USMLE STEP 2 CLINICAL KNOWLEDGE
(CK) LICENSE EXAM/ QUESTIONS AND
100% VERIFIED ANSWERS WITH RATIONALES
GRADED A+ LATEST
Question 1
A 67-year-old man presents with worsening shortness of breath and bilateral leg
swelling for 2 weeks. He has a history of hypertension and myocardial infarction.
On exam, there is elevated JVP, bibasilar crackles, and pitting edema to the knees.
Echocardiography shows reduced ejection fraction of 30%.
Which of the following medications has been shown to reduce mortality in this
condition?
A. Furosemide
B. Digoxin
C. Metoprolol succinate
D. Hydrochlorothiazide
E. Isosorbide dinitrate as monotherapy
Answer: C. Metoprolol succinate
Rationale:
This patient has HFrEF (heart failure with reduced ejection fraction). Evidence-
based therapies that reduce mortality include beta-blockers (metoprolol succinate,
carvedilol, bisoprolol), ACE inhibitors/ARBs, ARNI, MRAs, and SGLT2
inhibitors. Metoprolol succinate improves survival by reducing sympathetic
overactivation and myocardial remodeling.
,Question 2
A 24-year-old woman presents with fever, dysuria, and right flank pain. She is
tachycardic and has costovertebral angle tenderness. Urinalysis shows nitrites,
leukocyte esterase, and white blood cell casts.
What is the most appropriate initial treatment?
A. Oral nitrofurantoin
B. Oral amoxicillin
C. IV ceftriaxone
D. Oral ciprofloxacin only
E. No antibiotics until culture results return
Answer: C. IV ceftriaxone
Rationale:
This is acute pyelonephritis with systemic symptoms. Initial management requires
empiric IV antibiotics such as ceftriaxone or piperacillin-tazobactam depending on
severity. Oral nitrofurantoin is ineffective for upper urinary tract infections.
Question 3
A 58-year-old man with a history of chronic alcohol use presents with confusion,
ataxia, and horizontal nystagmus. He is malnourished and recently hospitalized.
What is the most appropriate immediate treatment?
A. Oral thiamine
B. IV glucose alone
C. IV thiamine before glucose
D. MRI brain
E. Haloperidol
Answer: C. IV thiamine before glucose
,Rationale:
This is Wernicke encephalopathy. Thiamine must be administered before glucose
to prevent worsening neurologic injury due to increased metabolic demand in a
thiamine-deficient brain.
Question 4
A 35-year-old woman presents with episodes of palpitations, headaches, and
sweating. Blood pressure is 180/110 mmHg during episodes. Plasma
metanephrines are elevated.
Which is the next best step in management?
A. Start beta-blocker alone
B. Abdominal CT scan
C. Start ACE inhibitor
D. Renal artery Doppler
E. Low-sodium diet only
Answer: B. Abdominal CT scan
Rationale:
This is pheochromocytoma. After biochemical confirmation (elevated
metanephrines), the next step is tumor localization with CT or MRI. Beta-blockers
should never be started before alpha-blockade.
Question 5
A newborn has cyanosis shortly after birth. Oxygen administration does not
improve saturation. Echocardiography shows transposition of the great arteries.
What is the most immediate lifesaving intervention?
A. Prostaglandin E1 infusion
B. Furosemide
C. Indomethacin
, D. Digoxin
E. Oxygen therapy alone
Answer: A. Prostaglandin E1 infusion
Rationale:
TGA requires maintaining ductus arteriosus patency with prostaglandin E1 to
allow mixing of oxygenated and deoxygenated blood until surgical correction.
Question 6
A 45-year-old man presents with progressive weakness, dry mouth, and blurred
vision. He works in agriculture. Examination shows ptosis and descending
paralysis.
Which toxin is most likely responsible?
A. Organophosphate poisoning
B. Botulinum toxin
C. Lead poisoning
D. Mercury exposure
E. Cyanide poisoning
Answer: B. Botulinum toxin
Rationale:
Botulism causes descending flaccid paralysis with cranial nerve involvement
(ptosis, diplopia, dysphagia). Organophosphates cause SLUDGE symptoms and
bronchorrhea.
Question 7
A 62-year-old woman has postmenopausal bleeding. Endometrial biopsy reveals
endometrial hyperplasia with atypia.
What is the most appropriate management?
A. Observation
B. Progestin therapy only
(CK) LICENSE EXAM/ QUESTIONS AND
100% VERIFIED ANSWERS WITH RATIONALES
GRADED A+ LATEST
Question 1
A 67-year-old man presents with worsening shortness of breath and bilateral leg
swelling for 2 weeks. He has a history of hypertension and myocardial infarction.
On exam, there is elevated JVP, bibasilar crackles, and pitting edema to the knees.
Echocardiography shows reduced ejection fraction of 30%.
Which of the following medications has been shown to reduce mortality in this
condition?
A. Furosemide
B. Digoxin
C. Metoprolol succinate
D. Hydrochlorothiazide
E. Isosorbide dinitrate as monotherapy
Answer: C. Metoprolol succinate
Rationale:
This patient has HFrEF (heart failure with reduced ejection fraction). Evidence-
based therapies that reduce mortality include beta-blockers (metoprolol succinate,
carvedilol, bisoprolol), ACE inhibitors/ARBs, ARNI, MRAs, and SGLT2
inhibitors. Metoprolol succinate improves survival by reducing sympathetic
overactivation and myocardial remodeling.
,Question 2
A 24-year-old woman presents with fever, dysuria, and right flank pain. She is
tachycardic and has costovertebral angle tenderness. Urinalysis shows nitrites,
leukocyte esterase, and white blood cell casts.
What is the most appropriate initial treatment?
A. Oral nitrofurantoin
B. Oral amoxicillin
C. IV ceftriaxone
D. Oral ciprofloxacin only
E. No antibiotics until culture results return
Answer: C. IV ceftriaxone
Rationale:
This is acute pyelonephritis with systemic symptoms. Initial management requires
empiric IV antibiotics such as ceftriaxone or piperacillin-tazobactam depending on
severity. Oral nitrofurantoin is ineffective for upper urinary tract infections.
Question 3
A 58-year-old man with a history of chronic alcohol use presents with confusion,
ataxia, and horizontal nystagmus. He is malnourished and recently hospitalized.
What is the most appropriate immediate treatment?
A. Oral thiamine
B. IV glucose alone
C. IV thiamine before glucose
D. MRI brain
E. Haloperidol
Answer: C. IV thiamine before glucose
,Rationale:
This is Wernicke encephalopathy. Thiamine must be administered before glucose
to prevent worsening neurologic injury due to increased metabolic demand in a
thiamine-deficient brain.
Question 4
A 35-year-old woman presents with episodes of palpitations, headaches, and
sweating. Blood pressure is 180/110 mmHg during episodes. Plasma
metanephrines are elevated.
Which is the next best step in management?
A. Start beta-blocker alone
B. Abdominal CT scan
C. Start ACE inhibitor
D. Renal artery Doppler
E. Low-sodium diet only
Answer: B. Abdominal CT scan
Rationale:
This is pheochromocytoma. After biochemical confirmation (elevated
metanephrines), the next step is tumor localization with CT or MRI. Beta-blockers
should never be started before alpha-blockade.
Question 5
A newborn has cyanosis shortly after birth. Oxygen administration does not
improve saturation. Echocardiography shows transposition of the great arteries.
What is the most immediate lifesaving intervention?
A. Prostaglandin E1 infusion
B. Furosemide
C. Indomethacin
, D. Digoxin
E. Oxygen therapy alone
Answer: A. Prostaglandin E1 infusion
Rationale:
TGA requires maintaining ductus arteriosus patency with prostaglandin E1 to
allow mixing of oxygenated and deoxygenated blood until surgical correction.
Question 6
A 45-year-old man presents with progressive weakness, dry mouth, and blurred
vision. He works in agriculture. Examination shows ptosis and descending
paralysis.
Which toxin is most likely responsible?
A. Organophosphate poisoning
B. Botulinum toxin
C. Lead poisoning
D. Mercury exposure
E. Cyanide poisoning
Answer: B. Botulinum toxin
Rationale:
Botulism causes descending flaccid paralysis with cranial nerve involvement
(ptosis, diplopia, dysphagia). Organophosphates cause SLUDGE symptoms and
bronchorrhea.
Question 7
A 62-year-old woman has postmenopausal bleeding. Endometrial biopsy reveals
endometrial hyperplasia with atypia.
What is the most appropriate management?
A. Observation
B. Progestin therapy only
