Massachusetts United States Medical
Licensing Examination Step 2 Questions
And Correct Answers (Verified Answers)
Plus Rationale 2026 Q&A| Instant
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1. A 64-year-old man presents with progressive exertional dyspnea and
lower extremity edema. On exam his jugular venous pressure is
elevated to the angle of the jaw and there is a holosystolic murmur at
the left lower sternal border that increases with inspiration. Which of
the following is the most likely underlying pathophysiology?
A. Left ventricular outflow obstruction
B. Mitral valve prolapse
C. Functional tricuspid regurgitation due to right ventricular dilation
D. Primary pulmonary valve stenosis
Functional tricuspid regurgitation occurs when right ventricular
dilation from volume or pressure overload prevents leaflet
coaptation, producing a holosystolic murmur that increases with
inspiration.
2. A 23-year-old woman with a history of type 1 diabetes presents with
polyuria, polydipsia, and fatigue. Her blood glucose is 430 mg/dL,
serum sodium is 130 mEq/L, and serum bicarbonate is 22 mEq/L. What
is the most appropriate initial management?
A. Oral metformin
B. Intravenous sodium bicarbonate
C. Intravenous regular insulin and fluids
D. Subcutaneous long-acting insulin
In hyperglycemia with signs of dehydration and acidosis, initial
, management is IV fluids and regular insulin to correct volume and
glucose abnormalities.
3. A 45-year-old man presents with fatigue and intermittent epigastric
discomfort. Labs show AST 450 U/L, ALT 470 U/L, alkaline phosphatase
110 U/L, and total bilirubin 1.2 mg/dL. Viral hepatitis panels are
negative. He reports daily acetaminophen use for chronic back pain.
What is the most likely mechanism of his liver injury?
A. Autoimmune hepatitis
B. Hepatocellular necrosis from toxic metabolite accumulation
C. Cholestasis from bile duct obstruction
D. Steatosis from alcohol metabolism
Acetaminophen toxicity produces a toxic metabolite (NAPQI) that
causes hepatocellular necrosis, leading to markedly elevated AST and
ALT.
4. A 72-year-old woman with a history of hypertension presents with
sudden onset right arm weakness and expressive aphasia. CT head
shows no hemorrhage. Which vessel is most likely occluded?
A. Left anterior cerebral artery
B. Left middle cerebral artery
C. Right middle cerebral artery
D. Basilar artery
Expressive aphasia and right arm weakness localize to the left MCA
distribution involving frontal lobe motor and language areas.
5. A 19-year-old college student presents with fever, headache,
photophobia, and stiff neck. Kernig and Brudzinski signs are positive.
Which CSF finding is most consistent with bacterial meningitis?
A. Lymphocytic pleocytosis and normal glucose
B. Elevated protein and low glucose with neutrophilic pleocytosis
C. Normal cell count and elevated protein
D. Neutrophilic pleocytosis with high protein and low glucose
Bacterial meningitis typically shows neutrophilic pleocytosis,
elevated protein, and low glucose due to high metabolic activity of
organisms.
6. A 30-year-old woman presents with hot flashes, irregular periods, and
elevated FSH levels. What is the most likely diagnosis?
, A. Polycystic ovary syndrome
B. Menopause
C. Cushing syndrome
D. Hyperprolactinemia
Elevated FSH with irregular periods and vasomotor symptoms in this
age group suggests menopause transition.
7. A 54-year-old man with a 30-pack-year history of smoking presents
with hematuria and flank pain. Imaging shows a mass in the right
kidney. Which paraneoplastic syndrome is most commonly associated
with this malignancy?
A. SIADH
B. Cushing syndrome
C. Polycythemia from increased EPO production
D. Hypoglycemia from IGF secretion
Renal cell carcinoma often secretes erythropoietin, resulting in
paraneoplastic polycythemia.
8. A 6-year-old boy presents with limping and knee pain, worse at night
and relieved by NSAIDs. Imaging shows a lesion in the metaphysis of a
long bone with “onion skin” periosteal reaction. Diagnosis?
A. Osteosarcoma
B. Giant cell tumor
C. Ewing sarcoma
D. Chondrosarcoma
Ewing sarcoma presents in children with onion-skin periosteal
reaction and pain that may awaken at night.
9. A 28-year-old man has sudden onset severe testicular pain and absent
cremasteric reflex. What is the best next step?
A. Start antibiotics for epididymitis
B. Perform Doppler ultrasound of the scrotum
C. Reassure and observe
D. Immediate orchiectomy
Suspected testicular torsion mandates Doppler ultrasound to assess
blood flow urgently.
10. A 60-year-old woman with atrial fibrillation is started on
warfarin. Which lab test is used to monitor therapy?
Licensing Examination Step 2 Questions
And Correct Answers (Verified Answers)
Plus Rationale 2026 Q&A| Instant
Download Pdf
1. A 64-year-old man presents with progressive exertional dyspnea and
lower extremity edema. On exam his jugular venous pressure is
elevated to the angle of the jaw and there is a holosystolic murmur at
the left lower sternal border that increases with inspiration. Which of
the following is the most likely underlying pathophysiology?
A. Left ventricular outflow obstruction
B. Mitral valve prolapse
C. Functional tricuspid regurgitation due to right ventricular dilation
D. Primary pulmonary valve stenosis
Functional tricuspid regurgitation occurs when right ventricular
dilation from volume or pressure overload prevents leaflet
coaptation, producing a holosystolic murmur that increases with
inspiration.
2. A 23-year-old woman with a history of type 1 diabetes presents with
polyuria, polydipsia, and fatigue. Her blood glucose is 430 mg/dL,
serum sodium is 130 mEq/L, and serum bicarbonate is 22 mEq/L. What
is the most appropriate initial management?
A. Oral metformin
B. Intravenous sodium bicarbonate
C. Intravenous regular insulin and fluids
D. Subcutaneous long-acting insulin
In hyperglycemia with signs of dehydration and acidosis, initial
, management is IV fluids and regular insulin to correct volume and
glucose abnormalities.
3. A 45-year-old man presents with fatigue and intermittent epigastric
discomfort. Labs show AST 450 U/L, ALT 470 U/L, alkaline phosphatase
110 U/L, and total bilirubin 1.2 mg/dL. Viral hepatitis panels are
negative. He reports daily acetaminophen use for chronic back pain.
What is the most likely mechanism of his liver injury?
A. Autoimmune hepatitis
B. Hepatocellular necrosis from toxic metabolite accumulation
C. Cholestasis from bile duct obstruction
D. Steatosis from alcohol metabolism
Acetaminophen toxicity produces a toxic metabolite (NAPQI) that
causes hepatocellular necrosis, leading to markedly elevated AST and
ALT.
4. A 72-year-old woman with a history of hypertension presents with
sudden onset right arm weakness and expressive aphasia. CT head
shows no hemorrhage. Which vessel is most likely occluded?
A. Left anterior cerebral artery
B. Left middle cerebral artery
C. Right middle cerebral artery
D. Basilar artery
Expressive aphasia and right arm weakness localize to the left MCA
distribution involving frontal lobe motor and language areas.
5. A 19-year-old college student presents with fever, headache,
photophobia, and stiff neck. Kernig and Brudzinski signs are positive.
Which CSF finding is most consistent with bacterial meningitis?
A. Lymphocytic pleocytosis and normal glucose
B. Elevated protein and low glucose with neutrophilic pleocytosis
C. Normal cell count and elevated protein
D. Neutrophilic pleocytosis with high protein and low glucose
Bacterial meningitis typically shows neutrophilic pleocytosis,
elevated protein, and low glucose due to high metabolic activity of
organisms.
6. A 30-year-old woman presents with hot flashes, irregular periods, and
elevated FSH levels. What is the most likely diagnosis?
, A. Polycystic ovary syndrome
B. Menopause
C. Cushing syndrome
D. Hyperprolactinemia
Elevated FSH with irregular periods and vasomotor symptoms in this
age group suggests menopause transition.
7. A 54-year-old man with a 30-pack-year history of smoking presents
with hematuria and flank pain. Imaging shows a mass in the right
kidney. Which paraneoplastic syndrome is most commonly associated
with this malignancy?
A. SIADH
B. Cushing syndrome
C. Polycythemia from increased EPO production
D. Hypoglycemia from IGF secretion
Renal cell carcinoma often secretes erythropoietin, resulting in
paraneoplastic polycythemia.
8. A 6-year-old boy presents with limping and knee pain, worse at night
and relieved by NSAIDs. Imaging shows a lesion in the metaphysis of a
long bone with “onion skin” periosteal reaction. Diagnosis?
A. Osteosarcoma
B. Giant cell tumor
C. Ewing sarcoma
D. Chondrosarcoma
Ewing sarcoma presents in children with onion-skin periosteal
reaction and pain that may awaken at night.
9. A 28-year-old man has sudden onset severe testicular pain and absent
cremasteric reflex. What is the best next step?
A. Start antibiotics for epididymitis
B. Perform Doppler ultrasound of the scrotum
C. Reassure and observe
D. Immediate orchiectomy
Suspected testicular torsion mandates Doppler ultrasound to assess
blood flow urgently.
10. A 60-year-old woman with atrial fibrillation is started on
warfarin. Which lab test is used to monitor therapy?
