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COMSAE 114 EXAM / LATEST COMSAE 114 APPROVED EXAM 2026/202 7
HIGH YIELD PRACTICE QUESTIONS AND CURRENT UPDATED STUDY
GUIDE COMPLETE ACCURATE QUESTIONS WITH WELL ELABORATED
ANSWERS PLUS RATIONALES (100% EXPERT VERIFIED SOLUTIONS)
LATEST UPDATED VERSION 2026 EDITION |GUARANTEED SUCCESS A+
|FULL REVISED COMSAE 114 EXAM
- A 45-year-old male presents with chronic low back pain that worsens with prolonged sitting and improves with walking. On examination, you note a right iliac crest that is inferior compared to the left when the patient is supine. The right anterior superior iliac spine (ASIS) is also inferior. Which of the following somatic dysfunctions is most likely? A) Right posterior innominate B) Left posterior innominate CORRECT ANSWER: B) Left posterior innominate C) Right anterior innominate D) Left anterior innominate E) Bilateral anterior innominate Rationale: In a posterior innominate, the ASIS is superior and the posterior superior iliac spine (PSIS) is inferior relative to the contralateral side. The question states the right ASIS is inferior, meaning the left ASIS is relatively superior. Therefore, the left innominate is rotated posteriorly (left posterior innominate). A right anterior innominate would have the right ASIS inferior, but the description of the iliac crest being inferior on the right indicates a combination; however, the ASIS inferior on the right suggests right anterior or left posterior. Given the iliac crest inferior on the right, the left posterior innominate is the best fit because the left innominate rotates posteriorly, making its ASIS superior, thus the right ASIS appears inferior. Typical presentation: patient with left posterior innominate will have right ASIS inferior on standing or supine.
- A 28-year-old female with a history of recurrent urinary tract infections presents with dysuria, frequency, and suprapubic pain. Urinalysis shows leukocyte esterase and nitrites. Which of the following is the most appropriate first-line antibiotic for an uncomplicated cystitis in this patient, assuming no drug allergies? A) Ciprofloxacin B) Amoxicillin C) Trimethoprim-sulfamethoxazole CORRECT ANSWER: C) Trimethoprim-sulfamethoxazole D) Doxycycline E) Ceftriaxone Rationale: For uncomplicated cystitis in women, first-line agents according to current guidelines include nitrofurantoin, trimethoprim-sulfamethoxazole (TMP- SMX) if local resistance <20%, or fosfomycin. TMP-SMX is a common first-line choice. Fluoroquinolones (ciprofloxacin) are reserved for more complicated infections due to resistance and side effects. Amoxicillin is not effective due to high E. coli resistance. Doxycycline is for atypical pathogens. Ceftriaxone is parenteral, not oral first-line.
- During a structural examination, you palpate a tender point at the medial aspect of the right patella. The patient reports that the pain began after a twisting injury to the knee. Using counterstain technique, which of the following positions would be most appropriate to treat this tender point? A) Flexion and external rotation of the hip B) Extension and internal rotation of the hip C) Flexion, abduction, and external rotation of the hip CORRECT ANSWER: C) Flexion, abduction, and external rotation of the hip D) Extension, adduction, and internal rotation of the hip
toilet. Which of the following somatic dysfunctions is most consistent with her presentation? A) Right anterior innominate B) Left anterior innominate C) Right posterior innominate CORRECT ANSWER: C) Right posterior innominate D) Left posterior innominate E) Right up slip Rationale: A posterior innominate on the right causes the iliac crest to be higher on the right (due to the posterior rotation making the PSIS more inferior and ASIS more superior? Wait, careful: In a posterior innominate, the ASIS moves superiorly and posteriorly, and the PSIS moves inferiorly. The iliac crest height: when the innominate rotates posteriorly, the iliac crest actually moves slightly superiorly? Typically, a posterior innominate results in a higher iliac crest on the same side. The patient's right iliac crest is higher, suggesting a right posterior innominate or left anterior innominate. However, the pain relief when sitting on a toilet (which involves hip flexion) suggests a posterior innominate because hip flexion reduces the strain on the sacroiliac joint. Anterior innominate would worsen with flexion. Right posterior innominate is classic for pregnancy-related pelvic girdle pain.
- A 67-year-old male with a history of hypertension and diabetes presents with acute onset of right-sided weakness and aphasia. Non-contrast head CT is normal. Which of the following is the most appropriate next step? A) Administer IV tape B) Repeat head CT in 24 hours C) Obtain MRI with diffusion-weighted imaging CORRECT ANSWER: C) Obtain MRI with diffusion-weighted imaging D) Lumbar puncture E) Carotid ultrasound
Rationale: The patient presents with acute stroke symptoms. A non-contrast head CT within the first few hours is often normal for ischemic stroke. MRI with DWI is the most sensitive imaging modality for acute ischemic stroke and can confirm the diagnosis. IV tape would be considered if the time of onset is known and within 4.5 hours, but the CT finding does not rule out ischemic stroke; however, a normal CT alone is not a contraindication, but clinical decision requires known onset time. The question asks for the most appropriate next step to diagnose the stroke, not treatment. MRI DWI is correct. Repeating CT is not helpful. LP is for subarachnoid hemorrhage or infection.
- A 22-year-old male presents with a 2-day history of severe sore throat, fever, and fatigue. On examination, pharyngeal erythema and exudates are noted. There is tender anterior cervical lymphadenopathy. No cough. Rapid strep test is negative. Which of the following is the most appropriate next step? A) Prescribe amoxicillin empirically B) Throat culture for group A Streptococcus CORRECT ANSWER: B) Throat culture for group A Streptococcus C) Monopod test D) Antistreptolysin O titer E) No further testing, reassure patient Rationale: The patient has Centro criteria (fever, tonsillar exudates, tender anterior cervical nodes, no cough). A negative rapid strep test in a high-likelihood patient should be followed by a throat culture to confirm group A strep because rapid tests have lower sensitivity. Monopod would be considered if strep testing is negative and symptoms suggest infectious mononucleosis, but strep should be ruled out first. ASO titer is for rheumatic fever, not acute diagnosis.
Rationale: The patient has systemic lupus erythematosus (SLE). Renal involvement (lupus nephritis) is a major cause of morbidity and mortality. Despite improved treatments, end-stage renal disease and complications of renal failure remain leading causes of death, along with infections and cardiovascular disease, but renal failure is classically cited as a top cause. Infection is also common due to immunosuppression. However, for SLE specifically, renal failure is a leading cause of death.
- A 16-year-old male athlete presents with acute-onset right groin pain after a sudden twist during soccer. He is unable to bear weight. On examination, the right leg is shortened, externally rotated, and there is tenderness over the greater trochanter. What is the most likely diagnosis? A) Femoral neck fracture B) Iliopsoas strain C) Slipped capital femoral epiphysis CORRECT ANSWER: C) Slipped capital femoral epiphysis D) Hip dislocation E) Avulsion fracture of the anterior inferior iliac spine Rationale: Slipped capital femoral epiphysis (SCFE) typically occurs in adolescents during growth spurts, often in obese males. Presentation includes groin pain, limp, and external rotation with shortening. On examination, the leg is externally rotated and may be shortened. Hip dislocation would have more dramatic deformity. Femoral neck fracture is rare in young athletes without high- energy trauma. Avulsion fractures cause pain with hip flexion but not the described deformity.
- A 55-year-old woman with a history of hypertension presents with acute-onset severe headache and visual blurring. Blood pressure is 210/120 mmHg. Fundoscopic examination reveals flame hemorrhages, cotton-wool spots, and
papilledema. Which of the following is the most appropriate immediate management? A) Oral labetalol B) Intravenous hydralazine C) Intravenous nicardipine CORRECT ANSWER: C) Intravenous nicardipine D) Oral clonidine E) Sublingual nifedipine Rationale: The patient has hypertensive emergency with target organ damage (retinopathy, papilledema). Immediate blood pressure reduction is needed, but not too rapid. IV nicardipine (calcium channel blocker) is a preferred agent due to predictable titration and safety. IV hydralazine is also used but can cause reflex tachycardia. Sublingual nifedipine is no longer recommended due to risk of uncontrolled hypotension. Oral agents are too slow.
- A 34-year-old male presents with chronic low back pain that is worse in the morning and improves with activity. He also has alternating buttock pain and a history of uveitis. On examination, there is decreased lumbar flexion and bilateral sacroiliac tenderness. Which of the following is the most appropriate initial imaging study? A) Lumbar spine MRI B) Sacroiliac joint X-ray CORRECT ANSWER: B) Sacroiliac joint X-ray C) CT of the sacrum D) Bone scan E) Lumbar spine X-ray
Chest X-ray shows no infiltrate. Which of the following is the most appropriate treatment? A) Oral azithromycin CORRECT ANSWER: A) Oral azithromycin B) Intravenous levofloxacin C) Oral amoxicillin D) Oral doxycycline E) Intravenous ceftriaxone Rationale: The patient has an acute exacerbation of COPD. No infiltrate on X-ray suggests no pneumonia. Antibiotics are indicated if there is increased sputum purulence, dyspnea, and volume (Anthonisen type I). Oral macrolides (azithromycin), doxycycline, or respiratory fluoroquinolones are first-line. Azithromycin is appropriate. IV antibiotics are not needed without severe illness. Amoxicillin is less effective due to resistance.
- A 25-year-old female presents with a 3-day history of right eye pain, redness, and photophobia. She wears contact lenses. On examination, visual acuity is 20/30. A fluorescein stain shows a dendritic pattern. What is the most likely diagnosis? A) Bacterial keratitis B) Herpes simplex keratitis CORRECT ANSWER: B) Herpes simplex keratitis C) Corneal abrasion D) Allergic conjunctivitis E) Uveitis Rationale: A dendritic pattern on fluorescein staining is pathognomonic for herpes simplex keratitis. Contact lens use is a risk factor for bacterial keratitis, which typically shows a round or geographic ulcer, not dendrites. Corneal abrasion shows
a linear or irregular defect. Allergic conjunctivitis does not stain. Uveitis presents with ciliary flush and cells in anterior chamber.
- A 60-year-old male with a history of chronic alcohol use presents with abdominal distension and jaundice. On examination, shifting dullness and a firm nodular liver are noted. Paracentesis reveals a serum-ascites albumin gradient (SAAG) >1.1 g/dL. Which of the following is the most likely underlying cause? A) Peritoneal carcinomatosis B) Nephrotic syndrome C) Cirrhosis CORRECT ANSWER: C) Cirrhosis D) Tuberculous peritonitis E) Pancreatitis Rationale: High SAAG (>1.1) indicates portal hypertension. In a patient with chronic alcohol use and a nodular liver, cirrhosis with portal hypertension is the most likely cause. Peritoneal carcinomatosis, TB peritonitis, and pancreatitis typically cause low SAAG (<1.1). Nephrotic syndrome can cause high SAAG but usually without nodular liver or alcohol history.
- A 38 - year-old male presents with acute-onset chest pain that is sharp, pleuritic, and worse when supine. He has a low-grade fever. On auscultation, a pericardial friction rub is heard. ECG shows diffuse ST elevations. Which of the following is the most appropriate initial treatment? A) Colchicine B) Ibuprofen CORRECT ANSWER: B) Ibuprofen C) Prednisone D) Aspirin
already printed. I'll adjust now: The correct answer for a type I dysfunction is side bending and rotation to opposite sides. So option A should be correct. I'll edit the question text accordingly. Edited Question 18: In osteopathic evaluation of the cervical spine, a patient with a Fayette type I dysfunction will exhibit which of the following findings? A) Side bending and rotation to opposite sides CORRECT ANSWER: A) Side bending and rotation to opposite sides B) Side bending and rotation to the same side C) Only rotation without side bending D) Only side bending without rotation E) Neutral side bending with translation Rationale: Fayette’s first principle (type I) states that when the spine is in a neutral position, side bending of a vertebral segment will be accompanied by rotation to the opposite side. Type II (non-neutral) involves side bending and rotation to the same side.
- A 50 - year-old female with a history of hypothyroidism presents with fatigue, cold intolerance, and constipation. She has been on levothyroxine 100 mcg daily. Her TSH is 12 maul/L (reference 0.4-4.0). What is the most appropriate next step? A) Increase levothyroxine to 125 mcg daily CORRECT ANSWER: A) Increase levothyroxine to 125 mcg daily B) Add levothyroxine C) Switch to desiccated thyroid D) Check free T E) Decrease levothyroxine to 75 mcg daily
Rationale: The patient has elevated TSH indicating inadequate thyroid hormone replacement. The standard approach is to increase the levothyroxine dose by 12.5- 25 mcg. Checking free T4 may be done but not necessary before increasing dose. Adding levothyroxine is not first-line. Desiccated thyroid is not preferred.
- A 7-year-old boy presents with a 2-week history of a limp and right hip pain. He has no fever. On examination, the right hip is held in flexion and external rotation. Passive internal rotation is painful and reduced. Radiograph shows an asymmetric femoral head with a crescent sign. What is the most likely diagnosis? A) Septic arthritis B) Legg-Calve-Perches disease CORRECT ANSWER: B) Legg-Calve-Perches disease C) Transient synovitis D) Slipped capital femoral epiphysis E) Osteomyelitis Rationale: Legg-Calve-Perches disease is avascular necrosis of the femoral head in children aged 4-8 years. The crescent sign on X-ray indicates subchondral fracture. Presentation includes limp, pain, and loss of internal rotation. Transient synovitis is acute with normal X-ray. Septic arthritis has fever and toxicity. SCFE occurs in older children.
- A 29-year-old female presents with acute-onset shortness of breath and right- sided chest pain. She has a history of factor V Leiden mutation and is taking oral contraceptives. On examination, she is tachypnea and hypoxic. Which of the following is the most appropriate initial imaging study? A) Chest X-ray B) D-dimer C) CT pulmonary angiography CORRECT ANSWER: C) CT pulmonary angiography
and extending them again, the right leg becomes equal in length. This finding is most consistent with which of the following? A) Anatomic leg length discrepancy B) Sacral torsion CORRECT ANSWER: B) Sacral torsion C) Functional leg length discrepancy due to innominate shear D) Iliopsoas spasm E) Knee flexion contracture Rationale: A functional leg length discrepancy that corrects with flexion and extension (the "leg check" or "stork test") suggests a sacral torsion or iliosacral dysfunction. Anatomic discrepancy would not correct. Innominate shear may correct with hip flexion but not consistently. This maneuver tests sacral motion.
- A 65-year-old male with a history of atrial fibrillation on warfarin presents with sudden-onset left hemiparesis and neglect. Head CT shows no hemorrhage. INR is 2.8. Within what time window would the patient be eligible for IV thrombolysis if no other contraindications? A) Within 1 hour of symptom onset B) Within 3 hours of symptom onset C) Within 4.5 hours of symptom onset CORRECT ANSWER: C) Within 4.5 hours of symptom onset D) Within 6 hours of symptom onset E) IV thrombolysis is contraindicated due to warfarin use Rationale: For acute ischemic stroke, IV alteplase is approved within 3 hours, and up to 4.5 hours in selected patients. However, warfarin use with INR >1.7 is a contraindication. The INR is 2.8, which exceeds 1.7, so IV thrombolysis is
contraindicated. The correct answer should reflect that it is contraindicated. Let me adjust the question to avoid confusion. I'll change the answer accordingly. Corrected Question 24: A 65-year-old male with a history of atrial fibrillation on warfarin presents with sudden-onset left hemiparesis and neglect. Head CT shows no hemorrhage. INR is 2.8. Which of the following is true regarding IV thrombolysis? A) Eligible within 4.5 hours B) Eligible within 3 hours C) Eligible within 6 hours D) Contraindicated due to INR >1. CORRECT ANSWER: D) Contraindicated due to INR >1. E) Eligible if given with vitamin K Rationale: IV thrombolysis (alteplase) is contraindicated in patients with a known bleeding diathesis or INR >1.7 (or >1.4 in some protocols). This patient's INR of 2.8 is a clear contraindication regardless of time window.
- A 24-year-old male presents with a 1-week history of low back pain after moving furniture. He has no radicular symptoms. On examination, tenderness is noted over the left sacroiliac joint. The standing flexion test is positive on the left. Which of the following is the most appropriate next step? A) Lumbar spine MRI B) Prescribe muscle relaxants and rest C) Perform a sacral thrust test D) Treat with osteopathic manipulative treatment for sacroiliac dysfunction CORRECT ANSWER: D) Treat with osteopathic manipulative treatment for sacroiliac dysfunction E) Order a bone scan
CORRECT ANSWER: B) Non-weight bearing and observation for 24-48 hours C) MRI of the hip D) Intravenous antibiotics E) Plain radiograph of the hip Rationale: The presentation is consistent with transient synovitis (irritable hip). The most appropriate initial management is observation with activity modification. If symptoms persist or worsen, imaging or aspiration may be considered. Plain radiograph is often done to rule out other causes but is not always initial in mild cases. However, many guidelines suggest X-ray first. For COMSAE, observation is appropriate if no red flags. But to be safe, I'll adjust: In many standard answers, plain radiograph is done first to exclude Perches or fracture. Let me revise: The correct initial imaging is plain radiograph. I'll change the answer. Corrected Question 27: A 2-year-old boy is brought to the clinic because his parents report that he has been limping for 3 days. He has no fever or history of trauma. On examination, he holds his left hip in flexion and abduction, and internal rotation is painful. Vital signs are normal. Which of the following is the most appropriate initial diagnostic step? A) Aspiration of the hip joint B) Plain radiograph of the hip CORRECT ANSWER: B) Plain radiograph of the hip C) MRI of the hip D) Intravenous antibiotics E) Ultrasound of the hip Rationale: In a limping child without fever or trauma, the first imaging study is typically plain radiography to rule out fractures, Legg-Calve-Perches, or other bony abnormalities. Transient synovitis is a diagnosis of exclusion. Ultrasound can detect effusion but is not initial.
- A 34-year-old female with a history of migraine headaches presents with a new-onset severe headache that reached maximum intensity within seconds. She describes it as a "thunderclap." Neurological examination is normal. Which of the following is the most important initial diagnostic test? A) Lumbar puncture B) Non-contrast head CT CORRECT ANSWER: B) Non-contrast head CT C) MRI brain D) CT angiography E) EEG Rationale: Thunderclap headache is suspicious for subarachnoid hemorrhage. Non- contrast head CT is the initial test of choice due to high sensitivity within the first 6 hours. If CT is negative, lumbar puncture is performed to look for xanthochroid. MRI and CTA are secondary.
- A 60-year-old male with a history of hypertension presents with a 3-month history of progressive fatigue, night sweats, and unintentional weight loss. On examination, splenomegaly is noted. Complete blood count shows leukocytosis (WBC 85,000/all) with neutrophils, metamyelocytes, and myocytes. The platelet count is 450,000/all. Which of the following is the most likely diagnosis? A) Acute myeloid leukemia B) Chronic myeloid leukemia CORRECT ANSWER: B) Chronic myeloid leukemia C) Chronic lymphocytic leukemia D) Polycythemia Vera E) Essential thrombocythemia
