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

Question 1: The most common cause of community-acquired pneumonia (CAP) in otherwise healthy adults is:

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

Correct answer: Streptococcus pneumoniae

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

Question 2: 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 3: 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?

Total abdominal hysterectomy
Uterine artery embolization
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 4: Which osteopathic technique uses a high-velocity, low-amplitude thrust to restore motion at a restricted joint?

Myofascial release
Counterstrain
Muscle energy
HVLA thrust (Correct answer)

Correct answer: HVLA thrust

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

Question 5: The Chapman reflex point for the heart is located anteriorly between which ribs?

1st and 2nd ribs on the left
4th and 5th ribs on the left
2nd and 3rd ribs on the left (Correct answer)
3rd and 4th 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 6: Which of the following motions will be most affected by plexopathy involving the medial chord of the brachial plexus?

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

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 7: 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?

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.
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.

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

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

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

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

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

Metoprolol succinate (Correct answer)
Labetalol
Propranolol
Carvedilol

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

Pneumonia
DVT
Wound infection (Correct answer)
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 12: What is the primary goal of lymphatic pump techniques in OMT?

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

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

Parietal lobe
Prefrontal cortex (Correct answer)
Cerebellum
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 14: 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?

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

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 15: 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:

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

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

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

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

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

Correct answer: Activating AMPK to reduce hepatic gluconeogenesis

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

Question 18: In a patient with acute coronary syndrome, which ECG finding indicates a complete occlusion requiring urgent reperfusion?

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

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 19: Atropine reverses bradycardia caused by organophosphate poisoning by which mechanism?

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

Correct answer: Competitively blocking muscarinic receptors

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

Question 20: A patient taking warfarin is started on trimethoprim-sulfamethoxazole for a UTI. Which effect is expected?

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

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

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

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

Norepinephrine
Serotonin
GABA
Dopamine (Correct answer)

Correct answer: Dopamine

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

Question 23: 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
Bouchard's node
Dupuytren's contracture (Correct answer)
Heberden node

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

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

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

Cohort study
Randomized double-blind placebo-controlled trial (Correct answer)
Case-control study
Cross-sectional 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 26: Which cranial nerve is responsible for the afferent limb of the corneal reflex?

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

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

SNRIs
MAOIs (Correct answer)
TCAs
SSRIs

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 28: 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?

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

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

Lambdoid suture
Sphenobasilar synchondrosis (SBS) (Correct answer)
Coronal suture
Sagittal 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 30: 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 flexion, Sidebent left, Rotated right
In extension, Sidebent left, Rotated left
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 31: The sodium-potassium ATPase pump maintains the resting membrane potential by moving:

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

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 32: 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:

Duodenal atresia
Pyloric stenosis (Correct answer)
Intussusception
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 33: Which imaging modality is first-line for evaluating suspected acute appendicitis in a pregnant woman?

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

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

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

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 35: 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?

Cervical incompetence
Recurrent ectopic pregnancy risk
Serial beta-hCG for gestational trophoblastic neoplasia (Correct answer)
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 36: In Kübler-Ross's stages of grief, which stage is characterized by the patient seeking to delay the inevitable through promises?

Bargaining (Correct answer)
Denial
Depression
Anger

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

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

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

Murphy's sign
Psoas sign (Correct answer)
Obturator sign
Rovsing'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 39: A missense mutation results in:

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

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 40: 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?

T8
T4
L2 (Correct answer)
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 41: 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 42: Which finding on urinalysis is most suggestive of acute glomerulonephritis?

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

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 43: 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?

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

Correct answer: Endometrial biopsy

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

Question 44: Which drug used for rheumatoid arthritis inhibits dihydrofolate reductase, requiring folate supplementation?

Leflunomide
Methotrexate (Correct answer)
Sulfasalazine
Hydroxychloroquine

Correct answer: Methotrexate

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

Question 45: 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 46: A patient with diabetes develops painless vision loss. Fundoscopic exam shows neovascularization. The diagnosis is:

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

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 47: 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 48: Which is the most common cause of small bowel obstruction in adults in the United States?

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

Correct answer: Adhesions from prior surgery

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

Question 49: 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:

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

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 50: 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?

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

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

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

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

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

Correct answer: IV penicillin G or ampicillin

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

Question 53: Which enzyme is deficient in Tay-Sachs disease, leading to accumulation of GM2 ganglioside?

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

Correct answer: Hexosaminidase A

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

Question 54: A mutation in which gene is most commonly associated with hereditary breast and ovarian cancer syndrome?

TP53
RB1
APC
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 55: In damage control surgery for a trauma patient with coagulopathy and hypothermia, the correct sequence is:

Angiography first → then surgery
Initial hemorrhage control → ICU resuscitation → definitive repair (Correct answer)
Observation only until stable
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 56: Which immunoglobulin class is the first to be produced in a primary immune response?

IgM (Correct answer)
IgE
IgG
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 57: 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?

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

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

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

Correct answer: Vitamin B6 (pyridoxine)

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

Question 59: 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
Kayexalate (sodium polystyrene sulfonate)
IV calcium gluconate (Correct answer)

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

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

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

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

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

Buprenorphine
Hydromorphone
Morphine (Correct answer)
Fentanyl

Correct answer: Morphine

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

Question 63: 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?

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

Correct answer: Diagnostic laparoscopy with biopsy

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

Question 64: According to Erikson's stages of psychosocial development, the primary task of adolescence (ages 12–18) is:

Industry vs. inferiority
Generativity vs. stagnation
Identity vs. role confusion (Correct answer)
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 65: A trauma patient has absent breath sounds on the left, hypotension, and tracheal deviation to the right. Immediate action is:

CT scan of chest
Intubation
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 66: Informed consent requires all of the following EXCEPT:

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

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

Atrophy
Autonomic changes
Articular restriction
Asymmetry (Correct answer)

Correct answer: Asymmetry

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

Question 68: 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:

Autonomy (Correct answer)
Justice
Beneficence
Non-maleficence

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

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

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

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

APACHE II scoring
Starling equation
Parkland formula (Correct answer)
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 72: 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
Flexed, rotated left, side-bent left
Extended, rotated right, side-bent right (Correct answer)
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 73: 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?

Loss of Achilles reflex
Down-going plantar response w/ Babinski's testing
Presence of incontinence (Correct answer)
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 74: 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
Magnesium sulfate
Nifedipine
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 75: 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
Cervical laceration
Retained placental fragments
Uterine atony (Correct answer)

Correct answer: Uterine atony

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

Question 76: 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?

Preterm labor
Cervical insufficiency (Correct answer)
Chorioamnionitis
Inevitable abortion

Correct answer: Cervical insufficiency

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

Question 77: A 7-year-old boy cannot sit still in class, interrupts others, and forgets homework daily. Which diagnosis is most likely?

Conduct disorder
Oppositional defiant disorder
ADHD combined type (Correct answer)
Autism spectrum 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 78: Which class of antibiotics inhibits bacterial cell wall synthesis by binding to PBPs and is bactericidal?

Aminoglycosides
Macrolides
Beta-lactams (Correct answer)
Fluoroquinolones

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 79: 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 80: Which drug class is the first-line treatment for chronic stable angina and works by reducing myocardial oxygen demand?

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

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 81: 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?

Hypothyroidism
Primary ovarian insufficiency
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 82: 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?

T12 is flexed
R is sidebent T12.
T12 is rotated R and sidebent R. (Correct answer)
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 83: 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
Cullen's sign
Kehr'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 84: The 'watershed' area between the superior and inferior mesenteric artery territories, most vulnerable to ischemia, is located at:

Sigmoid colon
Cecum
Hepatic flexure
Splenic flexure (Correct answer)

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 85: 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)
Renal cell carcinoma
Acute pyelonephritis
Ovarian torsion

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

Holding warfarin and administering oral vitamin K (Correct answer)
Fresh frozen plasma (FFP) transfusion
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 87: Which sleep stage is characterized by sleep spindles and K-complexes on EEG?

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

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

Atovaquone
Chloroquine
Mefloquine
Primaquine (Correct answer)

Correct answer: Primaquine

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

Question 89: The Galbreath technique is a mandibular drainage technique primarily used to treat dysfunction of which structure?

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

Correct answer: Eustachian tube / middle ear

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

Question 90: 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?

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

Correct answer: Laparoscopic detorsion

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

Question 91: 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
Acute appendicitis (Correct answer)
Ectopic pregnancy
Ovarian cyst

Correct answer: Acute appendicitis

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

Question 92: In classical conditioning, a previously neutral stimulus that elicits a conditioned response is called:

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

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

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

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 94: 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
Fluconazole 150 mg orally
Acyclovir orally
Metronidazole 2 g orally single dose (Correct answer)

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

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

Correct answer: Upregulating hepatic LDL receptors

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

Question 96: Which type of somatic dysfunction is described as Type I (group) mechanics in the thoracic spine?

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

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

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

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

Joint mobilization
Articulatory technique
Reciprocal inhibition
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 99: Which condition causes an anion gap metabolic acidosis with a normal osmol gap?

Ethylene glycol poisoning
Lactic acidosis (Correct answer)
Isopropanol poisoning
Methanol 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 100: Chvostek's sign (facial twitching with tapping CN VII) indicates which electrolyte abnormality?

Hypercalcemia
Hyponatremia
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 101: What is the end result of successfully treating a somatic dysfunction using indirect OMT techniques?

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

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

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

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

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

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

Clonazepam
Chlordiazepoxide
Diazepam
Lorazepam (Correct answer)

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 105: 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?

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

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 106: 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:

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

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

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

Correct answer: S phase

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

Question 108: Which nerve root level is primarily responsible for the knee jerk reflex and can be assessed via segmental facilitation at T12–L1?

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

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 109: 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?

Median
Radial (Correct answer)
Musculocutaneous
Axillary

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 110: 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?

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

Correct answer: Immediate cesarean delivery

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

Question 111: Which of the following is a positive symptom of schizophrenia?

Flat affect
Avolition
Alogia
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 112: Which vasopressor acts primarily on alpha-1 adrenergic receptors to increase SVR in septic shock?

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

Correct answer: Norepinephrine

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

Question 113: A patient presents to the ED with anaphylaxis and urticaria after a bee sting. First-line treatment is:

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

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

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

Correct answer: Replenishing glutathione stores

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

Question 115: 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?

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

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

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

Correct answer: Borderline personality disorder

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

Question 117: In a patient with suspected pulmonary embolism and moderate pretest probability, which is the most appropriate next diagnostic step?

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

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

Repeat the 1-hour test in 4 weeks
Check HbA1c to confirm diagnosis
Diagnose gestational diabetes and start insulin
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 119: Which antiepileptic drug works by blocking sodium channels and is a first-line treatment for partial and generalized tonic-clonic seizures?

Benzodiazepines
Valproic acid
Phenytoin (Correct answer)
Ethosuximide

Correct answer: Phenytoin

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

Question 120: In which plane(s) does the 1st cervical segment (AA) have the most degree of freedom?

Oblique
Sagittal
Transverse (Correct answer)
Transverse & Coronal

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

Vitamin B6 (pyridoxine)
Vitamin B12
Vitamin B1 (thiamine) (Correct answer)
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 122: Beck's triad (hypotension, muffled heart sounds, JVD) is the classic presentation of which emergency?

Tension pneumothorax
Hemothorax
Superior vena cava syndrome
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 123: Which of the following is regarded the most frequent L-Spine congenital anomaly?

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

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 124: 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?

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

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

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

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

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

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 127: 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?

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

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

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

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

Pedal pump
Rib raising to the thoraco-lumbar junction
L1 - L3 muscle energy
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 130: Which receptor does naloxone antagonize to reverse opioid overdose?

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

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

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

Correct answer: Leukocyte adhesion deficiency (LAD)

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

Question 132: In the diagnosis of systemic lupus erythematosus (SLE), which antibody is most specific (though not most sensitive)?

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

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 133: Contraindications to HVLA technique include all of the following EXCEPT:

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

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 134: 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?

Warm tissue alterations, hypertonic muscles, and reduced L-Spine ROM (Correct answer)
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.

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

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

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

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

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

Rationalization
Passive aggression (Correct answer)
Intellectualization
Projection

Correct answer: Passive aggression

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

Question 138: 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?

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

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

Collecting duct
Proximal convoluted tubule
Loop of Henle (Correct answer)
Distal 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 140: A patient with cirrhosis develops upper GI bleeding with hematemesis. Initial management should include:

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

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

Bipolar I disorder (Correct answer)
Bipolar II disorder
Major depressive 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 142: Which spinal level provides sympathetic innervation to the heart?

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

Correct answer: T1–T5

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

Question 143: Which OMT technique is most appropriate for a patient with rib dysfunction causing inhalation restriction (inhalation rib)?

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

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

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

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.

Question 145: Facilitated positional release (FPR) combines a position of ease with which additional element to enhance tissue relaxation?

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

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

Chill phase (Correct answer)
Crisis phase
Defervescence
Plateau phase

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 147: 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)
Amniocentesis for fetal lung maturity
Vaginal delivery with oxytocin augmentation

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

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

Correct answer: T1 - T3

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

Question 149: 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?

Posterior Scalene
Anterior Scalene (Correct answer)
Longus Colli
Sternocleidomastoid

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

Fibromyalgia
Polymyositis
Inclusion body myositis
Dermatomyositis (Correct answer)

Correct answer: Dermatomyositis

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

Question 151: 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)
F Rleft Sleft
E Rleft Sleft
N Rright 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 152: Which complement pathway is activated by antibody-antigen complexes and begins with C1q binding?

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

Correct answer: Classical pathway

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

Question 153: Strain-counterstrain tender points for lumbar flexion dysfunction are typically found:

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

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

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

Correct answer: 90 seconds

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

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.

Questions

40 min

Time Limit

70%

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