COMLEX-USA Level 1 Prep | COMSAE Phase 1 Form
113 Direct Content Practice Exam 200+ Questions
with Bold Italic Answers & Rationales for
Osteopathic Medical Students | pdf.
Section 1: Osteopathic Principles & Practice (OPP)
1. A 45-year-old male presents with chronic low back pain. Physical examination reveals
an apparent short left leg, 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. What is
the most likely sacral diagnosis?
A) Right-on-right torsion
B) Left unilateral flexion
C) Left-on-left torsion
D) Right unilateral flexion
E) Left-on-right torsion
Correct answer: C
Explanation: In a sacral torsion, the side of the oblique axis is named first, and the side of
the rotation is named second. The findings (deep sulcus on the right, shallow on the left;
ILA posterior on the left) indicate rotation around a left oblique axis. A "Left-on-left"
torsion means the axis is on the left and the base is rotating anteriorly on the left .
2. A patient with COPD is in respiratory distress. You note significant rib elevation and
restricted motion on the left side. Using a direct technique, you apply force to the
superior aspect of the left transverse process. Which rib dysfunction is being treated?
A) Pump handle
B) Bucket handle
,C) Caliper
D) Inhalation restriction of Rib 1
E) Exhalation restriction
Correct answer: B
*Explanation: The bucket handle component of rib motion involves the lateral
movement of the rib shaft. The dysfunctional transverse process acts as the pivot point.
Pump handle (A) involves anterior/posterior movement of the sternum, while caliper (C)
refers to ribs 11-12 .*
3. During a cranial evaluation, you place your hands on the patient’s head (CV4
position). You sense a phase where the occiput is externally rotating and the sphenoid is
internally rotating. Which phase of the primary respiratory mechanism is this?
A) Flexion phase
B) Extension phase
C) Midline phase
D) Torsion phase
E) Side-bending rotation phase
Correct answer: B
Explanation: In the cranial rhythmic impulse (CRI), during the flexion phase the sphenoid
rotates externally (widening) and the occiput rotates internally. During the extension
phase, the opposite occurs: the sphenoid internally rotates and the occiput externally
rotates .
4. A patient with chronic migraines presents for OMT. The physician finds tenderness at
the suboccipital triangle. Restriction of cervical flexion is noted. Which technique is most
appropriate?
A) High-velocity, low-amplitude thrust to C5
B) Muscle energy for the suboccipitals
C) Lymphatic pump
D) Rib raising
E) Sacral rocking
,Correct answer: B
Explanation: Tension-type headaches and migraines often originate from suboccipital
muscle tension (rectus capitis posterior major/minor, obliquus capitis). Muscle energy
technique (MET) is a gentle, effective OMT approach for treating muscle spasm and
restricted motion in the cervical spine .
5. A patient presents with acute torticollis involving the left sternocleidomastoid (SCM).
If there is a visceral component, which Chapman’s reflex point would likely be tender?
A) 2nd intercostal space, left sternal border
B) 1st intercostal space, right sternal border
C) Umbilicus, right lateral border
D) Tip of the 12th rib
E) 5th intercostal space, left mid-clavicular line
Correct answer: B
Explanation: Chapman’s reflexes are neurolymphatic points. The point for the upper
respiratory tract (including the SCM region and throat) is located in the 1st intercostal
space, right sternal border. The left 2nd intercostal space (A) correlates to the stomach .
6. A patient standing with a forward-bending test reveals a right thoracic rib hump.
What is the most likely structural spinal diagnosis?
A) Right thoracic convexity
B) Left thoracic convexity
C) Lumbarization of S1
D) Spondylolisthesis
E) Right sacral torsion
Correct answer: B
Explanation: A rib hump is caused by the rotation of the vertebrae. When the spinous
processes rotate toward the concave side of the curve. In a left thoracic convex curve
(Levoconvex scoliosis), the ribs on the left are pushed posteriorly, creating a hump on the
left during forward bend .
, 7. In a patient with chronic bronchitis, you perform OMT to increase lymphatic drainage.
Directing the patient into a supine position and applying rhythmic pressure to the
thoracic inlet while the patient exhales describes:
A) Pedal pump
B) Doming the diaphragm
C) Thoracic inlet pump
D) Spencer technique
E) Galbreath technique
Correct answer: C
Explanation: The Thoracic Inlet (or Thoracic Pump) technique is designed to increase
lymphatic return from the head, neck, and upper extremities. It is performed by applying
gentle pressure at the manubrium during patient exhalation, creating negative
intrathoracic pressure .
Section 2: Microbiology & Immunology
8. A 35-year-old female is intubated for status asthmaticus. On day 4, she develops
impaired attention and recall. She has a minor resting hand tremor. MRI and EEG are
normal. What is the most likely cause?
A) Alcohol withdrawal
B) Hypoxic brain injury
C) Medication effect
D) New-onset seizure disorder
E) Herpes simplex encephalitis
Correct answer: C
Explanation: The timeline and clinical setting point to a medication effect. High-dose
corticosteroids (prednisone) are known to cause neuropsychiatric symptoms (psychosis,
113 Direct Content Practice Exam 200+ Questions
with Bold Italic Answers & Rationales for
Osteopathic Medical Students | pdf.
Section 1: Osteopathic Principles & Practice (OPP)
1. A 45-year-old male presents with chronic low back pain. Physical examination reveals
an apparent short left leg, 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. What is
the most likely sacral diagnosis?
A) Right-on-right torsion
B) Left unilateral flexion
C) Left-on-left torsion
D) Right unilateral flexion
E) Left-on-right torsion
Correct answer: C
Explanation: In a sacral torsion, the side of the oblique axis is named first, and the side of
the rotation is named second. The findings (deep sulcus on the right, shallow on the left;
ILA posterior on the left) indicate rotation around a left oblique axis. A "Left-on-left"
torsion means the axis is on the left and the base is rotating anteriorly on the left .
2. A patient with COPD is in respiratory distress. You note significant rib elevation and
restricted motion on the left side. Using a direct technique, you apply force to the
superior aspect of the left transverse process. Which rib dysfunction is being treated?
A) Pump handle
B) Bucket handle
,C) Caliper
D) Inhalation restriction of Rib 1
E) Exhalation restriction
Correct answer: B
*Explanation: The bucket handle component of rib motion involves the lateral
movement of the rib shaft. The dysfunctional transverse process acts as the pivot point.
Pump handle (A) involves anterior/posterior movement of the sternum, while caliper (C)
refers to ribs 11-12 .*
3. During a cranial evaluation, you place your hands on the patient’s head (CV4
position). You sense a phase where the occiput is externally rotating and the sphenoid is
internally rotating. Which phase of the primary respiratory mechanism is this?
A) Flexion phase
B) Extension phase
C) Midline phase
D) Torsion phase
E) Side-bending rotation phase
Correct answer: B
Explanation: In the cranial rhythmic impulse (CRI), during the flexion phase the sphenoid
rotates externally (widening) and the occiput rotates internally. During the extension
phase, the opposite occurs: the sphenoid internally rotates and the occiput externally
rotates .
4. A patient with chronic migraines presents for OMT. The physician finds tenderness at
the suboccipital triangle. Restriction of cervical flexion is noted. Which technique is most
appropriate?
A) High-velocity, low-amplitude thrust to C5
B) Muscle energy for the suboccipitals
C) Lymphatic pump
D) Rib raising
E) Sacral rocking
,Correct answer: B
Explanation: Tension-type headaches and migraines often originate from suboccipital
muscle tension (rectus capitis posterior major/minor, obliquus capitis). Muscle energy
technique (MET) is a gentle, effective OMT approach for treating muscle spasm and
restricted motion in the cervical spine .
5. A patient presents with acute torticollis involving the left sternocleidomastoid (SCM).
If there is a visceral component, which Chapman’s reflex point would likely be tender?
A) 2nd intercostal space, left sternal border
B) 1st intercostal space, right sternal border
C) Umbilicus, right lateral border
D) Tip of the 12th rib
E) 5th intercostal space, left mid-clavicular line
Correct answer: B
Explanation: Chapman’s reflexes are neurolymphatic points. The point for the upper
respiratory tract (including the SCM region and throat) is located in the 1st intercostal
space, right sternal border. The left 2nd intercostal space (A) correlates to the stomach .
6. A patient standing with a forward-bending test reveals a right thoracic rib hump.
What is the most likely structural spinal diagnosis?
A) Right thoracic convexity
B) Left thoracic convexity
C) Lumbarization of S1
D) Spondylolisthesis
E) Right sacral torsion
Correct answer: B
Explanation: A rib hump is caused by the rotation of the vertebrae. When the spinous
processes rotate toward the concave side of the curve. In a left thoracic convex curve
(Levoconvex scoliosis), the ribs on the left are pushed posteriorly, creating a hump on the
left during forward bend .
, 7. In a patient with chronic bronchitis, you perform OMT to increase lymphatic drainage.
Directing the patient into a supine position and applying rhythmic pressure to the
thoracic inlet while the patient exhales describes:
A) Pedal pump
B) Doming the diaphragm
C) Thoracic inlet pump
D) Spencer technique
E) Galbreath technique
Correct answer: C
Explanation: The Thoracic Inlet (or Thoracic Pump) technique is designed to increase
lymphatic return from the head, neck, and upper extremities. It is performed by applying
gentle pressure at the manubrium during patient exhalation, creating negative
intrathoracic pressure .
Section 2: Microbiology & Immunology
8. A 35-year-old female is intubated for status asthmaticus. On day 4, she develops
impaired attention and recall. She has a minor resting hand tremor. MRI and EEG are
normal. What is the most likely cause?
A) Alcohol withdrawal
B) Hypoxic brain injury
C) Medication effect
D) New-onset seizure disorder
E) Herpes simplex encephalitis
Correct answer: C
Explanation: The timeline and clinical setting point to a medication effect. High-dose
corticosteroids (prednisone) are known to cause neuropsychiatric symptoms (psychosis,
