Ask any nephrologist—they will tell you that renal function is all that matters. Well, it’s pretty important for your Step 1 studying, too. From regulating electrolyte balance to dumping out life-threatening toxins, the kidneys are the unspoken heroes of the human body—and deservedly so, because they are complex machines with several moving parts. 

While it is a truly exciting organ system, it can be equally overwhelming to learn about as a medical student. Let’s talk about some basic renal physiology frameworks and get a taste of what can happen if this physiology gets wacky! 

High-Yield Renal Function Topics for Step 1

Basics of Normal Renal Function

The kidneys are composed of a couple million nephrons. The nephron contains an entrance where blood enters through the afferent arteriole into the glomerulus where blood is filtered into the tubule of the nephron. Blood pressure drives blood through the glomerulus, some of which makes its way through to become filtrate, the rest of which exits via the efferent arteriole. Through the tubule, substances are secreted and reabsorbed. The filtrate then heads to the collecting duct, where it funnels into the ureter, bladder, and ultimately to the toilet (or foley or diaper).

Like all organs, to prevent ischemia and subsequent injury, the kidney needs oxygen. Oxygen comes from blood, which is delivered to the kidneys by cardiac output. If anything gets too complex, think back to this: your basic understanding of the structure of the kidney. 

Nephron Physiology

The name of the game when it comes to compartmentalizing the nephron is knowing the type of ion channel and the drug(s) that work there. 

The proximal collecting tubule is the main site of reabsorption. It is here that all of the glucose (in a non-diabetic) and most of the sodium, chloride, bicarbonate, phosphate, water, and potassium get reabsorbed. Think carbonic anhydrase and SGLT2 transporters!!

The thick ascending limb of the loop of Henle contains the Na⁺/K⁺/2Cl⁻ cotransporter. Ions can pass through, but water cannot. This segment is critical for establishing the medullary osmotic gradient and is where loop diuretics (e.g., furosemide) act.

The distal (convoluted) tubule has a Na/Cl channel and again, no water channel. Thiazides work here, and notably, increase calcium absorption (an important side effect of thiazide diuretics!).

The collecting tubule is a specialized sodium channel (ENaC) and the V2 channel. Potassium-sparing diuretics work here to excrete sodium and water, and hang onto potassium. ADH acts here to hold onto water. 

Renin-Angiotensin-Aldosterone System

This system is so important that a relatively in-depth description is necessary. The renin–angiotensin–aldosterone system is a core regulator of blood pressure, circulating volume, and glomerular filtration.

Renin, a protease released by juxtaglomerular cells of the afferent arteriole, is secreted in response to decreased renal perfusion pressure, decreased sodium delivery to the kidneys, and increased sympathetic tone. Renin cleaves angiotensinogen (from the liver) into angiotensin I, which is then converted to angiotensin II by ACE, primarily in the lungs. Angiotensin II is a potent vasoconstrictor that preferentially constricts the efferent arteriole to maintain GFR and stimulates aldosterone secretion.

Finally, aldosterone acts on the distal tubule and collecting duct to increase sodium reabsorption and potassium excretion. The net effect of RAAS activation is increased blood pressure and increased circulating volume.

This system becomes exquisitely important because there are several drugs that target molecules within the RAAS system, like ACE inhibitors that block the formation of angiotensin II and aldosterone antagonists that limit sodium and water retention.

Key Clinical Connection: Sympathetic overactivity and activation of the RAAS system is implicated in the pathogenesis of heart failure. The body hangs onto too much water because of poor kidney perfusion, causing congestion and increased afterload/fluid overload for the already suffering heart.

Electrolyte Abnormalities

Good luck admitting your medicine patient and not coming across at least a few electrolyte derangements in their problem list. When kidney function goes awry, electrolyte abnormalities can be a life-threatening complication. Let’s talk about the ones that really matter:

HYPOnatremia is a dangerous abnormality that, if severe and/or acute, can lead to seizures and coma. If corrected too quickly, it can lead to permanent neurological damage (Osmotic Pontine Demyelination). To be on the safe side, aim to correct Na by 6-8 mEq/mL over a 24-hour period. Breaking down the etiologies of hyponatremia can be a separate blog post of its own, but remember the big three categories of hypovolemic, euvolemic, and hypervolemic hyponatremia as a basic framework.

Another true foil is HYPERkalemia. This can destabilize cardiac cellular membranes and lead to EKG changes and lethal arrhythmias. If this happens, it’s important to first stabilize those cardiac membranes with calcium gluconate, and then treat with insulin, glucose, and then get rid of the extra potassium either with a loop diuretic or with an oral potassium binding agent. If you are in a real bind, dialysis can get the potassium out of the blood. 

HYPERmagnesemia can depress deep tendon reflexes, cause hypotension, and even cardiac arrest. The classic case is a pre-eclamptic who is on too high a magnesium infusion. 

When it comes to calcium, high levels lead to the classic “bones (pain), groans (GI discomfort), (kidney) stones, and psych overtones” – a set of lab findings seen often in primary hyperparathyroidism. 

Low levels, on the other hand, cause muscle spasm and tetany.Key physical exam findings to look out for in HYPOcalcemia include Chovstek sign (twitching of the face when you tap the facial nerve) and Trosseau sign (involuntary hand and wrist muscle spasms after inflating a blood pressure cuff). 

Acute Kidney Injury

So how does renal function become damaged?? 

Kidney injury is common, and is a huge source of morbidity for both hospitalized patients and outpatients alike. I don’t make many promises when it comes to your USMLE exams, but I can promise you that some element of renal failure will show up on the test. More important than understanding any particular lab values or etiology is comprehending what drives renal failure from the pathophysiologic perspective, how these patients present, and how the different etiologies are treated.

We will use the terms renal failure and kidney injury relatively interchangeably; in reality, renal failure is more of an end-stage kidney injury. Kidney injury represents a decrease in the filtering function of the kidney – a lowering of the glomerular filtration rate (GFR). As the GFR (function) of the kidney worsens, the creatinine rises. Less creatinine is filtered into urine, and more hangs out in the blood, appearing on a basic metabolic panel blood test. For now, don’t worry about specific numbers and cutoffs, just realize that a rising creatinine represents poorer kidney functioning.

Why would the kidneys stop working as well as they once did? There are three big categories of renal failure, and to avoid frustration on the clinical wards, you must understand that a particular patient’s kidney injury can fall into more than one category, and categories can overlap (more on that later). For your USMLEs, though, your three big categories are “pre-renal,” “intrinsic renal,” and “post-renal.”

What would make you think a patient is suffering from renal failure?

Decreased urine output is the most classic of symptoms. Because the patient’s kidneys are having trouble making urine, you can expect to see fluid overload in the forms of peripheral edema, ascites, pulmonary edema, and pleural effusions. In labs, certainly look for a rising creatinine and BUN. When in doubt, always obtain urine studies, including a microscopic look at the urine itself. Finally, the presence of different types of casts can be pathognomonic for particular diseases (more on this below!)

1. Pre-Renal Failure

Pre-renal failure is a compromise of blood flow to the kidney, and is usually a function of dehydration. Your classic pre-renal patients are either suffering from a GI bug (vomiting and diarrhea), hyperemesis gravidarum, or overdiuresis. Renal ischemia can be caused by any compromise in feeding the kidney oxygenated blood. If lack of fluid/blood flow to the kidney continues long enough, the kidney can get ischemic, like in septic shock. If it goes on for long enough, it can start to have more of an ATN picture (which is an intrinsic cause of renal failure). The overlap of these two causes can drive students nuts. Don’t let it get you down, just realize that both can exist separately, but often overlap.

HY Clinical Scenarios:

• Severely dehydrated G1P0 at 7w3d
• Elderly patient found down at home with poor oral intake for several days
• Marathon runner with muscle cramps and dark urine after minimal fluid intake
• Burn patient with large surface-area burns and third-spacing of fluids
• Septic patient with hypotension and cool extremities early in the course
• Postpartum patient with acute hemorrhage and oliguria

Treatment Principles: Your patient needs some IV fluids or blood. Give it back to them!

2. Intrinsic Renal Failure

Intrinsic renal failure refers to diseases that damage the actual parts of the nephron – the glomerulus, the tubules, and the interstitium. While this is most commonly caused by drugs (antifungals, aminoglycosides, vancomycin – to name a few) or by prolonged renal ischemia, let’s take a closer look at how each disease specifically damages different parts of the nephron:

Glomerular Disease

These are the nephritic and nephrotic syndromes that can always be tricky to distinguish. Briefly, nephritis means inflammation at the level of the nephron, and nephrosis means 3.5+ grams/day of proteinuria.

Pure nephritic syndromes committed to memory include PSGN, IgA nephropathy, and rapidly progressing glomerulonephritis (including Goodpasture and Wegener’s/granulomatosis with polyangiitis).

High-yield nephrotic syndromes include minimal change disease (very common, usually in children), amyloidosis (multi-organ involvement), FSGS, and diabetic glomerulonephropathy. There’s a lot of nitty gritty detail contained in these diseases, and many others that we haven’t talked about. More than electron microscopy and other esoteric findings, focus on the disease process and pathophysiology. The rest will come with each pass through the material.

Acute Tubular Necrosis AKA Tubular Disease

Severe hypoxia, decreased forward flow (i.e., heart failure, hemorrhagic shock), anemia, and hypotension can all cause renal tubular ischemia, ATN, and intrinsic kidney failure.

Acute Interstitial Nephritis

Commonly a hypersensitivity reaction to drugs (NSAIDs, penicillins/cephalosporins, sulfonamides), this disease presents with a classic triad of fever, rash, and eosinophilia (along with evidence of an AKI, of course).

Casts

While cast formation in urine might not be of the highest yield, its ability to cinch a questionable diagnosis make casts too juicy to pass up. In order for a cast to form, a certain substance must coalesce inside the tubules in the kidney. Therefore, there must be an intrinsic renal process occurring for a cast to form. 

• WBC casts in the urine means a likely “urinary tract infection,” but not until there are white blood cells in the kidney itself (pyelonephritis), do we get casts. These can also be seen in acute interstitial nephritis. 
• RBC casts mean blood making its way into the tubule, usually from glomerulus breakdown from glomerulonephritis. 
• Muddy brown/granular casts are the result of tubular cells sloughing into the ducts, seen in acute tubular necrosis (ATN).

HY Clinical Scenarios: 

• ICU patient with prolonged hypotension who now has muddy brown casts
• Patient treated with aminoglycosides who develops rising creatinine days later
• Septic shock patient whose creatinine continues to rise despite fluids
• Child with cola-colored urine two weeks after a strep throat
• Diabetic patient with long-standing disease and heavy proteinuria

Treatment Principles: Intrinsic causes are often the hardest to treat; supportive care is king until the kidneys heal and start to put out urine again. Start by discontinuing any nephrotoxic agents, and working to encourage forward blood flow with inotropes if the heart is not functioning so well. Treatment of any etiology involves reversing and treating whatever the culprit is, and supporting the patient along the way.

3. Post-Renal Failure

As it sounds, the problem in POST-renal failure occurs AFTER blood is filtered through the kidney to form urine. If the passage of urine from the collecting duct to the toilet is obstructed, filtrate will back up in the tubule, flood the kidney, and injure it. Everything in the body depends on flow, and if filtrate can’t make its way out of the kidney, the kidney will get injured.

Working from distal-to-proximal, sources of obstruction can be clogged/clamped urinary catheter, obstructed distal urethra, obstructed prostatic urethra (BPH or cancer), renal calculus, or abdominal mass causing external compression of the ureter. Patient history and physical (and imaging, like renal ultrasound) will be most helpful in figuring out what is causing the problem.

If you are not sure what’s going on, placing a Foley can help to take post-renal obstruction off the list, and will also help keep track of inputs and outputs while the patient is being treated.

Treatment Principles: If something is obstructing, get it out of the way. Break up that too-big-to-pass stone, or call your urology colleagues to swiftly navigate a foley through the hypertrophied prostate.

Final Thoughts

I know that’s a ton of information all at once, and we haven’t even talked about singular disease processes! But the goal was to fill in whatever gaps in a big-picture, forest-for-the-trees, 30,000-foot view that you had, in order to comprehend what’s going on in normal kidney function and kidney injury. You are off to a great start, and have the framework to hang individual diseases onto.

A final tip in studying the renal system. Because it is so intimately intertwined with the cardiovascular system, do what you can to study these two systems close together. They are literally inseparable!

For even more high-yield Step 1 topics, check out these other posts on the blog:

• Now, That’s What I Call High-Yield: Pharmacology
• Now, That’s What I Call High-Yield: Musculoskeletal
• Now, That’s What I Call High-Yield: Neurology

Originally published February 2022 / Updated December 2025 by Avni Patel

Preparing for Step 2 is a huge milestone—congrats on making it this far in your medical training! You’ve survived clerkships, grown through real patient encounters, and now you’re gearing up for an exam that truly tests your clinical reasoning. And here’s the truth: Step 2 practice questions are one of the most powerful tools you have. Working through Qbanks forces you to apply what you’ve learned in a way that actually sticks, setting the foundation for long-term mastery and a score you’ll be proud of.

That said, it’s important to approach Step 2 questions strategically. You’re a busy med student with zero time to waste, so the way you use practice questions matters just as much as how many you get through! 

In this guide, we’ll break down the five major question types, walk you through how to tackle each one, and explain what makes the correct answer the best answer. We’ll wrap up with high-yield test-taking strategies to help you walk into exam day with confidence.

Let’s start by looking at what makes Step 2 questions a little different from what you’ve seen before.

Preparing for Step 2? Meet Blueprint’s combined Step 2 & Shelf Exams Qbank with 5,500+ practice questions that most closely match what you’ll see on your USMLE Step 2 and all of your shelf exams. Get started with a 7-day free trial!

Why Step 2 Practice Questions Require a Different Approach

You might be tempted to approach Step 2 the same way as Step 1, but it’s a different beast. Step 1 focuses heavily on basic sciences: memorization, pathways, and isolated facts. Step 2, on the other hand, is all about clinical reasoning, decision-making, and patient management. You’re not just recalling information anymore. You’re applying it to clinical scenarios. 

Some key differences between Step 1 and Step 2 include:

1. Step 2 has a clinical focus with real-world presentations, not ideal scenarios.

Real patients don’t always fit the textbook, which makes Step 2 questions more difficult because the questions stems aren’t idealized scenarios like they are in Step 1. While Step 1 is like listening to a clear station with just the main melody, Step 2 feels more like static on a radio with question stems often including extra details, comorbidities, and red herrings.“Buzzwords” are also less common in Step 2.

2. Step 2 has longer question stems.

Vignettes can be lengthy and detailed, mimicking real patient encounters. It’s crucial to sift through information efficiently and not lose sight of the big picture. Always approach the stem strategically and read the question first, then skim the stem for context and key details. 

3. You need to go beyond memorizing and demonstrate clinical readiness. 

Step 2 focuses on what’s best for patient care, rather than recalling every detail from a text book. The rote memorization of isolated facts, Anki cards, or buzzwords that may have carried you through Step 1 won’t be beneficial. Step 2 challenges you to develop your own decision-making frameworks and flowcharts for clinical management, guiding you through patient care scenarios in a logical, stepwise way.

4. More material, more to know. 

Step 2 tests on a broader range of topics than Step 1, covering clinical knowledge across all specialties. You’ll need to be familiar with the diagnosis and management of common and uncommon conditions, preventive care, and complications and side-effects, which makes the exam both wider in scope and more applied. Make sure to allocate enough time in your study schedule for content review, spaced repetition, and question banks. 

Understanding these differences between Step 1 and Step 2 early on will help you adjust your study strategy and approach questions in a way that maximizes your score!

Step 2 Practice Questions: How to Approach Each Question Type

Step 2 CK includes a variety of question types to test different clinical competencies. It’s important to recognize the style of question first and tailor your approach accordingly.

Here are the different question types you’ll encounter during Step 2: 

1. Diagnosis Questions 

Diagnosis-style questions ask you to determine the most likely condition based on a patient’s history of present illness, symptoms, risk factors, physical exam findings, labs, and imaging. Sometimes the answer choices list specific diseases (e.g., pulmonary embolism), while other times they ask about the underlying mechanism, associated clinical feature, or a downstream complication (e.g., right ventricular hypertrophy). Your goal is to create a differential diagnosis and select an answer that best fits the scenario. 

Sample Question

A 32-year-old woman presents with sudden-onset shortness of breath and sharp, pleuritic chest pain that began an hour ago. This morning she arrived from a flight after a business trip in Tokyo. Her heart rate is 118/min, respiratory rate is 26/min, and oxygen saturation is 90% on room air. Lung exam is clear. EKG shows sinus tachycardia. Which of the following is the most likely diagnosis?

A) Panic attack
B) Community-acquired pneumonia
C) Pulmonary embolism
D) Spontaneous pneumothorax 

Explanation

Sudden dyspnea, pleuritic chest pain, tachycardia, prolonged immobility during a long flight is the classic clot setup making pulmonary embolism (choice C) the correct answer.

How to Approach Diagnosis Questions

Start by summarizing the case with a “one-liner.”

What is the patient’s key symptom, timeline, and risk factor?

Consider the time course.

Rapid vs. gradual onset can significantly narrow the differential.

Identify the pertinent positives and negatives.

These high-yield details steer you toward one diagnosis over another. Pertinent positives: sudden dyspnea + pleuritic chest pain + sinus tachycardia + long flight. Pertinent negatives: no fever or lung crackles (rules out pneumonia) and no mention of absent lung sounds (rules out pneumothorax).

Most likely diagnosis: C) Pulmonary embolism. 

While Step 1 often emphasizes buzzwords like the S1Q3T3 EKG pattern, Step 2 is more focused on the most likely clinical presentation, in this case, sinus tachycardia. In other words, the absence of a classic “buzzword” should not be a reason to rule out an answer choice.

2. Management Questions 

These questions focus on the sequential care of a patient and often require you to distinguish between diagnostic evaluation and therapeutic intervention (e.g., imaging, endoscopy, pharmacotherapy, or surgery). 

Below are the three major formats you’ll encounter: 

2A. Next Best Diagnostic Step 

This applies when the patient’s presentation supports a broad differential and you need additional testing to narrow it.

Sample Question

A 46-year-old woman presents with a new, firm, nontender mass in her left breast that she noticed 2 weeks ago. It does not fluctuate with her menstrual cycle. She has no personal or family history of breast cancer. Your physical exam confirms a 2-cm irregular, fixed mass in the upper outer quadrant of the left breast. No skin changes or nipple discharge are present. What is the next best step in diagnosis?

A) Breast ultrasound only
B) Diagnostic mammogram
C) Breast MRI
D) Fine-needle aspiration without imaging

Explanation

In a woman over age 30 with a palpable breast mass, the next best diagnostic step is a diagnostic mammogram (choice B). Ultrasound is an appropriate answer choice for women under the age of 30. MRI is reserved for high-risk populations or when mammogram/US are inconclusive. FNA is not first-line when appropriate imaging has not yet been done.

2B. Next Best Treatment Step 

These questions ask what will stabilize the patient right now, not what is part of long-term or downstream management.

Sample Question

A 62-year-old woman presents with sudden, severe substernal chest pain radiating to her left arm. She is diaphoretic and nauseated. Vital signs: BP 88/54 mm Hg, HR 52/min. ECG shows 3-mm ST elevations in leads V2–V5. What is the next best step in management?

A) Start metoprolol
B) Give sublingual nitroglycerin
C) Begin high-intensity statin therapy
D) Activate the cardiac catheterization lab
E) Obtain serial troponin levels

Explanation

This patient has an anterior STEMI with hypotension, and the priority is reperfusion. The correct next step is activation of the cardiac catheterization lab for emergent PC (choice D). Aspirin, beta-blockers, statins, and troponins are part of MI management, but none stabilize the patient right now. 

2C. Next Best Medication 

These questions focus on the most appropriate pharmacologic therapy after establishing the likely diagnosis.

Sample Question

A 28-year-old woman comes in with irregular menstrual cycles, acne, and increased facial hair. BMI is 32 kg/m². Pelvic ultrasound reveals enlarged ovaries with multiple peripheral follicles. The pregnancy test is negative. She is not currently trying to conceive. Which medication is the most appropriate to alleviate symptoms?

A) Metformin
B) Leuprolide
C) Combined oral contraceptive pill
D) Clomiphene citrate

Explanation

The patient has classic PCOS. Since she is not trying to conceive, the next best pharmacologic step is a combined oral contraceptive pill (choice C), which regulates cycles, lowers androgen levels, and improves acne and hirsutism. If stimulating fertility is desired, clomiphene citrate can be used as first-line therapy to stimulate ovulation. 

How to Approach Management Questions

Identify whether the question requires a diagnosis, treatment, or medication.

Reading the last line of the question stem first often helps.

For diagnostic next steps…

Choose the test that gives the most immediate and actionable information that’s age appropriate.

For treatment next steps…

First, decide if the patient is stable or not stable. Stabilization always overrides testing or long-term therapy.

In high-acuity scenarios…

Think about what will keep this patient alive in the next 10 minutes? Reperfusion, airway support, fluid resuscitation, and hemorrhage control are common answers.

For medication questions…

Pick the first-line drug that best addresses the patient’s goals (symptom control vs fertility vs prevention).

Don’t get distracted by long-term management options.

Step 2 wants sequence, not a list of everything you’d eventually do. If two answers seem correct, pick the one that occurs sooner in the clinical timeline.

3. Prediction Questions 

These questions ask you to identify a patient’s most likely diagnosis then go a step further and pick the correct associated prognosis, complications, or treatment related to that diagnosis.

3A. Most Common Cause of Death/Prognosis:

These questions test your knowledge of what typically is the outcome for a disease trajectory. 

Sample Question

A 19-year-old man presents with progressive difficulty walking and frequent falls that started in early adolescence. On exam, he has dysarthria, absent lower extremity reflexes, and an ataxic gate. Laboratory studies reveal impaired glucose tolerance. Genetic testing confirms a GAA trinucleotide repeat expansion on chromosome 9. Which of the following is the most likely pathophysiologic process that may contribute to his premature death?

A) Respiratory muscle weakness
B) Hypertrophic cardiomyopathy leading to heart failure
C) Recurrent aspiration due to dysphagia
D) Severe diabetic microvascular complications
E) Cerebellar degeneration

Explanation

This patient presentation points to Friedreich’s ataxia. In Friedreich’s ataxia, while neurologic decline is prominent, cardiomyopathy leading to heart failure (or arrhythmia) remains the most common cause of death. Therefore, answer B is most likely.

3B. Most Likely Complication Following an Intervention/Procedure 

These questions ask what problem is most likely to occur during the course of an intervention or after a procedure.

Sample Question

A 48-year-old woman underwent a laparoscopic cholecystectomy 8 months ago for symptomatic cholelithiasis. She now presents with progressive painless jaundice, dark urine, and pale stools. Laboratory studies reveal elevated direct bilirubin. What is the most likely cause of her current presentation?

A) Retained gallstones in the common bile duct
B) Bile duct stricture due to surgical injury at time of cholecystectomy
C) Primary sclerosing cholangitis
D) Viral hepatitis

Explanation

The patient’s presentation indicates obstructive jaundice pathology. Given the delayed timeline and presentation, a bile duct stricture from prior surgical injury is most likely (choice B).

3C. Most Likely Side Effects of a Medication

These questions focus on common, clinically relevant adverse effects after starting a medication.

Sample Question

A 32-year-old woman presents for follow-up after being started on a long-term medication for recurrent episodes of mania and depression. She reports mild fatigue, weight gain, and constipation over the past few months. On exam, her thyroid gland is slightly enlarged but nontender. Laboratory studies reveal an elevated TSH with low-normal free T4. Which of the following medications is most likely responsible for her current laboratory findings?

A) Valproate
B) Lithium
C) Carbamazepine
D) Fluoxetine
E) Risperidone

Explanation

The patient has a history of bipolar disorder and the clinical scenario describes long-term lithium therapy. Lithium commonly causes hypothyroidism with elevated TSH, low/normal free T4 (choice B). 

How to Approach Prediction Questions

Lock in the diagnosis first

These are typically second-order questions. Use the scenario to narrow your differential before thinking about complications or management.

Pay attention to key words.

Watch out for “most common,” “likely,” or “frequent.” Step 2 favors real-world patterns over rare exceptions.

Use context clues.

Age, timing, and risk factors matter. Post-op complications differ by how long after surgery the patient presents. Think “timeline & probability.”

4. Primary Care: Disease Prevention and Surveillance Questions 

For these questions you’ll often be asked not just to diagnose or treat, but also how and when to screen, monitor, or counsel patients to prevent disease.

Here are some question types to be ready for: 

4A. Healthcare Maintenance 

These questions often test the USTFP guidelines that you’ve studied for your Family Medicine and Adult Outpatient Medicine shelf exams. 

Sample Question

A 62-year-old man comes for routine follow-up. He has a 45 pack-year smoking history but quit 5 years ago. He has no respiratory symptoms or known lung disease. Which of the following is the most appropriate next step regarding lung cancer screening?

A) No screening needed since he’s asymptomatic and quit smoking
B) Recommend annual low-dose CT scan of the chest
C) Chest X-ray now and in 1 year
D) Sputum cytology yearly
E) Routine lung cancer screening is not recommended

Explanation

Guidelines recommend annual low-dose CT for adults aged 50–80 with a 20+ pack-year smoking history, who currently smoke or quit within the past 15 years (choice B). Even if the patient quit recently, the elevated risk still warrants screening. Chest X-ray and sputum cytology are not recommended for screening.

4B. Normal/Abnormal Development 

These questions are most commonly seen when pediatric and OBGYN knowledge is tested. You need to master the normal presentation of labor, development, and more to be able to determine when something is abnormal. 

Sample Question

A 9‑month-old infant is brought to the pediatric clinic for a well‑child visit. On exam, the infant does not yet roll over in either direction, smiles, has a good pincer grasp but cannot wave hello, and only says mama. Which of the following is true about this infant’s development?

A) There is no concern, all of these findings are expected at this age.
B) Lack of rolling over is a concern requiring further motor development evaluation.
C) Lack of speaking 10+ words is concerning and warrants evaluation of a speech delay.
D) Not being able to wave hello is a concern and is expected at this age.

Explanation

By 9 months an infant should typically be able to crawl and pull to a stand, have a good pincer grasp, and say mama/dada (choice B). Speaking 10+ words and waving develops around 1 year. 

How to Approach Health Maintenance Questions 

Recognize the guideline being tested.

Most Step 2 preventive questions are about age, risk factors, or timing for screenings, vaccinations, and developmental milestones. 

First, master what’s normal.

Only then can you recognize what’s abnormal!

5. Ethics, Patient Safety, and Biostatistics 

Finally, the last type of questions are in the broad social sciences category. The best way to approach these is to review the content and do as many practice questions as you can. 

Here are some examples: 

5A. Ethics and Professionalism Questions 

These test your ability to navigate patient autonomy, informed consent, confidentiality, and decision-making capacity.

Sample Question

A 72-year-old man is admitted for acute exacerbation of chronic obstructive pulmonary disease. After several days of hospitalization, he refuses intubation and mechanical ventilation if his breathing worsens, stating that he values quality of life over prolonging life with invasive measures. He has no advance directive on file. On examination, he is alert, oriented, and fully capable of describing the risks and benefits of intubation. He clearly states that he does not want life-sustaining treatment and does not wish to discuss changing his mind. Which of the following is the most appropriate next step in management?

A) Proceed with intubation against his wishes.
B) Seek a court order to appoint a medical guardian.
C) Respect his decision and document his wishes in the medical record.
D) Admit him to psychiatry for further evaluation.

Explanation

The patient is competent and fully informed, and has expressed a clear refusal of life-sustaining treatment. Competent patients have the right to refuse medical interventions, even if refusal may result in death. Intubating against his wishes, seeking a court order, or psychiatric admission is unnecessary and unethical. Therefore, the answer is C. 

5B. Patient Safety/Quality Improvement 

Patient safety and quality improvement questions test your understanding of system-based practices that reduce errors, improve communication, and enhance overall healthcare delivery.

Sample Question

A 67‑year-old man is admitted for community‑acquired pneumonia. On day 2 of his hospital stay, a first‑year medical student reviewing the medication administration record notices that the patient missed two doses of his scheduled antibiotic, once on the evening shift and once on the night shift, with no documented reason. The student considers reporting this to the team but is unsure whether it’s “their place.” No one on the team seems aware of the missed doses. Which of the following interventions is most likely to improve communication and prevent missed medication doses on this unit?

A) Hold daily interdisciplinary “safety huddles” at the start of each shift.
B) Replace verbal hand‑offs with written notes only.
C) Allow only senior staff, not students, to report medication discrepancies.
D) Reduce antibiotic frequency from BID to once-daily to reduce dosing errors.
E) Delay all medication scheduling until attending physician review.

Explanation

Frequent communication failures especially during handoffs and shift changes are a major source of preventable medical errors. Safety huddles provide a regular platform for nurses, physicians, pharmacists, and other staff to highlight missed doses, reconcile medications, and collaboratively plan care (choice A). 

Other options are less effective or potentially unsafe. Limiting reporting to senior staff (C) discourages the open communication culture needed for safety. Reducing the antibiotic frequency (D) may not be clinically appropriate. Delaying medications (E) risks undertreatment. And replacing verbal handoffs with only written notes (B) may worsen miscommunication given the complexity of inpatient care.

How to Approach Patient Safety/Quality Improvement Questions

Recognize when the question is about systems and team processes.

Quality improvement is not just about individual patient management. It often revolves around communication, handoffs, rounds, or error prevention.

Think “what system change reduces error risk?”

Options often include checklists, structured rounding, huddles, and standardized communication protocols. Prioritize team‑wide, system-based changes that are highly reliable. Don’t depend on chance or memory. Beware of “fixes” that compromise care quality or individual responsibility. Reducing dosing frequency or delaying therapy are usually distractors.

Finally, consider inclusivity.

Tools that encourage even junior staff to speak up often improve safety culture.

5C. Biostatistics

You’ve seen these questions on Step 1 and they’ll also be on Step 2.

Sample Question

A 55-year-old man presents for evaluation of chronic cough. His physician orders a new rapid test for tuberculosis (TB) that has a sensitivity of 90% and a specificity of 95%. The prevalence of active TB in this patient’s population is less than 1%.Which of the following statements is most accurate regarding the interpretation of a positive test result in this patient?

A) The positive predictive value is very high because the test has excellent specificity.
B) The positive predictive value is low because the disease is uncommon in this population.
C) The negative predictive value is low due to the high sensitivity.
D) Sensitivity and specificity change depending on the patient’s age.

Explanation

PPV depends on disease prevalence. The positive predictive value is low because the disease is uncommon in this population (choice B). Even with high sensitivity and specificity, a rare condition will have a low probability that a positive result truly indicates disease. Sensitivity and specificity are intrinsic to the test and don’t change with age. 

Building a Study Plan That Incorporates Step 2 Practice Questions 

Creating a structured, personalized study plan will help you do well on Step 2. 

Here’s some tips that’ll help you crush it on exam day: 

1. Start early! 

There’s a lot of material to cover, and you simply can’t memorize every detail. Instead, give yourself time to practice learning how to think clincially and recognize patterns across different scenarios. Starting early also gives you room to experiment with different study strategies, see what works for you, and adjust your plan as you learn more about your strengths, weaknesses, and how you best retain information. 

2. Take a baseline test, and set a goal. 

Start by taking a full-length practice exam to see where you currently stand. Use this baseline to guide how you allocate study time and which areas need the most focus. I’ve seen students start with a 210 on their baseline practice test and jump all the way to 260 by test day! Remember, your starting score is just a starting point, it’s not your final destination. 

Below is the average Step 2 score published by the National Resident Matching Program for every speciality. This will give you a good sense of what your goal score should be. 

Source: NRMP

Check out this post on Step 2 percentiles to break down your Step 2 score and what it means!

3. Incorporate content review, spaced repetition, and question banks. 

Blend reading, videos, or notes with active practice using question banks. You’ve learned a lot during clinical rotations. Whether it’s Anki, the whiteboard method, or something else, pick a retention strategy and spaced repetition method that works best for you. It’s also important to practice applying this knowledge to exam-style question stems. 

4. Be consistent, and practice regularly. 

Short, focused study sessions every day are more effective than occasional marathon sessions. Regular practice helps reinforce concepts, improve recall, and build stamina for long exam blocks. The average dedicated period for Step 2 is four to six weeks, so aim for doing approximately 60-100 Step 2 practice questions a day. 

5. Study well during clerkships and for shelf exams. 

Take advantage of clinical rotations to connect real patient experiences to your studying. Observing presentations, management decisions, and outcomes in real time will make Step 2 material more intuitive and easier to remember. Learn the content well for your shelf exams. The better you understand it now, the smoother Step 2 will feel later.

Step 2 Test-Taking Strategies 

Step 2 isn’t just about what you know, it’s also about how you approach questions. 

Here are some tips that can really help on exam day: 

1. Have a routine. 

Develop a method for tackling every question and stick to it. Whether it’s underlining key details, mentally summarizing the patient, or running through your differential, having a repeatable process keeps you organized and confident.

2. Read with purpose. 

Instead of reading every line straight through, start by reading the last one or two sentences to understand what the question is asking. Then go back and review the full scenario for context. This helps you zero in on what’s actually being tested.

3. Focus on key clues. 

Identify the relevant positives and negatives in the patient’s history, labs, and exam. These details often point you toward the right answer and help you eliminate wrong answer choices that contradict the information provided. 

4. Think like a clinician. 

Step 2 questions usually center on patient care. Ask yourself: What would stabilize or help this patient first? Prioritize answers that reflect practical, real-world management you’ve seen on rotations.

5. Save the tricky ones for later. 

Flag questions that stump you and come back to them later after finishing the rest of the block. This keeps your momentum going and prevents you from wasting valuable time. While Step 2 is different from Step 1 because every point counts, panicking won’t help.

Final Thoughts

Preparing for Step 2 CK can feel overwhelming. But building a structured study plan, approaching questions systematically, understanding question types, and practicing clinical reasoning makes it far more manageable. Remember, you’ve seen most of these clinical encounters during clerkships and shelf exams, you just have to apply all that knowledge you’ve gathered.

Now empowered with these tips and tricks, you can tackle Step 2 with confidence! Good luck with your studying and be sure to reach out to Blueprint tutors if you need any assistance. 

For more (free!) tips from Blueprint tutors, check out these other posts:

• From Overwhelmed to Organized: How I Scored a 267 on USMLE Step 2
• The Step 2 Passing Score Just Increased. What Does This Mean for You
• Everything You Need To Know About the Structure of USMLE Step 2

Is exam day around the corner, and you’re still wondering how to handle Step 1 practice questions? If the anxiety is creeping in, don’t worry. A lot of other students are in the same boat. The good news is you’ll have a better chance of answering questions correctly if you follow a few tips and tricks!

In this post, we’ll cover strategies for tackling Step 1 practice questions that’ll enable you to walk into exam day brimming with confidence. As you’ll see, cracking the exam isn’t just about how much you know—it’s about the strategies you use when answering questions! 

What to Know About Step 1 Practice Questions 

As a rule of thumb, approach questions the same way every time and build this routine as you work on practice questions. The consistency will make you more efficient on test day and will prevent you from overlooking details. (They’ll be more on this shortly.) 

First-Order Questions 

First-order questions test direct recall of a fact. 

Example: “What is the mechanism of action of linezolid?”

Second-Order Questions 

Second-order questions build on that fact and apply it to a clinical scenario. 

Example: “Which other antibiotic has a similar mechanism of action (MOA) as linezolid?”

This second-order question requires you to know linezolid’s MOA and deduce which drug shares it.

Third-Order Questions 

Third-order questions require multiple layers of reasoning, linking pathophysiology, diagnosis, and management. 

Example: “A patient with a MRSA infection recently started an antibiotic. He presents with sweating, hypertension, tachycardia, clonus, and tremors. What other medication would you expect to see in their chart?” 

Here, you identify the presentation as serotonin syndrome, recognize linezolid as the antibiotic with that side effect, and determine which additional drugs (SSRIs, MAOIs, ondansetron, etc.) contribute to the syndrome.

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How to Approach Step 1 Practice Questions 

Now that you know what types of questions you’ll encounter, let’s look at some tricks that can help you answer them correctly.

Obviously, while these tips will help you tackle questions and narrow answer choices, it’s essential to have a solid grasp of the content to pass Step 1 and succeed in clinical rotations. No amount of strategy is going to help if you don’t know the material!

That said, here are four ways to approach questions that’ll help you get to the right answer: 

1. Read the actual question first. 

Step 1 is a marathon, not a sprint. Over eight hours of lengthy clinical vignettes, fatigue is inevitable. One of the best tips is to read the actual question first so that when you tackle the long stem, you’re already thinking ahead, filtering out red herrings, and highlighting key information. This will save you time and energy in the long run. 

For example, if the question is about a drug’s mechanism of action, you can often skip straight to identifying the medication rather than working through the full clinical diagnosis. The same applies to statistical problems. If you know the question is asking for an odds ratio, you can start setting up the formula before you even finish the prompt.

Here’s an example that illustrates the usefulness of reading the actual question first: 

Practice Question #1

A 56-year-old female presents with hematemesis to the ED. She was found at the bus stop by a passerby who had called for an ambulance. Her skin is pale, HR 110, BP 100/70, and she continues to vomit bright red blood. 

You are unable to obtain a history from her as she is not alert or orientated. However, the passerby informed EMS that there were multiple empty cans of beer near where the patient was lying. Appropriate resuscitation measures are performed. The patient’s conditions stabilize and you consult the GI team to perform an upper endoscopy. The results of the endoscopy finds a linear mucosal tear at the gastroesophageal junction. 

The patient’s actions that directly caused this mucosal tear can also result in which of the following acid-base disturbances? 

A) Metabolic alkalosis

B) Anion gap metabolic acidosis

C) Respiratory acidosis

D) Respiratory alkalosis 

E) Non-anion gap metabolic acidosis 

Question Analysis

First, do you know what kind of question this is? Think back to the examples we discussed above. 

If you said it’s a second-order question, you’re correct! That’s because you first need to identify what causes mucosal tears and the resulting acid-base disturbances. 

Now, if you read the actual question (in bold italics) first, you would save time on the long clinical vignette. That’s because you could focus only on the relevant details. 

In this example, the line stating “endoscopy finds a linear mucosal tear at the gastroesophageal junction” indicates a Mallory-Weiss tear. The most common cause is forceful vomiting, and the typical acid-base disturbance is metabolic alkalosis (choice A). 

In this example, you didn’t need to focus on the patient’s presentation, vital signs, or clinical management. By reading the question first, you would have saved yourself considerable time and effort. 

2. Identify pertinent positives and negatives.

Identifying relevant positives and negatives is also a great way to arrive at the right answer. For example:

Practice Question #2

A 1-week-old male newborn is brought to the pediatrician for his routine exam. He was born via cesarean delivery at 40 weeks and 2 days without any complications. The patient’s height and weight are within normal limits. When the cardiac exam is performed, a systolic ejection murmur with a wide, fixed, split S2 heart sound is heard over the second intercostal space.The rest of the physical exam is unremarkable. Which of the following congenital heart defects does this newborn have?

A) Coarctation of the aorta 

B) Atrial septal defect

C) Patent ductus arteriosus

D) Pulmonic stenosis

E) Ventricular septal defect 

Question Analysis

Note: From reading the question first, we know we’re trying to identify a congenital heart defect. 

Now let’s pick out pertinent positives and negatives in the stem. A “systolic ejection murmur with a fixed split S2 heart sound heard over the second intercostal space” is a key positive pointing to atrial septal defect (choice B), as this murmur is characteristic of that defect. 

This murmur also helps us rule out other options: 

• PDA would present as a “continuous machine-like murmur.” 
• Pulmonic stenosis presents as a “crescendo-decrescendo systolic ejection murmur with a wide split heard loudest at the upper left sternal border.” 
• VSD presents as a “holosystolic murmur heard loudest at the left lower sternal border.” 

A normal palpation of femoral pulses is a pertinent negative for coarctation of the aorta, which would present with diminished femoral pulses. 

By keeping the answer choices in mind as you read the stem, you can quickly highlight the pertinent positives and negatives, eliminate options, and get to the correct diagnosis. 

3. Narrow your options with the process of elimination. 

You’ve seen it before: two answer choices look correct, the clock is ticking, and suddenly Step 1 feels less like an exam and more like a mind game. Too often, we focus only on memorizing details, but mastering Step 1 means learning how to dissect the clinical vignette and eliminate distractors.

Narrow your options by comparing the key findings in the question stem to the hallmark features of each answer choice. 

One of the trickiest question styles is the one with multiple facets requiring you to select “increase” or “decrease.” Start with the information you know and rule out answer choices that don’t align. 

Here’s an example: 

Practice Question #3

An 84-year-old man presents with urinary frequency, nocturia, weak stream, and difficulty initiating urination. On a digital rectal exam, the prostate is enlarged, smooth, and non-tender. After the initiation of therapy, which of the following changes would most likely occur in this patient? 

1. Testosterone (T)
2. Dihydrotestosterone (DHT)
3. Estradiol (E)

A) 1. Decrease, 2. decrease, 3. decrease 

B) 1. Decrease, 2. decrease, 3. increase

C) 1. Decrease, 2. increase, 3. increase 

D) 1. Increase, 2. decrease, 3. increase

E) 1. Increase, 2. increase, 3. decrease 

Question Analysis

This is an example of a third-order question. First, based on the history and physical exam, we must recognize the patient has benign prostate hyperplasia. Then we need to recognize the treatment for this condition is finasteride. Finally, we need to identify how finasteride affects levels of testosterone, DHT, and estradiol. 

We recall that finasteride inhibits the enzyme 5-alpha reductase, which blocks the conversion of testosterone into the more potent androgen, DHT. With this knowledge, we can eliminate answer choices A, B, C, and E, hence allowing us to select answer choice D. Even though we may be unsure how finasteride affects the estradiol concentration, by using the process of elimination and our baseline clinical knowledge, we can arrive at the correct answer.

You can also narrow down answer choices by eliminating options that essentially say the same thing. For instance, if a question asks about the mechanism of action of penicillin and two answer choices are “inhibits the 30S ribosomal subunit” and “blocks bacterial protein synthesis,” you can rule out both. They describe the same mechanism, which actually applies to aminoglycosides, not penicillin.

4. Skip questions you don’t know the answer to (for now). 

Of course, there are going to be times when you just don’t know the answer. Take this for example: 

Practice Question #4

A 47-year-old M presents with a fever, scattered bruises over his extremities, and blood oozes from his arterial line sites. 

Concerned about a cancerous origin, you obtain a bone marrow aspirate that shows immature myeloid cells with blue, needle-shaped rods. Which chromosomal translocation would you expect these cells to have? 

A) t (14;18)

B) t (9;22)

C) t (8;14)

D) t (15;17)

E) t (11;14)

Question Analysis

Needle-shaped rods, known as Auer rods, are a sign of acute myeloid leukemia. But what if on test day you hit a blank and can’t recall the chromosomal translocation? 

Take a deep breath. Reassure yourself that you only need to get ~60-65% of the questions correct to pass Step 1. Flag and skip the question for now. Don’t dwell on it or panic. 

The best thing you can do in these moments is regroup and focus on the questions you know the answer to. That way you get as many points as you can. You can always circle back to answer questions during whatever time you have at the end of the block. 

Final Thoughts

If you understand the material but still find the questions challenging, keep practicing to build confidence and test-taking skills. When doing practice questions, develop a consistent strategy that works best for you and apply it to every question. This will allow you to head into test day with confidence, knowing you have a reliable strategy for tackling questions.

Best of luck with your prep, and be sure to reach out to Blueprint tutors for more personalized Step 1 support! 

For more (free!) Step 1 content, check out these other posts on the blog:

• What is the Step 1 Passing Score?
• How Hard Is Step 1 Now That It’s Pass/Fail? (Plus How to Increase Your Chances of Passing)
• When to Take USMLE Step 1: A Data-Driven View

As you transition from preclinical coursework to your clinical rotations, you’ll hear a lot more about the NBME Subject Examinations, aka shelf exams. These tests in core clerkships like Internal Medicine, Surgery, Pediatrics, OB/GYN, and Psychiatry offer medical schools and residency programs a standardized way to compare performance across students. Because of that, your shelf exam percentiles become an important part of how your clinical knowledge and progress are evaluated.

At the same time, shelf exams can feel…mysterious. You receive a numerical score and a percentile, but it’s not always clear what those numbers actually represent or how they’ll impact your clerkship grade. How competitive is a certain percentile, and how does the NBME determine these national rankings?

To help you make sense of it all, this guide breaks down the most common questions students have as they move through their rotations, including:

• How should you interpret shelf exam percentiles in the broader context of your grades and residency preparation?
• Can you compare scores at different points in the year?
• How do medical schools use this data, and will residency programs ever see it?

Before diving into those answers, let’s start with the basics: what shelf exams actually are, how they’re scored, and what goes into generating the shelf exam percentiles you see on your score report.

Approaching the end of your rotation and wondering if you’re on track with shelf exam prep? Take this FREE quiz from our Blueprint experts to find out!

What are shelf exams?

Shelf exams are standardized tests created and administered by the National Board of Medical Examiners (NBME) to assess how well students can apply knowledge they acquired during a rotation. This makes them quite different from your preclinical exams, which more or less tested your ability to memorize what you’d learned in class. 

You’ll take shelf exams for internal medicine, surgery, pediatrics, psychiatry, obstetrics and gynecology, family medicine, and occasionally for elective subjects like emergency medicine or neurology. 

Each shelf has approximately 110 multiple-choice questions, and is completed in under three hours. 

Because shelf exams are taken at the end of each rotation, students have to find time to study while logging long hours at the hospital. It’s important to know this going into your rotations, so you can create a manageable study schedule.

To learn more about shelf exam format and content, be sure to check out the NBME website. 

What are shelf exam percentiles?

After you complete a shelf exam, your score is reported as a scaled score and as a percentile. The raw number of questions you answered correctly is adjusted, accounting for the relative difficulty of your specific exam form. 

Because the NBME continuously refreshes its question bank, not every group of students takes the exact same version of a shelf exam. If your version of the pediatrics shelf exam happened to be slightly more difficult than average, your score would be adjusted upward to reflect that.

The percentile rank represents how your performance stacks up against a national reference group of U.S. medical students who took the same exam within the same time frame of the academic year. For instance, scoring in the 70th percentile means you performed better than 70% of students in that reference group and below 30%.

To learn more about shelf scoring, check out the NBME guidelines.

How to Interpret Your Shelf Exam Percentiles 

Your percentile is best interpreted as a relative performance indicator.

A percentile in the 50s represents solid, national-average performance and is sufficient for most rotations.

Percentiles between the 55th and 75th typically fall into high pass territory and reflect above-average mastery.

Percentiles above the 75th are considered excellent and are usually associated with honors designations if you’re only considering the shelf.

Your shelf exam percentile can depend on when you test!

An important detail is that percentiles aren’t static throughout the year. This matters because the average performance of test-takers tends to improve as the year progresses. 

For example, imagine an MS3 going through the core clerkships completing OB/GYN, IM, and Pediatrics and then taking the Family Medicine shelf later in the year. This means they scored better on that exam given all of the knowledge and experience he/she picked up on prior rotations. Compare that to a fresh MS3 starting out on Family Medicine for the first rotation and taking the shelf after just four weeks without other rotations under their belt.

As a result, the same raw or scaled score can correspond to different percentiles depending on when you take the test. For example, a raw score of 76 might correspond to the 65th percentile in Quarter 1, but only the 55th percentile in Quarter 3, simply because the overall pool of test-takers has gained more clinical experience by that point.

So remember that a “lower” percentile late in the year does not necessarily mean you performed worse—it might just reflect a higher-performing national cohort.

How Schools Use Shelf Exam Percentiles

While the NBME provides the raw and percentile data, each medical school determines how these scores factor into final clerkship grades. Depending on the school, the shelf exam typically counts for 30–50% of the final grade, with the remaining portion determined by clinical evaluations, professionalism, and other assessments such as standardized patient exams or written assignments.

Many schools are transitioning to pass/fail grading, but some of them use percentile-based thresholds to distinguish among pass, high Pass, and honors designations. For instance, one medical school might require at least the 5th percentile to pass, the 60th percentile for high pass, and the 80th percentile for honors. 

The exact cutoffs vary not only by institution but also by discipline. Surgery shelves often have slightly higher thresholds for honors, while psychiatry or family medicine may have lower ones due to differences in national averages. The important takeaway is that percentiles—not raw scores—drive most grading decisions.

Why Shelf Exam Percentiles Matter

Even though residency programs don’t see your shelf exam scores directly, they still matter because they influence your transcript and dean’s letter (MSPE). Additionally, honors designations (if your school has them) in core clerkships can enhance your application, especially in competitive specialties. 

Shelf exams also serve as a stepping stone to Step 2 CK and are a good predictive indicator for Step 2 performance. Because the question style, pacing, and clinical focus closely mirror the USMLE format, consistently high shelf percentiles are one of the best indicators of readiness for Step 2.

Conversely, if you consistently score below the national average, it may be a sign that you need to refine your test-taking strategy or knowledge integration before taking Step 2. Many students who struggle on shelf exams benefit from incorporating dedicated Step 2 Qbanks earlier in their rotations.

Lastly, schools use shelf performance to determine eligibility for honors societies such as Alpha Omega Alpha (AOA) or to nominate students for departmental awards to further boost their competitiveness.

Preparing for shelf exams and Step 2? Meet the combined Step 2 & Shelf Exams Qbank with 5,500+ practice questions that most closely match what you’ll see on your USMLE Step 2 and all of your shelf exams—get started with a 7-day free trial!

How do I improve my performance on shelf exams?

Success on shelf exams isn’t about cramming the week before. The most effective approach—and you’ll hear this same advice from everyone—is to integrate studying into your day-to-day clinical experiences. As you encounter real patients, identify related conditions or topics to review that evening. 

For example, if you admitted a patient with decompensated heart failure, review diuretic management, cardiomyopathy differentials, and the next diagnostic steps. This contextual learning improves both retention and understanding, not to mention it’ll make you look like a star on wards. 

Recall that the timing of shelf exams throughout the academic year helps maintain momentum. As you move from one rotation to another, build on previously learned material—internal medicine concepts, for example, will reappear in surgery, family medicine, and even psychiatry shelves. Viewing the exams as cumulative assessments rather than isolated hurdles encourages long-term retention and prepares you for Step 2 CK. 

Final Thoughts

We hope this guide has helped clarify some of the mystery around shelf exam percentiles, from understanding what they actually represent to how they factor into clerkship grades and residency applications. Knowing how to interpret your score report is an important part of navigating your clinical year with confidence.

As you move through each rotation, keep focusing on steady, integrated studying rather than last-minute cramming. The more you connect what you’re seeing in the hospital or clinic with high-yield concepts, the more prepared you’ll feel when exam day arrives. And remember: strong shelf performance isn’t just a box to check—it’s also one of the best predictors of how you’ll perform on Step 2!

For more (free!) content to help you through clinical years, check out these other posts on the blog:

• Which Are the Hardest Shelf Exams?
• How I Balanced My Clinical Rotations with Shelf Exam Studying
• The Ultimate Patient Case Presentation Template for Med Students

Shock is a topic you’re bound to come across on the USMLEs, so it’s important to be familiar with it. The good news is the pathophysiology of shock is an immensely high-yield topic. Studying it will help you understand the cardiovascular system and the impact changes in the system have on the whole body. 

Of course, the most important reason to understand shock is it’s an important pathology you need to recognize and treat in the real world. Your patient’s life depends on having a rapid and precise response to it!

In this post, we’ll cover what you need to know about shock for the USMLEs and beyond. To make sure we have the basics covered before diving into more detail, let’s begin by defining what precisely we mean when we say a patient is in shock.

What is shock? 

In general, shock is the condition when the body cannot adequately perfuse end organs, leading to cellular damage. There are different kinds of shock a patient can be in. Each has different underlying mechanisms. 

How do we determine what category of shock a patient is in? 

There are several measures used to diagnose which category of shock a patient is experiencing. 

These include: 

1. The Central Venous Pressure 

The central venous pressure (CVP) is a measure of pressure within the vena cava and is a surrogate for blood returning to the heart. 

2. The Pulmonary Capillary Wedge Pressure 

The pulmonary capillary wedge pressure (PCWP) helps determine the pressure within the left atria. 

3. Cardiac Output (CO) 

Cardiac output is the volume of blood leaving the heart in a given unit of time. This value is affected by heart rate and stroke volume, which is affected by preload (aka how much blood is in the heart prior to systole). 

4. The Systemic Venous Resistance (SVR) 

The systemic venous resistance is how much resistance the blood vessels in the periphery are creating. This can be thought of as how constricted the blood vessels may be. 

5. The Mixed Venous Oxygen 

Finally, the mixed venous oxygen is a measure of the amount of oxygen in the blood returning to the heart. If tissues extract an increased percentage of oxygen from the blood, the mixed venous oxygen will be decreased, and if the tissues are extracting a decreased percentage of oxygen, it’ll be increased.

When presented with a patient in shock, take note of the numbers above and you’ll likely know what kind they’re in without needing many other details. 

An additional piece of information that’ll help guide your diagnosis is whether the patient is “warm” or “cold.” We’ll have more on that shortly. 

Now that we’ve covered the basic shock measurements, let’s take a look at the different kinds of shock and how these measurements are used to diagnose them. 

What are the 4 kinds of shock?

1. Hemorrhagic/Hypovolemic Shock

Hemorrhagic/hypovolemic shock is the most common subtype of shock in the traumatized patient and should always be at the top of your mind when a patient may be bleeding. Burns may also lead to hypovolemic shock due to evaporation from the burned surfaces.

“Cup of Water” Exercise

To conceptualize this type of shock, I want you to sit for a second and imagine that the venous system is a cup of water that you suddenly dump half of the volume out of.

What happens to the pressure on the walls (the CVP)? It decreases. 

What would happen to the heart’s preload? It decreases. 

This would lead to decreased stroke volume and decreased cardiac output even in the setting of tachycardia as the hemorrhage progresses. 

Since the entire volume of the circulatory system is decreased, what would happen to the pressures inside the atria (PCWP)? They also decrease. 

Now, since the body is experiencing decreased blood pressure due to less volume inside the vessels, how may the vessels attempt to compensate to maintain blood pressure? That’s right, they vasoconstrict, which increases the SVR.

For the mixed venous oxygen in this scenario, tissues need the same amount of oxygen as they did before the hemorrhage, but now there’s less blood to deliver it. This means that each tissue is extracting a larger percentage of the oxygen from the blood that does reach it, which decreases the mixed venous oxygen.

Given that the body attempts to preserve vital organs in states of hemorrhagic shock, the skin is often left to the wayside and the patient is described as “cold and clammy.” 

The treatment for hemorrhagic shock is simple. Replace the volume! Giving packed red blood cells, fresh frozen plasma, and platelets in a 1:1:1 fashion or whole blood replaces what has been lost. 

Stopping the bleeding with surgery or interventional radiology will prevent further losses. 

These actions may be supplemented with medications such as pressors or crystalloid fluids to maintain blood pressure for adequate tissue perfusion.

2. Cardiogenic Shock

Cardiogenic shock is lack of perfusion from left heart dysfunction due to MI, heart failure, or arrhythmia resulting in decreased cardiac output, or valvular disorders. 

The main derangement in this scenario is a decrease in cardiac output. The lack of throughput in the heart results in the backup of blood in the venous circuit and a lack of blood in the arterial system. That buildup in the veins results in increased CVP and PCWP.

On the arterial side, this condition acts similarly to hemorrhagic shock because it appears there’s a decrease in blood volume because of a decreased cardiac output. This results, again, in increased SVR and decreased mixed venous oxygen content by the same thought process as hemorrhagic shock. 

These patients are also described as “cold and clammy” because the warm blood is staying in the heart rather than warming the skin. 

Treatment of cardiogenic shock entails treating the underlying cause and using medications to increase cardiac output.

3. Obstructive Shock

Thus far, we’ve discussed a decrease in blood volume and a broken pump. Obstructive shock, however, is an impediment of blood flow for a reason external to the heart itself.

Pulmonary Embolism & Tension Pneumothorax

Pulmonary embolism and tension pneumothorax are the first causes of obstructive shock we’ll discuss. These pathologies prevent blood circulation through the pulmonary circuit. When this happens, blood again backs up causing increased central venous pressure.

However, instead of the blood emptying into the left side of the heart, it remains in the pulmonary vasculature, causing a decrease in PCWP. The cardiac output subsequently decreases because of the lack of left ventricular preload. 

This lack of cardiac output causes increased SVR as before. Interestingly, in this case the mixed venous oxygen is increased. The way that I think about this is that the blood sits in the lungs and continues to be oxygenated and backs up to increase the mixed venous oxygen.

Cardiac Tamponade

The second case of obstructive shock is cardiac tamponade. For a thorough explanation of this, I’ll refer you to the blog post regarding high-yield cardiology topics. As a quick reminder, cardiac tamponade is when blood fills the sac surrounding the heart and impedes its ability to fill and pump. 

This will increase the CVP (due to lack of flow through the heart) as well as increase the PCWP because blood does make it to the heart (as opposed to PE). The SVR is increased due to lack of CO and the mixed venous oxygen is decreased because the blood does not sit in the lungs.

4. Distributive Shock 

The final category of shock involves the distribution system of the blood itself, the arteries. This is in the form of systemic vasodilation resulting in low blood pressure that isn’t high enough to perfuse tissues. 

This category is also split into two subcategories: sepsis/anaphylaxis and neurogenic shock. 

Sepsis/Anaphylaxis

Septic shock is the result of an infection where the anti-inflammatory and pro-inflammatory factors result in systemic vasodilation. Anaphylaxis, a type 1 hypersensitivity reaction, is the result of an allergen triggering a significant IgE response and histamine release which causes vasodilation. This vasodilation decreases the CVP and PCWP. 

When the vasodilation is detected, the heart increases its rate to increase cardiac output. The SVR is necessarily decreased, as this is the main derangement in these conditions. Because vasodilation is the cause of lack of perfusion, the blood doesn’t reach the tissues for oxygen extraction and, therefore, the mixed venous oxygen content is increased. Since the blood flow itself is not impaired, these patients are described as “warm and dry.” 

Neurogenic Shock

Finally, neurogenic shock is most often encountered after a traumatic brain injury in which the sympathetic tone is lost. This lack of tone decreases the CVP, PCWP, cardiac output, and SVR. Mixed venous oxygen content will usually be normal but occasionally increased. 

Note how neurogenic shock differs from spinal shock, which is often a result of trauma to the spine but the process is physiological rather than anatomic. The condition results in flaccid paralysis and the loss of sensation, reflexes, and autonomic function below the level of injury. This condition often resolves spontaneously over days to weeks.

Shock Cheat Sheet

Final Thoughts

As you can see, each type of shock has its own distinct characteristics that’ll help you identify it in a question prompt. I encourage you to review the table above and then create your own table by hand!

Think about the cardiovascular circuit in its entirety, and where each type of shock interrupts that process. This exercise is an important tool for every pathology you encounter throughout your medical training, as it will help you retain the information and apply it to patients in real-world scenarios.

Happy studying and good luck on the USMLEs!

For more (free!) high-yield topics to know for your USMLE exams, check out these other posts:

• Now, That’s What I Call High-Yield: Pharmacology
• Now, That’s What I Call High-Yield: Musculoskeletal
• Now, That’s What I Call High-Yield: Neurology

Residency interview season is an exciting but demanding time, and when it coincides with the holidays, the balancing act can feel overwhelming. Scheduling virtual or in-person interviews while attending socials and maintaining professionalism requires thoughtful planning and effort.

Trust me, I know firsthand—a short time ago, I had some similar struggles while trying to do interviews during the holiday season, as well as from the other side when I did interviews as chief resident.

With the two experiences in mind, allow me to share some advice on how to handle residency interviews during the holiday season with poise and efficiency so you can fulfill your responsibilities and still have time for some eggnog. Let’s dive in!

Want some practice answering the most common residency interview questions (that won’t require you to jump on Zoom in your family’s house)? Take this FREE interactive quiz that walks you through a mock interview, plus tips for answering each question!

The Challenges of Interviewing During the Holiday Season

1. Interview dates can clash with travel plans. 

Residency interview invitations often come with short notice, especially as previous applicants cancel their interview for whatever reason and new slots open up. This might leave you with little flexibility to rearrange prebooked travel for family gatherings or holidays and lead to difficult decisions, such as missing a family event or risking a spot at a program you’re interested in.

Such dilemmas are even more likely now as more programs (such as orthopedics and other surgical subspecialties) start to offer in-person interviews. While new invite offers are seen as blessings, booking last minute travel as a result of these cancellations can be costly. 

2. Becoming fatigued due to a packed schedule.

The holidays often bring added commitments—shopping, gift giving, celebrations, and family traditions. When combined with interview preparation, cross-country travel, and the interviews themselves, applicants may become physically and emotionally drained. Jet lag, social fatigue, and constant networking can make it harder to stay sharp during interviews or enjoy family/holiday moments. 

3. There may be expensive and limited travel options. 

Holiday travel is notoriously expensive, and accommodations in bustling cities or rural program locations may already be scarce. Flight overbookings, delays, or cancellations due to winter weather can further complicate the logistics of back-to-back travel. 

The Opportunities Provided by the Holiday Season

Now let’s take a look at the flipside: what are the advantages of interviewing during the most wonderful time of the year? There are a number of them, including the following: 

1. You have extra time to prepare. 

For those on a break from clinical rotations or academic studies, the holidays can provide uninterrupted time to focus on residency interview preparation. If you’re not a pro at this point in the season, or if you just needed a bit of practice on your elevator speech, this time off allows you to practice interview responses, research programs more thoroughly, and organize your travel schedule. 

2. Families can provide support. 

Being surrounded by family during the holiday season can offer an emotional lift. Loved ones can provide reassurance, help you rehearse for interviews, or assist in managing travel and accommodations. Their support can act as a counterbalance to the stress of the application process. 

3. You’ll have time to reflect. 

The slower pace of the holiday season can encourage applicants to step back and reflect on their residency priorities. Away from the day-to-day demands of medical school or clinical rotations, it’s easier to evaluate which programs align with your long-term goals and where you see yourself thriving both personally and professionally. 

4 Tips for Navigating Residency Interviews During the Holidays 

Here are some things to keep in mind when doing residency interviews this time of year: 

1. In general, be prepared for a busy November—especially if you’re a competitive applicant and expect the bulk of interview invitations to arrive before Thanksgiving (though for most applicants, the process continues into late January).
2. Consider using a vacation week or month in November or December to minimize time away from rotations. 
3. Keep in mind, interviews between Christmas and New Year’s will be sparse, but may still occur. 
4. Finally, be patient if you haven’t received many invitations by mid-November, but reach out to mentors or your school’s office of academic affairs for guidance. 

5 Tips for Creating a Scheduling Strategy 

The first step to a successful residency interview season is effective scheduling. Programs often offer limited dates, which may overlap with other obligations. 

Build a scheduling strategy through careful planning by doing the following: 

1. Track all interview invitations ASAP. 

Use a spreadsheet, app, or old-school written planner to log each program’s offered dates, deadlines to respond, and confirmation details. Don’t forget to account for travel time as well as any social or second look events that may fall outside the actual interview day. 

Bold, highlight or color-code confirmed dates and keep notes about any flexible options provided by coordinators. Use this calendar of interview dates and cross reference with family obligations, highlighting nonnegotiable events. Consider alternative dates to celebrate the holidays if you need to reschedule plans.

2. Prioritize your calendar. 

Rank programs based on your preferences and schedule high-priority programs first, if possible. 

Use your initial interviews to refine your performance. If you must reschedule or cancel, provide the program with early notice. 

As others cancel and interview spots open up, be sure to respond promptly to interview invitations, as reopened slots are often filled on a first-come, first-served basis.

3. Group interviews by location. 

Many programs, such as orthopedics, offer mostly in-person interviews. For these, aim to schedule multiple interviews in the same city or region consecutively to minimize travel.

Maybe December will be your West Coast interviews and January will be East Coast ones. Be smart with travel and book tickets early, choose flexible ticket options (the ones that allow refunds or rescheduling), and consolidate interviews geographically to minimize fatigue and costs.

4. Be flexible but prompt. 

If a conflict arises, notify the program coordinator promptly and politely request an alternative date. Most programs will accommodate rescheduling requests if you’re respectful and proactive. 

5. Avoid overbooking. 

While you may feel compelled to accept every invitation, overloading your schedule can lead to burnout, tardiness, or worse professional violations. Aim for a manageable (at maximum) 2-3 in-person or 3-4 virtual interviews per week, leaving room for recovery, travel, and reflection.

Staying Organized Amidst Chaos 

Interview season requires organization, especially during a time of year when distractions abound. Staying on top of your commitments ensures you present yourself in the most professional manner to each program.

Some ways of staying organized include: 

1. Crafting a centralized system. 

Use apps like Google Calendar or Thalamus to consolidate schedules, program details, and travel arrangements. 

2. Tracking program details. 

Before each interview, revisit the program’s website, alumni connections, or social media for updated insights. Maintain a cumulative sheet for each program that includes the program’s mission and values, unique aspects of their curriculum, or training opportunities such as electives, tracks, and specific faculty or research initiatives that interest you. 

3. Preparing for virtual interviews.

Preparation is just as important for virtual interviews! One thing you must do in preparation for a virtual interview is test your technology. Ensure your internet, camera, and microphone are functioning smoothly. Practice with friends or mentors to check angles, lighting, background, and sound.

Do the interview in a quiet, neutral space with minimal background distractions. And don’t forget to double-check interview times, especially when coordinating across time zones.

Balancing Holiday Obligations 

Of course, interviews aren’t the only things you have to navigate during the holidays. This time of year is important to friends and family, and they expect you to be part of the celebrations. And of course you want to be, but this is also a very important moment in your career. 

So, how do you balance these competing obligations, along with self care? 

Here’s some tips that’ll help: 

1. Remember, communicating with family and friends is important. 

Family often expects you to fully participate in every holiday tradition, but this holiday season, interviews are a priority. Clear communication about why your interviews are so important is essential so they don’t feel like they’re being ignored. Let them know you’re going to have more limited availability and why that’s the case.

2. Plan mini celebrations. 

If you can’t join larger gatherings, consider smaller, more flexible celebrations. It’s important not to completely neglect the holidays—small moments of celebration can boost your morale. Watch a holiday movie, decorate your space, or enjoy a festive meal.

3. Share updates. 

Keep your loved ones informed about your progress—they’ll appreciate feeling involved.

4. Protect interview prep time.

Block out dedicated hours for research and mock interviews. 

5. Make time for rest. 

Prioritize self-care by scheduling breaks for downtime, even if it’s just a quiet evening to recharge between commitments. Avoid sacrificing sleep for extra holiday activities or late night interview prep. 

After the Holidays: Reflect and Rank 

After the new year arrives, it’s good to do the following: 

1. Review post-interview impressions. 

Right after each interview, write down your thoughts on the program’s culture, faculty, facilities, and opportunities. These notes will be invaluable when creating your rank order list. 

2. Seek guidance. 

Discuss your experiences with mentors, advisors, or peers to gain perspective on your rankings. 

3. Trust your instincts. 

While metrics and reputation matter, ultimately, trust your gut. Choose programs that resonate with you professionally and where you feel at ease.

💙 Check out this post for tips on how to put your happiness first when ranking residency programs!

Final Thoughts 

Navigating residency interviews during the holidays requires adaptability, organization, and striking the right balance between enjoying yourself and making sure you’re ready. While this season can feel intense, it’s also an exciting opportunity to take the next step in your medical journey. With the right strategies, you can maintain focus, celebrate milestones, and present yourself as a strong candidate.

Good luck!

Mark your calendars for Friday, March 20, 2026, aka Match Day 2026—or in other words, the day you finally find out where you’ll be headed for residency!

If you’re participating in the Match this year, all of your long nights, tough exams, and early mornings have been leading up to this moment. Match Day 2026 is when everything you’ve worked for starts to come together and your next chapter officially begins!

If you’re not totally sure how The Match works or what you should be doing to prepare, don’t worry! We’ve got you covered. This guide walks you through the entire residency Match process, step by step, so you can feel confident and ready for the big day.

Let’s kick things off with the basics.

Match Day 2026: Some Basic Match Terms 

“The Match”

If you’re wondering just what “The Match” actually refers to, technically it’s the National Resident Matching Program (NRMP) process that pairs applicants with residency programs. It’s an umbrella term for the centralized NRMP process you’ll use to apply for residency. 

“Match Week”

This kicks off the Monday before Match Day. On this day, you’ll find out if you matched at any of the programs you applied to. Though you won’t know where you matched until Friday. 

As you can imagine, Match Week is a huge milestone for aspiring physicians as years of studying, exams, and clinical rotations are all leading to one decisive day! Families fly in, friends and classmates cheer, and many schools livestream events during the week so everyone can share the excitement. 

“Match Day”

This is truly one of the most important days in the life of a physician. It’s filled with pride, tears, laughter, and pure joy—a culmination of years of hard work. It was a day I’ll never forget. 

The emotions you go through during Match Week are hard to describe, but to give you a sense of what you can look forward to, I’d like to share my memories of those amazing few days with you. 

Here’s my Match Week story. 

My Match Experience

I vividly remember my own Match Week. The days prior, I was more nervous than I thought I’d be as my partner and I had decided to participate in the couples match, which added an extra layer of suspense. The thought that a single letter determined not just my future, but ours together, was definitely nerve wracking. 

As Match Week began, the energy was electric. We had around 30 friends and family members fly in from both sides to celebrate with us. Each day felt longer than the last. Thankfully, we received the Monday email notifying us that we matched. Now we had the rest of the week, with family in town, to wait to see where. 

On Match Day, the countdown began and hundreds of Baylor students opened their Match letters together. The ceremony on the quad was unforgettable—envelopes opening, cheers echoing, tears flowing. My partner and I opened ours surrounded by our families. We had matched as a couple! Later, we even made the Baylor College of Medicine newsletter front page. 

I hope your Match Week is just as memorable as mine! Up next: all the important deadlines and dates to keep you on track.

Match Day 2026 Timeline: Dates You Need to Know 

Registration Deadline: January 30, 2026

First things first, you must register with the NRMP and the Supplemental Offer and Assistance Program (SOAP). Additionally, you need to register for the application service R3. Standard registration is available until January 30, 2026.

Note that you must be registered before you can schedule your residency interviews (typically October-January)!

Rank Order Lists Open: February 2, 2026 

At 12:00 p.m. ET you’ll be able to enter your preferences into the NRMP’s R3 system. The R3 System (short for registration, ranking, and results) is the online platform used by the NRMP to manage every stage of the Match process.

In the system, you can build and edit your rank order list as many times as you’d like before final submission. Take your time here, since this list determines your Match outcome!

💡For tips on completing your rank order list, check out this other post: How to Make A Residency Rank List That Puts Your Happiness First

Rank List Deadline: March 4, 2026

Make sure your rank list is submitted and your registration is complete before 9 p.m. ET. Also, international medical graduate (IMG) applicants must meet the Educational Commission for Foreign Medical Graduates (ECFMG) verification requirements by this time. 

Match Week: March 16–20, 2026

This is when the magic happens! 

Here’s a breakdown of what you can expect: 

Monday, March 16

10 a.m. ET: Match Kickoff

Applicants learn if they matched via email and within the R3 system. This is just a notification of whether you matched or not. You’ll find out where you matched later… 

11 a.m. ET: SOAP Opens

If you didn’t match, you can enter the SOAP to apply for any remaining positions. SOAP applicants can start preparing applications at this time and contact programs with any questions.

SOAP stands for “Supplemental Offer and Acceptance Program.” This provides residency opportunities for eligible applicants who didn’t match this cycle. Though not a guarantee, SOAP allows unmatched candidates to apply to residency programs with unfilled positions, sometimes in the same specialty, but often in a less competitive specialty. SOAP is a win-win as it provides an opportunity for unmatched applicants to score a coveted US based, ACGME accredited residency spot and also allows programs to fill their open spots.

Having to go through SOAP isn’t the outcome applicants hope for, but the program is a critical safety net. For those eligible, applicants will gain access to the list of unfilled programs and they can apply to them directly. There are multiple “rounds” of offers during Match Week, and communication rules are strict to ensure fairness. 

Many choose to go through SOAP to secure a spot rather than wait for the next application cycle. If you’re curious about what you should do if you end up in this position, contact one of Blueprint’s residency counselors to learn more about your options. 

Tuesday, March 17

8:00 a.m. ET: SOAP Application Review

Programs begin reviewing SOAP applications. They may contact applicants and begin interviewing.

9:00 a.m. – 8:00 p.m ET: SOAP Rounds 1-4

Applicants receive round one offers by logging into the R3 system. Applicants have until the next round to accept/reject their SOAP offers. The List of Unfilled Programs is updated in the R3 system with each subsequent round.

Thursday, March 19

9:00 p.m. ET: SOAP Concludes 

SOAP ends with the posting of the final List of Unfilled Programs in the R3 system. The list is updated to include unfilled programs not participating in SOAP. 

Afterwards, applicants can begin contacting all remaining unfilled programs. See the updated List of Unfilled Programs for open residency spots. 

Friday, March 20

12 p.m. ET: Match Day 2026! 🎉 

At 12:00 p.m. ET, applicants finally learn where they’ve matched. This day is often celebrated with friends, family, and plenty of tears (of relief and joy)!

Tips to Help You De-Stress Before Match Day 2026 

Here are some things you can do if you’re feeling a bit nervous as the big day approaches: 

1. Don’t worry about worrying. 

Know that it’s totally normal to be a bit stressed. After all, Match Day is the culmination of your hard work from undergrad to medical school. It would actually be unusual to have zero stress around Match Day!

2. Stay positive. 

Limit doomscrolling and your exposure to negative stories surrounding Match Day nightmares. 

3. Rediscover your hobbies. 

Reconnect with the non-medical parts of yourself. Revisit hobbies you set aside during the busy interview season. Run, work out, build LEGO sets, cook, read, draw, or hike. Whatever you like, keep at it to give yourself a healthy distraction from the Match.

4. Hand over control. 

Lastly, rest easy knowing that you’ve done your part. You have, to the best of your ability, applied, interviewed, and ranked. The rest is up to the NRMP algorithm!

🧘‍♀️ Check out this post for more pre-Match de-stressing: 6 Stress Management Tips for Residency Match Week

Special Tips for IMGs

International medical graduates (IMGs) go through a similar Match process to that of their US counterparts each year. But there are some additional things IMGs should do!

If you’re an IMG, remember to:

• Make sure your ECFMG certification is complete before the rank list deadline.
• Double-check that all exam results (USMLE or COMLEX) are uploaded and verified.
• Consider broadening your list to include community programs or those with a track record of accepting IMGs.
  

Final Thoughts

Match Day 2026 may feel far away now, but it’ll be here before you know it! Between now and then, you’ll fill out applications, interview and meet inspiring physicians, and reflect deeply on where you want to continue your medical journey. 

Take a deep breath. Bookmark your deadlines, set alarms, and interview well! And in a few months, you’ll be standing alongside your classmates, envelope (or email) in hand, celebrating the next chapter of medical training. 

Here’s to your Match Day 2026, and to the residency program that’ll become your new home! 🥳

If you’ve made it this far in your cardiology journey, congratulations! This is Part 2 of high yield cardiology to help guide you on your journey through Step 1 and beyond. (If you haven’t checked out Part 1 yet, now is the time.)

I want to reiterate here the importance of this system and how your understanding of it can help you grasp physiological concepts throughout the rest of your studies. That being said, let’s dive in!

High-Yield Cardiology Topics for Step 1

Congenital Heart Disease

Congenital heart disease is usually split into two categories: “Early cyanotic (Right-to-left shunting)” and “Late cyanotic (Left-to-right shunting).” 

The 5 cyanotic pathologies usually require surgical intervention or maintenance of the patent ductus arteriosus quickly after birth. These five defects are remembered because they all begin with “T” and can be remembered in a numerical order:

1. Truncus Arteriosus

This is a defect in which the truncus arteriosus fails to divide into the pulmonary trunk and the aorta resulting in 1 vessel (hence it is number 1 on the list). The aorticopulmonary septum is the structure which normally divides the aorta and pulmonary trunk, but it has failed to form here. Many of these patients will also have a ventricular septal defect. 

2. Transposition of the great arteries

Normally the aorta leaves the left ventricle with oxygenated blood and deoxygenated blood returns to the right atrium to then leave the right ventricle via the pulmonary artery to be reoxygenated. In this condition the aorta leaves via the right ventricle, before blood is oxygenated and takes blood to the rest of the body only for it to return to the right atria to be recirculated again. 

The pulmonary artery leaves the left ventricle to be oxygenated by the lungs which then returns to the left atria to be sent to the lungs again rather than systemically. This means that there are two—which why this is second on the list—distinct loops that are separate from each other. This defect is due to the aorticopulmonary trunk forming, but not spiraling as it should. The classic chest XR appearance is “egg on a string.” This defect is unfortunately incompatible with life without a way to mix the blood from these two systems such as a VSD, PFO, or PDA). 

3. Tricuspid atresia

“Tri,” meaning three, is third on the list. This is simply the absence of the tricuspid valve. This makes blood from the right atria unable to cross to the right atrium for circulation. You can imagine that for blood to get to the right ventricle, it would have to cross to the left atrium via an ASD and then from the left ventricle to the right ventricle via a VSD, which are both required for life.

4. Tetralogy of Fallot

The most famous of the congenital heart defects actually has four components and is fourth on the list for that reason. This condition is due to the infundibular septum shifting anterosuperiorally. 

Pulmonary stenosis is the most important prognosticator for these patients. Given the pulmonary stenosis, the right ventricle must pump through a higher resistance circuit causing hypertrophy and a “boot shaped heart” on chest XR. 

The third component is the overriding aorta in essence taking up the space that the pulmonary artery usually occupies.

Finally, the fourth component is a VSD. This condition has what are known as “tet spells” which occur when the baby cries exercises or anything that increases Right ventricle outflow obstruction. The solution is to squat which increases systemic resistance which decreases the right-to-left shunt and allows for increased oxygenation.

5. Total Anomalous Pulmonary Venous Return

TAPVR (5 letters) is when pulmonary veins drain into the right atria rather than the left. Often these patients have ASD or PDA to allow for right-to-left shunting.

Non-cyanotic lesions, left-to-right shunts include ventricular septal defect, atrial septal defect, and patent ductus arteriosus. These conditions increased the amount of blood volume in the right heart which increases pulmonary blood flow. This constantly increased volume causes remodeling of the vascular system which eventually causes pulmonary arterial hypertension which increases work for the right ventricle. When the right ventricle must work harder, hypertrophy occurs which will eventually overcome the forces of the left side of the heart, switching the left-to-right shunt to a right-to-left shunt.

Ischemia

Ischemia, at its core, is the lack of adequate oxygen delivery tissues when that be from hypoxia or from decreased blood volume/delivery. Oxygen is the currency and oxygen demand is the price that every tissue carries to be healthy. This price varies depending on how much work is being asked of the tissue, not unlike the electrical grid. When there is too much electrical demand in a city and no mechanism to increase the supply, brown outs (or full blackouts) occur, which are akin to ischemia in the human body. 

The heart, as opposed to other tissues, has a unique quality in that it extracts almost all of the oxygen that is supplied to it in the blood. This means that if the heart must work harder (increased oxygen demand) the only way to compensate is for increased blood delivery via increased hemoglobin, O2 saturation, or coronary flow. The ischemia that is caused when there is not an increase in oxygen delivery is termed angina. 

Symptoms are typically substernal chest pain that radiate to the jaw not unlike a STEMI, the difference being that angina is typically relieved by rest and worsened by increase in activity (increased oxygen demand). Once this ischemia progresses to cardiac muscle damage, you do have and MI.

Cardiomyopathies

Cardiomyopathy means that there is a pathology of the cardiac muscle. There is ischemic cardiomyopathy which means that the muscle has weakened due to adequate oxygen delivery. There is also nonischemic cardiomyopathy which means cardiac muscle damage from congenital abnormalities, alcohol, use, stress (Takotsubo), viruses, or hypertrophic cardiomyopathy. 

The highest yield of the nonischemic cardiomyopathies is hypertrophic cardiomyopathy. Inherited in an autosomal dominant pattern, think of this when the prompt gives you a patient who dies unexpectedly when playing a sport. The cause of this sudden death is from the septum growing too large and obstructing left ventricular outflow. As heart rate increases, the obstruction worsens. Therefore, lower heart rates and decreased contractility are important to avoid this death. What medications may also cause decreased heart rate? Beta blockers.

Heart Failure

Heart failure is the inability of the heart to push blood forward. This is an excellent topic to review the course of blood throughout the body. For example, if the left heart fails, blood builds up in the structure that is before it, AKA the lungs, which causes dyspnea. Right heart failure, most commonly due to left heart failure, causes backup in the venous system leading to peripheral edema, jugular venous distention, and hepatic congestion (Nutmeg liver). 

When thinking of causes of heart failure, think of ways that may make it difficult to push blood forward. Things like hypertension which increases afterload for the left ventricle and ischemia which damages the pump itself. For the right side, pulmonary hypertension and COPD make it difficult to push blood through the pulmonary circuit. It is important to know the medications that decrease mortality in these patients versus only treating symptoms. ACE inhibitors, ARBS, angiotensin receptor-neprilysin inhibitors,  beta-blockers and aldosterone all decrease mortality. Loop and thiazide diuretics help control symptoms but do not decrease mortality.

Shock

Shock is a massive, and extremely high yield topic and understanding shock will help you understand many aspects of cardiology and how the body works in general. Check out this post dedicated to the topic of shock to make it quick and easy to understand.

Tamponade

Surrounding your heart is a structure known as the pericardial sac. Between this sac and the heart itself is a potential space which can fill with blood under certain conditions, such as trauma. Blood in this space puts pressure on the heart which prevents it from functioning properly. 

A high yield constellation that should make you think of tamponade is Beck’s Triad. This triad consists of muffled heart sounds due to poor transmission through the fluid, hypotension, and jugular venous distention because the vein cannot empty into the heart. Treatment for this is pericardial window or pericardiocentesis. While these are the treatments, always remember the ABCs of trauma and do not forget the steps that take place beforehand!

Antihypertensives

This genre of medications is probably the most commonly prescribed of them all. ACE inhibitors (lisinopril) help to stop pathological changes in the heart and prevent renal damage in those with diabetes. Thiazide diuretics increase your calcium. Then there are calcium channel blockers, loop diuretics, and beta blockers. It would behoove you to review each of these in detail by understanding the one or two specific characteristics that really set them apart but understand the goal is the same, decrease blood pressure. 

Further Reading

We know—we barely scratched the surface. But that’s the challenge when aiming for the highest-yield coverage in limited space!

For even more high-yield Step 1 topics, check out these other posts on the blog:

• Now, That’s What I Call High-Yield: Pharmacology
• Now, That’s What I Call High-Yield: Musculoskeletal
• Now, That’s What I Call High-Yield: Neurology

Originally published January 2019, updated August 2025 by Landon Cluts

If your Step 1 exam is scheduled in 2026, you may be wondering whether you need to be following conventional advice about Step 1 dedicated periods. Should you follow the detailed study calendars that abound online? Should you use the entire study period which your medical school has provided you? And most importantly: is it worth spending so much time preparing for this exam now that no numerical grade is given?

In this post we offer some do’s and don’ts about how to build your study strategy in 2026!

Get ready to pass with Blueprint’s Step 1 Practice Bundle, including TWO full-length mock exams for the price of one! That’s 560 total questions (each exam has 7 blocks of 40 questions) written and timed like the real boards. 🤩 Get started today!

Do: Have a concrete study plan going into dedicated.

In the days and weeks leading up to the start of your dedicated, take some time to create a detailed study schedule. Without a written list of your daily tasks, it can be easy to fall behind on milestones for questions completed and content reviewed. By having a concrete plan, you can make sure you’re meeting your goals.

One pro tip: be sure to schedule in flex days. As you can imagine, life continues even during dedicated and it can help to create time for catching up on work! I also recommend adding in one practice exam a week and time for review it.

🪄 Create a personalized study schedule that tells you exactly what to study each day with Blueprint’s Med School Study Planner! Take the stress out of falling behind with the magical Rebalance button, which automatically redistributes your upcoming tasks with the click of a button.

Don’t: Try to use every resource in existence.

Studying for Step 1 can be overwhelming and it may feel comforting to have a lot of resources in your arsenal. Next thing you know, every couple hours you are juggling a new resource and can’t give each one the proper due diligence.

As with most things in life, quality over quantity applies again. Hone in on 3-4 key resources. For example, use the question bank of your preference to practice test-taking strategies and content review. Pair this with a textbook or video series along with flashcards for further content review. This will serve as a solid foundation. If you find yourself wanting more, add in another resource. 

Do: Aim to be significantly above the passing threshold on your practice exams.

With Step 1 being pass/fail, it’s especially tempting to lower your guard. Still, full-length NBME practice tests are a necessary tool in this pass/fail Step 1 era! They serve as the best indicator for whether you will indeed pass the actual exam. You will have a better chance to pass if you recreate the exam environment while studying. That’s why it’s especially important to take each practice exam under testing conditions (with timed breaks and closed books).

Although the practice tests may leave you stressed and exhausted, by accurately replicating the real testing experience you will make sure it’s not as new and stressful when the time comes to take the actual Step 1. Test day requires you to be on your A-game for eight hours! By practicing ahead of time, you can prepare your stamina for this ultra marathon.

A major change in practice exams is that a score is no longer provided at the end, only a probability of passing. In conjunction with your academic advisors or Step 1 tutor, determine what threshold of passing is best for you. After some period of dedicated, it is common to reach a plateau where there are only slight variations in performance.

Aim to take the actual Step 1 exam only when your practice exam scores are consistently, comfortably above the passing threshold. If you have time, try to take as many practice tests as feasible. Keep in mind that they are also a high-yield way to gain medical knowledge, which will better prepare you for rotations, as well as for your entire medical career.

Don’t: Deviate too much from other well-established methods for success.

Although students may never again try to ramp up studying to increase from a 250 to a 260 during their final weeks of preparation, most aspects of Step 1 studying didn’t change when the exam went pass/fail. 

You may be tempted to reduce the length of your dedicated study period or to follow a lighter schedule of studying. Remind yourself that passing Step 1 is a formidable goal by itself (and a wonderful accomplishment, once it’s achieved)!

This exam tests a broad knowledge base and you want to have a strong foundation, especially for future clinical exams. It’s best to follow the steps of those who came before you and to take advantage of the many study guides, calendars, and resources that were created when Step 1 was a graded exam.

Do: Use the test’s pass/fail grading to help lower your anxiety.

Although you will continue to study for this exam as hard as the previous students did when it was graded, you can alleviate some of your stress by reminding yourself that your actual score will not be recorded as long as you pass. 

Use the new pass/fail scoring as motivation to feel more confident that you can master Step 1, as long as you stick with your efforts and continue to make progress!

Don’t: Focus on merely passing Step 1 for the purpose of this exam only.

Keep in mind that you are not merely passing Step 1 to move on to the next step of medical school. You are also passing Step 1 to prepare for your time on clinical rotations, where you’ll be directly involved with patient care. 

All of your knowledge will come in handy when it’s time to present on patients, write progress notes, or interview patients to fill in a history of present illness. In order to learn as much as you can in hospitals and clinics, and to prepare to be the best physician possible, it is especially crucial to approach clinical experiences with a wide, comprehensive knowledge base.

Once preclinical, lecture-based courses are over, you will begin the lifelong learning that a career in medicine always involves. As a clinical medical student, resident, fellow, or attending physician, no one will be directly tracking how much you study or what multiple-choice questions you can answer correctly. Continuous learning is a personal responsibility (and privilege). And the earlier you start, the easier this path will be for you. 

Do: Use the Step 1 experience to help guide your subsequent Step 2 experience.

Step 1 and Step 2 are unique in how they both involve weeks of dedicated studying, a few thousand practice questions, and a LARGE amount of content. Because of this, many students find that certain daily habits or study routines are useful additions to their typical patterns during Step studying periods.

During your Step 1 dedicated study time, try different approaches: concentrated studying blocks, an exercise routine, or the pomodoro technique (worth checking out even because of its name!). Sprinkle in breaks and fun activities. Figure out whether you like to take notes as you complete practice questions and how you can learn most effectively. You’ll thank yourself later when the time comes to start Step 2 study period!

Don’t: Try to cram in Step 2 studying right now.

Step 2 has an increasingly important role after Step 1 became pass/fail. Although the content of these two exams overlap, studying for Step 2 before taking Step 1 is not a great strategy. Step 1 is highly detailed and includes many subjects, ranging from biochemical reactions to immunological pathways and disease mechanisms. This is why you will likely need as much Step 1 studying time as you can get—and even then, still won’t think it’s enough.

Also, Step 1 and Step 2 assess fundamentally different aspects of medicine. The Step 2 exam emphasizes diagnostic reasoning and clinical management, whereas Step 1 emphasizes foundational content recall and is more detail-oriented. Because of this difference, the way to approach Step 2 practice questions is different from the way to approach Step 1 practice questions, and studying for both exams simultaneously may be counter productive.

Final Thoughts

While Step 1 becoming pass/fail has alleviated some of the stress of the exam, this is still an arduous experience. Nonetheless, with a good dedicated study plan in place, it is nothing that cannot be overcome!

One final tip that helped me was to study with the mindset that every fact I learned could help someone one day. I know that dedicated can become monotonous, but knowing that what I was learning was important in serving patients brought joy to it. Ok, maybe not the Krebs cycle, but most of the exam!

Also, dedicated is fortunately a finite time period. Once exam day is over, you can move on to the next step in your training. Best of luck as you embark on this journey!