COMSAE Form 113 Practice Exam —
Version 1
Comprehensive Osteopathic Medical Self-Assessment Examination
Simulation
200 Board-Style Clinical Vignettes with Comprehensive Rationales
Question 1 [Osteopathic Principles & Practice (OMM)]
A 45-year-old male presents with chronic lower back pain and stiffness.
Physical examination reveals a Type II lumbar somatic dysfunction
characterized by sidebending and rotation in opposite directions, with
the greatest asymmetry appreciated at L3. The restriction is more
pronounced in flexion. Which of the following describes the correct
diagnosis and naming convention for this somatic dysfunction?
A) L3 F S_R_ (Flexed, Sidebent Left, Rotated Right)
B) L3 E S_R_ (Extended, Sidebent Right, Rotated Left)
C) L3 F S_R_ (Flexed, Sidebent Right, Rotated Left)
D) L3 E S_R_ (Extended, Sidebent Left, Rotated Right)
E) L3 S_R_ (Neutral, Sidebent Right, Rotated Left)
Correct Answer: C) L3 F S_R_ (Flexed, Sidebent Right, Rotated
Left)
Rationale: Type II somatic dysfunctions in the lumbar and thoracic
spine involve a single vertebral segment (or a small group) that is non-
neutral (either significantly flexed or extended). In Type II mechanics,
,sidebending and rotation occur in the SAME direction. When a segment
is flexed (F), sidebending and rotation occur to the same side. If
asymmetry is greatest in flexion and rotation is to the left, sidebending is
also to the right (or vice versa depending on exact convention, but note
that Type II groups sidebend and rotate together: e.g., F S_R_ means
flexed, sidebent right, rotated left or similar paired coupling).
Specifically, for Type II, sidebending and rotation are coupled to the
same side. Choice C correctly pairs flexion with coupled sidebending
and rotation.
----------------------------------------
Question 2 [Cardiovascular Medicine]
A 62-year-old man with a history of hypertension and hyperlipidemia
presents to the emergency department with sudden-onset, severe tearing
chest pain radiating to the back between the scapulae. His blood pressure
is 190/105 mmHg in the right arm and 140/85 mmHg in the left arm. A
diastolic murmur is heard along the right sternal border. Which of the
following is the most appropriate initial diagnostic imaging modality?
A) Electrocardiogram (ECG)
B) Transthoracic echocardiogram (TTE)
C) Computed tomography angiography (CTA) of the chest
D) Chest radiography
E) Coronary angiography
Correct Answer: C) Computed tomography angiography (CTA) of
the chest
Rationale: The patient presents with classic signs and symptoms of
acute aortic dissection (Stanford Type A vs B depending on ascending
,aorta involvement, manifesting as tearing chest pain, pulse/blood
pressure differential between arms, and aortic regurgitation murmur).
CTA of the chest with contrast is the diagnostic gold standard for stable
and unstable patients with suspected aortic dissection due to its rapid
acquisition time, high sensitivity, and specificity. While a chest X-ray
may show a widened mediastinum, it is neither sensitive nor specific
enough to rule out dissection.
----------------------------------------
Question 3 [Pulmonary Medicine]
A 24-year-old female presents with acute shortness of breath and
pleuritic chest pain that began suddenly 3 hours ago. She returned from a
14-hour international flight yesterday. Her vital signs are: BP 124/78
mmHg, HR 112/min, RR 24/min, SpO2 91% on room air. Examination
reveals clear breath sounds bilaterally and mild right calf tenderness
without significant swelling. Which of the following is the most likely
diagnosis?
A) Primary spontaneous pneumothorax
B) Acute pulmonary embolism
C) Community-acquired pneumonia
D) Asthma exacerbation
E) Costochondritis
Correct Answer: B) Acute pulmonary embolism
Rationale: This patient presents with classic risk factors (prolonged
immobilization/air travel) and clinical presentation (sudden-onset
dyspnea, pleuritic chest pain, tachypnea, tachycardia, hypoxia, and signs
of deep vein thrombosis like calf tenderness) suggestive of an acute
, pulmonary embolism (PE). Wells criteria score is high. Pulmonary
embolism must be urgently evaluated with CTA chest or ventilation-
perfusion (V/Q) scan.
----------------------------------------
Question 4 [Gastroenterology]
A 35-year-old man presents with chronic, nonbloody diarrhea,
abdominal cramping, and weight loss over the past 6 months. He also
notes painful red nodules on his shins and migrating joint pain in his
knees. Colonoscopy reveals transmural inflammation with noncaseating
granulomas and skip lesions from the terminal ileum to the colon. Which
of the following histological or pathological findings is most
characteristic of this condition?
A) Crypt abscesses restricted to the mucosa and submucosa
B) Pseudopolyps and continuous mucosal involvement starting at the
rectum
C) Transmural inflammation with lymphoid aggregates and fissuring
ulcers
D) Mucosal atrophy with blunting of duodenal villi
E) Mucosal ischemia with thumbprinting on barium enema
Correct Answer: C) Transmural inflammation with lymphoid
aggregates and fissuring ulcers
Rationale: The clinical presentation (chronic diarrhea, weight loss,
erythema nodosum, arthralgias) and endoscopic findings (skip lesions,
transmural inflammation, noncaseating granulomas) are pathognomonic
for Crohn disease. Crohn disease is characterized by transmural
inflammation, skip lesions, cobblestoning, and creeping fat. In contrast,
Version 1
Comprehensive Osteopathic Medical Self-Assessment Examination
Simulation
200 Board-Style Clinical Vignettes with Comprehensive Rationales
Question 1 [Osteopathic Principles & Practice (OMM)]
A 45-year-old male presents with chronic lower back pain and stiffness.
Physical examination reveals a Type II lumbar somatic dysfunction
characterized by sidebending and rotation in opposite directions, with
the greatest asymmetry appreciated at L3. The restriction is more
pronounced in flexion. Which of the following describes the correct
diagnosis and naming convention for this somatic dysfunction?
A) L3 F S_R_ (Flexed, Sidebent Left, Rotated Right)
B) L3 E S_R_ (Extended, Sidebent Right, Rotated Left)
C) L3 F S_R_ (Flexed, Sidebent Right, Rotated Left)
D) L3 E S_R_ (Extended, Sidebent Left, Rotated Right)
E) L3 S_R_ (Neutral, Sidebent Right, Rotated Left)
Correct Answer: C) L3 F S_R_ (Flexed, Sidebent Right, Rotated
Left)
Rationale: Type II somatic dysfunctions in the lumbar and thoracic
spine involve a single vertebral segment (or a small group) that is non-
neutral (either significantly flexed or extended). In Type II mechanics,
,sidebending and rotation occur in the SAME direction. When a segment
is flexed (F), sidebending and rotation occur to the same side. If
asymmetry is greatest in flexion and rotation is to the left, sidebending is
also to the right (or vice versa depending on exact convention, but note
that Type II groups sidebend and rotate together: e.g., F S_R_ means
flexed, sidebent right, rotated left or similar paired coupling).
Specifically, for Type II, sidebending and rotation are coupled to the
same side. Choice C correctly pairs flexion with coupled sidebending
and rotation.
----------------------------------------
Question 2 [Cardiovascular Medicine]
A 62-year-old man with a history of hypertension and hyperlipidemia
presents to the emergency department with sudden-onset, severe tearing
chest pain radiating to the back between the scapulae. His blood pressure
is 190/105 mmHg in the right arm and 140/85 mmHg in the left arm. A
diastolic murmur is heard along the right sternal border. Which of the
following is the most appropriate initial diagnostic imaging modality?
A) Electrocardiogram (ECG)
B) Transthoracic echocardiogram (TTE)
C) Computed tomography angiography (CTA) of the chest
D) Chest radiography
E) Coronary angiography
Correct Answer: C) Computed tomography angiography (CTA) of
the chest
Rationale: The patient presents with classic signs and symptoms of
acute aortic dissection (Stanford Type A vs B depending on ascending
,aorta involvement, manifesting as tearing chest pain, pulse/blood
pressure differential between arms, and aortic regurgitation murmur).
CTA of the chest with contrast is the diagnostic gold standard for stable
and unstable patients with suspected aortic dissection due to its rapid
acquisition time, high sensitivity, and specificity. While a chest X-ray
may show a widened mediastinum, it is neither sensitive nor specific
enough to rule out dissection.
----------------------------------------
Question 3 [Pulmonary Medicine]
A 24-year-old female presents with acute shortness of breath and
pleuritic chest pain that began suddenly 3 hours ago. She returned from a
14-hour international flight yesterday. Her vital signs are: BP 124/78
mmHg, HR 112/min, RR 24/min, SpO2 91% on room air. Examination
reveals clear breath sounds bilaterally and mild right calf tenderness
without significant swelling. Which of the following is the most likely
diagnosis?
A) Primary spontaneous pneumothorax
B) Acute pulmonary embolism
C) Community-acquired pneumonia
D) Asthma exacerbation
E) Costochondritis
Correct Answer: B) Acute pulmonary embolism
Rationale: This patient presents with classic risk factors (prolonged
immobilization/air travel) and clinical presentation (sudden-onset
dyspnea, pleuritic chest pain, tachypnea, tachycardia, hypoxia, and signs
of deep vein thrombosis like calf tenderness) suggestive of an acute
, pulmonary embolism (PE). Wells criteria score is high. Pulmonary
embolism must be urgently evaluated with CTA chest or ventilation-
perfusion (V/Q) scan.
----------------------------------------
Question 4 [Gastroenterology]
A 35-year-old man presents with chronic, nonbloody diarrhea,
abdominal cramping, and weight loss over the past 6 months. He also
notes painful red nodules on his shins and migrating joint pain in his
knees. Colonoscopy reveals transmural inflammation with noncaseating
granulomas and skip lesions from the terminal ileum to the colon. Which
of the following histological or pathological findings is most
characteristic of this condition?
A) Crypt abscesses restricted to the mucosa and submucosa
B) Pseudopolyps and continuous mucosal involvement starting at the
rectum
C) Transmural inflammation with lymphoid aggregates and fissuring
ulcers
D) Mucosal atrophy with blunting of duodenal villi
E) Mucosal ischemia with thumbprinting on barium enema
Correct Answer: C) Transmural inflammation with lymphoid
aggregates and fissuring ulcers
Rationale: The clinical presentation (chronic diarrhea, weight loss,
erythema nodosum, arthralgias) and endoscopic findings (skip lesions,
transmural inflammation, noncaseating granulomas) are pathognomonic
for Crohn disease. Crohn disease is characterized by transmural
inflammation, skip lesions, cobblestoning, and creeping fat. In contrast,
