First Aid for the USMLE Step 2 Ck, Eleventh Edition (2022)

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USMLE Step 2 CKEleventh EditionNew YorkChicagoSan FranciscoAthensLondonMadridMexico CityMilanNew DelhiSingaporeSydneyTorontoTAO LE, MD, MHSFounder, ScholarRxAssociate Clinical Professor, Department of MedicineUniversity of Louisville School of MedicineMONA ASCHA, MDFellow, Department of Plastic SurgeryJohns Hopkins UniversityMARINA BOUSHRA, MDEmergency Medicine and Critical Care MedicineCleveland Clinic Foundation, Cleveland, OhioCAROLINE COLEMAN, MDResident, Department of MedicineEmory University School of MedicineVIKAS BHUSHAN, MDFounder,First Aid for the USMLE Step 1Boracay, PhilippinesABHISHEK BHARDWAJ, MDPulmonologist and IntensivistCoast Pulmonary Associates, Orange County, CaliforniaAssistant Clinical Professor, Health SciencesUniversity of California, RiversideDANIEL GRIFFIN, DOIntensivist, Saint Francis Medical CenterSTEPHANIE JONES, PhDEmory University Laney Graduate SchoolKIMBERLY KALLIANOS, MDAssistant Professor, Department of Radiology and Biomedical ImagingUniversity of California, San Francisco School of Medicine

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Copyright © 2023, 2019, 2016, 2012, 2010, 2007, by Tao Le. 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 priorwritten permission of the publisher.ISBN: 978-1-26-485651-0MHID:1-26-485651-2The material in this eBook also appears in the print version of this title: ISBN: 978-1-26-485510-0,MHID: 1-26-485510-9.eBook conversion by codeMantraVersion 1.0All trademarks are trademarks of their respective owners. Rather than put a trademark symbol after every occurrence of a trademarked name, we usenames in an editorial fashion only, and to the benefit of the trademark owner, with no intention of infringement of the trademark. Where such designa-tions appear in this book, they have been printed with initial caps.McGraw Hill eBooks are available at special quantity discounts to use as premiums and sales promotions or for use in corporate training programs. Tocontact a representative, please visit the Contact Us page at www.mhprofessional.com.McGraw Hill, the McGraw Hill logo, Practice Makes Perfect, and related trade dress are trademarks or registered trademarks of McGraw Hill and/or its affiliates in the United States and other countries and may not be used without written permission. All other trademarks are the property of theirrespective owners. McGraw Hill is not associated with any product or vendor mentioned in this book.NOTICEMedicine is an ever-changing science. As new research and clinical experience broaden our knowledge, changes in treatment and drug therapy arerequired. The authors and the publisher of this work have checked with sources believed to be reliable in their efforts to provide information that is com-plete and generally in accord with the standards accepted at the time of publication. However, in view of the possibility of human error or changes inmedical sciences, neither the authors nor the publisher nor any other party who has been involved in the preparation or publication of this work warrantsthat the information contained herein is in every 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 the information contained herein with othersources. For example and in particular, readers are advised to check the product information sheet included in the package of each drug they plan toadminister to be certain that the information contained in this work is accurate and that changes have not been made in the recommended dose or in thecontraindications for 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 subject to these terms.Except as permitted under the Copyright Act of 1976 and the right to store and retrieve one copy of the work, you may not decompile, disassemble,reverse engineer, reproduce, modify, create derivative works based upon, transmit, distribute, disseminate, sell, publish or sublicense the work or anypart of it without McGraw-Hill Education’s prior consent. You may use the work for your own noncommercial and personal use; any other use of thework is strictly prohibited. Your right to use the work may be terminated if you fail to comply with these terms.THE WORK IS PROVIDED “AS IS.” McGRAW-HILL EDUCATION AND ITS LICENSORS MAKE NO GUARANTEES OR WARRANTIESAS TO THE ACCURACY, ADEQUACY OR COMPLETENESS OF OR RESULTS TO BE OBTAINED FROM USING THE WORK, INCLUD-ING ANY INFORMATION THAT CAN BE ACCESSED THROUGH THE WORK VIA HYPERLINK OR OTHERWISE, ANDEXPRESSLYDISCLAIM ANY WARRANTY, EXPRESS OR IMPLIED, INCLUDING BUT NOT LIMITED TO IMPLIED WARRANTIES OF MERCHANT-ABILITY OR FITNESS FOR A PARTICULAR PURPOSE. McGraw-Hill Education and its licensors do not warrant or guarantee that the functionscontained in the work will meet your requirements or that its operation will be uninterrupted or error free. Neither McGraw-Hill Education nor itslicensors shall be liable to you or anyone else for any inaccuracy, error or omission, regardless of cause, in the work or for any damages resultingtherefrom. McGraw-Hill Education has no responsibility for the content of any information accessed through the work. Under no circumstances shallMcGraw-Hill Education and/or its licensors be liable for any indirect, incidental, special, punitive, consequential or similar damages that result fromthe use of or inability 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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iiiDEDICATIONTo the contributors to this and past editions,who took time to share their knowledge, insight, andhumor for the benefit of students and physicians everywhere.

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vContentsContributing AuthorsviFaculty ReviewersviiiPrefaceixAcknowledgmentsxHow to ContributexiHow to Use This BookxiiSECTION 1: GUIDE TO EFFICIENT EXAMPREPARATION2Introduction2USMLE Step 2 CK—Computer-Based Testing Basics2Defining Your Goal10Study Resources12Test-Day Checklist13Testing Agencies14SECTION 2: DATABASE OF HIGH-YIELD FACTS15How to Use the Database16Cardiovascular17Dermatology87Endocrinology123Epidemiology157Health Systems Science177Gastrointestinal197Hematology/Oncology269Musculoskeletal313Neurology351Obstetrics427Gynecology467Pediatrics509Psychiatry585Pulmonary625Renal/Genitourinary675Multisystem717Rapid Review765SECTION 3: TOP-RATED REVIEW RESOURCES791How to Use the Database792Comprehensive794Question Banks794Internal Medicine, Emergency Medicine,Family Medicine795Neurology795OB/GYN795Pediatrics796Psychiatry796Surgery796Commercial Review Courses797Appendix I: Acronyms and Abbreviations799Appendix II: Common Laboratory Values807Index809About the Authors842

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viCONTRIBUTING AUTHORSManik Aggarwal, MD, MBBSFellow, Gastroenterology and HepatologyMayo Clinic, Rochester, MinnesotaJohn Carl Barba II, MPHMD CandidateOhio State University College of MedicineAnup Chalise, MBBS, MSNepalPaola Ghanem, MDPhysician, Department of Internal MedicineJohns Hopkins UniversityMyles Mowery, DO, MBAResident, Diagnostic and Interventional RadiologySpectrum Health/Michigan State UniversityGrand Rapids, MichiganWaneeza Mughees, MDResident, Obstetrics and GynecologyDrexel University College of Medicine, PhiladelphiaChristian Cuvillier Padilla, MDChief Resident, Internal MedicineCleveland Clinic and Cleveland Veterans Affairs Medical Center,Cleveland, OhioVivek Podder, MBBSInternBIRDEM General Hospital, BangladeshVikram Shee, MBBS, MScPhysician Case ManagerTeladoc Health, Inc.Collin Andrew Weintraub, MDResident, General SurgeryState University of New York Upstate Medical UniversityIMAGE AND ILLUSTRATION TEAMYoree Grace ChungMD/PhD CandidateEmory University School of MedicineNikitha Crasta, MBBSMangalore, IndiaSean Evans, MDResident, Internal MedicineEmory University School of MedicineVictor Jose Martinez Leon, MDResident, Internal MedicineEinstein Medical Center, PhiladelphiaAngel Xiao, MD, MSEResident, Orthopedic SurgeryUniversity of California–San Francisco

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viiASSOCIATE AUTHORSAparna Savitri Bhat, MDFellow, Pulmonary and Critical Care MedicineCleveland Clinic, Cleveland, OhioNaveena Daram, MDResident, Obstetrics and GynecologyWright State UniversityIfrah Fatima, MBBSResident, Internal MedicineUniversity of Missouri–Kansas City School of MedicineLindsay Friedman, MD, MSResident, General SurgeryRush University Medical CenterLuise Josefine Froessl, MDResidentUniversité d’Aix-Marseille, Faculté de MedecineIzhan Hamza, MBBSResidentUniversity of Texas Medical Branch, Internal MedicineAbdul Rehman Mustafa, MBBSAlfaisal University College of Medicine, Saudi ArabiaAaron Panicker, MDResident, Emergency MedicineUniversity of Florida College of MedicineAustin Patrick, DOResidentFranciscan Health Olympia FieldsFaateh Ahmad Rauf, MBBSCMH Lahore Medical College and Institute of Dentistry, PakistanJaimie Rogner, MD, MPHResident, Internal Medicine/PediatricsUniversity of Rochester Medical Center/Strong Memorial HospitalKyle Robert WagnerMD CandidateUniversity of Illinois College of Medicine, Peoria

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viiiFACULTY REVIEWERSBrooks DCash, MDProfessor, Department of MedicineChief, Gastroenterology, Hepatology, and NutritionUniversity of Texas Health Science Center at HoustonDimitri Cassimatis, MDAssociate Professor, Department of MedicineEmory University School of MedicineBradley Cole, MDAssistant Professor of NeurologyLoma Linda University School of MedicineMeredith KGreer, MDAssistant Professor, Department of MedicineEmory University School of MedicineJennifer OHowell, MDAssociate Professor, Department of Obstetrics and GynecologyDuke University Medical CenterMatthew Kraybill, PhDClinical NeuropsychologistCottage Health, Santa Barbara, CaliforniaPatrick MLank, MD, MSAssistant Professor, Department of Emergency MedicineNorthwestern University, Feinberg School of MedicineKachiu CLee, MD, MPHAssistant Professor (Adjunct), Department of DermatologyLewis Katz School of Medicine at Temple UniversityCarl Marfurt, PhDProfessor Emeritus, Department of Anatomy, Cell Biology andPhysiologyIndiana University School of Medicine–Northwest, GaryPeter Marks, MD, PhDCenter for Biologics Evaluation and ResearchUS Food and Drug AdministrationKristen LPagel, MD, MPHAssistant Professor, Department of PsychiatryUniversity of Utah School of MedicineMahesh Patel, MDProfessor, Department of MedicineUniversity of Illinois at Chicago College of MedicineDiane Payne, MD, MPTOrthopedic, Hand and Microvascular SurgeryOrthoAtlanta Newnan, GeorgiaSoroush Rais-Bahrami, MDProfessor of Urology and Radiology and Interim Chair, Departmentof UrologyUniversity of Alabama at Birmingham School of MedicineKeisha Ray, PhDAssistant Professor, McGovern Center for Humanities and EthicsUniversity of Texas Health Science Center at HoustonRachel Marie ESalas, MD, MEdProfessor, Neurology and NursingJohns Hopkins MedicineSarah Schimansky, MB BCh BAOResident, Department of OphthalmologyBristol Eye HospitalShireen Madani Sims, MDAssociate Professor and Vice Chair for Education, Obstetrics andGynecologyUniversity of Florida College of MedicineNathan WmSkelley, MDAssociate Professor, Medical Director of Orthopaedic SurgerySanford Health–University of South Dakota School of MedicineMatthew Sochat, MDPhysician, Hematology/OncologySoutheastern Medical Oncology CenterLorrel Toft, MDAssociate Professor of Cardiology, Department of MedicineUniversity of Nevada, Reno School of MedicineTisha Wang, MDProfessor of Clinical Medicine, Department of MedicineDavid Geffen School of Medicine at UCLASylvia Wassertheil-Smoller, PhDProfessor Emerita, Department of Epidemiology and PopulationHealthAlbert Einstein College of MedicineAdam Weinstein, MDAssociate Professor of Medical Sciences and PediatricsFrank H. Netter MD School of Medicine at Quinnipiac UniversityJames SYeh, MD, MPHDepartment of MedicineMassachusetts General Hospital, Harvard Medical SchoolKristal Young, MDClinical Instructor, Department of CardiologyHuntington Hospital, Pasadena, California

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ixPrefaceWith the 11th edition ofFirst Aid for the USMLE Step 2 CK, we continue our commitment to pro-viding students with the most high-yield and up-to-date preparation guide for the USMLE Step 2 CKexam. Preparation for and performance on the Step 2 CK exam are more important than ever with thetransition of the Step 1 exam to a pass/fail scoring system in 2022. With this in mind, we have greatlyexpanded the content and depth for the 11th edition. This revision includes:■Over 200 additional pages of content incorporating the most current evidence-based reviews and rec-ommendations to help students on the Step 2 CK exam and in clinical practice.■163 new and revised diagrams and illustrations, including more than 40 new diagnostic and manage-ment algorithms, to further drive home the next best diagnostic and management options.■140 new and revised photos/images to help visualize various disorders, descriptive findings, and clini-cal content tie-ins.■Extensive text revisions, new mnemonics, and clarifications curated by a team of 26 medical studentand resident physician authors who excelled on their USMLE exams and verified by a team of expertfaculty advisors and nationally recognized USMLE instructors.■Continued focus on clinical presentation and the best initial step in diagnosis and management, mir-roring the content outline and blueprint of Step 2 CK.■Vignette-style flash cards embedded in the margins to reinforce key concepts.■Heavily updated and revised Rapid Review section for last-minute preparation.■Revised rating of current high-yield review resources, with clear explanations of their relevance toStep 2 CK exam review.■Improved organization and integrations of text, illustrations, clinical images, tables, and algorithmsthroughout for focused review of high-yield topics.The 11th edition ofFirst Aid for the USMLE Step 2 CKtruly is a completely revised, in-depth, student-to-student guide for preparation for the Step 2 CK exam. The 11th edition would not have been pos-sible without the help from hundreds of students and faculty members who contributed their feedbackand suggestions. We invite students and faculty to continue sharing their thoughts and ideas to help usimproveFirst Aid for the USMLE Step 2 CK(see How to Contribute, p. xi).Tao LeLouisvilleVikas BhushanBoracayMona AschaBaltimoreAbhishek BhardwajOrange CountyMarina BoushraClevelandDaniel GriffinCape Girardeau, MissouriCaroline ColemanAtlantaStephanie JonesTumwater, WashingtonKimberly KallianosSan Francisco

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xAcknowledgmentsThis has been a collaborative project from the start. We gratefully acknowledge the thoughtful comments, correc-tions, and advice of the many medical students, international medical graduates, and faculty who have supportedthe authors in the continuing development ofFirst Aid for the USMLE Step 2 CK.Thanks to our publisher, McGraw Hill, for the valuable assistance of its staff, including Bob Boehringer, ChristinaThomas, and Jeffrey Herzich. For outstanding editorial work, we thank Megan Chandler and Lisa Nahach. We arealso grateful to our medical illustrator, Rachael Williams, and illustration manager, Susan Mazik. For administra-tive support we thank Miranda Carter, Katherine Knight, and Louise Petersen. A special thanks to GW, Inc. forremarkable production work.For contributions and corrections, we thank Ataa Ahmed, Arjun Basnet, Jeffrey Beach, Monica I. Burgos Claudio,Fiorella B. Castillo, Mallory Castillo, Christian Casteel, Anthony Chung, Jonathan Daou, Karanpal Dhaliwal, FadiDib, Celia Escamilla, Arber Frakulli, Mohan Bharadwaj Gudivada, Jacqueline Hairston, Nathaniel Hayward, LydiaKaotzani, Panagiotis Kaparaliotis, Alex Lu, Juliana Maya, Austin McCullough, Nupur Mishra, Mounika MukherjeePeethala, Majd Oteibi, Shannon D. Powell, Aubtin Saedi, Tanjot Saini, Angelica Maria Sanchez Ruiz, CharlesSanky, Maida Sarfraz Chaudhry, Neetu Scariya, Ryan Schusler, Tarif Shaaban, Tomonari Shimoda, Biraj SinghKarki, Colton Southall, Charles Starling, Ari Stone, Erica Stratton, Jennifer Tram, Nicholas Ting, VivekanandTiwari, Sheela Vaswani, and Earl Vialpando.Tao LeLouisvilleVikas BhushanBoracayMona AschaBaltimoreAbhishek BhardwajOrange CountyMarina BoushraClevelandDaniel GriffinCape Girardeau, MissouriCaroline ColemanAtlantaStephanie JonesTumwater, WashingtonKimberly KallianosSan Francisco

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xiHow to ContributeIn our effort to continue to produce a high-yield review source for the Step 2 CK exam, we invite you to submit anysuggestions or corrections. We also offer paid internships in medical education and publishing ranging from threemonths to one year (see below for details). Please send us your suggestions for the following:■Study and test-taking strategies for the Step 2 CK exam■New high-yield facts, mnemonics, diagrams, and illustrations■Low-yield topics to removeFor each entry incorporated into the next edition, you will receive up to a $20 gift certificate to Amazon as well aspersonal acknowledgment in the next edition. Diagrams, tables, partial entries, updates, corrections, and study hintsare also appreciated, and significant contributions will be compensated at the discretion of the authors. Also let usknow about material in this edition that you feel is low yield and should be deleted.The preferred way to submit entries, suggestions, or corrections is via our blog:www.firstaidteam.comWe are also reachable by e-mail atfirstaid@scholarrx.com.NOTE TO CONTRIBUTORSAll entries become property of the authors and are subject to editing and reviewing. Please verify all data and spell-ings carefully. If similar or duplicate entries are received, only the first entry received will be used. Include a refer-ence to a standard textbook to facilitate verification of the fact. Please follow the style, punctuation, and format ofthis edition if possible.INTERNSHIP OPPORTUNITIESThe author team is pleased to offer part-time and full-time paid internships in medical education and publishing tomotivated physicians. Internships may range from three months (eg, a summer) up to a full year. Participants willhave an opportunity to author, edit, and earn academic credit on a wide variety of projects, including the popularFirst Aidseries. Writing/editing experience, familiarity with Microsoft Word and Google Docs, and illustration skillsare highly desired. For more information, e-mail a résumé or a short description of your experience along with acover letter tofirstaidteam@usmle-rx.com.

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xiiHow to Use This BookWe have made many improvements and added several new features to this edition ofFirst Aid for the USMLE Step2 CK. In particular, we have added more than two hundred pages of content and hundreds of new illustrations andimages throughout the text to facilitate studying. We encourage you to read all aspects of the text to learn the ma-terial in context. We have also included comments in the margins and vignette questions to periodically test yourknowledge of key concepts. These questions are located in the lower corner of certain pages. To prevent peeking atthe answers, you’ll find the answer on the back of the same page in the lower corner. These questions are not alwaysrepresentative of test questions.To practice for the exam and simulate the actual test day, you can use theUSMLE-Rx Step 2 CK Qmaxquestiontest bank (www.usmle-rx.com). If you are constantly on the move, use theUSMLE-Rx Step 2 CKapp. The questionbank and this text are more than enough to allow many students to ace the exam.Good luck!

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Introduction2USMLE Step 2 CK—Computer-Based Testing Basics2WhoCanRegisteRFoRtheexam?2hoWWilltheCBtBestRuCtuRed?2testingConditions: WhatWilltheCBtBelike?3WhatdoestheCBtFoRmatmeanFoRme?3hoWdoiRegisteRtotaketheexamination?4WhatiFineedtoResCheduletheexamination?5WhataBouttime?6seCuRitymeasuRes6iFileaveduRingtheexamination, WhathappenstomysCoRe?6WhattypesoFQuestionsaReasked?6hoWlongWillihavetoWaitBeFoReigetmysCoRes?8hoWaRethesCoResRepoRted?9Defining Your Goal10Whentotaketheexam11hoWWillthestep2 CksCoReaFFeCtmymatCh?12Study Resources12QualityConsideRations12CliniCalRevieWBooks12testBanks12textsandnotes13CommeRCialCouRses13nBme/usmlepuBliCations13Test-Day Checklist13thingstoBRingWithyoutotheexam13Testing Agencies141S E C T I O N 1GUIDE TO EFFICIENT EXAM PREPARATION

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INTRODUCTIONThe United States Medical Licensing Examination (USMLE) Step 2 allowsyou to pull together your clinical experience on the wards with the numerous“factoids” and classical disease presentations that you have memorized overthe years. Where Step 1 stresses basic disease mechanisms and principles,Step 2 places more emphasis on clinical diagnosis and management, diseasepathogenesis, and preventive medicine. Previously, the Step 2 examinationconsisted of the Step 2 Clinical Knowledge examination (Step 2 CK), and theStep 2 Clinical Skills examination (Step 2 CS). However, recent changeshave removed the Step 2 CS exam as a requirement for ECFMG certificationafter the onset of the pandemic, and this change has been recorded as perma-nent by the ECFMG.The USMLE Step 2 CK is the second of three examinations that you mustpass to become a licensed physician in the United States. The computerizedStep 2 CK is a 1-day (9-hour) multiple-choice examination.USMLE STEP 2 CK—COMPUTER-BASED TESTING BASICSWHO CAN REGISTER FOR THE EXAM?The eligibility requirement for USMLE Step 2 CK exam is same as that ofUSMLE Step 1 and can be taken either before or after the Step 1 exam. Thismeans that you should be:■Officially enrolled in, or be a graduate of, a US or Canadian medicalschool leading to the MD degree (LCME accredited), or■Officially enrolled in, or be a graduate of, a US medical school leading tothe DO degree (COCA accredited), or■Officially enrolled in, or be a graduate of, a medical school outside the USand Canada and listed in the World Directory of Medical Schools as meet-ing ECFMG eligibility requirements and meet other ECFMG criteria.These criteria should be met at the time of application and on the test day.HOW WILL THE CBT BE STRUCTURED?The Step 2 CK exam is a computer-based test (CBT) administered by Prometric,Inc. It is a 1-day examination with a maximum of 318 items divided into eight1-hour blocks that are administered during a single 9-hour testing session. Thenumber of items in a block are displayed at the beginning of each block. Thisnumber may vary from block to block but will not exceed 40 items per block.Two question styles predominate throughout. The most common format isthesingle one-best-answerquestion. This is the traditional multiple-choiceformat in which you are tasked with selecting the “most correct” answer.Sequential item setscomprises the second question style. These are sets ofmultiple-choice questions that are related and must all be answered insequence without skipping a question in the set. As you answer questions in aset, the previous answers become locked and cannot be changed. These arethe only questions on the USMLE examination that are locked in such a way.There are no more than five sequential item sets within each USMLE Step 2CK exam.During the time allotted for each block in the USMLE Step 2 CK exam,you can answer test questions in any order and can also review responses andchange your answers (except for responses within the sequential item setsKEY FACTThe goal of the Step 2 CK is to applyyour knowledge of medical factsto clinical scenarios that you mayencounter as a resident.KEY FACTSometimes the answer to the previousquestion in a sequential question setis provided to you once you lock youranswer. Do not be disheartened ifyou got it wrong. Simply understandthat you now have an opportunity toget at least one answer correct in thesequence.2SECTION 1GUIDE TO EFFICIENT EXAM PREPARATION

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