First Aid for the USMLE Step 1 2023 (2023)

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FORTHE®New York / Chicago / San Francisco / Athens / London / Madrid / Mexico CityMilan / New Delhi / Singapore / Sydney / TorontoUSMLESTEP 12023FIRSTAIDTAO LE, MD, MHSFounder, ScholarRxAssociate Clinical Professor, Department of MedicineUniversity of Louisville School of MedicineVIKAS BHUSHAN, MDFounder,First Aid for the USMLE Step 1Boracay, PhilippinesCONNIE QIU, MD, PhDResident, Department of DermatologyJohns Hopkins HospitalPANAGIOTIS KAPARALIOTIS, MDUniversity of Athens Medical School, GreeceKIMBERLY KALLIANOS, MDAssistant Professor, Department of Radiology and Biomedical ImagingUniversity of California, San Francisco School of MedicineANUP CHALISE, MBBS, MS, MRCSEdKathmandu, NepalCAROLINE COLEMAN, MDResident, Department of MedicineEmory University School of Medicine

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First Aid for the® USMLE Step 1 2023: A Student-to-Student GuideCopyright © 2023 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 2022 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 757 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 757for 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 9LMN27 26 25 24 23 22ISBN 978-1-264-94662-4MHID 1-264-94662-7NoticeMedicine 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 © 2023. 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 medical students and physicians worldwide, whose adaptabilityto the ever-changing landscape of medical education and practiceenables them to provide the best care when it is needed most.

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vContentsContributing AuthorsviiAssociate AuthorsviiiFaculty AdvisorsixPrefacexiSpecial AcknowledgmentsxiiGeneral AcknowledgmentsxiiiHow to ContributexvHow to Use This BookxviiSelected USMLE Laboratory ValuesxviiiFirst Aid Checklist for the USMLE Step 1xx`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 Basics2Learning Strategies11Timeline for Study14Study Materials18Test-Taking Strategies19Clinical Vignette Strategies21If You Think You Failed22Testing Agencies22References23`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 S25`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 S27How to Use the Database28Biochemistry31Immunology93Microbiology121Pathology201Pharmacology227Public 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 S279Approaching the Organ Systems280Cardiovascular283Endocrine329Gastrointestinal363Hematology and Oncology409Musculoskeletal, Skin, and Connective Tissue449Neurology and Special Senses499Psychiatry571Renal597Reproductive631Respiratory679Rapid Review709`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 S741How to Use the Database742Question Banks744Web and Mobile Apps744Comprehensive745Anatomy, Embryology, and Neuroscience745Behavioral Science746Biochemistry746Cell Biology and Histology746Microbiology and Immunology746Pathology747Pharmacology747Physiology748`Abbreviations and Symbols749Image Acknowledgments757Index775About the Editors828

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viiContributing AuthorsCHRISTIAN FAABORG-ANDERSEN, MDResident, Department of MedicineMassachusetts General HospitalANNA LIGOCKI, MD, MSMedical University of Warsaw, PolandFAATEH AHMAD RAUF, MBBSCMH Lahore Medical College and Institute of Dentistry, PakistanJAIMIE LYNN ROGNER, MD, MPHResident, Departments of Medicine and PediatricsUniversity of Rochester Medical CenterPHILLIP YANG, MD, MSEResident, Department of AnesthesiologyWashington University–St. LouisELENI BOUZIANIUniversity of Athens Medical School, GreeceJULIANA MAYA CASTRO, MDResearch Fellow, Department of Obstetrics and GynecologyFundación Valle de Lili, Universidad Icesi, ColombiaCAROLINA CABAN RIVERALewis Katz School of Medicine at Temple UniversityClass of 2025COLLIN ANDREW WEINTRAUB, MDResident, Department of General SurgeryState University of New York, UpstateImageandIllustratIonteamYOOREE GRACE CHUNGEmory University School of MedicineMD/PhD CandidateSEAN EVANS, MDResident, Department of Internal MedicineEmory University School of MedicineANGEL XIAO, MDResident, Department of Orthopedic SurgeryUniversity of California, San FranciscoNIKITHA CRASTA, MBBSMangalore, IndiaANA GOGOLASHVILI, MDTbilisi State Medical University, Georgia

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viiiAssociate AuthorsATHANASIOS ANGISTRIOTIS, MDResident, Department of General SurgeryStony Brook University Hospital, NYMARGARET GINOZA, MD, MPHResident, Internal Medicine–PediatricsBaylor College of MedicineVASILEIOS PARASCHOU, MD, MScResident, Department of Medicine424 General Military Hospital, GreeceGEORGIOS MARIOS STERGIOPOULOS, MDUniversity of Patras Medical School, GreeceZURABI ZAALISHVILI, MDTbilisi State Medical University, GeorgiaANTHONY G. CHESEBROMD/PhD candidateRenaissance School of Medicine, Stony Brook UniversityTALEAH KHAN, MBBSCMH Lahore Medical College and Institute of Dentistry, PakistanDANUSHA SANCHEZ, MDPoznań University of Medical Sciences, PolandARVIND SURESHGeisel School of Medicine at DartmouthClass of 2023YAMNA JADOON, MDResident, Department of MedicineUMass Chan Medical School, BaystateImageandIllustratIonteam

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ixFaculty AdvisorsMARK A.W. ANDREWS, PhDProfessor and Director of PhysiologyLake Erie College of Osteopathic Medicine at Seton HillMARIA ANTONELLI, MDAssistant Professor, Division of RheumatologyCase Western Reserve University at MetroHealth Medical Center, ClevelandHERMAN SINGH BAGGA, MDClinical ProfessorLake Erie College of Osteopathic Medicine and Chatham UniversityJOE B. BLUMER, PhDAssociate Professor, Department of PharmacologyMedical University of South Carolina College of MedicineCHRISTOPHER M. BURNS, PhDProfessor of Basic Medical SciencesUniversity of Arizona College of Medicine, PhoenixBROOKS 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 MedicineMARTHA FANER, PhDAssociate Professor of Biochemistry and Molecular BiologyMichigan State University College of Osteopathic MedicineCONRAD FISCHER, MDAssociate Professor, Medicine, Physiology, and PharmacologyTouro College of MedicineAYAKO WENDY FUJITA, MDFellow, Division of Infectious DiseasesEmory University School of MedicineRAYUDU GOPALAKRISHNA, PhDAssociate Professor, Department of Integrative Anatomical SciencesKeck School of Medicine of University of Southern CaliforniaMEREDITH K. GREER, MDAssistant Professor, Department of MedicineEmory University School of MedicineAMBER J. HECK, PhDAssociate Professor, Department of Microbiology, Immunology, andGeneticsUniversity of North Texas Health Science Center, Fort WorthJENNIFER O. HOWELL, MDAssociate Professor, Obstetrics and GynecologyDuke Women’s Health AssociatesVASUDEVA G. KAMATH, MSc, PhDAssistant Professor of Biochemistry and Medical GeneticsTouro College of Osteopathic MedicineCLARK KEBODEAUX, PharmDClinical Associate Professor, Pharmacy Practice and ScienceUniversity of Kentucky College of PharmacyMATTHEW KRAYBILL, PhDClinical NeuropsychologistCottage Health, Santa Barbara, CaliforniaGERALD LEE, MDAssociate Professor, Departments of Pediatrics and MedicineEmory University School of MedicineKACHIU C. LEE, MD, MPHAssistant Professor (Adjunct), Department of DermatologyLewis Katz School of Medicine at Temple UniversityJAMES LYONS, MDAssociate Dean, Professor of Pathology and Family MedicineAlabama College of Osteopathic MedicineNILADRI KUMAR MAHATO, MBBS, PhDOhio University, AthensCARL MARFURT, PhDProfessor Emeritus, Department of Anatomy, Cell Biology and PhysiologyIndiana University School of Medicine–Northwest, Gary

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xPETER MARKS, MD, PhDCenter for Biologics Evaluation and ResearchUS Food and Drug AdministrationDOUGLAS A. MATA, MD, MPHSenior Pathologist and Associate Medical DirectorFoundation Medicine, Cambridge, MassachusettsKRISTEN L. PAGEL, MD, MPHAssistant Professor, Department of PsychiatryUniversity of Utah School of MedicineSAMAN BENTOTA, MDPhysician and MicrobiologistSri LankaSOROUSH RAIS-BAHRAMI, MDAssociate Professor of Urology and RadiologyUniversity of Alabama at Birmingham School of MedicineRICHARD P. RAMONELL, MDClinical Instructor, Department of MedicineUniversity of Pittsburgh School of MedicineKEISHA RAY, PhDAssistant Professor, McGovern Center for Humanities and EthicsUniversity of Texas Health Science Center at HoustonJOHN ROSE, DO, MScAssistant Professor of AnesthesiologyMount Sinai Morningside–WestSASAN SAKIANI, MDAssistant Professor of Medicine, Department of MedicineUniversity of Maryland School of MedicineSARAH SCHIMANSKY, MB BCh BAOResident, Department of OphthalmologyBristol Eye HospitalSHIREEN MADANI SIMS, MDProfessor, Obstetrics and GynecologyUniversity of Florida College of MedicineNATHAN WM. SKELLEY, MDAssociate Professor, Medical Director of Orthopaedic SurgerySanford Health–University of South Dakota School of MedicineTONY SLIEMAN, PhD, MScAssociate Professor, Department of Basic SciencesNew York Institute of Technology College of Osteopathic Medicine atArkansas State UniversityMATTHEW SOCHAT, MDPhysician, Hematology/OncologySoutheastern Medical Oncology CenterHOWARD M. STEINMAN, PhDAssistant Dean, Biomedical Science EducationAlbert Einstein College of MedicineLORREL TOFT, MDAssociate Professor of Cardiology, Department of MedicineUniversity of Nevada, Reno School of MedicineRICHARD P. USATINE, MDProfessor, Dermatology and Cutaneous SurgeryUniversity of Texas Health Science Center San AntonioSYLVIA WASSERTHEIL-SMOLLER, PhDProfessor Emerita, Department of Epidemiology and Population HealthAlbert Einstein College of MedicineADAM WEINSTEIN, MDAssociate Professor of Medical Sciences and PediatricsFrank H. Netter MD School of Medicine at Quinnipiac UniversityABHISHEK YADAV, MBBS, MScAssociate Professor of AnatomyGeisinger Commonwealth School of MedicineKRISTAL YOUNG, MDClinical Instructor, Department of CardiologyHuntington Hospital, Pasadena, CaliforniaDONG ZHANG, PhDAssociate Professor and Director of Center for Cancer ResearchNew York Institute of Technology College of Osteopathic Medicine

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xiPrefaceWith the 33rd edition ofFirst Aid for the USMLE Step 1we continue our commitment to providing students withthe most useful and up-to-date preparation guide for this exam. This edition represents an outstanding revision inmany ways, including:73 entirely new or heavily revised high-yield topics reflecting evolving trends in the USMLE Step 1.Extensive text revisions, new mnemonics, clarifications, and corrections curated by a team of 19 medical studentand resident physician authors who excelled on their Step 1 examinations, and verified by a team of expertfaculty advisors and nationally recognized USMLE instructors.Updated with 148 new and revised diagrams and illustrations as part of our ongoing collaboration withUSMLE-Rx and ScholarRx (MedIQ Learning, LLC).Updated with 159 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 the current pass/fail scoring system of the USMLE Step 1, and Step 1blueprint changes.Updated photos of patients and pathologies to include a variety of skin colors to better depict real-worldpresentations.Revised pharmacology sections to include only those drugs currently approved for the US market.Improved organization and integration of text, illustrations, clinical images, and tables throughout for focusedreview of high-yield topics.Updated Rapid Review section to better reflect exam contents by removing the ‘Classic/Relevant Treatments’section and adding in a ‘Pathophysiology of Important Diseases’ section.Revised ratings of current, high-yield review resources, with clear explanations of their relevance to USMLEreview. Replaced outdated resources with new ones recommended by Step takers.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. xv.)LouisvilleTao LeBoracayVikas BhushanBaltimoreConnie QiuKathmanduAnup ChaliseAthensPanagiotis KaparaliotisAtlantaCaroline ColemanSan FranciscoKimberly Kallianos

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xiiSpecial 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 contributionsto this edition through our voting, proofreading, and crowdsourcing platform: Amalia D. Ardeljan, Heather Beyea,Avneet Kaur, Yekaterina Khamzina, Alexandra Jan Mrani, and Ajay Ajit Pal Singh.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. Special thanks to our indexer, Dr.Anne Fifer. We are also grateful to our art manager, Susan Mazik, and illustrators, Stephanie Jones and RachaelJoy, for their creative work on the new and updated illustrations. Lastly, tremendous thanks to our compositor,GW Inc., especially Anne Banning, Gary Clark, Cindy Geiss, Denise Smith, and Gabby Sullivan.LouisvilleTao LeBoracayVikas BhushanBaltimoreConnie QiuKathmanduAnup ChaliseAthensPanagiotis KaparaliotisAtlantaCaroline ColemanSan FranciscoKimberly Kallianos

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xiiiEach 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 Ra’ed Ababneh, Hadi Abbas, Mohamed FouadAbdrabo, Ehsen Abdul-Kabir, Catreen Abouelsaad, Maria Acosta, Ataa Ahmed, Ibrahim Al-Zoubi, Isaiah Alexander,Majed Alghamdi, Hasan Alhelo, Ans Ali, Lubna Allawi, Yazmin Alejandra Heredia Allegretti, Sulaiman Alshakhs,Einer Arevalo-Rios, Rohan Arora, Stephanie Asdell, Raja Faizan Aurangzeb, Amir Bagheri, Wardah Bajwa, DavidBandy, Adhish Beri, Moussa Berro, Hershey Bhagat, Karun Bhattarai, Pratik Bhattarai, Lokesh Dahal Bikram, ArwaBohra, Niloofar Bondariyan, Scout Bownman-Gibson, Steven Braun, Lauren Burney, Jorge Cajias, Jack Carey,Kevin Cheng, Grigory Davidov, Sara Moghareh Dehkordy, Ainel Loy Diaz, Jeevan Divakaran, Manasa Dutta, AwabElnaeem, Zarifa Eshova, Lukas Franke, Jordan Frausto, Louna Ftouni, Allie Funderburk, Asmita Gera, LucianaGizzo, Megan Gosling, Camila M. Luis Gronau, Florian Guillot, Yassine Hamdaoui, Jack Healy, ChristopheHornung, Kayla Howard, Ibrahim Ibikunle, David Ibrahim, Abdelrhman Muqafaq Janem, Tareq Yara Jazzar,Dhruv Jivan, Bhavya Johani, Alec Kacew, Reema Khatri, Troy Kleber, Mariia Kukushkina, Daniel Lamanna, DafniaLeyva, Alwyn Louis, Carra Lyons, Abdelrahman Mahmoud, Sajjad Nazar Majeed, Haruki Majima, Freda QuimbaMalanyaon, Hamdan Mallick, Kshitij Manchanda, Jamal Masri, Michael Heustess McLatchey, Jose Antonio Meade,Akhil Meti, David Momtaz, Alejandra Moncayo, Dyese Moody, Andrew Moya, Waneeza Mughees, GeraldineNabeta, Sofia Nadav, Shamsun Nahar, Nelly Navarro, Kamil Nazer, Hyder Nizamani, Maria Felix Torres Nolasco,Hisashi Nomura, Rafy Souheil Farah Odeh, Gerald Olayan, Ider Oujamaa, Abhishek Pandey, Arun Paniker, NidhitPatel, Kevin Aldwych Zayas Pena, Zainab Pervaiz, Samantha Pfiffner, Vivek Podder, Prabhat Poudel, Kevin Pruitt,Yochitha Pulipati, Punnatorn Punkitnirundorn, Erik Rabin, Kirstin Reed, Asmaa Rjoob, Gessel Romero, AonRyalat, Richard Ryngel, Neha Sehgal, Kristina Sevcik, Tarif Shaaban, Muhammad Shahriar, Tina Sharma, EmilySherry, Kinan Al Shunaigat, Alondra Sierra, Joshua St. Louis, Michael Steadman, Ashley Su, Anastasiia Sumenkova,Lana Adel George Tannous, Nicholas Ting, Joshua Tobin, Jason Tung, Songphol Tungjitviboonkun, MehrbodVakhshoori, Sai akhil Veeramachaneni, Amanjot Virk, Christos Vrysis, Dayanara Wert, Jonathan Wikcock, WhitneyWood, Hafsa Yaseen, and Peleg Zohar.General Acknowledgments

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