High Yield USMLE step 2 CK lecture notes

High Yield USMLE step 2 CK lecture notes

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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 'what is the diagnosis' (around
30% of questions) and 'Next best step in the management' of the patient 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 diseases.

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

MY NOTES COVER ALL SUBJECTS [INTERNAL MEDICINE, SURGERY, PEDIATRICS,
PSYCHIATRY & OB-GYN] SYSTEM WISE. THEY ARE NOT WRITTEN SEPARATELY.

19th Aug 2009: Recently I have received so many questions regarding which subjects do these
notes cover.

During new modification, I have included everything system wise like orthopedics in
muskuloskeletal, trauma separately for surgery, ob-gyn in reproductive system, congenital heart
defect, rheumatic fever in cardiology, immunization in infectious disease and like wise. Please
go through all pages carefully. I have combined everything during my last revision in 2009 but
You will not miss any high yield subjects or topics.

I AM 100% SURE THAT ONCE YOU BUY THIS MATERIAL YOU WILL NOT READ ANY OTHER
MATERIAL FOR REVIEW.

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:

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.
Usually occur in morning, cold weather. Pain may relieve by little exercise like patient gets up and walk & pain
relieved (Physiology: 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]

How will you differentiate between unstable / Prinzmetal angina and MI? Angina means chest
pain comes and goes so even though chest pain occur at rest in unstable / Prinzmetal angina, you can
easily diagnose from the presentation in the question.

Best Initial test: EKG; Stress test for Stable angina
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, Bypass

Approach to patient present with Chest pain:

If hx, initial EKG & cardiac biomarkers negative – admit the pt and repeat EKG and biomarkers in 6-12
h
If initial EKG & biomarkers are nl, but high suspicion from hx – admit the pt and r/o CAD with stress test
/ angiography – if high risk pt [> 65 yr, prior CAD / ACS] – admit and evaluate for ischemia by stress
test or angiography [useful in further Mx – Angioplasty / Bypass] – if low risk [<65 yrs, no prior CAD /
ACS] – can do out patient stress test within 72 h
If second EKG & biomarkers are nl and low suspicion from hx – ruled out MI so start looking for other
causes of chest pain
If initial EKG & biomarkers are positive – admit & start treatment as per below

Patient with Stable/Unstable angina and MI should receive Aspirin, Nitrates and b-blockers (if no
contraindications like Asthma, low BP, Heart block etc.)
Patient should also receive oxygen (if oxygen saturation is low) and morphine (if patient is still having
chest pain; presence of pulmonary edema)
Stable Angina: once you make diagnosis of stable angina from stress test, do an angiography in high
risk patients (pt) [high risk stress test result (see below), angina despite of medical treatment, prior CAD,
occupation need for definitive diagnosis (pilot), age >65 yrs] which helps in further management like
medical Tx / Angioplasty / Bypass graft. In general, for stable angina without critical anatomy and ↓EF,
focus on medical Tx; If revascularization is required, angioplasty is preferred in limited number of discrete
lesions (normal EF, no DM); if 3 vessels disease or left main coronary artery disease on angiography, go
for bypass [CABG] [CABG has shown reduce in mortality in pt with 3 vessel disease & left main
coronary artery stenosis compare to Angioplasty]
Unstable Angina (due to vessel blockage by plaque so clot is forming): Neg CK-MB and Troponins
Non ST elevation MI [NSTEMI]: Positive CK-MB & Troponins (Tn)
Approach to UA & NSTEMI: Low risk Patients (neg CK-MB & Tn, no ST depression, <2 high
risk pt factors) – Medical Tx [Aspirin, Morphine + Nitrates + b-blockers + oxygen + morphine] +
Heparin (to prevent further clotting) (not thrombolytics)] → Stress test once patient is stable / before
discharge (D/C) → Angiography (only if recurrent angina or high risk stress test result) which helps in
deciding Med Tx / Angioplasty / CABG. Clopidogrel (only if angioplasty is planned). High risk Pt
(positive CK-MB & Tn, ST depression or elevation, >3 high risk pt factors] Med Tx as mentioned
above → Angiography which helps in deciding Med Tx / Angioplasty / CABG
STEMI (due to vessel blockage from disrupted plaques so clot is already formed): Angioplasty Vs
Thrombolytics → Thrombolytics [early presentation (<3 hrs) & delay in angioplasty] Vs Angioplasty
[Door-Balloon time <90 mins] + Medical Tx [Aspirin, Morphine + Nitrates + b-blockers + oxygen +
morphine] + Clopidogrel (only if angioplasty is planned) + Statins + Low molecular weight Heparin (If
not contraindicated) + ACE inhibitors (only If CHF, ↓EF, Ant wall MI) + Lidocaine (only If
ventricular arrhythmias)

Angioplasty is superior than thrombolytics for Unstable angina & MI but it is not readily available all the
time [Door-balloon time should be <90 min for maximum benefit. If delays in angioplasty, give
thrombolytics]

Criteria to use thrombolytics (If it is not contraindicated, if Angioplasty is not readily available) [C/I: prior
ICH, active internal bleeding, etc]

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

High Risk Pt Factors: age >65 yrs, >3 risk factors (DM, HTN, Smoking, ↑ lipids), recent PCI, prior
CAD, ST elevation >0.5 mm, positive CK-MB & Tn, ↓EF
CCB can be used in patients in whom b-blockers are contraindicated
Clopidogrel can be used in patient with ASA allergy

Different Clinical Scenario:

If patient comes to the office with c/o chest pain off & on but no pain at present, what will you do first? –
Stress test (EKG may not show anything cause no pain now so r/o CAD by stress testing)
If patient comes to the office with c/o chest pain off & on but no pain at present, on examination you find
4/6 grade systolic murmur / known case of AS, what will you do first? - Echocardiogram [Stress test is
C/I in symptomatic AS]
Patient with past medical h/o CAD & other comorbidities (which restrict from exercise) present with
symptoms suggestive of ischemia (i.e. c/o chest discomfort or feeling heavy in chest for few mins and
goes away, etc), next step? – Pharmacological Stress Testing [eg. Adenosine myocardial perfusing scan]
(to see the progression of ischemia and risk stratification of CAD) [Adenosine and Dipyridamole scan
are C/I in patient with COPD / Asthma. Use Dobutamine in those patient][Dobutamine may precipitate
tachyarrhythmias]
If above scenario but patient is able to exercise, next step? – exercise stress test
Different scenario for Stress Testing: Patient present with typical / atypical intermittent chest pain
(exercise stress test); Patient present with typical / atypical intermittent chest pain with comorbidities
which restrict patient from doing exercise (Adenosine scan); Patient present with typical / atypical
intermittent chest pain with comorbidities which restrict patient from doing exercise and has Asthma /
COPD (Dobutamine scan)
Patient with previous Unstable angina / MI / bypass present with typical intermittent chest pain,
EKG show changes (depression / elevation) or Stress test show ST depression / elevation, pt is on initial
treatment for chest pain, next step? Angiography (useful in further Mx – Angioplasty / Bypass)
Any male patient present with chest pain (usually 2-3 hrs after dinner to confuse us on the exam), next
step? – EKG. If EKG is done & is normal and patient’s pain relieved by sub-lingual nitroglycerine, next
step? – admit the patient and serial monitoring of cardiac enzymes (always rule out cardiac problem first)
Any male present with chest pain which didn’t relieve by nitroglycerine & EKG is non-specific, next
step? – admit the patient and serial monitoring of cardiac enzymes (always try to rule out cardiac cause
first)
Cocaine induced transmural ischemia (ST elevation on EKG), next step? – initial management of
ischemia (Oxygen, Aspirin, Nitroglycerin, Morphine) and Benzodiazepines; If patient continues to have
pain after administration of benzodiazepines, next step? – Give Phentolamine [alpha1-blocker] [cocaine
causes increase in Norepinephrine which causes HTN by prominent alpha1 action] – If still c/o pain, next
step? – Angiography
_________________________________________________________________________

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.

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

Croup – give trial of epinephrine before intubation
Acute epiglotitis – Laryngoscopy – intubation then IV ceftriaxone.

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immediately by clicking on "Click here" to download Quick USMLE Review Notes for Step
2 CK.

"Click Here" to know more about new modification

Lot of my buyers,
first buy my step 1
notes and after that
they buy my step 2
CK notes because
they liked my step 1
notes. Buy in save
some money. I
have just started
selling my step 2 CS
note.

Want to SAVE some
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check all feedbacks
in detail

Not only those who failed first time but also those who took exam first time and
have less time (3-4 weeks) for review, found these notes very useful.

Recent Updates:

Nov 10, 2009
NEW LIVE CHAT
when I'm available
Time: 7-9 PM

Free Sample Notes:
(Just click on it)

Internal Medicine
Gynecology

Sept 09, 2008

OB-GYN notes are
now typed.

Medicine is like a never
ending encyclopedia. It
is almost impossible to
remember everything
but We still have to
remember a
tremendous amount of
information. For the
USMLE exam, we all
read many different
materials but at the
end we can't go
through all the material
efficiently and that's
why we all need a high
yield notes which
contain all the
information we need
for this exam. Reason
for making these notes
is to simplify everything
in an easy to remember
way and cover all high
yield topics that are
most likely to be on the
real exam so we can
quickly review them at
last minute. There are
only 149 pages in my
step 2 notes.

Example: Check out my
Sample Internal
Medicine notes +
Gynecology notes and
then do some
questions from the
topics that I have
covered in my Sample
Internal Medicine notes
and Gynecology notes.
You will find more
than 70% of questions
from these notes.
Same is true for the
real exam. Hope you
will find my notes
helpful.

Oct 7, 2008

New comment I
received from my
recent buyer:

Hi Sir,
Remember me?
I got the Hy notes from
u during the last 4 days
of prep for step2!
Its actually for my
brother!
He got 92!

Thanks so much!
Keep going!

May 28, 2009

New comment I
received from my
recent buyer:

Hi Dear Dr. :

I had just passed my
step 2 CK 202/83...Not
a beutiful score but
PASSED!!

All i want to say is
Thank you so so
sssooo much!
I and so glad that i
found ur note in eBay
and bought it!

Now i plan to take CS
at the end of year, do
u have any suggest?

Thank you~~~ ^o^

You need Java to see this applet.

Price: $29.99

Aug 12, 2010
I have gone to the
nearby computer store
to instal winzip and I
have already
successfully made the
copies of the notes.
They are excellent.
Please do not worry
anymore, I am OK
now. I appreciate
your help.

Moreover. do you have
anything that will help
me on computer case
simulation to buy or
any idear that will help
me on that purpose ?

Once more , I thank
you immensely for your
help
________________

Aug 10, 2010
First, is page 49 of
your step 3 notes
blank? I recently
bought and dowloaded
the notes and pg 49
was blank.

Second, have you
heard of usmleconsult
Qbank (step 3) ? If
yes, do you
recommend?

Lastly, this is the most
organized notes I have
ever had. I wish I had
them before I took my
steps 1 & 2. I am IMG
and I need a high
score in step 3 to
make up for my low
scores in steps 1 & 2.

Keep up the good work
________________

Jun 17, 2010
Thank you, for replying
so promptly. I
previously purchased
step 2 ck from you and
it was excellent in
helping me to ace my
exam. Consequently, I
will use your cs notes
along with FA. I will
keep checking my
email.