So you’ve got Step 1 under your belt and you should be feeling pretty good about yourself. However, now that you’re preparing to take Step 2 (or 3), you may be wondering how Step 2 and 3 questions differ from Step 1, and whether you’ll need to change your approach. Not to worry! In this post, I’ll cover the techniques I teach my students for tackling question stems.

Before all else, remember that it is paramount to read a question actively. This means that while you read the question stem  really, even before you start reading it  you already know what you’re looking for. Active reading will help you concentrate on the important clues that will help you answer the question. This contrasts with passive reading, in which a reader tries to pick out which details are important as they read, without a predetermined idea of what to look for.

The Most Important Things to Look for in Almost Every USMLE Step 2 or Step 3 Question

1. The Age of the Patient In the Question

This information is critical in building your differential diagnosis, as different age groups tend to experience different problems. For example, if a patient presenting with a headache is under the age of 50, temporal arteritis is not going to be high in your differential diagnosis. However, if the patient is over the age of 50 at the onset of their first headache, we are much more likely to be thinking of serious causes, such as temporal arteritis and intracranial masses.

2. The Patient’s Gender

Sometimes the reason for this is obvious, as male patients do not usually suffer from uterine fibroids and pregnancy. Other times, it’s not as cut and dry, but can still be helpful. For example: females are more prone to most autoimmune diseases and urinary tract infections, while males often have cardiovascular disease at a younger age than their female counterparts.

3. Key Signs and Symptoms

This includes the quality of the symptoms and is probably obvious to most of you. The important part is to not get stuck on one clue and ignore the others. Chest pain with fever, chills, and cough is more likely pneumonia than chest pain with diaphoresis, nausea, and shortness of breath brought on by exertion.

4. Time Course of the Symptoms

This is probably where I see the most missed opportunities. Let’s look at the headache again. A headache that has been coming and going for years is not likely to be anything serious, whereas a very severe headache that had a sudden onset of minutes to hours ago raises concern for very serious things like subarachnoid hemorrhage. Fever is another example. Fevers that have been coming and going for weeks and months are not likely to be typical infectious processes although they can represent atypical infections like tuberculosis. This may seem obvious to you as you read this, but I have seen so many students miss questions due to overlooking the time course of the illness in question. This is often because they’re crunched for time, have testing anxiety, or are simply not paying enough attention to the clues in the question stem.

If you’ve read these and are still fretting over Step 2 CK and Step 3, rest assured there are four more essential elements to look out for in their question stems. So tune in for the second half of my post, coming soon!

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