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COMLEX Level 3 study materials
COMLEX Level 3 study resources

COMLEX Level 3 practice questions

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Question 1Osteopathic Principles, Practice, and Manipulative Treatment

A 28-year-old runner has a somatic dysfunction described as a forward sacral torsion. Which sacral motion finding is most consistent with this diagnosis?

  1. The sacral base is bilaterally restricted in extension with a deep sulcus on the left
  2. The sacrum rotates more freely toward the side of the oblique axis when the axis is engaged Correct answer.
  3. The sacrum rotates more freely toward the side opposite the axis of the involved oblique axis
  4. The sacral base is bilaterally restricted in flexion with a deep sulcus on the right

Explanation

In a forward sacral torsion the sacrum has rotated anteriorly on an oblique axis, and motion testing with the axis engaged shows freer rotation toward the side of the axis. Backward torsions show the opposite pattern, with freer rotation away from the axis side. Bilateral restriction patterns instead indicate a sacral flexion or extension dysfunction rather than a torsion.

Question 2Osteopathic Principles, Practice, and Manipulative Treatment

During a structural examination, a patient's right innominate is found to be anteriorly rotated. Which finding best supports this diagnosis?

  1. The right anterior superior iliac spine is inferior with a negative standing flexion test
  2. The right posterior superior iliac spine is superior with a positive standing flexion test on the right Correct answer.
  3. The pubic tubercle is superior on the right with a negative seated flexion test
  4. The right posterior superior iliac spine is inferior and the sacral sulcus is deep on the right

Explanation

An anteriorly rotated innominate carries the posterior superior iliac spine superiorly on the involved side, and the standing flexion test is positive because the ilium fails to follow the sacrum normally. The anterior superior iliac spine moves inferiorly in posterior rotation, not anterior rotation. A positive standing flexion test localizes the dysfunction to that side.

Question 3Osteopathic Principles, Practice, and Manipulative Treatment

A patient with acute low back pain has a tissue texture change and restricted motion at the L3-L4 segment with the vertebral body rotated right and sidebent left. Which spinal mechanics principle explains this coupled pattern?

  1. Type II mechanics, in which rotation and sidebending are independent of one another
  2. Type I (neutral) mechanics, in which rotation and sidebending are coupled to opposite sides Correct answer.
  3. Type I mechanics, in which rotation and sidebending occur to the same side at a neutral segment
  4. Type II (non-neutral) mechanics, in which rotation and sidebending are coupled to the same side

Explanation

In neutral (Type I) mechanics, several vertebrae move together and rotation is coupled to sidebending to the opposite side. Type II mechanics occurs at a single non-neutral segment, where rotation and sidebending are coupled to the same side. The described pattern is therefore a neutral group curve.

Question 4Osteopathic Principles, Practice, and Manipulative Treatment

A 45-year-old with chronic obstructive pulmonary disease is being evaluated for osteopathic manipulative treatment. Which lymphatic technique is most appropriate to assist clearance of respiratory secretions?

  1. Thoracic pump with the patient supine and the physician applying rhythmic pressure through the posterior thorax Correct answer.
  2. Pedal pump with the patient supine and the physician alternating dorsiflexion and plantar flexion
  3. Rib raising with the patient prone and the physician lifting the lower ribs anteriorly
  4. Cervical myofascial release with sustained traction on the upper trapezius

Explanation

The thoracic pump uses rhythmic compression of the thorax during exhalation and release during inhalation to promote lymphatic and venous return and mobilize secretions. Rib raising improves rib motion but is not primarily a lymphatic pump. Pedal pump addresses lower extremity lymphatics and does not directly target the thorax.

Question 5Osteopathic Principles, Practice, and Manipulative Treatment

A patient reports a headache that began after a fall, with tenderness and restricted motion at the occipitoatlantal joint. Which counterstrain tender point is most relevant to this somatic dysfunction?

  1. A tender point located in the posterior cervical triangle at the anterior aspect of the first rib
  2. A tender point located at the tip of the mastoid process
  3. A tender point located in the suboccipital region posterior to the mastoid process Correct answer.
  4. A tender point located at the lateral aspect of the spinous process of C2

Explanation

Occipitoatlantal somatic dysfunction is treated with a counterstrain tender point in the suboccipital region posterior to the mastoid process, using a position of ease and a 90-second hold. The anterior first rib tender point relates to thoracic outlet or rib dysfunction. Counterstrain positions are specific to the segment involved.

Question 6Osteopathic Principles, Practice, and Manipulative Treatment

A 60-year-old with a recent vertebral compression fracture and known osteoporosis is being considered for osteopathic manipulative treatment. Which approach is most appropriate?

  1. Aggressive articulatory technique to increase thoracic extension range of motion
  2. Indirect osteopathic manipulative treatment with gentle positioning and low force Correct answer.
  3. High-velocity low-amplitude thrust to the thoracic spine to restore segmental motion
  4. Direct myofascial release with strong longitudinal traction on the thoracic spine

Explanation

In patients with osteoporosis and a recent compression fracture, indirect and gentle techniques minimize the risk of further bony injury while addressing soft tissue and motion restrictions. High-velocity thrust and forceful direct techniques are contraindicated because of fracture risk. Treatment should be modified to the patient's bone quality and comfort.

Question 7Osteopathic Principles, Practice, and Manipulative Treatment

A patient is treated with muscle energy technique for a somatic dysfunction of the C5 vertebra. Which instruction best reflects the correct use of this technique?

  1. The patient inhales deeply while the physician applies sustained compression to the spinous process
  2. The patient performs an isometric contraction against the physician's counterforce while the physician holds the segment in a position of ease Correct answer.
  3. The patient performs a passive range-of-motion exercise while the physician monitors the tender point for 90 seconds
  4. The patient relaxes completely while the physician applies a high-velocity thrust at the end of the respiratory cycle

Explanation

Muscle energy technique uses a patient-initiated isometric contraction against a counterforce applied by the physician, followed by relaxation and repositioning to a new barrier. The contraction is voluntary and controlled, not a passive thrust. This distinguishes it from high-velocity thrust and counterstrain techniques.

Question 8Osteopathic Principles, Practice, and Manipulative Treatment

A 34-year-old woman has a somatic dysfunction of the upper thoracic spine with tissue texture changes in the paraspinal muscles. Which viscerosomatic reflex level is most consistent with a sympathetic influence from the heart?

  1. T5-T9
  2. T1-T4 Correct answer.
  3. T10-T12
  4. L1-L2

Explanation

Sympathetic innervation to the heart arises from the upper thoracic cord, roughly T1 through T4, so cardiac visceral dysfunction can produce facilitated segments and tissue changes at these levels. The T5-T9 levels correspond to the foregut and biliary structures. Lower thoracic and upper lumbar levels relate to midgut and hindgut viscera.

Question 9Osteopathic Principles, Practice, and Manipulative Treatment

A patient with a history of deep vein thrombosis in the left lower extremity requests treatment for a calf muscle restriction. Which action is most appropriate?

  1. Apply vigorous kneading to the left calf to break up the palpable restriction
  2. Avoid deep massage of the affected calf and defer treatment pending medical clearance Correct answer.
  3. Perform deep effleurage along the course of the left popliteal vein to improve venous return
  4. Perform high-velocity thrust to the left fibular head to restore motion

Explanation

Deep massage or vigorous manipulation over a region with recent or active deep vein thrombosis risks dislodging a clot and causing pulmonary embolism. Treatment should be deferred until the patient is anticoagulated and cleared. Gentle techniques elsewhere may be considered with medical approval.

Question 10Osteopathic Principles, Practice, and Manipulative Treatment

During a craniosacral evaluation, the physician notes a restriction in the cranial rhythmic impulse with a sense of decreased motility at the sphenobasilar synchondrosis. Which principle best describes the goal of treatment?

  1. Manipulate the cranial sutures to permanently fuse the sphenobasilar synchondrosis
  2. Suppress the cranial rhythmic impulse to reduce sympathetic tone
  3. Restore balanced motion of the cranial bones and dural membranes to support the primary respiratory mechanism Correct answer.
  4. Increase the amplitude of the cranial rhythmic impulse by forceful compression of the occiput

Explanation

Craniosacral treatment aims to restore balanced, symmetric motion of the cranial bones and dural membranes, supporting the primary respiratory mechanism. The technique uses light force and never seeks to fuse or forcefully compress structures. The goal is normalization of motion, not suppression of the rhythm.

Question 11Osteopathic Principles, Practice, and Manipulative Treatment

A 22-year-old athlete has an anteriorly rotated innominate on the right. Which muscle energy technique setup is most appropriate for correcting this dysfunction?

  1. The patient lies prone with the right knee flexed and the physician resists knee extension
  2. The patient lies supine with the right hip flexed and the physician resists hip extension to engage the anterior barrier Correct answer.
  3. The patient lies supine with the right hip extended and the physician resists hip flexion to engage the posterior barrier
  4. The patient lies supine with the left hip abducted and the physician resists adduction

Explanation

For an anteriorly rotated innominate, the restrictive barrier lies in hip extension, so the patient is positioned with the hip flexed and performs an isometric contraction of hip extension against resistance. This engages the barrier and corrects the anterior rotation. The opposite setup is used for posterior rotation.

Question 12Osteopathic Principles, Practice, and Manipulative Treatment

A 50-year-old presents with a somatic dysfunction of the thoracic spine described as a Type II dysfunction at T6, with the vertebra rotated right and sidebent right. Which position best describes the restrictive barrier for treatment?

  1. The segment is held in a neutral position with rotation and sidebending to opposite sides
  2. The segment is held in a neutral position with rotation and sidebending to the same side
  3. The segment is held in extension with rotation and sidebending to opposite sides
  4. The segment is held in flexion with rotation and sidebending to the same side Correct answer.

Explanation

A Type II (non-neutral) dysfunction occurs at a single segment that is flexed or extended, with rotation and sidebending to the same side. Treatment engages the restrictive barrier in that non-neutral position. Neutral mechanics with opposite coupling describes a Type I group curve.

Question 13Osteopathic Principles, Practice, and Manipulative Treatment

A patient with acute pancreatitis has a somatic dysfunction at the thoracolumbar junction. Which viscerosomatic relationship best explains this finding?

  1. Sympathetic fibers from T10-T12 refer to the thoracolumbar region Correct answer.
  2. Somatic fibers from the cervical plexus refer to the upper cervical spine
  3. Sympathetic fibers from T5-T9 refer to the upper thoracic spine
  4. Parasympathetic fibers from the sacral cord refer to the lower lumbar region

Explanation

The pancreas receives sympathetic innervation from T5-T9 and T10-T12, and visceral irritation can produce facilitated segments at these levels, including the thoracolumbar junction. Parasympathetic supply to the pancreas travels via the vagus, not the sacral cord. Referred somatic findings follow the segmental sympathetic outflow.

Question 14Osteopathic Principles, Practice, and Manipulative Treatment

A 70-year-old with a recent hip fracture and limited mobility is being evaluated. Which osteopathic technique is most appropriate to improve lower extremity circulation and lymphatic return?

  1. High-velocity low-amplitude thrust to the hip joint to restore motion
  2. Pedal pump applied with gentle alternating dorsiflexion and plantar flexion of the ankles Correct answer.
  3. Articulatory technique with forceful circumduction of the hip
  4. Direct myofascial release with strong traction on the hip flexors

Explanation

The pedal pump uses gentle, rhythmic ankle motion to promote venous and lymphatic return without stressing the fractured hip. Forceful hip techniques are contraindicated in the setting of recent fracture. The technique is low risk and can be performed with the patient supine.

Question 15Osteopathic Principles, Practice, and Manipulative Treatment

A patient has a somatic dysfunction of the left sacroiliac joint with a positive seated flexion test on the left. Which finding best localizes the dysfunction to the left sacroiliac joint?

  1. A positive standing flexion test on the left Correct answer.
  2. A positive seated flexion test on the right
  3. A negative standing flexion test on the left
  4. A negative seated flexion test on the right

Explanation

The standing flexion test is used to localize sacroiliac dysfunction; a positive test on the left indicates that the left innominate fails to follow the sacrum normally. The seated flexion test helps differentiate sacral from iliac dysfunction. Localization requires the positive standing flexion test on the involved side.

Question 16Osteopathic Principles, Practice, and Manipulative Treatment

A patient reports a tender point in the region of the lateral epicondyle of the humerus after repetitive lifting. Which counterstrain approach is most appropriate?

  1. Perform passive stretching of the wrist extensors to the point of pain
  2. Apply sustained deep pressure to the tender point for 30 seconds
  3. Place the upper extremity in a position of ease that reduces the tender point and hold for about 90 seconds Correct answer.
  4. Apply a high-velocity thrust to the elbow while the patient contracts the wrist extensors

Explanation

Counterstrain uses a position of ease that minimizes the tender point, held for approximately 90 seconds to allow reflex resetting. Deep pressure or stretching to the point of pain is not the counterstrain method. High-velocity thrust is a different technique with different indications.

Question 17Osteopathic Principles, Practice, and Manipulative Treatment

A 40-year-old with chronic pelvic pain has a somatic dysfunction of the pelvic diaphragm with restricted motion. Which technique is most appropriate for a myofascial restriction in this region?

  1. Indirect myofascial release with gentle traction and positioning to follow the tissue's ease Correct answer.
  2. Forceful compression of the pelvic diaphragm to break adhesions
  3. Aggressive trigger point injection of the pelvic floor
  4. High-velocity thrust applied through the pelvic floor

Explanation

Indirect myofascial release follows the tissue's ease and uses gentle traction and positioning to allow the fascia to unwind. Forceful compression or thrust through the pelvic floor is inappropriate and risks injury. Myofascial release respects the tissue's inherent motion.

Question 18Osteopathic Principles, Practice, and Manipulative Treatment

A patient with a somatic dysfunction at the C2-C3 level has a tissue texture change and restricted rotation. Which principle best explains the segmental facilitation seen in this region?

  1. Facilitated segments have lowered thresholds for afferent input and maintain increased sympathetic tone Correct answer.
  2. Facilitated segments have elevated thresholds for afferent input and reduced sympathetic tone
  3. Facilitated segments are purely structural and have no reflex component
  4. Facilitated segments are caused by loss of motor units and do not affect sympathetic tone

Explanation

Segmental facilitation refers to a lowered threshold for afferent input at a spinal segment, often with increased sympathetic tone, producing tissue texture changes and tenderness. This reflex component explains why somatic dysfunction can be associated with visceral and autonomic findings. It is not merely a structural or motor unit problem.

Question 19Osteopathic Principles, Practice, and Manipulative Treatment

A 55-year-old with a history of metastatic cancer and new-onset back pain is being evaluated for osteopathic manipulative treatment. Which consideration is most important before treatment?

  1. Screen for pathologic fracture or spinal instability and defer manipulation if present Correct answer.
  2. Proceed with high-velocity thrust to the painful segment to relieve pain
  3. Perform articulatory technique to increase spinal range of motion
  4. Apply deep soft tissue massage to the painful area to reduce muscle spasm

Explanation

New back pain in a patient with metastatic cancer raises concern for pathologic fracture or spinal instability, and manipulation should be deferred until this is evaluated. High-velocity thrust or deep massage over a potential lesion risks harm. Screening for red flags guides the choice of technique.

Question 20Osteopathic Principles, Practice, and Manipulative Treatment

A patient is being treated with strain-counterstrain for a tender point in the anterior cervical region. Which instruction best reflects the technique?

  1. Have the patient contract the cervical muscles against resistance for 5 seconds
  2. Position the patient to reduce the tender point and hold for about 90 seconds, then return slowly Correct answer.
  3. Apply sustained deep pressure to the tender point for 2 minutes
  4. Apply a rapid thrust to the cervical spine while the patient inhales

Explanation

Strain-counterstrain uses a position of ease that reduces the tender point, held for about 90 seconds, followed by a slow return to neutral. The technique does not use thrust, isometric contraction, or deep pressure. Its goal is to reset the proprioceptive reflex associated with the tender point.

Question 21Osteopathic Patient Care and Procedural Skills

A 62-year-old man is brought to the emergency department after a syncopal episode. He is pale and diaphoretic, with a heart rate of 118/min and blood pressure of 84/52 mmHg. Two large-bore IV lines are placed and a 1-L bolus of isotonic crystalloid is started. Which of the following is the most appropriate next step in the initial resuscitation of this patient?

  1. Administer a bolus of hypertonic saline
  2. Transfuse packed red blood cells while the fluid bolus is running Correct answer.
  3. Begin a norepinephrine infusion through a peripheral line
  4. Obtain a CT scan of the abdomen before further intervention

Explanation

In hemorrhagic shock, resuscitation requires simultaneous volume replacement and blood product administration rather than crystalloid alone, because crystalloid dilutes clotting factors and does not restore oxygen-carrying capacity. Activating the massive transfusion protocol early improves survival in patients who remain hypotensive after initial fluids.

Question 22Osteopathic Patient Care and Procedural Skills

A 34-year-old woman presents with dysuria and urinary frequency. A urine dipstick is positive for leukocyte esterase and nitrites. She has no fever, flank pain, or vaginal symptoms. Which of the following is the most appropriate management?

  1. Pelvic examination and empirical treatment for vaginitis
  2. Immediate intravenous antibiotics and hospital admission
  3. Empiric oral antibiotics for uncomplicated cystitis Correct answer.
  4. Urine culture and observation without antibiotics

Explanation

The combination of typical dysuria and frequency with positive leukocyte esterase and nitrite in a woman without vaginal symptoms or systemic signs is sufficient to diagnose uncomplicated cystitis and treat empirically. Routine urine culture is not required for a first episode of uncomplicated cystitis.

Question 23Osteopathic Patient Care and Procedural Skills

A 58-year-old man is undergoing a diagnostic lumbar puncture. He is positioned in the lateral decubitus position with his knees drawn to his chest. Which of the following landmarks best identifies the correct interspace for needle insertion?

  1. The space between the spinous processes of T12 and L1
  2. The space between the spinous processes of L5 and S1
  3. The space between the spinous processes of L1 and L2
  4. The space between the spinous processes of L4 and L5 Correct answer.

Explanation

The conus medullaris typically terminates at L1-L2 in adults, so lumbar puncture is performed below this level, most commonly at L3-L4 or L4-L5. Inserting at L4-L5 avoids the risk of spinal cord injury while still accessing the subarachnoid space.

Question 24Osteopathic Patient Care and Procedural Skills

A 45-year-old woman with type 2 diabetes has a hemoglobin A1c of 8.9% despite metformin at maximally tolerated dose. Which of the following is the most appropriate next step in her pharmacologic management?

  1. Add a sodium-glucose cotransporter-2 inhibitor Correct answer.
  2. Reinforce lifestyle changes alone for six months
  3. Discontinue metformin and start basal insulin
  4. Add a sulfonylurea as first-line add-on

Explanation

For a patient with type 2 diabetes and an A1c above target on metformin, adding an agent with proven cardiovascular and renal benefit such as an SGLT2 inhibitor is recommended. Metformin should generally be continued rather than replaced when adding a second agent.

Question 25Osteopathic Patient Care and Procedural Skills

A 70-year-old man is admitted with an acute exacerbation of chronic obstructive pulmonary disease. His oxygen saturation is 82% on room air. Which of the following is the most appropriate initial oxygen target?

  1. Titrate oxygen to maintain saturation at 94-98%
  2. Titrate oxygen to maintain saturation at 88-92% Correct answer.
  3. Administer high-flow oxygen regardless of saturation
  4. Withhold supplemental oxygen unless he becomes unresponsive

Explanation

In patients with COPD who may be chronic carbon dioxide retainers, oxygen should be titrated to a saturation of 88-92% to avoid worsening hypercapnia while still correcting hypoxemia. This target range balances adequate oxygenation against the risk of carbon dioxide narcosis.

Question 26Osteopathic Patient Care and Procedural Skills

A 28-year-old woman at 34 weeks of gestation presents with a blood pressure of 158/104 mmHg and a headache. She has no history of chronic hypertension. Which of the following is the most appropriate initial antihypertensive agent?

  1. Amlodipine
  2. Atenolol
  3. Labetalol Correct answer.
  4. Enalapril

Explanation

Labetalol is a first-line agent for severe hypertension in pregnancy because it is effective and has an established safety profile. Angiotensin-converting enzyme inhibitors and angiotensin receptor blockers are contraindicated in pregnancy due to fetal toxicity.

Question 27Osteopathic Patient Care and Procedural Skills

A 55-year-old man with a history of alcohol use disorder presents with confusion and ataxia. His serum sodium is 118 mEq/L. Which of the following is the most appropriate initial step in his management?

  1. Slow correction of sodium with monitoring for neurologic symptoms Correct answer.
  2. Administration of intravenous furosemide as monotherapy
  3. Rapid correction with hypertonic saline to reach 135 mEq/L within six hours
  4. Fluid restriction alone with reassessment in 24 hours

Explanation

Symptomatic hyponatremia requires careful correction, generally no faster than 8-10 mEq/L in the first 24 hours, to avoid osmotic demyelination syndrome. Hypertonic saline may be used for severe symptoms but must be titrated to a safe rate rather than a fixed target.

Question 28Osteopathic Patient Care and Procedural Skills

A 40-year-old woman presents with a three-day history of unilateral throbbing headache, nausea, and photophobia. She reports similar episodes in the past. Which of the following is the most appropriate abortive therapy?

  1. Amitriptyline
  2. Propranolol
  3. Topiramate
  4. Sumatriptan Correct answer.

Explanation

Triptans such as sumatriptan are effective abortive therapy for acute migraine attacks. Preventive agents such as amitriptyline, propranolol, and topiramate are used for frequent or disabling attacks rather than for acute relief.

Question 29Osteopathic Patient Care and Procedural Skills

A 68-year-old woman is scheduled for elective surgery and is taking warfarin for atrial fibrillation. Her CHA2DS2-VASc score is 4. Which of the following is the most appropriate perioperative management?

  1. Stop warfarin and bridge with a therapeutic heparin infusion Correct answer.
  2. Continue warfarin at the usual dose through surgery
  3. Stop warfarin five days before surgery without bridging
  4. Reduce the warfarin dose by half for two days before surgery

Explanation

For a patient with a high thromboembolic risk (CHA2DS2-VASc score of 4) undergoing surgery, warfarin is typically stopped about five days preoperatively and bridged with a therapeutic heparin infusion. Bridging reduces the risk of stroke during the period when anticoagulation is subtherapeutic.

Question 30Osteopathic Patient Care and Procedural Skills

A 30-year-old man sustains a deep laceration to the forearm while working with glass. The wound is contaminated with dirt and glass fragments. Which of the following is the most appropriate initial step in wound management?

  1. Apply a topical antibiotic and cover without irrigation
  2. Pack the wound with gauze and schedule closure in one week
  3. Close the wound primarily with sutures after applying antibiotic ointment
  4. Irrigate the wound with copious normal saline under pressure Correct answer.

Explanation

High-pressure irrigation with normal saline is essential for removing debris and reducing bacterial load in contaminated wounds before any closure is considered. Contaminated wounds generally should not be closed primarily because of the risk of infection.

Question 31Osteopathic Patient Care and Procedural Skills

A 72-year-old man is admitted with a hip fracture. He is bedbound and has a history of prior venous thromboembolism. Which of the following is the most appropriate pharmacologic prophylaxis?

  1. Intermittent pneumatic compression alone
  2. Low-molecular-weight heparin Correct answer.
  3. No prophylaxis because of bleeding risk
  4. Aspirin at a low dose

Explanation

Low-molecular-weight heparin is a standard pharmacologic prophylaxis for high-risk hospitalized patients, including those with hip fracture and prior venous thromboembolism. Mechanical prophylaxis alone is insufficient for a patient at high risk.

Question 32Osteopathic Patient Care and Procedural Skills

A 50-year-old woman presents with a two-week history of productive cough, fever, and pleuritic chest pain. Chest radiograph shows a right lower lobe infiltrate. Which of the following is the most appropriate initial antibiotic regimen for community-acquired pneumonia in a patient without comorbidities?

  1. Piperacillin-tazobactam
  2. Ceftriaxone plus azithromycin
  3. Azithromycin Correct answer.
  4. Vancomycin

Explanation

For a healthy outpatient without comorbidities, a macrolide such as azithromycin is an appropriate first-line regimen for community-acquired pneumonia. Broader coverage is reserved for patients with comorbidities or risk factors for resistant organisms.

Question 33Osteopathic Patient Care and Procedural Skills

A 60-year-old man with cirrhosis presents with hematemesis. He is hemodynamically stable after initial resuscitation. Which of the following is the most appropriate next step in management?

  1. Start an intravenous proton pump inhibitor and octreotide Correct answer.
  2. Give fresh frozen plasma routinely
  3. Perform an immediate surgical shunt
  4. Administer a nonselective beta-blocker intravenously

Explanation

For suspected variceal upper gastrointestinal bleeding, intravenous proton pump inhibitor and octreotide are started before endoscopy to stabilize clots and reduce portal pressure. Endoscopy should follow promptly for definitive diagnosis and therapy.

Question 34Osteopathic Patient Care and Procedural Skills

A 25-year-old woman is brought to the emergency department after a suspected opioid overdose. She has a respiratory rate of 6/min and pinpoint pupils. Which of the following is the most appropriate initial intervention?

  1. Administer flumazenil intravenously
  2. Give a bolus of sodium bicarbonate
  3. Perform immediate endotracheal intubation
  4. Administer naloxone intravenously Correct answer.

Explanation

Naloxone is a competitive opioid antagonist that rapidly reverses opioid-induced respiratory depression. It should be given promptly while supporting ventilation, with repeat dosing as needed because its duration may be shorter than that of the opioid.

Question 35Osteopathic Patient Care and Procedural Skills

A 65-year-old woman with a history of hypertension and diabetes presents with sudden onset of right-sided weakness and aphasia. Her last known well time was 45 minutes ago. Which of the following is the most appropriate immediate step?

  1. Obtain noncontrast head CT and check blood glucose Correct answer.
  2. Start a heparin infusion
  3. Administer aspirin immediately
  4. Perform a lumbar puncture

Explanation

Before thrombolysis can be considered for acute ischemic stroke, noncontrast head CT must exclude hemorrhage and blood glucose must be checked to rule out hypoglycemia as a mimic. These steps must be completed rapidly within the thrombolytic window.

Question 36Osteopathic Patient Care and Procedural Skills

A 22-year-old man presents with a deep partial-thickness burn involving 20% of his total body surface area. Which of the following is the most appropriate fluid resuscitation strategy?

  1. Normal saline at a fixed rate of 100 mL/h
  2. Lactated Ringer solution calculated by the Parkland formula, with half given in the first eight hours Correct answer.
  3. Colloid solution as the sole resuscitative fluid
  4. No fluids until the burn is debrided

Explanation

The Parkland formula estimates 4 mL/kg per percent total body surface area of lactated Ringer solution in the first 24 hours, with half given in the first eight hours from the time of injury. Lactated Ringer is preferred over normal saline because large volumes of saline cause hyperchloremic acidosis.

Question 37Osteopathic Patient Care and Procedural Skills

A 55-year-old man is undergoing a colonoscopy and is sedated with midazolam and fentanyl. During the procedure his oxygen saturation falls to 85% despite jaw thrust. Which of the following is the most appropriate next step?

  1. Continue the procedure without intervention
  2. Increase the midazolam dose to deepen sedation
  3. Provide bag-mask ventilation and consider reversing agents Correct answer.
  4. Administer additional fentanyl for comfort

Explanation

Hypoxemia during procedural sedation requires immediate airway support with bag-mask ventilation and consideration of reversal agents such as naloxone or flumazenil. Deepening sedation would worsen respiratory depression.

Question 38Osteopathic Patient Care and Procedural Skills

A 35-year-old woman presents with a firm, mobile, well-circumscribed breast mass. She is 35 years old and has no family history of breast cancer. Which of the following is the most appropriate initial diagnostic step?

  1. Observation for six months
  2. Mammography alone
  3. Excisional biopsy
  4. Breast ultrasound Correct answer.

Explanation

In a woman younger than 40 years with a palpable breast mass, ultrasound is the preferred initial imaging modality because of denser breast tissue. Tissue sampling follows if imaging is suspicious.

Question 39Osteopathic Patient Care and Procedural Skills

A 70-year-old man with benign prostatic hyperplasia presents with acute urinary retention. A urethral catheterization attempt is unsuccessful. Which of the following is the most appropriate next step?

  1. Forceful repeated urethral catheterization
  2. Administration of a diuretic
  3. Immediate transurethral resection of the prostate
  4. Suprapubic catheter placement Correct answer.

Explanation

When urethral catheterization fails, suprapubic catheterization provides bladder drainage and is preferred over repeated traumatic attempts. Urology consultation should follow for definitive management.

Question 40Osteopathic Patient Care and Procedural Skills

A 45-year-old woman is seen for a routine health maintenance visit. She has no chronic conditions and takes no medications. Which of the following screening tests is recommended for this patient?

  1. Cervical cancer screening Correct answer.
  2. Colonoscopy
  3. Prostate-specific antigen testing
  4. Mammography

Explanation

Cervical cancer screening with cytology or HPV testing is recommended for women beginning at age 21 or 25 depending on the guideline. Mammography typically begins at age 40-50 and colonoscopy at age 45, so those are not the best answer for a 45-year-old woman with no other risk factors in this context.

Question 41Osteopathic Patient Care and Procedural Skills

A 30-year-old man is diagnosed with a first episode of acute otitis media. He has no allergies. Which of the following is the most appropriate first-line antibiotic?

  1. Amoxicillin Correct answer.
  2. Trimethoprim-sulfamethoxazole
  3. Ciprofloxacin
  4. Azithromycin

Explanation

High-dose amoxicillin is the first-line antibiotic for acute otitis media because it covers the most common pathogens, including Streptococcus pneumoniae. Alternatives are reserved for allergy or treatment failure.

Question 42Osteopathic Patient Care and Procedural Skills

A 65-year-old woman with heart failure with reduced ejection fraction is admitted with worsening dyspnea. Which of the following medications has been shown to reduce mortality in this condition?

  1. Sacubitril-valsartan Correct answer.
  2. Furosemide
  3. Amlodipine
  4. Digoxin

Explanation

Sacubitril-valsartan, an angiotensin receptor-neprilysin inhibitor, reduces mortality and hospitalization in heart failure with reduced ejection fraction. Digoxin and loop diuretics improve symptoms but do not reduce mortality.

Question 43Osteopathic Patient Care and Procedural Skills

A 28-year-old woman at 28 weeks of gestation presents with a blood pressure of 150/98 mmHg and 3+ proteinuria. Which of the following is the most appropriate management?

  1. Magnesium sulfate for seizure prophylaxis and delivery planning Correct answer.
  2. Outpatient monitoring with weekly visits
  3. Methyldopa alone without further evaluation
  4. Immediate delivery regardless of fetal status

Explanation

Preeclampsia with severe features at 28 weeks requires magnesium sulfate for seizure prophylaxis and careful planning of delivery based on maternal and fetal status. Immediate delivery may be indicated in some cases but should be individualized.

Question 44Osteopathic Patient Care and Procedural Skills

A 40-year-old man is brought in after a fall from a ladder. He has a deformed right forearm with absent radial pulse. Which of the following is the most appropriate initial step?

  1. Assess and document neurovascular status, then immobilize and obtain radiographs Correct answer.
  2. Obtain an MRI of the forearm
  3. Administer analgesia and observe
  4. Apply traction to reduce the deformity immediately

Explanation

The initial step in suspected fracture-dislocation is a thorough neurovascular assessment, followed by immobilization and imaging. Reduction is performed promptly after assessment and imaging to restore perfusion.

Question 45Osteopathic Patient Care and Procedural Skills

A 50-year-old woman with a history of recurrent urinary tract infections presents with flank pain and fever. She is diagnosed with pyelonephritis and is stable for outpatient management. Which of the following is the most appropriate antibiotic choice?

  1. Nitrofurantoin
  2. Fosfomycin
  3. Trimethoprim alone
  4. Ciprofloxacin Correct answer.

Explanation

Fluoroquinolones such as ciprofloxacin achieve adequate renal tissue concentrations and are appropriate for outpatient pyelonephritis when local resistance is low. Nitrofurantoin and fosfomycin concentrate in the bladder and are inadequate for renal parenchymal infection.

Question 46Osteopathic Patient Care and Procedural Skills

A 58-year-old man is undergoing incision and drainage of a subcutaneous abscess on his back. Which of the following best describes the primary purpose of infiltrating the skin and subcutaneous tissue with a local anesthetic containing epinephrine?

  1. To provide systemic sedation and anxiolysis during the procedure
  2. To prevent bacterial seeding of the wound by producing local tissue acidosis
  3. To accelerate the onset of anesthesia by increasing nerve membrane permeability
  4. To prolong anesthesia and reduce intraoperative bleeding through local vasoconstriction Correct answer.

Explanation

Epinephrine is a vasoconstrictor that decreases local blood flow, which slows systemic absorption of the anesthetic and prolongs its effect while reducing bleeding at the operative site. This is the standard rationale for adding epinephrine to lidocaine in cutaneous procedures.

Question 47Osteopathic Patient Care and Procedural Skills

A 34-year-old woman requires suturing of a 4-cm laceration on the dorsum of her hand. Which of the following suture techniques and materials is most appropriate for minimizing tension on the mobile dorsal skin while achieving adequate wound edge approximation?

  1. Subcuticular absorbable sutures placed without any dermal bites
  2. Simple interrupted nonabsorbable sutures placed with slight eversion of wound edges
  3. Vertical mattress nonabsorbable sutures placed with slight eversion of wound edges Correct answer.
  4. Continuous running absorbable sutures placed with inverted wound edges

Explanation

Vertical mattress sutures combine a deep bite that relieves tension with a superficial bite that everts the wound edges, which is ideal on mobile skin such as the dorsum of the hand. Eversion promotes optimal healing and avoids a depressed scar.

Question 48Osteopathic Patient Care and Procedural Skills

A 62-year-old man is scheduled for a colonoscopy under moderate sedation. He has a history of obstructive sleep apnea and uses CPAP at home. Which of the following is the most important preoperative measure to reduce his risk of sedation-related respiratory compromise?

  1. Administering a benzodiazepine alone to avoid opioid-induced respiratory depression
  2. Performing the procedure without any supplemental oxygen to monitor desaturation
  3. Continuing his home CPAP and ensuring it is available during and after the procedure Correct answer.
  4. Premedicating with an antihistamine to reduce airway secretions

Explanation

Patients with obstructive sleep apnea are at increased risk for airway obstruction and hypoxemia during sedation, so continuing CPAP and ensuring its availability throughout the perioperative period is the key safety measure. Opioid-sparing strategies and monitoring are also important.

Question 49Osteopathic Patient Care and Procedural Skills

A 45-year-old woman presents with a 2-cm superficial skin abscess on her thigh that is fluctuant and surrounded by erythema. Which of the following is the most appropriate initial management?

  1. Warm compresses alone with observation for one week
  2. Incision and drainage with packing of the cavity Correct answer.
  3. Oral antibiotics alone without drainage
  4. Fine-needle aspiration of the abscess cavity

Explanation

The definitive treatment for a fluctuant cutaneous abscess is incision and drainage, which removes the purulent collection and allows healing. Antibiotics are adjunctive and do not replace drainage for a collection that is already formed.

Question 50Osteopathic Patient Care and Procedural Skills

A 70-year-old man with a history of benign prostatic hyperplasia requires intermittent urinary catheterization for urinary retention. Which of the following techniques best reduces the risk of urethral trauma during catheter insertion?

  1. Using a coudé catheter with the tip directed anteriorly during passage
  2. Inflating the balloon immediately upon appearance of urine at the catheter hub
  3. Advancing the catheter forcefully if resistance is met at the sphincter
  4. Lubricating the catheter generously and advancing gently with steady pressure Correct answer.

Explanation

Generous lubrication and gentle steady advancement minimize friction and mucosal injury during catheterization. Force should never be used when resistance is encountered, and the balloon should be inflated only after urine flow confirms bladder placement.