United States Medical Licensing Examination
Step Two Clinical Knowledge (USMLE Step 2
CK) National Assessment Question Bank actual
update graded A+ Comprehensive
Advanced Clinical Knowledge Examination
Instructions
This examination consists of 150 multiple-choice questions designed to assess clinical
knowledge and decision-making skills essential for the provision of patient care under
supervision. Each question presents a clinical vignette followed by five answer options. Select
the single best answer. Questions cover Internal Medicine, Surgery, Pediatrics, Obstetrics &
Gynecology, Psychiatry, Emergency Medicine, Preventive Medicine, Ethics, and Biostatistics. The
examination emphasizes diagnosis, diagnostic studies, management, next best steps, and health
promotion.
QUESTIONS
Cardiovascular System
Question 1
A 68-year-old man with a 40-pack-year smoking history presents with progressive exertional
dyspnea and nonproductive cough over the past 4 months. Physical examination reveals jugular
venous distention, a right ventricular heave, and a loud P2. Echocardiography shows right
ventricular hypertrophy and moderate tricuspid regurgitation. Pulmonary function tests
demonstrate a reduced DLCO. Which of the following is the most likely underlying diagnosis?
A. Chronic obstructive pulmonary disease
B. Interstitial lung disease
C. Pulmonary arterial hypertension
D. Left-sided heart failure
E. Pulmonary embolism
,Correct Answer: C
Rationale: This patient presents with features of pulmonary hypertension: dyspnea, cough, right
ventricular hypertrophy, loud P2, and reduced DLCO. Pulmonary arterial hypertension is a
progressive disorder characterized by elevated pulmonary arterial pressure. COPD typically
shows obstructive pattern on PFTs. Interstitial lung disease would show restrictive pattern with
reduced lung volumes. Left-sided heart failure would show pulmonary congestion. Chronic PE is
a cause but less likely given the chronic progressive presentation without acute episodes.
Question 2
A 72-year-old woman with hypertension and type 2 diabetes mellitus presents to the
emergency department with acute-onset substernal chest pain radiating to her left arm,
associated with diaphoresis and nausea. ECG shows 2-mm ST-segment elevation in leads V1-V4.
Her blood pressure is 148/92 mm Hg, heart rate 96/min, and oxygen saturation 96% on room
air. Aspirin and sublingual nitroglycerin have been administered. Which of the following is the
most appropriate next step in management?
A. Immediate coronary angiography with percutaneous coronary intervention
B. Intravenous thrombolytic therapy
C. Emergent coronary artery bypass grafting
D. Intravenous beta-blocker therapy
E. Observation with serial cardiac enzymes
Correct Answer: A
Rationale: This patient has an acute ST-segment elevation myocardial infarction (STEMI)
involving the anterior wall. Primary percutaneous coronary intervention (PCI) is the treatment
of choice if it can be performed within 90 minutes of first medical contact. Thrombolytics are an
alternative if PCI is not available within 120 minutes. CABG is not emergent in the acute setting.
Beta-blockers are adjunctive therapy, not the primary intervention. Observation would be
inappropriate for an acute STEMI.
Question 3
A 55-year-old man with a history of hypertension is found to have a blood pressure of 158/96
mm Hg on three separate occasions. He has no symptoms. Laboratory studies show serum
creatinine 1.2 mg/dL, potassium 4.1 mEq/L, and glucose 98 mg/dL. Urinalysis is unremarkable.
,Which of the following is the most appropriate initial antihypertensive medication for this
patient?
A. Hydrochlorothiazide
B. Lisinopril
C. Amlodipine
D. Metoprolol
E. Spironolactone
Correct Answer: B
Rationale: For a patient with hypertension and no compelling indications, initial therapy can
include a thiazide diuretic, ACE inhibitor, ARB, or calcium channel blocker. However, ACE
inhibitors (lisinopril) are particularly appropriate given their renal protective effects and
favorable metabolic profile. Hydrochlorothiazide is also acceptable but less preferred in patients
with metabolic syndrome. Amlodipine is appropriate but ACE inhibitors have additional
benefits. Metoprolol is no longer first-line for uncomplicated hypertension. Spironolactone is
reserved for resistant hypertension or specific indications.
Question 4
A 45-year-old woman presents with palpitations, fatigue, and heat intolerance. She has lost 10
pounds over the past 3 months despite increased appetite. Physical examination reveals a fine
tremor, hyperreflexia, and a diffusely enlarged thyroid gland. Laboratory studies show TSH <0.01
mIU/L and free T4 3.8 ng/dL. Which of the following is the most appropriate initial treatment?
A. Radioactive iodine ablation
B. Methimazole
C. Propylthiouracil
D. Propranolol
E. Thyroidectomy
Correct Answer: D
Rationale: In a patient with hyperthyroidism (Graves' disease suspected), initial management
should address symptoms. Propranolol provides rapid symptomatic relief of adrenergic
symptoms such as tremor, palpitations, and tachycardia. Methimazole and propylthiouracil are
definitive treatments but take weeks to achieve euthyroidism. Radioactive iodine and
thyroidectomy are definitive but not initial. Propranolol is started first while awaiting the effects
of antithyroid medications.
, Question 5
A 62-year-old man with known heart failure with reduced ejection fraction (HFrEF) presents
with worsening dyspnea, orthopnea, and peripheral edema. His medications include lisinopril,
carvedilol, and furosemide. Echocardiography shows an ejection fraction of 30%. Which of the
following medication classes has been shown to improve mortality in HFrEF and should be
considered for this patient?
A. Calcium channel blockers
B. Digoxin
C. Spironolactone
D. Hydralazine and isosorbide dinitrate
E. Ivabradine
Correct Answer: C
Rationale: Spironolactone (a mineralocorticoid receptor antagonist) has been shown to reduce
mortality in patients with HFrEF (NYHA class III-IV) when added to standard therapy. Calcium
channel blockers (especially non-dihydropyridines) are generally avoided in HFrEF. Digoxin
improves symptoms but not mortality. Hydralazine/isosorbide dinitrate is beneficial in African
American patients but not first-line for all. Ivabradine is for patients in sinus rhythm with heart
rate >70 despite maximally tolerated beta-blocker therapy.
Respiratory System
Question 6
A 34-year-old woman with no significant medical history presents with episodic wheezing, chest
tightness, and shortness of breath that occurs at night and early morning. Symptoms improve
with albuterol. Spirometry shows a pre-bronchodilator FEV1/FVC ratio of 70% and FEV1 72% of
predicted. After albuterol administration, FEV1 increases to 88% of predicted. Which of the
following is the most appropriate next step in management?
A. Start low-dose inhaled corticosteroid
B. Start long-acting beta-agonist monotherapy
C. Start oral corticosteroid taper
D. Continue as-needed albuterol only
E. Start leukotriene receptor antagonist
Correct Answer: A
Step Two Clinical Knowledge (USMLE Step 2
CK) National Assessment Question Bank actual
update graded A+ Comprehensive
Advanced Clinical Knowledge Examination
Instructions
This examination consists of 150 multiple-choice questions designed to assess clinical
knowledge and decision-making skills essential for the provision of patient care under
supervision. Each question presents a clinical vignette followed by five answer options. Select
the single best answer. Questions cover Internal Medicine, Surgery, Pediatrics, Obstetrics &
Gynecology, Psychiatry, Emergency Medicine, Preventive Medicine, Ethics, and Biostatistics. The
examination emphasizes diagnosis, diagnostic studies, management, next best steps, and health
promotion.
QUESTIONS
Cardiovascular System
Question 1
A 68-year-old man with a 40-pack-year smoking history presents with progressive exertional
dyspnea and nonproductive cough over the past 4 months. Physical examination reveals jugular
venous distention, a right ventricular heave, and a loud P2. Echocardiography shows right
ventricular hypertrophy and moderate tricuspid regurgitation. Pulmonary function tests
demonstrate a reduced DLCO. Which of the following is the most likely underlying diagnosis?
A. Chronic obstructive pulmonary disease
B. Interstitial lung disease
C. Pulmonary arterial hypertension
D. Left-sided heart failure
E. Pulmonary embolism
,Correct Answer: C
Rationale: This patient presents with features of pulmonary hypertension: dyspnea, cough, right
ventricular hypertrophy, loud P2, and reduced DLCO. Pulmonary arterial hypertension is a
progressive disorder characterized by elevated pulmonary arterial pressure. COPD typically
shows obstructive pattern on PFTs. Interstitial lung disease would show restrictive pattern with
reduced lung volumes. Left-sided heart failure would show pulmonary congestion. Chronic PE is
a cause but less likely given the chronic progressive presentation without acute episodes.
Question 2
A 72-year-old woman with hypertension and type 2 diabetes mellitus presents to the
emergency department with acute-onset substernal chest pain radiating to her left arm,
associated with diaphoresis and nausea. ECG shows 2-mm ST-segment elevation in leads V1-V4.
Her blood pressure is 148/92 mm Hg, heart rate 96/min, and oxygen saturation 96% on room
air. Aspirin and sublingual nitroglycerin have been administered. Which of the following is the
most appropriate next step in management?
A. Immediate coronary angiography with percutaneous coronary intervention
B. Intravenous thrombolytic therapy
C. Emergent coronary artery bypass grafting
D. Intravenous beta-blocker therapy
E. Observation with serial cardiac enzymes
Correct Answer: A
Rationale: This patient has an acute ST-segment elevation myocardial infarction (STEMI)
involving the anterior wall. Primary percutaneous coronary intervention (PCI) is the treatment
of choice if it can be performed within 90 minutes of first medical contact. Thrombolytics are an
alternative if PCI is not available within 120 minutes. CABG is not emergent in the acute setting.
Beta-blockers are adjunctive therapy, not the primary intervention. Observation would be
inappropriate for an acute STEMI.
Question 3
A 55-year-old man with a history of hypertension is found to have a blood pressure of 158/96
mm Hg on three separate occasions. He has no symptoms. Laboratory studies show serum
creatinine 1.2 mg/dL, potassium 4.1 mEq/L, and glucose 98 mg/dL. Urinalysis is unremarkable.
,Which of the following is the most appropriate initial antihypertensive medication for this
patient?
A. Hydrochlorothiazide
B. Lisinopril
C. Amlodipine
D. Metoprolol
E. Spironolactone
Correct Answer: B
Rationale: For a patient with hypertension and no compelling indications, initial therapy can
include a thiazide diuretic, ACE inhibitor, ARB, or calcium channel blocker. However, ACE
inhibitors (lisinopril) are particularly appropriate given their renal protective effects and
favorable metabolic profile. Hydrochlorothiazide is also acceptable but less preferred in patients
with metabolic syndrome. Amlodipine is appropriate but ACE inhibitors have additional
benefits. Metoprolol is no longer first-line for uncomplicated hypertension. Spironolactone is
reserved for resistant hypertension or specific indications.
Question 4
A 45-year-old woman presents with palpitations, fatigue, and heat intolerance. She has lost 10
pounds over the past 3 months despite increased appetite. Physical examination reveals a fine
tremor, hyperreflexia, and a diffusely enlarged thyroid gland. Laboratory studies show TSH <0.01
mIU/L and free T4 3.8 ng/dL. Which of the following is the most appropriate initial treatment?
A. Radioactive iodine ablation
B. Methimazole
C. Propylthiouracil
D. Propranolol
E. Thyroidectomy
Correct Answer: D
Rationale: In a patient with hyperthyroidism (Graves' disease suspected), initial management
should address symptoms. Propranolol provides rapid symptomatic relief of adrenergic
symptoms such as tremor, palpitations, and tachycardia. Methimazole and propylthiouracil are
definitive treatments but take weeks to achieve euthyroidism. Radioactive iodine and
thyroidectomy are definitive but not initial. Propranolol is started first while awaiting the effects
of antithyroid medications.
, Question 5
A 62-year-old man with known heart failure with reduced ejection fraction (HFrEF) presents
with worsening dyspnea, orthopnea, and peripheral edema. His medications include lisinopril,
carvedilol, and furosemide. Echocardiography shows an ejection fraction of 30%. Which of the
following medication classes has been shown to improve mortality in HFrEF and should be
considered for this patient?
A. Calcium channel blockers
B. Digoxin
C. Spironolactone
D. Hydralazine and isosorbide dinitrate
E. Ivabradine
Correct Answer: C
Rationale: Spironolactone (a mineralocorticoid receptor antagonist) has been shown to reduce
mortality in patients with HFrEF (NYHA class III-IV) when added to standard therapy. Calcium
channel blockers (especially non-dihydropyridines) are generally avoided in HFrEF. Digoxin
improves symptoms but not mortality. Hydralazine/isosorbide dinitrate is beneficial in African
American patients but not first-line for all. Ivabradine is for patients in sinus rhythm with heart
rate >70 despite maximally tolerated beta-blocker therapy.
Respiratory System
Question 6
A 34-year-old woman with no significant medical history presents with episodic wheezing, chest
tightness, and shortness of breath that occurs at night and early morning. Symptoms improve
with albuterol. Spirometry shows a pre-bronchodilator FEV1/FVC ratio of 70% and FEV1 72% of
predicted. After albuterol administration, FEV1 increases to 88% of predicted. Which of the
following is the most appropriate next step in management?
A. Start low-dose inhaled corticosteroid
B. Start long-acting beta-agonist monotherapy
C. Start oral corticosteroid taper
D. Continue as-needed albuterol only
E. Start leukotriene receptor antagonist
Correct Answer: A
