COMSAE 110 EXAM 2026/2027 ACTUAL EXAM –QUESTIONS AND CORRECT ANSWERS (VERIFIED ANSWERS) PLUS RATIONALES
2026 Q&A | INSTANT DOWNLOAD PDF.
*Core Domains:*
* Osteopathic Manipulative Medicine (OMM) and Principles
* Family Medicine and Community Health
* Internal Medicine and Subspecialties
* Pediatrics and Adolescent Medicine
* Obstetrics and Gynecology
* General Surgery and Surgical Subspecialties
* Psychiatry and Behavioral Health
* Emergency Medicine and Critical Care
* Medical Ethics, Jurisprudence, and Professionalism
*Introduction:*
*The COMSAE Phase 1 assessment is a comprehensive licensing preparation examination designed to evaluate an osteopathic medical studen
Section One: Questions 1–100
Question 1
A 45-year-old male presents with acute onset of severe pain, redness, and swelling in his left great toe. He notes it started suddenly last night
after a steak and beer dinner. On examination, the first metatarsophalangeal joint is erythematous, warm, and exquisitely tender. Synovial
fluid analysis reveals negatively birefringent, needle-shaped crystals. What is the first-line mechanism of action for the acute pharmacological
management of this patient's condition?
A. Inhibition of xanthine oxidase
B. Recombinant urate oxidase action
C. Inhibition of microtubule polymerization
D. Competitive antagonism of adenosine receptors
🟢 C. Inhibition of microtubule polymerization
🔴 RATIONALE: The patient is experiencing an acute gout flare, confirmed by negatively birefringent, needle-shaped uric acid crystals.
Colchicine is a first-line agent for acute gout flares and works by binding to tubulin, inhibiting microtubule polymerization, which disrupts
,leukocyte chemotaxis and degranulation. Xanthine oxidase inhibitors like allopurinol are used for chronic prophylactic management, not acute
flares.
Question 2
A 28-year-old G1P0 female at 32 weeks gestation presents to the emergency department complaining of a severe headache and visual spots
for the past 4 hours. Her blood pressure is 165/112 mmHg on two readings taken 15 minutes apart. Urinalysis reveals 3+ protein.
Fundoscopic examination shows no papilledema. Which of the following is the most appropriate next step to prevent maternal seizures?
A. Intravenous loading dose of diazepam
B. Intravenous loading dose of magnesium sulfate
C. Oral administration of clonazepam
D. Continuous infusion of phenytoin
🟢 B. Intravenous loading dose of magnesium sulfate
🔴 RATIONALE: This patient meets the diagnostic criteria for preeclampsia with severe features based on her blood pressure elevations and
neurological symptoms (headache, visual changes) at greater than 20 weeks gestation. Magnesium sulfate is the gold standard therapy used
for seizure prophylaxis in patients with preeclampsia with severe features. Benzodiazepines and phenytoin are not first-line agents for
eclampsia prevention.
Question 3
An 18-year-old female high school runner presents with a persistent ache in the anterior aspect of her right lower leg that worsens with
activity and improves with rest. On physical examination, there is focal, point tenderness over the anterior distal third of the right tibia. There
is no significant compartment tension or neurological deficit. Plain radiographs of the lower extremity are completely negative. What is the
most appropriate next diagnostic step to confirm the suspected diagnosis?
A. Magnetic resonance imaging of the right lower extremity
B. Electromyography and nerve conduction studies
C. Compartment pressure measurement testing
D. Triphasic radionuclide bone scan
🟢 A. Magnetic resonance imaging of the right lower extremity
🔴 RATIONALE: The clinical picture is highly suggestive of a tibial stress injury or stress fracture. Early stress fractures are frequently
radiolucent on initial plain X-rays (up to 4-6 weeks). Magnetic resonance imaging (MRI) is the most sensitive and specific diagnostic modality
to visualize early bone marrow edema and cortical stress lines without exposing the patient to radiation, preferred over a nuclear bone scan.
Question 4
A 62-year-old male smoker presents with a 3-month history of progressive, painless gross hematuria. He denies trauma, recent travel, or
dysuria. Physical examination is unremarkable. Urinalysis confirms packed red blood cells without casts or crystals. Which of the following is
the most definitive diagnostic evaluation required for this patient?
A. Renal and bladder ultrasound
B. Contrast-enhanced computed tomography urogram and cystoscopy
C. 24-hour urine collection for cytology and protein
D. Retrograde pyelogram with loop electrosurgical excision
,🟢 B. Contrast-enhanced computed tomography urogram and cystoscopy
🔴 RATIONALE: Unexplained, painless gross hematuria in an older adult male with a smoking history must be considered bladder or renal
malignancy until proven otherwise. The standard comprehensive diagnostic evaluation requires a CT urogram to evaluate the upper urinary
tract parenchyma and collecting systems, paired with direct cystoscopy to visually inspect the bladder mucosa.
Question 5
A 34-year-old female presents with a 2-week history of palpitations, heat intolerance, weight loss, and increased anxiety. Physical
examination reveals an enlarged, diffusely tender thyroid gland. Her thyroid-stimulating hormone (TSH) level is less than 0.01 uIU/mL, and
free T4 is elevated. A 24-hour radioactive iodine uptake scan demonstrates a diffusely decreased, low uptake pattern. What is the most likely
diagnosis?
A. Graves disease
B. Subacute granulomatous thyroiditis
C. Toxic multinodular goiter
D. Iodine-induced hyperthyroidism
🟢 B. Subacute granulomatous thyroiditis
🔴 RATIONALE: Subacute granulomatous thyroiditis (de Quervain's thyroiditis) characteristically presents with hyperthyroidism symptoms
following a viral prodrome, marked by an exquisitely painful, tender thyroid gland. The inflammatory destruction leaks preformed thyroid
hormone, suppressing TSH and leading to a low radioactive iodine uptake scan due to follicular cell damage. Graves and toxic nodular goiter
show high uptake.
Question 6
A 68-year-old female with a history of chronic osteoarthritis is admitted with severe epigastric pain, hematemesis, and hypotension. She
reports taking high-dose over-the-counter ibuprofen daily for the past 6 months. Endoscopy reveals a 2 cm ulcer in the gastric antrum with an
active visible vessel. Which of the following cellular mechanisms explains how this patient's long-term medication use directly caused this
mucosal injury?
A. Inhibition of systemic cyclooxygenase-1 leading to decreased prostaglandin E2
B. Acceleration of gastric mucosal epithelial cell apoptosis via leukotrienes
C. Direct cytotoxic lysis of parietal cells by lipophilic carboxylic acid compounds
D. Activation of H+/K+ ATPase pumps through up-regulated cyclic AMP pathways
🟢 A. Inhibition of systemic cyclooxygenase-1 leading to decreased prostaglandin E2
🔴 RATIONALE: Nonsteroidal anti-inflammatory drugs (NSAIDs) like ibuprofen non-selectively inhibit cyclooxygenase-1 (COX-1), which is
responsible for synthesizing cytoprotective prostaglandins (specifically PGE2 and PGI2) in the gastric mucosa. These prostaglandins
normally stimulate mucus and bicarbonate secretion and maintain mucosal blood flow. Their depletion leaves the stomach vulnerable to acid
injury.
Question 7
An 8-year-old boy is brought to the clinic by his mother because of recurrent, spontaneous epistaxis and prolonged bleeding from minor cuts.
His physical examination shows generalized petechiae on his lower extremities. Laboratory studies reveal a platelet count of 22,000/mm3,
, normal prothrombin time (PT), and normal activated partial thromboplastin time (aPTT). Peripheral blood smear shows large, isolated
platelets. What is the primary pathophysiological mechanism?
A. Autoantibody-mediated clearance of platelets in the spleen
B. Genetic deficiency of the glycoprotein Ib-IX-V complex
C. Sequestration of structurally abnormal platelets within the liver
D. ADAMTS13 protease deficiency leading to microthrombi
🟢 A. Autoantibody-mediated clearance of platelets in the spleen
🔴 RATIONALE: The clinical picture describes Immune Thrombocytopenia (ITP), an acquired autoimmune disorder characterized by isolated
thrombocytopenia. It is caused by anti-platelet autoantibodies (usually IgG against GPIb/IX or GPIIb/IIIa) that coat platelets, leading to their
premature destruction and clearance by splenic macrophages. PT and aPTT are normal because the coagulation cascade is unaffected.
Question 8
A 52-year-old male with long-standing poorly controlled hypertension presents for a routine visit. Physical examination confirms a blood
pressure of 152/96 mmHg. Osteopathic structural examination reveals tissue texture changes, asymmetry, and restricted motion from T1 to
T4 on the left side. These somatic dysfunctions are most likely mediated by which of the following neural pathways?
A. Parasympathetic viscerosomatic reflexes via the vagus nerve
B. Sympathetic viscerosomatic reflexes via the thoracic splanchnic nerves
C. Somatosomatic reflexes mediated through the accessory nerve
D. Somatovisceral pathways traveling via pelvic splanchnic pathways
🟢 B. Sympathetic viscerosomatic reflexes via the thoracic splanchnic nerves
🔴 RATIONALE: Prolonged visceral afferent irritation from an organ can cause somatic changes in structures sharing segments of the spinal
cord innervation, known as a viscerosomatic reflex. The heart and upper thoracic vasculature receive sympathetic innervation from the T1-T5
spinal cord segments. Chronic cardiovascular stress like hypertension causes sympathetic viscerosomatic reflexes manifesting as somatic
dysfunction in the T1-T4 paraspinal tissues.
Question 9
A 24-year-old male is brought to the emergency department after being found unresponsive in an alleyway. On exam, he is obtunded with a
respiratory rate of 6 breaths/minute, pinpoint pupils, and track marks along his bilateral antecubital fossae. Arterial blood gas on room air
reveals: pH 7.21, pCO2 62 mmHg, pO2 54 mmHg, and HCO3 24 mEq/L. Which of the following represents the patient's primary acid-base
disturbance?
A. Uncompensated metabolic acidosis
B. Acute respiratory acidosis
C. Chronic compensated respiratory acidosis
D. Mixed metabolic and respiratory acidosis
🟢 B. Acute respiratory acidosis
🔴 RATIONALE: The patient has an acute opioid overdose causing severe respiratory depression. This leads to hypoventilation and retention
of carbon dioxide. The arterial blood gas demonstrates a low pH (acidosis) and a high pCO2 (respiratory origin). Because the bicarbonate
(HCO3) is normal, the kidneys have not had time to compensate, establishing this as an acute respiratory acidosis.
2026 Q&A | INSTANT DOWNLOAD PDF.
*Core Domains:*
* Osteopathic Manipulative Medicine (OMM) and Principles
* Family Medicine and Community Health
* Internal Medicine and Subspecialties
* Pediatrics and Adolescent Medicine
* Obstetrics and Gynecology
* General Surgery and Surgical Subspecialties
* Psychiatry and Behavioral Health
* Emergency Medicine and Critical Care
* Medical Ethics, Jurisprudence, and Professionalism
*Introduction:*
*The COMSAE Phase 1 assessment is a comprehensive licensing preparation examination designed to evaluate an osteopathic medical studen
Section One: Questions 1–100
Question 1
A 45-year-old male presents with acute onset of severe pain, redness, and swelling in his left great toe. He notes it started suddenly last night
after a steak and beer dinner. On examination, the first metatarsophalangeal joint is erythematous, warm, and exquisitely tender. Synovial
fluid analysis reveals negatively birefringent, needle-shaped crystals. What is the first-line mechanism of action for the acute pharmacological
management of this patient's condition?
A. Inhibition of xanthine oxidase
B. Recombinant urate oxidase action
C. Inhibition of microtubule polymerization
D. Competitive antagonism of adenosine receptors
🟢 C. Inhibition of microtubule polymerization
🔴 RATIONALE: The patient is experiencing an acute gout flare, confirmed by negatively birefringent, needle-shaped uric acid crystals.
Colchicine is a first-line agent for acute gout flares and works by binding to tubulin, inhibiting microtubule polymerization, which disrupts
,leukocyte chemotaxis and degranulation. Xanthine oxidase inhibitors like allopurinol are used for chronic prophylactic management, not acute
flares.
Question 2
A 28-year-old G1P0 female at 32 weeks gestation presents to the emergency department complaining of a severe headache and visual spots
for the past 4 hours. Her blood pressure is 165/112 mmHg on two readings taken 15 minutes apart. Urinalysis reveals 3+ protein.
Fundoscopic examination shows no papilledema. Which of the following is the most appropriate next step to prevent maternal seizures?
A. Intravenous loading dose of diazepam
B. Intravenous loading dose of magnesium sulfate
C. Oral administration of clonazepam
D. Continuous infusion of phenytoin
🟢 B. Intravenous loading dose of magnesium sulfate
🔴 RATIONALE: This patient meets the diagnostic criteria for preeclampsia with severe features based on her blood pressure elevations and
neurological symptoms (headache, visual changes) at greater than 20 weeks gestation. Magnesium sulfate is the gold standard therapy used
for seizure prophylaxis in patients with preeclampsia with severe features. Benzodiazepines and phenytoin are not first-line agents for
eclampsia prevention.
Question 3
An 18-year-old female high school runner presents with a persistent ache in the anterior aspect of her right lower leg that worsens with
activity and improves with rest. On physical examination, there is focal, point tenderness over the anterior distal third of the right tibia. There
is no significant compartment tension or neurological deficit. Plain radiographs of the lower extremity are completely negative. What is the
most appropriate next diagnostic step to confirm the suspected diagnosis?
A. Magnetic resonance imaging of the right lower extremity
B. Electromyography and nerve conduction studies
C. Compartment pressure measurement testing
D. Triphasic radionuclide bone scan
🟢 A. Magnetic resonance imaging of the right lower extremity
🔴 RATIONALE: The clinical picture is highly suggestive of a tibial stress injury or stress fracture. Early stress fractures are frequently
radiolucent on initial plain X-rays (up to 4-6 weeks). Magnetic resonance imaging (MRI) is the most sensitive and specific diagnostic modality
to visualize early bone marrow edema and cortical stress lines without exposing the patient to radiation, preferred over a nuclear bone scan.
Question 4
A 62-year-old male smoker presents with a 3-month history of progressive, painless gross hematuria. He denies trauma, recent travel, or
dysuria. Physical examination is unremarkable. Urinalysis confirms packed red blood cells without casts or crystals. Which of the following is
the most definitive diagnostic evaluation required for this patient?
A. Renal and bladder ultrasound
B. Contrast-enhanced computed tomography urogram and cystoscopy
C. 24-hour urine collection for cytology and protein
D. Retrograde pyelogram with loop electrosurgical excision
,🟢 B. Contrast-enhanced computed tomography urogram and cystoscopy
🔴 RATIONALE: Unexplained, painless gross hematuria in an older adult male with a smoking history must be considered bladder or renal
malignancy until proven otherwise. The standard comprehensive diagnostic evaluation requires a CT urogram to evaluate the upper urinary
tract parenchyma and collecting systems, paired with direct cystoscopy to visually inspect the bladder mucosa.
Question 5
A 34-year-old female presents with a 2-week history of palpitations, heat intolerance, weight loss, and increased anxiety. Physical
examination reveals an enlarged, diffusely tender thyroid gland. Her thyroid-stimulating hormone (TSH) level is less than 0.01 uIU/mL, and
free T4 is elevated. A 24-hour radioactive iodine uptake scan demonstrates a diffusely decreased, low uptake pattern. What is the most likely
diagnosis?
A. Graves disease
B. Subacute granulomatous thyroiditis
C. Toxic multinodular goiter
D. Iodine-induced hyperthyroidism
🟢 B. Subacute granulomatous thyroiditis
🔴 RATIONALE: Subacute granulomatous thyroiditis (de Quervain's thyroiditis) characteristically presents with hyperthyroidism symptoms
following a viral prodrome, marked by an exquisitely painful, tender thyroid gland. The inflammatory destruction leaks preformed thyroid
hormone, suppressing TSH and leading to a low radioactive iodine uptake scan due to follicular cell damage. Graves and toxic nodular goiter
show high uptake.
Question 6
A 68-year-old female with a history of chronic osteoarthritis is admitted with severe epigastric pain, hematemesis, and hypotension. She
reports taking high-dose over-the-counter ibuprofen daily for the past 6 months. Endoscopy reveals a 2 cm ulcer in the gastric antrum with an
active visible vessel. Which of the following cellular mechanisms explains how this patient's long-term medication use directly caused this
mucosal injury?
A. Inhibition of systemic cyclooxygenase-1 leading to decreased prostaglandin E2
B. Acceleration of gastric mucosal epithelial cell apoptosis via leukotrienes
C. Direct cytotoxic lysis of parietal cells by lipophilic carboxylic acid compounds
D. Activation of H+/K+ ATPase pumps through up-regulated cyclic AMP pathways
🟢 A. Inhibition of systemic cyclooxygenase-1 leading to decreased prostaglandin E2
🔴 RATIONALE: Nonsteroidal anti-inflammatory drugs (NSAIDs) like ibuprofen non-selectively inhibit cyclooxygenase-1 (COX-1), which is
responsible for synthesizing cytoprotective prostaglandins (specifically PGE2 and PGI2) in the gastric mucosa. These prostaglandins
normally stimulate mucus and bicarbonate secretion and maintain mucosal blood flow. Their depletion leaves the stomach vulnerable to acid
injury.
Question 7
An 8-year-old boy is brought to the clinic by his mother because of recurrent, spontaneous epistaxis and prolonged bleeding from minor cuts.
His physical examination shows generalized petechiae on his lower extremities. Laboratory studies reveal a platelet count of 22,000/mm3,
, normal prothrombin time (PT), and normal activated partial thromboplastin time (aPTT). Peripheral blood smear shows large, isolated
platelets. What is the primary pathophysiological mechanism?
A. Autoantibody-mediated clearance of platelets in the spleen
B. Genetic deficiency of the glycoprotein Ib-IX-V complex
C. Sequestration of structurally abnormal platelets within the liver
D. ADAMTS13 protease deficiency leading to microthrombi
🟢 A. Autoantibody-mediated clearance of platelets in the spleen
🔴 RATIONALE: The clinical picture describes Immune Thrombocytopenia (ITP), an acquired autoimmune disorder characterized by isolated
thrombocytopenia. It is caused by anti-platelet autoantibodies (usually IgG against GPIb/IX or GPIIb/IIIa) that coat platelets, leading to their
premature destruction and clearance by splenic macrophages. PT and aPTT are normal because the coagulation cascade is unaffected.
Question 8
A 52-year-old male with long-standing poorly controlled hypertension presents for a routine visit. Physical examination confirms a blood
pressure of 152/96 mmHg. Osteopathic structural examination reveals tissue texture changes, asymmetry, and restricted motion from T1 to
T4 on the left side. These somatic dysfunctions are most likely mediated by which of the following neural pathways?
A. Parasympathetic viscerosomatic reflexes via the vagus nerve
B. Sympathetic viscerosomatic reflexes via the thoracic splanchnic nerves
C. Somatosomatic reflexes mediated through the accessory nerve
D. Somatovisceral pathways traveling via pelvic splanchnic pathways
🟢 B. Sympathetic viscerosomatic reflexes via the thoracic splanchnic nerves
🔴 RATIONALE: Prolonged visceral afferent irritation from an organ can cause somatic changes in structures sharing segments of the spinal
cord innervation, known as a viscerosomatic reflex. The heart and upper thoracic vasculature receive sympathetic innervation from the T1-T5
spinal cord segments. Chronic cardiovascular stress like hypertension causes sympathetic viscerosomatic reflexes manifesting as somatic
dysfunction in the T1-T4 paraspinal tissues.
Question 9
A 24-year-old male is brought to the emergency department after being found unresponsive in an alleyway. On exam, he is obtunded with a
respiratory rate of 6 breaths/minute, pinpoint pupils, and track marks along his bilateral antecubital fossae. Arterial blood gas on room air
reveals: pH 7.21, pCO2 62 mmHg, pO2 54 mmHg, and HCO3 24 mEq/L. Which of the following represents the patient's primary acid-base
disturbance?
A. Uncompensated metabolic acidosis
B. Acute respiratory acidosis
C. Chronic compensated respiratory acidosis
D. Mixed metabolic and respiratory acidosis
🟢 B. Acute respiratory acidosis
🔴 RATIONALE: The patient has an acute opioid overdose causing severe respiratory depression. This leads to hypoventilation and retention
of carbon dioxide. The arterial blood gas demonstrates a low pH (acidosis) and a high pCO2 (respiratory origin). Because the bicarbonate
(HCO3) is normal, the kidneys have not had time to compensate, establishing this as an acute respiratory acidosis.
