USMLE Step 2 Quiz
Practice Pulmonary Vascular Disease 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 65-year-old woman has sudden dyspnea and pleuritic chest pain shortly after a long flight. PMH: osteoarthritis. Meds: naproxen. Vitals: HR 118, BP 132/78, RR 26, SpO2 89% room air. Exam: clear lungs, tachycardia, mild unilateral calf tenderness. Labs: D-dimer elevated. CTPA demonstrates a lobar PE with mild right ventricular enlargement; troponin is slightly elevated. She remains normotensive.
Which of the following is the most appropriate next step in management?
This quiz focuses on Pulmonary Vascular Disease, 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 65-year-old woman has sudden dyspnea and pleuritic chest pain shortly after a long flight. PMH: osteoarthritis. Meds: naproxen. Vitals: HR 118, BP 132/78, RR 26, SpO2 89% room air. Exam: clear lungs, tachycardia, mild unilateral calf tenderness. Labs: D-dimer elevated. CTPA demonstrates a lobar PE with mild right ventricular enlargement; troponin is slightly elevated. She remains normotensive.
Which of the following is the most appropriate next step in management?
Explanation: This question tests USMLE Step 2 CK skills in understanding Pulmonary Vascular Disease and its management. Pulmonary Vascular Disease includes conditions like pulmonary embolism and hypertension, requiring specific diagnostic and management strategies. In this scenario, the vignette provides clinical clues such as post-flight dyspnea and lobar PE with mild RV enlargement, which suggest intermediate-risk pulmonary embolism. Choice B is correct because it aligns with the guideline to anticoagulate and monitor stable patients based on clinical stability. Choice A is incorrect because it fails to address the absence of shock, often leading to overtreatment with thrombolysis. Teaching strategies include emphasizing the importance of recognizing key clinical signs of pulmonary vascular disorders and applying evidence-based management protocols. Encourage practice with differential diagnosis and appropriate test selection.
A 50-year-old woman with prior DVT has suspected CTEPH based on V/Q mismatch and elevated PASP on echo. Meds: none. Exam: loud P2, RV heave. She asks what therapy offers potential cure rather than symptom control.
Which of the following is the most appropriate next step in management?
Explanation: This question tests USMLE Step 2 CK skills in understanding Pulmonary Vascular Disease and its management. Pulmonary Vascular Disease includes conditions like pulmonary embolism and hypertension, requiring specific diagnostic and management strategies. In this scenario, the vignette provides clinical clues such as prior DVT and V/Q mismatches suggesting CTEPH, which suggest potential for surgical cure. Choice A is correct because it aligns with the guideline to refer for PTE evaluation in operable CTEPH. Choice B is incorrect because it fails to address the thromboembolic cause, often leading to infectious misdiagnosis. Teaching strategies include emphasizing the importance of recognizing key clinical signs of pulmonary vascular disorders and applying evidence-based management protocols. Encourage practice with differential diagnosis and appropriate test selection.
A 65-year-old woman has sudden dyspnea after a long flight. D-dimer is elevated. CTPA shows PE. PMH: prior GI bleed 2 weeks ago requiring transfusion. Meds: pantoprazole. She is stable but high bleeding risk.
Which of the following is the most appropriate next step in management?
Explanation: This question tests USMLE Step 2 CK skills in understanding Pulmonary Vascular Disease and its management. Pulmonary Vascular Disease includes conditions like pulmonary embolism and hypertension, requiring specific diagnostic and management strategies. In this scenario, the vignette provides clinical clues such as post-flight PE with recent GI bleed, which suggest high bleeding risk. Choice A is correct because it aligns with the guideline to place IVC filter when anticoagulation is contraindicated. Choice B is incorrect because it fails to address bleeding risk, often leading to avoidance of necessary prevention. Teaching strategies include emphasizing the importance of recognizing key clinical signs of pulmonary vascular disorders and applying evidence-based management protocols. Encourage practice with differential diagnosis and appropriate test selection.
A 28-year-old woman presents to the emergency department with a sudden onset of sharp, right-sided pleuritic chest pain. She has no significant past medical history but started taking an oral contraceptive pill two months ago. Her vital signs are: temperature 37.0°C (98.6°F), heart rate 95/min, respiratory rate 18/min, blood pressure 125/75 mmHg, and oxygen saturation 99% on room air. Her lungs are clear to auscultation, and there is no unilateral leg swelling. The Wells score is calculated to be 1.5.
Which of the following is the most appropriate next step in management?
Explanation: This patient has a low pre-test probability for pulmonary embolism (PE) based on the Wells score of 1.5 (≤4 is low probability). According to diagnostic algorithms, for patients with low clinical probability of PE, the next step is to use a sensitive screening test like a D-dimer assay. A negative D-dimer result in this setting has a high negative predictive value and can effectively rule out PE, avoiding the need for radiation exposure and contrast from imaging. A positive D-dimer would then prompt further imaging.
A 68-year-old man who underwent a total hip arthroplasty 10 days ago presents to the emergency department with an acute onset of shortness of breath and right-sided chest pain. On examination, his heart rate is 115/min, respiratory rate is 24/min, blood pressure is 110/70 mmHg, and oxygen saturation is 91% on room air. His right calf is swollen, erythematous, and tender to palpation.
Which of the following is the most appropriate next diagnostic step?
Explanation: This patient has a high clinical probability of pulmonary embolism (PE) based on the Wells criteria (recent surgery, tachycardia, clinical signs of DVT). In patients with high pre-test probability, a D-dimer assay is not useful as it has a low negative predictive value and is likely to be positive. The most appropriate next step is definitive diagnostic imaging. CT pulmonary angiography (CTPA) is the gold standard for diagnosing PE in hemodynamically stable patients and should be performed promptly. While a lower extremity ultrasound may confirm a DVT, a negative result does not rule out PE, and CTPA would still be required.
A 55-year-old woman is diagnosed with an acute segmental pulmonary embolism via CT angiography. She is hemodynamically stable with a blood pressure of 130/80 mmHg and a heart rate of 90/min. Her serum creatinine is 1.0 mg/dL. She has no history of malignancy or severe liver disease.
Which of the following is the most appropriate initial treatment?
Explanation: For a hemodynamically stable patient with an acute pulmonary embolism and no significant contraindications (e.g., severe renal or hepatic disease), a direct oral anticoagulant (DOAC) such as rivaroxaban or apixaban is a first-line option and is preferred over vitamin K antagonists. Unfractionated heparin is typically reserved for patients who are hemodynamically unstable, have severe renal insufficiency, or in whom rapid reversal of anticoagulation might be necessary. Thrombolytic therapy is reserved for massive PE with hemodynamic instability. An IVC filter is indicated only if anticoagulation is contraindicated.
A 72-year-old woman is brought to the emergency department after a syncopal episode. She is lethargic and dyspneic. Her blood pressure is 80/50 mmHg, heart rate is 130/min, and respiratory rate is 30/min. Oxygen saturation is 85% on a non-rebreather mask. A bedside echocardiogram shows a dilated right ventricle with severe hypokinesis. A massive pulmonary embolism is strongly suspected.
Assuming no absolute contraindications, which of the following is the most appropriate immediate intervention?
Explanation: This patient presents with a massive pulmonary embolism, which is defined by the presence of hemodynamic instability (hypotension, SBP < 90 mmHg). In the absence of absolute contraindications (e.g., active bleeding, recent hemorrhagic stroke), the treatment of choice is systemic thrombolysis with a tissue plasminogen activator like alteplase. This intervention can rapidly dissolve the clot, reduce right ventricular afterload, and improve hemodynamics. Anticoagulation with heparin alone is insufficient for a massive PE. Delaying treatment for further imaging is inappropriate in a critically ill patient.
A 48-year-old man was treated for a first unprovoked deep vein thrombosis and pulmonary embolism 3 months ago with apixaban. He has completed the initial 3-month treatment phase and feels well. He has a low risk of bleeding.
Which of the following is the most appropriate recommendation for long-term management?
Explanation: For a patient with a first unprovoked venous thromboembolism (VTE), such as this patient's PE, the risk of recurrence after discontinuing anticoagulation is high. Current guidelines recommend extended (indefinite) anticoagulation for these patients, provided their bleeding risk is low to moderate. Apixaban, a DOAC, is an excellent choice for extended therapy. Limiting therapy to 3 or 6 months carries a significant risk of a recurrent, potentially fatal VTE. Aspirin is significantly less effective than anticoagulation for secondary prevention of VTE.
A 78-year-old man is diagnosed with an extensive pulmonary embolism. Two weeks prior, he suffered a hemorrhagic stroke. He is currently hemodynamically stable, but systemic anticoagulation is contraindicated due to the high risk of re-bleeding in the brain.
Which of the following is the most appropriate management for this patient?
Explanation: This patient has an absolute contraindication to anticoagulation due to his recent hemorrhagic stroke. In such situations, the primary indication for an inferior vena cava (IVC) filter is to prevent additional thrombi from the lower extremities from embolizing to the pulmonary circulation. Any form of anticoagulation, even at lower doses, would carry an unacceptably high risk of catastrophic intracranial hemorrhage. Surgical embolectomy is an invasive procedure reserved for patients with massive PE who have failed or have contraindications to thrombolysis, not for stable patients.
A 50-year-old woman with a known history of systemic sclerosis presents with progressive dyspnea. A transthoracic echocardiogram reveals an estimated pulmonary artery systolic pressure of 65 mmHg and signs of right ventricular dysfunction. Pulmonary function tests show a restrictive pattern.
Which of the following is the definitive test to confirm the diagnosis of pulmonary hypertension and guide therapy?
Explanation: While the echocardiogram is an excellent screening tool, right heart catheterization is the gold standard for the diagnosis of pulmonary hypertension (PH). It is required to confirm the diagnosis by directly measuring pulmonary artery pressures (mean PA pressure >20 mmHg at rest). It also measures the pulmonary capillary wedge pressure, which is essential to distinguish pre-capillary PH (like pulmonary arterial hypertension associated with connective tissue disease) from post-capillary PH (due to left heart disease). This distinction is critical as the treatments are entirely different.
A 60-year-old man with a history of recent knee surgery presents with acute shortness of breath and tachycardia. An ECG is performed and shows sinus tachycardia, a new right bundle branch block, and T-wave inversions in leads V1-V3. An arterial blood gas on room air shows pH 7.49, PaCO₂ 30 mmHg, and PaO₂ 60 mmHg.
These findings are most suggestive of which of the following diagnoses?
Explanation: This constellation of findings is classic for acute pulmonary embolism (PE). The risk factor (recent surgery), clinical presentation (dyspnea, tachycardia), ECG findings (sinus tachycardia, new RBBB, and anterior T-wave inversions suggesting right ventricular strain), and arterial blood gas (acute respiratory alkalosis with hypoxemia indicating an increased A-a gradient) all point towards PE. While an anterior MI can cause T-wave inversions, it would not typically cause a respiratory alkalosis.
A 38-year-old woman is diagnosed with WHO Group 1 pulmonary arterial hypertension (idiopathic) via right heart catheterization. Vasoreactivity testing with inhaled nitric oxide during the catheterization was negative. She has symptoms of dyspnea with moderate exertion (WHO functional class III).
Which of the following is an appropriate initial oral therapy for this patient?
Explanation: This patient has symptomatic (WHO class III) idiopathic pulmonary arterial hypertension (PAH) and is not a candidate for calcium channel blocker therapy because her vasoreactivity test was negative. Treatment should be initiated with an advanced PAH-specific therapy. Sildenafil, a phosphodiesterase-5 inhibitor, is a standard first-line oral agent that acts as a pulmonary vasodilator. Furosemide is for symptom management of fluid overload, and warfarin's role is debated but neither is a primary PAH therapy. Diltiazem is a calcium channel blocker and would be ineffective or harmful.
A 62-year-old man with a history of bilateral pulmonary emboli one year ago presents with progressively worsening dyspnea on exertion over the past 8 months. A transthoracic echocardiogram shows signs of severe pulmonary hypertension with right ventricular enlargement. He is currently on therapeutic anticoagulation.
Which of the following is the most appropriate next diagnostic test to evaluate for the most likely cause of his pulmonary hypertension?
Explanation: The patient's history of prior PE followed by the insidious onset of progressive dyspnea and signs of pulmonary hypertension (PH) is highly suggestive of chronic thromboembolic pulmonary hypertension (CTEPH). The recommended screening test of choice for CTEPH is the ventilation-perfusion (V/Q) scan. It is more sensitive than CTPA for detecting the chronic, organized, and often peripheral thrombi characteristic of CTEPH, which appear as mismatched perfusion defects. If the V/Q scan is positive, further evaluation with right heart catheterization and pulmonary angiography would follow.
A 50-year-old man is admitted with an acute pulmonary embolism and started on an unfractionated heparin infusion. His initial blood pressure was 120/80 mmHg. Twelve hours later, he becomes acutely more dyspneic. His blood pressure is now 95/65 mmHg, heart rate is 125/min, and he appears anxious and diaphoretic. His jugular venous pressure is now elevated to 12 cm H₂O.
Which of the following is the most likely cause of this patient's deterioration?
Explanation: The patient is developing signs of obstructive shock (borderline hypotension, tachycardia, elevated JVP) despite being on anticoagulation. This clinical picture is most consistent with progressive right ventricular (RV) failure. The large clot burden is causing persistently high pulmonary vascular resistance, and the RV cannot generate enough pressure to maintain cardiac output. This leads to RV dilation, increased RV end-diastolic pressure (seen as elevated JVP), and decreased left ventricular preload, causing hypotension. While recurrent PE is possible, decompensation from the initial clot is more common.
A 70-year-old woman with a history of metastatic breast cancer currently undergoing chemotherapy presents with sudden onset of dyspnea. On examination, her heart rate is 110/min and respiratory rate is 22/min. She has no clinical signs of DVT and denies hemoptysis. The treating physician believes that a pulmonary embolism is the most likely diagnosis.
Based on the Wells' criteria for pulmonary embolism, what is the most appropriate immediate next step?
Explanation: This patient has a high pre-test probability for pulmonary embolism (PE). Using the Wells' criteria: active cancer (+1 point), heart rate > 100/min (+1.5 points), and PE is the most likely diagnosis (+3 points). Her total score is 5.5, which places her in the 'PE likely' category (score > 4). For patients with a high clinical probability of PE, D-dimer testing is not recommended because a negative result does not reliably exclude PE. The appropriate next step is to proceed directly to definitive diagnostic imaging with CT pulmonary angiography.
A 66-year-old man presents to the emergency department with 2 hours of pleuritic chest pain and dyspnea. His only medical history is hypertension. He is taking lisinopril. Vital signs are BP 140/90 mmHg, HR 105/min, RR 20/min, and SpO2 94% on room air. A CT angiogram of the chest confirms a subsegmental pulmonary embolism in the right lower lobe.
Which of the following is the most appropriate next step in management?
Explanation: Current guidelines recommend anticoagulation for patients with a subsegmental pulmonary embolism (SSPE) who are symptomatic (like this patient with pleuritic pain and dyspnea) or have risk factors for VTE recurrence. Withholding anticoagulation may be considered only in highly selected, asymptomatic patients with no risk factors and a low risk of recurrence. Systemic thrombolysis is not indicated for a small, hemodynamically insignificant PE. An IVC filter is not indicated as the patient can be anticoagulated.
A 32-year-old woman at 28 weeks gestation presents with acute dyspnea and pleuritic chest pain. A ventilation-perfusion scan confirms a high probability of pulmonary embolism. Her vital signs are stable.
Which of the following is the most appropriate long-term treatment?
Explanation: Low-molecular-weight heparin (LMWH) is the anticoagulant of choice for the treatment of venous thromboembolism (VTE) during pregnancy. LMWH does not cross the placenta and has a well-established safety and efficacy profile for both the mother and fetus. Warfarin is teratogenic, especially in the first trimester, and is generally contraindicated. Direct oral anticoagulants (e.g., rivaroxaban) are also contraindicated due to a lack of safety data in pregnancy. Aspirin is not effective for the treatment of acute PE.
A 65-year-old woman with a history of stage 4 chronic kidney disease (eGFR 25 mL/min/1.73m²) and a prior anaphylactic reaction to iodinated contrast media presents with acute dyspnea. A pulmonary embolism is suspected. Her vital signs are stable, and her chest radiograph is unremarkable.
Which of the following is the most appropriate imaging study to diagnose pulmonary embolism in this patient?
Explanation: This patient has two major contraindications to CT pulmonary angiography (CTPA): severe chronic kidney disease and a severe allergy to iodinated contrast. In such cases, a ventilation-perfusion (V/Q) scan is the preferred alternative imaging modality for diagnosing PE. A V/Q scan does not use iodinated contrast and is safe in patients with renal failure. Since her chest radiograph is normal, the V/Q scan is likely to be diagnostic (either normal/low probability or high probability).
A 55-year-old patient is diagnosed with chronic thromboembolic pulmonary hypertension (CTEPH). Diagnostic workup including a V/Q scan, right heart catheterization, and pulmonary angiography confirms organized thrombi in the main and lobar pulmonary arteries. The patient is otherwise a good surgical candidate.
Which of the following is the most appropriate and potentially curative treatment for this patient?
Explanation: Pulmonary thromboendarterectomy (PTE) is the definitive, potentially curative treatment for patients with CTEPH who have surgically accessible chronic clots in the major pulmonary arteries. This procedure involves surgically removing the organized fibrous material from the pulmonary arterial tree, which can lead to a dramatic improvement in hemodynamics and symptoms. While all CTEPH patients require lifelong anticoagulation, it is not a curative therapy. Medical therapies like vasodilators are reserved for patients who are not surgical candidates or have persistent PH after surgery. Lung transplantation is a last resort.
A 25-year-old man presents to the emergency department with a 1-day history of sharp, left-sided chest pain. He denies shortness of breath. He has no past medical history, takes no medications, and has no recent travel or surgery. Vital signs are: heart rate 85/min, respiratory rate 14/min, blood pressure 115/70 mmHg, and SaO2 99% on room air. His physical exam is unremarkable, with no leg swelling.
Which of the following is the most appropriate next step in management?
Explanation: This patient has a very low pre-test probability for pulmonary embolism and meets all of the Pulmonary Embolism Rule-out Criteria (PERC): age <50, HR <100, SaO2 >94%, no unilateral leg swelling, no hemoptysis, no recent surgery/trauma, no prior VTE, and no hormone use. For patients who are PERC-negative, the likelihood of PE is extremely low (<2%), and no further diagnostic testing, including D-dimer, is indicated. This approach safely avoids unnecessary testing and radiation exposure.