1|Page
COMSAE Phase 1 Form 114 Actual
Exam | 400+ Q&A with
Rationales | Comprehensive
COMLEX Level 1 Prep for Med
Students
Master the COMSAE Phase 1 Form 114 with this comprehensive
study guide! This document contains 400 high-yield multiple-
choice questions with detailed rationales designed to mirror the
actual NBOME exam. Covering core topics like OPP, Cardiology,
Neurology, and Microbiology, this resource is ideal for med
students targeting a top COMLEX Level 1 score. Perfect for
ATSU, PCOM, KCU, Touro, and NYITCOM students. Boost your
confidence and ace your boards! Instant digital download
available
QUESTIONS 1–50
Question 1
A 28-year-old woman with no significant medical history presents with a 2-week
history of progressive weakness in her lower extremities, urinary urgency, and a
,2|Page
band-like sensation of tightness around her abdomen. Neurological examination
reveals bilateral lower extremity hyperreflexia, extensor plantar responses, and a
sensory level at T6. MRI of the thoracic spine demonstrates a well-circumscribed,
intradural, extramedullary mass at the T4–T5 level that is hyperintense on T2-
weighted imaging and enhances homogeneously with gadolinium. Which of the
following cell types is the most likely origin of this lesion?
A) Schwann cells
B) Arachnoid cap cells
C) Astrocytes
D) Oligodendrocytes
E) Ependymal cells
*Answer: A) Schwann cells
Rationale: The clinical presentation of progressive myelopathy with a sensory
level, bilateral upper motor neuron signs, and urinary urgency is consistent with
spinal cord compression. The MRI findings—an intradural, extramedullary,
well-circumscribed, enhancing mass—are classic for a nerve sheath tumor, most
commonly a schwannoma (or neurofibroma). Schwannomas arise from
Schwann cells, which produce the myelin sheath of peripheral nerves.
Meningiomas (arachnoid cap cells, choice B) are also intradural extramedullary
but are more common in the thoracic spine in women and typically show dural
attachment, but the classic "dural tail" sign is not described here. Astrocytomas
(choice C) and ependymomas (choice E) are intramedullary tumors.
Oligodendrogliomas (choice D) are primarily intracranial and rarely occur in
the spinal cord. Given the location and imaging characteristics, a schwannoma
is the most likely diagnosis, making Schwann cells the correct origin.
Question 2
A 55-year-old man with a 30-pack-year smoking history presents with hemoptysis
and weight loss. Chest CT reveals a 4-cm central lung mass with mediastinal
lymphadenopathy. Biopsy shows small cells with scant cytoplasm, nuclear molding,
and high mitotic rate. Immunohistochemistry is positive for chromogranin and
synaptophysin. Which paraneoplastic syndrome is most commonly associated with
this tumor type?
A) Hypercalcemia
B) Syndrome of inappropriate antidiuretic hormone secretion (SIADH)
C) Hypertrophic pulmonary osteoarthropathy
D) Dermatomyositis
E) Acanthosis nigricans
*Answer: B) SIADH
Rationale: The biopsy findings—small cells with scant cytoplasm, nuclear
,3|Page
molding, and high mitotic rate—are diagnostic of small cell lung carcinoma
(SCLC). SCLC is a neuroendocrine tumor, as confirmed by positive chromogranin
and synaptophysin. It is strongly associated with several paraneoplastic
syndromes, most commonly SIADH (due to ectopic ADH production), Lambert-
Eaton myasthenic syndrome, and Cushing syndrome (ectopic ACTH).
Hypercalcemia (choice A) is more typical of squamous cell lung carcinoma due
to parathyroid hormone-related protein (PTHrP). Hypertrophic pulmonary
osteoarthropathy (choice C) is associated with non-small cell lung cancer,
especially adenocarcinoma. Dermatomyositis (choice D) and acanthosis
nigricans (choice E) are less specific and not the most common paraneoplastic
findings in SCLC.
Question 3
A 32-year-old woman with systemic lupus erythematosus (SLE) presents with acute-
onset dyspnea and pleuritic chest pain. She is found to have a large pericardial
effusion on echocardiography. Which of the following autoantibodies is most specific
for the diagnosis of SLE?
A) Anti-dsDNA
B) Anti-Smith (anti-Sm)
C) Anti-Ro/SSA
D) Anti-La/SSB
E) Anticentromere
*Answer: B) Anti-Smith (anti-Sm)
Rationale: Anti-Smith (anti-Sm) antibodies are highly specific for systemic
lupus erythematosus (SLE) and are one of the American College of
Rheumatology classification criteria. Anti-dsDNA (choice A) is also specific for
SLE and correlates with disease activity, particularly lupus nephritis, but anti-
Sm is considered more specific. Anti-Ro/SSA (choice C) and anti-La/SSB (choice
D) are associated with Sjögren's syndrome and subacute cutaneous lupus, but
they are not as specific for SLE as anti-Sm. Anticentromere (choice E) is specific
for limited cutaneous systemic sclerosis (CREST syndrome). Given the clinical
scenario of SLE with pericarditis, anti-Sm is the most specific marker.
Question 4
A 67-year-old man with type 2 diabetes mellitus and hypertension presents with
sudden-onset, painless vision loss in his right eye. Fundoscopic examination reveals a
pale, swollen optic disc with blurred margins and a cherry-red spot at the fovea.
, 4|Page
Which artery is most likely occluded?
A) Central retinal artery
B) Central retinal vein
C) Ophthalmic artery
D) Posterior ciliary artery
E) Anterior ciliary artery
*Answer: A) Central retinal artery
Rationale: Acute, painless, monocular vision loss with a pale, swollen optic disc
and a cherry-red spot at the fovea is classic for central retinal artery occlusion
(CRAO). The cherry-red spot occurs because the fovea receives its blood supply
from the choroid (via the posterior ciliary arteries), which remains perfused,
while the surrounding pale retina is ischemic due to occlusion of the central
retinal artery. Central retinal vein occlusion (choice B) presents with sudden,
painless vision loss but fundoscopy shows retinal hemorrhages, disc edema, and
"blood and thunder" appearance, not a cherry-red spot. Ophthalmic artery
occlusion (choice C) would cause more severe ischemia involving both the retina
and choroid, with no cherry-red spot. Posterior ciliary artery occlusion (choice
D) would affect the choroid and optic nerve head, not the retina. Anterior ciliary
artery (choice E) supplies the conjunctiva and sclera.
Question 5
A 45-year-old woman presents with fatigue, weight gain, cold intolerance, and
constipation. Laboratory studies reveal elevated TSH and low free T4. She is started
on levothyroxine. After 6 weeks of therapy, her TSH remains elevated. She reports
taking her medication daily but often with her morning coffee and calcium
supplement. Which of the following is the most likely cause of her inadequate
response?
A) Impaired gastrointestinal absorption of levothyroxine
B) Inadequate starting dose of levothyroxine
C) Concurrent use of amiodarone
D) Development of thyroid hormone resistance
E) Poor compliance despite patient report
*Answer: A) Impaired gastrointestinal absorption of levothyroxine
Rationale: Levothyroxine absorption is significantly impaired by co-
administration with calcium supplements, iron preparations, antacids, and
certain foods such as coffee and high-fiber meals. The patient's habit of taking
levothyroxine with coffee and calcium is the most likely cause of her
persistently elevated TSH despite reported adherence. Inadequate starting dose
(choice B) is possible but less likely given the clear history of interfering
substances. Amiodarone (choice C) can cause hypothyroidism but is not
COMSAE Phase 1 Form 114 Actual
Exam | 400+ Q&A with
Rationales | Comprehensive
COMLEX Level 1 Prep for Med
Students
Master the COMSAE Phase 1 Form 114 with this comprehensive
study guide! This document contains 400 high-yield multiple-
choice questions with detailed rationales designed to mirror the
actual NBOME exam. Covering core topics like OPP, Cardiology,
Neurology, and Microbiology, this resource is ideal for med
students targeting a top COMLEX Level 1 score. Perfect for
ATSU, PCOM, KCU, Touro, and NYITCOM students. Boost your
confidence and ace your boards! Instant digital download
available
QUESTIONS 1–50
Question 1
A 28-year-old woman with no significant medical history presents with a 2-week
history of progressive weakness in her lower extremities, urinary urgency, and a
,2|Page
band-like sensation of tightness around her abdomen. Neurological examination
reveals bilateral lower extremity hyperreflexia, extensor plantar responses, and a
sensory level at T6. MRI of the thoracic spine demonstrates a well-circumscribed,
intradural, extramedullary mass at the T4–T5 level that is hyperintense on T2-
weighted imaging and enhances homogeneously with gadolinium. Which of the
following cell types is the most likely origin of this lesion?
A) Schwann cells
B) Arachnoid cap cells
C) Astrocytes
D) Oligodendrocytes
E) Ependymal cells
*Answer: A) Schwann cells
Rationale: The clinical presentation of progressive myelopathy with a sensory
level, bilateral upper motor neuron signs, and urinary urgency is consistent with
spinal cord compression. The MRI findings—an intradural, extramedullary,
well-circumscribed, enhancing mass—are classic for a nerve sheath tumor, most
commonly a schwannoma (or neurofibroma). Schwannomas arise from
Schwann cells, which produce the myelin sheath of peripheral nerves.
Meningiomas (arachnoid cap cells, choice B) are also intradural extramedullary
but are more common in the thoracic spine in women and typically show dural
attachment, but the classic "dural tail" sign is not described here. Astrocytomas
(choice C) and ependymomas (choice E) are intramedullary tumors.
Oligodendrogliomas (choice D) are primarily intracranial and rarely occur in
the spinal cord. Given the location and imaging characteristics, a schwannoma
is the most likely diagnosis, making Schwann cells the correct origin.
Question 2
A 55-year-old man with a 30-pack-year smoking history presents with hemoptysis
and weight loss. Chest CT reveals a 4-cm central lung mass with mediastinal
lymphadenopathy. Biopsy shows small cells with scant cytoplasm, nuclear molding,
and high mitotic rate. Immunohistochemistry is positive for chromogranin and
synaptophysin. Which paraneoplastic syndrome is most commonly associated with
this tumor type?
A) Hypercalcemia
B) Syndrome of inappropriate antidiuretic hormone secretion (SIADH)
C) Hypertrophic pulmonary osteoarthropathy
D) Dermatomyositis
E) Acanthosis nigricans
*Answer: B) SIADH
Rationale: The biopsy findings—small cells with scant cytoplasm, nuclear
,3|Page
molding, and high mitotic rate—are diagnostic of small cell lung carcinoma
(SCLC). SCLC is a neuroendocrine tumor, as confirmed by positive chromogranin
and synaptophysin. It is strongly associated with several paraneoplastic
syndromes, most commonly SIADH (due to ectopic ADH production), Lambert-
Eaton myasthenic syndrome, and Cushing syndrome (ectopic ACTH).
Hypercalcemia (choice A) is more typical of squamous cell lung carcinoma due
to parathyroid hormone-related protein (PTHrP). Hypertrophic pulmonary
osteoarthropathy (choice C) is associated with non-small cell lung cancer,
especially adenocarcinoma. Dermatomyositis (choice D) and acanthosis
nigricans (choice E) are less specific and not the most common paraneoplastic
findings in SCLC.
Question 3
A 32-year-old woman with systemic lupus erythematosus (SLE) presents with acute-
onset dyspnea and pleuritic chest pain. She is found to have a large pericardial
effusion on echocardiography. Which of the following autoantibodies is most specific
for the diagnosis of SLE?
A) Anti-dsDNA
B) Anti-Smith (anti-Sm)
C) Anti-Ro/SSA
D) Anti-La/SSB
E) Anticentromere
*Answer: B) Anti-Smith (anti-Sm)
Rationale: Anti-Smith (anti-Sm) antibodies are highly specific for systemic
lupus erythematosus (SLE) and are one of the American College of
Rheumatology classification criteria. Anti-dsDNA (choice A) is also specific for
SLE and correlates with disease activity, particularly lupus nephritis, but anti-
Sm is considered more specific. Anti-Ro/SSA (choice C) and anti-La/SSB (choice
D) are associated with Sjögren's syndrome and subacute cutaneous lupus, but
they are not as specific for SLE as anti-Sm. Anticentromere (choice E) is specific
for limited cutaneous systemic sclerosis (CREST syndrome). Given the clinical
scenario of SLE with pericarditis, anti-Sm is the most specific marker.
Question 4
A 67-year-old man with type 2 diabetes mellitus and hypertension presents with
sudden-onset, painless vision loss in his right eye. Fundoscopic examination reveals a
pale, swollen optic disc with blurred margins and a cherry-red spot at the fovea.
, 4|Page
Which artery is most likely occluded?
A) Central retinal artery
B) Central retinal vein
C) Ophthalmic artery
D) Posterior ciliary artery
E) Anterior ciliary artery
*Answer: A) Central retinal artery
Rationale: Acute, painless, monocular vision loss with a pale, swollen optic disc
and a cherry-red spot at the fovea is classic for central retinal artery occlusion
(CRAO). The cherry-red spot occurs because the fovea receives its blood supply
from the choroid (via the posterior ciliary arteries), which remains perfused,
while the surrounding pale retina is ischemic due to occlusion of the central
retinal artery. Central retinal vein occlusion (choice B) presents with sudden,
painless vision loss but fundoscopy shows retinal hemorrhages, disc edema, and
"blood and thunder" appearance, not a cherry-red spot. Ophthalmic artery
occlusion (choice C) would cause more severe ischemia involving both the retina
and choroid, with no cherry-red spot. Posterior ciliary artery occlusion (choice
D) would affect the choroid and optic nerve head, not the retina. Anterior ciliary
artery (choice E) supplies the conjunctiva and sclera.
Question 5
A 45-year-old woman presents with fatigue, weight gain, cold intolerance, and
constipation. Laboratory studies reveal elevated TSH and low free T4. She is started
on levothyroxine. After 6 weeks of therapy, her TSH remains elevated. She reports
taking her medication daily but often with her morning coffee and calcium
supplement. Which of the following is the most likely cause of her inadequate
response?
A) Impaired gastrointestinal absorption of levothyroxine
B) Inadequate starting dose of levothyroxine
C) Concurrent use of amiodarone
D) Development of thyroid hormone resistance
E) Poor compliance despite patient report
*Answer: A) Impaired gastrointestinal absorption of levothyroxine
Rationale: Levothyroxine absorption is significantly impaired by co-
administration with calcium supplements, iron preparations, antacids, and
certain foods such as coffee and high-fiber meals. The patient's habit of taking
levothyroxine with coffee and calcium is the most likely cause of her
persistently elevated TSH despite reported adherence. Inadequate starting dose
(choice B) is possible but less likely given the clear history of interfering
substances. Amiodarone (choice C) can cause hypothyroidism but is not
