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COMSAE Phase 1 ASA 114 – The Complete 176 Question
Test Bank All questions with correct verified answers &
detailed rationales – graded A+ for the newest 2026
actual exam
SECTION 1 – OSTEOPATHIC PRINCIPLES & PRACTICE (Questions 1–20)
Q1. A 45-year-old male presents with chronic low back pain. Physical examination
reveals a short left leg (apparent), a left posterior superior iliac spine (PSIS) that is
superior compared to the right, and a left anterior inferior iliac spine (AIIS) that is
inferior compared to the right. What is the most likely sacral diagnosis?
A. Left-on-left torsion
B. Right-on-right torsion
C. Left unilateral flexion
D. Right unilateral flexion
E. Left-on-right torsion
<details><summary>✅ Answer & Rationale</summary> **Correct Answer: A.
Left-on-left torsion** In a sacral torsion, the side of the oblique axis is named
first, and the side of the base rotation is named second. A deep sulcus on the right
and shallow on the left indicates the base is rotated anteriorly on the left. The ILA
being posterior on the left indicates the axis is on the left. Thus, left-on-left
torsion. </details>
Q2. A patient with COPD is in respiratory distress. You note significant rib
elevation and restricted motion on the left side during inspiration. Using a direct
technique, you apply a force to the superior aspect of the left transverse process.
Which rib dysfunction is being treated?
A. Pump handle
B. Bucket handle
pg. 1
,2
C. Caliper
D. Somatic dysfunction of rib 1
<details><summary>✅ Answer & Rationale</summary> **Correct Answer: B.
Bucket handle** The bucket handle component of rib motion involves lateral
movement of the rib shaft. The dysfunctional transverse process (the pivot point)
is treated by applying a force to correct the lateral motion. </details>
Q3. A patient with a history of chronic bronchitis presents with an acute
exacerbation and dyspnea. On osteopathic structural exam, you find restriction of
the rib cage in the mid-to-lower thoracic region with somatic dysfunction at
T4-T6. Which viscerosomatic reflex pattern is most likely?
A. Sympathetic via T1-T4 → upper GI
B. Sympathetic via T1-T5 → heart and lung
C. Sympathetic via T5-T9 → foregut
D. Parasympathetic via vagus → bronchioles
<details><summary>✅ Answer & Rationale</summary> **Correct Answer: B.
Sympathetic via T1-T5 → heart and lung** Viscerosomatic reflexes related to
pulmonary pathology often involve sympathetic innervation from T1-T5, with
referred somatic dysfunction in the upper to mid-thoracic spine and rib cage.
</details>
Q4. A 28-year-old female presents with unilateral pulsatile headaches,
photophobia, and nausea. OMM exam shows a tenderpoint at the articular pillar
of C2. Which autonomic pathway is most implicated in her symptoms?
A. Increased parasympathetic tone via CN X
B. Increased sympathetic tone from the superior cervical ganglion
C. Impaired venous drainage from the cervical spine
D. Somatic dysfunction of the atlanto-occipital joint
<details><summary>✅ Answer & Rationale</summary> **Correct Answer: B.
Increased sympathetic tone from the superior cervical ganglion** The superior
pg. 2
,3
cervical ganglion (located near C2-C3) provides sympathetic innervation to the
head, including the cerebral vasculature. Tenderpoint at C2 can reflect
sympathetic overactivity that contributes to migraine pathophysiology. </details>
Q5. A 45-year-old male presents with acute onset of severe left upper quadrant
pain that radiates to the left shoulder. He was in a motor vehicle collision two
hours ago. OMM exam reveals a left hemidiaphragm that is restricted in excursion
and tender. What is the most likely diagnosis?
A. Splenic rupture with Kehr’s sign
B. Acute pancreatitis with referred pain
C. Left lower lobe pneumonia
D. Perforated gastric ulcer
<details><summary>✅ Answer & Rationale</summary> **Correct Answer: A.
Splenic rupture with Kehr’s sign** Kehr’s sign – referred pain to the left shoulder
– occurs when diaphragmatic irritation (from blood) stimulates the phrenic nerve
(C3-C5). This is a surgical emergency. </details>
Q6. A 62-year-old male with a history of hypertension and diabetes presents with
a 3-day history of epigastric pain that radiates to the back. He is lying on the exam
table with his knees flexed. Physical exam reveals tenderness in the midepigastric
region. An osteopathic examination shows segmental facilitation at T7-T9. Which
viscerosomatic reflex is most likely?
A. Hepatic (gallbladder) dysfunction referring to T7-T9
B. Gastric (stomach) dysfunction referring to T6-T9
C. Pancreatic dysfunction referring to T7-T9
D. Renal (kidney) dysfunction referring to T10-L1
<details><summary>✅ Answer & Rationale</summary> **Correct Answer: C.
Pancreatic dysfunction referring to T7-T9** The pancreas receives sympathetic
innervation from T7-T9 (greater splanchnic nerve). Somatic findings in this region
are classic for acute or chronic pancreatitis. </details>
pg. 3
, 4
Q7. A 32-year-old female presents with chronic headaches. On osteopathic
structural exam, you find a tenderpoint at the occiput. Which viscerosomatic
reflex is most likely involved?
A. Sympathetic from T1-T4
B. Somatic dysfunction of the suboccipital region due to strain pattern
C. Parasympathetic via vagus nerve
D. Facilitation at T10-L2
<details><summary>✅ Answer & Rationale</summary> **Correct Answer: B.
Somatic dysfunction of the suboccipital region** The suboccipital region is a
common site of somatic dysfunction in patients with tension headaches and
cervicogenic headaches. </details>
Q8. A patient with a history of chronic constipation undergoes osteopathic
evaluation. Chapman reflex points are found in the lower abdomen. What is the
most likely associated visceral dysfunction?
A. Stomach
B. Colon
C. Liver
D. Kidneys
<details><summary>✅ Answer & Rationale</summary> **Correct Answer: B.
Colon** Chapman reflexes for the large intestine are located in the lower
abdomen and laterally on the thighs. They represent visceral irritation. </details>
Q9. A patient with chronic low back pain has a positive seated flexion test, a deep
sacral sulcus on the right, and a shallow left sacral sulcus. The left inferior lateral
angle (ILA) is posterior. What is the sacral diagnosis?
A. Right-on-right torsion
B. Left-on-left torsion
C. Left-on-right torsion
D. Right-on-left torsion
pg. 4
COMSAE Phase 1 ASA 114 – The Complete 176 Question
Test Bank All questions with correct verified answers &
detailed rationales – graded A+ for the newest 2026
actual exam
SECTION 1 – OSTEOPATHIC PRINCIPLES & PRACTICE (Questions 1–20)
Q1. A 45-year-old male presents with chronic low back pain. Physical examination
reveals a short left leg (apparent), a left posterior superior iliac spine (PSIS) that is
superior compared to the right, and a left anterior inferior iliac spine (AIIS) that is
inferior compared to the right. What is the most likely sacral diagnosis?
A. Left-on-left torsion
B. Right-on-right torsion
C. Left unilateral flexion
D. Right unilateral flexion
E. Left-on-right torsion
<details><summary>✅ Answer & Rationale</summary> **Correct Answer: A.
Left-on-left torsion** In a sacral torsion, the side of the oblique axis is named
first, and the side of the base rotation is named second. A deep sulcus on the right
and shallow on the left indicates the base is rotated anteriorly on the left. The ILA
being posterior on the left indicates the axis is on the left. Thus, left-on-left
torsion. </details>
Q2. A patient with COPD is in respiratory distress. You note significant rib
elevation and restricted motion on the left side during inspiration. Using a direct
technique, you apply a force to the superior aspect of the left transverse process.
Which rib dysfunction is being treated?
A. Pump handle
B. Bucket handle
pg. 1
,2
C. Caliper
D. Somatic dysfunction of rib 1
<details><summary>✅ Answer & Rationale</summary> **Correct Answer: B.
Bucket handle** The bucket handle component of rib motion involves lateral
movement of the rib shaft. The dysfunctional transverse process (the pivot point)
is treated by applying a force to correct the lateral motion. </details>
Q3. A patient with a history of chronic bronchitis presents with an acute
exacerbation and dyspnea. On osteopathic structural exam, you find restriction of
the rib cage in the mid-to-lower thoracic region with somatic dysfunction at
T4-T6. Which viscerosomatic reflex pattern is most likely?
A. Sympathetic via T1-T4 → upper GI
B. Sympathetic via T1-T5 → heart and lung
C. Sympathetic via T5-T9 → foregut
D. Parasympathetic via vagus → bronchioles
<details><summary>✅ Answer & Rationale</summary> **Correct Answer: B.
Sympathetic via T1-T5 → heart and lung** Viscerosomatic reflexes related to
pulmonary pathology often involve sympathetic innervation from T1-T5, with
referred somatic dysfunction in the upper to mid-thoracic spine and rib cage.
</details>
Q4. A 28-year-old female presents with unilateral pulsatile headaches,
photophobia, and nausea. OMM exam shows a tenderpoint at the articular pillar
of C2. Which autonomic pathway is most implicated in her symptoms?
A. Increased parasympathetic tone via CN X
B. Increased sympathetic tone from the superior cervical ganglion
C. Impaired venous drainage from the cervical spine
D. Somatic dysfunction of the atlanto-occipital joint
<details><summary>✅ Answer & Rationale</summary> **Correct Answer: B.
Increased sympathetic tone from the superior cervical ganglion** The superior
pg. 2
,3
cervical ganglion (located near C2-C3) provides sympathetic innervation to the
head, including the cerebral vasculature. Tenderpoint at C2 can reflect
sympathetic overactivity that contributes to migraine pathophysiology. </details>
Q5. A 45-year-old male presents with acute onset of severe left upper quadrant
pain that radiates to the left shoulder. He was in a motor vehicle collision two
hours ago. OMM exam reveals a left hemidiaphragm that is restricted in excursion
and tender. What is the most likely diagnosis?
A. Splenic rupture with Kehr’s sign
B. Acute pancreatitis with referred pain
C. Left lower lobe pneumonia
D. Perforated gastric ulcer
<details><summary>✅ Answer & Rationale</summary> **Correct Answer: A.
Splenic rupture with Kehr’s sign** Kehr’s sign – referred pain to the left shoulder
– occurs when diaphragmatic irritation (from blood) stimulates the phrenic nerve
(C3-C5). This is a surgical emergency. </details>
Q6. A 62-year-old male with a history of hypertension and diabetes presents with
a 3-day history of epigastric pain that radiates to the back. He is lying on the exam
table with his knees flexed. Physical exam reveals tenderness in the midepigastric
region. An osteopathic examination shows segmental facilitation at T7-T9. Which
viscerosomatic reflex is most likely?
A. Hepatic (gallbladder) dysfunction referring to T7-T9
B. Gastric (stomach) dysfunction referring to T6-T9
C. Pancreatic dysfunction referring to T7-T9
D. Renal (kidney) dysfunction referring to T10-L1
<details><summary>✅ Answer & Rationale</summary> **Correct Answer: C.
Pancreatic dysfunction referring to T7-T9** The pancreas receives sympathetic
innervation from T7-T9 (greater splanchnic nerve). Somatic findings in this region
are classic for acute or chronic pancreatitis. </details>
pg. 3
, 4
Q7. A 32-year-old female presents with chronic headaches. On osteopathic
structural exam, you find a tenderpoint at the occiput. Which viscerosomatic
reflex is most likely involved?
A. Sympathetic from T1-T4
B. Somatic dysfunction of the suboccipital region due to strain pattern
C. Parasympathetic via vagus nerve
D. Facilitation at T10-L2
<details><summary>✅ Answer & Rationale</summary> **Correct Answer: B.
Somatic dysfunction of the suboccipital region** The suboccipital region is a
common site of somatic dysfunction in patients with tension headaches and
cervicogenic headaches. </details>
Q8. A patient with a history of chronic constipation undergoes osteopathic
evaluation. Chapman reflex points are found in the lower abdomen. What is the
most likely associated visceral dysfunction?
A. Stomach
B. Colon
C. Liver
D. Kidneys
<details><summary>✅ Answer & Rationale</summary> **Correct Answer: B.
Colon** Chapman reflexes for the large intestine are located in the lower
abdomen and laterally on the thighs. They represent visceral irritation. </details>
Q9. A patient with chronic low back pain has a positive seated flexion test, a deep
sacral sulcus on the right, and a shallow left sacral sulcus. The left inferior lateral
angle (ILA) is posterior. What is the sacral diagnosis?
A. Right-on-right torsion
B. Left-on-left torsion
C. Left-on-right torsion
D. Right-on-left torsion
pg. 4
