USMLE STEP 2 CK EXAM 2026–2027 The Ultimate
Comprehensive Clinical Study Guide 320 Practice
Questions with Detailed Explanations & Exam Success
Strategies Aligned with the Latest NBME Content Outline &
Clinical Guidelines
SECTION 1: CARDIOVASCULAR SYSTEM (40 Questions)
1. A 68-year-old man with a history of hypertension and type 2 diabetes presents to
the emergency department with substernal chest pressure that began 2 hours ago
while shoveling snow. The pain radiates to his left arm and is associated with
diaphoresis and nausea. His ECG shows 2-mm ST-segment elevation in leads V1–V4.
His blood pressure is 110/70 mm Hg, heart rate 92 bpm, and oxygen saturation 96%
on room air. Which of the following is the most appropriate immediate management?
• A) Emergent percutaneous coronary intervention
• B) Intravenous thrombolytic therapy
• C) Sublingual nitroglycerin and observation
• D) Oral aspirin and discharge with outpatient cardiology follow-up
• E) Intravenous heparin and admission for medical management
2. A 55-year-old woman with a history of hypertension presents with progressive
shortness of breath on exertion and orthopnea. Physical examination reveals jugular
venous distention, crackles at the lung bases, and 2+ pitting edema in the lower
extremities. Echocardiography shows an ejection fraction of 30%. Which of the
following is the most appropriate initial pharmacotherapy?
• A) Angiotensin-converting enzyme inhibitor and beta-blocker
• B) Digoxin and furosemide
• C) Calcium channel blocker and hydralazine
• D) Spironolactone and dobutamine
, • E) Nitroglycerin and morphine
3. A 72-year-old man with a history of atrial fibrillation presents with sudden onset of
severe, tearing chest pain radiating to his back. His blood pressure is 180/110 mm Hg
in the right arm and 140/80 mm Hg in the left arm. Which of the following is the most
likely diagnosis?
• A) Aortic dissection
• B) Myocardial infarction
• C) Pulmonary embolism
• D) Pericarditis
• E) Esophageal rupture
4. A 45-year-old woman with no significant medical history presents with palpitations,
heat intolerance, and weight loss despite increased appetite. Physical examination
reveals a fine tremor and a diffusely enlarged thyroid gland. Her ECG shows atrial
fibrillation with a ventricular rate of 130 bpm. Which of the following is the most
appropriate initial management?
• A) Beta-blocker and methimazole
• B) Digoxin and warfarin
• C) Amiodarone and propylthiouracil
• D) Radioactive iodine ablation
• E) Cardioversion and aspirin
5. A 60-year-old man with a 40-pack-year smoking history presents with a 3-month
history of progressive dyspnea on exertion and a chronic cough productive of white
sputum. Physical examination reveals barrel-shaped chest, distant breath sounds,
and prolonged expiration. Pulmonary function tests show an FEV1/FVC ratio of 0.55.
Which of the following is the most appropriate next step in management?
• A) Smoking cessation counseling and inhaled bronchodilators
• B) Oral corticosteroids and antibiotics
• C) Chest CT scan and bronchoscopy
, • D) Oxygen therapy and pulmonary rehabilitation
• E) Lung volume reduction surgery
6. A 28-year-old woman with no significant medical history presents with acute onset
of sharp, pleuritic chest pain and shortness of breath. She recently returned from a
transatlantic flight 3 days ago. Her heart rate is 110 bpm, respiratory rate 24/min, and
oxygen saturation 92% on room air. Which of the following is the most appropriate
diagnostic test?
• A) CT pulmonary angiography
• B) D-dimer assay
• C) Ventilation-perfusion scan
• D) Chest X-ray
• E) ECG
7. A 75-year-old man with a history of coronary artery disease presents with
progressive dyspnea on exertion and lower extremity edema. Echocardiography
reveals severe aortic stenosis with a valve area of 0.8 cm². Which of the following is
the most appropriate management?
• A) Aortic valve replacement
• B) Balloon valvuloplasty
• C) Medical management with diuretics
• D) Antibiotic prophylaxis
• E) Transcatheter aortic valve replacement
8. A 50-year-old woman with a history of systemic lupus erythematosus presents with
chest pain that is worse when lying flat and improves when leaning forward. ECG
shows diffuse ST-segment elevation. Which of the following is the most likely
diagnosis?
• A) Pericarditis
• B) Myocardial infarction
, • C) Pulmonary embolism
• D) Aortic dissection
• E) Costochondritis
9. A 65-year-old man with a history of hypertension and hyperlipidemia presents with
a 2-week history of intermittent claudication in his right calf after walking one block.
His right ankle-brachial index is 0.65. Which of the following is the most appropriate
initial management?
• A) Supervised exercise program and statin therapy
• B) Peripheral artery bypass surgery
• C) Percutaneous transluminal angioplasty
• D) Warfarin and antiplatelet therapy
• E) Lumbar sympathectomy
10. A 32-year-old woman presents with palpitations, lightheadedness, and a
sensation of her heart "racing." ECG shows a regular, narrow-complex tachycardia at
180 bpm. Which of the following is the most appropriate initial management for a
hemodynamically stable patient?
• A) Vagal maneuvers
• B) Intravenous adenosine
• C) Synchronized cardioversion
• D) Intravenous amiodarone
• E) Oral beta-blockers
11. A 58-year-old man with a history of myocardial infarction 5 years ago presents
with progressive dyspnea on exertion and peripheral edema. Echocardiography
shows an ejection fraction of 25%. He is already on an ACE inhibitor, beta-blocker,
and furosemide. Which of the following medications should be added to his regimen?
• A) Spironolactone
• B) Digoxin
Comprehensive Clinical Study Guide 320 Practice
Questions with Detailed Explanations & Exam Success
Strategies Aligned with the Latest NBME Content Outline &
Clinical Guidelines
SECTION 1: CARDIOVASCULAR SYSTEM (40 Questions)
1. A 68-year-old man with a history of hypertension and type 2 diabetes presents to
the emergency department with substernal chest pressure that began 2 hours ago
while shoveling snow. The pain radiates to his left arm and is associated with
diaphoresis and nausea. His ECG shows 2-mm ST-segment elevation in leads V1–V4.
His blood pressure is 110/70 mm Hg, heart rate 92 bpm, and oxygen saturation 96%
on room air. Which of the following is the most appropriate immediate management?
• A) Emergent percutaneous coronary intervention
• B) Intravenous thrombolytic therapy
• C) Sublingual nitroglycerin and observation
• D) Oral aspirin and discharge with outpatient cardiology follow-up
• E) Intravenous heparin and admission for medical management
2. A 55-year-old woman with a history of hypertension presents with progressive
shortness of breath on exertion and orthopnea. Physical examination reveals jugular
venous distention, crackles at the lung bases, and 2+ pitting edema in the lower
extremities. Echocardiography shows an ejection fraction of 30%. Which of the
following is the most appropriate initial pharmacotherapy?
• A) Angiotensin-converting enzyme inhibitor and beta-blocker
• B) Digoxin and furosemide
• C) Calcium channel blocker and hydralazine
• D) Spironolactone and dobutamine
, • E) Nitroglycerin and morphine
3. A 72-year-old man with a history of atrial fibrillation presents with sudden onset of
severe, tearing chest pain radiating to his back. His blood pressure is 180/110 mm Hg
in the right arm and 140/80 mm Hg in the left arm. Which of the following is the most
likely diagnosis?
• A) Aortic dissection
• B) Myocardial infarction
• C) Pulmonary embolism
• D) Pericarditis
• E) Esophageal rupture
4. A 45-year-old woman with no significant medical history presents with palpitations,
heat intolerance, and weight loss despite increased appetite. Physical examination
reveals a fine tremor and a diffusely enlarged thyroid gland. Her ECG shows atrial
fibrillation with a ventricular rate of 130 bpm. Which of the following is the most
appropriate initial management?
• A) Beta-blocker and methimazole
• B) Digoxin and warfarin
• C) Amiodarone and propylthiouracil
• D) Radioactive iodine ablation
• E) Cardioversion and aspirin
5. A 60-year-old man with a 40-pack-year smoking history presents with a 3-month
history of progressive dyspnea on exertion and a chronic cough productive of white
sputum. Physical examination reveals barrel-shaped chest, distant breath sounds,
and prolonged expiration. Pulmonary function tests show an FEV1/FVC ratio of 0.55.
Which of the following is the most appropriate next step in management?
• A) Smoking cessation counseling and inhaled bronchodilators
• B) Oral corticosteroids and antibiotics
• C) Chest CT scan and bronchoscopy
, • D) Oxygen therapy and pulmonary rehabilitation
• E) Lung volume reduction surgery
6. A 28-year-old woman with no significant medical history presents with acute onset
of sharp, pleuritic chest pain and shortness of breath. She recently returned from a
transatlantic flight 3 days ago. Her heart rate is 110 bpm, respiratory rate 24/min, and
oxygen saturation 92% on room air. Which of the following is the most appropriate
diagnostic test?
• A) CT pulmonary angiography
• B) D-dimer assay
• C) Ventilation-perfusion scan
• D) Chest X-ray
• E) ECG
7. A 75-year-old man with a history of coronary artery disease presents with
progressive dyspnea on exertion and lower extremity edema. Echocardiography
reveals severe aortic stenosis with a valve area of 0.8 cm². Which of the following is
the most appropriate management?
• A) Aortic valve replacement
• B) Balloon valvuloplasty
• C) Medical management with diuretics
• D) Antibiotic prophylaxis
• E) Transcatheter aortic valve replacement
8. A 50-year-old woman with a history of systemic lupus erythematosus presents with
chest pain that is worse when lying flat and improves when leaning forward. ECG
shows diffuse ST-segment elevation. Which of the following is the most likely
diagnosis?
• A) Pericarditis
• B) Myocardial infarction
, • C) Pulmonary embolism
• D) Aortic dissection
• E) Costochondritis
9. A 65-year-old man with a history of hypertension and hyperlipidemia presents with
a 2-week history of intermittent claudication in his right calf after walking one block.
His right ankle-brachial index is 0.65. Which of the following is the most appropriate
initial management?
• A) Supervised exercise program and statin therapy
• B) Peripheral artery bypass surgery
• C) Percutaneous transluminal angioplasty
• D) Warfarin and antiplatelet therapy
• E) Lumbar sympathectomy
10. A 32-year-old woman presents with palpitations, lightheadedness, and a
sensation of her heart "racing." ECG shows a regular, narrow-complex tachycardia at
180 bpm. Which of the following is the most appropriate initial management for a
hemodynamically stable patient?
• A) Vagal maneuvers
• B) Intravenous adenosine
• C) Synchronized cardioversion
• D) Intravenous amiodarone
• E) Oral beta-blockers
11. A 58-year-old man with a history of myocardial infarction 5 years ago presents
with progressive dyspnea on exertion and peripheral edema. Echocardiography
shows an ejection fraction of 25%. He is already on an ACE inhibitor, beta-blocker,
and furosemide. Which of the following medications should be added to his regimen?
• A) Spironolactone
• B) Digoxin
