2026 COMSAE PHASE 1 FORM 114 –
PRACTICE EXAM Verified Questions with
Detailed Rationales
Question 1
A 45-year-old male presents with low back pain after lifting a box. Standing
flexion test shows superior movement of the right PSIS. Which somatic
dysfunction is most likely?
A) Right posterior innominate
B) Right anterior innominate
C) Left anterior innominate
D) Left sacral torsion
E) Right sacral torsion
Answer: B) Right anterior innominate
Rationale & Explanation:
The standing flexion test screens for iliosacral dysfunction. Normally, both PSIS
move equally superiorly. A positive test (one PSIS moves more cephalad) indicates
restricted motion on that side. Superior movement of the right PSIS means the
right ilium is fixed in an anterior rotation – the PSIS is relatively superior and the
ASIS is inferior. In a posterior innominate, the PSIS would appear more inferior.
Anterior innominate dysfunction is treated with muscle energy (direct technique)
or HVLA.
Question 2
A 28-year-old female with chronic headaches has OA joint restriction in flexion
and sidebending to the right. Which OMT is most appropriate?
A) HVLA thrust in the direction of restriction
B) Muscle energy for the suboccipitals
C) Counterstrain for the anterior tender point
,D) Myofascial release of the scalenes
E) Indirect technique into ease
Answer: A) HVLA thrust in the direction of restriction
Rationale & Explanation:
OA joint restriction in flexion and sidebending to the same side describes a Type
II somatic dysfunction (non-neutral mechanics – restricted in one direction, free
in the opposite). For Type II dysfunctions, direct HVLA engaging the restrictive
barrier is most appropriate. The thrust moves the joint into further restriction
(flexion + right sidebending) to reset normal motion. Muscle energy is an
alternative if HVLA is contraindicated (osteoporosis, patient preference).
Counterstrain uses indirect positioning (away from restriction) – not optimal here.
Question 3
A 67-year-old man with hypertension presents with sudden tearing chest pain
radiating to the back. BP is 188/102 mmHg in the right arm and 160/88 mmHg in
the left. Most likely diagnosis?
A) Acute myocardial infarction
B) Aortic dissection
C) Pulmonary embolism
D) Acute pericarditis
E) Esophageal rupture
Answer: B) Aortic dissection
Rationale & Explanation:
Classic presentation of aortic dissection (Type A, ascending aorta): sudden, severe
"tearing" or "ripping" chest pain radiating to the back. Blood pressure differential
between arms (≥20 mmHg systolic) suggests aortic arch involvement. Risk
factors: hypertension, connective tissue disorders (Marfan, Ehlers-Danlos),
bicuspid aortic valve. Initial imaging: chest CT angiography or TEE. Emergent
surgery for Type A; medical management (beta-blockers) for uncomplicated Type
B.
Question 4
,A 58-year-old man presents with crushing chest pain. ECG shows ST elevations in
leads V1–V4. Which coronary artery is most likely occluded?
A) Right coronary artery
B) Left circumflex
C) Left anterior descending (LAD)
D) Posterior descending artery
E) Ramus intermedius
Answer: C) Left anterior descending (LAD)
Rationale & Explanation:
ST elevations in V1–V4 = anterior wall myocardial infarction. The anterior wall
is supplied by the left anterior descending (LAD) artery. RCA occlusion →
inferior wall (II, III, aVF). LCx occlusion → lateral wall (I, aVL, V5–V6).
Posterior descending artery (usually from RCA) → posterior wall (tall R waves in
V1–V2, ST depression in anterior leads). LAD occlusion carries high risk of heart
failure, cardiogenic shock, and ventricular septal rupture.
Question 5
A patient with a 40-pack-year smoking history presents with chronic cough,
dyspnea, and a barrel-shaped chest. Spirometry shows an FEV1/FVC ratio of 60%.
Most likely diagnosis?
A) Asthma
B) COPD
C) Pulmonary fibrosis
D) Bronchiectasis
E) Heart failure
Answer: B) COPD
Rationale & Explanation:
COPD is characterized by airflow obstruction (post-bronchodilator FEV1/FVC <
0.70). The patient has major risk factors (smoking), chronic cough/dyspnea,
and barrel-shaped chest (hyperinflation). Asthma: typically reversible
obstruction, episodic symptoms. Pulmonary fibrosis: restrictive pattern (normal or
high FEV1/FVC, low FVC). Bronchiectasis: chronic cough with purulent sputum,
, clubbing, often post-infectious. GOLD criteria classify COPD severity by FEV1%
predicted.
Question 6
A 32-year-old pregnant woman at 28 weeks gestation presents with new-onset
hypertension (160/100 mmHg) and proteinuria (3+ on dipstick). She also reports
epigastric pain and headache. Which laboratory finding is most concerning?
A) Hemoglobin 11.5 g/dL
B) Platelet count 80,000/μL
C) Serum creatinine 0.9 mg/dL
D) AST 40 U/L
E) Uric acid 5.0 mg/dL
Answer: B) Platelet count 80,000/μL
Rationale & Explanation:
This patient presents with severe features of preeclampsia (BP ≥160/100,
proteinuria, epigastric pain, headache). Thrombocytopenia (platelets
<100,000/μL) is a severe feature indicating possible progression to HELLP
syndrome (Hemolysis, Elevated Liver enzymes, Low Platelets). Immediate
delivery is often indicated at ≥34 weeks; at 28 weeks, management requires
magnesium sulfate for seizure prophylaxis, antihypertensives, and fetal assessment.
Low platelets increase risk of bleeding during delivery or C-section.
Question 7
A 55-year-old female with rheumatoid arthritis for 10 years presents with
progressive dyspnea on exertion and a dry cough. HRCT shows bilateral peripheral
reticular opacities with honeycombing. Most likely diagnosis?
A) Sarcoidosis
B) Usual interstitial pneumonia (UIP)
C) Hypersensitivity pneumonitis
D) Cryptogenic organizing pneumonia
E) Lymphangitic carcinomatosis
Answer: B) Usual interstitial pneumonia (UIP)
PRACTICE EXAM Verified Questions with
Detailed Rationales
Question 1
A 45-year-old male presents with low back pain after lifting a box. Standing
flexion test shows superior movement of the right PSIS. Which somatic
dysfunction is most likely?
A) Right posterior innominate
B) Right anterior innominate
C) Left anterior innominate
D) Left sacral torsion
E) Right sacral torsion
Answer: B) Right anterior innominate
Rationale & Explanation:
The standing flexion test screens for iliosacral dysfunction. Normally, both PSIS
move equally superiorly. A positive test (one PSIS moves more cephalad) indicates
restricted motion on that side. Superior movement of the right PSIS means the
right ilium is fixed in an anterior rotation – the PSIS is relatively superior and the
ASIS is inferior. In a posterior innominate, the PSIS would appear more inferior.
Anterior innominate dysfunction is treated with muscle energy (direct technique)
or HVLA.
Question 2
A 28-year-old female with chronic headaches has OA joint restriction in flexion
and sidebending to the right. Which OMT is most appropriate?
A) HVLA thrust in the direction of restriction
B) Muscle energy for the suboccipitals
C) Counterstrain for the anterior tender point
,D) Myofascial release of the scalenes
E) Indirect technique into ease
Answer: A) HVLA thrust in the direction of restriction
Rationale & Explanation:
OA joint restriction in flexion and sidebending to the same side describes a Type
II somatic dysfunction (non-neutral mechanics – restricted in one direction, free
in the opposite). For Type II dysfunctions, direct HVLA engaging the restrictive
barrier is most appropriate. The thrust moves the joint into further restriction
(flexion + right sidebending) to reset normal motion. Muscle energy is an
alternative if HVLA is contraindicated (osteoporosis, patient preference).
Counterstrain uses indirect positioning (away from restriction) – not optimal here.
Question 3
A 67-year-old man with hypertension presents with sudden tearing chest pain
radiating to the back. BP is 188/102 mmHg in the right arm and 160/88 mmHg in
the left. Most likely diagnosis?
A) Acute myocardial infarction
B) Aortic dissection
C) Pulmonary embolism
D) Acute pericarditis
E) Esophageal rupture
Answer: B) Aortic dissection
Rationale & Explanation:
Classic presentation of aortic dissection (Type A, ascending aorta): sudden, severe
"tearing" or "ripping" chest pain radiating to the back. Blood pressure differential
between arms (≥20 mmHg systolic) suggests aortic arch involvement. Risk
factors: hypertension, connective tissue disorders (Marfan, Ehlers-Danlos),
bicuspid aortic valve. Initial imaging: chest CT angiography or TEE. Emergent
surgery for Type A; medical management (beta-blockers) for uncomplicated Type
B.
Question 4
,A 58-year-old man presents with crushing chest pain. ECG shows ST elevations in
leads V1–V4. Which coronary artery is most likely occluded?
A) Right coronary artery
B) Left circumflex
C) Left anterior descending (LAD)
D) Posterior descending artery
E) Ramus intermedius
Answer: C) Left anterior descending (LAD)
Rationale & Explanation:
ST elevations in V1–V4 = anterior wall myocardial infarction. The anterior wall
is supplied by the left anterior descending (LAD) artery. RCA occlusion →
inferior wall (II, III, aVF). LCx occlusion → lateral wall (I, aVL, V5–V6).
Posterior descending artery (usually from RCA) → posterior wall (tall R waves in
V1–V2, ST depression in anterior leads). LAD occlusion carries high risk of heart
failure, cardiogenic shock, and ventricular septal rupture.
Question 5
A patient with a 40-pack-year smoking history presents with chronic cough,
dyspnea, and a barrel-shaped chest. Spirometry shows an FEV1/FVC ratio of 60%.
Most likely diagnosis?
A) Asthma
B) COPD
C) Pulmonary fibrosis
D) Bronchiectasis
E) Heart failure
Answer: B) COPD
Rationale & Explanation:
COPD is characterized by airflow obstruction (post-bronchodilator FEV1/FVC <
0.70). The patient has major risk factors (smoking), chronic cough/dyspnea,
and barrel-shaped chest (hyperinflation). Asthma: typically reversible
obstruction, episodic symptoms. Pulmonary fibrosis: restrictive pattern (normal or
high FEV1/FVC, low FVC). Bronchiectasis: chronic cough with purulent sputum,
, clubbing, often post-infectious. GOLD criteria classify COPD severity by FEV1%
predicted.
Question 6
A 32-year-old pregnant woman at 28 weeks gestation presents with new-onset
hypertension (160/100 mmHg) and proteinuria (3+ on dipstick). She also reports
epigastric pain and headache. Which laboratory finding is most concerning?
A) Hemoglobin 11.5 g/dL
B) Platelet count 80,000/μL
C) Serum creatinine 0.9 mg/dL
D) AST 40 U/L
E) Uric acid 5.0 mg/dL
Answer: B) Platelet count 80,000/μL
Rationale & Explanation:
This patient presents with severe features of preeclampsia (BP ≥160/100,
proteinuria, epigastric pain, headache). Thrombocytopenia (platelets
<100,000/μL) is a severe feature indicating possible progression to HELLP
syndrome (Hemolysis, Elevated Liver enzymes, Low Platelets). Immediate
delivery is often indicated at ≥34 weeks; at 28 weeks, management requires
magnesium sulfate for seizure prophylaxis, antihypertensives, and fetal assessment.
Low platelets increase risk of bleeding during delivery or C-section.
Question 7
A 55-year-old female with rheumatoid arthritis for 10 years presents with
progressive dyspnea on exertion and a dry cough. HRCT shows bilateral peripheral
reticular opacities with honeycombing. Most likely diagnosis?
A) Sarcoidosis
B) Usual interstitial pneumonia (UIP)
C) Hypersensitivity pneumonitis
D) Cryptogenic organizing pneumonia
E) Lymphangitic carcinomatosis
Answer: B) Usual interstitial pneumonia (UIP)
