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Step 2 Sample Test Answers + Explanations 2026
USMLE STEP 2 Free 120 Explanations
Updated Feb 2025
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Updated as of Feb 2025
Here are the detailed explanations of the new Free 120 NBME STEP 2 Sample Test Questions so you don’t waste your time trying to find the correct answers and explanations. We had our expert USMLE tutors who scored 260+ on their exams refine these answers and explanations for you so you can spend your valuable time learning!
You can download the Free 120 STEP 2 Sample Test Questions on the USMLE website here. The order of answers and explanations here is based on the online NBME platform (not the pdf) as of February 2025.
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Table of Contents
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Block 1
Question 1:
The correct answer is B. This patient presents with sudden onset of flank/lumbar pain, gross hematuria, and unilateral hydronephrosis with hydroureter, strongly suggesting a ureteral stone. Non-contrast CT of the abdomen and pelvis is the gold standard for diagnosing ureteral stones. It provides a detailed view of the renal tract, identifying stones and their exact location, as well as any complications like obstruction.
Incorrect answers:
A. Captopril renography: Typically used for diagnosing renovascular hypertension due to renal artery stenosis, which is unrelated to this patient’s acute presentation.
C. MAG-3 renal scan with furosemide: Utilized to distinguish obstructive from non-obstructive hydronephrosis but is not indicated as the first-line test in acute obstruction suspected due to ureteral stone.
D. Radionuclide cystography & E. Retrograde pyelography: These are used for assessing vesicoureteral reflux and other structural abnormalities. They are not first-line for evaluating suspected stones.
F. Ultrasonography of the spinal column: Indicated for spinal dysraphism, often identified by external markers such as a tuft of hair or dimple in the lower back, which are absent in this case.
G. Voiding cystourethrography: Performed to assess vesicoureteral reflux, which commonly presents with recurrent urinary tract infections, not acute flank pain and hematuria “HY”.
Question 2:
The correct answer is F. This patient’s symptoms of numbness, absent deep tendon reflexes, and decreased vibration and proprioception are consistent with peripheral neuropathy, likely due to vitamin B12 deficiency. Chronic calcium carbonate use can impair B12 absorption by reducing gastric acid secretion, which is required to release B12 from food. Vitamin B12 supplementation is necessary to prevent further neurological damage and to restore B12 levels. This is particularly important in elderly patients or those with long-term antacid use.
Incorrect answers:
A. Alcohol cessation: Chronic alcohol use can contribute to neuropathy but typically also causes cerebellar dysfunction, leading to ataxia and an abnormal gait, which are not observed in this patient.
B. Calcium carbonate cessation: Stopping calcium carbonate may reduce B12 depletion, but replenishing B12 stores with supplementation is the more direct treatment.
C. Folic acid supplementation: Folic acid deficiency causes macrocytic anemia but does not typically result in peripheral neuropathy.
D. Niacin supplementation: Niacin deficiency presents as pellagra, characterized by diarrhea, dermatitis, and dementia, not peripheral neuropathy.
E. Vitamin B1 (thiamine) supplementation: Thiamine deficiency results in Wernicke encephalopathy, presenting as confusion, ataxia, and ophthalmoplegia, which are not seen in this case.
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Question 3:
The correct answer is D. This patient presents with acute onset of cough, hoarseness, inspiratory stridor at rest, and moderate respiratory distress following a recent upper respiratory tract infection, which is consistent with croup. Croup is commonly caused by the parainfluenza virus and results in subglottic airway edema. Nebulized epinephrine is indicated for severe croup, characterized by stridor at rest and the use of accessory muscles for breathing (e.g., suprasternal and subcostal retractions). It works by reducing airway edema and relieving obstruction.
Incorrect answers:
A. Intravenous dexamethasone & F. Oral prednisone: Steroids like dexamethasone are effective for reducing airway inflammation but act more slowly. They are used as adjunctive therapy rather than initial treatment in severe cases.
B. Nebulized albuterol: Albuterol is used for bronchospasm in asthma, not for airway edema seen in croup.
C. Nebulized budesonide: Used for the chronic management of asthma, not acute treatment of croup.
E. Oral albuterol: Not commonly used in clinical practice due to limited efficacy and potential side effects.
G. Subcutaneous epinephrine: Indicated for anaphylaxis and angioedema, not for croup.
Question 4:
The correct answer is D. This patient is in the end stage of a terminal illness with acute respiratory failure. He has verbally expressed his desire to avoid mechanical ventilation, as confirmed by his wife. Even without formal documentation, verbal statements regarding medical care preferences are ethically and legally significant, especially when corroborated by close family. Respecting the patient’s autonomy and prioritizing his wishes aligns with ethical medical practice. Providing palliative therapy ensures comfort and dignity in his remaining hours.
Incorrect answers:
A. Perform endotracheal intubation and begin mechanical ventilation: Violates the patient’s expressed wishes and autonomy.
B. Perform endotracheal intubation and then consult the hospital ethics committee: Unnecessary because the patient’s wishes are clear and validated by a close family member.
C. Perform endotracheal intubation only: Contradicts the patient’s stated preference against mechanical ventilation.
E. Seek a court order to assign a legal guardian: Impractical for an acute situation requiring immediate action and unnecessary when the patient’s wishes are known.
Question 5:
The correct answer is D. This child presents with specific difficulties in reading despite having an average IQ and age-appropriate daily living skills, which is characteristic of a learning disorder. Learning disorders affect specific academic skills (e.g., reading, mathematics, or writing) and are not associated with global intellectual impairment. The slow acquisition of English is expected given his recent adoption and prior Russian language background. His receptive language abilities and age-appropriate skills further confirm that this is a specific academic issue rather than a global developmental delay. In adopted children, language acquisition difficulties are common due to exposure to a new language environment, and these must be distinguished from true learning disabilities by assessing their native language proficiency and academic skills.
Incorrect answers:
A. Autism spectrum disorder: This child does not exhibit persistent deficits in social communication or interaction, nor restricted or repetitive patterns of behavior.
B. Fetal alcohol syndrome: The patient lacks the characteristic facial features (e.g., smooth philtrum, thin upper lip), growth restrictions, and CNS abnormalities associated with this condition.
C. Intellectual developmental disorder: The child’s average IQ and age-appropriate adaptive functioning exclude this diagnosis.
E. Post-traumatic stress disorder: Although the child has a traumatic background, there are no symptoms of re-experiencing, avoidance, or hyperarousal to suggest PTSD.
F. Reactive attachment disorder: The child demonstrates healthy emotional attachment and social engagement, which excludes this diagnosis.
Question 6:
The correct answer is F. The presence of a raised, fleshy lesion on the vulva in an elderly woman raises suspicion for vulvar cancer. The definitive method for diagnosing such a lesion is through histological examination via biopsy. Risk factors for vulvar cancer include advanced age, chronic lichen sclerosus, human papillomavirus (HPV) infection, and smoking. Early biopsy is crucial for identifying malignancy and initiating treatment promptly.
Incorrect answers:
A. Cytologic evaluation of the vulva: Cytology is not sufficient for diagnosing vulvar cancer; biopsy is the gold standard.
B. CT scan of the abdomen and pelvis: Imaging is used for staging after a diagnosis od cancer, not as an initial diagnostic step for a vulvar lesion.
C. Application of an antifungal cream: There is no evidence of fungal infection, such as erythema or pruritus.
D. Application of a corticosteroid cream: The lesion does not exhibit signs of inflammation or conditions like lichen sclerosis which presents as a white patch.
E. Colonoscopy: used for cervical cancer assessment. This is unrelated to the presentation of a vulvar lesion.
Question 7:
The correct answer is C. This patient presents with clinical signs of peripheral arterial disease (PAD), including absent pedal pulses and a femoral bruit. Dyslipidemia is a significant and modifiable risk factor for PAD, making lipid profile assessment crucial in this scenario. PAD is a strong predictor of systemic atherosclerosis, necessitating aggressive risk factor management, including lipid-lowering therapy, to prevent cardiovascular events. Identifying and managing dyslipidemia helps reduce cardiovascular morbidity and mortality associated with PAD.
Incorrect answers:
A. Pentoxifylline therapy: Indicated for symptomatic intermittent claudication in PAD but unnecessary for asymptomatic patients.
B. Peripheral artery catheterization: An invasive procedure used for patients undergoing revascularization for acute limb ischemia, not for initial evaluation.
D. Warfarin therapy: Warfarin is used for anticoagulation in conditions like atrial fibrillation or venous thromboembolism but is not indicated for PAD. Instead, antiplatelets are used for PAD.
E. No further management is indicated: The patient requires further evaluation and management of PAD risk factors; neglecting this would miss an opportunity to prevent progression and associated complications.
Question 8:
The correct answer is C. This patient’s fever, sore throat, and significant neutropenia (marked decrease in white blood cells with relative neutropenia) are consistent with drug-induced agranulocytosis, a known adverse effect of trimethoprim-sulfamethoxazole (TMP-SMX). Agranulocytosis is characterized by an acute reduction in circulating granulocytes, predominantly neutrophils, and is often associated with infections such as pharyngitis due to the impaired immune response. TMP-SMX-induced agranulocytosis typically resolves after discontinuation of the drug.
Incorrect answers:
A. Acute mononucleosis: Typically presents with fever, sore throat, and lymphocytosis with atypical lymphocytes, not neutropenia. In addition, splenomegaly and cervical lymphadenopathy are expected.
B. Acute myelogenous leukemia: Presents with pancytopenia and immature blast cells on the peripheral smear, which are absent here.
D. Allergic reaction to lisinopril: Lisinopril is associated with angioedema and cough but does not cause neutropenia.
E. Myelofibrosis: A chronic condition leading to pancytopenia, splenomegaly, teardrop cells on the smear, and bone marrow fibrosis, which are not seen in this case.
F. Sepsis syndrome: Sepsis can cause leukocytosis or leukopenia, but the temporal relationship with TMP-SMX use strongly suggests drug-induced agranulocytosis rather than sepsis.
Question 9:
The correct answer is B. This patient with Parkinson’s disease is experiencing postural instability, evidenced by frequent falls, backward falls when walking, and failure to maintain posture during a pull test. Physical therapy, particularly focusing on balance training and gait exercises, is the most effective intervention to reduce the risk of future falls. Physical therapy improves strength, stability, and movement coordination, which are critical for addressing postural instability in Parkinson’s disease.
Incorrect answers:
A. Biofeedback: may be used for somatic symptom disorder, no consistent evidence supports its effectiveness in managing postural instability related to Parkinson’s disease.
C. Pramipexole therapy, D. Ropinirole therapy, E. Rotigotine therapy: dopamine agonists used for Parkinson’s symptoms of rigidity and bradykinesia but do not address postural instability or fall prevention.
Question 10:
The correct answer is C. The patient’s right knee examination shows no evidence of significant injury and does not meet the Ottawa Knee Rule criteria for imaging “knee pain and any of the following:
1. Age ≥55 years.
2. Isolated tenderness of the patella.
3. Tenderness at the head of the fibula.
4. Inability to flex the knee to 90 degrees.
5. Inability to bear weight both immediately after the injury and for four steps in the emergency department”. In contrast, the right ankle examination reveals tenderness at the distal fibula and restricted range of motion, which meet the Ottawa Ankle Rule criteria for an X-ray to rule out a fracture “pain in the malleolar zone and any of the following:
1. Bone tenderness at the posterior edge or tip of the malleolus.
2. Inability to bear weight both immediately after the injury and for four steps in the emergency department.
The Ottawa Rules are a validated clinical tool to determine the need for imaging in acute knee and ankle injuries, helping reduce unnecessary X-rays. These rules emphasize clinical findings such as bone tenderness and the inability to bear weight.
Incorrect answers:
A. X-ray (Knee) & X-ray (Ankle): The knee findings do not meet Ottawa Knee Rule criteria, making an X-ray unnecessary.
B. X-ray (Knee) & No diagnostic testing indicated (Ankle): Overlooks the clear indications for imaging the ankle based on the Ottawa Ankle Rules.
D. No diagnostic testing indicated (Knee) & No diagnostic testing indicated (Ankle): Fails to address the concerning findings of distal fibula tenderness and limited motion in the ankle, which warrant imaging.
Question 11:
The correct answer is D. This patient presents with episodic headaches, palpitations, sweating, and hypertension, along with a 4-cm adrenal mass on CT imaging. These findings strongly suggest pheochromocytoma, a catecholamine-secreting adrenal tumor. The first step in confirming this diagnosis is measuring plasma free metanephrines or 24-hour urine fractionated metanephrines and catecholamines. Elevated levels confirm the biochemical diagnosis, guiding further management.
Incorrect answers:
A. 24-Hour urine collection for measurement of vanillylmandelic acid and 5-hydroxyindoleacetic acid: Used to diagnose neuroblastoma (vanillylmandelic acid) or carcinoid syndrome (5-hydroxyindoleacetic acid), not pheochromocytoma.
B. Adrenal venous sampling: Reserved for differentiating primary hyperaldosteronism causes, such as adrenal adenoma versus bilateral adrenal hyperplasia.
C. Laparoscopic left adrenalectomy and right adrenal biopsy: Surgery is premature without biochemical confirmation of pheochromocytoma, as it requires specific preoperative management to prevent hypertensive crises.
E. Transsphenoidal hypophysectomy: Relevant for pituitary tumors, not adrenal lesions.
Question 12:
The correct answer is B. This patient presents with symptoms of hyperglycemia (polyuria, polydipsia, weight loss), a blood glucose level of 578 mg/dL, and an elevated hemoglobin A1c of 10.7%, consistent with diabetes mellitus. The rapid onset of symptoms, significant weight loss, and low BMI strongly suggest type 1 diabetes mellitus (T1DM) rather than type 2 diabetes mellitus. In T1DM, there is an absolute deficiency of insulin due to autoimmune destruction of pancreatic beta cells. Insulin therapy is required to manage hyperglycemia and prevent diabetic ketoacidosis.
Incorrect answers:
A. Glyburide therapy: Sulfonylureas stimulate insulin secretion from functional beta cells, which are absent in T1DM.
C. Metformin therapy: Primarily used for type 2 diabetes to reduce hepatic glucose production; ineffective in T1DM.
D. Pioglitazone therapy: A thiazolidinedione that improves insulin sensitivity; not suitable for T1DM as it does not address the lack of insulin.
E. Sitagliptin therapy: A DPP-4 inhibitor used for type 2 diabetes to enhance incretin activity; ineffective in T1DM.
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Question 13:
The correct answer is B. This patient presents with severe shortness of breath, crackles extending halfway up the lung fields, low oxygen saturation, an S3 gallop, and hypotension shortly after a myocardial infarction. These findings are consistent with acute pulmonary edema due to acute left ventricular failure. The loss of functional myocardium from the myocardial infarction results in decreased cardiac output, increased left ventricular end-diastolic pressure, and pulmonary congestion.
Incorrect answers:
A. Acute dilation of the aortic root: Typically presents with severe chest pain and a widened mediastinum on chest X-ray, which is not described here.
C. Intravascular hypovolemia: Causes hypotension and tachycardia but is associated with dry mucous membranes and absent pulmonary edema.
D. New ventricular septal defect: Presents with a new loud holosystolic murmur best heard at the left lower sternal border and signs of left-to-right shunting, which are absent in this patient.
E. Ruptured papillary muscle: Leads to acute severe mitral regurgitation with a new loud holosystolic murmur and pulmonary edema, neither of which are noted in the patient.
Question 14:
The correct answer is E. This 12-year-old girl shows no signs of secondary sexual characteristics, but her presentation is not yet abnormal. Puberty typically begins between ages 8-13 in girls, and the absence of breast development (thelarche) by age 13 is the threshold for considering delayed puberty. This patient’s lack of breast development is still within the normal range for her age. Regular monitoring is sufficient unless she reaches age 13 without pubertal signs.
Incorrect answers:
A. Measurement of serum follicle-stimulating hormone and luteinizing hormone concentrations: There is no evidence of primary ovarian failure or hypothalamic-pituitary axis dysfunction requiring hormonal assessment.
B. Measurement of serum growth hormone and thyroxine concentrations: The patient’s growth and weight percentiles are normal, ruling out growth hormone deficiency or hypothyroidism.
C. MRI of the brain: There is no clinical suspicion of central causes of delayed puberty, such as a pituitary or hypothalamic tumor.
D. X-ray of the left hand and wrist to determine bone age: Bone age assessment is unnecessary unless there is significant growth delay or concern for abnormal skeletal maturity.
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Question 15:
The correct answer is A. This randomized controlled trial (RCT) found that the new antiarrhythmic drug reduced recurrent episodes of ventricular tachycardia, but the investigators incorrectly concluded that it decreases mortality from cardiac arrhythmia.
This is an example of extrapolation beyond data—the study did not assess mortality as an outcome, so making claims about mortality reduction is scientifically invalid. When interpreting study results, it is crucial to distinguish between statistical significance and clinical relevance, avoiding unwarranted extrapolation of findings to outcomes not directly measured, such as mortality.
Incorrect answers:
B. Insufficient power – The study found a statistically significant difference (p < 0.05), meaning it had sufficient power to detect an effect.
C. No information regarding confidence interval – While confidence intervals provide additional precision, the main flaw here is the overgeneralization of results, not a lack of interval reporting.
D. Selection bias – There is no mention of inappropriate participant selection or non-randomized allocation, making selection bias unlikely.
Question 16:
The correct answer is E. The newborn hemoglobin electrophoresis showing an FS pattern indicates that the infant has sickle cell disease (SCD). The absence of hemoglobin A confirms this diagnosis. SCD predisposes children to life-threatening infections, particularly due to functional asplenia from early splenic infarction. The most appropriate next step is to initiate penicillin prophylaxis to prevent invasive infections, particularly from Streptococcus pneumoniae. Prophylaxis is typically started by 2 months of age and continued until at least age 5.
Incorrect answers:
A. Deferoxamine therapy: Used for iron overload in transfusion-dependent patients, not for routine management of SCD.
B. Hydroxyurea therapy: Increases fetal hemoglobin (HbF) and reduces vaso-occlusive crises but is not started in asymptomatic neonates.
C. Iron supplementation: Not indicated unless there is iron deficiency anemia, which is rare in neonates with SCD.
D. Monthly blood transfusions: Reserved for specific complications of SCD, such as stroke prevention, and is not routine at this stage.
F. Vitamin B12 (cyanocobalamin) supplementation: Not indicated, as there is no evidence of vitamin B12 deficiency.
Question 17:
The correct answer is C. The patient has features consistent with DiGeorge syndrome (22q11.2 deletion syndrome), including congenital anomalies such as a cleft palate and ventricular septal defect, as well as recurrent infections (pneumonia and otitis media). A hallmark of DiGeorge syndrome is T-cell lymphopenia due to thymic hypoplasia or aplasia, which impairs the adaptive immune response and increases susceptibility to infections. A complete blood count in this patient would likely show lymphopenia secondary to the T-cell deficiency.
Incorrect answers:
A. Eosinophilia: Seen in parasitic infections, allergic reactions, and some autoimmune conditions, none of which are evident here.
B. Lymphocytosis: Typically occurs in viral infections such as infectious mononucleosis, which is not suggested by the history or presentation.
D. Neutropenia: More commonly associated with bone marrow suppression, congenital conditions like Kostmann syndrome, or aplastic anemia, none of which are relevant here.
E. Neutrophilia: Typical of bacterial infections or inflammatory conditions but does not explain the recurrent infections due to immunodeficiency.
Question 18:
The correct answer is E. The patient presents with hematemesis, mid-epigastric tenderness, and positive stool occult blood, which are consistent with an upper gastrointestinal (GI) bleed. Esophagogastroduodenoscopy (EGD) is the diagnostic and therapeutic procedure of choice for upper GI bleeding. It allows direct visualization of the esophagus, stomach, and duodenum, enabling identification and treatment of the bleeding source.
Incorrect answers:
A. Abdominal CT scan: Not first-line for GI bleeding; does not provide therapeutic capability.
B. Octreotide scan: Used for detecting ectopic endocrine activity, not for acute GI bleeding.
C. Technetium 99m scan: Used for slow or intermittent GI bleeds, but EGD is the preferred diagnostic tool for acute cases.
D. Colonoscopy: Evaluates the lower GI tract and is irrelevant for hematemesis, which indicates an upper GI source.
F. Mesenteric angiography: Reserved for cases of refractory bleeding when endoscopy is not diagnostic or therapeutic.
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Question 19:
The correct answer is D. The patient has an upper GI bleed confirmed by esophagogastroduodenoscopy, and the endoscopic findings likely reveal an actively bleeding lesion or a high-risk lesion for rebleeding, such as a visible vessel or adherent clot. Endoscopic hemostatic therapy, which includes techniques such as injection therapy, thermal coagulation, or application of hemostatic clips, is the most appropriate next step. These interventions control active bleeding and reduce the risk of rebleeding.
Incorrect answers:
A. Octreotide therapy: Used for variceal bleeding associated with portal hypertension, not for non-variceal bleeding.
B. Omeprazole therapy: Proton pump inhibitors are used for peptic ulcer disease to reduce acid production but do not control active bleeding.
C. Tyrosine kinase inhibitor therapy: Indicated for gastrointestinal stromal tumors, not for acute GI bleeding.
E. Endoscopic biopsy: Used for diagnosing suspected lesions but is not the priority in acute bleeding.
F. Endoscopic resection: Appropriate for removing tumors or polyps but not for managing acute bleeding.
Question 20:
The correct answer is B. This patient presents with a persistent, nonproductive cough following an upper respiratory tract infection, accompanied by post-tussive vomiting and bursts of coughing, which are characteristic of pertussis (whooping cough). Bordetella pertussis, the causative organism, is treated with a macrolide antibiotic such as azithromycin. Early treatment reduces bacterial transmission, although it may not significantly alter the course of symptoms once the paroxysmal stage has begun.
Incorrect answers:
A. Albuterol: Used for bronchospasm in asthma or COPD, which this patient does not have.
C. Levofloxacin: A fluoroquinolone used for severe or complicated bacterial infections but not indicated for pertussis.
D. Omeprazole: A proton pump inhibitor for GERD, unrelated to this patient’s symptoms.
E. Prednisone: An anti-inflammatory for asthma, COPD exacerbations, or autoimmune diseases, none of which are present here.
Question 21:
The correct answer is B. This neonate has elevated TSH and low free thyroxine (FT₄), indicating primary hypothyroidism. Congenital hypothyroidism is most commonly caused by thyroid dysgenesis. Early initiation of levothyroxine therapy is critical to prevent irreversible intellectual disability and developmental delays. Treatment should be initiated as soon as possible to ensure normal thyroid hormone levels during this critical period of brain development.
Incorrect answers:
A. Hydrocortisone therapy: Used for adrenal insufficiency, not primary hypothyroidism.
C. Monthly thyroglobulin measurement: Thyroglobulin is not a primary marker for assessing thyroid function or guiding management.
D. Monthly TSH and FT₄ measurements: Monitoring thyroid function is important but does not replace the need for immediate treatment.
E. Radioactive iodine uptake scan: Contraindicated in neonates due to the risks associated with radiation exposure.
F. Ultrasonography of the thyroid gland: May identify structural abnormalities, but it is not required for initial treatment and does not influence immediate management.
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Question 22:
The correct answer is D. This patient presents with progressive heart failure symptoms (dyspnea, orthopnea, pitting edema, S₃ gallop, pulmonary crackles) along with hypertension, exertional chest pain, and severe gingivitis (“meth mouth”), which are highly suggestive of chronic methamphetamine use.
Methamphetamine is a sympathomimetic stimulant that causes hypertension, tachycardia, and direct myocardial toxicity, leading to dilated cardiomyopathy and heart failure. Long-term use is also associated with dental decay and severe gingivitis, commonly referred to as ‘meth mouth’.
Incorrect answers:
A. Cocaine – Can cause myocardial ischemia and infarction, but is not strongly associated with dilated cardiomyopathy or gingivitis.
B. Heroin – More commonly leads to non-cardiogenic pulmonary edema, respiratory depression, and infectious complications rather than heart failure.
C. Methadone – Used for opioid dependence, associated with respiratory depression and QT prolongation, but not cardiomyopathy or gingivitis.
E. Toluene – Inhalant abuse can cause renal tubular acidosis and multi-organ damage, but it is not associated with heart failure or dental decay.
Question 23:
The correct answer is A. This patient presents with opioid overdose (lethargy, bradypnea), limb ischemia (cold, cyanotic extremity), and severe rhabdomyolysis (creatine kinase >50,000 U/L, hyperkalemia, metabolic acidosis). The USMLE/NBME emphasizes rhabdomyolysis as a common cause of myoglobin-induced AKI, making this the greatest risk.
Rhabdomyolysis leads to AKI through renal tubular obstruction, direct toxicity from myoglobin, and intravascular volume depletion. The elevated creatine kinase confirms significant muscle injury, and AKI is the most immediate and life-threatening complication in such cases.
Incorrect answers:
B. Acute liver failure – More commonly seen in acetaminophen overdose, not opioid toxicity.
C. Cardiac arrhythmia – Hyperkalemia from rhabdomyolysis can cause arrhythmias, but AKI is the primary risk.
D. Hypocalcemia & E. Hypophosphatemia – Electrolyte imbalances occur in rhabdomyolysis but are secondary to AKI and are not the greatest immediate risk.
Question 24:
The correct answer is E. This patient presents with chronic, intermittent non-bloody diarrhea, weight loss, and a history of drinking untreated freshwater from a spring-fed pond, which is highly suggestive of giardiasis.
Giardia lamblia is a protozoal parasite transmitted via ingestion of cyst-contaminated water, especially from rural or wilderness areas. It causes fat malabsorption, bloating, flatulence, and prolonged watery diarrhea. The presence of cysts or trophozoites on stool microscopy confirms the diagnosis.
Incorrect answers:
A. Campylobacter jejuni – Causes bloody diarrhea, often linked to undercooked poultry, not freshwater exposure.
B. Clostridioides difficile – Typically associated with recent antibiotic use, leading to pseudomembranous colitis.
C. Entamoeba histolytica – Causes dysentery (bloody diarrhea) and can lead to liver abscesses.
D. Escherichia coli – Various pathogenic strains cause gastroenteritis, but freshwater exposure is not a typical source.
F. Salmonella enteritidis – Associated with contaminated poultry/eggs, typically causing fever and bloody diarrhea.
G. Shigella dysenteriae – Produces severe dysentery, not prolonged, intermittent diarrhea.
Question 25:
The correct answer is E. This patient presents with acute unilateral pelvic pain, adnexal tenderness, and ultrasound findings of a simple ovarian cyst with free fluid, which strongly suggests an uncomplicated ruptured ovarian cyst.
Ovarian cyst rupture is common in reproductive-aged women, particularly mid-cycle, and results in mild-to-moderate pain that worsens with movement. The presence of free fluid on ultrasound is consistent with cyst rupture. In hemodynamically stable patients without signs of infection or ongoing bleeding, observation with pain management is the appropriate next step.
Incorrect answers:
A. Antibiotic therapy – Indicated for pelvic inflammatory disease (PID), but this patient has no fever, cervical motion tenderness, or purulent discharge, making infection unlikely.
B. Appendectomy – Acute appendicitis typically presents with fever, nausea, and right lower quadrant pain, not left adnexal tenderness.
C. CT scan-guided aspiration – Used for draining abscesses or evaluating uncertain pelvic masses; this case has a clear diagnosis.
D. Laparoscopy – Considered for suspected ovarian torsion, ruptured ectopic pregnancy, or severe hemorrhage; this patient is stable without signs of ongoing bleeding.
Question 26:
The correct answer is D. This patient presents with a 5-year history of intermittent dysphagia, regurgitation of undigested food, and aspiration pneumonia, which strongly suggests Zenker diverticulum.
Zenker diverticulum is a false diverticulum that forms at the pharyngoesophageal junction due to impaired cricopharyngeal muscle relaxation, leading to food retention, halitosis, and recurrent aspiration events.
Incorrect answers:
A. Achalasia – Causes progressive dysphagia to both solids and liquids, along with chest discomfort and weight loss, which are absent here.
B. Esophageal cancer – Presents with progressive dysphagia (first solids, then liquids), weight loss, and odynophagia, none of which are seen in this patient.
C. Hiatal hernia – Often presents with heartburn and regurgitation that improves with antacids, unlike the persistent regurgitation of undigested food seen in Zenker diverticulum.
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Question 27:
The correct answer is C. This patient is in active labor at 39 weeks’ gestation, showing regular contractions, progressive cervical dilation, and a reassuring fetal heart rate tracing (moderate variability, accelerations, no decelerations).
Labor is progressing normally, with cervical dilation from 6 cm to 9 cm within 30 minutes, indicating rapid progression. There are no maternal or fetal complications requiring intervention, so the best approach is expectant management, allowing labor to continue naturally.
Incorrect answers:
A. Advising the patient to begin pushing – Pushing is appropriate only when the cervix is fully dilated (10 cm). This patient is at 9 cm, so pushing prematurely could lead to maternal exhaustion or fetal distress.
B. Amnioinfusion – Indicated for variable decelerations due to umbilical cord compression, which are not present here.
D. Forceps-assisted vaginal delivery – Used when the cervix is fully dilated but delivery needs to be expedited due to maternal exhaustion or fetal distress. This patient is still in the active phase, making this intervention unnecessary.
E. Immediate cesarean delivery – Indicated for emergencies (e.g., cord prolapse, uterine rupture, persistent fetal distress). This patient has a reassuring fetal heart tracing and rapid cervical progress, so cesarean delivery is not required.
Question 28:
The correct answer is B. This patient presents with 3 months of postprandial epigastric pain without alarming features (e.g., weight loss, anemia, vomiting), which suggests peptic ulcer disease (PUD) or gastritis.
Endoscopy is the gold standard for diagnosing PUD and gastritis, allowing for direct visualization and biopsy to confirm the diagnosis and rule out H. pylori infection or malignancy.
Incorrect answers:
A. CT scan of the abdomen – More useful for detecting structural abnormalities (e.g., tumors, pancreatitis), not mucosal lesions like ulcers.
C. Examination of the stool for ova and parasites – Indicated for parasitic infections (e.g., Giardia, Entamoeba histolytica), which typically cause diarrhea and weight loss, not isolated epigastric pain.
D. Stool culture – Used for bacterial gastroenteritis (e.g., Salmonella, Shigella, Campylobacter), which presents with fever and diarrhea, not chronic postprandial pain.
E. Upper gastrointestinal series – Can detect ulcers, but is less sensitive than endoscopy and does not allow for biopsy or H. pylori testing.
Question 29:
The correct answer is C. This elderly woman with advanced dementia, dependent on a single caregiver, presents with multiple unexplained bruises and a distal radial fracture without a clear mechanism of injury. Her unkempt appearance and poor hygiene further suggest possible elder abuse and neglect.
Elder abuse should be considered in vulnerable populations, particularly when there are unexplained injuries, poor hygiene, and signs of neglect. Reporting to adult protective services is a legal and ethical obligation. In suspected elder abuse, mandatory reporting to Adult Protective Services (APS) is the appropriate next step to ensure the patient’s safety and initiate an investigation. Reporting to APC is an ethical obligation, even if you are not 100% sure. APS can assess the living environment and determine if further intervention, such as removal from the home or additional caregiver support, is necessary.
Incorrect answers:
A. Admit the patient to the hospital – Hospitalization provides temporary safety but does not address the underlying risk of ongoing abuse at home.
B & D. Arrange placement/provide phone numbers of nursing care facilities – Long-term placement may be needed, but reporting suspected abuse must occur first before determining next steps.
E. Recommend evaluation at a geriatric clinic – A comprehensive geriatric assessment may be beneficial, but it does not address the immediate safety concerns associated with potential abuse.
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Question 30:
The correct answer is B. This child has poorly controlled asthma, evidenced by weekly nighttime cough and exercise-induced symptoms that limit activity. Despite not using albuterol frequently, these symptoms indicate the need for a controller medication. According to asthma treatment guidelines, the addition of an inhaled corticosteroid (ICS) is indicated for persistent asthma, as evidenced by symptoms.
Inhaled corticosteroids (ICS), such as fluticasone, are the preferred long-term controller therapy for persistent asthma. They reduce airway inflammation, preventing symptoms and exacerbations.
Incorrect answers:
A. Oral theophylline – An older asthma treatment with significant side effects (e.g., nausea, tachycardia, toxicity risks) and is not first-line therapy.
C. Salmeterol (LABA) – Long-acting beta-agonists should not be used alone due to the risk of severe exacerbations; they are always combined with ICS if needed.
D. Oral prednisone – Indicated for acute exacerbations, but this patient requires long-term control, not short-term symptom relief.
E. No change in management – The patient’s nighttime and activity-limiting symptoms confirm poorly controlled asthma, requiring treatment escalation.
Question 31:
The correct answer is D. Premature closure occurs when a physician accepts a diagnosis too early without fully verifying it or considering alternative possibilities. Patients with complex medical conditions, such as cerebral palsy andsitus inversus, often have atypical presentations. Physicians must broaden their differential diagnosis and avoid anchoring bias to prevent missing critical conditions such as volvulus in this case.
In this case, the physician assumed gastroenteritis based on prior similar cases without considering the patient’s unique risk factors (cerebral palsy, situs inversus, severe scoliosis), which predispose her to volvulus. The failure to broaden the differential led to a missed diagnosis and delayed treatment, resulting in bowel necrosis and septic shock.
Incorrect answers:
A. Latent error – Refers to systemic or process-related failures (e.g., poor EHR design, understaffing) that increase the likelihood of errors, rather than a clinician’s cognitive bias.
B. Near miss – Describes an error that was caught before causing harm; in this case, the patient was harmed by the missed diagnosis.
C. Non-preventable error – This diagnosis could have been prevented with a more thorough evaluation.
E. Systems failure – Involves institutional breakdowns (e.g., equipment failure, poor communication between teams), whereas this error was due to individual clinical reasoning.
Question 32:
The correct answer is B. This patient presents with regional lymphadenopathy (tender axillary and epitrochlear nodes) and recent exposure to cats, which is highly suggestive of cat-scratch disease (CSD) caused by Bartonella henselae.
Key clinical features of CSD:
- History of cat scratches or bites, often from kittens.
- Localized lymphadenopathy (commonly axillary, cervical, or epitrochlear nodes).
- May have a small papule or pustule at the inoculation site.
- No systemic symptoms in immunocompetent individuals.
Incorrect answers:
A. Castleman disease – Presents with generalized lymphadenopathy, systemic symptoms (fever, night sweats), and organomegaly, which are not seen here.
C. Hidradenitis suppurativa – Chronic inflammatory skin disease with painful abscesses in the axilla, groin, and perineal areas; does not cause lymphadenopathy from a cat scratch.
D. T-cell lymphoma – Presents with widespread, persistent lymphadenopathy and systemic symptoms (fever, weight loss, night sweats); this patient’s localized lymphadenopathy and lack of systemic signs argue against lymphoma.
E. Tuberculosis – Causes chronic, painless lymphadenopathy, often with caseating necrosis and systemic symptoms; localized, tender lymph nodes after cat exposure are not typical.
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Question 33:
The correct answer is A. This patient has clustered pleomorphic microcalcifications on mammography, which is a classic finding of ductal carcinoma in situ (DCIS), an early, noninvasive form of breast cancer.
Key radiologic features of DCIS:
- Microcalcifications that are pleomorphic, clustered, or linear.
- No palpable mass or skin changes (commonly detected on routine mammography).
- Considered a precancerous lesion with a risk of progression to invasive ductal carcinoma.
Incorrect answers:
B. Fat necrosis – Associated with trauma or prior breast surgery, presents as a palpable mass, often with oil cysts and coarse calcifications, rather than clustered pleomorphic microcalcifications.
C. Fibroadenoma – Presents as a well-defined, mobile solid mass, not microcalcifications.
D. Mastitis – Causes breast redness, warmth, tenderness, and systemic symptoms (fever, malaise), which are absent here.
E. Sclerosing adenosis – A benign proliferative breast condition that can have calcifications, but they are not pleomorphic or clustered.
Question 34:
The correct answer is F. This patient, after a head-on motor vehicle collision, presents with decreased breath sounds on the right, chest and abdominal pain, and hypoxia (PaO₂ of 65 mm Hg) on ABG analysis, all of which are highly suggestive of hemothorax. Hemothorax occurs when blood accumulates in the pleural space due to trauma, and the initial management for this is tube thoracostomy (chest tube placement).
A tube thoracostomy allows for drainage of the blood and air from the pleural space, improving lung expansion and oxygenation. This intervention is crucial in preventing respiratory distress and complications from continued bleeding or fluid accumulation.
Incorrect answers:
A. Bronchoscopy – Typically used for airway management, foreign body removal, or visualization of airway pathology. Not indicated for traumatic hemothorax.
B. Intubation and mechanical ventilation – Indicated for respiratory failure. However, this patient’s hypoxia can be managed with a tube thoracostomy and supplemental oxygen, not necessarily mechanical ventilation at this stage.
C. Placement of a thoracic epidural – Typically used for pain control in thoracic surgeries or chronic pain management, not for trauma-related conditions like hemothorax.
D. Thoracentesis – Primarily used for diagnosing and draining pleural effusions; not for hemothorax. Tube thoracostomy is needed to drain significant blood accumulation in the pleural space.
E. Thoracotomy – A more invasive procedure, typically reserved for massive hemothorax or non-responsive cases; not the first-line treatment.
Question 35:
The correct answer is E. This patient initially had proteinuria during a urinary tract infection (UTI), which has since resolved on repeat urinalysis. Transient proteinuria can occur due to fever, infection, exercise, or stress, and it does not require further workup if it resolves.
Since the follow-up urinalysis is completely normal, no additional testing is necessary.
Incorrect answers:
A. Determination of urine albumin:creatinine ratio – Used for chronic proteinuria, such as in diabetic nephropathy. Not needed here because follow-up urinalysis is normal.
B. 24-hour urine collection for protein concentration – Used to quantify proteinuria in chronic kidney disease; unnecessary since proteinuria has resolved.
C. Ultrasonography of the kidneys – Indicated for structural abnormalities or renal obstruction. There is no suspicion of kidney disease in this patient.
D. Urine sulfosalicylic acid method – Used to detect non-albumin proteins (e.g., Bence-Jones proteins in multiple myeloma). This patient does not have persistent proteinuria or signs of multiple myeloma.
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Question 36:
The correct answer is D. This patient presents with a 2-week history of sore throat, anterior neck tenderness/fullness, fever, tachycardia, and no oropharyngeal exudates, which is highly suggestive of subacute thyroiditis (De Quervain’s thyroiditis).
Subacute thyroiditis is a self-limited, inflammatory disorder of the thyroid gland that often follows a viral upper respiratory infection. It leads to painful thyroid swelling, transient thyrotoxicosis, and systemic symptoms (e.g., fever, tachycardia, anxiety).
Incorrect answers:
A. Acute mononucleosis – Typically presents with fever, pharyngitis, posterior cervical lymphadenopathy, and atypical lymphocytosis; this patient lacks lymphadenopathy and pharyngeal exudates.
B. Gastroesophageal reflux disease (GERD) – Can cause chronic sore throat, but it does not cause fever, neck tenderness, or systemic symptoms.
C. Laryngitis – Characterized by hoarseness and voice changes; does not cause neck tenderness or thyroid involvement.
E. Tracheitis – Often caused by bacterial infections, presents with high fever, cough, and airway obstruction, and does not involve thyroid tenderness.
Question 37:
The correct answer is A. This patient meets the criteria for generalized anxiety disorder (GAD), evidenced by excessive worry about multiple domains (finances, job) for at least six months, along with associated symptoms of sleep disturbance, muscle tension, irritability, and fatigue.
In patients with a history of substance use disorder, buspirone is a preferred second-line non-addictive anxiolytic. While cognitive-behavioral therapy (CBT) and SSRIs (e.g., sertraline, escitalopram) are first-line treatments, buspirone is an alternative when SSRIs are not tolerated or preferred.
Incorrect answers:
B. Clonazepam is a benzodiazepine, which can cause dependence and relapse in patients with a history of substance use.
C. Diphenhydramine is an antihistamine, which can cause sedation but does not treat the underlying anxiety.
D. Imipramine is a tricyclic antidepressant (TCA), which is not first-line due to side effects (anticholinergic, cardiotoxicity). SSRIs are preferred for GAD.
E. Quetiapine is an atypical antipsychotic, which is not indicated for primary anxiety disorders due to metabolic side effects.
F. Temazepam is a benzodiazepine, inappropriate for this patient due to risk of dependence and addiction relapse.
Question 38:
The correct answer is C. This patient presents with acute respiratory distress, hypotension, and a widespread erythematous rash following amoxicillin exposure, which is highly suggestive of anaphylaxis.
Key diagnostic features of anaphylaxis:
- Cutaneous symptoms (e.g., erythematous, raised, demarcated rash)
- Respiratory distress (e.g., increased respiratory rate, dyspnea)
- Cardiovascular involvement (e.g., hypotension)
- Rapid onset after allergen exposure (e.g., amoxicillin use)
Epinephrine (intramuscular) is the first-line treatment for anaphylaxis because it:
- Reverses airway obstruction (bronchodilation)
- Increases blood pressure (vasoconstriction)
- Reduces swelling (decreasing capillary permeability)
Incorrect answers:
A. Administration of albuterol – Used for bronchospasm (e.g., asthma, COPD) but does not treat the systemic effects of anaphylaxis.
B. Administration of diphenhydramine – An H1 antihistamine, helpful as adjunctive therapy, but not first-line in anaphylaxis.
D. Complete blood count – Does not address the acute, life-threatening situation; immediate treatment is needed.
E. Observation only – Anaphylaxis is a medical emergency requiring immediate epinephrine to prevent airway compromise and cardiovascular collapse.
Question 39:
The correct answer is D. This patient’s chronic hematochezia, iron deficiency anemia, loose stools, and colonoscopy findings of coalesced ulcers with normal intervening mucosa (skip lesions) involving the ileum are highly suggestive of Crohn’s disease.
Key points about Crohn’s disease:
- Chronic inflammatory bowel disease affecting any part of the GI tract (commonly the terminal ileum and colon).
- Skip lesions with deep ulcers and normal intervening mucosa (vs. continuous inflammation in ulcerative colitis).
- Can cause anemia (due to malabsorption and chronic blood loss).
Smoking is a major risk factor for Crohn’s disease and is associated with:
- More aggressive disease progression
- Increased risk of complications (e.g., strictures, fistulas, surgery)
- Poor response to medical therapy
Smoking cessation is strongly recommended in all Crohn’s patients as it improves outcomes and reduces disease severity.
Incorrect answers:
A. Annual screening for lymphoproliferative disorders – Not routinely recommended in Crohn’s disease unless the patient is on immunosuppressive therapy (e.g., azathioprine, methotrexate).
B. Discontinuation of citalopram therapy – SSRIs (e.g., citalopram) do not worsen Crohn’s disease; anxiety is not a contraindication for treatment.
C. Prophylactic colectomy – Unlike ulcerative colitis, Crohn’s disease is not curable with colectomy since it can affect the entire GI tract. Surgery is reserved for complications (e.g., strictures, fistulas, perforation).
Question 40:
The correct answer is A. This patient has psychogenic non-epileptic seizures (PNES), as evidenced by:
- Seizure-like episodes without EEG changes during long-term video EEG monitoring.
- Prolonged duration (15-20 minutes), bilateral limb shaking, head movements, crying, and intermittent responsiveness, which are atypical for epileptic seizures.
- History of childhood trauma (sexual and physical abuse), a known risk factor for PNES.
- Lack of response to multiple antiepileptic drugs (AEDs), suggesting a non-epileptic cause.
PNES is a functional neurological disorder (conversion disorder) that manifests as seizure-like episodes without epileptiform activity. It is a psychological condition, not a true seizure disorder.
Cognitive Behavioral Therapy (CBT) is the first-line treatment for PNES, as it helps patients understand and manage psychological distress, reducing symptom frequency.
Incorrect answers:
B. Hypnotic therapy – Not the primary treatment for PNES; lacks strong evidence compared to CBT.
C. Increasing the dosage of pregabalin – PNES is not epilepsy, so additional AEDs provide no benefit and may cause unnecessary side effects.
D. Psychoanalytic therapy – CBT is the evidence-based approach, while psychoanalysis is less effective for PNES.
E. Surgical resection of the epileptogenic focus – There is no epileptogenic focus in PNES; surgery is only considered for medically refractory focal epilepsy with a clear seizure focus.
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