COMSAE Phase 1 Form 114 Study Guide | Complete
Practice Exam with Questions, Answers in Bold Italic,
and Detailed Explanations for Osteopathic Medical
Students
Are you preparing for the COMSAE (Comprehensive Osteopathic Medical Self-
Assessment Examination) Phase 1 Form 114? Do you need a comprehensive practice
exam that mirrors the actual NBOME assessment? This complete study guide
provides 200+ practice questions with correct answers in bold italic and detailed
rationales to help you assess your readiness for COMLEX-USA Level 1!
Question 1
A 62-year-old man presents to the emergency department with 45 minutes of severe
substernal chest pain that began while he was resting. He describes the pain as a
“crushing pressure” radiating to his left arm and jaw. He is diaphoretic and nauseated. His
past medical history includes hypertension, hyperlipidemia, and a 30-pack-year smoking
history.
Vital signs: BP 148/90 mmHg, HR 104/min, RR 20/min, SpO₂ 96% on room air.
ECG reveals ST-segment elevation in leads II, III, and aVF.
Which of the following is the most likely underlying mechanism of this patient’s
condition?
A. Coronary vasospasm causing transient myocardial ischemia
B. Rupture of an atherosclerotic plaque leading to thrombus formation
C. Embolization from the left atrium due to atrial fibrillation
D. Increased myocardial oxygen demand without coronary obstruction
Answer: B
,Rationale: This presentation is classic for an inferior STEMI. The most common mechanism
is rupture of an atherosclerotic plaque with subsequent platelet aggregation and thrombus
formation, leading to acute coronary artery occlusion (most often the right coronary artery).
Question 2
A 70-year-old woman with a history of hypertension and chronic heart failure presents with
progressive shortness of breath, orthopnea, and bilateral leg swelling over the past
week. She reports needing multiple pillows to sleep.
On examination, she has bilateral crackles, elevated jugular venous pressure, and 2+
pitting edema. Cardiac exam reveals an S3 gallop.
Which of the following best explains the physiologic mechanism contributing to her
worsening symptoms?
A. Decreased renin release leading to reduced fluid retention
B. Increased atrial natriuretic peptide causing sodium loss
C. Activation of the renin-angiotensin-aldosterone system causing sodium and water
retention
D. Suppression of sympathetic nervous system activity
Answer: C
Rationale: In heart failure, decreased cardiac output triggers activation of the RAAS system,
leading to sodium and water retention. While initially compensatory, this worsens volume
overload, causing pulmonary edema, JVD, and peripheral edema.
Question 3
A 23-year-old man is brought to the emergency department with fever, severe headache,
neck stiffness, and confusion that began earlier that day. His roommate reports that he
has become progressively disoriented.
On examination, the patient is febrile and has positive Kernig and Brudzinski signs.
Lumbar puncture reveals:
, Elevated opening pressure
Increased neutrophils
Decreased glucose
Elevated protein
What is the most appropriate next step in management?
A. Delay treatment until culture results return
B. Begin oral antibiotics
C. Start empiric IV ceftriaxone and vancomycin immediately
D. Administer corticosteroids only
Answer: C
Rationale: This is acute bacterial meningitis. Immediate empiric IV antibiotics are critical and
should not be delayed for culture confirmation. Ceftriaxone plus vancomycin covers the
most likely organisms.
Question 4
A 55-year-old man with a history of chronic alcohol use presents with progressive gait
instability, numbness in his feet, and memory problems. On examination, he has
decreased vibration and proprioception in the lower extremities and an ataxic gait.
Laboratory testing reveals macrocytic anemia.
Which of the following is the most likely underlying deficiency?
A. Vitamin B1 (thiamine)
B. Vitamin B6 (pyridoxine)
C. Vitamin B12 (cobalamin)
D. Folate
Answer: C
, Rationale: Vitamin B12 deficiency causes subacute combined degeneration of the spinal
cord, leading to loss of vibration/proprioception, ataxia, and neuropsychiatric symptoms,
along with macrocytic anemia.
Question 5
A 19-year-old woman presents with polyuria, polydipsia, nausea, and abdominal pain.
She is tachypneic with deep, rapid respirations. Laboratory studies show:
Glucose: 520 mg/dL
pH: 7.08
Bicarbonate: 10 mEq/L
Positive serum ketones
Which finding best indicates that treatment is effective?
A. Blood glucose decreases to 300 mg/dL
B. Persistent Kussmaul respirations
C. pH increases to 7.30
D. Serum potassium increases
Answer: C
Rationale: The key indicator of improvement in DKA is correction of metabolic acidosis,
reflected by normalization of pH. Glucose reduction alone does not indicate full resolution.
6.
A 68-year-old man with a history of chronic obstructive pulmonary disease (COPD)
presents with worsening shortness of breath and productive cough. He is cyanotic and
using accessory muscles to breathe.
Arterial blood gas shows:
pH: 7.32
PaCO₂: 60 mmHg
Practice Exam with Questions, Answers in Bold Italic,
and Detailed Explanations for Osteopathic Medical
Students
Are you preparing for the COMSAE (Comprehensive Osteopathic Medical Self-
Assessment Examination) Phase 1 Form 114? Do you need a comprehensive practice
exam that mirrors the actual NBOME assessment? This complete study guide
provides 200+ practice questions with correct answers in bold italic and detailed
rationales to help you assess your readiness for COMLEX-USA Level 1!
Question 1
A 62-year-old man presents to the emergency department with 45 minutes of severe
substernal chest pain that began while he was resting. He describes the pain as a
“crushing pressure” radiating to his left arm and jaw. He is diaphoretic and nauseated. His
past medical history includes hypertension, hyperlipidemia, and a 30-pack-year smoking
history.
Vital signs: BP 148/90 mmHg, HR 104/min, RR 20/min, SpO₂ 96% on room air.
ECG reveals ST-segment elevation in leads II, III, and aVF.
Which of the following is the most likely underlying mechanism of this patient’s
condition?
A. Coronary vasospasm causing transient myocardial ischemia
B. Rupture of an atherosclerotic plaque leading to thrombus formation
C. Embolization from the left atrium due to atrial fibrillation
D. Increased myocardial oxygen demand without coronary obstruction
Answer: B
,Rationale: This presentation is classic for an inferior STEMI. The most common mechanism
is rupture of an atherosclerotic plaque with subsequent platelet aggregation and thrombus
formation, leading to acute coronary artery occlusion (most often the right coronary artery).
Question 2
A 70-year-old woman with a history of hypertension and chronic heart failure presents with
progressive shortness of breath, orthopnea, and bilateral leg swelling over the past
week. She reports needing multiple pillows to sleep.
On examination, she has bilateral crackles, elevated jugular venous pressure, and 2+
pitting edema. Cardiac exam reveals an S3 gallop.
Which of the following best explains the physiologic mechanism contributing to her
worsening symptoms?
A. Decreased renin release leading to reduced fluid retention
B. Increased atrial natriuretic peptide causing sodium loss
C. Activation of the renin-angiotensin-aldosterone system causing sodium and water
retention
D. Suppression of sympathetic nervous system activity
Answer: C
Rationale: In heart failure, decreased cardiac output triggers activation of the RAAS system,
leading to sodium and water retention. While initially compensatory, this worsens volume
overload, causing pulmonary edema, JVD, and peripheral edema.
Question 3
A 23-year-old man is brought to the emergency department with fever, severe headache,
neck stiffness, and confusion that began earlier that day. His roommate reports that he
has become progressively disoriented.
On examination, the patient is febrile and has positive Kernig and Brudzinski signs.
Lumbar puncture reveals:
, Elevated opening pressure
Increased neutrophils
Decreased glucose
Elevated protein
What is the most appropriate next step in management?
A. Delay treatment until culture results return
B. Begin oral antibiotics
C. Start empiric IV ceftriaxone and vancomycin immediately
D. Administer corticosteroids only
Answer: C
Rationale: This is acute bacterial meningitis. Immediate empiric IV antibiotics are critical and
should not be delayed for culture confirmation. Ceftriaxone plus vancomycin covers the
most likely organisms.
Question 4
A 55-year-old man with a history of chronic alcohol use presents with progressive gait
instability, numbness in his feet, and memory problems. On examination, he has
decreased vibration and proprioception in the lower extremities and an ataxic gait.
Laboratory testing reveals macrocytic anemia.
Which of the following is the most likely underlying deficiency?
A. Vitamin B1 (thiamine)
B. Vitamin B6 (pyridoxine)
C. Vitamin B12 (cobalamin)
D. Folate
Answer: C
, Rationale: Vitamin B12 deficiency causes subacute combined degeneration of the spinal
cord, leading to loss of vibration/proprioception, ataxia, and neuropsychiatric symptoms,
along with macrocytic anemia.
Question 5
A 19-year-old woman presents with polyuria, polydipsia, nausea, and abdominal pain.
She is tachypneic with deep, rapid respirations. Laboratory studies show:
Glucose: 520 mg/dL
pH: 7.08
Bicarbonate: 10 mEq/L
Positive serum ketones
Which finding best indicates that treatment is effective?
A. Blood glucose decreases to 300 mg/dL
B. Persistent Kussmaul respirations
C. pH increases to 7.30
D. Serum potassium increases
Answer: C
Rationale: The key indicator of improvement in DKA is correction of metabolic acidosis,
reflected by normalization of pH. Glucose reduction alone does not indicate full resolution.
6.
A 68-year-old man with a history of chronic obstructive pulmonary disease (COPD)
presents with worsening shortness of breath and productive cough. He is cyanotic and
using accessory muscles to breathe.
Arterial blood gas shows:
pH: 7.32
PaCO₂: 60 mmHg
