usmle step 3 secrets

USMLE STEP This page intentionally left blank       USMLE STEP THEODORE X O’CONNELL, MD Program Director Family Medicine Residency Program Kaiser Permanente Napa-Solano Napa, California Assistant Clinical Professor Department of Community and Family Medicine University of California, San Francisco, School of Medicine San Francisco, California Assistant Clinical Professor Department of Family Medicine David Geffen School of Medicine at UCLA Los Angeles, California THOMAS E BLAIR, MD Resident Physician Emergency Medicine Harbor-UCLA Medical Center Los Angeles, California RYAN A PEDIGO, MD Chief Resident Physician Emergency Medicine Harbor-UCLA Medical Center Los Angeles, California 1600 John F Kennedy Blvd Ste 1800 Philadelphia, PA 19103-2899 USMLE STEP SECRETS Copyright © 2015 by Saunders, an imprint of Elsevier Inc ISBN: 978-1-4557-5399-4 All rights reserved No part of this publication may be reproduced or transmitted in any form or by any means, electronic or mechanical, including photocopying, recording, or any information storage and retrieval system, without permission in writing from the Publisher Details on how to seek permission, further information about the Publisher’s permissions policies, and our arrangements with organizations such as the Copyright Clearance Center and the Copyright Licensing Agency can be found at our website: www.elsevier.com/permissions This book and the individual contributions contained in it are protected under copyright by the Publisher (other than as may be noted herein) Notices Knowledge and best practice in this field are constantly changing As new research and experience broaden our understanding, changes in research methods, professional practices, or medical treatment may become necessary Practitioners and researchers must always rely on their own experience and knowledge in evaluating and using any information, methods, compounds, or experiments described herein In using such information or methods, they should be mindful of their own safety and the safety of others, including parties for whom they have a professional responsibility With respect to any drug or pharmaceutical products identified, readers are advised to check the most current information provided (i) on procedures featured or (ii) by the manufacturer of each product to be administered to verify the recommended dose or formula, the method and duration of administration, and contraindications It is the responsibility of practitioners, relying on their own experience and knowledge of their patients, to make diagnoses, to determine dosages and the best treatment for each individual patient, and to take all appropriate safety precautions To the fullest extent of the law, neither the Publisher nor the authors, contributors, or editors assume any liability for any injury and/or damage to persons or property as a matter of products liability, negligence or otherwise, or from any use or operation of any methods, products, instructions, or ideas contained in the material herein Library of Congress Cataloging-in-Publication Data O’Connell, Theodore X., author USMLE step / Theodore X O’Connell, Thomas E Blair, Ryan A Pedigo p ; cm (Secrets) Includes bibliographical references and index ISBN 978-1-4557-5399-4 (pbk : alk paper) I Blair, Thomas, 1984- , author II Pedigo, Ryan, author III Title IV Series: Secrets series [DNLM: Clinical Medicine Examination Questions WB 18.2] RC58 616.0076 dc23 2014042526 Senior Content Strategist: James Merritt Content Development Specialist: Julia Rose Roberts Publishing Services Manager: Anne Altepeter Senior Project Manager: Doug Turner Design Manager: Steven Stave Printed in the United States of America Last digit is the print number: 9 8 7 6 5 4 3 2 1 To Nichole, Ryan, Sean, and Claire I love you THEODORE X O’CONNELL To my wife, Jenny Blair, and my parents, Robert and Linda Blair Thank you for your limitless love, support, and encouragement THOMAS E BLAIR To my beautiful wife, Tiffany, for her unconditional love and support, and to my father for making me the man I am today RYAN A PEDIGO This page intentionally left blank       CONTENTS CHAPTER GENERAL PRINCIPLES  CHAPTER DISORDERS OF THE NERVOUS SYSTEM AND SPECIAL SENSES  22 CHAPTER DISORDERS OF THE RESPIRATORY SYSTEM  47 CHAPTER CARDIOVASCULAR DISORDERS  63 CHAPTER NUTRITIONAL AND DIGESTIVE SYSTEM DISORDERS  88 CHAPTER BEHAVIORAL AND EMOTIONAL DISORDERS  111 CHAPTER DISORDERS OF THE MUSCULOSKELETAL SYSTEM  124 CHAPTER DISORDERS OF THE SKIN AND SUBCUTANEOUS TISSUE  135 CHAPTER DISORDERS OF THE ENDOCRINE SYSTEM  154 CHAPTER 10 RENAL AND URINARY DISORDERS  166 CHAPTER 11 DISEASES AND DISORDERS OF THE FEMALE REPRODUCTIVE SYSTEM  175 CHAPTER 12 PREGNANCY, LABOR AND DELIVERY, THE FETUS, AND THE NEWBORN  189 CHAPTER 13 DISORDERS OF BLOOD  215 CHAPTER 14 DISORDERS OF THE MALE REPRODUCTIVE SYSTEM  234 CHAPTER 15 DISORDERS OF THE IMMUNE SYSTEM  239 CHAPTER 16 CLINICAL CASE SCENARIOS  253 vii This page intentionally left blank       This page intentionally left blank       This page intentionally left blank       Plate 1.  Leukocoria (white pupillary reflex) is the most common presenting feature of retinoblastoma and may be first noticed in family photographs See Figure 1-1, p (Courtesy of U Raina.) Plate 2.  Varicella dendritic keratitis Numerous dendrites are seen in this slit-lamp photograph with fluorescein staining of the dendritic lesions from active viral growth in the corneal epithelium See Figure 2-6, p 42 (From Krachmer JH et al Cornea 3rd ed Philadelphia: Mosby, 2010, Figure 80.2.) Plate 3.  Allergic contact dermatitis of the leg caused by an elastic wrap Notice the well-marginated distribution that differentiates it from cellulitis See Figure 8-1, p 136 (From Auerbach PS: Wilderness medicine, 6th ed Philadelphia: Mosby, 2011, Fig 82-46.) Plate 4.  Lichen planus Flat-topped, purple polygonal papules of lichen planus See Figure 8-2, p 137 (From Kliegman RM: Nelson textbook of pediatrics, 19th ed Philadelphia: Saunders, 2011, Fig 649-10.) Plate 5.  Erythema multiforme Bull’s-eye annular lesions with central vesicles and bullae See Figure 8-3, p 137 (From Goldman L, Schafer AI: Goldman’s Cecil medicine, 24th ed Philadelphia: Saunders, 2011, Fig 447-10) Plate 6.  Bullous pemphigoid Tense subepidermal bullae on an erythematous base See Figure 8-4, p 138 (From Goldman L, Schafer AI: Goldman’s Cecil medicine, 24th ed Philadelphia: Saunders, 2011, Fig 447-6.) Plate 7.  Dermatitis herpetiformis is characterized by pruritis, urticarial papules, and small vesicles See Figure 8-5, p 138 (From Feldman M, Friedman LS, Brandt LJ: Sleisenger and Fordtran’s gastrointestinal and liver disease, 9th ed Philadelphia: Saunders, 2010, Fig 22-26 Courtesy of Dr Timothy Berger, San Francisco, CA.) Plate 8.  Erythema nodosum on the legs of a young woman See Figure 8-6, p 140 (From Hochberg MA, Silman AJ, Smolen JS, Weinblatt ME: Rheumatology, 5th ed Philadelphia: Mosby, 2010, Fig 159.13.) Plate 9.  Melanoma (superficial spreading type) See Figure 8-7, p 141 (From Goldman L, Schafer AI: Goldman’s Cecil medicine, 24th ed Philadelphia: Saunders, 2011, Fig 210-3.) Plate 10.  Keratoacanthoma on the right upper lid Lesions are solitary, smooth, dome-shaped red papules or nodules with a central keratin plug See Figure 8-8, p 141 (From Albert DM, Miller JW: Albert & Jakobiec’s principles and practice of ophthalmology, 3rd ed Philadelphia: Saunders, 2008, Fig 250.3.) Plate 11.  An ulcerated basal cell carcinoma with rolled borders on the posterior ear See Figure 8-9, p 142 (From Abeloff MD, Armitage JO, Niederhuber JE, Kastan MB, McKenna WG: Abeloff’s clinical oncology, 4th ed Philadelphia: Churchill Livingstone, 2008, Fig 74-2.) Plate 12.  Squamous cell carcinoma on the lower lip See Figure 8-10, p 142 (From Rakel D, Rakel RE: Textbook of family medicine, 8th ed Philadelphia: Saunders, 2011, Fig 33-85 Copyright Richard P Usatine.) Plate 13.  Multiple actinic keratoses visible as thin, red, scaly lesions See Figure 8-11, p 143 (From Goldberg D: Procedures in cosmetic dermatology— Lasers and lights: Vol 1, 2nd ed Philadelphia: Saunders, 2008, Fig 5.2.) Plate 14.  Nailbed melanoma See Figure 8-12, p 143 (From Dartmouth University and Dermnet Weekly Clinic, July 30, 2001.) Plate 15.  Paget disease of the nipple Note the erythematous plaques around the nipple See Figure 8-13, p 143 (From Bolognia JL, Jorizzo JL, Rapini RP: Dermatology, 1st ed Edinburgh: Mosby, 2003, Fig 53.8.) Plate 16.  Kaposi sarcoma See Figure 8-14, p 144 (From Hoffman: Hematology: Basic Principles and Practice, 5th ed Philadelphia: Churchill Livingstone, 2008, Fig 121-35.) Plate 17.  Infantile hemangioma These lesions grow rapidly during the first few months of life once they appear (20% at birth), but they are asymptomatic unless they bleed, become infected, or obstruct a vital structure Complete resolution is typical before the age of years, and no treatment is usually required See Figure 8-15, p. 145 (From du Vivier A: Atlas of clinical dermatology, 3rd ed New York: Churchill Livingstone, 2002, Fig 8.28, with permission.) Plate 18.  Multiple café-au-lait macules on a child with neurofibromatosis type See Figure 8-16, p 145 (From Eichenfield LF Frieden IJ, Esterly NB: Neonatal dermatology, 2nd ed Philadelphia: Saunders, 2007, Fig 22-2.) Plate 19.  Tinea corporis Red ring-shaped lesions with scaling and some central clearing See Figure 8-18, p 146 (From Kliegman RM: Nelson textbook of pediatrics, 19th ed Philadelphia: Saunders, 2011, Fig 658-8.) Plate 20.  Impetigo Multiple crusted and oozing lesions See Figure 8-19, p 147 (From: Kliegman RM: Nelson textbook of pediatrics, 19th ed Philadelphia: Saunders, 2011, Fig 657-1.) Plate 21.  Sharply defined erythema and edema characteristic of erysipelas See Figure 8-20, p 147 (From Zaoutis LB, Chiang VW: Comprehensive pediatric hospital medicine, 1st ed Philadelphia: Mosby, 2007, Fig 156-2.) Plate 22.  Pityriasis rosea Both small oval plaques and multiple small papules are present See Figure 8-21, p 150 (From Habif TP: Clinical dermatology, 5th ed Philadelphia: Mosby, 2009, Fig 8-44.) Plate 23.  Slapped cheek appearance of erythema infectiosum See Figure 8-22, p 151 (From Baren JM, Rothrock SG, Brennan J, Brown L: Pediatric emergency medicine, 1st ed Philadelphia: Saunders, 2007, Fig 123-5.) Plate 24.  Herpes zoster Grouped vesicopustules on an erythematous base See Figure 8-23, p 151 (From Marx J, Hockberger R, Walls R Rosen’s emergency medicine: concepts and clinical practice, 7th ed Philadelphia: Mosby, 2009, Fig 118-28 Courtesy of David Effron, MD) Plate 25.  Keloid scar on the ear lobe after piercing See Figure 8-24, p 152 (From Kliegman RM: Nelson textbook of pediatrics, 19th ed Philadelphia: Saunders, 2011, Fig 651-1.) Plate 26.  Sickle cells show a sickle or crescent shape resulting from polymerization of hemoglobin S This smear also shows target cells and boat-shaped cells with a lesser degree of polymerization of hemoglobin S than in a classic sickle cell See Figure 13-1, p 216 (From Goldman L, Schafer AI: Goldman’s Cecil medicine, 24th ed Philadelphia: Saunders, 2011, Fig 160-7) Plate 27.  Megaloblastic changes of macrocytosis and a hypersegmented neutrophil See Figure 13-2, p 216 (From Goldman L, Schafer AI: Goldman’s Cecil medicine, 24th ed Philadelphia: Saunders, 2011, Fig 170-6) Plate 28.  Iron-deficiency anemia Pale red blood cells with an enlarged central area of pallor See Figure 13-3, p 217 (From McPherson R, Pincus M: Henry’s clinical diagnosis and management by laboratory methods, 21st ed Philadelphia: Saunders, 2006, Fig 31-2.) Plate 29.  Basophilic stippling Irregular basophilic granules in red blood cells; often associated with lead poisoning and thalassemia See Figure 13-4, p 217 (From McPherson R, Pincus M: Henry’s clinical diagnosis and management by laboratory methods, 21st ed Philadelphia: Saunders, 2006, Fig 29-23.) Plate 30.  Bite cells with Heinz bodies See Figure 13-5, p 217 (Courtesy of Dr Robert W McKenna, Department of Pathology, University of Texas Southwestern Medical School, Dallas, TX.) Plate 31.  Howell-Jolly bodies in peripheral blood erythrocytes These nuclear remnants indicate a lack of splenic filtrative function See Figure 13-6, p 218 (From Orkin SH, et al.: Nathan and Oski’s hematology of infancy and childhood, 7th ed Philadelphia: Saunders, 2009, Fig 14-4.) Plate 32.  Teardrop red blood cells, usually seen in myelofibrosis See Figure 13-7, p 218 (From Goldman L, Ausiello D: Cecil Medicine, 23rd ed Philadelphia: Saunders, 2008, Fig 161-13.) Plate 33.  Schistocytes and helmet cells Red blood cell fragments seen in microangiopathic hemolytic anemia and disseminated intravascular coagulation See Figure 13-8, p 218 (From McPherson R, Pincus M: Henry’s clinical diagnosis and management by laboratory methods, 21st ed Philadelphia: Saunders, 2006, Fig 29-19.) Plate 34.  Hereditary elliptocytosis A blood film reveals characteristic elliptical red blood cells See Figure 13-9, p 219 (From McPherson R, Pincus M: Henry’s clinical diagnosis and management by laboratory methods, 22nd ed Philadelphia: Saunders, 2011, Fig 30-16.) Plate 35.  Acanthocytes Irregularly spiculated red blood cells, frequently seen in abetalipoproteinemia or liver disease See Figure 13-10, p 219 (From McPherson R, Pincus M: Henry’s clinical diagnosis and management by laboratory methods, 21st ed Philadelphia: Saunders, 2006, Fig 29-20.) Plate 36.  Target cells are frequently seen in hemoglobin C disease and liver disease See Figure 13-11, p 219 (From McPherson R, Pincus M: Henry’s clinical diagnosis and management by laboratory methods, 21st ed Philadelphia: Saunders, 2006, Fig 29-18.) Plate 37.  Echinocytes, or burr cells (arrows), are the hallmark of uremia See Figure 13-12, p 220 (From Hoffman R, et al.: Hematology: basic principles and practice, 5th ed Philadelphia: Churchill Livingstone, 2008, Fig 156-1.) Plate 38.  Microangiopathic hemolytic anemia demonstrating red blood cell fragments, anisocytosis, polychromasia, and decreased platelets See Figure 13-13, p 220 (From Tschudy MM, Arcara KM: The Harriet Lane handbook, 19th ed Philadelphia: Mosby, 2011, Plate 7.) Plate 39.  Rouleaux formation of stacked red blood cells seen in multiple myeloma See Figure 13-14, p 220 (From Goldman L, Ausiello D: Cecil medicine, 23rd ed Philadelphia: Saunders, 2008, Fig 161-19.) A B Plate 40.  Malaria Peripheral blood film examples of various stages of Plasmodium falciparum A, Small ring forms B, A crescentic gametocyte with centrally placed chromatin See Figure 13-15, p 221 (From Hoffman R, et al.: Hematology: basic principles and practice, 5th ed Philadelphia: Churchill Livingstone, 2008, Fig 159-5) Plate 41.  Ringed sideroblasts seen in sideroblastic anemia See Figure 13-16, p 221 (From Goldman L, Ausiello D: Cecil medicine, 23rd ed Philadelphia: Saunders, 2008, Fig 163-5.) [...]... Understands 1 -step commands (no gesture) Good use of cup and spoon Can build tower of 6 cubes Runs well Ties shoelaces 2-4 mo 3- 4 mo 4-5 mo 5 mo 6-9 mo 7 mo 9 mo 10 mo 10 mo 9-10 mo 9-12 mo 9-12 mo 12-15 mo 13 mo 13- 15 mo 15 mo 15-18 mo 2 yr 2 yr 5 yr *Reduce the age of premature infants in the first 2 years for assessing development For example, for children born after 6 months of gestation, subtract 3 months... recommended, but should be discussed with patient If conventional Pap test is used, test annually, then every 2 -3 yr for women 30 yr who have had three negative cytology test results; if Pap and HPV tests are used, test every 3 yr if both HPV and cytology results are negative Annually; every 2 -3 yr after 3 normal exams Cervical Pap smear Begin at age 21 yr regardless of sexual activity Gynecologic Pelvic exam... the trueness of measurement; in other words, whether the test measures what it CHAPTER 1  GENERAL PRINCIPLES  15 Figure 1 -3.   Positive skew An excess of higher values makes this a nonnormal distribution (From O’Connell T USMLE Step 2 secrets 4th ed Philadelphia: Elsevier, 2014, Fig 3- 2.) claims to measure For example, if a valid IQ test is administered to a genius, the test should not indicate that he... significance in the medical literature 31 What three points about the P-value should be remembered for the Step 3 exam? 1 A study with a value of P < 0.05 may still have serious flaws 2 A low P-value does not imply causation 3 A study that has statistical significance does not necessarily have clinical significance For example, if drug X can lower blood pressure from 130 /80 to 129/80 mmHg with P < 0.0001,... the first 42 days after delivery)/100,000 live births 22 What five types of studies should you know for the Step 3 exam? From highest to lowest quality and desirability: (1) experimental studies, (2) prospective studies, (3) retrospective studies, (4) case series, and (5) prevalence surveys 23 What are experimental studies? Experimental studies are the gold standard They compare two equal groups in... of 2 years is more controversial and likely will not be asked in the USMLE 21 True or false: Current vaccine recommendations and schedules are always provided in the USMLE False However, because the timing of normal immunizations is constantly being updated, the administration schedule for common vaccines may be provided in the Step 3 exam Higheryield information relates to special patient populations... during the night, and awaken earlier in the morning It also takes longer for older persons to fall asleep (longer sleep latency) and they have less stage 3 and 4 and rapid eye movement sleep 9 Define pseudodementia How do you recognize it in the Step 3 exam? Depression in older individuals can resemble dementia Look for a history that would trigger depression (e.g., loss of a spouse, terminal or debilitating... reflex disappears and white is observed (known as leukocoria and classically caused by retinoblastoma; Fig 1-1) 13 True or false: Intermittent strabismus is normal before a certain age True It is normal for infants to have occasional ocular misalignment (strabismus) until 3 months of age After 3 months (or with constant eye deviation), strabismus should be evaluated and managed by an ophthalmologist to... self-examination is no longer recommended by the American Cancer Society Every 3 yr Annually Annually Testing is not recommended for asymptomatic individuals, even if they are at high risk Annual CT scan has been controversial, but in Dec 20 13 the USPSTF recommended an annual low-dose CT scan for asymptomatic adults aged 55-80 yr who have a 30 pack-year smoking history and currently smoke or have quit smoking... on the Step 3 exam Nothing happens to the incidence (the same number of people contract the disease every year), but the prevalence will increase because individuals with the disease live longer For short-term diseases (e.g., influenza) the incidence may be higher than the prevalence, whereas for chronic diseases (e.g., diabetes or hypertension) the prevalence is greater than the incidence 30 Define