COMLEX-USA (Comprehensive Osteopathic Medical Licensing Examination) — Questions and Answers

Question 1: Tender lumps along the distal palmar crease of a 54-year-old alcoholic male Pt's hand. The ring finger has subcutaneous lumps and palmar fascia contracture, as seen on a PE. What is the most likely Dx?

DeQuervain's disease
Heberden node
Bouchard's node
Dupuytren's contracture (Correct answer)

Correct answer: Dupuytren's contracture

The patient's symptoms of tender lumps along the distal palmar crease, subcutaneous lumps, and palmar fascia contracture, particularly affecting the ring finger, are classic signs of Dupuytren's contracture. This condition involves progressive fibrosis and shortening of the palmar fascia, leading to flexion deformities of the fingers. The patient's history of alcoholism is also a known risk factor for Dupuytren's contracture.

Question 2: The most common cause of community-acquired pneumonia (CAP) in otherwise healthy adults is:

Mycoplasma pneumoniae
Streptococcus pneumoniae (Correct answer)
Legionella pneumophila
Haemophilus influenzae

Correct answer: Streptococcus pneumoniae

Streptococcus pneumoniae remains the most common bacterial cause of CAP in adults across all age groups and severity levels.

Question 3: A 40-year-old man with diabetes presents to the emergency department with acute low back pain. He was sliding into home plate during a softball game earlier today when the pain began. The discomfort is acute and has spread to his right lower extremities. He says he feels an electric ache in his R foot. What are some of the things you'd anticipate to find if you examined him?

With palpation of Lumbar tissues, guarded ROM of the L-Spine, and enhanced deep tendon reflexes of the R lower extremities, there is severe, intense pain.
Palpation reveals a dull ache. Straight leg raising test results were positive.
With palpation and full active ROM of the L-Spine, edematous, swampy tissue is seen. On the dorsum of the foot, there is a loss of sensation.
Warm tissue alterations, hypertonic muscles, and reduced L-Spine ROM (Correct answer)

Correct answer: Warm tissue alterations, hypertonic muscles, and reduced L-Spine ROM

Explanation: The patient has a severe L-Spine SD. One of his lumbar discs had also herniated. Acute SD is linked to acute sharp pain (particularly when palpated). Edematous, erythematous, and swampy are common descriptions for acute tissue texture alterations. There is an increase in moisture on the surface of the skin, as well as associated hypertonic muscles. Muscle contraction and guarding will limit the range of motion in the affected areas.

Question 4: Which antidepressant class is associated with hypertensive crisis when combined with tyramine-rich foods?

TCAs
SSRIs
SNRIs
MAOIs (Correct answer)

Correct answer: MAOIs

MAOIs prevent tyramine breakdown in the gut; consuming tyramine-rich foods (aged cheese, cured meats) causes massive sympathetic activation and hypertensive crisis.

Question 5: The Wisconsin Card Sorting Test is used to assess dysfunction in which brain region?

Prefrontal cortex (Correct answer)
Cerebellum
Parietal lobe
Temporal lobe

Correct answer: Prefrontal cortex

The Wisconsin Card Sorting Test assesses cognitive flexibility and set-shifting, which are executive functions dependent on the prefrontal cortex.

Question 6: Which type of somatic dysfunction is described as Type I (group) mechanics in the thoracic spine?

Multiple segments in neutral with side-bending and rotation opposite (Correct answer)
Single segment, flexed or extended, with rotation and side-bending opposite
Single segment with side-bending and rotation same side
Multiple segments in flexion with same-side coupling

Correct answer: Multiple segments in neutral with side-bending and rotation opposite

Type I (Fryette's first law) involves neutral, multiple vertebral segments where side-bending and rotation occur in opposite directions.

Question 7: Beck's triad (hypotension, muffled heart sounds, JVD) is the classic presentation of which emergency?

Hemothorax
Superior vena cava syndrome
Tension pneumothorax
Cardiac tamponade (Correct answer)

Correct answer: Cardiac tamponade

Beck's triad (hypotension, muffled/distant heart sounds, and JVD) is the hallmark of cardiac tamponade from pericardial fluid compressing the heart.

Question 8: Which condition presents with colicky flank pain radiating to the groin, hematuria, and nausea — often described as the worst pain of the patient's life?

Ureterolithiasis (renal/ureteral stone) (Correct answer)
Ovarian torsion
Acute pyelonephritis
Renal cell carcinoma

Correct answer: Ureterolithiasis (renal/ureteral stone)

Ureteral colic from a kidney stone causes severe colicky flank-to-groin pain, hematuria, and nausea due to ureteral obstruction and spasm.

Question 9: Which imaging modality is first-line for evaluating suspected acute appendicitis in a pregnant woman?

CT scan of abdomen with contrast
Plain abdominal X-ray
MRI of the abdomen
Ultrasound (Correct answer)

Correct answer: Ultrasound

Ultrasound is the first-line imaging for suspected appendicitis in pregnancy to avoid fetal radiation exposure; MRI is used if ultrasound is inconclusive.

Question 10: In which plane(s) does the 1st cervical segment (AA) have the most degree of freedom?

Transverse (Correct answer)
Transverse & Coronal
Oblique
Sagittal

Correct answer: Transverse

Explanation: Rotation is the motion in the transverse plain. The stated segment on the one below is traditionally defined as segmental motion. The initial cervical segment (the AA joint - the atlas on the axis) has the most degrees of freedom in the transverse plane because rotation is its primary motion.

Question 11: A 24-year-old woman presents with 6 weeks of amenorrhea, vaginal bleeding, and left lower quadrant pain. Beta-hCG is 1,500 mIU/mL and transvaginal ultrasound shows no intrauterine gestational sac. She is hemodynamically stable. Which is the most appropriate management?

Dilation and curettage
Expectant management alone
Methotrexate administration (Correct answer)
Immediate laparotomy

Correct answer: Methotrexate administration

Methotrexate is indicated for hemodynamically stable ectopic pregnancy with beta-hCG <5,000 mIU/mL and no fetal cardiac activity on ultrasound.

Question 12: Contraindications to HVLA technique include all of the following EXCEPT:

Fracture at the treatment site
Cervical myelopathy
Osteoporosis
Muscle tension headache (Correct answer)

Correct answer: Muscle tension headache

Muscle tension headache is not a contraindication to HVLA and may actually benefit from careful cervical or suboccipital treatment.

Question 13: A 26-year-old woman has irregular periods, hirsutism, and obesity. Transvaginal ultrasound shows bilateral ovaries with 14 follicles each (< 10 mm). Testosterone is mildly elevated. What is the most likely diagnosis?

Polycystic ovary syndrome (Correct answer)
Hypothyroidism
Congenital adrenal hyperplasia
Cushing syndrome

Correct answer: Polycystic ovary syndrome

PCOS is diagnosed by Rotterdam criteria: oligo-anovulation, clinical or biochemical hyperandrogenism, and polycystic ovarian morphology (≥12 follicles per ovary).

Question 14: A 50-year-old man is experiencing low back pain. On examination, the TP of L5 is seen to be posterior on the R. The asymmetry is worsened by extending L5, but flexion restores rotational symmetry. Which of the following statements about this Pt's SD is the most accurate?

The Pt would be requested to rotate his torso to the L against isometric contraction when using a muscular energy (post-isometric relaxation) approach.
This patient has psoas syndrome on the right side.
In the stretched posture, L5 will oppose L-rotation. (Correct answer)
A group dysfunction of the high Lumbar area will be present because to the non-neutral L5 SD.

Correct answer: In the stretched posture, L5 will oppose L-rotation.

Explanation: The patient flexed L5, twisted R, and sidebent R. When the spine is extended, the symmetry worsens and L5 resists the rotation of L.

Question 15: A patient with a history of mania, grandiosity, decreased need for sleep, and hypersexuality is most likely diagnosed with:

Major depressive disorder
Bipolar I disorder (Correct answer)
Bipolar II disorder
Cyclothymia

Correct answer: Bipolar I disorder

Bipolar I disorder requires at least one manic episode (lasting ≥7 days) with symptoms of elevated mood, grandiosity, decreased sleep, and hypersexuality.

Question 16: Nitric oxide (NO) produces vasodilation primarily by activating which intracellular enzyme?

Adenylyl cyclase
Protein kinase C
Phosphodiesterase
Soluble guanylyl cyclase (Correct answer)

Correct answer: Soluble guanylyl cyclase

NO activates soluble guanylyl cyclase, increasing cGMP, which activates protein kinase G to cause smooth muscle relaxation and vasodilation.

Question 17: You notice that the thoracic segments T8-T12 are convex to the R in a 41-year-old man with back pain. Which statement about this group's SD is the most accurate?

Ribs 7 - 12 are limited in exhalation on the L
T9 is Rotated right, Sidebent right
T9's R TP is more anterior
T10's L TP is more caudad compared to its R (Correct answer)

Correct answer: T10's L TP is more caudad compared to its R

A convexity to the right in the thoracic spine (T8-T12) indicates that the spine is sidebent to the left (Sleft). For a group dysfunction (Type I mechanics), sidebending and rotation occur in opposite directions. Therefore, if sidebent left, the group is rotated right (Rright). In a sidebent left dysfunction, the transverse processes on the left side become more caudad (inferior) compared to the right, as the left side of the vertebral bodies approximates. Thus, T10's L TP being more caudad than its R is consistent with sidebending left.

Question 18: During which phase of the cell cycle does DNA replication occur?

G2 phase
M phase
S phase (Correct answer)
G1 phase

Correct answer: S phase

DNA synthesis and replication occur during S (synthesis) phase of the cell cycle.

Question 19: In Kübler-Ross's stages of grief, which stage is characterized by the patient seeking to delay the inevitable through promises?

Depression
Anger
Bargaining (Correct answer)
Denial

Correct answer: Bargaining

The bargaining stage involves attempts to negotiate with a higher power or fate to delay or prevent death, often including 'if only' statements.

Question 20: A 23-year-old competitive marathon runner presents with 4 months of secondary amenorrhea. Labs show low FSH, low LH, low estradiol, and normal prolactin. TSH is normal. What is the most likely diagnosis?

Premature ovarian insufficiency
Polycystic ovary syndrome
Hypothalamic amenorrhea (Correct answer)
Prolactinoma

Correct answer: Hypothalamic amenorrhea

Hypothalamic amenorrhea from excessive exercise causes suppression of GnRH, resulting in low FSH, low LH, and low estradiol, unlike POI (elevated FSH) or PCOS (elevated LH/androgens).

Question 21: Which neurotransmitter is most implicated in the pathophysiology of schizophrenia, based on the dopamine hypothesis?

Serotonin
Dopamine (Correct answer)
GABA
Norepinephrine

Correct answer: Dopamine

The dopamine hypothesis proposes that mesolimbic dopamine hyperactivity causes positive symptoms while mesocortical hypoactivity causes negative symptoms of schizophrenia.

Question 22: A missense mutation results in:

Insertion of an extra nucleotide
A single amino acid substitution (Correct answer)
A premature stop codon
Deletion of a codon

Correct answer: A single amino acid substitution

A missense mutation changes a single nucleotide such that it codes for a different amino acid, potentially altering protein function.

Question 23: The classic triad of Cushing's syndrome includes central obesity, hypertension, and:

Hypocalcemia
Hypothyroidism
Hyperpigmentation
Skin striae and muscle weakness (Correct answer)

Correct answer: Skin striae and muscle weakness

Cushing's syndrome classic features include central obesity, hypertension, purple striae, proximal muscle weakness, hirsutism, and easy bruising from excess cortisol.

Question 24: Which is the most common cause of small bowel obstruction in adults in the United States?

Hernia
Crohn's disease
Adhesions from prior surgery (Correct answer)
Malignancy

Correct answer: Adhesions from prior surgery

Adhesions from prior abdominal surgery account for approximately 60–75% of small bowel obstructions in adults.

Question 25: Chvostek's sign (facial twitching with tapping CN VII) indicates which electrolyte abnormality?

Hyponatremia
Hypercalcemia
Hypocalcemia (Correct answer)
Hypomagnesemia

Correct answer: Hypocalcemia

Chvostek's sign and Trousseau's sign (carpal spasm with BP cuff) are clinical signs of hypocalcemia causing neuromuscular hyperexcitability.

Question 26: Which drug used for rheumatoid arthritis inhibits dihydrofolate reductase, requiring folate supplementation?

Leflunomide
Hydroxychloroquine
Methotrexate (Correct answer)
Sulfasalazine

Correct answer: Methotrexate

Methotrexate inhibits dihydrofolate reductase, impairing nucleotide synthesis; folic acid supplementation reduces mucosal and hematologic side effects.

Question 27: Which surgical complication presents with fever, tachycardia, elevated WBC, and rigidity beginning 24–48 hours after bowel surgery?

Pulmonary embolism
Superficial wound infection
Urinary retention
Anastomotic leak (Correct answer)

Correct answer: Anastomotic leak

Anastomotic leak after bowel surgery presents with fever, tachycardia, leukocytosis, and peritoneal signs due to bowel contents leaking into the peritoneum.

Question 28: A 36-week pregnant woman has a positive Group B Streptococcus vaginal-rectal culture. Which antibiotic should be administered intrapartum for prophylaxis?

Oral clindamycin
IV vancomycin
IV erythromycin
IV penicillin G or ampicillin (Correct answer)

Correct answer: IV penicillin G or ampicillin

IV penicillin G is first-line intrapartum GBS prophylaxis, with ampicillin as an acceptable alternative.

Question 29: Direct compression of which of the following peripheral nerves can be caused by a posterior fibular head dysfunction?

Sciatic
Sural
Common fibular (aka common peroneal) (Correct answer)
Tibial

Correct answer: Common fibular (aka common peroneal)

The common fibular nerve (also known as the common peroneal nerve) is particularly vulnerable to compression as it wraps superficially around the neck of the fibula, just distal to the fibular head. A posterior fibular head dysfunction involves the fibular head being displaced backward, which can directly impinge upon and compress this nerve. Compression of the common fibular nerve can lead to symptoms such as foot drop and sensory deficits in the anterolateral leg and dorsum of the foot.

Question 30: In a patient with acute coronary syndrome, which ECG finding indicates a complete occlusion requiring urgent reperfusion?

T-wave inversions in V1–V3
ST depression in V1–V4
New ST elevation ≥1 mm in 2 contiguous leads (STEMI) (Correct answer)
Prolonged QT interval

Correct answer: New ST elevation ≥1 mm in 2 contiguous leads (STEMI)

ST-elevation MI (STEMI) indicates complete coronary artery occlusion and requires immediate reperfusion via PCI or thrombolytics.

Question 31: Which personality disorder is characterized by a pervasive pattern of instability in relationships, self-image, and affect, along with impulsivity and fear of abandonment?

Antisocial personality disorder
Narcissistic personality disorder
Histrionic personality disorder
Borderline personality disorder (Correct answer)

Correct answer: Borderline personality disorder

Borderline personality disorder features identity disturbance, unstable intense relationships, impulsivity, affective instability, and frantic efforts to avoid abandonment.

Question 32: A patient repeatedly arrives late to appointments despite genuine attempts to be on time. Which defense mechanism best explains this behavior?

Projection
Passive aggression (Correct answer)
Rationalization
Intellectualization

Correct answer: Passive aggression

Passive aggression involves indirect expression of hostility through behaviors like tardiness, forgetfulness, or inefficiency.

Question 33: What is the primary goal of lymphatic pump techniques in OMT?

Reduce cerebrospinal fluid pressure
Increase arterial blood pressure
Stretch thoracic fascia
Enhance lymphatic flow and immune function (Correct answer)

Correct answer: Enhance lymphatic flow and immune function

Lymphatic pump techniques (thoracic, pedal, abdominal) augment lymphatic circulation to reduce edema and support immune function.

Question 34: Which of the following is regarded the most frequent L-Spine congenital anomaly?

Facet hypertorphy
Facet tropism (Correct answer)
Lumbarization
Spina bifida occulta

Correct answer: Facet tropism

Explanation: A misalignment of the facet joint is known as facet tropism. It is the most common L-Spine abnormality, according to Osteopathic principles in practice.

Question 35: Which cranial nerve is responsible for the afferent limb of the corneal reflex?

CN II
CN VII
CN V1 (ophthalmic branch of trigeminal) (Correct answer)
CN III

Correct answer: CN V1 (ophthalmic branch of trigeminal)

The ophthalmic branch (V1) of the trigeminal nerve carries sensory input from the cornea as the afferent limb of the corneal reflex.

Question 36: A patient in alcohol withdrawal develops confusion, ophthalmoplegia, and ataxia. Which vitamin deficiency causes this triad?

Vitamin B1 (thiamine) (Correct answer)
Vitamin B12
Vitamin B6 (pyridoxine)
Niacin (B3)

Correct answer: Vitamin B1 (thiamine)

Wernicke's encephalopathy is caused by thiamine (B1) deficiency and presents with the classic triad of confusion, ophthalmoplegia, and ataxia.

Question 37: Your L thumb is more anterior than your R while analyzing a mid-thoracic SD. When the Pt is in flexion, your thumbs become more symmetrical; however, the discomfort is too strong to inspect the Pt in extension. The following is the most probable Dx:

F Rright Sright (Correct answer)
E Rleft Sleft
N Rright Sleft
F Rleft Sleft

Correct answer: F Rright Sright

The finding "L thumb is more anterior than your R" indicates that the left transverse process is anterior, meaning the vertebra is rotated to the right (Rright). The statement "discomfort is too strong to inspect the Pt in extension" suggests a restriction in extension, implying the vertebra is stuck in flexion (F). According to Fryette's Type II mechanics for non-neutral dysfunctions, rotation and sidebending occur to the same side. Therefore, if the vertebra is flexed and rotated right, it must also be sidebent right (Sright), leading to a diagnosis of F Rright Sright.

Question 38: In acute cholecystitis, which physical exam finding is pain with palpation of the RUQ that increases with inspiration?

Murphy's sign (Correct answer)
Grey-Turner's sign
Kehr's sign
Cullen's sign

Correct answer: Murphy's sign

Murphy's sign is cessation of inspiration due to pain when the examiner presses the RUQ and the inflamed gallbladder descends to meet the fingers.

Question 39: In a patient with suspected pulmonary embolism and moderate pretest probability, which is the most appropriate next diagnostic step?

V/Q scan
CT pulmonary angiography (CTPA) (Correct answer)
Empiric anticoagulation
D-dimer assay

Correct answer: CT pulmonary angiography (CTPA)

With moderate pretest probability for PE, CTPA is the preferred diagnostic test; D-dimer is used to rule out PE only with low pretest probability.

Question 40: C3 is bent to the left, sidebent, and rotated to the left. How would you position C3 if you were to utilize a direct ME approach to fix this problem?

In extension, Sidebent right, Rotated right
In extension, Sidebent left, Rotated left
In flexion, Sidebent left, Rotated right
In flexion, Sidebent right, Rotated right (Correct answer)

Correct answer: In flexion, Sidebent right, Rotated right

The dysfunction described as "C3 is bent to the left, sidebent, and rotated to the left" implies that the vertebra is stuck in an extended position, sidebent left, and rotated left (E Sleft Rleft). For a direct muscle energy (ME) approach, the patient is positioned into the restrictive barrier. The restrictive barriers for an E Sleft Rleft dysfunction are flexion, sidebending right, and rotation right. Therefore, the correct position for direct ME treatment is in flexion, sidebent right, and rotated right.

Question 41: During menses, a 16-year-old female experiences low, midline, wave-like cramping pelvic pain. The pain has been there for three months and has become increasingly severe. Her pain frequently radiates to her L-Spine and is accompanied by nausea. Which OMM approach, in conjunction to suitable oral drugs, can most successfully reduce the Pt's symptoms by modifying sympathetic tone?

Release of celiac ganglion
Sacral inhibition
To the thoraco-lumbar junction, rib raising & paraspinal inhibition (Correct answer)
Release of the pelvic diaphragm

Correct answer: To the thoraco-lumbar junction, rib raising & paraspinal inhibition

Explanation: Dysmenorrhea symptoms and indicators are present in the patient. Pain is caused by uterine vasoconstriction, anoxia, and prostaglandin-mediated prolonged contractions. T10 - L2 segments supply sympathetic innervation to the uterus. Because rib elevation and paraspinal inhibition reduce sympathetic tone, these treatments successfully increase blood flow and relax the uterus, reducing pain.

Question 42: A patient with cirrhosis develops upper GI bleeding with hematemesis. Initial management should include:

Oral propranolol
Urgent endoscopy without stabilization
IV access, fluid resuscitation, and octreotide drip (Correct answer)
Emergency TIPS procedure

Correct answer: IV access, fluid resuscitation, and octreotide drip

Initial management of variceal bleeding includes large-bore IV access, volume resuscitation, octreotide (to reduce portal pressure), antibiotics, and blood transfusion as needed before endoscopy.

Question 43: A patient develops fever, purulent wound discharge, and erythema on post-op day 5 from an appendectomy. The most likely cause is:

DVT
Wound infection (Correct answer)
Pneumonia
Atelectasis

Correct answer: Wound infection

Wound infection typically presents 3–7 days after surgery with fever, erythema, warmth, and purulent discharge at the incision site.

Question 44: A 35-year-old woman comes in for a typical PE. When examining her posture from the side, you notice that an imaginary plum line drawn from the ceiling to the floor would pass posterior to the apex of the coronal suture, through the external meatus, through most of the bodies of the C-Spine, through the shoulder joint, through the bodies of the L-Spine, just posterior to the axis of the hip, slightly anterior to the axis of the knee joint, and through the external meatus. Which of the following statements most accurately characterizes this patient's posture?

Anterior postural deviation
Ideal posture (Correct answer)
Flat back posture
Military posture

Correct answer: Ideal posture

The described path of the imaginary plum line through specific anatomical landmarks (posterior to coronal suture, through external meatus, C-spine bodies, shoulder joint, L-spine bodies, posterior to hip axis, anterior to knee joint, and through external malleolus) precisely defines ideal posture. This alignment minimizes stress on joints and muscles, indicating optimal biomechanical balance. Any significant deviation from this line would characterize other postural types like flat back or military posture.

Question 45: Which complement pathway is activated by antibody-antigen complexes and begins with C1q binding?

Lectin pathway
Alternative pathway
Terminal pathway
Classical pathway (Correct answer)

Correct answer: Classical pathway

The classical complement pathway is activated when C1q binds to antibody-antigen complexes, initiating the complement cascade.

Question 46: Neck pain is reported by a patient. After a comprehensive examination, you discover that several muscles are in spasm. The most painful muscle arises from the cervical vertebra's TPs and attaches to rib 1. What kind of muscle is it?

Anterior Scalene (Correct answer)
Longus Colli
Sternocleidomastoid
Posterior Scalene

Correct answer: Anterior Scalene

The question describes a muscle originating from the transverse processes of cervical vertebrae and attaching to the first rib. This anatomical description perfectly matches the anterior scalene muscle, which typically originates from the transverse processes of C3-C6 and inserts onto the first rib. The middle scalene also attaches to the first rib but usually originates from C2-C7, while the posterior scalene attaches to the second rib.

Question 47: Which phase of fever is characterized by peripheral vasoconstriction and shivering?

Crisis phase
Defervescence
Plateau phase
Chill phase (Correct answer)

Correct answer: Chill phase

The chill (prodromal) phase of fever involves peripheral vasoconstriction and shivering as the body raises its temperature to the new hypothalamic set point.

Question 48: A patient taking warfarin is started on trimethoprim-sulfamethoxazole for a UTI. Which effect is expected?

No change in INR
Decreased warfarin absorption
Decreased anticoagulation due to CYP induction
Increased anticoagulation due to CYP2C9 inhibition (Correct answer)

Correct answer: Increased anticoagulation due to CYP2C9 inhibition

TMP-SMX inhibits CYP2C9, which metabolizes S-warfarin, leading to increased warfarin levels and elevated INR/bleeding risk.

Question 49: In damage control surgery for a trauma patient with coagulopathy and hypothermia, the correct sequence is:

Observation only until stable
Angiography first → then surgery
Initial hemorrhage control → ICU resuscitation → definitive repair (Correct answer)
Full repair → ICU → second look

Correct answer: Initial hemorrhage control → ICU resuscitation → definitive repair

Damage control surgery limits OR time to control hemorrhage and contamination, followed by ICU resuscitation of the 'lethal triad' (hypothermia, coagulopathy, acidosis), then return to OR for definitive repair.

Question 50: A 29-year-old woman at 33 weeks gestation has regular uterine contractions with cervical dilation of 2 cm. Which tocolytic agent is CONTRAINDICATED at this gestational age?

Subcutaneous terbutaline
Nifedipine
Magnesium sulfate
Indomethacin (Correct answer)

Correct answer: Indomethacin

Indomethacin is contraindicated after 32 weeks gestation due to risk of premature closure of the ductus arteriosus and fetal renal impairment.

Question 51: Leg edema affects a 25-year-old woman in her 36th week of pregnancy. What is the most effective first treatment

Pedal pump
L1 - L3 muscle energy
Rib raising to the thoraco-lumbar junction
Thoracic inlet release (Correct answer)

Correct answer: Thoracic inlet release

Explanation: The thoracic inlet should be released prior to lymphatic pumping procedures to remove any impedance entering the thoracic duct and, ultimately, the central circulation.

Question 52: A patient refuses a blood transfusion on religious grounds despite life-threatening blood loss. The ethical principle guiding the physician to respect this decision is:

Beneficence
Non-maleficence
Justice
Autonomy (Correct answer)

Correct answer: Autonomy

Autonomy requires respecting a competent patient's right to make their own medical decisions, even when the physician disagrees with the choice.

Question 53: Which finding in a patient with blunt abdominal trauma most reliably indicates splenic injury?

Battle's sign
Cullen's sign
Kehr's sign (left shoulder tip pain) (Correct answer)
Murphy's sign

Correct answer: Kehr's sign (left shoulder tip pain)

Kehr's sign (referred left shoulder pain from diaphragmatic irritation by blood) is a classic finding in splenic injury due to subdiaphragmatic hemorrhage.

Question 54: The Still technique in OMT is a combination of which two traditional techniques?

Myofascial release and cranial
Articulatory and muscle energy
Counterstrain and HVLA (Correct answer)
Lymphatic pump and soft tissue

Correct answer: Counterstrain and HVLA

A.T. Still's original technique combines elements of counterstrain positioning with an HVLA-type activating force through the barrier.

Question 55: The malfunctioning T12 segment has limitation in a transverse plane and around a transverse axis in a patient with low back pain. T12's position best describes which of the following dysfunctions?

R is sidebent T12.
T12 is rotated R and sidebent R. (Correct answer)
T12 is flexed
T12 is rotated to the left.

Correct answer: T12 is rotated R and sidebent R.

Explanation: Flexion and extension are the two types of vertebral motion around a transverse axis. As a result, T12 must be either flexed or stretched. In a transverse plane, vertebral motion is rotation. As a result, T12 needs to be rotated as well. If one understands Fryette's concepts, one must conclude that if a vertebra is flexed, extended, and rotated, it must also be sidebent to the same side.

Question 56: A 28-year-old woman at 38 weeks gestation presents with severe headache, visual disturbances, and blood pressure of 158/105 mmHg. Urine dipstick shows 3+ proteinuria. Which is the definitive treatment?

Delivery of the fetus (Correct answer)
IV labetalol
Oral nifedipine
Magnesium sulfate

Correct answer: Delivery of the fetus

Delivery of the fetus and placenta is the only definitive treatment for preeclampsia, as the placenta is the underlying cause.

Question 57: Which osteopathic technique uses a high-velocity, low-amplitude thrust to restore motion at a restricted joint?

HVLA thrust (Correct answer)
Counterstrain
Muscle energy
Myofascial release

Correct answer: HVLA thrust

HVLA (high-velocity, low-amplitude) thrust techniques use a rapid, precisely directed force to restore joint mobility.

Question 58: A patient on warfarin has an INR of 8.0 with no active bleeding. Management should include:

Fresh frozen plasma (FFP) transfusion
Holding warfarin and administering oral vitamin K (Correct answer)
Prothrombin complex concentrate (PCC)
IV vitamin K only

Correct answer: Holding warfarin and administering oral vitamin K

For supratherapeutic INR (>4.5–10) without bleeding, holding warfarin and giving oral vitamin K is appropriate; IV vitamin K and FFP/PCC are reserved for active bleeding.

Question 59: Which of the following statements about a patient with an anterior fibular head SD is correct?

It's very common in typical ankle sprains.
It can cause a foot drop.
The SD will enhance the amount of plantar flexion that is passive.
The synovial articulation of the tibio-fibular joint resists posterior glide. (Correct answer)

Correct answer: The synovial articulation of the tibio-fibular joint resists posterior glide.

An anterior fibular head somatic dysfunction means the fibular head is displaced anteriorly relative to the tibia. In this position, the proximal tibiofibular joint, which is a synovial articulation, will be at its anterior limit of motion. Consequently, any attempt to move the fibular head posteriorly (a posterior glide) will be met with resistance, as it is already restricted in that direction.

Question 60: A 22-year-old sexually active woman has lower abdominal pain, cervical motion tenderness, uterine tenderness, and mucopurulent cervical discharge with temperature of 38.3°C. Which organism is most likely responsible?

Chlamydia trachomatis or Neisseria gonorrhoeae (Correct answer)
Treponema pallidum
Gardnerella vaginalis
Trichomonas vaginalis

Correct answer: Chlamydia trachomatis or Neisseria gonorrhoeae

Pelvic inflammatory disease is most commonly caused by ascending infection from Chlamydia trachomatis and/or Neisseria gonorrhoeae.

Question 61: The antidote for acetaminophen overdose, N-acetylcysteine (NAC), works by:

Alkalinizing the urine
Replenishing glutathione stores (Correct answer)
Inhibiting CYP2E1
Directly binding NAPQI

Correct answer: Replenishing glutathione stores

NAC serves as a glutathione precursor, replenishing hepatic glutathione stores to detoxify the toxic NAPQI metabolite of acetaminophen.

Question 62: A patient with nephrotic syndrome has massive proteinuria, hypoalbuminemia, and pitting edema. The most common cause in adults is:

Focal segmental glomerulosclerosis (FSGS)
Membranous nephropathy (Correct answer)
IgA nephropathy
Minimal change disease

Correct answer: Membranous nephropathy

Membranous nephropathy is the most common cause of nephrotic syndrome in adults, often idiopathic but associated with anti-PLA2R antibodies.

Question 63: A patient with diabetes develops painless vision loss. Fundoscopic exam shows neovascularization. The diagnosis is:

Proliferative diabetic retinopathy (Correct answer)
Central retinal artery occlusion
Age-related macular degeneration
Non-proliferative diabetic retinopathy

Correct answer: Proliferative diabetic retinopathy

Proliferative diabetic retinopathy is defined by new vessel formation (neovascularization) on the retina or disc, which can cause vitreous hemorrhage and blindness.

Question 64: Which benzodiazepine is preferred in elderly patients due to its lack of active metabolites?

Lorazepam (Correct answer)
Diazepam
Clonazepam
Chlordiazepoxide

Correct answer: Lorazepam

Lorazepam (along with oxazepam and temazepam — the 'LOT' drugs) lacks active metabolites and is safer in elderly patients with impaired hepatic metabolism.

Question 65: Which drug class is the first-line treatment for chronic stable angina and works by reducing myocardial oxygen demand?

Nitrates
Ranolazine
Beta-blockers (Correct answer)
Calcium channel blockers

Correct answer: Beta-blockers

Beta-blockers reduce heart rate and contractility, decreasing myocardial oxygen demand and are first-line for chronic stable angina prophylaxis.

Question 66: A patient appears with an absent triceps tendon reflex and weakness in the extensors of the hand, wrist, and elbow due to a neurological deficiency. Which nerve is the most likely to be affected?

Radial (Correct answer)
Median
Axillary
Musculocutaneous

Correct answer: Radial

Explanation: The radial nerve innervates the extensors of the upper extremity (elbow, triceps, wrist & hand). An absent triceps (C7) reflex & wrist drop will indicate radial nerve pathology

Question 67: A woman at 34 weeks gestation has platelet count 68,000/μL, AST 210 U/L, elevated LDH, and severe headache. HELLP syndrome is diagnosed. What is the most critical next step?

Plasma exchange transfusion
Prompt delivery regardless of gestational age (Correct answer)
Corticosteroids and delay delivery 48 hours
IV magnesium sulfate alone

Correct answer: Prompt delivery regardless of gestational age

HELLP syndrome is a life-threatening variant of severe preeclampsia; delivery is the definitive and required treatment regardless of gestational age.

Question 68: Which spinal level provides sympathetic innervation to the heart?

T6–T9
T1–T5 (Correct answer)
C3–C5
T10–L2

Correct answer: T1–T5

Cardiac sympathetic fibers originate from T1–T5 preganglionic neurons and are targeted when treating cardiac somatic dysfunction.

Question 69: During ATLS primary survey, which is assessed as part of the 'C' component of ABCDE?

Cervical spine stabilization
Catheter placement
Consciousness level
Circulation and hemorrhage control (Correct answer)

Correct answer: Circulation and hemorrhage control

In ATLS, C stands for Circulation with hemorrhage control — including assessment of blood pressure, pulses, and control of external bleeding.

Question 70: Which muscle energy technique principle involves the patient contracting against the physician's unyielding resistance to mobilize a restricted segment?

Reciprocal inhibition
Articulatory technique
Joint mobilization
Post-isometric relaxation (Correct answer)

Correct answer: Post-isometric relaxation

Post-isometric relaxation (PIR) uses the reflex relaxation that follows an isometric contraction to gain increased range of motion.

Question 71: Which beta-blocker is cardioselective (beta-1 selective) and commonly used in heart failure?

Metoprolol succinate (Correct answer)
Carvedilol
Labetalol
Propranolol

Correct answer: Metoprolol succinate

Metoprolol succinate (extended-release) is a beta-1 selective blocker proven to reduce mortality in heart failure with reduced ejection fraction.

Question 72: Wernicke's area, responsible for language comprehension, is located in which brain region?

Inferior frontal gyrus, dominant hemisphere
Inferior parietal lobule
Primary auditory cortex
Superior temporal gyrus, dominant hemisphere (Correct answer)

Correct answer: Superior temporal gyrus, dominant hemisphere

Wernicke's area is in the posterior superior temporal gyrus of the dominant hemisphere and is critical for language comprehension.

Question 73: The mechanism of action of metformin in type 2 diabetes primarily involves:

Activating AMPK to reduce hepatic gluconeogenesis (Correct answer)
Stimulating insulin secretion from beta cells
Inhibiting dipeptidyl peptidase-4
Blocking SGLT-2 in the kidney

Correct answer: Activating AMPK to reduce hepatic gluconeogenesis

Metformin activates AMPK, which decreases hepatic gluconeogenesis and increases peripheral insulin sensitivity without causing hypoglycemia.

Question 74: A 34-year-old woman at 30 weeks gestation has painless vaginal bleeding. Ultrasound shows the placenta completely covering the internal cervical os. She is currently stable. What is the most appropriate management?

Immediate cesarean section
Pelvic rest, hospitalization, and planned delivery at 36–37 weeks (Correct answer)
Vaginal delivery with oxytocin augmentation
Amniocentesis for fetal lung maturity

Correct answer: Pelvic rest, hospitalization, and planned delivery at 36–37 weeks

Stable placenta previa at 30 weeks is managed conservatively with pelvic rest and monitoring, with planned cesarean at 36–37 weeks.

Question 75: A patient with chronic kidney disease has a serum potassium of 6.8 mEq/L and peaked T waves on EKG. First-line immediate treatment is:

Furosemide IV
Sodium bicarbonate IV
IV calcium gluconate (Correct answer)
Kayexalate (sodium polystyrene sulfonate)

Correct answer: IV calcium gluconate

IV calcium gluconate immediately stabilizes the cardiac membrane in hyperkalemia, preventing arrhythmia, though it does not lower potassium levels.

Question 76: The Chapman reflex point for the heart is located anteriorly between which ribs?

1st and 2nd ribs on the left
3rd and 4th ribs on the left
2nd and 3rd ribs on the left (Correct answer)
4th and 5th ribs on the left

Correct answer: 2nd and 3rd ribs on the left

The anterior Chapman point for the heart is found between the 2nd and 3rd ribs on the left side of the sternum.

Question 77: A patient presents with symmetric proximal muscle weakness, elevated CK, and Gottron's papules. The diagnosis is:

Inclusion body myositis
Dermatomyositis (Correct answer)
Fibromyalgia
Polymyositis

Correct answer: Dermatomyositis

Dermatomyositis presents with proximal muscle weakness, elevated CK, and pathognomonic skin findings including Gottron's papules (knuckles) and heliotrope rash.

Question 78: A patient presents to the ED with anaphylaxis and urticaria after a bee sting. First-line treatment is:

Diphenhydramine IV
Methylprednisolone IV
Epinephrine 0.3–0.5 mg IM (thigh) (Correct answer)
Albuterol nebulizer

Correct answer: Epinephrine 0.3–0.5 mg IM (thigh)

Epinephrine IM (anterolateral thigh) is the first and most critical treatment for anaphylaxis; antihistamines and steroids are adjuncts but do not replace epinephrine.

Question 79: A patient on isoniazid (INH) develops peripheral neuropathy. Which supplement should be given to prevent this side effect?

Folate
Thiamine (B1)
Vitamin B12 (cobalamin)
Vitamin B6 (pyridoxine) (Correct answer)

Correct answer: Vitamin B6 (pyridoxine)

INH inhibits pyridoxine (B6) metabolism; supplementing pyridoxine prevents INH-induced peripheral neuropathy.

Question 80: Which of the following motions will be most affected by plexopathy involving the medial chord of the brachial plexus?

Finger abduction (Correct answer)
Shoulder external rotation
Shoulder abduction
Elbow flexion

Correct answer: Finger abduction

The medial cord of the brachial plexus gives rise to the ulnar nerve and the medial root of the median nerve. The ulnar nerve is responsible for innervating most of the intrinsic muscles of the hand, including the dorsal and palmar interossei, which are crucial for finger abduction and adduction. Therefore, plexopathy involving the medial cord would most significantly affect finger abduction due to ulnar nerve compromise.

Question 81: At a 24-week prenatal visit, a 1-hour 50g glucose challenge test returns 158 mg/dL. What is the next appropriate step?

Diagnose gestational diabetes and start insulin
Repeat the 1-hour test in 4 weeks
Check HbA1c to confirm diagnosis
Perform a 3-hour 100g oral glucose tolerance test (Correct answer)

Correct answer: Perform a 3-hour 100g oral glucose tolerance test

An abnormal 1-hour GCT (≥140 mg/dL) is a screening result only; a 3-hour 100g OGTT is required for diagnostic confirmation of gestational diabetes.

Question 82: A 55-year-old woman presents with abdominal bloating, early satiety, and increased girth for 3 months. CA-125 is 480 U/mL. CT shows bilateral adnexal masses with peritoneal implants. Which histological subtype of ovarian cancer is most common?

Clear cell carcinoma
High-grade serous adenocarcinoma (Correct answer)
Endometrioid carcinoma
Mucinous adenocarcinoma

Correct answer: High-grade serous adenocarcinoma

High-grade serous adenocarcinoma accounts for approximately 70% of epithelial ovarian cancers and is the most common and deadly subtype.

Question 83: Chronic renal insufficiency affects a 45-year-old diabetic male. An analysis of the structure is likely to reveal:

T8 and T9 fibrotic paraspinals
T5 and T6 have severe acute tender points.
T10 - L1 ropy paraspinals (Correct answer)
Ropy paraspinals at C3

Correct answer: T10 - L1 ropy paraspinals

Explanation: Tissue texture changes at the thoraco-lumbar junction have been linked to renal insufficiency. Ropy and fibrotic are two adjectives that describe chronic tissue texture alterations. T11-L1 Kidneys

Question 84: Which opioid analgesic is contraindicated in patients with renal failure due to accumulation of its active metabolite morphine-6-glucuronide?

Hydromorphone
Fentanyl
Buprenorphine
Morphine (Correct answer)

Correct answer: Morphine

Morphine's active metabolite morphine-6-glucuronide (M6G) accumulates in renal failure, causing prolonged sedation and respiratory depression.

Question 85: The Galbreath technique is a mandibular drainage technique primarily used to treat dysfunction of which structure?

Sinuses
Temporomandibular joint
Cervical lymph nodes
Eustachian tube / middle ear (Correct answer)

Correct answer: Eustachian tube / middle ear

The Galbreath technique uses rhythmic mandibular traction to open the Eustachian tube and facilitate middle ear drainage.

Question 86: In the initial management of an acute burn patient, fluid resuscitation in the first 24 hours is guided by which formula?

APACHE II scoring
Parkland formula (Correct answer)
Starling equation
Henderson-Hasselbalch equation

Correct answer: Parkland formula

The Parkland formula (4 mL × weight in kg × % TBSA burned) with lactated Ringer's guides IV fluid resuscitation in major burns in the first 24 hours.

Question 87: Facilitated positional release (FPR) combines a position of ease with which additional element to enhance tissue relaxation?

Muscle contraction
Heat application
Compressive or torsional activating force (Correct answer)
Respiratory cooperation

Correct answer: Compressive or torsional activating force

FPR adds a compressive or torsional activating force to the position of ease to facilitate rapid soft-tissue release.

Question 88: Which type of collagen is most abundant in articular cartilage?

Type III collagen
Type IV collagen
Type I collagen
Type II collagen (Correct answer)

Correct answer: Type II collagen

Type II collagen is the predominant collagen in hyaline cartilage, providing tensile strength and resisting compression.

Question 89: In the diagnosis of systemic lupus erythematosus (SLE), which antibody is most specific (though not most sensitive)?

Anti-Sm (Correct answer)
Anti-dsDNA
Anti-histone
ANA

Correct answer: Anti-Sm

Anti-Smith (anti-Sm) antibody is highly specific for SLE (~99% specific) though present in only ~25% of patients; ANA is most sensitive.

Question 90: According to Erikson's stages of psychosocial development, the primary task of adolescence (ages 12–18) is:

Generativity vs. stagnation
Identity vs. role confusion (Correct answer)
Industry vs. inferiority
Intimacy vs. isolation

Correct answer: Identity vs. role confusion

Erikson's stage for adolescence is identity vs. role confusion, during which individuals explore and develop a coherent sense of personal identity.

Question 91: Which complication of cirrhosis involves bacterial translocation causing spontaneous infection of ascitic fluid?

Spontaneous bacterial peritonitis (SBP) (Correct answer)
Hepatorenal syndrome
Hepatic encephalopathy
Hepatopulmonary syndrome

Correct answer: Spontaneous bacterial peritonitis (SBP)

SBP occurs when gut bacteria translocate into ascitic fluid; diagnosed by PMN count >250 cells/mm³ in ascites; treated with cefotaxime.

Question 92: Informed consent requires all of the following EXCEPT:

Disclosure of risks and benefits
Voluntariness
Patient agreement with the physician's recommendation (Correct answer)
Patient comprehension

Correct answer: Patient agreement with the physician's recommendation

Informed consent requires disclosure, comprehension, capacity, and voluntariness — it does not require the patient to agree with the physician; they retain the right to refuse.

Question 93: A trauma patient has absent breath sounds on the left, hypotension, and tracheal deviation to the right. Immediate action is:

Intubation
CT scan of chest
Needle decompression of the left chest (Correct answer)
Chest X-ray

Correct answer: Needle decompression of the left chest

Tension pneumothorax (absent breath sounds, hypotension, tracheal deviation away from the affected side) is a clinical diagnosis requiring immediate needle decompression.

Question 94: For numerous years, a 56-year-old man has suffered with chronic pyrosis and regurgitation after meals. The patient has been taking antacids and over-the-counter famotidine, but they are no longer helping him. The patient admits to drinking five to six beers and four cups of coffee per day, as well as smoking half a pack of cigarettes every day. These signs and symptoms are common in:

Dyspepsia
Peptic ulcer disease
GERD (Correct answer)
Mallory Weiss syndrome

Correct answer: GERD

The patient's chronic symptoms of pyrosis (heartburn) and regurgitation after meals, persisting despite antacid and H2 blocker use, are classic indicators of Gastroesophageal Reflux Disease (GERD). Lifestyle factors like daily alcohol, coffee, and cigarette consumption are known to exacerbate GERD symptoms. While other conditions like peptic ulcer disease or dyspepsia can share some symptoms, the chronic nature and specific presentation of heartburn and regurgitation strongly point to GERD.

Question 95: A 50-year-old woman reports 9 months of hot flashes, night sweats, and vaginal dryness. FSH is 58 mIU/mL and estradiol is 12 pg/mL. She has had no menses for 13 months. What is the diagnosis?

Primary ovarian insufficiency
Hypothyroidism
Menopause (Correct answer)
Pituitary adenoma

Correct answer: Menopause

Menopause is defined as 12 consecutive months of amenorrhea with elevated FSH (>40 mIU/mL) and low estradiol in a woman typically over 45 years.

Question 96: Atropine reverses bradycardia caused by organophosphate poisoning by which mechanism?

Reactivating acetylcholinesterase
Competitively blocking muscarinic receptors (Correct answer)
Increasing sympathetic tone directly
Blocking nicotinic receptors

Correct answer: Competitively blocking muscarinic receptors

Atropine competitively antagonizes muscarinic acetylcholine receptors, reversing the excess cholinergic (SLUDGE) effects of organophosphate poisoning.

Question 97: Which vasopressor acts primarily on alpha-1 adrenergic receptors to increase SVR in septic shock?

Norepinephrine (Correct answer)
Dopamine (low dose)
Dobutamine
Milrinone

Correct answer: Norepinephrine

Norepinephrine stimulates alpha-1 receptors (vasoconstriction) with modest beta-1 effects, making it the first-line vasopressor for septic shock.

Question 98: What is the end result of successfully treating a somatic dysfunction using indirect OMT techniques?

Increased joint laxity
Muscle hypertrophy
Joint cavitation
Resolution of all four TART criteria (Correct answer)

Correct answer: Resolution of all four TART criteria

Successful OMT resolves somatic dysfunction, eliminating the TART findings: tissue texture changes, asymmetry, restriction, and tenderness.

Question 99: The sliding filament theory of muscle contraction states that sarcomere shortening results from:

Shortening of actin and myosin filaments
Myosin heads pulling actin toward the M line (Correct answer)
Z-disc disintegration
Titin protein contraction

Correct answer: Myosin heads pulling actin toward the M line

During muscle contraction, myosin heads bind actin and pull the thin filaments toward the center (M line), shortening the sarcomere without changing filament length.

Question 100: Which finding on pulmonary function tests is characteristic of obstructive lung disease such as COPD?

Reduced FEV1/FVC ratio (<0.70) (Correct answer)
Normal spirometry with reduced DLCO
Reduced FVC with normal FEV1/FVC ratio
Increased TLC with normal FEV1/FVC

Correct answer: Reduced FEV1/FVC ratio (<0.70)

Obstructive disease (COPD, asthma) is defined by an FEV1/FVC ratio <0.70, reflecting air trapping and increased expiratory resistance.

Question 101: Fluconazole treats fungal infections by inhibiting which enzyme, reducing ergosterol synthesis?

14-alpha demethylase (CYP51) (Correct answer)
Beta-glucan synthase
Squalene epoxidase
Dihydroorotate dehydrogenase

Correct answer: 14-alpha demethylase (CYP51)

Azole antifungals including fluconazole inhibit CYP51 (lanosterol 14-alpha demethylase), blocking ergosterol synthesis and disrupting fungal cell membranes.

Question 102: The sodium-potassium ATPase pump maintains the resting membrane potential by moving:

2 Na+ out and 3 K+ in per cycle
3 Na+ out and 2 K+ in per cycle (Correct answer)
Equal Na+ and K+ in opposite directions
3 Na+ in and 2 K+ out per cycle

Correct answer: 3 Na+ out and 2 K+ in per cycle

The Na+/K+ ATPase pumps 3 Na+ out and 2 K+ in per ATP hydrolyzed, making it electrogenic and contributing to the negative resting membrane potential.

Question 103: Strain-counterstrain tender points for lumbar flexion dysfunction are typically found:

On the spinous processes posteriorly
On the anterior abdominal wall or ASIS region (Correct answer)
At the iliac crest posteriorly
At the posterior superior iliac spine

Correct answer: On the anterior abdominal wall or ASIS region

Anterior lumbar strain-counterstrain tender points (L1–L5) are located anteriorly on the lower abdominal wall or near the ASIS.

Question 104: A patient with longstanding rheumatoid arthritis develops proteinuria and renal insufficiency. Kidney biopsy shows amyloid deposits. The amyloid protein is:

ATTR amyloid (transthyretin)
AA amyloid (serum amyloid A protein) (Correct answer)
Abeta amyloid
AL amyloid (immunoglobulin light chains)

Correct answer: AA amyloid (serum amyloid A protein)

Secondary (AA) amyloidosis results from chronic inflammatory conditions like RA, depositing serum amyloid A–derived fibrils in kidneys, liver, and spleen.

Question 105: A 30-year-old woman complains of abdominal pain, anorexia, exhaustion, and weakness. A physical examination indicates a hyperpigmented area in the palmar creases, as well as thin axillary hair. Low sodium levels, as well as high potassium and calcium levels, were discovered in the lab. What level of the spine would you expect tissue texture changes as a result of the above condition's viscerosomatic response?

L2 (Correct answer)
T4
T8
T10

Correct answer: L2

Explanation: This Pt has Addison's disease, which is a disease of the adrenal gland & would cause a viscerosomatic response at T10.

Question 106: Which of the following is a positive symptom of schizophrenia?

Alogia
Avolition
Flat affect
Hallucinations (Correct answer)

Correct answer: Hallucinations

Hallucinations are positive symptoms of schizophrenia (additions to normal experience); flat affect, alogia, and avolition are negative symptoms (losses of normal function).

Question 107: Lithium toxicity is increased by which commonly prescribed drug class due to reduced renal clearance?

ACE inhibitors (NSAIDs both decrease lithium excretion)
Beta-blockers
NSAIDs (Correct answer)
Calcium channel blockers

Correct answer: NSAIDs

NSAIDs reduce prostaglandin-mediated renal blood flow, decreasing lithium excretion and raising serum lithium levels into the toxic range.

Question 108: Which of the following biomechanical or structural anomalies best explains why a COPD patient has a larger AP chest diameter?

Permanent inhaled rib positions come from the loss of elastic fibers and continuous air trapping. (Correct answer)
The ribs will be pulled superiorly by continuous auxiliary muscle action, resulting in an enlarged thoracic cage.
As a compensatory strategy for chronic deoxygenation of peripheral tissues, the thoracic cage expands physiologically.
Chronic hypoxia causes fibrotic alterations in the diaphragm, resulting in a flattened diaphragm and greater overall lung capacity.

Correct answer: Permanent inhaled rib positions come from the loss of elastic fibers and continuous air trapping.

In COPD, the loss of elastic fibers in the lungs and airways leads to chronic air trapping and hyperinflation. This persistent hyperinflation causes the diaphragm to flatten and the ribs to be held in a continuously elevated, inhaled position. This sustained 'inhaled' rib position is what contributes to the characteristic increase in the anterior-posterior (AP) chest diameter, commonly known as a barrel chest.

Question 109: Which structure in the nephron is primarily responsible for concentrating urine through countercurrent multiplication?

Collecting duct
Loop of Henle (Correct answer)
Distal convoluted tubule
Proximal convoluted tubule

Correct answer: Loop of Henle

The loop of Henle creates a hyperosmotic medullary gradient via countercurrent multiplication, enabling the collecting duct to concentrate urine.

Question 110: A 50-year-old postmenopausal woman presents with vaginal bleeding. Transvaginal ultrasound shows an endometrial stripe of 6 mm. What is the next step in evaluation?

Endometrial biopsy (Correct answer)
Repeat Pap smear
Pelvic MRI
Colposcopy with biopsy

Correct answer: Endometrial biopsy

Postmenopausal bleeding with endometrial stripe ≥5 mm requires endometrial biopsy to exclude endometrial carcinoma.

Question 111: Which enzyme is deficient in Tay-Sachs disease, leading to accumulation of GM2 ganglioside?

Sphingomyelinase
Glucocerebrosidase
Alpha-galactosidase A
Hexosaminidase A (Correct answer)

Correct answer: Hexosaminidase A

Tay-Sachs disease results from deficiency of hexosaminidase A, causing GM2 ganglioside accumulation in lysosomes.

Question 112: A patient presents with cervical somatic dysfunction. On exam, C4 is found to be ERS right. This means C4 is:

Extended, rotated left, side-bent left
Extended, rotated right, side-bent right (Correct answer)
Flexed, rotated left, side-bent left
Flexed, rotated right, side-bent right

Correct answer: Extended, rotated right, side-bent right

ERS right means the segment is Extended, Rotated right, and Side-bent right — the group behaves as a unit in extension.

Question 113: The 'watershed' area between the superior and inferior mesenteric artery territories, most vulnerable to ischemia, is located at:

Cecum
Sigmoid colon
Splenic flexure (Correct answer)
Hepatic flexure

Correct answer: Splenic flexure

The splenic flexure of the colon is a watershed zone between SMA and IMA territories and is most vulnerable to ischemic colitis.

Question 114: The bile salt-independent fraction of bile secretion is driven primarily by which mechanism?

Glucuronidation
Active Na+ reabsorption
Bicarbonate secretion by cholangiocytes (Correct answer)
Cholesterol secretion

Correct answer: Bicarbonate secretion by cholangiocytes

Cholangiocytes secrete bicarbonate via CFTR and AE2 exchangers, driving water flow and contributing to the bile salt-independent fraction of bile.

Question 115: The placebo effect in clinical trials is best controlled by which study design?

Case-control study
Cross-sectional study
Randomized double-blind placebo-controlled trial (Correct answer)
Cohort study

Correct answer: Randomized double-blind placebo-controlled trial

A randomized double-blind placebo-controlled trial controls for placebo effect by ensuring neither patients nor investigators know who received the active treatment.

Question 116: A patient presents with sudden onset of tearing chest pain radiating to the back, with unequal blood pressures in bilateral arms. The most likely diagnosis is:

Pulmonary embolism
Acute MI
Esophageal rupture
Aortic dissection (Correct answer)

Correct answer: Aortic dissection

Aortic dissection classically presents with sudden severe tearing or ripping chest/back pain and pulse or blood pressure differentials between extremities.

Question 117: A 27-year-old woman at 10 weeks gestation has beta-hCG of 185,000 mIU/mL, vaginal bleeding, and a uterine ultrasound showing a 'snowstorm' appearance with no fetal parts. After uterine evacuation, what must be closely monitored?

Serial beta-hCG for gestational trophoblastic neoplasia (Correct answer)
Cervical incompetence
Recurrent ectopic pregnancy risk
Uterine adhesion formation (Asherman syndrome)

Correct answer: Serial beta-hCG for gestational trophoblastic neoplasia

Complete hydatidiform moles require serial beta-hCG surveillance after evacuation because 15–20% progress to gestational trophoblastic neoplasia.

Question 118: In counterstrain technique, the physician holds the patient in a position of comfort for how long?

60 seconds
90 seconds (Correct answer)
120 seconds
30 seconds

Correct answer: 90 seconds

Counterstrain requires maintaining the position of comfort for 90 seconds to allow the tender point to resolve.

Question 119: Which antimalarial drug causes hemolytic anemia in patients with G6PD deficiency?

Atovaquone
Chloroquine
Primaquine (Correct answer)
Mefloquine

Correct answer: Primaquine

Primaquine generates oxidative stress that overwhelms G6PD-deficient RBCs, leading to hemolysis; always screen for G6PD before prescribing.

Question 120: A patient with type 1 diabetes presents with nausea, abdominal pain, Kussmaul breathing, and blood glucose of 450 mg/dL. Treatment priority is:

Bicarbonate infusion first
Potassium replacement first
Insulin infusion first
IV fluid resuscitation first (Correct answer)

Correct answer: IV fluid resuscitation first

In DKA, IV fluids are the first priority to restore volume and perfusion; insulin and potassium replacement follow after initial fluid resuscitation.

Question 121: Which condition causes an anion gap metabolic acidosis with a normal osmol gap?

Isopropanol poisoning
Methanol poisoning
Lactic acidosis (Correct answer)
Ethylene glycol poisoning

Correct answer: Lactic acidosis

Lactic acidosis causes an elevated anion gap metabolic acidosis; isopropanol causes elevated osmol gap without anion gap; methanol and ethylene glycol cause both gaps.

Question 122: Statins (HMG-CoA reductase inhibitors) lower LDL cholesterol primarily by:

Upregulating hepatic LDL receptors (Correct answer)
Increasing bile acid excretion
Inhibiting intestinal cholesterol absorption
Activating lipoprotein lipase

Correct answer: Upregulating hepatic LDL receptors

By inhibiting hepatic cholesterol synthesis, statins upregulate LDL receptors on hepatocytes, increasing clearance of LDL from plasma.

Question 123: A patient presents with projectile vomiting, visible peristaltic waves, and a palpable olive-shaped mass in the epigastrium at 3 weeks of age. The diagnosis is:

Intussusception
Duodenal atresia
Pyloric stenosis (Correct answer)
Malrotation with volvulus

Correct answer: Pyloric stenosis

Hypertrophic pyloric stenosis classically presents at 3–6 weeks with non-bilious projectile vomiting, visible peristalsis, and a palpable pyloric 'olive'; labs show hypochloremic hypokalemic metabolic alkalosis.

Question 124: A patient with HIV and CD4 count of 50 cells/μL presents with painless, creamy white oral plaques that scrape off. The most likely diagnosis is:

Kaposi's sarcoma
Aphthous ulcers
Oral hairy leukoplakia
Oral candidiasis (thrush) (Correct answer)

Correct answer: Oral candidiasis (thrush)

Oral candidiasis (thrush) presents as removable white plaques on the buccal mucosa in immunocompromised patients; oral hairy leukoplakia cannot be scraped off.

Question 125: In the TART mnemonic for identifying somatic dysfunction, what does the 'A' represent?

Atrophy
Asymmetry (Correct answer)
Autonomic changes
Articular restriction

Correct answer: Asymmetry

TART stands for Tissue texture changes, Asymmetry, Restriction of motion, and Tenderness — the four criteria for somatic dysfunction.

Question 126: A mutation in which gene is most commonly associated with hereditary breast and ovarian cancer syndrome?

TP53
APC
RB1
BRCA1/2 (Correct answer)

Correct answer: BRCA1/2

BRCA1 and BRCA2 mutations are the most common inherited cause of breast and ovarian cancer syndrome.

Question 127: A nulliparous woman delivers vaginally at term and has 700 mL of blood loss within the first hour after placental delivery. The uterus is boggy on exam. What is the most common cause of this complication?

Coagulopathy
Uterine atony (Correct answer)
Retained placental fragments
Cervical laceration

Correct answer: Uterine atony

Uterine atony accounts for approximately 80% of postpartum hemorrhage cases and is the most common cause.

Question 128: Electronic fetal monitoring at 38 weeks shows late decelerations after each contraction with absent variability and baseline FHR of 140 bpm. What is the most appropriate management?

IV fluid bolus and continue monitoring
Oxygen by face mask and lateral position change
Immediate cesarean delivery (Correct answer)
Amnioinfusion

Correct answer: Immediate cesarean delivery

Late decelerations with absent variability represent a Category III (ominous) fetal heart rate pattern requiring immediate delivery.

Question 129: Cognitive behavioral therapy (CBT) for depression is based primarily on which theoretical framework?

Cognitive triad (Beck's model) (Correct answer)
Operant conditioning
Classical conditioning
Psychodynamic theory

Correct answer: Cognitive triad (Beck's model)

Beck's cognitive triad (negative views of self, world, and future) underpins CBT, which aims to identify and restructure maladaptive thought patterns.

Question 130: In classical conditioning, a previously neutral stimulus that elicits a conditioned response is called:

Unconditioned stimulus (UCS)
Conditioned stimulus (CS) (Correct answer)
Conditioned response (CR)
Unconditioned response (UCR)

Correct answer: Conditioned stimulus (CS)

After repeated pairing with an unconditioned stimulus, a neutral stimulus becomes a conditioned stimulus that elicits the conditioned response on its own.

Question 131: What level of the spine should a patient with a parathyroid adenoma have checked for a viscerosomatic reflex?

T12 - L2
T10 - T12
T1 - T3 (Correct answer)
T5 - T6

Correct answer: T1 - T3

Explanation: The viscerosomatic response from the heart, lungs, and esophagus is linked to spinal levels.

Question 132: Which finding on urinalysis is most suggestive of acute glomerulonephritis?

Red blood cell (RBC) casts (Correct answer)
Waxy casts
Fatty casts
Hyaline casts

Correct answer: Red blood cell (RBC) casts

RBC casts in the urine are pathognomonic for glomerulonephritis, indicating that red cells have passed through the damaged glomerular basement membrane into the tubular lumen.

Question 133: A 16-year-old girl has sudden onset severe right lower quadrant pain, nausea, and vomiting. Ultrasound shows an enlarged right ovary (6 cm) with absent Doppler blood flow. Which intervention is most appropriate?

IV antibiotics and observation
Right salpingo-oophorectomy
Appendectomy
Laparoscopic detorsion (Correct answer)

Correct answer: Laparoscopic detorsion

Ovarian torsion requires urgent laparoscopic detorsion to restore blood flow; oophorectomy is reserved for clearly non-viable ovaries.

Question 134: Which nerve root level is primarily responsible for the knee jerk reflex and can be assessed via segmental facilitation at T12–L1?

L3–L4 (Correct answer)
L1–L2
L2–L3
L4–L5

Correct answer: L3–L4

The patellar (knee jerk) reflex is mediated by L3–L4 nerve roots; somatic dysfunction at L3–L4 may affect this reflex.

Question 135: The structural exam indicates the following in a patient with a history of tension HA's: C5 is resistant to L lateral translation. The R articular pillar of C2 resists anterior glide and has a right-sided fullness. What else is most likely true about PE based on the given information?

The AA joint is Rotated right
C5 is Rotated left (Correct answer)
C2 is flexed
C2 is Rotated left

Correct answer: C5 is Rotated left

The finding that "C5 is resistant to L lateral translation" means that the vertebral body is shifted to the right, indicating it is sidebent to the left (Sleft). In the cervical spine, sidebending and rotation are coupled to the same side (Type II mechanics). Therefore, if C5 is sidebent left, it is also rotated left (Rleft). This makes 'C5 is Rotated left' a direct and accurate deduction from the given physical exam information.

Question 136: Which sleep stage is characterized by sleep spindles and K-complexes on EEG?

Stage N3 (NREM 3)
Stage N2 (NREM 2) (Correct answer)
Stage N1 (NREM 1)
REM sleep

Correct answer: Stage N2 (NREM 2)

Stage N2 NREM sleep features sleep spindles (12–14 Hz bursts) and K-complexes (large biphasic waves) and constitutes the largest portion of total sleep.

Question 137: A 21-year-old woman presents with vaginal itching, dysuria, and a frothy, malodorous yellow-green discharge. Wet prep shows motile pear-shaped organisms. What is the treatment of choice?

Clindamycin vaginal cream
Acyclovir orally
Metronidazole 2 g orally single dose (Correct answer)
Fluconazole 150 mg orally

Correct answer: Metronidazole 2 g orally single dose

Trichomonas vaginalis infection is treated with single-dose oral metronidazole 2g, with concurrent partner treatment required.

Question 138: A 7-year-old boy cannot sit still in class, interrupts others, and forgets homework daily. Which diagnosis is most likely?

Autism spectrum disorder
Oppositional defiant disorder
ADHD combined type (Correct answer)
Conduct disorder

Correct answer: ADHD combined type

ADHD combined type presents with both inattention (forgetfulness) and hyperactivity-impulsivity (can't sit still, interrupting) in multiple settings.

Question 139: Which receptor does naloxone antagonize to reverse opioid overdose?

Sigma (σ) receptor
Delta (δ) receptor only
Kappa (κ) receptor only
Mu (μ) receptor primarily (Correct answer)

Correct answer: Mu (μ) receptor primarily

Naloxone is a competitive antagonist primarily at mu (μ) opioid receptors, reversing respiratory depression, sedation, and miosis of opioid overdose.

Question 140: A 45-year-old woman has heavy menstrual bleeding, urinary frequency, and a 14-week-size uterus on exam. Ultrasound confirms multiple intramural fibroids. She wishes to maintain fertility. What is the most appropriate surgical treatment?

Uterine artery embolization
Total abdominal hysterectomy
Endometrial ablation
Myomectomy (Correct answer)

Correct answer: Myomectomy

Myomectomy removes fibroids while preserving the uterus and is the preferred surgical option for women who desire future fertility.

Question 141: A child has recurrent pyogenic infections with bacteria and fungi. Flow cytometry shows absent CD18. Which condition is this?

Chediak-Higashi syndrome
Leukocyte adhesion deficiency (LAD) (Correct answer)
DiGeorge syndrome
Chronic granulomatous disease

Correct answer: Leukocyte adhesion deficiency (LAD)

LAD type I results from CD18 (beta-2 integrin) deficiency, preventing neutrophils from migrating to infection sites.

Question 142: Which class of antibiotics inhibits bacterial cell wall synthesis by binding to PBPs and is bactericidal?

Fluoroquinolones
Aminoglycosides
Macrolides
Beta-lactams (Correct answer)

Correct answer: Beta-lactams

Beta-lactam antibiotics (penicillins, cephalosporins, carbapenems) bind penicillin-binding proteins (PBPs) to inhibit cell wall cross-linking, causing bacterial lysis.

Question 143: A 32-year-old nulliparous woman presents with cyclic pelvic pain, progressive dysmenorrhea, and dyspareunia. CA-125 is mildly elevated. What is the gold standard for diagnosis?

Diagnostic laparoscopy with biopsy (Correct answer)
Transvaginal ultrasound
Endometrial biopsy
MRI of the pelvis

Correct answer: Diagnostic laparoscopy with biopsy

Diagnostic laparoscopy with histological confirmation of ectopic endometrial tissue is the gold standard for diagnosing endometriosis.

Question 144: Which sign, elicited by passive right hip flexion with knee extended while supine, suggests peritoneal irritation from appendicitis?

Obturator sign
Psoas sign (Correct answer)
Rovsing's sign
Murphy's sign

Correct answer: Psoas sign

The psoas sign is positive when extension of the right hip (or passive flexion against resistance) causes RLQ pain, suggesting a retrocecal appendix irritating the psoas muscle.

Question 145: Which antiepileptic drug works by blocking sodium channels and is a first-line treatment for partial and generalized tonic-clonic seizures?

Phenytoin (Correct answer)
Valproic acid
Ethosuximide
Benzodiazepines

Correct answer: Phenytoin

Phenytoin stabilizes the inactive state of voltage-gated Na+ channels, reducing neuronal excitability and preventing seizure propagation.

Question 146: Which OMT technique is most appropriate for a patient with rib dysfunction causing inhalation restriction (inhalation rib)?

HVLA in neutral position
Counterstrain only
Treat during inhalation phase
Treat during exhalation phase (Correct answer)

Correct answer: Treat during exhalation phase

An inhalation rib is stuck in inhalation, so treatment force is applied during the exhalation phase to move it further into exhalation.

Question 147: A 54-year-old man comes into your office complaining of acute low back discomfort. The ache began while he was working on his automobile the day before yesterday and has now spread to his lower extremities. What additional information in this patient's Hx would have the most impact on the immediate Dx and Tx?

Down-going plantar response w/ Babinski's testing
Presence of incontinence (Correct answer)
Loss of Achilles reflex
Unilateral loss of cremasteric reflex

Correct answer: Presence of incontinence

The spread of low back pain to the lower extremities, combined with the presence of incontinence, is a critical red flag for Cauda Equina Syndrome. This condition involves compression of the nerve roots in the lumbar spine, leading to neurological deficits including bowel and bladder dysfunction. Cauda Equina Syndrome is a surgical emergency requiring immediate diagnosis and intervention to prevent permanent neurological damage, making incontinence the most impactful information for immediate diagnosis and treatment.

Question 148: A 19-year-old woman at 18 weeks gestation presents with painless cervical dilation to 4 cm and no uterine contractions. Membranes are intact. Which diagnosis is most likely?

Cervical insufficiency (Correct answer)
Chorioamnionitis
Inevitable abortion
Preterm labor

Correct answer: Cervical insufficiency

Cervical insufficiency (incompetent cervix) presents with painless cervical dilation in the second trimester without uterine contractions.

Question 149: Guyon's canal nerve entrapment is likely to result in:

Weakness in finger abduction (Correct answer)
Weakness in wrist flexion
Weakness in the thumb abductor
Weakness in wrist adduction

Correct answer: Weakness in finger abduction

Explanation: Guyon's canal (pisohamate) is found at the wrist. The pisiform bone is on the medial border, the hamate is on the lateral border, the flexor retinaculum is on the roof, and the pisohamate ligament is on the floor. The Guyon's canal houses the ulnar nerve. The hypothenar muscles, adductor pollicis, interossi, and 3rd and 4th lumbricals would all be affected by nerve entrapment. Abduction and adduction of the fingers are controlled by the interossi.

Question 150: A 35-year-old woman presents with right lower quadrant pain, fever, anorexia, and elevated WBC. Rebound tenderness at McBurney's point is present. Diagnosis is:

Mesenteric adenitis
Ectopic pregnancy
Ovarian cyst
Acute appendicitis (Correct answer)

Correct answer: Acute appendicitis

Acute appendicitis classically presents with periumbilical pain migrating to the RLQ (McBurney's point), fever, anorexia, and leukocytosis.

Question 151: The therapeutic effect of ACE inhibitors in heart failure is primarily due to:

Positive inotropy
Direct vasodilation via NO release
Increasing aldosterone levels
Reduction in preload and afterload via decreased angiotensin II (Correct answer)

Correct answer: Reduction in preload and afterload via decreased angiotensin II

ACE inhibitors block conversion of angiotensin I to II, reducing vasoconstriction (afterload) and aldosterone-mediated sodium retention (preload).

Question 152: Which immunoglobulin class is the first to be produced in a primary immune response?

IgG
IgE
IgM (Correct answer)
IgA

Correct answer: IgM

IgM is the first antibody class produced during a primary immune response due to its pentameric structure enabling early complement activation.

Question 153: Which cranial suture is most commonly assessed during a cranial osteopathic exam for primary respiratory mechanism (PRM)?

Sphenobasilar synchondrosis (SBS) (Correct answer)
Coronal suture
Sagittal suture
Lambdoid suture

Correct answer: Sphenobasilar synchondrosis (SBS)

The sphenobasilar synchondrosis is the key articulation assessed in cranial OMT as it reflects overall cranial rhythmic impulse motion.

Question 154: Okazaki fragments are synthesized on which strand during DNA replication?

Lagging strand (Correct answer)
Non-template strand
Leading strand
Template strand

Correct answer: Lagging strand

Okazaki fragments are short DNA segments synthesized discontinuously on the lagging strand, which runs antiparallel to the direction of replication fork movement.

COMLEX-USA (Comprehensive Osteopathic Medical Licensing Examination)

The COMLEX-USA is a series of three licensure examinations (Level 1, 2-CE, and 3) administered by the NBOME that assess osteopathic medical students and graduates on foundational biomedical sciences, clinical knowledge, and osteopathic principles for licensure in the United States.

352

Questions

480 min

Time Limit

70%

To Pass

Checking for saved progress...

Exam Rules

You can skip questions and return to them later
Flag questions for review before submitting
No feedback shown until you submit the entire exam
Unanswered questions count as wrong — answer everything
10 pretest questions are mixed in and don't affect your score
Timer auto-submits when time runs out
Your progress is auto-saved every 30 seconds