COMSAE - Comprehensive Osteopathic Medical Self-Assessment Examination Respiratory System Questions and Answers — Questions and Answers
Question 1: A 55-year-old male with a history of COPD presents with a 3-day history of productive cough, fever, and right-sided pleuritic chest pain. A chest X-ray confirms a right middle lobe pneumonia. From an osteopathic perspective, which of the following viscerosomatic reflex findings is most likely to be appreciated on physical examination?
- A. Paraspinal tissue texture changes and hypertonicity at C3-C5 on the right.
- B. Boggy and tender tissue texture changes at the T10-T11 spinous processes.
- C. Paraspinal tissue texture changes and hypertonicity at T2-T7 on the right. (Correct answer)
- D. A tender anterior Chapman's point in the 7th intercostal space on the left.
Correct answer: C. Paraspinal tissue texture changes and hypertonicity at T2-T7 on the right.
The sympathetic innervation to the lung parenchyma and visceral pleura originates from the T2-T7 spinal levels. Therefore, a viscerosomatic reflex from a right-sided pneumonia would manifest as somatic dysfunction, including paraspinal tissue texture changes, hypertonicity, and tenderness, at the T2-T7 levels ipsilateral to the infection.
Question 2: A 68-year-old female presents to the emergency department with the sudden onset of dyspnea and sharp, left-sided chest pain. She returned from an international flight 2 days ago. Her heart rate is 115/min, respiratory rate is 28/min, and oxygen saturation is 91% on room air. An EKG shows sinus tachycardia with an S1Q3T3 pattern. Which of the following is the most definitive diagnostic test for her suspected condition?
- A. D-dimer assay
- B. Lower extremity venous Doppler ultrasound
- C. Chest X-ray
- D. Computed tomography (CT) pulmonary angiography (Correct answer)
Correct answer: D. Computed tomography (CT) pulmonary angiography
The patient's presentation is classic for a pulmonary embolism (PE). While D-dimer can help rule out PE in low-risk patients and a venous Doppler can identify a DVT (the source of most PEs), the gold standard for definitively diagnosing a pulmonary embolism is a CT pulmonary angiography, which directly visualizes any filling defects within the pulmonary arteries.
Question 3: An osteopathic physician is treating a patient with pneumonia to improve lymphatic drainage and respiratory function. The physician focuses on treating the anatomical structure that serves as the primary muscle of respiration and whose proper function is critical for the pressure gradients that drive lymphatic flow. Dysfunction of which nerve would most directly impair this structure?
- A. Phrenic nerve (Correct answer)
- B. Vagus nerve
- C. Long thoracic nerve
- D. Intercostal nerves
Correct answer: A. Phrenic nerve
The diaphragm is the primary muscle of respiration. Its contraction and relaxation are essential for creating the thoracoabdominal pressure gradient that drives both air movement and the return of lymph fluid. The diaphragm is innervated by the phrenic nerve, which originates from the C3, C4, and C5 spinal nerve roots.
Question 4: A 28-year-old male complains of sharp pain near his sternum after a severe coughing fit. On examination, the anterior aspect of his right 4th rib moves superiorly during inhalation but is restricted during exhalation. This is identified as a pump-handle, inhaled rib somatic dysfunction. Which of the following best describes the primary motion of this rib group?
- A. An increase in the transverse diameter of the thorax, similar to a bucket handle.
- B. An increase in the anteroposterior (AP) diameter of the thorax. (Correct answer)
- C. A caliper-like motion where the free ends move towards the midline.
- D. A torsional motion along the long axis of the rib.
Correct answer: B. An increase in the anteroposterior (AP) diameter of the thorax.
The upper ribs (typically ribs 2-6) exhibit 'pump-handle' motion. During inhalation, the anterior aspect of these ribs moves superiorly and anteriorly, which increases the anteroposterior (AP) diameter of the thoracic cage. This is distinct from the 'bucket-handle' motion of the lower ribs, which increases the transverse diameter.
Question 5: A 45-year-old patient is recovering from bronchitis and presents with persistent, localized right-sided chest wall pain that worsens with deep breathing. Osteopathic examination reveals a tender point over the 8th rib, which moves freely with inhalation but is restricted in its inferior motion during exhalation. This finding is consistent with an inhaled rib 8. Which muscle would be targeted using muscle energy technique (MET) to correct this dysfunction?
- A. Pectoralis minor
- B. Anterior scalene
- C. Latissimus dorsi (Correct answer)
- D. Quadratus lumborum
Correct answer: C. Latissimus dorsi
The latissimus dorsi muscle has a broad origin, including the thoracolumbar fascia and iliac crest, and it inserts on the humerus. Importantly, its fibers also attach to the lower ribs (9-12, but has influence on 7-8). For an inhaled rib dysfunction (stuck in inhalation), the goal of MET is to engage a muscle that assists with exhalation to pull the rib inferiorly. Activating the latissimus dorsi by having the patient adduct their arm against resistance is a primary method for treating inhaled dysfunctions of the lower ribs.
Question 6: An osteopathic physician is developing a treatment plan for an elderly patient with pneumonia and significant pulmonary congestion. To maximize the efficacy of lymphatic drainage, the physician decides to first treat the area of terminal lymphatic drainage for the entire left side of the body and the right lower body. Which OMT technique most directly addresses this anatomical region?
- A. Rib raising technique
- B. Thoracic inlet myofascial release (Correct answer)
- C. Pedal pump technique
- D. Sacral inhibition
Correct answer: B. Thoracic inlet myofascial release
The thoracic duct, which drains lymph from the majority of the body (left side of head, neck, chest, left arm, and entire body below the diaphragm), terminates by emptying into the venous circulation at the junction of the left subclavian and internal jugular veins. This junction is located within the thoracic inlet (superior thoracic aperture). Therefore, performing thoracic inlet myofascial release is crucial to ensure this terminal drainage point is free of restrictions before performing techniques to mobilize fluid from distal areas.
COMSAE - Comprehensive Osteopathic Medical Self-Assessment Examination Respiratory System Questions and Answers
A 55-year-old male with a history of COPD presents with a 3-day history of productive cough, fever, and right-sided pleuritic chest pain.
A chest X-ray confirms a right middle lobe pneumonia.
From an osteopathic perspective, which of the following viscerosomatic reflex findings is most likely to be appreciated on physical examination?