A 71-year-old man with HTN and CAD develops sudden severe back pain; BP 200/115, unequal arm pressures, new diastolic murmur. Which diagnostic test should be performed next?
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USMLE Step 2 Quiz
Practice Hypertension And Vascular Disorders in USMLE Step 2 with focused quiz questions that help you check what you know, review explanations, and build confidence with test-style prompts.
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A 71-year-old man with HTN and CAD develops sudden severe back pain; BP 200/115, unequal arm pressures, new diastolic murmur. Which diagnostic test should be performed next?
This quiz focuses on Hypertension And Vascular Disorders, giving you a quick way to practice the rules, question types, and explanations that matter most for USMLE Step 2.
Try each quiz question before looking at the correct answer. Use the explanations to review missed ideas, then come back to similar questions until the pattern feels familiar.
A 71-year-old man with HTN and CAD develops sudden severe back pain; BP 200/115, unequal arm pressures, new diastolic murmur. Which diagnostic test should be performed next?
Explanation: This question tests knowledge of hypertension and vascular disorders relevant to USMLE Step 2 CK. Hypertension management involves accurate diagnosis, assessment of severity, and implementation of appropriate treatment strategies. In this scenario, the patient's presentation of sudden severe back pain, BP 200/115, unequal arm pressures, and new diastolic murmur indicate aortic dissection. The correct answer, A, is justified because CT angiography of the chest and abdomen confirms the diagnosis and extent of dissection in this vascular emergency. In contrast, B is incorrect due to MRI brain focusing on unrelated neurologic issues without addressing the aortic pathology. Effective teaching strategies include reinforcing the understanding of evidence-based guidelines for aortic disorders, emphasizing the importance of context-specific decision-making, and practicing the identification of vascular emergencies.
A 64-year-old man with sudden tearing chest pain has BP 210/120; CT confirms type B aortic dissection without malperfusion. What is the most appropriate next step in management?
Explanation: This question tests knowledge of hypertension and vascular disorders relevant to USMLE Step 2 CK. Hypertension management involves accurate diagnosis, assessment of severity, and implementation of appropriate treatment strategies. In this scenario, the patient's presentation of sudden tearing chest pain, BP 210/120, and type B aortic dissection without malperfusion indicate need for medical management. The correct answer, A, is justified because IV beta-blocker controls heart rate and BP to stabilize uncomplicated type B dissection per guidelines. In contrast, B is incorrect due to emergent surgery being reserved for complicated cases with malperfusion. Effective teaching strategies include reinforcing the understanding of evidence-based guidelines for aortic dissection, emphasizing the importance of context-specific decision-making, and practicing the identification of vascular emergencies.
A 66-year-old smoker with diabetes has nonhealing toe ulcer and rest pain; ABI 0.35, cool foot, weak pulses. What is the most appropriate next step in management?
Explanation: This question tests knowledge of hypertension and vascular disorders relevant to USMLE Step 2 CK. Hypertension management involves accurate diagnosis, assessment of severity, and implementation of appropriate treatment strategies. In this scenario, the patient's presentation of nonhealing toe ulcer, rest pain, ABI 0.35, cool foot, and weak pulses indicate critical limb ischemia in PAD. The correct answer, A, is justified because urgent vascular revascularization evaluation is needed to prevent tissue loss and amputation. In contrast, B is incorrect due to supervised walking being inappropriate for rest pain and severe ischemia. Effective teaching strategies include reinforcing the understanding of evidence-based guidelines for PAD, emphasizing the importance of context-specific decision-making, and practicing the identification of vascular disorders.
A 60-year-old man with HTN presents with sudden chest pain and neurologic deficits; BP 205/115, CXR widened mediastinum. Which diagnostic test should be performed next?
Explanation: This question tests knowledge of hypertension and vascular disorders relevant to USMLE Step 2 CK. Hypertension management involves accurate diagnosis, assessment of severity, and implementation of appropriate treatment strategies. In this scenario, the patient's presentation of sudden chest pain, neurologic deficits, BP 205/115, and widened mediastinum indicate aortic dissection with complications. The correct answer, A, is justified because CT angiography urgently confirms dissection and guides management in this emergency. In contrast, B is incorrect due to head CT alone missing the aortic pathology causing symptoms. Effective teaching strategies include reinforcing the understanding of evidence-based guidelines for aortic disorders, emphasizing the importance of context-specific decision-making, and practicing the identification of vascular emergencies.
A 58-year-old woman with long-standing HTN, CKD, and smoking presents with severe headache and blurred vision; BP 240/130, papilledema. What is the most appropriate next step in management?
Explanation: This question tests knowledge of hypertension and vascular disorders relevant to USMLE Step 2 CK. Hypertension management involves accurate diagnosis, assessment of severity, and implementation of appropriate treatment strategies. In this scenario, the patient's presentation of severe headache, blurred vision, BP 240/130, and papilledema indicate hypertensive emergency with end-organ damage. The correct answer, B, is justified because IV labetalol allows controlled BP reduction in an ICU setting to prevent further neurologic deterioration, aligning with guidelines for malignant hypertension. In contrast, A is incorrect due to using oral clonidine for discharge, which is inappropriate for acute end-organ involvement requiring inpatient monitoring. Effective teaching strategies include reinforcing the understanding of evidence-based guidelines for hypertensive crises, emphasizing the importance of context-specific decision-making, and practicing the identification of end-organ damage in hypertension.
A 55-year-old African American man is diagnosed with stage 1 hypertension during a routine health screening. His blood pressure is 145/92 mmHg on two separate occasions. He has no other medical conditions, and his laboratory results, including renal function and electrolytes, are within normal limits. He does not smoke and drinks alcohol socially. His BMI is 28 kg/m².
Which of the following is the most appropriate initial pharmacologic therapy for this patient?
Explanation: For initial monotherapy of uncomplicated hypertension in African American patients, current guidelines recommend either a thiazide-type diuretic or a long-acting dihydropyridine calcium channel blocker as first-line therapy. Both hydrochlorothiazide and amlodipine would be appropriate choices. ACE inhibitors and ARBs are generally less effective as monotherapy in this population. Beta-blockers are not considered first-line agents unless there is a specific indication.
A 62-year-old man with a history of poorly controlled hypertension is brought to the emergency department by his wife due to acute confusion and a severe headache that started 2 hours ago. His blood pressure is 230/135 mmHg. On examination, he is disoriented to time and place. Funduscopic examination reveals papilledema. There are no focal neurologic deficits. A non-contrast CT scan of the head shows no evidence of acute hemorrhage.
Which of the following is the most appropriate initial management for this patient's blood pressure?
Explanation: This patient has hypertensive encephalopathy, a hypertensive emergency characterized by severe hypertension and signs of cerebral edema (confusion, papilledema). The goal is to carefully lower the blood pressure to prevent further end-organ damage without causing cerebral hypoperfusion. The recommended approach is to lower the mean arterial pressure (MAP) by no more than 25% over the first few hours (or 10-20% in the first hour). Intravenous labetalol is an appropriate first-line agent. Rapid normalization of blood pressure with hydralazine or sublingual nifedipine is dangerous and can lead to ischemic stroke. Oral medications are inappropriate for a true emergency.
A 58-year-old man with a long-standing history of hypertension presents to the emergency department with the sudden onset of severe, tearing chest pain that radiates to his back between the scapulae. His blood pressure is 190/110 mmHg in the right arm and 165/95 mmHg in the left arm. Heart rate is 115/min. A diastolic murmur is heard at the right sternal border. The ECG shows sinus tachycardia with left ventricular hypertrophy.
Which of the following is the most immediate therapeutic goal in managing this patient?
Explanation: The clinical presentation is classic for an acute aortic dissection. The most critical initial step in medical management is to reduce aortic wall stress by decreasing heart rate and blood pressure. This limits the propagation of the dissection. The goal is to rapidly lower the heart rate to <60/min and the systolic blood pressure to 100-120 mmHg using intravenous beta-blockers (e.g., labetalol, esmolol) followed by a vasodilator (e.g., nitroprusside) if needed. Thrombolytics are contraindicated as they would be catastrophic. Pericardiocentesis is only for tamponade, and an IABP would worsen the dissection.
A 60-year-old man with a 10-year history of type 2 diabetes mellitus is found to have a blood pressure of 150/94 mmHg. A recent urinalysis shows a urine albumin-to-creatinine ratio of 150 mg/g (normal <30 mg/g). His serum creatinine is 1.1 mg/dL, and potassium is 4.5 mEq/L.
In addition to lifestyle modifications, which of the following medication classes is most appropriate for initial management of this patient's hypertension?
Explanation: This patient has hypertension with a compelling indication: diabetes mellitus with albuminuria. Angiotensin-converting enzyme (ACE) inhibitors or angiotensin II receptor blockers (ARBs) are the first-line antihypertensive agents in this population. They have been shown to slow the progression of diabetic nephropathy, independent of their blood pressure-lowering effect, by reducing intraglomerular pressure and proteinuria. While other agents may be needed to achieve blood pressure goals, an ACE inhibitor or ARB should be part of the initial regimen.
A 75-year-old woman with a history of atrial fibrillation (not on anticoagulation) and peripheral arterial disease is brought to the emergency department with a 3-hour history of sudden, severe pain in her left leg. The leg is cool to the touch, pale, and she is unable to move her foot. Palpation reveals absent dorsalis pedis and posterior tibial pulses on the left. Pulses on the right are present.
After confirming the diagnosis with Doppler ultrasound, which of the following is the most appropriate immediate step in management?
Explanation: This patient presents with acute limb ischemia, characterized by the '6 Ps' (pain, pallor, pulselessness, poikilothermia, paralysis, paresthesias). This is a vascular emergency. The most likely cause in this patient is an arterial embolism from her atrial fibrillation. The immediate management, while awaiting vascular surgery consultation for revascularization (e.g., thrombectomy or thrombolysis), is to start an intravenous heparin infusion. This prevents further propagation of the thrombus and thrombosis in the distal microvasculature. Delaying anticoagulation can worsen the ischemia.
An 80-year-old man with diffuse atherosclerosis and coronary artery disease presents with new-onset hypertension with blood pressures consistently around 170/95 mmHg. His physician starts him on lisinopril. Two weeks later, he returns complaining of dizziness. His blood pressure is 150/90 mmHg, but his serum creatinine has increased from a baseline of 1.0 mg/dL to 2.5 mg/dL. Physical examination reveals a right-sided upper abdominal bruit.
What is the most likely underlying cause of this patient's hypertension and acute kidney injury?
Explanation: The patient's presentation of new-onset, severe hypertension in an elderly individual with widespread atherosclerosis, an abdominal bruit, and a significant rise in creatinine after initiation of an ACE inhibitor is classic for atherosclerotic renal artery stenosis. In patients with significant bilateral stenosis (or stenosis in a solitary kidney), the glomerular filtration rate is dependent on angiotensin II-mediated efferent arteriole constriction. ACE inhibitors block this mechanism, leading to a precipitous drop in GFR and acute kidney injury. Fibromuscular dysplasia is a cause of RAS but typically presents in younger women.
A 70-year-old man undergoes a screening abdominal ultrasound as recommended for his age and smoking history. The study reveals an infrarenal abdominal aortic aneurysm with a maximum diameter of 4.6 cm. The patient is asymptomatic.
Which of the following is the most appropriate management for this finding?
Explanation: The management of asymptomatic abdominal aortic aneurysms (AAAs) is based on their size. Elective repair (either open or endovascular) is generally recommended when the aneurysm diameter reaches 5.5 cm in men, or if it is rapidly expanding (>0.5 cm in 6 months). For smaller aneurysms, such as the 4.6 cm one in this patient, the risk of rupture is low and is outweighed by the risks of surgery. Therefore, the standard of care is surveillance with serial imaging (typically ultrasound) every 6-12 months to monitor for expansion. Anticoagulation is not indicated and does not prevent aneurysm growth.
A 68-year-old man with hypertension, benign prostatic hyperplasia (BPH), and dyslipidemia is being evaluated for optimization of his medications. His current blood pressure is 155/95 mmHg on hydrochlorothiazide. He reports significant nocturia and a weak urinary stream.
Which of the following antihypertensive medications would be the most beneficial addition for this patient?
Explanation: This patient has both hypertension and symptomatic benign prostatic hyperplasia. Alpha-1 adrenergic blockers, such as doxazosin, prazosin, and terazosin, are effective antihypertensive agents that also relax the smooth muscle in the bladder neck and prostate, thereby improving urinary symptoms associated with BPH. This makes them an excellent choice for patients with both conditions. The other options would help with blood pressure but would not provide any benefit for his BPH symptoms.
A 60-year-old man presents to the emergency department with tearing chest pain radiating to the back. There is a 30 mmHg difference in systolic blood pressure between his arms. He is hemodynamically stable, with a blood pressure of 160/90 mmHg and a heart rate of 95/min. His serum creatinine is 1.0 mg/dL.
Which of the following is the most appropriate initial imaging study to confirm the suspected diagnosis?
Explanation: The clinical presentation is highly suspicious for acute aortic dissection. In a hemodynamically stable patient, CT angiography (CTA) is the imaging modality of choice. It is rapid, widely available, and highly sensitive and specific for diagnosing dissection, showing the intimal flap, and determining the extent of the dissection (e.g., Stanford type A vs. B). A chest X-ray may show a widened mediastinum but is not diagnostic. Transthoracic echo has low sensitivity for dissection. Transesophageal echo is also very sensitive and specific, but it is more invasive and is typically used for unstable patients who cannot be moved to the CT scanner or when CTA is contraindicated.
A 65-year-old woman with a history of hypertension is found to have bilateral renal artery stenosis on an MRA performed for other reasons. Her blood pressure is well-controlled at 130/80 mmHg on amlodipine. Her serum creatinine is 1.2 mg/dL.
Which of the following medication classes is absolutely contraindicated in this patient?
Explanation: In patients with bilateral renal artery stenosis, renal perfusion and glomerular filtration are highly dependent on the vasoconstrictive effect of angiotensin II on the efferent arterioles. The use of ACE inhibitors or angiotensin II receptor blockers (ARBs) will block this mechanism, leading to efferent arteriole dilation and a precipitous fall in GFR, which can cause acute renal failure. Therefore, ACE inhibitors and ARBs are contraindicated in patients with known significant bilateral renal artery stenosis. The other listed medication classes are safe to use.
A 50-year-old man presents with a blood pressure of 220/125 mmHg, blurry vision, and shortness of breath. Physical examination reveals bilateral rales on lung auscultation. A chest X-ray shows pulmonary edema. An ECG demonstrates left ventricular hypertrophy with strain pattern. Laboratory studies are notable for a troponin level of 0.8 ng/mL (normal <0.04 ng/mL).
Which of the following intravenous medications is most appropriate for this patient's condition?
Explanation: This patient has a hypertensive emergency with evidence of two forms of acute end-organ damage: acute heart failure (pulmonary edema) and myocardial ischemia (elevated troponin). In this specific setting, an intravenous vasodilator that reduces both preload and afterload is ideal. Intravenous nitroglycerin is the agent of choice as it is a potent venodilator, reducing preload and alleviating pulmonary edema, and also a coronary vasodilator, which helps with myocardial ischemia. While labetalol is often a first-line agent, its beta-blockade can worsen acute heart failure. Esmolol has the same issue. Hydralazine is an arterial vasodilator that can cause reflex tachycardia, which would be detrimental in the setting of myocardial ischemia.
A 38-year-old woman presents for evaluation of difficult-to-control hypertension. Her blood pressure has been consistently elevated above 150/95 mmHg despite adherence to a three-drug regimen including a thiazide diuretic, an ACE inhibitor, and a calcium channel blocker. She reports occasional muscle weakness and headaches. Her serum potassium is 3.1 mEq/L. She has no family history of early-onset hypertension. Body mass index is 26 kg/m². Physical examination is otherwise unremarkable.
Which of the following is the most appropriate next step to establish the diagnosis?
Explanation: This patient presents with resistant hypertension and spontaneous hypokalemia, which is highly suggestive of primary aldosteronism. The most appropriate initial screening test for primary aldosteronism is the plasma aldosterone concentration to plasma renin activity ratio. A high aldosterone level in the setting of suppressed renin activity is diagnostic. After screening, confirmatory testing and imaging are typically pursued.
A 67-year-old man with a 30-pack-year smoking history and type 2 diabetes mellitus presents with a 6-month history of cramping pain in his right calf. The pain occurs after walking two blocks and is consistently relieved by 2-3 minutes of rest. He has no pain at rest. Physical examination reveals diminished dorsalis pedis and posterior tibial pulses on the right. His ankle-brachial index is 0.65 on the right and 0.95 on the left.
In addition to aspirin and a statin, which of the following is the most appropriate initial intervention for this patient's primary complaint?
Explanation: This patient has classic symptoms of intermittent claudication due to peripheral arterial disease (PAD), confirmed by the low ankle-brachial index. The cornerstone of initial management for claudication is a structured, supervised exercise program. This has been shown to improve walking distance and quality of life. Medical management with risk factor modification (smoking cessation), antiplatelet therapy (aspirin), and a statin is also crucial. Invasive interventions like angioplasty or surgical bypass are reserved for patients with limb-threatening ischemia or debilitating symptoms refractory to conservative management.
A 45-year-old man with a history of cocaine use and nonadherence to antihypertensive medication presents with a blood pressure of 210/140 mmHg and acute, severe substernal chest pain. An ECG shows ST-segment elevations in the anterior leads. Troponin levels are markedly elevated. He is diaphoretic and in moderate respiratory distress.
This patient's condition is considered a hypertensive emergency. Which of the following medications should be specifically avoided in his initial management?
Explanation: This patient is presenting with a hypertensive emergency complicated by an acute myocardial infarction, likely precipitated by cocaine use. While beta-blockers are a cornerstone of MI therapy, they should be used with extreme caution or avoided in the setting of acute cocaine intoxication. Unopposed alpha-adrenergic stimulation from cocaine can lead to paradoxical hypertension and worsening coronary vasoconstriction if a pure beta-blocker is given. Labetalol has both alpha- and beta-blocking properties, but pure beta-blockade is the concern. A calcium channel blocker like nicardipine and a vasodilator like nitroglycerin are preferred for blood pressure and ischemia control in this specific scenario. Aspirin is indicated for the MI.
A 35-year-old woman is evaluated for new-onset hypertension, with recent blood pressure readings around 160/105 mmHg. Over the past year, she has gained 30 pounds, primarily in her abdomen. She also reports easy bruising and notes the appearance of wide, purplish stretch marks on her abdomen. Her fasting blood glucose is 135 mg/dL.
Which of the following is the best initial screening test for the suspected underlying condition?
Explanation: This patient's constellation of symptoms—central obesity, hypertension, hyperglycemia, easy bruising, and purple striae—is classic for Cushing's syndrome (hypercortisolism), which is a cause of secondary hypertension. The best initial screening tests to confirm hypercortisolism are a 24-hour urinary free cortisol measurement, a late-night salivary cortisol measurement, or a low-dose dexamethasone suppression test. An abdominal CT would be a subsequent step to localize the source (e.g., adrenal adenoma) if hypercortisolism is confirmed biochemically.