COMSAE Phase 1 Level 1 Comprehensive
Osteopathic Medical Self-Assessment Examination
V3
1. A 65-year-old male presents with a chief complaint of a persistent cough and weight loss of
15 lbs over the last two months. He reports a 40-pack-year smoking history. Physical exam
reveals decreased breath sounds in the right upper lobe. A chest X-ray shows a central hilar
mass. Laboratory results indicate a serum calcium of 12.8 mg/dL. What is the most likely
diagnosis?
A. Squamous cell carcinoma
B. Small cell carcinoma
C. Adenocarcinoma of the lung
D. Large cell carcinoma
Correct Answer: A
Explanation: Squamous cell carcinoma of the lung is classically associated with a central
location and the paraneoplastic production of parathyroid hormone-related protein
(PTHrP), leading to hypercalcemia. Adenocarcinoma is typically peripheral and the most
common in non-smokers. A common pitfall is confusing squamous cell (central/PTHrP)
with small cell (central/ACTH/ADH) carcinomas; remember ‘S’ for Squamous, Smoking,
and Stones (hypercalcemia).
,2. A 28-year-old female presents to the clinic for a routine check-up. Osteopathic physical
examination reveals that T5 is rotated right and sidebent right. Which of the following
describes the most likely positional diagnosis for T5?
A. T5 Neutral, Sidebent Left, Rotated Right
B. T5 Extended, Rotated Right, Sidebent Right
C. T5 Flexed, Rotated Right, Sidebent Right
D. T5 Neutral, Sidebent Right, Rotated Left
Correct Answer: C
Explanation: According to Fryette’s Second Law, which applies to non-neutral (flexed or
extended) mechanics in the thoracic and lumbar spine, rotation and sidebending occur to
the same side. Since the question states the segment is rotated right and sidebent right, it
must be either flexed or extended; options B and C both follow this rule, but typically,
single segment dysfunctions are Type II. Critical thinking involves recognizing that Type I
mechanics (Neutral) involve sidebending and rotation to opposite sides.
3. A 45-year-old male is being treated for hypertension with a new medication. Two weeks
later, he presents with a dry, non-productive cough. Which of the following is the most likely
mechanism of this patient’s side effect?
A. Accumulation of Bradykinin
B. Decreased production of Angiotensin II
C. Inhibition of Calcium channels
,D. Antagonism of AT1 receptors
Correct Answer: A
Explanation: ACE inhibitors prevent the conversion of Angiotensin I to Angiotensin II but
also inhibit the breakdown of bradykinin. The accumulation of bradykinin leads to
bronchial irritation and the characteristic dry cough. Switching to an ARB (Angiotensin
Receptor Blocker) would avoid this side effect because ARBs do not affect bradykinin
levels.
4. A 54-year-old female presents with fatigue and cold intolerance. Physical exam reveals a
non-tender, enlarged thyroid gland and delayed relaxation of the Achilles tendon reflex. Labs
show an elevated TSH and low free T4. What is the most likely finding on thyroid biopsy?
A. Psammoma bodies
B. Orphan Annie eye nuclei
C. Extensive fibrosis extending into surrounding tissues
D. Hurthle cells and lymphocytic infiltrate
Correct Answer: D
Explanation: Hashimoto thyroiditis is the most common cause of hypothyroidism in
iodine-sufficient regions and is characterized histologically by a lymphocytic infiltrate with
germinal centers and Hurthle cells (oxyphilic cells). Orphan Annie eye nuclei and
psammoma bodies are characteristic of papillary thyroid carcinoma. It is vital to
, distinguish the painless goiter of Hashimoto’s from the painful goiter of De Quervain
(subacute) thyroiditis.
5. A 19-year-old college student presents with a headache, stiff neck, and high fever. Physical
exam shows a positive Brudzinski sign and a petechial rash on the lower extremities. Lumbar
puncture reveals gram-negative diplococci. What is the recommended prophylaxis for the
patient’s close contacts?
A. Ceftriaxone
B. Rifampin
C. Penicillin G
D. Vancomycin
Correct Answer: B
Explanation: The patient has meningococcal meningitis caused by Neisseria meningitidis,
a gram-negative diplococcus. Rifampin is the classic choice for prophylaxis of close contacts
to eradicate nasopharyngeal carriage. Clinical significance lies in rapid identification and
public health intervention to prevent outbreaks in crowded settings like dormitories.
6. A 70-year-old male with a history of chronic atrial fibrillation presents with sudden onset
sharp abdominal pain and bloody diarrhea. Physical examination is notable for a soft
abdomen with minimal tenderness despite the severity of the pain. What is the most likely
diagnosis?
A. Acute cholecystitis
Osteopathic Medical Self-Assessment Examination
V3
1. A 65-year-old male presents with a chief complaint of a persistent cough and weight loss of
15 lbs over the last two months. He reports a 40-pack-year smoking history. Physical exam
reveals decreased breath sounds in the right upper lobe. A chest X-ray shows a central hilar
mass. Laboratory results indicate a serum calcium of 12.8 mg/dL. What is the most likely
diagnosis?
A. Squamous cell carcinoma
B. Small cell carcinoma
C. Adenocarcinoma of the lung
D. Large cell carcinoma
Correct Answer: A
Explanation: Squamous cell carcinoma of the lung is classically associated with a central
location and the paraneoplastic production of parathyroid hormone-related protein
(PTHrP), leading to hypercalcemia. Adenocarcinoma is typically peripheral and the most
common in non-smokers. A common pitfall is confusing squamous cell (central/PTHrP)
with small cell (central/ACTH/ADH) carcinomas; remember ‘S’ for Squamous, Smoking,
and Stones (hypercalcemia).
,2. A 28-year-old female presents to the clinic for a routine check-up. Osteopathic physical
examination reveals that T5 is rotated right and sidebent right. Which of the following
describes the most likely positional diagnosis for T5?
A. T5 Neutral, Sidebent Left, Rotated Right
B. T5 Extended, Rotated Right, Sidebent Right
C. T5 Flexed, Rotated Right, Sidebent Right
D. T5 Neutral, Sidebent Right, Rotated Left
Correct Answer: C
Explanation: According to Fryette’s Second Law, which applies to non-neutral (flexed or
extended) mechanics in the thoracic and lumbar spine, rotation and sidebending occur to
the same side. Since the question states the segment is rotated right and sidebent right, it
must be either flexed or extended; options B and C both follow this rule, but typically,
single segment dysfunctions are Type II. Critical thinking involves recognizing that Type I
mechanics (Neutral) involve sidebending and rotation to opposite sides.
3. A 45-year-old male is being treated for hypertension with a new medication. Two weeks
later, he presents with a dry, non-productive cough. Which of the following is the most likely
mechanism of this patient’s side effect?
A. Accumulation of Bradykinin
B. Decreased production of Angiotensin II
C. Inhibition of Calcium channels
,D. Antagonism of AT1 receptors
Correct Answer: A
Explanation: ACE inhibitors prevent the conversion of Angiotensin I to Angiotensin II but
also inhibit the breakdown of bradykinin. The accumulation of bradykinin leads to
bronchial irritation and the characteristic dry cough. Switching to an ARB (Angiotensin
Receptor Blocker) would avoid this side effect because ARBs do not affect bradykinin
levels.
4. A 54-year-old female presents with fatigue and cold intolerance. Physical exam reveals a
non-tender, enlarged thyroid gland and delayed relaxation of the Achilles tendon reflex. Labs
show an elevated TSH and low free T4. What is the most likely finding on thyroid biopsy?
A. Psammoma bodies
B. Orphan Annie eye nuclei
C. Extensive fibrosis extending into surrounding tissues
D. Hurthle cells and lymphocytic infiltrate
Correct Answer: D
Explanation: Hashimoto thyroiditis is the most common cause of hypothyroidism in
iodine-sufficient regions and is characterized histologically by a lymphocytic infiltrate with
germinal centers and Hurthle cells (oxyphilic cells). Orphan Annie eye nuclei and
psammoma bodies are characteristic of papillary thyroid carcinoma. It is vital to
, distinguish the painless goiter of Hashimoto’s from the painful goiter of De Quervain
(subacute) thyroiditis.
5. A 19-year-old college student presents with a headache, stiff neck, and high fever. Physical
exam shows a positive Brudzinski sign and a petechial rash on the lower extremities. Lumbar
puncture reveals gram-negative diplococci. What is the recommended prophylaxis for the
patient’s close contacts?
A. Ceftriaxone
B. Rifampin
C. Penicillin G
D. Vancomycin
Correct Answer: B
Explanation: The patient has meningococcal meningitis caused by Neisseria meningitidis,
a gram-negative diplococcus. Rifampin is the classic choice for prophylaxis of close contacts
to eradicate nasopharyngeal carriage. Clinical significance lies in rapid identification and
public health intervention to prevent outbreaks in crowded settings like dormitories.
6. A 70-year-old male with a history of chronic atrial fibrillation presents with sudden onset
sharp abdominal pain and bloody diarrhea. Physical examination is notable for a soft
abdomen with minimal tenderness despite the severity of the pain. What is the most likely
diagnosis?
A. Acute cholecystitis
