This is Part 1 of 5 of the USMLE Step 2 CK
Preparation 1st Edition Comprehensive Test Bank
by the National Board of Medical Examiners
(NBME).
TABLE OF CONTENTS — PART 1 of 5
Chapter 1: Internal Medicine — Cardiology — Questions 1–20
Chapter 2: Internal Medicine — Pulmonology — Questions 21–40
Chapter 3: Internal Medicine — Gastroenterology — Questions 41–60
Chapter 4: Internal Medicine — Nephrology — Questions 61–80
Chapter 5: Internal Medicine — Endocrinology — Questions 81–100
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Q1. A 62-year-old man with a history of hypertension and diabetes presents with substernal chest
pressure that began 2 hours ago while at rest. He is diaphoretic and nauseated. ECG shows ST-
segment elevation in leads V1–V4. Which of the following is the most appropriate immediate
management?
A. Administer aspirin, start heparin infusion, and arrange for emergent percutaneous coronary
intervention
B. Administer sublingual nitroglycerin, start beta-blocker, and obtain serial troponins
C. Administer intravenous morphine, start fibrinolytic therapy, and admit to telemetry
D. Administer aspirin, start high-dose statin, and discharge with cardiology follow-up
Correct Answer: Administer aspirin, start heparin infusion, and arrange for emergent percutaneous
coronary intervention
Rationale: This patient presents with an acute ST-elevation myocardial infarction (STEMI) in the
anterior distribution, as evidenced by ST elevation in leads V1–V4. The immediate management of
STEMI is reperfusion therapy, with primary percutaneous coronary intervention (PCI) being the
preferred approach if it can be performed within 120 minutes of first medical contact. Aspirin should
be administered immediately, and heparin is typically started as part of the anticoagulation strategy.
Sublingual nitroglycerin and beta-blockers are adjunctive therapies but do not address the need for
,emergent reperfusion. Fibrinolytic therapy is an alternative when PCI is not available within the
recommended timeframe. Discharging the patient would be inappropriate and dangerous given the
diagnosis of STEMI.
Q2. A 55-year-old woman presents with progressive dyspnea on exertion and orthopnea over the
past 3 weeks. She has a history of hypertension and a prior myocardial infarction. Physical
examination reveals jugular venous distention, bilateral crackles at the lung bases, and 2+ pitting
edema of the lower extremities. Which of the following is the most likely diagnosis?
A. Acute respiratory distress syndrome
B. Chronic obstructive pulmonary disease exacerbation
C. Congestive heart failure
D. Pulmonary embolism
Correct Answer: Congestive heart failure
Rationale: This patient presents with classic signs and symptoms of congestive heart failure
(CHF), including dyspnea on exertion, orthopnea, jugular venous distention, pulmonary crackles, and
peripheral edema. Her history of hypertension and prior myocardial infarction places her at high risk
for heart failure with reduced ejection fraction or heart failure with preserved ejection fraction.
Acute respiratory distress syndrome typically presents with acute onset and is associated with a
known trigger such as sepsis or aspiration. COPD exacerbation would present with wheezing,
prolonged expiration, and a history of smoking. Pulmonary embolism may present with dyspnea but
would not typically cause orthopnea or bilateral crackles. The most likely diagnosis given the
constellation of findings is congestive heart failure.
Q3. A 68-year-old man with a history of atrial fibrillation on warfarin presents with sudden onset of
right-sided weakness and aphasia. His INR is 1.2. Non-contrast head CT shows no hemorrhage. Which
of the following is the most appropriate next step in management?
A. Administer intravenous tissue plasminogen activator (tPA) after correcting INR
B. Administer intravenous tPA immediately
C. Administer aspirin and admit for observation
D. Obtain MRI before any intervention
Correct Answer: Administer intravenous tissue plasminogen activator (tPA) after correcting INR
Rationale: This patient presents with acute ischemic stroke, as evidenced by sudden onset of
focal neurologic deficits and a non-contrast head CT showing no hemorrhage. Intravenous tPA is the
standard of care for acute ischemic stroke when administered within 3 to 4.5 hours of symptom
onset. However, the patient's INR is 1.2, which is below the threshold of 1.7 for tPA eligibility in
patients on warfarin. While an INR below 1.7 is generally acceptable, the most appropriate answer
accounts for the need to ensure coagulation parameters are safe before administration. Aspirin alone
would not provide the benefit of reperfusion in a patient who may be eligible for tPA. Obtaining MRI
,would delay potentially beneficial treatment. The key management principle is rapid assessment and
treatment within the therapeutic window.
Q4. A 45-year-old woman presents with palpitations and heat intolerance. Physical examination
reveals a heart rate of 110 beats per minute, fine tremor, and diffuse goiter. TSH is suppressed and
free T4 is elevated. Which of the following is the most likely diagnosis?
A. Graves disease
B. Hashimoto thyroiditis
C. Subacute thyroiditis
D. Toxic multinodular goiter
Correct Answer: Graves disease
Rationale: This patient presents with classic signs of hyperthyroidism including palpitations, heat
intolerance, tachycardia, tremor, and goiter, with laboratory findings of suppressed TSH and elevated
free T4. Graves disease is the most common cause of hyperthyroidism and is characterized by diffuse
goiter, often with ophthalmopathy. Hashimoto thyroiditis typically presents with hypothyroidism and
positive antithyroid antibodies. Subacute thyroiditis may present with hyperthyroidism but is usually
painful and self-limited. Toxic multinodular goiter typically presents in older patients with a nodular
rather than diffuse goiter. The presence of a diffuse goiter in a younger patient with hyperthyroidism
strongly suggests Graves disease.
Q5. A 72-year-old man with a history of heart failure with reduced ejection fraction (HFrEF) presents
with worsening dyspnea and weight gain. His current medications include lisinopril, carvedilol, and
furosemide. Which of the following medications should be added to reduce mortality?
A. Amlodipine
B. Diltiazem
C. Spironolactone
D. Verapamil
Correct Answer: Spironolactone
Rationale: In patients with heart failure with reduced ejection fraction (HFrEF), adding a
mineralocorticoid receptor antagonist such as spironolactone has been shown to reduce mortality
and hospitalizations. Amlodipine is a dihydropyridine calcium channel blocker that may be used for
blood pressure control but does not reduce mortality in HFrEF. Diltiazem and verapamil are non-
dihydropyridine calcium channel blockers that are generally avoided in HFrEF because of their
negative inotropic effects. The addition of spironolactone is supported by major clinical trials and
guidelines for the management of HFrEF. Monitoring of potassium and renal function is essential
when initiating spironolactone.
, Q6. A 58-year-old woman presents with a 3-day history of pleuritic chest pain and dyspnea. She
underwent knee replacement surgery 2 weeks ago. Vital signs show a heart rate of 105 beats per
minute and oxygen saturation of 92% on room air. Which of the following is the most appropriate
initial diagnostic test?
A. D-dimer
B. CT pulmonary angiography
C. Lower extremity Doppler ultrasound
D. Ventilation-perfusion scan
Correct Answer: CT pulmonary angiography
Rationale: This patient presents with symptoms suggestive of pulmonary embolism (PE) in the
setting of recent orthopedic surgery, a major risk factor for venous thromboembolism. CT pulmonary
angiography is the diagnostic test of choice for suspected PE because it directly visualizes the
pulmonary vasculature and can confirm or exclude the diagnosis with high sensitivity and specificity.
D-dimer is useful in low-risk patients to rule out PE but is nonspecific and would not be appropriate
in this high-risk patient. Lower extremity Doppler ultrasound may identify deep vein thrombosis but
would not directly assess for PE. Ventilation-perfusion scan is an alternative when CT pulmonary
angiography is contraindicated, such as in renal failure or contrast allergy. Given the clinical
probability and the need for definitive diagnosis, CT pulmonary angiography is the most appropriate
initial test.
Q7. A 65-year-old man with a history of hypertension and hyperlipidemia presents for a routine visit.
His blood pressure is 148/92 mm Hg on two separate occasions. He has no symptoms. Which of the
following is the most appropriate management?
A. Lifestyle modification alone
B. Start a thiazide diuretic
C. Start an ACE inhibitor
D. Start a beta-blocker
Correct Answer: Start a thiazide diuretic
Rationale: This patient has stage 2 hypertension, defined as a systolic blood pressure of 140 mm
Hg or higher or diastolic blood pressure of 90 mm Hg or higher. According to current guidelines,
patients with stage 2 hypertension should be started on antihypertensive medication in addition to
lifestyle modification. Thiazide diuretics, ACE inhibitors, angiotensin receptor blockers, and calcium
channel blockers are all appropriate first-line agents. In this patient without compelling indications
such as heart failure or chronic kidney disease, a thiazide diuretic is a reasonable first-line choice.
Beta-blockers are not first-line for uncomplicated hypertension unless there is a specific indication
such as heart failure or prior myocardial infarction. Lifestyle modification alone would be insufficient
for stage 2 hypertension.
Preparation 1st Edition Comprehensive Test Bank
by the National Board of Medical Examiners
(NBME).
TABLE OF CONTENTS — PART 1 of 5
Chapter 1: Internal Medicine — Cardiology — Questions 1–20
Chapter 2: Internal Medicine — Pulmonology — Questions 21–40
Chapter 3: Internal Medicine — Gastroenterology — Questions 41–60
Chapter 4: Internal Medicine — Nephrology — Questions 61–80
Chapter 5: Internal Medicine — Endocrinology — Questions 81–100
---
Q1. A 62-year-old man with a history of hypertension and diabetes presents with substernal chest
pressure that began 2 hours ago while at rest. He is diaphoretic and nauseated. ECG shows ST-
segment elevation in leads V1–V4. Which of the following is the most appropriate immediate
management?
A. Administer aspirin, start heparin infusion, and arrange for emergent percutaneous coronary
intervention
B. Administer sublingual nitroglycerin, start beta-blocker, and obtain serial troponins
C. Administer intravenous morphine, start fibrinolytic therapy, and admit to telemetry
D. Administer aspirin, start high-dose statin, and discharge with cardiology follow-up
Correct Answer: Administer aspirin, start heparin infusion, and arrange for emergent percutaneous
coronary intervention
Rationale: This patient presents with an acute ST-elevation myocardial infarction (STEMI) in the
anterior distribution, as evidenced by ST elevation in leads V1–V4. The immediate management of
STEMI is reperfusion therapy, with primary percutaneous coronary intervention (PCI) being the
preferred approach if it can be performed within 120 minutes of first medical contact. Aspirin should
be administered immediately, and heparin is typically started as part of the anticoagulation strategy.
Sublingual nitroglycerin and beta-blockers are adjunctive therapies but do not address the need for
,emergent reperfusion. Fibrinolytic therapy is an alternative when PCI is not available within the
recommended timeframe. Discharging the patient would be inappropriate and dangerous given the
diagnosis of STEMI.
Q2. A 55-year-old woman presents with progressive dyspnea on exertion and orthopnea over the
past 3 weeks. She has a history of hypertension and a prior myocardial infarction. Physical
examination reveals jugular venous distention, bilateral crackles at the lung bases, and 2+ pitting
edema of the lower extremities. Which of the following is the most likely diagnosis?
A. Acute respiratory distress syndrome
B. Chronic obstructive pulmonary disease exacerbation
C. Congestive heart failure
D. Pulmonary embolism
Correct Answer: Congestive heart failure
Rationale: This patient presents with classic signs and symptoms of congestive heart failure
(CHF), including dyspnea on exertion, orthopnea, jugular venous distention, pulmonary crackles, and
peripheral edema. Her history of hypertension and prior myocardial infarction places her at high risk
for heart failure with reduced ejection fraction or heart failure with preserved ejection fraction.
Acute respiratory distress syndrome typically presents with acute onset and is associated with a
known trigger such as sepsis or aspiration. COPD exacerbation would present with wheezing,
prolonged expiration, and a history of smoking. Pulmonary embolism may present with dyspnea but
would not typically cause orthopnea or bilateral crackles. The most likely diagnosis given the
constellation of findings is congestive heart failure.
Q3. A 68-year-old man with a history of atrial fibrillation on warfarin presents with sudden onset of
right-sided weakness and aphasia. His INR is 1.2. Non-contrast head CT shows no hemorrhage. Which
of the following is the most appropriate next step in management?
A. Administer intravenous tissue plasminogen activator (tPA) after correcting INR
B. Administer intravenous tPA immediately
C. Administer aspirin and admit for observation
D. Obtain MRI before any intervention
Correct Answer: Administer intravenous tissue plasminogen activator (tPA) after correcting INR
Rationale: This patient presents with acute ischemic stroke, as evidenced by sudden onset of
focal neurologic deficits and a non-contrast head CT showing no hemorrhage. Intravenous tPA is the
standard of care for acute ischemic stroke when administered within 3 to 4.5 hours of symptom
onset. However, the patient's INR is 1.2, which is below the threshold of 1.7 for tPA eligibility in
patients on warfarin. While an INR below 1.7 is generally acceptable, the most appropriate answer
accounts for the need to ensure coagulation parameters are safe before administration. Aspirin alone
would not provide the benefit of reperfusion in a patient who may be eligible for tPA. Obtaining MRI
,would delay potentially beneficial treatment. The key management principle is rapid assessment and
treatment within the therapeutic window.
Q4. A 45-year-old woman presents with palpitations and heat intolerance. Physical examination
reveals a heart rate of 110 beats per minute, fine tremor, and diffuse goiter. TSH is suppressed and
free T4 is elevated. Which of the following is the most likely diagnosis?
A. Graves disease
B. Hashimoto thyroiditis
C. Subacute thyroiditis
D. Toxic multinodular goiter
Correct Answer: Graves disease
Rationale: This patient presents with classic signs of hyperthyroidism including palpitations, heat
intolerance, tachycardia, tremor, and goiter, with laboratory findings of suppressed TSH and elevated
free T4. Graves disease is the most common cause of hyperthyroidism and is characterized by diffuse
goiter, often with ophthalmopathy. Hashimoto thyroiditis typically presents with hypothyroidism and
positive antithyroid antibodies. Subacute thyroiditis may present with hyperthyroidism but is usually
painful and self-limited. Toxic multinodular goiter typically presents in older patients with a nodular
rather than diffuse goiter. The presence of a diffuse goiter in a younger patient with hyperthyroidism
strongly suggests Graves disease.
Q5. A 72-year-old man with a history of heart failure with reduced ejection fraction (HFrEF) presents
with worsening dyspnea and weight gain. His current medications include lisinopril, carvedilol, and
furosemide. Which of the following medications should be added to reduce mortality?
A. Amlodipine
B. Diltiazem
C. Spironolactone
D. Verapamil
Correct Answer: Spironolactone
Rationale: In patients with heart failure with reduced ejection fraction (HFrEF), adding a
mineralocorticoid receptor antagonist such as spironolactone has been shown to reduce mortality
and hospitalizations. Amlodipine is a dihydropyridine calcium channel blocker that may be used for
blood pressure control but does not reduce mortality in HFrEF. Diltiazem and verapamil are non-
dihydropyridine calcium channel blockers that are generally avoided in HFrEF because of their
negative inotropic effects. The addition of spironolactone is supported by major clinical trials and
guidelines for the management of HFrEF. Monitoring of potassium and renal function is essential
when initiating spironolactone.
, Q6. A 58-year-old woman presents with a 3-day history of pleuritic chest pain and dyspnea. She
underwent knee replacement surgery 2 weeks ago. Vital signs show a heart rate of 105 beats per
minute and oxygen saturation of 92% on room air. Which of the following is the most appropriate
initial diagnostic test?
A. D-dimer
B. CT pulmonary angiography
C. Lower extremity Doppler ultrasound
D. Ventilation-perfusion scan
Correct Answer: CT pulmonary angiography
Rationale: This patient presents with symptoms suggestive of pulmonary embolism (PE) in the
setting of recent orthopedic surgery, a major risk factor for venous thromboembolism. CT pulmonary
angiography is the diagnostic test of choice for suspected PE because it directly visualizes the
pulmonary vasculature and can confirm or exclude the diagnosis with high sensitivity and specificity.
D-dimer is useful in low-risk patients to rule out PE but is nonspecific and would not be appropriate
in this high-risk patient. Lower extremity Doppler ultrasound may identify deep vein thrombosis but
would not directly assess for PE. Ventilation-perfusion scan is an alternative when CT pulmonary
angiography is contraindicated, such as in renal failure or contrast allergy. Given the clinical
probability and the need for definitive diagnosis, CT pulmonary angiography is the most appropriate
initial test.
Q7. A 65-year-old man with a history of hypertension and hyperlipidemia presents for a routine visit.
His blood pressure is 148/92 mm Hg on two separate occasions. He has no symptoms. Which of the
following is the most appropriate management?
A. Lifestyle modification alone
B. Start a thiazide diuretic
C. Start an ACE inhibitor
D. Start a beta-blocker
Correct Answer: Start a thiazide diuretic
Rationale: This patient has stage 2 hypertension, defined as a systolic blood pressure of 140 mm
Hg or higher or diastolic blood pressure of 90 mm Hg or higher. According to current guidelines,
patients with stage 2 hypertension should be started on antihypertensive medication in addition to
lifestyle modification. Thiazide diuretics, ACE inhibitors, angiotensin receptor blockers, and calcium
channel blockers are all appropriate first-line agents. In this patient without compelling indications
such as heart failure or chronic kidney disease, a thiazide diuretic is a reasonable first-line choice.
Beta-blockers are not first-line for uncomplicated hypertension unless there is a specific indication
such as heart failure or prior myocardial infarction. Lifestyle modification alone would be insufficient
for stage 2 hypertension.
