USMLE Step 2 CK Exam Questions and Answers (2025
Edition) – 300+ NBME-Style Clinical Case Questions with
Verified Answers, High-Yield Explanations & Step-by-Step
Rationales
1. A 21-year-old man comes to student health services because of a 6-month history of increasingly frequent episodes of moderate
chest pain. The first episode occurred while he was sitting in traffic and feeling stressed because he was late for a college class.
At that time, he had the sudden onset of moderate chest pain, a rapid heartbeat, sweating, and nausea. He says he felt as though
he were going to die. The episode lasted approximately 10 minutes. He had a similar episode 1 month later while on a date; the
symptoms were so severe that he abruptly ended the date. During the past 3 weeks, he has experienced two to three episodes
weekly. He says he fears having an episode while in public or on a date, so he has decreased his participation in social activities
and the amount of time he spends outside of his apartment. He has no history of serious illness and takes no medications. He does
not drink alcohol or use other substances. Vital signs are within normal limits. Physical examination discloses no abnormalities.
On mental status examination, he has an anxious mood and full range of affect. Which of the following is the most likely
diagnosis?
(A) Agoraphobia
(B) Generalized anxiety disorder
(C) Illness anxiety disorder (hypochondriasis)
(D) Social anxiety disorder (social phobia)
(E) Somatic symptom disorder
2. A 35-year-old man is brought to the emergency department by a friend 30 minutes after the sudden onset of right-sided weakness
and difficulty speaking. The symptoms began while he was lifting weights at the gym. He has not had headache or changes in
vision. He has no history of serious illness and takes no medications. He does not smoke cigarettes or drink alcohol. He exercises
regularly. His speech is incoherent, but he can understand what others are saying. Vital signs are within normal limits. No bruits
are heard over the carotid arteries. Cardiopulmonary examination shows no abnormalities. There is swelling and mild tenderness
of the right lower extremity. No cords are palpated. Neurologic examination shows a right facial droop and right upper extremity
weakness. An MRI of the brain shows an acute stroke in the left middle cerebral artery territory. Carotid ultrasonography shows
no abnormalities. Which of the following is the most appropriate next step in diagnosis?
(A) Adenosine stress test
(B) Cardiac catheterization
(C) Cardiac MRI with gadolinium
(D) CT angiography
(E) Echocardiography with bubble study
3. A 65-year-old man comes to the office because of a 2-year history of progressive shortness of breath on exertion and a 6-month
history of nonproductive cough. He now has shortness of breath when walking to his mailbox. He has not had fever, weight loss,
or chest pain. He has not had recent sick contacts, has had no occupational exposures, and does not own any pets. He has difficult-
to-control atrial fibrillation, hypertension, chronic obstructive pulmonary disease, and migraines. Medications are amiodarone,
warfarin, lisinopril, tiotropium, and propranolol. Temperature is 37.0°C (98.6°F), pulse is 80/min and irregular, respirations are
16/min, and blood pressure is 110/70 mm Hg. There is no jugular venous distention. Auscultation of the lungs discloses fine
crackles bilaterally, both anteriorly and posteriorly, but no egophony. The remainder of the physical examination discloses no
abnormalities. An adverse effect of which of the following medications is the most likely cause of these findings?
(A) Amiodarone
1
, (B) Lisinopril
(C) Propranolol
(D) Tiotropium
(E) Warfarin
4. An 18-month-old boy is brought to the emergency department by his mother 30 minutes after he fell from his bed onto the floor.
Two months ago, he sustained a fracture of the right humerus when he fell while playing in the park. The fracture healed quickly
with immobilization and casting. His mother sustained several bone fractures in early childhood, but she currently does not have
any medical concerns. On arrival, the boy is crying. Pulse is 162/min, respirations are 48/min, and blood pressure is 122/80 mm
Hg. Examination discloses bluish sclera and ecchymoses and tenderness over the right tibia. X-ray of the right lower extremity
confirms a fracture of the tibia. The right lower extremity is immobilized with a cast. Limitation of physical activity is
recommended to prevent future fractures. Given this patient's condition, it is most appropriate for which of the following types
of screening to be done regularly?
(A) Audiography
(B) DEXA scan
(C) Echocardiography
(D) Retinal examination
(E) Serum calcium and vitamin D concentrations
5. A 70-year-old woman is admitted to the hospital because of a 1-hour history of shortness of breath. She has lung cancer and
dementia, Alzheimer type, and has had a decline in mental status during the past month. She lives with her boyfriend of 20 years;
he has cared for her and has taken care of the home since she was diagnosed with dementia 2 years ago. She has one adult son
who lives out of state, but she speaks to him on the phone daily. The patient's neighbor, who is a nurse and a long-term friend,
takes her to all medical appointments and ensures she takes her medications appropriately. The patient is unable to understand
the poor prognosis of her condition. She has not designated a health care power of attorney. Which of the following is the most
appropriate person to make medical decisions for this patient?
(A) Boyfriend
(B) Neighbor
(C) Patient
(D) Physician
(E) Son
6. A 4-month-old female infant is recovering in the hospital 5 days after uncomplicated surgical repair of a ventricular septal defect
via median sternotomy utilizing cardiopulmonary bypass. She was extubated on postoperative day 1 and by postoperative day 4
she was no longer receiving any inotropic infusions or intravenous drugs. She is breast-feeding well; plans are made for discharge
from the hospital the next morning. However, on the next morning she develops a temperature of 38.8°C (101.8°F), cool and
clammy skin, cold distal extremities, delayed capillary refill, and minimal urine output. Cardiac rhythm strip and tracing of arterial
blood pressure are shown. Which of the following is the most appropriate next step in evaluation?
(A) Cardiac catheterization
(B) CT angiography
(C) Echocardiography
(D) Electrophysiology study
(E) MRI of the heart
2
,7. Patient Information
Age: 6 years
Sex Assigned at Birth: F
Race/Ethnicity: unspecified
Site of Care: emergency department
History
Reason for Visit/Chief Concern: "My daughter's eyes and legs are swollen."
History of Present Illness:
• 2-week history of cough, congestion, and runny nose that seems to be improving
• parents report the patient's eyes seemed swollen 4 days ago, which they initially attributed to the patient's cold
• 2-day history of swelling over the tops of her feet
• this morning she was unable to put on her shoes because her feet were too swollen
Past Medical History:
• unremarkable
Medications:
• none
Vaccinations:
• up-to-date
Allergies:
• no known drug allergies
Family History:
• mother age 30 years, father age 32 years, and twin sisters age 10 years: alive with no chronic conditions
Physical Examination
Temp Pulse Resp BP O2 Sat Ht Wt BMI
37.0°C 140/min 20/min 120/70 mm Hg 99% 115 cm (3 ft 9 25 kg (55 lb) 19 kg/m2
in)
(98.6°F) on RA 50th %ile 90th %ile 95th %ile
• Appearance: mildly uncomfortable
• Skin: 2+ pitting edema of both extremities up to the knees
• HEENT: periorbital edema, no erythema; PERRLA; ocular movements are intact
• Pulmonary: clear to auscultation
• Cardiac: regular rhythm; no murmurs
• Abdominal: normoactive bowel sounds; soft, mildly distended, mildly tender to palpation in all quadrants
Diagnostic Studies
Urine
Specific gravity 1.020 (N=1.003–1.029)
Protein Large
Ketones Negative
Blood Negative
Leukocyte esterase Negative
WBCs Negative
RBCs 5–10/hpf
Question: Which of the following additional laboratory findings are most likely to be decreased in this patient?
(A) Hemoglobin
(B) Serum albumin concentration
(C) Serum C3 and C4 concentrations
(D) Serum triglycerides concentration
(E) Serum urea nitrogen concentration
3
, 8. A 9-year-old girl is brought to the clinic for a routine examination. She has a 4-year history of asthma. Her only medication is
inhaled albuterol with a spacer as needed. She uses it only occasionally and has not used it at all during the past 4 weeks. Her
father reports that his daughter has an episode of coughing that awakens her at night once weekly. He also says that his daughter
has a sedentary lifestyle because "she coughs if she runs too much." No one in the family smokes cigarettes, and there are no
pets. Gas heaters are used in the home. The patient is at the 25th percentile for height and 90th percentile for weight and BMI.
Respirations are 16/min. Lungs are clear to auscultation. There is no clubbing of the digits. The remainder of the examination
shows no abnormalities. Which of the following is the most appropriate next step in management?
(A) Add oral theophylline to the regimen
(B) Add fluticasone by metered-dose inhaler with a spacer to the regimen
(C) Add salmeterol by metered-dose inhaler with a spacer to the regimen
(D) Begin a 5-day course of oral prednisone
(E) No change in management is necessary
9. A 30-year-old man comes to the office to establish primary care. Medical history is unremarkable and he takes no medications.
His father had a myocardial infarction at age 48 years. The patient has smoked one-half pack of cigarettes daily for 10 years. He
does not drink alcoholic beverages. He is 168 cm (5 ft 6 in) tall and weighs 82 kg (180 lb); BMI is 29 kg/m 2. Vital signs are
within normal limits. The patient is not in distress. Physical examination discloses no abnormalities. Smoking cessation is
recommended. Which of the following is the most appropriate screening study for this patient at this time?
(A) ECG
(B) Fasting serum lipid studies
(C) Serum chemistry profile
(D) No screening studies are indicated
10. An 82-year-old woman comes to the office because of a 1-month history of increasing numbness of her feet. She has no history
of serious illness. She has taken over-the-counter calcium carbonate tablets for intermittent abdominal pain during the past 40
years; she takes no other medications. She has drunk two glasses of wine with dinner nightly for 50 years. On examination,
gastrocnemius deep tendon reflexes are absent. Babinski sign is absent bilaterally. Light touch to the distal lower extremities and
feet produces a tingling sensation. Sensation to vibration over the great toes is severely decreased. There is a mild to moderate
decrease in proprioception of the great toes. Which of the following is most likely to prevent progression of these neurologic
findings?
(A) Alcohol cessation
(B) Calcium carbonate cessation
(C) Folic acid supplementation
(D) Niacin supplementation
(E) Vitamin B1 (thiamine) supplementation
(F) Vitamin B12 (cyanocobalamin) supplementation
4
Edition) – 300+ NBME-Style Clinical Case Questions with
Verified Answers, High-Yield Explanations & Step-by-Step
Rationales
1. A 21-year-old man comes to student health services because of a 6-month history of increasingly frequent episodes of moderate
chest pain. The first episode occurred while he was sitting in traffic and feeling stressed because he was late for a college class.
At that time, he had the sudden onset of moderate chest pain, a rapid heartbeat, sweating, and nausea. He says he felt as though
he were going to die. The episode lasted approximately 10 minutes. He had a similar episode 1 month later while on a date; the
symptoms were so severe that he abruptly ended the date. During the past 3 weeks, he has experienced two to three episodes
weekly. He says he fears having an episode while in public or on a date, so he has decreased his participation in social activities
and the amount of time he spends outside of his apartment. He has no history of serious illness and takes no medications. He does
not drink alcohol or use other substances. Vital signs are within normal limits. Physical examination discloses no abnormalities.
On mental status examination, he has an anxious mood and full range of affect. Which of the following is the most likely
diagnosis?
(A) Agoraphobia
(B) Generalized anxiety disorder
(C) Illness anxiety disorder (hypochondriasis)
(D) Social anxiety disorder (social phobia)
(E) Somatic symptom disorder
2. A 35-year-old man is brought to the emergency department by a friend 30 minutes after the sudden onset of right-sided weakness
and difficulty speaking. The symptoms began while he was lifting weights at the gym. He has not had headache or changes in
vision. He has no history of serious illness and takes no medications. He does not smoke cigarettes or drink alcohol. He exercises
regularly. His speech is incoherent, but he can understand what others are saying. Vital signs are within normal limits. No bruits
are heard over the carotid arteries. Cardiopulmonary examination shows no abnormalities. There is swelling and mild tenderness
of the right lower extremity. No cords are palpated. Neurologic examination shows a right facial droop and right upper extremity
weakness. An MRI of the brain shows an acute stroke in the left middle cerebral artery territory. Carotid ultrasonography shows
no abnormalities. Which of the following is the most appropriate next step in diagnosis?
(A) Adenosine stress test
(B) Cardiac catheterization
(C) Cardiac MRI with gadolinium
(D) CT angiography
(E) Echocardiography with bubble study
3. A 65-year-old man comes to the office because of a 2-year history of progressive shortness of breath on exertion and a 6-month
history of nonproductive cough. He now has shortness of breath when walking to his mailbox. He has not had fever, weight loss,
or chest pain. He has not had recent sick contacts, has had no occupational exposures, and does not own any pets. He has difficult-
to-control atrial fibrillation, hypertension, chronic obstructive pulmonary disease, and migraines. Medications are amiodarone,
warfarin, lisinopril, tiotropium, and propranolol. Temperature is 37.0°C (98.6°F), pulse is 80/min and irregular, respirations are
16/min, and blood pressure is 110/70 mm Hg. There is no jugular venous distention. Auscultation of the lungs discloses fine
crackles bilaterally, both anteriorly and posteriorly, but no egophony. The remainder of the physical examination discloses no
abnormalities. An adverse effect of which of the following medications is the most likely cause of these findings?
(A) Amiodarone
1
, (B) Lisinopril
(C) Propranolol
(D) Tiotropium
(E) Warfarin
4. An 18-month-old boy is brought to the emergency department by his mother 30 minutes after he fell from his bed onto the floor.
Two months ago, he sustained a fracture of the right humerus when he fell while playing in the park. The fracture healed quickly
with immobilization and casting. His mother sustained several bone fractures in early childhood, but she currently does not have
any medical concerns. On arrival, the boy is crying. Pulse is 162/min, respirations are 48/min, and blood pressure is 122/80 mm
Hg. Examination discloses bluish sclera and ecchymoses and tenderness over the right tibia. X-ray of the right lower extremity
confirms a fracture of the tibia. The right lower extremity is immobilized with a cast. Limitation of physical activity is
recommended to prevent future fractures. Given this patient's condition, it is most appropriate for which of the following types
of screening to be done regularly?
(A) Audiography
(B) DEXA scan
(C) Echocardiography
(D) Retinal examination
(E) Serum calcium and vitamin D concentrations
5. A 70-year-old woman is admitted to the hospital because of a 1-hour history of shortness of breath. She has lung cancer and
dementia, Alzheimer type, and has had a decline in mental status during the past month. She lives with her boyfriend of 20 years;
he has cared for her and has taken care of the home since she was diagnosed with dementia 2 years ago. She has one adult son
who lives out of state, but she speaks to him on the phone daily. The patient's neighbor, who is a nurse and a long-term friend,
takes her to all medical appointments and ensures she takes her medications appropriately. The patient is unable to understand
the poor prognosis of her condition. She has not designated a health care power of attorney. Which of the following is the most
appropriate person to make medical decisions for this patient?
(A) Boyfriend
(B) Neighbor
(C) Patient
(D) Physician
(E) Son
6. A 4-month-old female infant is recovering in the hospital 5 days after uncomplicated surgical repair of a ventricular septal defect
via median sternotomy utilizing cardiopulmonary bypass. She was extubated on postoperative day 1 and by postoperative day 4
she was no longer receiving any inotropic infusions or intravenous drugs. She is breast-feeding well; plans are made for discharge
from the hospital the next morning. However, on the next morning she develops a temperature of 38.8°C (101.8°F), cool and
clammy skin, cold distal extremities, delayed capillary refill, and minimal urine output. Cardiac rhythm strip and tracing of arterial
blood pressure are shown. Which of the following is the most appropriate next step in evaluation?
(A) Cardiac catheterization
(B) CT angiography
(C) Echocardiography
(D) Electrophysiology study
(E) MRI of the heart
2
,7. Patient Information
Age: 6 years
Sex Assigned at Birth: F
Race/Ethnicity: unspecified
Site of Care: emergency department
History
Reason for Visit/Chief Concern: "My daughter's eyes and legs are swollen."
History of Present Illness:
• 2-week history of cough, congestion, and runny nose that seems to be improving
• parents report the patient's eyes seemed swollen 4 days ago, which they initially attributed to the patient's cold
• 2-day history of swelling over the tops of her feet
• this morning she was unable to put on her shoes because her feet were too swollen
Past Medical History:
• unremarkable
Medications:
• none
Vaccinations:
• up-to-date
Allergies:
• no known drug allergies
Family History:
• mother age 30 years, father age 32 years, and twin sisters age 10 years: alive with no chronic conditions
Physical Examination
Temp Pulse Resp BP O2 Sat Ht Wt BMI
37.0°C 140/min 20/min 120/70 mm Hg 99% 115 cm (3 ft 9 25 kg (55 lb) 19 kg/m2
in)
(98.6°F) on RA 50th %ile 90th %ile 95th %ile
• Appearance: mildly uncomfortable
• Skin: 2+ pitting edema of both extremities up to the knees
• HEENT: periorbital edema, no erythema; PERRLA; ocular movements are intact
• Pulmonary: clear to auscultation
• Cardiac: regular rhythm; no murmurs
• Abdominal: normoactive bowel sounds; soft, mildly distended, mildly tender to palpation in all quadrants
Diagnostic Studies
Urine
Specific gravity 1.020 (N=1.003–1.029)
Protein Large
Ketones Negative
Blood Negative
Leukocyte esterase Negative
WBCs Negative
RBCs 5–10/hpf
Question: Which of the following additional laboratory findings are most likely to be decreased in this patient?
(A) Hemoglobin
(B) Serum albumin concentration
(C) Serum C3 and C4 concentrations
(D) Serum triglycerides concentration
(E) Serum urea nitrogen concentration
3
, 8. A 9-year-old girl is brought to the clinic for a routine examination. She has a 4-year history of asthma. Her only medication is
inhaled albuterol with a spacer as needed. She uses it only occasionally and has not used it at all during the past 4 weeks. Her
father reports that his daughter has an episode of coughing that awakens her at night once weekly. He also says that his daughter
has a sedentary lifestyle because "she coughs if she runs too much." No one in the family smokes cigarettes, and there are no
pets. Gas heaters are used in the home. The patient is at the 25th percentile for height and 90th percentile for weight and BMI.
Respirations are 16/min. Lungs are clear to auscultation. There is no clubbing of the digits. The remainder of the examination
shows no abnormalities. Which of the following is the most appropriate next step in management?
(A) Add oral theophylline to the regimen
(B) Add fluticasone by metered-dose inhaler with a spacer to the regimen
(C) Add salmeterol by metered-dose inhaler with a spacer to the regimen
(D) Begin a 5-day course of oral prednisone
(E) No change in management is necessary
9. A 30-year-old man comes to the office to establish primary care. Medical history is unremarkable and he takes no medications.
His father had a myocardial infarction at age 48 years. The patient has smoked one-half pack of cigarettes daily for 10 years. He
does not drink alcoholic beverages. He is 168 cm (5 ft 6 in) tall and weighs 82 kg (180 lb); BMI is 29 kg/m 2. Vital signs are
within normal limits. The patient is not in distress. Physical examination discloses no abnormalities. Smoking cessation is
recommended. Which of the following is the most appropriate screening study for this patient at this time?
(A) ECG
(B) Fasting serum lipid studies
(C) Serum chemistry profile
(D) No screening studies are indicated
10. An 82-year-old woman comes to the office because of a 1-month history of increasing numbness of her feet. She has no history
of serious illness. She has taken over-the-counter calcium carbonate tablets for intermittent abdominal pain during the past 40
years; she takes no other medications. She has drunk two glasses of wine with dinner nightly for 50 years. On examination,
gastrocnemius deep tendon reflexes are absent. Babinski sign is absent bilaterally. Light touch to the distal lower extremities and
feet produces a tingling sensation. Sensation to vibration over the great toes is severely decreased. There is a mild to moderate
decrease in proprioception of the great toes. Which of the following is most likely to prevent progression of these neurologic
findings?
(A) Alcohol cessation
(B) Calcium carbonate cessation
(C) Folic acid supplementation
(D) Niacin supplementation
(E) Vitamin B1 (thiamine) supplementation
(F) Vitamin B12 (cyanocobalamin) supplementation
4
