United States Medical Licensing Examination (USMLE) Internal Medicine and Clinical Knowledge (Step 2 CK) Syllabus

Internal Medicine and Clinical Knowledge (Step 2 CK) syllabus — full chapter and topic list

Expand any chapter to see its topics and sub-topics. This is the whole examinable outline for Internal Medicine and Clinical Knowledge (Step 2 CK) in United States Medical Licensing Examination (USMLE), not a summary of it.

1. 1

   Cardiovascular Disorders

   5 topics

   • Acute coronary syndromes
     • STEMI and NSTEMI management
     • Reperfusion strategies
   • Heart failure and arrhythmias
     • Systolic vs diastolic failure
     • Atrial fibrillation and SVT
   • Hypertension and dyslipidemia
   • Valvular and pericardial disease
   • Vascular and aortic emergencies
2. 2

   Pulmonary and Critical Care

   5 topics

   • Respiratory failure and ARDS
   • Obstructive airway exacerbations
   • Pulmonary embolism workup
   • Pleural disease and effusions
   • Sepsis and shock management
3. 3

   Gastroenterology and Hepatology

   5 topics

   • GI bleeding evaluation
   • Inflammatory bowel disease management
   • Liver disease and cirrhosis complications
   • Pancreatitis and biliary disease
   • Functional GI and screening
4. 4

   Endocrinology and Renal Medicine

   5 topics

   • Diabetes and metabolic emergencies
     • DKA and HHS
   • Thyroid and adrenal management
   • Fluid, electrolyte, and acid-base correction
   • Acute kidney injury and dialysis indications
   • Chronic kidney disease management
5. 5

   Infectious Disease and Hematology-Oncology

   5 topics

   • Antimicrobial selection and stewardship
   • HIV and opportunistic infections
   • Healthcare-associated infections
   • Oncologic emergencies
   • Anemia and coagulopathy workup
6. 6

   Rheumatology and Neurology

   5 topics

   • Systemic autoimmune disease
   • Inflammatory and degenerative arthritis
   • Stroke and TIA management
   • Seizure and headache evaluation
   • Neuromuscular and movement disorders

Internal Medicine and Clinical Knowledge (Step 2 CK) flashcards for United States Medical Licensing Examination (USMLE)

21 of 67 cards from the Internal Medicine and Clinical Knowledge (Step 2 CK) deck — real questions with worked answers.

1. What are the three serial troponin findings and ECG criteria that distinguish STEMI from NSTEMI in acute coronary syndrome?

   STEMI: ST elevation >=1mm in >=2 contiguous limb leads or >=2mm in precordial leads (or new LBBB) PLUS elevated troponin. NSTEMI: elevated troponin WITHOUT persistent ST elevation (may show ST depression/T-wave inversion). Unstable angina: ischemic symptoms with NO troponin rise.

2. What is the immediate initial pharmacologic management ('MONA-B' plus) for a patient presenting with acute coronary syndrome?

   Aspirin (chewed, 162-325 mg), a P2Y12 inhibitor (e.g., ticagrelor/clopidogrel), anticoagulation (heparin), high-intensity statin, beta-blocker (if no contraindication), nitrates for pain, and oxygen only if SpO2 <90%. STEMI requires emergent reperfusion (PCI within 90 min, or fibrinolysis if PCI unavailable within 120 min).

3. In acute STEMI, which coronary artery occlusion corresponds to inferior leads (II, III, aVF), and what management precaution does it demand?

   Right coronary artery (most commonly). Suspect right ventricular infarction-obtain right-sided leads (V4R). Avoid nitrates and other preload-reducing agents because the RV is preload-dependent; treat hypotension with IV fluids.

4. How is the New York Heart Association (NYHA) functional classification of heart failure defined (Classes I-IV)?

   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. Which four drug classes are guideline-directed therapy proven to reduce mortality in heart failure with reduced ejection fraction (HFrEF)?

   (1) ARNI (or ACE inhibitor/ARB), (2) beta-blocker (carvedilol, metoprolol succinate, or bisoprolol), (3) mineralocorticoid receptor antagonist (spironolactone/eplerenone), and (4) SGLT2 inhibitor. Diuretics relieve congestion but do not reduce mortality.

6. What is the first-line management of unstable atrial fibrillation (hypotension, ischemia, pulmonary edema) versus stable AF?

   Unstable: immediate synchronized cardioversion. Stable: rate control (beta-blocker or non-dihydropyridine CCB) and anticoagulation based on CHA2DS2-VASc score; rhythm control as needed.

7. What is the CHA2DS2-VASc score and the threshold for recommending oral anticoagulation in atrial fibrillation?

   CHF (1), Hypertension (1), Age >=75 (2), Diabetes (1), Stroke/TIA/thromboembolism (2), Vascular disease (1), Age 65-74 (1), Sex category female (1). Anticoagulate men with score >=2 and women >=3; consider it at >=1 (men)/>=2 (women).

8. What blood pressure threshold defines hypertension by ACC/AHA 2017 guidelines, and what are the stages?

   Normal <120/<80; Elevated 120-129/<80; Stage 1: 130-139 or 80-89; Stage 2: >=140 or >=90. Hypertensive crisis: >180/>120.

9. What is the difference between a hypertensive urgency and a hypertensive emergency, and how does management differ?

   Both have BP >180/120. Emergency = acute target-organ damage (encephalopathy, stroke, MI, aortic dissection, pulmonary edema, AKI, eclampsia) requiring IV agents to lower BP ~10-20% in the first hour. Urgency = no end-organ damage; lower BP gradually over 24-48h with oral agents.

10. According to ACC/AHA, which patient groups warrant high-intensity statin therapy for dyslipidemia?

    (1) Clinical ASCVD; (2) LDL >=190 mg/dL; (3) diabetics aged 40-75 with high risk; (4) 10-year ASCVD risk >=20%. High-intensity statins (atorvastatin 40-80 mg, rosuvastatin 20-40 mg) lower LDL by >=50%.

11. What murmur characterizes aortic stenosis, and what is the management for symptomatic severe AS?

    Crescendo-decrescendo (ejection) systolic murmur at the right upper sternal border radiating to the carotids, with delayed/diminished carotid upstroke (pulsus parvus et tardus). Symptomatic severe AS (angina, syncope, heart failure) requires aortic valve replacement (SAVR or TAVR); avoid vasodilators/nitrates.

12. How do you distinguish acute pericarditis from STEMI on ECG and exam?

    Pericarditis: diffuse (not territorial) ST elevation with PR depression, pleuritic chest pain relieved by sitting forward, and a friction rub. STEMI: regional ST elevation with reciprocal changes. Pericarditis is treated with NSAIDs + colchicine.

13. What is Beck's triad of cardiac tamponade, and what is the definitive treatment?

    Hypotension, jugular venous distention, and muffled heart sounds. Also pulsus paradoxus (>10 mmHg inspiratory drop in SBP) and electrical alternans. Definitive treatment: urgent pericardiocentesis.

14. What clinical features and management define acute aortic dissection (Stanford classification)?

    Sudden tearing chest/back pain, BP differential between arms, widened mediastinum. Stanford A (ascending aorta) needs emergent surgery; Stanford B (descending only) is managed medically with rapid HR/BP control (IV beta-blocker first, e.g., esmolol/labetalol, then nitroprusside) targeting SBP 100-120 and HR <60.

15. What is the classic presentation and immediate management of a ruptured abdominal aortic aneurysm (AAA)?

    Triad of hypotension, pulsatile abdominal mass, and abrupt abdominal/back/flank pain. Unstable patients go straight to emergent surgical repair; stable patients can have CT angiography. AAA repair is indicated at diameter >=5.5 cm, rapid growth, or symptoms.

16. How are acute respiratory failure types I and II distinguished by ABG?

    Type I (hypoxemic): PaO2 <60 mmHg with normal/low PaCO2 (e.g., pneumonia, ARDS, PE). Type II (hypercapnic): PaCO2 >50 mmHg with respiratory acidosis (e.g., COPD, neuromuscular weakness, drug overdose).

17. What are the Berlin criteria for diagnosing ARDS?

    (1) Acute onset within 1 week of insult; (2) bilateral pulmonary infiltrates on imaging not fully explained by effusion/atelectasis; (3) not fully explained by cardiac failure/fluid overload (PCWP <=18 or no LA hypertension); (4) hypoxemia by PaO2/FiO2: mild 200-300, moderate 100-200, severe <100 (on PEEP >=5).

18. What is the lung-protective ventilation strategy for ARDS?

    Low tidal volume (6 mL/kg ideal body weight), plateau pressure <30 cmH2O, permissive hypercapnia, adequate PEEP, and prone positioning for severe ARDS (PaO2/FiO2 <150). This strategy reduces mortality.

19. What is the stepwise treatment of an acute COPD exacerbation?

    Inhaled short-acting bronchodilators (albuterol + ipratropium), systemic corticosteroids (e.g., prednisone 40 mg x5 days), antibiotics if increased dyspnea + sputum volume + purulence, controlled oxygen targeting SpO2 88-92%, and noninvasive positive-pressure ventilation (BiPAP) for respiratory acidosis (pH <7.35).

20. What defines status asthmaticus and how is a severe asthma exacerbation managed?

    Severe asthma unresponsive to initial bronchodilators. Management: continuous/repeated nebulized albuterol + ipratropium, systemic corticosteroids, IV magnesium sulfate, oxygen; consider intubation for fatigue, silent chest, or rising PaCO2 (a normalizing/rising CO2 in a tiring asthmatic signals impending respiratory failure).

21. What is the Wells criteria-based diagnostic pathway for suspected pulmonary embolism?

    Low/intermediate probability (Wells <=4): obtain D-dimer-if negative, PE excluded; if positive, do CT pulmonary angiography. High probability (Wells >4): go directly to CTPA. Use V/Q scan if contrast/contraindication to CT (e.g., renal failure).

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