First Aid for the USMLE STEP 2 CK Clinical Knowledge: A Student to Student Guide 6th edition Le, Bhushan, Skapik eBook


  • Download: First Aid for the USMLE Step 2 CK 6th edition eBook
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  • Published: 2007
  • ISBN-13: 978-0071487955
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First Aid for the USMLE Step 2 CK 6th edition eBook


Contributing Authors vii

Faculty Reviewers ix

Preface xi

Acknowledgments xiii

How to Contribute xv


Introduction 2

USMLE Step 2 CK—Computer-Based Testing Basics 2

Defining Your Goal 8

Study Resources 10

Test-Day Checklist 12

Testing Agencies 12


First Aid for the International Medical Graduate 14

First Aid for the Student with a Disability 35


How to Use the Database 38

Cardiovascular 39

Dermatology 69

Endocrinology 107

Epidemiology 121

Ethics and Legal Issues 133

Gastrointestinal 139

Hematology/Oncology 175

Infectious Disease 203


For more information about this title, click here


Musculoskeletal 239

Neurology 263

Obstetrics 295

Gynecology 325

Pediatrics 353

Psychiatry 387

Pulmonary 411

Renal/Genitourinary 429

Selected Topics in Emergency Medicine 451

Rapid Review 467


How to Use the Database 495

Comprehensive 497

Online Comprehensive Review 502

Internal Medicine 503

Neurology 509

OB/GYN 511

Pediatrics 515

Psychiatry 519

Surgery 524

Miscellaneous 529

Commercial Review Courses 530

Appendix: Abbreviations and Symbols 531

Index 537

About the Authors 559


The United States Medical Licensing Examination (USMLE) Step 2 allows

you to pull together your clinical experience on the wards with the numerous

“factoids” and classical disease presentations that you have memorized over

the years. Whereas Step 1 stresses basic disease mechanisms and principles,

Step 2 places more emphasis on clinical diagnosis and management, disease

pathogenesis, and preventive medicine.

The Step 2 exam is now composed of two parts:

■ The Step 2 Clinical Knowledge examination (Step 2 CK)

■ The Step 2 Clinical Skills examination (Step 2 CS)

The USMLE Step 2 CK is the second of three examinations that you must

pass in order to become a licensed physician in the United States. The computerized

Step 2 CK is a one-day (nine-hour) multiple-choice exam.

Students are also required to take the Step 2 CS, which is a one-day live

exam in which students examine 12 standardized patients. The goal of the

Step 2 CS is to ensure that students from more than 1600 medical schools

worldwide, with varying curricula and educational standards, can collect and

interpret a history, perform a physical exam, and communicate with patients

at a comparable level. For more information on this examination, please refer

to First Aid for the USMLE Step 2 CS. Information about the Step 2 CS format

and about eligibility, registration, and scoring can be found at

The information found in this section as well as in the remainder of the

book will address only the Step 2 CK.


How Will the CBT Be Structured?

The Step 2 CK is a computer-based test (CBT) administered by Prometric,

Inc. It is a one-day exam with 368 questions divided into eight 60-minute

blocks of 46 questions each. A new form of testing software called FRED is

now being used by the USMLE. FRED is different from the Step 1 exam you

took in that you can now highlight and strike out test choices as well as make

brief notes to yourself. During the time allotted for each block, the examinee

can answer test questions in any order as well as review responses and change

answers just as in the Step 1 exam—but examinees cannot go back and

change answers from previous blocks. Once an examinee finishes a block, he

or she must click on a screen icon to continue to the next block. Time not

used during a testing block will be added to your overall break time, but it

cannot be used to complete other testing blocks. Expect to spend up to nine

hours at the test center.

Testing Conditions: What Will the CBT Be Like?

Even if you’re familiar with CBT and the Prometric test centers, FRED is a

new testing format that you should access from the USMLE CD-ROM or

Web site ( and try out prior to the exam.

If you familiarize yourself with the FRED testing interface ahead of time,

you can skip the 15-minute tutorial offered on exam day and add those minutes

to your allotted break time of 45 minutes.

The goal of the Step 2 CK is to

apply your knowledge of

medical facts to clinical

scenarios you may encounter

as a resident.



For security reasons, examinees are not allowed to bring personal electronic

equipment into the testing area—which means that digital watches,

watches with computer communication and/or memory capability, cellular

telephones, and electronic paging devices are all prohibited. Food and beverages

are prohibited as well. Examinees are given laminated writing surfaces

for note taking, but these must be returned after the examination. The testing

centers are monitored by audio and video surveillance equipment.

You should become familiar with a typical question screen (see Figure

1-1). A window to the left displays all the questions in the block and shows you

the unanswered questions (marked with an “i”). Some questions will contain

figures or color illustrations adjacent to the question. Although the contrast

and brightness of the screen can be adjusted, there are no other ways to manipulate

the picture (e.g., zooming, panning). Larger images are accessed

with an “exhibit” button. The examinee can also call up a window displaying

normal lab values. You may mark questions to review at a later time by clicking

the check mark at the top of the screen. The annotation feature functions

like the provided erasable dry boards and allows you to jot down notes during

F I G U R E 1 – 1 . Typical FRED Question Screen











Highlight and









the exam. Play with the highlighting/strike-out and annotation feature with

the vignettes and multiple answers.

You should also do a few practice blocks to get a feel for which tools actually

help you process questions more efficiently and accurately. If you find

that you are not using the marking, annotation, or highlighting tools, then

keyboard shortcuts can save you time over using a mouse.

What Does the CBT Format Mean for Me?

The CBT format is the same format as that of the USMLE Step 1. If you are

uncomfortable with this testing format, spend some time playing with a Windows-

based system and pointing and clicking icons or buttons with a mouse.

The USMLE also offers an opportunity to take a simulated test, or practice

session, at a Prometric center. The session is divided into three one-hour

blocks of 50 test items each. The USMLE Step 2 CK sample test items (150

questions) that are available on the CD-ROM or on the USMLE Web site

( are the same as those used at CBT practice sessions. No

new items will be presented. The cost is about $42 for U.S. and Canadian

students but is higher for international students. The student receives a

printed percent-correct score after completing the session. No explanations of

questions are provided. You may register for a practice session online at

How Do I Register to Take the Exam?

Information on Step 2 CK format, content, and registration requirements can

be found on the USMLE Web site. To register for the exam in the United

States and Canada, apply online at the National Board of Medical Examiners

(NBME) Web site ( A printable version of the application is

also available on this site.

The preliminary registration process for the USMLE Step 2 CK is as follows:

■ Complete a registration form and send examination fees to the NBME


■ Select a three-month block in which you wish to be tested (e.g.,


■ Attach a passport-type photo to your completed application form.

■ Complete a Certification of Identification and Authorization Form. This

must be signed by an official at your medical school (e.g., the registrar’s office)

to verify your identity. This is a new form and is valid for five years, allowing

you to use only your USMLE identification number for future


■ Send your certified application form to the NMBE for processing. (Applications

may be submitted more than six months before the test date, but

examinees will not receive their scheduling permits until six months prior

to the eligibility period.)

■ The NBME will process your application within four to six weeks and will

send you a fluorescent orange slip of paper that will serve as your scheduling


■ Once you have received your orange scheduling permit, decide when and

where you would like to take the exam. For a list of Prometric locations

nearest you, visit

Keyboard shortcuts:

A–E—Letter choices.

Enter or Spacebar—Move to

next question.

Esc—Exit pop-up Lab and

Exhibit windows.

Alt-T—Countdown timers

for current session and

overall test.



■ Call Prometric’s toll-free number or visit to arrange a

time to take the exam.

■ The Step 2 CK is offered on a year-round basis except for the first two

weeks in January. For the most up-to-date information on available testing

days at your preferred testing location, refer to

Your orange scheduling permit will contain the following important information:

■ Your USMLE identification number

■ The eligibility period in which you may take the exam

■ Your “scheduling number,” which you will need to make your exam appointment

with Prometric

■ Your candidate identification number, or CIN, which you must enter at

your Prometric workstation in order to access the exam

Prometric has no access to the codes and will not be able to supply these

numbers. Do not lose your permit! You will not be allowed to take the Step 2

CK unless you present your permit along with an unexpired, governmentissued

photo identification that contains your signature (e.g., driver’s license,

passport). Make sure the name on your photo ID exactly matches the name

that appears on your scheduling permit.

What If I Need to Reschedule the Exam?

You can change your date and/or center within your three-month period without

charge by contacting Prometric. If space is available, you may reschedule

up to five days before your test date. If you need to reschedule outside your

initial three-month period, you can apply for a single three-month extension

(e.g., April/May/June can be extended through July/August/September) after

your eligibility period has begun (visit for more information).

This extension currently costs $50. For other rescheduling needs, you must

submit a new application along with another application fee.

What About Time?

Time is of special interest on the CBT exam. Here is a breakdown of the

exam schedule:

Tutorial 15 minutes

60-minute question blocks (46 questions per block) 8 hours

Break time (includes time for lunch) 45 minutes

Total test time 9 hours

The computer will keep track of how much time has elapsed during the

exam. However, the computer will show you only how much time you have

remaining in a given block. Therefore, it is up to you to determine if you are

pacing yourself properly.

The computer will not warn you if you are spending more than the 45

minutes allotted for break time. However, you can elect not to use all of your

break time, or you can gain extra break time either by skipping the tutorial or

by finishing a block ahead of the allotted time.

Because the exam is

scheduled on a “first-come,

first-served” basis, you should

be sure to call Prometric as

soon as you receive your

scheduling permit!


If I Leave During the Exam, What Happens to My Score?

You are considered to have started the exam once you have entered your CIN

onto the computer screen. In order to receive an official score, you must finish

the entire exam. This means that you must start and either finish or run

out of time for each block of the exam. If you do not complete all the blocks,

your exam will be documented on your USMLE score transcript as an incomplete

attempt, but no actual score will be reported.

The exam ends when all blocks have been completed or time has expired.

As you leave the testing center, you will receive a written test-completion notice

to document your completion of the exam.

What Types of Questions Are Asked?

■ Almost all questions on the Step 2 CK are case based. A substantial

amount of extraneous information may be given, or a clinical scenario

may be followed by a question that could be answered without actually requiring

that you read the case. It is your job to determine which information

is superfluous and which is pertinent to the case at hand.

■ Subject areas vary randomly from question to question.

■ Most questions have a single best answer, but some matching sets call for

multiple responses (the number to select will be specified). The part of the

vignette that actually asks the question—the stem—is usually found at the

end of the scenario. From student experience, there are a few stems that

are consistently addressed throughout the exam:

■ What is the most likely diagnosis? (40%)

■ Which of the following is the most appropriate initial step in management?


■ Which of the following is the most appropriate next step in management?


■ Which of the following is the most likely cause of . . . ? (5%)

■ Which of the following is the most likely pathogen . . . ? (3%)

■ Which of the following would most likely prevent . . . ? (2%)

■ Other (10%)

■ Note the age and race of the patient in each clinical scenario. When ethnicity

is given, it is often relevant. Know these well (see high-yield facts),

especially for more common diagnoses.

■ Be able to recognize key facts that distinguish major diagnoses.

■ Questions often describe clinical findings instead of naming eponyms

(e.g., they cite “audible hip click” instead of “positive Ortolani’s sign”).

■ Questions about acute patient management (e.g., trauma) in an emergency

setting are common.

The cruel reality of the Step 2 CK is that no matter how much you study,

there will still be questions you will not be able to answer with confidence. If

you recognize that a question is not solvable in a reasonable period of time,

make an educated guess and move on; you will not be penalized for guessing.

Also keep in mind that 10–20% of the USMLE exam questions are “experimental”

and will not count toward your score.

How Long Will I Have to Wait Before I Get My Scores?

The USMLE reports scores three to four weeks after the examinee’s test date.

During peak times, however, reports may take up to six weeks to be scored.



Official information concerning the time required for score reporting is

posted on the USMLE Web site,

How Are the Scores Reported?

Like the Step 1 score report, your Step 2 CK report includes your pass/fail status,

two numeric scores, and a performance profile organized by discipline

and disease process (see Figures 1-2A and 1-2B). The first score is a three-digit

scaled score based on a predefined proficiency standard. In 2006, the required

passing score was 182, which required answering 60–70% of questions correctly.

The second score scale, the two-digit score, defines 75 as the minimum

passing score (equivalent to a score of 182 on the first scale). This score is not

a percentile. Any adjustments in the required passing score will be available

on the USMLE Web site.


First Aid for the USMLE Step 2 CK 6th edition eBook