COMSAE PHASE 1 FORM 116 REAL EXAM 2026: HIGH-YIELD
QUESTIONS WITH ANSWERS & DETAILED RATIONALES —
COMPLETE NBOME OSTEOPATHIC BOARD REVIEW FOR
CARDIOLOGY, PULMONOLOGY, NEUROLOGY, OMM,
MICROBIOLOGY & ENDOCRINOLOGY | COMLEX-USA LEVEL 1
PREP
Core Domains
Cardiology
Pulmonology
Neurology
Osteopathic Principles and Practice (OMM/OPP)
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 116. It evaluates mastery of
cardiology, pulmonology, neurology, osteopathic manipulative
medicine, microbiology, and endocrinology through single-best-
answer, multiple-choice questions organized into four sections of 44
questions each, mirroring the official NBOME blueprint. 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 62-year-old man presents with exertional chest pain that
radiates to the left shoulder and resolves with rest. He has a
30-pack-year smoking history and hyperlipidemia. Which of
the following pathophysiologic mechanisms best explains his
symptoms?
A. Coronary vasospasm
B. Fixed atherosclerotic plaque causing demand-supply mismatch
C. Coronary artery dissection
D. Embolic occlusion of the coronary artery
B. Fixed atherosclerotic plaque causing demand-supply
mismatch
Rationale: Stable angina is caused by a fixed atherosclerotic plaque
that limits coronary blood flow. When myocardial oxygen demand
increases with exertion, the fixed stenosis cannot dilate to meet
demand, resulting in ischemia and pain. Coronary vasospasm occurs
in Prinzmetal angina at rest. Coronary dissection and embolic
occlusion cause acute coronary syndromes.
2. A 70-year-old woman with a history of hypertension and
diabetes presents with acute dyspnea, orthopnea, and pink
frothy sputum. Chest X-ray reveals cardiomegaly with bilateral
perihilar "bat-wing" opacities. Which of the following is the
most appropriate immediate management?
,A. Oral furosemide
B. Intravenous furosemide
C. Oral metoprolol
D. Oral lisinopril
B. Intravenous furosemide
Rationale: Acute cardiogenic pulmonary edema is a medical
emergency requiring immediate intravenous loop diuretic therapy. IV
furosemide provides rapid preload reduction and symptomatic relief.
Oral medications have delayed onset and are inappropriate for acute
decompensation. Metoprolol and lisinopril are used for chronic
management, not acute pulmonary edema.
3. A 55-year-old man presents with syncope while shaving.
Physical exam reveals a harsh crescendo-decrescendo systolic
murmur at the right second intercostal space radiating to the
carotids, and a diminished S2. Which of the following is the
most likely diagnosis?
A. Aortic regurgitation
B. Aortic stenosis
C. Hypertrophic cardiomyopathy
D. Mitral stenosis
B. Aortic stenosis
Rationale: Aortic stenosis classically presents with a harsh
crescendo-decrescendo systolic murmur at the right upper sternal
border radiating to the carotids, with a diminished or absent A2
component of S2. The classic triad of symptoms includes angina,
syncope, and dyspnea on exertion. Syncope while shaving (Valsalva-
, like maneuver) is a classic presentation. Aortic regurgitation
produces an early diastolic murmur.
4. A 28-year-old woman presents with palpitations and
lightheadedness. ECG reveals a narrow QRS complex
tachycardia at 190 beats per minute with retrograde P waves
visible just after the QRS complex. 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. Retrograde P waves visible just after
the QRS complex (pseudo-R' in V1) are characteristic. The rhythm is
regular and narrow-complex. Atrial fibrillation is irregularly
irregular. Atrial flutter shows sawtooth waves. Ventricular
tachycardia has a wide QRS complex.
5. A 65-year-old man with a history of anterior myocardial
infarction presents with acute dyspnea and a new holosystolic
murmur at the left lower sternal border associated with a
thrill. Echocardiogram reveals a left-to-right shunt at the
ventricular level. Which of the following is the most likely
complication?
A. Papillary muscle rupture
B. Ventricular septal rupture
QUESTIONS WITH ANSWERS & DETAILED RATIONALES —
COMPLETE NBOME OSTEOPATHIC BOARD REVIEW FOR
CARDIOLOGY, PULMONOLOGY, NEUROLOGY, OMM,
MICROBIOLOGY & ENDOCRINOLOGY | COMLEX-USA LEVEL 1
PREP
Core Domains
Cardiology
Pulmonology
Neurology
Osteopathic Principles and Practice (OMM/OPP)
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 116. It evaluates mastery of
cardiology, pulmonology, neurology, osteopathic manipulative
medicine, microbiology, and endocrinology through single-best-
answer, multiple-choice questions organized into four sections of 44
questions each, mirroring the official NBOME blueprint. 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 62-year-old man presents with exertional chest pain that
radiates to the left shoulder and resolves with rest. He has a
30-pack-year smoking history and hyperlipidemia. Which of
the following pathophysiologic mechanisms best explains his
symptoms?
A. Coronary vasospasm
B. Fixed atherosclerotic plaque causing demand-supply mismatch
C. Coronary artery dissection
D. Embolic occlusion of the coronary artery
B. Fixed atherosclerotic plaque causing demand-supply
mismatch
Rationale: Stable angina is caused by a fixed atherosclerotic plaque
that limits coronary blood flow. When myocardial oxygen demand
increases with exertion, the fixed stenosis cannot dilate to meet
demand, resulting in ischemia and pain. Coronary vasospasm occurs
in Prinzmetal angina at rest. Coronary dissection and embolic
occlusion cause acute coronary syndromes.
2. A 70-year-old woman with a history of hypertension and
diabetes presents with acute dyspnea, orthopnea, and pink
frothy sputum. Chest X-ray reveals cardiomegaly with bilateral
perihilar "bat-wing" opacities. Which of the following is the
most appropriate immediate management?
,A. Oral furosemide
B. Intravenous furosemide
C. Oral metoprolol
D. Oral lisinopril
B. Intravenous furosemide
Rationale: Acute cardiogenic pulmonary edema is a medical
emergency requiring immediate intravenous loop diuretic therapy. IV
furosemide provides rapid preload reduction and symptomatic relief.
Oral medications have delayed onset and are inappropriate for acute
decompensation. Metoprolol and lisinopril are used for chronic
management, not acute pulmonary edema.
3. A 55-year-old man presents with syncope while shaving.
Physical exam reveals a harsh crescendo-decrescendo systolic
murmur at the right second intercostal space radiating to the
carotids, and a diminished S2. Which of the following is the
most likely diagnosis?
A. Aortic regurgitation
B. Aortic stenosis
C. Hypertrophic cardiomyopathy
D. Mitral stenosis
B. Aortic stenosis
Rationale: Aortic stenosis classically presents with a harsh
crescendo-decrescendo systolic murmur at the right upper sternal
border radiating to the carotids, with a diminished or absent A2
component of S2. The classic triad of symptoms includes angina,
syncope, and dyspnea on exertion. Syncope while shaving (Valsalva-
, like maneuver) is a classic presentation. Aortic regurgitation
produces an early diastolic murmur.
4. A 28-year-old woman presents with palpitations and
lightheadedness. ECG reveals a narrow QRS complex
tachycardia at 190 beats per minute with retrograde P waves
visible just after the QRS complex. 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. Retrograde P waves visible just after
the QRS complex (pseudo-R' in V1) are characteristic. The rhythm is
regular and narrow-complex. Atrial fibrillation is irregularly
irregular. Atrial flutter shows sawtooth waves. Ventricular
tachycardia has a wide QRS complex.
5. A 65-year-old man with a history of anterior myocardial
infarction presents with acute dyspnea and a new holosystolic
murmur at the left lower sternal border associated with a
thrill. Echocardiogram reveals a left-to-right shunt at the
ventricular level. Which of the following is the most likely
complication?
A. Papillary muscle rupture
B. Ventricular septal rupture
