COMSAE Phase 1 Form 114 exam
Questions And Well Graded Solutions
With Rationales Updated 2026-2027
Master your boards with this ultimate 176-question COMSAE Phase
1 Form 114 practice set. Exactly formatted for COMLEX Level 1, it
covers high-yield pathology, pharmacology, microbiology, and
critical Osteopathic Principles & Practice (OPP), including sacral
torsions and Fryette's laws. Each single-best-answer multiple-
choice question is paired with a comprehensive, italicized
diagnostic rationale. Ideal for active DO students looking to clear
their school's baseline 400 benchmark
Question 1: A 28-year-old female presents with a distinct, migratory, butterfly-shaped
rash across her cheeks and nasal bridge that worsens after sun exposure.
Laboratory testing reveals positive antinuclear antibodies (ANA) and anti-double-
stranded DNA (anti-dsDNA) antibodies. What is the most likely diagnosis?
A. Systemic lupus erythematosus
B. Dermatomyositis
C. Rosacea
D. Seborrheic dermatitis
A. Systemic lupus erythematosus
Rationale: Systemic lupus erythematosus (SLE) is a chronic autoimmune disease
characterized by a malar (butterfly) rash that exhibits photosensitivity. The presence
of highly specific antibodies like anti-dsDNA confirms the diagnosis. Dermatomyositis
presents with a heliotrope rash and proximal muscle weakness. Rosacea lacks
systemic autoantibodies. Seborrheic dermatitis presents with greasy scales in the
nasolabial folds.
Question 2: A 45-year-old male undergoes a physical examination. The physician
notes a somatic dysfunction of the T5 thoracic vertebra. Palpation reveals that the T5
spinous process rotates preferentially to the right and sidebends preferentially to the
right. When the patient flexes his spine, the asymmetry worsens, but it improves
significantly when he extends his spine. According to Fryette's principles, how should
this somatic dysfunction be named?
A. T5 Neutral R(R) S(L)
B. T5 Extended R(R) S(R)
C. T5 Flexed R(L) S(L)
D. T5 Extended R(L) S(R)
B. T5 Extended R(R) S(R)
,Rationale: Under Fryette's Principle II, non-neutral thoracic dysfunctions occur at a
single vertebral segment where rotation and sidebending occur to the same side.
Because the asymmetry improves in extension, the restriction is in flexion, meaning
the vertebra is trapped in an extended position. The positional diagnosis is named
for its directional preferences: Extended, Rotated Right, and Sidebent Right.
Question 3: A 62-year-old male with a history of chronic smoking presents with an
emergency onset of severe, tearing chest pain that radiates directly to his back
between his scapulae. His blood pressure is 180/100 mmHg in the right arm and
140/85 mmHg in the left arm. What is the most immediate life-threatening condition
to suspect?
A. Acute myocardial infarction
B. Acute aortic dissection
C. Pulmonary embolism
D. Tension pneumothorax
B. Acute aortic dissection
Rationale: A tearing or ripping chest pain radiating to the back, coupled with an
asymmetric blood pressure differential between the upper extremities (>20 mmHg
variation), is highly indicative of an acute aortic dissection. Acute myocardial
infarction typically features crushing retrosternal pain radiating to the jaw or left arm.
Pulmonary embolism presents with pleuritic chest pain and dyspnea. Tension
pneumothorax causes absent breath sounds on the affected side.
Question 4: A 34-year-old patient presents with symptoms highly suggestive of acute
appendicitis. During an osteopathic structural exam, the physician looks for a
Chapman's reflex point to help confirm the visceral involvement. Where is the
anterior Chapman's reflex point for the appendix located?
A. At the tip of the right 12th rib
B. At the tip of the right 11th rib
C. At the periumbilical region
D. At the right 5th intercostal space
B. At the tip of the right 11th rib
Rationale: The anterior Chapman's reflex point for the appendix is specifically
located at the tip of the right 11th rib. The posterior point is located at the transverse
process of T11. The tip of the 12th rib relates to the kidneys. The 5th intercostal
space relates to the liver and gallbladder.
Question 5: A 19-year-old male is brought to the clinic due to severe lethargy,
vomiting, and a deep, rapid breathing pattern. His blood glucose is 450 mg/dL, and
arterial blood gas reveals a pH of 7.15 with a low bicarbonate level. urinalysis is
strongly positive for ketones. Which of the following enzymes is directly activated by
the hormone that is deficient in this patient?
A. Glycogen synthase
B. Glycogen phosphorylase
C. Hormone-sensitive lipase
D. Pyruvate carboxylase
A. Glycogen synthase
,Rationale: The patient is experiencing diabetic ketoacidosis (DKA) due to a profound
deficiency of insulin. Insulin normally acts to lower blood glucose by promoting
storage pathways. It directly activates glycogen synthase via dephosphorylation to
encourage glycogen synthesis. Glycogen phosphorylase and hormone-sensitive
lipase are activated by glucagon and epinephrine, which run counter to insulin.
Question 6: A 52-year-old male presents with severe pain, redness, and swelling in
his right first metatarsophalangeal joint that woke him up in the middle of the night.
Arthrocentesis shows needle-shaped, negatively birefringent crystals under polarized
light microscopy. Which of the following medications is a first-line agent used to treat
the acute flare-up of this condition?
A. Allopurinol
B. Indomethacin
C. Febuxostat
D. Probenecid
B. Indomethacin
Rationale: The clinical scenario describes an acute gout flare, evidenced by the
classic presentation in the first MTP joint and needle-shaped, negatively birefringent
urate crystals. First-line treatments for acute gout include NSAIDs (such as
indomethacin), colchicine, or corticosteroids. Allopurinol, febuxostat, and probenecid
are used for long-term uric acid lowering therapy but can actually worsen an acute
attack if started during the flare.
Question 7: A 3-year-old child presents with a barking cough, inspiratory stridor, and
hoarseness following a two-day history of low-grade fever and coryza. An X-ray of
the neck demonstrates subglottic narrowing known as the "steeple sign." What is the
most common causative organism of this disease?
A. Respiratory syncytial virus
B. Parainfluenza virus
C. Haemophilus influenzae type b
D. Bordetella pertussis
B. Parainfluenza virus
Rationale: The child is presenting with croup (laryngotracheobronchitis), which is
classically characterized by a barking cough, stridor, and the "steeple sign" on an AP
neck X-ray. The parainfluenza virus is the most common viral etiology of croup.
Respiratory syncytial virus (RSV) commonly causes bronchiolitis. Haemophilus
influenzae type b causes epiglottitis, which exhibits a "thumbprint sign." Bordetella
pertussis causes whooping cough.
Question 8: A 44-year-old female presents with chronic fatigue, weight gain,
constipation, and cold intolerance. Physical exam shows a diffuse, non-tender
enlargement of the thyroid gland. Laboratory tests show elevated serum TSH and
decreased free T4 levels. What histological feature is most characteristic of this
patient's underlying condition?
A. Hurthle cells and lymphocytic infiltrates with germinal centers
B. Distended follicles filled with abundant colloid
, C. Papillary projections with orphan Annie eye nuclei
D. Fibrous tissue invading past the thyroid capsule
A. Hurthle cells and lymphocytic infiltrates with germinal centers
Rationale: The patient has Hashimoto's thyroiditis, the most common cause of
hypothyroidism in iodine-sufficient areas. Histology reveals widespread lymphocytic
infiltration, germinal centers, and Hurthle cells (enlarged follicular cells with
eosinophilic cytoplasm). Distended follicles describe a colloid goiter. Orphan Annie
eye nuclei are seen in papillary thyroid carcinoma. Fibrous invasion characterizes
Riedel's thyroiditis.
Question 9: An osteopathic physician performs a structural exam on a patient and
finds a left-on-left sacral torsion. Which of the following findings is most consistent
with this specific diagnosis?
A. A shallow right sacral sulcus
B. A posterior/prominent left ILA
C. A positive right spring test
D. A positive left seated flexion test
D. A positive left seated flexion test
Rationale: For a left-on-left (L-on-L) sacral torsion, the sacrum rotates left on a left
oblique axis. The seated flexion test is positive on the side opposite the axis, which
is the left side. In an L-on-L forward torsion, the right sacral sulcus is deep (not
shallow), and the right inferior lateral angle (ILA) is posterior and inferior (prominent).
Forward torsions yield a negative spring test because the sacral base can still spring
forward.
Question 10: A 68-year-old male with a history of atrial fibrillation presents to the
emergency room with sudden, excruciating abdominal pain out of proportion to the
physical examination findings. An abdominal CT angiography reveals an occlusion in
a major abdominal vessel. Which vessel is most likely occluded?
A. Celiac trunk
B. Superior mesenteric artery
C. Inferior mesenteric artery
D. Renal artery
B. Superior mesenteric artery
Rationale: Severe abdominal pain out of proportion to physical exam findings in a
patient with a history of atrial fibrillation is a classic presentation for acute mesenteric
ischemia, usually caused by an embolic occlusion of the superior mesenteric artery
(SMA). The SMA supplies the bowel from the duodenum to the splenic flexure,
making it highly vulnerable to systemic emboli originating from the left atrium.
Question 11: A 50-year-old chronic alcoholic is brought to the clinic by his family due
to confusion, ataxia, and abnormal eye movements including nystagmus. The
physician suspects a vitamin deficiency. A deficiency in which of the following
vitamins is responsible for this condition?
A. Vitamin B1 (Thiamine)
B. Vitamin B3 (Niacin)
Questions And Well Graded Solutions
With Rationales Updated 2026-2027
Master your boards with this ultimate 176-question COMSAE Phase
1 Form 114 practice set. Exactly formatted for COMLEX Level 1, it
covers high-yield pathology, pharmacology, microbiology, and
critical Osteopathic Principles & Practice (OPP), including sacral
torsions and Fryette's laws. Each single-best-answer multiple-
choice question is paired with a comprehensive, italicized
diagnostic rationale. Ideal for active DO students looking to clear
their school's baseline 400 benchmark
Question 1: A 28-year-old female presents with a distinct, migratory, butterfly-shaped
rash across her cheeks and nasal bridge that worsens after sun exposure.
Laboratory testing reveals positive antinuclear antibodies (ANA) and anti-double-
stranded DNA (anti-dsDNA) antibodies. What is the most likely diagnosis?
A. Systemic lupus erythematosus
B. Dermatomyositis
C. Rosacea
D. Seborrheic dermatitis
A. Systemic lupus erythematosus
Rationale: Systemic lupus erythematosus (SLE) is a chronic autoimmune disease
characterized by a malar (butterfly) rash that exhibits photosensitivity. The presence
of highly specific antibodies like anti-dsDNA confirms the diagnosis. Dermatomyositis
presents with a heliotrope rash and proximal muscle weakness. Rosacea lacks
systemic autoantibodies. Seborrheic dermatitis presents with greasy scales in the
nasolabial folds.
Question 2: A 45-year-old male undergoes a physical examination. The physician
notes a somatic dysfunction of the T5 thoracic vertebra. Palpation reveals that the T5
spinous process rotates preferentially to the right and sidebends preferentially to the
right. When the patient flexes his spine, the asymmetry worsens, but it improves
significantly when he extends his spine. According to Fryette's principles, how should
this somatic dysfunction be named?
A. T5 Neutral R(R) S(L)
B. T5 Extended R(R) S(R)
C. T5 Flexed R(L) S(L)
D. T5 Extended R(L) S(R)
B. T5 Extended R(R) S(R)
,Rationale: Under Fryette's Principle II, non-neutral thoracic dysfunctions occur at a
single vertebral segment where rotation and sidebending occur to the same side.
Because the asymmetry improves in extension, the restriction is in flexion, meaning
the vertebra is trapped in an extended position. The positional diagnosis is named
for its directional preferences: Extended, Rotated Right, and Sidebent Right.
Question 3: A 62-year-old male with a history of chronic smoking presents with an
emergency onset of severe, tearing chest pain that radiates directly to his back
between his scapulae. His blood pressure is 180/100 mmHg in the right arm and
140/85 mmHg in the left arm. What is the most immediate life-threatening condition
to suspect?
A. Acute myocardial infarction
B. Acute aortic dissection
C. Pulmonary embolism
D. Tension pneumothorax
B. Acute aortic dissection
Rationale: A tearing or ripping chest pain radiating to the back, coupled with an
asymmetric blood pressure differential between the upper extremities (>20 mmHg
variation), is highly indicative of an acute aortic dissection. Acute myocardial
infarction typically features crushing retrosternal pain radiating to the jaw or left arm.
Pulmonary embolism presents with pleuritic chest pain and dyspnea. Tension
pneumothorax causes absent breath sounds on the affected side.
Question 4: A 34-year-old patient presents with symptoms highly suggestive of acute
appendicitis. During an osteopathic structural exam, the physician looks for a
Chapman's reflex point to help confirm the visceral involvement. Where is the
anterior Chapman's reflex point for the appendix located?
A. At the tip of the right 12th rib
B. At the tip of the right 11th rib
C. At the periumbilical region
D. At the right 5th intercostal space
B. At the tip of the right 11th rib
Rationale: The anterior Chapman's reflex point for the appendix is specifically
located at the tip of the right 11th rib. The posterior point is located at the transverse
process of T11. The tip of the 12th rib relates to the kidneys. The 5th intercostal
space relates to the liver and gallbladder.
Question 5: A 19-year-old male is brought to the clinic due to severe lethargy,
vomiting, and a deep, rapid breathing pattern. His blood glucose is 450 mg/dL, and
arterial blood gas reveals a pH of 7.15 with a low bicarbonate level. urinalysis is
strongly positive for ketones. Which of the following enzymes is directly activated by
the hormone that is deficient in this patient?
A. Glycogen synthase
B. Glycogen phosphorylase
C. Hormone-sensitive lipase
D. Pyruvate carboxylase
A. Glycogen synthase
,Rationale: The patient is experiencing diabetic ketoacidosis (DKA) due to a profound
deficiency of insulin. Insulin normally acts to lower blood glucose by promoting
storage pathways. It directly activates glycogen synthase via dephosphorylation to
encourage glycogen synthesis. Glycogen phosphorylase and hormone-sensitive
lipase are activated by glucagon and epinephrine, which run counter to insulin.
Question 6: A 52-year-old male presents with severe pain, redness, and swelling in
his right first metatarsophalangeal joint that woke him up in the middle of the night.
Arthrocentesis shows needle-shaped, negatively birefringent crystals under polarized
light microscopy. Which of the following medications is a first-line agent used to treat
the acute flare-up of this condition?
A. Allopurinol
B. Indomethacin
C. Febuxostat
D. Probenecid
B. Indomethacin
Rationale: The clinical scenario describes an acute gout flare, evidenced by the
classic presentation in the first MTP joint and needle-shaped, negatively birefringent
urate crystals. First-line treatments for acute gout include NSAIDs (such as
indomethacin), colchicine, or corticosteroids. Allopurinol, febuxostat, and probenecid
are used for long-term uric acid lowering therapy but can actually worsen an acute
attack if started during the flare.
Question 7: A 3-year-old child presents with a barking cough, inspiratory stridor, and
hoarseness following a two-day history of low-grade fever and coryza. An X-ray of
the neck demonstrates subglottic narrowing known as the "steeple sign." What is the
most common causative organism of this disease?
A. Respiratory syncytial virus
B. Parainfluenza virus
C. Haemophilus influenzae type b
D. Bordetella pertussis
B. Parainfluenza virus
Rationale: The child is presenting with croup (laryngotracheobronchitis), which is
classically characterized by a barking cough, stridor, and the "steeple sign" on an AP
neck X-ray. The parainfluenza virus is the most common viral etiology of croup.
Respiratory syncytial virus (RSV) commonly causes bronchiolitis. Haemophilus
influenzae type b causes epiglottitis, which exhibits a "thumbprint sign." Bordetella
pertussis causes whooping cough.
Question 8: A 44-year-old female presents with chronic fatigue, weight gain,
constipation, and cold intolerance. Physical exam shows a diffuse, non-tender
enlargement of the thyroid gland. Laboratory tests show elevated serum TSH and
decreased free T4 levels. What histological feature is most characteristic of this
patient's underlying condition?
A. Hurthle cells and lymphocytic infiltrates with germinal centers
B. Distended follicles filled with abundant colloid
, C. Papillary projections with orphan Annie eye nuclei
D. Fibrous tissue invading past the thyroid capsule
A. Hurthle cells and lymphocytic infiltrates with germinal centers
Rationale: The patient has Hashimoto's thyroiditis, the most common cause of
hypothyroidism in iodine-sufficient areas. Histology reveals widespread lymphocytic
infiltration, germinal centers, and Hurthle cells (enlarged follicular cells with
eosinophilic cytoplasm). Distended follicles describe a colloid goiter. Orphan Annie
eye nuclei are seen in papillary thyroid carcinoma. Fibrous invasion characterizes
Riedel's thyroiditis.
Question 9: An osteopathic physician performs a structural exam on a patient and
finds a left-on-left sacral torsion. Which of the following findings is most consistent
with this specific diagnosis?
A. A shallow right sacral sulcus
B. A posterior/prominent left ILA
C. A positive right spring test
D. A positive left seated flexion test
D. A positive left seated flexion test
Rationale: For a left-on-left (L-on-L) sacral torsion, the sacrum rotates left on a left
oblique axis. The seated flexion test is positive on the side opposite the axis, which
is the left side. In an L-on-L forward torsion, the right sacral sulcus is deep (not
shallow), and the right inferior lateral angle (ILA) is posterior and inferior (prominent).
Forward torsions yield a negative spring test because the sacral base can still spring
forward.
Question 10: A 68-year-old male with a history of atrial fibrillation presents to the
emergency room with sudden, excruciating abdominal pain out of proportion to the
physical examination findings. An abdominal CT angiography reveals an occlusion in
a major abdominal vessel. Which vessel is most likely occluded?
A. Celiac trunk
B. Superior mesenteric artery
C. Inferior mesenteric artery
D. Renal artery
B. Superior mesenteric artery
Rationale: Severe abdominal pain out of proportion to physical exam findings in a
patient with a history of atrial fibrillation is a classic presentation for acute mesenteric
ischemia, usually caused by an embolic occlusion of the superior mesenteric artery
(SMA). The SMA supplies the bowel from the duodenum to the splenic flexure,
making it highly vulnerable to systemic emboli originating from the left atrium.
Question 11: A 50-year-old chronic alcoholic is brought to the clinic by his family due
to confusion, ataxia, and abnormal eye movements including nystagmus. The
physician suspects a vitamin deficiency. A deficiency in which of the following
vitamins is responsible for this condition?
A. Vitamin B1 (Thiamine)
B. Vitamin B3 (Niacin)
