1
Kaplan USMLE Step 2 CK Comprehensive Practice
Examination Advanced-Level Multiple-Choice
Questions with Detailed Rationales
SECTION 1: Internal Medicine – Cardiology (Questions 1–20)
Question 1
A 68-year-old man with a history of hypertension and type 2 diabetes presents to the
emergency department with acute-onset substernal chest pain radiating to his left arm,
accompanied by diaphoresis and nausea. His ECG shows ST-segment elevation in leads V1–V4.
His blood pressure is 110/70 mmHg, heart rate is 92 bpm, and oxygen saturation is 96% on
room air. Which of the following is the most appropriate initial management?
A. Aspirin 324 mg chewed, sublingual nitroglycerin, and primary percutaneous coronary
intervention (PCI)
B. Aspirin 81 mg, oxygen at 4 L/min, and intravenous morphine
C. Aspirin 324 mg chewed, intravenous heparin, and fibrinolytic therapy
D. Aspirin 324 mg chewed, sublingual nitroglycerin, and admission for medical management
CorreCt Answer: A
Rationale: This patient presents with an acute ST-segment elevation myocardial infarction
(STEMI) as evidenced by ST-segment elevation in leads V1–V4 (anterior wall MI). The most
appropriate initial management for STEMI includes aspirin 324 mg chewed, sublingual
nitroglycerin (if no contraindications), and immediate reperfusion therapy. Primary PCI is the
preferred reperfusion strategy if it can be performed within 90 minutes of first medical contact.
Fibrinolytic therapy is an alternative if PCI is not available within this time frame. Oxygen should
,2
be administered only if the patient is hypoxemic (SpO₂ < 90%), not routinely. Morphine should
be used cautiously and is no longer first-line for pain management in acute coronary syndrome.
Question 2
A 55-year-old woman with a history of hypertension presents with progressive shortness of
breath on exertion, orthopnea, and peripheral edema over the past 3 weeks. On examination,
she has jugular venous distension, crackles at both lung bases, and 2+ pitting edema in her
lower extremities. An echocardiogram shows a left ventricular ejection fraction of 35%. Which
of the following is the most appropriate initial medication regimen for this patient?
A. Lisinopril, furosemide, and metoprolol succinate
B. Digoxin, furosemide, and spironolactone
C. Hydralazine, isosorbide dinitrate, and furosemide
D. Amlodipine, furosemide, and carvedilol
CorreCt Answer: A
Rationale: This patient has heart failure with reduced ejection fraction (HFrEF). Guideline-
directed medical therapy includes an ACE inhibitor (lisinopril), a beta-blocker (metoprolol
succinate), and a diuretic (furosemide) for symptom management. This combination has been
shown to reduce mortality and hospitalizations. Digoxin is used for symptom control in patients
with persistent symptoms despite optimal therapy but is not first-line. Hydralazine and
isosorbide dinitrate are alternatives for patients who cannot tolerate ACE inhibitors/ARBs.
Amlodipine is not a first-line agent for HFrEF.
Question 3
A 72-year-old man with a history of atrial fibrillation presents to the emergency department
with sudden-onset right-sided weakness, facial droop, and difficulty speaking that began 2
hours ago. His NIH Stroke Scale score is 14. His INR is 1.2 (he has not taken his warfarin for 3
,3
days). A non-contrast head CT shows no evidence of hemorrhage. Which of the following is the
most appropriate management?
A. Administer intravenous alteplase (tPA) immediately
B. Administer intravenous heparin and admit for observation
C. Administer aspirin 325 mg and admit for stroke unit care
D. Perform mechanical thrombectomy
CorreCt Answer: A
Rationale: This patient presents with an acute ischemic stroke within the 4.5-hour window for
intravenous alteplase (tPA). The absence of hemorrhage on CT and an INR < 1.7 (indicating
subtherapeutic anticoagulation) make him a candidate for tPA. The NIH Stroke Scale score of 14
indicates moderate-to-severe stroke. Mechanical thrombectomy would be considered if there is
a large vessel occlusion but requires additional imaging; tPA should not be delayed while
awaiting this assessment. Aspirin alone is insufficient for acute stroke management in a tPA-
eligible patient.
Question 4
A 45-year-old woman presents with episodic palpitations, anxiety, and diaphoresis. During an
episode, her blood pressure is 180/100 mmHg and heart rate is 140 bpm. Between episodes,
she is asymptomatic with normal vital signs. Laboratory studies reveal elevated plasma
metanephrines. Which of the following is the most likely diagnosis?
A. Pheochromocytoma
B. Carcinoid syndrome
C. Hyperthyroidism
D. Panic disorder
CorreCt Answer: A
, 4
Rationale: The episodic nature of symptoms (palpitations, anxiety, diaphoresis, hypertension,
tachycardia) along with elevated plasma metanephrines is classic for pheochromocytoma, a
catecholamine-secreting tumor of the adrenal medulla. Carcinoid syndrome presents with
flushing, diarrhea, and wheezing. Hyperthyroidism causes persistent symptoms, not episodic.
Panic disorder would not explain the elevated metanephrines or hypertension.
Question 5
A 60-year-old man with a history of coronary artery disease presents with progressive dyspnea
on exertion and fatigue. On examination, he has a systolic ejection murmur at the right upper
sternal border that radiates to the carotids, with a delayed carotid upstroke. Echocardiography
reveals a peak aortic valve gradient of 55 mmHg and valve area of 0.8 cm². Which of the
following is the most appropriate management?
A. Medical management with diuretics and afterload reduction
B. Aortic valve replacement
C. Percutaneous balloon aortic valvuloplasty
D. Observation with annual echocardiography
CorreCt Answer: B
Rationale: This patient has severe aortic stenosis (peak gradient > 40 mmHg, valve area < 1.0
cm²) with symptoms (dyspnea, fatigue). Symptomatic severe aortic stenosis is a Class I
indication for aortic valve replacement (surgical or transcatheter). Medical management is
ineffective and does not improve survival. Balloon valvuloplasty provides only temporary relief
and is reserved for patients who are not candidates for surgery or as a bridge to surgery.
Observation is inappropriate for symptomatic severe aortic stenosis.
Question 6
A 28-year-old woman with no significant medical history presents with acute-onset sharp chest
pain that is worse with inspiration and improves when leaning forward. She reports a low-grade
Kaplan USMLE Step 2 CK Comprehensive Practice
Examination Advanced-Level Multiple-Choice
Questions with Detailed Rationales
SECTION 1: Internal Medicine – Cardiology (Questions 1–20)
Question 1
A 68-year-old man with a history of hypertension and type 2 diabetes presents to the
emergency department with acute-onset substernal chest pain radiating to his left arm,
accompanied by diaphoresis and nausea. His ECG shows ST-segment elevation in leads V1–V4.
His blood pressure is 110/70 mmHg, heart rate is 92 bpm, and oxygen saturation is 96% on
room air. Which of the following is the most appropriate initial management?
A. Aspirin 324 mg chewed, sublingual nitroglycerin, and primary percutaneous coronary
intervention (PCI)
B. Aspirin 81 mg, oxygen at 4 L/min, and intravenous morphine
C. Aspirin 324 mg chewed, intravenous heparin, and fibrinolytic therapy
D. Aspirin 324 mg chewed, sublingual nitroglycerin, and admission for medical management
CorreCt Answer: A
Rationale: This patient presents with an acute ST-segment elevation myocardial infarction
(STEMI) as evidenced by ST-segment elevation in leads V1–V4 (anterior wall MI). The most
appropriate initial management for STEMI includes aspirin 324 mg chewed, sublingual
nitroglycerin (if no contraindications), and immediate reperfusion therapy. Primary PCI is the
preferred reperfusion strategy if it can be performed within 90 minutes of first medical contact.
Fibrinolytic therapy is an alternative if PCI is not available within this time frame. Oxygen should
,2
be administered only if the patient is hypoxemic (SpO₂ < 90%), not routinely. Morphine should
be used cautiously and is no longer first-line for pain management in acute coronary syndrome.
Question 2
A 55-year-old woman with a history of hypertension presents with progressive shortness of
breath on exertion, orthopnea, and peripheral edema over the past 3 weeks. On examination,
she has jugular venous distension, crackles at both lung bases, and 2+ pitting edema in her
lower extremities. An echocardiogram shows a left ventricular ejection fraction of 35%. Which
of the following is the most appropriate initial medication regimen for this patient?
A. Lisinopril, furosemide, and metoprolol succinate
B. Digoxin, furosemide, and spironolactone
C. Hydralazine, isosorbide dinitrate, and furosemide
D. Amlodipine, furosemide, and carvedilol
CorreCt Answer: A
Rationale: This patient has heart failure with reduced ejection fraction (HFrEF). Guideline-
directed medical therapy includes an ACE inhibitor (lisinopril), a beta-blocker (metoprolol
succinate), and a diuretic (furosemide) for symptom management. This combination has been
shown to reduce mortality and hospitalizations. Digoxin is used for symptom control in patients
with persistent symptoms despite optimal therapy but is not first-line. Hydralazine and
isosorbide dinitrate are alternatives for patients who cannot tolerate ACE inhibitors/ARBs.
Amlodipine is not a first-line agent for HFrEF.
Question 3
A 72-year-old man with a history of atrial fibrillation presents to the emergency department
with sudden-onset right-sided weakness, facial droop, and difficulty speaking that began 2
hours ago. His NIH Stroke Scale score is 14. His INR is 1.2 (he has not taken his warfarin for 3
,3
days). A non-contrast head CT shows no evidence of hemorrhage. Which of the following is the
most appropriate management?
A. Administer intravenous alteplase (tPA) immediately
B. Administer intravenous heparin and admit for observation
C. Administer aspirin 325 mg and admit for stroke unit care
D. Perform mechanical thrombectomy
CorreCt Answer: A
Rationale: This patient presents with an acute ischemic stroke within the 4.5-hour window for
intravenous alteplase (tPA). The absence of hemorrhage on CT and an INR < 1.7 (indicating
subtherapeutic anticoagulation) make him a candidate for tPA. The NIH Stroke Scale score of 14
indicates moderate-to-severe stroke. Mechanical thrombectomy would be considered if there is
a large vessel occlusion but requires additional imaging; tPA should not be delayed while
awaiting this assessment. Aspirin alone is insufficient for acute stroke management in a tPA-
eligible patient.
Question 4
A 45-year-old woman presents with episodic palpitations, anxiety, and diaphoresis. During an
episode, her blood pressure is 180/100 mmHg and heart rate is 140 bpm. Between episodes,
she is asymptomatic with normal vital signs. Laboratory studies reveal elevated plasma
metanephrines. Which of the following is the most likely diagnosis?
A. Pheochromocytoma
B. Carcinoid syndrome
C. Hyperthyroidism
D. Panic disorder
CorreCt Answer: A
, 4
Rationale: The episodic nature of symptoms (palpitations, anxiety, diaphoresis, hypertension,
tachycardia) along with elevated plasma metanephrines is classic for pheochromocytoma, a
catecholamine-secreting tumor of the adrenal medulla. Carcinoid syndrome presents with
flushing, diarrhea, and wheezing. Hyperthyroidism causes persistent symptoms, not episodic.
Panic disorder would not explain the elevated metanephrines or hypertension.
Question 5
A 60-year-old man with a history of coronary artery disease presents with progressive dyspnea
on exertion and fatigue. On examination, he has a systolic ejection murmur at the right upper
sternal border that radiates to the carotids, with a delayed carotid upstroke. Echocardiography
reveals a peak aortic valve gradient of 55 mmHg and valve area of 0.8 cm². Which of the
following is the most appropriate management?
A. Medical management with diuretics and afterload reduction
B. Aortic valve replacement
C. Percutaneous balloon aortic valvuloplasty
D. Observation with annual echocardiography
CorreCt Answer: B
Rationale: This patient has severe aortic stenosis (peak gradient > 40 mmHg, valve area < 1.0
cm²) with symptoms (dyspnea, fatigue). Symptomatic severe aortic stenosis is a Class I
indication for aortic valve replacement (surgical or transcatheter). Medical management is
ineffective and does not improve survival. Balloon valvuloplasty provides only temporary relief
and is reserved for patients who are not candidates for surgery or as a bridge to surgery.
Observation is inappropriate for symptomatic severe aortic stenosis.
Question 6
A 28-year-old woman with no significant medical history presents with acute-onset sharp chest
pain that is worse with inspiration and improves when leaning forward. She reports a low-grade
