11 USMLE Step 2 CK Clinical Review Questions with Answers (Set 8)

These 11 USMLE Step 2 CK clinical review questions are short clinical cases on diagnosis and next-step management, including Ursodeoxycholic acid, Systemic thrombolysis, Emphysematous pyelonephritis, Toxic shock syndrome, Upper endoscopy. 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 32-year-old woman presents with fatigue and pruritus. Labs show elevated alkaline phosphatase and positive anti–mitochondrial antibodies. What is the most appropriate initial treatment?

A- Azathioprine
B- Prednisone
C- Ursodeoxycholic acid
D- Vitamin K

C- Ursodeoxycholic acid- Primary biliary cholangitis presents with pruritus, cholestatic labs, and anti-mitochondrial antibodies. Ursodeoxycholic acid slows disease progression.
The correct answer is C

 

Question 2. A 70-year-old hospitalized patient suddenly develops dyspnea and hypotension. CT angiography confirms a massive pulmonary embolism. What is the most appropriate treatment?

A- Aspirin
B- Intravenous heparin only
C- Systemic thrombolysis
D- Warfarin therapy

C- Systemic thrombolysis- Massive PE with hemodynamic instability requires systemic thrombolysis (e.g., alteplase). Anticoagulation alone is insufficient in unstable patients.
The correct answer is C

 

Question 3. A 24-year-old man presents with fever, sore throat, and severe fatigue. Examination shows posterior cervical lymphadenopathy and splenomegaly. The heterophile antibody test is positive. Which of the following is the most important management recommendation?

A- Begin amoxicillin therapy
B- Avoid contact sports
C- Start antiviral therapy
D- Start corticosteroids

B- Avoid contact sports- Infectious mononucleosis can cause splenic enlargement, increasing the risk of rupture. Patients should avoid contact sports for several weeks.
The correct answer is B

 

Question 4. A 63-year-old woman with diabetes presents with fever, flank pain, and dysuria. CT scan shows gas within the renal parenchyma. What is the most likely diagnosis?

A- Acute pyelonephritis
B- Emphysematous pyelonephritis
C- Renal abscess
D- Xanthogranulomatous pyelonephritis

B- Emphysematous pyelonephritis- Gas-forming infection of the kidney, most commonly seen in diabetic patients, is diagnostic of emphysematous pyelonephritis, a life-threatening condition.
The correct answer is B

 

Question 5. A 74-year-old woman presents with acute onset right-sided weakness and slurred speech that began 2 hours ago. CT scan of the head shows no hemorrhage. Her blood pressure is 210/115 mmHg. What is the most appropriate next step in management?

A- Administer intravenous alteplase immediately
B- Lower blood pressure with intravenous labetalol
C- Start aspirin therapy
D- Wait 24 hours and repeat CT scan

B- Lower blood pressure with intravenous labetalol- Thrombolysis requires BP <185/110 mmHg. In acute ischemic stroke with very high BP, the first step is careful BP reduction before alteplase can be given.
The correct answer is B

 

Question 6. A 61-year-old man presents with severe abdominal pain that began suddenly after a large meal. Pain radiates to the back. Lipase is markedly elevated. Ultrasound shows gallstones without bile duct dilation. What is the most appropriate next step in management?

A- Cholecystectomy during the same hospitalization
B- Endoscopic retrograde cholangiopancreatography (ERCP)
C- Immediate laparotomy
D- Start antibiotics

A- Cholecystectomy during the same hospitalization- Gallstone pancreatitis without cholangitis or obstruction is treated with supportive care followed by cholecystectomy during the same admission to prevent recurrence.
The correct answer is A

 

Question 7. A child has chronic diarrhea and failure to thrive. Stool is positive for fat. The sweat chloride test is elevated. Which mechanism explains the GI symptoms?

A- Decreased pancreatic enzyme secretion
B- Increased bile acid synthesis
C- Increased gastric acid production
D- Increased intestinal chloride secretion

A- Decreased pancreatic enzyme secretion- Cystic fibrosis causes thick secretions → pancreatic duct obstruction → malabsorption and steatorrhea.
The correct answer is A

 

Question 8. A patient has progressive weakness and ptosis that improves with rest. Autoantibodies are directed against postsynaptic acetylcholine receptors. Which finding is expected?

A- Decreased ACh release at the presynaptic terminal
B- Increasing muscle action potential amplitude with repeated stimulation
C- Increased AChE activity
D- Increased thymic mass

D- Increased thymic mass- Myasthenia gravis is associated with thymic hyperplasia (most patients) or thymoma (about 10–15%), so a chest CT is done at diagnosis. Repetitive nerve stimulation shows a DECREMENTAL response. Decreased presynaptic ACh release with an increasing response on repeated stimulation describes Lambert-Eaton syndrome.
The correct answer is D

 

Question 9. A man presents with episodic palpitations, headache, and sweating. Urine shows elevated metanephrines. The tumor most likely arises from which embryologic tissue?

A- Endoderm
B- Mesoderm
C- Neural crest
D- Surface ectoderm

C- Neural crest- Pheochromocytoma arises from chromaffin cells derived from neural crest.
The correct answer is C

 

Question 10. A 35-year-old man presents with fever, hypotension, and a diffuse rash after a minor surgical procedure. Labs show elevated creatinine and liver enzymes. Blood cultures are pending. What is the most likely diagnosis?

A- Anaphylaxis
B- Septic shock due to gram-negative bacteria
C- Toxic shock syndrome
D- Viral exanthem

C- Toxic shock syndrome- Toxic shock syndrome is caused by toxin-producing Staphylococcus aureus or Streptococcus pyogenes, presenting with fever, hypotension, rash, and multi-organ involvement.
The correct answer is C

 

Question 11. A 49-year-old man presents with progressive dysphagia to solids over the past several months. He has lost 15 pounds. He has a 30-pack-year smoking history. What is the most appropriate next diagnostic test?

A- Barium swallow
B- Chest CT scan
C- Esophageal manometry
D- Upper endoscopy

D- Upper endoscopy- Progressive dysphagia with weight loss suggests esophageal cancer. Upper endoscopy with biopsy is the best initial diagnostic test.
The correct answer is D

 

High-yield points from this set

  • Primary biliary cholangitis presents with pruritus, cholestatic labs, and anti-mitochondrial antibodies.
  • Massive PE with hemodynamic instability requires systemic thrombolysis (e.g., alteplase).
  • Infectious mononucleosis can cause splenic enlargement, increasing the risk of rupture.
  • Gas-forming infection of the kidney, most commonly seen in diabetic patients, is diagnostic of emphysematous pyelonephritis, a life-threatening condition.
  • Thrombolysis requires BP <185/110 mmHg.

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