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 What to Do in Step 2 CK  

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The purpose of this post is to help people prepare for Step 2 CK. I purposefully did not title this as 'How to get a 99 in Step 2 CK' even though I got one using these preparation techniques. The reason is that it takes more than knowing how to prepare to get a 99. How much sacrifice and effort you put into your preparation is most important.

Some of you may already know me, from my post on how to prepare for step 1. I posted it in answer to a question on 'What to Do' in Step 1, and it's purpose is to guide people in how to prepare for step 1 rather than how to get a 99 even though, again, I got one using those prep techniques. I'm posting a link to that thread:

For those who still don't know me. I am an Old IMG from the Philippines. Graduated way back in 1989. I took Step 1 last April 24, 2006 and got a 99/256. Took Step 2 CK last November 20, 2006 and got 99/258. Back in late 2004, when I started this journey and like most of you was dreaming of 99's. Whenever, I see someone posting that they got 99's, 2 things always pop up in my mind, wishing that it was me and wondering how it's done. And always, when I read what they write about how they did it, it talks of what books they read, what lecture they listened to and what QBanks they used. Of course, the problem was, everybody seems to be doing the same things and most of them are not getting 99's and some are even failing. So the only conclusion I can make is the secret does not lie in the preparation materials rather in how you used the preparation materials. And since different people have different starting points and different capabilities, their preparations and the materials they used must be adjusted accordingly.

Someone once asked me in this forum if the reason I know so much about USMLE is I had taken it before. The answer is no, this is the first time I am taking all the Steps. The reason I seem to know a lot about it is that it has always in my nature to know as much as I can about any task set before me. I have never failed an exam in my life and even though USMLE is supposed to be really tough especially for old Grads, I'm not about to let this be my first time. So, I set out to discover as much as I can about the exam, analyzing it and planning out what I hoped was a coherent well thought out study plan taking into consideration my special situation (a very old graduate) and my own prep capabilities.

It is not enough to study hard, one has to study smart too. I believe that with proper prep and hard work, anyone can pass this exam, hence this "what to do". It is also my belief that with proper prep and really hard work, most can get high 80's and even 90's. Someday I'll probably write a post about how to get double 99's but for now I'll stick to proper preparation for Step 2 CK.

So How do you prep for Step 2 CK? Well, for one thing, most of what I wrote on how to prep for Step 1 still applies to step 2. KA, KR, TP still applies, although some details differ. What to Master, Know and Be Familiar with still applies although the emphasis is radically different. There is enough differences that if you prepare for both steps in exactly the same way without adjustments, you will tend to do better in one than the other. Explains why double 99's are uncommon though.

When I started my own review, I was approaching Step 2 CK in exactly the same way I was approaching Step 1. I chose books using the same criteria, looking for books that discussed important concepts in more details rather than just using review books. It wasn't until 6 weeks into my review that I realized my error. There is a difference.

Firstly, in Step 2 CK you have to master the horses rather than the zebras. You have to know the variations in presentations of common cases their workup in detail and their treatment, including diagnostic criterias that determine whether treatment is even advised or not. Zebras still are important but they are as rare as in real life. Most cases will be typical appearance of common diseases. Atypical appearances of common disease are also common and responsible for a lot of the vagueness. As for zebras, you just have to know enough that you don't mistake them for horses.

In Step 1, there usually are more zebras than in step 2. The reason is that in Step 1, you are studying important basic medical science concepts and sometimes, these concepts are best illustrated by rare cases. For example, Prader Willi Syndrome is rare and yet illustrates a very important principle in genetics, namely imprinting. Another example, Lung CA in Step 1 will probably be Small Cell due to para-neoplastic syndrome, rather than AdenoCA and Squamous Cell which you expect to be more common in Step 2.

Next, whereas Step 1 emphasizes facts, Step 2 CK emphasizes decision making. Where Step 1 tests how much you know and understand about medicine, Step 2 concentrates primarily on your ability to use what you know and understand about medicine in decision making. 60% of what you need to know in Step 2 CK, you've learned when you did Step 1. But the 40% you don't is just as important(Which means unless you are a fairly recent grad, you still have to read Texts). Then you have to show that you have the ability to use what you know in clinical decision making.

In Step 2 CK 75% of the Q's deal with Diagnosis, Work-up and Treatment. The other 25% covers Pathophysio, Preventive Medicine, Biostatistics and Ethics.

The most important skill one should develop is the ability to diagnose the case presented even if the clinical presentation is vague. Even though most of the question will deal with Work-up and Treatment and occasionally pathophysiology, you still must be able to diagnose the case BEFORE you can even begin to think about Work-up and Treatment.

The major complaint of a lot of people (including me) about Step 2 CK is the "vagueness" of the questions. And the reason for the vagueness of the questions is the way the q's are constructed. Clinical cases are almost never presented classically in Step 2 CK which is so unlike Step 1, where almost all clinical case presentation is classical.

Someone who prepares a Step 2 CK clinical case will usually begin by writing down all the classic signs, symptoms and laboratory results for a certain diagnosis (as is done in Step 1). In the second pass, he will eliminate or alter a lot of signs, symptoms and laboratory result from the presenting case so long as it does not alter the final diagnosis, ie. If you really look at it long and hard, you will realize the diagnosis remains the same. Now to make it even more difficult, on a third pass, he will add signs, symptom and laboratory results that although positive will not really alter your main diagnosis. To make it even harder, he will put on even more irrelevant positives and negatives so you have those kilometric case, that's so hard to read, understand and clearly time-killers.

Why do this? To test if you can decide which diagnostic clues are relevant and irrelevant. In actual medical practice, patients never present classically, and part of being a good diagnostician is the ability to flesh out relevant and irrelevant facts. Which is one of the reasons why people with longer clinical experience tend to do better in Step 2, since we usually study classic clinical presentations in med school. Whereas, people with longer clinical experience tends to experience a lot of atypical cases.

For example, whereas, the classic presentation of Sarcoidosis is a black, female, in Step 2 CK don't be surprise if the patient is a white male instead. SLE is possible in males, although classically , patients are females. Not all patients with Lyme Disease will present with rash. Therefore, being able to diagnosis properly despite missing or over-abundant information is crucial to doing well. Atypical presentations abound, but they still will be common cases, therefore be careful not to mistake them for zebras.

Next, for every diagnosis, it is important to know how to work it up and treat them. However, for common cases, one should know in what order work up and treatment should be done, what steps to do depending on diagnostic test results and what to do next depending on the outcome of treatment already done. For some cases, time since presentation, is an important factor in what actions one should take. I'll illustrate this further next time.

Actually I wanted to finish the whole of part I first before posting this, however, my step 2 CS is on March 23 already and between reviewing, trip preparation and work, there is limited time to write this all down before I leave for LA. Since, I've received lots of PM's on when this will be posted, I've decided to post this. I'll try to finish them by April. There are 3 Parts, Part 1 deals with the difference between Step 1 and Step 2 CK as well as things to note about Step 2 CK. Part II which deals with preparation materials (Kaplan Notes still the best, not because it is really great but others are just not that good) and Part III, which deals with specific prep problems on Step 2 and how to deal with them. I've chosen not to rewrite preparation methods common to both Step 1 and Step 2 and advise people to just read my Step 1 post instead.

I would also like to apologize to everybody whose q's I've failed to answer, or took a long time in answering due to time constraint.

Anyway, if anyone has any questions, I will be back after the Holy Week (fon non-christians, Holy Week is first week of April) and unless you're in LA at the Hacienda Hotel between 16 and 24, I will be seeing you then.


Thx askdoc, very informative.


Great work, eagerly waiting for Parts 2 & 3....


somebody told me that the kaplan lecture notes are the abstract of the kaplan videos is that true??
PLEASE reply
because i dont want to buy the videos and find out that i wasted my money


hi spitmetal
i also thought the same but if ur patient n listen to those lect they r really informative n tell u how to approach a case esp in cardio. rheumat. respi. endo. git. neuro.......OBGYN lect r real good n i think u dont have to read kaplan book once u have gone through obgyn lect. but one thing is sure that lot of material is missin from step 2 ck kaplan books and these lect complete them. i will say its worth 40$.
good l


im sorry i meant good luck


thanks mkadi


Sorry for the late posts. Took an extended vacation. However, now I'm back and we'll continue the discussion.

Let's take an example of a case, say Acute Cholecystitis. You have to know how to diagnose it first. If diagnostic workup have not yet been done then, UTZ Abdomen is next and depending on findings either further diagnostic workup is needed or therapy. Now for therapy choice is cholecystectomy or cool it down first with fluids and anti-biotics. Here time of presentation is important. First 72 hours after start of symptom, you operate (laparoscopic chlecystectomy first choice), after 72 hours, cool down inflammation (with fluids, antibiotics) before scheduling elective cholecystectomy 5 to 6 weeks later. (Of course this is not complete as depending on diagnostic findings and therapeutic outcomes, other course of action may be needed. but this will suffice for illustration purposes only.)

The actual case presentation may end anywhere in this narrative and you are expected to know what to do next. But first you have to be able to diagnose the case since it will be presented as a case with no diagnosis.

Another example is Acetaminophen poisoning. Here time of presentation is crucial. On first 2 hour, gastric lavage, 2-4 hours activated charcoal, at 4 hour draw blood levels to decide if will use acetylcysteine. This case, time of presentation is most important criteria to decide what to do. (This case actually illustrates another problem with Step 2 CK since other sources will insists that lavage and activated charcoal is only effective first 24 hours. Will discuss this further later)

Now don't get me wrong, only about 20 to 25% of the q's will be of this type, the rest will be more straightforward and they will mostly be the more common cases. However, since we don't know how common a case should be for USMLE to consider it common, the more cases you know how to handle this way, the higher the probability you will score high, since you'll be able to answer these types of questions and still be able to answer the more straightforward question. Another advantage is that a bigger proportion of Step 3 questions will be this way and it will help you to have a leg up when you prepare for that.

So the best way to study for Step 2CK is to find diagnostic algorithms and therapeutic protocols whenever they exist. Kaplan Notes have good protocols but not complete. Step Up Medicine have some protocols, but others are just lists of diagnostic and therapeutics done for a specific case (no indication of which comes first). Blueprints also have a lot of them. I'll discuss them in more detail in part 2. You can also learn them in UW and Kaplan QBank although usually it is not presented in complete detail since the q's are focused on certain aspects of each case. The best way is to know them beforehand and see how they apply when you answer the QBanks.

If given a specific case, say acute pancreatitis, you know step by step workup and treatment, then you have mastered that case correctly.

Now another reason for the complaint of vagueness of the exam has to do with the fact that even when you have diagnosed the case correctly, one or two variables in the presentation can alter management acutely. For example, Primary Hyperparathyroidism is managed surgically except when patient is over 50 and asymptomatic. Another example, a patient you have diagnosed with hepatitis may be fulminant or suffering from hepatic encephalopathy, which changes your therapeutic and diagnostic options, and you have to be able to recognize them clinically, since the case will not tell you outright. If you noticed that all answer choices seem correct, you may have failed to notice tiny details that changes the clinical picture entirely. In contrast in Step 1, once you get the diagnosis, that's it.

One way to cover this is to know diagnostic criteria for interventions. For example, Thrombolytic therapy can only be done if there is an ST-segment elevation in 2 contiguous leads on a patient with pain onset within six hours. Failure to meet this criteria even if the case points strongly to a diagnosis of MI means you don't do thrombolytic therapy.

Now, around 15% of Step 2 CK is pathophysiology, hence if you did step one and mastered pathophysio, you have an advantage in Step 2 CK. Kaplan Medicine is not heavy on pathophysio, so Step Up Medicine is a good supplement to cover this. (It's not complete, but short of going back to Step 1 Patho or Harrison's and Cecil, this will do.) Although most pathophysio questions will be straightforward (After an appropriate clinical case presentation which you have to diagnose first), there are what I would call "Applied Pathophysiology".

To illustrate:

Patient has acute shortness of breath and xray show whiteout of both lungs. You know it's either Left Heart Failure or ARDS. The case presentation will be vague enough that you will not be able to pinpoint if it's one or the other. The question asks you what to do next. Knowing pathophysio of Left heart failure is increased pressure in left heart causing backflow of fluid to lungs, vs. ARDS where fluid in lungs is secondary increased capillary permeability, answer should be Pulmonary Capillary Wedge Pressure or PCWP.

Another case:

Patient have recurrent episodes of gout. You are asked what to do next. You already know that you don't treat hyperuricemia on a single attack of gout. The list includes treatment with probenecid and treatment with allopurinol, and treatment with colchicine. Of course the right answer would be to measure 24 hour urine uric acid and if high give allopurinol and if low give probenecid. Colchicine is used for acute attacks. Knowing pathophysiology is important in answering this question.

Now we will pause here and will continue with Part 2 next time.


thanks askdoc...i really respect you and want to thank you from core of my heart,actually thanks is not the right word fit for what u have given us...i really appreciate ur all analytical posts and would juz say "they(ur posts) are juz golden words--wow awesome"....wish you long 'n' good health life and all the very best for bright future--hope oneday get chance to meet u after dr goljansmiling face..!i mean every word i said..!thank you once again..looking forward for more such analytical things...

god bless you!



thanks very much askdoc for your effort to help us..,
you are exactly just how a doctor should be..,

good luck to you in your life


hi askdoc

i think ''keepgoing' has pretty much said everything that i wanted to say to u

thank you so much


how was your cs, hope it went well


waiting desperately for netx part


I was suppose to write this part last, however, based on the various pms I have received, a lot of people may want this ahead. This is actually a Step by Step program of how I would do my review of Step 2 CK if I were to do it all over again. This is not exactly how I did it, since I had committed lots of errors and had to change my review methodology as my own review progressed. This program of review makes a lot of assumptions. You just finished Step 1 fairly recently, say last 2 months. You had properly concentrated on Patho, Micro-Immuno and Pharma so you are relatively strong in this area.(So you do not have to do additional reviews) You have no problem with diagnosis.(Otherwise, we'll have to drill you on that too.) This uses Kaplan Notes, Step Up Medicine, UW QBank and Kaplan QBank only. This can be finished in 3 to 3.5 months depending on your study speed and time commitment. (Around 8 to 10 hrs per day) Also that you have some relatively recent clinical experience.(last 2 years or so.)

I would not be explaining all the rationale for studying particular ways or using particular resources. I will write the reasons and analysis when I continue Part 2 and 3 later. For some people, this method will fit quite well. For most people, it will work to a certain extent, for a few people, it may not work at all. Different Strokes for Different Folks. That is why I prefer to write a road map with analysis so people can choose techniques and methods that best suit them and organize study materials that they prefer rather than have someone pick it for them. For example, Lectures for me are a bore and waste too much time (Since I am a very fast reader) so I tend to avoid them. However, I know for others, they are indispensable, so feel free to try variations of my methods. You'll get more suggestions on different variations when I finished Parts 2 and 3.

As I've said in part 1, the most important skill you have to develop is the ability to diagnose, since most cases will require to diagnose it first before you can answer the questions. If you are good at this, feel free to skip this part. The best way to diagnose better is to know as much classic presentations of disease as you are able. The more diseases you know, the less chance of getting fooled by those atypical presentations. Of course, normally we use differential diagnosis to work through the proper diagnosis, but since each questions allows you only 78 seconds to read, diagnose and come up with the answer, using that approach may be too time consuming. Although some people recommend Underground Clinical Vignettes, I believe they are overpriced and not needed. A better book will be Pretest Physical Diagnosis. About 80% of it's 500 q's are cases presented classically. And if you can name all the disease entities by just reading the case without looking at the answer choices, then you are really an ace in diagnosis.

We'll start the review with Kaplan Notes Surgery. As I've stated in part 1, it is better to review the topics in the order of diagnosis, work-up and treatment. Kaplan Notes Surgery is to a big extent organized that way. Treatment is simply operate or not operate (although occasionally you have to know the procedure done, eg. Nissen fundoplasty, etc.) The diagnostic algorithm is fairly straightforward too. If you can work up and diagnose each of the disease entitiy in Kaplan Notes Surgery then you're done with Surgery. You can of course choose to listen to the lecture if you want or supplement your reading.

You have to evaluate yourself and I recommend using Kaplan QBook. Don't get me wrong, Kaplan QBook will not teach you how to answer the complicated questions in the exam. You need UW and Kaplan QBank for that. However, QBook will tell you if you absorbed the material you read, or your eyes just glanced through the text while your mind was elsewhare. Set your own target. 80% is good if you are aiming for 80's to low 90's. Nothing lower than 70%, if you want to pass.

The next subject to work with will be OB-Gyne. Not all the topics in Kaplan OB-Gyne is arranged in the right diagnosis-workup-treatment format, but if you read through the text, you will be able to come up with an outline that roughtly follows the format. You can even write the algorithm on the sidebar for easier review. OB-Gyne has more complicated work-up and treatment algorithms but is simpler than IM and Peds. It has little pathophysio except with regards to hormones. Blueprints is a good supplement for this part but not really needed. Of course then do QBook with 80% target.

The above 2 subject will probably take around 2 weeks if done properly. Then onto IM-Peds which will be really hard work. Prepare to spend roughly 4 weeks here. Since, roughly 50 to 60% of Peds is IM, Kaplan chose not to repeat similar topics in Peds, therefore Kaplan Peds cannot stand alone in review. Doing Kaplan IM before Kaplan Peds will make Peds less confusing. Due to the sheer number of disease entities and the complexity of both workup and treatment in IM, this is probably the hardest of all the subjects. Plus both IM and Peds have extensive coverage of pathophysio in the actual exam. I chose Step Up Medicine to supplement IM, partially because if covers about 25% more disease entities than Kaplan, but also substantially covers the major pathophysio concept you have to know. If you have not yet done Step 1, or did poorly in Pathophysio section, it may pay to review Goljan as Step Up may not be enough. NMS Medicine has good Pathophysio coverage, however it is twice the length of Step Up and not as good as Goljan. Both Harrison's and Cecil's may also be too large and detailed.

Blueprints IM and Pedia have good coverage on Diagnostic Algorithms, but poor in Treatment Protocols. Also Blueprint Pedia tend to cover too much Zebras. So it's your choice if you want to add them to your review. Then of course, Kaplan Qbook and aim for 80%.

One more week to cover Kaplan Psych, Ethics and Epidemiology.

Then we proceed to QBanks. People have always asked me which QBank I would choose and my answer is, as much as possible do both Kaplan and UW QBank. I'll discuss in detail the reason why in Part 2, but for this step by step guide, we presume you'll be using both.

Start with UW QBank as this is probably one of the best study tool you have to help you ace Step 2 CK. (I emphasize the word HELP, because it is not a guarantee that you'll get a 99) UW QBank has more difficult questions than the actual exam (although the level of difficulty of the hardest questions seem to be the same for both exam). Do not try to use UW QBank as an assessment tool as the correlation to actual score in the exam is a bit low. Many people (but not all) with relatively low scores in UW scored high in the actual exam and vice versa. It depends on how much they learned from doing UW. Use the QBank to sharpen your knowledge of the topics covered rather than learning them there for the first time. It is better that when you review the answers, you go "Why didn't I think of that" or " Now that's how to differentiate those 2" rather than " Oh the answer is C, let me memorize that"

How do you best use UW for your review? Well, I would do 3 blocks per day, timed, mixed, unuse. You can limit it to a group of subjects, maybe 3 or 4 topics (eg, Cardio, Pulmo, Neuro), your choice. This will take 3 hours. You review the answers for another 3 hours. It is important not only to review wrong answers and know why you got it wrong, but also to review right answers and make sure you got it right for the right reasons. Often we are down to 2 answer choices and we happen to make the right choice, Or we choose the right answer but for the wrong reason. Both can lower your score in the actual exam since there is no guarantee that you'll be that lucky in the actual exam. The remaining 4 hours, use it to review any topic in Kaplan, Step Up or other review materials that covers specific concepts you missed in the QBank. Once you finished the entire Qbank, use extra time to redo questions you got wrong. (Use the filter)

You will be finished with UW in about 2 to 3 weeks. Take NBME and if you have desired score, schedule your exam in 2 to 3 weeks. Then sign up for Kaplan QBank. Do 4 to 8 blocks per day to simulate exam conditions. This will also let you know if what you learned in UW has been carried over to Kaplan. Consistently good performance in all 3 QBanks is a better guarantee of what your final score will be than any single parameter.

I would like to apologize for not being able to answer all Q's or answering them late. Reviewing for step 3, researching IM programs(for 2008 Match), answering pm's, writing these posts, work and other commitments is very hectic. I would try to finish part 2 and part 3 in 2 weeks time, 1 post per week.


hai,thanks for guidence,that really help in preparation,iam just starting for step2 ,and i think it will help me to score better,i wish very good luck to u in everything


thanks alot askdoc
waiting for part 2 and 3


hey man u r awesome
i scored 239 / 99 in step i and ur posts helped me bigtime, i printed them and highlighted them , they were of tremendous help in me last read, it helped me get 99
i still havge it with me
thnx for all that
i wish u best of luck in ur exams and whatever else u do


can u tell me if step 3 questions (uw , qbook. etc) help in step 2 ?


Thanks for the post. Is step-up to CK good....or step-up to medicine is better..or get both? Which is the best source for giving work-up information??? I wanted a source that gives in what order to do diagnostic tests. Thanxs.


v r still waiting for ur next posts !!

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