Usmle step 1 Sample Test Questions
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- USMLE Step 1 Test Question Formats
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USMLE Step 1 Sample Test Questions A Joint Program of the Federation of State Medical Boards of the United States, Inc., and the National Board of Medical Examiners ®
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This booklet updated March 2016. Copyright © 2016 by the Federation of State Medical Boards of the United States, Inc. (FSMB), and the National Board of Medical Examiners ® (NBME ® ). All rights reserved. Printed in the United States of America. The United States Medical Licensing Examination (USMLE ® ) is a joint program of the FSMB and the NBME. 2
CONTENTS
USMLE Step 1 Test Question Formats ……………………………….. 3 Introduction to USMLE Step 1 Sample Test Questions ……………… 4 Normal Laboratory Values …………………………………………….. 5 USMLE Step 1 Sample Test Questions……………………………….. 7 Answer Form for USMLE Step 1 Sample Test Questions……………. 44 Answer Key for USMLE Step 1 Sample Test Questions……………… 45
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USMLE Step 1 Test Question Formats
Single-Item Questions A single patient-centered vignette is associated with one question followed by four or more response options. The response options are lettered (ie, A, B, C, D, E). A portion of the questions involves interpretation of graphic or pictorial materials. You are required to select the best answer to the question. Other options may be partially correct, but there is only ONE BEST answer. This is the traditional, most frequently used multiple-choice question format on the examination.
The following are strategies for answering one-best-answer items:
Read each patient vignette and question carefully. It is important to understand what is being asked.
Try to generate an answer and then look for it in the response option list.
Alternatively, read each response option carefully, eliminating those that are clearly incorrect.
Of the remaining options, select the one that is most correct.
If unsure about an answer, it is better to guess since unanswered questions are automatically counted as wrong answers. Example Item
A 32-year-old woman with type 1 diabetes mellitus has had progressive renal failure over the past 2 years. She has not yet started dialysis. Examination shows no abnormalities. Her hemoglobin concentration is 9 g/dL, hematocrit is 28%, and mean corpuscular volume is 94 μm 3 . A blood smear shows normochromic, normocytic cells. Which of the following is the most likely cause?
(A) Acute blood loss (B)
Chronic lymphocytic leukemia (C)
Erythrocyte enzyme deficiency (D)
Erythropoietin deficiency (E)
Immunohemolysis (F)
Microangiopathic hemolysis (G)
Polycythemia vera (H)
Sickle cell disease (I)
Sideroblastic anemia (J)
β-Thalassemia trait
(Answer: D) NOTE: Some item types that appear on the Step 1 examination are NOT depicted in the sample items provided in this booklet, ie, items with multimedia features, such as audio. Also, when additional item formats are added to the exam, notice will be provided at the USMLE Web site: www.usmle.org. You must monitor the Web site to stay informed about the types of items that occur in the exam, and must practice with the downloadable sample test items available on the USMLE Web site to be fully prepared for the examination.
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Introduction to USMLE Step 1 Sample Test Questions
The following pages include 117 sample test questions. Most of these questions are the same as those you install on your computer from the USMLE Web site. Please note that reviewing the sample questions as they appear on pages 7-43 is not a substitute for practicing with the test software. You should download and run the Step 1 tutorial and practice test items that are provided on the USMLE website well before your test date. The sample materials available at the USMLE Web site include additional items and item formats that do not appear in this booklet, such as items with associated audio or video findings. You should become familiar with all item formats that will be used in the actual examination.
individual examinations. In the actual examination, questions will be presented in random order; they will not be grouped according to specific content. The questions will be presented one at a time in a format designed for easy on-screen reading, including use of the Normal Laboratory Values Table (included here on pages 5 and 6) and some pictorials. Photographs, charts, and x-rays in this booklet are not of the same quality as the pictorials used in the actual examination. In addition, you will be able to adjust the brightness and contrast of pictorials on the computer screen.
To take the following sample test questions as they would be timed in the actual examination, you should allow a maximum of 1 hour for each 40-item block, and a maximum of 55 minutes, 30 seconds for the 37-item block, for a total of 2 hours, 55 minutes, 30 seconds. Please note that the third block has 37 items instead of 40 because the multimedia items have been removed, and the recommended time to complete the block has been adjusted accordingly. Please be aware that most examinees perceive the time pressure to be greater during an actual examination. All examinees are strongly encouraged to practice with the downloadable version to become familiar with all item formats and exam timing.
An answer form for recording answers is provided on page 44. An answer key is provided on page 45. In the actual examination, answers will be selected on the screen; no answer form will be provided.
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LABORATORY VALUES * Included in the Biochemical Profile (SMA-12)
REFERENCE RANGE SI REFERENCE INTERVALS BLOOD, PLASMA, SERUM * Alanine aminotransferase (ALT), serum ................. 8-20 U/L ................................................... 8-20 U/L Amylase, serum ....................................................... 25-125 U/L ................................................ 25-125 U/L * Aspartate aminotransferase (AST), serum .............. 8-20 U/L .................................................... 8-20 U/L Bilirubin, serum (adult) Total // Direct ................... 0.1-1.0 mg/dL // 0.0-0.3 mg/dL ................ 2-17 μmol/L // 0-5 μmol/L * Calcium, serum (Ca 2+ ) ............................................ 8.4-10.2 mg/dL .......................................... 2.1-2.8 mmol/L * Cholesterol, serum .................................................. Rec:<200 mg/dL ...................................... <5.2 mmol/L Cortisol, serum ........................................................ 0800 h: 5-23 μg/dL // 1600 h: 3-15 μg/dL 138-635 nmol/L // 82-413 nmol/L 2000 h: < 50% of 0800 h ........................... Fraction of 0800 h: < 0.50 Creatine kinase, serum ............................................ Male: 25-90 U/L ....................................... 25-90 U/L Female: 10-70 U/L ................................... 10-70 U/L * Creatinine, serum .................................................... 0.6-1.2 mg/dL ........................................... 53-106 μmol/L Electrolytes, serum Sodium (Na + ) ........................................................ 136-145 mEq/L ......................................... 136-145 mmol/L * Potassium (K + ) ...................................................... 3.5-5.0 mEq/L ........................................... 3.5-5.0 mmol/L Chloride (Cl – ) ........................................................ 95-105 mEq/L .......................................... 95-105 mmol/L Bicarbonate (HCO 3 – ) ............................................. 22-28 mEq/L ............................................ 22-28 mmol/L Magnesium (Mg 2+ ) ................................................ 1.5-2.0 mEq/L ........................................... 0.75-1.0 mmol/L Estriol, total, serum (in pregnancy) 24-28 wks // 32-36 wks ......................................... 30-170 ng/mL // 60-280 ng/mL ................ 104-590 nmol/L // 208-970 nmol/L 28-32 wks // 36-40 wks ......................................... 40-220 ng/mL // 80-350 ng/mL ................ 140-760 nmol/L // 280-1210 nmol/L Ferritin, serum ......................................................... Male: 15-200 ng/mL ................................ 15-200 μg/L Female: 12-150 ng/mL ............................. 12-150 μg/L Follicle-stimulating hormone, serum/plasma ......... Male: 4-25 mIU/mL ................................. 4-25 U/L Female: premenopause 4-30 mIU/mL ...... 4-30 U/L midcycle peak 10-90 mIU/mL ............... 10-90 U/L postmenopause 40-250 mIU/mL ........... 40-250 U/L Gases, arterial blood (room air) pH ......................................................................... 7.35-7.45 .................................................. [H + ] 36-44 nmol/L P CO 2 ...................................................................... 33-45 mm Hg ............................................ 4.4-5.9 kPa P
O 2 ........................................................................ 75-105 mm Hg .......................................... 10.0-14.0 kPa * Glucose, serum ........................................................ Fasting: 70-110 mg/dL ............................. 3.8-6.1 mmol/L 2-h postprandial: < 120 mg/dL ................ < 6.6 mmol/L Growth hormone - arginine stimulation .................. Fasting: < 5 ng/mL ................................... < 5 μg/L provocative stimuli: > 7 ng/mL ............. > 7 μg/L Immunoglobulins, serum IgA ....................................................................... 76-390 mg/dL ............................................ 0.76-3.90 g/L IgE ........................................................................ 0-380 IU/mL ............................................ 0-380 kIU/L IgG ....................................................................... 650-1500 mg/dL ....................................... 6.5-15 g/L IgM ....................................................................... 40-345 mg/dL ........................................... 0.4-3.45 g/L Iron ......................................................................... 50-170 μg/dL ............................................ 9-30 μmol/L Lactate dehydrogenase, serum ................................ 45-90 U/L .................................................. 45-90 U/L Luteinizing hormone, serum/plasma ...................... Male: 6-23 mIU/mL ................................. 6-23 U/L Female: follicular phase 5-30 mIU/mL .... 5-30 U/L midcycle 75-150 mIU/mL ...................... 75-150 U/L postmenopause 30-200 mIU/mL ........... 30-200 U/L Osmolality, serum ................................................... 275-295 mOsmol/kg H 2 O ......................... 275-295 mOsmol/kg H 2 O Parathyroid hormone, serum, N-terminal ............... 230-630 pg/mL ......................................... 230-630 ng/L * Phosphatase (alkaline), serum (p-NPP at 30°C) ..... 20-70 U/L ................................................. 20-70 U/L * Phosphorus (inorganic), serum ................................ 3.0-4.5 mg/dL ........................................... 1.0-1.5 mmol/L Prolactin, serum (hPRL) ......................................... < 20 ng/mL ............................................... < 20 μg/L * Proteins, serum Total (recumbent) ................................................. 6.0-7.8 g/dL .............................................. 60-78 g/L Albumin ................................................................ 3.5-5.5 g/dL ............................................... 35-55 g/L Globulin ............................................................... 2.3-3.5 g/dL ............................................... 23-35 g/L Thyroid-stimulating hormone, serum or plasma ..... 0.5-5.0 μU/mL .......................................... 0.5-5.0 mU/L Thyroidal iodine ( 123
I) uptake .................................. 8%-30% of administered dose/24 h .......... 0.08-0.30/24 h Thyroxine (T 4 ), serum ............................................. 5-12 μg/dL ................................................ 64-155 nmol/L Triglycerides, serum ................................................ 35-160 mg/dL ............................................ 0.4-1.81 mmol/L Triiodothyronine (T 3 ), serum (RIA) ....................... 115-190 ng/dL .......................................... 1.8-2.9 nmol/L Triiodothyronine (T 3 ) resin uptake .......................... 25%-35% .................................................. 0.25-0.35 * Urea nitrogen, serum .............................................. 7-18 mg/dL ............................................... 1.2-3.0 mmol/L * Uric acid, serum ...................................................... 3.0-8.2 mg/dL ........................................... 0.18-0.48 mmol/L 6
LABORATORY VALUES (continued from previous page) REFERENCE RANGE SI REFERENCE INTERVALS BODY MASS INDEX (BMI) Body mass index ...................................................... Adult: 19-25 kg/m 2
CEREBROSPINAL FLUID Cell count ................................................................. 0-5/mm 3 ............................................................ 0-5 x 10 6 /L
Chloride ................................................................... 118-132 mEq/L ................................................ 118-132 mmol/L Gamma globulin ....................................................... 3%-12% total proteins ...................................... 0.03-0.12 Glucose ................................................................... 40-70 mg/dL .................................................... 2.2-3.9 mmol/L Pressure ................................................................... 70-180 mm H 2 O .............................................. 70-180 mm H 2 O Proteins, total .......................................................... <40 mg/dL ...................................................... <0.40 g/L HEMATOLOGIC Bleeding time (template) ......................................... 2-7 minutes ....................................................... 2-7 minutes Erythrocyte count ..................................................... Male: 4.3-5.9 million/mm 3 ............................... 4.3-5.9 x 10 12 /L
Female: 3.5-5.5 million/mm 3 ............................ 3.5-5.5 x 10 12 /L
Erythrocyte sedimentation rate (Westergren)........... Male: 0-15 mm/h ............................................. 0-15 mm/h Female: 0-20 mm/h .......................................... 0-20 mm/h Hematocrit ............................................................... Male: 41%-53% ............................................... 0.41-0.53 Female: 36%-46% ............................................ 0.36-0.46 Hemoglobin A 1c ....................................................... < 6% ................................................................. < 0.06 Hemoglobin, blood................................................... Male: 13.5-17.5 g/dL ....................................... 2.09-2.71 mmol/L Female: 12.0-16.0 g/dL .................................... 1.86-2.48 mmol/L Hemoglobin, plasma ................................................ 1-4 mg/dL ......................................................... 0.16-0.62 mmol/L Leukocyte count and differential Leukocyte count ..................................................... 4500-11,000/mm 3 ............................................. 4.5-11.0 x 10 9 /L
Segmented neutrophils ......................................... 54%-62% ......................................................... 0.54-0.62 Bands.................................................................... 3%-5% ............................................................. 0.03-0.05 Eosinophils .......................................................... 1%-3% ............................................................. 0.01-0.03 Basophils .............................................................. 0%-0.75% ......................................................... 0-0.0075 Lymphocytes ....................................................... 25%-33% .......................................................... 0.25-0.33 Monocytes ........................................................... 3%-7% ............................................................. 0.03-0.07 Mean corpuscular hemoglobin ................................. 25.4-34.6 pg/cell .............................................. 0.39-0.54 fmol/cell Mean corpuscular hemoglobin concentration ......... 31%-36% Hb/cell ............................................ 4.81-5.58 mmol Hb/L Mean corpuscular volume ....................................... 80-100 μm 3 ....................................................... 80-100 fL Partial thromboplastin time (activated) ................... 25-40 seconds ................................................... 25-40 seconds Platelet count ............................................................ 150,000-400,000/mm 3 ...................................... 150-400 x 10 9 /L
Prothrombin time ..................................................... 11-15 seconds ................................................... 11-15 seconds Reticulocyte count.................................................... 0.5%-1.5% ........................................................ 0.005-0.015 Thrombin time ......................................................... <2 seconds deviation from control .................. <2 seconds deviation from control Volume Plasma ................................................................... Male: 25-43 mL/kg ........................................... 0.025-0.043 L/kg Female: 28-45 mL/kg ....................................... 0.028-0.045 L/kg Red cell .................................................................. Male: 20-36 mL/kg .......................................... 0.020-0.036 L/kg Female: 19-31 mL/kg ...................................... 0.019-0.031 L/kg SWEAT Chloride.................................................................... 0-35 mmol/L .................................................... 0-35 mmol/L URINE Calcium ................................................................... 100-300 mg/24 h .............................................. 2.5-7.5 mmol/24 h Chloride.................................................................... Varies with intake ............................................. Varies with intake Creatinine clearance ................................................. Male: 97-137 mL/min Female: 88-128 mL/min Estriol, total (in pregnancy) 30 wks .................................................................... 6-18 mg/24 h .................................................... 21-62 μmol/24 h 35 wks .................................................................... 9-28 mg/24 h .................................................... 31-97 μmol/24 h 40 wks .................................................................... 13-42 mg/24 h .................................................. 45-146 μmol/24 h 17-Hydroxycorticosteroids ...................................... Male: 3.0-10.0 mg/24 h .................................... 8.2-27.6 μmol/24 h Female: 2.0-8.0 mg/24 h................................... 5.5-22.0 μmol/24 h 17-Ketosteroids, total ............................................... Male: 8-20 mg/24 h .......................................... 28-70 μmol/24 h Female: 6-15 mg/24 h....................................... 21-52 μmol/24 h Osmolality ............................................................... 50-1400 mOsmol/kg H 2 O
Potassium ................................................................ Varies with diet ................................................ Varies with diet Proteins, total .......................................................... <150 mg/24 h .................................................. <0.15 g/24 h Sodium .................................................................... Varies with diet ................................................ Varies with diet Uric acid ................................................................... Varies with diet ................................................ Varies with diet 7
USMLE STEP 1 SAMPLE TEST QUESTIONS
BLOCK 1, ITEMS 1-40
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An otherwise healthy 26-year-old woman has had petechiae on her legs during the last 24 hours. Laboratory studies show: Hemoglobin 13.1 g/dL Hematocrit 39.7% Leukocyte count 8500/mm 3
Neutrophils 65%
Lymphocytes 30%
Monocytes 5%
Mean corpuscular volume 82.2 μm
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Platelet count 20,000/mm 3
A peripheral blood smear shows normal red cell morphology; a bone marrow smear shows mature megakaryocytic hyperplasia. Which of the following is the most likely diagnosis?
(A) Acute megakaryocytic leukemia (B) Acute myelogenous leukemia (C) Aplastic anemia (D) Immune thrombocytopenic purpura (E) Epstein-Barr viral infection (F) Papovavirus infection (G) Thrombotic thrombocytopenic purpura
An 83-year-old man comes to the physician because of a 2-day history of constant severe pain of his right knee. He had a similar episode 1 year ago that subsided in 1 month without treatment. His temperature is 37.7°C (99.9°F). Examination of the right knee shows swelling; there is no overlying warmth or apparent deformity. Palpation and movement of the right knee produce pain; range of motion is limited by pain. An x-ray of the right knee shows large subchondral cysts and linear meniscal calcifications. Examination of fluid obtained on joint aspiration of the knee shows:
Amount
2 mL Appearance cloudy with diminished viscosity and crystals present Leukocyte count 49,000/mm 3
Segmented neutrophils 65%
Lymphocytes 35%
His pain is moderately improved after the joint aspiration and injection of corticosteroids. Treatment with ibuprofen during the next week significantly improves his condition. Histologic examination of the joint fluid aspirate is most likely to show which of the following types of crystals?
(A) Calcium pyrophosphate (B) Cholesterol (C) Oxalic acid (D) Potassium phosphate
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3. A 16-year-old boy comes to the physician because of a rash on his left inner thigh that first appeared 2 days after he returned from a hunting trip with friends in Minnesota. A photograph of the rash is shown. Without treatment, this patient is at increased risk for which of the following?
(A) Carditis (B) Glomerulonephritis (C) Hepatitis (D) Pancreatitis (E) Thrombocytopenia
A previously healthy 24-year-old woman comes to the emergency department because of fever and diarrhea for the past 5 days. She has more than 10 bowel movements daily, accompanied by abdominal cramping and the passage of mucus and blood clots. She has not traveled out of the United States. Tympanic temperature is 39°C (102.2°F). Bowel sounds are increased. Test of stool for occult blood is positive. Which of the following is the most likely causal organism?
(A) Bacillus cereus (B) Cryptosporidium parvum (C) Giardia lamblia (D) Shigella sonnei (E) Staphylococcus aureus
An 84-year-old woman who resides in an assisted living facility is brought to the emergency department because of fever and cough for 1 week. The cough has been productive of foul-smelling, yellow-green sputum for 24 hours. She has a 2-year history of dementia, Alzheimer type. Her temperature is 38.5°C (101.3°F), pulse is 80/min, respirations are 20/min, and blood pressure is 116/66 mm Hg. Coarse inspiratory crackles are heard over the right lung field. Laboratory studies show a leukocyte count of 13,500/mm 3 (72% segmented neutrophils, 8% bands, 1% eosinophils, 16% lymphocytes, and 3% monocytes). A CT scan shows a cavitary lesion in the superior segment of the right lower lobe. The lesion has a thick wall and an irregular peripheral margin; there is no displacement of the adjacent bronchovascular bundle. Which of the following is the most likely cause of the lung lesion in this patient?
(A) Antecedent viral pneumonia (B) Aspiration of gastric contents (C) Bronchial obstruction by metastatic carcinoma (D) Lung infarction secondary to arterial thrombosis (E) Primary carcinoma of the lung (F) Secondary infection of a congenital lung cyst (G) Septic embolism from an extrapulmonary site
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A 55-year-old man comes to the physician because of a 2-week history of recurrent, widespread blister formation. Physical examination shows lesions that are most numerous in the flexural areas including the axillae and groin. The blisters do not break easily, and there are no oral lesions. These blisters are most likely the result of adhesion failure involving which of the following?
(A) Basement membrane (B) Dermal papillae (C) Langerhans cells (D) Melanocytes (E) Merkel cells
A 59-year-old man is brought to the emergency department because of a 4-day history of nausea, vomiting, and diarrhea. He also has been confused and agitated during this period. He has a history of mild hypertension. His current medication is a diuretic. His temperature is 37°C (98.6°F), pulse is 108/min, respirations are 26/min, and blood pressure is 70/47 mm Hg. Physical examination shows delayed capillary refill of the lips and nail beds and cool extremities. His oxyhemoglobin saturation in a central vein is 60% (N=70–75). These findings are most consistent with which of the following types of shock?
(B) Distributive (C) Hypovolemic (D) Obstructive (E) Septic
A 7-month-old infant is brought to the physician's office because of poor weight gain despite large food intake. He has had two episodes of pneumonia and has frequent bulky stools. He coughs frequently. X-rays of the lungs show increased markings and hyperinflation. Trypsin is absent in a fresh stool sample, and the fat content is increased. Which of the following is the most likely cause of this infant's disorder?
(A) Autoimmune disorder (B) Defective ion transport at epithelial surfaces (C) Disaccharidase deficiency (D) Inability to synthesize apolipoprotein B (E) Villous atrophy of the jejunum
A 65-year-old man is brought to the emergency department 30 minutes after the onset of acute chest pain at rest that radiates to his left arm. His pulse is 110/min, respirations are 20/min, and blood pressure is 150/80 mm Hg. Physical examination shows diaphoresis. The lungs are clear to auscultation of the chest. An ECG shows a new left bundle branch block. The tentative diagnosis of acute coronary syndrome is made. Treatment with oxygen via nasal cannula, oral aspirin, and sublingual nitroglycerin, followed by an intravenous dose of a β-adrenergic blocker, is begun. Which of the following sets of changes is most likely to occur in this patient after the intravenous dose?
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