First Aid for the USMLE Step 1 (2021)

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FORTHE®New York / Chicago / San Francisco / Athens / London / Madrid / Mexico CityMilan / New Delhi / Singapore / Sydney / TorontoUSMLESTEP 12021FIRSTAIDTAO LE, MD, MHSFounder, ScholarRxAssociate Clinical Professor, Department of MedicineUniversity of Louisville School of MedicineVIKAS BHUSHAN, MDFounder,First Aid for the USMLE Step 1Boracay, PhilippinesMATTHEW SOCHAT, MDPhysician, Hematology/OncologySoutheastern Medical Oncology CenterKRISTINA DAMISCH, MDUniversity of Iowa Carver College of MedicineClass of 2020JORDAN ABRAMS, MDResident, Department of Anesthesiology,Perioperative and Pain MedicineMount Sinai West and Mount Sinai Morningside HospitalsKIMBERLY KALLIANOS, MDAssistant Professor, Department of Radiology and Biomedical ImagingUniversity of California, San Francisco School of MedicineHUMOOD BOQAMBAR, MB BCh BAOAssistant Registrar, Department of Orthopedic SurgeryFarwaniya HospitalCONNIE QIULewis Katz School of Medicine at Temple UniversityMD/PhD CandidateCAROLINE COLEMAN, MDResident, Department of MedicineEmory University School of Medicine

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First Aid for the® USMLE Step 1 2021: A Student-to-Student GuideCopyright © 2021 by Tao Le and Vikas Bhushan. All rights reserved. Printed in the United States of America. Except aspermitted under the United States Copyright Act of 1976, no part of this publication may be reproduced or distrib-uted in any form or by any means, or stored in a data base or retrieval system, without the prior written permission ofthe publisher.Previous editions copyright © 1991 through 2020 by Tao Le and Vikas Bhushan. First edition copyright © 1990, 1989by Vikas Bhushan, Jeffrey Hansen, and Edward Hon.Photo and line art credits for this book begin on page 753 and are considered an extension of this copyright page.Portions of this book identified with the symbolare copyright © USMLE-Rx.com (MedIQ Learning, LLC).Portions of this book identified with the symbolare copyright © Dr. Richard Usatine.Portions of this book identified with the symbolare under license from other third parties. Please refer to page 753for a complete list of those image source attribution notices.First Aid for the® is a registered trademark of McGraw Hill.1 2 3 4 5 6 7 8 9LMN25 24 23 22 21 20ISBN 978-1-260-46752-9MHID 1-260-46752-XNoticeMedicine is an ever-changing science. As new research and clinical experience broaden our knowledge,changes in treatment and drug therapy are required. The authors and the publisher of this work have checkedwith sources believed to be reliable in their efforts to provide information that is complete and generally inaccord with the standards accepted at the time of publication. However, in view of the possibility of humanerror 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 inevery respect accurate or complete, and they disclaim all responsibility for any errors or omissions or for theresults obtained from use of the information contained in this work. Readers are encouraged to confirm theinformation contained herein with other sources. For example and in particular, readers are advised to checkthe product information sheet included in the package of each drug they plan to administer to be certainthat the information contained in this work is accurate and that changes have not been made in the recom-mended dose or in the contraindications for administration. This recommendation is of particular importancein connection with new or infrequently used drugs.This book was set in Electra LT Std by GW Inc.The editors were Bob Boehringer and Christina M. Thomas.Project management was provided by GW Inc.The production supervisor was Jeffrey Herzich.LSC Communications was printer and binder.This book is printed on acid-free paper.Copyright © 2021. Exclusive rights by McGraw Hill for manufacture and export. This book cannot be reexported fromthe country to which it is consigned by McGraw Hill. The International Edition is not available in North America.McGraw Hill books are available at special quantity discounts to use as premiums and sales promotions,or for use in corporate training programs. To contact a representative please visit the Contact Us pages atwww.mhprofessional.com.

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DedicationTo all healthcare workers and first responders worldwide leadingthe fight against COVID-19. We salute your ongoing efforts andhonor those who have lost their lives in service to others.

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vContentsContributing AuthorsviiAssociate AuthorsviiiFaculty AdvisorsixForewordxiPrefacexiiiSpecial 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 Agencies25References25``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 Database30Biochemistry33Immunology95Microbiology123Pathology205Pharmacology231Public Health Sciences259

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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 S283Approaching the Organ Systems284Cardiovascular287Endocrine333Gastrointestinal367Hematology and Oncology413Musculoskeletal, Skin, and Connective Tissue455Neurology and Special Senses503Psychiatry575Renal601Reproductive635Respiratory683Rapid Review713``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 S737How to Use the Database738Question Banks740Web and Mobile Apps740Comprehensive741Anatomy, Embryology, and Neuroscience741Behavioral Science742Biochemistry742Cell Biology and Histology743Microbiology and Immunology743Pathology743Pharmacology744Physiology744``Abbreviations and Symbols745Image Acknowledgments753Index775About the Editors842

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viiContributing AuthorsLILIT ASLANYAN, DOResident, Department of MedicineNew York University Winthrop HospitalANUP CHALISE, MBBSResident, Department of General SurgeryNepal Medical College and Teaching HospitalWEELIC CHONGSidney Kimmel Medical College at Thomas Jefferson UniversityMD/PhD CandidatePANAGIOTIS KAPARALIOTIS, MDResident, Department of PathologySt. Sophia’s Children’s Hospital, GreeceMITCHELL A. KATONA, MD, MPHResident, Division of Emergency MedicineDell Medical SchoolANDREA LEAL LOPEZ, MDITESM School of Medicine Ignacio A. Santos, MexicoVASILY OVECHKO, MDResident, Department of Pediatric OncologyDmitry Rogachev National Medical Research Center of PediatricHematology, Oncology and ImmunologyVIVEK PODDER, MBBSTairunnessa Memorial Medical College and Hospital, BangladeshROHAN BIR SINGH, MDFellow, Department of OphthalmologyMassachusetts Eye and Ear, Harvard Medical SchoolImageandIllustratIonteamYOOREE GRACE CHUNGEmory University School of MedicineMD/PhD CandidateSTEPHANIE JONES, PhDEmory University Laney Graduate SchoolVICTOR JOSE MARTINEZ LEON, MDResident, Department of MedicineEinstein Medical Center PhiladelphiaANGEL XIAO, MSEEmory University School of MedicineClass of 2022ALIREZA ZANDIFAR, MDResearch Fellow, Department of RadiologyChildren’s Hospital of Philadelphia

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viiiAssociate AuthorsERIC L. BARASHWake Forest School of MedicineClass of 2022LAUREN CLAUSJohns Hopkins University School of MedicineClass of 2021CHRISTIAN FAABORG-ANDERSENEmory University School of MedicineClass of 2022ELIE FLATOWTouro College of Osteopathic Medicine - HarlemClass of 2021SAMIRA RAHIM IBRAHIMWest Virginia School of Osteopathic MedicineClass of 2021TROY KLEBEREmory University School of MedicineMD/MSCR CandidateMARGARET C. SLACKUniversity of Washington School of MedicineClass of 2022REBECCA H. YUSaba University School of MedicineClass of 2022MATTHEW WELLS, DOResident, Department of Orthopedic SurgeryWilliam Beaumont Army Medical CenterSEAN EVANSEmory University School of MedicineClass of 2022ImageandIllustratIonteam

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ixFaculty AdvisorsDIANA ALBA, MDAssistant Professor, Division of Endocrinology, Diabetes, and MetabolismUniversity 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 DallasCARRIE BOHNERT, MPAStandardized Patient EducatorSHELDON CAMPBELL, MD, PhDProfessor of Laboratory MedicineYale School of MedicineBROOKS D. CASH, MDChief, Gastroenterology, Hepatology, and NutritionUniversity of Texas Health Science Center at HoustonDIMITRI CASSIMATIS, MDAssociate Professor, Department of MedicineEmory University School of MedicineCATHERINE CHILES, MDAssociate Clinical Professor of PsychiatryYale School of MedicineBRADLEY COLE, MDAssistant Professor of NeurologyLoma Linda University School of MedicineSAKINA FARHAT, MDConsultant Gastroenterologist and HepatologistState 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 CaliforniaMEREDITH K. GREER, MDFellow, Department of MedicineEmory University School of MedicineSUSAN HADLER, MD, MSProfessor Emerita of Pathology and Laboratory MedicineUniversity of North Carolina School of MedicineMELANIE SCHORR HAINES, MDAssistant Professor, Department of MedicineHarvard Medical SchoolAMBER J. HECK, PhDAssociate Professor, Department of Medical EducationTCU and UNTHSC School of MedicineJEFFREY W. HOFMANN, MD, PhDFellow, Department of PathologyUniversity of California, San Francisco School of MedicineCLARK KEBODEAUX, PharmDClinical Associate 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, MDAssociate Professor, Departments of Pediatrics and MedicineEmory University School of MedicineKACHIU C. LEE, MD, MPHAssistant Clinical Professor, Department of DermatologyThe Warren Alpert Medical School of Brown University

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xWARREN 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 MedicineCARL MARFURT, PhDProfessor Emeritus, Department of Anatomy, Cell Biology and PhysiologyIndiana University School of Medicine Northwest, GaryPETER MARKS, MD, PhDCenter for Biologics Evaluation and ResearchUS Food and Drug AdministrationDOUGLAS A. MATA, MD, MPHDepartment of PathologyMemorial Sloan Kettering Cancer CenterKRISTEN L. PAGEL, MD, MPHAssistant Professor, Department of PsychiatryUniversity of Utah School of MedicineVICKI M. PARK, PhD, MSAssistant DeanUniversity of Tennessee College of MedicineDIANE E.S. PAYNE, MD, MPTAssistant Professor, Department of Orthopedic SurgeryEmory University School of MedicineSOROUSH RAIS-BAHRAMI, MDAssociate Professor of Urology and RadiologyUniversity of Alabama at Birmingham School of MedicineRICHARD P. RAMONELL, MDFellow, Department of MedicineEmory University School of MedicineJOHN C. ROSE, DOClinical Instructor, Department of AnesthesiologyMount Sinai Morningside-WestSASAN SAKIANI, MDProfessor, Department of MedicineUniversity of Maryland Medical CenterSHIREEN MADANI SIMS, MDChief, Division of Gynecology, Gynecologic Surgery, and ObstetricsUniversity of Florida School of MedicineHOWARD M. STEINMAN, PhDAssistant Dean, Biomedical Science EducationAlbert Einstein College of MedicineRICHARD P. USATINE, MDProfessor, Dermatology and Cutaneous SurgeryUniversity of Texas Health Science Center San AntonioTISHA 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, MDAssociate Professor of Medical Education and Pediatric NephrologyGeisel School of Medicine at DartmouthABHISHEK YADAV, MBBS, MScAssociate Professor of AnatomyGeisinger Commonwealth School of MedicineKRISTAL YOUNG, MDClinical Instructor, Department of CardiologyHuntington Hospital, Pasadena, CaliforniaDONG ZHANG, PhDAssociate Professor of Biochemistry and Cancer BiologyNew York Institute of Technology College of Osteopathic Medicine

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xiForeword“If you see something that is not right, not fair, not just, you have a moral obligation to do something.”Congressman John LewisFirst Aid for the USMLE Step 1began over 30 years ago as a resource to prepare aspiring physicians for their firstmedical board exam. Since then, it has become one of the most well-known textbooks used by medical studentsworldwide. While we closely follow the USMLE’s lead in most respects, the widespread use of our book also providesan opportunity for us to be leaders in medical education.In prior editions, there has been an unfortunate absence of diversity in both the text and images. This year, westrongly affirm that representing a broad spectrum of patients is essential for preparing for a successful medicalcareer. The practice of medicine is inextricably intertwined with social determinants of health, and socioculturalunderstanding complements scientific knowledge for the future physician. Failing to provide representation of adiversity of people limits the educational experience and is to the detriment of future patients. We here describe ourapproach to improving the representation of race, ethnicity, sex, and gender, recognizing that we are neither expertsnor authorities on diversity, equity, and inclusion.We first surveyed our existing visual depictions of patients and pathologies. Of nearly 70 illustrations showing skintone or sex in the 2020 edition, every single one showed pink/light beige skin, and all but one was male-appearing,excluding reproductive anatomy illustrations. To address this lack of diversity, we revised our illustrations to betterreflect Fitzpatrick skin types I-VI and introduced more female-appearing and gender-neutral illustrations.We also reviewed our use of language in the text. With respect to race and ethnicity, we transitioned from using“African-American” to “Black,” as not all Black patients are American or have African ancestry. We now capitalize“Black” in accordance with major journalistic organizations. We also switched from “Caucasian” to “White,” whichwe hope will be more accurate and inclusive.We found many opportunities to improve the language used to describe disabled and ill patients as well. We nowuse person-first language such as “patients with diabetes” instead of “diabetic patients.” Dated references to “mentalretardation” have been replaced with “intellectual disability.” We also removed other stigmatizing terms such as“alcoholics,” “smokers,” “epileptics,” and “bulimics” and replaced with appropriate person-first language.Finally, we reviewed our use of terminology surrounding sex and gender identity. We opted for more neutrallanguage by changing most uses of gendered pronouns to “they/them/theirs,” as well as changing “mother” to“pregnant patient.” We also removed gendered terms such as “girl,” “boy,” “woman,” and “man” in favor of “female”and “male” when referring to biological sex.

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xiiWe acknowledge that our approach is imperfect and challenges remain. We also recognize that there may bediffering perspectives that need to be addressed and balanced. However, just as the medical community learnsinvaluable lessons from its patients, we greatly value input from our peers and colleagues. We enthusiasticallyencourage feedback on our efforts to better represent all people. If you have comments or suggestions, please submitthem via our website atwww.firstaidteam.com. Alternatively, you can email us atfirstaid@scholarrx.com. Thankyou for your help in makingFirst Aid for the USMLE Step 1an increasingly inclusive and useful resource.LouisvilleTao LeBoracayVikas BhushanGoldsboro, NCMatthew SochatKuwaitHumood BoqambarIowa CityKristina DamischPhiladelphiaConnie QiuNew York CityJordan AbramsAtlantaCaroline ColemanSan FranciscoKimberly Kallianos

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xiiiPrefaceWith the 31st 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:104 entirely new or heavily revised high-yield topics reflecting evolving trends in the USMLE Step 1.Updated ethics section and introduction of new communications skills section to reflect the recently changedStep 1 exam.Extensive text revisions, new mnemonics, clarifications, and corrections curated by a team of 25 medical studentand resident physician authors who excelled on their Step 1 examinations and verified by a team of expert facultyadvisors and nationally recognized USMLE instructors.Updated with 179 new and revised diagrams and illustrations as part of our ongoing collaboration withUSMLE-Rx and ScholarRx (MedIQ Learning, LLC).Updated with 62 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 exam preparation advice for USMLE Step 1 pass/fail, Step 1 blueprint changes, and COVID-19impacts.Revised language to support diversity, equity, and inclusion.Updated study tips on the opening page of each chapter.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 BhushanGoldsboro, NCMatthew SochatKuwaitHumood BoqambarIowa CityKristina DamischPhiladelphiaConnie QiuNew York CityJordan AbramsAtlantaCaroline ColemanSan 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.We provide special acknowledgment and thanks to the following individuals who made exemplary contributions tothis edition through our voting, proofreading, and crowdsourcing platform: Moatasem Al-Janabi, Syeda Akila Ally,Grigory Davidov, Harpreet Dhanjal, Lucia Dominguez, Chinedum Enete, Emma Fenske, Heather Finlay-Morreale,Louna Ftouni, Margaret Ginoza, Fariah Asha Haque, E. Paige Hart, Zeid Hassan, I-Chun Hung, Karawan Hussein,Urma Jalil, Dana Jorgenson, Alvin Jose, Alec Kacew, Clara Kerwin, Shaima Khandaker, Joanna Liao, Annalisa Lopez,Freda Quimba Malanyaon, Jessica Marks, Juliana Maya, Tuba Mirza, Mardochere Morisset, Waneeza Mughees, BillisParas, Neesirg Patel, Gabrielle Pierce, Faateh Ahmad Rauf, Amitoz Saini, Danusha Sanchez, Andrea Sánchez, EmilyCharlotte Sparks, John Spikes II, James Ting, Collin Weintraub, and María Daniela Orellana Zambrano.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, McGrawHill, for the valuable assistance of its staff, including Bob Boehringer, Jeffrey Herzich, Christina Thomas, KristianSanford, and Don Goyette.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.For exceptional editorial leadership, enormous thanks to Megan Chandler, Mauri Loemker, Julie Mangoff, andEmma D. Underdown. Special thanks to our indexer, Dr. Anne Fifer. We are also grateful to our illustrators,SusanMazik,ArtemisaGogollari,andMarvinBundo,fortheircreativeworkonthenewandupdatedillustrations. Lastly, tremendous thanks to GW Inc., especially Anne Banning, Victoria Brown, Gary Clark, CindyGeiss, and Denise Smith.LouisvilleTao LeBoracayVikas BhushanGoldsboro, NCMatthew SochatKuwaitHumood BoqambarIowa CityKristina DamischPhiladelphiaConnie QiuNew York CityJordan AbramsAtlantaCaroline ColemanSan 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, Nursultan Abdreyev, Youni Abdul,Lana Abusalem, Bradley Acott, Temiloluwa Adejuyigbe, Gauri Adhikari, Ather Adnan, Rasim Agaev, HuzaifaAhmad, Rija Ahmad, Oluwabukola Ajagbe, Tongwa B. Aka, Nataly Kobra Akbarshahi, Shahad Aladnan, AmrAlalwani, Nida Alam, Qutaiba Al-bustanji, Jose Alfonso, Maged Algazzar, Majed Alghamdi, Ahmed Al-Maidama,AbdulmajeedAlmehmadi,FerasAl-Moussally,MariaAlwan,SalmanAlyahya,HamzaAmin,ChelseaAmo-Tweneboah, Cara Anderson, Gina Andraos, Akanksha Reddy Annadi, Lordsfavour Anukam, Ali Arafa, AmaliaArdeljan,AmaliaDorisArdeljan,StephanieAsdell,ChristopherAzzam,WardahBajwa,BraytonBallenger,Charlotte Banayan, Dileni C. Bandarage, Alyssa Barré, Isabella Batki, Jeffrey Baum, Tal Bavli, Jerrin Bawa, AlexBelaia, Dimitri Benner, Alexandra Bennett, Ashley Best, Alexandros Bestavasvili, Rohan Bhan, Krish Bharat, SaeedBhuiyan, Pavit Bhullar, Jennifer Black, Lisle Blackbourn, William Bloom, Alina Bobrova, Luisa Brito, ChrysBuckley, Olena Budarina, Jessica Budiselic, Eamonn Byrnes, Alfonso Caetta, Gabriela Maria Calderon, SantiagoCallegari, Sergio Camba, Xi Cao, Cristian Agapito Rosa Carrasquillo, Katie Carsky, Alicia Casella, Yasmin Chaiep,Tina Chen, Santosh Cherian, Devina Chintaman, Akshit Chitkara, Maruf Chowdhury, Matthew J. Christensen,Meaghan Clark, Courtney Cleveland, Aravind R. D., Yann Dacquay, Mohammed Dairywala, Jonathan Daou,Aimen Asim Dar, Naveena Daram, Joe Demian, Andres Diaz, Amin Dice, Taurah Dizadare, Andreea BiancaDobre, Courtney Duckworth, Ismail Faruk Durmus, Manasa Dutta, Nikolas Echeverry, Matthew Eli, AwabElnaeem, Mohamed Kamal El-Naeim, Karim Eltaib, Holly Everett, Sarrah Fadul, Amin Farsani, Samia Fatima,Yasmin Fazli, Kristina Flores, Farrar Ford, Katy Franks, Kyle Fratta, Shany Freund, Racha Ftouni, Ron Gadot, DonGalinea-Faigao, Abhishek Gami, Henriette De La Garza, Daniel Gatazka, Nicolas Curi Gawlinski, Leo Georges,Ashley Ghaemi, Paola Ghanem, Ahmad Munir Gharaibeh, Elie Ghasb, Brennan Gibson, Sam Gieg, Aastha Gohil,Sanya Goswami, Sourabh Goyal, Jan Andre Grauman, Shreya Gulati, Avni Gupta, Nanditha Guruvaiah, RossyGuzman, Noon Hagmusa, Natalie Hassell, Christine Laura Heisen, Ghayda Hemadneh, Aryan Hemani, TrevorHenderson, Briana Hernandez, Sarah Hossain, Sarahbeth Howes, Janie Hu, Vivian Hu, Jonathan Hunter, LisaHysa, Ebuka Ibuoka, Mina Iskandar, Beck Jacobsen, Yamna Jadoon, Saira Jahangir, Ala Jamal, Tesmol James, SalemJaramne, Prayag Jariwala, Chloe Jensen, Hassan El Jesr, Bijay Jeswani, Ankit Juneja, Simrat Kahlon, Nabyl Kalaf,Anastasia Kalantarova, Mohammed Kamareddine, Nivedita Kar, Arneet Kaur, Wajiha Kazmi, Azmeer Khamisani,Ahmed Ali Khan, Jawad Khan, Sunil Babu Khanal, Bhumika Khanna, David S. Kim, Alex Kinzer, Anna Kislik,Ramya Kommidi, Nicholas Koutrakis, Kushal Kriplani, Jonas Kruse, Mariia Kukushkina, Nimisha Kumar, NatalieGeneral Acknowledgments

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xviLaBossier, Nery y Mara Lamothe, Megan Lane, Joanna Lee, Victor Lee, Chime Lhatso, Xiantian Lin, Alwyn Louis,Joshua St. Louise, Alexander Lu, Lisa-Qiao MacDonald, Divya Madhavarapu, Osama Magableh, Jalal Maghfour,Reema Mahdi, Jainil Maheshwari, Rose Maisner, Freda Malanyaon, Mayra Malik, Mahir Mameledzija, NikhilMankuzhy, Abdul Mannan, Yusra Mansour, Rebecca Irene Marshall, Bridget Martinez, Penelope Martinez, ShielahMauntana, O’Brian Mbakwe, Ashley McNeal, Bryan Medina, Mario Mekhail, Sherin Menachery, David Merkley,Ibrahim El Mikati, Stephan A. Miller, Damir Mingaleev, Sarim Mirza, Niall James Moffett, Deena Mohamed,Mahmoud Mohamed, Kompal Mohan, John Moon, Mohammad Murcy, Sakthi Murugan, Youjin Na, GeraldineNabeta, Rahul Nachnani, Shamsun Nahar, Zaid R. Kh Najdawi, Alice Nassar, Zachary Nelson, Judith Nnah,Ahmed Noor, Ahmen Noor, Eric Nturibi, Anuli Nwankwo, Ahmad Obeidat, Ross O’Hagan, Cristal Osborne, OlgaOstrovetsky, Ademola Osundeko, Majd Oteibi, Reinis Ozolins, Sophia Padelford, Andrew Palosaari, Zonghao Pan,Niranjan Pandey, Mark Parker, Harshita Pasupuleti, Anmol Patel, Dharmik Patel, Krunal Patel, Manan Patel, NehaPatel, Austin Patrick, Harry Paul, Dmytro Pavlenko, Matthew Pavlica, Dorian Perez, Samantha Perovski, SahirPervaiz, Sofia Phirtskhalava, Mark Pilarski, Fanny Pimentel, Denise Powell, Shannon Powell, Meenu Prasad, JacobProaño, Kevin Pruitt, Laith Rahabneh, Masum Rahman, Juhi Ramchandani, Lisnaldy Ramirez, Naresa Ramjohn,Vaishnavi Rao, Adel Rasheed, Samyukta Ravi, Sreeram Ravi, Vishnu VB Reddy, Rafey Rehman, Jose Issac Reyes,Kyle Robbins, Samuel Roberts, Quayd Robertson, Pedro Garcia Rodriguez, Helio Manuel Grullón Rodríguez,Gessel Romero, Ariel Rucker, Angelica Maria Sanchez Ruiz, Megan Ryon, Bradley Ryva, Chantal Saberian,George Saboura, Sumeet Saini, Allie Sakowicz, Vishad Samami, Jasneet Sandhu, Omar Sanduka, Prakriti Sapkota,Dhruv Sarwal, Abeer Sarwar, M. Sathyanarayanan, Emma Schulte, Michael Schwarz, Justin Sedgewick, JessicaSefen, Neha Sehgal, Sirous Seifirad, Nicole Sequeira, Muhanad Shaib, Fahad Shaikh, Ahmed Shakir, JeffreyShapiro, Muhammad Usman Sharif, Kanika Sharma, Manisha Sharma, Tina Sharma, Michelle Sheena, EmilySherry, Minghan Shi, Sami Shoura, Melanie Shpigel, Robert Shvarts, Naomi Siddiquee, Christina Siems, AnanthaSingarajah, Manik Inder Singh, Ramzi Y. Skaik, Bryn Smith, Emilie Song, Rishabh Soni, Luke Sorensen, SuganiyaSrikanthan, Abhinav Srinath, Hala M. Staitieh, Brett Stark, Hafsa Omer Sulaiman, Saranya Sundaram, MichaelSyrett, Nikolaos Syrigos, Basel Tamimi, Hamza Tariq, Aalap K. Trivedi, Amy Tsai, Athanasios Tsimpouras, ShannonTung, Akemini Udoro, Sheela Vaswani, Jasmine Vatani, Sandra Azareli Garcia Velázquez, Allen Wang, Shelly Wang,Kaystin Weisenberger, Andrew White, Peter Williams, Stephanie Wottrich, Maria Yan, Hafsa Yaseen, Forrest Yeh,Hsinyu Yin, Susan Yohannan, Jamie Yoon, Zurabi Zaalishvili, Syed Zeeshan Haider Zaidi, Caroline Zhao, MichaelZheng, and Patrick Ziarnowski.

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xviiThis edition 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 Styleor our diversity initiative as discussedin the Foreword.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, 2021, receive priority consideration for the 2022 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 Aid/ScholarRx team is pleased to offer paid editorial and coaching positions. We are looking for passionate,experienced, and dedicated medical students and recent graduates. Participants will have an opportunity to workon a wide variety of projects, including the popularFirst Aidseries and the growing line of USMLE-Rx/ScholarRxproducts, including Rx Bricks. Please use our webform at https://www.usmle-rx.com/join-the-first-aid-team/ to apply,and include a CV and writing examples.For 2021, we are actively seeking passionate medical students and graduates with a specific interest in improving ourmedical illustrations, expanding our database of photographs (including clinical images depicting diverse skin types),and developing the software that supports our crowdsourcing platform. We welcome people with prior experienceand talent in these areas. Relevant skills include clinical imaging, digital photography, digital asset management,information design, medical illustration, graphic design, tutoring, and software development.

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xixHow to Use This BookCONGRATULATIONS:You now possess the book that has guided nearly two million students to USMLE successfor over 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.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, USMLE-Rx Step 1 Flash Facts), and practice questions (eg, the USMLE-Rx Step 1 Qmax). Read thechapter in the book, then test your comprehension by using cases, flash cards, and questions that cover the sametopics. Maintain access to more comprehensive resources (eg, ScholarRx Bricks and USMLE-Rx Step 1 Expressvideos) 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)10–40 U/L10–40 U/L*Alkaline phosphatase25–100 U/L25–100 U/LAmylase, serum25–125 U/L25–125 U/L*Aspartate aminotransferase (AST, GOT at 30°C)12–38 U/L12–38 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/dL2.1–2.6 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+)136–146 mEq/L95–105 mEq/L3.5–5.0 mEq/L22–28 mEq/L1.5–2 mEq/L136–146 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: 70–100 mg/dL3.8–6.1 mmol/LGrowth hormone−arginine stimulationFasting: < 5 ng/mLProvocative stimuli: > 7 ng/mL< 5μg/L> 7μg/LOsmolality, serum275–295 mOsmol/kg H2O275–295 mOsmol/kg H2O*Phosphorus (inorganic), serum3.0–4.5 mg/dL1.0–1.5 mmol/LProlactin, serum (hPRL)Male: < 17 ng/mLFemale: < 25 ng/mL< 17 μg/L< 25 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 plasma0.4–4.0μU/mL0.4–4.0 mIU/L*Urea nitrogen, serum (BUN)7–18 mg/dL25–64 nmol/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 IntervalsCell count0–5/mm30–5×106/LGlucose40–70 mg/dL2.2–3.9 mmol/LProteins, total< 40 mg/dL< 0.40 g/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/hrFemale: 0–20 mm/hr0–15 mm/hr0–20 mm/hrHematocritMale: 41–53%Female: 36–46%0.41–0.530.36–0.46Hemoglobin, bloodMale: 13.5–17.5 g/dLFemale: 12.0–16.0 g/dL135–175 g/L120–160 g/LHemoglobin, plasma< 4 mg/dL< 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 hemoglobin25–35 pg/cell0.39–0.54 fmol/cellMean corpuscular hemoglobin concentration31%–36% Hb/cell4.8–5.6 mmol Hb/LMean corpuscular volume80–100μm380–100 fLPartial thromboplastin time (activated)25–40 sec25–40 secPlatelet count150,000–400,000/mm3150–400×109/LProthrombin time11–15 sec11–15 secReticulocyte count0.5–1.5% of RBCs0.005–0.015UrineCreatinine clearanceMale: 97–137 mL/minFemale: 88–128 mL/min97–137 mL/min88–128 mL/minOsmolality50–1200 mOsmol/kg H2O50–1200 mOsmol/kg H2OProteins, total< 150 mg/24 hr< 0.15 g/24 hrOtherBody mass indexAdult: 19–25 kg/m219–25 kg/m2

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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.Be familiar with COVID-19 cancellation and rescheduling policies.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 test simulations in question banks.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 Agencies25`References25S E C T I O N IGuide to EfficientExam Preparation“One important key to success is self-confidence. An important key to self-confidence is preparation.”—Arthur Ashe“Wisdom is not a product of schooling but of the lifelong attempt toacquire it.”—Albert Einstein“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 wouldnormally pass in order to become a licensed physician in the UnitedStates. The USMLE is a joint endeavor of the National Board of MedicalExaminers (NBME) and the Federation of State Medical Boards (FSMB).The USMLE serves as the single examination system domestically andinternationally for those seeking medical licensure in the United States.The Step 1 exam includes test items that can be grouped by the organiza-tional constructs outlined in Table 1 (in order of tested frequency). In late2020, the NBME increased the number of items assessing communicationskills. While pharmacology is still tested, they are focusing on drug mecha-nisms rather than on pharmacotherapy. You will generally not be required toidentify specific medications indicated for a specific condition. Instead, youwill be asked more about mechanisms and side effects.`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 tioni3How 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 concepts60–70General principles12–16Patient care: diagnosis20–25Behavioral health & nervous systems/special senses9–13Communication and interpersonal skills6–9Respiratory & renal/urinary systems9–13Practice-based learning & improvement4–6Reproductive & endocrine systems9–13DisciplineRange, %Blood & lymphoreticular/immune systems7–11Pathology44–52Multisystem processes & disorders6–10Physiology25–35Musculoskeletal, skin & subcutaneous tissue6–10Pharmacology15–22Cardiovascular system5–9Biochemistry & nutrition14–24Gastrointestinal system5–9Microbiology10–15Biostatistics & epidemiology/population health4–6Immunology6–11Social sciences: communication skills/ethics6–9Gross anatomy & embryology11–15Histology & cell biology8–13Behavioral sciences8–15Genetics5–9*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, cell phones, tablets, and calculators. Examinees are alsoprohibited from carrying in their books, notes, pens/pencils, and scratchpaper. Food and beverages are also prohibited in the testing area. Thetesting centers are monitored by audio and video surveillance equipment.However, most testing centers allot each examinee a small locker outsidethe testing area in which he or she can store snacks, beverages, andpersonal 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 choicesEsc—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, Hb, WBC, platelets,Na+, K+).

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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($155 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. Be aware that your exam maybe canceled because of circumstances related to the COVID-19 pandemicor other unforeseen events. If that were to happen, you should receive anemail from Prometric containing notice of the cancellation and instructionsonrescheduling.Visitwww.prometric.comforupdatesregardingtheirCOVID-19 cancellation and rescheduling policies.Although requests for taking the exam may be completed more than six monthsbefore the test date, examinees will not receive their scheduling permits earlierthan six months before the eligibility period. The eligibility period is the three-month period you have chosen to take the exam. Most medical students choosethe 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, you mustspeak with a Prometric representative; leaving a voicemail message will notsuffice. To avoid a rescheduling fee, you will need to request a change at least31 calendar days before your appointment. Please note that your rescheduledtest date must fall within your assigned three-month eligibility period.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.`Be familiar with Prometric’s policies forcancellation and rescheduling due toCOVID-19.`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 thetutorial, or utilize the tutorial time to addpersonal notes to your scratch paper.`Be careful to watch the clock on your breaktime.

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