United States Medical Licensing Examination
Step One – Comprehensive Medical
Knowledge Assessment Question Bank actual
update graded A+ 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 (ranging from high-yield foundational concepts to complex
clinical integration)
SECTION 1: CARDIOVASCULAR SYSTEM
Question 1
A 65-year-old man with a 40-pack-year smoking history presents with progressive shortness of
breath and a nonproductive cough. Physical examination reveals jugular venous distention,
hepatomegaly, and peripheral edema. Cardiac auscultation reveals a loud P₂ and a systolic
murmur that increases with inspiration. Which of the following hemodynamic parameters is
most likely elevated in this patient?
A) Left ventricular end-diastolic pressure
B) Pulmonary capillary wedge pressure
C) Right ventricular systolic pressure
D) Aortic systolic pressure
E) Left atrial pressure
Correct Answer: C) Right ventricular systolic pressure
,Rationale: This patient presents with signs of right-sided heart failure (jugular venous
distention, hepatomegaly, peripheral edema) and pulmonary hypertension (loud P₂). The
systolic murmur that increases with inspiration is consistent with tricuspid regurgitation. These
findings indicate elevated right ventricular systolic pressure, which occurs in pulmonary
hypertension and right ventricular failure. Left-sided pressures (A, B, E) would be elevated in
left-sided heart failure, while aortic pressure (D) is not directly related to these findings.
Question 2
A 58-year-old woman with hypertension and type 2 diabetes mellitus is started on a new
medication. Two weeks later, she develops a dry cough that is worse at night. Which of the
following medications is most likely responsible for her symptoms?
A) Amlodipine
B) Hydrochlorothiazide
C) Lisinopril
D) Metoprolol
E) Losartan
Correct Answer: C) Lisinopril
Rationale: Lisinopril, an ACE inhibitor, commonly causes a dry cough due to accumulation of
bradykinin in the respiratory tract. This adverse effect occurs in approximately 10-20% of
patients. Amlodipine (A) causes peripheral edema, hydrochlorothiazide (B) causes electrolyte
disturbances, metoprolol (D) causes bradycardia and fatigue, and losartan (E) is an ARB that
does not typically cause cough.
Question 3
A 72-year-old man with a history of myocardial infarction presents with palpitations and
lightheadedness. ECG shows a regular, wide-complex tachycardia at 180 beats per minute with
no discernible P waves. He is hemodynamically stable. Which of the following is the most
appropriate initial management?
A) Immediate synchronized cardioversion
B) Intravenous adenosine
C) Intravenous amiodarone
D) Vagal maneuvers
E) Oral metoprolol
Correct Answer: C) Intravenous amiodarone
,Rationale: This patient has monomorphic ventricular tachycardia (regular wide-complex
tachycardia, no P waves, rate >120). In hemodynamically stable patients, intravenous
amiodarone or procainamide is the treatment of choice. Adenosine (B) is used for
supraventricular tachycardia. Vagal maneuvers (D) are ineffective for ventricular tachycardia.
Immediate cardioversion (A) is indicated only for unstable patients. Oral metoprolol (E) is not
appropriate for acute termination.
Question 4
A 45-year-old man with no significant medical history presents with chest pain that is worse
when lying flat and improves when leaning forward. ECG shows diffuse ST-segment elevation
and PR-segment depression. Which of the following is the most likely diagnosis?
A) Acute myocardial infarction
B) Pericarditis
C) Pulmonary embolism
D) Aortic dissection
E) Stable angina
Correct Answer: B) Pericarditis
Rationale: Acute pericarditis presents with pleuritic chest pain that improves with leaning
forward and worsens when supine. ECG findings include diffuse ST-segment elevation and PR-
segment depression. Acute myocardial infarction (A) shows localized ST elevation with
reciprocal changes. Pulmonary embolism (C) typically shows sinus tachycardia and S1Q3T3
pattern. Aortic dissection (D) presents with tearing chest pain radiating to the back.
Question 5
A 60-year-old woman with hypertension is found to have a blood pressure of 165/95 mmHg
despite treatment with lisinopril and hydrochlorothiazide. She has a history of gout. Which of
the following antihypertensive agents would be most appropriate to add to her regimen?
A) Amlodipine
B) Losartan
C) Spironolactone
D) Atenolol
E) Clonidine
Correct Answer: B) Losartan
, Rationale: Losartan is an angiotensin receptor blocker (ARB) that is preferred in patients with
gout because it has uricosuric effects. Thiazide diuretics (already on hydrochlorothiazide)
increase uric acid levels and can worsen gout. Amlodipine (A) is a calcium channel blocker that
would be acceptable but losartan provides additional benefit. Spironolactone (C) is a potassium-
sparing diuretic. Atenolol (D) and clonidine (E) are not preferred in this scenario.
Question 6
A 28-year-old woman presents with palpitations, heat intolerance, and weight loss despite
increased appetite. Physical examination reveals a diffuse, nontender goiter with a bruit. Which
of the following laboratory findings is most consistent with her diagnosis?
A) Elevated TSH, low free T4
B) Low TSH, elevated free T4
C) Normal TSH, elevated free T4
D) Elevated TSH, elevated free T4
E) Low TSH, low free T4
Correct Answer: B) Low TSH, elevated free T4
Rationale: This patient has Graves disease, the most common cause of hyperthyroidism. In
primary hyperthyroidism, TSH is suppressed (low) due to negative feedback from elevated
thyroid hormones, and free T4 is elevated. Elevated TSH with low free T4 (A) indicates primary
hypothyroidism. Normal TSH with elevated free T4 (C) suggests subclinical hyperthyroidism or
assay interference.
Question 7
A 55-year-old man with a history of chronic alcohol use presents with jaundice, ascites, and
confusion. Laboratory studies show elevated liver enzymes and prolonged prothrombin time. A
liver biopsy shows micronodular cirrhosis with fatty change and Mallory-Denk bodies. Which of
the following is the most likely diagnosis?
A) Wilson disease
B) Alpha-1 antitrypsin deficiency
C) Alcoholic liver disease
D) Hemochromatosis
E) Primary biliary cholangitis
Correct Answer: C) Alcoholic liver disease
Step One – Comprehensive Medical
Knowledge Assessment Question Bank actual
update graded A+ 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 (ranging from high-yield foundational concepts to complex
clinical integration)
SECTION 1: CARDIOVASCULAR SYSTEM
Question 1
A 65-year-old man with a 40-pack-year smoking history presents with progressive shortness of
breath and a nonproductive cough. Physical examination reveals jugular venous distention,
hepatomegaly, and peripheral edema. Cardiac auscultation reveals a loud P₂ and a systolic
murmur that increases with inspiration. Which of the following hemodynamic parameters is
most likely elevated in this patient?
A) Left ventricular end-diastolic pressure
B) Pulmonary capillary wedge pressure
C) Right ventricular systolic pressure
D) Aortic systolic pressure
E) Left atrial pressure
Correct Answer: C) Right ventricular systolic pressure
,Rationale: This patient presents with signs of right-sided heart failure (jugular venous
distention, hepatomegaly, peripheral edema) and pulmonary hypertension (loud P₂). The
systolic murmur that increases with inspiration is consistent with tricuspid regurgitation. These
findings indicate elevated right ventricular systolic pressure, which occurs in pulmonary
hypertension and right ventricular failure. Left-sided pressures (A, B, E) would be elevated in
left-sided heart failure, while aortic pressure (D) is not directly related to these findings.
Question 2
A 58-year-old woman with hypertension and type 2 diabetes mellitus is started on a new
medication. Two weeks later, she develops a dry cough that is worse at night. Which of the
following medications is most likely responsible for her symptoms?
A) Amlodipine
B) Hydrochlorothiazide
C) Lisinopril
D) Metoprolol
E) Losartan
Correct Answer: C) Lisinopril
Rationale: Lisinopril, an ACE inhibitor, commonly causes a dry cough due to accumulation of
bradykinin in the respiratory tract. This adverse effect occurs in approximately 10-20% of
patients. Amlodipine (A) causes peripheral edema, hydrochlorothiazide (B) causes electrolyte
disturbances, metoprolol (D) causes bradycardia and fatigue, and losartan (E) is an ARB that
does not typically cause cough.
Question 3
A 72-year-old man with a history of myocardial infarction presents with palpitations and
lightheadedness. ECG shows a regular, wide-complex tachycardia at 180 beats per minute with
no discernible P waves. He is hemodynamically stable. Which of the following is the most
appropriate initial management?
A) Immediate synchronized cardioversion
B) Intravenous adenosine
C) Intravenous amiodarone
D) Vagal maneuvers
E) Oral metoprolol
Correct Answer: C) Intravenous amiodarone
,Rationale: This patient has monomorphic ventricular tachycardia (regular wide-complex
tachycardia, no P waves, rate >120). In hemodynamically stable patients, intravenous
amiodarone or procainamide is the treatment of choice. Adenosine (B) is used for
supraventricular tachycardia. Vagal maneuvers (D) are ineffective for ventricular tachycardia.
Immediate cardioversion (A) is indicated only for unstable patients. Oral metoprolol (E) is not
appropriate for acute termination.
Question 4
A 45-year-old man with no significant medical history presents with chest pain that is worse
when lying flat and improves when leaning forward. ECG shows diffuse ST-segment elevation
and PR-segment depression. Which of the following is the most likely diagnosis?
A) Acute myocardial infarction
B) Pericarditis
C) Pulmonary embolism
D) Aortic dissection
E) Stable angina
Correct Answer: B) Pericarditis
Rationale: Acute pericarditis presents with pleuritic chest pain that improves with leaning
forward and worsens when supine. ECG findings include diffuse ST-segment elevation and PR-
segment depression. Acute myocardial infarction (A) shows localized ST elevation with
reciprocal changes. Pulmonary embolism (C) typically shows sinus tachycardia and S1Q3T3
pattern. Aortic dissection (D) presents with tearing chest pain radiating to the back.
Question 5
A 60-year-old woman with hypertension is found to have a blood pressure of 165/95 mmHg
despite treatment with lisinopril and hydrochlorothiazide. She has a history of gout. Which of
the following antihypertensive agents would be most appropriate to add to her regimen?
A) Amlodipine
B) Losartan
C) Spironolactone
D) Atenolol
E) Clonidine
Correct Answer: B) Losartan
, Rationale: Losartan is an angiotensin receptor blocker (ARB) that is preferred in patients with
gout because it has uricosuric effects. Thiazide diuretics (already on hydrochlorothiazide)
increase uric acid levels and can worsen gout. Amlodipine (A) is a calcium channel blocker that
would be acceptable but losartan provides additional benefit. Spironolactone (C) is a potassium-
sparing diuretic. Atenolol (D) and clonidine (E) are not preferred in this scenario.
Question 6
A 28-year-old woman presents with palpitations, heat intolerance, and weight loss despite
increased appetite. Physical examination reveals a diffuse, nontender goiter with a bruit. Which
of the following laboratory findings is most consistent with her diagnosis?
A) Elevated TSH, low free T4
B) Low TSH, elevated free T4
C) Normal TSH, elevated free T4
D) Elevated TSH, elevated free T4
E) Low TSH, low free T4
Correct Answer: B) Low TSH, elevated free T4
Rationale: This patient has Graves disease, the most common cause of hyperthyroidism. In
primary hyperthyroidism, TSH is suppressed (low) due to negative feedback from elevated
thyroid hormones, and free T4 is elevated. Elevated TSH with low free T4 (A) indicates primary
hypothyroidism. Normal TSH with elevated free T4 (C) suggests subclinical hyperthyroidism or
assay interference.
Question 7
A 55-year-old man with a history of chronic alcohol use presents with jaundice, ascites, and
confusion. Laboratory studies show elevated liver enzymes and prolonged prothrombin time. A
liver biopsy shows micronodular cirrhosis with fatty change and Mallory-Denk bodies. Which of
the following is the most likely diagnosis?
A) Wilson disease
B) Alpha-1 antitrypsin deficiency
C) Alcoholic liver disease
D) Hemochromatosis
E) Primary biliary cholangitis
Correct Answer: C) Alcoholic liver disease
