COMSAE Comprehensive Osteopathic Medical Self-Assessment Exam — Questions and Answers

Question 1: A 19-year-old male sustains a deep laceration from a piece of metal while working in a machine shop. Within hours, the area becomes red, swollen, and warm. Which of the following cells is the primary mediator of the initial, non-specific inflammatory response by migrating first to the site of injury?

B-lymphocyte
Macrophage
Neutrophil (Correct answer)
Natural Killer (NK) cell

Correct answer: Neutrophil

Neutrophils are the most abundant type of white blood cell and are the first responders of the innate immune system to sites of acute inflammation and tissue injury. Their primary roles include phagocytosis of pathogens and debris, and the release of antimicrobial factors to combat infection. Macrophages arrive later, B-lymphocytes are part of the adaptive immune response, and NK cells primarily target virally infected cells and tumor cells.

Question 2: A 70-year-old man with BPH presents with urinary frequency, nocturia, weak stream, and post-void dribbling. Which medication class reduces prostate size by blocking testosterone conversion?

Anticholinergics
Alpha-1 blockers (tamsulosin)
Beta-3 agonists
5-alpha reductase inhibitors (finasteride) (Correct answer)

Correct answer: 5-alpha reductase inhibitors (finasteride)

5-alpha reductase inhibitors block conversion of testosterone to dihydrotestosterone (DHT), the primary androgen driving prostate growth, thereby reducing prostate volume.

Question 3: A 45-year-old immigrant presents with intense nocturnal pruritus. Examination reveals burrows in the finger web spaces and erythematous papules on the wrists and genitalia. Which pathogen is responsible?

Phthirus pubis
Pediculus humanus capitis
Demodex folliculorum
Sarcoptes scabiei (Correct answer)

Correct answer: Sarcoptes scabiei

Scabies is caused by Sarcoptes scabiei mite infestation; characteristic features are intense nocturnal pruritus, burrows in interdigital spaces, and involvement of genitalia.

Question 4: Which of the following ABCDE features of a pigmented skin lesion is MOST associated with early melanoma detection?

Border that is well-defined and regular
Asymmetry — one half does not match the other (Correct answer)
Diameter less than 6 mm
A uniform tan color throughout the lesion

Correct answer: Asymmetry — one half does not match the other

Asymmetry is a hallmark of melanoma; benign nevi are typically symmetric, whereas melanoma grows irregularly in different directions.

Question 5: A 25-year-old man has gross hematuria, hearing loss, and a family history of renal failure. Electron microscopy shows thinning and splitting of the glomerular basement membrane. What is the diagnosis?

Minimal change disease
Alport syndrome (Correct answer)
Membranous nephropathy
IgA nephropathy

Correct answer: Alport syndrome

Alport syndrome is an X-linked hereditary nephritis caused by mutations in type IV collagen genes, presenting with hematuria, sensorineural hearing loss, and characteristic GBM splitting.

Question 6: An osteopathic physician is performing a structural exam and notes tissue texture changes, asymmetry, restriction of motion, and tenderness in the T5-T9 paraspinal region on the right. These findings, known by the acronym TART, are the diagnostic criteria for:

Chapman's point
Viscerosomatic reflex
Myofascial trigger point
Somatic dysfunction (Correct answer)

Correct answer: Somatic dysfunction

The acronym TART (Tissue texture change, Asymmetry, Restriction of motion, and Tenderness) represents the cardinal findings used to diagnose somatic dysfunction, which is defined as impaired or altered function of related components of the body's framework. While a viscerosomatic reflex can cause a somatic dysfunction, TART is the diagnosis itself. Chapman's points and trigger points are specific palpatory findings but do not encompass all four elements of the TART criteria.

Question 7: A 34-year-old patient presents with acute right-sided sacroiliac joint pain after lifting a heavy box. Physical examination reveals a positive standing flexion test on the right, a deep sacral sulcus on the left, and a posterior and inferior inferior lateral angle (ILA) on the right. This combination of findings is most indicative of what type of sacral somatic dysfunction?

Left-on-left sacral torsion
Right-on-right sacral torsion (Correct answer)
Left-on-right sacral torsion
Right unilateral sacral flexion

Correct answer: Right-on-right sacral torsion

In a right-on-right sacral torsion, the sacrum is rotated right on a right oblique axis. This results in the left sacral sulcus feeling deeper (more anterior) and the right ILA feeling more posterior and inferior. The positive standing flexion test on the right indicates the side of sacroiliac dysfunction. These three findings together are the classic presentation for a right-on-right forward sacral torsion.

Question 8: 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?

D. A torsional motion along the long axis of the rib.
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.
A. An increase in the transverse diameter of the thorax, similar to a bucket handle.

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 9: A 65-year-old male presents with painless hematuria. What is the most likely diagnosis?

Glomerulonephritis
Urinary tract infection
Bladder cancer (Correct answer)
Renal calculi

Correct answer: Bladder cancer

Painless gross hematuria, especially in an older male, is a classic red flag symptom for bladder cancer. While other conditions can cause hematuria, the absence of pain strongly suggests a malignancy rather than stones or infection. Prompt investigation, such as cystoscopy, is essential to rule out or diagnose bladder cancer in such cases.

Question 10: Which feature best distinguishes prerenal AKI from intrinsic renal AKI?

FeNa >2% and muddy brown casts
BUN:creatinine ratio >20:1 and FeNa <1% (Correct answer)
Eosinophiluria on urinalysis
Proteinuria >3.5 g/day

Correct answer: BUN:creatinine ratio >20:1 and FeNa <1%

In prerenal AKI the tubules are intact so they avidly reabsorb sodium (FeNa <1%) and urea, raising the BUN:creatinine ratio above 20:1.

Question 11: A 6-year-old with a family history of asthma and allergic rhinitis presents with intensely pruritic, erythematous, lichenified patches in the antecubital and popliteal fossae. Which immunological finding is most commonly elevated in this condition?

IgE (Correct answer)
IgM
IgA
IgG

Correct answer: IgE

Atopic dermatitis is associated with elevated serum IgE levels and Th2-predominant immune responses, often part of the atopic triad.

Question 12: A 45-year-old presents with well-demarcated, erythematous plaques with silvery-white scales on the elbows and scalp. Auspitz sign is positive. Which finding on histopathology is most characteristic of this condition?

Parakeratosis with neutrophils in the stratum corneum (Munro microabscesses) (Correct answer)
Hyperkeratosis with melanin incontinence
Acantholysis with suprabasal blistering
Spongiosis with eosinophilic infiltrate

Correct answer: Parakeratosis with neutrophils in the stratum corneum (Munro microabscesses)

Psoriasis classically shows parakeratosis, acanthosis, elongated rete ridges, and Munro microabscesses (neutrophils in the stratum corneum).

Question 13: On COMSAE, which acid-base disorder is expected in a patient with vomiting and nasogastric tube suctioning?

Respiratory alkalosis
Respiratory acidosis
Metabolic acidosis
Metabolic alkalosis (hypochloremic, hypokalemic) (Correct answer)

Correct answer: Metabolic alkalosis (hypochloremic, hypokalemic)

Loss of gastric HCl through vomiting or NG suction results in hypochloremic metabolic alkalosis with compensatory potassium loss via kidney aldosterone stimulation.

Question 14: In a patient with chronic kidney disease, which dietary modification helps prevent secondary hyperparathyroidism?

Potassium supplementation
High-protein diet
Phosphate restriction and phosphate binders (Correct answer)
Increased sodium intake

Correct answer: Phosphate restriction and phosphate binders

Phosphate retention in CKD stimulates PTH secretion; dietary phosphate restriction combined with oral phosphate binders prevents secondary hyperparathyroidism and renal osteodystrophy.

Question 15: A 45-year-old male presents with acute, colicky right upper quadrant pain that is exacerbated by fatty meals. On osteopathic structural exam, you note tissue texture changes and paraspinal hypertonicity from T5 to T9 on the right. Which of the following anterior Chapman's points would most likely be present in this patient?

In the 6th intercostal space on the right at the mid-mammary line (Correct answer)
On the tip of the twelfth rib on the right
In the 2nd intercostal space near the sternum on the right
In the 5th intercostal space from the mid-mammary line to the sternum on the left

Correct answer: In the 6th intercostal space on the right at the mid-mammary line

The patient's presentation is classic for biliary colic, likely due to cholelithiasis or cholecystitis. The viscerosomatic reflex for the gallbladder corresponds to spinal levels T5-T9. The anterior Chapman's point for the gallbladder is located in the 6th intercostal space on the right at the mid-mammary line. The 2nd intercostal space relates to the myocardium, the 5th on the left to the stomach, and the tip of the 12th rib to the appendix.

Question 16: A patient presents with symptoms of anxiety, including palpitations, mydriasis (dilated pupils), and diaphoresis. From an osteopathic perspective, hyperactivity of the sympathetic nervous system is a contributing factor. Somatic dysfunction in which of the following spinal regions would be the most direct target for OMT to modulate sympathetic tone to the head and neck?

T1-T4 (Correct answer)
T10-L2
Sacrum and Pelvis
OA-AA

Correct answer: T1-T4

The preganglionic sympathetic nerve cell bodies that provide innervation to the entire head and neck are located in the intermediolateral cell column of the spinal cord from approximately T1 to T4. These fibers ascend the sympathetic chain to synapse in the cervical ganglia. Therefore, treating somatic dysfunction in the T1-T4 region is a primary osteopathic approach to normalizing sympathetic tone to the head and neck.

Question 17: A 22-year-old presents with well-defined depigmented macules on the dorsum of hands, around the mouth, and on the genitalia. Wood's lamp examination shows chalk-white fluorescence. The macules are asymptomatic. Which is the most likely diagnosis?

Pityriasis versicolor
Vitiligo (Correct answer)
Tinea corporis
Albinism

Correct answer: Vitiligo

Vitiligo is an autoimmune condition causing melanocyte destruction, producing well-defined depigmented macules that fluoresce bright white under Wood's lamp.

Question 18: On COMSAE, which diuretic is most appropriate for a patient with heart failure and severe symptomatic edema requiring rapid fluid removal?

Hydrochlorothiazide
Acetazolamide
Spironolactone
Furosemide (loop diuretic) (Correct answer)

Correct answer: Furosemide (loop diuretic)

Loop diuretics like furosemide act at the thick ascending limb of the loop of Henle, producing the most potent diuresis and are first-line for acute fluid overload.

Question 19: Which serum finding distinguishes SIADH from hypovolemic hyponatremia?

Low ADH levels in SIADH
High urine osmolality and high urine sodium in SIADH with euvolemia (Correct answer)
High BUN:creatinine in SIADH
Low urine sodium in SIADH vs. high urine sodium in hypovolemia

Correct answer: High urine osmolality and high urine sodium in SIADH with euvolemia

SIADH is characterized by euvolemia, inappropriately concentrated urine (osmolality >100 mOsm/kg), and urine sodium >40 mEq/L, distinguishing it from hypovolemic states where kidneys retain sodium.

Question 20: A 68-year-old male with a history of heart failure with reduced ejection fraction and concurrent atrial fibrillation is being managed medically. His physician adds a medication that works by inhibiting the Na+/K+-ATPase pump in myocardial cells. This action leads to an increase in intracellular calcium. Which of the following effects is the primary therapeutic goal of this medication in this patient?

Coronary artery vasodilation and decreased platelet aggregation
Decreased systemic vascular resistance and increased heart rate
Increased myocardial contractility and decreased atrioventricular (AV) node conduction (Correct answer)
Inhibition of the renin-angiotensin-aldosterone system and potassium retention

Correct answer: Increased myocardial contractility and decreased atrioventricular (AV) node conduction

The medication described is digoxin. Its primary mechanism is the inhibition of the Na+/K+-ATPase pump, which increases intracellular sodium. This, in turn, reduces the activity of the Na+/Ca2+ exchanger, leading to increased intracellular calcium and thus stronger myocardial contractions (positive inotropy). Additionally, digoxin has a parasympathomimetic effect that slows conduction through the AV node, which is therapeutic for controlling the ventricular rate in atrial fibrillation.

Question 21: Which electrolyte abnormality is the most immediately life-threatening complication of acute renal failure requiring emergent treatment?

Hyperphosphatemia
Hyperkalemia (Correct answer)
Hyponatremia
Hypocalcemia

Correct answer: Hyperkalemia

Hyperkalemia is the most immediately dangerous complication of acute renal failure because it can cause fatal cardiac arrhythmias including ventricular fibrillation.

Question 22: A patient is diagnosed with a left unilateral sacral flexion. During the osteopathic structural exam, which of the following findings would be expected?

Positive seated flexion test on the left, deep sacral sulcus on the left, and posterior/inferior ILA on the left (Correct answer)
Positive seated flexion test on the right, deep sacral sulcus on the left, and posterior/inferior ILA on the left
Positive seated flexion test on the right, deep sacral sulcus on the right, and posterior/inferior ILA on the right
Positive seated flexion test on the left, shallow sacral sulcus on the left, and anterior/superior ILA on the left

Correct answer: Positive seated flexion test on the left, deep sacral sulcus on the left, and posterior/inferior ILA on the left

In a left unilateral sacral flexion, the sacrum is flexed on the left side. This results in the left sacral base (sulcus) moving anteriorly, making it feel deeper on palpation. The left inferior lateral angle (ILA) moves posterior and inferior. The side of dysfunction is the side that moves first and furthest during the seated flexion test, indicating sacroiliac joint restriction on that side. Therefore, the seated flexion test will be positive on the left.

Question 23: A 30-year-old develops target-shaped lesions (concentric rings) on the palms and soles after a recent herpes simplex virus infection. There is no mucosal involvement. Which condition does this most likely represent?

Erythema multiforme minor (Correct answer)
Toxic epidermal necrolysis
Stevens-Johnson syndrome
Fixed drug eruption

Correct answer: Erythema multiforme minor

Erythema multiforme minor presents with classic targetoid lesions, typically triggered by HSV or Mycoplasma pneumoniae, without significant mucosal or systemic involvement.

Question 24: A patient with a kidney stone passes it spontaneously and analysis shows calcium oxalate composition. Which dietary modification is most evidence-based?

High-protein diet
Low-calcium diet
Low-potassium diet
Increased fluid intake to >2.5 L/day (Correct answer)

Correct answer: Increased fluid intake to >2.5 L/day

Increased hydration to produce >2.5 L of urine daily is the most universally effective dietary intervention to prevent recurrent nephrolithiasis.

Question 25: Renal tubular acidosis type 1 (distal RTA) is associated with which metabolic abnormality?

Metabolic alkalosis with hypokalemia
High anion gap metabolic acidosis
Normal anion gap acidosis with alkaline urine and hyperkalemia
Normal anion gap metabolic acidosis with inability to acidify urine below pH 5.5 (Correct answer)

Correct answer: Normal anion gap metabolic acidosis with inability to acidify urine below pH 5.5

Distal RTA involves a defect in H+ secretion in the collecting duct, resulting in inability to lower urine pH below 5.5 despite systemic acidosis.

Question 26: A 65-year-old man with diabetes presents with creatinine 3.2 mg/dL, hyperkalemia, and metabolic acidosis with a normal anion gap. Which acid-base disorder is most likely?

Type 4 renal tubular acidosis (hyperkalemic RTA) (Correct answer)
High anion gap metabolic acidosis
Type 1 RTA (distal)
Type 2 RTA (proximal)

Correct answer: Type 4 renal tubular acidosis (hyperkalemic RTA)

Type 4 RTA is the most common RTA in adults, caused by hypoaldosteronism (often from diabetic nephropathy) leading to hyperkalemia and normal anion gap acidosis.

Question 27: A 55-year-old female with type 2 diabetes mellitus is started on empagliflozin. Which of the following best describes the primary mechanism of action of this medication?

It increases insulin sensitivity in peripheral tissues.
It increases insulin secretion from pancreatic beta cells.
It decreases hepatic glucose production.
It inhibits glucose reabsorption in the proximal convoluted tubule. (Correct answer)

Correct answer: It inhibits glucose reabsorption in the proximal convoluted tubule.

Empagliflozin is a sodium-glucose cotransporter-2 (SGLT2) inhibitor. SGLT2 is responsible for reabsorbing the majority of filtered glucose from the tubular fluid back into the blood in the proximal convoluted tubule of the kidney. By inhibiting this transporter, empagliflozin promotes the excretion of glucose in the urine, thereby lowering blood glucose levels.

Question 28: A 45-year-old woman with lupus develops worsening proteinuria and hematuria. Biopsy shows diffuse proliferative glomerulonephritis with subendothelial deposits (Class IV LN). What is the initial treatment?

Observation with close monitoring
High-dose corticosteroids plus mycophenolate or cyclophosphamide (Correct answer)
ACE inhibitors alone
Hydroxychloroquine alone

Correct answer: High-dose corticosteroids plus mycophenolate or cyclophosphamide

Class IV lupus nephritis (diffuse proliferative) is the most severe form and requires aggressive immunosuppression with high-dose corticosteroids combined with mycophenolate mofetil or cyclophosphamide.

Question 29: A physician is counseling the parents of a 5-month-old infant diagnosed with Severe Combined Immunodeficiency (SCID). Which of the following routine childhood immunizations is strictly contraindicated in this patient?

Hepatitis B (HepB)
Diphtheria-Tetanus-acellular Pertussis (DTaP)
Inactivated Poliovirus (IPV)
Measles-Mumps-Rubella (MMR) (Correct answer)

Correct answer: Measles-Mumps-Rubella (MMR)

The Measles-Mumps-Rubella (MMR) vaccine is a live-attenuated vaccine. Live vaccines are contraindicated in individuals with severe cellular immunodeficiency, such as SCID, because the weakened pathogen can replicate unchecked and cause a life-threatening infection. DTaP, IPV, and Hepatitis B are all inactivated or subunit vaccines and are safe to administer to immunocompromised patients, though the immune response may be suboptimal.

Question 30: Which hormone is primarily responsible for stimulating milk ejection (let-down reflex) during breastfeeding?

Prolactin
Oxytocin (Correct answer)
Progesterone
Estrogen

Correct answer: Oxytocin

Oxytocin, released from the posterior pituitary in response to suckling, causes myoepithelial cell contraction and milk ejection.

Question 31: 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?

B. Anterior scalene
D. Quadratus lumborum
C. Latissimus dorsi (Correct answer)
A. Pectoralis minor

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 32: A farmworker is brought to the emergency department with confusion, pinpoint pupils, profuse sweating, and muscle fasciculations. He is bradycardic and hypotensive. These symptoms are characteristic of poisoning by an agent that causes which of the following?

Blockade of nicotinic acetylcholine receptors at the neuromuscular junction
Increased release of norepinephrine from sympathetic nerve terminals
Blockade of muscarinic acetylcholine receptors
Inhibition of acetylcholinesterase (Correct answer)

Correct answer: Inhibition of acetylcholinesterase

This clinical presentation is classic for organophosphate poisoning, which is common in agricultural settings. Organophosphates are irreversible inhibitors of acetylcholinesterase (AChE). Inhibition of AChE leads to an accumulation of acetylcholine at both muscarinic and nicotinic synapses, causing a cholinergic crisis with symptoms like miosis, salivation, lacrimation, urination, defecation, GI distress, emesis (DUMBELS), as well as muscle fasciculations and weakness.

Question 33: Rhabdomyolysis-induced acute kidney injury is primarily caused by which mechanism?

Immune complex deposition in the glomerulus
Decreased cardiac output
Myoglobin tubular obstruction and direct tubular toxicity (Correct answer)
Postrenal ureteral obstruction

Correct answer: Myoglobin tubular obstruction and direct tubular toxicity

Myoglobin released from damaged muscle precipitates in renal tubules causing obstruction and direct oxidative tubular injury, leading to AKI.

Question 34: On COMSAE, a patient with Cushing's syndrome undergoes an overnight dexamethasone suppression test. Which finding is most consistent with a pituitary ACTH-secreting adenoma (Cushing's disease)?

Suppression with high-dose dexamethasone (Correct answer)
Suppression with low-dose dexamethasone
No suppression with either dose
Undetectable ACTH levels

Correct answer: Suppression with high-dose dexamethasone

Pituitary Cushing's disease retains partial feedback sensitivity and suppresses cortisol with high-dose (but not low-dose) dexamethasone.

Question 35: 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.
D. A tender anterior Chapman's point in the 7th intercostal space on the left.
C. Paraspinal tissue texture changes and hypertonicity at T2-T7 on the right. (Correct answer)
B. Boggy and tender tissue texture changes at the T10-T11 spinous processes.

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 36: A 58-year-old male with a history of chronic obstructive pulmonary disease (COPD) presents with increased shortness of breath and a productive cough. On osteopathic structural exam, you note boggy, edematous tissue texture changes and tenderness over the anterior chest at the 2nd intercostal spaces bilaterally, near the sternum. These findings are most consistent with viscerosomatic reflexes related to which of the following?

Esophagus
Myocardium
Lungs and bronchi (Correct answer)
Thyroid gland

Correct answer: Lungs and bronchi

The anterior Chapman's points for the lungs and bronchi are located in the 2nd, 3rd, and 4th intercostal spaces near the sternum. The finding of boggy, edematous tissue in a patient with a COPD exacerbation is a classic presentation of a viscerosomatic reflex, where visceral pathology (the lungs) causes somatic changes (the tissue texture abnormalities). The points for the myocardium are typically on the left in the 2nd intercostal space, the esophagus in the 2nd intercostal space, and the thyroid in the 2nd intercostal space, but the bilateral nature and strong clinical correlation with COPD point specifically to the lungs and bronchi.

Question 37: A 65-year-old presents with a dermatomal distribution of painful vesicles on an erythematous base on the right thorax. She had varicella as a child. Which antiviral should be initiated within 72 hours of onset?

Acyclovir (Correct answer)
Ganciclovir
Amantadine
Oseltamivir

Correct answer: Acyclovir

Herpes zoster (shingles) results from VZV reactivation; antiviral therapy with acyclovir, valacyclovir, or famciclovir within 72 hours reduces duration and risk of postherpetic neuralgia.

Question 38: A 50-year-old presents with greasy, yellowish scales on the scalp, nasolabial folds, and eyebrows. Which organism is implicated in the pathogenesis of seborrheic dermatitis?

Staphylococcus epidermidis
Trichophyton tonsurans
Malassezia furfur (Correct answer)
Candida albicans

Correct answer: Malassezia furfur

Malassezia furfur (a lipophilic yeast) colonizes sebaceous areas and triggers an inflammatory response causing seborrheic dermatitis.

Question 39: A 55-year-old diabetic presents with rapidly spreading erythema, warmth, swelling, and tenderness of the lower leg with a distinct raised, palpable border and fever. Which condition most likely explains the palpable, sharply demarcated border?

Necrotizing fasciitis involving fascia and muscle
Erysipelas involving the superficial dermis and lymphatics (Correct answer)
Folliculitis involving hair follicles
Cellulitis involving the deep dermis and subcutaneous tissue

Correct answer: Erysipelas involving the superficial dermis and lymphatics

Erysipelas involves the superficial dermis and dermal lymphatics, producing a sharply demarcated, raised, palpable border that distinguishes it from the indistinct borders of deeper cellulitis.

Question 40: A patient presents with oliguria, flank pain, and hematuria after starting an NSAID. Urinalysis shows muddy brown casts and elevated BUN/creatinine. What type of acute kidney injury is this?

Postrenal AKI
Intrinsic renal AKI (ATN) (Correct answer)
Interstitial nephritis
Prerenal AKI

Correct answer: Intrinsic renal AKI (ATN)

NSAIDs reduce prostaglandin-mediated afferent arteriole dilation, causing ischemia and acute tubular necrosis, characterized by muddy brown granular casts.

Question 41: A 60-year-old presents with a rough, scaly, erythematous macule on the dorsum of the hand. The lesion is described as a premalignant condition with potential to progress to squamous cell carcinoma. Which is the most likely diagnosis?

Actinic keratosis (Correct answer)
Lentigo simplex
Seborrheic keratosis
Dermatofibroma

Correct answer: Actinic keratosis

Actinic keratosis is a premalignant lesion caused by chronic UV exposure that can progress to squamous cell carcinoma if untreated.

Question 42: A patient presents with left-sided chest pain, shortness of breath, and diminished breath sounds on the left side. What is the most likely diagnosis?

Myocardial infarction
Pneumothorax (Correct answer)
Pulmonary embolism
Pneumonia

Correct answer: Pneumothorax

A pneumothorax, or collapsed lung, is the most likely diagnosis given the patient's symptoms of left-sided chest pain, shortness of breath, and diminished breath sounds on the left side. These findings are classic for air accumulating in the pleural space, which compresses the lung and prevents it from expanding fully. The diminished breath sounds occur because less air is moving into the affected lung.

Question 43: Which OMT technique is most appropriate to address Chapman's reflex points associated with renal dysfunction?

Soft tissue/inhibitory pressure at anterior Chapman's point lateral to umbilicus (Correct answer)
Myofascial release of thoracolumbar fascia
Muscle energy for lumbar somatic dysfunction
HVLA to lumbar spine

Correct answer: Soft tissue/inhibitory pressure at anterior Chapman's point lateral to umbilicus

Anterior Chapman's reflex points for the kidneys are located lateral to the umbilicus, and treatment involves gentle rotary friction or inhibitory pressure to normalize viscerosomatic reflexes.

Question 44: Which stone type is most likely in a patient with recurrent urinary tract infections caused by urease-producing organisms like Proteus mirabilis?

Calcium oxalate stones
Struvite (magnesium ammonium phosphate) stones (Correct answer)
Uric acid stones
Cystine stones

Correct answer: Struvite (magnesium ammonium phosphate) stones

Urease-producing bacteria hydrolyze urea to ammonia, alkalinizing urine and promoting precipitation of struvite (MgNH4PO4) stones that can form staghorn calculi.

Question 45: A 55-year-old post-menopausal woman with type 2 diabetes has an HbA1c of 7.8%. Which medication is preferred to reduce cardiovascular mortality in a patient with established heart failure?

Metformin
GLP-1 receptor agonist
Sulfonylurea
SGLT-2 inhibitor (empagliflozin) (Correct answer)

Correct answer: SGLT-2 inhibitor (empagliflozin)

SGLT-2 inhibitors like empagliflozin have demonstrated significant reduction in cardiovascular death and heart failure hospitalization in diabetic patients.

Question 46: What does the TART acronym in osteopathic practice stand for?

Texture, Alignment, Rotation, Tenderness
Tenderness, Asymmetry, Range of motion, Tissue texture changes (Correct answer)
Tension, Asymmetry, Reflex, Tone
Tenderness, Alignment, Reflex, Tone

Correct answer: Tenderness, Asymmetry, Range of motion, Tissue texture changes

The TART acronym is a mnemonic used in osteopathic practice to describe the diagnostic criteria for somatic dysfunction. TART stands for Tenderness, Asymmetry, Range of motion (restriction), and Tissue texture changes. These four components guide osteopathic physicians in identifying and characterizing musculoskeletal impairments during physical examination.

Question 47: In a pregnant woman at 10 weeks gestation, which hormone produced by the corpus luteum maintains the endometrium until placental function is established?

hCG
Progesterone (Correct answer)
Estradiol
LH

Correct answer: Progesterone

Progesterone from the corpus luteum maintains the decidualized endometrium during early pregnancy until the placenta assumes steroidogenesis at approximately 10-12 weeks.

Question 48: Which hormone is primarily responsible for the maintenance of pregnancy?

Progesterone (Correct answer)
Human chorionic gonadotropin (hCG)
Estrogen
Prolactin

Correct answer: Progesterone

Progesterone is the primary hormone responsible for maintaining pregnancy. It prepares the uterine lining for implantation, prevents uterine contractions that could lead to miscarriage, and helps maintain the quiescent state of the myometrium. While hCG is important in early pregnancy for stimulating progesterone production, and estrogen also plays a role, progesterone is directly responsible for sustaining the pregnancy itself.

Question 49: A 38-year-old man with hypertension has hypokalemia and elevated aldosterone with suppressed renin. Which is the most likely diagnosis?

Primary hyperaldosteronism (Conn's syndrome) (Correct answer)
Cushing's syndrome
Secondary hyperaldosteronism
Renal artery stenosis

Correct answer: Primary hyperaldosteronism (Conn's syndrome)

Primary hyperaldosteronism features autonomous aldosterone production causing hypertension and hypokalemia with suppressed renin due to negative feedback.

Question 50: Which neurological condition is associated with "butterfly" lesions in the white matter of the brain?

Ependymoma
Glioblastoma multiforme (Correct answer)
Meningioma
Multiple sclerosis

Correct answer: Glioblastoma multiforme

Glioblastoma multiforme (GBM) is a highly aggressive primary brain tumor known for its characteristic 'butterfly' appearance on imaging. This pattern occurs when the tumor infiltrates across the corpus callosum, connecting and affecting both cerebral hemispheres. The extensive white matter involvement and rapid growth are hallmarks of GBM, distinguishing it from other neurological conditions.

Question 51: A patient with a history of chronic bronchitis presents with a productive cough for the past three months. Which histological finding is most characteristic?

Alveolar macrophage infiltration
Loss of alveolar walls
Hyperplasia of goblet cells (Correct answer)
Interstitial fibrosis

Correct answer: Hyperplasia of goblet cells

Chronic bronchitis is pathologically characterized by hypertrophy and hyperplasia of the mucus-secreting goblet cells within the bronchial lining. This increase in goblet cells leads to excessive mucus production, which is the underlying cause of the persistent productive cough that defines the condition. Therefore, hyperplasia of goblet cells is the most characteristic histological finding.

Question 52: What is the most common cause of nephrotic syndrome in US adults?

Minimal change disease
Diabetic nephropathy (Correct answer)
Membranous nephropathy
Focal segmental glomerulosclerosis

Correct answer: Diabetic nephropathy

Diabetic nephropathy is the leading cause of nephrotic syndrome and end-stage renal disease in adults in the United States.

Question 53: Muscle energy technique (MET) is a direct and active form of osteopathic manipulative treatment. The primary physiologic principle that allows MET to be effective in relaxing a hypertonic muscle is:

Crossed extensor reflex
Autogenic inhibition
Post-isometric relaxation (Correct answer)
Reciprocal inhibition

Correct answer: Post-isometric relaxation

Post-isometric relaxation is the key principle behind the most common form of muscle energy technique. After a patient performs a sustained, gentle isometric contraction against a physician's counterforce, a refractory state occurs in the muscle, allowing for a new, greater range of motion to be achieved during the subsequent relaxation phase. While autogenic and reciprocal inhibition are related neurologic principles, post-isometric relaxation specifically describes the phenomenon utilized in this MET application.

Question 54: A 32-year-old factory worker develops pruritic vesicles and erythema on both hands after starting a new job using epoxy resins. Patch testing shows a reaction to epoxy resin. What type of hypersensitivity reaction is this?

Type I (IgE-mediated)
Type IV (delayed-type/cell-mediated) (Correct answer)
Type III (immune complex-mediated)
Type II (cytotoxic)

Correct answer: Type IV (delayed-type/cell-mediated)

Allergic contact dermatitis is a classic Type IV (delayed-type) hypersensitivity reaction mediated by sensitized T lymphocytes, peaking 48–72 hours after exposure.

Question 55: A 29-year-old patient is started on fluoxetine for major depressive disorder. The physician counsels the patient that the most common initial side effects, such as headache and gastrointestinal upset, are related to the medication's primary mechanism of action. Which of the following best describes this mechanism?

Inhibition of monoamine oxidase A and B
Antagonism of postsynaptic dopamine D2 receptors
Blocking the reuptake of both norepinephrine and dopamine
Selective inhibition of serotonin reuptake (Correct answer)

Correct answer: Selective inhibition of serotonin reuptake

Fluoxetine is a selective serotonin reuptake inhibitor (SSRI). Its therapeutic effect and many of its side effects are due to its primary mechanism of action: blocking the serotonin transporter (SERT), which leads to increased concentrations of serotonin in the synaptic cleft.

Question 56: Which maneuver is used to assess the anterior cruciate ligament (ACL) integrity in the knee?

Lachman test (Correct answer)
McMurray test
Thompson test
Apley compression test

Correct answer: Lachman test

The Lachman test is the most sensitive and reliable clinical maneuver used to assess the integrity of the anterior cruciate ligament (ACL) in the knee. During the test, the examiner stabilizes the thigh and applies an anterior translational force to the tibia while the knee is flexed at 20-30 degrees. Excessive anterior translation or a soft, mushy endpoint indicates a positive test, suggesting an ACL injury.

Question 57: A 45-year-old woman presents with weight gain, cold intolerance, constipation, and a TSH of 12 mIU/L with low free T4. Which is the most appropriate initial treatment?

Liothyronine
Levothyroxine (Correct answer)
Radioactive iodine
Methimazole

Correct answer: Levothyroxine

Levothyroxine (synthetic T4) is the first-line treatment for hypothyroidism due to its stable half-life and reliable conversion to active T3.

Question 58: Which of the following conditions is associated with a widened pulse pressure and bounding pulses?

Pulmonary hypertension
Mitral stenosis
Aortic stenosis
Aortic regurgitation (Correct answer)

Correct answer: Aortic regurgitation

Aortic regurgitation (AR) is characterized by a widened pulse pressure and bounding pulses. In AR, the aortic valve fails to close completely during diastole, causing blood to flow back into the left ventricle. This leads to an increased stroke volume and a rapid rise and fall in arterial pressure, resulting in a high systolic pressure, low diastolic pressure (widened pulse pressure), and strong, palpable 'bounding' pulses.

Question 59: The life cycle of the Human Immunodeficiency Virus (HIV) requires the synthesis of a DNA copy from its RNA genome, which is then integrated into the host cell's chromosome. This process is mediated by which of the following viral enzymes?

Protease
Reverse transcriptase (Correct answer)
RNA polymerase
Integrase

Correct answer: Reverse transcriptase

Reverse transcriptase is the key enzyme used by retroviruses like HIV to convert their single-stranded RNA genome into double-stranded DNA (a process called reverse transcription). This DNA provirus can then be integrated into the host genome by the viral enzyme integrase. Protease is involved later in the viral life cycle, cleaving viral polyproteins into their functional forms. Host cell RNA polymerase is used to transcribe the integrated viral DNA.

Question 60: A 16-year-old girl presents with primary amenorrhea, short stature, webbed neck, and shield chest. Karyotype is 45,X. Which is the most likely diagnosis?

Klinefelter syndrome
Androgen insensitivity syndrome
Turner syndrome (Correct answer)
Mullerian agenesis

Correct answer: Turner syndrome

Turner syndrome (45,X) presents with ovarian dysgenesis, short stature, and characteristic somatic features including webbed neck and shield chest.

Question 61: On COMSAE, which finding differentiates primary adrenal insufficiency (Addison's disease) from secondary adrenal insufficiency?

Hyponatremia
Hypoglycemia
Fatigue
Hyperpigmentation (Correct answer)

Correct answer: Hyperpigmentation

Hyperpigmentation in Addison's disease results from elevated ACTH stimulating melanocortin receptors, which does not occur in secondary adrenal insufficiency where ACTH is low.

Question 62: A 62-year-old male who underwent a total gastrectomy for gastric cancer four years ago presents with progressive fatigue, a 'pins and needles' sensation in his lower extremities, and difficulty with balance. Laboratory studies show a hemoglobin of 9.5 g/dL and a mean corpuscular volume (MCV) of 115 fL. Which of the following nutritional deficiencies is the most likely cause of his signs and symptoms?

Iron
Vitamin C
Cobalamin (Vitamin B12) (Correct answer)
Thiamine (Vitamin B1)

Correct answer: Cobalamin (Vitamin B12)

Total gastrectomy removes parietal cells, which are responsible for producing intrinsic factor. Intrinsic factor is essential for the absorption of Vitamin B12 (cobalamin) in the terminal ileum. Its absence leads to B12 deficiency, causing both macrocytic anemia and the neurological symptoms of subacute combined degeneration of the spinal cord.

Question 63: A 16-year-old presents with open and closed comedones, papules, and pustules on the face. Which mechanism is most responsible for the pathogenesis of acne vulgaris?

Follicular plugging with keratin and sebum combined with Cutibacterium acnes proliferation (Correct answer)
Autoimmune destruction of sebaceous glands
Staphylococcus aureus superficial skin infection
IgE-mediated mast cell degranulation in the dermis

Correct answer: Follicular plugging with keratin and sebum combined with Cutibacterium acnes proliferation

Acne vulgaris results from follicular hyperkeratinization causing plugging, excess sebum production, C. acnes overgrowth, and resultant inflammation.

Question 64: A 22-year-old athlete presents with scaling, itching, and erythema between the toes with maceration. KOH preparation shows branching hyphae. Which organism is most likely responsible?

Malassezia furfur
Microsporum canis
Trichophyton rubrum (Correct answer)
Candida albicans

Correct answer: Trichophyton rubrum

Tinea pedis (athlete's foot) is most commonly caused by Trichophyton rubrum, a dermatophyte that infects keratinized tissue.

Question 65: A 68-year-old female is diagnosed with multiple myeloma. Her initial lab work shows a hemoglobin of 9.2 g/dL, serum creatinine of 2.5 mg/dL, and serum calcium of 12.1 mg/dL. An X-ray reveals multiple lytic lesions in the vertebrae. Which of these findings is NOT part of the classic CRAB criteria for diagnosing symptomatic multiple myeloma?

Thrombocytosis (Platelets > 450,000/µL) (Correct answer)
Hypercalcemia (Calcium > 11 mg/dL)
Anemia (Hemoglobin < 10 g/dL)
Renal insufficiency (Creatinine > 2 mg/dL)

Correct answer: Thrombocytosis (Platelets > 450,000/µL)

The CRAB criteria are used to identify end-organ damage in multiple myeloma and are an indication to begin treatment. The acronym stands for: C - Calcium elevation (>11 mg/dL), R - Renal insufficiency (serum creatinine >2 mg/dL or creatinine clearance <40 mL/min), A - Anemia (hemoglobin <10 g/dL or >2 g/dL below the lower limit of normal), and B - Bone disease (one or more osteolytic lesions). Thrombocytosis is not part of the CRAB criteria; in fact, thrombocytopenia can sometimes be seen in advanced disease due to bone marrow infiltration.

Question 66: A patient with nephrotic syndrome has serum albumin of 1.8 g/dL. Which complication is this patient at highest risk for due to loss of anticoagulant proteins?

Renal vein thrombosis (Correct answer)
Arterial thrombosis only
Pulmonary embolism only
Deep vein thrombosis only

Correct answer: Renal vein thrombosis

Nephrotic syndrome causes urinary loss of antithrombin III and protein C/S, creating a hypercoagulable state; renal vein thrombosis is the most classic complication.

Question 67: In a patient with ESRD, which chronic complication results from impaired renal conversion of 25-OH vitamin D to its active form?

Hyperkalemia
Renal osteodystrophy (Correct answer)
Metabolic alkalosis
Nephrotic syndrome

Correct answer: Renal osteodystrophy

Loss of 1-alpha hydroxylase activity in the kidney prevents conversion of 25-OH vitamin D to 1,25-(OH)₂ vitamin D (calcitriol), leading to hypocalcemia, secondary hyperparathyroidism, and renal osteodystrophy.

Question 68: Which diuretic class acts on the thick ascending limb of the loop of Henle and is most potent for volume removal in acute pulmonary edema?

Loop diuretics (Correct answer)
Potassium-sparing diuretics
Osmotic diuretics
Thiazide diuretics

Correct answer: Loop diuretics

Loop diuretics (e.g., furosemide) inhibit the Na-K-2Cl cotransporter in the thick ascending loop, producing the greatest diuresis of any diuretic class.

Question 69: 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?

D. Intercostal nerves
C. Long thoracic nerve
A. Phrenic nerve (Correct answer)
B. Vagus nerve

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 70: A patient complains of mid-back pain. Layer-by-layer palpation reveals ropy, hypertonic paraspinal muscles at the T5-T9 level on the left, along with skin that feels boggy and moist. The patient has a history of gastritis. This clinical picture is most representative of which of the following phenomena?

Chapman's reflex
Somato-somatic reflex
Somato-visceral reflex
Viscero-somatic reflex (Correct answer)

Correct answer: Viscero-somatic reflex

A viscero-somatic reflex occurs when visceral pathology (e.g., gastritis) causes reflex changes in segmentally related somatic tissues. The stomach's sympathetic innervation comes from T5-T9. Therefore, irritation of the stomach can lead to palpable tissue texture changes, asymmetry, restricted motion, and tenderness (TART changes) in the paraspinal tissues of this region, as described in the vignette.

Question 71: A 24-year-old woman presents with galactorrhea and amenorrhea. MRI shows a 5mm pituitary lesion. Prolactin level is 120 ng/mL. What is the most appropriate first-line treatment?

Observation only
Cabergoline (dopamine agonist) (Correct answer)
Surgical resection
Bromocriptine injection

Correct answer: Cabergoline (dopamine agonist)

Cabergoline, a dopamine agonist, is first-line for prolactinoma because dopamine normally inhibits prolactin secretion, and the medication effectively reduces tumor size.

Question 72: Which of the following describes the physiological principle behind the muscle energy technique (MET) of post-isometric relaxation?

Applying deep pressure to a tender point to release muscle tension
Using the respiratory cycle to influence fascial tension
Stretching the muscle spindle to cause a reflex muscle contraction
Activating the Golgi tendon organ to induce reflex muscle inhibition (Correct answer)

Correct answer: Activating the Golgi tendon organ to induce reflex muscle inhibition

Post-isometric relaxation, a common form of muscle energy technique, involves having the patient perform an isometric contraction against the physician's counterforce. This contraction activates the Golgi tendon organs within the muscle's tendon, which then send inhibitory signals to the spinal cord, leading to a reflex relaxation (lengthening) of the muscle immediately following the contraction. This period of relaxation allows the physician to gently move the joint further into the restrictive barrier.

Question 73: A 28-year-old female presents with low back pain and constipation. Osteopathic examination reveals a sacral somatic dysfunction. Which of the following osteopathic manipulative treatment (OMT) techniques would be particularly effective for addressing both the somatic dysfunction and the patient's visceral symptoms?

Sacral rocking (articulatory technique) (Correct answer)
Rib raising
Cervical spine muscle energy
Thoracic spine high-velocity, low-amplitude (HVLA)

Correct answer: Sacral rocking (articulatory technique)

Sacral rocking is an articulatory technique that is often indicated for sacral somatic dysfunctions. It is particularly beneficial for patients presenting with pelvic symptoms related to visceral organs, such as constipation or dysmenorrhea, due to its influence on the pelvic parasympathetic nerves (S2-S4). The other techniques listed target different regions and would not be the most direct or effective for this patient's combination of symptoms.

Question 74: In glycolysis, what is the end product that enters the citric acid cycle under aerobic conditions?

Glucose
Pyruvate
Lactate
Acetyl-CoA (Correct answer)

Correct answer: Acetyl-CoA

Under aerobic conditions, the end product of glycolysis, pyruvate, does not directly enter the citric acid cycle. Instead, pyruvate is transported into the mitochondria and undergoes oxidative decarboxylation, where it is converted into Acetyl-CoA. This Acetyl-CoA then serves as the crucial entry point for the carbon atoms into the citric acid cycle, where further energy is extracted.

Question 75: In a patient with multiple endocrine neoplasia type 1 (MEN1), which triad of tumors is classically expected?

Parathyroid, pituitary, and pancreatic tumors (Correct answer)
Pheochromocytoma, medullary thyroid cancer, and parathyroid tumors
Parathyroid, adrenal, and thyroid tumors
Pituitary, adrenal, and thyroid tumors

Correct answer: Parathyroid, pituitary, and pancreatic tumors

MEN1 (Wermer's syndrome) involves mutations in the menin tumor suppressor gene causing parathyroid adenomas, pituitary tumors, and pancreatic neuroendocrine tumors.

Question 76: A 45-year-old male with a history of bipolar disorder states during an office visit, 'I've decided I can't take it anymore. I'm going to drive my car off the Millersville bridge on my way home today.' The patient appears calm but resolute. What is the physician's most appropriate and immediate action?

Contact the patient's family to ask them to remove his car keys.
Arrange for an immediate psychiatric evaluation, initiating involuntary commitment if necessary. (Correct answer)
Perform osteopathic cranial manipulative medicine to calm the patient's nervous system.
Prescribe a new mood stabilizer and schedule a follow-up for the next day.

Correct answer: Arrange for an immediate psychiatric evaluation, initiating involuntary commitment if necessary.

When a patient expresses clear suicidal ideation with a specific plan, intent, and means, they are at high, imminent risk of self-harm. The physician has a duty to protect the patient. The most appropriate and legally required action is to ensure the patient's immediate safety by arranging for an emergency psychiatric evaluation, which may require an involuntary commitment or 'hold'. While other options might be part of a broader treatment plan, they do not address the acute, life-threatening danger.

Question 77: A 70-year-old farmer presents with an indurated, erythematous nodule on the lower lip that ulcerates and does not heal. Biopsy shows malignant squamous cells with keratin pearls. Which risk factor is most strongly associated with this diagnosis?

BRCA1 gene mutation
Human papillomavirus type 16 infection
Immunosuppression from organ transplant
Chronic UV radiation exposure (Correct answer)

Correct answer: Chronic UV radiation exposure

Squamous cell carcinoma of the lip and skin is most strongly associated with chronic UV radiation exposure, particularly in fair-skinned, outdoor workers.

Question 78: Which of the following core tenets of osteopathic medicine best describes the principle that the human body has an inherent capacity to defend, repair, and heal itself?

Structure and function are reciprocally interrelated.
Rational treatment is based on an understanding of body unity, self-regulation, and the interrelationship of structure and function.
The body is a unit; the person is a unit of body, mind, and spirit.
The body is capable of self-regulation, self-healing, and health maintenance. (Correct answer)

Correct answer: The body is capable of self-regulation, self-healing, and health maintenance.

The tenet that 'The body is capable of self-regulation, self-healing, and health maintenance' specifically articulates the osteopathic principle of the body's innate healing capacity. Osteopathic manipulative treatment (OMT) is often aimed at removing somatic barriers to allow this inherent capacity to function optimally. The other options are also core tenets but do not specifically address the self-healing mechanism.

Question 79: A patient is hospitalized and receives unfractionated heparin for a deep vein thrombosis. Five days later, their platelet count drops from 250,000/µL to 90,000/µL, and a new pulmonary embolism is suspected. What is the most likely underlying pathophysiology of this condition?

Vitamin K antagonism leading to decreased platelet production
Autoantibody formation against the heparin-platelet factor 4 (PF4) complex (Correct answer)
Direct heparin-induced platelet aggregation
Bone marrow suppression from a direct toxic effect of heparin

Correct answer: Autoantibody formation against the heparin-platelet factor 4 (PF4) complex

This clinical scenario is classic for Heparin-Induced Thrombocytopenia (HIT), specifically type II. The pathophysiology involves the formation of IgG antibodies against the complex formed by heparin and platelet factor 4 (PF4). This antibody-heparin-PF4 complex then binds to and activates platelets via their FcγIIa receptors, leading to platelet aggregation, thrombocytopenia, and a paradoxical prothrombotic state. Type I HIT is a non-immune, direct effect of heparin causing mild, transient thrombocytopenia without thrombosis.

Question 80: A 72-year-old male presents with exertional dyspnea and a harsh, crescendo-decrescendo systolic murmur best heard at the right upper sternal border. Which of the following physical exam findings would be most consistent with severe aortic stenosis?

A brisk, collapsing carotid pulse
A widely split S2 that increases with inspiration
A low-amplitude and delayed carotid upstroke (Correct answer)
A holosystolic murmur radiating to the axilla

Correct answer: A low-amplitude and delayed carotid upstroke

Severe aortic stenosis classically presents with a 'pulsus parvus et tardus,' which is a weak (parvus) and delayed (tardus) carotid upstroke, due to the obstruction of left ventricular outflow. A brisk, collapsing pulse is seen in aortic regurgitation. A widely split S2 is associated with conditions like pulmonic stenosis or right bundle branch block. A holosystolic murmur radiating to the axilla is characteristic of mitral regurgitation.

Question 81: On COMSAE, which medication should be held 24-48 hours before administration of iodinated contrast in a patient with chronic kidney disease?

Aspirin
Lisinopril
Furosemide
Metformin (Correct answer)

Correct answer: Metformin

Metformin should be held before contrast administration in CKD patients because contrast-induced nephropathy can reduce metformin excretion, causing lactic acidosis.

Question 82: Which urinalysis finding is most characteristic of nephrotic syndrome?

WBC casts
Hematuria with dysmorphic RBCs
Massive proteinuria (>3.5 g/day) (Correct answer)
RBC casts

Correct answer: Massive proteinuria (>3.5 g/day)

Nephrotic syndrome is defined by proteinuria >3.5 g/day, hypoalbuminemia, edema, and hyperlipidemia.

Question 83: A 28-year-old woman has oligomenorrhea, hirsutism, and an LH:FSH ratio of 3:1. Pelvic ultrasound shows bilateral ovarian cysts. Which is the most likely diagnosis?

Hypothyroidism
Polycystic ovary syndrome (PCOS) (Correct answer)
Hyperprolactinemia
Premature ovarian insufficiency

Correct answer: Polycystic ovary syndrome (PCOS)

PCOS is characterized by hyperandrogenism, oligoovulation, and polycystic ovaries, often with an elevated LH:FSH ratio.

Question 84: A 70-year-old presents with tense bullae on the trunk and extremities. The Nikolsky sign is negative. Direct immunofluorescence shows linear IgG and C3 deposits at the dermoepidermal junction. Which is the most likely diagnosis?

Pemphigus vulgaris
Epidermolysis bullosa acquisita
Bullous pemphigoid (Correct answer)
Dermatitis herpetiformis

Correct answer: Bullous pemphigoid

Bullous pemphigoid features tense subepidermal bullae with linear IgG/C3 at the BMZ, targeting BP180 and BP230 antigens; the Nikolsky sign is negative.

Question 85: Which type of epithelium lines the respiratory tract?

Pseudostratified columnar epithelium with cilia (Correct answer)
Transitional epithelium
Simple squamous epithelium
Stratified squamous epithelium

Correct answer: Pseudostratified columnar epithelium with cilia

The respiratory tract, from the nasal cavity down to the bronchi, is primarily lined by pseudostratified columnar epithelium with cilia. This specialized epithelium appears stratified but is actually a single layer of cells of varying heights, all attached to the basement membrane. The cilia on the surface, along with goblet cells that produce mucus, work together to trap and sweep foreign particles and pathogens out of the respiratory system.

Question 86: A 30-year-old woman presents with chronic diarrhea, abdominal bloating, and an intensely pruritic, papulovesicular rash on her elbows and buttocks. A skin biopsy confirms dermatitis herpetiformis. Which of the following serologic tests is considered the most specific for the underlying gastrointestinal condition?

Anti-Saccharomyces cerevisiae antibodies (ASCA)
Perinuclear anti-neutrophil cytoplasmic antibodies (p-ANCA)
Anti-smooth muscle antibodies (ASMA)
Anti-tissue transglutaminase (tTG) IgA antibody (Correct answer)

Correct answer: Anti-tissue transglutaminase (tTG) IgA antibody

The patient's clinical picture, including dermatitis herpetiformis, is pathognomonic for celiac disease. The most sensitive and specific serologic screening test for celiac disease is the anti-tissue transglutaminase (tTG) IgA antibody. ASCA is associated with Crohn's disease, p-ANCA is often found in ulcerative colitis, and ASMA is a marker for autoimmune hepatitis.

Question 87: On COMSAE, which lab finding is most consistent with Graves' disease?

Elevated TSH, elevated free T4
Low TSH, low free T4, positive TPO antibodies
Low TSH, elevated free T4, positive TSI antibodies (Correct answer)
Elevated TSH, low free T4

Correct answer: Low TSH, elevated free T4, positive TSI antibodies

Graves' disease is an autoimmune hyperthyroidism caused by TSH receptor-stimulating immunoglobulins (TSI), resulting in low TSH and elevated thyroid hormones.

Question 88: What is the preferred treatment for an acute gout flare?

Probenecid
Febuxostat
Colchicine (Correct answer)
Allopurinol

Correct answer: Colchicine

Colchicine is a preferred treatment for an acute gout flare, especially when initiated early in the attack. It works by inhibiting neutrophil migration and activity, thereby reducing the inflammatory response to uric acid crystals in the joint. While other medications like NSAIDs or corticosteroids can also be used, colchicine is specifically effective in targeting the inflammatory cascade of gout.

Question 89: A 55-year-old man with CKD Stage 3 has serum phosphate of 5.8 mg/dL. Which treatment best addresses hyperphosphatemia in this patient?

Increased dietary calcium
High-dose vitamin D supplementation
Loop diuretics
Dietary phosphate restriction and phosphate binders with meals (Correct answer)

Correct answer: Dietary phosphate restriction and phosphate binders with meals

Phosphate binders taken with meals prevent intestinal phosphate absorption, and dietary restriction limits intake, together managing hyperphosphatemia in CKD.

Question 90: Which dermatologic condition is characterized by silvery scales and plaques on the extensor surfaces?

Eczema
Psoriasis (Correct answer)
Lichen planus
Tinea corporis

Correct answer: Psoriasis

Psoriasis is a chronic inflammatory skin condition characterized by well-demarcated, erythematous (red) plaques covered with silvery scales. These lesions commonly appear on extensor surfaces such as the elbows, knees, and scalp. It is an autoimmune condition where skin cells grow too quickly, leading to the characteristic thick, scaly patches.

Question 91: A diabetic patient is found unconscious with a blood glucose of 32 mg/dL. Which is the immediate treatment if IV access cannot be established?

Glucagon IM injection (Correct answer)
Oral glucose gel
Epinephrine IM
Dextrose 50% IV

Correct answer: Glucagon IM injection

Glucagon IM stimulates hepatic glycogenolysis and gluconeogenesis, raising blood glucose when IV access is unavailable in severe hypoglycemia.

Question 92: Which enzyme deficiency in congenital adrenal hyperplasia (CAH) causes hypertension, hypokalemia, and ambiguous genitalia in females?

11-beta hydroxylase deficiency (Correct answer)
3-beta hydroxysteroid dehydrogenase deficiency
21-hydroxylase deficiency
17-alpha hydroxylase deficiency

Correct answer: 11-beta hydroxylase deficiency

11-beta hydroxylase deficiency leads to accumulation of 11-deoxycorticosterone (a potent mineralocorticoid) causing hypertension, while excess androgens virilize female fetuses.

Question 93: Which of the following techniques is a direct osteopathic manipulative treatment?

Craniosacral therapy
Counterstrain
Myofascial release (indirect)
High-velocity, low-amplitude (HVLA) thrust (Correct answer)

Correct answer: High-velocity, low-amplitude (HVLA) thrust

High-velocity, low-amplitude (HVLA) thrust is a direct osteopathic manipulative treatment technique. Direct techniques involve moving the dysfunctional body part towards the restrictive barrier, engaging it, and then applying a corrective force. HVLA specifically uses a rapid, therapeutic force of brief duration that travels a short distance within the anatomic range of motion, often resulting in an audible 'pop' or 'click'.

Question 94: A 65-year-old with a history of heavy sun exposure presents with a pearly, translucent nodule with rolled borders and telangiectasias on the nose. Which is the most likely diagnosis?

Basal cell carcinoma (Correct answer)
Keratoacanthoma
Squamous cell carcinoma
Melanoma

Correct answer: Basal cell carcinoma

Basal cell carcinoma classically presents as a pearly papule or nodule with rolled borders and telangiectasias on sun-exposed areas, especially the nose.

Question 95: A 50-year-old man with type 2 diabetes develops progressive proteinuria. Kidney biopsy shows Kimmelstiel-Wilson nodules. What pathological process is demonstrated?

Nodular glomerulosclerosis (Correct answer)
Minimal change disease
Membranous nephropathy
Focal segmental glomerulosclerosis

Correct answer: Nodular glomerulosclerosis

Kimmelstiel-Wilson nodules represent nodular glomerulosclerosis, the pathological hallmark of advanced diabetic nephropathy caused by mesangial matrix expansion.

Question 96: A 75-year-old female with severe osteoporosis presents for osteopathic manipulative treatment (OMT) for lumbar pain. Which of the following OMT modalities is considered a relative to absolute contraindication in this patient?

Myofascial Release
Balanced Ligamentous Tension
High-Velocity, Low-Amplitude (HVLA) (Correct answer)
Counterstrain

Correct answer: High-Velocity, Low-Amplitude (HVLA)

High-Velocity, Low-Amplitude (HVLA) techniques involve a rapid, therapeutic force of brief duration that travels a short distance within the anatomic range of motion. Due to the risk of fracture in patients with compromised bone integrity, severe osteoporosis is a well-established contraindication for HVLA. The other listed techniques are indirect or soft tissue modalities that are generally considered safe in this population.

Question 97: Which finding best distinguishes prerenal azotemia from acute tubular necrosis (ATN)?

FENa > 2%
BUN:Cr ratio < 15
Muddy brown casts in urine
Fractional excretion of sodium (FENa) < 1% (Correct answer)

Correct answer: Fractional excretion of sodium (FENa) < 1%

In prerenal azotemia, intact tubular function avidly reabsorbs sodium, yielding FENa < 1%, whereas ATN causes tubular dysfunction resulting in FENa > 2%.

Question 98: Which finding on renal biopsy is most consistent with IgA nephropathy (Berger disease)?

Diffuse effacement of podocyte foot processes
Subepithelial 'spike and dome' deposits
Linear IgG deposits along the GBM
Mesangial IgA deposits on immunofluorescence (Correct answer)

Correct answer: Mesangial IgA deposits on immunofluorescence

IgA nephropathy is characterized by mesangial IgA immune complex deposits seen on immunofluorescence, often following mucosal infections.

Question 99: Which of the following virulence factors of Staphylococcus aureus directly impairs opsonization and phagocytosis by binding to the Fc region of IgG?

Protein A (Correct answer)
Exfoliative toxin
Hyaluronidase
Coagulase

Correct answer: Protein A

Protein A is a surface protein on *S. aureus* that binds to the Fc portion of IgG antibodies. This incorrect orientation prevents the antibody from being recognized by phagocyte Fc receptors, thereby inhibiting opsonization and phagocytosis, which is a key immune evasion mechanism. Coagulase promotes fibrin clotting, hyaluronidase breaks down connective tissue, and exfoliative toxin causes skin blistering.

Question 100: A patient with chronic kidney disease stage 4 develops anemia. Which is the primary mechanism of anemia in CKD?

Iron deficiency from dietary restriction
Vitamin B12 deficiency
Hemolysis from uremic toxins
Decreased erythropoietin production by damaged kidneys (Correct answer)

Correct answer: Decreased erythropoietin production by damaged kidneys

The peritubular fibroblasts of the kidney produce erythropoietin; CKD-related fibrosis and destruction reduce EPO synthesis, causing normocytic normochromic anemia.

Question 101: What type of immune cell is primarily involved in antibody production?

Macrophages (Correct answer)
B lymphocytes
T lymphocytes
Natural killer cells

Correct answer: Macrophages

Macrophages are crucial antigen-presenting cells (APCs) that phagocytose pathogens and present their antigens to T helper cells. This antigen presentation is a critical step in initiating the adaptive immune response, which includes the activation and differentiation of B lymphocytes into plasma cells, the actual antibody producers. Therefore, while not directly producing antibodies, macrophages play a primary and indispensable role in orchestrating the immune response that leads to antibody production.

Question 102: 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
C. Chest X-ray
D. Computed tomography (CT) pulmonary angiography (Correct answer)
B. Lower extremity venous Doppler ultrasound

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 103: A 40-year-old woman presents with facial flushing, erythema across the nose and cheeks, telangiectasias, and papulopustules. She reports flares with sun exposure, hot beverages, and alcohol. Which diagnosis is most likely?

Rosacea (Correct answer)
Systemic lupus erythematosus
Perioral dermatitis
Seborrheic dermatitis

Correct answer: Rosacea

Rosacea is characterized by central facial erythema, flushing, telangiectasias, and papulopustules triggered by heat, alcohol, spicy food, and UV exposure.

Question 104: Which osteopathic structural finding is classically associated with viscerosomatic reflexes from the pancreas?

T5-T9 somatic dysfunction (Correct answer)
T1-T4 somatic dysfunction
L1-L3 somatic dysfunction
C3-C5 somatic dysfunction

Correct answer: T5-T9 somatic dysfunction

The pancreas has sympathetic innervation from T5-T9 via the splanchnic nerves, so pancreatic pathology commonly produces somatic dysfunction in this thoracic region.

Question 105: A 65-year-old male with a long history of chronic hepatitis C infection is diagnosed with cirrhosis. During an upper endoscopy for evaluation of dyspepsia, numerous large, tortuous veins are noted in the distal esophagus. What is the primary pathophysiologic mechanism responsible for the formation of these varices?

Hepatic encephalopathy
Increased synthesis of prothrombin
Decreased plasma oncotic pressure
Portal hypertension (Correct answer)

Correct answer: Portal hypertension

Cirrhosis causes fibrosis and increased resistance to blood flow through the liver, leading to elevated pressure in the portal venous system, a condition known as portal hypertension. This increased pressure forces blood to be shunted through collateral vessels, such as the submucosal veins in the distal esophagus, causing them to become dilated and tortuous (varices).

Question 106: What is a core tenet of osteopathic medicine?

Treatment should focus exclusively on symptoms.
The body is a unit; the person is a unity of body, mind, and spirit. (Correct answer)
The body functions independently of its structure.
Disease is only caused by structural abnormalities.

Correct answer: The body is a unit; the person is a unity of body, mind, and spirit.

A core tenet of osteopathic medicine is the holistic view that the body is a unit, and the person is a unity of body, mind, and spirit. This principle emphasizes the interconnectedness of all body systems and the influence of mental and spiritual factors on health. Osteopathic physicians consider the whole person when diagnosing and treating patients, rather than focusing solely on symptoms or isolated body parts.

Question 107: What is the primary function of mitochondria in eukaryotic cells?

Protein synthesis
Energy production (Correct answer)
Structural support
DNA replication

Correct answer: Energy production

Mitochondria are often referred to as the 'powerhouses' of the cell because their primary function is energy production. Through cellular respiration, they generate adenosine triphosphate (ATP), the main energy currency of the cell, from glucose and other fuel molecules. This process is crucial for nearly all cellular activities requiring energy.

Question 108: Which finding on renal ultrasound is most characteristic of autosomal dominant polycystic kidney disease (ADPKD)?

Hydronephrosis with ureteral dilation
Unilateral cyst with contralateral normal kidney
Small echogenic kidneys bilaterally
Bilaterally enlarged kidneys with multiple cysts (Correct answer)

Correct answer: Bilaterally enlarged kidneys with multiple cysts

ADPKD is characterized by bilateral renal enlargement due to progressive replacement of normal parenchyma by numerous fluid-filled cysts derived from PKD1 or PKD2 mutations.

Question 109: Which medication is first-line to slow progression of diabetic nephropathy in a patient with type 2 diabetes and proteinuria?

ACE inhibitors or ARBs (Correct answer)
Thiazide diuretics
Calcium channel blockers
Beta-blockers

Correct answer: ACE inhibitors or ARBs

ACE inhibitors and ARBs reduce intraglomerular pressure and proteinuria, providing renoprotective effects beyond blood pressure control in diabetic nephropathy.

Question 110: A 30-year-old man presents with recurrent hematuria coinciding with upper respiratory infections (synpharyngitic hematuria). Kidney biopsy shows mesangial IgA deposits. What is the diagnosis?

Post-streptococcal GN
IgA nephropathy (Berger disease) (Correct answer)
Henoch-Schönlein purpura nephritis
Alport syndrome

Correct answer: IgA nephropathy (Berger disease)

IgA nephropathy (Berger disease) is characterized by mesangial IgA immune complex deposition, presenting with gross hematuria during mucosal infections (within 1-2 days).

Question 111: A 25-year-old hiker presents with a pruritic, erythematous, and vesicular rash on his forearms that appeared 48 hours after clearing a trail. He recalls brushing against several plants. This clinical presentation is characteristic of which type of hypersensitivity reaction?

Type I (Anaphylactic)
Type IV (Delayed-type) (Correct answer)
Type III (Immune complex)
Type II (Cytotoxic)

Correct answer: Type IV (Delayed-type)

The rash described is classic for allergic contact dermatitis, such as from poison ivy. This is a Type IV, or delayed-type, hypersensitivity reaction. It is mediated by T-lymphocytes, not antibodies, and characteristically takes 24-72 hours to develop after re-exposure to the antigen (in this case, urushiol oil from the plant). Type I is immediate and IgE-mediated, Type II is antibody-mediated against cell surfaces, and Type III involves deposition of antigen-antibody complexes.

Question 112: An osteopathic physician is evaluating a 40-year-old patient with chronic fatigue syndrome and depression. During the cranial examination, the physician notes a markedly decreased rate and amplitude of the cranial rhythmic impulse (CRI). This finding is most often associated with which of the following states?

Increased systemic vitality and wellness
States of stress, depression, or chronic illness (Correct answer)
Acute febrile illness
Following a session of vigorous exercise

Correct answer: States of stress, depression, or chronic illness

The cranial rhythmic impulse (CRI) is considered in osteopathic medicine to be a palpable reflection of the body's inherent vitality and health. A decrease in its rate and amplitude is classically associated with states that deplete vitality, such as chronic stress, depression, fatigue, and chronic infections. Conversely, factors like fever and exercise tend to temporarily increase the rate.

Question 113: A 55-year-old male with a history of ST-elevation myocardial infarction (STEMI) is being discharged. In addition to aspirin and a P2Y12 inhibitor, which of the following medication classes provides a mortality benefit and should be initiated prior to discharge for secondary prevention?

Calcium channel blockers
Beta-blockers (Correct answer)
Loop diuretics
Nitrates

Correct answer: Beta-blockers

For secondary prevention after an acute coronary syndrome, beta-blockers, ACE inhibitors/ARBs, and statins have been shown to provide a mortality benefit. Beta-blockers reduce myocardial oxygen demand, decrease the risk of ventricular arrhythmias, and have anti-hypertensive effects. Nitrates are used for symptom control of angina but do not offer a mortality benefit. Calcium channel blockers are second-line agents for symptom control if beta-blockers are contraindicated or not tolerated. Loop diuretics are used for managing symptoms of heart failure but do not have a primary role in secondary prevention of ACS unless heart failure is present.

Question 114: A 28-year-old develops widespread pruritic wheals of various sizes that resolve within 24 hours without leaving bruising or scarring. She denies systemic symptoms. Which mechanism is responsible?

T-cell mediated cytotoxicity
Immune complex deposition in dermal vessels
IgE-mediated mast cell degranulation releasing histamine (Correct answer)
Complement-mediated lysis of keratinocytes

Correct answer: IgE-mediated mast cell degranulation releasing histamine

Urticaria is caused by IgE-mediated mast cell degranulation releasing histamine and other mediators, causing transient wheals that resolve without trace.

Question 115: A patient presents with oliguria, hematuria, and periorbital edema 2-3 weeks after a streptococcal throat infection. Urinalysis shows RBC casts. What is the most likely diagnosis?

Post-streptococcal glomerulonephritis (Correct answer)
Nephrotic syndrome
Acute tubular necrosis
IgA nephropathy

Correct answer: Post-streptococcal glomerulonephritis

Post-streptococcal glomerulonephritis presents with nephritic syndrome (hematuria, RBC casts, hypertension) occurring 2-3 weeks after Group A strep pharyngitis.

Question 116: A 24-year-old male presents with a 6-month history of recurrent bloody diarrhea, lower abdominal cramping, and tenesmus. Colonoscopy reveals continuous, erythematous, and friable mucosa starting at the rectum and extending proximally to the splenic flexure. The inflammation is confined to the mucosal and submucosal layers. Which of the following is the most likely diagnosis?

Irritable bowel syndrome
Ulcerative colitis (Correct answer)
Crohn's disease
Celiac disease

Correct answer: Ulcerative colitis

The patient's presentation of bloody diarrhea, tenesmus, and colonoscopic findings of continuous inflammation limited to the mucosa starting in the rectum are classic for ulcerative colitis. Crohn's disease typically presents with discontinuous (skip lesions) and transmural inflammation and can occur anywhere in the GI tract. Irritable bowel syndrome does not have inflammatory findings on colonoscopy, and celiac disease primarily affects the small intestine.

Question 117: Which of the following is the goal of osteopathic manipulative treatment (OMT)?

To replace pharmacologic interventions
To treat infectious diseases directly
To align the spine exclusively
To restore the body’s self-healing capabilities (Correct answer)

Correct answer: To restore the body’s self-healing capabilities

The primary goal of osteopathic manipulative treatment (OMT) is to restore the body’s inherent self-healing and self-regulating capabilities. OMT involves a variety of hands-on techniques used to diagnose, treat, and prevent illness or injury by addressing somatic dysfunctions. By improving musculoskeletal function, OMT aims to enhance overall physiological function and promote the body's natural ability to heal.

Question 118: Which of the following coagulation factors are dependent on Vitamin K for their synthesis and function?

Factors XI, XII, and prekallikrein
Factors V, VIII, and XI
Factors II, VII, IX, and X (Correct answer)
Factors I (Fibrinogen), V, and XIII

Correct answer: Factors II, VII, IX, and X

The synthesis of several crucial coagulation factors requires vitamin K as a cofactor for a post-translational modification called gamma-carboxylation. This modification allows the factors to bind calcium and interact with phospholipid surfaces. The vitamin K-dependent clotting factors are Factors II (prothrombin), VII, IX, and X, as well as the anticoagulant proteins C and S.

Question 119: The sympathetic nervous system innervates the kidney via which spinal levels, relevant to osteopathic viscerosomatic reflexes?

L2–L4
T10–L1 (Correct answer)
C1–C4
S2–S4

Correct answer: T10–L1

Renal sympathetic innervation originates from T10–L1, and somatic dysfunction at these levels can reflect renal pathology through viscerosomatic reflex arcs.

Question 120: A patient with chronic kidney disease has a GFR of 22 mL/min/1.73 m². According to KDIGO staging, what CKD stage is this?

Stage 5
Stage 2
Stage 3b
Stage 4 (Correct answer)

Correct answer: Stage 4

KDIGO defines CKD Stage 4 as GFR 15–29 mL/min/1.73 m², which corresponds to severely decreased kidney function.

Question 121: A patient with type 2 diabetes has an HbA1c of 9.2% despite lifestyle modification. Which medication class improves insulin sensitivity primarily in peripheral tissues?

Thiazolidinediones (Correct answer)
DPP-4 inhibitors
Sulfonylureas
Alpha-glucosidase inhibitors

Correct answer: Thiazolidinediones

Thiazolidinediones (e.g., pioglitazone) activate PPAR-gamma receptors, enhancing insulin sensitivity in muscle and adipose tissue.

Question 122: A hospitalized patient develops oliguria after receiving aminoglycoside antibiotics for 7 days. Urinalysis shows muddy brown granular casts. What type of acute kidney injury is present?

Acute tubular necrosis (ATN) (Correct answer)
Prerenal azotemia
Postrenal obstruction
Acute interstitial nephritis

Correct answer: Acute tubular necrosis (ATN)

Aminoglycosides are directly nephrotoxic to proximal tubular cells, causing ATN characterized by muddy brown granular casts from sloughed tubular epithelial cells.

Question 123: What is the most common initial treatment for acute bacterial sinusitis?

Antihistamines
Corticosteroids
Amoxicillin-clavulanate (Correct answer)
Decongestants

Correct answer: Amoxicillin-clavulanate

For acute bacterial sinusitis, Amoxicillin-clavulanate is the most common initial antibiotic treatment. This combination antibiotic is often preferred due to its broader spectrum of activity, including coverage against beta-lactamase-producing bacteria, which are common in sinus infections. It helps to eradicate the bacterial infection and alleviate symptoms.

Question 124: What is the term for a restriction of motion in the musculoskeletal system?

Osteoarthritis
Hypermobility
Homeostasis (Correct answer)
Somatic dysfunction (Correct answer)

Correct answer: Homeostasis

Somatic dysfunction is the term used in osteopathic medicine to describe impaired or altered function of related components of the somatic (body framework) system. This includes skeletal, arthrodial, and myofascial structures, as well as related vascular, lymphatic, and neural elements. It is characterized by a restriction of motion, often accompanied by tenderness, asymmetry, and tissue texture changes.

Question 125: A 32-year-old man presents with bilateral gynecomastia, small firm testes, and infertility. Karyotype shows 47,XXY. Which of the following best describes this condition?

Klinefelter syndrome (Correct answer)
Kallmann syndrome
Androgen insensitivity syndrome
Turner syndrome

Correct answer: Klinefelter syndrome

Klinefelter syndrome (47,XXY) presents with hypogonadism, infertility, gynecomastia, and small firm testes due to seminiferous tubule dysgenesis.

Question 126: Which osteopathic technique is indicated to address lymphatic drainage of the renal and pelvic region?

Occipital decompression
Cervical soft tissue
Pelvic diaphragm release (Correct answer)
Thoracic pump technique

Correct answer: Pelvic diaphragm release

The pelvic diaphragm release improves lymphatic and venous drainage from the pelvic and lower abdominal viscera including the kidneys.

Question 127: A patient stabilized on warfarin for atrial fibrillation is prescribed a new medication. Several weeks later, their INR is found to be dangerously elevated without any change in diet or warfarin dose. The new medication is most likely a potent inhibitor of which cytochrome P450 enzyme?

CYP3A4
CYP2D6
CYP2C9 (Correct answer)
CYP1A2

Correct answer: CYP2C9

Warfarin is a substrate for several CYP enzymes, but its more potent S-enantiomer is primarily metabolized by CYP2C9. Inhibition of CYP2C9 by another drug (such as amiodarone, fluconazole, or trimethoprim-sulfamethoxazole) will decrease the metabolism of S-warfarin, leading to higher plasma levels and an increased anticoagulant effect, reflected by a dangerously elevated INR.

Question 128: 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
D. Sacral inhibition
B. Thoracic inlet myofascial release (Correct answer)
C. Pedal pump technique

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.

Question 129: A 35-year-old presents with flaccid bullae that rupture easily, leaving raw erosions. The Nikolsky sign is positive. Direct immunofluorescence shows IgG deposits in a 'fishnet' pattern throughout the epidermis. Which diagnosis is most likely?

Dermatitis herpetiformis
Linear IgA bullous dermatosis
Pemphigus vulgaris (Correct answer)
Bullous pemphigoid

Correct answer: Pemphigus vulgaris

Pemphigus vulgaris is characterized by IgG autoantibodies against desmoglein 1 and 3, causing suprabasal acantholysis, flaccid bullae, and a positive Nikolsky sign.

Question 130: A 22-year-old male of Mediterranean descent presents with fatigue, jaundice, and dark urine after being treated with a sulfonamide antibiotic for a urinary tract infection. A complete blood count reveals normocytic anemia, and a peripheral smear shows Heinz bodies and bite cells. This presentation is most characteristic of a deficiency in which of the following enzymes?

Pyruvate kinase
Glucose-6-phosphate dehydrogenase (Correct answer)
Factor VIII
Fibrinogen

Correct answer: Glucose-6-phosphate dehydrogenase

This patient's presentation is classic for Glucose-6-phosphate dehydrogenase (G6PD) deficiency, an X-linked recessive disorder. G6PD is crucial for protecting red blood cells from oxidative stress. Exposure to triggers like certain drugs (e.g., sulfonamides, primaquine), infections, or fava beans causes oxidative damage to hemoglobin, leading to the formation of Heinz bodies and subsequent extravascular hemolysis by splenic macrophages, creating 'bite cells'. Pyruvate kinase deficiency also causes hemolytic anemia but is not typically triggered by oxidative stress in this manner. Fibrinogen and Factor VIII are clotting factors, and deficiencies would lead to bleeding disorders.

Question 131: A 4-year-old child presents with massive proteinuria (5g/day), hypoalbuminemia, generalized edema, and hyperlipidemia. Biopsy shows effacement of foot processes on electron microscopy. What is the most likely diagnosis?

Minimal change disease (Correct answer)
Focal segmental glomerulosclerosis
Membranoproliferative GN
Membranous nephropathy

Correct answer: Minimal change disease

Minimal change disease is the most common nephrotic syndrome in children, showing normal light microscopy but effacement of podocyte foot processes on electron microscopy.

Question 132: Which cranial nerve is responsible for motor innervation to the muscles of mastication?

Glossopharyngeal nerve (CN IX)
Hypoglossal nerve (CN XII)
Facial nerve (CN VII)
Trigeminal nerve (CN V3 - mandibular branch) (Correct answer)

Correct answer: Trigeminal nerve (CN V3 - mandibular branch)

The Trigeminal nerve (CN V) is responsible for motor innervation to the muscles of mastication (chewing). Specifically, the mandibular branch (V3) of the trigeminal nerve innervates muscles such as the masseter, temporalis, and pterygoids. It also provides sensory innervation to the face, but its motor component is critical for jaw movement.

Question 133: A 45-year-old man with a history of heavy alcohol use presents to the emergency department with severe, constant epigastric pain that radiates to his back. The pain began 10 hours ago and is associated with nausea and two episodes of vomiting. On examination, he is febrile and has marked tenderness in the epigastric region. Which of the following laboratory findings is the most specific for diagnosing his condition?

Serum amylase >3 times the upper limit of normal
Serum lipase >3 times the upper limit of normal (Correct answer)
Elevated C-reactive protein
Leukocytosis

Correct answer: Serum lipase >3 times the upper limit of normal

The clinical presentation is highly suggestive of acute pancreatitis. While both serum amylase and lipase are typically elevated, serum lipase is more specific to the pancreas and remains elevated for a longer period than amylase. Amylase can be elevated in other conditions, such as salivary gland disorders or bowel obstruction. C-reactive protein and leukocytosis are non-specific markers of inflammation.

Question 134: A 65-year-old female with a history of rheumatoid arthritis presents with symmetrical pain, swelling, and stiffness in the small joints of her hands and feet, which is worse in the morning. Which of the following physical exam findings would be most specific for this patient's condition?

Boutonnière and swan-neck deformities (Correct answer)
Positive Finkelstein's test
Crepitus on passive range of motion
Heberden's nodes

Correct answer: Boutonnière and swan-neck deformities

Rheumatoid arthritis (RA) is a chronic autoimmune disease characterized by inflammation of synovial joints. Boutonnière (flexion of the PIP joint and hyperextension of the DIP joint) and swan-neck (hyperextension of the PIP joint and flexion of the DIP joint) deformities are characteristic, though often later, findings in RA due to inflammation and damage to the extensor tendons. Heberden's nodes are seen in osteoarthritis, Finkelstein's test is for de Quervain's tenosynovitis, and crepitus is a non-specific finding common in many arthropathies.

Question 135: A patient with recurrent UTIs and urinary frequency is found to have a neurogenic bladder. Osteopathic management would focus on which spinal region to address parasympathetic innervation of the bladder?

T10–L2
S2–S4 (Correct answer)
C3–C5
T1–T4

Correct answer: S2–S4

Parasympathetic innervation to the detrusor muscle of the bladder arises from S2–S4 via the pelvic splanchnic nerves.

Question 136: A 19-year-old started trimethoprim-sulfamethoxazole for a urinary tract infection. Three weeks later she develops widespread erythematous targetoid lesions involving mucosal surfaces, with epidermal detachment >30% of the body surface area. Which condition best describes this presentation?

Erythema multiforme major
Toxic epidermal necrolysis (TEN) (Correct answer)
Pemphigus vulgaris
Bullous pemphigoid

Correct answer: Toxic epidermal necrolysis (TEN)

Toxic epidermal necrolysis (TEN) is a severe drug reaction with epidermal detachment >30% BSA and mucosal involvement, most commonly triggered by sulfonamides and anticonvulsants.

Question 137: A 24-year-old graduate student presents with a long history of unstable interpersonal relationships, frantic efforts to avoid real or imagined abandonment, and recurrent suicidal gestures. She describes a chronic feeling of 'emptiness' and has episodes of intense, inappropriate anger. Which of the following personality disorders best fits this clinical presentation?

Borderline Personality Disorder (Correct answer)
Avoidant Personality Disorder
Obsessive-Compulsive Personality Disorder
Narcissistic Personality Disorder

Correct answer: Borderline Personality Disorder

This combination of symptoms, particularly the frantic efforts to avoid abandonment, identity disturbance (chronic feelings of emptiness), impulsivity (suicidal gestures), and affective instability (intense anger), is the hallmark of Borderline Personality Disorder, which is a Cluster B personality disorder.

Question 138: A 45-year-old male is being treated for a severe MRSA infection with intravenous vancomycin. During the infusion, he develops diffuse erythema and flushing of his face, neck, and upper torso, accompanied by pruritus and mild hypotension. What is the most likely direct cause of this reaction?

Formation of drug-hapten complexes leading to immune activation
A cytokine storm induced by bacterial lysis
Direct degranulation of mast cells and basophils (Correct answer)
An IgE-mediated type I hypersensitivity reaction

Correct answer: Direct degranulation of mast cells and basophils

This patient is experiencing Vancomycin Infusion Reaction (VIR), also known as red man syndrome. This is an anaphylactoid reaction, not a true allergic (IgE-mediated) reaction. It is caused by the rapid infusion of vancomycin, which directly stimulates mast cells and basophils to release histamine, leading to the characteristic flushing, erythema, and pruritus.

Question 139: A 25-year-old woman notices well-circumscribed patches of hair loss on the scalp. Examination reveals smooth scalp skin with 'exclamation point' hairs at the periphery of patches. Which is the most likely diagnosis?

Alopecia areata (Correct answer)
Traction alopecia
Androgenetic alopecia
Tinea capitis

Correct answer: Alopecia areata

Alopecia areata is an autoimmune condition causing well-demarcated patches of non-scarring hair loss with characteristic 'exclamation point' hairs at patch margins.

Question 140: A 3-year-old boy presents with his fourth episode of pneumonia in the past year, in addition to recurrent otitis media. The causative organisms have consistently been encapsulated bacteria like Streptococcus pneumoniae. Physical exam is notable for an absence of tonsillar tissue. Laboratory studies show markedly decreased levels of IgG, IgA, and IgM. Which of the following is the most likely diagnosis?

X-linked (Bruton) Agammaglobulinemia (XLA) (Correct answer)
DiGeorge Syndrome
Severe Combined Immunodeficiency (SCID)
Chronic Granulomatous Disease (CGD)

Correct answer: X-linked (Bruton) Agammaglobulinemia (XLA)

X-linked Agammaglobulinemia (XLA) is a primary immunodeficiency characterized by a failure of B-cell precursors to mature, leading to a profound deficiency of all immunoglobulin isotypes. This results in recurrent sinopulmonary infections with encapsulated bacteria, typically beginning after 6 months of age as maternal antibodies wane. The absence of B-cells also leads to underdeveloped lymphoid tissues, such as tonsils. SCID affects both B and T cells, CGD is a defect in phagocyte function, and DiGeorge syndrome is primarily a T-cell deficiency.

Question 141: A 62-year-old male with chronic back pain has been managed with long-term, high-dose opioid therapy. While patients typically develop tolerance to many side effects of opioids, which of the following adverse effects is least likely to diminish over time?

Nausea and vomiting
Sedation
Respiratory depression
Constipation (Correct answer)

Correct answer: Constipation

While tolerance develops to most of the central nervous system effects of opioids, such as sedation, euphoria, and respiratory depression, tolerance to the gastrointestinal effects, particularly constipation, develops very slowly or not at all. Opioids decrease GI motility and secretions, leading to persistent constipation that often requires proactive management throughout the duration of therapy.

Question 142: A 72-year-old right-handed man is brought to the emergency department after a sudden onset of left-sided weakness and sensory loss. His symptoms primarily affect his leg and foot, with relative sparing of his arm and face. He also exhibits abulia (lack of will) and new-onset urinary incontinence. Occlusion of which cerebral artery is the most likely cause of his symptoms?

Posterior Cerebral Artery (PCA)
Anterior Cerebral Artery (ACA) (Correct answer)
Middle Cerebral Artery (MCA)
Basilar Artery

Correct answer: Anterior Cerebral Artery (ACA)

The anterior cerebral artery (ACA) supplies the medial portions of the frontal and parietal lobes. This territory includes the motor and sensory cortices for the contralateral leg and foot. Therefore, an ACA stroke classically presents with contralateral weakness and sensory loss that is greater in the leg than the arm or face. Associated frontal lobe signs, such as abulia and urinary incontinence, are also common.

Question 143: An osteopathic physician is performing a structural exam on a patient with a history of recurrent urinary tract infections and flank pain. The physician notes boggy tissue texture changes, paraspinal muscle hypertonicity, and tenderness at the T10-T11 vertebral levels. This viscerosomatic reflex is most commonly associated with pathology of which organ system?

Descending and sigmoid colon
Appendix and cecum
Liver and gallbladder
Kidneys and upper ureters (Correct answer)

Correct answer: Kidneys and upper ureters

The sympathetic innervation to the kidneys and upper ureters originates from the T10-T11 spinal cord segments. Visceral pathology in these organs can cause a reflexive facilitation and somatic dysfunction at these corresponding spinal levels. The appendix is typically T12, the liver/gallbladder is T6-T9, and the descending/sigmoid colon is T12-L2.

COMSAE Comprehensive Osteopathic Medical Self-Assessment Exam

The COMSAE (Comprehensive Osteopathic Medical Self-Assessment Examination) is developed by the National Board of Osteopathic Medical Examiners (NBOME) as a formative self-assessment tool for osteopathic medical students preparing for COMLEX-USA Level examinations. It covers Osteopathic Principles and Practice (OPP), all major organ systems including musculoskeletal, cardiovascular, nervous, respiratory, gastrointestinal, endocrine, reproductive, and renal systems, as well as pharmacology and microbiology.

160

Questions

200 min

Time Limit

60%

To Pass

Checking for saved progress...

Exam Rules

You can skip questions and return to them later
Flag questions for review before submitting
No feedback shown until you submit the entire exam
Unanswered questions count as wrong — answer everything
10 pretest questions are mixed in and don't affect your score
Timer auto-submits when time runs out
Your progress is auto-saved every 30 seconds