presents with sudden-onset chest pain radiating to his left arm.
He is diaphoretic and nauseated. ECG shows ST-segment elevation in leads II, III, and
aVF. Which is the most likely diagnosis?
,A) Pulmonary embolism
B) Acute inferior myocardial infarction
C) Aortic dissection
D) Pericarditis
Answer: B
Rationale: ST elevation in leads II, III, and aVF indicates an inferior wall myocardial
infarction. The right coronary artery (RCA) typically supplies this territory. The symptoms of
chest pain radiating to the arm, diaphoresis, and nausea support an acute coronary
syndrome .
3. A 60-year-old man with a history of hypertension presents with sudden severe
headache, neck stiffness, and photophobia. What is the next best step?
A) MRI of the brain
B) Non-contrast CT of the head
C) Lumbar puncture immediately
D) Start empiric antibiotics
Answer: B
Rationale: Sudden severe headache ("thunderclap headache") suggests subarachnoid
hemorrhage; non-contrast CT is the initial test. Lumbar puncture is next if CT is negative .
4. A 55-year-old man with hypertension presents with severe headache and vomiting.
BP is 220/120 mmHg. Fundoscopy shows papilledema. What is the most appropriate
next step?
A) Oral clonidine
B) IV antihypertensive therapy (e.g., nicardipine, labetalol)
C) Captopril 25 mg PO
D) Observation with repeat BP in 1 hour
Answer: B
Rationale: Hypertensive emergency with end-organ damage (papilledema) requires
immediate IV blood pressure reduction, not oral agents .
5. A 60-year-old man presents with progressive difficulty swallowing solids more
than liquids, regurgitation of undigested food, and weight loss. Most likely
diagnosis?
,A) Achalasia
B) Esophageal cancer
C) Peptic stricture
D) Diffuse esophageal spasm
Answer: A
Rationale: Progressive dysphagia to solids and liquids with regurgitation suggests
achalasia. Esophageal cancer can cause rapidly progressive dysphagia, but achalasia is a
motility disorder with a characteristic "bird-beak" appearance on barium swallow .
6. A 55-year-old woman with type 2 diabetes presents with bilateral foot numbness
and burning pain that worsens at night. Which is the most appropriate initial
pharmacotherapy?
A) Aspirin
B) Gabapentin
C) Hydrocodone
D) Metformin
Answer: B
Rationale: Diabetic peripheral neuropathy is initially treated with gabapentin or pregabalin,
which are first-line agents for neuropathic pain .
7. A 65-year-old man presents with progressive dyspnea on exertion, orthopnea, and
peripheral edema. An echocardiogram shows a reduced ejection fraction of 30%.
Which is the most likely diagnosis?
A) Heart failure with reduced ejection fraction (HFrEF)
B) Heart failure with preserved ejection fraction
C) Constrictive pericarditis
D) Restrictive cardiomyopathy
Answer: A
Rationale: HFrEF is characterized by an EF of <40%, typically with left ventricular dilation.
Clinical symptoms include dyspnea, orthopnea, and peripheral edema. First-line treatment
includes ACE inhibitors, beta-blockers, and diuretics .
8. A 30-year-old woman with Graves' disease is being treated with methimazole. She
reports fever, sore throat, and malaise. Complete blood count shows absolute
neutrophil count of 300/μL. What is the most appropriate immediate action?
, A) Continue methimazole and add antibiotics
B) Discontinue methimazole and start propylthiouracil
C) Discontinue methimazole and obtain blood cultures
D) Administer granulocyte colony-stimulating factor
Answer: C
Rationale: Agranulocytosis is a complication of methimazole. Drug should be stopped
immediately. Blood cultures and broad-spectrum antibiotics are critical; G-CSF may be
considered later. Switching to PTU does not resolve neutropenia .
9. A 24-year-old man has 3 days of watery diarrhea, vomiting, and abdominal cramps
after eating at a picnic. No blood or fever. Which pathogen is most likely?
A) Shigella sonnei
B) Norovirus
C) Salmonella enteritidis
D) Vibrio cholerae
Answer: B
Rationale: Norovirus causes acute non-bloody watery diarrhea, vomiting, and cramps
without fever, often foodborne. Shigella and Salmonella typically cause fever and bloody
diarrhea .
10. A 35-year-old woman presents with fatigue, joint pain, and a malar rash.
Laboratory studies reveal positive antinuclear antibodies (ANA) and anti-double-
stranded DNA antibodies. What is the most likely diagnosis?
A) Rheumatoid arthritis
B) Systemic lupus erythematosus
C) Sjögren's syndrome
D) Scleroderma
Answer: B
Rationale: The combination of malar rash, arthralgias, positive ANA, and positive anti-
dsDNA antibodies is classic for SLE .
11. A 65-year-old man with benign prostatic hyperplasia has a serum PSA of 6.2
ng/mL. Digital rectal exam reveals a nodule in the right lobe. What is the most
appropriate next step?
