USMLE Step 1 Exam Guide 2026: FREE Pass/Fail Plan + May 14 Format
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A 58-year-old man presents with crushing chest pain radiating to his left arm. The pain started 30 minutes ago while he was at rest. He is diaphoretic and short of breath. Vital signs: BP 100/60 mmHg, HR 110 bpm, RR 22/min, SpO2 92% on room air. ECG shows ST-segment elevation in leads II, III, and aVF. Which is the most appropriate next step in management?
Usmle Step2 Internal Medicine
Question · Easy
P-R-I-L: the -pril arena anthem
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Complete 2026 USMLE Step 1 guide. Pass/fail since Jan 2022, $695 fee, format change May 14, 2026 (14 blocks x 30 min x 20 Qs, 55-min break, 5-min tutorial). FREE practice, high-yield content, 6-week dedicated plan.
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A patient with terminal cancer refuses a life-saving transfusion. What determines whether you must honor that refusal?
Social Sciences: Legal/Ethical Issues & Professionalism/Systems-based Practice & Patient Safety
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A 72-year-old woman with hypertension and diabetes presents with dyspnea on exertion and orthopnea. On examination, she has bibasilar crackles, an S3 gallop, and 2+ pitting edema in her lower extremities. Echocardiography shows a left ventricular ejection fraction of 35%. Which medication has been shown to reduce mortality in this patient?
Question · Medium
Chapter 1: Human Development & Well-Patient Care
1.1 Infant, Child & Adolescent Development & Growth
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Cheat sheet
A 45-year-old man is brought to the emergency department with palpitations and lightheadedness. His pulse is irregularly irregular at 140 bpm. ECG shows no P waves and irregularly irregular QRS complexes. His blood pressure is 110/70 mmHg. Which of the following is the most appropriate initial management?
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An incapacitated patient has no advance directive. Which standard must the surrogate apply first?
A 65-year-old man with a history of atrial fibrillation presents with sudden-onset right-sided weakness and aphasia. CT scan of the head shows no hemorrhage. The patient is outside the window for thrombolysis. Which of the following is the most appropriate next step?
Question · Hard
A 28-year-old athlete collapses during a basketball game. He is found to be pulseless. AED analysis shows ventricular fibrillation. Which of the following is the most important factor in determining survival from sudden cardiac arrest?
A 16-year-old asks for treatment of a sexually transmitted infection and does not want the parents told. Can you treat?
A 55-year-old woman presents with dyspnea and fatigue. She has a harsh crescendo-decrescendo systolic murmur at the right upper sternal border radiating to the carotids. The murmur decreases with handgrip and increases with standing. What is the most likely diagnosis?
1.2 Adult Development, Aging & Geriatric Assessment
A 62-year-old man with known coronary artery disease presents with episodes of chest pain occurring with exertion that are relieved by rest. He is currently pain-free. ECG shows normal sinus rhythm with Q waves in leads V1-V3. Troponins are negative. Which medication should be added to his regimen to prevent future cardiac events?
A nursing error caused brief hypoglycemia that the patient never noticed and that left no injury. What is your obligation?
A 68-year-old man with COPD presents with increased dyspnea and productive cough with purulent sputum. He has been using his albuterol inhaler more frequently. On examination, he is tachypneic with diffuse wheezing. Which of the following findings would indicate the need for hospitalization?
A 45-year-old man presents with acute-onset pleuritic chest pain and dyspnea. He recently returned from a long flight. D-dimer is elevated. CT pulmonary angiography shows a pulmonary embolism in the left pulmonary artery. His blood pressure is 110/70 mmHg and he is not hypoxic. Which is the most appropriate treatment?
Which quality-improvement tool is retrospective and which is prospective?
A 35-year-old woman with asthma presents with wheezing and shortness of breath. Peak expiratory flow is 40% of predicted. She has been using her albuterol inhaler every 2 hours without relief. Arterial blood gas shows pH 7.48, PCO2 32, PO2 70. Which of the following is the most appropriate next step?
1.3 Preventive Health, Immunization & Well-Patient Screening
A 58-year-old man with a 40 pack-year smoking history presents with hemoptysis and a new cough. Chest X-ray shows a 4 cm mass in the left upper lobe. CT-guided biopsy confirms small cell lung cancer. MRI of the brain shows no metastases. Which is the most appropriate initial treatment?
Rank these safety interventions by durability: staff education, a checklist, and a connector that physically cannot mate with the wrong port.
A 22-year-old college student develops fever, cough, and malaise. Chest X-ray shows diffuse interstitial infiltrates. Cold agglutinins are positive. Which antibiotic is most appropriate?
A 55-year-old man with obstructive sleep apnea is being evaluated. He has a BMI of 38 and complains of daytime somnolence. Polysomnography shows an apnea-hypopnea index (AHI) of 35 events per hour. Which of the following is the most effective treatment?
Which urine indices separate prerenal azotemia from acute tubular necrosis?
Renal & Urinary System & Reproductive Systems
A 45-year-old man with a history of alcohol use disorder presents with hematemesis and melena. Vital signs: BP 90/60 mmHg, HR 120 bpm. On examination, he has palmar erythema and spider angiomata. Which is the most appropriate immediate management?
Chapter 2: Immune System & Immunologic Disorders
2.1 Primary & Secondary Immunodeficiencies
A 28-year-old woman presents with diarrhea, abdominal pain, and weight loss over 6 months. Colonoscopy shows skip lesions with cobblestone appearance of the mucosa. Biopsy shows non-caseating granulomas and transmural inflammation. Which is the most appropriate initial treatment?
How fast may chronic hyponatremia be corrected, and what happens if you exceed that rate?
A 55-year-old man presents with RUQ pain after eating a fatty meal. Ultrasound shows gallstones and gallbladder wall thickening. He has a fever of 38.5°C (101.3°F) and WBC of 15,000/μL. Which is the most appropriate management?
A 60-year-old man presents with progressive dysphagia to solids and then liquids. He has a 20-pound weight loss over 3 months. Barium swallow shows a "bird beak" appearance of the distal esophagus. What is the most likely diagnosis?
Acute scrotal pain: which findings point to torsion rather than epididymitis?
A 35-year-old woman presents with right upper quadrant pain, jaundice, and pruritus. She is 32 weeks pregnant. Laboratory studies show elevated alkaline phosphatase, bilirubin, and bile acids. Liver ultrasound shows no gallstones or biliary dilation. What is the most appropriate management?
2.2 Hypersensitivity Reactions, Allergy & Anaphylaxis
A 50-year-old man undergoes screening colonoscopy. A 1.5 cm pedunculated polyp is found in the sigmoid colon and removed. Pathology shows tubular adenoma with low-grade dysplasia. The remainder of the colon is normal. When should his next colonoscopy be performed?
What separates a nephritic from a nephrotic presentation?
A 25-year-old man is brought to the ED after a motorcycle accident. He is hypotensive (BP 80/50) and has distended neck veins. Heart sounds are muffled. Which of the following is the most appropriate next step?
Usmle Step2 Surgery
A 40-year-old man presents with severe epigastric pain radiating to the back. He has nausea and vomiting. Serum lipase is 1200 U/L. CT shows peripancreatic fluid collections. Which is the most important initial management?
A patient with recurrent calcium oxalate stones asks whether to cut back on dietary calcium. What do you advise?
A 65-year-old woman with atrial fibrillation presents with acute abdominal pain, nausea, and bloody diarrhea. She is on warfarin with an INR of 3.5. CT shows pneumatosis intestinalis and portal venous gas. Which is the most appropriate next step?
2.3 Autoimmune & Rheumatologic Disease Principles
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