KAPLAN USMLE STEP 2 CK COMPREHENSIVE CLINICAL MASTERY
EXAMINATION Advanced Multiple-Choice Questions with
Detailed Evidence-Based Rationales
SECTION ONE: CARDIOLOGY (Questions 1-25)
1. A 62-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 is 8/10, radiates to the left arm, and is associated with diaphoresis
and nausea. ECG shows ST-segment elevation in leads V1-V4. His blood pressure is 145/90
mm Hg, heart rate 96 bpm, and oxygen saturation 96% on room air. Which of the following is
the most appropriate immediate management?
A. Sublingual nitroglycerin and observation
B. Intravenous thrombolytic therapy
C. Percutaneous coronary intervention (PCI) within 90 minutes
D. Oral aspirin and discharge with cardiology follow-up
E. Intravenous beta-blocker and telemetry monitoring
CorreCt Answer: C
,Rationale: This patient presents with an acute ST-segment elevation myocardial infarction
(STEMI) involving the anterior wall (leads V1-V4). For STEMI, percutaneous coronary
intervention (PCI) is the preferred reperfusion strategy if it can be performed within 90 minutes
of first medical contact. Aspirin should be given immediately, but PCI is the definitive treatment.
Thrombolytics are an alternative if PCI is not available within 90-120 minutes.
2. A 55-year-old woman with a history of hypertension presents with progressive dyspnea on
exertion and orthopnea. Physical examination reveals an S3 gallop, jugular venous distension,
and bilateral crackles at the lung bases. Echocardiography shows an ejection fraction of 30%.
Which medication has been shown to reduce mortality in this condition?
A. Digoxin
B. Hydralazine and isosorbide dinitrate
C. Spironolactone
D. Carvedilol
E. Amlodipine
CorreCt Answer: D
,Rationale: This patient has heart failure with reduced ejection fraction (HFrEF). Beta-blockers
(carvedilol, metoprolol succinate, bisoprolol) have been shown to reduce mortality in HFrEF.
Spironolactone also reduces mortality but is typically added later. Digoxin improves symptoms
but does not reduce mortality.
3. A 68-year-old man with a history of atrial fibrillation presents with sudden onset of severe,
sharp chest pain that radiates to his back. His blood pressure is 100/60 mm Hg in the right
arm and 85/50 mm Hg in the left arm. Which of the following is the most likely diagnosis?
A. Acute myocardial infarction
B. Pulmonary embolism
C. Aortic dissection
D. Pericarditis
E. Esophageal rupture
CorreCt Answer: C
Rationale: Aortic dissection classically presents with sudden, severe "tearing" chest pain
radiating to the back, with a pulse or blood pressure differential between arms. Risk factors
include hypertension and aortic root dilation. Immediate CT angiography is diagnostic.
, 4. A 45-year-old man presents with palpitations, lightheadedness, and shortness of breath.
ECG shows a narrow-complex tachycardia at 180 bpm with no visible P waves. Which of the
following is the most appropriate initial management for a hemodynamically stable patient?
A. Immediate synchronized cardioversion
B. Vagal maneuvers
C. Intravenous amiodarone
D. Intravenous adenosine
E. Oral beta-blocker
CorreCt Answer: D
Rationale: This patient has supraventricular tachycardia (SVT), likely AV nodal reentrant
tachycardia. For hemodynamically stable patients, adenosine is the first-line medication. Vagal
maneuvers can be attempted but are less reliable. Synchronized cardioversion is for unstable
patients.
EXAMINATION Advanced Multiple-Choice Questions with
Detailed Evidence-Based Rationales
SECTION ONE: CARDIOLOGY (Questions 1-25)
1. A 62-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 is 8/10, radiates to the left arm, and is associated with diaphoresis
and nausea. ECG shows ST-segment elevation in leads V1-V4. His blood pressure is 145/90
mm Hg, heart rate 96 bpm, and oxygen saturation 96% on room air. Which of the following is
the most appropriate immediate management?
A. Sublingual nitroglycerin and observation
B. Intravenous thrombolytic therapy
C. Percutaneous coronary intervention (PCI) within 90 minutes
D. Oral aspirin and discharge with cardiology follow-up
E. Intravenous beta-blocker and telemetry monitoring
CorreCt Answer: C
,Rationale: This patient presents with an acute ST-segment elevation myocardial infarction
(STEMI) involving the anterior wall (leads V1-V4). For STEMI, percutaneous coronary
intervention (PCI) is the preferred reperfusion strategy if it can be performed within 90 minutes
of first medical contact. Aspirin should be given immediately, but PCI is the definitive treatment.
Thrombolytics are an alternative if PCI is not available within 90-120 minutes.
2. A 55-year-old woman with a history of hypertension presents with progressive dyspnea on
exertion and orthopnea. Physical examination reveals an S3 gallop, jugular venous distension,
and bilateral crackles at the lung bases. Echocardiography shows an ejection fraction of 30%.
Which medication has been shown to reduce mortality in this condition?
A. Digoxin
B. Hydralazine and isosorbide dinitrate
C. Spironolactone
D. Carvedilol
E. Amlodipine
CorreCt Answer: D
,Rationale: This patient has heart failure with reduced ejection fraction (HFrEF). Beta-blockers
(carvedilol, metoprolol succinate, bisoprolol) have been shown to reduce mortality in HFrEF.
Spironolactone also reduces mortality but is typically added later. Digoxin improves symptoms
but does not reduce mortality.
3. A 68-year-old man with a history of atrial fibrillation presents with sudden onset of severe,
sharp chest pain that radiates to his back. His blood pressure is 100/60 mm Hg in the right
arm and 85/50 mm Hg in the left arm. Which of the following is the most likely diagnosis?
A. Acute myocardial infarction
B. Pulmonary embolism
C. Aortic dissection
D. Pericarditis
E. Esophageal rupture
CorreCt Answer: C
Rationale: Aortic dissection classically presents with sudden, severe "tearing" chest pain
radiating to the back, with a pulse or blood pressure differential between arms. Risk factors
include hypertension and aortic root dilation. Immediate CT angiography is diagnostic.
, 4. A 45-year-old man presents with palpitations, lightheadedness, and shortness of breath.
ECG shows a narrow-complex tachycardia at 180 bpm with no visible P waves. Which of the
following is the most appropriate initial management for a hemodynamically stable patient?
A. Immediate synchronized cardioversion
B. Vagal maneuvers
C. Intravenous amiodarone
D. Intravenous adenosine
E. Oral beta-blocker
CorreCt Answer: D
Rationale: This patient has supraventricular tachycardia (SVT), likely AV nodal reentrant
tachycardia. For hemodynamically stable patients, adenosine is the first-line medication. Vagal
maneuvers can be attempted but are less reliable. Synchronized cardioversion is for unstable
patients.
