Repeated USMLE Questions Step 2 CK- Review- 55

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Q- A 64-year-old man presents to the emergency department with severe epigastric pain radiating to the back. He is febrile and tachycardic. Labs show lipase 1,800 U/L. RUQ ultrasound shows gallstones. Despite IV fluids and pain control, he develops hypotension and worsening hypoxemia over the next 12 hours.

What is the best next step in management?

A-Administer broad-spectrum antibiotics immediately

B-Endoscopic retrograde cholangiopancreatography (ERCP) now

C-Start oral feeding to reduce catabolism

D-Transfer to ICU for aggressive supportive care

D-Transfer to ICU for aggressive supportive care- This is severe acute pancreatitis with systemic complications (shock/respiratory failure). The next step is ICU-level supportive care (fluids, oxygen/ventilation support, monitoring). Antibiotics are not routine unless infected necrosis is suspected. ERCP is for cholangitis or persistent biliary obstruction.

 

Q- A 29-year-old woman presents with fatigue and easy bruising. CBC shows Hb 7.6 g/dL, platelets 18,000/mm³. Peripheral smear shows schistocytes. Creatinine is elevated. Coagulation studies are normal. She is confused on exam.

What is the most appropriate immediate treatment?

A-Fresh frozen plasma

B-Heparin infusion

C-Platelet transfusion

D-Plasma exchange

D-Plasma exchange- This is classic TTP (thrombocytopenia, microangiopathic hemolytic anemia, neurologic symptoms, renal injury, normal PT/aPTT). Plasma exchange is lifesaving and must be started immediately.

 

Q- A 52-year-old man with a mechanical aortic valve takes warfarin. He presents with a severe headache and vomiting. CT scan shows an intracranial hemorrhage. INR is 5.2.

What is the best immediate reversal strategy?

A-Fresh frozen plasma only

B-Intravenous vitamin K only

C-Prothrombin complex concentrate plus intravenous vitamin K

D-Stop warfarin and observe

C-Prothrombin complex concentrate plus intravenous vitamin K- Life-threatening bleeding on warfarin requires rapid reversal with PCC (fast) plus IV vitamin K (sustained). FFP is slower and higher volume.

 

Q- A 31-year-old woman presents with 2 days of pelvic pain and fever. She has purulent cervical discharge and cervical motion tenderness. Pregnancy test is negative. She is diagnosed with pelvic inflammatory disease and started on antibiotics. Two days later, she returns with worsening pain and a palpable adnexal mass.

What is the most likely diagnosis?

A-Appendicitis

B-Ectopic pregnancy

C-Ovarian torsion

D-Tubo-ovarian abscess

D-Tubo-ovarian abscess- PID complicated by persistent/worsening pain, fever, and adnexal mass suggests a tubo-ovarian abscess, which may require IV antibiotics and drainage.

 

Q- A 46-year-old man presents with progressive weakness and paresthesias. He recently had a diarrheal illness. On exam, he has symmetric ascending weakness and absent deep tendon reflexes. Vital capacity is decreasing.

What is the most appropriate next step?

A-Administer corticosteroids

B-Begin intravenous immunoglobulin (IVIG)

C-Reassure and discharge home

D-Start oral antibiotics

B-Begin intravenous immunoglobulin (IVIG)- This is Guillain-Barré syndrome. With worsening weakness and declining vital capacity, treat with IVIG or plasmapheresis and monitor respiratory status closely. Steroids do not help.

 

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