New Free 120 - Answers & Explanations (BW)

Explanations for the 2020-2022 Official Step 2 CK Practice Questions | Ben White 30/10/21, 12:36 AM
Explanations for the 2020-2022

Official Step 2 CK Practice
Questions
Medicine // 04.21.21
Update: The March 2021 pdff is still identical outside of some minor
formatting changes.
The NBME released a completely new set of questions in March 2020,

which was the first major update since basically 2015. (The August 2020
pdf is the same.)
The 2019 set, which is completely different, is available and explained

here for more free questions
These are in the order of the PDF linked above.
Block 1
1. C – While you may have initially been thinking of alcohol withdrawal,

the case presents you with signs/symptoms of decompensated
cirrhosis including hepatic encephalopathy from hyperammonemia
(AMS, asterixis). Treatment is oral lactulose, which helps clear
ammonia via the power of horrible diarrhea.
2. F – Keep in mind that “not all that wheezes is asthma.” Wheezing is a
sign of obstructive lung disease, not a diagnostic feature, so consider
asthma alternatives in adults. Hemoptysis and fever help change the
game. Eosinophilic granulomatosis with polyangiitis (Churg-Strauss)
and granulomatosis with polyangiitis (née Wegener’s) both cause
lung disease, but did you know they can also cause peripheral
neuropathy The former over the latter more commonly has
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neuropathy and presents with asthma, but the latter can easily do the
same. ANCA can be positive in both and helps confirm the diagnosis
of systemic vasculitis as a unifying cause.
3. D – Urinary retention due to pelvic organ prolapse. Multiple vaginal
deliveries are the risk factor/cause.
4. D – This patient has neutropenic fever. Methimazole can cause
agranulocytosis.
5. A – Concerning for meningitis. Yes, even with abdominal pain, which
can be so severe that it can mimic appendicitis. Remember that
splenectomy status predisposes to infection with encapsulated
organisms such as meningococcus. This may also be purposefully
vague, as in real life this could also certainly be an abdominal process
like actual appendicitis, for which you might get an appendix
ultrasound or CT of the abdomen/pelvis in addition to starting empiric
antibiotics, but that’s not an answer choice.*
6. A – Also meningitis. There’s a vaccine for that, which everyone in
college is supposed to get.
7. D – Every pregnant patient gets tested for HIV during routine initial
prenatal workup/testing as well as again during the third trimester.
8. E – Quitters gonna quit.
9. C – When old men stop peeing so well, consider the poorly designed
straw-crusher, the prostate. Chronic outlet obstruction isn’t so great,
but it also predisposes to acute prostatitis which in turn can further
worsen said obstruction when the gland swells. First thing to do is
see how much the gentlemen is backed up, which in turn tells us if he
has earned catheterization. Old people and UTIs go together like
[insert your own clever comparison].
10. E – That’s a septic joint, not just RA (RA is a risk factor). Full-blown
fever and intraarticular pus.
11. C – We have event rates of 35% for EST and 15% for EPCS, and the
number needed to treat (NNT) is the inverse of the absolute risk
reduction or 1/ARR. ARR = Control event rate minus experiment event
rate. So, we have ARR = 0.35 – 0.15 = 0.2, and therefore NNT = 1/0.2
= 5. Boom, math.
12. B – This is a great RCT. The issue is that EPCS is a specialized
treatment not as widely and emergently available as the usual GI-doc
on call.
13. B – It works. P < 0.001 for that parameter.
14. A – With treatment adherence, most HIV-positive individuals will die
of the same things as the rest of us: the American way of life.
15. A – Initial treatment for inadequate sleep and various types of
“insomnia” is sleep hygiene modification. Certainly, her smoking and
nicotine activation aren’t helping, but there’s no such therapy as
“setting a date for smoking cessation.” Americans are terrible with
sleep, and many who struggle are doing all the wrong things like
using electronic devices late in the evening, dealing with neverending
light pollution, caffeine and cigarettes too late in the day, going to
bed too late, blah blah blah.
16. B – Rapidly progressive dementia (with or without personality
changes, psychiatric disturbances, and sudden/jerky movements)
raises the possibility of Creutzfeldt-Jakob disease, for which CSF
protein 14-3-3 is an important marker.
17. C – Slow submersion warming is key when dealing with frostbite. Air
and towels/dressings are poor conductors of temperature.
18. D – She has thrombocytopenia, likely related to a lupus flare given
underlying SLE as well as evidence of active arthritis with joint
effusions. Thrombocytopenia in lupus can occur via an ITP-like
autoantibody phenomenon. In fact, some patients with lupus initially
present with immune thrombocytopenic purpura (ITP) prior to
developing other lupus symptoms. Whether a lupus flare or true ITP
in the setting of other autoimmune conditions, the initial treatment of
an active bout is prednisone. Refractory cases of ITP can be treated
by splenectomy.
19. B – Mitral regurgitation explains the soft S1 and holosystolic murmur
loudest at the apex. Acute heart failure with pulmonary edema. In the
context of a recent URI, this is most concerning for viral myocarditis.
Rheumatic fever can also present with carditis, but in this case, the
patient has otherwise recovered from other symptoms.
20. E – Bilious vomiting in the newborn includes the full differential
(duodenal atresia, midgut malrotation and volvulus, jejunoileal atresia,
meconium ileus and necrotizing enterocolitis), but rapidly-ill bilious
vomiting combined with fever, distension, and tenderness after a few
days to a week or so is most concerning for midgut volvulus. Most
other causes present soon after birth with the exception of
necrotizing enterocolitis, usually affecting premature babies within a
couple of weeks after birth. Diagnosis with upper GI.
21. A – Using the most expensive things isn’t always a great use of
limited resources. In a very elderly patient with dementia and multiple
medical comorbidities, you probably don’t need the most long-lasting
most-expensive stents when the long-term survival prospects of the
patient are dismal.
22. A – This is a potentially fatal decision. Patients can choose to deny
care, but when someone is making the “wrong” choice, it’s important
to make sure they have the capacity to do so: do they understand
their situation, their options, and the possible consequences of their
actions If so, that’s fine.
23. E – The banana bag You might be thinking of Flumazenil to reverse
his benzo use, but be wary of using in an otherwise stable chronic
user as this can precipitate seizures. He’s also probably drunk, but
that we’ll just wait out. In this case, he’s awake and protecting his
airway but he’s encephalopathic. When an alcoholic is
encephalopathic, think Wernicke’s and give thiamine. Even if they’re
just plain ole drunk you’re not going to hurt them.
24. B – These are the signs and symptoms of testicular torsion, a surgical
emergency.
25. C – This is a diffuse pontine glioma, a death sentence. You don’t
really need to know that, because the stem tells you of the poor
prognosis. Whenever someone is presented with a serious diagnosis,
any treatment discussion starts with establishing a baseline
understanding of the disease process and then discussing goals of
care.
26. B – We have a middle-aged black female as the setup. Pulmonary
disease with CXR showing bilateral hilar adenopathy. She has
cutaneous involvement of the face. Cutaneous involvement is present
in 1/3 of systemic cases but can have a variety of appearances.
27. E – Statin-myopathy is assessed laboratorily with serum CK.
28. C – Source control followed by symptomatic relief. Have you seriously
ever heard of anyone doing any of that other crazy stuff
29. A – ECT works. It works really well, and it works really fast. This
gentleman is wasting away and is unable to care for himself.
30. E – USPSTF recommends clinicians screen all adults age 18-79 for
hepatitis C infection.
31. D – Non-immediate “delayed” penicillin allergy. The question info is a
bit over the top, but the answer choices are mostly related to
allergies, which gives you a hint. If someone has an antibiotic allergy,
just use another antibiotic.
32. B – People low on the totem pole aren’t going to feel comfortable
speaking up unless encouraged.
33. D – If you thought that looked like a squamous cell carcinoma, that’s
because it is. A keratoacanthoma is the name of the erupting-volcano
variant, though some keratoacanthomas will resolve spontaneously
and others progressive to invasive cancer.
34. D – USPSTF recommends all men 35 and older (women 45 and
older) are screened for lipid disorders, and age 20+ for those with
increased risk of CAD.
35. C – Routine imaging for pyelonephritis at presentation is not generally
helpful. But CT imaging for those who do not respond to antibiotics is
indicated to evaluate for complicating factors like renal abscess or
nephrolithiasis that cannot be treated with antibiotics alone.

36. D – We can simplify this with the general framework that if significant
hypotension doesn’t resolve with volume repletion, then we move on
to pressors.
37. A – She is currently prediabetic. But not for long.
38. D – No lying.
39. C – Acute kidney injury with volume overload, presumably from the
ACE-inhibitor.
40. C – Hereditary weak bones, mobile joints, and hearing loss are a good
fit for osteogenesis imperfecta. Scoliosis and short stature are also
common, particularly in more severe cases.
Block 2
41. B – The goal is to hopefully make sure she is safe (and if she is at-risk
for partner abuse to provide her with resources). On a related note,
unlike for children and elders, there is no reporting mechanism for
partner abuse.
42. B – He’s got a cyanosis-level from an aortic embolism. His floppy,
akinetic LV is the risk factor for thrombus generation, which was
subsequently squeezed out and lodged distally. The other choices
would not result in isolated symmetric lower body symptoms.
43. B – This is all to say he has chronic lung disease. He has findings of
possible fibrosis on CXR and a history certainly concerning for
smoking-related lung disease. HRCT will tell us if he has a pattern
characteristic of UIP (e.g. idiopathic pulmonary fibrosis) or something
potentially more treatable like NSIP or just run of the mill COPD.
44. B – Recurrent vomiting results in a hypokalemic hypochloremic
metabolic alkalosis (i.e. you lose acid and keep having to make more).
45. C – CTs evaluate the kidneys, but they do a very poor job evaluating
the bladder. Direct cystoscopy is needed to clear the lower urinary
tract of an underlying bleeding mass. Smokers are at increased risk
of bladder cancer.
46. E – “Bone broke must fix.”

47. D – Hypertension is the number 1 risk factor for stroke. Additionally,
while smoking cessation is also important, it takes years for the
deleterious vascular effects of smoking to normalize.
Antihypertension therapy is needed right now and has a much higher
likelihood of success than stopping someone’s habit of a lifetime.
48. B – They are presumably trying to demonstrate that she has an acute
viral-type syndrome given the flu-like illness with fever, muscle
aches, and generalized misery. COVID-19 wasn’t an answer choice.
Note the CXR says “interstitial infiltrates,” which is the Step code
phrase for atypical infection (as opposed to consolidative
pneumonia).
49. D – Dyslexia is one of several different learning disorders.
50. C – Inflamed painful infected external auditory canal is consistent
with otitis externa. Earplugs are a risk factor, both from microabrasion
trauma and/or from contact dermatitis.
51. C – Most acute sinusitis is viral, not bacterial. Most antibiotic use for
sinusitis is futile. Nasal irrigation and decongestant therapy are the
hallmark treatments to relieve drainage pathway obstruction and give
the body the ability to drain secretions properly.
52. D – Children with VATER often have tracheomalacia (part of the T),
which can be associated with TEF and esophageal atresia.
Tracheomalacia results in dynamic airway obstruction due to airway
collapse on expiration (greater when forced).
53. D – Chest pain in the setting of a recent URI and with the low-grade
ST elevation in multiple leads is the classic setting for pericarditis.
The scratchy sound is the “pericardial rub.” Echo will assess for a
pericardial effusion (and its size/significance), pericardial thickening,
as well as assess for overall cardiac function.
54. B – Idiopathic and viral pericarditis treatment is anti-inflammatory.
Data show that Colchicine is a useful NSAID adjunct for all
pericarditis treatment, not just recurrent or prolonged cases as was
once commonly assumed.

55. D – He is not safe, you have enough information to act.
56. E – She has multiple sclerosis. Clinically, neurologic lesions/deficits
separated in time and space. MRI can show us evidence of
demyelination in the brain to go along with her optic neuritis. These
features are more important than oligoclonal bands in the CSF.
57. E – She has no significant cognitive deficits and is thus still normal
enough to not require a dementia workup. In real life, I have plenty of
evidence she’d get that MRI.
58. D – Serotonin syndrome. The most important next step is to remove
the offending serotonergic agents.
59. E – He would seem to be psychotic. While people with schizophrenia
or delusional disorders are on average no more dangerous than other
folks, safety is paramount. Danger to self or others and all that.
60. A – Vesicular rash in the immune-compromised is a common
scenario for Varicella-Zoster reactivation. Visceral zoster involvement
can result in severe pain that can be mistaken for an acute abdomen.
Treatment with acyclovir or valacyclovir.
61. E – Vulvar cancer is rarer than cervical cancer but has many of the
same risk factors including HPV. Another risk factor worth knowing is
lichen sclerosis, which results in thin itchy vulvar skin.
62. E – Thyroid nodules are best evaluated by thyroid ultrasound. While
larger nodules (>1.5 cm) are more likely to be malignant, there are
plenty of very large completely benign nodules that would be
inappropriate to biopsy.
63. E – AZT monotherapy during the intrapartum and postpartum period
(in addition to maternal therapy throughout pregnancy) is
recommended for all neonates of HIV-positive mothers to reduce
transmission and is very effective (less than 1%).
64. B – Prolactinomas (pituitary adenomas that secrete prolactin and as a
result can cause amenorrhea/infertility/lactation) can be treated with
dopamine agonists like cabergoline. This is because dopamine
normally inhibits pituitary prolactin production. In many cases, tumors

can completely involute with pharmacologic therapy alone.
65. E – This constellation of symptoms in a premature infant by around
two weeks of life is concerning for NEC. The diagnosis is commonly
made with abdominal radiographs, which can demonstrate bowel
dilation and pneumatosis (and when more severe, frank
pneumoperitoneum).
66. E – You can’t turf out emergency care that you are equipped to
perform just because a patient can’t pay. Dumping is why EMTALA
was created in the first place.
67. E – Pseudoseizures are diagnosed in EMUs with video EEG. You
match the behavior with the EEG to see if there are epileptiform
discharges that correspond to the episodes. While this is clearly
absurd for an epileptic seizure (impossible movements, insane
duration, and no postictal period), there are plenty of cases of bizarre
seizure patterns that are VEEG proven.
68. D – Pleurisy (or potentially costochondritis) secondary associated
with a URI, either way, treat with NSAIDs.
69. B – This person recently had normal cycles, essentially excluding A
and C. We have no reason to suspect D. And the normal prolactin
excludes E. Hypothalamic hypogonadism can have many causes,
among them chronic stress and anxiety, as seen in patients with
eating disorders, sufferers of PTSD, etc.
70. B – Menopause. Elevated FSH and no period for over a year confirm.
71. E – Penicillin prophylaxes is indicated in all children with sickle cell
younger than 5 to prevent severe pneumococcal infection.
72. B – Jaundice in the newborn. When unconjugated, typically
“physiologic,” with two common causes breastfeeding jaundice (due
to insufficient intake) and breast-milk jaundice. In this case, however,
the bilirubinemia is conjugated (“direct”), which suggests cholestasis.
Ultrasound is needed to evaluate the liver and biliary system.
73. D – Relentless dry cough is a common reaction to ACE inhibitor
therapy.
74. E – Opioids result in floppy babies who don’t breathe well, just like
they do in adults.
75. D – Obstructive sleep apnea can result in ADHD-like symptoms,
irritability, and poor growth. The snoring is a tip-off, and
tonsil/adenoid enlargement is the main cause of intermittent airway
obstruction during sleep in children.
76. D – Lisfranc (tarso-metastarsal) dislocations in the setting of Charcot
arthropathy (diabetic neuropathic joint). Initial treatment for acute
Charcot joint is immobilization to prevent progressive deformity.
77. C – Parents don’t get to withhold lifesaving emergency treatment
from their children, religion or not.
78. C – Cyanotic newborn with a single S2 is suggestive of a truncus
arteriosis congenital heart defect (a VSD combined with a single
ventricular outflow track comprising both the pulmonary and
systemic circulation). The pulmonary circulation is thus torrential
resulting in pulmonary edema. Like other CHD that result in early
cyanosis, these patients are ductus-dependent for oxygenation
mixing and should receive prostaglandin to maintain a PDA.
79. A – Vasospastic angina (formerly known as Prinzmetal angina). Rest
angina/chest pain rapidly relieved by nitrates in a patient without
coronary disease. Commonly treated with calcium channel blockers.
An alternative possibility that would also yield the correct answer is
esophageal spasm, but there’s been no workup to support that
etiology save for the presence of non-CAD-related chest pain.
80. D – There is AV concordance (all QRS have a preceding P wave), but
we have intermittent dropped beats consistent with a second degree
AV block. The PR-interval of the conducted beats is always the same,
so we have Mobitz 2. Progressively lengthening PR-interval prior to a
dropped QRS is Mobitz 1 (Wenkebach).
Block 3
81. B – You know people make mistakes of all types after a few drinks.
82. A – Help her feel better. That’s the point of hospice.
83. D – With family members with both primary hyperparathyroidism and
an “adrenal tumor” (let’s guess pheochromocytoma), we have two
out of the MEN2A triad. The third is medullary thyroid cancer.
84. A – People with CVID are at increased risk of lymphoma. B-
symptoms like fever, weight loss, and night sweats combined with
lymphadenopathy are highly concerning.
85. E – I think the description here is a little odd, but a helpful reader
suggested cigarette burns, which I think is probably correct.
Alternatives could be a blistering burn secondary to intentional hot
water submersion or really serious spanking, potentially with a welt-
causing object. Either way, not an accidental/expected pattern.
Whenever the story doesn’t make sense or there are any concerning
physical exam findings, it is critical to work up for nonaccidental
trauma.
86. E – History is clearly gallbladder (“biliary colic”). Now cholecystitis, so
evaluate with ultrasound. Minimal lipase bumps can be seen with
other GI and biliary issues, but also note that gallstones can also
cause pancreatitis, so it’s certainly possible for her to also have that
brewing. If you suspect gallbladder/biliary issues, always start with
US.
87. B – Tracing shows a prolonged severe fetal bradycardia. This is bad.
Causes include cord prolapse, placental abruption, uterine rupture,
and uterine tachysystole. Umbilical cord prolapse is particularly
common after AROM, where rapid descent of the fetal head
compresses the umbilical cord, limiting blood flow as it’s squeezed
inferiorly by the contracting uterus. Vertex station doesn’t actually
matter as once previously thought, but a nondilated cervix (less than
6 cm) is a risk factor.
88. F – How many people with sats in the 80s have you seen not getting
O2
89. A – Ulcerative colitis is a risk factor for colon cancer. The skin lesions
are a description of erythema nodosum.
90. A – Trauma and critical illness can cause acute insulin resistance.
91. A – Don’t be a dick.
92. C – Hyperaldosteronism = hypertension + hypokalemia. Adrenal
adenomas are a common cause of primary hyperaldosteronism.
93. F – Necrotizing fasciitis = looks like bad cellulitis but then you add
skin breakdown and necrotic goo.
94. D – The key to dealing with occupational exposures is safe practices.
That means anything producing a particle or fume needs a respirator.
You can’t fix the damage already done.
95. D – Spironolactone helps reduce ascites production and is the
diuretic of choice for the initial treatment of portal hypertensive
ascites.
96. C – Severe hypertriglyceridemia is an important risk factor for/cause
of pancreatitis. Fibrates remain the drug of choice for severe HTG
(TGs > 500 mg/dL).
97. B – Cirrhotic wanderer, completely disoriented. While potentially just
intoxicated or suffering from hepatic encephalopathy, the question is
again probably getting at Wernicke’s encephalopathy. Treatment is
thiamine. It’s harmless, and that why lots of drunks get the banana
bag.
98. B – Algorithmic standard approaches that reduce variability are the
hallmark of high-quality care. Not everyone can receive heparin, but
everyone needs to have a DVT prophylaxis plan so they don’t fall
through the cracks.
99. A – Subtraction.
100. C – Stop. Wrong sided surgery is a big no-no. Everyone on the team
should feel empowered to stop a surgery or procedure if something
in the preprocedural checklist is amiss.
101. E – PEEP is like cowbell. Okay not really but when gas exchange is
insufficient with increased FiO2, PEEP will help open alveoli and
increase the functional area available for ventilation.

102. A – TCA overdoses are potentially fatal due to the drugs’ cardiac
effects. The most dangerous is that fast sodium channel blockage
can lengthen the QRS and result in fatal ventricular arrhythmias.
103. C – The test of choice for AAA screening is ultrasound. Cheap and
radiation-free.
104. A – Back pain, normocytic anemia, fatigue, and hypercalcemia. These
are concerning for a hematopoietic process, particularly multiple
myeloma. Serum protein electrophoresis will demonstrate the M-
spike.
105. D – The decreasing and irregular periods coupled with high FSH
suggest early menopause. Estrogen helps with bone strength. The
lack predisposes to osteoporosis.
106. E – Increased bleeding with normal labs (or an isolated mildly
prolonged PTT) is always a good picture for von Willebrand disease,
the most common bleeding disorder. Yes, the PTT is slightly elevated
(which can happen), but that’s also why they probably gave you boy
and girl siblings to help you not pick hemophilia.
107. E – Colon cancer is a surgical disease.
108. B – Part of the DSM-V criteria for generalized anxiety disorder:
“Excessive anxiety and worry (apprehensive expectation), occurring
more days than not for at least 6 months, about a number of events
or activities (such as work or school performance).”
109. A – Ascites with a neutrophil count higher than 250 is consistent with
spontaneous bacterial peritonitis. Treatment of choice is a third-gen
cephalosporin like cefotaxime or ceftriaxone.
110. E – AED-induced bone disease is a problem with long term therapy.
Carbamazepine and phenobarbital both induce CYP450 and can
cause vitamin D deficiency.
111. A – Write it out. Abbreviations are like assumptions.
112. D – When it comes to development questions, always make sure
before you pick something other than normal if offered. Tanner
stages are available for review here.

113. D – Implantable birth control is much more effective than methods
that require active effort.
114. F – Malignant pleural effusion. Cancer is full of protein.
115. E – Ah, ye old “inconsistent condoms” code phrase for STDs.
116. B – Externally normally developed female with a 46XY male
karyotype, elevated testosterone, and no internal sex organs is
consistent with complete androgen insensitivity syndrome. While
somewhat controversial particularly with regards to timing,
gonadecotmy is recommended to remove the undescended gonads
to prevent cancer. In this case, she’s already gone through puberty. If
gonadectomy is performed earlier in childhood, than puberty will
need to be induced with HRT.
117. C – HCTZ (and other symporter and loop diuretics) can result in
diuretic-induced hyperuricemia and cause or worsen gout.
118. D – This is the MSG symptom complex, sometimes historically and
pejoratively called “Chinese Restaurant Syndrome.” While MSG gets a
bad wrap, real MSG sensitivity is rare.
119. C – Don’t be a dick. But you don’t have to entirely give up either: she
may come around after her crazy simmers for a while.
120. F – Sciatica.
Corrections, clarifications, copy/paste errors etc can be

made/asked/mocked in the comments below.

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Explanations for the 2020-2022 Official Step 2 CK Practice Questions | Ben White 30/10/21, 12:36 AM

Explanations for the 2020-2022

The NBME released a completely new set of questions in March 2020,

The 2019 set, which is completely different, is available and explained

These are in the order of the PDF linked above.

1. C – While you may have initially been thinking of alcohol withdrawal,

nephrolithiasis that cannot be treated with antibiotics alone.

46. E – “Bone broke must fix.”

once commonly assumed.

normally inhibits pituitary prolactin production. In many cases, tumors

increase the functional area available for ventilation.

stages are available for review here.

Corrections, clarifications, copy/paste errors etc can be

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