COMLEX LEVEL 1 (COMPREHENSIVE
OSTEOPATHIC MEDICAL LICENSING
EXAMINATION LEVEL 1) EXAM–
COMPREHENSIVE EXAM WITH
ANSWERS AND RATIONALES
1. A 45-year-old male with a history of alcohol use
disorder presents with jaundice, ascites, and
asterixis. Laboratory studies reveal elevated AST
(120 U/L), ALT (80 U/L), and bilirubin. Liver biopsy
shows micronodular cirrhosis and Mallory-Denk
bodies. Which of the following is the most likely
underlying mechanism of liver injury in this patient?
A) Direct hepatocyte toxicity from acetaldehyde
accumulation
B) Immune-mediated destruction of bile canaliculi
C) Alpha-1 antitrypsin deficiency with abnormal
protein accumulation
D) Autoimmune destruction of hepatocytes
Correct answer: A
Rationale: Alcohol metabolism produces
acetaldehyde, which is directly toxic to hepatocytes
,and promotes oxidative stress, leading to alcoholic
liver disease.
2. A 25-year-old woman presents with acute onset of
shortness of breath and pleuritic chest pain one week
after an uncomplicated vaginal delivery. She is
tachycardic and hypoxic. CT angiography reveals
bilateral pulmonary emboli. Which of the following
inherited thrombophilias is most strongly associated
with this presentation?
A) Factor V Leiden mutation
B) Prothrombin G20210A mutation
C) Protein C deficiency
D) Antithrombin III deficiency
Correct answer: A
Rationale: Factor V Leiden (APC resistance) is the
most common inherited thrombophilia in Caucasians
and increases risk of venous thromboembolism,
especially in pregnancy and postpartum.
3. A 60-year-old man with a 40-pack-year smoking
history presents with hemoptysis and weight loss.
Chest X-ray shows a right hilar mass. Bronchoscopy
reveals a tumor obstructing the right main bronchus.
Biopsy shows small round blue cells with scant
,cytoplasm, nuclear molding, and necrosis. Which of
the following is the most likely diagnosis?
A) Squamous cell carcinoma
B) Adenocarcinoma
C) Small cell lung carcinoma
D) Large cell carcinoma
Correct answer: C
Rationale: Small cell lung carcinoma presents with
central (hilar) mass, strong association with smoking,
and histology showing small round blue cells with
nuclear molding.
4. A 32-year-old female presents with fatigue, joint
pain, and a malar rash. Laboratory studies show ANA
positive (1:640, homogenous pattern), anti-dsDNA
positive, and low C3 and C4. Which of the following is
the most likely diagnosis?
A) Rheumatoid arthritis
B) Systemic lupus erythematosus
C) Sjögren's syndrome
D) Scleroderma
Correct answer: B
, Rationale: Positive ANA, anti-dsDNA, low
complement, and malar rash are diagnostic of
systemic lupus erythematosus.
5. A 55-year-old man with hypertension and diabetes
presents with sudden onset of severe, tearing chest
pain radiating to the back. Blood pressure is 160/100
mmHg in the right arm and 100/70 mmHg in the left
arm. Which of the following is the most likely
diagnosis?
A) Acute myocardial infarction
B) Pulmonary embolism
C) Aortic dissection
D) Pericarditis
Correct answer: C
Rationale: Aortic dissection presents with tearing
chest pain radiating to the back and blood pressure
differential between arms.
6. A 2-year-old child presents with recurrent
episodes of tonic-clonic seizures, developmental
delay, and a musty odor to the urine. Which of the
following is the most likely underlying metabolic
disorder?
OSTEOPATHIC MEDICAL LICENSING
EXAMINATION LEVEL 1) EXAM–
COMPREHENSIVE EXAM WITH
ANSWERS AND RATIONALES
1. A 45-year-old male with a history of alcohol use
disorder presents with jaundice, ascites, and
asterixis. Laboratory studies reveal elevated AST
(120 U/L), ALT (80 U/L), and bilirubin. Liver biopsy
shows micronodular cirrhosis and Mallory-Denk
bodies. Which of the following is the most likely
underlying mechanism of liver injury in this patient?
A) Direct hepatocyte toxicity from acetaldehyde
accumulation
B) Immune-mediated destruction of bile canaliculi
C) Alpha-1 antitrypsin deficiency with abnormal
protein accumulation
D) Autoimmune destruction of hepatocytes
Correct answer: A
Rationale: Alcohol metabolism produces
acetaldehyde, which is directly toxic to hepatocytes
,and promotes oxidative stress, leading to alcoholic
liver disease.
2. A 25-year-old woman presents with acute onset of
shortness of breath and pleuritic chest pain one week
after an uncomplicated vaginal delivery. She is
tachycardic and hypoxic. CT angiography reveals
bilateral pulmonary emboli. Which of the following
inherited thrombophilias is most strongly associated
with this presentation?
A) Factor V Leiden mutation
B) Prothrombin G20210A mutation
C) Protein C deficiency
D) Antithrombin III deficiency
Correct answer: A
Rationale: Factor V Leiden (APC resistance) is the
most common inherited thrombophilia in Caucasians
and increases risk of venous thromboembolism,
especially in pregnancy and postpartum.
3. A 60-year-old man with a 40-pack-year smoking
history presents with hemoptysis and weight loss.
Chest X-ray shows a right hilar mass. Bronchoscopy
reveals a tumor obstructing the right main bronchus.
Biopsy shows small round blue cells with scant
,cytoplasm, nuclear molding, and necrosis. Which of
the following is the most likely diagnosis?
A) Squamous cell carcinoma
B) Adenocarcinoma
C) Small cell lung carcinoma
D) Large cell carcinoma
Correct answer: C
Rationale: Small cell lung carcinoma presents with
central (hilar) mass, strong association with smoking,
and histology showing small round blue cells with
nuclear molding.
4. A 32-year-old female presents with fatigue, joint
pain, and a malar rash. Laboratory studies show ANA
positive (1:640, homogenous pattern), anti-dsDNA
positive, and low C3 and C4. Which of the following is
the most likely diagnosis?
A) Rheumatoid arthritis
B) Systemic lupus erythematosus
C) Sjögren's syndrome
D) Scleroderma
Correct answer: B
, Rationale: Positive ANA, anti-dsDNA, low
complement, and malar rash are diagnostic of
systemic lupus erythematosus.
5. A 55-year-old man with hypertension and diabetes
presents with sudden onset of severe, tearing chest
pain radiating to the back. Blood pressure is 160/100
mmHg in the right arm and 100/70 mmHg in the left
arm. Which of the following is the most likely
diagnosis?
A) Acute myocardial infarction
B) Pulmonary embolism
C) Aortic dissection
D) Pericarditis
Correct answer: C
Rationale: Aortic dissection presents with tearing
chest pain radiating to the back and blood pressure
differential between arms.
6. A 2-year-old child presents with recurrent
episodes of tonic-clonic seizures, developmental
delay, and a musty odor to the urine. Which of the
following is the most likely underlying metabolic
disorder?
