COMSAE Phase 2 Level 2-CE Comprehensive
Osteopathic Medical Self-Assessment Examination
V2
1. A 45-year-old male presents with acute onset low back pain. Physical examination reveals
a positive seated flexion test on the left. The sacral sulcus is deeper on the right, and the
inferior lateral angle (ILA) is posterior and inferior on the left. L5 is found to be neutral,
sidebent left, and rotated right. Which of the following is the most likely sacral diagnosis?
A. Left-on-left sacral torsion
B. Right-on-right sacral torsion
C. Left-on-right sacral torsion
D. Right-on-left sacral torsion
Correct Answer: D
Explanation: A positive seated flexion test on the left indicates a sacral dysfunction on the
left side. For backward torsions, L5 rotates in the same direction as the sacral rotation,
whereas for forward torsions L5 rotates opposite. In this case, the posterior ILA on the left
and L5 rotation confirm a right-on-left backward torsion. Common pitfalls include
confusing the axis side with the side of the positive seated flexion test.
,2. A 68-year-old female with a history of heart failure with reduced ejection fraction (HFrEF,
EF 30%) presents for follow-up. She is currently taking lisinopril, carvedilol, and furosemide.
Her blood pressure is 128/78 mmHg and heart rate is 68/min. Laboratory results show a
potassium of 4.1 mEq/L and creatinine of 1.1 mg/dL. Which of the following is the most
appropriate next step to improve survival?
A. Add spironolactone
B. Increase carvedilol dose
C. Add digoxin
D. Switch lisinopril to sacubitril/valsartan
Correct Answer: D
Explanation: In patients with symptomatic HFrEF already on an ACE inhibitor and beta-
blocker, switching to an Angiotensin Receptor-Neprilysin Inhibitor (ARNI) like
sacubitril/valsartan is recommended to further reduce morbidity and mortality.
Spironolactone is also indicated for NYHA Class II-IV heart failure with low EF, but current
guidelines prioritize ARNI therapy earlier in the management. Digoxin is primarily used for
symptom control and does not improve mortality in HFrEF patients.
3. A 28-year-old G1P0 at 32 weeks gestation presents with a sudden onset of painless vaginal
bleeding. Ultrasound confirms the placenta is covering the internal cervical os. Which of the
following is the most appropriate next step in management?
A. Digital cervical examination
,B. Immediate cesarean delivery
C. Expectant management and pelvic rest
D. Induction of labor with oxytocin
Correct Answer: C
Explanation: Placenta previa is characterized by painless vaginal bleeding in the third
trimester. Digital cervical examination is strictly contraindicated as it can cause massive
hemorrhage by disrupting the placenta. Most patients are managed expectantly with pelvic
rest until reaching 36-37 weeks gestation unless hemodynamic instability or fetal distress
occurs.
4. A 2-year-old male is brought to the emergency department with a barking cough and
inspiratory stridor that worsens when he is agitated. He has a low-grade fever. Radiograph of
the neck shows subglottic narrowing. What is the most appropriate initial pharmacological
treatment?
A. Inhaled albuterol
B. Intravenous ribavirin
C. Dexamethasone
D. Oral amoxicillin
Correct Answer: C
, Explanation: Croup, caused by the parainfluenza virus, presents with a barking cough and
the ‘steeple sign’ on X-ray. A single dose of corticosteroids (dexamethasone) is the standard
treatment for mild to severe cases to reduce airway edema. Racemic epinephrine is added
if stridor is present at rest, but antibiotics are not indicated as the cause is viral.
5. A 32-year-old female presents with persistent sadness, loss of interest in activities, and
difficulty sleeping for the past 3 weeks. She also reports hearing voices of deceased relatives
telling her she is worthless. She has no history of mania. What is the most likely diagnosis?
A. Schizoaffective disorder
B. Schizophrenia
C. Major depressive disorder with psychotic features
D. Brief psychotic disorder
Correct Answer: C
Explanation: The patient meets criteria for Major Depressive Disorder (MDD) and exhibits
psychosis occurring exclusively during the depressive episode. Schizoaffective disorder
requires a period of at least two weeks of delusions or hallucinations in the absence of a
major mood episode. Clinical distinction relies on the timeline of mood symptoms relative
to psychotic symptoms.
Osteopathic Medical Self-Assessment Examination
V2
1. A 45-year-old male presents with acute onset low back pain. Physical examination reveals
a positive seated flexion test on the left. The sacral sulcus is deeper on the right, and the
inferior lateral angle (ILA) is posterior and inferior on the left. L5 is found to be neutral,
sidebent left, and rotated right. Which of the following is the most likely sacral diagnosis?
A. Left-on-left sacral torsion
B. Right-on-right sacral torsion
C. Left-on-right sacral torsion
D. Right-on-left sacral torsion
Correct Answer: D
Explanation: A positive seated flexion test on the left indicates a sacral dysfunction on the
left side. For backward torsions, L5 rotates in the same direction as the sacral rotation,
whereas for forward torsions L5 rotates opposite. In this case, the posterior ILA on the left
and L5 rotation confirm a right-on-left backward torsion. Common pitfalls include
confusing the axis side with the side of the positive seated flexion test.
,2. A 68-year-old female with a history of heart failure with reduced ejection fraction (HFrEF,
EF 30%) presents for follow-up. She is currently taking lisinopril, carvedilol, and furosemide.
Her blood pressure is 128/78 mmHg and heart rate is 68/min. Laboratory results show a
potassium of 4.1 mEq/L and creatinine of 1.1 mg/dL. Which of the following is the most
appropriate next step to improve survival?
A. Add spironolactone
B. Increase carvedilol dose
C. Add digoxin
D. Switch lisinopril to sacubitril/valsartan
Correct Answer: D
Explanation: In patients with symptomatic HFrEF already on an ACE inhibitor and beta-
blocker, switching to an Angiotensin Receptor-Neprilysin Inhibitor (ARNI) like
sacubitril/valsartan is recommended to further reduce morbidity and mortality.
Spironolactone is also indicated for NYHA Class II-IV heart failure with low EF, but current
guidelines prioritize ARNI therapy earlier in the management. Digoxin is primarily used for
symptom control and does not improve mortality in HFrEF patients.
3. A 28-year-old G1P0 at 32 weeks gestation presents with a sudden onset of painless vaginal
bleeding. Ultrasound confirms the placenta is covering the internal cervical os. Which of the
following is the most appropriate next step in management?
A. Digital cervical examination
,B. Immediate cesarean delivery
C. Expectant management and pelvic rest
D. Induction of labor with oxytocin
Correct Answer: C
Explanation: Placenta previa is characterized by painless vaginal bleeding in the third
trimester. Digital cervical examination is strictly contraindicated as it can cause massive
hemorrhage by disrupting the placenta. Most patients are managed expectantly with pelvic
rest until reaching 36-37 weeks gestation unless hemodynamic instability or fetal distress
occurs.
4. A 2-year-old male is brought to the emergency department with a barking cough and
inspiratory stridor that worsens when he is agitated. He has a low-grade fever. Radiograph of
the neck shows subglottic narrowing. What is the most appropriate initial pharmacological
treatment?
A. Inhaled albuterol
B. Intravenous ribavirin
C. Dexamethasone
D. Oral amoxicillin
Correct Answer: C
, Explanation: Croup, caused by the parainfluenza virus, presents with a barking cough and
the ‘steeple sign’ on X-ray. A single dose of corticosteroids (dexamethasone) is the standard
treatment for mild to severe cases to reduce airway edema. Racemic epinephrine is added
if stridor is present at rest, but antibiotics are not indicated as the cause is viral.
5. A 32-year-old female presents with persistent sadness, loss of interest in activities, and
difficulty sleeping for the past 3 weeks. She also reports hearing voices of deceased relatives
telling her she is worthless. She has no history of mania. What is the most likely diagnosis?
A. Schizoaffective disorder
B. Schizophrenia
C. Major depressive disorder with psychotic features
D. Brief psychotic disorder
Correct Answer: C
Explanation: The patient meets criteria for Major Depressive Disorder (MDD) and exhibits
psychosis occurring exclusively during the depressive episode. Schizoaffective disorder
requires a period of at least two weeks of delusions or hallucinations in the absence of a
major mood episode. Clinical distinction relies on the timeline of mood symptoms relative
to psychotic symptoms.
