Explanations for the 2018-2019 Official Step 2 CK Practice Questions | Ben White 30/10/21, 12:44 AM

Explanations for the 2018-2019

Official Step 2 CK Practice
Questions
Medicine // 06.09.18

The NBME recently released an “updated May 2018” official “USMLE Step
2 CK Sample Test Questions,” but these are actually completely
unchanged over the past two years since the June 2016 update, which
was itself almost unchanged from the 2015 set.

Since it’s been a couple years, I’ve included the explanations below (which
are, again, unchanged). You might see the comments on the old post for
possible additional questions you may have. The multimedia question
explanations are also at the bottom of this page.

Last year, helpful reader Jarrett made a list converting the question order
from the online FRED version to the pdf numbers. I didn’t go through in
detail to see if the online version order has changed, but the multimedia
questions were in the same spots except that the block 3 question had
shifted by one, so they may have done a little something.

Block 1

1. E – Intermittent polyarthritis with positive ANA (sensitive but not

specific) and anti-DNA (very specific) means lupus. You don’t even
need the non-painful mouth ulcers.
2. C – Anesthesia to the anterolateral thigh is the distribution of the
lateral femoral cutaneous nerve. LFC neuropathy can be caused
by compression near the inguinal ligament (say, from a hematoma).
Note that it’s the compression of the nerve that causes decreased
sensation, not the hematoma itself.

https://www.benwhite.com/medicine/explanations-for-the-2018-2019-official-step-2-ck-practice-questions/ Page 1 of 17

https://t.me/USMLENBME2CK
Explanations for the 2018-2019 Official Step 2 CK Practice Questions | Ben White 30/10/21, 12:44 AM

3. H – Recurrent infections with abscesses should raise the suspicion of

chronic granulomatous disease. Suppurative arthritis does even
more, if you’re likely to remember that. The real diagnosis is made
from the Step 1 style question. Nitroblue tetrazolium is the test used
to diagnose CGD, which is a defect in NADPH oxidase (the oxidative
burst that kills Staph aureus).
4. D – Unstable and hypotensive patients after blunt trauma get
laparotomies (don’t put an unstable patient in the CT scanner). In
addition to saline and blood products, definitive surgery is how you
address the C in ABC.
5. B – Alcohol raises GGT. The other liver enzyme lab to remember is
the 2:1 or greater AST/ALT ratio associated with alcoholic liver
disease.
6. D – The patient has a small bowel obstruction, likely due to adhesions
from prior surgery, evident clinically and confirmed by radiograph
(grossly dilated small bowel without distal colonic dilation to suggest
paralytic ileus). Conservative treatment in a stable patient involves
NG tube decompression and NPO. A CT can be obtained for further
characterization and to look signs of bowel compromise (and would
be in real life), but there is no reason to delay appropriate care to get
it.
7. A – Proximal muscle weakness + skin findings = dermatomyositis.
Yes, kids can get this. In this case, they’ve gone to the trouble of
describing Gottron’s papules (“flat-topped red papules over all
knuckles”) and the heliotrope rash (purple-red discoloration over the
eyelids). Please note the USMLE will never actually say things
“heliotrope” on the actual exam. They always describe.
8. A – Autonomy matters. If a patient has the capacity to make medical
decisions (i.e. understands the risks) and is not an imminent harm to
self or others (i.e. suicidal or homicidal), then he cannot be held
against his will. We don’t institutionalize people just for
noncompliance with medical treatment.

https://www.benwhite.com/medicine/explanations-for-the-2018-2019-official-step-2-ck-practice-questions/ Page 2 of 17

https://t.me/USMLENBME2CK
Explanations for the 2018-2019 Official Step 2 CK Practice Questions | Ben White 30/10/21, 12:44 AM

9. A – This patient likely has classical Galactosemia, caused by a

deficiency in galactose-1-P uridyl transferase deficiency, the
enzyme that converts galactose and lactose to glucose. Intolerance
to dairy, hepatomegaly/liver disease/jaundice with hypoglycemia due
to decreased gluconeogenesis, and reducing substances in urine are
classic. Listlessness and lethargy ensue with mental retardation and
eventually death if untreated. Cataracts are also common. Hereditary
Fructose Intolerance can present essentially identically. If you didn’t
get to the underlying condition, the answer is still A. By process of
elimination, given the serum hypoglycemia but no urine glucose, the
issue is the inability to make glucose from stores (not to absorb it).
10. C – Meningitis/encephalitis symptoms (fever, headache, altered
mental status) with monocytic predominance and only mildly
elevated protein on CSF studies go along with viral meningitis, such
as HSV. Additional features (MRI findings of bitemporal signal
changes and RBCs in the CSF from hemorrhagic necrosis) slam-dunk
it but probably not necessary to memorize.
11. D – Microcytic anemia is essentially always iron-deficiency unless
there is a reason to suspect a thalassemia. In this case, extensive
surgery has removed nutrient absorbing small bowel (the duodenum
and proximal jejunum absorb iron).
12. D – First-line treatment for panic disorder (and all anxiety disorders)
is SSRI therapy. The only time you answer “benzodiazepine” (which
wasn’t offered as a choice, because it would be arguable) for a panic
disorder question is when they ask you what drug is “most likely to
treat the episode” or something along those lines. BZDs work
immediately; SSRIs take time.
13. C – Polycystic ovarian syndrome (PCOS) is treated with estrogen-
containing birth control (OCPs). Metformin would be an additional
appropriate pharmacotherapy.
14. D – Euvolemic hyponatremia means SIADH. Both brain and lung
insults are common causes. Nonphysiologic secretion is

https://www.benwhite.com/medicine/explanations-for-the-2018-2019-official-step-2-ck-practice-questions/ Page 3 of 17

https://t.me/USMLENBME2CK
Explanations for the 2018-2019 Official Step 2 CK Practice Questions | Ben White 30/10/21, 12:44 AM

“inappropriate,” of course.
15. A – Repetitious vomiting leads to the classic hypokalemic
hypochloremic metabolic alkalosis, as well as run of the mill
dehydration (hyponatremic hypovolemia). So—low sodium, low
potassium, low chloride, high bicarbonate.
16. B – Endometriosis is a common cause of infertility and is associated
with chronic pelvic/abdominal pain and excruciating periods. Gold
standard for diagnosis is laparoscopy (visualization of “chocolate
cysts”).
17. D – Consider bacterial sinusitis to be analogous to bacterial
pneumonia. All are possible, but Strep pneumo is the most common.
18. B – Diabetes get diabetic nephropathy. Don’t over-think things.
19. B – A cohort study (as opposed to a randomized controlled trial) is
ripe for selection bias, which occurs when the treatment and control
groups are not truly comparable. Matching for some factors (age,
gender) doesn’t mean you’ve controlled for all possible confounders.
That’s what randomization does *
20. D – Atopic dermatitis (eczema) is the “itch that rashes.” It’s one leg of
the allergic triad: asthma, allergic rhinitis, and atopic
dermatitis. Treatment is with topical steroids and rigorous emollient
therapy.
21. B – Repetitive vomiting (be it due to viral gastroenteritis or bulimia)
leads to hypokalemic hypochloremic metabolic alkalosis. Alkalosis
means elevated bicarbonate, which in this case is created as the
byproduct of increased stomach acid production.
22. D – Abscessed Bartholin’s cysts get incised and drained. When
recurrent, they can be marsupialized, which isn’t as fun as it sounds.
23. B – Catecholamines, such as those released by a functioning
pheochromocytoma, are made by the chromaffin cells of the adrenal
medulla. Episodic headache/hypertension is the tip-off here.
24. A – Even if you forget the signs/symptoms of Kawasaki’s disease,
which you shouldn’t (strawberry tongue is a giveaway), just

https://www.benwhite.com/medicine/explanations-for-the-2018-2019-official-step-2-ck-practice-questions/ Page 4 of 17

https://t.me/USMLENBME2CK
Explanations for the 2018-2019 Official Step 2 CK Practice Questions | Ben White 30/10/21, 12:44 AM

remember it’s essentially the diagnosis for any child with 5 days or
more of fever. Treatment is aspirin (the one time it’s okay in children,
otherwise let’s avoid Reye’s syndrome) and IVIG.
25. C – Macrocytic anemia with sensory changes is indicative of B12
deficiency. Causes include the classic pernicious anemia, but don’t
forget the complications of GI surgery. Intrinsic factor is made by the
stomach’s parietal cells.
26. B – This patient has chronic (6 weeks) symptomatic hypotension
while not coincidentally on three BP meds: a diuretic, a beta blocker,
and an ACE inhibitor. The most likely explanation and easiest/fastest
intervention is to reduce her polypharmacy.
27. F – Premature babies get neonatal respiratory distress syndrome due
to surfactant deficiency.
28. B – Multiple lytic bone lesions equals multiple myeloma.
Blastic/sclerotic lesions should make you think of metastatic prostate
cancer (in men) and breast cancer (in women).
29. B – Two things make this aortic dissection instead of a heart attack or
pulmonary embolism. First, the diastolic murmur is that of aortic
insufficiency/regurgitation, which is happening because the
dissection is involving the aortic root. Second, the presence of
diminished femoral pulses implies that the dissection also involves
the descending thoracic aorta distal to the takeoff of the
brachiocephalic and left subclavian arteries (which supply the arms).
Only an issue in the aorta can cause that constellation of symptoms.
30. F – TTP always seems like too many disparate symptoms but just
remember the pentad: thrombocytopenia, microangiopathic
hemolytic anemia, neurologic symptoms, renal failure, and fever. If
the symptoms list seems super long, keep TTP in mind.
31. A – An egg allergy is the most common contraindication to receiving
the flu vaccine.
32. G – Pleuritic chest pain and hypoxia with a normal chest x-ray should
lead you to pulmonary embolism. There’s usually enough total lung

https://www.benwhite.com/medicine/explanations-for-the-2018-2019-official-step-2-ck-practice-questions/ Page 5 of 17

https://t.me/USMLENBME2CK
Explanations for the 2018-2019 Official Step 2 CK Practice Questions | Ben White 30/10/21, 12:44 AM

and blood flow, but it’s the VQ mismatch that’s the issue.
33. F – SIGECAPS+. Patient has MDD and developing panic disorder.
Both of these can be treated first-line with SSRI therapy, such as
paroxetine (Paxil).
34. E – An acutely swollen painful great toe means gout (podagra). Gout
is an inflammatory crystalline arthropathy. Aspiration reveals white
cells and negatively-birefringent needle-shaped crystals.
Pseudogout, which has rhomboid positively-birefringent crystals,
more commonly affects the knee.
35. F – Vasculitides like Wegener’s granulomatosis, microscopic
polyangiitis, and others can cause poly-symptom disease and
glomerulonephritis (hence the hematuria and proteinuria). Positive
ANCA, (either P-ANCA or C-ANCA depending on the variant) is the
key laboratory finding.
36. E – LLQ pain with fever equals diverticulitis. The test of the choice is
a CT scan of the abdomen with contrast.
37. C – Bipolar disorder is the only reasonable answer, as evidenced by
the increased energy, elevated mood, labile affect, and poor
judgment and focus. You don’t develop ADHD at 32.
38. A – Sudden respiratory failure after rupture of membranes means
amniotic fluid embolism (it’s not like a fat embolism; it’s actually an
allergic reaction). Can happen during labor or secondary to trauma.
Hypotension and coagulopathy ensue.
39. D – Fever, pain, and swelling behind the ear mean mastoiditis
(remember the mastoid air cells ). The cause is nearly universally
direct spread from otitis media.
40. E – Exfoliative and blistering drug reactions come in three severities
of the same mechanism: erythema multiforme, Stevens-Johnson
syndrome, and toxic epidermal necrolysis. Diffuse involvement
(>30%) is consistent with toxic epidermal necrolysis (TEN), which
carries a 30-40% mortality.

https://www.benwhite.com/medicine/explanations-for-the-2018-2019-official-step-2-ck-practice-questions/ Page 6 of 17

https://t.me/USMLENBME2CK
Explanations for the 2018-2019 Official Step 2 CK Practice Questions | Ben White 30/10/21, 12:44 AM

Block 2

41. E – Pseudogout (calcium pyrophosphate deposition disease) is an

inflammatory arthritis with a predilection for the knee that causes
synovial calcifications.
42. A – Low pH means acidemia. Renal failure causes metabolic acidosis
(hence low bicarb). Low CO2 is the respiratory compensation. If it
was vice versa, the pH would be high (alkalemia).
43. A – Lisinopril and especially spironolactone (a K-sparing diuretic) can
both cause hyperkalemia. Renal failure (severe AKI or ESRD) is also a
major cause of hyperkalemia, but not in this case with the only mildly
elevated Cr and BUN levels.
44. A – The differential for chronic diarrhea in an AIDS patient includes
bacterial, viral, and parasitic causes as well as HIV enteropathy.
Cryptosporidium is a protozoa that classically causes watery diarrhea
in AIDS patients, especially those exposed to unclean water sources
(hence the traveling to Asia). CMV is a reactivation infection and MAC
is ubiquitous; disease caused by either of these pathogens is due to
severely depressed immunity (i.e. CD4 < 50).
45. A – Headache and stiff neck clue you to meningitis. In a college
student, that’s enough for the diagnosis of meningococcal
meningitis. Stop reading. The treatment is ceftriaxone.
46. F – Weight loss and worsening lung symptoms in a smoker mean lung
cancer. Non-small cell is by far the most common variety. The small
cell variety on tests will usually have fun paraneoplastic syndromes.
47. B – Wide split fixed S2 is an ASD.
48. C – Weight loss and iron deficiency anemia are concerning for colon
cancer with occult blood loss. Colonoscopy is required. Parasitic
causes of iron deficiency (e.g. hookworm) are first tested with stool
ova & parasite screening.
49. A – Dermatomal rash means zoster (a chickenpox/varicella
reactivation disease). Immune insults, like chemotherapy, predispose

https://www.benwhite.com/medicine/explanations-for-the-2018-2019-official-step-2-ck-practice-questions/ Page 7 of 17

https://t.me/USMLENBME2CK
Explanations for the 2018-2019 Official Step 2 CK Practice Questions | Ben White 30/10/21, 12:44 AM

to zoster flares.
50. D – Transillumination of a scrotal mass equals a hydrocele, which is
due to a patent processus vaginalis.
51. E – Working up serious hypoglycemia involves measurement of both
insulin and C-peptide (the cleaved by-product of endogenous
proinsulin) to assess for hyperinsulinemia and distinguish
endogenous (e.g. insulinoma) from exogenous (e.g. Munchausen’s)
causes. “Nurse” is a common Munchausen tip-off (someone with the
know-how and skills to pull it off well).
52. C – Interstitial nephropathy (also known as tubulointerstitial nephritis)
is most commonly an allergic-type reaction to medications, typified
by eosinophils in the urine. The nonspecific maculopapular reaction is
also the common type of drug reaction rash and is seen in a minority
of cases, as is low-grade fever (not critical to the question). Several
medications can cause this: penicillins, cephalosporins, and NSAIDs
are the most common.
53. D – Pinpoint pupils are a classic tip off for opioid use (caused by
parasympathetic activation). Additionally, neither alcohol nor
barbiturates would be likely choices in this context because they
have similar effects (along with benzodiazepines).
54. C – Patients who have the capacity to make medical decisions are
allowed to refuse life-saving medical treatment. You should offer it
but accept her refusal.
55. B – A p-value less than 0.05 means that the results are statistically
significant. However, most would agree that roughly 7 hours
difference in cold duration is clinically insignificant.
56. E – ABCs. Patient has an airway (evidenced by breath sounds without
mention of other complicating factors like unconsciousness). Move
on to breathing. Asymmetry implies a hemo-, pneumo-, or
hemopneumothorax, which requires a chest tube immediately.
57. E – Crescents mean rapidly progressive glomerulonephritis (RPGN—
bad news bears). Immune complexes along the basement membrane

https://www.benwhite.com/medicine/explanations-for-the-2018-2019-official-step-2-ck-practice-questions/ Page 8 of 17

https://t.me/USMLENBME2CK
Explanations for the 2018-2019 Official Step 2 CK Practice Questions | Ben White 30/10/21, 12:44 AM

mean Type II, such as seen with lupus, IgA nephropathy, acute
proliferative glomerulonephritis, and Henoch-Schönlein purpura.
Treated with immune suppression, which in the acute phase always
means steroids.
58. A – Cough is often the only sign of asthma. Exercise-induced asthma
is exercise-induced asthma.
59. E – Bronze diabetes and arthritis means hemochromatosis. They
never say the words “bronze diabetes” on board questions, but it
doesn’t mean it’s not there. You don’t want an awesome tan on the
boards.
60. A – Repeated microtrauma from repetitive stress can cause
thrombosis. DVT leads to erythema and venous engorgement, the
other choices do not. For bonus points, the eponym for effort-
induced upper extremity DVT is “Paget–Schroetter disease” (for
those keeping track at home).
61. D – The radiograph is showing complete collapse of the left lung (2/2
mucous plugging) with resultant severe ipsilateral mediastinal shift.
An acute shift can have the same effect as any other “tension”-type
process, causing impaired venous return to the heart and decreased
cardiac output via the Starling mechanism.
62. E – Weight gain, fatigue, and constipation go with hypothyroidism.
High LDL cholesterol actually does too, but the question is doable
even when ignoring the lab values.
63. A – Organ donation is a complex organizational dance, and the
regional procurement organization manages the nitty-gritty aspects.
64. A – They’ve listed the criteria for ADHD. Note that conduct disorder is
the kid-version of antisocial behavior. If the kid breaks rules and
messes up but doesn’t seem evil, then it’s not conduct disorder.
65. D – Abdominal pain is a common presenting complaint of DKA, which
is a common presentation of new-onset type 1 diabetes. Note the
glucose of 360.
66. E – Abnormal vaginal bleeding in a woman over 35 requires an

https://www.benwhite.com/medicine/explanations-for-the-2018-2019-official-step-2-ck-practice-questions/ Page 9 of 17

https://t.me/USMLENBME2CK
Explanations for the 2018-2019 Official Step 2 CK Practice Questions | Ben White 30/10/21, 12:44 AM

endometrial biopsy to rule out endometrial cancer.

67. A – It’s not clear that the glucose is a fasting value or not, but it’s
clear that the patient has symptoms of diabetes in the context insulin
resistance (obese kid with acanthosis nigricans). Diet and exercise
are always necessary in DM2 and can reverse many early cases. With
a 10% weight loss, for example, the patient may not require
pharmacotherapy.
68. B – Marfan syndrome (you know, hinted at by the familial tall stature
and weak hypermobile joints) is associated with a dilated/aneurysmal
aortic root, which can worsen, dissect and/or rupture if not
monitored.
69. D – Meniere disease is characterized by recurrent vertigo attacks
associated with ear fullness, tinnitus, and hearing loss.
70. C – Follow your ABCs. Tachycardia and hypotension mean severe
volume loss necessitating aggressive intravenous fluid resuscitation.
71. A – Totally healthy people with indirect hyperbilirubinemia means
Gilbert syndrome (which causes decreased bilirubin conjugation due
to reduced glucuronyltransferase activity).
72. D – Mitral valve stenosis is a sequela of rheumatic heart disease that
can lead to LAE and left-sided heart failure if left untreated.
73. B – Folic acid prevents neural tube defects. End stop.
74. A – The primary mechanism by which beta-blockers reduce angina is
via decreased contractility, which reduces the oxygen demand of the
myocardium (which has a constrained supply due to coronary artery
disease). Lowering heart rate also helps, but that isn’t one of your
choices.
75. B – One of the S in SIGECAPS is for suicidality. Depression is
extremely common, and it’s also underdiagnosed and undertreated in
cancer patients.
76. C – Again, acute RUQ pain (especially in an obese woman) should set
off the gallstone alarms. Fever and other systemic signs, white count,
etc lead you down the acute cholecystitis. Simple pain leads you to

https://www.benwhite.com/medicine/explanations-for-the-2018-2019-official-step-2-ck-practice-questions/ Page 10 of 17

https://t.me/USMLENBME2CK
Explanations for the 2018-2019 Official Step 2 CK Practice Questions | Ben White 30/10/21, 12:44 AM

symptomatic cholelithiasis. Either way the first step is to get a RUQ

sono to see those stones HIDA is used as an adjunctive study
in cases of cholelithiasis to assess for cystic duct obstruction (and
thus likely acute cholecystitis) in equivocal cases.
77. D – Walking pneumonia is treated with macrolide antibiotics as first
line. Patchy infiltrates in a patient with clinical pneumonia symptoms
who otherwise young, healthy, and walking around…think
mycoplasma.
78. B – They describe claudication and vascular insufficiency with strong
flow in the groin and no palpable flow distally in the dorsalis pedis,
placing the level of stenosis somewhere in between (i.e.
femoropopliteal). Diabetes and smoking are two big risk factors for
peripheral arterial disease (PAD).
79. C – We can only put the laboratory tests into context if we have an
accurate gestational age. Since her LMP is unreliable (totally
unknown), we need an ultrasound to date her pregnancy. The most
common cause of an abnormal MSAFP is wrong dates.
80. B – Post-traumatic AV fistula Just like dialysis AV fistulae have bruits
and thrills, so do non-purposefully created ones. These can take a
long time to form but can be associated with steal syndromes due
to decreased perfusion to the distal extremity, venous incompetence,
varicosities, and eventually stenoses due to unreasonably high flow,
and even high-output heart failure.

Block 3

81. A – This patient has urge incontinence, which is commonly caused by

detrusor instability (and can be treated with anticholinergics like
oxybutynin). This is opposed to stress incontinence, the other most
common type, which is worsened by abdominal
pressure/coughing/laughing/etc and can be caused by pelvic floor
prolapse secondary to multiple childbirths etc. Neurogenic bladder
can cause overflow incontinence.
https://www.benwhite.com/medicine/explanations-for-the-2018-2019-official-step-2-ck-practice-questions/ Page 11 of 17

https://t.me/USMLENBME2CK
Explanations for the 2018-2019 Official Step 2 CK Practice Questions | Ben White 30/10/21, 12:44 AM

82. B – Lumbar strain doesn’t require specific treatment or workup. Bed

rest (old school idea) has actually been shown to worsen outcomes.
83. A – Most common palpable breast mass in women less than 30 is
fibroadenoma. In women between 30-50, it’s a cyst (or fibrocystic
changes of the breast). Greater than 50, malignancy.
84. E – The thing you do with things that look like skin cancer is excise
them completely.
85. D – A boot-shaped heart means Tetrology of Fallow on board exams.
Outside of that rare straight-up buzzword giveaway, TOF is by far the
most common cause of cyanotic heart disease.
86. A – Via urinalysis and renal ultrasound, we’ve excluded
serious/treatable causes of renal hypertension including Conn’s
disease (hyperaldosteronism) and renal artery stenosis such as due
to fibromuscular dysplasia. That leaves her obesity.
87. B – Asymptomatic bacteriuria is never treated, except in pregnancy,
when it should always be treated due to its association with preterm
labor. Treat with an oral antibiotic that covers gram negatives (like E
coli), such as amoxicillin or nitrofurantoin.
88. D – You know what causes sudden onset headache and neck
stiffness Subarachnoid hemorrhage. The first episode can be
transient, the so-called sentinel bleed before a catastrophic
aneurysmal bleed.
89. D – The description of a primary lung cancer with associated muscle
weakness is leading you to Lambert-Eaton myasthenic syndrome, a
paraneoplastic autoimmune condition where antibodies attack the
presynaptic calcium channels of the neuromuscular junction. Lung-
cancer paraneoplasias are test favorites.
90. A – Frequent turning prevents the development of pressure ulcers in
patients with decreased mobility.
91. A – PTSD symptoms that begin within 4 weeks of a traumatic event
and last 4 weeks or less is acute stress disorder (ASD).
92. B – The drugs of choice for Alzheimer’s-type dementia (i.e. general

https://www.benwhite.com/medicine/explanations-for-the-2018-2019-official-step-2-ck-practice-questions/ Page 12 of 17

https://t.me/USMLENBME2CK
Explanations for the 2018-2019 Official Step 2 CK Practice Questions | Ben White 30/10/21, 12:44 AM

dementia without specific factors to make you consider other

diagnoses) are the cholinesterase inhibitors, the most important of
which is Donepezil.
93. D – Painless uterine bleeding goes with placenta previa. Painful
uterine bleeding goes with placental abruption. Ruptured vasa previa
results in rapid loss of the fetus.
94. F – Septic arthritis (rapidly warm swollen joint +/- fever) must be
tapped, followed by antibiotics. Untreated, the joint can be destroyed
in days. Minor trauma can predispose to hematogenous bacterial
spread.
95. B – The first imaging test in acute stroke is a noncontrast CT scan of
the head. At 12 hours out, it may show ischemic strokes, but more
importantly, it will diagnose hemorrhagic strokes, for which
reperfusion and antiplatelet therapies are contraindicated.
96. B – Myocardial infarction causes heart muscle death (as the name
implies). Lose enough muscle and you get systolic heart failure.
97. B – Thick, white, and acidic means candidal vulvovaginitis (aka a
yeast infection). Bacterial vaginosis typically only causes foul/fishy
odor (and is alkaline, has a positive whiff test, clue cells on wet
mount, etc).
98. E – Thrombocytopenia without antiplatelet antibodies or
splenomegaly implies a platelet production problem (e.g.
myelofibrosis). History of radiation therapy is a risk factor. The only
way to know what’s happening at the factory is a bone marrow
biopsy.
99. C – Multinodular goiter Say it five times fast. Feels good, doesn’t it
The first half describes blatant hyperthyroidism. The thyroid scan is
now demonstrating an enlarged gland with multiple nodules
(“areas”), some avid/hyperfunctioning and other relatively depressed
(either not “hyper”-functioning and thus relatively cold or actually
cold, most commonly filled with colloid).
100. C – Obstructive sleep apnea (OSA) is diagnosed exclusively by

https://www.benwhite.com/medicine/explanations-for-the-2018-2019-official-step-2-ck-practice-questions/ Page 13 of 17

https://t.me/USMLENBME2CK
Explanations for the 2018-2019 Official Step 2 CK Practice Questions | Ben White 30/10/21, 12:44 AM

polysomnography (aka a sleep study).

101. E – Everyone should get a flu shot. Diabetics are relatively immune
suppressed and deserve it even more.
102. D – A nagging persistent dry cough is a common side effect of ACE-
inhibitors due to bradykinin accumulation (bradykinin is normally
degraded by ACE). Along with angioedema, it’s an important reason
for discontinuation; the solution for both is to switch to an
angiotensin II-receptor blocker (ARB) like losartan, which does not
affect ACE activity directly.
103. A – RUQ pain and nausea after meals is concerning for symptomatic
cholelithiasis. The test of choice is RUQ sono to assess for stones.
104. A – It’s a cholesteatoma, which can be congenital (rare) or acquired
(much more common). Even if you have no idea what that is (look it
up), it’s the only answer with “proliferation” to go along with the
mass. None of the others mention anything remotely mass-like.
105. A – The most common cause of hypothyroidism in developed
countries is Hashimoto’s thyroiditis. In developing countries, it’s
iodine deficiency.
106. D – If environmental, food, or exposure allergies ever include
shortness of breath, hoarseness, or anything remotely airway-
involving or anaphylaxis-like, then carry an epi-pen.
107. D – STDs are always double-treated for both chlamydia and
gonorrhea, as coinfection is extremely common, and clearance is
crucial to prevent reinfection and continued spread. That means
anyone with cervicitis or urethritis gets azithromycin or doxycycline
with ceftriaxone.
108. D – The majority of twins are born premature, which is even more
true for triplets. Only monochorionic twins experience twin-twin
transfusion syndrome (as they have to share a blood supply in order
for the problem to occur).
109. B – Confusion and tremulousness a few days after an unexpected
hospital admission on the USMLE means alcohol withdrawal

https://www.benwhite.com/medicine/explanations-for-the-2018-2019-official-step-2-ck-practice-questions/ Page 14 of 17

https://t.me/USMLENBME2CK
Explanations for the 2018-2019 Official Step 2 CK Practice Questions | Ben White 30/10/21, 12:44 AM

(unanticipated detox).
110. B – The STD that forms a painful ulcer aka chancroid = H ducreyi
(ducreyi makes you cry, as they say).
111. D – The lungs are clear. Location, JVD, and lack of heart sounds
mean cardiac tamponade from hemorrhage into the pericardium.
Pericardiocentesis is the next step. Don’t forget, if you see tension
pneumothorax or a water-bottle heart (from tamponade) on chest
xray, you’ve already delayed life-saving therapy.
112. D – The inclusion bodies signify that this patient has a CMV infection
of the renal transplant, which can originate from either the donor or
recipient but are activated/unmasked by immune suppression. CMV
is an important cause of morbidity and mortality in renal transplants
and both the donor/recipient are routinely screened.
113. E – Don’t let the carpal tunnel history fool you. Numbness of the
pinkie and half of the ring finger is ulnar entrapment (cubital tunnel
syndrome, which happens at the elbow); carpal tunnel syndrome is
the median nerve at the wrist (affecting thumb, index, middle, and
half of the ring)
114. E – Genital warts don’t hurt and they turn white with vinegar (acetic
acid). No systemic therapy works (although there is now a vaccine),
but cryotherapy (as well as laser and electrocautery) can help. HPV
will remain, however, and the lesions can recur.
115. C – Remember cystic fibrosis in young people with worsening
obstructive lung disease and frequent infections. The infertility in
males is secondary to failure of the vas deferens to develop
properly (in women, it’s due to thick cervical mucus). Sweat chloride
test makes the diagnosis.
116. D – Fever, AMS, and muscle rigidity in a patient on antipsychotics
(aka ‘neuroleptics’) means neuroleptic malignant syndrome (NMS).
Very rare, very dangerous.
117. B – IBS is a “functional” G.I. problem, which means that it is a
diagnosis of exclusion (must rule out IBD, Celiac, etc). You may have

https://www.benwhite.com/medicine/explanations-for-the-2018-2019-official-step-2-ck-practice-questions/ Page 15 of 17

https://t.me/USMLENBME2CK
Explanations for the 2018-2019 Official Step 2 CK Practice Questions | Ben White 30/10/21, 12:44 AM

enjoyed its recent popular appearance on television as a disturbing

anthropomorphized walking bowel. Common symptoms include
diarrhea, constipation, pain relieved by defecation, and flatulence,
often subject to a degree of emotional valence. As such, like
headaches, IBS symptoms can be improved by TCA therapy, such as
nortriptyline.
118. D – They hit you over the head with hypocalcemia symptoms before
giving the value. Hidden in there is the pancreatic insufficiency
causing steatorrhea and fat-soluble vitamin deficiency (A, D, E, and
K).
119. B – The patient has rhabdomyolysis from a prolonged visit with the
floor. The ridiculously high CK confirms the diagnosis. Rhabo causes
renal failure and requires aggressive fluid resuscitation.
120. B – Type II error is the possibility of producing a false negative (a
negative result when it should be positive). A smaller sample size
may not be able to detect a small (but real) treatment effect and thus
increases the chance of type II error.

Multimedia questions:
Block 1

7. A – Classic Moro reflex, entirely expected and normal until it disappears

around age 4 months. If you have never seen a newborn before, also note
that the mom is concerned about delayed milestones at two weeks of
age, which is a red flag for BS: babies aren’t even smiling socially yet by
two weeks.

Block 2

3. D – Pill-rolling resting tremor of Parkinson’s disease secondary to loss

of dopamine neurons in the substantia nigra.

https://www.benwhite.com/medicine/explanations-for-the-2018-2019-official-step-2-ck-practice-questions/ Page 16 of 17

https://t.me/USMLENBME2CK
Explanations for the 2018-2019 Official Step 2 CK Practice Questions | Ben White 30/10/21, 12:44 AM

18. A – I’m going to point out that a normal healthy kid with no cardiac
history or symptoms and no family history of sudden cardiac death for a
pre-sports physical is probably going to have a benign exam no matter
what you think you hear. HOCM is what you want to exclude theoretically,
but here we don’t have a real systolic murmur, just a little vibratory flow
murmur at LLSB.

33. E – This one is a bit silly. The lung exam is normal outside of the super
common basilar crackles. Everything except for PE you would expect to
hear a more impressive auscultation abnormality. But for this question: B
and C take longer than 3 days. D we would expect fever, productive cough
etc. Bronchitis would be possible, but still more often to have at least
productive cough if not fever. PE, on the other hand, classically has a
nonproductive cough, hypoxemia, and tachycardia. All three are present.
And then they mention her med: OCPs, which are an important
predisposing factor for PE in young women for whom it is otherwise a rare
entity. Young lady on OCPs is a classic set-up for an STD question (who
needs condoms ) or a PE question, one of the two.

Block 3

10 D – Statistical significance (a low p-value) does not equal clinical

significance. A favorite teaching point when it comes to interpreting
literature.

11 C –A & D are conjectures: the kind of statements people drop

inappropriately in the conclusion of a weak paper to make it sound
important. E is an exclusion criterion. B is the opposite: including 0 is
equivalent to something not being significantly different.

Corrections, clarifications, copy/paste errors etc can be

made/asked/mocked in the comments below.

https://www.benwhite.com/medicine/explanations-for-the-2018-2019-official-step-2-ck-practice-questions/ Page 17 of 17

https://t.me/USMLENBME2CK