COMSAE Phase 2 Level 2-CE Comprehensive
Osteopathic Medical Self-Assessment Examination
V2
1. A 28-year-old female at 34 weeks gestation presents with a sudden onset of painless
vaginal bleeding. Ultrasound reveals 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. Pelvic rest and observation
C. Immediate vaginal delivery
D. Emergent cesarean section
Correct Answer: B
Explanation: This patient has placenta previa, which requires pelvic rest and avoidance of
digital cervical exams to prevent catastrophic hemorrhage. Clinical management depends
on the stability of the mother and fetus; if both are stable and the pregnancy is preterm,
expectant management is preferred. A common examination pitfall is performing a digital
exam, which is strictly contraindicated until placenta previa is ruled out by ultrasound.
,2. A 65-year-old male with a history of smoking and hypertension presents with sudden onset
of severe tearing chest pain radiating to his back. His blood pressure is 190/110 mmHg. A
chest X-ray shows a widened mediastinum. What is the most appropriate initial diagnostic
study?
A. Electrocardiogram
B. Transthoracic echocardiogram
C. Cardiac catheterization
D. CT Angiography of the chest
Correct Answer: D
Explanation: The clinical presentation is highly suggestive of an aortic dissection, for
which CT angiography is the gold standard for rapid diagnosis in stable patients. This
condition requires immediate blood pressure control and surgical consultation if it
involves the ascending aorta (Stanford Type A). Pitfalls include delaying imaging for
cardiac enzyme results when the presentation is classic for vascular catastrophe.
3. A 12-year-old male presents with a cough, wheezing, and shortness of breath that worsens
at night. He uses an albuterol inhaler three times a week. He has symptoms twice a week.
What is the most appropriate classification of his asthma?
A. Intermittent
B. Mild persistent
C. Moderate persistent
,D. Severe persistent
Correct Answer: B
Explanation: Mild persistent asthma is defined by symptoms occurring more than twice a
week but not daily, and nighttime awakenings 3-4 times per month. Proper classification is
essential for determining whether to initiate long-term controller therapy like inhaled
corticosteroids. Clinicians often fail to account for nighttime symptoms, which can lead to
under-treating a patient’s underlying airway inflammation.
4. During an osteopathic structural exam, a patient is found to have a sacral torsion. L5 is
found to be rotated left and sidebent left. Which of the following sacral findings is most likely
present?
A. Left-on-left forward torsion
B. Right-on-left backward torsion
C. Right-on-right forward torsion
D. Left-on-right backward torsion
Correct Answer: B
Explanation: According to Fryette’s laws and sacral mechanics, L5 always rotates in the
opposite direction of the sacral rotation and sidebends toward the side of the sacral base.
In a right-on-left backward torsion, the sacrum rotates right, so L5 must rotate left; since it
is a backward torsion, L5 is often non-neutral. Mastering the L5-sacrum relationship is a
frequent test topic on COMLEX-USA exams for diagnosing pelvic dysfunctions.
, 5. A 45-year-old male presents with acute onset of severe pain, redness, and swelling in his
right first metatarsophalangeal joint. Arthrocentesis shows negatively birefringent needle-
shaped crystals. What is the most appropriate first-line treatment for the acute flare?
A. Allopurinol
B. Probenecid
C. Febuxostat
D. Indomethacin
Correct Answer: D
Explanation: Acute gouty arthritis is best managed with NSAIDs like indomethacin,
colchicine, or corticosteroids. Allopurinol and febuxostat are for chronic management and
should not be started during an acute flare as they can worsen the symptoms by shifting
urate levels. A major clinical pitfall is initiating urate-lowering therapy too early, which can
prolong the patient’s pain and inflammation.
6. A 5-year-old girl is brought to the clinic for a ‘barking’ cough and inspiratory stridor that
started last night. She has a low-grade fever but is not in respiratory distress. What is the
most appropriate next step?
A. Single dose of oral dexamethasone
B. Nebulized racemic epinephrine
C. Lateral neck X-ray
D. Amoxicillin-clavulanate
Osteopathic Medical Self-Assessment Examination
V2
1. A 28-year-old female at 34 weeks gestation presents with a sudden onset of painless
vaginal bleeding. Ultrasound reveals 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. Pelvic rest and observation
C. Immediate vaginal delivery
D. Emergent cesarean section
Correct Answer: B
Explanation: This patient has placenta previa, which requires pelvic rest and avoidance of
digital cervical exams to prevent catastrophic hemorrhage. Clinical management depends
on the stability of the mother and fetus; if both are stable and the pregnancy is preterm,
expectant management is preferred. A common examination pitfall is performing a digital
exam, which is strictly contraindicated until placenta previa is ruled out by ultrasound.
,2. A 65-year-old male with a history of smoking and hypertension presents with sudden onset
of severe tearing chest pain radiating to his back. His blood pressure is 190/110 mmHg. A
chest X-ray shows a widened mediastinum. What is the most appropriate initial diagnostic
study?
A. Electrocardiogram
B. Transthoracic echocardiogram
C. Cardiac catheterization
D. CT Angiography of the chest
Correct Answer: D
Explanation: The clinical presentation is highly suggestive of an aortic dissection, for
which CT angiography is the gold standard for rapid diagnosis in stable patients. This
condition requires immediate blood pressure control and surgical consultation if it
involves the ascending aorta (Stanford Type A). Pitfalls include delaying imaging for
cardiac enzyme results when the presentation is classic for vascular catastrophe.
3. A 12-year-old male presents with a cough, wheezing, and shortness of breath that worsens
at night. He uses an albuterol inhaler three times a week. He has symptoms twice a week.
What is the most appropriate classification of his asthma?
A. Intermittent
B. Mild persistent
C. Moderate persistent
,D. Severe persistent
Correct Answer: B
Explanation: Mild persistent asthma is defined by symptoms occurring more than twice a
week but not daily, and nighttime awakenings 3-4 times per month. Proper classification is
essential for determining whether to initiate long-term controller therapy like inhaled
corticosteroids. Clinicians often fail to account for nighttime symptoms, which can lead to
under-treating a patient’s underlying airway inflammation.
4. During an osteopathic structural exam, a patient is found to have a sacral torsion. L5 is
found to be rotated left and sidebent left. Which of the following sacral findings is most likely
present?
A. Left-on-left forward torsion
B. Right-on-left backward torsion
C. Right-on-right forward torsion
D. Left-on-right backward torsion
Correct Answer: B
Explanation: According to Fryette’s laws and sacral mechanics, L5 always rotates in the
opposite direction of the sacral rotation and sidebends toward the side of the sacral base.
In a right-on-left backward torsion, the sacrum rotates right, so L5 must rotate left; since it
is a backward torsion, L5 is often non-neutral. Mastering the L5-sacrum relationship is a
frequent test topic on COMLEX-USA exams for diagnosing pelvic dysfunctions.
, 5. A 45-year-old male presents with acute onset of severe pain, redness, and swelling in his
right first metatarsophalangeal joint. Arthrocentesis shows negatively birefringent needle-
shaped crystals. What is the most appropriate first-line treatment for the acute flare?
A. Allopurinol
B. Probenecid
C. Febuxostat
D. Indomethacin
Correct Answer: D
Explanation: Acute gouty arthritis is best managed with NSAIDs like indomethacin,
colchicine, or corticosteroids. Allopurinol and febuxostat are for chronic management and
should not be started during an acute flare as they can worsen the symptoms by shifting
urate levels. A major clinical pitfall is initiating urate-lowering therapy too early, which can
prolong the patient’s pain and inflammation.
6. A 5-year-old girl is brought to the clinic for a ‘barking’ cough and inspiratory stridor that
started last night. She has a low-grade fever but is not in respiratory distress. What is the
most appropriate next step?
A. Single dose of oral dexamethasone
B. Nebulized racemic epinephrine
C. Lateral neck X-ray
D. Amoxicillin-clavulanate
