First Aid for the USMLE Step 1 2020, 30th Edition (2020)

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FORTHE®New York / Chicago / San Francisco / Athens / London / Madrid / Mexico CityMilan / New Delhi / Singapore / Sydney / TorontoUSMLESTEP 12020FIRSTAIDTAO LE, MD, MHSFounder, ScholarRxAssociate Clinical Professor, Department of MedicineUniversity of Louisville School of MedicineVIKAS BHUSHAN, MDBoracayMATTHEW SOCHAT, MDFellow, Department of Hematology/OncologySt. Louis University School of MedicineSARAH SCHIMANSKY, MB BCh BAOResident, Department of OphthalmologyRoyal United Hospitals BathKIMBERLY KALLIANOS, MDAssistant Professor, Department of Radiology and Biomedical ImagingUniversity of California, San Francisco School of MedicineVAISHNAVI VAIDYANATHAN, MDResident, Department of Pediatric NeurologyBarrow Neurological Institute at Phoenix Children’s HospitalJORDAN ABRAMSSt. George’s University School of MedicineClass of 2020

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Copyright © 2020 by Tao Le and Vikas Bhushan. All rights reserved. Except as permitted under the United States Copyright Act of 1976,no part of this publication may be reproduced or distributed in any form or by any means, or stored in a database or retrieval system,without the prior written permission of the publisher.ISBN: 978-1-26-046205-0MHID:1-26-046205-6The material in this eBook also appears in the print version of this title: ISBN: 978-1-26-046204-3,MHID: 1-26-046204-8.eBook conversion by codeMantraVersion 1.0All trademarks are trademarks of their respective owners. Rather than put a trademark symbol after every occurrence of a trademarkedname, we use names in an editorial fashion only, and to the benefit of the trademark owner, with no intention of infringement of thetrademark. Where such designations appear in this book, they have been printed with initial caps.McGraw-Hill Education eBooks are available at special quantity discounts to use as premiums and sales promotions or for use in corpo-rate training programs. To contact a representative, please visit the Contact Us page at www.mhprofessional.com.NoticeMedicine is an ever-changing science. As new research and clinical experience broaden our knowledge, changes in treatment and drugtherapy are required. The authors and the publisher of this work have checked with sources believed to be reliable in their efforts toprovide information that is complete and generally in accord with the standards accepted at the time of publication. However, in viewof the possibility of human error or changes in medical sciences, neither the authors nor the publisher nor any other party who has beeninvolved in the preparation or publication of this work warrants that the information contained herein is in every respect accurate or com-plete, and they disclaim all responsibility for any errors or omissions or for the results obtained from use of the information contained inthis work. Readers are encouraged to confirm the information contained herein with other sources. For example and in particular, readersare advised to check the product information sheet included in the package of each drug they plan to administer to be certain that theinformation contained in this work is accurate and that changes have not been made in the recommended dose or in the contraindicationsfor administration. This recommendation is of particular importance in connection with new or infrequently used drugs.TERMS OF USEThis is a copyrighted work and McGraw-Hill Education and its licensors reserve all rights in and to the work. Use of this work is subjectto these terms. Except as permitted under the Copyright Act of 1976 and the right to store and retrieve one copy of the work, you maynot decompile, disassemble, reverse engineer, reproduce, modify, create derivative works based upon, transmit, distribute, disseminate,sell, publish or sublicense the work or any part of it without McGraw-Hill Education’s prior consent. You may use the work for yourown noncommercial and personal use; any other use of the work is strictly prohibited. Your right to use the work may be terminated ifyou fail to comply with these terms.THE WORK IS PROVIDED “AS IS.” McGRAW-HILL EDUCATION AND ITS LICENSORS MAKE NO GUARANTEES OR WAR-RANTIES AS TO THE ACCURACY, ADEQUACY OR COMPLETENESS OF OR RESULTS TO BE OBTAINED FROM USINGTHE WORK, INCLUDING ANY INFORMATION THAT CAN BE ACCESSED THROUGH THE WORK VIA HYPERLINK OROTHERWISE, ANDEXPRESSLY DISCLAIM ANY WARRANTY, EXPRESS OR IMPLIED, INCLUDING BUT NOT LIMITEDTO IMPLIED WARRANTIES OF MERCHANTABILITY OR FITNESS FOR A PARTICULAR PURPOSE. McGraw-Hill Educationand its licensors do not warrant or guarantee that the functions contained in the work will meet your requirements or that its opera-tion will be uninterrupted or error free. Neither McGraw-Hill Education nor its licensors shall be liable to you or anyone else for anyinaccuracy, error or omission, regardless of cause, in the work or for any damages resulting therefrom. McGraw-Hill Education has noresponsibility for the content of any information accessed through the work. Under no circumstances shall McGraw-Hill Education and/or its licensors be liable for any indirect, incidental, special, punitive, consequential or similar damages that result from the use of orinability to use the work, even if any of them has been advised of the possibility of such damages. This limitation of liability shall applyto any claim or cause whatsoever whether such claim or cause arises in contract, tort or otherwise.

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DedicationTo the contributors to this and past editions, who tooktime to share their knowledge, insight, and humor for thebenefit of students and physicians everywhere.

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vContentsContributing AuthorsviiAssociate AuthorsviiiFaculty AdvisorsixThirtieth Anniversary ForewordxiPrefacexiiiSpecial AcknowledgmentsxivGeneral AcknowledgmentsxvHow to ContributexviiHow to Use This BookxixSelected USMLE Laboratory ValuesxxFirst Aid Checklist for the USMLE Step 1xxii``S E C T I O N IG U I D E TO E F F I C I E N T E X A M P R E PA R AT I O N1Introduction2USMLE Step 1—The Basics2Defining Your Goal12Learning Strategies13Timeline for Study16Study Materials20Test-Taking Strategies22Clinical Vignette Strategies23If You Think You Failed24Testing Agencies24References25``S E C T I O N I S U P P L E M E N TS P E C I A L S I T UAT I O N S27``S E C T I O N I IH I G H - Y I E L D G E N E R A L P R I N C I P L E S29How to Use the Database30Biochemistry33Immunology95Microbiology123Pathology205Pharmacology229Public Health Sciences255

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vi``S E C T I O N I I IH I G H - Y I E L D O R G A N S YS T E M S275Approaching the Organ Systems276Cardiovascular279Endocrine325Gastrointestinal357Hematology and Oncology403Musculoskeletal, Skin, and Connective Tissue445Neurology and Special Senses489Psychiatry553Renal577Reproductive611Respiratory659Rapid Review689``S E C T I O N I VTO P - R AT E D R E V I E W R E S O U R C E S711How to Use the Database712Question Banks and Books714Web and Mobile Apps714Comprehensive715Anatomy, Embryology, and Neuroscience715Behavioral Science716Biochemistry716Cell Biology and Histology716Microbiology and Immunology717Pathology717Pharmacology718Physiology718``Abbreviations and Symbols719Image Acknowledgments727Index749About the Editors808

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viiContributing AuthorsMAJED H. ALGHAMDI, MBBSResident, Joint Program of Preventive MedicineJeddah, Saudi ArabiaLILIT ASLANYANNew York Institute of Technology College of Osteopathic MedicineClass of 2020HUMOOD BOQAMBAR, MB BCh BAOAssistant Registrar, Department of Orthopaedic SurgeryFarwaniya HospitalWEELIC CHONGSidney Kimmel Medical College at Thomas Jefferson UniversityMD/PhD CandidateKRISTINA DAMISCHUniversity of Iowa Carver College of MedicineClass of 2020YUMI KOVIC, MDResident, Department of PsychiatryUniversity of Massachusetts Medical SchoolKAITLYN MELNICK, MDResident, Department of Neurological SurgeryUniversity of Florida College of Medicine, GainesvilleMARY KATHERINE MONTES de OCA, MDResident, Department of Obstetrics and GynecologyDuke University HospitalSCOTT MOORE, DOAssistant Professor of Medical Laboratory SciencesWeber State UniversityVASILY OVECHKO, MDResident, Department of SurgeryRussian Medical Academy of Continuous Professional EducationVIVEK PODDERMBBS StudentTairunnessa Memorial Medical College and Hospital, BangladeshCONNIE QIULewis Katz School of Medicine at Temple UniversityMD/PhD CandidateImageandIllustratIonteamCAROLINE COLEMANEmory University School of MedicineClass of 2020MATTHEW HO ZHI GUANGUniversity College Dublin (MD), DFCI (PhD)MD/PhD CandidateVICTOR JOSE MARTINEZ LEON, MDCentral University of VenezuelaALIREZA ZANDIFAR, MDResearch FellowIsfahan University of Medical Sciences, Iran

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viiiAssociate AuthorsHUZAIFA AHMAD, MDResident, Department of MedicineGeorgetown University Hospital/MedStar Washington Hospital CenterALEXANDER R. ASLESENKirksville College of Osteopathic MedicineClass of 2020ANUP K. BHATTACHARYA, MDResident, Mallinckrodt Institute of RadiologyWashington University School of MedicineANUP CHALISE, MBBSResident, Department of General SurgeryNepal Medical College and Teaching HospitalASHTEN R. DUNCAN, MPHUniversity of Oklahoma-Tulsa School of Community MedicineClass of 2021SARINA KOILPILLAISt. George’s University School of MedicineClass of 2020LAUREN N. LESSOR, MPH, MDResident, Department of PediatricsMercy Health – St. Vincent Medical CenterROHAN BIR SINGH, MDFellow, Department of OphthalmologyMassachusetts Eye and EarHarvard Medical SchoolYAMNA JADOON, MDResearch AssociateAga Khan UniversityDANA M. JORGENSONChicago College of Osteopathic MedicineClass of 2020MITCHELL A. KATONAUniversity of Texas Health Science Center, Long School of MedicineClass of 2020TAYLOR MANEY, MDResident, Department of AnesthesiologyBrigham and Women’s HospitalImageandIllustratIonteam

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ixFaculty AdvisorsDIANA ALBA, MDClinical InstructorUniversity of California, San Francisco School of MedicineMARK A.W. ANDREWS, PhDProfessor of PhysiologyLake Erie College of Osteopathic Medicine at Seton HillMARIA ANTONELLI, MDAssistant Professor, Division of RheumatologyMetroHealth Medical Center, Case Western Reserve UniversityHERMAN SINGH BAGGA, MDUrologist, Allegheny Health NetworkUniversity of Pittsburgh Medical Center PassavantSHIN C. BEH, MDAssistant Professor, Department of Neurology & NeurotherapeuticsUT Southwestern Medical Center at DallasJOHN R. BUTTERLY, MDProfessor of MedicineDartmouth Geisel School of MedicineSHELDON CAMPBELL, MD, PhDProfessor of Laboratory MedicineYale School of MedicineBROOKS D. CASH, MDProfessor of Medicine, Division of GastroenterologyUniversity of South Alabama School of MedicineSHIVANI VERMA CHMURA, MDAdjunct Clinical Faculty, Department of PsychiatryStanford University School of MedicineBRADLEY COLE, MDAssistant Professor of Basic SciencesLoma Linda University School of MedicineLINDA S. COSTANZO, PhDProfessor, Physiology & BiophysicsVirginia Commonwealth University School of MedicineMANAS DAS, MD, MSDirector, Clinical Anatomy, Embryology, and HistologyUniversity of Massachusetts Medical SchoolANTHONY L. DeFRANCO, PhDProfessor, Department of Microbiology and ImmunologyUniversity of California, San Francisco School of MedicineCHARLES S. DELA CRUZ, MD, PhDAssociate Professor, Department of Pulmonary and Critical Care MedicineYale School of MedicineSAKINA FARHAT, MDConsulting GastroenterologistState University of New York Downstate Medical CenterCONRAD FISCHER, MDAssociate Professor, Medicine, Physiology, and PharmacologyTouro College of MedicineRAYUDU GOPALAKRISHNA, PhDAssociate Professor, Department of Integrative Anatomical SciencesKeck School of Medicine of University of Southern CaliforniaRYAN C.W. HALL, MDAssistant Professor, Department of PsychiatryUniversity of South Florida School of MedicineLOUISE HAWLEY, PhDImmediate Past Professor and Chair, Department of MicrobiologyRoss University School of MedicineJEFFREY W. HOFMANN, MD, PhDResident, Department of PathologyUniversity of California, San Francisco School of MedicineCLARK KEBODEAUX, PharmDClinical Assistant Professor, Pharmacy Practice and ScienceUniversity of Kentucky College of PharmacyKRISTINE KRAFTS, MDAssistant Professor, Department of Basic SciencesUniversity of Minnesota School of MedicineMATTHEW KRAYBILL, PhDClinical NeuropsychologistCottage Health, Santa Barbara, CaliforniaGERALD LEE, MDAssistant Professor, Departments of Pediatrics and MedicineEmory University School of Medicine

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xKACHIU C. LEE, MD, MPHAssistant Clinical Professor, Department of DermatologyThe Warren Alpert Medical School of Brown UniversityWARREN LEVINSON, MD, PhDProfessor, Department of Microbiology and ImmunologyUniversity of California, San Francisco School of MedicineJAMES LYONS, MDProfessor of Pathology and Family MedicineAlabama College of Osteopathic MedicinePETER MARKS, MD, PhDCenter for Biologics Evaluation and ResearchUS Food and Drug AdministrationDOUGLAS A. MATA, MD, MPHBrigham Education Institute and Brigham and Women’s HospitalHarvard Medical SchoolVICKI M. PARK, PhD, MSAssistant DeanUniversity of Tennessee College of MedicineSOROUSH RAIS-BAHRAMI, MDAssistant Professor, Departments of Urology and RadiologyUniversity of Alabama at Birmingham School of MedicineSASAN SAKIANI, MDFellow, Transplant HepatologyCleveland ClinicMELANIE SCHORR, MDAssistant in MedicineMassachusetts General HospitalSHIREEN MADANI SIMS, MDChief, Division of Gynecology, Gynecologic Surgery, and ObstetricsUniversity of Florida School of MedicineNATHAN W. SKELLEY, MDAssistant Professor, Department of Orthopaedic SurgeryUniversity of Missouri, The Missouri Orthopaedic InstituteHOWARD M. STEINMAN, PhDAssistant Dean, Biomedical Science EducationAlbert Einstein College of MedicineSUPORN SUKPRAPRUT-BRAATEN, PhDDirector of Research, Graduate Medical EducationUnity Health, Searcy, ArkansasRICHARD P. USATINE, MDProfessor, Dermatology and Cutaneous SurgeryUniversity of Texas Health Science Center San AntonioJ. MATTHEW VELKEY, PhDAssistant Dean, Basic Science EducationDuke University School of MedicineTISHA WANG, MDAssociate Clinical Professor, Department of MedicineDavid Geffen School of Medicine at UCLASYLVIA WASSERTHEIL-SMOLLER, PhDProfessor Emerita, Department of Epidemiology and Population HealthAlbert Einstein College of MedicineADAM WEINSTEIN, MDAssistant Professor, Pediatric Nephrology and Medical EducationGeisel School of Medicine at DartmouthABHISHEK YADAV, MBBS, MScAssociate Professor of AnatomyGeisinger Commonwealth School of MedicineKRISTAL YOUNG, MDClinical Instructor, Department of CardiologyHuntington Hospital, Pasadena, California

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xiThirtieth Anniversary ForewordOur exam experiences remain vivid in our minds to this day as we reflect on 30 years ofFirst Aid. In 1989, ourbig idea was to cobble together a “quick and dirty” study guide so that we would never again have to deal with theUSMLE Step 1. We passed, but in a Faustian twist, we now relive the exam yearly while preparing each new edition.Like all students before us, we noticed that certain topics tended to appear frequently on examinations. So wecompulsively bought and rated review books and pored through a mind-numbing number of “recall” questions,distilling each into short facts. We had a love-hate relationship with mnemonics. They went against our purist desiresfor conceptual knowledge, but remained the best way to absorb the vocabulary and near-random associations thatunlocked questions and eponyms.To pull it all together, we used a then “state-of-the-art” computer database (Paradox/MS DOS 4) that fortuitouslylimited our entries to 256 characters. That length constraint (which predated Twitter by nearly two decades) imposedextreme brevity. The three-column layout created structure—and this was the blueprint upon whichFirst Aidwasfounded.The printed, three-column database was first distributed in 1989 at the University of California, San Francisco.The next year, the official first edition was self-published under the titleHigh-Yield Basic Science Boards Review: AStudent-to-Student Guide. The following year, our new publisher dismissed theHigh-Yieldtitle as too confusing andcame up withFirst Aid for the Boards. We thought the name was a bit cheesy, but it proved memorable. Interestingly,our “High-Yield” name resurfaced years later as the title of a competing board review series.We lived in San Francisco and Los Angeles during medical school and residency. It was before the Web, andbefore med students could afford cell phones and laptops, so we relied on AOL e-mail and bulky desktops. One ofus would drive down to the other person’s place for multiple weekends of frenetic revisions fueled by triple-Swisswhite chocolate lattes from the Coffee Bean & Tea Leaf, with R.E.M. and the Nusrat Fateh Ali Khan playing in thebackground. Everything was marked up on 11- by 17-inch “tearsheets,” and at the end of the marathon weekendwe would converge at the local 24-hour Kinko’s followed by the FedEx box near LAX (10 years before these twogreat institutions merged). These days we work with our online collaborative platform A.nnotate, GoToMeeting, andubiquitous broadband Internet, and sadly, we rarely get to see each other.What hasn’t changed, however, is the collaborative nature of the book. Thousands of authors, editors, andcontributors have enriched our lives and made this book possible. Most helped for a year or two and moved on, buta few, like Ted Hon, Chirag Amin, and Andi Fellows, made lasting contributions. Like the very first edition, the teamis always led by student authors who live and breathe (and fear) the exam, not professors years away from that reality.We’re proud of the precedent thatFirst Aidset for the many excellent student-to-student publications that followed.More importantly,First Aiditself owes its success to the global community of medical students and internationalmedical graduates (IMGs) who each year contribute ideas, suggestions, and new content. In the early days, weused book coupons and tear-out business reply mail forms. These days, we get many thousands of comments andsuggestions each year via our blog FirstAidTeam.com and A.nnotate.

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xiiAt the end of the day, we don’t take any of this for granted. Students are expected to synthesize an ever increasingamount of information, and we have a bigger challenge ahead of us to try to keepFirst Aidindispensable to studentsand IMGs. We want and need your participation in theFirst Aidcommunity. (See How to Contribute, p. xvii.) Withyour help, we hope editingFirst Aidwill continue to be just as fun and rewarding as the past 30 years have been.LouisvilleTao LeBoracayVikas BhushanFirst Aid for the USMLE Step 1Through the Years

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xiiiPrefaceWith the 30th edition ofFirst Aid for the USMLE Step 1,we continue our commitment to providing students withthe most useful and up-to-date preparation guide for the USMLE Step 1. This edition represents an outstandingrevision in many ways, including:50 entirely new or heavily revised high-yield topics reflecting evolving trends in the USMLE Step 1.Reorganization of high-yield topics in Pharmacology, Endocrine, and Reproductive chapters for improved study.Extensive text revisions, new mnemonics, clarifications, and corrections curated by a team of more than 30medical student and resident physician authors who excelled on their Step 1 examinations and verified by a teamof expert faculty advisors and nationally recognized USMLE instructors.Updated with 178 new and revised diagrams and illustrations as part of our ongoing collaboration withUSMLE-Rx and ScholarRx (MedIQ Learning, LLC).Updated with 75 new and revised photos to help visualize various disorders, descriptive findings, and basicscience concepts. Additionally, revised imaging photos have been labeled and optimized to show both normalanatomy and pathologic findings.Updated study tips on the opening page of each chapter.Improved integration of clinical images and illustrations to better reinforce and learn key anatomic concepts.Improved organization and integration of text, illustrations, clinical images, and tables throughout for focusedreview of high-yield topics.Revised and expanded ratings of current, high-yield review resources, with clear explanations of their relevanceto USMLE review.Real-time Step 1 updates and corrections can be found exclusively on our blog, www.firstaidteam.com.We invite students and faculty to share their thoughts and ideas to help us continually improveFirst Aid for theUSMLE Step 1through our blog and collaborative editorial platform. (See How to Contribute, p. xvii.)LouisvilleTao LeBoracayVikas BhushanSt. LouisMatthew SochatPhoenixVaishnavi VaidyanathanBristolSarah SchimanskyNew York CityJordan AbramsSan FranciscoKimberly Kallianos

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xivSpecial AcknowledgmentsThis has been a collaborative project from the start. We gratefully acknowledge the thousands of thoughtfulcomments, corrections, and advice of the many medical students, international medical graduates, and faculty whohave supported the authors in our continuing development ofFirst Aid for the USMLE Step 1.For support and encouragement throughout the process, we are grateful to Thao Pham, Jinky Flang, and JonathanKirsch, Esq. Thanks to Louise Petersen for organizing and supporting the project. Thanks to our publisher, McGraw-Hill, for the valuable assistance of its staff, including Bob Boehringer, Jeffrey Herzich, and Christina Thomas.We are also very grateful to Dr. Fred Howell and Dr. Robert Cannon of Textensor Ltd for providing us extensivecustomization and support for their powerful Annotate.co collaborative editing platform (www.annotate.co), whichallows us to efficiently manage thousands of contributions. Thanks to Dr. Richard Usatine and Dr. Kristine Kraftsfor their outstanding image contributions. Thanks also to Jean-Christophe Fournet (www.humpath.com), Dr. EdUthman, and Dr. Frank Gaillard (www.radiopaedia.org) for generously allowing us to access some of their strikingphotographs.Forexceptionaleditorialleadership,enormousthankstoKathleenNaylor,ChristineDiedrichandEmmaUnderdown. Thank you to our USMLE-Rx/ScholarRx team of editors, Jessie Schanzle, Ruth Kaufman, JaneneMatragrano, Susan Mazik, Isabel Nogueira, Sharon Prevost, Jen Shimony, and Hannah Warnshuis. Special thanks toour indexer Dr. Anne Fifer. We are also grateful to our medical illustrator, Hans Neuhart, for his creative work on thenew and updated illustrations. Lastly, tremendous thanks to Graphic World, especially Anne Banning, Sandy Brown,Gary Clark, and Cindy Geiss.LouisvilleTao LeBoracayVikas BhushanSt. LouisMatthew SochatPhoenixVaishnavi VaidyanathanBristolSarah SchimanskyNew York CityJordan AbramsSan FranciscoKimberly Kallianos

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xvEach year we are fortunate to receive the input of thousands of medical students and graduates who provide newmaterial, clarifications, and potential corrections through our website and our collaborative editing platform.This has been a tremendous help in clarifying difficult concepts, correcting errata from the previous edition, andminimizing new errata during the revision of the current edition. This reflects our long-standing vision of a true,student-to-student publication. We have done our best to thank each person individually below, but we recognizethat errors and omissions are likely. Therefore, we will post an updated list of acknowledgments at our website, www.firstaidteam.com/bonus/. We will gladly make corrections if they are brought to our attention.For submitting contributions and corrections, many thanks to Raed Ababneh, Antara Afrin, Rasim Agaev, VanyaAggarwal, Ataa Ahmed, Hasan Alarouri, Basim Ali, Muhammad Faizan Ali, Moatasem Al-Janabi, MohamedAlmahmodi, Chima Amadi, Arman Amin, Jacqueline Aredo, Ranya Baddourah, Daniel Badin, Nida Bajwa, DileniBandarage, Jerrin Bawa, Esra Bayram, Craig Beavers, Jacqueline Bekhit, Matthias Bergmann, Stephanie Biecker,Aaron Birnbaum, Prateek Bommu, Nathaniel Borochov, Susan Brands, Olivia W. Brooks, Meghan Brown, StanleyBudzinski, Kevin Budziszewski, Pavel Burski, Elisa M. Cairns, Sergio Camba, Katie Carsky, Esteban Casasola,Marielys Castro, Jesse Chait, Bliss Chang, Santosh Cherian, Heewon Choi, Charilaos Chourpiliadis, MarufChowdhury, Matthew J. Christensen, Matthew Yat Hon Chung, Alexander Ciaramella, Dillon Clancy, Sofija Conic,M. Marwan Dabbagh, Parag Das, Ketan Dayma, Elmer De Camps, Charles de Leeuw, Xavier De Pena, ChristopherDeAngelo, Elliott Delgado, Anthony DeMarinis, Stacy Diaz, Evan Dishion, Nicola Helen Duzak, Emily Edwards,Alec Egan, Mohamed Elashwal, Osama El-Gabalawy, Matthew Eli, Awab Elnaeem, Sally El Sammak, Dylan Erwin,Stephanie Estevez-Marin, Gray Evans, Najat Fadlallah, Aria Fariborzi, Richard Ferro, Adam Fletcher, Kimberly A.Foley, Kyle Fratta, Samantha Friday, Nikhila Gandrakota, Siva Garapati, Nicolas Curi Gawlinski, Joanna Georgakas,Beth Anne George, Ashley Ghaemi, E. Sophia Gonzalez, Justin Graff, Gabriel Graham, Donovan Griggs, DavidGruen, Gursewak Hadday, Jacqueline Hairston, Hunter Harrison, Gull Shahmir Hasnat, Maximillan Hawkins,Grecia Haymee, Briana Hernandez, Robin Hilder, Tammy Hua, Derrek Humphries, Audrey Hunt, Nanki Hura,Danny Ibrahim, Jyothik Varun Inampudi, Hnin Ingyin, Maham Irfan, Mina Iskandar, Kritika Iyer, Christina Jacobs,Arpit Jain, Neil K. Jain, Ala Jamal, Natalie Jansen, Jordan Jay, Mohammad Jmasi, Colton Junod, Talia Kamdjou,Filip Kaniski, Lydia Kaoutzani, Panagiotis Kaparaliotis, Srikrishna Karnatapu, Patrick Keller, Olivia Keller-Baruch,Cameron Kerl, Ahmed Ali Khan, Sara Khan, Shaima Khandaker, Samir Khouzam, Sonya Klein, Elana Kleinman,Andrew Ko, Soheil Kooraki, Anna Kukharchuk, Dennis Vu Kulp, Anil A. Kumar, Julie Kurek, Chloe Lahoud,Mike Lawandy, Ramy Lawandy, Jessica Lazar, Andrea Leal-Lopez, Lynda Lee, Chime Lhatso, Christine Lin,Benjamin Lodge, Soon Khai Low, Estefanía Henríquez Luthje, Lisa-Qiao MacDonald, Divya Madhavarapu, MahirMameledzija, Keerer Mann, Rajver Mann, Nadeen Mansour, Yusra Mansour, Bridget Martinez, Ahmad Mashlah,Rick Mathews, Amy McGregor, Alexandra & Joshua Medeiros & Fowler, Viviana Medina, Areeka Memon, PedroG. R. Menicucci, Ben Meyers, Stephan A. Miller, Fatima Mirza, Murli Mishra, Elana Molcho, Guarina Molina,John Moon, Nayla Mroueh, Neha Mylarapu, Behnam Nabavizadeh, Moeko Nagatsuka, Ghazal Naghibzadeh, AliceNassar, Nadya Nee, Lucas Nelson, Zach Nelson, Monica Nemat, Kenneth Nguyen, Michael Nguyen, ChristianGeneral Acknowledgments

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xviNieves, Nyia Njamfa, Ahmed Noor, Kyle Nyugen, Ahamd Obeidat, Gerald Olayan, Anndres Olson, Hasaan Omar,Daniel Ortiz, Michael O’Shea, Zonghao Pan, Vasilis Sebastian Paraschos, Christopher Parrino, Janak Patel, VanishaPatel, Cyril Patra, Rita Paulis, Dmytro Pavlenko, Nancy A. Pina, Alexander Polyak, Jackeline Porto, Shannon D.Powell, Jacob Pruett, Laith Rahabneh, Kamleshun Ramphul, Janhvi Rana, Nidaa Rasheed, Abdul Sattar Raslan,Tomas Ream, Rashelle Ripa, Amanda Michelle Ritchie, Helio Manuel Grullón Rodríguez, Sarah Rohrig, GesselRomero, Alexander Rose, Rachel Rose, Erica Rubin, Areesha Saati, Jeffrey Sackey, Raza H. Sagarwala, Chhavi Saini,Sergii Sakhno, Allie Sakowicz, Shadia Saleh, Roshun Sangani, Dhruv Sarwal, Abeer Sarwar, M. Sathyanarayanan,Neetu Scariya, Tonio Felix Schaffert, Melissa Schechter, Kathryn Scheinberg, Emma Schnuckle, Emma Schulte,Taylor Schweigert, Lee Seifert, Sheila Serin, Deeksha Seth, Omid Shafaat, Nirav Shah, Samir K. Shah, WasifNauman Shah, Muhanad Shaib, Ahmed Shakir, Purnima Sharma, Tina Sharma, Kayla Sheehan, Dr. PriyaShenwai, Sami Shoura, Kris Sifeldeen, Akhand Singh, Manik Inder Singh, Ramzi Y. Skaik, Samantha A. Smith,Timothy Smith, Emilie Song, Hang Song, Shichen Song, Luke Sorensen, Charles Starling, Jonathan AndrewStone, Nathan Stumpf, Johnny Su, Bahaa Eddine Succar, Saranya Sundaram, Steven Svoboda, Clara Sze, OliveTang, Brian Tanksley, Omar Tayh, Joshua Taylor, Valerie Teano, Warren Teltser, Steffanie Camilo Tertulien, RogerTorres, Michael Trainer, Andrew Trinh, Aalap K. Trivedi, Georgeanna Tsoumas, Elizabeth Tsui, Cem Turam,Methma Udawatta, Daramfon Udofia, Adaku Ume, Rio Varghese, Judith Vásquez, Earl Vialpando, Sagar Vinayak,Phuong Vo, Habiba Wada, Jason Wang, Tiffany Wang, Zoe Warczak, Mitchell Waters, Rachel Watson, ElizabethDouglas Weigel, Rabbi Michael Weingarten, Kaystin Weisenberger, Aidan Woodthorpe, Mattia Wruble, Angela Wu,Catherine Xie, Rebecca Xu, Nicholas Yeisley, Sammy Yeroushalmi, Melissas Yuan, Sahil Zaveri, and Yolanda Zhang.

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xviiThis version ofFirst Aid for the USMLE Step 1incorporates thousands of contributions and improvements suggestedby student and faculty advisors. We invite you to participate in this process. Please send us your suggestions for:Study and test-taking strategies for the USMLE Step 1New facts, mnemonics, diagrams, and clinical imagesHigh-yield topics that may appear on future Step 1 examsPersonal ratings and comments on review books, question banks, apps, videos, and coursesFor each new entry incorporated into the next edition, you will receiveup to a $20 Amazon.com gift cardas well aspersonal acknowledgment in the next edition. Significant contributions will be compensated at the discretion of theauthors. Also, let us know about material in this edition that you feel is low yield and should be deleted.All submissions including potential errata should ideally be supported with hyperlinks to a dynamically updated Webresource such as UpToDate, AccessMedicine, and ClinicalKey.We welcome potential errata on grammar and style if the change improves readability. Please note thatFirst Aidstyleis somewhat unique; for example, we have fully adopted theAMA Manual of Stylerecommendations on eponyms(“We recommend that the possessive form be omitted in eponymous terms”) and on abbreviations (no periods witheg, ie, etc). We also avoid periods in tables unless required for full sentences. Kindly refrain from submitting “styleerrata” unless you find specific inconsistencies with theAMA Manual of Style.Thepreferredwaytosubmitnewentries,clarifications,mnemonics,orpotentialcorrectionswithavalid,authoritative reference is via our website:www.firstaidteam.com.This website will be continuously updated with validated errata, new high-yield content, and a new online platformto contribute suggestions, mnemonics, diagrams, clinical images, and potential errata.Alternatively, you can email us at:firstaid@scholarrx.com.Contributions submitted byMay 15, 2020, receive priority consideration for the 2021 edition ofFirst Aid for theUSMLE Step 1. We thank you for taking the time to share your experience and apologize in advance that we cannotindividually respond to all contributors as we receive thousands of contributions each year.How to Contribute

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xviii``NOTE TO CONTRIBUTORSAll contributions become property of the authors and are subject to editing and reviewing. Please verify all data andspellings carefully. Contributions should be supported by at least two high-quality references.Check our website first to avoid duplicate submissions. In the event that similar or duplicate entries are received,only the first complete entry received with valid, authoritative references will be credited. Please follow the style,punctuation, and format of this edition as much as possible.``JOIN THE FIRST AID TEAMTheFirst Aidauthor team is pleased to offer part-time and full-time paid internships in medical education andpublishing to motivated medical students and physicians. Internships range from a few months (eg, a summer) upto a full year. Participants will have an opportunity to author, edit, and earn academic credit on a wide variety ofprojects, including the popularFirst Aidseries.For 2020, we are actively seeking passionate medical students and graduates with a specific interest in improving ourmedical illustrations, expanding our database of medical photographs, and developing the software that supports ourcrowdsourcing platform. We welcome people with prior experience and talent in these areas. Relevant skills includeclinical imaging, digital photography, digital asset management, information design, medical illustration, graphicdesign, tutoring, and software development.Please email us atfirstaid@scholarrx.comwith a CV and summary of your interest or sample work.

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xixHow to Use This BookCONGRATULATIONS:You now possess the book that has guided nearly two million students to USMLE successfor 30 years. With appropriate care, the binding should last the useful life of the book. Keep in mind that puttingexcessive flattening pressure on any binding will accelerate its failure. If you purchased a book that you believeis defective, pleaseimmediatelyreturn it to the place of purchase. If you encounter ongoing issues, you can alsocontact Customer Service at our publisher, McGraw-Hill Education, at https://www.mheducation.com/contact.html.START EARLY:Use this book as early as possible while learning the basic medical sciences. The first semester ofyour first year is not too early! Devise a study plan by reading Section I: Guide to Efficient Exam Preparation, andmake an early decision on resources to use by checking Section IV: Top-Rated Review Resources. Note thatFirst Aidis neither a textbook nor a comprehensive review book, and it is not a panacea for inadequate preparation.CONSIDERFIRST AIDYOUR ANNOTATION HUB:Annotate material from other resources, such as classnotes or comprehensive textbooks, into your book. This will keep all the high-yield information you need in oneplace. Other tips on keeping yourself organized:For best results, use fine-tipped ballpoint pens (eg, BIC Pro+, Uni-Ball Jetstream Sports, Pilot Drawing Pen,Zebra F-301). If you like gel pens, try Pentel Slicci, and for markers that dry almost immediately, considerStaedtler Triplus Fineliner, Pilot Drawing Pen, and Sharpies.Consider using pens with different colors of ink to indicate different sources of information (eg, blue forUSMLE-Rx Step 1 Qmax, green for UWorld Step 1 Qbank).Choose highlighters that are bright and dry quickly to minimize smudging and bleeding through the page(eg, Tombow Kei Coat, Sharpie Gel).Many students de-spine their book and get it 3-hole-punched. This will allow you to insert materials from othersources, including curricular materials.INTEGRATE STUDY WITH CASES, FLASH CARDS, AND QUESTIONS:To broaden your learning strategy,consider integrating yourFirst Aidstudy with case-based reviews (eg,First Aid Cases for the USMLE Step 1), flashcards (eg, First Aid Flash Facts), and practice questions (eg, the USMLE-Rx Step 1 Qmax). Read the chapter in thebook, then test your comprehension by using cases, flash cards, and questions that cover the same topics. Maintainaccess to more comprehensive resources (eg,First Aid for the Basic Sciences: General PrinciplesandOrgan Systemsand First Aid Express videos) for deeper review as needed.PRIME YOUR MEMORY:Return to your annotated Sections II and III several days before taking the USMLEStep 1. The book can serve as a useful way of retaining key associations and keeping high-yield facts fresh in yourmemory just prior to the exam. The Rapid Review section includes high-yield topics to help guide your studying.CONTRIBUTE TO FIRST AID:Reviewing the book immediately after your exam can help us improve the nextedition. Decide what was truly high and low yield and send us your comments. Feel free to send us scanned imagesfrom your annotatedFirst Aidbook as additional support. Of course, always remember thatall examinees are underagreement with the NBME to not disclose the specific details of copyrighted test material.

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xxBlood, Plasma, SerumReference RangeSI Reference Intervals*Alanine aminotransferase (ALT, GPT at 30°C)8–20 U/L8–20 U/LAmylase, serum25–125 U/L25–125 U/L*Aspartate aminotransferase (AST, GOT at 30°C)8–20 U/L8–20 U/LBilirubin, serum (adult)Total // Direct0.1–1.0 mg/dL // 0.0–0.3 mg/dL2–17μmol/L // 0–5μmol/L*Calcium, serum (Total)8.4–10.2 mg/dL2.1–2.8 mmol/L*Cholesterol, serum (Total)Rec: < 200 mg/dL< 5.2 mmol/L*Creatinine, serum (Total)0.6–1.2 mg/dL53–106μmol/L*Electrolytes, serumSodium (Na+)Chloride (Cl–)Potassium (K+)Bicarbonate (HCO3–)Magnesium (Mg2+)136–145 mEq/L95–105 mEq/L3.5–5.0 mEq/L22–28 mEq/L1.5–2 mEq/L136–145 mmol/L95–105 mmol/L3.5–5.0 mmol/L22–28 mmol/L0.75–1.0 mmol/LGases, arterial blood (room air)PO2PCO2pH75–105 mm Hg33–45 mm Hg7.35–7.4510.0–14.0 kPa4.4–5.9 kPa[H+] 36–44 nmol/L*Glucose, serumFasting: 70–110 mg/dL2-h postprandial: < 120 mg/dL3.8–6.1 mmol/L< 6.6 mmol/LGrowth hormone−arginine stimulationFasting: < 5 ng/mLprovocative stimuli: > 7 ng/mL< 5μg/L> 7μg/LOsmolality, serum275–295 mOsm/kg275–295 mOsm/kg*Phosphatase (alkaline), serum (p-NPP at 30°C)20–70 U/L20–70 U/L*Phosphorus (inorganic), serum3.0–4.5 mg/dL1.0–1.5 mmol/LProlactin, serum (hPRL)< 20 ng/mL< 20 μg/L*Proteins, serumTotal (recumbent)AlbuminGlobulins6.0–7.8 g/dL3.5–5.5 g/dL2.3–3.5 g/dL60–78 g/L35–55 g/L23–35 g/LThyroid-stimulating hormone, serum or plasma0.5–5.0μU/mL0.5–5.0 mU/L*Urea nitrogen, serum (BUN)7–18 mg/dL1.2–3.0 mmol/L*Uric acid, serum3.0–8.2 mg/dL0.18–0.48 mmol/L(continues)Selected USMLE Laboratory Values* = Included in the Biochemical Profile (SMA-12)

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xxiCerebrospinal FluidReference RangeSI Reference IntervalsGlucose40–70 mg/dL2.2–3.9 mmol/LHematologicErythrocyte countMale: 4.3–5.9 million/mm3Female: 3.5–5.5 million/mm34.3–5.9×1012/L3.5–5.5×1012/LErythrocyte sedimentation rate (Westergen)Male: 0–15 mm/hFemale: 0–20 mm/h0–15 mm/h0–20 mm/hHematocritMale: 41–53%Female: 36–46%0.41–0.530.36–0.46Hemoglobin, bloodMale: 13.5–17.5 g/dLFemale: 12.0–16.0 g/dL2.09–2.71 mmol/L1.86–2.48 mmol/LHemoglobin, plasma1–4 mg/dL0.16–0.62μmol/LLeukocyte count and differentialLeukocyte countSegmented neutrophilsBand formsEosinophilsBasophilsLymphocytesMonocytes4,500–11,000/mm354–62%3–5%1–3%0–0.75%25–33%3–7%4.5–11.0×109/L0.54–0.620.03–0.050.01–0.030–0.00750.25–0.330.03–0.07Mean corpuscular hemoglobin25.4–34.6 pg/cell0.39–0.54 fmol/cellMean corpuscular volume80–100μm380–100 fLPartial thromboplastin time (activated)25–40 seconds25–40 secondsPlatelet count150,000–400,000/mm3150–400×109/LProthrombin time11–15 seconds11–15 secondsReticulocyte count0.5–1.5% of red cells0.005–0.015SweatChloride0–35 mmol/L0–35 mmol/LUrineCreatinine clearanceMale: 97–137 mL/minFemale: 88–128 mL/minOsmolality50–1,400 mOsmol/kg H2OProteins, total< 150 mg/24 h< 0.15 g/24 h

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xxiiFirst Aid Checklist for the USMLE Step 1This is an example of how you might use the information in Section I to prepare for the USMLE Step 1.Refer to corresponding topics in Section I for more details.Years PriorMonths PriorWeeks PriorOne Week PriorOne Day PriorDay of ExamAfter ExamUse top-rated review resources for first-year medical school courses.Ask for advice from those who have recently taken the USMLE Step 1.Review computer test format and registration information.Register six months in advance.Carefully verify name and address printed on scheduling permit. Make surethe name on scheduling permit matches the name printed on your photo ID.Go online for test date ASAP.Define your exam goals (pass comfortably, beat the mean, ace the test)Set up a realistic timeline for study. Cover less crammable subjects first.Evaluate and choose study materials (review books, question banks).Use a question bank to simulate the USMLE Step 1 to pinpoint strengths andweaknesses in knowledge and test-taking skills.Do another test simulation in a question bank.Assess how close you are to your goal.Pinpoint remaining weaknesses. Stay healthy (exercise, sleep).Verify information on admission ticket (eg, location, date).Remember comfort measures (loose clothing, earplugs, etc).Work out test site logistics (eg, location, transportation, parking, lunch).Print or download your Scheduling Permit and Scheduling Confirmationto your phone.Relax.Lightly review short-term material if necessary. Skim high-yield facts.Get a good night’s sleep.Relax.Eat breakfast.Minimize bathroom breaks during exam by avoiding excessive morningcaffeine.Celebrate, regardless of how well you feel you did.Send feedback to us on our website atwww.firstaidteam.com.First Aid Checklist for the USMLE Step 1This is an example of how you might use the information in Section I to prepare for the USMLEStep 1. Refer to corresponding topics in Section I for more details.

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1`Introduction2`USMLE Step 1—TheBasics2`Defining Your Goal12`Learning Strategies13`Timeline for Study16`Study Materials20`Test-TakingStrategies22`Clinical VignetteStrategies23`If You Think YouFailed24`Testing Agencies24`References25S E C T I O N IGuide to EfficientExam Preparation“I don’t love studying. I hate studying. I like learning. Learning isbeautiful.”—Natalie Portman“Finally, from so little sleeping and so much reading, his brain dried upand he went completely out of his mind.”—Miguel de Cervantes Saavedra,Don Quixote“Sometimes the questions are complicated and the answers are simple.”—Dr. Seuss“He who knows all the answers has not been asked all the questions.”—Confucius“The expert in anything was once a beginner.”—Helen Hayes“It always seems impossible until it’s done.”—Nelson Mandela

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Guide toefficientexam PreParationSec tioni2``INTRODUCTIONRelax.This section is intended to make your exam preparation easier, not harder.Our goal is to reduce your level of anxiety and help you make the mostof your efforts by helping you understand more about the United StatesMedical Licensing Examination, Step 1 (USMLE Step 1). As a medicalstudent, you are no doubt familiar with taking standardized examinationsand quickly absorbing large amounts of material. When you first confrontthe USMLE Step 1, however, you may find it all too easy to becomesidetracked from your goal of studying with maximal effectiveness. Commonmistakes that students make when studying for Step 1 include the following:Starting to study (includingFirst Aid) too lateStarting to study intensely too early and burning outStarting to prepare for boards before creating a knowledge foundationUsing inefficient or inappropriate study methodsBuying the wrong resources or buying too many resourcesBuying only one publisher’s review series for all subjectsNot using practice examinations to maximum benefitNot understanding how scoring is performed or what the score meansNot using review books along with your classesNot analyzing and improving your test-taking strategiesGetting bogged down by reviewing difficult topics excessivelyStudying material that is rarely tested on the USMLE Step 1Failing to master certain high-yield subjects owing to overconfidenceUsingFirst Aidas your sole study resourceTrying to prepare for it all aloneIn this section, we offer advice to help you avoid these pitfalls and be moreproductive in your studies.``USMLE STEP 1—THEBASICSThe USMLE Step 1 is the first of three examinations that you must pass inorder to become a licensed physician in the United States. The USMLEis a joint endeavor of the National Board of Medical Examiners (NBME)and the Federation of State Medical Boards (FSMB). The USMLE servesas the single examination system for US medical students and internationalmedical graduates (IMGs) seeking medical licensure in the United States.`The test at a glance:8-hour examUp to a total of 280 multiple choice items7 test blocks (60 min/block)Up to 40 test items per block45 minutes of break time, plus another 15if you skip the tutorial

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Guide toefficientexam PreParationSec tioni3The Step 1 exam includes test items that can be grouped by the organiza-tional constructs outlined in Table 1 (in order of tested frequency).How Is the Computer-Based Test (CBT) Structured?The CBT Step 1 exam consists of one “optional” tutorial/simulation blockand seven “real” question blocks of up to 40 questions per block with nomore than 280 questions in total, timed at 60 minutes per block. A short11-question survey follows the last question block. The computer begins thesurvey with a prompt to proceed to the next block of questions.Once an examinee finishes a particular question block on the CBT, he orshe must click on a screen icon to continue to the next block. Examineescannotgo back and change their answers to questions from any previouslycompleted block. However, changing answers is allowedwithina block ofquestions as long as the block has not been ended and if time permits.What Is the CBT Like?Given the unique environment of the CBT, it’s important that you becomefamiliar ahead of time with what your test-day conditions will be like. Youcan access a 15-minute tutorial and practice blocks at http://orientation.nbme.org/Launch/USMLE/STPF1. This tutorial interface is very similar tothe one you will use in the exam; learn it now and you can skip taking itduring the exam, giving you up to 15 extra minutes of break time. You cangain experience with the CBT format by taking the 120 practice questions(3 blocks with 40 questions each) available online or by signing up for apractice session at a test center for a fee.T A B L E1 .Frequency of Various Constructs Tested on the USMLE Step 1.*CompetencyRange, %SystemRange, %Medical knowledge: applying foundationalscience concepts52–62General principles13–17Patient care: diagnosis20–30Behavioral health & nervous systems/special senses9–13Patient care: management7–12Respiratory & renal/urinary systems9–13Practice-based learning & improvement5–7Reproductive & endocrine systems9–13Communication/professionalism2–5Blood & lymphoreticular/immune systems7–11DisciplineRange, %Multisystem processes & disorders7–11Pathology45–52Musculoskeletal, skin & subcutaneous tissue6–10Physiology26–34Cardiovascular system6–10Pharmacology16–23Gastrointestinal system5–9Biochemistry & nutrition14–24Biostatistics & epidemiology/population health5–7Microbiology & immunology15–22Social sciences: communication skills/ethics3–5Gross anatomy & embryology11–15Histology & cell biology9–13Behavioral sciences8–12Genetics5–9*Percentages are subject to change at any time. www.usmle.org

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Guide toefficientexam PreParationSec tioni4For security reasons, examinees are not allowed to bring any personalelectronic equipment into the testing area. This includes both digital andanalog watches, iPods, tablets, calculators, cell phones, and electronic pagingdevices. Examinees are also prohibited from carrying in their books, notes,pens/pencils, and scratch paper. Food and beverages are also prohibitedin the testing area. The testing centers are monitored by audio and videosurveillance equipment. However, most testing centers allot each examineea small locker outside the testing area in which he or she can store snacks,beverages, and personal items.Questions are typically presented in multiple choice format, with 4–5possible answer options. There is a countdown timer on the lower left cornerof the screen as well. There is also a button that allows the examinee tomark a question for review. If a given question happens to be longer thanthe screen (which occurs very rarely), a scroll bar will appear on the right,allowing the examinee to see the rest of the question. Regardless of whetherthe examinee clicks on an answer choice or leaves it blank, he or she mustclick the “Next” button to advance to the next question.The USMLE features a small number of media clips in the form of audioand/or video. There may even be a question with a multimedia heart soundsimulation. In these questions, a digital image of a torso appears on thescreen, and the examinee directs a digital stethoscope to various auscultationpoints to listen for heart and breath sounds. The USMLE orientationmaterials include several practice questions in these formats. During theexam tutorial, examinees are given an opportunity to ensure that both theaudio headphones and the volume are functioning properly. If you arealready familiar with the tutorial and planning on skipping it, first skip aheadto the section where you can test your headphones. After you are sure theheadphones are working properly, proceed to the exam.The examinee can call up a window displaying normal laboratory values.In order to do so, he or she must click the “Lab” icon on the top part ofthe screen. Afterward, the examinee will have the option to choose between“Blood,”“Cerebrospinal,”“Hematologic,”or“SweatandUrine.”Thenormal values screen may obscure the question if it is expanded. Theexaminee may have to scroll down to search for the needed lab values. Youmight want to memorize some common lab values so you spend less time onquestions that require you to analyze these.The CBT interface provides a running list of questions on the left part of thescreen at all times. The software also permits examinees to highlight or crossout information by using their mouse. There is a “Notes” icon on the toppart of the screen that allows students to write notes to themselves for reviewat a later time. Finally, the USMLE has recently added new functionalityincludingtextmagnificationandreversecolor(whitetextonblackbackground). Being familiar with these features can save time and may helpyou better view and organize the information you need to answer a question.`Keyboard shortcuts:A, B, etc—letter choicesEnter or spacebar—move to nextquestionEsc—exit pop-up Calculator and Noteswindows`Be sure to test your headphones during thetutorial.`Heart sounds are tested via media questions.Make sure you know how different heartdiseases sound on auscultation.`Illustrations on the test include:Gross specimen photosHistology slidesMedical imaging (eg, x-ray, CT, MRI)Electron micrographsLine drawings`Familiarize yourself with the commonlytested lab values (eg, Hgb, WBC, platelets,Na+, K+).`Ctrl-Alt-Delete are the keys of death duringthe exam. Don’t touch them at the same time!

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Guide toefficientexam PreParationSec tioni5For those who feel they might benefit, the USMLE offers an opportunityto take a simulated test, or “CBT Practice Session” at a Prometric center.Students are eligible to register for this three-and-one-half-hour practicesession after they have received their scheduling permit.The same USMLE Step 1 sample test items (120 questions) available onthe USMLE website, www.usmle.org, are used at these sessions.No newitems will be presented.The practice session is available at a cost of $75(or more if taken outside of the US and Canada) and is divided into a shorttutorial and three 1-hour blocks of ~40 test items each. Students receive aprinted percent-correct score after completing the session.No explanationsof questions are provided.You may register for a practice session online at www.usmle.org. A separatescheduling permit is issued for the practice session. Students should allowtwo weeks for receipt of this permit.How Do I Register to Take the Exam?Prometric test centers offer Step 1 on a year-round basis, except for thefirst two weeks in January and major holidays. The exam is given every dayexcept Sunday at most centers. Some schools administer the exam on theirown campuses. Check with the test center you want to use before makingyour exam plans.US students can apply to take Step 1 at the NBME website. This applicationallows you to select one of 12 overlapping three-month blocks in which to betested (eg, April–May–June, June–July–August). Choose your three-montheligibility period wisely. If you need to reschedule outside your initial three-month period, you can request a one-time extension of eligibility for the nextcontiguous three-month period, and pay a rescheduling fee. The applicationalso includes a photo ID form that must be certified by an official at yourmedical school to verify your enrollment. After the NBME processes yourapplication, it will send you a scheduling permit.The scheduling permit you receive from the NBME will contain your USMLEidentification number, the eligibility period in which you may take the exam,and two additional numbers. The first of these is known as your “schedulingnumber.” You must have this number in order to make your exam appointmentwith Prometric. The second number is known as the “candidate identificationnumber,”orCIN.ExamineesmustentertheirCINsatthePrometricworkstation in order to access their exams. However, you will not be allowedto bring your permit into the exam and will be asked to copy your CIN ontoyour scratch paper. Prometric has no access to the codes.Make sure to bringa paper or electronic copy of your permit with you to the exam!Also bringan unexpired, government-issued photo ID that includes your signature (suchas adriver’s license or passport). Make sure the name on your photo ID exactlymatches the name that appears on your scheduling permit.`You can take a shortened CBT practice test ata Prometric center.`The Prometric website will display a calendarwith open test dates.

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Guide toefficientexam PreParationSec tioni6Once you receive your scheduling permit, you may access the Prometricwebsite or call Prometric’s toll-free number to arrange a time to take theexam. You may contact Prometric two weeks before the test date if youwant to confirm identification requirements. Although requests for takingthe exam may be completed more than six months before the test date,examinees will not receive their scheduling permits earlier than six monthsbefore the eligibility period. The eligibility period is the three-month periodyou have chosen to take the exam. Most medical students choose the April–June or June–August period. Because exams are scheduled on a “first-come,first-served” basis, it is recommended that you book an exam date on thePrometric website as soon as you receive your permit. Prometric will provideappointment confirmation on a print-out and by email. Be sure to read thelatestUSMLE Bulletin of Informationfor further details.What If I Need to Reschedule the Exam?You can change your test date and/or center by contacting Prometric at1-800-MED-EXAM (1-800-633-3926) or www.prometric.com. Make sure tohave your CIN when rescheduling. If you are rescheduling by phone, youmust speak with a Prometric representative; leaving a voicemail message willnot suffice. To avoid a rescheduling fee, you will need to request a changeat least 31 calendar days before your appointment. Please note that yourrescheduled test date must fall within your assigned three-month eligibilityperiod.When Should I Register for the Exam?You should plan to register as far in advance as possible ahead of yourdesired test date (eg, six months), but, depending on your particular testcenter, new dates and times may open closer to the date. Scheduling earlywill guarantee that you will get either your test center of choice or onewithin a 50-mile radius of your first choice. For most US medical students,the desired testing window is in June, since most medical school curriculafor the second year end in May or June. Thus, US medical students shouldplan to register before January in anticipation of a June test date. The timingof the exam is more flexible for IMGs, as it is related only to when theyfinish exam preparation. Talk with upperclassmen who have already takenthe test so you have real-life experience from students who went through asimilar curriculum, then formulate your own strategy.Where Can I Take the Exam?Your testing location is arranged with Prometric when you book your testdate (after you receive your scheduling permit). For a list of Prometriclocations nearest you, visit www.prometric.com.`The confirmation emails that Prometricand NBME send are not the same as thescheduling permit.`Test scheduling is done on a “first-come,first-served” basis. It’s important to schedulean exam date as soon as you receive yourscheduling permit.`Register six months in advance for seatingand scheduling preference.

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Guide toefficientexam PreParationSec tioni7How Long Will I Have to Wait Before I Get My Scores?The USMLE reports scores in three to four weeks, unless there are delaysin score processing. Examinees will be notified via email when their scoresare available. By following the online instructions, examinees will be able toview, download, and print their score report online for ~120 days after scorenotification, after which scores can only be obtained through requesting anofficial USMLE transcript. Additional information about score timetablesand accessibility is available on the official USMLE website.What About Time?Time is of special interest on the CBT exam. Here’s a breakdown of theexam schedule:15 minutesTutorial (skip if familiar with test format and features)7 hoursSeven 60-minute question blocks45 minutesBreak time (includes time for lunch)The computer will keep track of how much time has elapsed on the exam.However, the computer will show you only how much time you haveremaining in a given block. Therefore, it is up to you to determine if youare pacing yourself properly (at a rate of approximately one question per 90seconds).The computer does not warn you if you are spending more than yourallotted time for a break. You should therefore budget your time so thatyou can take a short break when you need one and have time to eat. Youmust be especially careful not to spend too much time in between blocks(you should keep track of how much time elapses from the time you finish ablock of questions to the time you start the next block). After you finish onequestion block, you’ll need to click to proceed to the next block of questions.If you do not click within 30 seconds, you will automatically be entered intoa break period.Break time for the day is 45 minutes, but you are not required to use all ofit, nor are you required to use any of it. You can gain extra break time (butnot extra time for the question blocks) by skipping the tutorial or by finishinga block ahead of the allotted time. Any time remaining on the clock whenyou finish a block gets added to your remaining break time. Once a newquestion block has been started, you may not take a break until you havereached the end of that block. If you do so, this will be recorded as an“unauthorized break” and will be reported on your final score report.Finally, be aware that it may take a few minutes of your break time to “checkout” of the secure resting room and then “check in” again to resume testing,soplanaccordingly.The“check-in”processmayincludefingerprints,pocket checks, and metal detector scanning. Some students recommendpocketless clothing on exam day to streamline the process.`Gain extra break time by skipping the tutorialor finishing a block early.`Be careful to watch the clock on your breaktime.

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