Quick USMLE Review Notes for Step 2 CK

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Quick USMLE Review Notes for Step 2 CK:

USMLE step 2 CK is more of a clinical exam, so they ask 'the most likely diagnosis'
(around 30% of questions) and 'the next best step in the management' style of questions
by giving different scenarios in the exam. So you must need the most complete
notes which covers the first line management of all diseases according to US
clinical standard, not like a general book which covers all possibilities for all

These notes helped me to get a score of 232/96



Click on download / Home Page on the right top corner to visit my website & review my notes to get an idea about how these notes coul be very helpful for your USMLE test.

In exam you will get most of the questions as follow:

Which of the following is most likely diagnosis?
What is the next step in management of this patient?
Which of the following is best initial diagnostic test?
Which of the following is most accurate diagnostic test?
All kind of questions-answers you will get in my notes.

Few Example:

Chest Pain:

Myocardial Ischemia / Myocardial Infarction: Substernal squeezing chest pain [not reproduce
by palpation, not change with change in position, not pleuritic]
Pericarditis: chest pain [relieve by leaning forward]
Costochondritis: chest pain [reproduce by palpation]
Dissecting aortic aneurysm: tearing chest pain radiate to back
Pneumonia: pleuritic chest pain
Pulmonary embolism: pleuritic chest pain, dyspnea, tachypnea
Esophageal spasm (nut cracker disease): h/o GERD, gastritis, pain occur after eating, normal

Stable angina: chest pain after exertion
Unstable angina: chest pain at rest [ST Depression] [D - E]
Myocardial Infarction: chest pain at rest [ST Elevation]
Prinzmetal angina: chest pain at rest [ST elevation - Transmural Ischemia] [due to coronary
artery spasm. Pain may relieve by little exercise like patient gets up and walking and pain relieve
because exercise causes increase in Adenosine which is a potent coronary vasodilator] [Best
diagnostic test
- Angiography shows No atherosclerosis] [Treatment: Ca++ channel blockers
(CCB), Nitrates] [Not Aspirin and b-blockers]

Patient with Stable/Unstable angina and MI should receive Aspirin, Nitrates and b-blockers (if
no contraindications like Asthma, etc.)
Patient should also receive oxygen (if oxygen saturation is low) and morphine (if patient is still
having pain)
Unstable Angina (clot is forming): above 2 steps + Heparin (not thrombolytics) + Statins   
MI (clot is already formed): above 2 steps + Thrombolytics (If certain criteria meets, see below) +
Statins + Low molecular weight Heparin (If not contraindicated) + ACE inhibitors (only If CHF due
to acute MI) + Lidocaine (only If ventricular arrhythmias)

Thrombolytics (If it is not contraindicated, if Angioplasty is not available):

Within 12 hrs of the onset of MI.
> 1 mm ST segment elevation in two contiguous EKG.
New LBBB (Left Bundle Branch Block).

Best Initial test: EKG
Most accurate diagnostic test: Angiography (Ischemia) / Cardiac Troponin & CK-MB
(Infarction) [Both begin to elevate in 4-6 hrs] [Cardiac Troponin remains elevated for 1-2 wks]
[CK-MB remains elevated for 2-3 days] [best test to check re-infarction within a week - CK-
MB because it disappears in 2-3 days]
Most accurate treatment for MI / Unstable angina: Angioplasty
Most important is to know when you will do diagnostic test and when you will start
treatment. Answer what they asked like best initial / most accurate
If patient comes with chest pain for last 1-hr and still having pain, what will you do first or best initial
test? - EKG
If patient comes with chest pain for last 1-hr and still having pain, EKG shows ST depression / ST
elevation, what will you do now? - Start treatment (all patient should receive above treatment
depends upon what they have like Unstable angina or MI or stable angina or Prinzmetal angina
If patient comes with chest pain off & on and no pain now in your office, what will you do first? -
Stress test (EKG may not show anything cause no pain now)                  
Classic presentation of Acute Appendicitis [pain start in mid epigastric region and then shifted to
RLQ, positive rebound tenderness, Psoas sign, Rovsing's sign, etc], next step? - Appendicectomy

Above presentation, On Abdominal exploration, Appendix is normal but ileum is inflamed (Crohn's
ileitis), next step? - Proceed with Appendicectomy and close the abdomen

Above presentation, On Abdominal exploration, Appendix is normal but ileum & cecum are
inflamed, next step? - Do nothing and close the abdomen [when cecum is inflamed, Appendicular
stump doesn't heal and it can cause fecal fistula which leads a hemicolectomy]    

Female patient without classical presentation of appendicitis, next step? - USG

Classic presentation of appendicitis but 6-7 days old pain, mass on abdominal palpation,
diagnosis? - Appendicular mass, next step? - IV fluid, bowel rest, IV antibiotics, serial

If above scenario, 24-hrs after starting treatment, patient is getting worse (spiking fever, tachycardia,
increase in localize tenderness), next step? - CT scan (Appendicular abscess) - Tx : CT guided

Mallory Weiss Tear - continuous retching followed by large painless bloody vomiting (mucosal
tear), best diagnostic test? - Endoscopy - Tx: resolve itself / laser photocoagulation

Boerhaave Syndrome - continuous retching followed by severe chest pain, Crepitation in the
neck, air in mediastinum on CXR (Esophageal rupture - distal third, posterolateral segment (no
serosa) is the most common site), best diagnostic test? - Gastrografin swallow - Emergency
Surgical repair.

Temporal Arteritis (Giant Cell Arteritis) - Unilateral pounding headache, Visual changes , Jaw
claudication , scalp tenderness - High dose Prednisone (Best Initial / 1st step in management)

DI - elevated serum osmolarity
Primary Polydipsia (Psychogenic) - both serum & urine diluted
- elevated urine osmolarity

Selective mutism - speak normally in other situation or at home
- < 3 yrs. of age, repetitive behavior, marked hearing impairment
Undetected hearing impairment - hereditary, repeated ear infection, symptoms same as autism
but detected at later age compare to autism.

Hemodynamically stable AF patient - Diltiazam or Metoprolol
Hemodynamically stable VF patient - Lidocaine or Amiodarone

Tx of Kawasaki disease - Aspirin + Immunoglobulin

Management of Hypotension in patient with DI - IV normal saline

First step in management of Hyperkalemia - IV Calcium gluconate
Most effective way to remove K+ from body - hemodialysis
Most rapid way to lower serum K+ Insulin + glucose

Herpes simplex keratitis - corneal vesicle & dendritic ulcers
Herpes zoster ophthalmics - burning & itching in periorbital area & vesicle on distribution of
ophthalmic nerve branches

Cardiogenic shock - low CO & High PCWP
ARDS - Normal PCWP
Septic shock - High CO , Low PCWP & Normal mixed venous O2
Hypovolemic shock - low CO, low PCWP, low mixed venous O2

High PCWP & low CVP - LV dysfunction
High PCWP & high CVP - Cardiac temponade
Respiratory distress & high CVP - Tension Pneumothorax

Croup &#8211; give trial of epinephrine before intubation
Acute epiglotitis - Laryngoscopy - intubation then IV ceftriaxone.

DM + ear infection & granulation, organism? - Pseudomonas

Comment I received about my hand writing:
I have received all three e mail, all in good order. HY are also written in hand but for some odd
reason I like hand writen material better then typed. I think it's because of ability to draw graphs and
connect the dots that's somewhat limited when you use MS Word. Do not really understand people
who complain about it.

Anyhow if you do get a chance, give me your two cents regarding how to prepare for USMLE Step
2 CS. I am foreigner attending med school in USA so that makes me somewhat less confident in my
ability to perform well especially for the exam that's  unpredictable to begin with. What did you use,
what works etc.

Thanks a lot and I will contact you if I feel that I could benefit from your USMLE 1 notes too.

Delivery of My notes:

You will be able to download my high yield notes immediately. After you complete
do NOT close browse but click on "Complete Purchase". It will take you to the
"thank you" page where you will be able to download these notes immediately.

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