COMSAE PHASE 1 FORM 114 TEST BANK |
200+ PRACTICE QUESTIONS WITH DETAILED
RATIONALES | NBOME OSTEOPATHIC
MEDICAL KNOWLEDGE SELF-ASSESSMENT
PREP 2026
• This practice set mirrors the COMSAE Phase 1 Form 114 blueprint — 200 high-
yield questions spanning all core osteopathic medical disciplines to sharpen your
readiness for the real exam.
• Study actively: attempt each question before revealing the answer, use the
EXPERT RATIONALE to reinforce concepts, and revisit any topic where you score
below 70%.
COMSAE PHASE 1 FORM 114 — 200 PRACTICE QUESTIONS
1. A 45-year-old male presents with crushing substernal chest pain radiating
to the left arm, diaphoresis, and nausea for 2 hours. ECG shows ST elevation
in leads II, III, and aVF. Which coronary artery is most likely occluded?
A. Left anterior descending artery
B. Left circumflex artery
C. Right coronary artery
D. Left main coronary artery
E. Posterior descending artery
✔ Correct Answer: C. Right coronary artery
EXPERT RATIONALE: ST elevation in leads II, III, and aVF indicates an inferior STEMI.
The right coronary artery (RCA) supplies the inferior wall of the left ventricle in
approximately 85% of individuals (right-dominant circulation). Occlusion of the RCA
is therefore the most common cause of inferior wall MI.
,2. A 28-year-old medical student is found to have somatic dysfunction at C2.
Using osteopathic principles, which cranial nerve is most likely to be affected
by dysfunction at this level?
A. Vagus nerve (CN X)
B. Accessory nerve (CN XI)
C. Hypoglossal nerve (CN XII)
D. Glossopharyngeal nerve (CN IX)
E. Facial nerve (CN VII)
✔ Correct Answer: B. Accessory nerve (CN XI)
EXPERT RATIONALE: The accessory nerve (CN XI) has spinal roots that originate
from C1–C5 and ascend through the foramen magnum. Somatic dysfunction at C2
can impair the spinal component of CN XI, affecting the sternocleidomastoid and
trapezius muscles. This is a classic osteopathic clinical correlation tested on
COMSAE.
3. A 62-year-old woman with a history of hypertension presents with sudden
onset severe headache described as "the worst headache of my life." CT of the
head is negative. What is the next best step?
A. MRI brain with contrast
B. Lumbar puncture
C. Start sumatriptan
D. EEG
E. Discharge with analgesics
✔ Correct Answer: B. Lumbar puncture
EXPERT RATIONALE: A thunderclap headache with a negative CT requires lumbar
puncture to rule out subarachnoid hemorrhage (SAH). CT misses up to 5% of SAH
,cases, especially after 6–12 hours. LP will reveal xanthochromia or elevated RBCs
that do not clear between tubes 1 and 4.
4. A 5-year-old boy presents with a barking cough, inspiratory stridor, and
low-grade fever. Lateral neck X-ray shows subglottic narrowing. What is the
most appropriate initial treatment?
A. Antibiotics
B. Nebulized racemic epinephrine and dexamethasone
C. Intubation
D. Humidified oxygen only
E. Heliox therapy
✔ Correct Answer: B. Nebulized racemic epinephrine and dexamethasone
EXPERT RATIONALE: This presentation is classic for croup
(laryngotracheobronchitis), most commonly caused by parainfluenza virus. The
"steeple sign" on X-ray confirms subglottic narrowing. Nebulized racemic
epinephrine reduces edema rapidly and dexamethasone reduces inflammation and
prevents recurrence. Antibiotics are not indicated as this is viral.
5. During an OMT session, a physician applies a high-velocity low-amplitude
(HVLA) thrust to the thoracic spine. Which of the following is an absolute
contraindication to this technique?
A. Acute muscle spasm
B. Osteoporosis with vertebral fracture
C. Somatic dysfunction with restricted motion
D. Mild disc herniation without neurologic deficit
E. Patient anxiety about the procedure
✔ Correct Answer: B. Osteoporosis with vertebral fracture
, EXPERT RATIONALE: HVLA is absolutely contraindicated in the presence of
fracture, severe osteoporosis, malignancy involving bone, acute inflammatory
arthritis, and severe herniated disc with neurologic compromise. Fracture risk
makes HVLA life-threatening in osteoporotic patients, as the force applied could
worsen or complete a fracture.
6. A 35-year-old woman presents with fatigue, weight gain, constipation, and
cold intolerance. TSH is 12 mIU/L and free T4 is low. What is the most
appropriate treatment?
A. Methimazole
B. Levothyroxine
C. Propylthiouracil
D. Radioactive iodine
E. Thyroidectomy
✔ Correct Answer: B. Levothyroxine
EXPERT RATIONALE: The clinical picture and labs confirm primary hypothyroidism
(elevated TSH, low free T4). Levothyroxine is the treatment of choice, replacing
deficient thyroid hormone. Methimazole and PTU are for hyperthyroidism;
radioactive iodine and thyroidectomy are used for hyperthyroid states or thyroid
cancer, not hypothyroidism.
7. A 72-year-old man presents with progressive resting tremor, bradykinesia,
and cogwheel rigidity. Which neurotransmitter pathway is most affected?
A. Serotonergic pathway
B. Cholinergic pathway
C. Dopaminergic nigrostriatal pathway
D. GABAergic pathway
200+ PRACTICE QUESTIONS WITH DETAILED
RATIONALES | NBOME OSTEOPATHIC
MEDICAL KNOWLEDGE SELF-ASSESSMENT
PREP 2026
• This practice set mirrors the COMSAE Phase 1 Form 114 blueprint — 200 high-
yield questions spanning all core osteopathic medical disciplines to sharpen your
readiness for the real exam.
• Study actively: attempt each question before revealing the answer, use the
EXPERT RATIONALE to reinforce concepts, and revisit any topic where you score
below 70%.
COMSAE PHASE 1 FORM 114 — 200 PRACTICE QUESTIONS
1. A 45-year-old male presents with crushing substernal chest pain radiating
to the left arm, diaphoresis, and nausea for 2 hours. ECG shows ST elevation
in leads II, III, and aVF. Which coronary artery is most likely occluded?
A. Left anterior descending artery
B. Left circumflex artery
C. Right coronary artery
D. Left main coronary artery
E. Posterior descending artery
✔ Correct Answer: C. Right coronary artery
EXPERT RATIONALE: ST elevation in leads II, III, and aVF indicates an inferior STEMI.
The right coronary artery (RCA) supplies the inferior wall of the left ventricle in
approximately 85% of individuals (right-dominant circulation). Occlusion of the RCA
is therefore the most common cause of inferior wall MI.
,2. A 28-year-old medical student is found to have somatic dysfunction at C2.
Using osteopathic principles, which cranial nerve is most likely to be affected
by dysfunction at this level?
A. Vagus nerve (CN X)
B. Accessory nerve (CN XI)
C. Hypoglossal nerve (CN XII)
D. Glossopharyngeal nerve (CN IX)
E. Facial nerve (CN VII)
✔ Correct Answer: B. Accessory nerve (CN XI)
EXPERT RATIONALE: The accessory nerve (CN XI) has spinal roots that originate
from C1–C5 and ascend through the foramen magnum. Somatic dysfunction at C2
can impair the spinal component of CN XI, affecting the sternocleidomastoid and
trapezius muscles. This is a classic osteopathic clinical correlation tested on
COMSAE.
3. A 62-year-old woman with a history of hypertension presents with sudden
onset severe headache described as "the worst headache of my life." CT of the
head is negative. What is the next best step?
A. MRI brain with contrast
B. Lumbar puncture
C. Start sumatriptan
D. EEG
E. Discharge with analgesics
✔ Correct Answer: B. Lumbar puncture
EXPERT RATIONALE: A thunderclap headache with a negative CT requires lumbar
puncture to rule out subarachnoid hemorrhage (SAH). CT misses up to 5% of SAH
,cases, especially after 6–12 hours. LP will reveal xanthochromia or elevated RBCs
that do not clear between tubes 1 and 4.
4. A 5-year-old boy presents with a barking cough, inspiratory stridor, and
low-grade fever. Lateral neck X-ray shows subglottic narrowing. What is the
most appropriate initial treatment?
A. Antibiotics
B. Nebulized racemic epinephrine and dexamethasone
C. Intubation
D. Humidified oxygen only
E. Heliox therapy
✔ Correct Answer: B. Nebulized racemic epinephrine and dexamethasone
EXPERT RATIONALE: This presentation is classic for croup
(laryngotracheobronchitis), most commonly caused by parainfluenza virus. The
"steeple sign" on X-ray confirms subglottic narrowing. Nebulized racemic
epinephrine reduces edema rapidly and dexamethasone reduces inflammation and
prevents recurrence. Antibiotics are not indicated as this is viral.
5. During an OMT session, a physician applies a high-velocity low-amplitude
(HVLA) thrust to the thoracic spine. Which of the following is an absolute
contraindication to this technique?
A. Acute muscle spasm
B. Osteoporosis with vertebral fracture
C. Somatic dysfunction with restricted motion
D. Mild disc herniation without neurologic deficit
E. Patient anxiety about the procedure
✔ Correct Answer: B. Osteoporosis with vertebral fracture
, EXPERT RATIONALE: HVLA is absolutely contraindicated in the presence of
fracture, severe osteoporosis, malignancy involving bone, acute inflammatory
arthritis, and severe herniated disc with neurologic compromise. Fracture risk
makes HVLA life-threatening in osteoporotic patients, as the force applied could
worsen or complete a fracture.
6. A 35-year-old woman presents with fatigue, weight gain, constipation, and
cold intolerance. TSH is 12 mIU/L and free T4 is low. What is the most
appropriate treatment?
A. Methimazole
B. Levothyroxine
C. Propylthiouracil
D. Radioactive iodine
E. Thyroidectomy
✔ Correct Answer: B. Levothyroxine
EXPERT RATIONALE: The clinical picture and labs confirm primary hypothyroidism
(elevated TSH, low free T4). Levothyroxine is the treatment of choice, replacing
deficient thyroid hormone. Methimazole and PTU are for hyperthyroidism;
radioactive iodine and thyroidectomy are used for hyperthyroid states or thyroid
cancer, not hypothyroidism.
7. A 72-year-old man presents with progressive resting tremor, bradykinesia,
and cogwheel rigidity. Which neurotransmitter pathway is most affected?
A. Serotonergic pathway
B. Cholinergic pathway
C. Dopaminergic nigrostriatal pathway
D. GABAergic pathway
