USMLE STEP 2 CK CHALLENGING QUESTIONS AND
ANSWERS 2024
Slipped Capital Femoral Epiphysis
requires immediate surgical screw fixation to reduce risk of AVN - ANSWER-Obese
Child
with dull hip PAIN or referred knee pain and a painful limp
with restricted ROM and inability to bear weight
on exam has limited rotation and abduction of the hip
Diagnosis & Tx?
Legg-Calve-Perthes Disease or Idiopathic Osteonecrosis (avascular necrosis) of the
femoral epiphysis.
-Flattened and fragmented femoral head on radiograph
Tx:
Mild: Observation
Moderate: bracing, hip abduction with a petrie cast
Extensive: osteotomy - ANSWER-chronic, progressive leg pain and limp in a 3-12 yo
Boy
Limited abduction and internal rotation. Atrophy of proximal thigh muscles.
Diagnosis & Tx?
pulsus paradoxus
-Associated with cardiac Tamponade
-Becktriad can diagnose acute cardiac tamponade:
1. JVD (Kussmaul sign (increased JVD on inspiration))
2. Hypotension
3. Distant heart sounds
fluid accumulation in pericardial cavity increases intrapericardial pressure restricting
venous return to the heart lowering R & L ventricular filling. Net result = Decreased
Preload, Stroke Volume , Cardiac output. - ANSWER-fall in systemic arterial pressure
by more than 10mmHg during inspiration. What is it? and what cardiac problem is it
associated with?
aortic stenosis
Most common causes:
,1. senile calcific aortic stenosis (Elderly)
2. bicuspid aortic valve (<70 yo)
3. rheumatic heart disease
high resistance generated by stenosed aortic valve causes concentric hypertrophy and
stiffening of the left ventricle (S4) leading to CHF. - ANSWER-Pulsus Parvus
(decreased pulse amplitude) and Pulsus Tardus (delayed pulse upstroke)
(weak,delayed carotid upstroke) and a single or paradoxically split S2 sound;
systolic murmur radiating to the carotids.
associated with what cardiac defect?
aortic regurgitation
-Congenital Bicuspid Aortic Valve, Rheumatic Heart Disease, Endocarditits, Aortic Root
Dilation (Marfan, Syphilis)
-tx: Vasodilator therapy (dihydropyridines or ACEIs) for isolated aortic regurgitation until
symptoms become severe enough to warrant valve replacement. - ANSWER-Bounding
or "water hammer" pulses, with widened pulse pressure and head bob with heartbeat
are associated with what cardiac defect? Common etiologies? Treatment?
meniscal tear
-MRI for diagnosis
-Mild, older patient: REST, NSAID
-Impaired activity, young: SURGERY - ANSWER-Acute popping sensation in knee with
catching, and locking, and slow onset joint effusion. patient complains of sensation of
instability. with joint line tenderness on exam.
What is the problem, Diagnosis, and management?
Pyloric stricture
-Upper Endoscopy required to confirm diagnosis and treatment is surgical.
-Common causes of GASTRIC OUTLET OBSTRUCTION: Gastric malignancy, PUD,
Crohns, Strictures from caustic ingestion, gastric bezoars. - ANSWER-postprandial
pain, vomiting with early satiety. Abdominal succussion splash. Patient ingested acid 3
months ago.
diagnosis? common causes?
diabetic gastroparesis
,-Treat with pro-motility agent such as metoclopramide, exercise, and low fat diet
-Gastric Emptying study would be helpful in evaluating - ANSWER-Chronic nausea,
vomiting and early satiety in a chronic diabetic.
What is the diagnosis? How is it treated?
Friedreich's ataxia
-AR (loss of function trinucleotide repeat (GAA) in Frataxin gene
-Mortality due to cardiac dysfunction (hypertrophic cardiomyopathy)
Genetic testing required to confirm diagnosis.
Management is supportive as no disease modifying therapies are available. - ANSWER-
Adolescent with progressive gait instability, dysarthria, wide based gait, marked atrophy
of medulla and dorsal columns of the spinal cord (loss of vibration and position sense),
and scoliosis.
What is the diagnosis? Risk of mortality?
TRACHOMA ( due to Chlamydia trachomatis)
-Treat with Oral Azithromycin - ANSWER-Child with conjunctival injection, watery
discharge, tarsal inflammation, and pale follicles. As well as rhinorrhea, Pharyngitis.
Diagnosis? Cause? Treatment?
Gonococcal conjunctivitis - ANSWER-Conjunctival injection, eye discharge and swollen
eyelids 2-5 days after birth?
Chlamydial conjunctivitis - ANSWER-Conjunctival injection, eye discharge and swollen
eyelids 5-14 days after birth?
Orbital cellulitis (Infection posterior to orbital septum)
Most common risk factor = SINUSITIS (ethmoid or maxillary)
NEED CT SCAN OF ORBITS AND SINUSES
IV ABX mainstay of tx and drainage - ANSWER-Abrupt onset of fever, proptosis,
restriction of extra ocular movements, swollen, red eyelids. Unilateral. Paranasal sinus
infection.
Diagnosis?
Tardive Dyskinesia
, Dopamine receptor upregulation and supersensitivity, from chronic blockade of
dopamine receptors. From first generation antipsychotics (potent D2 blockers).
Tx: Discontinue med, Switch to second gen antipsychotic (Clozapine), treat with
Valbenazine (Vesicular Monoamine Transporter 2 Inhibitor) - ANSWER-Patient with hx
of Schizoaffective disorder on treatment. Presenting with Orofacial dyskinesia (rhythmic
movements of face, smacking lips, sticking out tongue) and choreoathetoid movement
of trunk and extremities.
Underlying cause? How to treat it?
Huntington's disease
ATROPHY of the CAUDATE
AD
30-50yo - ANSWER-Choreiform movements (facial grimacing, ataxia, dystonia, tongue
protrusion, writhing movements), Psychiatric symptoms, dementia. Caudate nucleus
atrophy on MRI.
Diagnosis?
imperforate hymen
-Hymenal incision and drainage - ANSWER-Cyclic lower abdominal pain, Bulk
symptoms (defecatory and urinary dysfunction), primary amenorrhea, suprapubic mass,
blue tinged vaginal mass (Hematocolpos).
Diagnosis and treatment?
missed abortion - ANSWER-No vaginal bleeding, Closed Cervical Os, No fetal cardiac
activity or empty sac.
Type of Miscarriage?
threatened abortion - ANSWER-Vaginal Bleeding, Closed cervical os, Fetal cardiac
activity.
Type of miscarriage?
Inevitable abortion - ANSWER-Vaginal bleeding, dilated cervical os, products of
conception seen or felt at or above cervical os.
Type of miscarriage?
ANSWERS 2024
Slipped Capital Femoral Epiphysis
requires immediate surgical screw fixation to reduce risk of AVN - ANSWER-Obese
Child
with dull hip PAIN or referred knee pain and a painful limp
with restricted ROM and inability to bear weight
on exam has limited rotation and abduction of the hip
Diagnosis & Tx?
Legg-Calve-Perthes Disease or Idiopathic Osteonecrosis (avascular necrosis) of the
femoral epiphysis.
-Flattened and fragmented femoral head on radiograph
Tx:
Mild: Observation
Moderate: bracing, hip abduction with a petrie cast
Extensive: osteotomy - ANSWER-chronic, progressive leg pain and limp in a 3-12 yo
Boy
Limited abduction and internal rotation. Atrophy of proximal thigh muscles.
Diagnosis & Tx?
pulsus paradoxus
-Associated with cardiac Tamponade
-Becktriad can diagnose acute cardiac tamponade:
1. JVD (Kussmaul sign (increased JVD on inspiration))
2. Hypotension
3. Distant heart sounds
fluid accumulation in pericardial cavity increases intrapericardial pressure restricting
venous return to the heart lowering R & L ventricular filling. Net result = Decreased
Preload, Stroke Volume , Cardiac output. - ANSWER-fall in systemic arterial pressure
by more than 10mmHg during inspiration. What is it? and what cardiac problem is it
associated with?
aortic stenosis
Most common causes:
,1. senile calcific aortic stenosis (Elderly)
2. bicuspid aortic valve (<70 yo)
3. rheumatic heart disease
high resistance generated by stenosed aortic valve causes concentric hypertrophy and
stiffening of the left ventricle (S4) leading to CHF. - ANSWER-Pulsus Parvus
(decreased pulse amplitude) and Pulsus Tardus (delayed pulse upstroke)
(weak,delayed carotid upstroke) and a single or paradoxically split S2 sound;
systolic murmur radiating to the carotids.
associated with what cardiac defect?
aortic regurgitation
-Congenital Bicuspid Aortic Valve, Rheumatic Heart Disease, Endocarditits, Aortic Root
Dilation (Marfan, Syphilis)
-tx: Vasodilator therapy (dihydropyridines or ACEIs) for isolated aortic regurgitation until
symptoms become severe enough to warrant valve replacement. - ANSWER-Bounding
or "water hammer" pulses, with widened pulse pressure and head bob with heartbeat
are associated with what cardiac defect? Common etiologies? Treatment?
meniscal tear
-MRI for diagnosis
-Mild, older patient: REST, NSAID
-Impaired activity, young: SURGERY - ANSWER-Acute popping sensation in knee with
catching, and locking, and slow onset joint effusion. patient complains of sensation of
instability. with joint line tenderness on exam.
What is the problem, Diagnosis, and management?
Pyloric stricture
-Upper Endoscopy required to confirm diagnosis and treatment is surgical.
-Common causes of GASTRIC OUTLET OBSTRUCTION: Gastric malignancy, PUD,
Crohns, Strictures from caustic ingestion, gastric bezoars. - ANSWER-postprandial
pain, vomiting with early satiety. Abdominal succussion splash. Patient ingested acid 3
months ago.
diagnosis? common causes?
diabetic gastroparesis
,-Treat with pro-motility agent such as metoclopramide, exercise, and low fat diet
-Gastric Emptying study would be helpful in evaluating - ANSWER-Chronic nausea,
vomiting and early satiety in a chronic diabetic.
What is the diagnosis? How is it treated?
Friedreich's ataxia
-AR (loss of function trinucleotide repeat (GAA) in Frataxin gene
-Mortality due to cardiac dysfunction (hypertrophic cardiomyopathy)
Genetic testing required to confirm diagnosis.
Management is supportive as no disease modifying therapies are available. - ANSWER-
Adolescent with progressive gait instability, dysarthria, wide based gait, marked atrophy
of medulla and dorsal columns of the spinal cord (loss of vibration and position sense),
and scoliosis.
What is the diagnosis? Risk of mortality?
TRACHOMA ( due to Chlamydia trachomatis)
-Treat with Oral Azithromycin - ANSWER-Child with conjunctival injection, watery
discharge, tarsal inflammation, and pale follicles. As well as rhinorrhea, Pharyngitis.
Diagnosis? Cause? Treatment?
Gonococcal conjunctivitis - ANSWER-Conjunctival injection, eye discharge and swollen
eyelids 2-5 days after birth?
Chlamydial conjunctivitis - ANSWER-Conjunctival injection, eye discharge and swollen
eyelids 5-14 days after birth?
Orbital cellulitis (Infection posterior to orbital septum)
Most common risk factor = SINUSITIS (ethmoid or maxillary)
NEED CT SCAN OF ORBITS AND SINUSES
IV ABX mainstay of tx and drainage - ANSWER-Abrupt onset of fever, proptosis,
restriction of extra ocular movements, swollen, red eyelids. Unilateral. Paranasal sinus
infection.
Diagnosis?
Tardive Dyskinesia
, Dopamine receptor upregulation and supersensitivity, from chronic blockade of
dopamine receptors. From first generation antipsychotics (potent D2 blockers).
Tx: Discontinue med, Switch to second gen antipsychotic (Clozapine), treat with
Valbenazine (Vesicular Monoamine Transporter 2 Inhibitor) - ANSWER-Patient with hx
of Schizoaffective disorder on treatment. Presenting with Orofacial dyskinesia (rhythmic
movements of face, smacking lips, sticking out tongue) and choreoathetoid movement
of trunk and extremities.
Underlying cause? How to treat it?
Huntington's disease
ATROPHY of the CAUDATE
AD
30-50yo - ANSWER-Choreiform movements (facial grimacing, ataxia, dystonia, tongue
protrusion, writhing movements), Psychiatric symptoms, dementia. Caudate nucleus
atrophy on MRI.
Diagnosis?
imperforate hymen
-Hymenal incision and drainage - ANSWER-Cyclic lower abdominal pain, Bulk
symptoms (defecatory and urinary dysfunction), primary amenorrhea, suprapubic mass,
blue tinged vaginal mass (Hematocolpos).
Diagnosis and treatment?
missed abortion - ANSWER-No vaginal bleeding, Closed Cervical Os, No fetal cardiac
activity or empty sac.
Type of Miscarriage?
threatened abortion - ANSWER-Vaginal Bleeding, Closed cervical os, Fetal cardiac
activity.
Type of miscarriage?
Inevitable abortion - ANSWER-Vaginal bleeding, dilated cervical os, products of
conception seen or felt at or above cervical os.
Type of miscarriage?
