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USMLE Step 1 for International clients, Quizzes of Medicine

Duke University Medicine

USMLE Step 1 for International clientsUSMLE Step 1 for International clientsUSMLE Step 1 for International clientsUSMLE Step 1 for International clientsUSMLE Step 1 for International clientsUSMLE Step 1 for International clientsUSMLE Step 1 for International clients

Typology: Quizzes

2025/2026

Available from 04/09/2026

elias-munyiri 🇺🇸

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USMLE Step 1

Heterophile ab NEGATIVE Mono-like syndromes

*CMV

HHV-6

HIV

Toxoplasmosis

Wernicke's Aphasia

-word salad: well-articulated, nonsensical speech paired with lack of lang comprehension

-aud association cortex: post part of sup temporal gyrus

- supplied by MCA

Congenital Deficiency of Propionyl CoA Carboxylase

-prevents conversion of propionyl CoA to methylmalonyl CoA

-propionyl CoA derived from= val, ile, met, thr, odd # FA, cholesterol side chains

-Propionic Acidemia: poor feeding, vomiting, hypotonia, lethargy, dehydration, anion gap

acidosis

Down Synd Comorbidities

Neuro: MR, early onset Alzheimer's

Cardio: complete AV septal defect, VSD, ASD

GI: duodenal atresia, hirschprung disease

Endo: hypothyroid, DM1, obesity

Heme: ALL (> 5 yo) and AML (<5 yo)

Rheumatology: atlantoaxial stability

MCC of Hypoglycemia in EtOH-ics

Thiamine def= suppression of GNG (pyruvate DH) and TCA cyle (alpha-KG DH)

MCC of Hypoglycemia in advanced renal insuff

impaired clearance of insulin

Avoid Nitrates in Hypertrophic Cardiomyopathy bc...

Nitrates decrease preload, which will increase the LV outflow tract... BUT since the ventricle

is abnormally shaped, there is an outflow obstruction

Mets through BM

Clonal proliferation of cells can invade/ metastasize*

1. malignant cells to lose their cell-to-cell adhesion molecules (cadherins)

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USMLE Step 1

Heterophile ab NEGATIVE Mono-like syndromes *CMV HHV- 6 HIV Toxoplasmosis Wernicke's Aphasia

word salad: well-articulated, nonsensical speech paired with lack of lang comprehension
aud association cortex: post part of sup temporal gyrus
supplied by MCA Congenital Deficiency of Propionyl CoA Carboxylase
prevents conversion of propionyl CoA to methylmalonyl CoA
propionyl CoA derived from= val, ile, met, thr, odd # FA, cholesterol side chains
Propionic Acidemia: poor feeding, vomiting, hypotonia, lethargy, dehydration, anion gap acidosis Down Synd Comorbidities Neuro: MR, early onset Alzheimer's Cardio: complete AV septal defect, VSD, ASD GI: duodenal atresia, hirschprung disease Endo: hypothyroid, DM1, obesity Heme: ALL (> 5 yo) and AML (<5 yo) Rheumatology: atlantoaxial stability MCC of Hypoglycemia in EtOH-ics Thiamine def= suppression of GNG (pyruvate DH) and TCA cyle (alpha-KG DH) MCC of Hypoglycemia in advanced renal insuff impaired clearance of insulin Avoid Nitrates in Hypertrophic Cardiomyopathy bc... Nitrates decrease preload, which will increase the LV outflow tract... BUT since the ventricle is abnormally shaped, there is an outflow obstruction Mets through BM Clonal proliferation of cells can invade/ metastasize*

malignant cells to lose their cell-to-cell adhesion molecules (cadherins)

cell receptors to attach to laminin (a glycoprotein) in the basement membrane and to release metalloproteinases (e.g., collagenases, stromelysins, gelatinases) to degrade the basement membrane and other enzymes to degrade the interstitial connective tissue- tissue inhibitors of metalloproteinases neutralize these tumor-produced enzymes and limit the degree of invasion
cell receptors to attach to bronectin and other proteins in the extracellular matrix (ECM) and to break it down
malignant cells to produce cytokines that stimulate locomotion, so that they can move through basement membranes and the intracellular and extracellular matrices Bicuspid Aortic Valve Commonly presents in young, asymptomatic patient with soft systolic ejection at right 2nd ICS

can cause aortic regurg MCC of Vaginal Candidiasis

Abx use= reduces lactobacilli pop
High estrogen levels- preg
System corticosteroid therapy
Uncontrolled DM
Immunosuppression, including HIV Drug causes of SIADH

Carbamazepine
Cyclophosphamide
SSRI MC Ankle Sprain due to inversion of plantar-flexed foot
Ant Talofibular Lig dmg
ecchymosis at the ant-lat aspect of the ankle Upper Brachial Plexus Injury
Musculocutaneous and Suprascapular N.
dystocia mc in neonates; severe trauma mc in adults
should adduction, elbow extension, and forearm pronation Patent foramen ovale
failure of septum primum and septum secundum to fuse after birth
can lead to paradoxical emboli Ventricular Septal Defect

S. epidermidis

coag neg
novobiocin sens
infective endocarditis and infective arthritis in prosthetic pts Asymptomatic heart defect in turner's synd
nonstenotic bicuspid aortic valve
early systolic , high frequency click over right second IC space Cardiac Changes w/ Normal Aging
decreased left ventricular chamber size
shortened base- to- apex dimension
ventricular septum becomes sigmoid and shape, with basilar portion bulging into LV outflow tract
atrophy of myocardium causes increased interstitial connective tissue, often with concomitant extracellular amyloid deposition
lipofucin pigment accumulation within cardiomyocytes ARDS Characterized by the development of hypoxemia and bilateral pulmonary infiltrates in the absence of heart failure
begins with initial injury of pul alveoli (smoke inhal) or pul endothelium (sepsis) which leads to the recruitment of neutrophils- this worsens the situation and leads to intraalveolar accumulation and hyaline membrane formation
decreased lung compliance, increased work of breathing, worsened V/Q mismatch, and normal PCWP Renal Artery Stenosis (histo) medial fibroplasia, absent internal elastic lamina in areas of aneurysmal dilation Paget's Disease associate Bone Tm OSTEOSARCOMA! arising from tibia, femur, humerus, and other bones
pain doesnt resolve with OTC analgesics DNA Laddering (Gel Electrophoresis)
DNA fragments in multiples of 180 bp each
sensitive indicator of APOPTOSIS
laddering done by specific endonucleases during haryorrhexis, cleaving DNA at interucleosomal linker regions
this is not seen in cancer cells, since they evade apoptosis

Warburg Effect malignant cells undergo high rates of glycolysis to produce macromolecules necessary to sustain rapid cellular growth Risk Factors of Endometritis

C-section delivery
chorioamnionitis
group B strep colonization
intrauterine instrumentation
preterm delivery
prolonged labor
prolonged ruptured membranes
retained products of conception SIGNS AND SX OF POSTPARTUM ENDOMETRITIS
fever
leukocytosis
uterine tenderness
foul smelling vaginal discharge Metabolic derangements assoc with DKA metabolic acidosis, ketonemia, hyperglycemia, hyperkalemia, hyponatremia
hyperammonemia can be observed due to muscle degradation Pulmonary Embolism V/Q Mismatch, causes hypoxemia that increases ventilation and HR via a chemoreceptor reflex
hypocapnia b/c hypervent, but unable to compensate for hypoxemia
resp alkylosis= increased ph and decreased PaCO Acanthosis Nigracans
Obesity/ insulin resistance
Malignancy of GI or Lungs Congenital Pyloric Stenosis
thickening of stomach wall, hypertrophy of smooth muscle pyloric stenosis
palpable olive mass- epigastric region
nonbilious projectile vomiting at 2-6 weeks of age
assoc w/ Macrolides
hypokalemia, hypochloremic, metab alkalosis

inhib Ca2+ conductance
inhib transmitter release neonatal intravascular hemorrhage
mc in fragile germinal matrix
inc freq with decreased age and birth wt
mc complication would be long term neurodev impairment (alt consciousness, hypotonia, dec spont mvmnt)
s/sx of bleed: bulging ant frontanelle, hypotension, decerebrate posturing, tonic-clonic seizures, irreg respirations, coma Acute Rheumatic fever
endemic in dev countries
molecular mimicry: anti group a strep ab attack host antigens on cardiac and neuronal tissue approx 2-4 weeks post acute pharyngitis (aka cross reactivity of ab against bacterial and host antigens)
acute/subacute: migratory arthritis, pancarditis, Sydenham chorea
Chr: mitral regurg/ stenosis
tx: PCN Spironolactone + HF improve survival of CHF pts with low LV ejection fraction
block aldosterone's effect on heart and decrease fibrosis and ventricular remodeling
used with ace-inhib and beta-blockers Common S/E of Thiazide Diuretics acute kidney injury, decreased Na+ and K+, hyperuricemia/ acute gout, elevated glu and cholesterol levels Common S/E of ACE-Inhib cough, angioedema, inc K+ CCB (diphenhydropine) S/E periph edema, dizziness/ lightheadedness Beta Blocker S/E bronchospasm, bradycardia, fatigue, sexual dysfunction HTN and at risk for Osteoporosis THIAZIDES! increased bone mineral density b/c increase in Ca2+ abs in DCT Methylmalonyl-CoA mutase Def

- AR

increased urine: methylmalonic acid and propionic acid
hyperammonemia, ketotic hypoglycemia, and metab acidosis
newborns present with lethargy, vomiting, and tachypnea TCA Effect on Cardiac Na+ Channel BLOCKS cardiac fast Na+ channels= QT and QRS prolongation and arrhythmias
treated with Sodium Bicarb MC Complication post Subarachnoid Hemorrhage SAH sx: thunderclap ha, confusion, fever, nuchal rigidity MC Compl: VASOSPASM!
vessels surrounding ruptured aneurysm
cerebral ischemia and new onset confusion and/or focal neuro deficits (paresthesia, weakness, etc) 4-12 days post SAH
mech of vasospasm is related to impaired brain autoreg
not seen on CT, need transcranial color doppler
Nimodipine prescribed to prevent vasospasm post-SAH Most Serious Compl of SAH REBLEED!
sudden dev of severe confusion, HA, N/V, decreased consciousness, focal neuro deficits
seen on CT t(8;14) Burkitt lymphoma (c-myc activation)
cmyc is an oncogene
very aggressive, rapid proliferation of cell growth t(9;22) aka Philadelphia chromosome CML (BCR-ABL hybrid), rarely ALL
constitutive expression of tyrosine kinase
poor prognosis when expressed in ALL t(11;14) Mantle cell lymphoma (cyclin D1 activation)
cyclin D1 is a cell cycle regulator
this translocation continuously allows cells to go on in cell cycle without stopping/ apoptosis t(14;18)

M spike on serum protein electrophoresis
Ig light chains in urine (Bence Jones protein)
Activated IgG prod by plasma cells by IL-6, may lead to proteasome inhib
Rouleaux formation (RBCs stacked like poker chips in blood smear) CO Poisoning Normal PO2 (dissolved O2) Decreased %sat of Hb Decreased total O2 content = makes Fe2+ into Fe3+(ferric), leading to the formation of methemoglobin which cannot bind to O2- this causes a left shift on the saturation curve- methemoglobin will present with cyanosis causes dusky discoloration in skin Pure Red Cell Aplasia (PRCA)
Inhib of erythroid precursors and progenitors by IgG autoantibodies or cytotoxic T cells
Marrow failure characterized by hypoplasia of erythroid elements but normal granulopoiesis and thrombopoiesis
Assoc with thyoma, lymphocytic leukemias, and parvovirus B19 infection Asthma Dec FEV1/ FVC Exp wheeze Caused by env and genetics Chr Eosinophil Bronch: IL-5 by TH2 cells MPB= bronch epith dmg- mc in exercise induced asthma Cause of LVHF shortness of breath Impaired diastolic return of Pul v. because high end diastolic pressure causes an increase in hydrostatic pressure and transudate leaks out into the interstitium--> causes affected tissue to swell and increased resistance of movement due to decreased lung compliance = the neg pressure generated normally from inspiration isnt enough to distend the lungs, causing poor gas exchange and sob Reduced pulmonary compliance
LV Heart Failure + Pul Congestion
Pul Fibrosis
Insuff Surfactant

decreased compliance= decreased FRC Surfactant

cortisol/ thyroxine ↑synthesis
insulin ↓ synthesis Pulmonary infarction
Pulmonary infarction: MC site lower lobes
Saddle embolus: sudden death
dyspnea/tachypnea MC symptom/sign
respiratory alkalosis; hypoxemia; ↑D-dimers Caplan syndrome pneumoconiosis + cavitating rheumatoid nodules Perfusion-limited gas exchange
diffusion can increase only if blood flow increases
examples: N2O and O2 under normal conditions Diffusion-limited gas exchange
diffusion continues as long as pressure gradient exists across pulmonary membrane
examples: O2 during vigorous exercise at high altitude and CO pathophysiologic mechanisms that reduce diffusing capacity (1) increased thickness of the pulmonary membrane in restrictive diseases (the primary factor in silicosis and idiopathic pulmonary fibrosis) (2) collapse of alveoli and lung segments (atelectasis), which contributes to a decreased surface area available for gas exchange (e.g., with bed rest after surgery) (3) poor lung compliance, resulting in insufficient ventilation (e.g., silicosis) (4) destruction of alveolar units, which also decreases surface area (e.g., emphysema) Physiologic shunt
This occurs when blood is appropriately directed to the lungs but is not involved in gas exchange
EX bronchial arterial circulation= The bronchial arteries supply the bronchi and supporting lung parenchyma but are not involved in gas exchange at the level of the alveoli Physiological Shunts in Pathological Cases (Disease states)

FEV1 is reduced more than is FVC, and the FEV1/FVC ratio is reduced
increased TLC Mechanically Ventilated Patients
The amount of anatomic dead space increases considerably b/c the volume of space occupied by the respiratory apparatus from the patient's mouth to the ventilator must be considered to be anatomic dead space
Alveolar ventilation is altered, and care must be taken to ensure adequate oxygenation Decreased Alv Ventilation
falls to a level too low to provide sufficient oxygen to the tissue, patients must compensate by increasing the rate of breathing (tachypnea) or by taking larger-volume tidal breaths
taking larger tidal breaths would be better because it minimizes the effect of dead space on alveolar ventilation Elevated Alveolar-Arterial Gradient: V/Q Mismatch
Pulmonary embolism
Airway obstruction
Interstitial lung disease Elevated Alveolar-Arterial Gradient: Shunt
Intracardiac Shunt (VSD)
Intrapulmonary Shunt (pulmonary AVM, pneumonia, CHF)
Atelectasis Elevated Alveolar-Arterial Gradient: Diffusion defects
Pulmonary fibrosis
Emphysema
Asbestosis Ureteric Bud
caudal end of mesonephric duct
gives rise of ureter, pelvises, calyces, and collecting ducts
canalized by 10th week Metanephric Mesenchyme
interacts with ureteric bud that induces differentiation and formation of glomerulus through the distal convoluted tubules Renal Artery Stenosis

MCC: atherosclerosis or fibromuscular hyperplasia. In unilateral renal artery stenosis, hypertension may occur because decreased perfusion of the affected kidney is incorrectly "interpreted" as intravascular volume depletion, which triggers a neurohormonal cascade response (the RAAS and ADH)--> causing fluid retention and vasoconstriction resulting in hypertension
When both renal arteries are affected (bilateral renal artery stenosis), renal blood flow may become so compromised that the kidneys are unable to perform their normal recycling functions, resulting in the toxic accumulation of metabolic byproducts Loop Diuretic effect on Tubuloglomerular Feedback
The juxtaglomerular apparatus is informed of NaCl in the tubular lumen by virtue of its transport into the cells of the macula densa by the same Na+-K+-2Cl- cotransporter that is inhibited by loop diuretics
One reason for the potency of loop diuretics is their ability to blunt tubuloglomerular feedback and thereby maintain GFR (and urine production) despite increased NaCl traffic past the macula densa Acute Tubular Necrosis
MCC: acute renal failure-- which results when hypotension (ischemia, hypoxemia) or tubular toxins damage renal tubular epithelial cells
Dysfunction of these cells--> sodium and water reabsorption in the proximal tubule is impaired
Large amounts of NaCl and water are therefore presented to the macula densa-- via tubuloglomerular feedback, this decreases renal blood flow and GFR by stimulating vasoconstriction of the afferent arteriole
The subsequent decrease in GFR may play a role in limiting potentially life- threatening losses of sodium and water that might otherwise occur in ATN PCT: Isosmotic reabsorption reabsorption of fluid along the proximal tubule in which there is no change in tubular osmolality Glomerulotubular balance balance among GFR, peritubular oncotic pressure, and proximal tubular reabsorption Response to volume- depleted state Decreased RPF --> Increased filtration fraction to maintain GFR --> Increased peritubular oncotic pressure --> Increased proximal tubular reabsorption --> Increased ECF volume Response to volume- expanded state

These occur because the resting membrane potentials of nerves and muscle are directly related to the ratio of intracellular and extracellular potassium concentrations Drugs that cause hyperkalemia = inability of potassium to be moved intracellularly
digitalis
insulin
abuterol Patient with HTN and Hypokalemia = increased renin and increased aldosterone SECONDARY HYPERALDOSTERONISM
renovasc htn ( renal a. stenosis)
malignant HTN
renin secreting tm (JG cell tm)
diuretic use Patient with HTN and Hypokalemia = decreased renin and increased aldosterone PRIMARY HYPERALDOSTERONISM
Aldosterone prod Tm
Bilateral adrenal hyperplasia Patient with HTN and Hypokalemia = decreased renin and decreased aldosterone
CAH
Adrenal tumor
Cushing Synd
Exogenous mineralocorticoid MM Symptoms
fatigue= d/t anemia
constipation= d/t hypercalcemia
bone pain, mostly in the back and ribs= d/t osteoclast activating factor prod by myeloma cells
elevated serum protein= monoclonal protein
renal failure
"myeloma kidney"= excess excretion of free light chains (bj proteins), and when the levels exceed the reabs capacity they will precipitate with Tamm Horsfall protein and form casts that cause tubular obstruction and epithelial injury --> tubular dysfxn
glassy casts stain eosinophillic Leukocyte adhesion defciency (LAD)

due to selectin or CD11a/ CD18 deficiency aka and integrin defect
Delayed separation of the umbilical cord (usually separates and sloughs by the end of the second postnatal week)-- Neutrophil enzymes are important in cord separation; therefore in a histologic section of the surgically removed umbilical cord, no neutrophils would be seen adhering to venular endothelium or be seen in the interstitial tissue
Additional clinical findings include severe gingivitis, poor wound healing, and peripheral blood neutrophilic leukocytosis (loss of the marginating pool)
Recurrent bact infections without pus Lupus related thrombosis
DVT
hepatic v. thrombosis
placental thrombosis (recurrent preg loss)
stroke TX: lifelong anticoag Bone Marrow Stem Cells CD Opioids cause biliary colic
act on mu rec to constrict sphincter of oddi= increased pressure of common bile duct and gallbladder
need to discontinue drug and treat pain with other NSAIDS: ketorolac and diclofenac P-Glycoprotein
Also known as multidrug resistance protein 1 (MDR1)--transmembrane ATP-dep efflux pump protein with broad specificity for hydrophobic compounds
Classically seen in adrenal cell carcinoma but also expressed by other cancer cells (eg, colon, liver)
Used to pump out toxins, including chemotherapeutic agents (one mechanism of responsiveness or resistance to chemotherapy over time) Hereditary Orotic Aciduria defect in UMP Synthase physical and mental retardation megaloblastic anemia elev urinary orotic acid benefit from uridine supplement Spontaneous Intracranial Hemorrhage

Decreased CO
LVH and dilation
Austin Flint murmur= blood hits the anterior leaflet of of aortic valve
Aortic valve is incompetent= high-pitched diastolic blowing murmur --early diastole; decreases in intensity throughout diastole (decrescendo)
Turbulent flow back into left ventricle from the high-pressure aorta
Can cause Pul HTN
Causes: Syphillis (3) induced aortic aneurysm, CT disorders, endocarditis
sx: fatigue, syncope, SOB, palpitations Mitral Stenosis
Associated with large diastolic pressure difference between left atrium and ventricle
Increased left atrial pressures --> increased hydrostatic pressures in pulmonary circulation -
> pulmonary edema --> RVH and decreased CO
Sx of pulmonary edema: dyspnea, reduced exercise capacity
Opening snap + diastolic rumble (diastolic murmur)
Turbulent flow across stenotic mitral valve during ventricular filling
LA pushes on esoph
LA hypertrophy and dilation Mitral Regurg
mitral valve does not form good seal--> blood flows into left atrium during early systole
Precise symptoms of mitral regurgitation depend on temporal course of the mitral regurgitation
acute onset--> severe symptoms
chronic onset--> typically asymptomatic or minor symptoms
MVP: classically gives rise to a midsystolic "click" on auscultation
Turbulent flow into left atrium during ventricular systole
Murmur lasts throughout systole Systolic heart failure pump failure (impaired contractility, increased afterload) Diastolic heart failure impaired ventricular filling during diastole due to stiff ventricle or obstruction to ventricular filling (e.g., mitral stenosis) Estrogen-containing oral contraceptives
Inhibiting the LH surge that is responsible for ovulation
Estrogen-containing contraceptives provide a constant level of estrogen that maintains a

continual negative feedback on pituitary gonadotropin secretion, thereby stabilizing FSH and LH secretion Progesterone-only OCPs

50% effective in inhibiting ovulation
work primarily by thickening the cervical mucus and altering the motility and secretions of the fallopian tubes, as well as thinning the endometrium
All these changes make the uterus a less hospitable environment for implantation of a fertilized embryo
Inhibits implantation and therefore pregnancy, it does not prevent fertilization Precocious puberty
Normal karyotype
Premature maturation of arcuate nucleus in hypothalamus
Treat with GnRH agonists (e.g., leuprolide) 5a-Reductase deficiency
Normal karyotype
Insufficient conversion of testosterone to active dihydrotestosterone form
Female develops internal male genitalia
Ambiguous external then male external during puberty Klinefelter syndrome
47,XXY karyotype
Meiotic nondisjunction of X chroms
Male with eunuchoid body, gynecomastia, testicular atrophy, tall, long extremities, female hair distribution, dev delay, infertility, some psychosocial abnorm (lack of insight or judgment)
Testicular atrophy; fibrosis seminiferous tubules/Sertoli cells; Leydig cells prominent
Dysgenesis of seminiferous tubules --> decreased inhibin---> increased FSH
Abnormal Leydig cell function--> decreased testosterone --> increased LH--> increased estrogen Androgen insensitivity syndrome (male pseudohermaphroditism)
XY karyotype
Androgen receptor defect
Male internal genitalia but incompletely virilized, ambiguous, or female external genitalia
These individuals do not have male internal genitalia (no epididymis, seminal vesicles, vas deferens, prostate), and most have normal female-looking external genitalia with a blind- ending vaginal pouch

USMLE Step 1 for International clients, Quizzes of Medicine

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