COMSAE PHASE 2 FORM 116 EXAM QUESTIONS AND
VERIFIED ANSWERS WITH RATIONALES
Question 1: A 45-year-old patient presents with acute onset of severe chest
pain radiating to the back. Which osteopathic structural exam finding is most
consistent with a viscerosomatic reflex from the heart?
A. Tissue texture changes at T1-T4 on the left
B. Tissue texture changes at T5-T9 on the right
C. Tender points at the sacral base
D. Hypertonicity of the psoas muscle
CORRECT ANSWER: A. Tissue texture changes at T1-T4 on the left
Rationale: Cardiac sympathetic innervation originates from T1-T4 spinal segments
on the left side. Viscerosomatic reflexes in osteopathic medicine manifest as tissue
texture abnormalities, tenderness, and asymmetry in the corresponding paraspinal
areas due to facilitated segments.
Question 2: Which pharmacologic agent is the first-line treatment for a patient
diagnosed with community-acquired pneumonia who has no comorbidities?
A. Azithromycin
B. Doxycycline
C. Levofloxacin
D. Amoxicillin-clavulanate
CORRECT ANSWER: A. Azithromycin
Rationale: For outpatient community-acquired pneumonia in healthy adults without
comorbidities, macrolides like azithromycin are recommended as first-line therapy
due to coverage of atypical pathogens such as Mycoplasma and Chlamydia.
Question 3: During an OMT session, a physician identifies a somatic
dysfunction at L4 with extended, rotated right, and sidebent right (E Rr Sr)
mechanics. What is the appropriate muscle energy technique positioning?
A. Flex, rotate left, sidebend left
B. Extend, rotate left, sidebend left
C. Flex, rotate right, sidebend right
D. Neutral, rotate left, sidebend left
CORRECT ANSWER: A. Flex, rotate left, sidebend left
Rationale: In muscle energy technique, the physician positions the segment into the
barriers of motion opposite to the dysfunction (indirect approach initially, then
patient contracts into the restrictive barrier). For E Rr Sr, the freedoms are extension,
right rotation, right sidebending; thus, engage flexion, left rotation, left sidebending.
Question 4: A 62-year-old diabetic patient complains of burning pain in the
feet. Which physical exam test is most specific for confirming diabetic
peripheral neuropathy?
A. Monofilament testing
B. Ankle reflex testing
Page 1 of 44
,C. Vibration sense with 128 Hz tuning fork
D. Pinprick sensation
CORRECT ANSWER: A. Monofilament testing
Rationale: The 10g Semmes-Weinstein monofilament test is highly specific for
identifying loss of protective sensation in diabetic neuropathy and predicting ulcer
risk.
Question 5: What is the primary mechanism of action of omeprazole in
treating GERD?
A. H2 receptor antagonism
B. Irreversible inhibition of H+/K+ ATPase
C. Mucosal protection via prostaglandin stimulation
D. Prokinetic enhancement of gastric emptying
CORRECT ANSWER: B. Irreversible inhibition of H+/K+ ATPase
Rationale: Proton pump inhibitors like omeprazole covalently bind to the parietal
cell proton pump (H+/K+ ATPase), providing potent and long-lasting acid
suppression.
Question 6: In a patient with suspected acute appendicitis, which osteopathic
tender point location corresponds to the viscerosomatic reflex?
A. T10-T12 right paraspinal
B. L1-L2 anterior
C. Sacral base
D. Iliacus muscle
CORRECT ANSWER: A. T10-T12 right paraspinal
Rationale: The appendix receives sympathetic innervation via T10-T12, leading to
viscerosomatic reflexes presenting as tissue texture changes and tenderness in the
corresponding thoracic paraspinal region on the right.
Question 7: Which laboratory finding is most characteristic of primary
hypothyroidism?
A. Low TSH, high free T4
B. High TSH, low free T4
C. High TSH, high free T4
D. Low TSH, low free T4
CORRECT ANSWER: B. High TSH, low free T4
Rationale: In primary hypothyroidism (thyroid gland failure), negative feedback
results in elevated TSH with decreased circulating thyroid hormone levels.
Question 8: A patient with hypertension is started on lisinopril. Which
electrolyte abnormality should be monitored closely?
A. Hypokalemia
B. Hyperkalemia
Page 2 of 44
,C. Hyponatremia
D. Hypocalcemia
CORRECT ANSWER: B. Hyperkalemia
Rationale: ACE inhibitors like lisinopril reduce aldosterone secretion, leading to
potassium retention and potential hyperkalemia, especially in patients with renal
impairment or on potassium-sparing agents.
Question 9: During cranial osteopathic examination, a physician notes
restricted motion at the sphenobasilar synchondrosis. Which motion is
primarily affected in flexion?
A. External rotation of the sphenoid and occiput
B. Internal rotation of the sphenoid and occiput
C. Sidebending rotation
D. Torsion
CORRECT ANSWER: A. External rotation of the sphenoid and occiput
Rationale: In the cranial rhythmic impulse, flexion of the sphenobasilar
synchondrosis is associated with external rotation of the paired bones including the
sphenoid greater wings and occiput.
Question 10: What is the most common cause of traveler's diarrhea?
A. Enterotoxigenic E. coli
B. Shigella spp.
C. Giardia lamblia
D. Norovirus
CORRECT ANSWER: A. Enterotoxigenic E. coli
Rationale: Enterotoxigenic Escherichia coli (ETEC) is the leading bacterial etiology of
traveler's diarrhea in most regions due to heat-labile and heat-stable toxin
production.
Question 11: A 55-year-old male with low back pain has a positive straight leg
raise test at 45 degrees reproducing radicular pain. This finding suggests
compression of which nerve root?
A. L3
B. L4
C. L5
D. S1
CORRECT ANSWER: C. L5
Rationale: The straight leg raise test primarily assesses for L5 and S1 nerve root
irritation, with pain reproduction at 30-70 degrees indicating sciatic nerve tension
from disc herniation commonly affecting the L5 root.
Question 12: Which antihypertensive class is contraindicated in a pregnant
patient with preeclampsia?
Page 3 of 44
, A. Labetalol
B. Nifedipine
C. Methyldopa
D. ACE inhibitors
CORRECT ANSWER: D. ACE inhibitors
Rationale: ACE inhibitors and ARBs are teratogenic and contraindicated in
pregnancy due to risks of fetal renal dysplasia, oligohydramnios, and skull
hypoplasia.
Question 13: In osteopathic manipulative treatment, the Still technique is
classified as which type of approach?
A. Direct
B. Indirect
C. Balanced ligamentous tension
D. Myofascial release
CORRECT ANSWER: A. Direct
Rationale: The Still technique involves exaggerating the dysfunction into the
direction of ease followed by a quick articulatory movement through the restrictive
barrier, making it a direct method.
Question 14: A patient presents with moon facies, buffalo hump, and purple
striae. What is the most likely diagnosis?
A. Addison disease
B. Cushing syndrome
C. Hyperthyroidism
D. Pheochromocytoma
CORRECT ANSWER: B. Cushing syndrome
Rationale: These classic physical findings result from chronic glucocorticoid excess,
most commonly from exogenous steroids or endogenous overproduction in
Cushing syndrome.
Question 15: Which cranial nerve is tested by having the patient shrug their
shoulders against resistance?
A. CN IX
B. CN X
C. CN XI
D. CN XII
CORRECT ANSWER: C. CN XI
Rationale: The accessory nerve (CN XI) innervates the trapezius and
sternocleidomastoid muscles, responsible for shoulder shrugging and head turning.
Question 16: A 28-year-old female with recurrent urinary tract infections
should be evaluated for which anatomic abnormality?
Page 4 of 44
VERIFIED ANSWERS WITH RATIONALES
Question 1: A 45-year-old patient presents with acute onset of severe chest
pain radiating to the back. Which osteopathic structural exam finding is most
consistent with a viscerosomatic reflex from the heart?
A. Tissue texture changes at T1-T4 on the left
B. Tissue texture changes at T5-T9 on the right
C. Tender points at the sacral base
D. Hypertonicity of the psoas muscle
CORRECT ANSWER: A. Tissue texture changes at T1-T4 on the left
Rationale: Cardiac sympathetic innervation originates from T1-T4 spinal segments
on the left side. Viscerosomatic reflexes in osteopathic medicine manifest as tissue
texture abnormalities, tenderness, and asymmetry in the corresponding paraspinal
areas due to facilitated segments.
Question 2: Which pharmacologic agent is the first-line treatment for a patient
diagnosed with community-acquired pneumonia who has no comorbidities?
A. Azithromycin
B. Doxycycline
C. Levofloxacin
D. Amoxicillin-clavulanate
CORRECT ANSWER: A. Azithromycin
Rationale: For outpatient community-acquired pneumonia in healthy adults without
comorbidities, macrolides like azithromycin are recommended as first-line therapy
due to coverage of atypical pathogens such as Mycoplasma and Chlamydia.
Question 3: During an OMT session, a physician identifies a somatic
dysfunction at L4 with extended, rotated right, and sidebent right (E Rr Sr)
mechanics. What is the appropriate muscle energy technique positioning?
A. Flex, rotate left, sidebend left
B. Extend, rotate left, sidebend left
C. Flex, rotate right, sidebend right
D. Neutral, rotate left, sidebend left
CORRECT ANSWER: A. Flex, rotate left, sidebend left
Rationale: In muscle energy technique, the physician positions the segment into the
barriers of motion opposite to the dysfunction (indirect approach initially, then
patient contracts into the restrictive barrier). For E Rr Sr, the freedoms are extension,
right rotation, right sidebending; thus, engage flexion, left rotation, left sidebending.
Question 4: A 62-year-old diabetic patient complains of burning pain in the
feet. Which physical exam test is most specific for confirming diabetic
peripheral neuropathy?
A. Monofilament testing
B. Ankle reflex testing
Page 1 of 44
,C. Vibration sense with 128 Hz tuning fork
D. Pinprick sensation
CORRECT ANSWER: A. Monofilament testing
Rationale: The 10g Semmes-Weinstein monofilament test is highly specific for
identifying loss of protective sensation in diabetic neuropathy and predicting ulcer
risk.
Question 5: What is the primary mechanism of action of omeprazole in
treating GERD?
A. H2 receptor antagonism
B. Irreversible inhibition of H+/K+ ATPase
C. Mucosal protection via prostaglandin stimulation
D. Prokinetic enhancement of gastric emptying
CORRECT ANSWER: B. Irreversible inhibition of H+/K+ ATPase
Rationale: Proton pump inhibitors like omeprazole covalently bind to the parietal
cell proton pump (H+/K+ ATPase), providing potent and long-lasting acid
suppression.
Question 6: In a patient with suspected acute appendicitis, which osteopathic
tender point location corresponds to the viscerosomatic reflex?
A. T10-T12 right paraspinal
B. L1-L2 anterior
C. Sacral base
D. Iliacus muscle
CORRECT ANSWER: A. T10-T12 right paraspinal
Rationale: The appendix receives sympathetic innervation via T10-T12, leading to
viscerosomatic reflexes presenting as tissue texture changes and tenderness in the
corresponding thoracic paraspinal region on the right.
Question 7: Which laboratory finding is most characteristic of primary
hypothyroidism?
A. Low TSH, high free T4
B. High TSH, low free T4
C. High TSH, high free T4
D. Low TSH, low free T4
CORRECT ANSWER: B. High TSH, low free T4
Rationale: In primary hypothyroidism (thyroid gland failure), negative feedback
results in elevated TSH with decreased circulating thyroid hormone levels.
Question 8: A patient with hypertension is started on lisinopril. Which
electrolyte abnormality should be monitored closely?
A. Hypokalemia
B. Hyperkalemia
Page 2 of 44
,C. Hyponatremia
D. Hypocalcemia
CORRECT ANSWER: B. Hyperkalemia
Rationale: ACE inhibitors like lisinopril reduce aldosterone secretion, leading to
potassium retention and potential hyperkalemia, especially in patients with renal
impairment or on potassium-sparing agents.
Question 9: During cranial osteopathic examination, a physician notes
restricted motion at the sphenobasilar synchondrosis. Which motion is
primarily affected in flexion?
A. External rotation of the sphenoid and occiput
B. Internal rotation of the sphenoid and occiput
C. Sidebending rotation
D. Torsion
CORRECT ANSWER: A. External rotation of the sphenoid and occiput
Rationale: In the cranial rhythmic impulse, flexion of the sphenobasilar
synchondrosis is associated with external rotation of the paired bones including the
sphenoid greater wings and occiput.
Question 10: What is the most common cause of traveler's diarrhea?
A. Enterotoxigenic E. coli
B. Shigella spp.
C. Giardia lamblia
D. Norovirus
CORRECT ANSWER: A. Enterotoxigenic E. coli
Rationale: Enterotoxigenic Escherichia coli (ETEC) is the leading bacterial etiology of
traveler's diarrhea in most regions due to heat-labile and heat-stable toxin
production.
Question 11: A 55-year-old male with low back pain has a positive straight leg
raise test at 45 degrees reproducing radicular pain. This finding suggests
compression of which nerve root?
A. L3
B. L4
C. L5
D. S1
CORRECT ANSWER: C. L5
Rationale: The straight leg raise test primarily assesses for L5 and S1 nerve root
irritation, with pain reproduction at 30-70 degrees indicating sciatic nerve tension
from disc herniation commonly affecting the L5 root.
Question 12: Which antihypertensive class is contraindicated in a pregnant
patient with preeclampsia?
Page 3 of 44
, A. Labetalol
B. Nifedipine
C. Methyldopa
D. ACE inhibitors
CORRECT ANSWER: D. ACE inhibitors
Rationale: ACE inhibitors and ARBs are teratogenic and contraindicated in
pregnancy due to risks of fetal renal dysplasia, oligohydramnios, and skull
hypoplasia.
Question 13: In osteopathic manipulative treatment, the Still technique is
classified as which type of approach?
A. Direct
B. Indirect
C. Balanced ligamentous tension
D. Myofascial release
CORRECT ANSWER: A. Direct
Rationale: The Still technique involves exaggerating the dysfunction into the
direction of ease followed by a quick articulatory movement through the restrictive
barrier, making it a direct method.
Question 14: A patient presents with moon facies, buffalo hump, and purple
striae. What is the most likely diagnosis?
A. Addison disease
B. Cushing syndrome
C. Hyperthyroidism
D. Pheochromocytoma
CORRECT ANSWER: B. Cushing syndrome
Rationale: These classic physical findings result from chronic glucocorticoid excess,
most commonly from exogenous steroids or endogenous overproduction in
Cushing syndrome.
Question 15: Which cranial nerve is tested by having the patient shrug their
shoulders against resistance?
A. CN IX
B. CN X
C. CN XI
D. CN XII
CORRECT ANSWER: C. CN XI
Rationale: The accessory nerve (CN XI) innervates the trapezius and
sternocleidomastoid muscles, responsible for shoulder shrugging and head turning.
Question 16: A 28-year-old female with recurrent urinary tract infections
should be evaluated for which anatomic abnormality?
Page 4 of 44
