11 USMLE Step 2 CK Clinical Review Questions with Answers (Set 1)

These 11 USMLE Step 2 CK clinical review questions are short clinical cases on diagnosis and next-step management, including Bacterial meningitis, Heparin infusion, Monospot antibody test, Bronchiectasis, Acute pyelonephritis, IV thiamine. Each question includes the correct answer and an explanation.

Written by Dr. Ray Makar, MD, author of the Repeated USMLE Questions eBook series.

Prefer video? Watch daily USMLE case questions on MedFocus by Dr. Ray on YouTube.

How to use this page: read the question, pick your answer, then tap Show Answer and Explanation.

Questions

Question 1. A 25-year-old woman presents with a sudden-onset severe headache, photophobia, and neck stiffness. She has a fever of 38.9°C (102°F). Lumber puncture shows: Opening pressure: 280 mm H₂O WBC count: 2200/mm³ (90% neutrophils) Protein: 220 mg/dL Glucose: 30 mg/dL Which of the following is the most likely diagnosis?

A- Bacterial meningitis
B- Fungal meningitis
C- Subarachnoid hemorrhage
D- Viral meningitis

A- Bacterial meningitis- The CSF findings of very high WBC count with neutrophilic predominance, high protein, and very low glucose are characteristic of bacterial meningitis.
The correct answer is A

 

Question 2. A 62-year-old man with a history of hypertension and type 2 diabetes presents with sudden-onset right-sided weakness and difficulty speaking. On exam, he has expressive aphasia and right hemiparesis. A CT scan shows an ischemic stroke. Which of the following is the most appropriate initial management?

A- Administer IV alteplase if within 4.5 hours of onset
B- Begin IV heparin infusion
C- Observe and repeat the CT scan in 6 hours
D- Start aspirin immediately

A- Administer IV alteplase if within 4.5 hours of onset- In ischemic stroke, IV alteplase (tPA) is indicated within 4.5 hours if there are no contraindications. Aspirin is used if the patient presents outside the tPA window or if tPA is contraindicated.
The correct answer is A

 

Question 3. A 25-year-old woman presents with sudden-onset shortness of breath and pleuritic chest pain. She started oral contraceptive pills 3 months ago. On exam, she is tachycardic and has mild hypoxia. CT pulmonary angiography shows multiple filling defects. Which of the following is the best initial treatment?

A- Aspirin
B- Heparin infusion
C- Thrombolysis
D- Warfarin

B- Heparin infusion- Acute pulmonary embolism requires immediate anticoagulation with unfractionated or low molecular-weight heparin. Warfarin is for long-term therapy. Thrombolysis is reserved for massive PE with hemodynamic instability.
The correct answer is B

 

Question 4. A 30-year-old man presents with fever, malaise, and sore throat. On exam, he has generalized lymphadenopathy, hepatosplenomegaly, and a maculopapular rash after taking ampicillin. Which one of the following tests is most helpful for diagnosis?

A- Anti-streptolysin O titer
B- HIV ELISA
C- Monospot antibody test
D- Throat swab culture

C- Monospot antibody test- The clinical presentation suggests infectious mononucleosis (EBV infection). The heterophile antibody (Monospot) test confirms the diagnosis. Ampicillin rash is a classic clue.
The correct answer is C

 

Question 5. A 6-year-old boy presents with recurrent respiratory infections, failure to thrive, and foul-smelling, bulky stools. The sweat chloride test is positive. Which complication is most likely in this patient?

A- Bronchiectasis
B- Early-onset colon cancer
C- Renal failure
D- Rheumatic heart disease

A- Bronchiectasis- The child has cystic fibrosis, which predisposes to chronic lung infections and bronchiectasis due to impaired mucociliary clearance.
The correct answer is A

 

Question 6. A 23-year-old woman presents with fever, dysuria, and flank pain. She has costovertebral angle tenderness. Urinalysis shows WBC casts. Which of the following is the most likely diagnosis?

A- Acute cystitis
B- Acute pyelonephritis
C- Interstitial nephritis
D- Renal papillary necrosis

B- Acute pyelonephritis- Fever, flank pain, and WBC casts are classic for acute pyelonephritis. Cystitis lacks WBC casts.
The correct answer is B

 

Question 7. A 64-year-old man presents with crushing chest pain radiating to his left arm. ECG shows ST-elevation in V1-V4. Which of these arteries is most likely occluded?

A- Left anterior descending artery
B- Left circumflex artery
C- Posterior descending artery
D- Right coronary artery

A- Left anterior descending artery- ST-elevation in V1-V4 is diagnostic for anterior wall MI, which is most likely due to LAD occlusion.
The correct answer is A

 

Question 8. A 54-year-old man with a history of alcohol use disorder presents with confusion, ataxia, and nystagmus. Which of the following is the most appropriate immediate treatment?

A- IV dextrose
B- IV thiamine
C- IV glucose followed by thiamine
D- Oral folic acid

B- IV thiamine- Wernicke encephalopathy is caused by thiamine deficiency. Thiamine must be given before glucose to prevent worsening of neurologic symptoms.
The correct answer is B

 

Question 9. A 72-year-old woman presents with shortness of breath and swelling of the ankles. She has a history of long-standing hypertension. Echocardiography shows a normal left ventricular ejection fraction but concentric left ventricular hypertrophy. Which of the following is the most likely diagnosis?

A- Dilated cardiomyopathy
B- Hypertrophic cardiomyopathy
C- Heart failure with preserved ejection fraction
D- Restrictive cardiomyopathy

C- Heart failure with preserved ejection fraction- Long-standing hypertension leads to diastolic dysfunction and concentric LV hypertrophy, resulting in heart failure with preserved ejection fraction, also known as diastolic heart failure.
The correct answer is C

 

Question 10. A 25-year-old man presents with fever, cough, and chest pain. He has a history of intravenous drug use. On examination, a new holosystolic murmur is heard at the left lower sternal border. Blood cultures grow Staphylococcus aureus. Which cardiac valve is most likely involved?

A- Aortic
B- Mitral
C- Pulmonic
D- Tricuspid

D- Tricuspid- IV drug users are at high risk for right-sided infective endocarditis, most commonly affecting the tricuspid valve.
The correct answer is D

 

Question 11. A 68-year-old woman presents with a sudden onset of chest pain that radiates to her back. Blood pressure is 190/100 mmHg. She has a history of long-standing hypertension. CT angiography shows a tear in the intimal layer of the aorta. Which of the following is the most appropriate initial treatment?

A- Give aspirin
B- Immediate surgical repair
C- Start IV beta blocker
D- Start IV nitroglycerin

C- Start IV beta blocker-In aortic dissection, initial management is IV beta-blocker (e.g., esmolol) to reduce heart rate and shear stress before blood pressure reduction. Surgery is needed for Type A dissections, but beta-blockade is the first step.
The correct answer is C

 

High-yield points from this set

  • The CSF findings of very high WBC count with neutrophilic predominance, high protein, and very low glucose are characteristic of bacterial meningitis.
  • In ischemic stroke, IV alteplase (tPA) is indicated within 4.5 hours if there are no contraindications.
  • Acute pulmonary embolism requires immediate anticoagulation with unfractionated or low molecular-weight heparin.
  • The clinical presentation suggests infectious mononucleosis (EBV infection).
  • The child has cystic fibrosis, which predisposes to chronic lung infections and bronchiectasis due to impaired mucociliary clearance.

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