USMLE STEP 2 CK LATEST REVIEW
GUIDE 2026–2027 Featuring High-Yield
Clinical Cases, Practice Questions & Board
Exam Preparation
The Ultimate USMLE Step 2 CK Preparation Resource — 270 Exam-Quality
Questions with Detailed Rationales
Question 1
A 68-year-old man with a 40-pack-year smoking history presents to the emergency
department with acute onset substernal chest pressure that began 2 hours ago while
shoveling snow. The pain radiates to his left jaw and is associated with diaphoresis
and nausea. His initial ECG shows 2-mm ST-segment elevation in leads V1–V4.
His blood pressure is 145/90 mmHg, heart rate is 98 bpm, and oxygen saturation is
96% on room air. Which of the following is the most appropriate immediate
management?
A. Administer sublingual nitroglycerin and observe for 30 minutes.
B. Administer aspirin, oxygen, nitroglycerin, and arrange for emergent
percutaneous coronary intervention (PCI).
C. Administer thrombolytic therapy and admit to the medical intensive care unit.
D. Obtain a chest X-ray and serial troponins before initiating therapy.
Correct Answer: B
Rationale: This patient is presenting with an acute ST-elevation myocardial
infarction (STEMI) , as evidenced by ST-segment elevation in leads V1–V4
(anterior wall MI). The immediate management for STEMI is the MONA
protocol (Morphine, Oxygen, Nitroglycerin, Aspirin) followed by emergent
reperfusion therapy. The preferred reperfusion strategy is percutaneous
coronary intervention (PCI) if it can be performed within 90 minutes of first
medical contact. Option A is incorrect because observation without reperfusion is
,inappropriate for STEMI. Option C — thrombolytic therapy is indicated if PCI is
not available within 90 minutes, but PCI is preferred. Option D — delaying
therapy for a chest X-ray and serial troponins is inappropriate; treatment should not
be delayed.
Question 2
A 55-year-old woman with a history of hypertension and type 2 diabetes mellitus
presents with progressive dyspnea on exertion, orthopnea, and paroxysmal
nocturnal dyspnea over the past 3 weeks. On physical examination, she has jugular
venous distension, crackles at both lung bases, and 2+ pitting edema in her lower
extremities. An echocardiogram reveals an ejection fraction of 35%. Which of the
following medications has been shown to reduce mortality in patients with heart
failure with reduced ejection fraction (HFrEF)?
A. Digoxin
B. Carvedilol
C. Diltiazem
D. Hydralazine
Correct Answer: B
Rationale: Carvedilol is a beta-blocker that has been shown to reduce
mortality in patients with heart failure with reduced ejection fraction (HFrEF).
The core guideline-directed medical therapy (GDMT) for HFrEF includes beta-
blockers (carvedilol, metoprolol succinate, bisoprolol), ACE inhibitors/ARBs,
and mineralocorticoid receptor antagonists. Option A — digoxin reduces
hospitalizations but does not reduce mortality. Option C — diltiazem is a calcium
channel blocker that is contraindicated in HFrEF due to negative inotropic
effects. Option D — hydralazine in combination with nitrates has mortality benefit
in African American patients but is not first-line therapy.
Question 3
A 72-year-old man is brought to the emergency department by his wife because of
sudden onset of severe headache, nausea, and vomiting. His blood pressure is
210/120 mmHg. On neurological examination, he has no focal deficits. A non-
,contrast head CT shows no evidence of intracranial hemorrhage. Which of the
following is the most appropriate next step in management?
A. Administer IV labetalol to lower the blood pressure by 50% within 1 hour.
B. Administer IV sodium nitroprusside to achieve a target blood pressure of 140/90
mmHg.
C. Lower the blood pressure by 15–20% over the first hour using IV
antihypertensives.
D. Observe the patient without pharmacological intervention.
Correct Answer: C
Rationale: This patient is presenting with a hypertensive emergency (blood
pressure > 180/120 mmHg with evidence of end-organ damage, in this case severe
headache suggesting hypertensive encephalopathy). The goal in hypertensive
emergency is to reduce mean arterial pressure by no more than 20–25%
within the first hour, and then to a target of 160/100 mmHg over the next 2–6
hours. Option A is incorrect — a 50% reduction is too rapid and can cause
cerebral ischemia. Option B is incorrect — lowering to 140/90 mmHg too rapidly
is dangerous. Option D is incorrect — pharmacological intervention is indicated in
hypertensive emergency.
Question 4
A 45-year-old woman presents with palpitations, heat intolerance, and weight loss
despite increased appetite over the past 3 months. On examination, she has a fine
tremor, tachycardia, and a diffusely enlarged thyroid gland. Laboratory studies
reveal a suppressed TSH and elevated free T4. A thyroid scan shows diffusely
increased uptake. Which of the following is the most appropriate initial treatment?
A. Methimazole
B. Radioactive iodine ablation
C. Thyroidectomy
D. Propranolol alone
Correct Answer: A
, Rationale: This patient has Graves' disease (diffuse toxic goiter) presenting with
classic symptoms of hyperthyroidism. The most appropriate initial
treatment is methimazole, a thioamide that inhibits thyroid hormone
synthesis. Option B — radioactive iodine ablation is a definitive treatment but is
not first-line in younger patients due to the risk of hypothyroidism and may
exacerbate ophthalmopathy. Option C — thyroidectomy is reserved for patients
with large goiters, suspicious nodules, or contraindications to other
therapies. Option D — propranolol alone treats symptoms but does not address the
underlying hyperthyroidism.
Question 5
A 60-year-old man with a history of hypertension presents with a sudden onset of
severe, tearing chest pain that radiates to his back. His blood pressure is 180/100
mmHg in the right arm and 120/70 mmHg in the left arm. An ECG shows no
ischemic changes. A chest X-ray shows a widened mediastinum. Which of the
following is the most appropriate diagnostic test to confirm the diagnosis?
A. CT angiography of the chest
B. Transesophageal echocardiography
C. Magnetic resonance angiography
D. Aortography
Correct Answer: A
Rationale: This patient is presenting with classic findings of aortic dissection —
sudden, severe tearing chest pain radiating to the back, pulse deficit (differential
blood pressures between arms), and widened mediastinum on chest X-ray. CT
angiography of the chest is the diagnostic test of choice for aortic dissection due
to its high sensitivity and specificity, rapid availability, and ability to assess the
extent of dissection. Option B — transesophageal echocardiography is useful but
is more invasive and operator-dependent. Option C — MRA is less readily
available and takes longer. Option D — aortography is invasive and has been
largely replaced by CT angiography.
GUIDE 2026–2027 Featuring High-Yield
Clinical Cases, Practice Questions & Board
Exam Preparation
The Ultimate USMLE Step 2 CK Preparation Resource — 270 Exam-Quality
Questions with Detailed Rationales
Question 1
A 68-year-old man with a 40-pack-year smoking history presents to the emergency
department with acute onset substernal chest pressure that began 2 hours ago while
shoveling snow. The pain radiates to his left jaw and is associated with diaphoresis
and nausea. His initial ECG shows 2-mm ST-segment elevation in leads V1–V4.
His blood pressure is 145/90 mmHg, heart rate is 98 bpm, and oxygen saturation is
96% on room air. Which of the following is the most appropriate immediate
management?
A. Administer sublingual nitroglycerin and observe for 30 minutes.
B. Administer aspirin, oxygen, nitroglycerin, and arrange for emergent
percutaneous coronary intervention (PCI).
C. Administer thrombolytic therapy and admit to the medical intensive care unit.
D. Obtain a chest X-ray and serial troponins before initiating therapy.
Correct Answer: B
Rationale: This patient is presenting with an acute ST-elevation myocardial
infarction (STEMI) , as evidenced by ST-segment elevation in leads V1–V4
(anterior wall MI). The immediate management for STEMI is the MONA
protocol (Morphine, Oxygen, Nitroglycerin, Aspirin) followed by emergent
reperfusion therapy. The preferred reperfusion strategy is percutaneous
coronary intervention (PCI) if it can be performed within 90 minutes of first
medical contact. Option A is incorrect because observation without reperfusion is
,inappropriate for STEMI. Option C — thrombolytic therapy is indicated if PCI is
not available within 90 minutes, but PCI is preferred. Option D — delaying
therapy for a chest X-ray and serial troponins is inappropriate; treatment should not
be delayed.
Question 2
A 55-year-old woman with a history of hypertension and type 2 diabetes mellitus
presents with progressive dyspnea on exertion, orthopnea, and paroxysmal
nocturnal dyspnea over the past 3 weeks. On physical examination, she has jugular
venous distension, crackles at both lung bases, and 2+ pitting edema in her lower
extremities. An echocardiogram reveals an ejection fraction of 35%. Which of the
following medications has been shown to reduce mortality in patients with heart
failure with reduced ejection fraction (HFrEF)?
A. Digoxin
B. Carvedilol
C. Diltiazem
D. Hydralazine
Correct Answer: B
Rationale: Carvedilol is a beta-blocker that has been shown to reduce
mortality in patients with heart failure with reduced ejection fraction (HFrEF).
The core guideline-directed medical therapy (GDMT) for HFrEF includes beta-
blockers (carvedilol, metoprolol succinate, bisoprolol), ACE inhibitors/ARBs,
and mineralocorticoid receptor antagonists. Option A — digoxin reduces
hospitalizations but does not reduce mortality. Option C — diltiazem is a calcium
channel blocker that is contraindicated in HFrEF due to negative inotropic
effects. Option D — hydralazine in combination with nitrates has mortality benefit
in African American patients but is not first-line therapy.
Question 3
A 72-year-old man is brought to the emergency department by his wife because of
sudden onset of severe headache, nausea, and vomiting. His blood pressure is
210/120 mmHg. On neurological examination, he has no focal deficits. A non-
,contrast head CT shows no evidence of intracranial hemorrhage. Which of the
following is the most appropriate next step in management?
A. Administer IV labetalol to lower the blood pressure by 50% within 1 hour.
B. Administer IV sodium nitroprusside to achieve a target blood pressure of 140/90
mmHg.
C. Lower the blood pressure by 15–20% over the first hour using IV
antihypertensives.
D. Observe the patient without pharmacological intervention.
Correct Answer: C
Rationale: This patient is presenting with a hypertensive emergency (blood
pressure > 180/120 mmHg with evidence of end-organ damage, in this case severe
headache suggesting hypertensive encephalopathy). The goal in hypertensive
emergency is to reduce mean arterial pressure by no more than 20–25%
within the first hour, and then to a target of 160/100 mmHg over the next 2–6
hours. Option A is incorrect — a 50% reduction is too rapid and can cause
cerebral ischemia. Option B is incorrect — lowering to 140/90 mmHg too rapidly
is dangerous. Option D is incorrect — pharmacological intervention is indicated in
hypertensive emergency.
Question 4
A 45-year-old woman presents with palpitations, heat intolerance, and weight loss
despite increased appetite over the past 3 months. On examination, she has a fine
tremor, tachycardia, and a diffusely enlarged thyroid gland. Laboratory studies
reveal a suppressed TSH and elevated free T4. A thyroid scan shows diffusely
increased uptake. Which of the following is the most appropriate initial treatment?
A. Methimazole
B. Radioactive iodine ablation
C. Thyroidectomy
D. Propranolol alone
Correct Answer: A
, Rationale: This patient has Graves' disease (diffuse toxic goiter) presenting with
classic symptoms of hyperthyroidism. The most appropriate initial
treatment is methimazole, a thioamide that inhibits thyroid hormone
synthesis. Option B — radioactive iodine ablation is a definitive treatment but is
not first-line in younger patients due to the risk of hypothyroidism and may
exacerbate ophthalmopathy. Option C — thyroidectomy is reserved for patients
with large goiters, suspicious nodules, or contraindications to other
therapies. Option D — propranolol alone treats symptoms but does not address the
underlying hyperthyroidism.
Question 5
A 60-year-old man with a history of hypertension presents with a sudden onset of
severe, tearing chest pain that radiates to his back. His blood pressure is 180/100
mmHg in the right arm and 120/70 mmHg in the left arm. An ECG shows no
ischemic changes. A chest X-ray shows a widened mediastinum. Which of the
following is the most appropriate diagnostic test to confirm the diagnosis?
A. CT angiography of the chest
B. Transesophageal echocardiography
C. Magnetic resonance angiography
D. Aortography
Correct Answer: A
Rationale: This patient is presenting with classic findings of aortic dissection —
sudden, severe tearing chest pain radiating to the back, pulse deficit (differential
blood pressures between arms), and widened mediastinum on chest X-ray. CT
angiography of the chest is the diagnostic test of choice for aortic dissection due
to its high sensitivity and specificity, rapid availability, and ability to assess the
extent of dissection. Option B — transesophageal echocardiography is useful but
is more invasive and operator-dependent. Option C — MRA is less readily
available and takes longer. Option D — aortography is invasive and has been
largely replaced by CT angiography.
