USMLE Step 1: Clinical Case Questions

USMLE Step 1 clinical case questions are distinguished by a fairly lengthy presentation of a patient’s history, physical exam findings, and maybe even lab results. Your task is to read through this detailed information and arrive at the best answer to the question being asked.

Clinical Case Question Traps

The most important part of the clinical case question is the last sentence. This is the sentence that actually poses the question. Until this point, you cannot be sure exactly what you will be asked. Many students are tempted to simply skip to this last line, and then skim the case looking for necessary information to formulate an answer. Generally, this is not the best strategy.
Clinical case questions are often constructed by first writing a classic case, and then including one or two extra details. These details, by themselves, may suggest one or the other of the given answer options. To answer these questions correctly, you must read the whole case and treat all the information given as a whole. The total gestalt of the case is what is crucial, not any one individual fact.

Kaplan Expert Tip

You need to understand the case as a whole to avoid fixating on single pieces of information that lead to a wrong answer choice.

Question writers know that because of the length of the questions, candidates do not want to read the whole question if they can help it. They know that some test takers are scanning for that one critical piece of information. Because of this, single pieces of information may lead you away from the right answer to one of the incorrect distractors. Avoid this trap. You need to focus on the meaning of the case as a whole, not any one piece of it.

When reading through the case, choose what is important. Paraphrase the question and note key factors and symptoms as they are presented. This will help you remember them when formulating your answer. Then select the answer that best matches not some but all of the facts presented.

Clincal Case Practice Question 1

A 24-year-old woman presents with a fever and myalgias. She experienced brief, self-limited diarrhea 24 hours after attending a barbecue two weeks earlier. She remained asymptomatic until the day prior to presentation when she developed a fever of 39.4 C (103 F), conjunctivitis, and severe muscle pain. On physical examination she appears acutely ill and has a fever of 39.4 C. There is a diffuse maculopapular rash and generalized muscular tenderness. Several hemorrhages are noted beneath the fingernails. Admission hemogram reveals a white blood cell count of 15,000/mm3 with 25 percent eosinophils. The infectious form of the most likely causative agent is a(n)
(A) cyst
(B) cysticerci
(C) encysted larvae
(D) ovum
(E) rhabditiform larvae

The correct answer is C, encysted larvae.

Clincal Case Practice Question 2

A pair of brothers (35 and 38 years old) present with fairly dramatic pneumonias. On lung exam, rales are easily heard. Chest x-rays of both men reveal bilateral and diffuse infiltrates. The brothers spent a day together two weeks ago hiking in a mountainous area of Virginia where they entered a dusty cave. The most likely causative agent is
(A) Blastomyces dermatitidis
(B) Chlamydia trachomatis
(C) Coccidioides immitis
(D) Coxsackie A virus
(E) Haemophilus ducreyi
(F) Haemophilus influenzae
(G) Histoplasma capsulatum
(H) Influenza B virus
(I) Neisseria gonorrhoeae
(J) Neisseria meningitidis
(K) Streptococcus pyogenes

The correct answer is G, histoplasma capsulatum.


Clinical Case Question Strategy

Some test takers find these questions with a large number of options to be anxiety producing. They need not be. Some examinees feel that questions with many options are easier and actually take less time to do. The real danger with these types of questions is that students will waste too much time reading back and forth through the list of options.
The correct method of approaching these questions is to think of an answer, look for that answer, and then pick it. If none of the options look appealing, then take a guess and move to the next question. This is the same strategy we recommend for all questions, but it is most critical when there are a large number of options.
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