USMLE Step 2 Free 120 — Answer Explanations + Tutor Insights

This write-up aligns with the official Step 2 CK “Sample Test Questions” set, commonly called the “Free 120.” The official materials are available via the USMLE Step 2 CK sample questions page (PDF + interactive experience).

MedBoard Design Principles

The "one-sentence" frame

Start every question with: age + setting + key syndrome + the one risk factor that matters. That sentence should make the correct answer feel inevitable.

Discriminators beat encyclopedias

On Step 2, the best choice is usually the option that changes management now, not the option that "adds information." Prioritize safety, reversibility, and time-sensitivity.

NBME-style wrong answers

Most distractors are "right test/right drug, wrong moment" or "right disease, wrong vignette." Your job is to point to the missing discriminator.

Tutor Insight replaces generic tips

Each explanation ends with a practical connection: a quick decision rule, common trap, or high-yield association you'll reuse across Step 2 and shelves.

Score Interpretation & Readiness Heuristics

The Step 2 Free 120 reports a percent-correct. Step 2 CK is a scaled score, and there is no official direct percent-to-score conversion. Use the Free 120 primarily to assess timing, stamina, and whether misses are “knowledge gaps” versus “process errors.”

What “Small Score Differences” Mean And Why You Shouldn’t Over-interpret Tiny Changes

USMLE publishes score precision metrics (e.g., Step 2 CK standard error of measurement is ~6 points; other error indices are in the same single-digit range). Practically: small differences across practice forms can be noise rather than true change, especially if your study approach didn’t change.

Practical Readiness Bands (Percent-Correct On Free 120)

Free 120 %	What it usually suggests	What to do next
< 60%	Gaps are broad and/or process is unstable (timing, misreads, anchoring).	Shift to targeted systems review + daily timed blocks + error log; re-test after a real change in approach.
60–69%	Borderline zone; readiness depends on trend, other assessments, and how "clean" the misses are.	Patch high-yield weak areas, fix process errors, and look for stability across multiple recent standardized tests.
70–79%	Often a good readiness signal if consistent and your other self-assessments match.	Optimize test-day execution: pacing, second-best traps, and endurance.
80%+	Typically strong content + strong process.	Protect your performance: avoid burnout, keep practice exam cadence, drill weak niches only.

Important: these are rule-of-thumb readiness bands, not a score predictor. Also note: USMLE adjusted the Step 2 CK passing standard (effective July 1, 2025 for examinees testing on/after that date). Check current USMLE announcements for the latest pass standard.

Quick Answer Key

Q#	Answer	Q#	Answer
1	CT abdomen/pelvis	2	Vitamin B12 supplementation
3	Nebulized epinephrine	4	Provide palliative therapy only
5	Learning disorder	6	Vulvar biopsy
7	Serum lipid studies	8	Adverse effect of TMP-SMX (agranulocytosis)
9	Physical therapy	10	Knee: no imaging; Ankle: X-ray
11	Plasma/urine catecholamines & metanephrines	12	Insulin therapy
13	Acute left ventricular failure	14	No additional diagnostic steps
15	Extrapolation beyond data	16	Penicillin prophylaxis
17	Lymphopenia	18	Esophagogastroduodenoscopy
19	Endoscopic hemostatic therapy	20	Azithromycin
21	Levothyroxine therapy	22	Methamphetamine use
23	Acute kidney injury	24	Giardia lamblia
25	Observation only	26	Zenker diverticulum
27	Expectant management	28	Endoscopy
29	Contact adult protective services	30	Add inhaled fluticasone
31	Premature closure	32	Cat-scratch disease
33	Ductal carcinoma in situ	34	Tube thoracostomy
35	No additional testing indicated	36	Subacute thyroiditis
37	Buspirone	38	Epinephrine
39	Smoking cessation	40	Cognitive behavioral therapy
41	Ask staff about barriers to catheter removal	42	Rh(D) immune globulin
43	Kaposi sarcoma	44	Elder neglect
45	Patient decides (has capacity)	46	Alcohol abstinence
47	Mirtazapine	48	Serum albumin
49	Contact organ bank (OPO)	50	Intralesional corticosteroid
51	Ruptured abdominal aortic aneurysm	52	DASH diet
53	IV 3% saline bolus	54	Albuterol
55	Urine + plasma osmolality	56	Coronary artery disease
57	Diagnosis-driven chart reminders	58	Parkinson's disease
59	Agoraphobia	60	Transabdominal ultrasound
61	Bone age X-ray (hand/wrist)	62	Hepatocellular carcinoma
63	Pulmonary infarction	64	Spinal stenosis
65	Early gestational diabetes testing	66	Excess alcohol use
67	Central eschar (brown recluse)	68	Pericardiocentesis
69	Soap and water handwashing	70	Audiography
71	Unclear efficacy difference (dose-dependent)	72	2-week trial duration limitation
73	Publication bias	74	Pulmonary function testing
75	Bladder ultrasonography	76	Female factor infertility
77	Macular degeneration	78	Surgical biopsy of oral lesion
79	No further management	80	Small vessel disease
81	Factor VIII concentrate	82	Stop case: consent form missing
83	Dilated cardiomyopathy	84	Sputum culture
85	Fasting lipid studies	86	Serum FSH
87	Poison ivy/oak/sumac (flora)	88	Renal/bladder ultrasound
89	Dicloxacillin	90	↑Glucose, ↑Insulin, ↓Receptor responsiveness
91	Post-MI depression increases mortality risk	92	Monthly immune globulin replacement
93	Review drug–drug interaction	94	Explain futility / goals of care
95	Hypersensitivity pneumonitis	96	Amiodarone
97	Remove impaired physician + report internally	98	Preterm labor risk (uterine anomaly)
99	Lithium	100	No endocarditis prophylaxis
101	Assess alcohol/smoking/stress	102	Heat avoidance
103	Thyrotoxicosis	104	ARR = 2.6 per 1000 woman-years
105	Weight bear as tolerated; no further workup	106	Discuss adoption early
107	Gout	108	Vaginal discharge (BV) as key risk
109	Lyme antibody	110	Chronic myeloid leukemia
111	Neurogenic bladder	112	Normal adolescent development
113	Structured briefings + daily huddles	114	HIV RNA PCR
115	Son is surrogate	116	CT abdomen
117	Diverticulosis	118	Echocardiography
119	No abnormalities (factitious insulin)	120	Surgical debridement

Answer Explanations

Block 1 (1-40)

Question 1 — Flank pain + hematuria + hydronephrosis

Renal

Answer: CT abdomen/pelvis.

Why this is correct

• Colicky unilateral flank/lumbar pain + vomiting + hematuria + hydroureter/hydronephrosis is ureteral obstruction from a stone until proven otherwise.
• Noncontrast CT A/P localizes stones and defines obstruction level, which guides management.

Why the others are wrong (common wrong turns)

• Reflux studies (VCUG, radionuclide cystography) are for vesicoureteral reflux, not stone localization.
• Nuclear renal scans (e.g., MAG-3) help functional obstruction questions, usually after initial anatomy is clearer.

Tutor Insight

When the vignette already screams "stone," pick the test that finds stones (CT), not the test that finds reflux or renal perfusion problems.

Question 2 — Distal sensory loss + vibration/proprioception loss

Neuro

Answer: Vitamin B12 (cyanocobalamin) supplementation.

Why this is correct

• Loss of vibration/proprioception + neuropathy pattern points to posterior column involvement (subacute combined degeneration) and peripheral neuropathy from B12 deficiency.
• Management begins with replacing B12; don't "wait it out" because neurologic injury can become irreversible.

Why the others are wrong

• Folate treats megaloblastic anemia but does not fix (and can mask) B12-related neurologic disease.
• Niacin deficiency is pellagra (diarrhea/dermatitis/dementia); thiamine is Wernicke/beriberi—different syndromes.

Tutor Insight

On Step 2, vibration/proprioception loss is your B12 "alarm bell." Treat deficiency first; then work backward to the cause.

Question 3 — Croup with stridor at rest

Peds

Answer: Nebulized epinephrine.

Why this is correct

• Barking cough + hoarseness + inspiratory stridor after URI = viral croup.
• Stridor at rest with retractions = moderate/severe; nebulized epinephrine provides rapid reduction of upper-airway edema.
• (Steroids like dexamethasone are important too, but epi is the immediate relief step when severity is high.)

Why the others are wrong

• Albuterol targets lower-airway bronchospasm (wheeze), not upper-airway edema (stridor).
• Oral steroids help but aren't the fastest rescue for significant stridor at rest.

Tutor Insight

Two sounds, two locations: stridor = upper airway; wheeze = lower airway. Pick the drug that matches the anatomy.

Question 4 — End-stage cancer + previously expressed wishes

Ethics

Answer: Provide palliative therapy only.

Why this is correct

• When a patient's wishes are known (even verbally to a close surrogate), those wishes guide care in the absence of a written directive.
• Intubating "first and then deciding" violates the patient's stated refusal of mechanical ventilation.

Why the others are wrong

• Ethics consults are useful when wishes are unclear—not when the patient's preference is specific and credible.
• Court processes are too slow and unnecessary for an immediate, time-sensitive decision with clear prior wishes.

Tutor Insight

Ethics questions are usually about sequencing: first, capacity and patient wishes; then, surrogate hierarchy; then, ethics/legal escalation.

Question 5 — Reading difficulty with average IQ

Psych/Peds

Answer: Learning disorder.

Why this is correct

• Specific academic impairment (reading) despite average intelligence and functional daily skills is the hallmark of a specific learning disorder.
• Institutionalization can delay development, but the key is a focal academic deficit rather than global impairment.

Why the others are wrong

• Intellectual disability requires deficits in intellectual function and adaptive functioning; an average IQ argues against it.
• Autism/reactive attachment require core social/attachment pattern problems beyond isolated reading failure.

Tutor Insight

When you see "average IQ" explicitly, the test is steering you away from global cognitive diagnoses and toward domain-specific ones.

Question 6 — Elderly with suspicious vulvar lesion

Gyn/Onc

Answer: Biopsy of the vulva.

Why this is correct

• A new raised/fleshy vulvar lesion in an older woman is cancer until proven otherwise.
• Definitive diagnosis requires tissue. Imaging is staging, not first-line diagnosis.

Why the others are wrong

• Empiric antifungal/steroid therapy is inappropriate without a clear benign inflammatory/infectious pattern.
• CT/colonoscopy don't answer "what is this lesion?"—biopsy does.

Tutor Insight

For skin/mucosal lesions that could be malignancy, "look" is not enough. Step 2 wants "tissue is the issue."

Question 7 — PAD signs (absent pulses, femoral bruit)

Vascular

Answer: Serum lipid studies.

Why this is correct

• Peripheral arterial disease is a systemic atherosclerotic disease; risk-factor modification reduces MI/stroke risk.
• Checking lipids is actionable (statin intensification) even if the patient's leg symptoms are minimal.

Why the others are wrong

• Pentoxifylline is for symptomatic claudication (and is weak); absent pulses alone doesn't mandate it.
• Invasive angiography is for revascularization planning, not first-line risk modification.

Tutor Insight

PAD questions often secretly test "secondary prevention" more than "leg pain." Think statin/antiplatelet/smoking cessation.

Question 8 — Fever/sore throat on TMP-SMX + neutropenia

Heme/Infect

Answer: Adverse effect of trimethoprim-sulfamethoxazole (drug-induced agranulocytosis).

Why this is correct

• New infection symptoms plus marked leukopenia/neutropenia shortly after starting a high-risk medication suggests drug-induced agranulocytosis.
• TMP-SMX is a classic trigger; management is stopping the drug and supportive/antibiotic care as needed.

Why the others are wrong

• Mono causes atypical lymphocytosis, not neutropenia.
• AML would show blasts and broader marrow failure patterns.

Tutor Insight

On Step 2, "fever + sore throat + neutropenia after a new med" is a reflex: blame the drug first.

Question 9 — Parkinson's with frequent falls

Neuro

Answer: Physical therapy.

Why this is correct

• Falls in Parkinson's often reflect postural instability and gait dysfunction, which respond best to balance/gait training.
• Medication changes can help tremor/rigidity but are much less reliable for postural instability.

Why the others are wrong

• Adding dopamine agonists is not a "falls fix" and may worsen orthostasis or confusion.
• Biofeedback has inconsistent benefit for Parkinson-related gait instability.

Tutor Insight

When the primary problem is function (falls), reach for rehab first. Step 2 loves nonpharm interventions when they're the true fix.

Question 10 — Knee + ankle trauma imaging rules

MSK

Answer: Knee: no imaging; Ankle: X-ray.

Why this is correct

• Ottawa rules help avoid unnecessary imaging: knee imaging requires specific criteria; ankle imaging is indicated with malleolar tenderness or inability to bear weight.
• Distal fibula tenderness and limited movement meets ankle imaging criteria; knee findings do not meet knee criteria.

Why the others are wrong

• Ordering knee X-rays without Ottawa criteria is low-value.
• Skipping ankle imaging misses a potentially clinically relevant fracture.

Tutor Insight

Clinical decision rules show up because NBME wants you to be efficient and safe. Learn Ottawa ankle/knee cold.

Question 11 — Episodic headache/palpitations/sweats + adrenal mass

Endocrine

Answer: Plasma and urine catecholamine + metabolite (metanephrine) testing.

Why this is correct

• Classic pheochromocytoma symptom triad + adrenal mass = biochemical confirmation before surgery.
• Metanephrines (plasma or 24h urine) are sensitive markers for catecholamine-secreting tumors.

Why the others are wrong

• Surgery before biochemical confirmation is premature.
• Adrenal venous sampling is for hyperaldosteronism workups, not pheo.

Tutor Insight

Step 2 loves "biochemical first" for endocrine tumors—prove secretion before cutting.

Question 12 — Polyuria/polydipsia + weight loss + marked hyperglycemia

Endocrine

Answer: Insulin therapy.

Why this is correct

• Catabolic symptoms (weight loss) with significant hyperglycemia in a lean patient strongly suggests insulin deficiency (type 1 or LADA pattern).
• Insulin is required; oral agents are inadequate when endogenous insulin is insufficient.

Why the others are wrong

• Sulfonylureas, metformin, TZDs, DPP-4 inhibitors are type 2 options and won't address true insulin deficiency.

Tutor Insight

Weight loss + polyuria/polydipsia is a "catabolism clue." Catabolism pushes you toward insulin, not metformin.

Question 13 — Dyspnea/crackles + hypotension after MI

Cardio

Answer: Acute left ventricular failure.

Why this is correct

• Pulmonary edema findings after MI suggest pump failure (loss of contractile myocardium) causing increased pulmonary capillary pressure.
• Hypotension supports cardiogenic shock physiology rather than simple volume loss.

Why the others are wrong

• VSD or papillary muscle rupture would typically add a new loud holosystolic murmur (often with abrupt decompensation days post-MI).
• Hypovolemia would have flat neck veins and no pulmonary crackles.

Tutor Insight

Post-MI complication questions are time-based: mechanical ruptures classically occur days later and usually announce themselves with a new murmur.

Question 14 — 12-year-old without pubertal signs yet

Peds/Endo

Answer: No additional diagnostic steps are indicated.

Why this is correct

• Normal timing: puberty in girls can begin between ~8–13 years; absence of secondary sexual characteristics is not yet abnormal at age 12.
• Workup is triggered by lack of breast development by 13 or lack of menarche by 15 (or >3 years after thelarche).

Why the others are wrong

• Hormone labs, MRI, and bone age are for true delayed puberty, not normal variation.

Tutor Insight

Age cutoffs are testable. If the vignette says "12 and otherwise well," the correct move is often reassurance, not labs.

Question 15 — Trial result doesn't justify mortality claim

Biostats

Answer: Extrapolation of findings beyond the data.

Why this is correct

• If a trial measures a surrogate outcome (e.g., arrhythmia episodes) but concludes about mortality without measuring it, that's overreach.
• Good critical appraisal matches conclusions to measured endpoints.

Why the others are wrong

• Significance (p<0.05) argues against "insufficient power" as the key critique.
• Selection bias requires flawed enrollment; not implied by "wrong conclusion."

Tutor Insight

When the conclusion sounds "bigger" than the results table, the answer is usually extrapolation or surrogate endpoint misuse.

Question 16 — Newborn FS on electrophoresis

Peds/Heme

Answer: Penicillin prophylaxis.

Why this is correct

• FS pattern in a newborn suggests sickle cell disease (HbS with fetal Hb).
• Early penicillin prophylaxis reduces invasive pneumococcal infection risk in young children with SCD.

Why the others are wrong

• Hydroxyurea is typically for recurrent crises in older children; not standard in a newborn.
• Routine transfusions are for specific indications (e.g., stroke prevention), not universal prophylaxis.

Tutor Insight

Preventive care is huge on Step 2: SCD → vaccines + penicillin early + fever is an emergency.

Question 17 — Cleft palate + congenital heart defect + infections

Immunology

Answer: Lymphopenia.

Why this is correct

• Cardiac + palatal anomalies with recurrent infections suggests 22q11.2 deletion (DiGeorge) with thymic hypoplasia.
• T-cell deficiency presents as low lymphocyte count (lymphopenia), especially in infancy/early childhood.

Why the others are wrong

• Neutrophilia/eosinophilia are reactive patterns; they don't capture the core immunodeficiency signal here.

Tutor Insight

DiGeorge is a "three-system" clue: heart + face/palate + immune. When you see two, go hunting for the third.

Question 18 — Hematemesis (upper GI bleed)

GI

Answer: Esophagogastroduodenoscopy (EGD).

Why this is correct

• Bright red hematemesis = upper GI source until proven otherwise.
• EGD is both diagnostic and therapeutic (can identify and treat bleeding lesions immediately).

Why the others are wrong

• Colonoscopy evaluates lower GI bleeding; nuclear scans/angiography are usually for obscure/ongoing bleeding after endoscopy or for select situations.

Tutor Insight

GI bleed sequencing: stabilize first, then scope the most likely source. Hematemesis = EGD.

Question 19 — High-risk lesion on EGD with ongoing bleed

GI

Answer: Endoscopic hemostatic therapy.

Why this is correct

• If EGD identifies an active bleed or high-risk stigmata, immediate endoscopic hemostasis (injection/thermal/clips) is indicated.
• Definitive control of bleeding outranks purely medical therapy in this setting.

Why the others are wrong

• Octreotide is for suspected variceal bleeding, not generic non-variceal lesions.
• Biopsy/resection may be appropriate later, but hemostasis comes first when bleeding risk is acute.

Tutor Insight

When the scope shows "the culprit," Step 2 wants you to fix it right there if possible.

Question 20 — Paroxysmal cough for weeks (adult pertussis)

Infect

Answer: Azithromycin.

Why this is correct

• Prolonged paroxysmal cough (often with post-tussive symptoms) suggests pertussis; adults may lack the classic "whoop."
• Macrolides treat pertussis and reduce transmission (most important early, but still standard treatment).

Why the others are wrong

• Albuterol targets bronchospasm; PPIs treat reflux; steroids are not first-line for pertussis cough.

Tutor Insight

If cough is >2 weeks and comes in bursts, don't forget pertussis—especially if it's severe enough to cause chest wall pain.

Question 21 — Congenital hypothyroidism on newborn screen

Peds/Endo

Answer: Levothyroxine therapy.

Why this is correct

• High TSH with low free T4 in a neonate is primary hypothyroidism until proven otherwise.
• Immediate levothyroxine prevents irreversible neurodevelopmental injury.

Why the others are wrong

• Imaging can be helpful later but does not outrank starting therapy.
• "Monitor monthly first" delays treatment and risks avoidable harm.

Tutor Insight

Newborn screening positives are "treat-now" situations when the consequence is permanent (e.g., congenital hypothyroidism).

Question 22 — CHF + "meth mouth" dental disease in young patient

Cardio/Tox

Answer: Methamphetamine.

Why this is correct

• Methamphetamine is linked to cardiomyopathy/heart failure and severe dental decay/gingivitis.
• A young patient with new CHF + striking dental pathology strongly suggests chronic stimulant use.

Why the others are wrong

• Cocaine causes ischemia/arrhythmias but does not classically cause the "meth mouth" pattern.
• Opioids/inhalants don't fit the combined dental + cardiomyopathy signal as well.

Tutor Insight

On Step 2, substance questions are pattern questions: pair a "signature finding" (e.g., teeth) with a system complication (e.g., CHF).

Question 23 — Overdose + very high CK (rhabdo)

Renal

Answer: Acute kidney injury.

Why this is correct

• Prolonged immobilization after overdose → rhabdomyolysis (marked CK elevation).
• Myoglobin causes tubular injury and AKI; this is the highest-stakes near-term complication to anticipate and prevent with fluids.

Why the others are wrong

• Electrolyte issues occur, but the "big board" complication rhabdo points to is AKI.
• Liver failure suggests a different overdose pattern (e.g., acetaminophen).

Tutor Insight

Whenever you see CK sky-high, your next thought should be "kidneys" (and potassium), even if the stem is about something else.

Question 24 — Persistent non-bloody diarrhea after untreated water

Infect

Answer: Giardia lamblia.

Why this is correct

• Freshwater exposure + prolonged non-bloody diarrhea with bloating/flatulence is classic giardiasis.
• Protozoal infection fits duration and exposure better than bacterial invasive dysentery.

Why the others are wrong

• Campylobacter/Salmonella/Shigella typically produce inflammatory or bloody diarrhea and systemic illness.
• C. difficile tracks with antibiotic exposure.

Tutor Insight

Boards love "clean-looking water" as a trick. If it wasn't treated/filtered, Giardia stays on the table.

Question 25 — Suspected ruptured ovarian cyst, stable

OB/Gyn

Answer: Observation only.

Why this is correct

• Stable vitals + mild/moderate unilateral pelvic pain + cyst on ultrasound with free fluid is consistent with uncomplicated cyst rupture.
• Most uncomplicated ruptures are managed conservatively with analgesia and observation.

Why the others are wrong

• Laparoscopy is reserved for torsion, ectopic pregnancy, or hemodynamic instability/ongoing hemorrhage.
• Antibiotics treat PID; absent fever/cervical motion tenderness argues against it.

Tutor Insight

On Step 2, the torsion vs rupture split is severity: torsion is sudden severe pain + vomiting; rupture is often milder with free fluid.

Question 26 — Regurgitation of undigested food + aspiration risk

GI

Answer: Zenker diverticulum.

Why this is correct

• Older patient with intermittent dysphagia and regurgitation of undigested food points to a pharyngoesophageal pouch (Zenker).
• Food retention explains aspiration pneumonia risk.

Why the others are wrong

• Achalasia causes dysphagia to solids and liquids with esophageal symptoms; Zenker is more "throat-level" with regurgitation.
• Cancer usually causes progressive dysphagia and weight loss.

Tutor Insight

If the regurgitated material is undigested, think "proximal" (above the stomach)—Zenker becomes a front-runner.

Question 27 — Normal labor with reassuring tracing

OB

Answer: Expectant management.

Why this is correct

• Moderate variability and accelerations without concerning decelerations is reassuring fetal status.
• When labor is progressing and there's no distress, the safest course is to allow normal physiology to continue.

Why the others are wrong

• "Push now" requires complete dilation.
• Operative delivery or urgent C-section needs fetal or maternal indication.

Tutor Insight

OB questions often test restraint: don't intervene just because you can; intervene because the tracing or progress demands it.

Question 28 — Epigastric pain worse after meals (teen)

GI

Answer: Endoscopy.

Why this is correct

• Chronic epigastric pain with meal association suggests gastritis or ulcer disease; endoscopy directly visualizes mucosa and allows biopsy/testing (e.g., H. pylori).
• Endoscopy is the most definitive evaluation for mucosal pathology.

Why the others are wrong

• CT is not first-line for mucosal disease without red flags for masses/complications.
• Stool studies target infectious diarrhea; the primary symptom pattern is upper GI pain.

Tutor Insight

When the question is "what's happening to the lining," pick the test that looks at the lining (endoscopy), not the one that looks at anatomy from far away (CT).

Question 29 — Suspected elder abuse/neglect

Ethics

Answer: Contact adult protective services.

Why this is correct

• Multiple unexplained bruises/injuries in a dependent older adult with cognitive impairment is abuse/neglect until proven otherwise.
• Immediate priority is safety; reporting triggers investigation and support resources.

Why the others are wrong

• Hospital admission alone does not address ongoing risk once discharged.
• Offering phone numbers/placement discussions come after the mandated safety/reporting step.

Tutor Insight

For abuse scenarios: "ensure safety + report" beats "treat the injury" as the tested priority.

Question 30 — Asthma not controlled with SABA alone

Pulm

Answer: Add inhaled fluticasone (ICS) via MDI with spacer.

Why this is correct

• Nighttime symptoms and exercise limitation indicate persistent asthma, not intermittent.
• ICS is first-line controller therapy to reduce airway inflammation and prevent exacerbations.

Why the others are wrong

• LABA monotherapy is unsafe in asthma; if used, it's combined with ICS.
• Oral steroids are for acute exacerbations, not baseline control.

Tutor Insight

If the stem mentions nighttime symptoms, it's basically announcing: "add a controller."

Question 31 — Cognitive error: stopped thinking too early

QI/Safety

Answer: Premature closure.

Why this is correct

• Premature closure is accepting a diagnosis before it's adequately verified, often after recognizing a familiar pattern.
• Complex patients and atypical anatomy increase the risk of diagnostic error; the point is to keep the differential open until key exclusions are made.

Why the others are wrong

• Systems failures/latent errors are process problems; this vignette centers on clinician reasoning, not system breakdown.
• Near miss requires an error that almost harmed but didn't; this is about the cognitive misstep itself.

Tutor Insight

When the vignette says "the clinician decided quickly," the answer is often an error of thinking (anchoring, premature closure), not an equipment or policy failure.

Question 32 — Tender regional LAD + cat exposure

Infect

Answer: Cat-scratch disease (Bartonella henselae).

Why this is correct

• Localized tender lymphadenopathy (often axillary/epitrochlear) after cat contact points to Bartonella.
• Systemic "B symptoms" are absent, making lymphoma less likely.

Why the others are wrong

• Hidradenitis is a chronic abscessing skin disease, not isolated lymph node tenderness.
• TB/lymphoma typically involve systemic symptoms and broader patterns.

Tutor Insight

Epitrochlear nodes are a clue node: when they're tender and enlarged, boards want you to think infection (including Bartonella).

Question 33 — Pleomorphic clustered microcalcifications

Breast

Answer: Ductal carcinoma in situ (DCIS).

Why this is correct

• Pleomorphic microcalcifications in clusters on mammogram are classic for DCIS, an early noninvasive breast cancer.
• DCIS can be mammographically detected before a palpable mass exists.

Why the others are wrong

• Fibroadenoma is a well-circumscribed mass, more common in younger patients.
• Fat necrosis is usually post-trauma/surgery and has different imaging patterns.

Tutor Insight

When boards show "microcalcification" questions, your job is to identify the type: pleomorphic/clustered is the malignant-leaning pattern.

Question 34 — Trauma + hypoxia + decreased breath sounds (hemothorax)

Trauma

Answer: Tube thoracostomy.

Why this is correct

• After major trauma, decreased breath sounds with hypoxemia suggests pleural space pathology (hemo- or pneumothorax).
• Tube thoracostomy treats both and is the immediate stabilizing intervention when hemothorax is likely.

Why the others are wrong

• Thoracentesis is diagnostic/therapeutic for effusions, not acute trauma hemothorax management.
• Observation is unsafe in a hypoxic trauma patient with likely pleural pathology.

Tutor Insight

Trauma algorithms favor action over perfect diagnosis: when physiology and exam point to hemo/pneumothorax, treat it.

Question 35 — Transient proteinuria after UTI

Renal

Answer: No additional testing is indicated.

Why this is correct

• Protein on dipstick during acute illness (UTI, fever, exertion) can be transient.
• If repeat urinalysis after treatment is normal, further protein quantification workup is unnecessary.

Why the others are wrong

• Albumin/creatinine ratio or 24-hour collection is for persistent proteinuria.
• Imaging is for suspected structural disease, which is not suggested after normalization.

Tutor Insight

Boards often test "recheck after the transient trigger resolves" before you order a big nephrology workup.

Question 36 — Painful thyroid after URI (de Quervain)

Endocrine

Answer: Subacute thyroiditis

Why this is correct

• Subacute (de Quervain) thyroiditis classically follows a viral URI and presents with a painful, tender thyroid.
• Elevated ESR and initial hyperthyroidism (from gland destruction releasing hormone) are typical findings.

Why the others are wrong

• Graves disease causes painless goiter with hyperthyroidism.
• Hashimoto thyroiditis is typically painless chronic autoimmune thyroiditis.
• Acute suppurative thyroiditis is rare and presents with severe infection and abscess.

Tutor Insight

"Painful thyroid + recent viral illness + elevated ESR" = subacute thyroiditis. NSAIDs or steroids for pain; it's self-limited.

Question 37 — GAD with substance use history

Psych

Answer: Buspirone

Why this is correct

• Buspirone is a non-addictive anxiolytic ideal for patients with a history of substance use disorder.
• It has no abuse potential, no sedation, and no cross-tolerance with alcohol or benzodiazepines.

Why the others are wrong

• Benzodiazepines (lorazepam, alprazolam) have high abuse potential and are contraindicated in patients with substance use history.
• SSRIs are first-line for GAD but the question specifically tests knowledge of buspirone's safety in addiction history.

Tutor Insight

When boards mention "history of alcohol/substance abuse" + anxiety, they're testing whether you know to avoid benzos. Buspirone is the answer.

Question 38 — Anaphylaxis

Allergy

Answer: Epinephrine

Why this is correct

• Intramuscular epinephrine is the first-line treatment for anaphylaxis—it reverses bronchospasm, hypotension, and angioedema.
• Delay in epinephrine administration is associated with increased mortality.

Why the others are wrong

• Antihistamines (diphenhydramine) are adjunctive but do not address airway or cardiovascular collapse.
• Corticosteroids help prevent biphasic reactions but are too slow for acute management.
• IV fluids support blood pressure but do not treat the underlying pathophysiology.

Tutor Insight

Anaphylaxis = epinephrine IM (anterolateral thigh). Don't delay for any other intervention. This is always the answer on boards.

Question 39 — Crohn's disease counseling

GI

Answer: Smoking cessation

Why this is correct

• Smoking worsens Crohn's disease—it increases flares, need for surgery, and postoperative recurrence.
• Smoking cessation is the single most important lifestyle modification for Crohn's patients.

Why the others are wrong

• Diet modifications may help symptoms but do not change disease course like smoking cessation does.
• Interestingly, smoking is protective in ulcerative colitis (opposite effect)—a common boards distinction.

Tutor Insight

Remember: Smoking hurts Crohn's, helps UC. When asked about counseling a Crohn's patient who smokes, the answer is always smoking cessation.

Question 40 — Psychogenic nonepileptic seizures (PNES)

Neuro/Psych

Answer: Cognitive behavioral therapy

Why this is correct

• PNES are not true epileptic seizures; they are a conversion/functional neurological disorder.
• CBT is the evidence-based treatment, helping patients understand triggers and develop coping strategies.

Why the others are wrong

• Antiepileptic drugs (AEDs) are ineffective since PNES are not caused by abnormal electrical activity.
• Benzodiazepines may be given acutely but are not appropriate long-term management.
• Ignoring or dismissing the patient is harmful; PNES cause real distress and require treatment.

Tutor Insight

PNES diagnosis is confirmed by video EEG showing no epileptiform activity during events. Treatment is psychiatric (CBT), not neurologic (AEDs).

Block 2 (41-80)

Question 41 — QI: rising central line days and CLABSIs

QI

Answer: Ask unit clinicians to identify the most common factors leading to nonremoval of central venous catheters.

Why this is correct

• QI starts with understanding the process and barriers (root cause analysis) before implementing interventions.
• Frontline clinicians often know the real-world reasons lines stay in longer than necessary.

Why the others are wrong

• Routine line changes increase harm and don't address why lines weren't removed.
• RCTs are slow and not the first move in a local systems improvement effort.

Tutor Insight

When the vignette is "QI," the first answer is often "diagnose the system" before "treat the system."

Question 42 — Rh-negative pregnancy and sensitization risk

OB

Answer: Administer Rh(D) immune globulin.

Why this is correct

• Rh-negative mothers exposed to fetal Rh-positive blood are at risk for developing anti-D antibodies.
• Rh(D) immune globulin prevents maternal sensitization after bleeding events and at routine prophylaxis windows per obstetric practice.

Why the others are wrong

• Repeating titers does not prevent sensitization.
• Invasive procedures (amniocentesis) are not used solely to "address" sensitization risk in this context.

Tutor Insight

The board-friendly move is prevention: if there's any plausible fetomaternal hemorrhage in an Rh– patient, think RhIG.

Question 43 — Violaceous painless skin lesions + systemic symptoms

Derm/Onc

Answer: Kaposi sarcoma.

Why this is correct

• Painless violaceous macules/plaques are classic for Kaposi sarcoma (HHV-8), especially with immunosuppression/HIV risk.
• Weight loss supports systemic disease rather than isolated benign dermatitis.

Why the others are wrong

• Lichen planus is pruritic purple papules with Wickham striae, not violaceous tumor-like lesions.
• Seborrheic dermatitis and actinic keratoses have different morphology and are not tied to systemic wasting.

Tutor Insight

Color is a clue: "violaceous" is a board keyword that should trigger Kaposi in the right context.

Question 44 — Declining self-care after caregiver change

Ethics/Geri

Answer: Elder neglect.

Why this is correct

• Missed appointments, poor hygiene/appearance, and worsening chronic disease control after a caregiver moves in suggests neglect.
• Neglect can be subtle—no bruises required.

Why the others are wrong

• Dietary indiscretion doesn't explain missed care and global deterioration.
• UTI or malignancy would need supporting symptoms/labs; the pattern is social-environmental timing.

Tutor Insight

When the timeline is "things got worse right after someone moved in," boards want you to consider a social diagnosis, not just a lab diagnosis.

Question 45 — Capacity + POA confusion

Ethics

Answer: Tell the family that the decision is the patient's to make if he has decision-making capacity.

Why this is correct

• Power of attorney is activated when the patient lacks capacity; it does not override a competent patient.
• Capacity is functional: understand, appreciate, reason, and communicate a choice.

Why the others are wrong

• Family meetings are supportive but don't replace the patient's autonomous decision.
• Reviewing POA doesn't change the principle: capacity = patient decides.

Tutor Insight

Ethics shortcut: if the patient can speak and think clearly in the vignette, capacity is likely intact unless the stem says otherwise.

Question 46 — Recurrent pancreatitis + alcohol use disorder

GI

Answer: Abstinence from alcoholic beverages.

Why this is correct

• Preventing recurrence means targeting the most likely cause. Alcohol is a major driver of recurrent acute pancreatitis.
• Abstinence reduces future episodes and long-term pancreatic injury.

Why the others are wrong

• Insurance, diet counseling, and housing support may help overall stability but do not directly remove the pancreatitis trigger.

Tutor Insight

When asked "best discharge instruction," pick the one that removes the causal lever the vignette highlights.

Question 47 — Depression + insomnia in patient with epilepsy

Psych

Answer: Mirtazapine.

Why this is correct

• Mirtazapine treats depression and is sedating, helping comorbid insomnia.
• It's a reasonable option when avoiding agents that can lower seizure threshold is a priority.

Why the others are wrong

• Bupropion lowers seizure threshold and is activating—poor fit for epilepsy + insomnia.
• Benzodiazepines are not depression treatment and carry dependence risk.

Tutor Insight

When insomnia is a dominant complaint, pick an antidepressant whose side effect becomes a feature (mirtazapine/trazodone-type logic).

Question 48 — Nephrotic syndrome labs in child

Renal/Peds

Answer: Serum albumin concentration.

Why this is correct

• Nephrotic syndrome: heavy protein loss in urine → low oncotic pressure → edema.
• Hypoalbuminemia is the key lab that explains the edema.

Why the others are wrong

• Complement levels are more relevant for nephritic syndromes (e.g., post-strep GN).
• Triglycerides are typically elevated, not decreased.

Tutor Insight

If the question asks you to pick the "most expected lab," choose the one tied directly to the symptom you see (edema → albumin).

Question 49 — Suspected brain death and donation process

Ethics

Answer: Contact the organ bank / organ procurement organization.

Why this is correct

• When brain death is established by accepted criteria, donation discussions are typically handled through the OPO process.
• Early notification preserves organ viability and ensures appropriate counseling by trained personnel.

Why the others are wrong

• Ethics consult is not the first step when the protocol is clear.
• Lack of an advance directive does not automatically preclude donation; the process evaluates eligibility and consent appropriately.

Tutor Insight

Many ethics questions are "follow the protocol." If there's a standard institutional pathway (like OPO), Step 2 expects you to use it.

Question 50 — Keloid after ear piercing

Derm

Answer: Intralesional corticosteroid injection.

Why this is correct

• Keloids grow beyond wound borders; intralesional steroids reduce collagen synthesis and flatten lesions.
• Conservative options are preferred before excision because surgery alone can worsen recurrence.

Why the others are wrong

• Needle aspiration does nothing for solid fibrous tissue.
• Wide excision without adjunct therapy often leads to larger keloids.

Tutor Insight

If the lesion is "bigger than the original wound," it's a keloid—treat with intralesional steroids ± silicone/sheets, not aspiration.

Question 51 — Sudden severe abdominal pain + hypotension in older smoker

Vascular

Answer: Ruptured abdominal aortic aneurysm.

Why this is correct

• Classic rupture: older patient with heavy smoking history + acute abdominal/back pain + hypotension (shock).
• Immediate recognition matters because mortality is high without urgent surgical care.

Why the others are wrong

• Pancreatitis/perforated ulcer can cause pain, but profound hypotension with this risk profile strongly favors AAA rupture.
• Small bowel obstruction typically does not present with sudden shock.

Tutor Insight

When the vignette combines "older smoker" + "sudden pain" + "hypotension," boards are asking you to think AAA rupture fast.

Question 52 — Stage 1 HTN lifestyle counseling

Preventive

Answer: DASH diet.

Why this is correct

• For mild hypertension without urgent indications, lifestyle interventions are first-line.
• DASH diet is a well-established pattern that lowers blood pressure, especially with sodium reduction and weight loss.

Why the others are wrong

• Starting medications is usually reserved for higher stage BP or higher risk profiles when lifestyle fails or risk is elevated.
• Single supplements (fish oil/calcium) are not primary HTN interventions.

Tutor Insight

Lifestyle questions are about "big levers": weight loss, DASH, sodium, exercise, alcohol reduction—not niche supplements.

Question 53 — Seizure due to severe hyponatremia

Renal

Answer: Bolus IV 3% hypertonic saline.

Why this is correct

• Seizure is a severe symptom of hyponatremia indicating cerebral edema risk.
• Hypertonic saline raises sodium quickly enough to stop life-threatening neurologic symptoms.

Why the others are wrong

• Antiepileptics don't fix the cause; correcting sodium does.
• Isotonic saline may be too slow for severe symptoms and can be wrong in SIADH-type contexts.

Tutor Insight

Hyponatremia management is symptom-driven: mild = slow; seizure/coma = hypertonic now.

Question 54 — Acute wheeze after chemical exposure

Pulm

Answer: Albuterol therapy.

Why this is correct

• Acute irritant exposure can trigger bronchospasm (reactive airway response) with wheeze and dyspnea.
• Short-acting beta agonists provide rapid bronchodilation.

Why the others are wrong

• Bronchoscopy/CT are not first-line if the picture is bronchospasm with stable vitals and supportive imaging.
• Intubation is for impending respiratory failure, not moderate bronchospasm.

Tutor Insight

If the stem says "wheezing after exposure," the immediate correct action is usually bronchodilator first, diagnostics later.

Question 55 — Hyponatremia evaluation step

Renal

Answer: Measure urine and plasma osmolality.

Why this is correct

• Hyponatremia workup starts by classifying tonicity and ADH activity: plasma osmolality and urine osmolality are the core discriminators.
• These tests distinguish pseudohyponatremia, hypertonic hyponatremia, and true hypotonic hyponatremia with appropriate/inappropriate ADH.

Why the others are wrong

• Brain imaging doesn't explain hyponatremia mechanism and is usually not first-line unless focal neuro findings suggest another process.

Tutor Insight

Boards love hyponatremia algorithms: osmolality first, then volume status, then urine sodium.

Question 56 — Stress test with significant ST depression

Cardio

Answer: Coronary artery disease.

Why this is correct

• Exercise-induced ST-segment depression indicates myocardial ischemia.
• Longstanding diabetes markedly increases CAD risk, including silent ischemia.

Why the others are wrong

• Valvular murmurs do not explain ischemic ST changes on exertion.
• "Normal findings" conflicts directly with the abnormal stress ECG.

Tutor Insight

In diabetics, "no chest pain" doesn't reassure. Silent ischemia is common—trust objective ischemia signs.

Question 57 — Improving guideline adherence (asthma PFTs)

QI

Answer: Diagnosis-driven reminders in patient charts.

Why this is correct

• Point-of-care reminders directly prompt clinicians when decisions are being made.
• This reduces forgetfulness and workflow friction, improving compliance with standards.

Why the others are wrong

• Waiting-room flyers rely on patient action and are less reliable for provider behavior change.
• Annual chart audits are delayed feedback and less effective than immediate prompts.

Tutor Insight

If the goal is provider behavior change, the strongest lever is usually a real-time prompt inside the workflow.

Question 58 — REM sleep behavior disorder association

Neuro

Answer: Parkinson's disease.

Why this is correct

• Acting out dreams (loss of REM atonia) is REM sleep behavior disorder, strongly associated with synucleinopathies.
• Constipation is a common prodromal non-motor Parkinson feature, reinforcing the link.

Why the others are wrong

• Narcolepsy involves daytime sleepiness/cataplexy, not violent dream enactment.
• Alzheimer's does not have the same strong association with REM behavior disorder as Parkinson's.

Tutor Insight

REM behavior disorder is a board-style "future Parkinson's flag." If you see dream-enactment violence, think synucleinopathy.

Question 59 — Panic attacks + avoidance of public places

Psych

Answer: Agoraphobia.

Why this is correct

• Panic attacks are brief surges of intense fear with autonomic symptoms.
• When patients start avoiding places/situations due to fear of having another attack and being unable to escape/get help, that's agoraphobia.

Why the others are wrong

• GAD is chronic worry without discrete panic episodes.
• Social anxiety is fear of scrutiny/embarrassment, not fear of panic symptoms occurring.

Tutor Insight

Agoraphobia is about "escape difficulty" and "help availability," not "people judging me."

Question 60 — Third-trimester painless bleeding after intercourse

OB

Answer: Transabdominal ultrasonography.

Why this is correct

• Painless bright red bleeding in late pregnancy suggests placenta previa.
• Ultrasound must locate the placenta before any digital exam; digital exam can trigger catastrophic hemorrhage in previa.

Why the others are wrong

• Digital cervical exam is contraindicated until previa is excluded.
• Immediate C-section is not automatic unless bleeding is severe/unstable or placenta location and gestational age mandate delivery.

Tutor Insight

For third-trimester bleeding, the "don't kill the patient" rule is: ultrasound first, fingers later.

Question 61 — Short stature + delayed puberty evaluation

Peds/Endo

Answer: X-rays of the left hand and wrist (bone age).

Why this is correct

• Bone age helps distinguish constitutional growth delay from pathologic causes of short stature/puberty delay.
• Delayed bone age suggests remaining growth potential and supports constitutional delay.

Why the others are wrong

• Cortisol testing is for Cushing's features; broad labs without a targeted question are less useful than bone age first here.

Tutor Insight

Step 2 growth questions: bone age is the "branch point" test—most other labs depend on what bone age suggests.

Question 62 — Chronic hepatitis B complication risk

GI/Onc

Answer: Hepatocellular carcinoma.

Why this is correct

• Chronic HBV infection increases HCC risk (even without cirrhosis), making HCC the key long-term complication to remember.
• Persistent antigen positivity with IgG anti-HBc indicates chronic infection pattern.

Why the others are wrong

• Cryoglobulinemia is more classically tied to HCV than HBV.
• PAN and MPGN can be HBV-associated but are less "default" board complication than HCC.

Tutor Insight

If the vignette is HBV, the exam often wants "HCC risk" as the highest-yield long-term consequence.

Question 63 — Post-op pleuritic pain + hemoptysis + Hampton's hump

Pulm

Answer: Pulmonary infarction.

Why this is correct

• Recent surgery + pleuritic chest pain + hemoptysis suggests pulmonary embolism with infarction.
• A pleural-based wedge-shaped opacity (Hampton's hump) supports pulmonary infarction from PE.

Why the others are wrong

• Pneumonia would more likely have fever/purulent sputum and different imaging patterns.
• Air embolism is immediate peri-procedural collapse, not days later.

Tutor Insight

Hemoptysis + pleuritic pain in a post-op patient is PE until proven otherwise; Hampton's hump is a classic confirmatory hint.

Question 64 — Neurogenic claudication

MSK/Neuro

Answer: Spinal stenosis.

Why this is correct

• Leg pain/tingling triggered by standing/walking and relieved by sitting or spine flexion is neurogenic claudication.
• Degenerative lumbar stenosis is common in older adults and is posture-dependent.

Why the others are wrong

• Vascular claudication improves with rest regardless of posture and correlates with abnormal vascular studies.
• Peripheral neuropathy is not posture-dependent and is typically distal symmetric.

Tutor Insight

Relief with flexion is the "secret handshake" for spinal stenosis (shopping cart sign).

Question 65 — High-risk early gestational diabetes screening

OB

Answer: Early glucose testing (fasting glucose tolerance test).

Why this is correct

• Obesity plus prior large-for-gestational-age infants strongly raises risk for undiagnosed preexisting glucose intolerance or early GDM.
• High-risk patients are screened at the first prenatal visit rather than waiting for routine 24–28 week screening.

Why the others are wrong

• AFP timing is later and screens neural tube defects, not diabetes.
• Antiphospholipid screening is for recurrent losses or specific thrombotic patterns, not LGA history.

Tutor Insight

The board move is recognizing "screen earlier than usual" when the risk profile is loud.

Question 66 — Young adult HTN: reversible cause clue

Cardio/Preventive

Answer: Excessive alcohol use.

Why this is correct

• Chronic heavy alcohol intake is a modifiable contributor to hypertension.
• Reducing intake can normalize blood pressure in some patients, making it a high-value target.

Why the others are wrong

• Smoking is not a classic chronic HTN cause (it increases cardiovascular risk but isn't the main driver of persistent hypertension).
• Pheochromocytoma causes episodic symptoms; the vignette points to lifestyle consistency.

Tutor Insight

When a young person has HTN, Step 2 wants a secondary cause or reversible behavior—alcohol is a common "gotcha."

Question 67 — Brown recluse bite expected evolution

Derm

Answer: Central eschar at the bite site.

Why this is correct

• Necrotic arachnidism classically progresses to localized tissue necrosis with a central dark eschar.
• Localized necrosis is more typical than diffuse limb gangrene.

Why the others are wrong

• Rapidly spreading erythema or streaking suggests bacterial cellulitis/lymphangitis instead.
• Generalized edema/palpable purpura point toward different systemic processes.

Tutor Insight

Necrosis with a central eschar is the "board photo" for brown recluse—don't confuse it with nec fasc signs (pain out of proportion + systemic toxicity).

Question 68 — Penetrating chest trauma + tamponade physiology

Trauma

Answer: Pericardiocentesis.

Why this is correct

• Penetrating injury near the heart with hypotension, JVD, muffled heart sounds suggests cardiac tamponade.
• Immediate decompression restores preload and cardiac output.

Why the others are wrong

• Needle decompression/chest tube is for tension pneumothorax (different mechanism and exam).
• CT is for stable patients; unstable patients need life-saving bedside interventions.

Tutor Insight

Trauma = ABCs. If the "C" problem is tamponade, pericardiocentesis is the immediate board answer.

Question 69 — Preventing C. difficile spread

Infect

Answer: Wash hands with soap and water.

Why this is correct

• C. difficile forms spores that are not reliably killed by alcohol-based sanitizers.
• Soap and water physically remove spores; contact precautions also matter.

Why the others are wrong

• Alcohol gel is insufficient against spores.
• Surgical masks don't address fecal–oral spore transmission.

Tutor Insight

If the organism makes spores (C. diff), default to soap + water. This is a classic board micro-control point.

Question 70 — Osteogenesis imperfecta complication screening

Peds

Answer: Audiography.

Why this is correct

• Recurrent fractures + blue sclera strongly suggests OI, which is associated with hearing loss.
• Audiology screening is a practical step to detect a treatable complication early.

Why the others are wrong

• DEXA is for osteoporosis; OI is a collagen structural disorder and is diagnosed clinically/genetically.
• Routine echo/retinal exams are not the primary screening focus in typical OI presentations.

Tutor Insight

When a genetic diagnosis is obvious, Step 2 often pivots to "what complication do you screen next?"

Question 71 — Buprenorphine vs methadone efficacy statement

Psych/Addiction

Answer: There is an unclear difference in efficacy between the two drugs at these doses.

Why this is correct

• Both methadone and buprenorphine are effective maintenance treatments; head-to-head superiority depends on dose and context.
• Overly specific "percentage better" claims are usually wrong unless a study provides those exact estimates.

Why the others are wrong

• Absolute superiority claims ("always better") are rarely true across trials.
• Combining opioids with benzodiazepines increases respiratory depression risk; simplistic endorsements can be unsafe.

Tutor Insight

When two standard-of-care treatments are compared, Step 2 often rewards the cautious, evidence-consistent answer over "extreme" choices.

Question 72 — Systematic review limitation: too short intervention window

Biostats

Answer: Inclusion of trials with an intervention duration of 2 weeks.

Why this is correct

• Maintenance therapy outcomes in opioid use disorder require longer time horizons; 2-week trials poorly reflect real-world effectiveness and retention.
• Short trials can underestimate relapse dynamics and long-term adherence effects.

Why the others are wrong

• Restricting to RCTs generally strengthens causal inference.
• Excluding pregnancy limits generalizability but isn't as central a flaw as unrealistic duration for a chronic condition.

Tutor Insight

Ask: "Is the study long enough for the disease?" Chronic disease + tiny duration = generalizability problem.

Question 73 — Bias: positive studies more likely published

Biostats

Answer: Publication bias.

Why this is correct

• Systematic reviews can overestimate benefits if negative/null trials remain unpublished and therefore not captured.
• This is the classic "file drawer problem."

Why the others are wrong

• Detection bias requires different measurement intensity between groups; not implied here.
• Funding bias requires explicit sponsor influence clues; the vignette points to publication likelihood.

Tutor Insight

If the answer choice literally says "positive studies more likely to be published," that's the definition of publication bias—take it.

Question 74 — Suspected COPD diagnostic test

Pulm

Answer: Pulmonary function testing (spirometry).

Why this is correct

• Chronic cough + progressive dyspnea + prolonged expiratory phase in a smoker suggests COPD.
• Spirometry confirms airflow obstruction (reduced FEV1/FVC) and grades severity.

Why the others are wrong

• CT or echo may be useful later, but spirometry is the foundational diagnostic test for COPD.
• TB testing is for different symptom patterns and exposures.

Tutor Insight

If the stem asks you to "diagnose COPD," the correct answer is almost always spirometry, not imaging.

Question 75 — Post-op oliguria + pelvic fractures

Trauma/Uro

Answer: Ultrasonography of the bladder.

Why this is correct

• Pelvic fractures raise concern for bladder injury or obstruction/retention contributing to low urine output.
• Bladder ultrasound is fast and bedside-friendly to assess retention/distension and help triage post-renal causes.

Why the others are wrong

• CT is slower and not the immediate first check when a bedside assessment can clarify post-renal obstruction quickly.
• Transfusion doesn't address the mechanism of oliguria unless hemorrhagic shock is evident.

Tutor Insight

Oliguria after surgery is an "AKI classification" problem: always ask prerenal vs intrinsic vs postrenal—bladder scan is the fastest postrenal check.

Question 76 — Infertility with PID history

OB/Gyn

Answer: Female factor infertility (tubal damage).

Why this is correct

• PID can cause tubal scarring and obstruction, a common cause of infertility.
• Hysterosalpingography is often used to evaluate tubal patency when female factor is suspected.

Why the others are wrong

• Male factor is less likely when the vignette highlights PID and tubal injury risk.
• Assuming "she'll conceive soon" ignores the known long-term PID complication.

Tutor Insight

PID is a Step 2 infertility keyword: it's there to make you think "tubal factor" immediately.

Question 77 — Metamorphopsia (wavy lines) in older adult

Ophtho

Answer: Macular degeneration.

Why this is correct

• Distorted central vision (straight lines appear wavy) is classic for macular pathology, especially AMD.
• AMD is painless and affects central tasks like reading.

Why the others are wrong

• Cataracts cause generalized blurring and glare, not distortion of lines.
• Acute angle-closure glaucoma is painful with a red eye and halos.

Tutor Insight

If the stem describes "wavy lines," mentally picture an Amsler grid—this points to the macula.

Question 78 — White oral lesion in chewing tobacco user

ENT/Onc

Answer: Surgical biopsy of the oral lesion.

Why this is correct

• Leukoplakia is a premalignant lesion; tobacco use increases dysplasia/SCC risk.
• Biopsy is required to determine dysplasia/malignancy; "watchful waiting" is unsafe in a high-risk setting.

Why the others are wrong

• Nystatin is for candidiasis (usually scrapable white plaques), not fixed leukoplakia.
• Cytology is less definitive than biopsy for grading dysplasia.

Tutor Insight

When the risk factor is strong (chewing tobacco) and the lesion is persistent, Step 2 wants tissue diagnosis, not empiric treatment.

Question 79 — Asymptomatic cerumen

ENT

Answer: No further management is indicated.

Why this is correct

• Cerumen is protective; if there are no symptoms (hearing loss, pain, fullness), intervention isn't required.
• Unnecessary removal can cause trauma or infection.

Why the others are wrong

• Cotton swabs often worsen impaction and cause abrasions.
• Irrigation/manual removal is for symptomatic cases or when visualization is necessary for evaluation.

Tutor Insight

Boards increasingly reward "do nothing" when the patient is asymptomatic and the finding is benign.

Question 80 — Basal ganglia stroke mechanism in hypertensive pattern

Neuro

Answer: Small vessel disease.

Why this is correct

• Lacunar strokes from small vessel lipohyalinosis often affect deep structures (basal ganglia/internal capsule) and produce pure motor deficits.
• Hypertension is a key risk factor for small vessel disease.

Why the others are wrong

• Amyloid angiopathy causes lobar hemorrhage patterns in older adults.
• Large emboli more often cause cortical deficits (aphasia, neglect) rather than isolated deep motor syndromes.

Tutor Insight

Deep brain + "pure motor" presentation is a lacunar vibe—boards want small vessel disease as the mechanism.

Block 3 (81-120)

Question 81 — Hemophilia A hemarthrosis treatment

Heme

Answer: Factor VIII concentrate.

Why this is correct

• Hemophilia A is factor VIII deficiency; joint bleeding (hemarthrosis) is a classic presentation.
• Acute bleeding episodes require replacement of the missing factor to stop bleeding and prevent joint destruction.

Why the others are wrong

• Factor IX treats hemophilia B, not A.
• FFP contains factors but is less precise; concentrates are preferred when available.

Tutor Insight

When hemophilia type is given, Step 2 is testing a direct mapping: A→VIII, B→IX.

Question 82 — Missing signed consent form in the OR

Ethics

Answer: Do not proceed; stop the case until consent is verified.

Why this is correct

• Valid informed consent must be verifiable; surgeon recollection is not adequate documentation.
• A sedated patient cannot provide informed consent in the moment, so proceeding is unsafe and unethical.

Why the others are wrong

• Asking a sedated patient to confirm is unreliable and not legally sound.
• A spouse cannot override the need for documented consent unless the patient lacks capacity and a surrogate decision is appropriate—which isn't the scenario here.

Tutor Insight

OR ethics often reduces to "stop and verify." If you can't prove consent/site/procedure, you don't cut.

Question 83 — CHF exam pattern with alcohol risk

Cardio

Answer: Dilated cardiomyopathy.

Why this is correct

• Symptoms and signs of congestive heart failure (S3, crackles, edema, hepatomegaly) with global dysfunction point to dilated cardiomyopathy.
• Chronic alcohol use is a classic reversible/partially reversible cause of dilated cardiomyopathy.

Why the others are wrong

• Regional wall-motion abnormalities suggest ischemic disease rather than global dilation.
• Large pericardial effusion would suggest tamponade physiology (JVD, muffled sounds, hypotension) more than S3 CHF pattern.

Tutor Insight

S3 is a "volume overload/dilated ventricle" clue. If you see S3 + edema, think dilated cardiomyopathy/HFrEF framework.

Question 84 — CF exacerbation/pneumonia evaluation

Pulm

Answer: Sputum culture.

Why this is correct

• CF patients often have chronic colonization; cultures guide targeted antibiotics and stewardship.
• If not improving or with recurrent exacerbations, knowing organism and sensitivities matters.

Why the others are wrong

• CT angiography is for PE; immunoglobulin panels are for primary immunodeficiency patterns, not typical CF pneumonia management.
• Transbronchial biopsy is invasive and not first-line for routine infectious exacerbations.

Tutor Insight

When the patient has a history of resistant bugs (CF, bronchiectasis), culture early—Step 2 wants targeted therapy, not guesswork.

Question 85 — Primary prevention with strong family history

Preventive

Answer: Fasting serum lipid studies.

Why this is correct

• Family history of premature MI plus smoking/overweight increases ASCVD risk.
• Lipid screening identifies dyslipidemia and guides prevention strategy (lifestyle ± statin).

Why the others are wrong

• ECG is not a screening test for CAD in asymptomatic patients.
• "No screening" ignores meaningful modifiable risk assessment.

Tutor Insight

Preventive questions: pick the test that changes long-term management (lipids, BP, smoking), not a low-yield screening ECG.

Question 86 — Menopause confirmation when needed

OB/Gyn

Answer: Serum follicle-stimulating hormone (FSH).

Why this is correct

• Vasomotor symptoms plus amenorrhea in the appropriate age range strongly suggests perimenopause/menopause.
• If labs are needed for confirmation, FSH rises due to decreased estrogen/inhibin feedback.

Why the others are wrong

• LH can also rise but is less commonly used for confirmation than FSH.
• Pelvic ultrasound is not first-line without bleeding or pelvic mass symptoms.

Tutor Insight

Menopause is usually clinical. When the test asks "which lab," it's almost always FSH.

Question 87 — Linear itchy rash after outdoor exposure

Derm

Answer: Flora (poison ivy/oak/sumac contact dermatitis).

Why this is correct

• Pruritic rash spreading to exposed areas, often in linear streaks, fits allergic contact dermatitis from urushiol.
• Outdoor/wooded exposures and summer timing support the diagnosis.

Why the others are wrong

• Food allergy would be generalized urticaria/angioedema and often systemic symptoms.
• Soap allergy tends to be broader in distribution corresponding to contact areas, not linear streaking.

Tutor Insight

"Linear, itchy, vesicular rash" is a high-yield clue phrase—think poison ivy and treat with topical steroids (or systemic if severe).

Question 88 — First febrile UTI in child under 2

Peds

Answer: Ultrasonography of the kidneys and bladder.

Why this is correct

• Febrile UTI in a young child warrants evaluation for structural abnormalities with renal/bladder ultrasound.
• Ultrasound is noninvasive and avoids radiation.

Why the others are wrong

• VCUG is typically reserved for abnormal ultrasound findings or recurrent UTIs.
• CT urography is excessive and adds radiation.

Tutor Insight

Peds UTI imaging is stepwise: ultrasound first; VCUG only when the first test or recurrence suggests reflux risk.

Question 89 — Lactational mastitis

OB

Answer: Dicloxacillin therapy.

Why this is correct

• Breastfeeding + localized erythema/tenderness + fever suggests mastitis (usually S. aureus).
• Dicloxacillin (or cephalexin) covers typical organisms; continue breastfeeding/pumping to relieve milk stasis.

Why the others are wrong

• Breast binders worsen milk stasis.
• FNA is for suspected abscess (fluctuant mass or failure to improve with antibiotics).

Tutor Insight

Mastitis management is antibiotics + drainage via nursing/pumping. Stopping breastfeeding usually makes it worse.

Question 90 — Type 2 diabetes physiology progression

Endocrine

Answer: Increased glucose; increased insulin; decreased insulin receptor responsiveness.

Why this is correct

• Early type 2 diabetes is insulin resistance with compensatory hyperinsulinemia.
• As disease progresses, glucose rises because insulin effectiveness is reduced and beta-cell compensation eventually fails.

Why the others are wrong

• Normal receptor responsiveness doesn't fit insulin resistance.
• "Normal insulin" early doesn't fit the compensatory phase of type 2 diabetes.

Tutor Insight

Boards like the two-phase model: insulin resistance → hyperinsulinemia → beta-cell fatigue. The stem usually lands you in phase 1 or phase 2.

Question 91 — Depression after MI prognosis

Psych/Cardio

Answer: It is likely to increase mortality risk (e.g., roughly doubling short-term death risk).

Why this is correct

• Post-MI depression is associated with worse outcomes, including increased mortality, partly through adherence and physiologic stress pathways.
• Recognizing and treating depression is both mental health care and cardiac risk care.

Why the others are wrong

• "No impact on mortality" contradicts known associations tested by NBME-style questions.
• Rest/avoidance does not reduce ischemia risk; it often worsens rehabilitation participation.

Tutor Insight

When a vignette ties depression to a medical disease course (MI), the test wants you to treat it as a prognostic factor, not "just mood."

Question 92 — Recurrent sinopulmonary infections + low IgA/IgG/IgM

Immunology

Answer: Monthly immune globulin replacement therapy.

Why this is correct

• Low multiple immunoglobulin isotypes with recurrent bacterial respiratory infections is common variable immunodeficiency.
• IVIG replacement provides passive immunity and reduces infections.

Why the others are wrong

• Inhaled tobramycin is for CF chronic Pseudomonas management, not global antibody deficiency.
• Daily TMP-SMX is for specific opportunistic prophylaxis, not first-line for CVID baseline management.

Tutor Insight

If more than one Ig class is low, think CVID and treat with IVIG—Step 2 is testing the pattern, not the rare exception.

Question 93 — Warfarin patient + TMP-SMX + supratherapeutic INR

Heme

Answer: Review for potential drug–drug interaction.

Why this is correct

• TMP-SMX potentiates warfarin effects, raising INR and bleeding risk.
• When INR jumps after a new medication, interaction review is the most likely explanation and the key management step.

Why the others are wrong

• Diet changes can affect INR, but the time relationship to starting TMP-SMX is a stronger causal clue.
• Imaging tests do not explain pharmacologic INR elevation.

Tutor Insight

Warfarin questions are often "what changed?" Antibiotics (TMP-SMX, metronidazole) are classic INR-raisers.

Question 94 — Terminal cancer + recurrent obstruction; request for nonbeneficial surgery

Ethics

Answer: Explain the futility of the operation to the patient and family (goals-of-care discussion).

Why this is correct

• Physicians are not obligated to offer interventions unlikely to provide benefit and likely to cause harm.
• The ethical move is to communicate prognosis and shift to comfort-focused goals when appropriate.

Why the others are wrong

• "Do it because family wants it" ignores professional responsibility and nonmaleficence.
• Transfer-for-surgery is not a solution when the intervention is nonbeneficial; it delays honest counseling.

Tutor Insight

Futility questions test whether you can say "no" compassionately and redirect to palliation.

Question 95 — Occupational exposure + reticulonodular pattern

Pulm

Answer: Hypersensitivity pneumonitis.

Why this is correct

• Subacute systemic symptoms plus cough/dyspnea after organic dust exposure suggests hypersensitivity pneumonitis.
• HP is an immune-mediated inflammatory response to inhaled antigens (mold/wood dust) and can produce diffuse crackles and interstitial changes.

Why the others are wrong

• Asthma does not explain weight loss and interstitial reticulonodular imaging.
• Sarcoid classically has bilateral hilar adenopathy; silicosis requires silica exposure, not wood dust.

Tutor Insight

If the vignette gives you a job exposure and then gives you an interstitial pattern, Step 2 wants an occupational lung diagnosis more than an "infection" label.

Question 96 — Progressive dyspnea with amiodarone use

Pulm

Answer: Amiodarone (pulmonary toxicity).

Why this is correct

• Amiodarone can cause interstitial pneumonitis/fibrosis presenting with progressive dyspnea and nonproductive cough.
• Medication history plus diffuse crackles without infectious features supports drug toxicity.

Why the others are wrong

• ACE inhibitors cause cough but not diffuse crackles and progressive impairment of gas exchange in the same way.
• Bronchodilators don't fit an interstitial toxicity pattern.

Tutor Insight

Whenever a stem asks "which medication is the cause," look for the drug with the strongest classic toxicity signature—amiodarone is a frequent culprit.

Question 97 — Impaired physician at work (smells of alcohol)

Ethics

Answer: Report to clinic administrator and have him stop seeing patients; continue clinic without him.

Why this is correct

• Patient safety is the immediate priority; an impaired clinician must be removed from patient care duties.
• Reporting through institutional leadership initiates appropriate evaluation and policy-based action.

Why the others are wrong

• Letting him continue risks harm.
• State medical board reporting is generally not the first step for a first observed incident; internal reporting and removal from duty come first (then escalation as policy requires).

Tutor Insight

Impaired colleague questions are a two-step: (1) stop the risk now, (2) report through the right channel. Don't "handle it privately."

Question 98 — Solitary kidney suggesting Müllerian anomaly risk

OB/Gyn

Answer: Increased risk of preterm labor (often via associated uterine anomaly such as bicornuate uterus).

Why this is correct

• Renal agenesis can be associated with Müllerian duct anomalies (uterine malformations).
• Uterine anomalies increase risk of adverse pregnancy outcomes, including preterm labor and malpresentation.

Why the others are wrong

• Macrosomia is linked to diabetes; multiple gestation to ovulation induction; preeclampsia to different maternal risk factors.
• Oligohydramnios is more tied to fetal renal issues; maternal single-kidney status alone isn't the classic driver.

Tutor Insight

Boards like embryology cross-links: urinary tract anomalies can "hint" reproductive tract anomalies. Translate the hint into a pregnancy risk.

Question 99 — Bipolar medication toxicity after dehydration

Psych

Answer: Lithium.

Why this is correct

• Lithium has a narrow therapeutic index; dehydration decreases renal clearance and increases levels.
• Toxicity can present with confusion, GI symptoms, tremor, and conduction abnormalities.

Why the others are wrong

• Acetaminophen toxicity is hepatic; bupropion lowers seizure threshold; antipsychotics cause EPS/QT issues but not the classic dehydration-driven toxicity story.

Tutor Insight

If the stem says "bipolar + dehydration + confusion," lithium should be your first suspect.

Question 100 — Dental procedure and endocarditis prophylaxis

Cardio/Preventive

Answer: No antibiotic prophylaxis recommended.

Why this is correct

• Endocarditis prophylaxis is reserved for high-risk cardiac conditions (prosthetic valves, prior endocarditis, select congenital heart disease, transplant valvulopathy).
• A simple murmur without high-risk features does not qualify.

Why the others are wrong

• Choosing an antibiotic "just in case" increases resistance and adverse reaction risk (especially with penicillin allergy history).
• Broad agents (e.g., vancomycin) are unnecessary and inappropriate in prophylaxis without indication.

Tutor Insight

Boards love this: most people do NOT need dental prophylaxis. Memorize the short list of who does.

Question 101 — Oligospermia: first step is reversible risk factor review

Repro

Answer: Ask about alcohol intake, smoking, and stress level.

Why this is correct

• Male infertility workup starts with history for reversible contributors before advanced interventions.
• Alcohol, smoking, and high stress can reduce sperm parameters; identifying modifiable factors is high value.

Why the others are wrong

• Testosterone supplementation can worsen spermatogenesis by suppressing intratesticular testosterone.
• IVF is premature without addressing potentially reversible factors.

Tutor Insight

Infertility questions frequently start with "history and basics" before "procedures and hormones." Don't jump ahead.

Question 102 — Heat rash with tiny clear vesicles

Derm

Answer: Heat avoidance (cooling measures).

Why this is correct

• Tiny clear "dew drop" vesicles after heat exposure suggests miliaria crystallina.
• Management is simply cooling and reducing sweating; it resolves spontaneously.

Why the others are wrong

• No features of infection: antibiotics/antivirals are unnecessary.
• Antifungal therapy is for tinea patterns, not sweat duct blockage.

Tutor Insight

If the vignette screams "environmental trigger," treat the environment first—Step 2 often rewards the simplest causal fix.

Question 103 — Weight loss + atrial fibrillation + diffuse goiter

Endocrine

Answer: Thyrotoxicosis.

Why this is correct

• Weight loss, anxiety/insomnia, frequent stools, and atrial fibrillation are classic hyperthyroid physiology.
• Diffuse enlargement suggests Graves or thyroiditis depending on other findings (bruit, eye signs, uptake).

Why the others are wrong

• Pheochromocytoma causes episodic spells, not diffuse goiter with chronic GI hypermotility.
• Cushing/Addison have opposite weight and BP patterns and different skin findings.

Tutor Insight

Atrial fibrillation in a hyperadrenergic patient should make you reflexively check thyroid—NBME loves that link.

Question 104 — Absolute risk reduction calculation

Biostats

Answer: 2.6 (per 1000 woman-years).

Why this is correct

• ARR = event rate (control) – event rate (treatment).
• If placebo incidence is 3.6/1000 and treatment is 0.97/1000, ARR ≈ 2.63/1000 → rounds to 2.6.

Why the others are wrong

• Using just one group's incidence (e.g., 3.6) confuses baseline risk with absolute reduction.
• Overestimates typically come from subtracting incorrectly or using the wrong numerator.

Tutor Insight

ARR is always "two rows, one subtraction." Don't let fancy units distract you.

Question 105 — Hereditary multiple exostoses (EXT mutation)

MSK

Answer: Bear weight as tolerated; no further workup needed (given reassuring imaging stability).

Why this is correct

• Osteochondromas in hereditary multiple exostoses are usually benign and stable; unchanged imaging argues against malignant transformation.
• With a minor injury and no red-flag features, conservative management is appropriate.

Why the others are wrong

• Biopsy/MRI is reserved for concerning features (rapid growth after maturity, persistent pain unrelated to trauma, cartilage cap changes).
• Non–weight-bearing restrictions are unnecessary if stability and function are preserved.

Tutor Insight

Tumor questions often test "when not to chase it." Stability over time is a powerful benign sign.

Question 106 — When to tell a child about adoption

Psych/Peds

Answer: As early as possible, even if she can't fully process it yet.

Why this is correct

• Early, age-appropriate disclosure supports trust and allows the child to integrate adoption into identity development over time.
• Delaying increases risk of betrayal feelings if discovered later.

Why the others are wrong

• Waiting for a specific age or administrative event is arbitrary and can harm family trust.

Tutor Insight

Psychosocial questions often reward transparency and gradual developmentally appropriate conversations over "one big reveal."

Question 107 — Acute monoarthritis in first MTP with risk meds

Rheum

Answer: Gout.

Why this is correct

• Sudden severe pain in the great toe is classic podagra.
• Thiazide diuretics increase uric acid and raise gout risk; diabetes/HTN cluster increases risk as well.

Why the others are wrong

• OA is chronic and gradual, not abrupt severe inflammation.
• Cellulitis is skin-focused; gout is intra-articular with extreme tenderness and swelling.

Tutor Insight

Medication clues matter: thiazides and gout are a classic Step 2 pairing.

Question 108 — Risk factor for post-procedure pelvic infection

OB/Gyn

Answer: Type of vaginal discharge (suggesting bacterial vaginosis).

Why this is correct

• BV (homogeneous gray-white discharge, elevated pH) reflects altered vaginal flora and increases risk of post-procedure pelvic infection.
• Identifying BV pre-procedure can change prophylaxis and management planning.

Why the others are wrong

• Resolved URI history is unrelated.
• HSV matters if active lesions are present; BV is a stronger generic risk for ascending infection in this context.

Tutor Insight

When asked "what increases post-op pelvic infection," think "ascending flora" issues—BV is a common test target.

Question 109 — Facial palsy + meningitis symptoms in Lyme-endemic region

Neuro/Infect

Answer: Serum Lyme (Borrelia burgdorferi) antibody testing.

Why this is correct

• Lyme can cause cranial neuropathy (facial palsy) and aseptic meningitis; geography supports pretest probability.
• Serology is an appropriate diagnostic step for suspected disseminated Lyme manifestations.

Why the others are wrong

• ACE level is for sarcoidosis; ANA is for autoimmune disease—neither fits the regional infectious pattern.
• CMV is unlikely in this setting and would not explain classic Lyme neuro pattern plus geography.

Tutor Insight

NBME loves geographic anchors. If they tell you "New Jersey" plus facial palsy + meningitis-ish symptoms, think Lyme.

Question 110 — Marked leukocytosis with left shift + splenomegaly

Heme/Onc

Answer: Chronic myeloid leukemia.

Why this is correct

• CML presents with high WBC count and immature granulocytes across maturation stages (left shift) rather than blasts predominance.
• Splenomegaly and constitutional symptoms support a chronic myeloproliferative process.

Why the others are wrong

• AML/ALL have high blast percentages and acute illness patterns.
• CLL is lymphocytosis in older adults, not granulocytic left shift.

Tutor Insight

If you see "mature leukocytosis with a ladder of myeloid precursors," think CML and (in the background) BCR-ABL.

Question 111 — Myelomeningocele complication

Peds/Neuro

Answer: Neurogenic bladder.

Why this is correct

• Neural tube defects with lower extremity deficits imply sacral nerve involvement affecting bladder function.
• Neurogenic bladder is common and requires monitoring to prevent hydronephrosis/UTIs.

Why the others are wrong

• Heart malformations and cryptorchidism are not the characteristic high-frequency complications compared with bladder dysfunction and hydrocephalus.
• Cognitive outcomes vary; bladder dysfunction is a more direct anatomic consequence.

Tutor Insight

For spina bifida, the two "must remember" sequelae are hydrocephalus and neurogenic bladder—boards test both.

Question 112 — Teen boundary testing and peers

Psych

Answer: Normal development.

Why this is correct

• Adolescents commonly test limits, prioritize peers, and engage in some risk-taking behavior.
• Absent a persistent pattern of violating others' rights or severe impairment, this can be within normal developmental behavior.

Why the others are wrong

• Conduct disorder requires repetitive serious violations (aggression, cruelty, theft, destruction) beyond a few episodes of trespassing.
• ODD is a persistent pattern of angry/defiant behavior across settings, not isolated peer-driven acts.

Tutor Insight

Psych developmental questions often test your threshold for pathology: frequency + severity + impairment must be clear before labeling a disorder.

Question 113 — ICU team communication improvement

QI

Answer: Conduct weekly structured team briefings and daily huddles.

Why this is correct

• Regular structured communication builds a shared mental model and reduces miscommunication in complex care.
• Daily huddles allow real-time updates and rapid correction when patients deviate from expected course.

Why the others are wrong

• One-off education or individual discussions don't reliably maintain shared situational awareness.
• Team consistency helps but does not replace structured communication routines.

Tutor Insight

When the vignette says "communication," the best answer is usually "structured, recurring communication," not "more training."

Question 114 — Mono-like illness with negative Monospot + HIV risk context

Infect

Answer: HIV RNA PCR testing.

Why this is correct

• Acute HIV can present as a mononucleosis-like syndrome with negative heterophile antibody testing early.
• HIV RNA PCR detects infection before antibody tests turn positive.

Why the others are wrong

• EBV serology is less likely when Monospot is negative and risk factors/epidemiology support acute HIV.
• HBsAg testing is for hepatitis syndromes, which don't match the described illness pattern.

Tutor Insight

When the test says "flu/mono symptoms + negative Monospot," it's nudging you toward acute HIV—RNA testing is the early diagnostic tool.

Question 115 — No advance directive; dementia; who decides?

Ethics

Answer: Son (adult child surrogate).

Why this is correct

• When a patient lacks capacity and no designated proxy exists, surrogate hierarchy generally prioritizes legal spouse and then adult children.
• A long-term partner is typically not the default surrogate absent legal documentation (varies by jurisdiction, but boards often use the standard hierarchy).

Why the others are wrong

• The patient cannot decide if dementia prevents understanding/appreciation.
• Neighbors and clinicians are not default surrogates when family exists.

Tutor Insight

Ethics hierarchy questions are about who has legal standing—boards usually prioritize spouse/children over partners unless legally designated.

Question 116 — RLQ pain + chronic diarrhea; evaluate Crohn complications

GI

Answer: CT scan of the abdomen.

Why this is correct

• RLQ pain with chronic diarrhea raises suspicion for Crohn's disease; CT helps assess complications (abscess, fistula, obstruction) and alternative diagnoses.
• CT offers broad evaluation when appendicitis vs IBD complication is in the differential.

Why the others are wrong

• Ultrasound can miss deeper bowel complications in adults and is less comprehensive for IBD complications.
• Meckel scan targets painless lower GI bleeding patterns, not chronic diarrhea with RLQ pain.

Tutor Insight

When appendicitis is "not quite right" because of chronic symptoms, Step 2 expects you to broaden to Crohn and pick a test that sees beyond the appendix.

Question 117 — Painless bright red rectal bleeding in older adult

GI

Answer: Diverticulosis.

Why this is correct

• Diverticular bleeding is classically sudden, painless, and can be brisk bright red blood per rectum in older adults.
• NSAID use increases risk of lower GI bleeding, including diverticular bleeding.

Why the others are wrong

• Anal fissures are painful with defecation.
• Upper GI sources usually cause melena; UC presents with chronic diarrhea and systemic symptoms.

Tutor Insight

Lower GI bleed differentials often boil down to pain: painless BRBPR in an older adult = diverticulosis until proven otherwise.

Question 118 — Post-cardiac surgery infant decompensation

Cardio/Peds

Answer: Echocardiography.

Why this is correct

• Acute poor perfusion signs after cardiac surgery require rapid evaluation for cardiac causes (tamponade, ventricular dysfunction, residual defect).
• Echo is rapid, noninvasive, and immediately actionable.

Why the others are wrong

• Cardiac catheterization and CT angiography are more invasive/slow; not first-line in an acutely decompensating infant.
• MRI is too slow and logistically challenging in unstable patients.

Tutor Insight

Post-op decompensation? Choose the fastest test that can show the most dangerous reversible problems—echo usually wins.

Question 119 — Hypoglycemia with high insulin but normal C-peptide

Endocrine

Answer: No abnormalities on imaging (consistent with factitious insulin administration).

Why this is correct

• Exogenous insulin causes high insulin with low/normal C-peptide (because C-peptide is produced only with endogenous insulin secretion).
• Because the insulin is not coming from a tumor, imaging would not show a pancreatic mass.

Why the others are wrong

• Insulinoma would raise both insulin and C-peptide (endogenous production).
• Pancreatic adenocarcinoma/pseudocyst do not cause hypoglycemia with this lab pattern.

Tutor Insight

C-peptide is the "origin label" for insulin. High insulin + low C-peptide = injected insulin until proven otherwise.

Question 120 — Necrotizing fasciitis

Surgery/Infect

Answer: Surgical debridement.

Why this is correct

• Necrotizing fasciitis is rapidly progressive infection with high mortality; definitive management is immediate surgical exploration and debridement.
• Antibiotics are essential but cannot substitute for removing necrotic tissue and controlling the source.

Why the others are wrong

• Imaging (MRI) can delay life-saving surgery when clinical suspicion is high.
• Observation or aspiration is dangerously insufficient for a necrotizing process.

Tutor Insight

Step 2 "pain out of proportion" + rapid progression = OR. If you hesitate, you pick the wrong answer.

Sources:

• USMLE Step 2 CK Sample Test Questions (PDF + interactive experience): https://www.usmle.org/exam-resources/step-2-ck-materials/step-2-ck-sample-test-questions

• USMLE Score Interpretation Guidelines (includes score precision metrics): https://www.usmle.org/sites/default/files/2022-05/USMLE%20Step%20Examination%20Score%20Interpretation%20Guidelines_5_24_22_0.pdf

• USMLE announcement on Step 2 CK passing standard change (July 1, 2025): https://www.usmle.org/change-step-2-ck-passing-standard-begins-july-1-2025

NOTE: This page is written as an independent educational guide. It does not reproduce USMLE question stems or answer choices.