Step 2 Prep 

Step 2 Prep and Checklist: Early, Dedicated, and Checklist

By Mike

Early: While preparing for your shelf exams, make sure to complete UWorld and if possible, the associated Dorian Anki cards for that shelf. These topics and similar questions will repeatedly come up on the rotations and on the NBMEs and Step 1 & 2. On each rotation, try to read about the management of your patients (I usually used UptoDate or Pubmed), especially for “bread and butter” cases for the specialty (pancreatitis, DKA in your pediatrics rotations, CHF, COPD, cirrhosis, sepsis in your medicine rotation, gallbladder pathology, post-op complications, appendicitis, hernias, hemorrhoids on your surgery rotation).

Dedicated: Take 2-4 weeks for dedicated study if possible. Often a 3-4 week step 2 prep prior to your true dedicated period consisting of completing 1-2 40 question blocks of UWorld daily will help you identify your weaknesses. I would recommend creating Anki cards based on your incorrect questions or unsuspending your incorrects from the Anking Deck. Click here for a link to our Anki Guide.

During dedicated itself, you will want to complete this checklist prior to taking Step 2:

€   Complete UWorld

€   Review UWorld Incorrects

€   Complete 2-3 NBME Forms (9-12)

€   Complete the New Free 120

€   Complete Amboss cards and associated questions: “Statistical analysis of data”, “Epidemiology”, “Quality and Safety”, and “Ethical Principles”. You are typically   allotted 5 free articles a day so you should be able to complete these even without an Amboss subscription.

€   Identify logistics of travel, caffeine source and snacks during the exam (these are important!)

For each pathology you are routinely getting incorrect, try to consider the pathophysiology of the disorder and be able to describe a clinical vignette as if you were writing the question. Consider 1) What the next step in management would be in the acute setting, 2) What the management and maintenance/surveillance (medications, lifestyle modification, rehabilitation, preventative care including vaccination) would be in the chronic setting, and 3) What risk factors for this pathology would entail.

When approaching questions, take into account the what the question writer is trying to assess. Typically, I read and highlight the first sentence of the vignette and the last sentence, which is the clinical question you are being asked. I then will read the question with that in mind. I usually start with a differential diagnosis based on the chief complaint and history and work to narrow the diagnosis based on information given in the question (just like in real life).

Using anki can be a good way to form a preliminary differential diagnosis based on certain “buzzwords” or exam findings. For example, if a patient has “tearing” chest pain, you will be more inclined to consider aortic pathology. However, using CONTEXT is more important on Step 2/NBMEs, as the prompts will often only give a few symptoms, so you will be asked to determine what pathology this presentation IS MOST CONSISTENT WITH.

For example, consider the following prompt:

1) A 65-year-old woman 1 day s/p open appendectomy complicated by perforation with peritonitis presents with dyspnea and hypoxemia. PMH includes hypothyroidism, SLE, CAD, breast adenocarcinoma s/p resection and radiation 10 years ago. Her hospital stay has been complicated by gram negative sepsis requiring 2 L Lactated Ringers and antibiotics. Her current medications include intravenous piperacillin-tazobactam (Zosyn), vancomycin, home hydroxychloroquine, levothyroxine, subcutaneous enoxaparin. Her dyspnea began 1 hour ago, and you have been paged regarding an oxygen desaturation to 85% 20 minutes ago requiring 2L O2 by NC. Vitals are HR 110 T 100.5 F BP 110/80 RR 24 SpO2 82% on 4L NC. Exam reveals JVP 7 cm without change on inspiration, increased work of breathing, and bilateral lung crackles on auscultation. DP and radial pulses are 2+ bilaterally. Cardiac examination reveals 2/6 systolic ejection murmur over the upper right sternal border without additional heart sounds. ABG reveals PaO2 59 PCo2 51. Other than IV bolus of additional fluids and continued antibiotics, what is the next step in management?

A. Spiral CT Angiography

B. Intravenous Hydrocortisone

C. Administration of Positive Pressure to the airway

D. CT of abdomen with and without contrast

E. Intravenous norepinephrine infusion

2) What is the most likely cause of her presentation?

A. Decreased cardiac contractility

B. Adrenal failure from prolonged steroid use

C. Occlusion of the pulmonary artery

D. Cytokine release and inflammation from acute insult

E. Acute myocardial ischemia

Answers

1.  C

2.  D

Approach:

A 65-year-old woman 1 day s/p open appendectomy complicated by perforation with peritonitis presents with dyspnea and hypoxemia. PMH includes hypothyroidism, SLE, CAD, breast adenocardinoma s/p resection and radiation. Her hospital stay has been complicated by gram negative sepsis requiring 2 L Lactated Ringers and antibiotics. Her current medications include intravenous piperacillin-tazobactam (Zosyn), vancomycin, home hydroxychloroquine, levothyroxine, subcutaneous enoxaparin. Her dyspnea began 1 hour ago, and the nurse has paged you regarding an oxygen desaturation to 85% 20 minutes ago requiring 2L O2 by NC. Vitals are HR 110 T 100.5 F BP 110/80 RR 24 SpO2 82% on 4L NC. Exam reveals JVP 7 cm without change on inspiration, increased work of breathing, and bilateral lung crackles on auscultation. DP and radial pulses are 2+ bilaterally. Cardiac examination reveals 2/6 systolic ejection murmur over the upper right sternal border without additional heart sounds. ABG reveals PaO2 59 PCO2 51. Other than IV bolus of additional fluids and continued antibiotics, what is the next step in management?

I start by reading the first and last sentences. I know that I will have to evaluated for a cause of dyspnea/hypoxemia (CC) and provide management for this patient. Already the question stem is telling my that we will give IV fluids and antibiotics, which clues me in to potential sepsis. Currently, my differential includes:

PE, ARDS, MI, cardiogenic shock, TRALI, central apnea/hypoventilation

As I read, I see this patient has a PMH of CAD and cancer (breast adenocarcinoma), which increase likelihood of PE and MI. She is also postop, so she may have received blood products (TRALI), opioids (hypoventilation), or had sepsis (causing ARDS). Moving onto the exam, I see that JVP is normal (6-8 cm) and there is no S3. This makes MI and cardiogenic shock less likely. I see signs of acute respiratory failure (PaO2<60 and PCO2>50 on ABG), and a SpO2/FiO2 ratio of 82%/(.21+4x0.4)=221 (this is extra, I know, but ARDS is defined by SpO2/FiO2 ratio <300.) Also, this patient failed to improve on 4L NC and has bilateral crackles on auscultation, which clues me in to ARDS, likely secondary to lung insult from sepsis. A PE is possible, but the question stem does not note any lower extremity tenderness (DVT), and she has bilateral crackles, and she has received LWMH (enoxaparin), so a PE is less likely. You should always try to rule out a PE in this setting of a post-op patient or prolonged hospitalization. She did not receive blood products, so TRALI is out. She is tachypneic, so central hypoventilation is out. Thus, her presentation is most consistent with ARDS.

When I know the diagnosis, I try to determine management on my own before reading the answers. I know in sepsis we obtain blood cultures, administer fluids and antibiotics, and pressors only if hypotension is unresponsive to volume resuscitation. For ARDS, I know these patients require PEEP, either with CPAP/BiPAP or mechanical ventilation if they are unable to protect their airway. I also know examiners love to go after ABCs (airway, breathing, circulation), which should almost always be established first before other interventions.

1)  When reading the answers, I see “C. Administration of Positive Pressure to airway”, which fits my initial thinking. I will read the other answers but none of them fit this emergent situation.

2)  ARDS is caused by acute alveolar damage at the alveolar-capillary interface following an acute insult (within 1 week) that causes increased vessel permeability and leakage of protein into alveoli. This is a type of interstitial restrictive lung disease.

Obviously in real life you won’t have the luxury of completing questions you wrote yourself but try to think about what the examiner is assessing. In this case I wanted to know the test taker understands 1) How to differentiate causes of respiratory distress in the post-operative period and 2) Management of acute situations with the ABCs.

Questions separated into 1) diagnosis, 2) next steps/management, 3) prevention/risk factors/healthcare maintenance. The NBME forms and UWorld practice exams are representative of the distribution of topics and question formats.

Lastly, confidence is important on these exams. It is important to know going into and during the exam that you are fully prepared. 

You can always theoretically “study more”, but know that NBMEs and UWorld tend to be a very accurate predictor of the content that will show up on Step 2. If you complete the checklist from earlier, you will be well prepared for the exam. 

If you are interested in predicting a score, https://www.predictmystepscore.com/ is a good resource. Best of luck!