USMLE Step 2 CK-øvespørgsmål

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Alle 15 spørgsmål i overblik

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1. 1. A 72-year-old man reports two episodes of syncope while climbing stairs. Examination shows a crescendo-decrescendo systolic murmur at the right upper sternal border that radiates to both carotids, and the carotid upstroke is slow and low in volume. Which diagnosis best explains these findings?

   • A. Mitral regurgitation
   • B. Hypertrophic cardiomyopathy
   • C. Aortic regurgitation
   • D. Aortic stenosis
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   Svar: D. Aortic stenosis

   A slow, low volume carotid upstroke with a systolic ejection murmur radiating to the carotids points to a fixed obstruction at the aortic valve, and exertional syncope means the stenosis is severe enough that cardiac output cannot rise with demand. Mitral regurgitation gives a holosystolic murmur at the apex that radiates to the axilla, and aortic regurgitation is diastolic with a bounding rather than a weak pulse. Hypertrophic cardiomyopathy can sound similar, but its murmur gets louder with Valsalva while the aortic stenosis murmur softens, because less preload means less flow across a fixed valve.

2. 2. A test with a sensitivity of 95 percent and a specificity of 70 percent was validated in a referral clinic. It is now used to screen a general population where the disease is far less common. Which value falls the most in the new setting?

   • A. Sensitivity
   • B. Specificity
   • C. Positive predictive value
   • D. Negative predictive value
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   Svar: C. Positive predictive value

   Sensitivity and specificity describe how the test behaves in people who do and do not have the disease, so they do not move when prevalence changes. Predictive values do. When prevalence drops, most positives are now false positives, so positive predictive value falls while negative predictive value rises. This is why a test that looks convincing in a specialty clinic can generate mostly false alarms when it is turned into a population screen.

3. 3. Complete the sentence.

   In a trial, the event rate is 20 percent in the control group and 15 percent in the treatment group. The absolute risk reduction is 5 percent, so the number needed to treat is _____.

   Muligheder for felt 1: 4, 5, 20, 100

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   Svar: 20

   Number needed to treat is 1 divided by the absolute risk reduction, so 1 divided by 0.05 gives 20. Relative risk reduction for the same numbers is 25 percent, which sounds far more impressive from the same data, and that gap is exactly why trials are often reported in relative terms. Always convert to absolute risk reduction before you judge how much a treatment actually buys.

4. 4. Screening recommendations usually specify an age to stop as well as an age to start. What is the main reason for the upper age limit?

   • A. Older adults cannot tolerate the screening test
   • B. Disease incidence falls sharply with age
   • C. Insurance stops covering the test
   • D. The benefit of screening appears only after years, so a person with limited life expectancy takes on the harms without living long enough to gain
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   Svar: D. The benefit of screening appears only after years, so a person with limited life expectancy takes on the harms without living long enough to gain

   Screening harms are immediate: false positives, biopsies, overdiagnosis and the treatment that follows it. The benefit, fewer deaths from the disease, arrives years later. When remaining life expectancy is shorter than that lag, the arithmetic turns negative. Incidence of most screened cancers actually rises with age rather than falling, which is why the stopping rule is about life expectancy and comorbidity, not about age alone.

5. 5. Which feature best distinguishes preeclampsia from chronic hypertension in a pregnant patient?

   • A. Blood pressure elevation documented before 20 weeks of gestation
   • B. A family history of hypertension
   • C. New onset hypertension after 20 weeks of gestation
   • D. Hypertension that persists more than 12 weeks after delivery
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   Svar: C. New onset hypertension after 20 weeks of gestation

   The dividing line is timing. Hypertension present before 20 weeks, or still present more than 12 weeks after delivery, is chronic hypertension. New hypertension after 20 weeks with proteinuria or with end organ dysfunction such as thrombocytopenia, elevated transaminases, renal impairment, pulmonary edema or new neurologic symptoms is preeclampsia. The two can coexist, which is called preeclampsia superimposed on chronic hypertension, and that combination raises risk more than either alone.

6. 6. Which findings belong to the diagnostic picture of a manic episode?

   Vælg alle, der passer.

   • A. A decreased need for sleep with normal or high energy the next day
   • B. Flight of ideas or racing thoughts
   • C. Psychomotor retardation with hypersomnia
   • D. An increase in goal directed activity or agitation
   • E. Anhedonia present nearly every day for two weeks
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   Svar: A. A decreased need for sleep with normal or high energy the next day, B. Flight of ideas or racing thoughts, D. An increase in goal directed activity or agitation

   A manic episode needs a distinct period of elevated, expansive or irritable mood together with increased activity or energy, plus symptoms such as decreased need for sleep, racing thoughts, distractibility, inflated self esteem, pressured speech or risky goal directed behavior. Decreased need for sleep is not the same as insomnia: the patient sleeps little and still feels fine. Psychomotor retardation with hypersomnia and two weeks of anhedonia describe a major depressive episode, which is the other pole and not part of mania.

7. 7. A 9-month-old has sudden episodes of crying while drawing his knees up, alternating with periods of lethargy. Examination reveals a sausage shaped mass in the right abdomen and a stool sample mixed with blood and mucus. Which is the most appropriate next diagnostic step?

   • A. Abdominal ultrasound
   • B. Upper gastrointestinal contrast series
   • C. CT of the abdomen with contrast
   • D. Colonoscopy
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   Svar: A. Abdominal ultrasound

   The picture is classic for intussusception, which peaks between about 6 and 36 months. Ultrasound is the first line study because it is fast, needs no radiation and shows the telescoped bowel as a target or donut on cross section. CT would answer the question too but costs radiation in an infant, an upper GI series looks at the wrong segment, and colonoscopy has no diagnostic role here.

8. 8. Complete the sentence.

   The Apgar score rates a newborn's color, heart rate, reflex irritability, muscle tone and respiratory effort, and it is assigned at _____ minute and again at _____ minutes after birth.

   Muligheder for felt 1: 1, 2, 5

   Muligheder for felt 2: 3, 5, 10

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   Svar: 1, 5

   Five components are each scored 0, 1 or 2, for a total of 0 to 10, at 1 and 5 minutes. If the 5 minute score stays low, scoring is repeated at intervals while the infant is assessed. The score describes the newborn's condition and how it responds over time, and it is not what triggers resuscitation, which begins on clinical assessment without waiting for a number.

9. 9. Three days after an open abdominal operation a patient has distension, nausea and no flatus. Bowel sounds are absent. An abdominal radiograph shows gas distributed evenly through the small bowel and the colon, with no transition point and no distal collapse. Which explanation fits best?

   • A. Adhesive small bowel obstruction
   • B. Postoperative ileus
   • C. Sigmoid volvulus
   • D. Perforated viscus
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   Svar: B. Postoperative ileus

   The discriminating detail is the pattern of gas. Mechanical obstruction produces dilated bowel proximally, a transition point and a collapsed segment beyond it. Ileus is a failure of coordinated motility along the whole tract, so gas sits everywhere including the colon with no transition. Volvulus gives a characteristic dilated closed loop, and a perforated viscus is suggested by free air under the diaphragm and peritoneal signs, neither of which is described here.

10. 10. Which statements describe requirements for valid informed consent?

    Vælg alle, der passer.

    • A. The patient is told the nature and purpose of the proposed intervention
    • B. Risks, expected benefits and the reasonable alternatives, including doing nothing, are disclosed
    • C. The patient has decision making capacity and the decision is voluntary and free of coercion
    • D. Consent is valid only if a family member countersigns the form
    • E. A relative may override the refusal of an adult who has capacity
    Vis svar og forklaring

    Svar: A. The patient is told the nature and purpose of the proposed intervention, B. Risks, expected benefits and the reasonable alternatives, including doing nothing, are disclosed, C. The patient has decision making capacity and the decision is voluntary and free of coercion

    Valid consent needs disclosure, capacity, voluntariness and comprehension, and the signed form is only evidence that the conversation happened. Alternatives, including no intervention at all, are part of the disclosure, because a patient cannot weigh an option they were never told about. A competent adult's decision does not require a relative's approval and cannot be overridden by one.

11. 11. An adult patient with full decision making capacity refuses a blood transfusion on religious grounds and states clearly that she understands she may die without it. Which response is most appropriate?

    • A. Seek a court order authorizing transfusion
    • B. Ask her adult children to consent on her behalf
    • C. Confirm that she understands the consequences and alternatives, then respect the refusal
    • D. Wait until she loses consciousness and then transfuse
    Vis svar og forklaring

    Svar: C. Confirm that she understands the consequences and alternatives, then respect the refusal

    An adult with capacity may refuse any intervention, including one that is life sustaining, and the reason for the refusal does not have to be one the clinician agrees with. The physician's job is to confirm capacity, make sure the refusal is informed and voluntary, document it, and continue offering the care the patient does accept. Surrogates and courts step in when capacity is absent, not to overrule a capacitated adult, and transfusing after she becomes unconscious would defeat a decision she made while capable.

12. 12. According to Light's criteria, which findings identify a pleural effusion as an exudate?

    Vælg alle, der passer.

    • A. A pleural fluid to serum protein ratio above 0.5
    • B. A pleural fluid to serum lactate dehydrogenase ratio above 0.6
    • C. A pleural fluid lactate dehydrogenase above two thirds of the upper limit of normal for serum
    • D. A pleural fluid glucose identical to the serum glucose
    • E. An effusion occurring in decompensated heart failure
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    Svar: A. A pleural fluid to serum protein ratio above 0.5, B. A pleural fluid to serum lactate dehydrogenase ratio above 0.6, C. A pleural fluid lactate dehydrogenase above two thirds of the upper limit of normal for serum

    Light's criteria need only one of the three to be met for the fluid to count as an exudate, which makes them very sensitive and somewhat prone to labeling a transudate as an exudate. The distinction matters because it splits the differential: exudates come from inflammation, infection or malignancy that leaks protein across the pleura, while transudates come from pressure problems such as heart failure, cirrhosis or nephrotic syndrome. Fluid glucose equal to serum is unremarkable, and heart failure is the classic transudate.

13. 13. Complete the sentence.

    A diagnosis of schizophrenia requires continuous signs of the illness for at least _____ months, while a presentation that has lasted between one and six months is called _____.

    Muligheder for felt 1: 1, 3, 6

    Muligheder for felt 2: brief psychotic disorder, schizophreniform disorder, schizoaffective disorder

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    Svar: 6, schizophreniform disorder

    The psychotic disorders are separated mainly by duration. Under one month is brief psychotic disorder, one to six months is schizophreniform disorder, and six months or more of continuous signs, counting prodromal and residual periods, is schizophrenia, with at least one month of active symptoms inside that window. Schizoaffective disorder is defined differently: it needs a mood episode plus a period of psychosis lasting two weeks or more without prominent mood symptoms.

14. 14. Which headache history feature most strongly suggests a secondary rather than a primary headache?

    • A. A throbbing unilateral headache with photophobia that eases after sleep
    • B. Sudden onset pain that reaches maximum intensity within a minute
    • C. A bilateral band like pressure that builds through the workday
    • D. Pain that improves after caffeine
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    Svar: B. Sudden onset pain that reaches maximum intensity within a minute

    A thunderclap headache, one that peaks within about a minute, is the classic red flag for subarachnoid hemorrhage and other vascular causes, and it warrants urgent evaluation rather than symptomatic treatment. Other red flags include a first severe headache after age 50, fever with neck stiffness, focal neurologic deficits, papilledema, pain that worsens with position or Valsalva, and headache in someone who is immunosuppressed or has cancer. The other three options describe familiar primary patterns, migraine and tension type headache.

15. 15. Which set of laboratory findings best fits iron deficiency anemia?

    • A. Low mean corpuscular volume, low ferritin, high total iron binding capacity
    • B. Low mean corpuscular volume, high ferritin, low total iron binding capacity
    • C. High mean corpuscular volume, normal ferritin, normal total iron binding capacity
    • D. Normal mean corpuscular volume, low vitamin B12, high methylmalonic acid
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    Svar: A. Low mean corpuscular volume, low ferritin, high total iron binding capacity

    In iron deficiency the stores empty first, so ferritin falls, and the liver makes more transferrin to scavenge what iron is left, which raises total iron binding capacity. Red cells made without enough iron end up small, so the mean corpuscular volume drops. Anemia of chronic disease is the trap: it is also microcytic or normocytic, but ferritin is normal or high because it is an acute phase reactant and total iron binding capacity is low. The high volume and the B12 patterns point to macrocytic causes instead.

Hvad Step 2 CK tester, og hvorfor den nu vejer tungere

Step 2 CK er eksamen i klinisk viden i rækken af United States Medical Licensing Examination, et fælles program mellem Federation of State Medical Boards og National Board of Medical Examiners. I januar 2022 holdt Step 1 op med at rapportere et trecifret tal og begyndte kun at rapportere bestået eller ikke bestået. Step 2 CK blev ikke ændret, så den blev den eneste USMLE-talscore, de fleste turnusprogrammer nogensinde ser. Netop den ændring er grunden til, at denne side findes.

Eksamen er én dag med multiple choice-blokke, flere timer lang, og den bedømmes med tal. Antallet af spørgsmål, blokopdelingen, tiden per blok og den aktuelle beståelsesgrænse fastsættes af USMLE-programmet og er blevet justeret mere end én gang, så læs de tal på usmle.org og i den aktuelle indholdsoversigt frem for at stole på et tal fra et forumindlæg.

Indholdet er klinisk. Intern medicin bærer den største andel, mens kirurgi, pædiatri, obstetrik og gynækologi samt psykiatri fylder det meste af resten, plus sundhedsfremme og screening, patientsikkerhed, etik og kommunikation, og anvendt biostatistik. De fleste spørgsmål er sygehistorier, der spørger efter en diagnose, det næste diagnostiske skridt, den mest sandsynlige mekanisme, eller hvordan et resultat bør ændre det, du tror.

Sådan bruger du smagsprøven, og sådan læser du stoffet

De her 15 spørgsmål er bygget op om ræsonnementsskridtet frem for om genkaldelse. De spørger, hvilket fund der indsnævrer differentialdiagnosen, hvad den næste diagnostiske test giver dig, hvilken egenskab ved en test der flytter sig, når prævalensen flytter sig, og hvordan et varighedskriterium skiller to psykiatriske diagnoser. Det er den vane, Step 2 CK belønner, for en sygehistorie giver dig som regel data nok til at nå frem til svaret, hvis du ved, hvad hvert stykke skal bruges til.

Tag alle 15 i ét stræk uden noter, og læs så forklaringen til hvert spørgsmål, også dem du svarede rigtigt på. At gætte rigtigt og at vide er ikke det samme, og kun forklaringen fortæller dig, hvilket af de to der skete. Behandl et forkert svar som et emne frem for som et faktum. Missede du spørgsmålet om pleuravæske og spørgsmålet om anæmi, er lektien, at du læser prøvesvar én værdi ad gangen i stedet for som et mønster.

En ærlig bemærkning. Denne side er eksamenstræning skrevet af StudyPDF-teamet ud fra den offentliggjorte indholdsoversigt til Step 2 CK. Det er ikke medicinsk vejledning, og ingen af spørgsmålene er rigtige eksamensspørgsmål. Hvor en rigtig sygehistorie ville bede dig vælge et lægemiddel eller en dosis, spørger denne smagsprøve til ræsonnementet i stedet.

Sådan bygger StudyPDF fulde øveprøver ud fra dit materiale

Femten spørgsmål kan vise dig, hvor dit kliniske ræsonnement er tyndt. De kan ikke gøre dig klar til en heldagseksamen alene, og en generisk spørgsmålsbank rammer aldrig det, som den shelf-eksamen du skal op i næste måned, eller noterne fra dit eget klinikophold, lægger vægt på.

StudyPDF arbejder ud fra dit materiale i stedet. Du uploader din Step 2-repetitionsbog, dine noter fra klinikopholdet, et slidesæt eller PDF-handoutsene fra dit klinikophold, og Bo, studieagenten, bygger fuldlange øveprøver ud fra præcis de sider. Hvert spørgsmål bygger på dit materiale, og hver forklaring henviser til, hvor svaret kom fra, så du kan springe direkte til siden, når noget ser forkert ud. Du kan lave nye prøver så tit du vil, holde dem på ét område som kardiologi eller obstetrik, og følge med i hvilke begreber du bliver ved med at misse fra gang til gang.

Du behøver ikke et dokument for at komme i gang. Har du ikke noget at uploade, så nævn et emne i stedet, for eksempel syre-base-forstyrrelser, screening i graviditeten eller etikken i stedfortrædende beslutninger, så skriver Bo en øveprøve ud fra det. Gratis at komme i gang.