COMSAE PHASE 1 FORM 114 PRACTICE
EXAM 2026: HIGH-YIELD QUESTIONS WITH
ANSWERS & RATIONALES COMPLETE
REVIEW OF CARDIOLOGY,
PULMONOLOGY, NEUROLOGY, OMM,
MICROBIOLOGY, AND ENDOCRINOLOGY |
PDF
Core Domains
Cardiology
Pulmonology
Neurology
Osteopathic Manipulative Medicine (OMM)
Microbiology and Immunology
Endocrinology
Introduction
This comprehensive examination assesses the foundational biomedical science
knowledge and osteopathic principles required for success on the COMSAE
Phase 1 Form 114. It evaluates mastery of cardiology, pulmonology, neurology,
osteopathic manipulative medicine, microbiology, and endocrinology through
single-best-answer, multiple-choice questions. The exam emphasizes
integration of basic science mechanisms with clinical presentations, laboratory
findings, and diagnostic reasoning. Candidates must demonstrate competency
in identifying disease pathophysiology, interpreting diagnostic studies,
applying osteopathic principles, and understanding pharmacologic
mechanisms. This assessment prepares osteopathic medical students for the
COMLEX-USA Level 1 while reinforcing evidence-based clinical decision-
making.
,Section One: Questions 1–176
1. A 58-year-old man presents with crushing substernal chest pain
radiating to the left jaw that began 45 minutes ago. ECG reveals ST-
segment elevations in leads V1 through V4. Which coronary artery is
most likely occluded?
A. Right coronary artery
B. Left circumflex artery
C. Left anterior descending artery
D. Posterior descending artery
C. Left anterior descending artery
Rationale: ST-segment elevations in precordial leads V1–V4 indicate an
anteroseptal myocardial infarction. The left anterior descending (LAD) artery
supplies the anterior wall of the left ventricle, the interventricular septum, and
the cardiac apex. Occlusion of the LAD is commonly referred to as the "widow-
maker" lesion because of the large territory of myocardium at risk. Right
coronary artery occlusion typically produces inferior wall changes in leads II,
III, and aVF. Left circumflex occlusion produces lateral wall changes in leads I,
aVL, V5, and V6.
2. A 72-year-old woman with a history of hypertension and diabetes
presents with acute onset dyspnea, orthopnea, and bilateral crackles
on auscultation. Chest X-ray reveals cardiomegaly with pulmonary
vascular congestion. Echocardiogram shows an ejection fraction of
30%. Which medication has been shown to reduce mortality in this
condition?
A. Digoxin
B. Furosemide
C. Carvedilol
D. Amlodipine
C. Carvedilol
,Rationale: Carvedilol is a beta-blocker with proven mortality benefit in heart
failure with reduced ejection fraction (HFrEF). The three beta-blockers with
mortality benefit in HFrEF are carvedilol, metoprolol succinate, and bisoprolol.
Digoxin reduces hospitalizations but does not reduce mortality. Furosemide
provides symptomatic relief but does not improve survival. Amlodipine, a
dihydropyridine calcium channel blocker, is neutral in terms of mortality in
HFrEF.
3. A 65-year-old man presents with syncope and exertional dyspnea.
Auscultation reveals a harsh crescendo-decrescendo systolic murmur
at the right upper sternal border radiating to the carotids. Which of the
following is the most likely diagnosis?
A. Mitral regurgitation
B. Aortic stenosis
C. Hypertrophic cardiomyopathy
D. Ventricular septal defect
B. Aortic stenosis
Rationale: Aortic stenosis classically presents with a harsh crescendo-
decrescendo systolic murmur at the right upper sternal border that radiates to
the carotids. The classic triad of symptoms includes angina, syncope, and
dyspnea on exertion. Mitral regurgitation produces a holosystolic murmur at
the apex radiating to the axilla. Hypertrophic cardiomyopathy produces a
systolic murmur that increases with Valsalva maneuver. Ventricular septal
defect produces a holosystolic murmur at the left lower sternal border.
4. A 45-year-old man presents with palpitations. ECG reveals a narrow
QRS complex tachycardia at 180 beats per minute with no visible P
waves. Which of the following is the most likely diagnosis?
A. Atrial fibrillation
B. Atrial flutter
C. Atrioventricular nodal reentrant tachycardia
D. Ventricular tachycardia
, C. Atrioventricular nodal reentrant tachycardia
Rationale: AVNRT is the most common cause of paroxysmal supraventricular
tachycardia. It presents with a narrow QRS complex tachycardia, often with no
visible P waves because they are buried within the QRS complex. Atrial
fibrillation is irregularly irregular. Atrial flutter shows sawtooth flutter waves.
Ventricular tachycardia has a wide QRS complex.
5. A 60-year-old man with a history of myocardial infarction presents
with a new holosystolic murmur at the apex radiating to the axilla.
Echocardiogram reveals severe mitral regurgitation. Which of the
following is the most likely underlying cause?
A. Papillary muscle rupture
B. Aortic dissection
C. Pericardial effusion
D. Atrial septal defect
A. Papillary muscle rupture
Rationale: Papillary muscle rupture is a catastrophic complication of
myocardial infarction that typically occurs 2–7 days after the event. It most
commonly affects the posteromedial papillary muscle because it has a single
blood supply from the posterior descending artery. The resulting acute severe
mitral regurgitation presents with a new holosystolic murmur, pulmonary
edema, and cardiogenic shock.
6. A 55-year-old man presents with fever, night sweats, and a new
diastolic murmur. Blood cultures are positive for Streptococcus
viridans. Which of the following is the most likely diagnosis?
A. Acute pericarditis
B. Infective endocarditis
C. Myocarditis
D. Rheumatic fever
B. Infective endocarditis
EXAM 2026: HIGH-YIELD QUESTIONS WITH
ANSWERS & RATIONALES COMPLETE
REVIEW OF CARDIOLOGY,
PULMONOLOGY, NEUROLOGY, OMM,
MICROBIOLOGY, AND ENDOCRINOLOGY |
Core Domains
Cardiology
Pulmonology
Neurology
Osteopathic Manipulative Medicine (OMM)
Microbiology and Immunology
Endocrinology
Introduction
This comprehensive examination assesses the foundational biomedical science
knowledge and osteopathic principles required for success on the COMSAE
Phase 1 Form 114. It evaluates mastery of cardiology, pulmonology, neurology,
osteopathic manipulative medicine, microbiology, and endocrinology through
single-best-answer, multiple-choice questions. The exam emphasizes
integration of basic science mechanisms with clinical presentations, laboratory
findings, and diagnostic reasoning. Candidates must demonstrate competency
in identifying disease pathophysiology, interpreting diagnostic studies,
applying osteopathic principles, and understanding pharmacologic
mechanisms. This assessment prepares osteopathic medical students for the
COMLEX-USA Level 1 while reinforcing evidence-based clinical decision-
making.
,Section One: Questions 1–176
1. A 58-year-old man presents with crushing substernal chest pain
radiating to the left jaw that began 45 minutes ago. ECG reveals ST-
segment elevations in leads V1 through V4. Which coronary artery is
most likely occluded?
A. Right coronary artery
B. Left circumflex artery
C. Left anterior descending artery
D. Posterior descending artery
C. Left anterior descending artery
Rationale: ST-segment elevations in precordial leads V1–V4 indicate an
anteroseptal myocardial infarction. The left anterior descending (LAD) artery
supplies the anterior wall of the left ventricle, the interventricular septum, and
the cardiac apex. Occlusion of the LAD is commonly referred to as the "widow-
maker" lesion because of the large territory of myocardium at risk. Right
coronary artery occlusion typically produces inferior wall changes in leads II,
III, and aVF. Left circumflex occlusion produces lateral wall changes in leads I,
aVL, V5, and V6.
2. A 72-year-old woman with a history of hypertension and diabetes
presents with acute onset dyspnea, orthopnea, and bilateral crackles
on auscultation. Chest X-ray reveals cardiomegaly with pulmonary
vascular congestion. Echocardiogram shows an ejection fraction of
30%. Which medication has been shown to reduce mortality in this
condition?
A. Digoxin
B. Furosemide
C. Carvedilol
D. Amlodipine
C. Carvedilol
,Rationale: Carvedilol is a beta-blocker with proven mortality benefit in heart
failure with reduced ejection fraction (HFrEF). The three beta-blockers with
mortality benefit in HFrEF are carvedilol, metoprolol succinate, and bisoprolol.
Digoxin reduces hospitalizations but does not reduce mortality. Furosemide
provides symptomatic relief but does not improve survival. Amlodipine, a
dihydropyridine calcium channel blocker, is neutral in terms of mortality in
HFrEF.
3. A 65-year-old man presents with syncope and exertional dyspnea.
Auscultation reveals a harsh crescendo-decrescendo systolic murmur
at the right upper sternal border radiating to the carotids. Which of the
following is the most likely diagnosis?
A. Mitral regurgitation
B. Aortic stenosis
C. Hypertrophic cardiomyopathy
D. Ventricular septal defect
B. Aortic stenosis
Rationale: Aortic stenosis classically presents with a harsh crescendo-
decrescendo systolic murmur at the right upper sternal border that radiates to
the carotids. The classic triad of symptoms includes angina, syncope, and
dyspnea on exertion. Mitral regurgitation produces a holosystolic murmur at
the apex radiating to the axilla. Hypertrophic cardiomyopathy produces a
systolic murmur that increases with Valsalva maneuver. Ventricular septal
defect produces a holosystolic murmur at the left lower sternal border.
4. A 45-year-old man presents with palpitations. ECG reveals a narrow
QRS complex tachycardia at 180 beats per minute with no visible P
waves. Which of the following is the most likely diagnosis?
A. Atrial fibrillation
B. Atrial flutter
C. Atrioventricular nodal reentrant tachycardia
D. Ventricular tachycardia
, C. Atrioventricular nodal reentrant tachycardia
Rationale: AVNRT is the most common cause of paroxysmal supraventricular
tachycardia. It presents with a narrow QRS complex tachycardia, often with no
visible P waves because they are buried within the QRS complex. Atrial
fibrillation is irregularly irregular. Atrial flutter shows sawtooth flutter waves.
Ventricular tachycardia has a wide QRS complex.
5. A 60-year-old man with a history of myocardial infarction presents
with a new holosystolic murmur at the apex radiating to the axilla.
Echocardiogram reveals severe mitral regurgitation. Which of the
following is the most likely underlying cause?
A. Papillary muscle rupture
B. Aortic dissection
C. Pericardial effusion
D. Atrial septal defect
A. Papillary muscle rupture
Rationale: Papillary muscle rupture is a catastrophic complication of
myocardial infarction that typically occurs 2–7 days after the event. It most
commonly affects the posteromedial papillary muscle because it has a single
blood supply from the posterior descending artery. The resulting acute severe
mitral regurgitation presents with a new holosystolic murmur, pulmonary
edema, and cardiogenic shock.
6. A 55-year-old man presents with fever, night sweats, and a new
diastolic murmur. Blood cultures are positive for Streptococcus
viridans. Which of the following is the most likely diagnosis?
A. Acute pericarditis
B. Infective endocarditis
C. Myocarditis
D. Rheumatic fever
B. Infective endocarditis
