USMLE Step 1 & Step 2 CK Comprehensive
Question Bank: 150 High-Yield Multiple-Choice
Questions with Detailed Rationales for
Advanced Medical Board Examination
Preparation a well detailed practice exam
2025/2026 graded A+ well written !!!
QUESTION 1
A 65-year-old man with a 30-pack-year smoking history presents with a 3-month history of
progressive hoarseness and a sensation of a "lump in the throat." Flexible laryngoscopy reveals
a unilateral vocal cord palsy. CT imaging of the neck and chest is most likely to reveal which of
the following?
A. Aortic arch aneurysm
B. Pancoast tumor
C. Left atrial enlargement
D. Thyroid goiter
E. Esophageal diverticulum
Correct Answer: B
Rationale: Unilateral vocal cord palsy with hoarseness in a smoker suggests involvement of the
recurrent laryngeal nerve. The left recurrent laryngeal nerve has a longer course, looping under
the aortic arch, but the right recurrent laryngeal nerve loops under the right subclavian artery. A
Pancoast tumor (superior sulcus tumor) at the lung apex can invade the recurrent laryngeal
nerve, causing vocal cord paralysis. Aortic arch aneurysm more commonly affects the left
,recurrent laryngeal nerve, but the presentation with smoking history and the need for chest CT
makes Pancoast tumor the most likely diagnosis to investigate.
QUESTION 2
A 28-year-old woman with a history of systemic lupus erythematosus presents with acute onset
of shortness of breath and pleuritic chest pain. She is found to have a large pericardial effusion
on echocardiography. Which of the following is the most specific finding on electrocardiography
for pericarditis in this patient?
A. Diffuse ST-segment elevation
B. PR-segment depression
C. Electrical alternans
D. Sinus tachycardia
E. Low-voltage QRS complexes
Correct Answer: C
Rationale: Electrical alternans—beat-to-beat variation in the amplitude of the QRS complex—is
the most specific electrocardiographic finding for large pericardial effusion with cardiac
tamponade. Diffuse ST-segment elevation and PR-segment depression are characteristic of
acute pericarditis but are not specific for effusion. Low-voltage QRS complexes and sinus
tachycardia can occur with pericardial effusion but are less specific.
QUESTION 3
A 55-year-old man with hypertension and gout presents for routine follow-up. His blood
pressure is 158/92 mmHg despite treatment with amlodipine 10 mg daily. He has had two gout
flares in the past year. Which antihypertensive agent should be AVOIDED as add-on therapy?
A. Losartan
B. Lisinopril
C. Hydrochlorothiazide
D. Metoprolol
E. Spironolactone
Correct Answer: C
Rationale: Thiazide diuretics (hydrochlorothiazide) decrease urinary uric acid excretion by
competing with uric acid for secretion in the proximal tubule, raising serum uric acid and
,precipitating gout flares. Losartan (an ARB) is uricosuric and preferred in hypertensive patients
with gout. Lisinopril, metoprolol, and spironolactone do not significantly affect uric acid levels.
QUESTION 4
A 70-year-old woman with congestive heart failure on furosemide develops generalized
weakness and muscle cramps. ECG shows flattened T waves and prominent U waves. What is
the PRIMARY mechanism responsible for her ECG findings?
A. Hyperkalemia from aldosterone excess
B. Hypokalemia from increased Na+/K+ exchange in the collecting duct
C. Hypernatremia from free water loss
D. Metabolic acidosis from H+ retention
E. Hypercalcemia from vitamin D activation
Correct Answer: B
Rationale: Furosemide, a loop diuretic, increases distal sodium delivery, promoting Na+/K+
exchange in the collecting duct, leading to hypokalemia. Hypokalemia causes flattened T waves
and prominent U waves on ECG. The other options do not explain these characteristic ECG
findings.
QUESTION 5
A 45-year-old woman presents with hypertension, proximal muscle weakness, and easy
bruising. Laboratory studies show hyperglycemia and hypokalemia. An overnight
dexamethasone suppression test shows inadequate cortisol suppression. Which of the following
is the most likely diagnosis?
A. Cushing disease
B. Adrenal adenoma
C. Ectopic ACTH syndrome
D. Pseudo-Cushing syndrome
E. Primary adrenal insufficiency
Correct Answer: A
Rationale: The combination of hypertension, proximal muscle weakness, easy bruising,
hyperglycemia, and hypokalemia suggests Cushing syndrome. Inadequate cortisol suppression
after overnight dexamethasone indicates a pituitary source (Cushing disease) or ectopic ACTH.
, Cushing disease is the most common cause of endogenous Cushing syndrome. An adrenal
adenoma would show low ACTH. Pseudo-Cushing is associated with conditions like depression
and alcoholism.
QUESTION 6
A 22-year-old man with infectious mononucleosis develops a diffuse maculopapular rash after
receiving antibiotics for a presumed streptococcal pharyngitis. Which antibiotic was MOST likely
administered?
A. Amoxicillin
B. Azithromycin
C. Cephalexin
D. Doxycycline
E. Clindamycin
Correct Answer: A
Rationale: Amoxicillin and other aminopenicillins cause a characteristic maculopapular rash in
patients with infectious mononucleosis (Epstein-Barr virus infection). This rash is non-allergic
and does not represent a true penicillin allergy. The other antibiotics are not associated with
this specific reaction in EBV infection.
QUESTION 7
A 60-year-old man presents with acute onset of vertigo, nausea, and difficulty walking.
Neurologic examination reveals nystagmus, ipsilateral facial pain and temperature loss,
contralateral pain and temperature loss in the extremities, and Horner syndrome. Which artery
is most likely occluded?
A. Anterior inferior cerebellar artery
B. Posterior inferior cerebellar artery
C. Superior cerebellar artery
D. Posterior cerebral artery
E. Middle cerebral artery
Correct Answer: B
Rationale: This presentation is classic for lateral medullary syndrome (Wallenberg syndrome)
caused by occlusion of the posterior inferior cerebellar artery (PICA). Findings include ipsilateral
Question Bank: 150 High-Yield Multiple-Choice
Questions with Detailed Rationales for
Advanced Medical Board Examination
Preparation a well detailed practice exam
2025/2026 graded A+ well written !!!
QUESTION 1
A 65-year-old man with a 30-pack-year smoking history presents with a 3-month history of
progressive hoarseness and a sensation of a "lump in the throat." Flexible laryngoscopy reveals
a unilateral vocal cord palsy. CT imaging of the neck and chest is most likely to reveal which of
the following?
A. Aortic arch aneurysm
B. Pancoast tumor
C. Left atrial enlargement
D. Thyroid goiter
E. Esophageal diverticulum
Correct Answer: B
Rationale: Unilateral vocal cord palsy with hoarseness in a smoker suggests involvement of the
recurrent laryngeal nerve. The left recurrent laryngeal nerve has a longer course, looping under
the aortic arch, but the right recurrent laryngeal nerve loops under the right subclavian artery. A
Pancoast tumor (superior sulcus tumor) at the lung apex can invade the recurrent laryngeal
nerve, causing vocal cord paralysis. Aortic arch aneurysm more commonly affects the left
,recurrent laryngeal nerve, but the presentation with smoking history and the need for chest CT
makes Pancoast tumor the most likely diagnosis to investigate.
QUESTION 2
A 28-year-old woman with a history of systemic lupus erythematosus presents with acute onset
of shortness of breath and pleuritic chest pain. She is found to have a large pericardial effusion
on echocardiography. Which of the following is the most specific finding on electrocardiography
for pericarditis in this patient?
A. Diffuse ST-segment elevation
B. PR-segment depression
C. Electrical alternans
D. Sinus tachycardia
E. Low-voltage QRS complexes
Correct Answer: C
Rationale: Electrical alternans—beat-to-beat variation in the amplitude of the QRS complex—is
the most specific electrocardiographic finding for large pericardial effusion with cardiac
tamponade. Diffuse ST-segment elevation and PR-segment depression are characteristic of
acute pericarditis but are not specific for effusion. Low-voltage QRS complexes and sinus
tachycardia can occur with pericardial effusion but are less specific.
QUESTION 3
A 55-year-old man with hypertension and gout presents for routine follow-up. His blood
pressure is 158/92 mmHg despite treatment with amlodipine 10 mg daily. He has had two gout
flares in the past year. Which antihypertensive agent should be AVOIDED as add-on therapy?
A. Losartan
B. Lisinopril
C. Hydrochlorothiazide
D. Metoprolol
E. Spironolactone
Correct Answer: C
Rationale: Thiazide diuretics (hydrochlorothiazide) decrease urinary uric acid excretion by
competing with uric acid for secretion in the proximal tubule, raising serum uric acid and
,precipitating gout flares. Losartan (an ARB) is uricosuric and preferred in hypertensive patients
with gout. Lisinopril, metoprolol, and spironolactone do not significantly affect uric acid levels.
QUESTION 4
A 70-year-old woman with congestive heart failure on furosemide develops generalized
weakness and muscle cramps. ECG shows flattened T waves and prominent U waves. What is
the PRIMARY mechanism responsible for her ECG findings?
A. Hyperkalemia from aldosterone excess
B. Hypokalemia from increased Na+/K+ exchange in the collecting duct
C. Hypernatremia from free water loss
D. Metabolic acidosis from H+ retention
E. Hypercalcemia from vitamin D activation
Correct Answer: B
Rationale: Furosemide, a loop diuretic, increases distal sodium delivery, promoting Na+/K+
exchange in the collecting duct, leading to hypokalemia. Hypokalemia causes flattened T waves
and prominent U waves on ECG. The other options do not explain these characteristic ECG
findings.
QUESTION 5
A 45-year-old woman presents with hypertension, proximal muscle weakness, and easy
bruising. Laboratory studies show hyperglycemia and hypokalemia. An overnight
dexamethasone suppression test shows inadequate cortisol suppression. Which of the following
is the most likely diagnosis?
A. Cushing disease
B. Adrenal adenoma
C. Ectopic ACTH syndrome
D. Pseudo-Cushing syndrome
E. Primary adrenal insufficiency
Correct Answer: A
Rationale: The combination of hypertension, proximal muscle weakness, easy bruising,
hyperglycemia, and hypokalemia suggests Cushing syndrome. Inadequate cortisol suppression
after overnight dexamethasone indicates a pituitary source (Cushing disease) or ectopic ACTH.
, Cushing disease is the most common cause of endogenous Cushing syndrome. An adrenal
adenoma would show low ACTH. Pseudo-Cushing is associated with conditions like depression
and alcoholism.
QUESTION 6
A 22-year-old man with infectious mononucleosis develops a diffuse maculopapular rash after
receiving antibiotics for a presumed streptococcal pharyngitis. Which antibiotic was MOST likely
administered?
A. Amoxicillin
B. Azithromycin
C. Cephalexin
D. Doxycycline
E. Clindamycin
Correct Answer: A
Rationale: Amoxicillin and other aminopenicillins cause a characteristic maculopapular rash in
patients with infectious mononucleosis (Epstein-Barr virus infection). This rash is non-allergic
and does not represent a true penicillin allergy. The other antibiotics are not associated with
this specific reaction in EBV infection.
QUESTION 7
A 60-year-old man presents with acute onset of vertigo, nausea, and difficulty walking.
Neurologic examination reveals nystagmus, ipsilateral facial pain and temperature loss,
contralateral pain and temperature loss in the extremities, and Horner syndrome. Which artery
is most likely occluded?
A. Anterior inferior cerebellar artery
B. Posterior inferior cerebellar artery
C. Superior cerebellar artery
D. Posterior cerebral artery
E. Middle cerebral artery
Correct Answer: B
Rationale: This presentation is classic for lateral medullary syndrome (Wallenberg syndrome)
caused by occlusion of the posterior inferior cerebellar artery (PICA). Findings include ipsilateral
