Domande di esercitazione USMLE Step 2 CK

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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
   Mostra risposta e spiegazione

   Risposta: 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
   Mostra risposta e spiegazione

   Risposta: 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 _____.

   Opzioni per lo spazio 1: 4, 5, 20, 100

   Mostra risposta e spiegazione

   Risposta: 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
   Mostra risposta e spiegazione

   Risposta: 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
   Mostra risposta e spiegazione

   Risposta: 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?

   Seleziona tutte le risposte corrette.

   • 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
   Mostra risposta e spiegazione

   Risposta: 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
   Mostra risposta e spiegazione

   Risposta: 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.

   Opzioni per lo spazio 1: 1, 2, 5

   Opzioni per lo spazio 2: 3, 5, 10

   Mostra risposta e spiegazione

   Risposta: 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
   Mostra risposta e spiegazione

   Risposta: 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?

    Seleziona tutte le risposte corrette.

    • 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
    Mostra risposta e spiegazione

    Risposta: 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
    Mostra risposta e spiegazione

    Risposta: 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?

    Seleziona tutte le risposte corrette.

    • 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
    Mostra risposta e spiegazione

    Risposta: 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 _____.

    Opzioni per lo spazio 1: 1, 3, 6

    Opzioni per lo spazio 2: brief psychotic disorder, schizophreniform disorder, schizoaffective disorder

    Mostra risposta e spiegazione

    Risposta: 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
    Mostra risposta e spiegazione

    Risposta: 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
    Mostra risposta e spiegazione

    Risposta: 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.

Cosa verifica lo Step 2 CK e perché oggi pesa di più

Lo Step 2 CK è l'esame di conoscenze cliniche nella sequenza dello United States Medical Licensing Examination, un programma congiunto della Federation of State Medical Boards e del National Board of Medical Examiners. A gennaio 2022 lo Step 1 ha smesso di comunicare un numero a tre cifre e ha iniziato a comunicare solo promosso o bocciato. Lo Step 2 CK non è cambiato, quindi è diventato l'unico punteggio numerico USMLE che la maggior parte dei programmi di specializzazione statunitensi vede. È per quel singolo cambiamento che questa pagina esiste.

L'esame è una sola giornata di blocchi a scelta multipla, lunga diverse ore, e si valuta con un punteggio numerico. Il numero di quesiti, la struttura dei blocchi, il tempo per blocco e il punteggio minimo di superamento in vigore li fissa il programma USMLE e sono stati modificati più di una volta, quindi leggi quei numeri su usmle.org e nello schema di contenuto aggiornato invece di fidarti di un numero preso da un post su un forum.

Il contenuto è clinico. La medicina interna ha la fetta più grande, con chirurgia, pediatria, ostetricia e ginecologia e psichiatria a coprire quasi tutto il resto, più mantenimento della salute e screening, sicurezza del paziente, etica e comunicazione, e biostatistica applicata. La maggior parte dei quesiti sono vignette cliniche che chiedono una diagnosi, il passo diagnostico successivo, il meccanismo più probabile, o come un risultato dovrebbe cambiare quello che credi.

Come usare questo assaggio e come studiare il materiale

Queste 15 domande sono costruite attorno al passo di ragionamento invece che alla memoria. Chiedono quale reperto restringe la diagnosi differenziale, cosa ti fa guadagnare il prossimo esame diagnostico, quale proprietà di un test si muove quando si muove la prevalenza, e come un criterio di durata separa due diagnosi psichiatriche. È l'abitudine che lo Step 2 CK premia, perché una vignetta clinica di solito ti dà abbastanza dati per arrivare alla risposta se sai a cosa serve ogni pezzo.

Fai tutte e 15 le domande d'un fiato senza appunti, poi leggi la spiegazione di ogni domanda, comprese quelle a cui hai risposto giusto. Indovinare e sapere sono cose diverse, e solo la spiegazione ti dice quale delle due è successa. Considera una risposta sbagliata un argomento e non un dettaglio. Se hai sbagliato la domanda sul liquido pleurico e quella sull'anemia, la lezione è che leggi i pannelli di laboratorio un valore alla volta invece che come un quadro d'insieme.

Una nota onesta. Questa pagina è esercitazione per l'esame scritta dal team di StudyPDF partendo dallo schema di contenuto pubblicato dello Step 2 CK. Non è un'indicazione medica e nessuna di queste è una domanda d'esame reale. Dove una vignetta vera ti chiederebbe di scegliere un farmaco o una dose, questo assaggio chiede invece del ragionamento.

Come StudyPDF crea test completi dai tuoi materiali

Quindici domande possono mostrarti dove il tuo ragionamento clinico è debole. Da sole non bastano a prepararti per un esame di un'intera giornata, e una banca dati generica non corrisponde mai a ciò su cui insiste lo shelf exam che farai il mese prossimo o agli appunti che ti ha dato il tuo tirocinio.

StudyPDF parte invece dal tuo materiale. Carichi il tuo manuale di ripasso per lo Step 2, gli appunti di tirocinio, una presentazione di lezione o le dispense in PDF del tuo clerkship, e Bo, l'agente di studio, crea test completi da quelle pagine esatte. Ogni domanda nasce dal tuo materiale e ogni spiegazione indica da dove viene la risposta, così puoi saltare subito alla pagina quando qualcosa non ti torna. Puoi generare test nuovi quante volte vuoi, restringerli a un'area sola come la cardiologia o l'ostetricia, e tenere traccia dei concetti che continui a sbagliare tra un tentativo e l'altro.

Per iniziare non serve un documento. Se non hai niente da caricare, nomina invece un argomento, per esempio i disturbi dell'equilibrio acido base, lo screening prenatale o l'etica delle decisioni prese da un rappresentante, e Bo ci scrive sopra un test. Inizi gratis.