COMLEX-USA Comprehensive Practice
Examination V3.1: Advanced Clinical
Integration and Osteopathic Principles with
Multisystem Complexity a well detailed exam
2025/2026 graded A+ upgraded !!!
Target Audience: Osteopathic medical students preparing for COMLEX-USA Levels 1, 2-CE, and 3
with emphasis on clinical reasoning and integrative thinking
Difficulty Level: Advanced/Hard with complex, multi-step clinical scenarios requiring synthesis
of basic sciences, clinical medicine, and osteopathic principles
Exam Format: Single-best-answer multiple-choice questions aligned with NBOME COMLEX-USA
blueprint with emphasis on higher-order cognitive skills
Osteopathic Emphasis: Deep integration of OMM/OMT, viscerosomatic reflexes, Chapman
points, cranial osteopathy, and osteopathic principles across all systems with complex clinical
presentations
SECTION 1: OSTEOPATHIC PRINCIPLES, PRACTICE, AND MANIPULATIVE TREATMENT
(OMM/OPP) - ADVANCED CLINICAL INTEGRATION
Question 1
A 58-year-old male with a 30-year history of type 2 diabetes mellitus presents with chronic
bilateral lower extremity pain, burning dysesthesias, and progressive weakness. On osteopathic
structural examination, you identify significant somatic dysfunction at T10-L2 with associated
paraspinal muscle hypertonicity, restricted segmental motion, and Chapman points at the right
12th rib posteriorly. Additionally, you note a tender point in the right gluteus medius muscle
belly that reproduces the patient's radicular pain. Which of the following represents the most
comprehensive osteopathic diagnostic formulation incorporating both somatic and visceral
components?
A) Segmental facilitation at T10-L2 secondary to diabetic nephropathy with associated gluteal
tender point representing a somatic dysfunction
,B) Diabetic peripheral neuropathy with secondary myofascial pain syndrome and compensatory
gait abnormalities
C) Somatic dysfunction at T10-L2 with viscerosomatic reflex from pancreatic dysfunction and
associated piriformis syndrome
D) Chronic sacroiliac joint dysfunction with secondary lumbar spine compensatory changes and
diabetic neuropathy
E) Lumbar radiculopathy from degenerative disc disease exacerbated by diabetic autonomic
neuropathy
Correct Answer: A) Segmental facilitation at T10-L2 secondary to diabetic nephropathy with
associated gluteal tender point representing a somatic dysfunction
Rationale: This question requires integration of viscerosomatic reflex principles with clinical
presentation. The T10-L2 segmental level corresponds to the kidneys, which are affected in
diabetic nephropathy. The Chapman point at the right 12th rib posteriorly correlates with
kidney dysfunction, not gluteal pathology. The tender point in the gluteus medius represents a
myofascial component of the somatic dysfunction pattern. Diabetic peripheral neuropathy (B)
would present with stocking-glove distribution, not segmental T10-L2 findings. Pancreatic
dysfunction (C) would reflex to T6-T10, not T10-L2. Sacroiliac dysfunction (D) would present
with different findings. Degenerative disc disease (E) would show radicular findings but would
not explain the viscerosomatic component or Chapman points. This comprehensive formulation
integrates the somatic findings (segmental dysfunction, tender point) with the visceral
component (diabetic nephropathy) through viscerosomatic reflex mechanisms.
Question 2
A 45-year-old female presents with chronic tension-type headaches, cervicalgia, and episodic
vertigo. Cranial osteopathic examination reveals the sphenoid is rotated to the left and sidebent
to the right, while the occiput is rotated to the right and sidebent to the left, with both bones
showing compensatory strain patterns. The temporal bones are internally rotated bilaterally,
and the occipitomastoid sutures are restricted. Which of the following represents the most
likely primary cranial dysfunction and its most appropriate osteopathic treatment approach?
A) Sphenobasilar synchondrosis torsion strain with secondary temporal bone dysfunction;
treatment with CV4 and temporal bone release
B) Sphenobasilar synchondrosis sidebending rotation strain with temporal bone involvement;
treatment with sphenopalatine ganglion release and occipitomastoid suture mobilization
C) Lateral strain of the sphenobasilar synchondrosis with temporal bone rotation; treatment
with V-spread technique and frontal lift
,D) Compression strain of the sphenobasilar synchondrosis with secondary occipitomastoid
restriction; treatment with decompression and balanced membranous tension
E) Combined strain pattern involving the sphenoid, occiput, and temporal bones with primary
occipitomastoid dysfunction; treatment with direct temporal bone mobilization
Correct Answer: B) Sphenobasilar synchondrosis sidebending rotation strain with temporal
bone involvement; treatment with sphenopalatine ganglion release and occipitomastoid
suture mobilization
Rationale: The description indicates the sphenoid and occiput are sidebent in the same
direction (both to opposite sides) and rotated in opposite directions, which defines a
sidebending rotation strain pattern. This is more complex than simple torsion or lateral strain.
Temporal bone involvement (internal rotation bilaterally) is common with this pattern.
Occipitomastoid suture restriction contributes to the headache and vertigo symptoms.
Treatment should address both the primary SBS strain and the secondary temporal bone
involvement. CV4 (A) is appropriate for compression strains. V-spread and frontal lift (C) address
other aspects of cranial dysfunction but not the sidebending rotation pattern specifically.
Compression strain (D) does not match the description. Isolated temporal bone mobilization (E)
would not address the primary SBS dysfunction. The sphenopalatine ganglion release helps
address the autonomic component contributing to the tension-type headaches.
Question 3
A 62-year-old male with a history of chronic obstructive pulmonary disease (COPD) presents
with progressive dyspnea, orthopnea, and chronic productive cough. Pulmonary function
testing shows an FEV1/FVC ratio of 48% with significant hyperinflation. On osteopathic
examination, you identify a Type I dysfunction at T3-T7 with the vertebrae rotated and sidebent
to the left, a right rib exhalation dysfunction involving ribs 3-6, and significant restriction of the
thoracic diaphragm with decreased excursion on the right. Additionally, you note a Chapman
point at the left 3rd-4th intercostal space. Which of the following represents the most
appropriate comprehensive osteopathic treatment sequence addressing the patient's
pulmonary and musculoskeletal dysfunctions?
A) Treat the thoracic Type I dysfunction with high-velocity low-amplitude (HVLA) technique,
followed by rib raising to address the rib dysfunction, and then doming of the diaphragm to
improve respiratory mechanics
B) Begin with diaphragmatic release to improve ventilation, followed by rib mobilization for the
exhalation dysfunction, and finish with myofascial release of the thoracic paraspinal muscles
C) Address the rib exhalation dysfunction with muscle energy technique to improve inspiratory
, capacity, followed by thoracic articulation to correct the Type I dysfunction, and conclude with
lymphatic pump techniques
D) Perform indirect counterstrain for the Chapman point, followed by balanced ligamentous
tension for the thoracic dysfunction, and complete with gentle rib raising
E) Initiate treatment with thoracic inlet release to improve lymphatic drainage, followed by
direct fascial release of the diaphragm, and conclude with pedal pump for venous return
Correct Answer: C) Address the rib exhalation dysfunction with muscle energy technique to
improve inspiratory capacity, followed by thoracic articulation to correct the Type I
dysfunction, and conclude with lymphatic pump techniques
Rationale: In a COPD patient with significant respiratory compromise, the treatment sequence
should prioritize interventions that immediately improve ventilation. Rib exhalation dysfunction
directly limits inspiratory capacity (the ribs are stuck in exhalation), so treating this first with
muscle energy technique will improve the patient's ability to inhale. The Type I dysfunction at
T3-T7 should be addressed next with articulation rather than HVLA (A) because HVLA may be
too aggressive in a COPD patient with hyperinflation and potential osteoporosis. The Chapman
point at the left 3rd-4th intercostal space correlates with the left lung, consistent with COPD
pathology. Lymphatic pump techniques will help clear secretions and improve pulmonary
function. Starting with diaphragmatic release (B) is appropriate but should follow rib
mobilization. Indirect counterstrain (D) may not be aggressive enough for the functional
restrictions. Thoracic inlet release and pedal pump (E) address lymphatic and circulatory
components but should not be the primary interventions. The sequence should be: improve
mechanics (ribs), correct segmental dysfunction (thoracic), and enhance lymphatic drainage
(pump techniques).
Question 4
A 55-year-old female with chronic pelvic pain, dysmenorrhea, and a history of endometriosis
presents for osteopathic evaluation. She reports that her symptoms are worse during menses
and are associated with low back pain, right-sided sciatica, and constipation. On examination,
you identify significant sacral dysfunction with the sacrum flexed on the right and extended on
the left, a right anterior innominate dysfunction, and a tender point in the right pyriformis
muscle. Additionally, you note a Chapman point in the left groin area superior to the inguinal
ligament and a viscerosomatic reflex at T11-L1. Which of the following represents the most
likely primary visceral dysfunction and the most appropriate comprehensive osteopathic
treatment plan?
Examination V3.1: Advanced Clinical
Integration and Osteopathic Principles with
Multisystem Complexity a well detailed exam
2025/2026 graded A+ upgraded !!!
Target Audience: Osteopathic medical students preparing for COMLEX-USA Levels 1, 2-CE, and 3
with emphasis on clinical reasoning and integrative thinking
Difficulty Level: Advanced/Hard with complex, multi-step clinical scenarios requiring synthesis
of basic sciences, clinical medicine, and osteopathic principles
Exam Format: Single-best-answer multiple-choice questions aligned with NBOME COMLEX-USA
blueprint with emphasis on higher-order cognitive skills
Osteopathic Emphasis: Deep integration of OMM/OMT, viscerosomatic reflexes, Chapman
points, cranial osteopathy, and osteopathic principles across all systems with complex clinical
presentations
SECTION 1: OSTEOPATHIC PRINCIPLES, PRACTICE, AND MANIPULATIVE TREATMENT
(OMM/OPP) - ADVANCED CLINICAL INTEGRATION
Question 1
A 58-year-old male with a 30-year history of type 2 diabetes mellitus presents with chronic
bilateral lower extremity pain, burning dysesthesias, and progressive weakness. On osteopathic
structural examination, you identify significant somatic dysfunction at T10-L2 with associated
paraspinal muscle hypertonicity, restricted segmental motion, and Chapman points at the right
12th rib posteriorly. Additionally, you note a tender point in the right gluteus medius muscle
belly that reproduces the patient's radicular pain. Which of the following represents the most
comprehensive osteopathic diagnostic formulation incorporating both somatic and visceral
components?
A) Segmental facilitation at T10-L2 secondary to diabetic nephropathy with associated gluteal
tender point representing a somatic dysfunction
,B) Diabetic peripheral neuropathy with secondary myofascial pain syndrome and compensatory
gait abnormalities
C) Somatic dysfunction at T10-L2 with viscerosomatic reflex from pancreatic dysfunction and
associated piriformis syndrome
D) Chronic sacroiliac joint dysfunction with secondary lumbar spine compensatory changes and
diabetic neuropathy
E) Lumbar radiculopathy from degenerative disc disease exacerbated by diabetic autonomic
neuropathy
Correct Answer: A) Segmental facilitation at T10-L2 secondary to diabetic nephropathy with
associated gluteal tender point representing a somatic dysfunction
Rationale: This question requires integration of viscerosomatic reflex principles with clinical
presentation. The T10-L2 segmental level corresponds to the kidneys, which are affected in
diabetic nephropathy. The Chapman point at the right 12th rib posteriorly correlates with
kidney dysfunction, not gluteal pathology. The tender point in the gluteus medius represents a
myofascial component of the somatic dysfunction pattern. Diabetic peripheral neuropathy (B)
would present with stocking-glove distribution, not segmental T10-L2 findings. Pancreatic
dysfunction (C) would reflex to T6-T10, not T10-L2. Sacroiliac dysfunction (D) would present
with different findings. Degenerative disc disease (E) would show radicular findings but would
not explain the viscerosomatic component or Chapman points. This comprehensive formulation
integrates the somatic findings (segmental dysfunction, tender point) with the visceral
component (diabetic nephropathy) through viscerosomatic reflex mechanisms.
Question 2
A 45-year-old female presents with chronic tension-type headaches, cervicalgia, and episodic
vertigo. Cranial osteopathic examination reveals the sphenoid is rotated to the left and sidebent
to the right, while the occiput is rotated to the right and sidebent to the left, with both bones
showing compensatory strain patterns. The temporal bones are internally rotated bilaterally,
and the occipitomastoid sutures are restricted. Which of the following represents the most
likely primary cranial dysfunction and its most appropriate osteopathic treatment approach?
A) Sphenobasilar synchondrosis torsion strain with secondary temporal bone dysfunction;
treatment with CV4 and temporal bone release
B) Sphenobasilar synchondrosis sidebending rotation strain with temporal bone involvement;
treatment with sphenopalatine ganglion release and occipitomastoid suture mobilization
C) Lateral strain of the sphenobasilar synchondrosis with temporal bone rotation; treatment
with V-spread technique and frontal lift
,D) Compression strain of the sphenobasilar synchondrosis with secondary occipitomastoid
restriction; treatment with decompression and balanced membranous tension
E) Combined strain pattern involving the sphenoid, occiput, and temporal bones with primary
occipitomastoid dysfunction; treatment with direct temporal bone mobilization
Correct Answer: B) Sphenobasilar synchondrosis sidebending rotation strain with temporal
bone involvement; treatment with sphenopalatine ganglion release and occipitomastoid
suture mobilization
Rationale: The description indicates the sphenoid and occiput are sidebent in the same
direction (both to opposite sides) and rotated in opposite directions, which defines a
sidebending rotation strain pattern. This is more complex than simple torsion or lateral strain.
Temporal bone involvement (internal rotation bilaterally) is common with this pattern.
Occipitomastoid suture restriction contributes to the headache and vertigo symptoms.
Treatment should address both the primary SBS strain and the secondary temporal bone
involvement. CV4 (A) is appropriate for compression strains. V-spread and frontal lift (C) address
other aspects of cranial dysfunction but not the sidebending rotation pattern specifically.
Compression strain (D) does not match the description. Isolated temporal bone mobilization (E)
would not address the primary SBS dysfunction. The sphenopalatine ganglion release helps
address the autonomic component contributing to the tension-type headaches.
Question 3
A 62-year-old male with a history of chronic obstructive pulmonary disease (COPD) presents
with progressive dyspnea, orthopnea, and chronic productive cough. Pulmonary function
testing shows an FEV1/FVC ratio of 48% with significant hyperinflation. On osteopathic
examination, you identify a Type I dysfunction at T3-T7 with the vertebrae rotated and sidebent
to the left, a right rib exhalation dysfunction involving ribs 3-6, and significant restriction of the
thoracic diaphragm with decreased excursion on the right. Additionally, you note a Chapman
point at the left 3rd-4th intercostal space. Which of the following represents the most
appropriate comprehensive osteopathic treatment sequence addressing the patient's
pulmonary and musculoskeletal dysfunctions?
A) Treat the thoracic Type I dysfunction with high-velocity low-amplitude (HVLA) technique,
followed by rib raising to address the rib dysfunction, and then doming of the diaphragm to
improve respiratory mechanics
B) Begin with diaphragmatic release to improve ventilation, followed by rib mobilization for the
exhalation dysfunction, and finish with myofascial release of the thoracic paraspinal muscles
C) Address the rib exhalation dysfunction with muscle energy technique to improve inspiratory
, capacity, followed by thoracic articulation to correct the Type I dysfunction, and conclude with
lymphatic pump techniques
D) Perform indirect counterstrain for the Chapman point, followed by balanced ligamentous
tension for the thoracic dysfunction, and complete with gentle rib raising
E) Initiate treatment with thoracic inlet release to improve lymphatic drainage, followed by
direct fascial release of the diaphragm, and conclude with pedal pump for venous return
Correct Answer: C) Address the rib exhalation dysfunction with muscle energy technique to
improve inspiratory capacity, followed by thoracic articulation to correct the Type I
dysfunction, and conclude with lymphatic pump techniques
Rationale: In a COPD patient with significant respiratory compromise, the treatment sequence
should prioritize interventions that immediately improve ventilation. Rib exhalation dysfunction
directly limits inspiratory capacity (the ribs are stuck in exhalation), so treating this first with
muscle energy technique will improve the patient's ability to inhale. The Type I dysfunction at
T3-T7 should be addressed next with articulation rather than HVLA (A) because HVLA may be
too aggressive in a COPD patient with hyperinflation and potential osteoporosis. The Chapman
point at the left 3rd-4th intercostal space correlates with the left lung, consistent with COPD
pathology. Lymphatic pump techniques will help clear secretions and improve pulmonary
function. Starting with diaphragmatic release (B) is appropriate but should follow rib
mobilization. Indirect counterstrain (D) may not be aggressive enough for the functional
restrictions. Thoracic inlet release and pedal pump (E) address lymphatic and circulatory
components but should not be the primary interventions. The sequence should be: improve
mechanics (ribs), correct segmental dysfunction (thoracic), and enhance lymphatic drainage
(pump techniques).
Question 4
A 55-year-old female with chronic pelvic pain, dysmenorrhea, and a history of endometriosis
presents for osteopathic evaluation. She reports that her symptoms are worse during menses
and are associated with low back pain, right-sided sciatica, and constipation. On examination,
you identify significant sacral dysfunction with the sacrum flexed on the right and extended on
the left, a right anterior innominate dysfunction, and a tender point in the right pyriformis
muscle. Additionally, you note a Chapman point in the left groin area superior to the inguinal
ligament and a viscerosomatic reflex at T11-L1. Which of the following represents the most
likely primary visceral dysfunction and the most appropriate comprehensive osteopathic
treatment plan?
