USMLE Step 2 CK & Step 1 Integration: Advanced
Clinical Vignettes in Internal Medicine, Surgery,
Pediatrics, Obstetrics & Gynecology, Psychiatry,
and Neurology for Comprehensive Board Review a
well detailed practice exam 2025/2026 graded A+
well written !!!
QUESTION 1
A 68-year-old man with a 50-pack-year smoking history presents with a 2-month history of
hoarseness and a nonproductive cough. He has lost 10 pounds unintentionally. Laryngoscopy
reveals a left vocal cord paralysis. Chest CT shows a 4-cm mass in the left upper lobe with chest
wall invasion. Which of the following is the most likely diagnosis?
A. Squamous cell carcinoma
B. Adenocarcinoma
C. Small cell lung cancer
D. Large cell carcinoma
E. Carcinoid tumor
Correct Answer: A
Rationale: Squamous cell carcinoma is strongly associated with smoking and often presents as
central masses that can invade the chest wall and recurrent laryngeal nerve, causing vocal cord
paralysis. Adenocarcinoma is more peripheral. Small cell lung cancer is also central but typically
presents with rapid growth and paraneoplastic syndromes; it is less likely to cause chest wall
invasion. Large cell carcinoma is a diagnosis of exclusion. Carcinoid tumors are slow-growing and
less aggressive.
,QUESTION 2
A 24-year-old woman with no significant medical history presents with acute onset of right
lower quadrant abdominal pain, nausea, and vomiting. She has a temperature of 38.2°C
(100.8°F). On examination, she has rebound tenderness and guarding in the right lower
quadrant. Urinalysis is normal. What is the most appropriate next step?
A. CT scan of the abdomen and pelvis with contrast
B. Transvaginal ultrasound
C. Diagnostic laparoscopy
D. Antibiotic therapy and observation
E. MRI of the abdomen
Correct Answer: A
Rationale: In a young woman with suspected appendicitis, CT of the abdomen and pelvis with
contrast is the most sensitive and specific imaging study to confirm the diagnosis and rule out
other causes (e.g., ovarian pathology). Transvaginal ultrasound is useful for gynecologic causes
but less sensitive for appendicitis. Diagnostic laparoscopy is invasive and not first-line.
Antibiotics alone are not definitive. MRI is rarely used acutely.
QUESTION 3
A 55-year-old man with hypertension and diabetes presents with a 3-day history of progressive
shortness of breath and orthopnea. He has a cough with pink, frothy sputum. On examination,
he has crackles up to the mid-lung fields, jugular venous distension, and lower extremity
edema. Blood pressure is 160/95 mmHg, heart rate 110 bpm. An ECG shows sinus tachycardia
with nonspecific ST-T changes. Which of the following is the most appropriate initial treatment?
A. Furosemide IV
B. Nitroglycerin sublingual
C. Oxygen and morphine
D. Lisinopril oral
E. Digoxin IV
Correct Answer: A
Rationale: This patient presents with acute pulmonary edema due to heart failure with fluid
overload. The initial treatment is to reduce preload with loop diuretics such as IV furosemide.
Nitroglycerin can help reduce preload and afterload but is not the primary initial agent. Oxygen
,and morphine are supportive but do not remove fluid. Lisinopril is a long-term therapy. Digoxin
is not first-line for acute pulmonary edema.
QUESTION 4
A 32-year-old woman presents with a 6-month history of fatigue, weight gain, cold intolerance,
and constipation. Physical examination reveals a bradycardia, dry skin, and delayed deep tendon
reflexes. Laboratory studies show TSH 12.5 mIU/L (normal 0.4–4.0), free T4 0.5 ng/dL (normal
0.8–1.8). Anti-thyroid peroxidase antibodies are positive. Which of the following is the most
appropriate treatment?
A. Levothyroxine 25 mcg daily
B. Levothyroxine 50 mcg daily
C. Liothyronine 25 mcg daily
D. Methimazole 5 mg daily
E. Radioactive iodine ablation
Correct Answer: B
Rationale: This is classic primary hypothyroidism due to Hashimoto thyroiditis. The starting
dose of levothyroxine in a young, otherwise healthy patient is approximately 1.6 mcg/kg/day,
typically 50–100 mcg daily. A dose of 25 mcg is too low. Liothyronine (T3) is not standard.
Methimazole and radioactive iodine are used for hyperthyroidism.
QUESTION 5
A 70-year-old man with a history of prostate cancer treated with radiation 5 years ago presents
with new-onset lower back pain and difficulty walking. He has had 10-pound weight loss over
the past 2 months. Neurologic examination reveals decreased strength in the lower extremities
and decreased sensation in the perineal area. Which of the following is the most appropriate
next step?
A. Lumbar spine MRI
B. CT of the abdomen and pelvis
C. Bone scan
D. Plain radiographs of the spine
E. Serum PSA
Correct Answer: A
, Rationale: The patient presents with back pain, lower extremity weakness, and saddle
anesthesia, suggestive of spinal cord compression (cauda equina syndrome) due to metastatic
prostate cancer. MRI of the entire spine is the imaging modality of choice to identify the level
and extent of compression and to guide urgent decompression. CT, bone scan, plain films, and
PSA are not as urgent or specific for cord compression.
QUESTION 6
A 45-year-old woman with a history of systemic lupus erythematosus (SLE) presents with acute-
onset severe headache, confusion, and generalized tonic-clonic seizures. Her blood pressure is
160/95 mmHg. Urinalysis shows proteinuria and red cell casts. Which of the following is the
most likely cause of her neurologic symptoms?
A. Posterior reversible encephalopathy syndrome (PRES)
B. CNS vasculitis
C. Hypertensive encephalopathy
D. Stroke
E. Seizure disorder
Correct Answer: B
Rationale: CNS vasculitis is a known complication of SLE, presenting with seizures, confusion,
and headache. The presence of active lupus nephritis (proteinuria, red cell casts) suggests
systemic lupus activity. PRES can occur with hypertension, but the blood pressure is not
extremely high. Hypertensive encephalopathy typically occurs with malignant hypertension.
Stroke is less likely without focal deficits. Seizure disorder is not the primary cause.
QUESTION 7
A 60-year-old man with a history of chronic obstructive pulmonary disease (COPD) presents
with progressive dyspnea and a productive cough. He has smoked 2 packs per day for 40 years.
On examination, he has a barrel chest, diminished breath sounds, and prolonged expiration.
Spirometry shows FEV1/FVC ratio of 0.55, FEV1 40% predicted. Which of the following is the
most appropriate long-term therapy to reduce exacerbations?
A. Inhaled corticosteroids alone
B. Long-acting beta-agonists (LABA) alone
C. LABA plus inhaled corticosteroid (ICS)
Clinical Vignettes in Internal Medicine, Surgery,
Pediatrics, Obstetrics & Gynecology, Psychiatry,
and Neurology for Comprehensive Board Review a
well detailed practice exam 2025/2026 graded A+
well written !!!
QUESTION 1
A 68-year-old man with a 50-pack-year smoking history presents with a 2-month history of
hoarseness and a nonproductive cough. He has lost 10 pounds unintentionally. Laryngoscopy
reveals a left vocal cord paralysis. Chest CT shows a 4-cm mass in the left upper lobe with chest
wall invasion. Which of the following is the most likely diagnosis?
A. Squamous cell carcinoma
B. Adenocarcinoma
C. Small cell lung cancer
D. Large cell carcinoma
E. Carcinoid tumor
Correct Answer: A
Rationale: Squamous cell carcinoma is strongly associated with smoking and often presents as
central masses that can invade the chest wall and recurrent laryngeal nerve, causing vocal cord
paralysis. Adenocarcinoma is more peripheral. Small cell lung cancer is also central but typically
presents with rapid growth and paraneoplastic syndromes; it is less likely to cause chest wall
invasion. Large cell carcinoma is a diagnosis of exclusion. Carcinoid tumors are slow-growing and
less aggressive.
,QUESTION 2
A 24-year-old woman with no significant medical history presents with acute onset of right
lower quadrant abdominal pain, nausea, and vomiting. She has a temperature of 38.2°C
(100.8°F). On examination, she has rebound tenderness and guarding in the right lower
quadrant. Urinalysis is normal. What is the most appropriate next step?
A. CT scan of the abdomen and pelvis with contrast
B. Transvaginal ultrasound
C. Diagnostic laparoscopy
D. Antibiotic therapy and observation
E. MRI of the abdomen
Correct Answer: A
Rationale: In a young woman with suspected appendicitis, CT of the abdomen and pelvis with
contrast is the most sensitive and specific imaging study to confirm the diagnosis and rule out
other causes (e.g., ovarian pathology). Transvaginal ultrasound is useful for gynecologic causes
but less sensitive for appendicitis. Diagnostic laparoscopy is invasive and not first-line.
Antibiotics alone are not definitive. MRI is rarely used acutely.
QUESTION 3
A 55-year-old man with hypertension and diabetes presents with a 3-day history of progressive
shortness of breath and orthopnea. He has a cough with pink, frothy sputum. On examination,
he has crackles up to the mid-lung fields, jugular venous distension, and lower extremity
edema. Blood pressure is 160/95 mmHg, heart rate 110 bpm. An ECG shows sinus tachycardia
with nonspecific ST-T changes. Which of the following is the most appropriate initial treatment?
A. Furosemide IV
B. Nitroglycerin sublingual
C. Oxygen and morphine
D. Lisinopril oral
E. Digoxin IV
Correct Answer: A
Rationale: This patient presents with acute pulmonary edema due to heart failure with fluid
overload. The initial treatment is to reduce preload with loop diuretics such as IV furosemide.
Nitroglycerin can help reduce preload and afterload but is not the primary initial agent. Oxygen
,and morphine are supportive but do not remove fluid. Lisinopril is a long-term therapy. Digoxin
is not first-line for acute pulmonary edema.
QUESTION 4
A 32-year-old woman presents with a 6-month history of fatigue, weight gain, cold intolerance,
and constipation. Physical examination reveals a bradycardia, dry skin, and delayed deep tendon
reflexes. Laboratory studies show TSH 12.5 mIU/L (normal 0.4–4.0), free T4 0.5 ng/dL (normal
0.8–1.8). Anti-thyroid peroxidase antibodies are positive. Which of the following is the most
appropriate treatment?
A. Levothyroxine 25 mcg daily
B. Levothyroxine 50 mcg daily
C. Liothyronine 25 mcg daily
D. Methimazole 5 mg daily
E. Radioactive iodine ablation
Correct Answer: B
Rationale: This is classic primary hypothyroidism due to Hashimoto thyroiditis. The starting
dose of levothyroxine in a young, otherwise healthy patient is approximately 1.6 mcg/kg/day,
typically 50–100 mcg daily. A dose of 25 mcg is too low. Liothyronine (T3) is not standard.
Methimazole and radioactive iodine are used for hyperthyroidism.
QUESTION 5
A 70-year-old man with a history of prostate cancer treated with radiation 5 years ago presents
with new-onset lower back pain and difficulty walking. He has had 10-pound weight loss over
the past 2 months. Neurologic examination reveals decreased strength in the lower extremities
and decreased sensation in the perineal area. Which of the following is the most appropriate
next step?
A. Lumbar spine MRI
B. CT of the abdomen and pelvis
C. Bone scan
D. Plain radiographs of the spine
E. Serum PSA
Correct Answer: A
, Rationale: The patient presents with back pain, lower extremity weakness, and saddle
anesthesia, suggestive of spinal cord compression (cauda equina syndrome) due to metastatic
prostate cancer. MRI of the entire spine is the imaging modality of choice to identify the level
and extent of compression and to guide urgent decompression. CT, bone scan, plain films, and
PSA are not as urgent or specific for cord compression.
QUESTION 6
A 45-year-old woman with a history of systemic lupus erythematosus (SLE) presents with acute-
onset severe headache, confusion, and generalized tonic-clonic seizures. Her blood pressure is
160/95 mmHg. Urinalysis shows proteinuria and red cell casts. Which of the following is the
most likely cause of her neurologic symptoms?
A. Posterior reversible encephalopathy syndrome (PRES)
B. CNS vasculitis
C. Hypertensive encephalopathy
D. Stroke
E. Seizure disorder
Correct Answer: B
Rationale: CNS vasculitis is a known complication of SLE, presenting with seizures, confusion,
and headache. The presence of active lupus nephritis (proteinuria, red cell casts) suggests
systemic lupus activity. PRES can occur with hypertension, but the blood pressure is not
extremely high. Hypertensive encephalopathy typically occurs with malignant hypertension.
Stroke is less likely without focal deficits. Seizure disorder is not the primary cause.
QUESTION 7
A 60-year-old man with a history of chronic obstructive pulmonary disease (COPD) presents
with progressive dyspnea and a productive cough. He has smoked 2 packs per day for 40 years.
On examination, he has a barrel chest, diminished breath sounds, and prolonged expiration.
Spirometry shows FEV1/FVC ratio of 0.55, FEV1 40% predicted. Which of the following is the
most appropriate long-term therapy to reduce exacerbations?
A. Inhaled corticosteroids alone
B. Long-acting beta-agonists (LABA) alone
C. LABA plus inhaled corticosteroid (ICS)
