COMSAE Phase 3 Comprehensive Osteopathic
Medical Self-Assessment Examination V3
1. A 65-year-old male with a history of type 2 diabetes mellitus and hypertension presents
with a three-month history of fatigue and exertional dyspnea. Physical examination reveals a
2/6 holosystolic murmur at the apex radiating to the axilla. His blood pressure is 145/95
mmHg. Which of the following is the most appropriate next step in management to reduce
morbidity and mortality?
A. Initiating Metoprolol
B. Starting Lisinopril
C. Starting Furosemide
D. Referral for mitral valve replacement
Correct Answer: B
Explanation: The patient presents with signs of mitral regurgitation and uncontrolled
hypertension. In patients with mitral regurgitation, afterload reduction using ACE
inhibitors like lisinopril is crucial to reduce the regurgitant volume and improve cardiac
output. This approach helps prevent progressive left ventricular remodeling and reduces
mortality in the setting of concurrent hypertension.
,2. A 28-year-old female presents for evaluation of chronic neck pain. Physical examination
reveals a restricted motion of the atlanto-axial (AA) joint, which is found to be rotated left.
The patient has a known history of Rheumatoid Arthritis with cervical spine involvement.
Which of the following osteopathic treatments is strictly contraindicated in this patient?
A. Muscle Energy
B. High-Velocity Low-Amplitude (HVLA)
C. Strain-Counterstrain
D. Myofascial Release
Correct Answer: B
Explanation: Patients with Rheumatoid Arthritis are at high risk for atlanto-axial
instability due to laxity of the transverse ligament of the dens. Performing HVLA in the
cervical region for these patients carries a significant risk of dens subluxation and spinal
cord injury. Therefore, HVLA is strictly contraindicated, while gentler techniques like
Muscle Energy or Myofascial Release may be considered with caution.
3. A 52-year-old female presents with a chief complaint of a ‘lump’ in her neck. Ultrasound
reveals a 1.5 cm solid nodule in the right lobe of the thyroid. Serum TSH is 2.5 uIU/mL
(normal range 0.5-5.0). What is the next most appropriate step in management?
A. Fine-needle aspiration (FNA) biopsy
B. Radioactive iodine uptake scan
C. Total thyroidectomy
,D. Repeat ultrasound in 6 months
Correct Answer: A
Explanation: For thyroid nodules larger than 1 cm with a normal TSH, fine-needle
aspiration (FNA) biopsy is the gold standard diagnostic step to rule out malignancy. A
radioactive iodine scan is indicated only if the TSH is low (hyperthyroid), to determine if
the nodule is ‘hot’ or ‘cold’. A normal TSH indicates a non-functioning nodule, necessitating
biopsy for tissue diagnosis.
4. A 72-year-old male is admitted for a hip fracture repair. On postoperative day 2, he
becomes acutely agitated, disoriented to time and place, and begins seeing insects on the
walls. His vital signs are stable, but his attention span is severely limited. What is the most
likely diagnosis?
A. Dementia
B. Delirium
C. Schizophrenia
D. Major Depressive Disorder with Psychosis
Correct Answer: B
Explanation: Delirium is characterized by an acute, fluctuating change in mental status,
inattention, and altered level of consciousness, often triggered by medical illness or surgery
in elderly patients. Unlike dementia, which is chronic and progressive, delirium is
, reversible and often associated with visual hallucinations. Identifying the underlying cause,
such as infection or medication side effects, is the primary management goal.
5. A 45-year-old male presents with acute onset of severe pain in his first
metatarsophalangeal (MTP) joint. The joint is erythematous, swollen, and tender.
Arthrocentesis reveals needle-shaped, negatively birefringent crystals. Which of the following
is the most appropriate long-term management strategy to prevent future attacks?
A. Daily Allopurinol
B. Daily Colchicine
C. Daily Ibuprofen
D. Daily Prednisone
Correct Answer: A
Explanation: The presence of negatively birefringent, needle-shaped crystals confirms a
diagnosis of gout. Allopurinol is a xanthine oxidase inhibitor used for long-term urate-
lowering therapy to prevent recurrent attacks and complications like tophi. It should not be
started during an acute flare without prophylactic anti-inflammatory coverage, but it
remains the mainstay for long-term management.
6. A 34-year-old G2P1 female at 34 weeks gestation presents with sudden onset of painful
vaginal bleeding. Physical examination reveals a firm, tender uterus. Fetal heart rate
monitoring shows late decelerations. What is the most likely diagnosis?
A. Placenta previa
Medical Self-Assessment Examination V3
1. A 65-year-old male with a history of type 2 diabetes mellitus and hypertension presents
with a three-month history of fatigue and exertional dyspnea. Physical examination reveals a
2/6 holosystolic murmur at the apex radiating to the axilla. His blood pressure is 145/95
mmHg. Which of the following is the most appropriate next step in management to reduce
morbidity and mortality?
A. Initiating Metoprolol
B. Starting Lisinopril
C. Starting Furosemide
D. Referral for mitral valve replacement
Correct Answer: B
Explanation: The patient presents with signs of mitral regurgitation and uncontrolled
hypertension. In patients with mitral regurgitation, afterload reduction using ACE
inhibitors like lisinopril is crucial to reduce the regurgitant volume and improve cardiac
output. This approach helps prevent progressive left ventricular remodeling and reduces
mortality in the setting of concurrent hypertension.
,2. A 28-year-old female presents for evaluation of chronic neck pain. Physical examination
reveals a restricted motion of the atlanto-axial (AA) joint, which is found to be rotated left.
The patient has a known history of Rheumatoid Arthritis with cervical spine involvement.
Which of the following osteopathic treatments is strictly contraindicated in this patient?
A. Muscle Energy
B. High-Velocity Low-Amplitude (HVLA)
C. Strain-Counterstrain
D. Myofascial Release
Correct Answer: B
Explanation: Patients with Rheumatoid Arthritis are at high risk for atlanto-axial
instability due to laxity of the transverse ligament of the dens. Performing HVLA in the
cervical region for these patients carries a significant risk of dens subluxation and spinal
cord injury. Therefore, HVLA is strictly contraindicated, while gentler techniques like
Muscle Energy or Myofascial Release may be considered with caution.
3. A 52-year-old female presents with a chief complaint of a ‘lump’ in her neck. Ultrasound
reveals a 1.5 cm solid nodule in the right lobe of the thyroid. Serum TSH is 2.5 uIU/mL
(normal range 0.5-5.0). What is the next most appropriate step in management?
A. Fine-needle aspiration (FNA) biopsy
B. Radioactive iodine uptake scan
C. Total thyroidectomy
,D. Repeat ultrasound in 6 months
Correct Answer: A
Explanation: For thyroid nodules larger than 1 cm with a normal TSH, fine-needle
aspiration (FNA) biopsy is the gold standard diagnostic step to rule out malignancy. A
radioactive iodine scan is indicated only if the TSH is low (hyperthyroid), to determine if
the nodule is ‘hot’ or ‘cold’. A normal TSH indicates a non-functioning nodule, necessitating
biopsy for tissue diagnosis.
4. A 72-year-old male is admitted for a hip fracture repair. On postoperative day 2, he
becomes acutely agitated, disoriented to time and place, and begins seeing insects on the
walls. His vital signs are stable, but his attention span is severely limited. What is the most
likely diagnosis?
A. Dementia
B. Delirium
C. Schizophrenia
D. Major Depressive Disorder with Psychosis
Correct Answer: B
Explanation: Delirium is characterized by an acute, fluctuating change in mental status,
inattention, and altered level of consciousness, often triggered by medical illness or surgery
in elderly patients. Unlike dementia, which is chronic and progressive, delirium is
, reversible and often associated with visual hallucinations. Identifying the underlying cause,
such as infection or medication side effects, is the primary management goal.
5. A 45-year-old male presents with acute onset of severe pain in his first
metatarsophalangeal (MTP) joint. The joint is erythematous, swollen, and tender.
Arthrocentesis reveals needle-shaped, negatively birefringent crystals. Which of the following
is the most appropriate long-term management strategy to prevent future attacks?
A. Daily Allopurinol
B. Daily Colchicine
C. Daily Ibuprofen
D. Daily Prednisone
Correct Answer: A
Explanation: The presence of negatively birefringent, needle-shaped crystals confirms a
diagnosis of gout. Allopurinol is a xanthine oxidase inhibitor used for long-term urate-
lowering therapy to prevent recurrent attacks and complications like tophi. It should not be
started during an acute flare without prophylactic anti-inflammatory coverage, but it
remains the mainstay for long-term management.
6. A 34-year-old G2P1 female at 34 weeks gestation presents with sudden onset of painful
vaginal bleeding. Physical examination reveals a firm, tender uterus. Fetal heart rate
monitoring shows late decelerations. What is the most likely diagnosis?
A. Placenta previa
