STEP 2 CK NBME EXAM COMPLETE VERIFIED ANSWERS AND
QUESTIONS - MOST RECENT EDITION 2026/2027
USMLE STEP 2 CK TEST
Q1. A 65-year-old man presents with crushing chest pain radiating to the left arm,
diaphoresis, and nausea for 2 hours. ECG shows ST elevation in leads II, III, and
aVF. BP is 90/60 mmHg. The MOST appropriate next step is:
✔ ANSWER: A. IV fluids and emergent percutaneous coronary intervention
(PCI)
Explanation: This is an inferior STEMI (ST elevation in II, III, aVF = RCA
territory). The hypotension in inferior MI may reflect RV infarction; IV fluids are
critical before PCI. Avoid nitrates in RV infarction.
Q2. A 55-year-old woman with atrial fibrillation is on warfarin. She develops
sudden right hemiplegia and aphasia. CT head is negative for hemorrhage. What
is the next best step?
✔ ANSWER: A. IV tPA (alteplase) if INR ≤1.7 and within 4.5-hour window
Explanation: Acute ischemic stroke within 4.5 hours: give tPA after ruling out
hemorrhage and checking INR. INR must be ≤1.7 for tPA eligibility.
Q3. A 70-year-old man has increasing exertional dyspnea and a harsh systolic
ejection murmur at the right upper sternal border that radiates to the carotids.
Echo shows AVA 0.8 cm². What is the BEST management?
✔ ANSWER: A. Surgical aortic valve replacement (SAVR) or TAVR
Explanation: AVA <1.0 cm² = severe aortic stenosis. Symptomatic severe AS
requires valve replacement. TAVR is for high surgical risk patients; SAVR for
low-intermediate risk.
Q4. A 45-year-old man has a BP of 165/100 on three readings. Labs: K+ 3.0,
Na+ 146, bicarb 28, aldosterone/renin ratio >30. Best next step?
✔ ANSWER: A. CT adrenal to evaluate for adrenal adenoma
,Explanation: High aldosterone/renin ratio (>20-30) with hypokalemia and
metabolic alkalosis = primary hyperaldosteronism (Conn syndrome). CT adrenal
is next step after biochemical diagnosis.
Q5. A 60-year-old post-MI patient has an EF of 30%. He is on metoprolol and
aspirin. What additional medication reduces mortality the most?
✔ ANSWER: A. ACE inhibitor (e.g., lisinopril)
Explanation: Post-MI with reduced EF: ACE inhibitors reduce mortality by
reducing afterload and preventing ventricular remodeling. Add spironolactone if
EF still <35% with symptoms.
Q6. A 30-year-old woman has palpitations and an ECG showing delta waves,
short PR interval, and wide QRS. She develops rapid irregular wide-complex
tachycardia. What drug is CONTRAINDICATED?
✔ ANSWER: A. Adenosine (and digoxin, verapamil, beta-blockers)
Explanation: WPW with atrial fibrillation: AV nodal blockers (adenosine, digoxin,
verapamil, beta-blockers) are contraindicated as they may cause paradoxical
acceleration via accessory pathway. Use procainamide or DC cardioversion.
Q7. A 68-year-old man has progressive dyspnea, JVD, pulsus paradoxus of 18
mmHg, and muffled heart sounds. Echo shows pericardial effusion. What is the
next step?
✔ ANSWER: A. Emergent pericardiocentesis
Explanation: Beck's triad (JVD, hypotension, muffled sounds) + pulsus
paradoxus >10 = cardiac tamponade. Emergent pericardiocentesis is life-saving.
IV fluids as bridge.
Q8. A 72-year-old woman is found unresponsive. Monitor shows ventricular
fibrillation. What is the FIRST intervention?
✔ ANSWER: A. Immediate defibrillation (unsynchronized shock)
Explanation: VFib = shockable rhythm. Defibrillate immediately. Do not delay for
CPR first if a defibrillator is available. After shock: CPR 2 min, then reassess.
Q9. A patient with dilated cardiomyopathy (EF 25%) has dyspnea at rest (NYHA
IV). Currently on ACEI, beta-blocker, and furosemide. What should be added?
✔ ANSWER: A. Spironolactone (aldosterone antagonist)
Explanation: NYHA III-IV HFrEF: aldosterone antagonist
(spironolactone/eplerenone) reduces mortality. Check K+ before starting. Also
consider ARNI (sacubitril/valsartan) to replace ACEI.
,Q10. A 50-year-old man has BP 145/92 and protein of 300 mg/day on urinalysis.
He has no edema or other findings. Best first-line antihypertensive?
✔ ANSWER: A. ACE inhibitor or ARB
Explanation: Hypertension with proteinuria (even without diabetes) = ACEI or
ARB are nephroprotective first-line agents. They reduce intraglomerular pressure
and proteinuria.
Q11. A 65-year-old man with known CAD has stable angina. He is currently on
aspirin. What medication reduces anginal episodes and is the first-line anti-
anginal?
✔ ANSWER: A. Beta-blocker (e.g., metoprolol)
Explanation: Beta-blockers are first-line for stable angina (reduce O2 demand).
They also reduce mortality in CAD. Add long-acting nitrates or CCB if symptoms
persist.
Q12. A 78-year-old woman has a BP of 80/60, HR 38, and complete heart block
on ECG (P waves not conducting). She is symptomatic. Immediate
management?
✔ ANSWER: A. Transcutaneous pacing (then transvenous pacing) and atropine
1 mg IV
Explanation: Symptomatic complete heart block: immediate transcutaneous
pacing, atropine as bridge. Temporary transvenous pacing if no response.
Permanent pacemaker definitive treatment.
Q13. A 25-year-old woman has sudden severe chest pain with dyspnea. Echo
shows aortic regurgitation and CT shows aortic root dilation to 5.5 cm. She is tall
with long extremities and lens dislocation. What is the diagnosis and
management?
✔ ANSWER: A. Marfan syndrome — emergent surgical repair of aortic root
Explanation: Marfan syndrome with aortic root >5 cm (or >4.5 cm with rapid
expansion/family history) requires surgical repair. Beta-blockers reduce rate of
aortic dilation.
Q14. A 55-year-old man with hyperlipidemia has an LDL of 145 and is on
maximum statin dose. What is the next step to further lower LDL?
✔ ANSWER: A. Add ezetimibe
, Explanation: Ezetimibe inhibits intestinal cholesterol absorption and is added to
statin for further LDL reduction. PCSK9 inhibitors are reserved for very high-risk
patients with statin intolerance or inadequate response.
Q15. A 60-year-old with hypertension has a new murmur: holosystolic, loudest at
apex, radiating to axilla. He recently had a MI. Most likely diagnosis?
✔ ANSWER: A. Mitral regurgitation (papillary muscle dysfunction/rupture post-
MI)
Explanation: Post-MI mitral regurgitation from papillary muscle dysfunction
presents as holosystolic murmur at apex radiating to axilla. Complete rupture
causes sudden hemodynamic collapse. Echo confirms.
● PULMONOLOGY
Q16. A 30-year-old man with asthma uses his albuterol inhaler >2 times/week but
has no nighttime symptoms and normal FEV1. What is the correct classification
and treatment?
✔ ANSWER: A. Mild intermittent asthma — SABA (albuterol) PRN only, no
daily controller needed
Explanation: NHLBI classification: ≤2 days/week symptoms, no nighttime
awakening, FEV1 ≥80% = Mild Intermittent. Treatment = SABA PRN. Step up to
persistent if more frequent.
Q17. A 55-year-old smoker has FEV1/FVC of 0.60 post-bronchodilator and FEV1
55% predicted. How is COPD severity classified?
✔ ANSWER: A. GOLD Stage 2 (Moderate) — FEV1 50-79% predicted
Explanation: GOLD staging: FEV1/FVC <0.70 confirms obstruction. FEV1 50-
79% = GOLD 2 (Moderate). Management: LAMA, LABA, pulmonary rehab. Add
ICS if frequent exacerbations.
Q18. A 45-year-old woman returns from a long flight with sudden pleuritic chest
pain and dyspnea. HR 110, SpO2 91%. CXR is normal. What is the best next
diagnostic step?
✔ ANSWER: A. CT pulmonary angiography (CTPA)
Explanation: Hemodynamically stable patient with suspected PE: CTPA is the
gold standard. V/Q scan if contrast contraindicated. D-dimer only useful to RULE
OUT PE if low pretest probability (Wells score).
QUESTIONS - MOST RECENT EDITION 2026/2027
USMLE STEP 2 CK TEST
Q1. A 65-year-old man presents with crushing chest pain radiating to the left arm,
diaphoresis, and nausea for 2 hours. ECG shows ST elevation in leads II, III, and
aVF. BP is 90/60 mmHg. The MOST appropriate next step is:
✔ ANSWER: A. IV fluids and emergent percutaneous coronary intervention
(PCI)
Explanation: This is an inferior STEMI (ST elevation in II, III, aVF = RCA
territory). The hypotension in inferior MI may reflect RV infarction; IV fluids are
critical before PCI. Avoid nitrates in RV infarction.
Q2. A 55-year-old woman with atrial fibrillation is on warfarin. She develops
sudden right hemiplegia and aphasia. CT head is negative for hemorrhage. What
is the next best step?
✔ ANSWER: A. IV tPA (alteplase) if INR ≤1.7 and within 4.5-hour window
Explanation: Acute ischemic stroke within 4.5 hours: give tPA after ruling out
hemorrhage and checking INR. INR must be ≤1.7 for tPA eligibility.
Q3. A 70-year-old man has increasing exertional dyspnea and a harsh systolic
ejection murmur at the right upper sternal border that radiates to the carotids.
Echo shows AVA 0.8 cm². What is the BEST management?
✔ ANSWER: A. Surgical aortic valve replacement (SAVR) or TAVR
Explanation: AVA <1.0 cm² = severe aortic stenosis. Symptomatic severe AS
requires valve replacement. TAVR is for high surgical risk patients; SAVR for
low-intermediate risk.
Q4. A 45-year-old man has a BP of 165/100 on three readings. Labs: K+ 3.0,
Na+ 146, bicarb 28, aldosterone/renin ratio >30. Best next step?
✔ ANSWER: A. CT adrenal to evaluate for adrenal adenoma
,Explanation: High aldosterone/renin ratio (>20-30) with hypokalemia and
metabolic alkalosis = primary hyperaldosteronism (Conn syndrome). CT adrenal
is next step after biochemical diagnosis.
Q5. A 60-year-old post-MI patient has an EF of 30%. He is on metoprolol and
aspirin. What additional medication reduces mortality the most?
✔ ANSWER: A. ACE inhibitor (e.g., lisinopril)
Explanation: Post-MI with reduced EF: ACE inhibitors reduce mortality by
reducing afterload and preventing ventricular remodeling. Add spironolactone if
EF still <35% with symptoms.
Q6. A 30-year-old woman has palpitations and an ECG showing delta waves,
short PR interval, and wide QRS. She develops rapid irregular wide-complex
tachycardia. What drug is CONTRAINDICATED?
✔ ANSWER: A. Adenosine (and digoxin, verapamil, beta-blockers)
Explanation: WPW with atrial fibrillation: AV nodal blockers (adenosine, digoxin,
verapamil, beta-blockers) are contraindicated as they may cause paradoxical
acceleration via accessory pathway. Use procainamide or DC cardioversion.
Q7. A 68-year-old man has progressive dyspnea, JVD, pulsus paradoxus of 18
mmHg, and muffled heart sounds. Echo shows pericardial effusion. What is the
next step?
✔ ANSWER: A. Emergent pericardiocentesis
Explanation: Beck's triad (JVD, hypotension, muffled sounds) + pulsus
paradoxus >10 = cardiac tamponade. Emergent pericardiocentesis is life-saving.
IV fluids as bridge.
Q8. A 72-year-old woman is found unresponsive. Monitor shows ventricular
fibrillation. What is the FIRST intervention?
✔ ANSWER: A. Immediate defibrillation (unsynchronized shock)
Explanation: VFib = shockable rhythm. Defibrillate immediately. Do not delay for
CPR first if a defibrillator is available. After shock: CPR 2 min, then reassess.
Q9. A patient with dilated cardiomyopathy (EF 25%) has dyspnea at rest (NYHA
IV). Currently on ACEI, beta-blocker, and furosemide. What should be added?
✔ ANSWER: A. Spironolactone (aldosterone antagonist)
Explanation: NYHA III-IV HFrEF: aldosterone antagonist
(spironolactone/eplerenone) reduces mortality. Check K+ before starting. Also
consider ARNI (sacubitril/valsartan) to replace ACEI.
,Q10. A 50-year-old man has BP 145/92 and protein of 300 mg/day on urinalysis.
He has no edema or other findings. Best first-line antihypertensive?
✔ ANSWER: A. ACE inhibitor or ARB
Explanation: Hypertension with proteinuria (even without diabetes) = ACEI or
ARB are nephroprotective first-line agents. They reduce intraglomerular pressure
and proteinuria.
Q11. A 65-year-old man with known CAD has stable angina. He is currently on
aspirin. What medication reduces anginal episodes and is the first-line anti-
anginal?
✔ ANSWER: A. Beta-blocker (e.g., metoprolol)
Explanation: Beta-blockers are first-line for stable angina (reduce O2 demand).
They also reduce mortality in CAD. Add long-acting nitrates or CCB if symptoms
persist.
Q12. A 78-year-old woman has a BP of 80/60, HR 38, and complete heart block
on ECG (P waves not conducting). She is symptomatic. Immediate
management?
✔ ANSWER: A. Transcutaneous pacing (then transvenous pacing) and atropine
1 mg IV
Explanation: Symptomatic complete heart block: immediate transcutaneous
pacing, atropine as bridge. Temporary transvenous pacing if no response.
Permanent pacemaker definitive treatment.
Q13. A 25-year-old woman has sudden severe chest pain with dyspnea. Echo
shows aortic regurgitation and CT shows aortic root dilation to 5.5 cm. She is tall
with long extremities and lens dislocation. What is the diagnosis and
management?
✔ ANSWER: A. Marfan syndrome — emergent surgical repair of aortic root
Explanation: Marfan syndrome with aortic root >5 cm (or >4.5 cm with rapid
expansion/family history) requires surgical repair. Beta-blockers reduce rate of
aortic dilation.
Q14. A 55-year-old man with hyperlipidemia has an LDL of 145 and is on
maximum statin dose. What is the next step to further lower LDL?
✔ ANSWER: A. Add ezetimibe
, Explanation: Ezetimibe inhibits intestinal cholesterol absorption and is added to
statin for further LDL reduction. PCSK9 inhibitors are reserved for very high-risk
patients with statin intolerance or inadequate response.
Q15. A 60-year-old with hypertension has a new murmur: holosystolic, loudest at
apex, radiating to axilla. He recently had a MI. Most likely diagnosis?
✔ ANSWER: A. Mitral regurgitation (papillary muscle dysfunction/rupture post-
MI)
Explanation: Post-MI mitral regurgitation from papillary muscle dysfunction
presents as holosystolic murmur at apex radiating to axilla. Complete rupture
causes sudden hemodynamic collapse. Echo confirms.
● PULMONOLOGY
Q16. A 30-year-old man with asthma uses his albuterol inhaler >2 times/week but
has no nighttime symptoms and normal FEV1. What is the correct classification
and treatment?
✔ ANSWER: A. Mild intermittent asthma — SABA (albuterol) PRN only, no
daily controller needed
Explanation: NHLBI classification: ≤2 days/week symptoms, no nighttime
awakening, FEV1 ≥80% = Mild Intermittent. Treatment = SABA PRN. Step up to
persistent if more frequent.
Q17. A 55-year-old smoker has FEV1/FVC of 0.60 post-bronchodilator and FEV1
55% predicted. How is COPD severity classified?
✔ ANSWER: A. GOLD Stage 2 (Moderate) — FEV1 50-79% predicted
Explanation: GOLD staging: FEV1/FVC <0.70 confirms obstruction. FEV1 50-
79% = GOLD 2 (Moderate). Management: LAMA, LABA, pulmonary rehab. Add
ICS if frequent exacerbations.
Q18. A 45-year-old woman returns from a long flight with sudden pleuritic chest
pain and dyspnea. HR 110, SpO2 91%. CXR is normal. What is the best next
diagnostic step?
✔ ANSWER: A. CT pulmonary angiography (CTPA)
Explanation: Hemodynamically stable patient with suspected PE: CTPA is the
gold standard. V/Q scan if contrast contraindicated. D-dimer only useful to RULE
OUT PE if low pretest probability (Wells score).
