High Yield Pulmonology for Step 2 CK: The Ultimate Review Guide
Pulmonology shows up constantly on Step 2 CK, but most students don’t have one place to review it the way the exam tests it: pattern recognition + the next best step. If your study sessions feel like memorizing scattered facts (and still missing questions), you’re not alone.
This high yield pulmonology Step 2 CK blog is built like a classmate-to-classmate walkthrough—clean PFT patterns, the must-know acute management algorithms, and the imaging clues that repeatedly show up in vignettes. Use it to refresh your core knowledge, then reinforce it with question blocks so your “next step” reflex gets fast.
How to Use This Guide
Here’s a simple way to turn this into points:
Read one section (5–10 minutes).
Do 5–10 pulm questions immediately after.
For every miss, write the algorithm from memory in one minute.
Revisit the same section two days later and do another mini block.
That loop—read → apply → rewrite—turns concepts into exam-day muscle memory.
1. Obstructive vs Restrictive Lung Disease: The Foundation of Step 2 Pulmonology
Most people lose easy points because they overthink PFTs. The fix is to learn one reliable approach for obstructive vs restrictive lung disease and stick to it.
↓ FEV1
FVC normal or ↓
↓ FEV1/FVC (often < 0.70)
Often ↑ RV (air trapping), sometimes ↑ TLC
Common causes: asthma, COPD, bronchiectasis, cystic fibrosis.
Restrictive Pattern
↓ TLC (the defining feature)
↓ FEV1 and ↓ FVC together
Normal or ↑ FEV1/FVC
DLCO helps separate intrinsic vs extrinsic causes
Common causes: interstitial lung disease, sarcoidosis, obesity, and neuromuscular weakness.
DLCO: The “Extra Clue”
Low DLCO: emphysema, interstitial lung disease, pulmonary vascular disease
Normal DLCO: asthma, chronic bronchitis, obesity, neuromuscular weakness
High-yield takeaway: Once you lock down pulmonary embolism diagnosis, every shortness-of-breath question becomes less scary. And when you practice pulmonary function test interpretation with this exact sequence, you’ll stop guessing.
2. Asthma Exacerbation Treatment: Step-by-Step Management for Step 2 CK
This is one of the most tested acute topics on Step 2 because the steps are predictable and the stakes are high. You want the asthma exacerbation treatment algorithm to feel automatic.
Chronic Control (The Important “Updated” Concept)
Modern practice emphasizes avoiding “reliever-only” strategies for many adults/adolescents and ensuring patients get inhaled corticosteroid (ICS) exposure to reduce severe exacerbations. On Step 2, you’ll still see the stepladder logic—just remember the principle: uncontrolled asthma usually means you need more controller therapy, not just more rescue use.
Typical escalation patterns:
Low-dose ICS (or an ICS-containing reliever strategy in many regimens)
Add LABA and/or increase ICS dose depending on severity and regimen
Higher-dose ICS/LABA for persistent symptoms
Add-ons for severe disease (e.g., LAMA; phenotype-guided biologics)
Acute Asthma Exacerbation: The Classic Algorithm
A medically accurate asthma exacerbation treatment sequence looks like this:
SABA (albuterol)—repeat frequently or continuous nebs if severe
Add ipratropium for moderate–severe exacerbations
Systemic corticosteroids early (don’t wait to see if it “settles”)
Oxygen as needed to maintain adequate saturation
IV magnesium sulfate for severe cases or poor response
Intubation/ventilation if impending respiratory failure
The “CO₂ Trap” That Signals Danger
Asthma patients typically hyperventilate early, so they often start with low CO₂. A normal or rising CO₂ in a severe exacerbation can mean fatigue and impending failure—exactly the kind of clue Step 2 loves.
Red flags:
“Silent chest”
Altered mental status
Exhaustion, worsening work of breathing
Worsening acidosis or rising CO₂
If you memorize one clinical sentence: Normal/rising CO₂ during asthma exacerbation treatment is an alarm bell.
3. COPD Exacerbation Management: What Step 2 CK Expects You to Know
COPD questions are “asthma-like,” but with two big differences: oxygen targets and early use of noninvasive ventilation. Nail the basics and COPD exacerbation management becomes one of the easiest scoring areas.
Chronic COPD (Quick and Test-Friendly)
Start with long-acting bronchodilators (LAMA or LABA)
Escalate to dual therapy if symptoms persist
Add ICS mainly when exacerbations are frequent (often tied to phenotype/eosinophils)
Acute COPD Exacerbation: The Step 2 Sequence
A medically accurate COPD exacerbation management plan is:
Short-acting bronchodilators (albuterol + ipratropium)
Systemic steroids (short course is typical)
Antibiotics if bacterial features are present
classic exam trigger: increased sputum purulence plus increased dyspnea and/or sputum volume
also commonly included: need for ventilatory support
Oxygen titration to SpO₂ 88–92%
BiPAP/NIV for hypercapnic respiratory failure (often the “best next step”)
High-yield tip: If the vignette screams hypercapnic distress and the patient can protect their airway, BiPAP is the star move in COPD exacerbation management.
4. Pneumonia Treatment Algorithm: CAP, HAP/VAP, and Aspiration
Pneumonia questions are about matching the setting and severity to appropriate empiric coverage. Keep it structured, and the pneumonia treatment algorithm becomes straightforward.
CAP (Community-Acquired Pneumonia)
Outpatient, low risk: amoxicillin or doxycycline are common first-line options; macrolide monotherapy depends on local resistance patterns.
Inpatient (non-ICU): beta-lactam + macrolide or respiratory fluoroquinolone
ICU/severe CAP: beta-lactam + macrolide or beta-lactam + respiratory fluoroquinolone (then adjust based on risks)
HAP/VAP
Broader coverage: anti-pseudomonal therapy
Add MRSA coverage when risk factors are present or the stem strongly implies it
Aspiration: The Nuance That Keeps This Accurate
A big modern clarification: not every aspiration needs “anaerobe-heavy” antibiotics.
Aspiration pneumonitis (chemical injury): often a witnessed event with rapid symptoms; supportive care is key and antibiotics are not automatically required.
Aspiration pneumonia (infectious): develops more like pneumonia and may often be treated similarly to CAP. Add anaerobic coverage mainly when abscess/necrotizing infection is suspected (cavitation, foul-smelling sputum, severe periodontal disease).
That framing is both clinically accurate and testable, and it keeps your pneumonia treatment algorithm decision-making clean.
5. Pulmonary Embolism Diagnosis: The Step 2 CK Approach
For PE, Step 2 wants you to choose the next test based on pretest probability. If you learn the flow, pulmonary embolism diagnosis questions become predictable.
Presentation Clues
Sudden dyspnea
Pleuritic chest pain
Tachycardia
Hypoxemia
Risk factors (surgery, immobilization, malignancy, OCPs, pregnancy, prior DVT/PE)
The Decision Pathway
Low/intermediate probability → D-dimer
High probability → CT pulmonary angiography (CTPA) (or an appropriate alternative if contraindicated)
Treatment Split (Stable vs Unstable)
Stable PE → anticoagulation
Massive PE with hypotension/shock → reperfusion therapy (e.g., thrombolysis depending on scenario)
IVC filter → if anticoagulation is contraindicated
High-yield tip: The exam repeats this endlessly unstable PE is an emergency; stable PE is anticoagulate. That’s the core of pulmonary embolism diagnosis logic.
6. Pleural Effusion Workup: Light’s Criteria Made Simple
Pleural effusions are algorithmic. The goal is to identify the fluid type and narrow the cause. If you know the numbers, the pleural effusion workup becomes a points-generator.
Step 1: Recognize it
CXR clues include blunting of the costophrenic angle and a meniscus sign.
Step 2: Sample it (Most New Effusions)
New or unexplained effusions generally get thoracentesis unless the cause is obvious and rapidly responsive (Step 2 often pushes sampling if anything feels atypical).
Step 3: Light’s Criteria
Exudate if any of the following:
Pleural protein/serum protein > 0.5
Pleural LDH/serum LDH > 0.6
Pleural LDH > 2/3 upper limit of normal serum LDH
Transudates: CHF, cirrhosis, nephrotic syndrome
Exudates: pneumonia, malignancy, TB, PE
If you only remember one fact for pleural effusion workup, make it Light’s criteria—because it’s tested constantly.
7. ARDS Management: High-Yield Review for Step 2 CK
ARDS is one of the most recognizable ICU syndromes on Step 2: acute illness, bilateral opacities, severe hypoxemia, and not primarily cardiac failure. Once you identify it, the key is lung-protective ventilation—the center of ARDS management.
Recognize ARDS (Berlin-Style Concept)
Acute onset (within ~1 week of a trigger)
Bilateral opacities
Hypoxemia (often framed as PaO₂/FiO₂ ≤ 300)
Not explained by heart failure/volume overload
Common triggers: sepsis, pneumonia, aspiration, pancreatitis, trauma/transfusion.
What Step 2 Wants You To Do
Low tidal volume ventilation (~6 mL/kg predicted body weight)
Appropriate PEEP
Conservative fluids
Consider prone positioning in severe cases
High-yield tip: “bilateral white-out” with a low oxygenation ratio → answer is lung-protective ventilation. That’s ARDS management in one line.
8. Chest X-Ray Interpretation: High-Yield Patterns You Should Recognize Fast
Step 2 often describes the film rather than showing it. A basic structure for chest x-ray interpretation keeps you from missing the obvious.
A Quick Systematic Approach (ABCDE)
Airway: trachea midline?
Bones: fractures?
Cardiac: size and borders?
Diaphragm: costophrenic angles, free air?
Everything else: lung fields, pleura, devices, masses
Buzzword-to-Diagnosis Matches
Bilateral hilar lymphadenopathy → sarcoidosis
Hyperinflation + flattened diaphragm → COPD
Blunted costophrenic angle → pleural effusion
Diffuse bilateral infiltrates after sepsis/trauma → ARDS
Cavitary upper lobe lesion → TB vs malignancy (use context)
High-yield tip: Most chest X-ray interpretation questions are really “recognize the pattern, then choose the next step.”
9. Lung Cancer Screening Guidelines: What to Know for Step 2 CK
Guideline questions are “free points” if you memorize the criteria. Lung cancer screening guidelines are a common example.
Who Should Be Screened?
Annual low-dose CT for patients who meet typical USPSTF-style criteria:
Age 50–80
≥20 pack-year history
Current smoker or quit within 15 years
High-Yield Lung Cancer Patterns
Squamous cell: central, cavitation, PTHrP → hypercalcemia
Adenocarcinoma: peripheral; common overall and often described in non-smokers
Small cell: central neuroendocrine; SIADH/Lambert-Eaton/Cushing; usually treated with chemo/radiation rather than surgery
Once you know lung cancer screening guidelines, you’ll also answer many “risk and prevention” stems quickly.
10. Sarcoidosis & Interstitial Lung Disease: The Quick Test-Day Distinction
Two common Step 2 scenarios:
Sarcoidosis: noncaseating granulomas + bilateral hilar lymphadenopathy ± hypercalcemia
Fibrotic interstitial lung disease (e.g., IPF): progressive dyspnea + dry cough + restrictive PFT pattern ± honeycombing on CT
The practical point: sarcoidosis often responds to steroids when clinically significant; IPF management is typically antifibrotic, focused on modern care rather than “steroids for everyone.”
Takeaway
If you’re trying to maximize points with efficient review, focus on algorithms and pattern recognition. Bookmark this and revisit it during dedicated, especially after question blocks.
This high yield pulmonology Step 2 CK guide is designed to be the thing you return to when you miss a vignette and need a fast, accurate reset. If you want structured support turning these algorithms into consistent score gains, MedBoardTutors can help you build the same reasoning a strong tutor uses—without the overwhelm. Schedule a free consultation now to learn more about how we can help you.
Which section gives you the most trouble: PFT patterns, acute asthma decisions, or ICU ventilation?
