Medical Council Step exam for International Medical Graduates / ECFMG Certification USMLE Step 2 CK: Surgery, OB-GYN, Pediatrics & Psychiatry Syllabus

Define abnormal uterine bleeding terms: menorrhagia, metrorrhagia, and oligomenorrhea.

Menorrhagia = heavy/prolonged bleeding at regular intervals. Metrorrhagia = irregular bleeding between periods. Oligomenorrhea = infrequent menses (cycles >35 days).

What does the PALM-COEIN classification of abnormal uterine bleeding stand for?

Structural (PALM): Polyp, Adenomyosis, Leiomyoma, Malignancy/hyperplasia. Non-structural (COEIN): Coagulopathy, Ovulatory dysfunction, Endometrial, Iatrogenic, Not otherwise classified.

Which contraceptive methods are most effective (Tier 1), and which are contraindicated in women with a history of estrogen-sensitive conditions or migraine with aura?

Tier 1 (most effective): implants and IUDs (LARC), plus sterilization. Combined estrogen-containing methods are contraindicated in migraine with aura, history of VTE, and active breast cancer.

What are absolute contraindications to combined oral contraceptive pills (estrogen)?

History of VTE/thromboembolism, smoker ≥35 years old (≥15 cigarettes/day), migraine with aura, uncontrolled hypertension, active breast cancer, active liver disease, and history of stroke or CAD.

What is the classic presentation and treatment of pelvic inflammatory disease (PID)?

Lower abdominal pain, cervical motion tenderness, adnexal/uterine tenderness in a sexually active woman. Treatment: ceftriaxone IM plus doxycycline, with metronidazole added for anaerobic coverage.

How are the common cervicitis pathogens treated: Chlamydia trachomatis vs Neisseria gonorrhoeae?

Chlamydia: doxycycline (or azithromycin in pregnancy). Gonorrhea: ceftriaxone IM. Treat empirically for both given high co-infection; treat partners.

What are the cervical cancer screening guidelines for ages 21–29 vs 30–65?

Ages 21–29: Pap cytology every 3 years. Ages 30–65: co-testing (Pap + HPV) every 5 years, OR Pap alone every 3 years, OR primary HPV testing every 5 years. Begin at 21 regardless of sexual activity.

What tumor marker is associated with epithelial ovarian cancer, and what is the most common ovarian malignancy in young women?

CA-125 is elevated in epithelial ovarian cancer (most common overall). In young women (<20), germ cell tumors predominate (e.g., dysgerminoma; markers LDH, hCG, AFP).

Define menopause and the characteristic hormonal changes.

Menopause = 12 consecutive months of amenorrhea (mean age ~51). Hormonally: markedly elevated FSH (and LH), with low estradiol, due to ovarian follicular depletion.

What is the most common cause of female infertility, and the initial test to confirm ovulation?

Ovulatory dysfunction (e.g., PCOS) is the most common cause. A mid-luteal (day 21) serum progesterone >3 ng/mL confirms ovulation.

What are the 5 components of the APGAR score, and at what times is it assessed?

Appearance (color), Pulse (HR), Grimace (reflex irritability), Activity (muscle tone), Respiration. Each scored 0–2; assessed at 1 and 5 minutes (and every 5 min if low).

In neonatal resuscitation, what is the most important initial step for a non-vigorous, apneic newborn?

Effective positive-pressure ventilation (PPV) is the priority — most neonatal arrests are respiratory in origin. Warm, dry, stimulate, and clear airway first.

By what age do infants typically double and triple their birth weight, and at what age do they sit unsupported and walk?

Double birth weight by ~6 months, triple by ~12 months. Sit unsupported ~6 months; walk independently ~12 months.

What live vaccines are given at 12–15 months, and why are they delayed until then?

MMR and varicella (live vaccines) are given at 12–15 months; delayed because maternal antibodies present earlier can interfere with the immune response, and live vaccines are generally avoided before 12 months.

Differentiate the rashes of measles, roseola, and erythema infectiosum (fifth disease).

Measles: cephalocaudal maculopapular rash + Koplik spots + cough/coryza/conjunctivitis. Roseola (HHV-6): high fever for 3–4 days THEN rash appears as fever breaks. Fifth disease (parvovirus B19): 'slapped cheek' rash followed by lacy reticular rash.

What organism causes epiglottitis, and what is the classic clinical presentation?

Historically Haemophilus influenzae type b (now rare due to Hib vaccine); also strep. Presents with the '3 Ds' — drooling, dysphagia, distress — with tripoding, high fever, and a 'thumbprint sign' on lateral neck X-ray. Do not agitate; secure airway.

What is the genetic mechanism and karyotype of Down syndrome, and a key prenatal screening finding?

Trisomy 21 (most often from meiotic nondisjunction), karyotype 47,XX or 47,XY +21. Prenatal: increased nuchal translucency, low PAPP-A, low AFP/estriol, high hCG and inhibin A (quad screen).

Contrast the inheritance and key features of cystic fibrosis vs Duchenne muscular dystrophy.

CF: autosomal recessive, CFTR mutation (chloride channel), recurrent pulmonary infections + pancreatic insufficiency, diagnosed by sweat chloride test. DMD: X-linked recessive, dystrophin absence, proximal weakness + Gowers sign + calf pseudohypertrophy, elevated CK.

What physical findings should raise suspicion for child abuse (non-accidental trauma)?

Injuries inconsistent with the developmental stage or reported history, posterior rib fractures, metaphyseal corner ('bucket-handle') fractures, retinal hemorrhages (shaken baby), patterned/immersion burns, and bruising in non-ambulatory infants ('those who don't cruise rarely bruise').

What is the most common pediatric emergency cause of cardiac arrest, and the recommended CPR compression-to-ventilation ratio for a single rescuer?

Respiratory failure/hypoxia is the leading cause (arrest is usually secondary to respiratory). Single-rescuer pediatric CPR ratio is 30:2 (15:2 for two rescuers).

What are the DSM-5 criteria for a major depressive episode (number and duration of symptoms)?

≥5 of 9 symptoms (SIG E CAPS) for ≥2 weeks, including at least one of depressed mood or anhedonia. Symptoms: Sleep, Interest, Guilt, Energy, Concentration, Appetite, Psychomotor changes, Suicidality, plus depressed mood/anhedonia.

Differentiate generalized anxiety disorder, panic disorder, and the duration criteria.

GAD: excessive worry about multiple domains on most days for ≥6 months. Panic disorder: recurrent unexpected panic attacks plus ≥1 month of worry about future attacks or maladaptive behavior change. First-line treatment for both: SSRIs.

What are the DSM-5 criteria for schizophrenia, including duration?

≥2 of: delusions, hallucinations, disorganized speech, disorganized/catatonic behavior, negative symptoms (at least one must be one of the first three), for ≥1 month of active symptoms, with continuous signs ≥6 months and functional decline.

Distinguish schizophreniform disorder, brief psychotic disorder, and schizophrenia by duration.

Brief psychotic disorder: symptoms 1 day to <1 month with full return to baseline. Schizophreniform: 1–6 months. Schizophrenia: ≥6 months (including prodromal/residual).

What is the CAGE questionnaire used to screen for, and what do the letters stand for?

Screens for alcohol use disorder. C - felt need to Cut down; A - Annoyed by criticism of drinking; G - Guilty about drinking; E - Eye-opener (drink in the morning). ≥2 positive answers is clinically significant.

Contrast the management of alcohol withdrawal vs opioid withdrawal.

Alcohol withdrawal (can be life-threatening; tremor, seizures, delirium tremens): treat with benzodiazepines. Opioid withdrawal (uncomfortable but rarely life-threatening; flu-like, mydriasis, piloerection): treat with methadone/buprenorphine or clonidine for symptoms.

What is serotonin syndrome, its classic triad, and treatment?

Excess serotonergic activity (e.g., SSRI + MAOI or tramadol). Triad: neuromuscular hyperactivity (clonus, hyperreflexia, tremor), autonomic instability (hyperthermia, tachycardia), and altered mental status. Treatment: stop agent, supportive care, cyproheptadine.

Compare neuroleptic malignant syndrome (NMS) and serotonin syndrome key distinguishing features.

NMS (antipsychotics): slow onset (days), 'lead-pipe' rigidity, hyporeflexia, bradykinesia, very high CK; treat with dantrolene/bromocriptine. Serotonin syndrome (serotonergic drugs): rapid onset (hours), hyperreflexia/clonus (esp. lower limbs); treat with cyproheptadine.

What are the strongest demographic and clinical risk factors for completed suicide (SAD PERSONS)?

Sex (male), Age (elderly/adolescent), Depression, Previous attempt (strongest predictor), Ethanol/substance use, Rational thinking loss (psychosis), Social support lacking, Organized plan, No spouse, Sickness/chronic illness.

In the psychiatric emergency setting, what is the safest disposition for a patient with active suicidal ideation, a plan, and intent?

Immediate hospitalization (involuntary if necessary) with one-to-one observation in a safe environment; remove access to lethal means. Do not discharge a patient with active intent and a plan.