These 10 Step 2 CK–style clinical questions focus on what the exam loves to ask: the first step and the next best step in common emergencies and medical problems. Pick an answer, then open Answer and Explanation to check yourself.
Questions written by Dr. Ray Makar, retired dermatologist and USMLE teacher.
Emergencies: What Do You Do First?
Q1. A patient develops severe hypotension, a rash and bronchospasm after a bee sting. What is the first-line treatment?
A. Antihistamines
B. Corticosteroids
C. Epinephrine
D. Oxygen
Answer and Explanation
C. Epinephrine. Anaphylaxis is treated first with intramuscular epinephrine (0.3–0.5 mg in the anterolateral thigh), repeated every 5–15 minutes if needed. Antihistamines and steroids are only add-ons and do not reverse airway swelling or shock.
Q2. A patient with asthma has acute wheezing and shortness of breath. Which medication gives rapid relief?
A. Fluticasone
B. Ipratropium
C. Montelukast
D. Salbutamol (albuterol)
Answer and Explanation
D. Salbutamol (albuterol). A short-acting β2-agonist works within minutes. Inhaled steroids (fluticasone) and montelukast are controller drugs. Ipratropium can be added in severe attacks but is not the main rescue drug.
Q3. A patient suddenly develops severe shortness of breath after a central line is placed. He is hypotensive, the trachea is shifted to the left, and breath sounds are absent on the right. What is the next best step?
A. Chest x-ray
B. CT scan of the chest
C. Immediate needle decompression
D. Intubation
Answer and Explanation
C. Immediate needle decompression. This is a tension pneumothorax, a clinical diagnosis. Do not wait for imaging. Decompress immediately with a needle (2nd intercostal space at the midclavicular line or 4th–5th space at the anterior axillary line), then place a chest tube.
Q4. A patient with kidney failure has a potassium of 7.2 mEq/L and peaked T waves on the ECG. What should be given first?
A. Intravenous calcium gluconate
B. Intravenous insulin with glucose
C. Oral sodium polystyrene sulfonate
D. Furosemide
Answer and Explanation
A. Intravenous calcium gluconate. Calcium stabilizes the heart muscle within minutes and protects against arrhythmias, but it does not lower potassium. Next, shift potassium into cells (insulin with glucose, albuterol), then remove it from the body (diuretics, binders, dialysis).
Neurology
Q5. A 68-year-old man develops weakness of the left arm and leg and slurred speech that began 90 minutes ago. What is the first test to order?
A. CT angiography of the neck only
B. Lumbar puncture
C. MRI of the brain with contrast
D. Noncontrast CT of the head
Answer and Explanation
D. Noncontrast CT of the head. The first step in suspected stroke is to rule out bleeding quickly, because hemorrhage is a contraindication to thrombolysis. If there is no bleed and the patient is within the treatment window, alteplase or tenecteplase can be given.
Q6. A 45-year-old woman has a sudden, severe “worst headache of my life” that started 10 hours ago. A noncontrast CT of the head is normal. What is the next best step?
A. Discharge with analgesics
B. Lumbar puncture
C. MRI of the brain in 1 week
D. Start a triptan
Answer and Explanation
B. Lumbar puncture. Subarachnoid hemorrhage must be ruled out. CT becomes less sensitive after about 6 hours, so a normal CT is followed by lumbar puncture looking for xanthochromia or red cells that do not clear.
Q7. A 48-year-old man with chronic alcohol use has confusion, ophthalmoplegia and an unsteady gait. What is the most appropriate initial treatment?
A. Folic acid
B. Intravenous glucose before vitamins
C. Oral vitamin B12
D. Thiamine before glucose
Answer and Explanation
D. Thiamine before glucose. This is Wernicke encephalopathy (confusion, ophthalmoplegia, ataxia). Give IV thiamine first. Glucose without thiamine can worsen the condition, because glucose metabolism uses up the remaining thiamine.
Medicine: Labs and Diagnosis
Q8. A 72-year-old man has progressive confusion and lethargy. His calcium is 14.5 mg/dL. What is the next best step in management?
A. Calcitonin and intravenous fluids
B. Emergent dialysis
C. Oral bisphosphonates
D. Prednisone
Answer and Explanation
A. Calcitonin and intravenous fluids. Severe symptomatic hypercalcemia is treated with aggressive IV normal saline plus calcitonin (fast-acting), then an IV bisphosphonate such as zoledronic acid for longer control. Dialysis is reserved for kidney failure or cases that don’t respond.
Q9. A 24-year-old woman has fatigue and pallor. Her hemoglobin is 9 g/dL, MCV is 70 fL and ferritin is low. What is the most likely diagnosis?
A. Anemia of chronic disease
B. Iron deficiency anemia
C. Megaloblastic anemia
D. Thalassemia minor
Answer and Explanation
B. Iron deficiency anemia. Microcytic anemia with low ferritin means iron deficiency. In a young woman, heavy menstrual bleeding is a common cause. Ferritin is normal or high in anemia of chronic disease and normal in thalassemia minor.
Q10. A 34-year-old woman develops sudden shortness of breath and chest pain 5 days after hip surgery. She is hemodynamically stable, and a pulmonary embolism is strongly suspected. What is the best test to confirm the diagnosis?
A. Chest x-ray
B. CT pulmonary angiography
C. D-dimer
D. Echocardiography
Answer and Explanation
B. CT pulmonary angiography. When clinical suspicion is high, go straight to CT pulmonary angiography (a V/Q scan is used if contrast is contraindicated). D-dimer is useful only to rule out PE when suspicion is low.
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