United States Medical Licensing Examination
Step One – Comprehensive Medical
Knowledge Assessment Question Bank actual
update Version 2.0 – Advanced
High-Yield Practice Examination
Examination Format: 150 Multiple-Choice Questions (Single Best Answer)
Target Audience: Medical Students Preparing for USMLE Step 1
Difficulty Level: Advanced / Mixed (integrating foundational sciences with clinical application)
Time Allotment: 3 hours 45 minutes (150 minutes)
SECTION 1: CARDIOVASCULAR SYSTEM
Question 1
A 68-year-old man with a history of hypertension and diabetes presents with acute-onset severe
chest pain that radiates to his back. His blood pressure is 180/95 mmHg in the right arm and
110/70 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
E) Esophageal rupture
Correct Answer: C) Aortic dissection
Rationale: Aortic dissection presents with severe, tearing chest pain radiating to the back and
differential blood pressures between arms. This is a medical emergency requiring immediate
imaging and surgical consultation. Acute MI (A) typically presents with pressure-type chest pain
,without differential pressures. Pulmonary embolism (B) presents with acute dyspnea and
pleuritic chest pain.
Question 2
A 55-year-old woman with heart failure with preserved ejection fraction presents with
worsening dyspnea and leg edema. Which of the following medications is most appropriate for
managing her symptoms?
A) Spironolactone
B) Carvedilol
C) Lisinopril
D) Digoxin
E) Hydralazine
Correct Answer: A) Spironolactone
Rationale: Spironolactone has been shown to reduce hospitalizations in HFpEF (TOPCAT trial).
Carvedilol (B) and lisinopril (C) are primarily for HFrEF. Digoxin (D) is used for symptom control in
HFrEF with atrial fibrillation. Hydralazine (E) is used in African American patients with HFrEF.
Question 3
A 42-year-old man presents with palpitations, diaphoresis, and headache. During the episode,
his blood pressure is 220/120 mmHg. Which of the following laboratory findings would most
support the suspected diagnosis?
A) Elevated plasma metanephrines
B) Elevated serum aldosterone
C) Elevated urinary cortisol
D) Elevated serum renin
E) Elevated serum calcium
Correct Answer: A) Elevated plasma metanephrines
Rationale: Pheochromocytoma is diagnosed by elevated plasma or urinary metanephrines. The
classic presentation includes paroxysmal hypertension, palpitations, diaphoresis, and headache.
Elevated aldosterone (B) suggests primary aldosteronism. Elevated cortisol (C) suggests Cushing
syndrome.
,Question 4
A 65-year-old man with a history of myocardial infarction presents with progressive shortness of
breath and orthopnea. Echocardiogram shows an ejection fraction of 30%. Which of the
following is the most appropriate initial pharmacotherapy?
A) Carvedilol, lisinopril, and furosemide
B) Digoxin, furosemide, and metolazone
C) Amlodipine, carvedilol, and spironolactone
D) Lisinopril, amlodipine, and hydrochlorothiazide
E) Metoprolol, diltiazem, and furosemide
Correct Answer: A) Carvedilol, lisinopril, and furosemide
Rationale: The standard triple therapy for HFrEF includes a beta-blocker (carvedilol), ACE
inhibitor (lisinopril), and diuretic (furosemide) for symptom control. This regimen improves
mortality and reduces hospitalizations. Calcium channel blockers (C, D) are not recommended in
HFrEF.
Question 5
A 28-year-old woman with no significant medical history presents with acute chest pain that
worsens with inspiration and improves when leaning forward. ECG shows diffuse PR depression
and ST elevation. Which of the following is the most likely diagnosis?
A) Pericarditis
B) Acute myocardial infarction
C) Pulmonary embolism
D) Costochondritis
E) Pneumothorax
Correct Answer: A) Pericarditis
Rationale: Pericarditis presents with pleuritic chest pain that improves with leaning forward and
worsens supine. ECG findings include diffuse ST elevation and PR depression. Acute MI (B)
shows localized ST elevation. Pulmonary embolism (C) shows sinus tachycardia. Costochondritis
(D) is a diagnosis of exclusion.
Question 6
A 70-year-old man with atrial fibrillation is started on apixaban for stroke prevention. Which of
the following is the most appropriate monitoring parameter?
, A) INR
B) aPTT
C) Anti-Xa levels
D) Platelet count
E) Renal function
Correct Answer: E) Renal function
Rationale: Apixaban is a direct factor Xa inhibitor that does not require routine monitoring of
INR (A) or aPTT (B). Renal function should be monitored as it affects drug clearance. Anti-Xa
levels (C) are not routinely checked. Platelet count (D) is monitored for heparin-induced
thrombocytopenia.
Question 7
A 52-year-old man with hypertension and hyperlipidemia presents with exertional chest pain
relieved by rest. ECG shows ST-segment depression during exercise stress testing. Which of the
following is the most appropriate next step?
A) Coronary angiography
B) Medical management with aspirin and statin
C) Stress echocardiography
D) Cardiac CT angiography
E) Admission for observation
Correct Answer: A) Coronary angiography
Rationale: This patient has stable angina with positive stress test findings, indicating significant
coronary artery disease. Coronary angiography is indicated for definitive diagnosis and potential
intervention. Medical management (B) may be appropriate after anatomy is defined.
Question 8
A 45-year-old woman presents with syncope and a systolic ejection murmur that increases with
squatting and decreases with Valsalva maneuver. Which of the following is the most likely
diagnosis?
A) Aortic stenosis
B) Hypertrophic cardiomyopathy
C) Mitral valve prolapse
Step One – Comprehensive Medical
Knowledge Assessment Question Bank actual
update Version 2.0 – Advanced
High-Yield Practice Examination
Examination Format: 150 Multiple-Choice Questions (Single Best Answer)
Target Audience: Medical Students Preparing for USMLE Step 1
Difficulty Level: Advanced / Mixed (integrating foundational sciences with clinical application)
Time Allotment: 3 hours 45 minutes (150 minutes)
SECTION 1: CARDIOVASCULAR SYSTEM
Question 1
A 68-year-old man with a history of hypertension and diabetes presents with acute-onset severe
chest pain that radiates to his back. His blood pressure is 180/95 mmHg in the right arm and
110/70 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
E) Esophageal rupture
Correct Answer: C) Aortic dissection
Rationale: Aortic dissection presents with severe, tearing chest pain radiating to the back and
differential blood pressures between arms. This is a medical emergency requiring immediate
imaging and surgical consultation. Acute MI (A) typically presents with pressure-type chest pain
,without differential pressures. Pulmonary embolism (B) presents with acute dyspnea and
pleuritic chest pain.
Question 2
A 55-year-old woman with heart failure with preserved ejection fraction presents with
worsening dyspnea and leg edema. Which of the following medications is most appropriate for
managing her symptoms?
A) Spironolactone
B) Carvedilol
C) Lisinopril
D) Digoxin
E) Hydralazine
Correct Answer: A) Spironolactone
Rationale: Spironolactone has been shown to reduce hospitalizations in HFpEF (TOPCAT trial).
Carvedilol (B) and lisinopril (C) are primarily for HFrEF. Digoxin (D) is used for symptom control in
HFrEF with atrial fibrillation. Hydralazine (E) is used in African American patients with HFrEF.
Question 3
A 42-year-old man presents with palpitations, diaphoresis, and headache. During the episode,
his blood pressure is 220/120 mmHg. Which of the following laboratory findings would most
support the suspected diagnosis?
A) Elevated plasma metanephrines
B) Elevated serum aldosterone
C) Elevated urinary cortisol
D) Elevated serum renin
E) Elevated serum calcium
Correct Answer: A) Elevated plasma metanephrines
Rationale: Pheochromocytoma is diagnosed by elevated plasma or urinary metanephrines. The
classic presentation includes paroxysmal hypertension, palpitations, diaphoresis, and headache.
Elevated aldosterone (B) suggests primary aldosteronism. Elevated cortisol (C) suggests Cushing
syndrome.
,Question 4
A 65-year-old man with a history of myocardial infarction presents with progressive shortness of
breath and orthopnea. Echocardiogram shows an ejection fraction of 30%. Which of the
following is the most appropriate initial pharmacotherapy?
A) Carvedilol, lisinopril, and furosemide
B) Digoxin, furosemide, and metolazone
C) Amlodipine, carvedilol, and spironolactone
D) Lisinopril, amlodipine, and hydrochlorothiazide
E) Metoprolol, diltiazem, and furosemide
Correct Answer: A) Carvedilol, lisinopril, and furosemide
Rationale: The standard triple therapy for HFrEF includes a beta-blocker (carvedilol), ACE
inhibitor (lisinopril), and diuretic (furosemide) for symptom control. This regimen improves
mortality and reduces hospitalizations. Calcium channel blockers (C, D) are not recommended in
HFrEF.
Question 5
A 28-year-old woman with no significant medical history presents with acute chest pain that
worsens with inspiration and improves when leaning forward. ECG shows diffuse PR depression
and ST elevation. Which of the following is the most likely diagnosis?
A) Pericarditis
B) Acute myocardial infarction
C) Pulmonary embolism
D) Costochondritis
E) Pneumothorax
Correct Answer: A) Pericarditis
Rationale: Pericarditis presents with pleuritic chest pain that improves with leaning forward and
worsens supine. ECG findings include diffuse ST elevation and PR depression. Acute MI (B)
shows localized ST elevation. Pulmonary embolism (C) shows sinus tachycardia. Costochondritis
(D) is a diagnosis of exclusion.
Question 6
A 70-year-old man with atrial fibrillation is started on apixaban for stroke prevention. Which of
the following is the most appropriate monitoring parameter?
, A) INR
B) aPTT
C) Anti-Xa levels
D) Platelet count
E) Renal function
Correct Answer: E) Renal function
Rationale: Apixaban is a direct factor Xa inhibitor that does not require routine monitoring of
INR (A) or aPTT (B). Renal function should be monitored as it affects drug clearance. Anti-Xa
levels (C) are not routinely checked. Platelet count (D) is monitored for heparin-induced
thrombocytopenia.
Question 7
A 52-year-old man with hypertension and hyperlipidemia presents with exertional chest pain
relieved by rest. ECG shows ST-segment depression during exercise stress testing. Which of the
following is the most appropriate next step?
A) Coronary angiography
B) Medical management with aspirin and statin
C) Stress echocardiography
D) Cardiac CT angiography
E) Admission for observation
Correct Answer: A) Coronary angiography
Rationale: This patient has stable angina with positive stress test findings, indicating significant
coronary artery disease. Coronary angiography is indicated for definitive diagnosis and potential
intervention. Medical management (B) may be appropriate after anatomy is defined.
Question 8
A 45-year-old woman presents with syncope and a systolic ejection murmur that increases with
squatting and decreases with Valsalva maneuver. Which of the following is the most likely
diagnosis?
A) Aortic stenosis
B) Hypertrophic cardiomyopathy
C) Mitral valve prolapse
