What is the initial empiric antibiotic regimen and oxygenation target for an acute exacerbation of Chronic Obstructive Pulmonary Disease (COPD)?

Supplemental oxygen targeting SpO2 88–92% (avoiding hypercapnic respiratory drive blunting), inhaled short-acting bronchodilators (Albuterol + Ipratropium), systemic oral Prednisone (40 mg x 5 days), and empiric antibiotics (Azithromycin or Doxycycline or Amox-Clav).

What is the diagnosis and empiric antibiotic therapy for Spontaneous Bacterial Peritonitis (SBP)?

Diagnostic paracentesis showing ascitic fluid absolute neutrophil count (ANC) >=250 cells/mm3. Empiric therapy: IV third-generation cephalosporin (Cefotaxime or Ceftriaxone) plus IV Albumin (on days 1 and 3) to prevent hepatorenal syndrome.

What are the classic Light's criteria used to distinguish exudative from transudative pleural effusions?

Effusion is exudative if >=1 of the following: 1. Pleural fluid protein / serum protein ratio >0.5; 2. Pleural fluid LDH / serum LDH ratio >0.6; 3. Pleural fluid LDH > 2/3 the upper limit of normal serum LDH.

What are the hallmarks and initial resuscitation guidelines for Septic Shock?

Persistent sepsis-induced hypotension requiring vasopressors to maintain MAP >=65 mmHg and serum lactate >2 mmol/L despite adequate fluid resuscitation. Early management (within 1 hour): Blood cultures before broad-spectrum IV antibiotics, 30 mL/kg IV crystalloids, and Norepinephrine as first-line vasopressor.

How do you differentiate Pre-renal Acute Kidney Injury (AKI) from Acute Tubular Necrosis (ATN) based on urinary indices?

Pre-renal: BUN/Cr ratio >20:1, Urine Osmolality >500 mOsm/kg, Urine Na 40 mEq/L, FeNa >2% ('muddy brown' granular casts).

What are the classic physical exam and echocardiographic findings of Cardiac Tamponade?

Beck's Triad: Hypotension, Jugular venous distension, and muffled heart sounds; plus Pulsus Paradoxus (SBP drop >10 mmHg on inspiration). Echo shows diastolic collapse of the right atrium and right ventricle, and IVC plethora.

What is the dangerous complication of correcting severe chronic Hypernatremia too rapidly?

Cerebral edema and brain herniation caused by rapid water shift into hypertonic neuronal cells ('from high to low, the brain will blow').

What mechanical ventilation strategy is proven to reduce mortality in patients with ARDS?

Low tidal volume ventilation (lung-protective ventilation: 4–8 mL/kg of predicted body weight) targeting plateau airway pressure <=30 cm H2O, coupled with permissive hypercapnia and titration of PEEP.

What are the classic laboratory findings and diagnostic confirmation test for Primary Adrenal Insufficiency (Addison Disease)?

Hyponatremia, hyperkalemia, non-anion gap metabolic acidosis, and hypoglycemia with elevated ACTH and skin hyperpigmentation. Confirmed by Cosyntropin (synthetic ACTH) stimulation test demonstrating failure of serum cortisol to rise >=18 mcg/dL.

What is the hallmark presentation and diagnostic workup of Nephrotic Syndrome in adults?

Proteinuria >3.5 g/day, hypoalbuminemia (<3.0 g/dL), peripheral edema, hyperlipidemia, and lipiduria ('Maltese cross' oval fat bodies). Workup includes renal biopsy to distinguish FSGS, Membranous nephropathy, or Minimal change disease.

What is the definition of Hepatorenal Syndrome and its initial medical management?

Functional renal failure in advanced cirrhosis with portal hypertension and ascites, with absence of intrinsic renal disease or shock. Management: Volume expansion with IV Albumin plus splanchnic vasoconstrictors (Terlipressin, or Octreotide + Midodrine, or Norepinephrine).

What is the next best diagnostic step in a solitary pulmonary nodule (<30 mm) found incidentally with high-risk features on chest CT?

Flexible bronchoscopy with biopsy or percutaneous transthoracic needle biopsy if intermediate probability, or surgical resection (VATS/wedge resection) if high pretest probability of malignancy.

What is the management difference between Stanford Type A and Stanford Type B Aortic Dissections?

Type A (involves ascending aorta): Emergent open surgical repair (high risk of cardiac tamponade, aortic rupture, coronary occlusion). Type B (descending aorta distal to left subclavian): Medical management with aggressive blood pressure and heart rate control (unless complicated by malperfusion/rupture).

What four drug classes form the guideline-directed medical therapy (GDMT) backbone that reduces mortality in Heart Failure with Reduced Ejection Fraction (HFrEF)?

1. ARNI (Sacubitril-Valsartan) or ACEi/ARB; 2. Beta-blocker (Carvedilol, Metoprolol succinate, or Bisoprolol); 3. Mineralocorticoid receptor antagonist (Spironolactone or Eplerenone); 4. SGLT2 inhibitor (Empagliflozin or Dapagliflozin).

What interventions shift potassium intracellularly in acute hyperkalemia following membrane stabilization?

1. Intravenous regular insulin (10 units) with 50 mL 50% Dextrose (D50W); 2. High-dose inhaled Beta-2 agonist (Albuterol); 3. Intravenous Sodium Bicarbonate (if concurrent metabolic acidosis).

What is the immediate, life-saving first step in the management of severe Hyperkalemia with ECG changes (peaked T waves, widened QRS)?

Intravenous Calcium Gluconate (10%) or Calcium Chloride to stabilize the cardiac myocyte membrane against fatal arrhythmias (does not alter serum potassium levels).

What is the immediate management for a hemodynamically UNSTABLE patient (hypotension, SBP <90 mmHg) with massive Acute Pulmonary Embolism?

Intravenous systemic thrombolysis (tissue plasminogen activator, Alteplase/tPA) or catheter-directed embolectomy/surgical thrombectomy if thrombolytic contraindications exist, alongside supportive IV fluids and oxygen/vasopressors.

What are the definitive ECG criteria and immediate treatment for Ventricular Fibrillation (VF) or Pulseless Ventricular Tachycardia (pVT)?

Immediate unsynchronized defibrillation (shock) followed by immediate CPR for 2 minutes before rhythm/pulse check; intravenous Epinephrine 1 mg every 3–5 minutes and Amiodarone (300 mg bolus, then 150 mg) for shock-refractory VF/pVT.

What physical exam signs indicate Severe Aortic Stenosis?

Pulsus parvus et tardus (slow-rising, weak carotid pulse), late-peaking systolic ejection murmur at the right upper sternal border radiating to carotids, and soft or absent second heart sound (single S2 / paradoxically split S2).

What is the classic clinical triad and urinalysis finding of Acute Interstitial Nephritis (AIN)?

Triad: Fever, maculopapular rash, and peripheral eosinophilia (often drug-induced by PPIs, NSAIDs, penicillins). Urinalysis shows WBC casts, sterile pyuria, and urinary eosinophils (Hansel or Wright stain).

What is the diagnostic test of choice and management for a patient presenting with classic symptoms of Pheochromocytoma?

24-hour urinary fractionated metanephrines and catecholamines or plasma free metanephrines. Management: Alpha-adrenergic blockade first (Phenoxybenzamine) for 10–14 days, followed by Beta-blockers 2–3 days prior to surgical adrenalectomy.

What are the emergency indications for Hemodialysis in acute kidney injury ('AEIOU')?

A = Acidosis (refractory metabolic acidosis pH 6.5 mEq/L or with ECG changes); I = Ingestions (salicylates, lithium, ethylene glycol, methanol); O = Overload (refractory pulmonary edema); U = Uremia (uremic pericarditis, encephalopathy, bleeding).

What is the CHADS2-VASc score used for, and at what threshold is oral anticoagulation recommended in nonvalvular Atrial Fibrillation?

Stratifies stroke risk in nonvalvular AF. Direct oral anticoagulants (DOACs: Apixaban, Rivaroxaban, Dabigatran) are recommended for men with score >=2 and women with score >=3 (score of 1 in men or 2 in women may be considered).

What is the definitive initial management for acute ST-Elevation Myocardial Infarction (STEMI)?

Emergent Primary Percutaneous Coronary Intervention (PCI) with a door-to-balloon time <90 minutes (or <120 minutes if transferred). If PCI cannot be performed within 120 minutes, administer intravenous fibrinolysis within 30 minutes of arrival.

What is the diagnostic approach and primary medical treatment for Primary Hyperaldosteronism (Conn Syndrome)?

Screening with morning plasma aldosterone concentration to plasma renin activity ratio (PAC/PRA >20 with PAC >15 ng/dL), confirmed by oral sodium loading or saline suppression test. Medical treatment: Mineralocorticoid receptor antagonists (Spironolactone or Eplerenone).

What is the dangerous complication of correcting chronic severe Hyponatremia too rapidly, and what is the maximum recommended correction rate?

Osmotic Demyelination Syndrome (Central Pontine Myelinolysis). Correct serum sodium by no more than 8–10 mEq/L in a 24-hour period ('from low to high, your pons will die').

What is the diagnostic test of choice and initial management for suspected Acute Aortic Dissection in a hemodynamically stable patient?

CT Angiography of the chest and abdomen (or TEE if unstable/renal failure). Initial management: IV Beta-blockers (Esmolol or Labetalol) targeting SBP 100–120 mmHg and HR <60 bpm before initiating vasodilators like Nitroprusside.

What is the acute management of stable, symptomatic Paroxysmal Supraventricular Tachycardia (PSVT / AVNRT)?

1. Vagal maneuvers (Valsalva, carotid sinus massage). 2. If unsuccessful, rapid intravenous bolus of Adenosine (6 mg, followed by 12 mg if needed). If patient becomes hemodynamically unstable, perform immediate synchronized cardioversion.

What is the initial diagnostic test of choice in a hemodynamically stable patient with high clinical probability for Acute Pulmonary Embolism (PE)?

CT Pulmonary Angiography (CTPA). If renal insufficiency or severe iodinated contrast allergy is present, perform a Ventilation-Perfusion (V/Q) lung scan.

What is the definitive acute treatment for Cardiac Tamponade?

Emergent ultrasound-guided pericardiocentesis or surgical creation of a pericardial window.

What are the Berlin Definition criteria for Acute Respiratory Distress Syndrome (ARDS)?

1. Acute onset within 1 week of clinical insult; 2. Bilateral opacities on chest radiography not fully explained by effusions/atelectasis/masses; 3. Respiratory failure not fully explained by cardiac failure/fluid overload; 4. PaO2/FiO2 ratio =5 cm H2O.

What are the indications for Aortic Valve Replacement (AVR) in severe aortic stenosis?

Onset of any classic symptoms (Angina, Syncope, Dyspnea/Heart failure) or asymptomatic patients with Left Ventricular Ejection Fraction (LVEF) <50% or undergoing other cardiac surgery.

USMLE Step 2 CK — Internal Medicine, Cardiology, Pulmonology & Nephrology Management

Evidence-based clinical guidelines, next best steps in management, acute coronary syndromes, heart failure, pulmonary embolism, ARDS, and acute kidney injury.

Level: advanced
Languages: en → en
Cards: 32
Markdown: USMLE Step 2 CK — Internal Medicine, Cardiology, Pulmonology & Nephrology Management (.md)

Flashcards (32)

#	Front (Term / Question)	Back (Definition / Answer)
1	What is the initial empiric antibiotic regimen and oxygenation target for an acute exacerbation of Chronic Obstructive Pulmonary Disease (COPD)?	Supplemental oxygen targeting SpO2 88–92% (avoiding hypercapnic respiratory drive blunting), inhaled short-acting bronchodilators (Albuterol + Ipratropium), systemic oral Prednisone (40 mg x 5 days), and empiric antibiotics (Azithromycin or Doxycycline or Amox-Clav).
2	What is the diagnosis and empiric antibiotic therapy for Spontaneous Bacterial Peritonitis (SBP)?	Diagnostic paracentesis showing ascitic fluid absolute neutrophil count (ANC) >=250 cells/mm3. Empiric therapy: IV third-generation cephalosporin (Cefotaxime or Ceftriaxone) plus IV Albumin (on days 1 and 3) to prevent hepatorenal syndrome.
3	What are the classic Light's criteria used to distinguish exudative from transudative pleural effusions?	Effusion is exudative if >=1 of the following: 1. Pleural fluid protein / serum protein ratio >0.5; 2. Pleural fluid LDH / serum LDH ratio >0.6; 3. Pleural fluid LDH > 2/3 the upper limit of normal serum LDH.
4	What are the hallmarks and initial resuscitation guidelines for Septic Shock?	Persistent sepsis-induced hypotension requiring vasopressors to maintain MAP >=65 mmHg and serum lactate >2 mmol/L despite adequate fluid resuscitation. Early management (within 1 hour): Blood cultures before broad-spectrum IV antibiotics, 30 mL/kg IV crystalloids, and Norepinephrine as first-line vasopressor.
5	How do you differentiate Pre-renal Acute Kidney Injury (AKI) from Acute Tubular Necrosis (ATN) based on urinary indices?	Pre-renal: BUN/Cr ratio >20:1, Urine Osmolality >500 mOsm/kg, Urine Na <20 mEq/L, FeNa <1% (hyaline casts). ATN: BUN/Cr ratio <15:1, Urine Osmolality <350 mOsm/kg, Urine Na >40 mEq/L, FeNa >2% ('muddy brown' granular casts).
6	What are the classic physical exam and echocardiographic findings of Cardiac Tamponade?	Beck's Triad: Hypotension, Jugular venous distension, and muffled heart sounds; plus Pulsus Paradoxus (SBP drop >10 mmHg on inspiration). Echo shows diastolic collapse of the right atrium and right ventricle, and IVC plethora.
7	What is the dangerous complication of correcting severe chronic Hypernatremia too rapidly?	Cerebral edema and brain herniation caused by rapid water shift into hypertonic neuronal cells ('from high to low, the brain will blow').
8	What mechanical ventilation strategy is proven to reduce mortality in patients with ARDS?	Low tidal volume ventilation (lung-protective ventilation: 4–8 mL/kg of predicted body weight) targeting plateau airway pressure <=30 cm H2O, coupled with permissive hypercapnia and titration of PEEP.
9	What are the classic laboratory findings and diagnostic confirmation test for Primary Adrenal Insufficiency (Addison Disease)?	Hyponatremia, hyperkalemia, non-anion gap metabolic acidosis, and hypoglycemia with elevated ACTH and skin hyperpigmentation. Confirmed by Cosyntropin (synthetic ACTH) stimulation test demonstrating failure of serum cortisol to rise >=18 mcg/dL.
10	What is the hallmark presentation and diagnostic workup of Nephrotic Syndrome in adults?	Proteinuria >3.5 g/day, hypoalbuminemia (<3.0 g/dL), peripheral edema, hyperlipidemia, and lipiduria ('Maltese cross' oval fat bodies). Workup includes renal biopsy to distinguish FSGS, Membranous nephropathy, or Minimal change disease.
11	What is the definition of Hepatorenal Syndrome and its initial medical management?	Functional renal failure in advanced cirrhosis with portal hypertension and ascites, with absence of intrinsic renal disease or shock. Management: Volume expansion with IV Albumin plus splanchnic vasoconstrictors (Terlipressin, or Octreotide + Midodrine, or Norepinephrine).
12	What is the next best diagnostic step in a solitary pulmonary nodule (<30 mm) found incidentally with high-risk features on chest CT?	Flexible bronchoscopy with biopsy or percutaneous transthoracic needle biopsy if intermediate probability, or surgical resection (VATS/wedge resection) if high pretest probability of malignancy.
13	What is the management difference between Stanford Type A and Stanford Type B Aortic Dissections?	Type A (involves ascending aorta): Emergent open surgical repair (high risk of cardiac tamponade, aortic rupture, coronary occlusion). Type B (descending aorta distal to left subclavian): Medical management with aggressive blood pressure and heart rate control (unless complicated by malperfusion/rupture).
14	What four drug classes form the guideline-directed medical therapy (GDMT) backbone that reduces mortality in Heart Failure with Reduced Ejection Fraction (HFrEF)?	1. ARNI (Sacubitril-Valsartan) or ACEi/ARB; 2. Beta-blocker (Carvedilol, Metoprolol succinate, or Bisoprolol); 3. Mineralocorticoid receptor antagonist (Spironolactone or Eplerenone); 4. SGLT2 inhibitor (Empagliflozin or Dapagliflozin).
15	What interventions shift potassium intracellularly in acute hyperkalemia following membrane stabilization?	1. Intravenous regular insulin (10 units) with 50 mL 50% Dextrose (D50W); 2. High-dose inhaled Beta-2 agonist (Albuterol); 3. Intravenous Sodium Bicarbonate (if concurrent metabolic acidosis).
16	What is the immediate, life-saving first step in the management of severe Hyperkalemia with ECG changes (peaked T waves, widened QRS)?	Intravenous Calcium Gluconate (10%) or Calcium Chloride to stabilize the cardiac myocyte membrane against fatal arrhythmias (does not alter serum potassium levels).
17	What is the immediate management for a hemodynamically UNSTABLE patient (hypotension, SBP <90 mmHg) with massive Acute Pulmonary Embolism?	Intravenous systemic thrombolysis (tissue plasminogen activator, Alteplase/tPA) or catheter-directed embolectomy/surgical thrombectomy if thrombolytic contraindications exist, alongside supportive IV fluids and oxygen/vasopressors.
18	What are the definitive ECG criteria and immediate treatment for Ventricular Fibrillation (VF) or Pulseless Ventricular Tachycardia (pVT)?	Immediate unsynchronized defibrillation (shock) followed by immediate CPR for 2 minutes before rhythm/pulse check; intravenous Epinephrine 1 mg every 3–5 minutes and Amiodarone (300 mg bolus, then 150 mg) for shock-refractory VF/pVT.
19	What physical exam signs indicate Severe Aortic Stenosis?	Pulsus parvus et tardus (slow-rising, weak carotid pulse), late-peaking systolic ejection murmur at the right upper sternal border radiating to carotids, and soft or absent second heart sound (single S2 / paradoxically split S2).
20	What is the classic clinical triad and urinalysis finding of Acute Interstitial Nephritis (AIN)?	Triad: Fever, maculopapular rash, and peripheral eosinophilia (often drug-induced by PPIs, NSAIDs, penicillins). Urinalysis shows WBC casts, sterile pyuria, and urinary eosinophils (Hansel or Wright stain).
21	What is the diagnostic test of choice and management for a patient presenting with classic symptoms of Pheochromocytoma?	24-hour urinary fractionated metanephrines and catecholamines or plasma free metanephrines. Management: Alpha-adrenergic blockade first (Phenoxybenzamine) for 10–14 days, followed by Beta-blockers 2–3 days prior to surgical adrenalectomy.
22	What are the emergency indications for Hemodialysis in acute kidney injury ('AEIOU')?	A = Acidosis (refractory metabolic acidosis pH <7.1); E = Electrolytes (severe refractory hyperkalemia >6.5 mEq/L or with ECG changes); I = Ingestions (salicylates, lithium, ethylene glycol, methanol); O = Overload (refractory pulmonary edema); U = Uremia (uremic pericarditis, encephalopathy, bleeding).
23	What is the CHADS2-VASc score used for, and at what threshold is oral anticoagulation recommended in nonvalvular Atrial Fibrillation?	Stratifies stroke risk in nonvalvular AF. Direct oral anticoagulants (DOACs: Apixaban, Rivaroxaban, Dabigatran) are recommended for men with score >=2 and women with score >=3 (score of 1 in men or 2 in women may be considered).
24	What is the definitive initial management for acute ST-Elevation Myocardial Infarction (STEMI)?	Emergent Primary Percutaneous Coronary Intervention (PCI) with a door-to-balloon time <90 minutes (or <120 minutes if transferred). If PCI cannot be performed within 120 minutes, administer intravenous fibrinolysis within 30 minutes of arrival.
25	What is the diagnostic approach and primary medical treatment for Primary Hyperaldosteronism (Conn Syndrome)?	Screening with morning plasma aldosterone concentration to plasma renin activity ratio (PAC/PRA >20 with PAC >15 ng/dL), confirmed by oral sodium loading or saline suppression test. Medical treatment: Mineralocorticoid receptor antagonists (Spironolactone or Eplerenone).
26	What is the dangerous complication of correcting chronic severe Hyponatremia too rapidly, and what is the maximum recommended correction rate?	Osmotic Demyelination Syndrome (Central Pontine Myelinolysis). Correct serum sodium by no more than 8–10 mEq/L in a 24-hour period ('from low to high, your pons will die').
27	What is the diagnostic test of choice and initial management for suspected Acute Aortic Dissection in a hemodynamically stable patient?	CT Angiography of the chest and abdomen (or TEE if unstable/renal failure). Initial management: IV Beta-blockers (Esmolol or Labetalol) targeting SBP 100–120 mmHg and HR <60 bpm before initiating vasodilators like Nitroprusside.
28	What is the acute management of stable, symptomatic Paroxysmal Supraventricular Tachycardia (PSVT / AVNRT)?	1. Vagal maneuvers (Valsalva, carotid sinus massage). 2. If unsuccessful, rapid intravenous bolus of Adenosine (6 mg, followed by 12 mg if needed). If patient becomes hemodynamically unstable, perform immediate synchronized cardioversion.
29	What is the initial diagnostic test of choice in a hemodynamically stable patient with high clinical probability for Acute Pulmonary Embolism (PE)?	CT Pulmonary Angiography (CTPA). If renal insufficiency or severe iodinated contrast allergy is present, perform a Ventilation-Perfusion (V/Q) lung scan.
30	What is the definitive acute treatment for Cardiac Tamponade?	Emergent ultrasound-guided pericardiocentesis or surgical creation of a pericardial window.
31	What are the Berlin Definition criteria for Acute Respiratory Distress Syndrome (ARDS)?	1. Acute onset within 1 week of clinical insult; 2. Bilateral opacities on chest radiography not fully explained by effusions/atelectasis/masses; 3. Respiratory failure not fully explained by cardiac failure/fluid overload; 4. PaO2/FiO2 ratio <=300 with PEEP >=5 cm H2O.
32	What are the indications for Aortic Valve Replacement (AVR) in severe aortic stenosis?	Onset of any classic symptoms (Angina, Syncope, Dyspnea/Heart failure) or asymptomatic patients with Left Ventricular Ejection Fraction (LVEF) <50% or undergoing other cardiac surgery.