COMSAE PHASE II — FORM 114
Comprehensive Osteopathic Medical Self-Assessment Examination
200 High-Yield Clinical Vignettes, Practice Questions, & Rationales
Question 1 [Pulmonary / Internal Medicine]
[Internal Medicine - Form 114 Item #1] A 58-year-old man with a 30
pack-year smoking history presents with progressive dyspnea and
chronic productive cough. Pulmonary function testing reveals an
FEV1/FVC ratio of 0.62 and FEV1 of 52% predicted, with no significant
reversibility after bronchodilator administration. Which of the following
is the most appropriate initial pharmacotherapy?
A. Inhaled long-acting muscarinic antagonist (LAMA)
B. Inhaled short-acting beta-2 agonist as monotherapy
C. Long-term oral prednisone therapy
D. Daily oral azithromycin monotherapy
E. Intravenous methylprednisolone
Clinical Rationale & OMM Integration:
This patient has moderate COPD (GOLD 2). Initial management for
stable COPD with persistent symptoms includes long-acting
bronchodilators such as an inhaled LAMA (e.g., tiotropium) or LABA
to improve FEV1 and reduce exacerbations. Short-acting agents are
reserved for rescue use. Inhaled corticosteroids are added later for
frequent exacerbators with elevated eosinophils.
,Question 2 [Endocrinology / Internal Medicine]
[Internal Medicine - Form 114 Item #2] A 45-year-old woman is
evaluated for palpitations and fatigue. Laboratory studies show TSH <
0.01 mIU/L and free T4 of 3.2 ng/dL. Radioiodine uptake scan reveals
diffuse, homogeneous increased uptake throughout the thyroid gland.
Which of the following antibodies is most specific for this patient's
underlying condition?
A. Anti-thyroperoxidase (anti-TPO) antibodies
B. Thyrotropin receptor antibodies (TRAb)
C. Anti-thyroglobulin antibodies
D. Islet cell cytoplasmic antibodies
E. Anti-mitochondrial antibodies
Clinical Rationale & OMM Integration:
Graves disease is the most common cause of hyperthyroidism,
characterized by thyrotropin receptor antibodies (TRAb) or thyroid-
stimulating immunoglobulins (TSI) that stimulate the TSH receptor.
Anti-TPO and anti-thyroglobulin are elevated in Hashimoto
thyroiditis.
,Question 3 [Nephrology / Internal Medicine]
[Internal Medicine - Form 114 Item #3] A 65-year-old man with type 2
diabetes mellitus and hypertension is found to have a serum creatinine of
1.8 mg/dL and a urine albumin-to-creatinine ratio of 350 mg/g. Which of
the following medications is indicated to slow the progression of
diabetic nephropathy?
A. Amlodipine
B. Lisinopril
C. Hydrochlorothiazide
D. Metoprolol succinate
E. Furosemide
Clinical Rationale & OMM Integration:
ACE inhibitors (e.g., lisinopril) or ARBs are first-line therapy for
diabetic patients with albuminuria (ACR > 30 mg/g) and hypertension
or chronic kidney disease. They reduce intraglomerular pressure by
efferent arteriolar vasodilation, thereby reducing proteinuria and
slowing nephropathy progression.
, Question 4 [Neurology / Emergency Medicine]
[Internal Medicine - Form 114 Item #4] A 72-year-old man presents
with acute-onset right-sided weakness and aphasia starting 90 minutes
ago. Non-contrast CT of the head shows no acute hemorrhage. Blood
pressure is 168/95 mm Hg. What is the most appropriate next step in
management?
A. Intravenous alteplase (tPA) administration
B. Endovascular thrombectomy evaluation only after 24 hours
C. Aspirin 325 mg and clopidogrel loading dose
D. Immediate blood pressure reduction to < 120/80 mm Hg using
labetalol
E. Diagnostic cerebral angiography
Clinical Rationale & OMM Integration:
This patient presents within the 4.5-hour window for acute ischemic
stroke and has no contraindications (no hemorrhage on CT). IV
thrombolysis with alteplase (or tenecteplase) is indicated. Blood
pressure must be < 185/110 mm Hg prior to administration.
Comprehensive Osteopathic Medical Self-Assessment Examination
200 High-Yield Clinical Vignettes, Practice Questions, & Rationales
Question 1 [Pulmonary / Internal Medicine]
[Internal Medicine - Form 114 Item #1] A 58-year-old man with a 30
pack-year smoking history presents with progressive dyspnea and
chronic productive cough. Pulmonary function testing reveals an
FEV1/FVC ratio of 0.62 and FEV1 of 52% predicted, with no significant
reversibility after bronchodilator administration. Which of the following
is the most appropriate initial pharmacotherapy?
A. Inhaled long-acting muscarinic antagonist (LAMA)
B. Inhaled short-acting beta-2 agonist as monotherapy
C. Long-term oral prednisone therapy
D. Daily oral azithromycin monotherapy
E. Intravenous methylprednisolone
Clinical Rationale & OMM Integration:
This patient has moderate COPD (GOLD 2). Initial management for
stable COPD with persistent symptoms includes long-acting
bronchodilators such as an inhaled LAMA (e.g., tiotropium) or LABA
to improve FEV1 and reduce exacerbations. Short-acting agents are
reserved for rescue use. Inhaled corticosteroids are added later for
frequent exacerbators with elevated eosinophils.
,Question 2 [Endocrinology / Internal Medicine]
[Internal Medicine - Form 114 Item #2] A 45-year-old woman is
evaluated for palpitations and fatigue. Laboratory studies show TSH <
0.01 mIU/L and free T4 of 3.2 ng/dL. Radioiodine uptake scan reveals
diffuse, homogeneous increased uptake throughout the thyroid gland.
Which of the following antibodies is most specific for this patient's
underlying condition?
A. Anti-thyroperoxidase (anti-TPO) antibodies
B. Thyrotropin receptor antibodies (TRAb)
C. Anti-thyroglobulin antibodies
D. Islet cell cytoplasmic antibodies
E. Anti-mitochondrial antibodies
Clinical Rationale & OMM Integration:
Graves disease is the most common cause of hyperthyroidism,
characterized by thyrotropin receptor antibodies (TRAb) or thyroid-
stimulating immunoglobulins (TSI) that stimulate the TSH receptor.
Anti-TPO and anti-thyroglobulin are elevated in Hashimoto
thyroiditis.
,Question 3 [Nephrology / Internal Medicine]
[Internal Medicine - Form 114 Item #3] A 65-year-old man with type 2
diabetes mellitus and hypertension is found to have a serum creatinine of
1.8 mg/dL and a urine albumin-to-creatinine ratio of 350 mg/g. Which of
the following medications is indicated to slow the progression of
diabetic nephropathy?
A. Amlodipine
B. Lisinopril
C. Hydrochlorothiazide
D. Metoprolol succinate
E. Furosemide
Clinical Rationale & OMM Integration:
ACE inhibitors (e.g., lisinopril) or ARBs are first-line therapy for
diabetic patients with albuminuria (ACR > 30 mg/g) and hypertension
or chronic kidney disease. They reduce intraglomerular pressure by
efferent arteriolar vasodilation, thereby reducing proteinuria and
slowing nephropathy progression.
, Question 4 [Neurology / Emergency Medicine]
[Internal Medicine - Form 114 Item #4] A 72-year-old man presents
with acute-onset right-sided weakness and aphasia starting 90 minutes
ago. Non-contrast CT of the head shows no acute hemorrhage. Blood
pressure is 168/95 mm Hg. What is the most appropriate next step in
management?
A. Intravenous alteplase (tPA) administration
B. Endovascular thrombectomy evaluation only after 24 hours
C. Aspirin 325 mg and clopidogrel loading dose
D. Immediate blood pressure reduction to < 120/80 mm Hg using
labetalol
E. Diagnostic cerebral angiography
Clinical Rationale & OMM Integration:
This patient presents within the 4.5-hour window for acute ischemic
stroke and has no contraindications (no hemorrhage on CT). IV
thrombolysis with alteplase (or tenecteplase) is indicated. Blood
pressure must be < 185/110 mm Hg prior to administration.
