COMSAE Phase 1 Form 114 Real Exam
Questions And Well Graded Solutions With
Rationales Updated 2026-2027
Ace your boards with this comprehensive study guide for the COMSAE Phase 1 Form 114
exam. It features complete, verified multiple-choice questions with correct answers
highlighted. Each item includes deep, high-yield clinical rationales covering high-stakes
topics: Type I & II spinal mechanics, cranial strain patterns, sacral torsions, high-yield
pathology, and pharmacology. Perfect for osteopathic medical students seeking to meet
school benchmarks and secure solid COMLEX Level 1 pass predictability.
Question 1: A 24-year-old male presents with acute lower back pain after lifting
heavy boxes. Physical examination reveals that the right L4 transverse process is
more posterior than the left. The asymmetry worsens during lumbar flexion and
normalizes during lumbar extension. What is the correct somatic dysfunction?
A) L4 Neutral, Rotated Right, Sidebent Left
B) L4 Flexed, Rotated Left, Sidebent Left
C) L4 Extended, Rotated Right, Sidebent Right
D) L4 Extended, Rotated Left, Sidebent Left
E) L4 Neutral, Rotated Left, Sidebent Right
Rationale
The asymmetry normalizes in extension, indicating an extension (E) somatic
dysfunction (Type II mechanics). Type II mechanics dictate that rotation and
sidebending occur to the same side. Because the right transverse process is
posterior, the vertebra is rotated right (R_R) and sidebent right (S_R).
• Choices A, B, D, and E do not match these criteria.
Question 2: Which of the following cranial techniques is specifically designed to
enhance the amplitude of the cranial rhythmic impulse (CRI)?
A) Venous sinus traction
B) Bulb compression (CV4)
C) V-spread technique
D) Frontal lift
E) Parietal lift
Rationale
Compression of the fourth ventricle (CV4) is explicitly utilized to encourage fluid
movement, enhance the amplitude of the CRI, and assist with autonomic nervous
system balancing.
• Choices A, C, D, and E target specific sutural restrictions or venous drainage but do
not primarily amplify the CRI.
Question 3: A 45-year-old female presents with pain along the medial aspect of her
right knee. Palpation reveals a tender point on the medial surface of the tibia,
approximately 2 cm below the joint line, at the insertion of the pes anserinus. Which
, position is used for counterstrain treatment?
A) Flexion, Abduction, External Rotation
B) Flexion, Adduction, Internal Rotation
C) Extension, Abduction, External Rotation
D) Extension, Adduction, Internal Rotation
E) Pure Abduction without flexion
Rationale
The medial knee tender point (often associated with the medial meniscus or pes
anserinus) is treated with hip/knee flexion, adduction, and internal rotation of the
tibia.
• Choices A, C, D, and E will stretch the tissue rather than shorten it, worsening the
tender point.
Question 4: A 19-year-old college student presents with a sore throat, fever, and
generalized fatigue. Physical examination reveals posterior cervical
lymphadenopathy and splenomegaly. A heterophile antibody test is positive. Which
virus is the most likely causative agent?
A) Cytomegalovirus
B) Human Herpesvirus 6
C) Epstein-Barr Virus
D) Adenovirus
E) Coxsackievirus A
Rationale
The clinical presentation of fever, sore throat, lymphadenopathy, splenomegaly, and
a positive heterophile antibody (Monospot) test is diagnostic for Infectious
Mononucleosis caused by the Epstein-Barr Virus (EBV).
• Choice A causes a similar syndrome but is heterophile negative. Choices B, D, and
E do not match this classic diagnostic profile.
Question 5: A 32-year-old pregnant female at 28 weeks gestation presents with
heartburn. Autonomic reflex pathways would predict somatic manifestations from the
stomach to map to which of the following spinal cord segments?
A) T5-T9
B) T10-T11
C) T12-L2
D) C3-C5
E) T1-T4
Rationale
The stomach receives its sympathetic innervation from the greater splanchnic nerve,
which originates from the T5-T9 segments of the spinal cord.
• Choices B, C, D, and E represent lower GI tracts, pelvic structures, the diaphragm,
or head/neck structures respectively.
Question 6: During a newborn examination, the physician notes that the infant’s
occiput is compressed anteriorly against the atlas. This condition can compress
which of the following cranial nerves passing through the jugular foramen?
A) CN VII
, B) CN V
C) CN IX
D) CN XII
E) CN VI
Rationale
The jugular foramen is formed by the petrous portion of the temporal bone and the
occipital bone. Cranial nerves IX, X, and XI pass through it. Occipital condylar
compression can cause dysfunction here.
• Choices A, B, D, and E pass through different foramina (e.g., internal acoustic
meatus, superior orbital fissure, hypoglossal canal).
Question 7: A 50-year-old male with a history of chronic alcoholism presents to the
emergency department with confusion, ataxia, and ophthalmoplegia. A deficiency in
which of the following cofactors is responsible for this condition?
A) Pyridoxine
B) Riboflavin
C) Thiamine
D) Niacin
E) Cobalamin
Rationale
The triad of confusion, ataxia, and ophthalmoplegia is classic for Wernicke
encephalopathy, which results from vitamin B1 (thiamine) deficiency common in
severe alcoholism.
• Choices A, B, D, and E present with different classic deficiencies (e.g., pellagra,
anemia, peripheral neuropathy).
Question 8: Evaluation of a patient’s rib cage reveals that during inhalation, ribs 6
through 10 move freely, but during exhalation, they stop moving early. What is the
key rib to treat for this dysfunction?
A) Rib 6
B) Rib 10
C) Rib 8
D) Rib 1
E) Rib 11
Rationale
The rib group stops moving early during exhalation, meaning it prefers inhalation
(Inhalation Somatic Dysfunction/Exhalation Restriction). For an inhalation rib
dysfunction, the key rib is the bottom rib of the moving group.
• Choices A, C, D, and E are incorrect because Rib 10 is the lowest rib in the 6-10
group.
Question 9: A 28-year-old female presents with persistent diarrhea, weight loss, and
abdominal pain. A biopsy of the terminal ileum shows transmural inflammation,
noncaseating granulomas, and a cobblestone appearance. Which of the following
complications is she at highest risk for?
A) Toxic megacolon
B) Adenocarcinoma of the rectosigmoid
, C) Fistula formation
D) Primary sclerosing cholangitis
E) Ischemic colitis
Rationale
The description points to Crohn's Disease (transmural inflammation, terminal ileum,
noncaseating granulomas). Transmural inflammation predisposes patients to
penetrating disease and fistula tract formations.
• Choices A, B, and D are more heavily associated with Ulcerative Colitis.
Question 10: An 8-year-old boy presents with a high fever, a barking cough, and
inspiratory stridor. A neck X-ray demonstrates subglottic narrowing (the steeple
sign). What is the most likely viral etiology?
A) Parainfluenza virus
B) Respiratory syncytial virus
C) Influenza A virus
D) Rhinovirus
E) Coronavirus
Rationale
Laryngotracheobronchitis (croup) presents with a barking cough, stridor, and the
"steeple sign" on X-ray, caused predominantly by Parainfluenza virus.
• Choice B causes bronchiolitis in younger infants. Choices C, D, and E do not
typically cause classic croup.
Question 11: A patient is diagnosed with a somatic dysfunction where the right
innominate is rotated anteriorly. Which muscle can be utilized as the activating force
during Muscle Energy technique to correct this?
A) Rectus femoris
B) Iliopsoas
C) Hamstrings
D) Gluteus medius
E) Tensor fascia lata
Rationale
To correct an anterior innominate dysfunction, the innominate must be pulled
posteriorly. The hamstring muscles originate on the ischial tuberosity and will pull the
innominate posteriorly when contracted against resistance.
• Choice B would pull it further anteriorly.
Question 12: A 65-year-old male presents with progressive vision loss. Fundoscopic
exam reveals drusen deposits in the macula. What is the primary pathophysiologic
mechanism of this disease?
A) Increased intraocular pressure
B) Degeneration of the retinal pigment epithelium
C) Glycation of the lens proteins
D) Retinal detachment
E) Autoimmune uveitis
Rationale
Questions And Well Graded Solutions With
Rationales Updated 2026-2027
Ace your boards with this comprehensive study guide for the COMSAE Phase 1 Form 114
exam. It features complete, verified multiple-choice questions with correct answers
highlighted. Each item includes deep, high-yield clinical rationales covering high-stakes
topics: Type I & II spinal mechanics, cranial strain patterns, sacral torsions, high-yield
pathology, and pharmacology. Perfect for osteopathic medical students seeking to meet
school benchmarks and secure solid COMLEX Level 1 pass predictability.
Question 1: A 24-year-old male presents with acute lower back pain after lifting
heavy boxes. Physical examination reveals that the right L4 transverse process is
more posterior than the left. The asymmetry worsens during lumbar flexion and
normalizes during lumbar extension. What is the correct somatic dysfunction?
A) L4 Neutral, Rotated Right, Sidebent Left
B) L4 Flexed, Rotated Left, Sidebent Left
C) L4 Extended, Rotated Right, Sidebent Right
D) L4 Extended, Rotated Left, Sidebent Left
E) L4 Neutral, Rotated Left, Sidebent Right
Rationale
The asymmetry normalizes in extension, indicating an extension (E) somatic
dysfunction (Type II mechanics). Type II mechanics dictate that rotation and
sidebending occur to the same side. Because the right transverse process is
posterior, the vertebra is rotated right (R_R) and sidebent right (S_R).
• Choices A, B, D, and E do not match these criteria.
Question 2: Which of the following cranial techniques is specifically designed to
enhance the amplitude of the cranial rhythmic impulse (CRI)?
A) Venous sinus traction
B) Bulb compression (CV4)
C) V-spread technique
D) Frontal lift
E) Parietal lift
Rationale
Compression of the fourth ventricle (CV4) is explicitly utilized to encourage fluid
movement, enhance the amplitude of the CRI, and assist with autonomic nervous
system balancing.
• Choices A, C, D, and E target specific sutural restrictions or venous drainage but do
not primarily amplify the CRI.
Question 3: A 45-year-old female presents with pain along the medial aspect of her
right knee. Palpation reveals a tender point on the medial surface of the tibia,
approximately 2 cm below the joint line, at the insertion of the pes anserinus. Which
, position is used for counterstrain treatment?
A) Flexion, Abduction, External Rotation
B) Flexion, Adduction, Internal Rotation
C) Extension, Abduction, External Rotation
D) Extension, Adduction, Internal Rotation
E) Pure Abduction without flexion
Rationale
The medial knee tender point (often associated with the medial meniscus or pes
anserinus) is treated with hip/knee flexion, adduction, and internal rotation of the
tibia.
• Choices A, C, D, and E will stretch the tissue rather than shorten it, worsening the
tender point.
Question 4: A 19-year-old college student presents with a sore throat, fever, and
generalized fatigue. Physical examination reveals posterior cervical
lymphadenopathy and splenomegaly. A heterophile antibody test is positive. Which
virus is the most likely causative agent?
A) Cytomegalovirus
B) Human Herpesvirus 6
C) Epstein-Barr Virus
D) Adenovirus
E) Coxsackievirus A
Rationale
The clinical presentation of fever, sore throat, lymphadenopathy, splenomegaly, and
a positive heterophile antibody (Monospot) test is diagnostic for Infectious
Mononucleosis caused by the Epstein-Barr Virus (EBV).
• Choice A causes a similar syndrome but is heterophile negative. Choices B, D, and
E do not match this classic diagnostic profile.
Question 5: A 32-year-old pregnant female at 28 weeks gestation presents with
heartburn. Autonomic reflex pathways would predict somatic manifestations from the
stomach to map to which of the following spinal cord segments?
A) T5-T9
B) T10-T11
C) T12-L2
D) C3-C5
E) T1-T4
Rationale
The stomach receives its sympathetic innervation from the greater splanchnic nerve,
which originates from the T5-T9 segments of the spinal cord.
• Choices B, C, D, and E represent lower GI tracts, pelvic structures, the diaphragm,
or head/neck structures respectively.
Question 6: During a newborn examination, the physician notes that the infant’s
occiput is compressed anteriorly against the atlas. This condition can compress
which of the following cranial nerves passing through the jugular foramen?
A) CN VII
, B) CN V
C) CN IX
D) CN XII
E) CN VI
Rationale
The jugular foramen is formed by the petrous portion of the temporal bone and the
occipital bone. Cranial nerves IX, X, and XI pass through it. Occipital condylar
compression can cause dysfunction here.
• Choices A, B, D, and E pass through different foramina (e.g., internal acoustic
meatus, superior orbital fissure, hypoglossal canal).
Question 7: A 50-year-old male with a history of chronic alcoholism presents to the
emergency department with confusion, ataxia, and ophthalmoplegia. A deficiency in
which of the following cofactors is responsible for this condition?
A) Pyridoxine
B) Riboflavin
C) Thiamine
D) Niacin
E) Cobalamin
Rationale
The triad of confusion, ataxia, and ophthalmoplegia is classic for Wernicke
encephalopathy, which results from vitamin B1 (thiamine) deficiency common in
severe alcoholism.
• Choices A, B, D, and E present with different classic deficiencies (e.g., pellagra,
anemia, peripheral neuropathy).
Question 8: Evaluation of a patient’s rib cage reveals that during inhalation, ribs 6
through 10 move freely, but during exhalation, they stop moving early. What is the
key rib to treat for this dysfunction?
A) Rib 6
B) Rib 10
C) Rib 8
D) Rib 1
E) Rib 11
Rationale
The rib group stops moving early during exhalation, meaning it prefers inhalation
(Inhalation Somatic Dysfunction/Exhalation Restriction). For an inhalation rib
dysfunction, the key rib is the bottom rib of the moving group.
• Choices A, C, D, and E are incorrect because Rib 10 is the lowest rib in the 6-10
group.
Question 9: A 28-year-old female presents with persistent diarrhea, weight loss, and
abdominal pain. A biopsy of the terminal ileum shows transmural inflammation,
noncaseating granulomas, and a cobblestone appearance. Which of the following
complications is she at highest risk for?
A) Toxic megacolon
B) Adenocarcinoma of the rectosigmoid
, C) Fistula formation
D) Primary sclerosing cholangitis
E) Ischemic colitis
Rationale
The description points to Crohn's Disease (transmural inflammation, terminal ileum,
noncaseating granulomas). Transmural inflammation predisposes patients to
penetrating disease and fistula tract formations.
• Choices A, B, and D are more heavily associated with Ulcerative Colitis.
Question 10: An 8-year-old boy presents with a high fever, a barking cough, and
inspiratory stridor. A neck X-ray demonstrates subglottic narrowing (the steeple
sign). What is the most likely viral etiology?
A) Parainfluenza virus
B) Respiratory syncytial virus
C) Influenza A virus
D) Rhinovirus
E) Coronavirus
Rationale
Laryngotracheobronchitis (croup) presents with a barking cough, stridor, and the
"steeple sign" on X-ray, caused predominantly by Parainfluenza virus.
• Choice B causes bronchiolitis in younger infants. Choices C, D, and E do not
typically cause classic croup.
Question 11: A patient is diagnosed with a somatic dysfunction where the right
innominate is rotated anteriorly. Which muscle can be utilized as the activating force
during Muscle Energy technique to correct this?
A) Rectus femoris
B) Iliopsoas
C) Hamstrings
D) Gluteus medius
E) Tensor fascia lata
Rationale
To correct an anterior innominate dysfunction, the innominate must be pulled
posteriorly. The hamstring muscles originate on the ischial tuberosity and will pull the
innominate posteriorly when contracted against resistance.
• Choice B would pull it further anteriorly.
Question 12: A 65-year-old male presents with progressive vision loss. Fundoscopic
exam reveals drusen deposits in the macula. What is the primary pathophysiologic
mechanism of this disease?
A) Increased intraocular pressure
B) Degeneration of the retinal pigment epithelium
C) Glycation of the lens proteins
D) Retinal detachment
E) Autoimmune uveitis
Rationale
