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NBOME COMSAE Phase 1 Form 115 High-Yield
Prep Questions And Well Graded Solutions With
Rationales Updated 2026- 2027
Master the NBOME COMSAE Phase 1 Form 115 with this comprehensive, high-yield practice resource. Features high-density multiple-choice questions mapping directly to official exam trends, including critical neurology pathways, reproductive pathology, complex cranial/sacral OMM mechanics, and autonomic pharmacology. Each item includes precise diagnostic rationales designed to maximize your study efficiency, boost retention, and confidently clear the 400+ threshold for COMLEX Level 1 success
Question 1
A 24-year-old medical student presents to the clinic complaining of recurrent nosebleeds and small, red, blanching spots on her lips and oral mucosa. She mentions that her father has a history of severe gastrointestinal bleeding of unknown origin. Which of the following is the most likely mode of inheritance for this patient's underlying condition? A) Autosomal recessive B) X-linked recessive C) X-linked dominant D) Autosomal dominant D) Autosomal dominant Rationale: This patient presents with signs and symptoms highly characteristic of Hereditary Hemorrhagic Telangiectasia (HHT), also known as Osler-Weber-Rendu syndrome. This condition is characterized by localized malformations of vascular tissue, leading to telangiectasias on the skin and mucous membranes (such as the lips and tongue) and recurrent epistaxis. It is inherited in an autosomal dominant fashion. Autosomal recessive, X-linked recessive, and X-linked dominant inheritance patterns are incorrect because HHT is caused by mutations in genes like ENG or ACVRL1, which follow an autosomal dominant pattern with variable expressivity.
Question 2
A 45-year-old male is brought to the emergency department after a high-speed motor vehicle collision. On physical examination, the physician notes bilateral periorbital ecchymosis ("raccoon eyes") and mastoid ecchymosis (Battle's sign). Clear fluid is also seen leaking from his right ear canal. A fracture of which of the following bones is most strongly associated with these clinical findings? A) Frontal bone
B) Temporal bone C) Zygomatic bone D) Mandible B) Temporal bone Rationale: "Raccoon eyes," Battle's sign, and cerebrospinal fluid (CSF) otorrhea are classic clinical signs of a basilar skull fracture. The base of the skull consists of parts of the temporal bone, occipital bone, sphenoid bone, ethmoid bone, and frontal bone. Among the options, fractures involving the petrous portion of the temporal bone are the most common source of Battle's sign and CSF leaks through the ear canal. Frontal, zygomatic, and mandible fractures do not typically produce this specific constellation of basilar skull signs.
Question 3
An osteopathic physician evaluates a patient with mid-back pain. Structural examination reveals that T6 rotates preferredly to the right and sidebends preferredly to the right. When the patient extends their spine, the asymmetry worsens, but when the patient flexes their spine, the asymmetry resolves completely. Which of the following represents the correct structural diagnosis for this spinal segment? A) T6 Neutral S R R L B) T6 Flexed S R R R C) T6 Extended S L R L D) T6 Flexed S R R L B) T6 Flexed S R R R Rationale: Type II somatic dysfunctions involve a single vertebral segment, show asymmetry that worsens in either flexion or extension, and display sidebending and rotation to the same side. Because this segment improves in flexion, it is a "Flexed" dysfunction. Because it worsens in extension, the restriction is in extension. It rotates right and sidebends right. Therefore, the standard somatic dysfunction notation is T Flexed, Sidebent Right, Rotated Right (T6 F S R R R). The other options incorrectly list neutral mechanics (Type I) or the incorrect direction of sidebending and rotation.
aldosterone, it prevents sodium reabsorption and potassium excretion, which can lead to hyperkalemia, especially in patients with baseline renal impairment. Furosemide, hydrochlorothiazide, and metolazone are potassium-wasting diuretics that typically cause hypokalemia rather than hyperkalemia.
Question 6
A 19-year-old male presents with sudden onset weakness in his right upper extremity after a falling injury during a football game. Physical examination reveals a loss of the biceps tendon reflex and an inability to supinate the right forearm. His arm is held in an adducted, internally rotated position with an extended elbow. Which of the following nerve roots are most likely damaged in this patient? A) C5-C B) C7-C C) C8-T D) T1-T A) C5-C Rationale: This presentation describes Erb-Duchenne palsy ("waiter's tip" deformity), which results from an injury to the upper trunk of the brachial plexus involving the C and C6 nerve roots. This injury typically occurs due to an excessive increase in the angle between the neck and the shoulder. It paralyzes the deltoid, biceps brachii, and brachialis muscles. C8-T1 injury results in Klumpke palsy, which presents with a "claw hand" deformity due to loss of intrinsic hand muscles.
Question 7
A 31-year-old female presents to the physician with a 3-month history of fatigue, unexpected weight gain, and generalized muscle aches. Physical examination reveals slow relaxation of her deep tendon reflexes and mild, diffuse enlargement of the thyroid gland. Laboratory studies demonstrate an elevated thyroid-stimulating hormone (TSH) and a decreased free T4 level. Which of the following autoantibodies is most specific for diagnosing the underlying cause of this patient's presentation?
A) Anti-double-stranded DNA antibodies B) Anti-thyroid peroxidase antibodies C) Anti-TSH receptor antibodies D) Anti-smooth muscle antibodies B) Anti-thyroid peroxidase antibodies Rationale: This patient presents with primary hypothyroidism, most commonly caused by Hashimoto thyroiditis (chronic autoimmune thyroiditis) in developed nations. Anti-thyroid peroxidase (anti-TPO) and anti-thyroglobulin antibodies are highly associated with this destructive autoimmune process. Anti-TSH receptor antibodies are seen in Graves disease (hyperthyroidism). Anti-dsDNA is specific for SLE, and anti-smooth muscle is associated with autoimmune hepatitis.
Question 8
An osteopathic structural exam on a 28-year-old athlete reveals a restriction in the sacroiliac joint. The physician notes that during the respiratory cycle, the sacral base moves anteriorly during exhalation and posteriorly during inhalation. Around which of the following axes does this physiological motion occur? A) Superior transverse axis B) Middle transverse axis C) Inferior transverse axis D) Oblique axis A) Superior transverse axis Rationale: Respiratory and craniosacral motion of the sacrum occurs around the superior transverse axis, located approximately at the level of S2. During inhalation, the sacral base moves posteriorly (counternutation), and during exhalation, it moves anteriorly (nutation). Postural motion occurs around the middle transverse axis, and innominate rotation occurs around the inferior transverse axis.
Amphotericin B and oral flucytosine, followed by long-term consolidation therapy with fluconazole. Fluconazole monotherapy is insufficient for the initial induction phase in meningeal disease.
Question 11
During an osteopathic examination of a patient with chronic shoulder tightness, the physician evaluates the motion of the radial head. The patient's right forearm is found to prefer pronation, and there is a distinct restriction when attempting passive supination. What is the correct somatic dysfunction diagnosis for this patient's right radial head? A) Anterior radial head B) Posterior radial head C) Medial radial head D) Lateral radial head B) Posterior radial head Rationale: The radial head moves reciprocally relative to the distal radius during forearm motion. During pronation, the distal radius moves anteriorly, causing the proximal radial head to glide posteriorly. Because this patient's forearm prefers pronation, the radial head is stuck in its posterior position, making it a posterior radial head dysfunction. Conversely, an anterior radial head prefers supination.
Question 12
A 62-year-old male presents with a persistent, non-healing ulcer on his lower lip that has gradually enlarged over the past 8 months. He is a retired farmer with a history of significant sun exposure and a 40 pack-year smoking history. Biopsy of the lesion reveals nests of atypical squamous cells infiltrating the dermis, along with prominent keratin pearls. Which of the following is the most likely diagnosis? A) Basal cell carcinoma
B) Melanoma C) Squamous cell carcinoma D) Actinic keratosis C) Squamous cell carcinoma Rationale: Squamous cell carcinoma (SCC) characteristically arises on the lower lip due to UV sun exposure and tobacco use. Histologically, it is defined by infiltrating sheets of atypical keratinocytes with keratin pearls. Basal cell carcinoma typically affects the upper lip/face and exhibits peripheral palisading of nuclei. Actinic keratosis is a premalignant precursor confined to the epidermis.
Question 13
A 3-year-old boy is brought to the pediatrician due to developmental delay and unusual behaviors. His mother notes that he frequently bites his own fingers and lips, causing noticeable scarring. Laboratory testing reveals an elevated serum uric acid level. This patient's condition is caused by a deficiency in an enzyme directly involved in which of the following biochemical pathways? A) Purine salvage pathway B) Pyrimidine synthesis pathway C) De novo purine synthesis D) Urea cycle A) Purine salvage pathway Rationale: This presentation describes Lesch-Nyhan syndrome, an X-linked recessive disorder characterized by intellectual disability, hyperuricemia, and severe self-mutilating behavior. It is caused by a deficiency of hypoxanthine-guanine phosphoribosyltransferase (HGPRT), an essential enzyme in the purine salvage pathway. Deficiency leads to excess hypoxanthine and guanine conversion into uric acid.
Question 14
A 50-year-old female presents with worsening fatigue, generalized pruritus, and a yellowing of her sclerae over the last few months. Laboratory evaluation reveals a significantly elevated serum alkaline phosphatase (ALP) level and normal
Question 16
A 29-year-old female with a history of intravenous drug use presents to the emergency department with a high fever, chills, and a new murmur. Echocardiography reveals a large vegetation on the tricuspid valve. Blood cultures return positive for a Gram-positive, catalase-positive, coagulase-positive coccus in clusters. Which of the following is the most likely causative organism? A) Streptococcus pneumoniae B) Staphylococcus epidermidis C) Staphylococcus aureus D) Streptococcus viridans C) Staphylococcus aureus Rationale: Staphylococcus aureus is a Gram-positive, catalase-positive, coagulasepositive coccus that characteristically causes acute endocarditis in intravenous drug users, frequently targeting the tricuspid valve. Staphylococcus epidermidis is coagulase-negative and mostly targets prosthetic valves. Streptococcus species are catalase-negative.
Question 17
A 55-year-old male with a history of poorly controlled hypertension presents with acute, severe, tearing chest pain that radiates to his back. His blood pressure is 185/105 mmHg in his right arm and 145/85 mmHg in his left arm. A chest X-ray reveals a widened mediastinum. Which of the following vascular layers is primarily involved in the initiation of this patient's pathology? A) Tunica intima B) Tunica media C) Tunica adventitia D) Internal elastic lamina A) Tunica intima Rationale: This patient is presenting with an acute aortic dissection, characterized by a tearing pain radiating to the back and asymmetric blood pressures between arms. Aortic dissection initiates with a tear in the tunica intima, allowing high-pressure blood to enter and propagate a false lumen through the tunica media.
Question 18
A 9-month-old infant is brought to the clinic due to poor weight gain, persistent nonproductive cough, and foul-smelling, bulky stools. A sweat chloride test is performed and returns significantly elevated. This patient's underlying condition is caused by a misfolded protein that is prematurely degraded in which of the following cellular compartments? A) Golgi apparatus B) Lysosome C) Endoplasmic reticulum D) Peroxisome C) Endoplasmic reticulum Rationale: This clinical vignette describes Cystic Fibrosis, caused by a mutation in the CFTR gene (most commonly Delta-F508). This mutation leads to abnormal protein folding. The misfolded CFTR protein is recognized by cellular quality control mechanisms and degraded in the endoplasmic reticulum before reaching the cell membrane.
Question 19
During a cranial structural examination, an osteopathic physician notes that the sphenoid and occiput have rotated in opposite directions around a single anteroposterior axis. During this movement, the greater wings of the sphenoid are elevated on the left side. What is the correct terminology for this cranial somatic dysfunction? A) Right torsion B) Left torsion C) Left sidebending/rotation D) Flexion dysfunction B) Left torsion Rationale: A cranial torsion occurs when the sphenoid and occiput rotate in opposite directions around a single anteroposterior axis. Torsions are named for the greater
=D) Impaired release of acetylcholine from the pre-synaptic terminal C) Autoantibodies against post-synaptic acetylcholine receptors Rationale: Myasthenia gravis is an autoimmune disorder caused by autoantibodies directed against post-synaptic nicotinic acetylcholine receptors at the neuromuscular junction. This reduces the number of functional receptors, causing fatiguable muscle weakness that worsens with use and improves with rest. Destruction of pre-synaptic voltage-gated calcium channels describes Lambert-Eaton myasthenic syndrome.
Question 22
A 22-year-old female presents with a 2-day history of burning on urination, increased urinary frequency, and suprapubic pain. She denies any flank pain or fever. A urine dipstick is positive for leukocyte esterase and nitrites. Culture of the urine grows a Gram-negative rod that is lactose-fermenting and indole-positive. What is the most likely causative organism? A) Proteus mirabilis B) Klebsiella pneumoniae C) Escherichia coli D) Staphylococcus saprophyticus C) Escherichia coli Rationale: Escherichia coli is the leading cause of urinary tract infections (UTIs) in young women. It is a Gram-negative, lactose-fermenting rod that is indole-positive. Proteus mirabilis is indole-negative and urease-positive. Klebsiella is lactosefermenting but indole-negative. Staphylococcus saprophyticus is a Gram- positive coccus.
Question 23
An osteopathic physician is performing a structural exam on a patient with low back pain. The physician palpatively diagnoses a left-on-left sacral torsion. Which of the following findings is most consistent with this specific sacral somatic dysfunction? A) L5 is rotated to the right
B) The right sacral base is posterior =C) The left seated flexion test is positive D) The spring test is positive B) The right sacral base is posterior Rationale: In a left-on-left (L on L) sacral torsion, the sacrum rotates to the left around a left oblique axis. This causes the right sacral base to move anteriorly and the left sacral base to move relatively posteriorly. L5 always rotates in the opposite direction of the sacral rotation, so L5 will rotate right. Forward torsions (like L on L) have a negative spring test.
Question 24
A 48-year-old male with a history of alcohol use disorder presents to the emergency department with severe, epigastric abdominal pain that radiates directly to his back. He reports multiple episodes of vomiting. On examination, he is tachycardic and has marked epigastric tenderness. Laboratory evaluation reveals a serum lipase level that is five times the upper limit of normal. Which of the following complications is most likely to develop within the first 24 to 48 hours of admission? A) Pancreatic pseudocyst B) Acute respiratory distress syndrome (ARDS) C) Pancreatic adenocarcinoma D) Splenic artery aneurysm B) Acute respiratory distress syndrome (ARDS) Rationale: Acute pancreatitis can trigger a systemic inflammatory response syndrome (SIRS) due to the release of circulating pancreatic enzymes (like trypsin and phospholipase A2). These enzymes damage alveolar capillaries, leading to acute respiratory distress syndrome (ARDS), a severe early complication. Pancreatic pseudocysts take weeks to develop.
suppressing the pulsatile release of Gonadotropin-Releasing Hormone (GnRH). This leads to decreased LH and FSH secretion, resulting in anovulation and amenorrhea.
Question 27
An osteopathic physician uses Spencer technique to treat a patient with adhesive capsulitis of the right shoulder. What is the correct chronological sequence of the first three stages within this seven-stage articulation protocol? A) Extension, Flexion, Circumduction with compression B) Flexion, Extension, Circumduction with traction C) Extension, Flexion, Circumduction with traction D) Flexion, Extension, Circumduction with compression C) Extension, Flexion, Circumduction with traction _Rationale: The Spencer technique is a classic 7-stage muscle energy and articulatory protocol for the shoulder. The correct sequence of steps is: 1) Extension,
- Flexion, 3) Circumduction with traction, 4) Circumduction with compression, 5) Adduction/Abduction, 6) Internal rotation, and 7) Abduction with traction/muscle energy._
Question 28
A 68-year-old female presents with sudden, severe, painless vision loss in her right eye. Fundoscopic examination reveals a pale retina with a prominent "cherry-red spot" located at the macula. Which of the following is the most likely diagnosis? A) Central retinal vein occlusion B) Retinal detachment C) Central retinal artery occlusion D) Acute angle-closure glaucoma
C) Central retinal artery occlusion Rationale: Central retinal artery occlusion (CRAO) presents as sudden, painless, monocular vision loss. The classic fundoscopic finding is a pale, ischemic retina with a distinct "cherry-red spot" because the macula maintains its blood supply from the underlying ciliary arteries. Retinal vein occlusion presents with a "blood and thunder" appearance.
Question 29
A 4-year-old boy is brought to the emergency department with a 3-day history of high fever, barking cough, and inspiratory stridor. An anteroposterior neck X-ray demonstrates subglottic narrowing, often referred to as the "steeple sign." Which of the following viruses is the most common cause of this patient's illness? A) Respiratory syncytial virus (RSV) B) Parainfluenza virus C) Influenza A virus D) Adenovirus B) Parainfluenza virus Rationale: This patient is presenting with Croup (laryngotracheobronchitis), characterized by a barking cough, inspiratory stridor, and the radiologic "steeple sign" due to subglottic edema. The most common causative pathogen is human parainfluenza virus type 1 (a paramyxovirus). RSV is most tightly linked to bronchiolitis in younger infants.
Question 30
A 72-year-old male presents with progressive difficulty urinating, a weak urinary stream, and frequent nighttime urination. A digital rectal examination reveals a smooth, symmetrically enlarged, firm prostate gland without distinct nodules. Which of the following anatomical zones of the prostate is the primary site of hyperplasia in this condition? A) Peripheral zone
calcium level of 12.2 mg/dL (normal: 8.5-10.5 mg/dL). A biopsy of the mass is performed. Which of the following histological findings is most likely? A) Small round blue cells B) Keratin pearls and intercellular bridges C) Glandular formation with mucin production D) Sheets of uniform lymphocytes B) Keratin pearls and intercellular bridges Rationale: This patient has squamous cell carcinoma of the lung, which is strongly associated with smoking, presents as a central hilar mass, and can produce parathyroid hormone-related peptide (PTHrP), causing hypercalcemia. Histologically, squamous cell carcinoma is characterized by keratin pearls and intercellular bridges. Small round blue cells describe small cell lung carcinoma.
Question 33
A 26-year-old female presents with a 3-day history of a painful, swollen right knee. She notes that she returned from a vacation in Las Vegas 2 weeks ago. Physical examination reveals an erythematous, warm, exquisitely tender right knee with limited range of motion, as well as a few scattered pustules on her distal extremities. Joint fluid analysis reveals a high white blood cell count with Gram-negative diplococci. Which of the following organisms is responsible? A) Staphylococcus aureus B) Neisseria gonorrhoeae C) Borrelia burgdorferi D) Chlamydia trachomatis B) Neisseria gonorrhoeae Rationale: Neisseria gonorrhoeae is a Gram-negative diplococcus that is a leading cause of septic arthritis in sexually active young adults. It often presents as a monoarticular arthritis or a migratory polyarthralgia associated with tenosynovitis and a pustular skin rash. Chlamydia trachomatis can cause reactive arthritis but is not found as a culturable Gram-negative diplococcus in joint fluid.
Question 34
A 42-year-old female presents with a 2-month history of worsening fatigue, generalized weakness, and cold intolerance. She also reports a recent pattern of heavy and irregular menstrual periods. Physical examination reveals dry skin and delayed relaxation of her patellar reflexes. Which of the following changes in the hypothalamic-pituitary-ovarian axis best explains her menorrhagia? A) Increased LH secretion causing excess androgen production B) Decreased TRH causing direct ovarian failure C) Increased TSH and TRH stimulating excess prolactin secretion D) Decreased GnRH pulsatility leading to endometrial atrophy C) Increased TSH and TRH stimulating excess prolactin secretion Rationale: In primary hypothyroidism, low levels of thyroid hormones lead to a compensatory increase in hypothalamic Thyrotropin-Releasing Hormone (TRH). TRH acts as a prolactin-releasing factor. Elevated prolactin levels inhibit GnRH secretion, disrupting normal LH/FSH pulsatility and leading to anovulation, irregular shedding, and menorrhagia.
Question 35
An osteopathic physician identifies a somatic dysfunction at the atlanto-axial (AA) joint during a routine physical exam. Which of the following motions is primarily evaluated and treated at this specific cervical segment? A) Flexion/Extension B) Sidebending C) Rotation D) Lateral translation C) Rotation Rationale: The atlanto-axial (AA) joint is anatomically specialized for rotation, accounting for approximately 50% of the total rotation of the cervical spine. Flexion and extension occur primarily at the atlanto-occipital (AO) joint. Somatic dysfunction at the AA joint is documented and treated purely in terms of rotation.
