COMSAE Phase 2 – BSA 118 Practice Exam
Ultimate Prep Guide: Comprehensive
Questions, Answers, & Rationales for
High-Yield COMLEX Review
Question 1
A 62-year-old male presents to the emergency department
with a 3-hour history of crushing substernal chest pain that
radiates to his left jaw. He is diaphoretic and lightheaded. An
electrocardiogram (ECG) reveals ST-segment elevations in
leads II, III, and aVF. Physical examination reveals an
asymmetric tissue texture change, exquisite tenderness, and
rotational restriction at the T2–T4 levels on the right. Which
of the following is the most likely location of the coronary
artery occlusion, and which autonomic reflex explains the
thoracic spinal findings?
A. Left anterior descending artery; Parasympathetic
viscerosomatic reflex
B. Left anterior descending artery; Sympathetic
somatovisceral reflex
C. Right coronary artery; Parasympathetic somatovisceral
reflex
D. Right coronary artery; Sympathetic viscerosomatic reflex
,Rationale: This patient is experiencing an acute inferior wall
myocardial infarction (MI), as evidenced by ST elevations in
leads II, III, and aVF. The inferior wall of the myocardium is
primarily supplied by the right coronary artery (RCA) in right-
dominant individuals (approximately 85% of the population).
Visceral pathology, such as myocardial ischemia, sends
afferent nociceptive signals via sympathetic pathways back to
the spinal cord segments that innervate the heart (T1–T5).
These signals excite somatic motor and sensory neurons in
the dorsal horn, leading to localized musculoskeletal changes
(TART changes) in the corresponding thoracic paraspinal
tissues. This phenomenon is a viscerosomatic reflex mediated
by the sympathetic nervous system.
Question 2
A 28-year-old G1P0 female at 38 weeks gestation presents to
the labor and delivery unit reporting regular, painful uterine
contractions every 4 minutes. A sterile vaginal exam reveals
the cervix is 5 cm dilated, 80% effaced, and the fetus is at 0
station. Structural examination reveals a prominent tissue
texture abnormality and hypertonicity at the bilateral sacral
sulci. Palpation reveals a right sacral base that is anterior, and
a left ILA that is posterior and inferior. Springing over the
lumbosacral junction is restricted. What is the correct
diagnosis of this patient's sacral dysfunction?
A. Right unilateral sacral flexion
B. Left unilateral sacral flexion
C. Left sacral rotation on a left oblique axis
,D. Right sacral rotation on a left oblique axis
Rationale: Pregnancy and labor introduce significant
mechanical and hormonal changes (such as increased relaxin)
that predispose the pelvis to somatic dysfunction. The
physical findings indicate a right unilateral sacral flexion. In
this dysfunction, the right sacral base moves anteriorly, which
causes the right sacral sulcus to feel deep. Consequently, the
opposite inferior lateral angle (ILA)—the left side—moves
posterior and inferior. A negative spring test (or restricted
springing) confirms that a sacral base has moved anteriorly,
as it resists being pushed further forward, distinguishing it
from an extension dysfunction.
Question 3
A 45-year-old female presents with severe, episodic right
upper quadrant abdominal pain that radiates to her right
scapula, typically occurring 30 minutes after eating fatty
meals. Physical examination is positive for Murphy's sign.
Osteopathic structural evaluation reveals a distinct
viscerosomatic reflex. At which spinal level would you most
likely find tissue texture changes and somatic dysfunction
associated with this condition?
A. T1–T4 on the left
B. T5–T9 on the left
C. T1–T4 on the right
D. T5–T9 on the right
, Rationale: The patient's presentation is classic for acute
cholecystitis or biliary colic. The gallbladder and hepatobiliary
system receive their sympathetic innervation from the T5–T9
segments of the spinal cord via the greater splanchnic nerve.
Due to the anatomical asymmetry of the liver and gallbladder,
these viscerosomatic reflex changes manifest as paraspinal
tissue texture changes, hypertonicity, and tenderness
specifically on the right side of the thoracic spine between T5
and T9. Left-sided T5–T9 changes are more typically
associated with gastric or splenic pathology.
Question 4
A 54-year-old male with a history of chronic alcohol use
disorder is brought to the clinic by his family, who notes he
has become increasingly confused over the past two days. On
examination, the patient exhibits a coarse, flapping tremor of
his hands when his wrists are extended. He is disoriented to
time and place. Laboratory evaluation shows an elevated
serum ammonia level. Which of the following is the first-line
pharmacological treatment for this patient's underlying
neuropsychiatric condition?
A. Rifaximin
B. Lactulose
C. Ceftriaxone
D. Chlordiazepoxide
Rationale: The patient is presenting with hepatic
encephalopathy, secondary to decompensated liver disease
from chronic alcohol use, highlighted by asterixis (the flapping
Ultimate Prep Guide: Comprehensive
Questions, Answers, & Rationales for
High-Yield COMLEX Review
Question 1
A 62-year-old male presents to the emergency department
with a 3-hour history of crushing substernal chest pain that
radiates to his left jaw. He is diaphoretic and lightheaded. An
electrocardiogram (ECG) reveals ST-segment elevations in
leads II, III, and aVF. Physical examination reveals an
asymmetric tissue texture change, exquisite tenderness, and
rotational restriction at the T2–T4 levels on the right. Which
of the following is the most likely location of the coronary
artery occlusion, and which autonomic reflex explains the
thoracic spinal findings?
A. Left anterior descending artery; Parasympathetic
viscerosomatic reflex
B. Left anterior descending artery; Sympathetic
somatovisceral reflex
C. Right coronary artery; Parasympathetic somatovisceral
reflex
D. Right coronary artery; Sympathetic viscerosomatic reflex
,Rationale: This patient is experiencing an acute inferior wall
myocardial infarction (MI), as evidenced by ST elevations in
leads II, III, and aVF. The inferior wall of the myocardium is
primarily supplied by the right coronary artery (RCA) in right-
dominant individuals (approximately 85% of the population).
Visceral pathology, such as myocardial ischemia, sends
afferent nociceptive signals via sympathetic pathways back to
the spinal cord segments that innervate the heart (T1–T5).
These signals excite somatic motor and sensory neurons in
the dorsal horn, leading to localized musculoskeletal changes
(TART changes) in the corresponding thoracic paraspinal
tissues. This phenomenon is a viscerosomatic reflex mediated
by the sympathetic nervous system.
Question 2
A 28-year-old G1P0 female at 38 weeks gestation presents to
the labor and delivery unit reporting regular, painful uterine
contractions every 4 minutes. A sterile vaginal exam reveals
the cervix is 5 cm dilated, 80% effaced, and the fetus is at 0
station. Structural examination reveals a prominent tissue
texture abnormality and hypertonicity at the bilateral sacral
sulci. Palpation reveals a right sacral base that is anterior, and
a left ILA that is posterior and inferior. Springing over the
lumbosacral junction is restricted. What is the correct
diagnosis of this patient's sacral dysfunction?
A. Right unilateral sacral flexion
B. Left unilateral sacral flexion
C. Left sacral rotation on a left oblique axis
,D. Right sacral rotation on a left oblique axis
Rationale: Pregnancy and labor introduce significant
mechanical and hormonal changes (such as increased relaxin)
that predispose the pelvis to somatic dysfunction. The
physical findings indicate a right unilateral sacral flexion. In
this dysfunction, the right sacral base moves anteriorly, which
causes the right sacral sulcus to feel deep. Consequently, the
opposite inferior lateral angle (ILA)—the left side—moves
posterior and inferior. A negative spring test (or restricted
springing) confirms that a sacral base has moved anteriorly,
as it resists being pushed further forward, distinguishing it
from an extension dysfunction.
Question 3
A 45-year-old female presents with severe, episodic right
upper quadrant abdominal pain that radiates to her right
scapula, typically occurring 30 minutes after eating fatty
meals. Physical examination is positive for Murphy's sign.
Osteopathic structural evaluation reveals a distinct
viscerosomatic reflex. At which spinal level would you most
likely find tissue texture changes and somatic dysfunction
associated with this condition?
A. T1–T4 on the left
B. T5–T9 on the left
C. T1–T4 on the right
D. T5–T9 on the right
, Rationale: The patient's presentation is classic for acute
cholecystitis or biliary colic. The gallbladder and hepatobiliary
system receive their sympathetic innervation from the T5–T9
segments of the spinal cord via the greater splanchnic nerve.
Due to the anatomical asymmetry of the liver and gallbladder,
these viscerosomatic reflex changes manifest as paraspinal
tissue texture changes, hypertonicity, and tenderness
specifically on the right side of the thoracic spine between T5
and T9. Left-sided T5–T9 changes are more typically
associated with gastric or splenic pathology.
Question 4
A 54-year-old male with a history of chronic alcohol use
disorder is brought to the clinic by his family, who notes he
has become increasingly confused over the past two days. On
examination, the patient exhibits a coarse, flapping tremor of
his hands when his wrists are extended. He is disoriented to
time and place. Laboratory evaluation shows an elevated
serum ammonia level. Which of the following is the first-line
pharmacological treatment for this patient's underlying
neuropsychiatric condition?
A. Rifaximin
B. Lactulose
C. Ceftriaxone
D. Chlordiazepoxide
Rationale: The patient is presenting with hepatic
encephalopathy, secondary to decompensated liver disease
from chronic alcohol use, highlighted by asterixis (the flapping
