USMLE Step 2 CK (Clinical Knowledge) tests your ability to apply medical knowledge and clinical science to patient care under supervision, with an emphasis on health promotion and disease prevention. It is reported as a three-digit score.
CliniQuiz.AI generates clinical-vignette practice questions aligned to the Step 2 CK blueprint across the major disciplines and organ systems:
Internal medicine, surgery, and pediatrics
Obstetrics & gynecology and psychiatry
Diagnosis, management, and next-best-step reasoning
Screening, prevention, and patient safety
Each question includes a thorough explanation, and the AI tutor helps you reason through diagnosis and management step by step. Try a free sample quiz below—no sign-up needed.
Sample Questions
A 56-year-old woman with nonischemic dilated cardiomyopathy is admitted to the cardiac intensive care unit for progressive dyspnea, orthopnea, and decreasing urine output. Her medications include carvedilol, sacubitril/valsartan, spironolactone, and furosemide. She has no fever or chest pain. Blood pressure is 72/44 mm Hg, pulse is 118/min, respirations are 28/min, and oxygen saturation is 93% on 4 L/min of oxygen by nasal cannula. She is somnolent but arousable. Examination shows cool extremities, delayed capillary refill, jugular venous distention, and bilateral pulmonary crackles. Urine output has been 10 mL/hour over the past 3 hours. Serum creatinine is 2.3 mg/dL, compared with a baseline of 1.0 mg/dL, and lactate is 5.4 mmol/L. ECG shows sinus tachycardia without acute ischemic changes. Bedside echocardiography shows a left ventricular ejection fraction of 15% with global hypokinesis, preserved right ventricular function, and no significant valvular abnormality or pericardial effusion. A pulmonary artery catheter shows a cardiac index of 1.4 L/min/m² and a pulmonary capillary wedge pressure of 29 mm Hg. In addition to respiratory support, which of the following intravenous infusions is most appropriate to initiate first?
Dopamine infusion
Norepinephrine infusion
Dobutamine infusion
Sodium nitroprusside infusion
Milrinone infusion
Show answer and explanation
Answer: Norepinephrine infusion
This patient has cardiogenic shock with severe hypotension, low cardiac output, elevated left-sided filling pressure, and end-organ hypoperfusion. Norepinephrine is the preferred initial vasopressor in this setting because its predominant alpha-1 effect raises arterial pressure, while modest beta-1 activity provides some inotropic support. It can be titrated toward an initial mean arterial pressure of approximately 65 mm Hg, individualized to perfusion response. Additional inotropic support may be needed if low output persists.
A 34-year-old man comes to the emergency department due to a painful, persistent erection. He reports that the erection began 6 hours ago after sexual intercourse and has not subsided despite ejaculation and taking a cold shower. He has a history of major depressive disorder and insomnia, for which he was recently prescribed a new medication. He does not use illicit drugs or phosphodiesterase-5 inhibitors. His temperature is 37.0°C (98.6°F), blood pressure is 132/82 mmHg, and heart rate is 98/min. Physical examination shows a fully rigid and exquisitely tender penile shaft. The glans penis and corpus spongiosum are soft. Cavernosal blood gas analysis reveals a pH of 7.10, pO2 of 25 mm Hg, and pCO2 of 70 mm Hg. Which of the following is the most appropriate next step in management?
Aspiration of the corpora cavernosa and injection of phenylephrine
Intravenous administration of normal saline and opioid analgesics
Color Doppler ultrasonography of the penis
Observation and application of perineal ice packs
Creation of a distal cavernosal-spongiosal shunt
Show answer and explanation
Answer: Aspiration of the corpora cavernosa and injection of phenylephrine
This patient is experiencing ischemic (low-flow) priapism, an acute urologic emergency characterized by a painful, fully rigid erection that lasts greater than 4 hours. It is caused by impaired venous outflow from the corpora cavernosa. The patient's recent prescription for insomnia and depression is likely trazodone, a well-known pharmacologic trigger for ischemic priapism. The diagnosis is confirmed by the cavernosal blood gas, which typically shows hypoxia (pO2 < 30 mm Hg), hypercarbia (pCO2 > 60 mm Hg), and acidosis (pH < 7.25). The most appropriate first-line treatment is immediate corporal aspiration to remove stagnant blood, often followed by irrigation with normal saline and intracavernosal injection of a pure alpha-1 adrenergic agonist (e.g., phenylephrine). Phenylephrine induces cavernous smooth muscle contraction, promoting venous outflow and detumescence.
A 65-year-old man comes to the clinic for a routine follow-up. He has a 15-year history of type 2 diabetes mellitus and hypertension. His current medications include lisinopril, amlodipine, dapagliflozin, and insulin glargine. He feels well and reports no fatigue, nausea, vomiting, or pruritus. Blood pressure is 132/80 mm Hg and pulse is 72/min. Physical examination shows no lower extremity edema. Laboratory studies show: Hemoglobin 10.8 g/dL, Serum sodium 138 mEq/L, Serum potassium 4.9 mEq/L, Serum bicarbonate 20 mEq/L, Serum creatinine 2.8 mg/dL, Estimated glomerular filtration rate (eGFR) 24 mL/min/1.73 m2, Serum calcium 8.8 mg/dL, Serum phosphorus 4.2 mg/dL. Urine albumin-to-creatinine ratio is 850 mg/g. Which of the following is the most appropriate next step in the management of this patient's condition?
Initiation of sevelamer
Initiation of an erythropoiesis-stimulating agent
Referral for vascular access planning
Discontinuation of lisinopril
Initiation of maintenance hemodialysis
Show answer and explanation
Answer: Referral for vascular access planning
This patient has an estimated glomerular filtration rate (eGFR) of 24 mL/min/1.73 m2, which places him in Chronic Kidney Disease (CKD) Stage 4 (defined as an eGFR between 15 and 29 mL/min/1.73 m2). Clinical guidelines recommend that preparation for renal replacement therapy (RRT) should begin during CKD Stage 4. This includes comprehensive education about RRT modalities, timely nephrology referral, and referral to a vascular surgeon for vein mapping and arteriovenous fistula (AVF) placement. Creating an AVF early allows adequate time (often several months) for the fistula to mature before hemodialysis is required, thereby avoiding the need for a central venous catheter and its associated high risk of infection and thrombosis.
A 68-year-old man presents to the emergency department with a 90-minute history of severe, squeezing substernal chest pain that radiates to his jaw. He has a history of type 2 diabetes mellitus, hypertension, and hyperlipidemia. His current medications include metformin, lisinopril, and atorvastatin. On physical examination, he appears diaphoretic and anxious. His blood pressure is 155/92 mmHg, heart rate is 98/min, and respiratory rate is 18/min. Oxygen saturation is 98% on room air. An electrocardiogram reveals 2-mm ST-segment depressions in leads V4 through V6, with no ST-segment elevations. Initial high-sensitivity cardiac troponin I is significantly elevated. The patient is immediately given chewable aspirin and sublingual nitroglycerin, which mildly improve his symptoms. Which of the following is the most appropriate next step in the management of this patient?
Perform immediate synchronized cardioversion
Administer unfractionated heparin and a P2Y12 receptor blocker
Administer intravenous alteplase
Administer intravenous esmolol
Discharge home with a prescription for clopidogrel and arrange outpatient stress testing
Show answer and explanation
Answer: Administer unfractionated heparin and a P2Y12 receptor blocker
This patient is presenting with a non-ST-segment elevation myocardial infarction (NSTEMI), evidenced by ischemic symptoms, ST-segment depressions, and elevated cardiac biomarkers. The standard of care for NSTEMI includes anti-ischemic therapy, dual antiplatelet therapy (aspirin plus a P2Y12 inhibitor such as clopidogrel or ticagrelor), and systemic anticoagulation (such as unfractionated heparin, enoxaparin, or bivalirudin). This combination significantly reduces the risk of recurrent ischemic events and prepares the patient for an early invasive strategy (coronary angiography).
A 10-year-old boy is brought to the clinic by his mother due to dark, cola-colored urine and puffiness around his eyes that started yesterday. His mother mentions that 3 weeks ago he had a skin infection on his face characterized by honey-colored crusts, which resolved after treatment with topical mupirocin. His temperature is 37.1 C (98.8 F), blood pressure is 142/90 mm Hg, and pulse is 88/min. Physical examination shows periorbital edema and 1+ bilateral pitting edema of the lower extremities. Laboratory testing shows a blood urea nitrogen of 32 mg/dL and a serum creatinine of 1.3 mg/dL. Serum complement C3 levels are significantly decreased, while C4 levels are normal. Urinalysis reveals 3+ blood, 1+ protein, and the presence of red blood cell casts. Which of the following is most likely to be seen on renal biopsy in this patient?
Mesangial IgA immune complex deposits on immunofluorescence
Linear IgG deposition along the glomerular basement membrane
Normal light microscopy with diffuse podocyte foot process effacement
Thinning and longitudinal splitting of the glomerular basement membrane
Subepithelial electron-dense humps on electron microscopy
Show answer and explanation
Answer: Subepithelial electron-dense humps on electron microscopy
This patient has classic poststreptococcal glomerulonephritis (PSGN), presenting with nephritic syndrome (hematuria, red blood cell casts, hypertension, edema, and acute kidney injury) following a streptococcal skin infection (impetigo). PSGN typically occurs 2 to 4 weeks after impetigo or 1 to 2 weeks after streptococcal pharyngitis. It is characterized by decreased serum C3 levels and normal C4 levels due to activation of the alternative complement pathway. Although a renal biopsy is rarely needed for diagnosis in classic pediatric cases, it would show enlarged, hypercellular glomeruli on light microscopy, 'lumpy-bumpy' granular deposits of IgG and C3 on immunofluorescence, and characteristic subepithelial electron-dense humps on electron microscopy.
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Frequently Asked Questions
What is the passing score for Step 2 CK?
218, for exams taken on or after July 1, 2025. It was 214 before then. Scores are reported on a scale of 1 to 300.
What is the average Step 2 CK score?
250, with a standard deviation of 15, for first-time takers from US and Canadian MD schools who tested between July 2024 and June 2025. USMLE puts the measurement error at about 8 points, so a 245 and a 250 reflect very similar ability.
How long is Step 2 CK, and how many questions does it have?
About 316 questions in a single 9-hour session. Since May 7, 2026 the exam has 16 blocks of 30 minutes with up to 20 questions each, plus at least 55 minutes of break time. Before that it was eight 60-minute blocks.
What is the Step 2 CK pass rate?
For the July 2024 to June 2025 reporting year, 98% of first-time takers from US MD schools passed, along with 96% from US DO schools and 90% from schools outside the US.
What does Step 2 CK cover?
Internal medicine dominates at 55 to 65% of questions, followed by pediatrics (17 to 27%), obstetrics and gynecology (10 to 20%), psychiatry (10 to 15%), and surgery (5 to 15%). Most questions ask you to make a diagnosis, pick the right lab or imaging study, or choose the next step in management.
How much does Step 2 CK matter for residency?
A great deal, now that Step 1 is pass/fail. In the 2024 NRMP Program Director Survey, 83% of programs used the Step 2 score when deciding whom to interview. Some set a target score: 30% did for MD applicants, 22% for DO applicants, and 36% for international graduates.
Can I retake Step 2 CK to raise my score?
No. A passing score is permanent and goes on your transcript, so sit the exam when your practice scores are where you want them, not just above 218. If you fail, the usual USMLE limits apply: at most three attempts in 12 months and four in total.
How much does Step 2 CK cost?
$695 for exams in 2026 and 2027, plus a $235 region fee if you test outside the US and Canada. International applicants now register through FSMB rather than ECFMG. See the full USMLE cost breakdown.
How should I prepare for Step 2 CK?
Build on your clerkship shelf exams, then use dedicated study for timed 30-minute blocks that match the new format. CliniQuiz has more than 2,700 Step 2 CK vignettes focused on diagnosis and next best step, each with an explanation for every answer option. Our Step 2 CK guide has a full study plan.