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

24 sample cards from the USMLE Step 2 CK: Internal Medicine & Subspecialties deck

Sampled from the end of the deck, so these are different cards from the ones shown on the syllabus page.

1. What is the first-line pharmacologic therapy for type 2 diabetes and which agents have cardiovascular/renal benefit?

   Metformin is first-line. SGLT2 inhibitors and GLP-1 receptor agonists provide cardiovascular and renal benefit and are preferred add-ons (or first-line) in patients with ASCVD, heart failure, or CKD.

2. How are primary hypothyroidism and hyperthyroidism distinguished by TSH/T4, and what are first-line treatments?

   Primary hypothyroidism: high TSH, low free T4 -> levothyroxine. Hyperthyroidism: low TSH, high free T4/T3 -> methimazole (PTU in first trimester/thyroid storm), beta-blocker for symptoms, +/- radioactive iodine.

3. What are the features and management of thyroid storm?

   Fever, tachyarrhythmia, agitation/delirium, GI symptoms (Burch-Wartofsky score). Treat with beta-blocker (propranolol), PTU/methimazole, then iodine (>=1 hour after thionamide), and glucocorticoids; supportive cooling and fluids.

4. How is primary adrenal insufficiency (Addison disease) diagnosed and treated, including adrenal crisis?

   Low morning cortisol with high ACTH; confirm with cosyntropin stimulation test (inadequate cortisol rise). Treat with hydrocortisone plus fludrocortisone. Adrenal crisis: high-dose IV hydrocortisone, aggressive saline, and treat precipitant.

5. What is the screening test for Cushing syndrome and the first-line test for primary hyperaldosteronism?

   Cushing: 1 mg overnight dexamethasone suppression test, late-night salivary cortisol, or 24-hr urinary free cortisol. Primary hyperaldosteronism: plasma aldosterone-to-renin ratio (elevated).

6. What defines AIDS, and when should antiretroviral therapy (ART) be started in HIV?

   AIDS = HIV with CD4 <200 cells/uL or an AIDS-defining illness. ART should be started in ALL HIV-positive patients regardless of CD4 count, as soon as possible after diagnosis.

7. What is the typical preferred first-line ART regimen for treatment-naive HIV patients?

   An integrase strand transfer inhibitor (INSTI)-based regimen, e.g., bictegravir/tenofovir alafenamide/emtricitabine, or dolutegravir plus 2 NRTIs. INSTI regimens are preferred for efficacy and tolerability.

8. At what CD4 counts are prophylaxis started for PCP, toxoplasmosis, and MAC in HIV?

   PCP: CD4 <200 -> TMP-SMX. Toxoplasmosis: CD4 <100 with positive IgG -> TMP-SMX. MAC: routine prophylaxis no longer recommended if ART started promptly; historically CD4 <50 -> azithromycin.

9. What are the core principles of antimicrobial stewardship?

   Use the narrowest effective agent, de-escalate based on culture/sensitivities, use the shortest effective duration, choose the right route, obtain cultures before antibiotics, and reassess at 48-72 hours ('antibiotic time-out').

10. Which antibiotics cover Pseudomonas aeruginosa, and which cover MRSA?

    Antipseudomonal: piperacillin-tazobactam, cefepime, ceftazidime, meropenem, ciprofloxacin, aztreonam. Anti-MRSA: vancomycin, linezolid, daptomycin (not for pneumonia), ceftaroline, TMP-SMX, doxycycline.

11. What differentiates rheumatoid arthritis from osteoarthritis clinically?

    RA: symmetric, inflammatory, MCP/PIP and wrist involvement, morning stiffness >1 hour, RF/anti-CCP positive, spares DIP. OA: asymmetric, mechanical, DIP (Heberden) and PIP (Bouchard) nodes, brief morning stiffness, no systemic inflammation.

12. How are acute gout and pseudogout distinguished on synovial fluid analysis?

    Gout: negatively birefringent, needle-shaped monosodium urate crystals (yellow when parallel to polarizer). Pseudogout (CPPD): positively birefringent, rhomboid calcium pyrophosphate crystals; chondrocalcinosis on X-ray.

13. What is the first-line treatment for an acute gout flare and for long-term urate-lowering?

    Acute flare: NSAIDs, colchicine, or glucocorticoids. Long-term urate-lowering (for recurrent attacks/tophi/stones): allopurinol or febuxostat, titrated to a serum urate <6 mg/dL; do not stop during an acute flare.

14. Compare large-, medium-, and small-vessel vasculitis with one classic example of each.

    Large-vessel: giant cell arteritis, Takayasu. Medium-vessel: polyarteritis nodosa, Kawasaki. Small-vessel: granulomatosis with polyangiitis (c-ANCA/PR3), microscopic polyangiitis and eosinophilic GPA (p-ANCA/MPO), IgA vasculitis.

15. How is giant cell (temporal) arteritis diagnosed and treated, and why is it urgent?

    Older patient with new headache, jaw claudication, vision changes, scalp tenderness, elevated ESR/CRP; confirm with temporal artery biopsy or imaging. Start high-dose glucocorticoids IMMEDIATELY (do not wait for biopsy) to prevent irreversible blindness.

16. What autoantibodies are associated with SLE, and which is most specific?

    ANA is sensitive (screening) but not specific. Anti-dsDNA (correlates with nephritis/disease activity) and anti-Smith are highly specific. Anti-Ro/La associate with neonatal lupus; antiphospholipid antibodies with thrombosis.

17. How is anemia classified by MCV, with examples of each category?

    Microcytic (MCV <80): iron deficiency, thalassemia, anemia of chronic disease, sideroblastic. Normocytic (80-100): acute blood loss, hemolysis, chronic disease, renal. Macrocytic (>100): B12/folate deficiency, alcohol, hypothyroidism, drugs, myelodysplasia.

18. How do iron deficiency and anemia of chronic disease differ on iron studies?

    Iron deficiency: low ferritin, high TIBC, low iron, low transferrin saturation. Anemia of chronic disease: low/normal-to-high ferritin, low TIBC, low iron, normal/low transferrin saturation (iron sequestration).

19. What are key oncologic emergencies and their initial management?

    Tumor lysis syndrome: hydration, allopurinol/rasburicase, treat electrolytes. Febrile neutropenia: empiric broad-spectrum antibiotics (cefepime) within 1 hour. Spinal cord compression: dexamethasone + emergent MRI + radiation/surgery. Hypercalcemia: IV fluids + bisphosphonate. SVC syndrome.

20. What are the dose-limiting toxicities of doxorubicin, bleomycin, cisplatin, and vincristine?

    Doxorubicin: cardiotoxicity (dilated cardiomyopathy). Bleomycin: pulmonary fibrosis. Cisplatin: nephrotoxicity and ototoxicity/peripheral neuropathy. Vincristine: peripheral neuropathy.

21. What are the USPSTF screening recommendations for breast, cervical, and colorectal cancer?

    Breast: biennial mammography ages 40-74. Cervical: Pap every 3 years (21-29), Pap+HPV co-test every 5 years or HPV alone (30-65). Colorectal: begin at age 45 (colonoscopy q10 yr, FIT yearly, or other options) through 75.

22. What is the lung cancer screening recommendation, and how is prostate cancer screening approached?

    Lung: annual low-dose CT for ages 50-80 with >=20 pack-year history who currently smoke or quit within 15 years. Prostate: shared decision-making for PSA ages 55-69; not routinely recommended >=70.

23. What are key components of a comprehensive geriatric assessment and the Beers criteria's purpose?

    Assessment covers function (ADLs/IADLs), cognition, mood, gait/falls, nutrition, continence, polypharmacy, and social support. Beers criteria list potentially inappropriate medications in older adults (e.g., benzodiazepines, anticholinergics, first-gen antihistamines).

24. What are the principles of palliative care and the difference between palliative care and hospice?

    Palliative care: symptom relief and quality of life at any disease stage, alongside curative treatment. Hospice: comfort-focused care for terminal illness with prognosis <=6 months, forgoing curative treatment; both emphasize patient goals.

What this deck covers

USMLE Step 2 CK: Internal Medicine & Subspecialties flashcards FAQ