Best USMLE QBank for High Scores – USMLEed
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Oct 13, 2025
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About This Presentation
Ace the USMLE Step 1 exam with the best USMLE QBank. Access 1000s of questions, detailed explanations, and smart analytics to guide your prep at USMLEed.
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Slide Content
Match Strategy
Clinical Rotations
International CV
Step 2 CK
Step 1
A ONE STOP SOLUTION
FOR USMLE
https://nextstepscareer.com
[email protected]
HYD: +91 88850 14877
BLR: +91 90358 20146
Clinical Rotations
International CV
Step 2 CK
Step 1
A ONE STOP SOLUTION
FOR USMLE
https://nextstepscareer.com
[email protected]
HYD: +91 88850 14877
BLR: +91 90358 20146
At Next Steps, we firmly believe that comprehending our students is paramount. Our dedicated
team is committed to monitoring student progress regularly. Through our mentorship program,
Next Steps gains deeper insights into each student every week, ultimately leading to tangible
improvements in their USMLE scores within a specific timeframe.
Why Next Steps
so special & unique ?
02
team is committed to monitoring student progress regularly. Through our mentorship program,
Next Steps gains deeper insights into each student every week, ultimately leading to tangible
improvements in their USMLE scores within a specific timeframe.
Why Next Steps
so special & unique ?
02
OUR MISSION
Our mission is to simplify the USMLE journey by eliminating myths and
challenges, providing clear guidance and expert support. With our proven
strategies, we ensure a 100% success rate in USMLE Step 1 and Step 2 CK,
helping you achieve your medical career goals. Uniquely crafted and most
updated USMLE preparation program aimed at maximizing your residency
match chances.
ABOUT
NEXT STEPS
At Next Steps, we help USMLE aspirants from scratch to
match. Like we provide guidance for Step 1, Step 2CK, CV
building, Clinical Rotations, and Residency Match Strategy.
OUR VISION
Our vision for the USMLE Next Steps Prep Course stems from recognizing the absence of a
robust platform offering the latest, thorough, and adaptable content for both USMLE Step 1
and 2CK. Hence, we've conceived a vision centered on our innovative WSS Methodology.
Whether you're a full-time student, working professional, or international student, our
flexible scheduling options allow you to balance your studies with other commitments.
03
Our mission is to simplify the USMLE journey by eliminating myths and
challenges, providing clear guidance and expert support. With our proven
strategies, we ensure a 100% success rate in USMLE Step 1 and Step 2 CK,
helping you achieve your medical career goals. Uniquely crafted and most
updated USMLE preparation program aimed at maximizing your residency
match chances.
ABOUT
NEXT STEPS
At Next Steps, we help USMLE aspirants from scratch to
match. Like we provide guidance for Step 1, Step 2CK, CV
building, Clinical Rotations, and Residency Match Strategy.
OUR VISION
Our vision for the USMLE Next Steps Prep Course stems from recognizing the absence of a
robust platform offering the latest, thorough, and adaptable content for both USMLE Step 1
and 2CK. Hence, we've conceived a vision centered on our innovative WSS Methodology.
Whether you're a full-time student, working professional, or international student, our
flexible scheduling options allow you to balance your studies with other commitments.
03
Non-US IMG USMLE Aspirants
2017
2019
2021
2023
2025
EXCITING NEWS FROM NEXT STEPS USMLE!
NEXT STEPS USMLE has experienced a notable
increase in enrollment for 2025 compared to
2024, highlighting our dedication to
excellence in USMLE preparation.
The increasing number of students aiming
for postgraduate opportunities in the USA
indicates the growing recognition of USMLE
credentials and the career prospects they
offer.
GRAPH
Over the years, students have achieved average 68% match success rate in the USA.
95% pass rate in USMLE Step 1 & Step 2 CK.
NEXT STEPS USMLE is recognized as a leading institution in the USMLE training
sector, known for our expert faculty, comprehensive curriculum, and personalized
approach to student learning.
Growth Rate
04
2017
2019
2021
2023
2025
EXCITING NEWS FROM NEXT STEPS USMLE!
NEXT STEPS USMLE has experienced a notable
increase in enrollment for 2025 compared to
2024, highlighting our dedication to
excellence in USMLE preparation.
The increasing number of students aiming
for postgraduate opportunities in the USA
indicates the growing recognition of USMLE
credentials and the career prospects they
offer.
GRAPH
Over the years, students have achieved average 68% match success rate in the USA.
95% pass rate in USMLE Step 1 & Step 2 CK.
NEXT STEPS USMLE is recognized as a leading institution in the USMLE training
sector, known for our expert faculty, comprehensive curriculum, and personalized
approach to student learning.
Growth Rate
04
Next Steps Study Flow
Guidance with
the Mentor &
revising the plan
Phase 3 :
Crash Course
40hrs - Step 1
80+hrs -
Step 2CK
Start
Finish
Phase 1 :
Recorded and Live Classes
of total of 300+hrs for step
1 and 200+ hrs for Step 2CK
Phase 2 : Integrated
clinical Vignettes
for 75+hrs for Step 1
and 50hr for
Step 2CK
Guidance with the
Mentor & revising
the plan
Phase 4 :
1000 + high yield
cases for Step 1 and
Step 2 CK
Low score in
self assessment
High score in
Self Assessment
05
Before Exam Rapid
Review Series for
Step 1 & 2 CK
Guidance with
the Mentor &
revising the plan
Phase 3 :
Crash Course
40hrs - Step 1
80+hrs -
Step 2CK
Start
Finish
Phase 1 :
Recorded and Live Classes
of total of 300+hrs for step
1 and 200+ hrs for Step 2CK
Phase 2 : Integrated
clinical Vignettes
for 75+hrs for Step 1
and 50hr for
Step 2CK
Guidance with the
Mentor & revising
the plan
Phase 4 :
1000 + high yield
cases for Step 1 and
Step 2 CK
Low score in
self assessment
High score in
Self Assessment
05
Before Exam Rapid
Review Series for
Step 1 & 2 CK
Study Exam
Our approach to learning differs from
the traditional method of starting with
lectures and then moving on to
questions. Instead, we begin with
questions and detailed explanations,
making it easier for students to answer
questions in real-time exams.
Our Integrated Clinical Vignettes series
offers a completely application-based
learning experience.
Integrated Clinical Vignettes (ICV) Classes
Conventional Learning
Method
(Lectures)
Concept Learning
Applying
Concepts ExamICV Methodology of Learning
Test Discussion
(MCQ Discussion)
Conventional Learning Method
06
Our approach to learning differs from
the traditional method of starting with
lectures and then moving on to
questions. Instead, we begin with
questions and detailed explanations,
making it easier for students to answer
questions in real-time exams.
Our Integrated Clinical Vignettes series
offers a completely application-based
learning experience.
Integrated Clinical Vignettes (ICV) Classes
Conventional Learning
Method
(Lectures)
Concept Learning
Applying
Concepts ExamICV Methodology of Learning
Test Discussion
(MCQ Discussion)
Conventional Learning Method
06
Quiz Section with 3000+ Step 1 & 3100+
Step 2 CK questions
USMLE mastery lies in adeptly answering application-
based questions. At Next Steps, our program is
meticulously crafted to ensure students are
consistently challenged.
With weekly mock tests covering the syllabus of each
respective week, quarterly self-assessment tests,
subject-wise examinations, and crucially, daily tests
tailored for Step 2CK, our approach to USMLE learning
emphasizes question-based comprehension over
traditional lecture-based methods.
Most importantly, our grading system is enhanced by
robust analytics, providing key insights into student
performance. Through our quiz analytics feature,
students can self-assess and compare their progress
with peers globally in detail. Daily tests tailored for Step
1 and step 2 CK
07
Step 2 CK questions
USMLE mastery lies in adeptly answering application-
based questions. At Next Steps, our program is
meticulously crafted to ensure students are
consistently challenged.
With weekly mock tests covering the syllabus of each
respective week, quarterly self-assessment tests,
subject-wise examinations, and crucially, daily tests
tailored for Step 2CK, our approach to USMLE learning
emphasizes question-based comprehension over
traditional lecture-based methods.
Most importantly, our grading system is enhanced by
robust analytics, providing key insights into student
performance. Through our quiz analytics feature,
students can self-assess and compare their progress
with peers globally in detail. Daily tests tailored for Step
1 and step 2 CK
07
Exclusively for Next Steps Students
Comprehensive Study Material for Step 1
All books are non-commercial; original copies are exclusively for Next Steps Students (Mid 2025).
Other Handbook Series
08
Comprehensive Study Material for Step 1
All books are non-commercial; original copies are exclusively for Next Steps Students (Mid 2025).
Other Handbook Series
08
MODULE 1.1 - CARDIAC ANATOMY
Borders of heart
Comprehensive Study Material for Step 1
Here’s a quick preview of our Step 1 notes -
CARDIOVASCULAR SYSTEM DAY 1
As the aorta is muscular structure it appears as a well defined circle
It is usually present in front and close to the vertebra body
Right : superior vena cava and right atrium
Left: Left ventricle, pulmonary trunk, aorta
Inferiorly: Right ventricle
Superiorly: Right and left atria, superior vena cava, ascending aorta, pulmonary trunk
Right ventricle is better visualised in lateral x ray
Right ventricle forms majority of anterior surface of the heart
Clinical scenario
In the right ventricle we commonly use a single lead pacemaker, in the left ventricle we use
a biventricular pacemaker.
CT ABDOMEN AT L-1 LEVEL
09
Borders of heart
Comprehensive Study Material for Step 1
Here’s a quick preview of our Step 1 notes -
CARDIOVASCULAR SYSTEM DAY 1
As the aorta is muscular structure it appears as a well defined circle
It is usually present in front and close to the vertebra body
Right : superior vena cava and right atrium
Left: Left ventricle, pulmonary trunk, aorta
Inferiorly: Right ventricle
Superiorly: Right and left atria, superior vena cava, ascending aorta, pulmonary trunk
Right ventricle is better visualised in lateral x ray
Right ventricle forms majority of anterior surface of the heart
Clinical scenario
In the right ventricle we commonly use a single lead pacemaker, in the left ventricle we use
a biventricular pacemaker.
CT ABDOMEN AT L-1 LEVEL
09
ECG LEADS
BRANCHES OF COMMON ILIAC ARTERY
External iliac artery
Common femoral artery(external iliac continues as)
We check for femoral pulse below the inguinal ligament
Inferior epigastric artery(superiorly and medially)
Supplies the lower abdominal wall
Deep circumflex(laterally)
Internal iliac artery
Superior gluteal artery
Inferior gluteal artery
Obturator artery
During cardiac catheterisation, a catheter is inserted through the femoral vein.
FEMORAL TRIANGLE-
Borders
Superiorly: Inguinal ligament
Medially: Adductor longus
Laterally : Sartorius
Structures in femoral Traingle: VAN(medial to lateral)
V- Vein(femoral vein)
A - Artery(femoral artery)
N - Nerve
Space medial to vein contains lymph nodes and
It's a common site for femoral hernia
CORONARY BLOOD FLOW
Limb leads
aVR(right wrist)
aVL(left wrist)
aVF(left foot)
Lead I,II,III
Chest leads
V1, V2, V3, V4, V5, V6
Coronary circulation
As the Inferior vena cava lacks a thick muscular layer, it appears as a collapsed structure.
It is usually on the right side of the vertebral body.
Abdominal aorta gives rise to common iliac artery.
10
BRANCHES OF COMMON ILIAC ARTERY
External iliac artery
Common femoral artery(external iliac continues as)
We check for femoral pulse below the inguinal ligament
Inferior epigastric artery(superiorly and medially)
Supplies the lower abdominal wall
Deep circumflex(laterally)
Internal iliac artery
Superior gluteal artery
Inferior gluteal artery
Obturator artery
During cardiac catheterisation, a catheter is inserted through the femoral vein.
FEMORAL TRIANGLE-
Borders
Superiorly: Inguinal ligament
Medially: Adductor longus
Laterally : Sartorius
Structures in femoral Traingle: VAN(medial to lateral)
V- Vein(femoral vein)
A - Artery(femoral artery)
N - Nerve
Space medial to vein contains lymph nodes and
It's a common site for femoral hernia
CORONARY BLOOD FLOW
Limb leads
aVR(right wrist)
aVL(left wrist)
aVF(left foot)
Lead I,II,III
Chest leads
V1, V2, V3, V4, V5, V6
Coronary circulation
As the Inferior vena cava lacks a thick muscular layer, it appears as a collapsed structure.
It is usually on the right side of the vertebral body.
Abdominal aorta gives rise to common iliac artery.
10
Right coronary artery(RCA) - between right atrium and ventricle
It supplies SA node, in case of occlusion it leads to
Severe hypotension
Jugular venous distension
Do not use vasodilators
Left coronary artery(LCA)- between left atrium and ventricle
Left circumflex(LCX)
Left anterior descending (LAD)
Dominance circulation - depends on which coronary artery gives posterior
descending artery(PDA)
PDA supplies
AV node
Posterior one third of interventricular septum
Posterior two thirds of ventricular walls
Posteromedial papillary muscle
Anterior part of papillary muscle has dual blood supply so even in
case of occlusion of one of the arteries the muscle is still
functional.
Posterior part is solely supplied by PDA, in case of occlusion
this part ruptures leading to mitral regurgitation.
While answering a question if PDA option is not available, look
for dominance of circulation RCA or LCA or LCX will be the 2nd
best option.
11
It supplies SA node, in case of occlusion it leads to
Severe hypotension
Jugular venous distension
Do not use vasodilators
Left coronary artery(LCA)- between left atrium and ventricle
Left circumflex(LCX)
Left anterior descending (LAD)
Dominance circulation - depends on which coronary artery gives posterior
descending artery(PDA)
PDA supplies
AV node
Posterior one third of interventricular septum
Posterior two thirds of ventricular walls
Posteromedial papillary muscle
Anterior part of papillary muscle has dual blood supply so even in
case of occlusion of one of the arteries the muscle is still
functional.
Posterior part is solely supplied by PDA, in case of occlusion
this part ruptures leading to mitral regurgitation.
While answering a question if PDA option is not available, look
for dominance of circulation RCA or LCA or LCX will be the 2nd
best option.
11
If PDA arises from RCA(most common occurs in 85% of population),
it is known as right dominant
If PDA arises from LCA it is known as left dominant(in 15%)
ECG AND CORONARY VESSEL CORRELATION
If ST elevations occur in
V1- V4= LAD/LCA(anterior wall MI)
I, aVL, V5-6 = LCX(lateral wall MI)
II, III, aVF= RCA (in right-dominant circulation) (inferior wall MI)
Occlusion commonly occurs a LAD> RCA >LCX
Clinical scenario
Pt with history of Rheumatic fever + opening snap followed by late diastolic rumble at 5th
intercostal space in Lt midclavicular line, = the valvular defect is mitral stenosis leads to
enlarged left atrium, which in turn compresses the esophagus.
CENTRAL VENOUS CATHETER
Indications :
Rapid infusion of IV fluids
Unable to find peripheral veins
Commonly used veins
Subclavian vein—-> superior vena cava
Internal jugular vein
Note : h/o of tearing chest pain commonly points towards aortic dissection.
12
it is known as right dominant
If PDA arises from LCA it is known as left dominant(in 15%)
ECG AND CORONARY VESSEL CORRELATION
If ST elevations occur in
V1- V4= LAD/LCA(anterior wall MI)
I, aVL, V5-6 = LCX(lateral wall MI)
II, III, aVF= RCA (in right-dominant circulation) (inferior wall MI)
Occlusion commonly occurs a LAD> RCA >LCX
Clinical scenario
Pt with history of Rheumatic fever + opening snap followed by late diastolic rumble at 5th
intercostal space in Lt midclavicular line, = the valvular defect is mitral stenosis leads to
enlarged left atrium, which in turn compresses the esophagus.
CENTRAL VENOUS CATHETER
Indications :
Rapid infusion of IV fluids
Unable to find peripheral veins
Commonly used veins
Subclavian vein—-> superior vena cava
Internal jugular vein
Note : h/o of tearing chest pain commonly points towards aortic dissection.
12
MODULE 1.2 - EXERCISE HEART’S RESPONSE
With exercise
Central response
Increased sympathetic output and decreased parasympathetic
output(only to heart) leading to
Increased heart rate and contractility leading to increased to cardiac output
Increased blood flow to muscle
Splanchnic arteriolar constriction via alpha receptors
Local response
Def: Muscles change their environment to maximise the blood flow and
washout metabolic wastes.
Your muscle contracts using ATP and releases ADP and lactate
(vasoactive metabolites).
These vasoactive metabolites causes
Local vasodilation and decreases total peripheral resistance
Changes in cardiac parameters
Increase of
Heart rate
Stroke volume
Venous return
Cardiac output
Pulse pressure (SBP, DBP)
A-V O2 difference(increased oxygen utilization by muscle)
Total peripheral resistance decrease
Increased venous return via constriction of veins, means increased
blood flow/return to heart
13
With exercise
Central response
Increased sympathetic output and decreased parasympathetic
output(only to heart) leading to
Increased heart rate and contractility leading to increased to cardiac output
Increased blood flow to muscle
Splanchnic arteriolar constriction via alpha receptors
Local response
Def: Muscles change their environment to maximise the blood flow and
washout metabolic wastes.
Your muscle contracts using ATP and releases ADP and lactate
(vasoactive metabolites).
These vasoactive metabolites causes
Local vasodilation and decreases total peripheral resistance
Changes in cardiac parameters
Increase of
Heart rate
Stroke volume
Venous return
Cardiac output
Pulse pressure (SBP, DBP)
A-V O2 difference(increased oxygen utilization by muscle)
Total peripheral resistance decrease
Increased venous return via constriction of veins, means increased
blood flow/return to heart
13
Exclusively for Next Steps Students
High-Yield 1000+ Cases for USMLE Step 1
All books are non-commercial; original copies are exclusively for Next Steps Students (Mid 2025).
Other Handbook Series
14
High-Yield 1000+ Cases for USMLE Step 1
All books are non-commercial; original copies are exclusively for Next Steps Students (Mid 2025).
Other Handbook Series
14
1. A patient has painless mass in the testis. What lymph nodes drain the testis ?
Para aortic lymph nodes. If you can't remember all
of them, at least remember these :
Lymph node Structures drained
Para aortic
A Pair of testes, ovaries, kidneys, fallopian tubes, fundus
of uterus
External iliac Body of uterus, cervix & upper part of bladder
Internal iliac
Lower part of bladder, some part of cervix, anal canal
above the dentate line
Superficial inguinal
Anal canal below the dentate line, scrotum, vulva.
Hilar lymphadenopathy : seen in Lung cancer, Tuberculosis & Sarcoidosis (bilateral).
Patient has a cat + painful lymphadenopathy = Bartonella henselae (cat scratch disease).
2. An elderly man has back pain. MRI shows multiple vertebral lesions. He also complains of
urine retention. What findings will be seen on digital rectal examination ?
Important prostate findings :
Enlarged, nodular, indurated prostate Prostate cancer (above case).
Enlarged, symmetrical, smooth prostate Benign prostatic hyperplasia.
Tender prostate Prostatitis.
3. A patient is unable to maintain an erection. How would you manage this patient ?
Diagnosis : erectile dysfunction
Treatment : if psychogenic reassure.
If organic, DOC = Sildenafil (Phosphodiesterase 5 inhibitor leads to increased
cGMP levels increased Nitric oxide activity smooth muscle relaxation &
vasodilation).
Indications of Sildenafil :
Erectile dysfunction
Pulmonary hypertension
Which phosphodiesterase inhibitor is used in BPH ? = Tadalafil.
High-Yield 1000+ Cases for USMLE Step 1
15
Here’s a quick preview of our Step 1 notes -
REPRODUCTIVE SYSTEM
Para aortic lymph nodes. If you can't remember all
of them, at least remember these :
Lymph node Structures drained
Para aortic
A Pair of testes, ovaries, kidneys, fallopian tubes, fundus
of uterus
External iliac Body of uterus, cervix & upper part of bladder
Internal iliac
Lower part of bladder, some part of cervix, anal canal
above the dentate line
Superficial inguinal
Anal canal below the dentate line, scrotum, vulva.
Hilar lymphadenopathy : seen in Lung cancer, Tuberculosis & Sarcoidosis (bilateral).
Patient has a cat + painful lymphadenopathy = Bartonella henselae (cat scratch disease).
2. An elderly man has back pain. MRI shows multiple vertebral lesions. He also complains of
urine retention. What findings will be seen on digital rectal examination ?
Important prostate findings :
Enlarged, nodular, indurated prostate Prostate cancer (above case).
Enlarged, symmetrical, smooth prostate Benign prostatic hyperplasia.
Tender prostate Prostatitis.
3. A patient is unable to maintain an erection. How would you manage this patient ?
Diagnosis : erectile dysfunction
Treatment : if psychogenic reassure.
If organic, DOC = Sildenafil (Phosphodiesterase 5 inhibitor leads to increased
cGMP levels increased Nitric oxide activity smooth muscle relaxation &
vasodilation).
Indications of Sildenafil :
Erectile dysfunction
Pulmonary hypertension
Which phosphodiesterase inhibitor is used in BPH ? = Tadalafil.
High-Yield 1000+ Cases for USMLE Step 1
15
Here’s a quick preview of our Step 1 notes -
REPRODUCTIVE SYSTEM
Other conditions that might be confused with fetal alcohol syndrome :
Down syndrome : flat facial profile, epicanthal folds, slanted eyes, single palmar crease.
Fragile X syndrome : long narrow face, large ears, prominent jaw, large testis.
Williams syndrome : wide mouth, supravalvular aortic stenosis, friendliness with strangers.
Adverse effects of Sildenafil :
Facial flushing
Famous USMLE question : Nitrates + Sildenafil = Hypotension (therefore, never given them
together).
Blue vision (as sildenafil can inhibit phosphodiesterase 6).
4. An 18 year old male with delayed puberty. He has stage 1 pubic hair and axillary hair +-
infertility, anosmia ?
Kallmann syndrome
Pathogenesis : impaired migration of GnRH producing neurons from olfactory bulb to
Hypothalamus decreased production of GnRH.
Complication ? = Infertility, Osteoporosis (due to low estrogen).
5. A pregnant woman is continuously drinking alcohol. What defects can the baby get ?
Fetal alcohol syndrome
Facial abnormalities : smooth philtrum, thin upper lip, small palpebral fissures,
midface hypoplasia, flat nasal bridge.
Limb defects : short limbs, contractures.
Heart defects : VSD > ASD, TOF.
Neuro : microcephaly, holoprosencephaly, intellectual disability.
Short height and low weight for age.
Why Holoprosencephaly ? = due to impaired migration of neurons and glial cells.
16
Down syndrome : flat facial profile, epicanthal folds, slanted eyes, single palmar crease.
Fragile X syndrome : long narrow face, large ears, prominent jaw, large testis.
Williams syndrome : wide mouth, supravalvular aortic stenosis, friendliness with strangers.
Adverse effects of Sildenafil :
Facial flushing
Famous USMLE question : Nitrates + Sildenafil = Hypotension (therefore, never given them
together).
Blue vision (as sildenafil can inhibit phosphodiesterase 6).
4. An 18 year old male with delayed puberty. He has stage 1 pubic hair and axillary hair +-
infertility, anosmia ?
Kallmann syndrome
Pathogenesis : impaired migration of GnRH producing neurons from olfactory bulb to
Hypothalamus decreased production of GnRH.
Complication ? = Infertility, Osteoporosis (due to low estrogen).
5. A pregnant woman is continuously drinking alcohol. What defects can the baby get ?
Fetal alcohol syndrome
Facial abnormalities : smooth philtrum, thin upper lip, small palpebral fissures,
midface hypoplasia, flat nasal bridge.
Limb defects : short limbs, contractures.
Heart defects : VSD > ASD, TOF.
Neuro : microcephaly, holoprosencephaly, intellectual disability.
Short height and low weight for age.
Why Holoprosencephaly ? = due to impaired migration of neurons and glial cells.
16
Vaginal pH >4.5 Vaginal pH >4.5
7. A female has foul smelling, gray vaginal discharge ?
Bacterial vaginosis
Bacterial vaginosis (by
Gardnerella vaginalis)
Trichomoniasis (by
trichomonas vaginalis)
Thin, off - white or gray,
foul smelling (fishy odor)
discharge.
Usually no inflammation
(redness, pruritus).
Thin, yellow - green, frothy/
bubbly, foul smelling
discharge.
Vaginal inflammation present.
Acute cervicitis (strawberry
cervix) that can lead to
dyspareunia, post coital bleed.
Normal pH (4 - 4.5)
Candida vaginitis (by
candida albicans)
Thick, white (cottage
cheese like) discharge.
Vaginal inflammation
present.
Treatment : Metronidazole
Microscopic Examination :
clue cells (epithelial cells
coated with bacteria).
Positive KOH whiff test (foul
smell after adding KOH).
Treatment : Metronidazole
Microscopic Examination : motile
pear shaped trichomonads.
Treatment : Azoles
Microscopic Examination
: pseudohyphae.
In which of them do we need to treat the partner as well ? = Trichomoniasis.
17
.
6. A 23 year old female comes with sudden onset severe lower abdominal pain and nausea. On
examination adnexal mass is present. Urine Pregnancy Test is negative . Doppler USG shows
absent blood flow to ovary ?
Ovarian / Adnexal torsion Pathogenesis : Twisting of ovary around infundibulopelvic ligament &
ovarian ligament Impaired venous and arterial flow edema and necrosis. Risk factor
- ovarian enlargement due to preexisting cyst, tumor, etc.
Clinical features
Sudden onset severe U/L lower abdomen / pelvic pain
Palpable adnexal mass
Question may mention that the female had intermittent symptoms earlier (indicating
partial torsion) and now have severe symptoms.
Diagnosis : Pelvic USG with Doppler - absent
Treatment : emergency surgery
Differentials :
Ruptured ectopic pregnancy : question will give positive UPT, history of secondary
amenorrhea, vaginal bleed.
Acute appendicitis : Dopper will be normal
7. A female has foul smelling, gray vaginal discharge ?
Bacterial vaginosis
Bacterial vaginosis (by
Gardnerella vaginalis)
Trichomoniasis (by
trichomonas vaginalis)
Thin, off - white or gray,
foul smelling (fishy odor)
discharge.
Usually no inflammation
(redness, pruritus).
Thin, yellow - green, frothy/
bubbly, foul smelling
discharge.
Vaginal inflammation present.
Acute cervicitis (strawberry
cervix) that can lead to
dyspareunia, post coital bleed.
Normal pH (4 - 4.5)
Candida vaginitis (by
candida albicans)
Thick, white (cottage
cheese like) discharge.
Vaginal inflammation
present.
Treatment : Metronidazole
Microscopic Examination :
clue cells (epithelial cells
coated with bacteria).
Positive KOH whiff test (foul
smell after adding KOH).
Treatment : Metronidazole
Microscopic Examination : motile
pear shaped trichomonads.
Treatment : Azoles
Microscopic Examination
: pseudohyphae.
In which of them do we need to treat the partner as well ? = Trichomoniasis.
17
.
6. A 23 year old female comes with sudden onset severe lower abdominal pain and nausea. On
examination adnexal mass is present. Urine Pregnancy Test is negative . Doppler USG shows
absent blood flow to ovary ?
Ovarian / Adnexal torsion Pathogenesis : Twisting of ovary around infundibulopelvic ligament &
ovarian ligament Impaired venous and arterial flow edema and necrosis. Risk factor
- ovarian enlargement due to preexisting cyst, tumor, etc.
Clinical features
Sudden onset severe U/L lower abdomen / pelvic pain
Palpable adnexal mass
Question may mention that the female had intermittent symptoms earlier (indicating
partial torsion) and now have severe symptoms.
Diagnosis : Pelvic USG with Doppler - absent
Treatment : emergency surgery
Differentials :
Ruptured ectopic pregnancy : question will give positive UPT, history of secondary
amenorrhea, vaginal bleed.
Acute appendicitis : Dopper will be normal
female virilized
at puberty +
amenorrhoea
5
Deficiency
46, XY
( DHT)
testosterone,
androstenedione,
estrogen
Mullerian agenesis
46, XX
N/ testosterone,
DHT
(testosterone:DHT
ratio > 20)
Developed breast - estrogen OK
Developed axillary and pubic hair - Testosterone OK
Lab findings:
Normal FSH.
1. A patient had knee pain and started on ibuprofen for 3 weeks. Now he has high blood
pressure, proteinuria and increased creatinine. Why ?
Due to involvement of afferent arteriole.
Normally, prostaglandins dilate afferent arteriole NSAIDs inhibit prostaglandins
decreased dilation of afferent arteriole.
Important renal points related go NSAIDs :
Can lead to Pre renal AKI due to decreased dilation of afferent arteriole.
Patient started on NSAID + gets edema + why? = due to decreased clearance of sodium
by kidneys retention of sodium retention of water.
A Patient is started on NSAID + gets dark urine renal papillary necrosis.
A Patient is started on NSAID + gets rash and eosinophils in urine Acute interstitial
nephritis.
androgens
RENAL SYSTEM -
21 yr old female 21 yr old female
+ amenorrhoea
+ Tanner 5 breast
+ blind end vagina + amenorrhoea
+ Tanner 5 breast
+ blind end vagina
+ tanner 5 pubic hair
+ tanner 1 pubic hair,
Axillary hair Axillary hair
Hirsutism + Acne
Worse in
Pregnancy
(because of
(Dec. estrogen
from testosterone)
[don't confuse it with
PCOS]
Lab findings:
α reductase
Androgen Insensitive
Syndrome
( Testicular
Feminization syn.)
Lab findings:
Diagnosis:
USG and
46 , XY
Hysterosalpingography
showing absent or
hypoplastic uterus
Normal / LH
Normal estrogen
from foetus)
Aromatase
Deficiency
46 , XX
testosterone
LH
estrogen
8.
18
at puberty +
amenorrhoea
5
Deficiency
46, XY
( DHT)
testosterone,
androstenedione,
estrogen
Mullerian agenesis
46, XX
N/ testosterone,
DHT
(testosterone:DHT
ratio > 20)
Developed breast - estrogen OK
Developed axillary and pubic hair - Testosterone OK
Lab findings:
Normal FSH.
1. A patient had knee pain and started on ibuprofen for 3 weeks. Now he has high blood
pressure, proteinuria and increased creatinine. Why ?
Due to involvement of afferent arteriole.
Normally, prostaglandins dilate afferent arteriole NSAIDs inhibit prostaglandins
decreased dilation of afferent arteriole.
Important renal points related go NSAIDs :
Can lead to Pre renal AKI due to decreased dilation of afferent arteriole.
Patient started on NSAID + gets edema + why? = due to decreased clearance of sodium
by kidneys retention of sodium retention of water.
A Patient is started on NSAID + gets dark urine renal papillary necrosis.
A Patient is started on NSAID + gets rash and eosinophils in urine Acute interstitial
nephritis.
androgens
RENAL SYSTEM -
21 yr old female 21 yr old female
+ amenorrhoea
+ Tanner 5 breast
+ blind end vagina + amenorrhoea
+ Tanner 5 breast
+ blind end vagina
+ tanner 5 pubic hair
+ tanner 1 pubic hair,
Axillary hair Axillary hair
Hirsutism + Acne
Worse in
Pregnancy
(because of
(Dec. estrogen
from testosterone)
[don't confuse it with
PCOS]
Lab findings:
α reductase
Androgen Insensitive
Syndrome
( Testicular
Feminization syn.)
Lab findings:
Diagnosis:
USG and
46 , XY
Hysterosalpingography
showing absent or
hypoplastic uterus
Normal / LH
Normal estrogen
from foetus)
Aromatase
Deficiency
46 , XX
testosterone
LH
estrogen
8.
18
Acute interstitial nephritis (or Tubulointerstitial nephritis).
Features :
Fever, maculopapular rash, wbc & wbc casts in urine, hematuria, joint pain, flank pain.
TIP : Eosinophils in urine = Acute interstitial nephritis. USMLE often asks you to diagnose
the condition, or identify the trigger, or next best step.
Triggers : DRAINS
Diuretics (Loops & thiazides)
Rifampin
Antibiotics (penicillin & cephalosporins),
Allopurinol Proton pump Inhibitors
NSAIDs
Sulfa drugs (including TMP - SMX)
Diagnosis : urine findings as described above Increased BUN, creatinine
CBC : increased eosinophils.
Next best step : Stop the drug.
3. A patient loses proteins, sodium, amino acids, and calcium in urine. Where is the
defect ?
PCT
Diagnosis : fanconi syndrome
Pathogenesis : PCT cant reabsorb anything everything goes out in urine, especially
Amino acids, glucose, bicarbonate & phosphate.
TIP : Amino acids in urine = Fanconi syndrome (very specific association in
USMLE).
Etiology? : many reasons but remember the drugs :
Ifosfamide (alkylating agent that cross links DNA)
Cisplatin (cross links DNA)
Tenofovir (reverse transcriptase inhibitor used in HIV)
Expired tetracyclines (inhibit 30s ribosomal subunit)
Arrows : they can ask you the serum level of all the things and your answer will be :
amino acids glucose bicarbonate phosphate.
Another important Fanconi :
Fanconi anemia = Cytopenias + Hypoplastic or absent thumb / radial bones.
4. A patient has diabetes, hypertension, dyslipidemia, prostatic hyperplasia. He
smokes and drinks beer. A mass is seen in the kidney and biopsy shows clear cells.
From this history, what is the most likely risk factor for this condition ?
SMOKING.
Diagnosis : renal cell carcinoma
Where does it originate from ? = PCT.
Classic presentation ? = flank pain, a palpable mass, hematuria.
Important Complication? = Left sided varicocele (due to tumor invasion in the renal vein).
Histology : clear cells filled with glycogen.
2. 3 days after starting TMP - SMX, a patient gets WBC casts in urine ?
Gross : yellowish tumor due to lipid deposition. Images are important :
19
Features :
Fever, maculopapular rash, wbc & wbc casts in urine, hematuria, joint pain, flank pain.
TIP : Eosinophils in urine = Acute interstitial nephritis. USMLE often asks you to diagnose
the condition, or identify the trigger, or next best step.
Triggers : DRAINS
Diuretics (Loops & thiazides)
Rifampin
Antibiotics (penicillin & cephalosporins),
Allopurinol Proton pump Inhibitors
NSAIDs
Sulfa drugs (including TMP - SMX)
Diagnosis : urine findings as described above Increased BUN, creatinine
CBC : increased eosinophils.
Next best step : Stop the drug.
3. A patient loses proteins, sodium, amino acids, and calcium in urine. Where is the
defect ?
PCT
Diagnosis : fanconi syndrome
Pathogenesis : PCT cant reabsorb anything everything goes out in urine, especially
Amino acids, glucose, bicarbonate & phosphate.
TIP : Amino acids in urine = Fanconi syndrome (very specific association in
USMLE).
Etiology? : many reasons but remember the drugs :
Ifosfamide (alkylating agent that cross links DNA)
Cisplatin (cross links DNA)
Tenofovir (reverse transcriptase inhibitor used in HIV)
Expired tetracyclines (inhibit 30s ribosomal subunit)
Arrows : they can ask you the serum level of all the things and your answer will be :
amino acids glucose bicarbonate phosphate.
Another important Fanconi :
Fanconi anemia = Cytopenias + Hypoplastic or absent thumb / radial bones.
4. A patient has diabetes, hypertension, dyslipidemia, prostatic hyperplasia. He
smokes and drinks beer. A mass is seen in the kidney and biopsy shows clear cells.
From this history, what is the most likely risk factor for this condition ?
SMOKING.
Diagnosis : renal cell carcinoma
Where does it originate from ? = PCT.
Classic presentation ? = flank pain, a palpable mass, hematuria.
Important Complication? = Left sided varicocele (due to tumor invasion in the renal vein).
Histology : clear cells filled with glycogen.
2. 3 days after starting TMP - SMX, a patient gets WBC casts in urine ?
Gross : yellowish tumor due to lipid deposition. Images are important :
19
Possible paraneoplastic manifestations ?
Hypercalcemia of malignancy (due to release of PTHrP).
Thrombocytopenia
Anemia (anemia of chronic disease or kidney may not produce enough
erythropoietin).
Polycythemia (excess production of erythropoietin).
Cushing syndrome (release of ACTH).
How does it spread ? = hematogenous route
Important association ? = Von hippel lindau syndrome.
Important risk factor : Smoking.
SMOKING IS THE MAJOR RISK FOR :
Renal cell carcinoma
Small cell and squamous cell carcinoma of lung
Bladder cancer (Transition cell carcinoma)
Pancreatic cancer
Oropharyngeal cancer
5. A patient has recurrent kidney infections. A CT is shown.
Diagnosis : Horseshoe kidney (CT very important).
Pathogenesis : inferior poles of both kidneys fuse fused
kidneys get trapped by Inferior mesenteric artery
failure of kidney ascent.
Important complications :
Renal stones
Ureteropelvic junction obstruction
Infections
Renal cancer
Important association ? = Turner syndrome.
20
Hypercalcemia of malignancy (due to release of PTHrP).
Thrombocytopenia
Anemia (anemia of chronic disease or kidney may not produce enough
erythropoietin).
Polycythemia (excess production of erythropoietin).
Cushing syndrome (release of ACTH).
How does it spread ? = hematogenous route
Important association ? = Von hippel lindau syndrome.
Important risk factor : Smoking.
SMOKING IS THE MAJOR RISK FOR :
Renal cell carcinoma
Small cell and squamous cell carcinoma of lung
Bladder cancer (Transition cell carcinoma)
Pancreatic cancer
Oropharyngeal cancer
5. A patient has recurrent kidney infections. A CT is shown.
Diagnosis : Horseshoe kidney (CT very important).
Pathogenesis : inferior poles of both kidneys fuse fused
kidneys get trapped by Inferior mesenteric artery
failure of kidney ascent.
Important complications :
Renal stones
Ureteropelvic junction obstruction
Infections
Renal cancer
Important association ? = Turner syndrome.
20
6. A diabetic patient has edema, hypertension, oliguria, increased BUN/ Cr, nausea,
vomit, pruritus, fatigue, some proteinuria (any if these could be present). What will be
present on microscopic examination of kidneys.
This is diabetic kidney disease
PATHOGENESIS (important) : Non enzymatic glycosylation of glomerular basement
membrane
Lead to increased permeability + thickening of basement membrane + thickening and
stiffening of renal arterioles (affects efferent arteriole > afferent arteriole).
This leads to hyperfiltration initially, therefore increased GFR.
Over time, intraglomerular pressure increases.
To compensate, glomerular hypertrophy occurs increased overall renal size.
Ultimately, there is scarring of glomerulus (known as Glomerulosclerosis) low GFR.
Microscopic Examination of kidneys :
Kimmelstein wilson nodules (eosinophilic, hypocellular nodules).
Glomerular basement membrane thickening.
Mesangial expansion.
7. A diabetic patient has edema, hypertension, oliguria, increased BUN/ Cr, nausea,
vomit, pruritus, fatigue, some proteinuria (any if these could be present). How will you
manage this patient ?
Management of diabetic kidney disease is important.
DOC = ACEi or ARBs (Nephroprotective).
Strict glycemic control.
SGLT 2 inhibitors can also be given.
21
vomit, pruritus, fatigue, some proteinuria (any if these could be present). What will be
present on microscopic examination of kidneys.
This is diabetic kidney disease
PATHOGENESIS (important) : Non enzymatic glycosylation of glomerular basement
membrane
Lead to increased permeability + thickening of basement membrane + thickening and
stiffening of renal arterioles (affects efferent arteriole > afferent arteriole).
This leads to hyperfiltration initially, therefore increased GFR.
Over time, intraglomerular pressure increases.
To compensate, glomerular hypertrophy occurs increased overall renal size.
Ultimately, there is scarring of glomerulus (known as Glomerulosclerosis) low GFR.
Microscopic Examination of kidneys :
Kimmelstein wilson nodules (eosinophilic, hypocellular nodules).
Glomerular basement membrane thickening.
Mesangial expansion.
7. A diabetic patient has edema, hypertension, oliguria, increased BUN/ Cr, nausea,
vomit, pruritus, fatigue, some proteinuria (any if these could be present). How will you
manage this patient ?
Management of diabetic kidney disease is important.
DOC = ACEi or ARBs (Nephroprotective).
Strict glycemic control.
SGLT 2 inhibitors can also be given.
21
8. A patient has chronic kidney disease. When should you start hemodialysis ?
These are the indications of dialysis (AEIOU) :
Acidosis : Metabolic acidosis (pH <7.1 that is refractory to drugs).
Electrolytes : Hyperkalemia (>6.5 mEq/L or ECG changes or Ventricular arrhythmias).
Ingestion : toxic alcohols (eg methanol), salicylate toxicity, lithium.
Overload : volume overload refractory to diuretics.
Uremia : Encephalopathy (any AMS), Pericarditis (friction rub), Bleeding.
9. A child has recurrent UTIs + gross kidney image given.
Vesicoureteral reflux (loom at the dilated ureter & kidney).
Etio :
Short intramural ureter..
Bladder outlet obstruction (eg Posterior urethral valve)
Diagnosis : voiding cystourethrogram shows backflow of urine when child tries to
urinate.
Complication ? : recurrent UTIs, hydronephrosis, renal scarring.
10. A patient with heart failure is taking loop diuretics. Now he has hypokalemia. What
should be done ?
Start potassium sparing diuretics.
Spironolactone, Eplerenone : Aldosterone receptor antagonists in cortical collecting
duct.
Triamterene, Amiloride : inhibit Epithelial sodium channels (ENAC) in collecting
duct.
Indications : Hyperaldosteronism (eg : conn syndrome)
Heart failure + hypokalemia
Spironolactone : given in ascites & as an antiandrogen (eg : PCOS).
Amiloride : given in Nephrogenic diabetes insipidus.
How does spironolactone work as an anti androgen ? = it inhibits androgen
receptors, 17 - alpha hydroxylase & 17,20 - lyase.
Side effects :
Hyperkalemia Arrhythmias.
Gynecomastia by Spironolactone
Normal anion gap metabolic acidosis by Spironolactone.
22
These are the indications of dialysis (AEIOU) :
Acidosis : Metabolic acidosis (pH <7.1 that is refractory to drugs).
Electrolytes : Hyperkalemia (>6.5 mEq/L or ECG changes or Ventricular arrhythmias).
Ingestion : toxic alcohols (eg methanol), salicylate toxicity, lithium.
Overload : volume overload refractory to diuretics.
Uremia : Encephalopathy (any AMS), Pericarditis (friction rub), Bleeding.
9. A child has recurrent UTIs + gross kidney image given.
Vesicoureteral reflux (loom at the dilated ureter & kidney).
Etio :
Short intramural ureter..
Bladder outlet obstruction (eg Posterior urethral valve)
Diagnosis : voiding cystourethrogram shows backflow of urine when child tries to
urinate.
Complication ? : recurrent UTIs, hydronephrosis, renal scarring.
10. A patient with heart failure is taking loop diuretics. Now he has hypokalemia. What
should be done ?
Start potassium sparing diuretics.
Spironolactone, Eplerenone : Aldosterone receptor antagonists in cortical collecting
duct.
Triamterene, Amiloride : inhibit Epithelial sodium channels (ENAC) in collecting
duct.
Indications : Hyperaldosteronism (eg : conn syndrome)
Heart failure + hypokalemia
Spironolactone : given in ascites & as an antiandrogen (eg : PCOS).
Amiloride : given in Nephrogenic diabetes insipidus.
How does spironolactone work as an anti androgen ? = it inhibits androgen
receptors, 17 - alpha hydroxylase & 17,20 - lyase.
Side effects :
Hyperkalemia Arrhythmias.
Gynecomastia by Spironolactone
Normal anion gap metabolic acidosis by Spironolactone.
22
Exclusively for Next Steps Students
Comprehensive Study Material for Step 2 CK
All books are non-commercial; original copies are exclusively for Next Steps Students (Mid 2025).
Other Handbook Series
23
Comprehensive Study Material for Step 2 CK
All books are non-commercial; original copies are exclusively for Next Steps Students (Mid 2025).
Other Handbook Series
23
IBS is characterized by recurrent abdominal pain (≥1 day/week for the past 3 months) related to
defecation and is typically associated with abnormal bowel habits (eg, diarrhea and/or
constipation). It is the most common gastrointestinal disorder and occurs most frequently in
women age < 45. Its seen to be exacerbated in pregnancy for unknown reasons.
Clinical features of irritable bowel syndrome - .
#Rome IV diagnostic criteria
Recurrent abdominal pain/discomfort ≥1 days/week for past 3 months & ≥2 of the following:
Related to defecation (improves or worsens)
Change in stool frequency
Change in stool form
Classification
IBS-D: diarrhea is the predominant symptom
IBS-C: constipation is the predominant symptom
IBS-M: mixed diarrhea and constipation
IBS-U: criteria for IBS are met but bowel movements can't be categorized into the
above subgroups
Alarm features
Older age of onset (≥50)
Gastrointestinal bleeding
Nocturnal diarrhea (ie, fasting state)
Worsening pain
Unintended weight loss
Iron deficiency anemia
Elevated C-reactive protein
Positive fecal lactoferrin or calprotectin
Family history of early colon cancer or IBD
Labs:
In patients with diarrhea:
Fecal calprotectin and CRP
Celiac disease serology
Stool testing for giardiasis
CBC
Colonoscopy only for patients with redflags.
Irritable bowel syndrome
24
Comprehensive Study Material for Step 2 CK
Here’s a quick preview of our Step 2 CK notes -
GASTROINTESTINAL SYSTEM DAY 3
MODULE 3.1
defecation and is typically associated with abnormal bowel habits (eg, diarrhea and/or
constipation). It is the most common gastrointestinal disorder and occurs most frequently in
women age < 45. Its seen to be exacerbated in pregnancy for unknown reasons.
Clinical features of irritable bowel syndrome - .
#Rome IV diagnostic criteria
Recurrent abdominal pain/discomfort ≥1 days/week for past 3 months & ≥2 of the following:
Related to defecation (improves or worsens)
Change in stool frequency
Change in stool form
Classification
IBS-D: diarrhea is the predominant symptom
IBS-C: constipation is the predominant symptom
IBS-M: mixed diarrhea and constipation
IBS-U: criteria for IBS are met but bowel movements can't be categorized into the
above subgroups
Alarm features
Older age of onset (≥50)
Gastrointestinal bleeding
Nocturnal diarrhea (ie, fasting state)
Worsening pain
Unintended weight loss
Iron deficiency anemia
Elevated C-reactive protein
Positive fecal lactoferrin or calprotectin
Family history of early colon cancer or IBD
Labs:
In patients with diarrhea:
Fecal calprotectin and CRP
Celiac disease serology
Stool testing for giardiasis
CBC
Colonoscopy only for patients with redflags.
Irritable bowel syndrome
24
Comprehensive Study Material for Step 2 CK
Here’s a quick preview of our Step 2 CK notes -
GASTROINTESTINAL SYSTEM DAY 3
MODULE 3.1
Management
Non-Pharmacological treatment - Dietary adjustments
Soluble fiber supplements (e.g., psyllium) + Avoidance of trigger foods (e.g., trial of
elimination diet) Lifestyle changes
Pharmacological treatment
Diarrhea dominant: loperamide, rifaximin etc
Constipation dominant: Polyethylene glycol (PEG)
Abdominal pain: Antispasmodics (e.g., dicyclomine, hyoscyamine) , Tricyclic
antidepressants(e.g., amitriptyline)
Acute mesenteric ischemia:
Acute reduction in arterial or venous blood flow to the small intestine; may result in bowel
ischemia or infarct
Etiology:
1.Acute mesenteric artery embolism
Most common cause of AMI
Risk factors include atrial fibrillation
Most commonly involves the SMA
2. Acute mesenteric artery thrombosis
Risk factors include visceral atherosclerosis
3.Nonocclusive mesenteric ischemia
Most commonly occurs in critically ill patients with low cardiac output
4.Mesenteric venous thrombosis
Risk factors include infection, malignancy, portal hypertension, estrogen therapy, and
hypercoagulability disorders
Clinical features:
Patients with acute mesenteric artery embolism typically present with the classic triad of
severe abdominal pain, bloody diarrhea, and atrial fibrillation
Peritonitis and acute abdomen in late stages
Investigation: CTA abdomen and pelvis (diagnostic)
Treatment
Initial treatment : Administer supplemental oxygen, Begin IV fluid resuscitation, NPO, IV
Antibiotics and heparin.
Definitive treatment: Emergency laparotomy is indicated if there are signs of peritonitis,
intestinal infarct, or hemodynamic instability.
Surgical: Bowel resection (of necrotic segment)
Revascularization: open embolectomy and/or mesenteric bypass surgery
25
Non-Pharmacological treatment - Dietary adjustments
Soluble fiber supplements (e.g., psyllium) + Avoidance of trigger foods (e.g., trial of
elimination diet) Lifestyle changes
Pharmacological treatment
Diarrhea dominant: loperamide, rifaximin etc
Constipation dominant: Polyethylene glycol (PEG)
Abdominal pain: Antispasmodics (e.g., dicyclomine, hyoscyamine) , Tricyclic
antidepressants(e.g., amitriptyline)
Acute mesenteric ischemia:
Acute reduction in arterial or venous blood flow to the small intestine; may result in bowel
ischemia or infarct
Etiology:
1.Acute mesenteric artery embolism
Most common cause of AMI
Risk factors include atrial fibrillation
Most commonly involves the SMA
2. Acute mesenteric artery thrombosis
Risk factors include visceral atherosclerosis
3.Nonocclusive mesenteric ischemia
Most commonly occurs in critically ill patients with low cardiac output
4.Mesenteric venous thrombosis
Risk factors include infection, malignancy, portal hypertension, estrogen therapy, and
hypercoagulability disorders
Clinical features:
Patients with acute mesenteric artery embolism typically present with the classic triad of
severe abdominal pain, bloody diarrhea, and atrial fibrillation
Peritonitis and acute abdomen in late stages
Investigation: CTA abdomen and pelvis (diagnostic)
Treatment
Initial treatment : Administer supplemental oxygen, Begin IV fluid resuscitation, NPO, IV
Antibiotics and heparin.
Definitive treatment: Emergency laparotomy is indicated if there are signs of peritonitis,
intestinal infarct, or hemodynamic instability.
Surgical: Bowel resection (of necrotic segment)
Revascularization: open embolectomy and/or mesenteric bypass surgery
25
Atherosclerosis (smoking, dyslipidemia) causes narrowing of celiac and superior mesenteric
arteries causing narrowing of the lumen
Clinical features
Crampy, postprandial epigastric pain
Food aversion & weight loss
Signs of malnutrition, abdominal bruit .
Diagnosis
CT angiography (preferred), Doppler ultrasonography
Management
Risk reduction (eg, tobacco reduction), nutritional support
Endovascular or open surgical revascularization
Colonic ischemia / Ischemic colitis
Colonic ischemia is usually nonocclusive in etiology, usually in “watershed” ischemia with
underlying atherosclerotic disease or state of low blood flow ( eg, hypovolemia, hemorrhagic
shock).
Clinical features:
Moderate abdominal pain & tenderness
Hematochezia, diarrhea
Leukocytosis, lactic acidosis
Etiology
Chronic mesenteric ischemia
26
arteries causing narrowing of the lumen
Clinical features
Crampy, postprandial epigastric pain
Food aversion & weight loss
Signs of malnutrition, abdominal bruit .
Diagnosis
CT angiography (preferred), Doppler ultrasonography
Management
Risk reduction (eg, tobacco reduction), nutritional support
Endovascular or open surgical revascularization
Colonic ischemia / Ischemic colitis
Colonic ischemia is usually nonocclusive in etiology, usually in “watershed” ischemia with
underlying atherosclerotic disease or state of low blood flow ( eg, hypovolemia, hemorrhagic
shock).
Clinical features:
Moderate abdominal pain & tenderness
Hematochezia, diarrhea
Leukocytosis, lactic acidosis
Etiology
Chronic mesenteric ischemia
26
Diagnosis:
CT scan: Colonic wall thickening, fat stranding
Endoscopy: Edematous and friable mucosa
Management:
IV fluids and bowel rest
Antibiotics with enteric anaerobic coverage
Colonic resection if necrosis develops
27
CT scan: Colonic wall thickening, fat stranding
Endoscopy: Edematous and friable mucosa
Management:
IV fluids and bowel rest
Antibiotics with enteric anaerobic coverage
Colonic resection if necrosis develops
27
Exclusively for Next Steps Students
High-Yield 1000+ Cases for USMLE Step 2 CK
All books are non-commercial; original copies are exclusively for Next Steps Students (Mid 2025).
Other Handbook Series
28
High-Yield 1000+ Cases for USMLE Step 2 CK
All books are non-commercial; original copies are exclusively for Next Steps Students (Mid 2025).
Other Handbook Series
28
1. A 50 year old male comes for routine evaluation. He got his influenza shot recently.
There is no past medical history. What other vaccine should be given ?
Zoster vaccine
Inactivated, Recombinant subunit vaccine
All Adults > 50 years of age.
Do not confuse this with Varicella vaccine :
Live attenuated vaccine
Dose 1 : 12-15 month of age
Dose 2 : 4-6 years of age
2. A 19 y/o college student is preparing to move into a dormitory. The student is
advised to receive a vaccination to protect against certain infectious diseases
commonly spread in communal living environments. Which vaccine is most
appropriate ?
Conjugate meningococcal vaccine
MENINGOCOCCAL VACCINE :
Dose 1 : At age of 11-12 years
Dose 2 : At age of 16 years or 5 years after the first dose.
Vaccinate high risk patients (even if they are >18 y/o) :
College student living in dormitories
Military recruits
Asplenia or functional asplenia
Complement deficiency (C5-C9)
Outbreak
Travel to endemic country
3. A 30 y/o woman is planning a trip to sub-Saharan Africa. She will be traveling for
3 months and plans to stay in both urban and rural areas. She has no significant
medical history. During her pre-travel consultation the physician discusses necessary
vaccinations for her trip. Which vaccine is recommended for this patient prior to
traveling to sub-Saharan Africa?
Hepatitis A
HEPATITIS A VACCINATION :
Who needs a Hep A vaccine ? :
All children >12 months of age.
People travelling to hep A endemic areas.
People involved in gay sex.
IV drug users
Chronic liver disease
High-Yield 1000+ Cases for USMLE Step 2 CK
29
Here’s a quick preview of our Step 2 CK notes -
SCREENING AND VACCINATION
There is no past medical history. What other vaccine should be given ?
Zoster vaccine
Inactivated, Recombinant subunit vaccine
All Adults > 50 years of age.
Do not confuse this with Varicella vaccine :
Live attenuated vaccine
Dose 1 : 12-15 month of age
Dose 2 : 4-6 years of age
2. A 19 y/o college student is preparing to move into a dormitory. The student is
advised to receive a vaccination to protect against certain infectious diseases
commonly spread in communal living environments. Which vaccine is most
appropriate ?
Conjugate meningococcal vaccine
MENINGOCOCCAL VACCINE :
Dose 1 : At age of 11-12 years
Dose 2 : At age of 16 years or 5 years after the first dose.
Vaccinate high risk patients (even if they are >18 y/o) :
College student living in dormitories
Military recruits
Asplenia or functional asplenia
Complement deficiency (C5-C9)
Outbreak
Travel to endemic country
3. A 30 y/o woman is planning a trip to sub-Saharan Africa. She will be traveling for
3 months and plans to stay in both urban and rural areas. She has no significant
medical history. During her pre-travel consultation the physician discusses necessary
vaccinations for her trip. Which vaccine is recommended for this patient prior to
traveling to sub-Saharan Africa?
Hepatitis A
HEPATITIS A VACCINATION :
Who needs a Hep A vaccine ? :
All children >12 months of age.
People travelling to hep A endemic areas.
People involved in gay sex.
IV drug users
Chronic liver disease
High-Yield 1000+ Cases for USMLE Step 2 CK
29
Here’s a quick preview of our Step 2 CK notes -
SCREENING AND VACCINATION
6. A 50 year old male presents to the clinic for a routine check up . He has no GI
symptoms and past medical history is not significant. His family history includes his
mother being diagnosed with colon cancer at the age of 65 years. Appropriate step in
colorectal cancer screening Begin screening with colonoscopy every 10 years Colon
cancer screening guidelines :
Individual at average risk (no family history
or a single first degree relative diagnosed
with CRC at age >60 years).
Start at 45 years and colonoscopy every
10 years
Start screening at age of 40 years or 10
years before the age of diagnosis in
relative (whichever is earlier) every 5
years.
OR
Individual with >/= 1 first degree relative
with CRC diagnosed at age < 60 years
OR
High risk adenoma (villous, sessile,
>10mm, high grade dysplasia)
Individual with Inflammatory bowel disease
Start screening 8-10 years after initial
diagnosis and repeat every 1-3 years
Start screening at the age of 10 years every
A child diagnosed with FAP
4. A 30 y/o man comes in with yellowing of the skin. He recently travelled to Africa, with
adequate malaria prophylaxis, but took no vaccines. LFT shows increased AST, ALT.
He has no past medical history. Next Best Step ?
Hep A vaccine
Post exposure prophylaxis of Hep A :
Age <=40 + immunocompetent Hep A vaccine.
Age >40 or immunocompromised or chronic liver disease Hep A vaccine +
immunoglobulin.
5. A 13 y/o girl comes in for a routine checkup. She is asymptomatic, and is up to date
with influenza shot & meningococcal vaccine. She was administered all age
appropriate vaccines during infancy. She is sexually inactive but plans to have an
intercourse with her boyfriend. Apart from discussing contraception, what should be
done ?
Administer
HPV vaccine
HPV vaccine : All children (male & female) between the age of 9 - 26 should be given
vaccine. Ideal schedule
1st dose : at age of 11-12 years
2nd dose : 6-12 months after 1st dose
If initial dose taken at the age of 9 - 14 years : 2 dose series (0 - 6 months).
If initial dose taken at age >/= 15 years : 3 dose series (0, 1-2 month and 6 months).
Contraindications : Pregnancy (no need to do UPT before vaccine), Allergic
reaction.
Individual with >/=2 first degree relative
with CRC at any age
30
symptoms and past medical history is not significant. His family history includes his
mother being diagnosed with colon cancer at the age of 65 years. Appropriate step in
colorectal cancer screening Begin screening with colonoscopy every 10 years Colon
cancer screening guidelines :
Individual at average risk (no family history
or a single first degree relative diagnosed
with CRC at age >60 years).
Start at 45 years and colonoscopy every
10 years
Start screening at age of 40 years or 10
years before the age of diagnosis in
relative (whichever is earlier) every 5
years.
OR
Individual with >/= 1 first degree relative
with CRC diagnosed at age < 60 years
OR
High risk adenoma (villous, sessile,
>10mm, high grade dysplasia)
Individual with Inflammatory bowel disease
Start screening 8-10 years after initial
diagnosis and repeat every 1-3 years
Start screening at the age of 10 years every
A child diagnosed with FAP
4. A 30 y/o man comes in with yellowing of the skin. He recently travelled to Africa, with
adequate malaria prophylaxis, but took no vaccines. LFT shows increased AST, ALT.
He has no past medical history. Next Best Step ?
Hep A vaccine
Post exposure prophylaxis of Hep A :
Age <=40 + immunocompetent Hep A vaccine.
Age >40 or immunocompromised or chronic liver disease Hep A vaccine +
immunoglobulin.
5. A 13 y/o girl comes in for a routine checkup. She is asymptomatic, and is up to date
with influenza shot & meningococcal vaccine. She was administered all age
appropriate vaccines during infancy. She is sexually inactive but plans to have an
intercourse with her boyfriend. Apart from discussing contraception, what should be
done ?
Administer
HPV vaccine
HPV vaccine : All children (male & female) between the age of 9 - 26 should be given
vaccine. Ideal schedule
1st dose : at age of 11-12 years
2nd dose : 6-12 months after 1st dose
If initial dose taken at the age of 9 - 14 years : 2 dose series (0 - 6 months).
If initial dose taken at age >/= 15 years : 3 dose series (0, 1-2 month and 6 months).
Contraindications : Pregnancy (no need to do UPT before vaccine), Allergic
reaction.
Individual with >/=2 first degree relative
with CRC at any age
30
1. A 12 y/o boy has fever, joint pain and a new holosystolic murmur heard best at the apex. He
had a sore throat about 3 weeks ago that resolved without treatment. He has tender, swollen
knees and ankles and a non-pruritic, erythematous rash on his trunk. What is the most
appropriate test to confirm the diagnosis?
ASO titres
Diagnosis : Acute rheumatic fever (ARF)
Usually a history of pharyngitis or tonsillitis is present.
Causative agent ? : S. pyogenes (GAS)
Root mechanism ? : Molecular mimicry
Diagnosis : 2 major or 1 major + 2 minor criteria
Major criteria
Migratory polyarthritis
Subcutaneous nodules
Erythema marginatum
Cardiac involvement
Minor criteria
Polyarthralgia
Fever
Increased ESR, CRP Prolonged PR
Interval on ECG
year, and perform prophylactic
proctocolectomy at 16-20 years.
Every 10 years
Every 3-5 years
Hyperplastic polyp < 10 mm
Hyperplastic polyp >/= 10 mm
7. A 45 y/o female who has a positive test for MLH1 gene mutation, diagnosed 20 years back
comes in for routine checkup. Her colonoscopy & endometrial biopsy are normal. Next Best Step
?
Prophylactic hysterectomy
Lynch syndrome diagnostic criteria :
At least 3 relatives should be affected, & one of them should be the first degree relative of
the other two.
At least 2 generations should be involved.
At least 1 relative should have cancer before 50 years of age.
Screening & prevention :
Colonoscopy starting at age 20-25, every 1-2 years.
Endometrial biopsy & TVS starting at age 30-35, every year.
Prophylactic hysterectomy & bilateral oophorectomy at age >=40 or as soon as child
bearing is done.
INFECTIOUS DISEASES
31
had a sore throat about 3 weeks ago that resolved without treatment. He has tender, swollen
knees and ankles and a non-pruritic, erythematous rash on his trunk. What is the most
appropriate test to confirm the diagnosis?
ASO titres
Diagnosis : Acute rheumatic fever (ARF)
Usually a history of pharyngitis or tonsillitis is present.
Causative agent ? : S. pyogenes (GAS)
Root mechanism ? : Molecular mimicry
Diagnosis : 2 major or 1 major + 2 minor criteria
Major criteria
Migratory polyarthritis
Subcutaneous nodules
Erythema marginatum
Cardiac involvement
Minor criteria
Polyarthralgia
Fever
Increased ESR, CRP Prolonged PR
Interval on ECG
year, and perform prophylactic
proctocolectomy at 16-20 years.
Every 10 years
Every 3-5 years
Hyperplastic polyp < 10 mm
Hyperplastic polyp >/= 10 mm
7. A 45 y/o female who has a positive test for MLH1 gene mutation, diagnosed 20 years back
comes in for routine checkup. Her colonoscopy & endometrial biopsy are normal. Next Best Step
?
Prophylactic hysterectomy
Lynch syndrome diagnostic criteria :
At least 3 relatives should be affected, & one of them should be the first degree relative of
the other two.
At least 2 generations should be involved.
At least 1 relative should have cancer before 50 years of age.
Screening & prevention :
Colonoscopy starting at age 20-25, every 1-2 years.
Endometrial biopsy & TVS starting at age 30-35, every year.
Prophylactic hysterectomy & bilateral oophorectomy at age >=40 or as soon as child
bearing is done.
INFECTIOUS DISEASES
31
Sydenham chorea
Most common cause of pediatric chorea.
Can be associated with anxiety, irritability,
OCD, inappropriate laughter or agitation.
Along with Jones criteria to confirm diagnosis any 1 of the following should be positive :
ASO titre or Anti DNAse B should be elevated.
Positive throat culture for group A streptococcus.
Positive rapid antigen test.
Treatment : Oral penicillin V or IM penicillin G.
Prevention : Penicillin.
2. A 10 y/o boy has fever & joint pain. He had a sore throat about 4 weeks ago that
resolved spontaneously. He has tender, swollen knees and ankles and a non-pruritic,
erythematous rash on his trunk. ECHO is normal & there are no murmurs. How long
treatment should be given ?
Penicillin G every 4 weeks until the patient turns 21 y/o.
Antibiotic prophylaxis for ARF : Penicillin every 4 weeks.
Duration :
ARF without carditis
5 years or until 21 y/o (whichever is
longer)
10 years or until 21 y/o (whichever is
longer)
10 years or until 40 y/o (whichever is
longer)
ARF with carditis but no residual cardiac
disease
ARF with carditis & persistent cardiac
disease
3. A 50 y/o man has had profuse watery diarrhea & fever for the past 2 days. His
temperature is 101°F. He was recently discharged from the hospital after a week-long
treatment of pneumonia. CBC showed leukocytosis. Treatment for this patient ?
Oral fidaxomicin
Diagnosis : C difficile infection
Important risk factors : elderly, recent hospitalization, recent antibiotics, PPIs,
chemotherapy, underlying IBD.
Any of the above risk factors + watery diarrhea, fever, leukocytosis +-
abdominal pain think of C difficile.
Diagnosis : stool PCR for toxins.
Pseudomembrane on colonoscopy (confirmatory) usually not the answer as it is
not done routinely.
Non severe C difficile : WBCs <15k + serum creatinine <1.5 mg/dL.
Severe C difficile : WBCs >15k or serum creatinine >1.5 mg/dL.
Fulminant infection : WBCs >15 k or serum creatinine >1.5 mg/dL
32
Most common cause of pediatric chorea.
Can be associated with anxiety, irritability,
OCD, inappropriate laughter or agitation.
Along with Jones criteria to confirm diagnosis any 1 of the following should be positive :
ASO titre or Anti DNAse B should be elevated.
Positive throat culture for group A streptococcus.
Positive rapid antigen test.
Treatment : Oral penicillin V or IM penicillin G.
Prevention : Penicillin.
2. A 10 y/o boy has fever & joint pain. He had a sore throat about 4 weeks ago that
resolved spontaneously. He has tender, swollen knees and ankles and a non-pruritic,
erythematous rash on his trunk. ECHO is normal & there are no murmurs. How long
treatment should be given ?
Penicillin G every 4 weeks until the patient turns 21 y/o.
Antibiotic prophylaxis for ARF : Penicillin every 4 weeks.
Duration :
ARF without carditis
5 years or until 21 y/o (whichever is
longer)
10 years or until 21 y/o (whichever is
longer)
10 years or until 40 y/o (whichever is
longer)
ARF with carditis but no residual cardiac
disease
ARF with carditis & persistent cardiac
disease
3. A 50 y/o man has had profuse watery diarrhea & fever for the past 2 days. His
temperature is 101°F. He was recently discharged from the hospital after a week-long
treatment of pneumonia. CBC showed leukocytosis. Treatment for this patient ?
Oral fidaxomicin
Diagnosis : C difficile infection
Important risk factors : elderly, recent hospitalization, recent antibiotics, PPIs,
chemotherapy, underlying IBD.
Any of the above risk factors + watery diarrhea, fever, leukocytosis +-
abdominal pain think of C difficile.
Diagnosis : stool PCR for toxins.
Pseudomembrane on colonoscopy (confirmatory) usually not the answer as it is
not done routinely.
Non severe C difficile : WBCs <15k + serum creatinine <1.5 mg/dL.
Severe C difficile : WBCs >15k or serum creatinine >1.5 mg/dL.
Fulminant infection : WBCs >15 k or serum creatinine >1.5 mg/dL
32
Oral rehydration solution
+ Hypotension / shock / toxic megacolon
Treatment:
Non severe or severe infection :
1st line = oral vancomycin or oral fidaxomicin.
2nd line = oral metronidazole.
Fulminant infection : oral vancomycin +- IV metronidazole.
If severe or fulminant infection does not resolve 48 - 72 hours of drugs fecal
microbiota transplantation.
Differentials : could be anything, eg : chemotherapy induced diarrhea, antibiotic
induced diarrhea but none of them have fever + leukocytosis.
4. A 37 y/o HIV positive man has had bloody diarrhea and abdominal pain for the past week.
His CD4 count is 30. His temperature is 99.5°F. Stool studies are negative for ova & parasites.
Diagnosis?
CMV colitis
Bloody diarrhea in HIV patients (especially with low CD4 count) think of CMV.
Severe / profuse watery diarrhea in HIV think of cryptosporidium (have acid fast
stain positive oocysts in stool).
Watery diarrhea (and other nonspecific symptoms like weight loss) in HIV,
especially if CD4 count is <50 think of MAC.
TIP : HIV patient + vision changes always consider CMV retinitis as an
important differential.
Diagnosis : Stool analysis if negative, do lower endoscopy + biopsy (CMV colitis can
show linear ulcers grossly & inclusion bodies with owl eye appearance on
microscopy).
Treatment for CMV colitis : ganciclovir followed by valganciclovir.
5. A 10 y/o child has had watery diarrhea for the past 3 days. He has no fever or blood in stool.
His mucus membranes are dry and skin turgor is decreased. His capillary refill time and vitals
are normal. Pulses are normal. There is no weight loss. NBS ?
Oral fluid replenishment
Management of dehydration in children
Mild - moderate dehydration
Increased thirst
Dry mucous membranes
Decreased skin turgor
Sunken fontanelle, eyes
Tachycardia
Decreased urination
Severe dehydration
AMS (eg : lethargy, confusion)
Delayed capillary refill (>3 seconds)
Absent tear production
Significant weight loss
Rapid, weak pulse
Hypotension, tachypnea
Oliguria / anuria
IV isotonic crystalloids (normal saline
or ringer’s lactate) : ~ 20 mL/kg
33
+ Hypotension / shock / toxic megacolon
Treatment:
Non severe or severe infection :
1st line = oral vancomycin or oral fidaxomicin.
2nd line = oral metronidazole.
Fulminant infection : oral vancomycin +- IV metronidazole.
If severe or fulminant infection does not resolve 48 - 72 hours of drugs fecal
microbiota transplantation.
Differentials : could be anything, eg : chemotherapy induced diarrhea, antibiotic
induced diarrhea but none of them have fever + leukocytosis.
4. A 37 y/o HIV positive man has had bloody diarrhea and abdominal pain for the past week.
His CD4 count is 30. His temperature is 99.5°F. Stool studies are negative for ova & parasites.
Diagnosis?
CMV colitis
Bloody diarrhea in HIV patients (especially with low CD4 count) think of CMV.
Severe / profuse watery diarrhea in HIV think of cryptosporidium (have acid fast
stain positive oocysts in stool).
Watery diarrhea (and other nonspecific symptoms like weight loss) in HIV,
especially if CD4 count is <50 think of MAC.
TIP : HIV patient + vision changes always consider CMV retinitis as an
important differential.
Diagnosis : Stool analysis if negative, do lower endoscopy + biopsy (CMV colitis can
show linear ulcers grossly & inclusion bodies with owl eye appearance on
microscopy).
Treatment for CMV colitis : ganciclovir followed by valganciclovir.
5. A 10 y/o child has had watery diarrhea for the past 3 days. He has no fever or blood in stool.
His mucus membranes are dry and skin turgor is decreased. His capillary refill time and vitals
are normal. Pulses are normal. There is no weight loss. NBS ?
Oral fluid replenishment
Management of dehydration in children
Mild - moderate dehydration
Increased thirst
Dry mucous membranes
Decreased skin turgor
Sunken fontanelle, eyes
Tachycardia
Decreased urination
Severe dehydration
AMS (eg : lethargy, confusion)
Delayed capillary refill (>3 seconds)
Absent tear production
Significant weight loss
Rapid, weak pulse
Hypotension, tachypnea
Oliguria / anuria
IV isotonic crystalloids (normal saline
or ringer’s lactate) : ~ 20 mL/kg
33
6. A 20 y/o man from rural Egypt presents with recurrent dysuria. Urinalysis reveals RBCs 8/hpf.
Microscopic findings are given below. Diagnosis ?
Schistosomiasis
Clinical features :
Pruritic rash at the site of entry, fever, fatigue.
Hematuria, dysuria, bladder outlet obstruction.
Complication ? : Squamous cell carcinoma of bladder.
Diagnosis : microscopic examination of urine
+- eosinophilia on CBC
Treatment : Praziquantel
7. A 29 y/o woman develops severe pain, swelling, and erythema around her lower abdominal
incision site 2 days after a C- section. She becomes febrile and hypotensive. Examination
reveals crepitus and rapidly spreading necrosis of the subcutaneous tissues. What Is the most
common bacterial cause of this condition ?
S pyogenes.
Surgical site infection :
Microbiology :
First 48-72 hours : S pyogenes > C perfringens (organisms that cause necrotizing
fasciitis).
After 48-72 hours : site specific organism, For GI/GU procedure, E.coli is the most
common organism.
Risk factors : smoking, steroids, diabetes, obesity.
Clinical features :
Superficial site infection (skin and subcutaneous tissue) :
➔ Localized tenderness, erythema, warmth and swelling +- fever.
➔ Purulent discharge from incision.
Deep incisional infection (fascia and muscular layer) :
➔ Wound dehiscence
➔ Localized tenderness, fever
➔ Purulent discharge from incision
➔ Necrotizing fasciitis → Cloudy gray discharge + crepitus in surrounding tissue.
Diagnosis :
Wound culture and gram stain
Abscess culture
Treatment : immediate surgical exploration + IV antibiotics.
34
Microscopic findings are given below. Diagnosis ?
Schistosomiasis
Clinical features :
Pruritic rash at the site of entry, fever, fatigue.
Hematuria, dysuria, bladder outlet obstruction.
Complication ? : Squamous cell carcinoma of bladder.
Diagnosis : microscopic examination of urine
+- eosinophilia on CBC
Treatment : Praziquantel
7. A 29 y/o woman develops severe pain, swelling, and erythema around her lower abdominal
incision site 2 days after a C- section. She becomes febrile and hypotensive. Examination
reveals crepitus and rapidly spreading necrosis of the subcutaneous tissues. What Is the most
common bacterial cause of this condition ?
S pyogenes.
Surgical site infection :
Microbiology :
First 48-72 hours : S pyogenes > C perfringens (organisms that cause necrotizing
fasciitis).
After 48-72 hours : site specific organism, For GI/GU procedure, E.coli is the most
common organism.
Risk factors : smoking, steroids, diabetes, obesity.
Clinical features :
Superficial site infection (skin and subcutaneous tissue) :
➔ Localized tenderness, erythema, warmth and swelling +- fever.
➔ Purulent discharge from incision.
Deep incisional infection (fascia and muscular layer) :
➔ Wound dehiscence
➔ Localized tenderness, fever
➔ Purulent discharge from incision
➔ Necrotizing fasciitis → Cloudy gray discharge + crepitus in surrounding tissue.
Diagnosis :
Wound culture and gram stain
Abscess culture
Treatment : immediate surgical exploration + IV antibiotics.
34
1. A 24 y/o woman consumed several tables of tylenol 2 hours ago. On examination she is
anxious but her vitals are stable. She denies any symptoms at this time. NBS ? give activated
charcoal and measure serum acetaminophen level at 4 hrs from ingestion.
Management of acute acetaminophen toxicity :
Give empiric N-acetylcysteine if :
>=8 hours of ingestion.
Signs of liver injury (eg : transaminitis) are present.
2. A 45 y/o female has RUQ pain, nausea & low grade fever. Murphy's sign is positive. WBCs are
increased. USG is non diagnostic. Which investigation will confirm the diagnosis ?
HIDA scan
Confirmatory test for acute cholecystitis, especially done if USG is non diagnostic.
Normally Radioactive tracer is injected after 4 hrs gallbladder is visualized
normal patency of gallbladder and biliary system
Results :
Acute cholecystitis : Gallbladder is not visualized due to obstruction of cystic duct
either due to stone or inflammation.
Biliary obstruction : Failure of tracer to move from biliary duct to small intestine.
3. A 3 y/o boy is brought by his parents due to sudden onset lower chest pain. The child was
playing when he developed the pain. He is asymptomatic but is drooling and has refused to eat
since the incident. There is mild discomfort when palpating his upper abdomen. A chest X-ray
is shown. NBS ?
GASTROINTESTINAL SYSTEM
35
anxious but her vitals are stable. She denies any symptoms at this time. NBS ? give activated
charcoal and measure serum acetaminophen level at 4 hrs from ingestion.
Management of acute acetaminophen toxicity :
Give empiric N-acetylcysteine if :
>=8 hours of ingestion.
Signs of liver injury (eg : transaminitis) are present.
2. A 45 y/o female has RUQ pain, nausea & low grade fever. Murphy's sign is positive. WBCs are
increased. USG is non diagnostic. Which investigation will confirm the diagnosis ?
HIDA scan
Confirmatory test for acute cholecystitis, especially done if USG is non diagnostic.
Normally Radioactive tracer is injected after 4 hrs gallbladder is visualized
normal patency of gallbladder and biliary system
Results :
Acute cholecystitis : Gallbladder is not visualized due to obstruction of cystic duct
either due to stone or inflammation.
Biliary obstruction : Failure of tracer to move from biliary duct to small intestine.
3. A 3 y/o boy is brought by his parents due to sudden onset lower chest pain. The child was
playing when he developed the pain. He is asymptomatic but is drooling and has refused to eat
since the incident. There is mild discomfort when palpating his upper abdomen. A chest X-ray
is shown. NBS ?
GASTROINTESTINAL SYSTEM
35
BUTTON BATTERIES - HALO OR DOUBLE RIM EFFECT
4. A 6 week old infant has yellowing of the skin and eyes over the past 5 days. He was born full
term via normal vaginal delivery. The baby appears jaundiced with dark urine and pale stools.
The liver is palpated to be enlarged and firm. Labs show elevated total and direct bilirubin
levels. An abdominal USG reveals a nonvisualized gallbladder. Diagnosis ?
Endoscopic removal
FOREIGN BODY IN ESOPHAGUS :
Clinical features :
Sudden onset throat or chest pain.
High risk features :
Respiratory symptoms (eg : dyspnea, wheezing, etc).
Obstructive symptoms (eg : drooling, inability to swallow, etc).
If the object is a button battery, magnet or a sharp item (eg: fish bone, needle, pins).
Management :
Secure airway if signs of respiratory distress are present.
Obtain X-rays : PA & lateral views check if high risk features are present or not.
High risk features present Endoscopic removal.
No high risk features serial x-rays.
COIN IN ESOPHAGUS
36
4. A 6 week old infant has yellowing of the skin and eyes over the past 5 days. He was born full
term via normal vaginal delivery. The baby appears jaundiced with dark urine and pale stools.
The liver is palpated to be enlarged and firm. Labs show elevated total and direct bilirubin
levels. An abdominal USG reveals a nonvisualized gallbladder. Diagnosis ?
Endoscopic removal
FOREIGN BODY IN ESOPHAGUS :
Clinical features :
Sudden onset throat or chest pain.
High risk features :
Respiratory symptoms (eg : dyspnea, wheezing, etc).
Obstructive symptoms (eg : drooling, inability to swallow, etc).
If the object is a button battery, magnet or a sharp item (eg: fish bone, needle, pins).
Management :
Secure airway if signs of respiratory distress are present.
Obtain X-rays : PA & lateral views check if high risk features are present or not.
High risk features present Endoscopic removal.
No high risk features serial x-rays.
COIN IN ESOPHAGUS
36
Biliary atresia
Clinical feature :
Onset after 2 weeks of birth
Jaundice
Acholic stool, dark urine
Hepatomegaly
Diagnosis : Increased direct bilirubin
Normal / mildly increased AST, ALT and GGT
NBS : USG (absent or hypoplastic gallbladder)
Liver biopsy results : intrahepatic bile duct proliferation, portal tract edema, fibrosis.
Treatment :
Kasai procedure (hepatoportoenterostomy)
Definitive : Liver transplantation
Biliary cyst : USG shows cystic dilation of biliary tree.
TIP : dark urine, acholic stools, & conjugated hyperbilirubinemia in a neonate,
NBS abdominal USG.
5. A 9 month old boy has intermittent severe crying episodes during which he pulls his knees to
his chest. He has vomited multiple times and his parents report that his last stool was bloody
and mucus-filled. On examination his abdomen is tender and a mass is palpable in the right
upper quadrant. Treatment ?
Air enema
Diagnosis : INTUSSUSCEPTION
Clinical features :
Recurrent episodes of colicky pain with legs drawn up towards the abdomen.
Vomiting
Abdominal tenderness
Palpable sausage shaped mass in RUQ with retraction in RLQ
Currant jelly stools.
High pitched sounds on auscultation
Lethargy, pallor, shock and altered mental status may be present.
Lead points :
Recent viral illness or rotavirus vaccine (leads to hypertrophy of Peyer patches).
Meckel’s diverticulum
Polyps
Henoch - Schöonlein purpura
Diagnosis : NBS = USG (Target sign)
Differentials (other conditions that can have dark urine, acholic stools, & conjugated
hyperbilirubinemia in neonates) :
Infections (eg : CMV, toxoplasma, etc) genetic or metabolic conditions : USG is
either normal or shows hepatomegaly only.
37
Clinical feature :
Onset after 2 weeks of birth
Jaundice
Acholic stool, dark urine
Hepatomegaly
Diagnosis : Increased direct bilirubin
Normal / mildly increased AST, ALT and GGT
NBS : USG (absent or hypoplastic gallbladder)
Liver biopsy results : intrahepatic bile duct proliferation, portal tract edema, fibrosis.
Treatment :
Kasai procedure (hepatoportoenterostomy)
Definitive : Liver transplantation
Biliary cyst : USG shows cystic dilation of biliary tree.
TIP : dark urine, acholic stools, & conjugated hyperbilirubinemia in a neonate,
NBS abdominal USG.
5. A 9 month old boy has intermittent severe crying episodes during which he pulls his knees to
his chest. He has vomited multiple times and his parents report that his last stool was bloody
and mucus-filled. On examination his abdomen is tender and a mass is palpable in the right
upper quadrant. Treatment ?
Air enema
Diagnosis : INTUSSUSCEPTION
Clinical features :
Recurrent episodes of colicky pain with legs drawn up towards the abdomen.
Vomiting
Abdominal tenderness
Palpable sausage shaped mass in RUQ with retraction in RLQ
Currant jelly stools.
High pitched sounds on auscultation
Lethargy, pallor, shock and altered mental status may be present.
Lead points :
Recent viral illness or rotavirus vaccine (leads to hypertrophy of Peyer patches).
Meckel’s diverticulum
Polyps
Henoch - Schöonlein purpura
Diagnosis : NBS = USG (Target sign)
Differentials (other conditions that can have dark urine, acholic stools, & conjugated
hyperbilirubinemia in neonates) :
Infections (eg : CMV, toxoplasma, etc) genetic or metabolic conditions : USG is
either normal or shows hepatomegaly only.
37
Treatment : AIr / water soluble enema
Differentials :
Meckel's diverticulum : usually painless rectal bleeding, abdominal pain in the right lower
quadrant and no classic history of drawing legs close to the chest.
Malrotation with volvulus : Bilious vomiting, abdominal distension, upper GI series.
6. A young man has a sore throat & a history of pain in the submandibular area that worsens
while eating. There is a palpable mass in the submandibular area. There is minimal pharyngeal
erythema & no fever. Diagnosis ?
Sialolithiasis
Risk factors : smoking, dehydration, anticholinergics.
Features :
Recurrent pain while eating.
Swelling
Stone may be palpable or visible.
Diagnosis : usually clinical
To confirm : CT without contrast > USG.
Treatment : symptomatic (NSAIDs, gland massage, sialogogues).
Differentials :
Sialadenitis : presents with pain, swelling, erythema, purulent discharge. Fever could
be present.
Sialadenosis : painless swelling/ enlargement of salivary gland, eg : eating disorders,
alcohol use disorder, malnutrition.
Salivary gland tumor : presents with painless unilateral enlargement which can be
mobile. B symptoms could be present.
7. A 65 y/o man has LLQ abdominal pain, fever & nausea. He has chronic constipation. BP is 128/80
mmHg. There is tenderness in LLQ without guarding or rebound. WBCs are elevated. NBS ?
Abdominal CT with contrast
Diagnosis : DIVERTICULITIS
Clinical features :
Fever, LLQ pain (+- palpable mass)
Hematochezia
Urinary urgency/ frequency could be present (but urinalysis will show sterile pyuria).
38
Differentials :
Meckel's diverticulum : usually painless rectal bleeding, abdominal pain in the right lower
quadrant and no classic history of drawing legs close to the chest.
Malrotation with volvulus : Bilious vomiting, abdominal distension, upper GI series.
6. A young man has a sore throat & a history of pain in the submandibular area that worsens
while eating. There is a palpable mass in the submandibular area. There is minimal pharyngeal
erythema & no fever. Diagnosis ?
Sialolithiasis
Risk factors : smoking, dehydration, anticholinergics.
Features :
Recurrent pain while eating.
Swelling
Stone may be palpable or visible.
Diagnosis : usually clinical
To confirm : CT without contrast > USG.
Treatment : symptomatic (NSAIDs, gland massage, sialogogues).
Differentials :
Sialadenitis : presents with pain, swelling, erythema, purulent discharge. Fever could
be present.
Sialadenosis : painless swelling/ enlargement of salivary gland, eg : eating disorders,
alcohol use disorder, malnutrition.
Salivary gland tumor : presents with painless unilateral enlargement which can be
mobile. B symptoms could be present.
7. A 65 y/o man has LLQ abdominal pain, fever & nausea. He has chronic constipation. BP is 128/80
mmHg. There is tenderness in LLQ without guarding or rebound. WBCs are elevated. NBS ?
Abdominal CT with contrast
Diagnosis : DIVERTICULITIS
Clinical features :
Fever, LLQ pain (+- palpable mass)
Hematochezia
Urinary urgency/ frequency could be present (but urinalysis will show sterile pyuria).
38
CT abdomen with contrast (not colonoscopy due to risk of perforation).
Colonoscopy is done after the resolution of the acute phase to rule out malignancy.
CBC : leukocytosis
Treatment :
If no high risk features or complications present : supportive OPD management
(fluids, antibiotics).
If high risk features (sepsis / SIRS, immunosuppression, comorbidities, age >70) :
supportive IPD management.
Complications : perforation, obstruction, abscess.
For perforation, obstruction surgery.
Abscess <4 cm IV antibiotics. Abscess >4 cm CT guided
percutaneous drainage + IV antibiotics.
Differentials :
Angiodysplasia : usually presents with RLQ pain, hematochezia & no fever.
Appendicitis : usually have RLQ pain, and CT will show appendiceal inflammation.
Diagnosis :
39
Colonoscopy is done after the resolution of the acute phase to rule out malignancy.
CBC : leukocytosis
Treatment :
If no high risk features or complications present : supportive OPD management
(fluids, antibiotics).
If high risk features (sepsis / SIRS, immunosuppression, comorbidities, age >70) :
supportive IPD management.
Complications : perforation, obstruction, abscess.
For perforation, obstruction surgery.
Abscess <4 cm IV antibiotics. Abscess >4 cm CT guided
percutaneous drainage + IV antibiotics.
Differentials :
Angiodysplasia : usually presents with RLQ pain, hematochezia & no fever.
Appendicitis : usually have RLQ pain, and CT will show appendiceal inflammation.
Diagnosis :
39
Her you can observe, Dr. Sandra’s concept
of integrating histology with renal system
pathology which was presented in the
class.
Next Steps advocates for pictographic
learning, a method proven to enhance
students' retention abilities.
Dr. Spoorti is explaining a CT scan of the
chest and identifying cardiac structures in
this snapshot.
Experience the most updated
Lectures of Next Steps
40
of integrating histology with renal system
pathology which was presented in the
class.
Next Steps advocates for pictographic
learning, a method proven to enhance
students' retention abilities.
Dr. Spoorti is explaining a CT scan of the
chest and identifying cardiac structures in
this snapshot.
Experience the most updated
Lectures of Next Steps
40
Dr. Alekhya explaining GOUT treatment and
management and strong identifiers of GOUT
in this image.
In this image, Dr.Krishna is providing an
in-depth explanation on how to identify
and memorize the structures across a
brain image with ease.
In this image, Dr. Swathi is elaborating
on the efficacy of drugs and its
correlation with questions regarding the
agonist action of a drug.
In this integrated session, various tongue
conditions are presented together to help
students grasp and remember the
concept more easily. Dr. Monica has
included key testing points for each
condition to facilitate memorization as
well.
41
management and strong identifiers of GOUT
in this image.
In this image, Dr.Krishna is providing an
in-depth explanation on how to identify
and memorize the structures across a
brain image with ease.
In this image, Dr. Swathi is elaborating
on the efficacy of drugs and its
correlation with questions regarding the
agonist action of a drug.
In this integrated session, various tongue
conditions are presented together to help
students grasp and remember the
concept more easily. Dr. Monica has
included key testing points for each
condition to facilitate memorization as
well.
41
Course content released when you finish previous
module
You are expected to finish a topic in time, before
moving to next one
WSS Methodology: Watch, Study, Solve. Students
first watch instructional videos, then delve into
studying the accompanying book content, and
finally apply their knowledge by solving related
problems.
Introduction
A Self Paced Study Pro
Doubt Resolution System:
Students can post their doubts related to specific topics
in the discussion/doubts section.
Response Time:
Our teaching team guarantees to address these doubts
within 24 hours.
Notification System:
Once a doubt is answered by a team member, students
receive a notification.
Facilitating Progress:
This process enables students to proceed with their
courses smoothly.
Enhanced Understanding:
By clearing doubts promptly, students gain a clearer
understanding of topics before moving on to the next
stage of learning.
Discussion/Doubts Section
George - 1 Day ago
42
module
You are expected to finish a topic in time, before
moving to next one
WSS Methodology: Watch, Study, Solve. Students
first watch instructional videos, then delve into
studying the accompanying book content, and
finally apply their knowledge by solving related
problems.
Introduction
A Self Paced Study Pro
Doubt Resolution System:
Students can post their doubts related to specific topics
in the discussion/doubts section.
Response Time:
Our teaching team guarantees to address these doubts
within 24 hours.
Notification System:
Once a doubt is answered by a team member, students
receive a notification.
Facilitating Progress:
This process enables students to proceed with their
courses smoothly.
Enhanced Understanding:
By clearing doubts promptly, students gain a clearer
understanding of topics before moving on to the next
stage of learning.
Discussion/Doubts Section
George - 1 Day ago
42
NEXT
STEPS
6
UNIQUE
FEATURES
DOUBTS CLEARANCE SESSIONS
As part of our Mentorship Program, Student doubts
are cleared time to time.
WEEKLY MOCK TEST
Real time exam simulation tests conducted on
scheduled week syllabus
LIVE CLASSES
Live sessions are conducted
throughout the year regularly
making the curriculum more handy.
DAILY TESTS
For Step 1 and Step 2 CK, Next Steps
conducts daily tests to reinforce topics
and enhance students' ability to solve
questions effectively.
04
VIDEO BANK
Explanations for weekly mock tests are in the form of
Video explanations for all the questions
05
03
02
01
MONITORED SELF STUDY PLAN
Your Mentor monitors your progress assigned during your start of the
prep and follow up with direct interaction meets time to time
06
43
STEPS
6
UNIQUE
FEATURES
DOUBTS CLEARANCE SESSIONS
As part of our Mentorship Program, Student doubts
are cleared time to time.
WEEKLY MOCK TEST
Real time exam simulation tests conducted on
scheduled week syllabus
LIVE CLASSES
Live sessions are conducted
throughout the year regularly
making the curriculum more handy.
DAILY TESTS
For Step 1 and Step 2 CK, Next Steps
conducts daily tests to reinforce topics
and enhance students' ability to solve
questions effectively.
04
VIDEO BANK
Explanations for weekly mock tests are in the form of
Video explanations for all the questions
05
03
02
01
MONITORED SELF STUDY PLAN
Your Mentor monitors your progress assigned during your start of the
prep and follow up with direct interaction meets time to time
06
43
Biweekly doubt-clearing sessions
1 Class on difficult topics posted by students in that
particular week
Regular Mentorship Session conducted every week
(Student can attend at anytime and have direct interaction with mentor)
Recording videos of live classes will be available in
the app within 24-48 hrs
1 Year Access to Live Classes:
USMLE Step 1 Preparation
USMLE Step 2 CK Preparation
300 Hrs of Lecture Videos
Full Notes of all the topics
Daily Tests
Our USMLE Prep Course Includes
Weekend Mock Tests
USMLE Step 1 Crash Course
1 Year access to on demand doubts clearance portal
50 Direct Interactive Sessions with Mentors
(1 Year Access)
(Hard Copy)
(Covering respective day of syllabus)
(Covering respective week of syllabus)
(3 Months)
(Covering every weekend in 1 year period)
Please note that the course content may be subject to occasional modifications
44
Integrated Clinical Vignettes covering all systems
2-3 live classes per week
1 Class on difficult topics posted by students in that
particular week
Regular Mentorship Session conducted every week
(Student can attend at anytime and have direct interaction with mentor)
Recording videos of live classes will be available in
the app within 24-48 hrs
1 Year Access to Live Classes:
USMLE Step 1 Preparation
USMLE Step 2 CK Preparation
300 Hrs of Lecture Videos
Full Notes of all the topics
Daily Tests
Our USMLE Prep Course Includes
Weekend Mock Tests
USMLE Step 1 Crash Course
1 Year access to on demand doubts clearance portal
50 Direct Interactive Sessions with Mentors
(1 Year Access)
(Hard Copy)
(Covering respective day of syllabus)
(Covering respective week of syllabus)
(3 Months)
(Covering every weekend in 1 year period)
Please note that the course content may be subject to occasional modifications
44
Integrated Clinical Vignettes covering all systems
2-3 live classes per week
3000+ Practice Questions by System Wise
Full length Crash Course Videos
Full Access to the USMLE Dissection Handbook Series
100 Days Access to the Next Steps USMLE App
15 Direct Interactive Sessions with Mentors
USMLE Crash Course Step 1/Step 2 CK
(Hard Copies Included)
6 Unit Tests
Final Grand Test
100 Days Access to Doubt Clearance Portal
Access to all live classes including doubt clearance
sessions during the course.
Interactive sessions with mentor every weekend.
3 months
Please note that the course content may be subject to occasional modifications
45
Full length Crash Course Videos
Full Access to the USMLE Dissection Handbook Series
100 Days Access to the Next Steps USMLE App
15 Direct Interactive Sessions with Mentors
USMLE Crash Course Step 1/Step 2 CK
(Hard Copies Included)
6 Unit Tests
Final Grand Test
100 Days Access to Doubt Clearance Portal
Access to all live classes including doubt clearance
sessions during the course.
Interactive sessions with mentor every weekend.
3 months
Please note that the course content may be subject to occasional modifications
45
Research Publications
We provide you with a dedicated group of
research peers and an experienced
research mentor with a substantial
portfolio of hundreds of publications.
Case Report Publications
The CV training program remains
incomplete until you engage with our
assignments involving case reports
from various hospitals. These
assignments serve as valuable
material for study, potential
publications, and presentations at our
globally conducted conferences.
International Conferences
Students have the option to participate in
international medical conferences, either
virtually or in person. This presents a
unique chance to present their work, such
as case reports or research findings, to a
panel of experts and conference
attendees. A certificate of participation will
be awarded, enhancing your CV.
46
We provide you with a dedicated group of
research peers and an experienced
research mentor with a substantial
portfolio of hundreds of publications.
Case Report Publications
The CV training program remains
incomplete until you engage with our
assignments involving case reports
from various hospitals. These
assignments serve as valuable
material for study, potential
publications, and presentations at our
globally conducted conferences.
International Conferences
Students have the option to participate in
international medical conferences, either
virtually or in person. This presents a
unique chance to present their work, such
as case reports or research findings, to a
panel of experts and conference
attendees. A certificate of participation will
be awarded, enhancing your CV.
46
ACLS & BLS Workshop
Take your USMLE CV to the next level! Enroll
in our live ACLS and BLS workshop and
gain invaluable medical training. Learn
life-saving techniques, get hands-on
experience, and earn AHA certification
from top-notch instructors.
Electronic Medical Records
(EMR) Training
While many physicians grasp this concept
during their practice post-residency,
acquiring billing and coding knowledge
before entering residency can set you apart
as an exceptional candidate.
Revenue Cycle Management
It is important to know about the complete
insurance based healthcare system. While
many physicians grasp this concept
during their practice post-residency,
acquiring billing and coding knowledge
before entering residency can set you
apart as an exceptional candidate.
6 Components of Our International CV Program
47
Take your USMLE CV to the next level! Enroll
in our live ACLS and BLS workshop and
gain invaluable medical training. Learn
life-saving techniques, get hands-on
experience, and earn AHA certification
from top-notch instructors.
Electronic Medical Records
(EMR) Training
While many physicians grasp this concept
during their practice post-residency,
acquiring billing and coding knowledge
before entering residency can set you apart
as an exceptional candidate.
Revenue Cycle Management
It is important to know about the complete
insurance based healthcare system. While
many physicians grasp this concept
during their practice post-residency,
acquiring billing and coding knowledge
before entering residency can set you
apart as an exceptional candidate.
6 Components of Our International CV Program
47
Premium Clinical Rotations for the enthusiastic
USMLE aspirants
Next Steps provides Clinical Rotations to USMLE aspirants with an exceptional
and invaluable opportunity for their USMLE journey. Featuring immersive
hands-on rotations across diverse medical specialties, access to preferred
residency programs, and budget-friendly options without additional charges,
Next Steps emerges as a standout selection.
Why should you go with us?
Exclusive Hands-On Rotations
Affiliated with Preferred Residency Programs
Tailored and Individualized Hospital Letter of Recommendations
Monthly Allocation and Types of rotations
Thriving Satisfaction: Exceptional Value in Our Quality Rotations
Accelerated Success with Next Steps
In-patient & Out- patient Rotation
48
USMLE aspirants
Next Steps provides Clinical Rotations to USMLE aspirants with an exceptional
and invaluable opportunity for their USMLE journey. Featuring immersive
hands-on rotations across diverse medical specialties, access to preferred
residency programs, and budget-friendly options without additional charges,
Next Steps emerges as a standout selection.
Why should you go with us?
Exclusive Hands-On Rotations
Affiliated with Preferred Residency Programs
Tailored and Individualized Hospital Letter of Recommendations
Monthly Allocation and Types of rotations
Thriving Satisfaction: Exceptional Value in Our Quality Rotations
Accelerated Success with Next Steps
In-patient & Out- patient Rotation
48
Our USMLE Residency Match Strategy
June-August (CV Review and PS Review)
We’ll fine-tune your CV to highlight your strengths and achievements, making you a
standout candidate.
Our experts will review and help you refine your PS to tell your unique story.
Obtain MSPE (Medical Student Performance Evaluation) from your college and upload it
in ERAS portal
August-September (Interview Preparation Program)
Two group sessions covering outreach emails, the ERAS application process, and key
deadlines.
One one-on-one session for ERAS application review, focusing on the experiences
section.
Assistance in finalizing your list of programs for application.
October-November (Mock Interview Sessions)
Program Outreach Support – Guidance on reaching out to interested programs via
email.
Interview Preparation - Two one-on-one coaching sessions to enhance interview skills.
Mock Interviews (1-2 sessions) scheduled based on your interview dates.
December - January
(Post-Interview Communication)
Advice on sending follow-up emails to interviewed programs.
February (Rank Order List)
Work with our experts to finalize your ROL, considering multiple critical factors.
March (SOAP)
If unmatched, receive guidance on the Supplemental Offer and Acceptance Program
(SOAP) application process.
49
June-August (CV Review and PS Review)
We’ll fine-tune your CV to highlight your strengths and achievements, making you a
standout candidate.
Our experts will review and help you refine your PS to tell your unique story.
Obtain MSPE (Medical Student Performance Evaluation) from your college and upload it
in ERAS portal
August-September (Interview Preparation Program)
Two group sessions covering outreach emails, the ERAS application process, and key
deadlines.
One one-on-one session for ERAS application review, focusing on the experiences
section.
Assistance in finalizing your list of programs for application.
October-November (Mock Interview Sessions)
Program Outreach Support – Guidance on reaching out to interested programs via
email.
Interview Preparation - Two one-on-one coaching sessions to enhance interview skills.
Mock Interviews (1-2 sessions) scheduled based on your interview dates.
December - January
(Post-Interview Communication)
Advice on sending follow-up emails to interviewed programs.
February (Rank Order List)
Work with our experts to finalize your ROL, considering multiple critical factors.
March (SOAP)
If unmatched, receive guidance on the Supplemental Offer and Acceptance Program
(SOAP) application process.
49
Next Steps USMLE is delighted to announce that
we have supported over 5000+ USMLE students
through more than 100 offline and online
awareness events.
Our mission at Next Steps is to fulfill the dreams of
aspiring doctors by guiding them on their journey
to becoming physicians in the USA.
We take pride in witnessing hundreds of students
achieve success in USMLE Step 1 and Step 2 CK
through our mentorship program.
Let Next Steps USMLE be your partner in realizing
your dream of practicing medicine in the United
States.
Next Steps USMLE Awareness Program
50
we have supported over 5000+ USMLE students
through more than 100 offline and online
awareness events.
Our mission at Next Steps is to fulfill the dreams of
aspiring doctors by guiding them on their journey
to becoming physicians in the USA.
We take pride in witnessing hundreds of students
achieve success in USMLE Step 1 and Step 2 CK
through our mentorship program.
Let Next Steps USMLE be your partner in realizing
your dream of practicing medicine in the United
States.
Next Steps USMLE Awareness Program
50
OUR TEAM
DR. SANDRA OKANKOW
M.D Internal Medicine
St Barnabas Hospital Bronx
DR. GOUTHAM EDULA
MBBS, MS Biochemistry
Senior Scientist and Senior
Research physician
DR. AKRUTHI
Richmond university
medical center NY
DR. KRISHNA SINGH
Resident at St. Vincent’s
Medical Center
(Internal Medicine)
DR. AlEKHYA REDDY K
MD Internal Medicine
(Kasturba medical
college, gold medalist)
DR. KEERTHI PALAGATI
Resident at Jackson Health
System (General Surgery
Preliminary)
DR. SPURTHY ANUGU, MD
PGY1 pediatric resident
Ascension St John
Hospital, MI
DR RAVULA KUSUMA
CHOWDARY
PGY2 Internal Medicine
University of Kentucky
DR RAKESH
Internal Medicine
University of Kentucky
51
DR. SANDRA OKANKOW
M.D Internal Medicine
St Barnabas Hospital Bronx
DR. GOUTHAM EDULA
MBBS, MS Biochemistry
Senior Scientist and Senior
Research physician
DR. AKRUTHI
Richmond university
medical center NY
DR. KRISHNA SINGH
Resident at St. Vincent’s
Medical Center
(Internal Medicine)
DR. AlEKHYA REDDY K
MD Internal Medicine
(Kasturba medical
college, gold medalist)
DR. KEERTHI PALAGATI
Resident at Jackson Health
System (General Surgery
Preliminary)
DR. SPURTHY ANUGU, MD
PGY1 pediatric resident
Ascension St John
Hospital, MI
DR RAVULA KUSUMA
CHOWDARY
PGY2 Internal Medicine
University of Kentucky
DR RAKESH
Internal Medicine
University of Kentucky
51
Next Steps Match Gallery...
52
52
Next Steps Students Gallery...
53
53
Next Steps
BLS & ACLS Workshop
Gallery
54
BLS & ACLS Workshop
Gallery
54
Greeshma Mathyari
Next steps provides really good coaching with supportive
mentors, interactive live classes and personalized study
plans, tailored to each student's needs.
Justin Jose
They are very helpful for your USMLE preparations . The
staff are very cooperative with all concerns you have and
will help you to make the best decision.
Raghu Kumar
Its an excellent platform, it keeps me on track of my step
exam prep as well as cv building simultaneously.
Sanjay Keerthipati
Next Steps is a fantastic resource for those preparing for the
USMLE exam. The staff is knowledgeable and experienced,
and they support throughout the entire process.
Dr Niyati Shah
The live classes, doubt-solving is amazing. Mentor coordinator
and whole team are really helpful in usmle journey. The
environment is very supportive even for minor doubts.
Rahitya Manchineela
The team is very helpful in every aspect regarding USMlE
journey and it's very helpful for me to study in an
organized way
Plaksha Reddy
Next steps has really efficient study plans and knowledgable
mentors for guidance.…
Quader Naseer
A great tool for those getting ready for the USMLE is Next
Steps. The team is skilled and informed, and they offer
thorough and efficient help throughout the entire procedure.
(Fathima Institute of Medical Sciences, Kadapa)
(Gomel State Medical University, Belarus)
(Ayaan Institute of Medical Sciences, Hyderabad)
(Petre Shotadze Tbilisi Medical Academy, Georgia) (Odessa National Medical University, Ukraine)
(West China School of Medicine, China)
(Kempegowda Institute of Medical Sciences, Bangalore)
(RVM Medical College, Mulugu)
Bharath Korrapati
Recommended for usmle aspirants who want to boost
their CV. They help you to publish atleast 2 research
articles and case presentations
Usha Topalkatti
It’s been good experience working with this team. Quite
friendly enough . Been a good journey
(SV Medical College, Tirupati)
(Spartan Health Sciences University, Caribbean)
Anjali Gorantla
I shadowed under Dr.Shazad at glen oaks Chicago, with
next steps I had the best US CLINICAL experience. I had
access to the inpatients and outpatients and I learned a
lot under Dr. Shazad.
Sindhu Kattekola
All members of Nextsteps are giving supportive, trusting,
focused, goal oriented, respectful, clear communication
and understanding my situation, Mentoring was awesome.
(Guntur Medical College, AP)
(Kamineni Institute of Medical Sciences)
What They Say About NEXT STEPS
Hera Ali
Enrolling in the Next Steps Course was a pivotal decision for my
preparation. It provided me with a fresh perspective on key
concepts, helping me approach them in a way I hadn't considered
before.
(Batterjee Medical College for Science and Technology)
Seshu Priya
The live classes, guidance for research and the recorded classes
are really good very detailed explanation is provided and mentor is
very supportive and is ready to help me in every way possible
through my USMLE journey.
(Malla Reddy Institute Of Medical Sciences)
55
Next steps provides really good coaching with supportive
mentors, interactive live classes and personalized study
plans, tailored to each student's needs.
Justin Jose
They are very helpful for your USMLE preparations . The
staff are very cooperative with all concerns you have and
will help you to make the best decision.
Raghu Kumar
Its an excellent platform, it keeps me on track of my step
exam prep as well as cv building simultaneously.
Sanjay Keerthipati
Next Steps is a fantastic resource for those preparing for the
USMLE exam. The staff is knowledgeable and experienced,
and they support throughout the entire process.
Dr Niyati Shah
The live classes, doubt-solving is amazing. Mentor coordinator
and whole team are really helpful in usmle journey. The
environment is very supportive even for minor doubts.
Rahitya Manchineela
The team is very helpful in every aspect regarding USMlE
journey and it's very helpful for me to study in an
organized way
Plaksha Reddy
Next steps has really efficient study plans and knowledgable
mentors for guidance.…
Quader Naseer
A great tool for those getting ready for the USMLE is Next
Steps. The team is skilled and informed, and they offer
thorough and efficient help throughout the entire procedure.
(Fathima Institute of Medical Sciences, Kadapa)
(Gomel State Medical University, Belarus)
(Ayaan Institute of Medical Sciences, Hyderabad)
(Petre Shotadze Tbilisi Medical Academy, Georgia) (Odessa National Medical University, Ukraine)
(West China School of Medicine, China)
(Kempegowda Institute of Medical Sciences, Bangalore)
(RVM Medical College, Mulugu)
Bharath Korrapati
Recommended for usmle aspirants who want to boost
their CV. They help you to publish atleast 2 research
articles and case presentations
Usha Topalkatti
It’s been good experience working with this team. Quite
friendly enough . Been a good journey
(SV Medical College, Tirupati)
(Spartan Health Sciences University, Caribbean)
Anjali Gorantla
I shadowed under Dr.Shazad at glen oaks Chicago, with
next steps I had the best US CLINICAL experience. I had
access to the inpatients and outpatients and I learned a
lot under Dr. Shazad.
Sindhu Kattekola
All members of Nextsteps are giving supportive, trusting,
focused, goal oriented, respectful, clear communication
and understanding my situation, Mentoring was awesome.
(Guntur Medical College, AP)
(Kamineni Institute of Medical Sciences)
What They Say About NEXT STEPS
Hera Ali
Enrolling in the Next Steps Course was a pivotal decision for my
preparation. It provided me with a fresh perspective on key
concepts, helping me approach them in a way I hadn't considered
before.
(Batterjee Medical College for Science and Technology)
Seshu Priya
The live classes, guidance for research and the recorded classes
are really good very detailed explanation is provided and mentor is
very supportive and is ready to help me in every way possible
through my USMLE journey.
(Malla Reddy Institute Of Medical Sciences)
55
HYD: +91 88850 14877
BNG: +91 90358 20146
USA: +1 (551) 344-9151
Hyderabad Address: 3rd Floor, M Square Building, behind Swiggy Onboarding
Office, Patrika Nagar, Madhapur, Hyderabad, Telangana - 500081.
Bangalore Address: No:1 , Sudharsanamma Arcade, Next Steps Offlice 1st floor,
8th Cross, 24th Main Rd, 2nd Phase, J. P. Nagar, Bengaluru, Karnataka - 560068.
BNG: +91 90358 20146
USA: +1 (551) 344-9151
Hyderabad Address: 3rd Floor, M Square Building, behind Swiggy Onboarding
Office, Patrika Nagar, Madhapur, Hyderabad, Telangana - 500081.
Bangalore Address: No:1 , Sudharsanamma Arcade, Next Steps Offlice 1st floor,
8th Cross, 24th Main Rd, 2nd Phase, J. P. Nagar, Bengaluru, Karnataka - 560068.
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