COMSAE COMPREHENSIVE OSTEOPATHIC MEDICAL SELF-ASSESSMENT EXAMINATION – PHASE 3
QUESTIONS AND CORRECT ANSWERS (VERIFIED ANSWERS) PLUS RATIONALES 2026 Q&A |LATEST EXAM
UPDATE 2026/2027..
Core Domains
Internal Medicine and Subspecialties
Obstetrics and Gynecology
Pediatrics and Adolescent Medicine
Surgery and Surgical Subspecialties
Psychiatry and Behavioral Health
Emergency Medicine and Acute Care
Osteopathic Principles and Practice (OPP) and Manipulative Treatment (OMT)
Preventive Medicine, Public Health, and Epidemiology
Medical Ethics, Jurisprudence, and Patient Safety
Introduction
This comprehensive assessment is designed to evaluate a candidate's readiness for the complexities of clinical
practice, building upon the foundational knowledge assessed in previous phases. It measures the ability to
synthesize and apply a vast body of medical knowledge in high-stakes, patient-centered scenarios. The
examination emphasizes the integration of osteopathic principles, evidence-based medicine, and critical decision-
making skills essential for effective and safe patient management. Through a combination of multiple-choice
questions and complex clinical vignettes, candidates are challenged to demonstrate their proficiency in diagnosis,
,treatment, and the ethical, legal, and regulatory frameworks that govern modern healthcare. The focus is on real-
world application, testing the candidate's capacity to prioritize, manage, and coordinate care across diverse patient
populations and clinical settings.
SECTION ONE: QUESTIONS 1–100
1. A 72-year-old male with a history of hypertension and type 2 diabetes presents with a 2-day history of
severe, sharp low back pain that is worse at night and not relieved by rest. He denies any trauma. His
temperature is 38.3°C (101.0°F). On physical examination, there is marked tenderness to palpation over the
L3-L4 spinous processes. A plain radiograph of the lumbar spine is unremarkable. What is the most
appropriate next step in management?
A. Prescribe a course of oral corticosteroids
B. Order an MRI of the lumbar spine with and without contrast
C. Recommend physical therapy and a non-steroidal anti-inflammatory drug (NSAID)
D. Perform a diagnostic sacroiliac joint injection
🟢B
🔴 RATIONALE: The patient's presentation of severe, night-time back pain, fever, and focal spinal tenderness
without trauma is highly suggestive of a vertebral osteomyelitis or a spinal epidural abscess. An unremarkable
plain radiograph does not exclude these conditions, as early changes may not be visible. An MRI with contrast is
the gold standard imaging modality for diagnosing these serious spinal infections and should be the next step
to confirm the diagnosis and guide treatment. Corticosteroids (A) could worsen an infection. Physical therapy
(C) is contraindicated. A sacroiliac injection (D) is not indicated for this presentation.
,2. A 55-year-old female with a history of hypothyroidism presents with progressive dysphagia to solids over
the past 3 months. She has also noted a sensation of a lump in her throat. On examination, her thyroid is
enlarged and firm. Laboratory studies reveal a TSH of 2.5 mIU/L (normal 0.4–4.0). What is the most
appropriate next step in evaluation?
A. Obtain a thyroid ultrasound
B. Initiate levothyroxine therapy
C. Perform a barium swallow study
D. Reassure the patient and schedule a follow-up in 6 months
🟢A
🔴 RATIONALE: In a patient with a firm, enlarged thyroid and new onset dysphagia, the primary concern is for a
thyroid malignancy or a goiter causing compressive symptoms. A thyroid ultrasound is the initial imaging
modality of choice to evaluate the gland's structure, size, and the presence of any nodules, which can guide
further management. A barium swallow (C) would be more useful for esophageal motility disorders, not for
evaluating a thyroid mass. Levothyroxine (B) is not indicated as the TSH is normal. Reassurance (D) is
inappropriate given the progressive symptoms.
3. A 28-year-old primigravida at 39 weeks gestation presents to the labor and delivery unit with regular,
painful contractions occurring every 3-4 minutes. Her cervix is 4 cm dilated and 100% effaced. The fetal
heart rate tracing shows moderate variability with no accelerations or decelerations. Her membranes are
intact. She requests an epidural for pain control. Which of the following is the most significant
contraindication to placing an epidural at this time?
A. Her platelet count is 90,000/µL
B. She has a history of a single urinary tract infection in the second trimester
, C. Her body mass index (BMI) is 30 kg/m²
D. She is currently receiving intravenous magnesium sulfate for preeclampsia
🟢A
🔴 RATIONALE: A platelet count of 90,000/µL is a relative but significant contraindication to neuraxial blockade
(epidural) due to an increased risk of epidural hematoma. While a platelet count >100,000/µL is generally
considered safe, a count of <80,000-100,000/µL warrants caution. A history of a UTI (B), obesity (C), or receiving
magnesium sulfate (D) for preeclampsia are not contraindications to epidural placement, though they may
present other management challenges.
4. A 6-year-old child is brought to the emergency department with a 1-day history of high fever, stridor, and
a "barking" cough. He is sitting upright and appears anxious, with intercostal and subcostal retractions. His
oxygen saturation is 92% on room air. Which of the following is the most appropriate immediate
management?
A. Administer racemic epinephrine via nebulizer
B. Perform a lateral neck radiograph
C. Obtain a blood culture and start intravenous antibiotics
D. Administer a dose of dexamethasone orally
🟢D
🔴 RATIONALE: This patient has classic signs of moderate to severe croup (laryngotracheobronchitis), including
stridor, barking cough, and respiratory distress. The most appropriate immediate management includes
administering corticosteroids. Dexamethasone, given orally or intramuscularly, is the treatment of choice to
reduce airway inflammation. Racemic epinephrine (A) is used for more severe cases with significant respiratory
QUESTIONS AND CORRECT ANSWERS (VERIFIED ANSWERS) PLUS RATIONALES 2026 Q&A |LATEST EXAM
UPDATE 2026/2027..
Core Domains
Internal Medicine and Subspecialties
Obstetrics and Gynecology
Pediatrics and Adolescent Medicine
Surgery and Surgical Subspecialties
Psychiatry and Behavioral Health
Emergency Medicine and Acute Care
Osteopathic Principles and Practice (OPP) and Manipulative Treatment (OMT)
Preventive Medicine, Public Health, and Epidemiology
Medical Ethics, Jurisprudence, and Patient Safety
Introduction
This comprehensive assessment is designed to evaluate a candidate's readiness for the complexities of clinical
practice, building upon the foundational knowledge assessed in previous phases. It measures the ability to
synthesize and apply a vast body of medical knowledge in high-stakes, patient-centered scenarios. The
examination emphasizes the integration of osteopathic principles, evidence-based medicine, and critical decision-
making skills essential for effective and safe patient management. Through a combination of multiple-choice
questions and complex clinical vignettes, candidates are challenged to demonstrate their proficiency in diagnosis,
,treatment, and the ethical, legal, and regulatory frameworks that govern modern healthcare. The focus is on real-
world application, testing the candidate's capacity to prioritize, manage, and coordinate care across diverse patient
populations and clinical settings.
SECTION ONE: QUESTIONS 1–100
1. A 72-year-old male with a history of hypertension and type 2 diabetes presents with a 2-day history of
severe, sharp low back pain that is worse at night and not relieved by rest. He denies any trauma. His
temperature is 38.3°C (101.0°F). On physical examination, there is marked tenderness to palpation over the
L3-L4 spinous processes. A plain radiograph of the lumbar spine is unremarkable. What is the most
appropriate next step in management?
A. Prescribe a course of oral corticosteroids
B. Order an MRI of the lumbar spine with and without contrast
C. Recommend physical therapy and a non-steroidal anti-inflammatory drug (NSAID)
D. Perform a diagnostic sacroiliac joint injection
🟢B
🔴 RATIONALE: The patient's presentation of severe, night-time back pain, fever, and focal spinal tenderness
without trauma is highly suggestive of a vertebral osteomyelitis or a spinal epidural abscess. An unremarkable
plain radiograph does not exclude these conditions, as early changes may not be visible. An MRI with contrast is
the gold standard imaging modality for diagnosing these serious spinal infections and should be the next step
to confirm the diagnosis and guide treatment. Corticosteroids (A) could worsen an infection. Physical therapy
(C) is contraindicated. A sacroiliac injection (D) is not indicated for this presentation.
,2. A 55-year-old female with a history of hypothyroidism presents with progressive dysphagia to solids over
the past 3 months. She has also noted a sensation of a lump in her throat. On examination, her thyroid is
enlarged and firm. Laboratory studies reveal a TSH of 2.5 mIU/L (normal 0.4–4.0). What is the most
appropriate next step in evaluation?
A. Obtain a thyroid ultrasound
B. Initiate levothyroxine therapy
C. Perform a barium swallow study
D. Reassure the patient and schedule a follow-up in 6 months
🟢A
🔴 RATIONALE: In a patient with a firm, enlarged thyroid and new onset dysphagia, the primary concern is for a
thyroid malignancy or a goiter causing compressive symptoms. A thyroid ultrasound is the initial imaging
modality of choice to evaluate the gland's structure, size, and the presence of any nodules, which can guide
further management. A barium swallow (C) would be more useful for esophageal motility disorders, not for
evaluating a thyroid mass. Levothyroxine (B) is not indicated as the TSH is normal. Reassurance (D) is
inappropriate given the progressive symptoms.
3. A 28-year-old primigravida at 39 weeks gestation presents to the labor and delivery unit with regular,
painful contractions occurring every 3-4 minutes. Her cervix is 4 cm dilated and 100% effaced. The fetal
heart rate tracing shows moderate variability with no accelerations or decelerations. Her membranes are
intact. She requests an epidural for pain control. Which of the following is the most significant
contraindication to placing an epidural at this time?
A. Her platelet count is 90,000/µL
B. She has a history of a single urinary tract infection in the second trimester
, C. Her body mass index (BMI) is 30 kg/m²
D. She is currently receiving intravenous magnesium sulfate for preeclampsia
🟢A
🔴 RATIONALE: A platelet count of 90,000/µL is a relative but significant contraindication to neuraxial blockade
(epidural) due to an increased risk of epidural hematoma. While a platelet count >100,000/µL is generally
considered safe, a count of <80,000-100,000/µL warrants caution. A history of a UTI (B), obesity (C), or receiving
magnesium sulfate (D) for preeclampsia are not contraindications to epidural placement, though they may
present other management challenges.
4. A 6-year-old child is brought to the emergency department with a 1-day history of high fever, stridor, and
a "barking" cough. He is sitting upright and appears anxious, with intercostal and subcostal retractions. His
oxygen saturation is 92% on room air. Which of the following is the most appropriate immediate
management?
A. Administer racemic epinephrine via nebulizer
B. Perform a lateral neck radiograph
C. Obtain a blood culture and start intravenous antibiotics
D. Administer a dose of dexamethasone orally
🟢D
🔴 RATIONALE: This patient has classic signs of moderate to severe croup (laryngotracheobronchitis), including
stridor, barking cough, and respiratory distress. The most appropriate immediate management includes
administering corticosteroids. Dexamethasone, given orally or intramuscularly, is the treatment of choice to
reduce airway inflammation. Racemic epinephrine (A) is used for more severe cases with significant respiratory
