USMLE Questions Bank

A 55-year-old man comes to the office because of a 4- to 6-week history of what he describes as "chest pounding" that worsens when he lies on his back. He also reports occasional episodes of nonexertional chest pain lasting 1 to 2 minutes. He is unable to further characterize the pain. He says that he has had moderate shortness of breath after walking three blocks, but he has not had nocturnal dyspnea. Medical history is remarkable for type 2 diabetes mellitus and gastroesophageal reflux disease. Current medications include simvastatin, metformin, esomeprazole, and 81-mg aspirin. The patient has smoked one pack of cigarettes daily for the past 35 years. Family history is remarkable for myocardial infarction in his father at age 58 years. The patient is 183 cm (6 ft) tall and weighs 91 kg (200 lb); BMI is 27 kg/m2. Temperature is 36.7°C (98.1°F), pulse is 88/min, respirations are 16/min, and blood pressure is 165/55 mm Hg. There is no jugular venous distention. Carotid pulses are brisk and bounding. Auscultation of the lungs discloses mild, diffuse wheezes. Cardiac examination discloses a point of maximal impulse that is displaced laterally. There is a soft S1 and S2; a grade 3/6 blowing murmur is audible at the lower left sternal border that extends through two-thirds of diastole. Systolic and diastolic bruits are heard over both femoral arteries. Results of laboratory studies are shown:
Serum
Cholesterol
Total 300 mg/dL
HDL 30 mg/dL
LDL 180 mg/dL
Triglycerides 190 mg/dL
Urea nitrogen 28 mg/dL
Creatinine 1.4 mg/dL

Blood
Hemoglobin 13.0 g/dL
WBC 10,500/mm3

ECG shows normal sinus rhythm and left ventricular hypertrophy. Chest x-ray shows an enlarged cardiac silhouette and prominent ascending aorta.
#Step3

A 43-year-old man comes to the office because of a 2-week history of fatigue and mild pain in his right armpit. He has not had fever or weight loss. Medical history is remarkable for type 2 diabetes mellitus and hypercholesterolemia. Medications are metformin, simvastatin, and aspirin. He is a social worker and frequently visits clients in homeless shelters. He lives alone with two dogs and a cat and has one male sexual partner. Vital signs are within normal limits. He appears well. Examination of the right upper extremity shows an erythematous axilla with a 4-cm, mobile, tender, nonfluctuant axillary lymph node and a tender, 1-cm epitrochlear lymph node. Abdominal examination shows no hepatosplenomegaly.
#Step2

A 20-year-old woman is brought to the urgent care center because of a 2-month history of progressive weakness of her arms. She also has a 1-week history of moderate back pain and headache. Her only medication is ibuprofen as needed for pain. Muscle strength is 3/5 in the upper extremities. Sensation to pinprick is decreased over the upper extremities. MRI of the spine shows a central syrinx in the cervical spinal cord.
#Step1

A 63-year-old man comes to the office because of a 10-minute episode of right eye blindness 2 days ago. The episode resolved spontaneously and there was no associated eye pain. Medical history is remarkable for hypertension and type 2 diabetes mellitus. Medications include hydrochlorothiazide, metoprolol, glipizide, simvastatin, and 81-mg aspirin. He is 183 cm (6 ft) tall and weighs 104 kg (229 lb); BMI is 31 kg/m2. Vital signs are within normal limits. Physical examination discloses pupils that are equal in size and reactive to light. Visual fields are intact. Visual acuity is 20/20 in both eyes with corrective lenses. Cardiac examination discloses a regular rate and rhythm with no murmurs. Neurologic examination discloses no abnormalities.
#Step3

Two days after admission to the hospital for treatment of a fractured femur and closed head injury sustained in a motor vehicle collision, an 8-year-old girl has a brief, generalized tonic-clonic seizure. CT scan of the head on admission disclosed no abnormalities. She has no history of serious illness. Oral acetaminophen was initiated for pain, and the patient underwent open reduction and internal fixation of the fracture. She receives no routine medications. Today, she appears drowsy but responds to questions appropriately. She is at the 55th percentile for height, weight, and BMI. Temperature is 36.8°C (98.2°F), pulse is 92/min, respirations are 24/min, and blood pressure is 106/64 mm Hg. Pulse oximetry on room air shows an oxygen saturation of 95%. Pupils are equal and reactive to light and accommodation. Ocular movements are full. Muscle strength is 5/5, and deep tendon reflexes are normal. Results of serum studies are shown: Na+ 122 mEq/L K+ 3.8 mEq/L Cl− 94 mEq/L HCO3− 24 mEq/L Glucose 80 mg/dL Calcium 8.8 mg/dL
#Step2

A 27-year-old woman comes to the emergency department because of a 1-hour history of severe shortness of breath. She has just returned from a cross-country flight. She has a history of borderline hypertension. Her temperature is 36.9°C (98.5°F), pulse is 113/min, respirations are 28/min, and blood pressure is 138/85 mm Hg. Physical examination shows that the right calf has an increased circumference compared with the left calf, and there is tenderness behind the right knee.
#Step1

A 12-year-old girl with a seizure disorder is brought to the emergency department 40 minutes after her aunt found her unconscious in her backyard. The aunt reports that the patient is visiting her for the summer. On arrival, the patient is awake but drowsy. She says she is embarrassed because she forgot to bring her anticonvulsant medication from home. She requests that you not call her mother "because she will yell and get angry." Temperature is 37.0°C (98.6°F), pulse is 74/min, respirations are 16/min, and blood pressure is 100/70 mm Hg. Physical examination shows no focal neurologic deficits. The patient requests that she receive one dose of carbamazepine now and that she be given a prescription to fill at the nearby pharmacy.
#Step3

A 39-year-old man comes to the office because of a 6-week history of mild fatigue and increased thirst and urination. During this time, he also has had a 6.8-kg (15-lb) weight loss despite no change in appetite. He is otherwise asymptomatic. He has no history of serious illness and takes no medications. He is 180 cm (5 ft 11 in) tall and weighs 61 kg (135 lb); BMI is 19 kg/m2. Temperature is 37.0°C (98.6°F), pulse is 80/min, respirations are 18/min, and blood pressure is 118/70 mm Hg. Examination shows no abnormalities. Results of laboratory studies are shown:
Serum
Na+ 135 mEq/L
K+ 4.2 mEq/L
Cl− 100 mEq/L
Urea nitrogen 25 mg/dL
Glucose 578 mg/dL

Blood
Hemoglobin A1c 10.7%

#Step2