COMSAE Phase 2 Level 2-CE Comprehensive
Osteopathic Medical Self-Assessment Examination
V1
1. A 58-year-old male with a history of hypertension and tobacco use presents to the
emergency department with substernal chest pain radiating to the left arm. Physical
examination reveals tissue texture changes at T2-T4 on the left. Which of the following
viscerosomatic reflex levels is most specifically associated with the myocardial tissue in this
patient?
A. T12-L2
B. T5-T9
C. T10-T11
D. T1-T5
Correct Answer: D
Explanation: The heart receives sympathetic innervation from the T1-T5 spinal levels,
which manifests as viscerosomatic reflexes in the paravertebral tissues of these segments
during acute myocardial ischemia. Recognizing these patterns is crucial for osteopathic
physicians to support a clinical diagnosis of visceral pathology through musculoskeletal
findings. A common pitfall is confusing these levels with the T5-T9 range, which primarily
corresponds to upper gastrointestinal organs like the stomach and liver.
,2. A 24-year-old primigravida at 34 weeks gestation presents with a blood pressure of
165/110 mmHg and 3+ proteinuria. She complains of a severe headache and visual blurring.
What is the most appropriate next step in the management of this patient?
A. Immediate cesarean delivery
B. Administration of corticosteroids and discharge
C. Bed rest and weekly follow-up
D. Administration of magnesium sulfate and antihypertensives
Correct Answer: D
Explanation: This patient presents with preeclampsia with severe features, necessitating
seizure prophylaxis with magnesium sulfate and blood pressure control to prevent
maternal stroke. While delivery is the definitive treatment, the immediate priority is
stabilizing the patient and preventing eclamptic seizures. A common mistake is proceeding
directly to surgery without first initiating medical stabilization of the hypertensive
emergency.
3. A 4-year-old male is brought to the pediatrician due to several days of low-grade fever,
barking cough, and inspiratory stridor that worsens at night. What is the most likely causative
agent?
A. Respiratory syncytial virus
B. Haemophilus influenzae type b
C. Parainfluenza virus
,D. Staphylococcus aureus
Correct Answer: C
Explanation: Croup, or laryngotracheobronchitis, is most commonly caused by
Parainfluenza virus type 1 and typically presents with a hallmark ‘seal-like’ barking cough.
Clinical significance lies in distinguishing it from epiglottitis (caused by Hib), which
presents with high fever, drooling, and toxic appearance. Treatment usually involves a
single dose of dexamethasone and, in severe cases, racemic epinephrine.
4. A 62-year-old female with type 2 diabetes and chronic kidney disease (Stage 3b, GFR 38)
presents for routine follow-up. Her A1c is 8.2% despite diet and exercise. Which of the
following medications should be avoided or used with extreme caution due to her renal
function?
A. Liraglutide
B. Pioglitazone
C. Metformin
D. Sitagliptin
Correct Answer: C
Explanation: Metformin is contraindicated when the estimated glomerular filtration rate
(eGFR) falls below 30 mL/min/1.73m² and should be started with caution if the eGFR is
between 30-45. This is due to the increased risk of lactic acidosis, a rare but life-
threatening complication of biguanide therapy in the setting of renal failure. Clinical
, decision-making requires regular monitoring of creatinine and adjusting diabetic regimens
to ensure safety as kidney function declines.
5. A 72-year-old male presents with abdominal pain, distension, and inability to pass flatus
for two days. He had an appendectomy 20 years ago. Physical exam shows high-pitched
bowel sounds and tympany. X-ray reveals dilated loops of small bowel with air-fluid levels.
What is the most likely diagnosis?
A. Paralytic ileus
B. Small bowel obstruction
C. Sigmoid volvulus
D. Acute mesenteric ischemia
Correct Answer: B
Explanation: Adhesions from prior surgeries are the most common cause of small bowel
obstruction (SBO) in adults. The presence of ‘tinkling’ or high-pitched bowel sounds and
classic air-fluid levels on imaging strongly supports this diagnosis over a paralytic ileus,
where bowel sounds are typically absent. Failure to recognize the urgency of a potential
strangulated SBO can lead to bowel necrosis and perforation.
6. During a physical examination of a patient with suspected appendicitis, a physician
identifies a point of exquisite tenderness on the right anterior abdominal wall. According to
Chapman reflex points, where would the anterior point for the appendix be located?
A. Lateral to the pubic symphysis
Osteopathic Medical Self-Assessment Examination
V1
1. A 58-year-old male with a history of hypertension and tobacco use presents to the
emergency department with substernal chest pain radiating to the left arm. Physical
examination reveals tissue texture changes at T2-T4 on the left. Which of the following
viscerosomatic reflex levels is most specifically associated with the myocardial tissue in this
patient?
A. T12-L2
B. T5-T9
C. T10-T11
D. T1-T5
Correct Answer: D
Explanation: The heart receives sympathetic innervation from the T1-T5 spinal levels,
which manifests as viscerosomatic reflexes in the paravertebral tissues of these segments
during acute myocardial ischemia. Recognizing these patterns is crucial for osteopathic
physicians to support a clinical diagnosis of visceral pathology through musculoskeletal
findings. A common pitfall is confusing these levels with the T5-T9 range, which primarily
corresponds to upper gastrointestinal organs like the stomach and liver.
,2. A 24-year-old primigravida at 34 weeks gestation presents with a blood pressure of
165/110 mmHg and 3+ proteinuria. She complains of a severe headache and visual blurring.
What is the most appropriate next step in the management of this patient?
A. Immediate cesarean delivery
B. Administration of corticosteroids and discharge
C. Bed rest and weekly follow-up
D. Administration of magnesium sulfate and antihypertensives
Correct Answer: D
Explanation: This patient presents with preeclampsia with severe features, necessitating
seizure prophylaxis with magnesium sulfate and blood pressure control to prevent
maternal stroke. While delivery is the definitive treatment, the immediate priority is
stabilizing the patient and preventing eclamptic seizures. A common mistake is proceeding
directly to surgery without first initiating medical stabilization of the hypertensive
emergency.
3. A 4-year-old male is brought to the pediatrician due to several days of low-grade fever,
barking cough, and inspiratory stridor that worsens at night. What is the most likely causative
agent?
A. Respiratory syncytial virus
B. Haemophilus influenzae type b
C. Parainfluenza virus
,D. Staphylococcus aureus
Correct Answer: C
Explanation: Croup, or laryngotracheobronchitis, is most commonly caused by
Parainfluenza virus type 1 and typically presents with a hallmark ‘seal-like’ barking cough.
Clinical significance lies in distinguishing it from epiglottitis (caused by Hib), which
presents with high fever, drooling, and toxic appearance. Treatment usually involves a
single dose of dexamethasone and, in severe cases, racemic epinephrine.
4. A 62-year-old female with type 2 diabetes and chronic kidney disease (Stage 3b, GFR 38)
presents for routine follow-up. Her A1c is 8.2% despite diet and exercise. Which of the
following medications should be avoided or used with extreme caution due to her renal
function?
A. Liraglutide
B. Pioglitazone
C. Metformin
D. Sitagliptin
Correct Answer: C
Explanation: Metformin is contraindicated when the estimated glomerular filtration rate
(eGFR) falls below 30 mL/min/1.73m² and should be started with caution if the eGFR is
between 30-45. This is due to the increased risk of lactic acidosis, a rare but life-
threatening complication of biguanide therapy in the setting of renal failure. Clinical
, decision-making requires regular monitoring of creatinine and adjusting diabetic regimens
to ensure safety as kidney function declines.
5. A 72-year-old male presents with abdominal pain, distension, and inability to pass flatus
for two days. He had an appendectomy 20 years ago. Physical exam shows high-pitched
bowel sounds and tympany. X-ray reveals dilated loops of small bowel with air-fluid levels.
What is the most likely diagnosis?
A. Paralytic ileus
B. Small bowel obstruction
C. Sigmoid volvulus
D. Acute mesenteric ischemia
Correct Answer: B
Explanation: Adhesions from prior surgeries are the most common cause of small bowel
obstruction (SBO) in adults. The presence of ‘tinkling’ or high-pitched bowel sounds and
classic air-fluid levels on imaging strongly supports this diagnosis over a paralytic ileus,
where bowel sounds are typically absent. Failure to recognize the urgency of a potential
strangulated SBO can lead to bowel necrosis and perforation.
6. During a physical examination of a patient with suspected appendicitis, a physician
identifies a point of exquisite tenderness on the right anterior abdominal wall. According to
Chapman reflex points, where would the anterior point for the appendix be located?
A. Lateral to the pubic symphysis
