Medical Council Step exam for International Medical Graduates / ECFMG Certification USMLE Step 2 CK: Internal Medicine & Subspecialties Syllabus

USMLE Step 2 CK: Internal Medicine & Subspecialties syllabus — full chapter and topic list

Expand any chapter to see its topics and sub-topics. This is the whole examinable outline for USMLE Step 2 CK: Internal Medicine & Subspecialties in Medical Council Step exam for International Medical Graduates / ECFMG Certification, not a summary of it.

1. 1

   Cardiology & Pulmonology Management

   5 topics

   • Acute coronary syndrome diagnosis and management
   • Heart failure staging and guideline-directed therapy
   • Arrhythmia and anticoagulation management
   • COPD/asthma exacerbation management
   • Pneumonia, sepsis, and critical care basics
2. 2

   Gastroenterology, Nephrology & Endocrinology

   5 topics

   • GI bleeding and acute abdomen workup
   • Liver disease and hepatitis management
   • Electrolyte emergencies and AKI/CKD management
   • Diabetes management and DKA/HHS
   • Thyroid and adrenal disorder treatment
3. 3

   Infectious Disease & Rheumatology

   5 topics

   • HIV/AIDS diagnosis and antiretroviral therapy
   • Antimicrobial selection and stewardship
   • Sepsis recognition and management
   • Autoimmune and inflammatory arthropathies
   • Vasculitis and systemic rheumatic disease
4. 4

   Hematology-Oncology & Geriatrics

   5 topics

   • Anemia and cytopenia workup
   • Oncologic emergencies and chemotherapy toxicity
   • Cancer screening guidelines
   • Geriatric assessment, polypharmacy, falls
   • Palliative and end-of-life care

USMLE Step 2 CK: Internal Medicine & Subspecialties flashcards for Medical Council Step exam for International Medical Graduates / ECFMG Certification

20 of 56 cards from the USMLE Step 2 CK: Internal Medicine & Subspecialties deck — real questions with worked answers.

1. What ECG finding distinguishes STEMI from NSTEMI/unstable angina, and what is the immediate reperfusion goal for STEMI?

   STEMI shows new ST-segment elevation (or new LBBB); NSTEMI/UA have ST depression or T-wave inversion without ST elevation. Goal: primary PCI within 90 minutes of first medical contact (or fibrinolytics within 30 min if PCI unavailable >120 min).

2. What is the initial medical bundle ('MONA-BASH') for acute coronary syndrome?

   Aspirin (chewed, 162-325 mg) plus a P2Y12 inhibitor, anticoagulation (heparin), high-intensity statin, beta-blocker (if no contraindication), nitrates for pain, and oxygen only if SpO2 <90%. Morphine for refractory pain.

3. Which cardiac biomarker is most sensitive/specific for MI, and what is its time course?

   Troponin (I or T): rises 3-6 hours after injury, peaks at 24 hours, stays elevated 7-10 days. High-sensitivity troponin allows detection within 1-3 hours; serial measurements detect a rise/fall pattern.

4. How are the four NYHA functional classes of heart failure defined?

   Class I: no symptoms with ordinary activity. Class II: symptoms with ordinary activity. Class III: symptoms with less-than-ordinary activity. Class IV: symptoms at rest.

5. What are the four pillars of guideline-directed medical therapy (GDMT) for HFrEF?

   (1) ARNI (or ACEi/ARB), (2) beta-blocker (carvedilol, metoprolol succinate, or bisoprolol), (3) mineralocorticoid receptor antagonist (spironolactone/eplerenone), and (4) SGLT2 inhibitor (dapagliflozin/empagliflozin).

6. Define the ACC/AHA stages A-D of heart failure.

   Stage A: at risk, no structural disease/symptoms. Stage B: structural disease, no symptoms. Stage C: structural disease with current/prior symptoms. Stage D: refractory, advanced HF requiring specialized interventions.

7. What is the CHA2DS2-VASc score and when should anticoagulation be started in atrial fibrillation?

   CHF, HTN, Age >=75 (2), Diabetes, Stroke/TIA (2), Vascular disease, Age 65-74, Sex (female). Anticoagulate if score >=2 in men or >=3 in women; consider if 1 (men)/2 (women).

8. In atrial fibrillation, when is rate control preferred over rhythm control, and what agents are first-line for rate control?

   Rate control is preferred for most stable, older patients with persistent AF. First-line: beta-blockers or non-dihydropyridine calcium channel blockers (diltiazem/verapamil); digoxin as adjunct in HF/hypotension.

9. What is the immediate management of unstable atrial fibrillation with hemodynamic compromise?

   Synchronized electrical cardioversion. 'Unstable' = hypotension, chest pain/ischemia, acute heart failure, or altered mental status.

10. How do DOACs compare to warfarin for nonvalvular AF, and which patients still require warfarin?

    DOACs (apixaban, rivaroxaban, dabigatran, edoxaban) are preferred: no INR monitoring, fewer interactions, less intracranial bleeding. Warfarin is required for mechanical heart valves and moderate-severe mitral stenosis.

11. What defines a COPD exacerbation and what are the cornerstone treatments?

    Acute worsening of dyspnea, cough, and/or sputum (volume/purulence). Treat with inhaled short-acting bronchodilators (SABA +/- SAMA), systemic corticosteroids (prednisone ~40 mg x5 days), and antibiotics if increased purulence.

12. When is noninvasive positive pressure ventilation (BiPAP) indicated in a COPD exacerbation?

    For respiratory acidosis (pH <=7.35 with PaCO2 >=45), severe dyspnea with signs of respiratory muscle fatigue, or persistent hypoxemia despite oxygen. It reduces intubation and mortality.

13. How is the severity of an asthma exacerbation assessed and treated in the ED?

    Assess with peak flow/FEV1, SpO2, and work of breathing. Treat with oxygen, repeated/continuous SABA (albuterol) plus ipratropium, systemic corticosteroids, and IV magnesium sulfate for severe cases. Rising PaCO2 signals impending respiratory failure.

14. What CURB-65 criteria guide pneumonia disposition, and what does the score indicate?

    Confusion, Urea >19 mg/dL (BUN), Respiratory rate >=30, Blood pressure <90/60, age >=65. Score 0-1: outpatient; 2: consider admission; >=3: admit, consider ICU.

15. What is the empiric outpatient antibiotic regimen for community-acquired pneumonia in a previously healthy adult?

    Amoxicillin (high-dose) or doxycycline, or a macrolide where pneumococcal resistance is low. With comorbidities: respiratory fluoroquinolone (levofloxacin) OR beta-lactam plus macrolide.

16. State the Sepsis-3 definition of sepsis and septic shock.

    Sepsis = life-threatening organ dysfunction (SOFA increase >=2) from a dysregulated host response to infection. Septic shock = sepsis with vasopressors needed to keep MAP >=65 plus lactate >2 despite adequate fluid resuscitation.

17. What are the key elements of the Surviving Sepsis 'Hour-1 bundle'?

    Measure lactate, obtain blood cultures before antibiotics, give broad-spectrum antibiotics, begin 30 mL/kg crystalloid for hypotension or lactate >=4, and start vasopressors (norepinephrine first-line) to keep MAP >=65 if fluid-refractory.

18. What is the initial diagnostic and resuscitation approach to acute upper GI bleeding?

    Two large-bore IVs, fluid/blood resuscitation (transfuse to Hgb >=7), IV PPI, and urgent upper endoscopy within 24 hours. Add octreotide and ceftriaxone if variceal bleed is suspected in cirrhosis.

19. How do you distinguish upper from lower GI bleeding clinically?

    Upper GI bleed (proximal to ligament of Treitz): hematemesis, melena, elevated BUN/creatinine ratio. Lower GI bleed: hematochezia (though brisk upper bleeds can also cause it). NG lavage or endoscopy confirms source.

20. What signs suggest peritonitis/acute abdomen requiring urgent surgical evaluation?

    Rigid abdomen, rebound tenderness, guarding, absent bowel sounds, and pain out of proportion. Free air on upright X-ray/CT indicates perforation; suspect mesenteric ischemia with severe pain plus lactic acidosis.

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