1
COMSAE Phase 1 Form 113 – The Complete 176 Question Test
Bank All questions with correct verified answers & detailed
rationales – graded A+ for the newest 2026 actual exam
First, Understand the Exam
The COMSAE Phase 1 examination contains 176 items, divided into four sections of 44 questions each. All
examination questions are single-best-answer, multiple-choice format. Some questions include images or visual
exhibits as attachments, and some forms contain videos requiring headphones.
Content Areas – The Phase 1 content is defined by the same nine categories as the COMLEX-USA Dimension 1
topics, with the emphasis on scientific understanding of the mechanisms of clinical situations (rather than just
diagnosis or management). Expect high-yield integration of foundational sciences (anatomy, physiology,
pathology, pharmacology, microbiology, biochemistry, immunology, behavioral sciences) with osteopathic
principles and clinical vignettes.
How to Use this Test Bank – Each of the 176 questions below is modeled after the actual COMSAE Phase 1 Form
113 blueprint. Read the clinical vignette, select your answer, then review the bolded answer and the
detailed rationale. Pay special attention to the why behind each answer—this is what will move you from
memorization to clinical reasoning.
❖ SECTION 1 – OSTEOPATHIC PRINCIPLES & PRACTICE (OPP / OMM)
High-yield – sacral diagnosis, rib mechanics, Chapman reflexes, tenderpoints, and
viscerosomatic reflexes
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
pg. 1
,2
<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, with the inferior lateral angle (ILA) posterior
on the left, indicates rotation around a left oblique axis. “Left-on-left” means the
axis is on the left and the base is rotating anteriorly on the left. [reference:2] ,
[reference:3] </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
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. [reference:4]
</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
pg. 2
,3
<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.
Understanding segmental innervation is critical for correlating clinical
presentation with osteopathic treatment. [reference:5]–[reference:6] </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
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.
[reference:7] </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
pg. 3
, 4
– occurs when diaphragmatic irritation (from blood) stimulates the phrenic nerve
(C3-C5). Somatic dysfunction of the diaphragm is an expected osteopathic finding
in this setting. This is a surgical emergency requiring immediate attention.
</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, especially when pain radiates to the
back and is relieved by leaning forward (knee-chest position). This is a high-yield
clinical correlation. </details>
❖ SECTION 2 – ANATOMY & EMBRYOLOGY
High-yield – major arteries, nerves, pharyngeal arches, foramina, and structural
anomalies
Q7. A 64-year-old man presents with crushing substernal chest pain radiating to
his left arm. ECG shows ST-segment elevations in leads II, III, and aVF. Which
coronary artery is most likely occluded?
A. Left anterior descending
B. Left circumflex
C. Right coronary artery
pg. 4
COMSAE Phase 1 Form 113 – The Complete 176 Question Test
Bank All questions with correct verified answers & detailed
rationales – graded A+ for the newest 2026 actual exam
First, Understand the Exam
The COMSAE Phase 1 examination contains 176 items, divided into four sections of 44 questions each. All
examination questions are single-best-answer, multiple-choice format. Some questions include images or visual
exhibits as attachments, and some forms contain videos requiring headphones.
Content Areas – The Phase 1 content is defined by the same nine categories as the COMLEX-USA Dimension 1
topics, with the emphasis on scientific understanding of the mechanisms of clinical situations (rather than just
diagnosis or management). Expect high-yield integration of foundational sciences (anatomy, physiology,
pathology, pharmacology, microbiology, biochemistry, immunology, behavioral sciences) with osteopathic
principles and clinical vignettes.
How to Use this Test Bank – Each of the 176 questions below is modeled after the actual COMSAE Phase 1 Form
113 blueprint. Read the clinical vignette, select your answer, then review the bolded answer and the
detailed rationale. Pay special attention to the why behind each answer—this is what will move you from
memorization to clinical reasoning.
❖ SECTION 1 – OSTEOPATHIC PRINCIPLES & PRACTICE (OPP / OMM)
High-yield – sacral diagnosis, rib mechanics, Chapman reflexes, tenderpoints, and
viscerosomatic reflexes
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
pg. 1
,2
<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, with the inferior lateral angle (ILA) posterior
on the left, indicates rotation around a left oblique axis. “Left-on-left” means the
axis is on the left and the base is rotating anteriorly on the left. [reference:2] ,
[reference:3] </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
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. [reference:4]
</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
pg. 2
,3
<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.
Understanding segmental innervation is critical for correlating clinical
presentation with osteopathic treatment. [reference:5]–[reference:6] </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
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.
[reference:7] </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
pg. 3
, 4
– occurs when diaphragmatic irritation (from blood) stimulates the phrenic nerve
(C3-C5). Somatic dysfunction of the diaphragm is an expected osteopathic finding
in this setting. This is a surgical emergency requiring immediate attention.
</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, especially when pain radiates to the
back and is relieved by leaning forward (knee-chest position). This is a high-yield
clinical correlation. </details>
❖ SECTION 2 – ANATOMY & EMBRYOLOGY
High-yield – major arteries, nerves, pharyngeal arches, foramina, and structural
anomalies
Q7. A 64-year-old man presents with crushing substernal chest pain radiating to
his left arm. ECG shows ST-segment elevations in leads II, III, and aVF. Which
coronary artery is most likely occluded?
A. Left anterior descending
B. Left circumflex
C. Right coronary artery
pg. 4
