Content Outline 2014 Usmle Changed To Final

Introduction
The United States Medical Licensing Examination (USMLE) is a three-step examination for
medical licensure in the United States and is sponsored by the Federation of State Medical
Boards (FSMB) and the National Board of Medical Examiners (NBME).
The Composite Committee, appointed by the FSMB and NBME, establishes policies for the
USMLE program. Membership includes representatives from the FSMB, NBME, Educational
Commission for Foreign Medical Graduates (ECFMG), and the American public.
If changes in the USMLE program occur after the release of this Bulletin, they will be effective
when posted at the USMLE website. You must obtain the most recent information to
understand current USMLE rules. If you are unable to access updated USMLE information via
the Internet, contact the USMLE Secretariat in writing to obtain updated information.

The Three Steps of the USMLE

Step 1 assesses the examinees understanding and ability to apply important
concepts of the sciences basic to the practice of medicine, with special emphasis on
principles and mechanisms underlying health, disease, and modes of therapy. Step 1
assesses your mastery of the sciences that provide a foundation for the safe and
competent practice of medicine in the present, as well as the scientific principles
required for the maintenance of competence through lifelong learning.

Step 2 assesses the examinees ability to apply medical knowledge, skills, and
understanding of clinical science essential for the provision of patient care under
supervision, with an emphasis on health promotion and disease prevention. Step 2
focuses on principles of clinical sciences and basic patient-centered skills that
provide the foundation for the safe and competent practice of medicine.

The clinical skills examination is a separately administered component of Step 2 and is
referred to as Step 2 Clinical Skills, or Step 2 CS. The computer-based, multiple-choice
component of Step 2 is referred to as Step 2 Clinical Knowledge, or Step 2 CK.

USMLE Step 2 CS is administered at five regional test centers (CSEC Centers) in the
United States.

Step 3 assesses the examinees understanding of biomedical and clinical science
essential for the unsupervised practice of medicine, with an emphasis on patient
management in ambulatory settings. Step 3 provides a final assessment of physicians
assuming independent responsibility for delivering general medical care.

The Comprehensive Review of the USMLE

Background
The USMLE examination program was designed in the late 1980s and introduced during the
period 1992 to 1994. While the content and design for the USMLE Step examinations have
been continuously reviewed and refreshed, until 2004 there had been no in-depth review of
overall program design and structure since the sequence was first conceived. In 2004, the
USMLE Composite Committee called for a comprehensive review of the entire USMLE
program to determine if the purpose of USMLE was being effectively and efficiently
supported by the current design, structure, and format.
This call for a review led to a multiyear process of gathering opinions of USMLE stakeholders
on the value of USMLE and on ways it might be improved. These data, which were provided
to the Committee to Evaluate the USMLE Program (CEUP), helped to shape a series of CEUP
recommendations designed to enhance USMLE. The full CEUP report and recommendations
are available at the USMLE website.

Current Status
The CEUP report and the implications of its recommendations have been carefully reviewed
by the staff and governing bodies of ECFMG, FSMB, and NBME and have led to a series of
modifications to test content representation, to changes in a number of existing test formats,
and to developmental efforts intended to expand the types of competencies addressed by
USMLE. Up-to-date information on the current status of this process is posted on the USMLE
website.
Changes to the Step 3 examination will occur beginning in November 2014. During an
approximate one-month period (October 2014), it is likely that no Step 3 exams will be
administered. Step 3 examinees planning to test in November 2014 or later should check the
USMLE website for up-to-date information.

Overview Step 1

Step 1 assesses whether you understand and can apply important concepts of the sciences
basic to the practice of medicine, with special emphasis on principles and mechanisms
underlying health, disease, and modes of therapy. Step 1 ensures mastery of not only the
sciences that provide a foundation for the safe and competent practice of medicine in the
present, but also the scientific principles required for maintenance of competence through
lifelong learning. Step 1 is constructed according to an integrated content outline that
organizes basic science material along two dimensions: system and process.
Step 1 is a one-day examination. The testing day includes 322 multiple-choice items divided
into 7 blocks of 46 items; 60 minutes are allotted for completion of each block of test items.
On the test day, examinees have a minimum of 45 minutes of break time and a 15- minute
optional tutorial. The amount of time available for breaks may be increased by finishing a
block of test items or the optional tutorial before the allotted time expires.

Content Description

Introduction

Step 1 consists of multiple-choice questions prepared by examination committees composed
of faculty members, teachers, investigators, and clinicians with recognized prominence in
their respective fields. Committee members are selected to provide broad representation
from the academic, practice, and licensing communities across the United States and
Canada. The test is designed to measure basic science knowledge. Some questions test the
examinee's fund of information per se, but the majority of questions require the examinee to
interpret graphic and tabular material, to identify gross and microscopic pathologic and
normal specimens, and to solve problems through application of basic science principles.
Step 1 is constructed from an integrated content outline that organizes basic science content
according to general principles and individual organ systems. Test questions are classified in
one of these major areas depending on whether they focus on concepts and principles that
are important across organ systems or within individual organ systems.
Sections focusing on individual organ systems are subdivided according to normal and
abnormal processes, principles of therapy, and psychosocial, cultural, and environmental
considerations. Each examination covers content related to the traditionally defined
disciplines of anatomy, behavioral sciences, biochemistry, microbiology, pathology,
pharmacology, and physiology, as well as to interdisciplinary areas including genetics, aging,
immunology, nutrition, and molecular and cell biology. While not all topics listed in the
content outline are included in every examination, overall content coverage is comparable
in the various examination forms that will be taken by different examinees.
The Step 1 content outline describes the scope of the examination in detail but is not
intended as a curriculum development or study guide. It provides a flexible structure for test
construction that can readily accommodate new topics, emerging content domains, and
shifts in emphasis. The categorizations and content coverage are subject to change. Broadly
based learning that establishes a strong general understanding of concepts and principles in
the basic sciences is the best preparation for the examination.
Content Outlines

1. General Principles
Biochemistry and molecular biology
gene expression: DNA structure, replication, exchange, and epigenetics
gene expression: transcription
gene expression: translation, post-translational processing, modifications, and
disposition of proteins (degradation), including protein/glycoprotein synthesis,
intra/extracellular sorting, and processes/functions related to Golgi complex and rough
endoplasmic reticulum
structure and function of proteins and enzymes
energy metabolism
Biology of cells
adaptive cell responses and cellular homeostasis
intracellular accumulations
mechanisms of injury and necrosis
apoptosis
mechanisms of dysregulation
o cell biology of cancer, including genetics of cancer
o general principles of invasion and metastasis, including cancer staging
cell/tissue structure, regulation, and function, including cytoskeleton, organelles,
glycolipids, channels, gap junctions, extracellular matrix, and receptors
Human development and genetics
principles of pedigree analysis
o inheritance patterns
o occurrence and recurrence risk determination
population genetics: Hardy-Weinberg law, founder effects, mutation-selection
equilibrium
principles of gene therapy
genetic testing and counseling
genetic mechanisms
Biology of tissue response to disease
acute inflammatory responses (patterns of response)
o acute inflammation and mediator systems
o vascular response to injury, including mediators
o principles of cell adherence and migration
o microbicidal mechanisms and tissue injury
o clinical manifestations
chronic inflammatory responses
reparative processes
o wound healing, hemostasis, and repair; thrombosis, granulation tissue, angiogenesis,
fibrosis, scar/keloid formation
o regenerative processes
Gender, ethnic, and behavioral considerations affecting disease treatment and
prevention, including psychosocial, cultural, occupational, and environmental
progression through the life cycle, including birth through senescence
o cognitive, language, motor skills, and social and interpersonal development
o sexual development
o influence of developmental stage on physician-patient interview
psychological and social factors influencing patient behavior
o personality traits or coping style, including coping mechanisms
o psychodynamic and behavioral factors, related past experience
o family and cultural factors, including socioeconomic status, ethnicity, and gender
o adaptive behavioral responses to stress and illness
o maladaptive behavioral responses to stress and illness
o interactions between the patient and the physician or the health care system
o patient adherence (general and adolescent)
patient interviewing, consultation, and interactions with the family
o establishing and maintaining rapport
o data gathering
o approaches to patient education
o enticing patients to make lifestyle changes
o communicating bad news
o "difficult" interviews
o multicultural ethnic characteristics
medical ethics, jurisprudence, and professional behavior
o consent and informed consent to treatment
o physician-patient relationships
o death and dying
o birth-related issues
o issues related to patient participation in research
o interactions with other health professionals, including impaired physician and patient
safety
o sexuality and the profession; other "boundary" issues
o ethics of managed care
o organization and cost of health care delivery
Multisystem processes
nutrition
o generation, expenditure, and storage of energy at the whole-body level
o assessment of nutritional status across the life span, including calories, protein,
essential nutrients, hypoalimentation
o functions of nutrients
o protein-calorie malnutrition
o vitamin deficiencies and/or toxicities (including megaloblastic anemia with other
findings)
o mineral deficiencies and toxicities
temperature regulation
adaptation to environmental extremes, including occupational exposures
o physical and associated disorders (including temperature, radiation, burns,
decreased atmospheric pressure, high-altitude sickness, increased water pressure)
o chemical (including gases, vapors, smoke inhalation, agricultural hazards, organic
solvents, heavy metals, principles of poisoning and therapy)
fluid, electrolyte, and acid-base balance disorders
inherited metabolic disorders, including disorders related to amino acids, purines,
porphyrins, carnitine, fatty acids, and carbohydrates
Pharmacodynamic and pharmacokinetic processes
general principles
o pharmacokinetics: absorption, distribution, metabolism, excretion, dosage intervals
o mechanisms of drug action, structure-activity relationships (including anticancer
drugs)
o concentration- and dose-effect relationships, types of agonists and antagonists and
their actions
o individual factors altering pharmacokinetics and pharmacodynamics
o mechanisms of drug adverse effects, overdosage, toxicology
o mechanisms of drug interactions
o regulatory issues
o signal transduction, including structure/function of all components of signal
transduction pathway such as receptors, ligands
o cell cycle/cell cycle regulation
Microbial biology and infection
microbial identification and classification, including principles, microorganism
identification, and nonimmunologic lab diagnosis
bacteria
o structure
o processes, replication, and genetics
o oncogenesis
o antibacterial agents
viruses
o structure
o oncogenesis
o antiviral agents
fungi
o structure
o antifungal agents
parasites
o structure
o antiparasitic agents
prions
epidemiology, outbreaks, and infection control
Quantitative methods
fundamental concepts of measurement
o scales of measurement
o distribution, central tendency, variability, probability
o disease prevalence and incidence
o disease outcomes
o associations
o health impact
o sensitivity, specificity, predictive values
fundamental concepts of study design
o types of experimental studies
o types of observational studies
o sampling and sample size
o subject selection and exposure allocation
o outcome assessment
o internal and external validity
fundamental concepts of hypothesis testing and statistical inference
o confidence intervals
o statistical significance and Type I error
o statistical power and Type II error

2. Hematopoietic and Lymphoreticular Systems
Normal processes
embryonic development, fetal maturation, and perinatal changes
organ structure and function
cell/tissue structure and function
o production and function of erythrocytes, hemoglobin, O2 and CO2 transport,
transport proteins
o production and function of platelets
o production and function of coagulation and fibrinolytic factors
repair, regeneration, and changes associated with stage of life
Abnormal processes
infectious, inflammatory, and immunologic disorders
o infections of the blood, reticuloendothelial system, and endothelial cells
o autoimmunity and autoimmune diseases
o anemia of chronic disease
o non-immunologically mediated transfusion complications, transplant rejection
traumatic and mechanical injury
neoplastic disorders (including lymphoma, leukemia, multiple myeloma,
dysproteinemias, amyloidosis)
metabolic and regulatory disorders, including acquired
o nutritional anemias
o cythemia
o hemorrhagic and hemostatic disorders
o bleeding secondary to platelet disorders and disorders of primary hemostasis
vascular and endothelial disorders
systemic disorders affecting the hematopoietic and lymphoreticular system
idiopathic disorders
degenerative disorders
drug-induced adverse effects on the hematopoietic and lymphoreticular systems
congenital and genetic disorders affecting the hematopoietic and lymphoreticular
systems
Principles of therapeutics
mechanisms of action and use of drugs for treatment of disorders of the hematopoietic
system
o blood and blood products
o treatment of anemia, drugs stimulating erythrocyte production
o drugs stimulating leukocyte production
o anticoagulants, thrombolytic drugs
o antiplatelet drugs
o antimicrobials and antiparasitics
o antineoplastic and immunosuppressive drugs in the clinical context of disease
other therapeutic modalities
emotional and behavioral factors
influence on person, family, and society
occupational and other environmental risk factors
gender and ethnic factors

3. Central and Peripheral Nervous Systems
Normal processes
embryonic development, fetal maturation, and perinatal changes, including neural
tube derivatives, cerebral ventricles, neural crest derivatives
o spinal cord, including gross anatomy, blood supply, and spinal reflexes
o brain stem
o brain, including gross anatomy and blood supply; cognition, language, memory;
hypothalamic function; limbic system and emotional behavior; circadian rhythms and
sleep; control of eye movement
o sensory systems, including proprioception, pain, vision, hearing, balance, taste, and
olfaction
o motor systems, including brain and spinal cord, basal ganglia, and cerebellum
o autonomic nervous system
o peripheral nerve
o axonal transport
o excitable properties of neurons, axons and dendrites, including channels
o synthesis, storage, release, reuptake, and degradation of neurotransmitters and
neuromodulators
o pre- and postsynaptic receptor interactions, trophic and growth factors
o brain metabolism
o glia, myelin
o brain homeostasis: blood-brain barrier; cerebrospinal fluid formation and flow; choroid
plexus
repair, regeneration, and changes associated with stage of life, including definition of
brain death
Abnormal processes
infectious, inflammatory, and immunologic disorders (including demyelinating disorders,
myasthenia gravis and muscle channelopathies, and disorders of the eye and ear)
traumatic and mechanical disorders
neoplastic disorders, including primary and metastatic
metabolic and regulatory disorders
vascular disorders
systemic disorders affecting the nervous system
idiopathic disorders affecting the nervous system
congenital and genetic disorders, including metabolic
paroxysmal disorders
disorders of special senses
psychopathologic disorders, processes, and their evaluation
o early-onset disorders
o disorders related to substance use
o schizophrenia and other psychotic disorders
o mood disorders
o anxiety disorders
o somatoform disorders
o personality disorders
o physical and sexual abuse of children, adults, and elders
o other disorders
drug-induced adverse effects on the central and peripheral nervous system
neurologic pain syndromes
mechanisms of action and use of drugs for treatment of disorders of the nervous system
o anesthetics
o hypnotic sedatives
o psychopharmacologic agents
o anticonvulsants
o analgesics
o stimulants, amphetamines
o antiparkinsonian drugs and drugs for dementia, Alzheimer type; multiple sclerosis; and
restless legs syndrome
o skeletal muscle relaxants, botulinum toxin
o neuromuscular junction agonists and antagonists
o antiglaucoma drugs
o drugs used to decrease intracranial pressure
o antimigraine agents
o drugs affecting the autonomic nervous system, including all general autonomic
pharmacology
o antimicrobials, antineoplastic drugs, and antiparasitics
o drugs used to treat cerebrovascular disorders
o treatment for substance abuse disorders

4. Skin and Related Connective Tissue
Normal processes
cell/tissue structure and function, including barrier functions, thermal regulation, eccrine
function
repair, regeneration, and changes associated with stage of life or ethnicity
skin defense mechanisms and normal flora
Abnormal processes
o bacterial infections
o viral infections
o fungal infections, including mycoses, dermatophytosis
o parasitic infections, ectoparasitic infestations, and mycobacterial infections
o immune and autoimmune disorders
traumatic and mechanical disorders (including thermal injury, decubitus ulcers, effects
of ultraviolet light and radiation)
neoplastic disorders
o keratinocytes
o melanocytes
o vascular neoplasms
o other
metabolic, regulatory, and structural disorders
vascular disorders
systemic disorders affecting the skin
drug-induced adverse effects on the skin and related connective tissue
congenital and genetic disorders affecting the skin and related connective tissue
mechanisms of action and use of drugs for treatment of disorders of the skin and
connective tissue
o anti-inflammatory agents
o emollients
o sunscreen
o retinoids
o antimicrobial and antiparasitic agents
o cytotoxic and immunologic therapy and antineoplastic drugs

5. Musculoskeletal System
Normal processes
o biology of bones, joints, tendons, skeletal muscle
o exercise and physical conditioning
Abnormal processes
traumatic and mechanical disorders (including fractures, sprains, strains, dislocations,
joint injuries, repetitive motion injuries, and impingement syndrome)
metabolic, regulatory, and structural disorders (including osteomalacia, osteoporosis,
osteodystrophy, gout, and pseudogout)
vascular disorders
systemic disorders affecting the musculoskeletal system
drug-induced adverse effects on the musculoskeletal system
congenital and genetic disorders affecting the musculoskeletal system
mechanisms of action and use of drugs for treatment of disorders of the
musculoskeletal system
o nonsteroidal anti-inflammatory drugs and analgesics
o muscle relaxants
o antigout therapy
o immunosuppressive and antineoplastic drugs
o drugs affecting bone mineralization

6. Respiratory System
Normal processes
o airways, including mechanics and regulation of breathing
o lung parenchyma, including ventilation, perfusion, gas exchange
o pleura
o nasopharyx and sinuses
cell/tissue structure and function, including surfactant formation, alveolar structure
pulmonary defense mechanisms and normal flora
Abnormal processes
o infectious diseases
o infectious diseases of the upper respiratory tract
o pyogenic infectious diseases of the lower respiratory tract and pleura, viral
infections, and associated complications
o other infectious diseases of the lower respiratory tract
o immunologic disorders
o allergic and hypersensitivity disorders
o autoimmune disorders
o inflammatory disorders
o pneumoconioses
o acute and chronic alveolar injury
o chronic obstructive pulmonary disease
o restrictive pulmonary disease
neoplastic disorders (including upper airway, lower airway and lung parenchyma,
pleura, and metastatic tumors)
metabolic, regulatory, and structural disorders
vascular and circulatory disorders (including thromboembolic disease, pulmonary
hypertension, pulmonary edema, and pleural effusion)
systemic disorders affecting the respiratory system
drug-induced adverse effects on the respiratory system
congenital and genetic disorders affecting the respiratory system
mechanisms of action and use of drugs for treatment of disorders of the respiratory
system
o decongestants, cough suppressants, expectorants, mucolytics
o bronchodilator drugs
o anti-inflammatory and cytotoxic drugs
o antimicrobial agents and antiparasitic agents
o antineoplastic agents
o pulmonary vasodilators

7. Cardiovascular System
Normal processes
o chambers, valves
o cardiac cycle, mechanics, heart sounds, cardiac conduction
o hemodynamics, including systemic, pulmonary, coronary, and blood volume
o circulation in specific vascular beds
o heart muscle, metabolism, oxygen consumption, biochemistry, and secretory function
o endothelium and secretory function, vascular smooth muscle, microcirculation, and
lymph flow (including mechanisms of atherosclerosis)
o neural and hormonal regulation of the heart, blood vessels, and blood volume,
including responses to change in posture, exercise, and tissue metabolism
Abnormal processes
metabolic and regulatory disorders (including dysrhythmias, systolic and diastolic
dysfunction, low- and high-output heart failure, cor pulmonale, systemic hypertension,
ischemic heart disease, myocardial infarction, systemic hypotension and shock, and
dyslipidemias)
vascular disorders
systemic diseases affecting the cardiovascular system
congenital and genetic disorders of the heart and central vessels
drug-induced adverse effects on the cardiovascular system
mechanisms of action and use of drugs for treatment of disorders of the cardiovascular
system
o coronary and peripheral vasodilators
o antiarrhythmic drugs
o antihypertensive drugs
o measures used to combat hypotension and shock
o drugs affecting cholesterol and lipid metabolism
o drugs affecting blood coagulation, thrombolytic agents, and antiplatelet agents
o inotropic agents and treatment of heart failure
o immunosuppressive, antimicrobial, antineoplastic, and antiparasitic drugs
o drugs to treat peripheral arterial disease
o other pharmacotherapy

8. Gastrointestinal System
Normal processes
organ structure and function, including alimentary canal, liver and biliary system,
salivary glands and exocrine pancreas, motility, and digestion and absorption
o endocrine and neural regulatory functions, including GI hormones
o salivary, gastrointestinal, pancreatic, hepatic secretory products, including enzymes,
proteins, bile salts, and processes
o synthetic and metabolic functions of hepatocytes
gastrointestinal defense mechanisms and normal flora
Abnormal processes
o malocclusion
o hiatal hernia
o obstruction
o perforation of hollow viscus and blunt trauma
o inguinal, femoral, and abdominal wall hernias
o esophageal, intestinal, and colonic diverticula
neoplastic disorders, including benign and malignant
metabolic and regulatory disorders (including motility disorders, malabsorption, hepatic
failure, cholelithiasis, nutritional disorders)
vascular disorders (including portal hypertension, esophageal varices, hemorrhoids,
anal fissure, ischemia, angiodysplasia, thromboses, vasculitis)
systemic disorders affecting the gastrointestinal system
drug-induced adverse effects on the gastrointestinal system
congenital and genetic disorders affecting the gastrointestinal system
mechanisms of action and use of drugs for treatment of disorders of the gastrointestinal
system
o treatment and prophylaxis of peptic ulcer disease and gastroesophageal reflux
o drugs to alter gastrointestinal motility
o fluid replacement
o pancreatic replacement therapy and treatment of pancreatitis
o drugs for treatment of hepatic failure and biliary disease
o anti-inflammatory, immunosuppressive, antineoplastic, antimicrobial, and
antiparasitic drugs

9. Renal/Urinary System
Normal processes
o kidneys, ureters, bladder, urethra
o glomerular filtration and hemodynamics
o tubular reabsorption and secretion, including transport processes and proteins
o urinary concentration and dilution
o renal mechanisms in acid-base balance
o renal mechanisms in body fluid homeostasis
o micturition
cell/tissue structure and function, including renal metabolism and oxygen consumption,
hormones produced by or acting on the kidney
Abnormal processes
o infectious disorders
o upper urinary tract
o lower urinary tract
o inflammatory and immunologic disorders
o glomerular disorders
o tubular interstitial disease
neoplastic disorders, including primary and metastases
metabolic and regulatory disorders
o renal failure, acute and chronic
o tubular and collecting duct disorders
o renal calculi
vascular disorders
systemic diseases affecting the renal system
drug-induced adverse effects on the renal/urinary system
congenital and genetic disorders affecting the renal/urinary system
mechanisms of action and use of drugs for treatment of disorders of the renal and
urinary system
o diuretics, antidiuretic drugs
o drugs and fluids used to treat volume, electrolyte, and acid-base disorders
o drugs used to enhance renal perfusion
o anti-inflammatory, antimicrobial, immunosuppressive, antineoplastic, and
antiparasitic drugs
o drugs used to treat lower urinary tract system

10. Reproductive System
Normal processes
embryonic development, fetal maturation, and perinatal changes, including
gametogenesis
o female structure, including breast
o female function
o male structure
o male function
o intercourse, orgasm
o pregnancy, including ovulation, fertilization, implantation, labor and delivery, the
puerperium, lactation, gestational uterus, placenta
cell/tissue structure and function, including hypothalamic-pituitary-gonadal axis, sex
steroids, and gestational hormones
reproductive system defense mechanisms and normal flora
Abnormal processes
infectious, inflammatory, and immunologic disorders (female and male)
traumatic and mechanical disorders (female and male)
neoplastic disorders (including female reproductive, male reproductive, breast
[including fibrocystic changes], trophoblastic disease)
metabolic and regulatory processes (female and male)
prenatal and perinatal counseling and screening
systemic disorders affecting reproductive function
disorders relating to pregnancy, the puerperium, and the postpartum period
o obstetric problems
o complications affecting other organ systems
o disorders associated with the puerperium
o antepartum, intrapartum, postpartum disorders of the fetus
drug-induced adverse effects on the reproductive system
congenital and genetic disorders affecting the reproductive system
mechanisms of action and use of drugs for treatment of disorders of the reproductive
system and management of normal reproductive function
o female reproductive tract
o fertility drugs
o oral contraception, other methods of contraception
o estrogen, progesterone replacement, treatment of menopause
o stimulants and inhibitors of labor
o estrogen and progesterone antagonists
o stimulators and inhibitors of lactation
o male reproductive tract
o fertility drugs
o androgen replacement and antagonists
o gonadotropin-releasing hormone and gonadotropin replacement, including all
gonadotropin-releasing hormone antagonists
o abortifacients
o antineoplastics
o restoration of potency
other therapeutic modalities affecting the reproductive system
family planning and pregnancy
gender identity, sexual orientation, sexuality, libido
effects of traumatic stress syndrome, violence, rape, child abuse

11. Endocrine System
Normal processes
o hypothalamus, posterior and anterior pituitary gland
o thyroid gland
o parathyroid glands
o adrenal cortex, adrenal medulla
o pancreatic islets
o ovary and testis
o adipose tissue
cell/tissue structure and function, including hormone synthesis, secretion, action, and
metabolism
o peptide hormones
o steroid hormones, including vitamin D
o thyroid hormones
o catecholamine hormones
o renin-angiotensin system
Abnormal processes
neoplastic disorders (including pituitary, thyroid, parathyroid, adrenal cortex,
pancreatic islets, neural crest, pheochromocytoma)
metabolic and regulatory processes (including diabetes mellitus, pituitary,
hypothalamus, thyroid, parathyroid, pancreatic islet disorders, adrenal disorders)
vascular disorders
systemic disorders affecting the endocrine system
drug-induced adverse effects on the endocrine system
congenital and genetic disorders affecting the endocrine system
mechanisms of action and use of drugs for treatment of disorders of the endocrine
system
o hormones and hormone analogs
o stimulators of hormone production
o inhibitors of hormone production
o hormone antagonists
o potentiators of hormone action
o antiobesity agents
o nonhormonal therapy for endocrine disorders
o other treatment for diabetes

12. Immune System
Normal processes
development of cells of the adaptive immune response, including positive and
negative selection during immune development
structure, production, and function
o granulocytes, natural killer cells, macrophages, mast cells, dendritic cells, cell
receptors
o T lymphocytes, including T-lymphocyte receptors, accessory molecules, cell
activation and proliferation, cytotoxic T lymphocytes, and memory T lymphocytes
o B lymphocytes and plasma cells, including B-lymphocyte receptors, immunoglobulins,
cell activation and proliferation, including development of antibodies and memory B
lymphocytes
o structure and function of lymph nodes, host defense mechanisms, host barriers to
infection, mucosal immunity
o immunogenetics
o Rh and ABO antigens, including genetics
cellular basis of the immune response and immunologic mediators
o antigen processing and presentation in the context of MHC I and MHC II molecules,
including distribution of MHC I and MHC II on different cells, mechanism of MHC I and
MHC II deficiencies, and the genetics of MHC
o regulation of the adaptive immune response
o activation, function, and molecular biology of complement
o function and molecular biology of cytokines
basis of immunologic diagnosis
Abnormal processes
disorders with alterations in immunologic function
o abnormalities in adaptive immune responses
o deficiencies of phagocytic cells and natural killer cells
o complement deficiency
o HIV infection/AIDS
o Non-HIV infections of lymphocytes
o systemic diseases of immunologic function
o systemic disorders affecting the immune system and the effect of age on the function
of components of the immune system
immunologically mediated disorders
o type I, type II, type III hypersensitivity
o type IV hypersensitivity
o transplantation risks and rejection, including transfusion reactions
o isoimmunization, hemolytic disease of the newborn
drug-induced adverse effects on the immune system, including Jarisch-Herxheimer
mechanisms of action and use of drugs that specifically affect immune function
o vaccines (active and passive)
o antiretrovirals
o immunomodulating and antineoplastic drugs
o biologics, including monoclonal and polyclonal antibodies

Test Question Formats

Step 1 consists of multiple choice questions with only one best answer. Each question will be
structured with a statement or question followed by three to eleven response options, each
labeled with a letter (e.g: A, B, C, D, E) and arranged logically or alphabetically. Some
response options will be partially correct, but only one option will be the best and correct
answer. A portion of these questions will also involve the interpretaion of graphs and images.
The questions are prepared by examination committees composed of faculty members,
teachers, investigators, and clinicians with recognized prominence in their respective fields.
Committee members are selected to provide broad representation from the academic,
practice, and licensing communities across the United States and Canada.
Strategies for Answering the Test Questions

Read each question carefully. It is important to understand what is being asked.
Try to generate an answer and then look for it in the option list.
Alternatively, read each option carefully, eliminating those that are clearly
incorrect.
Of the remaining options, select the one that is most correct.
If unsure about an answer, it is better to guess since unanswered questions are
automatically counted as wrong answers.

Example Question
A 32-year-old woman with type 1 diabetes mellitus has had progressive renal failure
over the past 2 years. She has not yet started dialysis. Examination shows no
abnormalities. Her hemoglobin concentration is 9 g/dL, hematocrit is 28%, and mean
corpuscular volume is 94 m3. A blood smear shows normochromic, normocytic cells.
Which of the following is the most likely cause?
A. Acute blood loss
B. Chronic lymphocytic leukemia
C. Erythrocyte enzyme deficiency
D. Erythropoietin deficiency
E. Immunohemolysis
F. Microangiopathic hemolysis
G. Polycythemia vera
H. Sickle cell disease
I. Sideroblastic anemia
J. b-Thalassemia trait
(Answer: D)
Sequential Item Sets

A single patient-centered vignette may be associated with two or three consecutive
questions about the information presented. Each question is linked to the initial patient
vignette but is testing a different point. Questions are designed to be answered in sequential
order. You are required to select the one best answer to each question. Other options may
be partially correct, but there is only ONE BEST answer. You must click "Proceed to Next Item"
to view the next item in the set; once you click on this button, you will not be able to add or
change an answer to the displayed (previous) item.

Overview Step 2 Clinical Knowledge (Step 2 CK)

Step 2 assesses whether you can apply medical knowledge, skills, and understanding of
clinical science essential for the provision of patient care under supervision and includes
emphasis on health promotion and disease prevention. Step 2 ensures that due attention is
devoted to principles of clinical sciences and basic patient-centered skills that provide the
foundation for the safe and competent practice of medicine.
Step 2 CK is constructed according to an integrated content outline that organizes clinical
science material along two dimensions: physician task and disease category.
Step 2 CK is a one-day examination. The test items are divided into blocks, and test item
formats may vary within each block.
The number of items in a block will be displayed at the beginning of each block. This number
will vary among blocks, but will not exceed 45 items. The total number of items on the overall
examination form will not exceed 355 items. Regardless of the number of items, 60 minutes
are allotted for the completion of each block.
On the test day, examinees have a minimum of 45 minutes of break time and a 15- minute
optional tutorial. The amount of time available for breaks may be increased by finishing a
block of test items or the optional tutorial before the allotted time expires.
Content Description

Step 2 Clinical Knowledge (Step 2 CK) consists of multiple-choice questions prepared by
examination committees composed of faculty members, teachers, investigators, and
clinicians with recognized prominence in their respective fields. Committee members are
selected to provide broad representation from the academic, practice, and licensing
communities across the United States and Canada. Test questions focus on the principles of
clinical science that are deemed important for the practice of medicine under supervision in
postgraduate training. The examination is constructed from an integrated content outline
that organizes clinical science material along two dimensions.

Normal Conditions and Disease categories (Dimension 1) form the main axis for organizing the
outline. The first section deals with normal growth and development, basic concepts, and
general principles. The remaining sections deal with individual disorders.
Sections focusing on individual disorders are subdivided according to Physician Task
(Dimension 2). The first set of physician tasks, Promoting Preventive Medicine and Health
Maintenance, encompasses the assessment of risk factors, appreciation of epidemiologic
data, and the application of primary and secondary preventive measures.
The second set of tasks, Understanding Mechanisms of Disease, encompasses etiology,
pathophysiology, and effects of treatment modalities in the broadest sense.
The third set of tasks, Establishing a Diagnosis, pertains to interpretation of history and physical
findings and the results of laboratory, imaging, and other studies to determine the most likely
diagnosis or the most appropriate next step in diagnosis.
The fourth set of tasks, Applying Principles of Management, concerns the approach to care
of patients with chronic and acute conditions in ambulatory and inpatient settings. Questions
in this category will focus on the same topics covered in the diagnosis sections.
The diseases noted in the outline do not represent an all-inclusive registry of disorders about
which questions may be asked. They reflect the development of a "High-Impact Disease List"
that includes common problems, less common problems where early detection or treatability
are important considerations, and noteworthy exemplars of pathophysiology. Questions are
generally, but not exclusively, focused on the listed disorders. In addition, not all listed topics
are included on each examination.
The Step 2 CK content outline is not intended as a curriculum development or study guide. It
provides a flexible structure for test construction that can readily accommodate new topics,
emerging content domains, and shifts in emphases. The categorizations and content
coverage are subject to change. Broadly based learning that establishes a strong general
foundation of understanding of concepts and principles in the clinical sciences is the best
preparation for the examination.

Content Outlines

Infancy and Childhood
Normal growth and development
Adolescence
Sexuality; separation from parents/autonomy; physical changes of puberty
Senescence
Normal physical and mental changes associated with aging
Medical Ethics and Jurisprudence
Consent and informed consent to treatment (eg, full disclosure, alternate therapies, risks
and benefits, life-support, advance directives, health care proxy) and research issues
(eg, consent, placebos, conflict of interest, vulnerable populations)
Physician-patient relationship (eg, truth-telling, confidentiality, privacy, autonomy,
public reporting) and birth-related issues (eg, prenatal diagnosis, abortion, maternal-
fetal conflict)
Death and dying (eg, diagnosing death, organ donation, euthanasia, physician-
assisted suicide) and palliative care (eg, hospice, pain management, family
counseling, psychosocial and spiritual issues, fear and loneliness)
Applied Biostatistics and Clinical Epidemiology
Understanding statistical concepts of measurement in medical practice
Interpretation of the medical literature
Systems-Based Practice and Patient Safety
Systems-based practice and quality improvement (microsystems and teams including
hand-offs, standardization of processes, reducing deviance)
Patient safety, medical errors and near misses (sentinel events, problem identification,
root cause analysis)

2. Infectious and Parasitic Diseases
(Topic covered under each organ system)

3. Neoplasms

4. Immunologic Disorders
Health and Health Maintenance
Anaphylaxis and other allergic reactions
HIV infection/AIDS
Immunization against infectious agents (including infants, children, adults, the elderly;
patients having compromised immune systems)
Mechanisms of Disease
Abnormalities of cell-mediated immunity
Abnormalities of humoral immunity
Diagnosis
Anaphylactic reactions and shock
Connective tissue disorders (eg, mixed connective tissue disease and systemic lupus
erythematosus)
HIV infection/AIDS; deficiencies of cell-mediated immunity
Deficiencies of humoral immunity; combined immune deficiency
Principles of Management
(With emphasis on topics covered in Diagnosis)
Pharmacotherapy only
Management decision (treatment/diagnosis steps)
Treatment only

5. Diseases of the Blood and Blood-forming Organs
Anemia (iron deficiency, vitamin-related, drug-induced, sickle cell)
Infection(systemic)
Red cell disorders
Coagulation disorders
White cell disorders, including leukopenia, agranulocytosis, and neoplasms
Diagnosis
Anemia, disorders of red cells, hemoglobin, and iron metabolism (eg, blood loss; iron
deficiency anemia, nutritional deficiencies; pernicious anemia, other megaloblastic
anemias; hemolytic anemia; anemia associated with chronic disease; aplastic anemia,
pancytopenia; thalassemia; sickle cell disease; polycythemia vera; hemochromatosis)
Bleeding disorders, coagulopathies, thrombocytopenia (eg, hemophilia, von Willebrand
disease; qualitative and quantitative platelet deficiencies; disseminated intravascular
coagulation; hypofibrinogenemia; immune thrombocytopenic purpura; hemolytic-
uremic syndrome)
Neoplastic disorders (eg, Hodgkin disease, non-Hodgkin lymphomas; acute leukemia in
children; acute leukemia in adults; chronic leukemic states; mycosis fungoides; multiple
myeloma)
Eosinophilia and reactions to transfusion of blood components (including
complications) and leukopenic disorders, agranulocytosis
Infection (eg, sepsis, malaria, mononucleosis)
Treatment only

6. Mental Disorders
Early identification and intervention (eg, suicide potential, depression,
alcohol/substance abuse, family involvement in schizophrenia)
Biologic markers of mental disorders and mental retardation syndromes
Intended/unintended effects of therapeutic interventions, including effects of drugs on
neurotransmitters
Diagnosis
Mental disorders usually first diagnosed in infancy, childhood, or adolescence (eg,
mental retardation; communication disorders; pervasive developmental disorders;
attention-deficit/hyperactivity disorder; disruptive disorders; tic disorders; elimination
disorders)
Substance-related disorders (eg, alcohol and other substances)
Schizophrenia and other psychotic disorders
Mood disorders (eg, bipolar disorders; major unipolar depressive disorders; dysthymic
disorder; mood disorder due to a general medical condition; medication-induced
mood disorder)
Anxiety disorders (eg, panic disorder; phobia; obsessive-compulsive disorder; post-
traumatic stress disorder; generalized anxiety disorder; acute stress disorder; separation
anxiety disorder; anxiety due to a general medical condition; substance-induced
anxiety disorder)
Somatoform disorders (eg, factitious disorder; somatization disorder; pain disorder;
conversion disorder; hypochondriasis)
Other disorders/conditions (eg, sexual and gender identity disorders; personality
disorders; child, spouse, elder abuse; eating disorders; adjustment disorders; dissociative
disorders; psychological factors affecting medical conditions)
Treatment only

7. Diseases of the Nervous System and Special Senses
Cerebrovascular disease, cerebral infarction
Nutritional deficiencies, toxic injuries, and occupational disorders including lead,
carbon monoxide, and organophosphate poisoning
Infection involving the nervous system, eyes, or ears
Degenerative and demyelinating disorders, including Alzheimer disease and multiple
sclerosis
Localizing anatomy:
o brain and special senses
o brain stem
o spinal cord
o neuromuscular system
Anatomy of cerebral circulation
Increased intracranial pressure and altered state of consciousness
Infection
Degenerative/developmental and metabolic disorders
Diagnosis
Disorders of the eye (eg, blindness; glaucoma; infection; papilledema; optic atrophy;
retinal disorders; diabetic retinopathy; diplopia; cataract; neoplasms; vascular
disorders; uveitis; iridocyclitis; traumatic, toxic injury; toxoplasmosis)
Disorders of the ear, olfaction, and taste (eg, deafness, hearing loss, otitis, mastoiditis;
vertigo, tinnitus, Meniere disease; acoustic neuroma; traumatic, toxic injury)
Disorders of the nervous system:
o paroxysmal disorders (eg, headache; trigeminal neuralgia; seizure disorders; syncope)
o cerebrovascular disease (eg, intracerebral hemorrhage; ischemic disorders;
aneurysm, subarachnoid hemorrhage; cavernous sinus thrombosis)
o traumatic, toxic injury; including lead, carbon monoxide, and organophosphate
poisoning
o infections (eg, bacterial, fungal, viral, opportunistic infection in immunocompromised
patients; Lyme disease; abscess; neurosyphilis; Guillain-Barr syndrome)
o neoplasms (eg, primary; metastatic; neurofibromatosis)
o metabolic disorders (eg, metabolic encephalopathy, vitamin B12 [cobalamin]
deficiency, vitamin B1 [thiamine] deficiency; coma, confusion, delirium, dementia)
o degenerative and developmental disorders (eg, Alzheimer disease; Huntington
disease; parkinsonism; amyotrophic lateral sclerosis; Tay-Sachs disease; multiple
sclerosis; cerebral palsy; dyslexia)
o neuromuscular disorders, gait abnormalities, and disorders relating to the spine and
spinal nerve roots (eg, myasthenia gravis; muscular dystrophy; peripheral neuropathy;
neck pain; cervical radiculopathy; lumbosacral radiculopathy; spinal stenosis)
o sleep disorders (eg, narcolepsy, idiopathic hypersomnolence, restless legs syndrome,
REM sleep behavior disorder, circadian rhythm sleep disorder, sleep apnea)
Treatment only

8. Cardiovascular Disorders
Arterial hypertension
Atherosclerosis and coronary artery disease; hyperlipidemia
Prevention of rheumatic heart disease, thromboembolic disease, pulmonary emboli,
bacterial endocarditis
Cardiac output, resistance, central venous pressure
Valvular stenosis, incompetence
Congenital heart disease
Regulation of blood pressure
Disorders of the arteries and veins
Diagnosis
Dysrhythmias; palpitations, syncope (eg, premature beats; paroxysmal tachycardias;
atrial flutter and fibrillation; bradycardias; ventricular fibrillation; cardiac arrest)
Heart failure (congestive, diastolic, systolic dysfunction), dyspnea, fatigue, peripheral
edema of cardiac origin (eg, chronic heart failure; cor pulmonale)
Ischemic heart disease; chest pain of cardiac origin (eg, angina pectoris; coronary
insufficiency; myocardial infarction)
Diseases of the myocardium (eg, hypertrophic; myocarditis)
Diseases of the pericardium (eg, acute pericarditis; chronic constrictive
pericardiopathy; pericardial effusion; pericardial tamponade)
Valvular heart disease (eg, acute rheumatic fever; mitral and aortic valve disorders;
infective endocarditis)
Congenital cardiovascular disease (eg, patent ductus arteriosus; atrial septal defect;
ventricular septal defect; endocardial cushion defect; tetralogy of Fallot; coarctation
of the aorta)
Systemic hypotension, hypovolemia, cardiogenic shock; cyanosis
Arterial hypertension (eg, essential; secondary)
Atherosclerosis - lipoproteins
Disorders of the great vessels (eg, dissecting aortic aneurysm; ruptured aneurysm;
aortoiliac disease)
Peripheral arterial vascular diseases, vasculitis (eg, polyarteritis; temporal arteritis;
arteriovenous fistula)
Diseases of the veins, peripheral edema (eg, varicose veins; thrombophlebitis; deep
venous thrombosis)
Traumatic injury
Treatment only

9. Diseases of the Respiratory System
Chronic bronchitis, asthma, emphysema, carcinoma of the larynx, carcinoma of the
lung; pulmonary aspiration, atelectasis; tuberculosis
Ventilatory dysfunction (eg, obstructive disorders: asthma, chronic obstructive
pulmonary disease, cystic fibrosis, bronchitis, bronchiectasis, emphysema)
Respiratory failure, acute and chronic, including oxygenation failure (eg, interstitial
pneumonitis, pulmonary edema, acute respiratory distress syndrome, ventilation failure)
Circulatory dysfunction
Neoplastic disorders
Diagnosis
Disorders of the nose, paranasal sinuses, pharynx, larynx, and trachea (eg, rhinitis;
pharyngitis, tonsillitis, peritonsillar abscess; thrush; sinusitis; acute laryngotracheitis;
epiglottitis; carcinoma of the larynx; laryngeal/pharyngeal obstruction; trauma;
tracheoesophageal fistula)
Infections of the lung (eg, acute bronchiolitis; pneumonia; tuberculosis)
Obstructive airways disease (eg, chronic bronchitis, bronchiectasis; asthma,
bronchospasm, wheezing; emphysema, ?1-antitrypsin deficiency; cystic fibrosis)
Atelectasis, pulmonary aspiration
Pneumothorax, hemothorax, traumatic injury to the lungs and disorders involving the
pleura (eg, pleurisy; pleural effusion)
Pneumoconiosis, fibrosing or restrictive pulmonary disorders (eg, asbestosis; silicosis;
sarcoidosis)
Respiratory failure, hypoxia, hypercapnia, dyspnea (eg, respiratory distress syndrome of
the newborn; acute respiratory distress syndrome; acute and chronic respiratory failure;
drowning)
Pulmonary vascular disorders (eg, pulmonary embolism; pulmonary hypertension;
pulmonary edema)
Neoplastic disorders of the lungs and pleura (eg, primary tumors; metastatic tumors)
Treatment only

10. Nutritional and Digestive Disorders
Screening (eg, cancer)
Viral hepatitis and alcohol-related hepatopathy
Malabsorption/malnutrition
Jaundice
Infections/parasites
Obstruction/mechanical
Diagnosis
Disorders of the mouth, salivary glands, oropharynx, and esophagus (eg, dental
disorders; disorders of the salivary glands; esophageal reflux; dysphagia; motility
disorders of the esophagus; hiatal hernia; carcinoma of the esophagus)
Disorders of the stomach, small intestine, colon, and rectum/anus (eg, gastritis; peptic
ulcer disease; congenital disorders; malabsorption; appendicitis; granulomatous
enterocolitis; ischemic colitis; irritable bowel syndrome; diverticula; colonic polyps;
ulcerative colitis; peritonitis; bowel obstruction, volvulus, intussusception; hernia;
necrotizing enterocolitis; infection; carcinoma of the stomach, colon, and rectum;
antibiotic-associated colitis; hemorrhoids; anal fissures; anal fistula; perianal/perirectal
abscess)
Disorders of the pancreas (eg, pancreatitis; pseudocyst; carcinoma of the pancreas)
Disorders of the liver and biliary system (eg, hepatitis; cirrhosis; hepatic failure, hepatic
encephalopathy, jaundice; portal hypertension; ascites, esophageal varices;
cholelithiasis; cholecystitis; hepatic abscess, subphrenic abscess; neoplasms of the liver;
storage diseases; neoplasms of the biliary tract)
Traumatic injury and poisoning (including drain cleaner ingestion)
Treatment only

11. Gynecologic Disorders
Postmenarchal/reproductive
Peri/postmenopausal
Infections (eg, vulvovaginitis; pelvic inflammatory disease; toxic shock; sexually
transmitted disease; endometritis; urethritis; Bartholin gland abscess; abscess of the
breast; mastitis)
Urinary incontinence and obstruction
Menstrual and endocrinologic disorders; infertility
Diagnosis
Pelvic relaxation and urinary incontinence (eg, urinary tract infection; uterovaginal
prolapse; cystocele, rectocele, urethrocele)
Neoplasms (eg, cervical dysplasia, cancer; leiomyomata uteri; endometrial cancer;
ovarian neoplasms; neoplastic disorders of the breast; vulvar neoplasms)
Benign conditions of the breast
Menstrual and endocrinologic disorders (eg, amenorrhea [including undiagnosed
pregnancy]; abnormal uterine bleeding; dysmenorrhea; menopausal, postmenopausal
disorders [osteoporosis]; premenstrual syndrome; hirsutism, virilization; ovarian disorders
[ovarian failure, polycystic ovarian syndrome])
Sexual abuse and rape
Treatment only

12. Renal, Urinary, and Male Reproductive Systems
Infection (eg, urinary tract, sexually transmitted diseases [male])
Acute and chronic renal failure including risk factors and prevention and methods of
limiting progression
Male health maintenance examination (eg, testicular, prostatic)
Disorders of the male reproductive system
Urinary incontinence and obstruction, enuresis
Renal insufficiency/failure
Electrolyte and water metabolism and acid-base balance
Diagnosis
Disorders of the male reproductive system (eg, infections; torsion of the testis;
undescended testicle; neoplasms of the testis; benign prostatic hyperplasia; carcinoma
of the prostate; hypospadias; hydrocele, varicocele; urethral stricture, impotence,
premature ejaculation)
Disorders of the urinary bladder and urinary collecting system (eg, cystitis; pyelitis;
dysuria, hematuria, pyuria; carcinoma of the bladder; urolithiasis; ureteral reflux;
neurogenic bladder; urinary incontinence; enuresis; obstruction; hydronephrosis)
Disorders of the kidneys (eg, pyelonephritis; glomerulonephritis; interstitial nephropathy;
renal insufficiency and failure; oliguria, anuria, azotemia, uremia, renal osteodystrophy;
hypertensive renal disease; lupus nephritis; inherited disorders)
Traumatic injury
Treatment only

13. Disorders of Pregnancy, Childbirth, and the Puerperium
Prenatal care (eg, nutrition; prevention of iron deficiency; prevention of vitamin
deficiency; Rh immunoglobulin prophylaxis; prenatal diagnosis; teratology, diabetes
mellitus, urinary tract infection, ?-fetoprotein, rubella, genital herpes, streptococcal
infections)
Assessment of the at-risk pregnancy; risk of preterm labor
Intrapartum care; signs of fetal compromise
Contraception; sterilization; prevention of pregnancy after rape
Placenta, placental dysfunction
Pregnancy and labor, including infection
Postpartum disorders, including infection
Fetus and newborn
Diagnosis
Pregnancy and labor, including obstetric complications (eg, ectopic pregnancy;
spontaneous abortion/septic abortion; hypertension; third-trimester bleeding;
hydramnios; preterm labor, premature rupture of the membranes, normal labor;
multiple gestation; intrapartum fetal distress/fetal death; maternal mortality; fetal
growth and development abnormalities; congenital abnormalities; gestational
trophoblastic disease)
Nonobstetric complications of pregnancy (eg, major medical complications and
preexisting medical conditions; surgical complications; hyperemesis gravidarum)
Complications of the puerperium (eg, problems with breast-feeding; postpartum
hemorrhage; postpartum sepsis; postpartum depression, psychosis; mastitis; venous
thromboembolism)
Treatment only

14. Disorders of the Skin and Subcutaneous Tissues
Epidemiology and prevention of skin disorders secondary to exposure to the sun;
contact dermatitis and drug reactions; decubitus ulcers; dermatophytic skin disorders
Skin disorders, including cancer, infections, and inflammatory disorders
Diagnosis
Infections (eg, herpes simplex, herpes zoster, chickenpox; cellulitis, carbuncle, abscess,
gangrene; dermatophytoses; pilonidal cyst; viral warts; decubitus ulcers)
Neoplasms (eg, squamous cell carcinoma; melanoma; actinic keratosis, basal cell
carcinoma; pigmented nevi; hemangiomas)
Other skin disorders (eg, industrial, occupational, and atopic dermatitis; psoriasis;
seborrhea; acne)
Treatment only

15. Diseases of the Musculoskeletal System and Connective Tissue
Epidemiology, impact, and prevention of degenerative joint and disc disease
Prevention of disability due to musculoskeletal disorders or infection (eg, osteomyelitis;
septic arthritis; Lyme disease; gonococcal tenosynovitis)
Infections
Nerve compressions and degenerative, metabolic, and nutritional disorders
Inherited, congenital, or developmental disorders
Inflammatory or immunologic disorders
Diagnosis
Infections (eg, osteomyelitis; septic arthritis; Lyme disease; gonococcal tenosynovitis)
Degenerative, metabolic, and nutritional disorders (eg, degenerative joint disease;
degenerative disc disease; gout; rickets)
Inherited, congenital, or developmental disorders (eg, congenital hip dysplasia;
phocomelia; osteochondritis; slipped capital femoral epiphysis; scoliosis; syringomyelia,
dislocated hip in infantile spinal muscular atrophy)
Inflammatory, immunologic, and other disorders (eg, polymyalgia rheumatica; lupus
arthritis; polymyositis-dermatomyositis; rheumatoid arthritis; ankylosing spondylitis; bursitis;
tendinitis; myofascial pain; fibromyalgia; shoulder-hand syndrome; Dupuytren
contracture; Paget disease)
Neoplasms (eg, osteosarcoma; metastases to bone; pulmonary osteoarthropathy)
Traumatic injury and nerve compression and injury (eg, fractures, sprains, dislocations,
carpal tunnel syndrome; cauda equina syndrome, low back pain)
Treatment only

16. Endocrine and Metabolic Disorders
Diabetes mellitus, including prevention of morbidity and mortality due to complications
Screening (eg, cancer)
Thyroid function
Diabetes mellitus and carbohydrate metabolism
Parathyroid and calcium metabolism
Pituitary and hypothalamic function
Adrenal function
Diagnosis
Thyroid disorders (eg, nodule; carcinoma; acquired hypothyroidism; thyroiditis;
thyrotoxicosis; congenital hypothyroidism; goiter)
Diabetes mellitus (eg, type 1, type 2; ketoacidosis; hyperosmolar coma; chronic
complications)
Parathyroid and calcium disorders (eg, hyperparathyroidism; hypoparathyroidism), and
hypoglycemia and hyperinsulinism (eg, iatrogenic; insulinoma)
Pituitary, hypothalamic disorders (eg, diabetes insipidus; inappropriate ADH secretion;
panhypopituitarism; acromegaly)
Adrenal disorders (eg, corticoadrenal insufficiency; Cushing syndrome; adrenogenital
syndrome; hyperaldosteronism; pheochromocytoma)
Heat-related illness
Treatment only

17. Congenital Anomalies

18. Conditions Originating in the Perinatal Period
(Topic covered under Disorders of Pregnancy, Childbirth, and the Puerperium)

19. Symptoms, Signs, and Ill-defined Conditions

20. Injury and Poisoning


Step 2 CK consists of multiple choice questions with only one best answer. Each question will
be structured with a statement or question followed by three to twenty-six response options,
each labeled with a letter (e.g: A, B, C, D, E) and arranged logically or alphabetically. Some
response options will be partially correct, but only one option will be the best and correct
answer.
Strategies for Answering the Test Questions

Read each question carefully. It is important to understand what is being asked.

Alternatively, read each option carefully, eliminating those that are clearly
incorrect.
Example Question
A 32-year-old woman with type 1 diabetes mellitus has had progressive renal failure
over the past 2 years. She is not yet on dialysis. Examination shows no abnormalities.
Her hemoglobin concentration is 9 g/dL, hematocrit is 28%, and mean corpuscular
volume is 94 m3. A blood smear shows normochromic, normocytic cells. Which of the
following is the most likely cause?
A. Acute blood loss
B. Chronic lymphocytic leukemia
C. Erythrocyte enzyme deficiency
D. Erythropoietin deficiency
E. Immunohemolysis
F. Microangiopathic hemolysis
G. Polycythemia vera
H. Sickle cell disease
I. Sideroblastic anemia
J. -Thalassemia trait
(Answer: D)
Sequential Item Sets

questions about the information presented. Each question is linked to the initial patient
order. You are required to select the one best answer to each question. Other options may
be partially correct, but there is only ONE BEST answer. You must click Proceed to Next Item
to view the next item in the set; once you click on this button, you will not be able to add or
change an answer to the displayed (previous) item.
Matching Sets

This format consists of a series of questions related to a common topic. All matching sets
contain set-specific instructions, a list of lettered response options, and at least two questions.
There will be between four and twenty-six response options. Each set is preceded by a box
that indicates the number of questions in the set associated with the response options that
follow. Examinees are directed to select one answer for each question in the set. Questions
will be presented one at a time, with instructions and response options repeated for each
subsequent question.
Strategies for Answering Matching Sets

Begin each set by reading through the option list to become familiar with the
available responses.
Read each question carefully.
Within a set, some options may be used several times, while other options may
not be used at all. Respond to each question independently.
For matching sets with large numbers of options, try to generate an answer to the
question and then locate the answer in the option list. This is more efficient than
considering each option individually.
Example Questions (Matching Set)
(The response options for items 2-3 are the same. You will be required to select one
answer for each item in the set. )
A. Chronic lymphocytic leukemia
B. Drug reaction
C. Hodgkin disease
D. Infectious mononucleosis
E. Metastatic carcinoma
F. Sarcoidosis
G. Systemic lupus erythematosus
H. Toxoplasmosis
I. Tuberculosis
J. Tularemia
For each patient with lymphadenopathy, select the most likely diagnosis.
2. A previously healthy 30-year-old man has had fever, night sweats, pruritus, and an
enlarging lump above his left clavicle for 3 weeks. Examination shows a 3-cm,
nontender, rubbery, supraclavicular lymph node. An x-ray of the chest shows
mediastinal lymphadenopathy.
(Answer: C)
3. A 41-year-old woman comes to the physician for a follow-up examination. She has
taken aspirin for chronic headaches and phenytoin for a seizure disorder for 2 years.
Examination shows mild epigastric tenderness and bilateral, 3-cm, nontender axillary
lymph nodes. A lymph node biopsy shows hyperplasia.
(Answer: B)
Pharmaceutical Advertisement (Drug Ad) Format
The drug ad item format includes a rich stimulus presented in a manner commonly
encountered by a physician, eg, as a printed advertisement in a medical journal. Examinees
must interpret the presented material in order to answer questions on various topics, including
Decisions about care of an individual patient
Biostatistics/epidemiology
Pharmacology/therapeutics
Development and approval of drugs and dietary supplements
Medical ethics
Abstract Format
The abstract item format includes a summary of an experiment or clinical investigation
presented in a manner commonly encountered by a physician, eg, as an abstract that
accompanies a research report in a medical journal. Examinees must interpret the abstract in
order to answer questions on various topics, including
Use of diagnostic studies

Overview Step 2 CS (Clinical Skills)

Step 2 of the USMLE assesses the ability of examinees to apply medical knowledge, skills, and
understanding of clinical science essential for the provision of patient care under supervision,
and includes emphasis on health promotion and disease prevention. Step 2 ensures that due
attention is devoted to the principles of clinical sciences and basic patient- centered skills
that provide the foundation for the safe and effective practice of medicine.
Step 2 CS uses standardized patients to test medical students and graduates on their ability
to gather information from patients, perform physical examinations, and communicate their
findings to patients and colleagues.

1. On-Site Orientation

Each examination session begins with an on-site orientation. If you arrive during the on-site
orientation, you may be allowed to test; however, you will be required to sign a Late
Admission Form. If you arrive after the on-site orientation, you will not be allowed to test. You
will have to reschedule your testing appointment and will be required to pay the
rescheduling fee.
*The clinical skills evaluation centers are secured facilities. Once you enter the secured area
of the center for orientation, you may not leave that area until the examination is complete.

2. The Patient Encounter

Your Step 2 CS administration will include twelve patient encounters. These include a very
small number of nonscored patient encounters, which are added for pilot testing new cases
and other research purposes. Such cases are not counted in determining your score. You will
have15 minutes for each.
Announcements will tell you when to begin the patient encounter, when there are 5 minutes
remaining, and when the patient encounter is over. In some cases you may complete the
patient encounter in fewer than 15 minutes. If so, you may leave the examination room early,
but you are not permitted to re-enter. Be certain that you have obtained all necessary
information before leaving the examination room. Re-entering an examination room after
leaving will be considered misconduct. Continuing to engage the patient after the
announcement to stop has been made may be considered irregular behavior, will be
reported to the USMLE, and could jeopardize your continued participation in the USMLE
program.
If you are unsuccessful at Step 2 CS and must, therefore, repeat the examination, it is
possible that during your repeat examination you will see similarities to cases or
patients that you encountered on your prior attempt. Do not assume that the
underlying problems are the same or that the encounter will unfold in exactly the
same way. It is best if you approach each encounter, whether it seems familiar or not,
with an open mind, responding appropriately to the information provided, the history
gathered, and the results of the physical examination.
The Standardized Patient & Physical Examination
You should perform physical examination maneuvers correctly and expect that there
will be positive physical findings in some instances. Some may be simulated, but you
should accept them as real and factor them into your evolving differential diagnoses.
You should attend to appropriate hygiene and to patient comfort and modesty, as
you would in the care of real patients. Female patients will be wearing bras, which
you may ask them to loosen or move if necessary for a proper examination.
With real patients in a normal clinical setting, it is possible to obtain meaningful
information during your physical examination without being unnecessarily forceful in
palpating, percussing, or carrying out other maneuvers that involve touching. Your
approach to examining standardized patients should be no different. Standardized
patients are subjected to repeated physical examinations during the Step 2 CS
exam; it is critical that you apply no more than the amount of pressure that is
appropriate during maneuvers such as abdominal examination, examination of the
gall bladder and liver, eliciting CVA tenderness, examination of the ears with an
otoscope, and examination of the throat with a tongue depressor.
When you enter the room, you will usually encounter a standardized patient (if not, you will
be asked to communicate with a standardized patient over the telephone). By relating to the
patient in a patient-centered manner, asking relevant questions, and performing a focused
physical examination, you will be able to gather enough information to develop a preliminary
differential diagnosis and a diagnostic work-up plan, as well as begin to develop an effective
physician-patient relationship.
You will be expected to communicate with the standardized patients in a professional and
empathetic manner. As you would when encountering real patients, you should answer any
questions they may have, tell them what diagnoses you are considering, and advise them on
what tests and studies you will order to clarify their diagnoses.
The information you need to obtain in each encounter will be determined by the nature of
the patients problems. Your approach should be focused. You will not have time to do a
complete history and physical examination, nor will it be necessary to do so. Pursue the
relevant parts of the examination, based on the patients problems and other information
you learn during the encounter.
You will not have time to do a complete physical examination on every patient, nor will it be
necessary to do so. Pursue the relevant parts of the examination, based on the patient's
problems and other information you obtain during the history taking.
You should interact with the standardized patients as you would with any patients you may
see with similar problems. The only exception is that certain parts of the physical
examination must not be done: rectal, pelvic, genitourinary, inguinal hernia, female breast, or
corneal reflex examinations. If you believe one or more of these examinations are indicated,
you should include them in your proposed diagnostic work-up. All other examination
maneuvers are completely acceptable, including femoral pulse exam, inguinal node exam,
back exam, and axillary exam.
Another exception is that you should not swab the standardized patient's throat for a throat
culture. If you believe that this diagnostic/laboratory test is indicated, include it on your
proposed diagnostic workup.
Synthetic models, mannequins, or simulators provide an appropriate format for assessment of
sensitive examination skills such as genital or rectal examination. Specific instructions will be
provided in cases where this is necessary.
Excluding the restricted physical examination maneuvers, you should assume that you have
consent to do a physical examination on all standardized patients, unless you are explicitly
told not to do so as part of the examinee instructions for that case.
The cases are developed to present in a manner that simulates how patients present in real
clinical settings. Therefore, most cases are designed realistically to present more than one
diagnostic possibility. Based on the patient's presenting complaint and the additional
information you obtain as you begin taking the history, you should consider all possible
diagnoses and explore the relevant ones as time permits.
Telephone Patient Encounters
Telephone patient encounters begin like all encounters; you will read a doorway instruction
sheet that provides specific information about the patient. As with all patient encounters, as
soon as you hear the announcement that the encounter has begun, you may make notes
about the case before entering the examination room.
When you enter the room, sit at the desk in front of the telephone.
Do not dial any numbers.
To place the call, press the yellow speaker button.
You will be permitted to make only one phone call.
Do not touch any buttons on the phone until you are ready to end the call - touching any
buttons may disconnect you.
To end the call, press the yellow speaker button.
You will not be allowed to call back after you end the call.
Obviously, physical examination of the patient is not possible for telephone encounters, and
will not be required. However, for these cases, as for all others, you will have relevant
information and instructions and will be able to take a history and ask questions. As with other
cases, you will write a patient note after the encounter. Because no physical examination is
possible for telephone cases, leave that section of the patient note blank.

3. The Patient Note

Immediately after each patient encounter, you will have 10 minutes to complete a patient
note. If you leave the patient encounter early, you may use the additional time for the note.
You will be asked to type (on a computer) a patient note similar to the medical record you
would compose after seeing a patient in a clinic, office, or emergency department.
Examinees will not be permitted to handwrite the note, unless technical difficulties on the test
day make the patient note typing program unavailable.
Patient notes are rated by licensed, board-certified physicians who are well trained at
reading notes and can interpret most handwriting. However, extreme illegibility will be a
problem and can adversely impact a score. Everyone who writes patient notes by hand
should make them as legible as possible.
You should record pertinent medical history and physical examination findings obtained
during the encounter, as well as your initial differential diagnoses (maximum of three). The
diagnoses should be listed in order of likelihood. You should also indicate the pertinent
positive and negative findings obtained from the history and physical examination to support
each potential diagnosis.
While it is important that a physician be able to recognize findings that rule out certain serious
or life-threatening diagnoses, the task for Step 2 CS examinees is to record only the
most likelydiagnoses, along with findings (positive and negative) that support them.
Finally, you will list the diagnostic studies you would order next for that particular patient. If
you think a rectal, pelvic, inguinal hernia, genitourinary, female breast, or corneal reflex
examination, or a throat swab, would have been indicated in the encounter, list it as part of
the diagnostic studies. Treatment, consultations, or referrals should not be included.

Overview Step 3

Step 3 assesses whether you can apply medical knowledge and understanding of
biomedical and clinical science essential for the unsupervised practice of medicine, with
emphasis on patient management in ambulatory settings. It is the final examination in the
USMLE sequence leading to a license to practice medicine without supervision. The
examination material is prepared by examination committees broadly representing the
medical profession. The committees comprise recognized experts in their fields, including
both academic and non-academic practitioners, as well as members of state medical
licensing boards. Step 3 content reflects a data-based model of generalist medical practice
in the United States. The test items and cases reflect the clinical situations that a general, as-
yet undifferentiated, physician might encounter within the context of a specific setting. Step 3
provides a final assessment of physicians assuming independent responsibility for delivering
general medical care.

Purpose of the Step 3 Exam
The purpose of Step 3 is to determine if a physician possesses and can apply the medical
knowledge and understanding of clinical science considered essential for the unsupervised
practice of medicine, with emphasis on patient management in ambulatory care settings.
The inclusion of Step 3 in the USMLE sequence of licensing examinations ensures that attention
is devoted to the importance of assessing the knowledge and skills of physicians who are
assuming independent responsibility for providing general medical care to patients.
Step 3 emphasizes selected physician tasks, namely, evaluating severity of patient
problems and managing therapy. Assessment of clinical judgment will be prominent.
Clinical problems involve mainstream, high-impact diseases. Provision is made for less
common but important clinical problems as well.
Test items and cases are patient centered, starting with a description of a clinical
encounter (vignette). Both the multiple-choice items and case simulations pose action-
related challenges that require clinical decisions or judgment.
Emphasis is on ambulatory patient encounters; however, inpatient encounters of
significant complexity and reflecting contemporary trends also are represented.
Provision is made for incorporating applied basic and clinical science concepts,
especially as they relate to justification for prognosis or management. It is assumed that
basic science and clinical fundamentals have been assessed adequately in
theprerequisite Step 1 and Step 2 examinations.

Exam Layout
Step 3 is a two-day examination. You must complete each day of testing within 8 hours.
The first day of testing includes 336 multiple-choice items divided into 7 blocks of 48 items
each. There will be 60 minutes of time allowed for completion of each block of test
items. Items with an associated pharmaceutical ad or abstract are included in some of these
multiple choice blocks. Those blocks that include these item types will contain 4647 items
per block. The timing will remain the same for all blocks. There is a maximum of 7 hours of
testing on the first day. There is also a minimum of 45 minutes of break time and a 15-minute
optional tutorial. Note that the amount of time available for breaks may be increased by
finishing a block of test items or the optional tutorial before the allotted time expires.
The second day of testing includes 144 multiple-choice items, divided into 4 blocks of 36
items. These blocks will take 45 minutes. The total time allotted for these blocks is 3 hours. The
second day also includes a Primum Tutorial and instructions for which approximately 15
minutes are allowed. This is followed by 12 case simulations, for which 4 hours are allotted. A
minimum of 45 minutes is available for break time. There is an optional survey at the end of
the second day, which can be completed if time allows. The timing and structure of the Step
3 testing days may change without notice.

The Exam

The bulk of Step 3 is intended to challenge you to consider the severity of illness and to
manage ambulatory patients who have previously diagnosed, frequently occurring chronic
illnesses and behavioral/emotional problems. The expected outcome of the USMLE process is
a general unrestricted license to practice medicine without supervision.
Step 3 patients are intended to reflect the diversity of health care populations with respect to
age, sex, cultural group, and occupation. The patient population mix is intended to be
representative of data collected from various national databases that study health care in
the United States.
Clinical Settings

Assessing the patient's situation in the context of his or her environment or family is an
important element of many Step 3 questions. The exam questions are usually arranged by the
setting in which the patient encounter first occurs; there are two clinical settings on this exam.
To help orient you, each setting is described at the beginning of the corresponding test block.
As is done for the actual examination, the sample test items are arranged in blocks that are
organized by one of the two clinical settings.

Setting I: Office/Health Center
You see patients in two locations: an office suite, which is adjacent to a hospital, or a
community-based health center. Patients are seen for routine and urgent care. The
laboratory and radiology departments have a full range of services available. Your office
practice is in a primary care generalist group. Occasionally you will see a patient cared for
by one of your associates and reference may be made to the patient's medical records.
Known patients may be managed by telephone. You may have to respond to questions
about information appearing in the public media, which will require interpretation of the
medical literature.

Setting II: Emergency Department and Inpatient Facilities
You encounter patients in the emergency department and inpatient facilities, including the
hospital, the adjacent nursing home/extended-care facility, and detoxification unit. Most
patients in the emergency department are new to you and are seeking urgent care, but
occasionally you arrange to meet there with a known patient who has telephoned you. You
have general admitting privileges to the hospital, including to the children's and women's
services. On occasion you see patients in the critical care unit. Postoperative patients are
usually seen in their rooms unless the recovery room is specified. You may also be called to
see patients in the psychiatric unit. There is a short-stay unit where you may see patients
undergoing same-day operations or being held for observation. Also available to you is a full
range of social services, including rape crisis intervention, family support, and security
assistance backed up by local police.
Clinical Encounter Frame

The content description that follows is not intended as a study guide, but rather is a model of
the range of challenges that will be met in the actual practice of medicine. Successful
completion of at least one year of postgraduate training in a program accredited by the
Accreditation Council for Graduate Medical Education or the American Osteopathic
Association should be helpful preparation for Step 3.

Initial Workup Continuing Care Urgent Intervention
Patient
Encounters
Description
Characterized by
initial assessment and
management of
clinical problems
among patients seen
principally
in ambulatory
settings for thefirst
time. These
encounters may also
include new
problems arising in
patients for whom a
history is available.
Characterized by
continuing
management of
previously diagnosed
clinical problems
among patients known
to the physician and
seen principally in
ambulatory settings.
Encounters focused on
health maintenance
are located in this
frame. Also included
are patient encounters
characterized by
acute exacerbations
or complications,
principally of chronic,
progressive conditions
among patients known
to the physician. These
encounters may occur
in in-patient settings.
Characterized by
prompt assessment
and management of
life-threatening and
organ- threatening
emergencies, usually
occurring in
emergency
department settings.
Occasionally, these
encounters may
occur in the context
of a hospitalized
patient.
Clinical
Problems
Include ill-defined
signs and symptoms;
behavioral-
emotional; acute
limited; initial
manifestation and
Include frequently
occurring chronic
diseases and
behavioral-emotional
problems. Periodic
health evaluations of
Include severe life-
threatening and
organ-threatening
conditions and
exacerbations of
Initial Workup Continuing Care Urgent Intervention
presentation of
chronic illness.
established patients
are included here.
chronic illness.
Emphasized
Physician
Tasks
Include data
gathering and initial
clinical intervention.
Assessment of
patients may lead to
urgent intervention.
Include recognition of
new problems in an
existing condition,
assessment of severity,
establishing prognosis,
monitoring therapy,
and long-term
management.
Include rapid
assessment of
complex
presentations,
assessment of
patients'
deteriorating
condition, and
prompt decision
making.
Physician Tasks

Applying Scientific Concepts

Objectives focus on identifying the underlying processes or pathways responsible for a given
condition, recognizing associated disease conditions and complications, and recognizing
and evaluating clinical findings or diagnostic studies to identify the underlying factors (eg,
anatomic structure).

Formulating a Diagnosis

History and Physical Examination objectives focus on interpreting the patient's history,
knowing pertinent factors in the patient's history, interpreting the history in terms of risk
factors for the patient, recognizing and interpreting pertinent physical findings, and
knowing required techniques in the physical examination.
Laboratory and Diagnostic Studies objectives focus on selecting the appropriate routine,
initial, invasive, special, or follow-up studies; interpreting the results of laboratory or
diagnostic tests; knowing the value of and indications for screening tests; and predicting
the most likely test result.
Diagnosis objectives focus on selecting the most likely diagnosis in light of history,
physical, or diagnostic test findings. Includes interpreting pictorial material and
establishing a diagnosis.
Prognosis objectives focus on interpreting the vignette, evaluating the severity of the
patient's condition, and making judgment on the current status or prognosis of the
patient as to the need for further action.

Managing the Patient

Health Maintenance objectives focus on identifying risk factors, knowing incidence within
patient groups at risk, knowing preliminary steps to ensure effectiveness of intended
therapy, and selecting appropriate preventive therapeutic agents or techniques.
Clinical Intervention objectives focus on knowing priorities in emergency management,
knowing present and long-term management of selected conditions, and knowing
appropriate surgical treatment, including pre- and post-surgical events. They also include
knowing pre- and post-procedural management and the appropriate follow-up
schedule or monitoring approach.
Clinical Therapeutics objectives focus on selecting the appropriate pharmacotherapy,
recognizing actions of drugs as applied to patient management, and knowing the
importance of educating patients about effects of drugs and drug-drug interactions.
Legal/ethical and health care systems objectives focus on issues such as patient
autonomy, physician/patient relationships, use of unorthodox or experimental therapies,
end-of-life considerations, treatment of minors, and physician error versus negligence.

Evaluative Objectives

Applying Scientific Concepts
Identifies the cause/causal agent or predisposing factor(s); or, given an effect, what is the
cause.
Identifies the underlying processes/pathways that account for, or contribute to, the
expression or resolution of a given condition.
Recognizes or evaluates given clinical or physical findings to identify the underlying
anatomic structure or physical location.
Interprets results of clinical studies

Obtaining History and Perfoming a Physical Examination
Knows signs/symptoms of selected disorders.
Knows individual's risk factors for development of condition leading to encounter. Given
current symptoms in presented history, identifies pertinent factor(s) in history.
Predicts the most likely additional physical finding; selects either the finding itself, or the
appropriate examination technique that would result in the finding.
Given a specific problem, knows what to ask in obtaining pertinent additional history.

Using Laboratory and Diagnostic Studies
Selects appropriate routine or initial laboratory or diagnostic studies, or study needed to
ensure effectiveness of intended therapy, or study most likely to establish/confirm the
diagnosis.
Interprets the clinical impact of laboratory or diagnostic test findings.
Predicts the most likely laboratory or diagnostic test result.

Formulating the Most Likely Diagnosis
Selects the most likely diagnosis or knows the most likely presumptive or preliminary
diagnosis.

Evaluating the Severity of Patient Problems (Prognosis)
Evaluates severity of patient condition and identifies indications for consultation or
diagnostic assessment.
Assesses severity of patient condition and makes judgment as to current status, prognosis,
or need for further action.
Recognizes factors in the history, or physical or laboratory study findings (given symptoms),
that affect patient prognosis or outcome, or determine therapy.
Interprets laboratory or diagnostic study results and identifies current status of patient.
Recognizes associated disease conditions, including complications, or indicators for
potential disease complications, of a given disease.
Recognizes characteristics of disease relating to natural history or course of disease,
including progression, severity, duration, and transmission of disease.
Knows appropriate counseling of patient or family regarding current and future problems,
including risk factors related to present encounter.

Management of Health Maintenance and Disease Prevention
Knows risk factors for conditions amenable to prevention or detection in an asymptomatic
patient, or knows the potential condition itself.
Knows pertinent incidence statistics and identifies patient groups at risk; knows incidence
of symptomless/dangerous disorders among various groups.
Knows common screening tests for conditions amenable to prevention or detection in an
asymptomatic patient or population.
Selects appropriate preventive, therapeutic agent/technique. Knows timing of
vaccinations.

Clinical Interventions
Evaluates severity of patient condition in terms of need for referral for surgical
treatments/procedures versus other nonsurgical options.
Knows immediate management or priority in management, specifically in emergency or
acute cases.
Knows most appropriate management of selected conditions.
Knows appropriate long-term treatment or management goals.
Knows appropriate surgical management among surgical options.
Knows pre/post surgical or procedural management.
Knows indications for admission to the hospital or to another appropriate setting.
Knows most appropriate follow-up monitoring approach regarding the management plan.
Knows most appropriate discharge planning.
Knows components of rehabilitation program.
Educates patient or family regarding self-care.
Knows relevant roles of allied health personnel.
Knows appropriate use and procedures regarding hospice care.

Clinical Therapeutics
Selects most appropriate pharmacotherapy.
Assesses patient adherence with treatment regimen, recognizes techniques to increase
adherence or understanding of the disease state, and knows how adherence may be
affected by providing instructions with therapy.
Recognizes factors that alter drug requirements for a patient.
Knows adverse effects of various drugs, or recognizes signs and symptoms of drug (and
drug-drug) interactions resulting from polypharmacy in the therapeutic regimen and
knows steps to prevent polypharmacy.
Knows contraindications of various medications.
Modifies therapeutic regimen within the context of continuing care.

Communication
Recognizes physician's best choice of words in eliciting history or further description of the
patient's problem; knows statements that facilitate communication with the patient.

Content Outlines

Normal Development
Infancy/Childhood (eg, normal growth and development)
Adolescence (eg, sexuality, physical changes of puberty)
Adult (eg, normal physical findings and lifestyle issues)
Senescence (eg, normal physical and mental changes of aging)
Medical Ethics and Jurisprudence
Consent and Informed Consent to Treatment (eg, full disclosure, advance
directives/health care proxy, permission to treat, competency, autonomy)
Physician/Patient Relationship (eg, truth-telling, confidentiality, privacy, adult
maltreatment [including elder abuse], child maltreatment [child abuse])
Death and Dying (eg, diagnosing death, organ donation, euthanasia/physician-
assisted suicide, palliative care)
Applied Biostatistics and Clinical Epidemiology
Understanding Statistical Concepts (eg, understanding statistical concepts,
calculations of one thing/multiple things, mixed calculations/interpretations)
Interpretation of the Medical Literature (eg, interpretation of a study statement,
reading a table or graph, evaluation of the validity of the author's conclusion,
identification of the study flaw, design of a study)
Systems-Based Care and Patient Safety
Systems-Based Practice and Quality Improvement (eg, microsystems and teams
including hand-offs, standardization of processes, reducing deviance)
Patient Safety, Medical Errors and Near Misses (eg, sentinel events, problem
identification, root cause analysis)

2. Disorders of the Nervous System and Special Senses
Degenerative/Developmental Disorders (eg, Alzheimer disease, Parkinson disease,
multiple sclerosis, cerebral palsy)
Neuromuscular/Degenerative Disorders (eg, paraplegia, myasthenia gravis, spinal
stenosis, neuritis)
Cerebrovascular Diseases (eg, intracranial hemorrhage, transient cerebral ischemias,
stroke, vascular dementia [multi-infarct dementia])
Peripheral Nerve Diseases (eg, carpal tunnel syndrome, nerve compression,
neuropathy)
Headache and Movement Disorders (eg, seizure disorder, trigeminal neuralgia, Bell
palsy, torticollis)
Sleep Disorders (eg, night terrors and sleepwalking, cataplexy and narcolepsy)
Neoplasms (eg, meningioma, metastatic lesions)
Infectious Diseases (eg, tetanus, Creutzfeldt-Jakob disease, meningitis, encephalitis)
Trauma and Toxic Effects (eg, intracranial injury, brain death, coma, concussion)
Disorders of the Eye (eg, glaucoma, retinal detachment, cataract, corneal abrasion)
Disorders of the Ear (eg, perforation of tympanic membrane, acoustic neuroma,
hearing loss, vertigo)

3. Disorders of the Respiratory System
Obstructive Airways Disease (eg, cystic fibrosis, chronic bronchitis, emphysema,
asthma)
Pneumoconiosis/Fibrosing or Restrictive Pulmonary Disorders (eg, sarcoidosis,
asbestosis, pneumoconiosis, pulmonary fibrosis)
Respiratory Failure & Pulmonary Vascular Disease (eg, pulmonary hypertension,
respiratory distress syndrome, atelectasis, pulmonary embolism)
Upper Respiratory Conditions (eg, sinusitis, peritonsillar abscess, otitis, streptococcal
throat infection)
Neoplasms (eg, mesothelioma, paraneoplastic syndrome)
Lung Infections (eg, pulmonary tuberculosis, pneumonia, influenza, respiratory
syncytial virus)
Trauma and Toxic Effects (eg, pleurisy, pleural effusion, pneumothorax, drowning and
nonfatal submersion)

4. Cardiovascular Disorders
Hypotension (eg, orthostatic hypotension, hypotensive emergency)
Ischemic Heart Disease and Atherosclerosis (eg, myocardial infarction, ischemic
heart disease, angina pectoris, hyperlipidemia, arteriosclerosis)
Congestive Heart Failure (eg, congestive heart failure, left heart failure)
Dysrhythmias (eg, atrioventricular block, paroxysmal supraventricular tachycardia,
fibrillation and flutter, cardiac arrest)
Disorders of the Great Vessels (eg, atherosclerosis of aorta, dissecting aneurysm,
aortic aneurysm)
Valvular Heart Disease (eg, rheumatic heart disease, endocarditis, valve disorders,
functional murmurs)
Peripheral Arterial Vascular Diseases (eg, Raynaud syndrome, intermittent
claudication, arterial embolism/thrombosis)
Diseases of Veins (eg, phlebitis/thrombophlebitis, deep venous thrombosis, varicose
veins, venous insufficiency)
Congenital Disease (eg, ventricular/atrial septal defect, patent ductus arteriosus,
coarctation of aorta, tetralogy of Fallot)
Diseases of Myocardium (eg, hypertensive cardiomegaly, hypertrophic
cardiomyopathy, myocarditis)
Diseases of Pericardium (eg, pericarditis, pericardial tamponade)
Trauma and Toxic Effects (eg, cardiovascular injury, fat embolism)

5. Nutritional and Digestive System Disorders
Mouth, Salivary Glands, and Esophagus (eg, malignant neoplasm of mouth/salivary
glands/esophagus, esophageal varices, esophagitis/esophageal reflux,
diaphragmatic hernia)
Stomach (eg, neoplasm of stomach, gastric ulcer problems, peptic ulcer problems,
gastritis and duodenitis)
Small Intestine/Colon and Rectum (eg, inflammatory bowel disease, diverticula, anal
fissure or fistula, celiac disease)
Gallbladder and Bile Duct (eg, calculus of gallbladder, cholangitis, obstruction of
common bile duct and biliary atresia)
Liver (eg, acute hepatic failure, cirrhosis, ascites, fatty liver disease)
Pancreas (eg, neoplasm of pancreas or Islets of Langerhans, pancreatitis, cyst and
pseudocyst of pancreas)
Nutritional Disorders (eg, obesity, malnutrition and malabsorption)
Infections (eg, gastroenteritis, coxsackievirus, candidiasis of mouth [thrush], hepatitis
A/B/C, Helicobacter pylori)
Trauma and Toxic Effects (eg, food poisoning, hernia of abdominal cavity, ventral
hernia)

6. Behavioral/Emotional Disorders
Psychotic Disorders (eg, schizophrenia, paranoid state, psychotic disorder)
Anxiety Disorders (eg, panic disorder [panic attacks], phobic disorders, obsessive-
compulsive disorders, posttraumatic stress disorder)
Mood Disorders (eg, dysthymic disorder, depressive disorders, bipolar disorders,
postpartum depression)
Somatoform Disorders (eg, somatization disorder, malingering, conversion disorder,
hypochondriasis [including body dysmorphic disorder])
Eating Disorders and Other Impulse Control Disorders (eg, bulimia, disorders of impulse
control [gambling, shoplifting], binge eating disorder)
Disorders Originating in Infancy/Childhood/Adolescence (eg, oppositional defiant
disorder, attention-deficit/hyperactivity disorder, developmental speech or language
disorder, autistic disorder)
Personality Disorders (eg, antisocial personality disorder, dependent personality
disorder, paranoid personality disorder, schizoid personality disorder)
Psychosocial Problems (eg, psychosexual dysfunction, bereavement)
Substance Use Disorders (eg, alcohol abuse and dependence, alcohol withdrawal
syndrome, cocaine/opiates/sedatives/hypnotics abuse and dependence)
Toxic Effects (eg, poisoning by psychotropic agents, including antidepressants)

7. Disorders of the Musculoskeletal System
Degenerative/Metabolic Disorders (eg, gout, osteoarthritis, avascular necrosis of
bone, disc displacement)
Inflammatory/Immunologic Disorders (eg, ankylosis/spondylopathy, rheumatoid
arthritis, synovitis/tenosynovitis, myalgia and myositis)
Hereditary Developmental Disorders (eg, genu valgum or varum, congenital
dislocation of hip, scoliosis, varus/valgus deformities of feet)
Neoplasms (eg, secondary malignant neoplasm of bone and bone marrow,
osteosarcoma)
Infections (eg, infective arthritis, infective myositis, Lyme disease, osteomyelitis)
Traumatic Injuries (eg, tears, fractures, dislocations, contusions)

8. Disorders of the Skin/Subcutaneous Tissue
Skin Eruptions (eg, contact dermatitis, erythema multiforme, psoriasis, decubitus ulcer)
Disorders of Nails/Hair/Sweat Glands (eg, ingrowing nail, seborrhea
capitis/folliculitis/sycosis, hirsutism, hyperhidrosis)
Lumps/Tumors of the Skin (eg, malignant melanoma of skin/lip, keratoderma,
sebaceous cyst, neurofibromatosis)
Infections (eg, tinea infections, cellulitis and abscess, erythema infectiosum,
molluscum contagiosum)
Trauma and Toxic Effects (eg, wounds or burns affecting the skin or subcutaneous
tissue, keloid scar, Stevens-Johnson syndrome, frostbite)

9. Disorders of the Endocrine System
Thyroid Disorders (eg, malignant neoplasm of thyroid gland, thyrotoxicosis,
hypothyroidism, thyroiditis)
Diabetes Mellitus (eg, ketoacidosis, renal manifestations, neurologic manifestations,
hypoglycemic shock)
Adrenal Disorders (eg, neuroblastoma, hyperaldosteronism, congenital adrenal
hyperplasia, corticoadrenal insufficiency [Addison disease])
Parathyroid/Pituitary Disorders (eg, hyperparathyroidism, hypoparathyroidism,
prolactinoma, pheochromocytoma)
Trauma and Toxic Effects (eg, heat syncope, heat stroke and sun stroke, heat
exhaustion)

10. Renal and Urinary Disorders
Lower Urinary Tract (eg, neurogenic bladder, enuresis/incontinence of urine, urinary
obstruction, cystitis)
Upper Urinary Tract (eg, glomerulonephritis, renal failure/insufficiency, polycystic
kidney disease, calculus of kidney/ureter/urinary tract)
Fluid, Electrolyte, and Acid-Base Disorders (eg, dehydration, hypovolemia, electrolyte
imbalances, metabolic disorders)
Infections (eg, pyelonephritis, urethritis, urinary tract infection)
Trauma and Toxic Effects (eg, extravasation of urine)

11. Diseases/Disorders of the Female Reproductive System
Breast (eg, fibrocystic/solitary cyst of breast, hypertrophy of breast, disorders of
lactation, mastitis)
Uterus (eg, leiomyoma of uterus, postcoital bleeding, endometriosis of uterus, uterine
prolapse)
Ovary, Fallopian Tube, & Broad Ligament (eg, ovarian or fallopian tube torsion,
ovarian cyst, ovarian failure, benign neoplasm of ovary)
Cervix (eg, cervix uteri, cervicitis and endocervicitis, dysplasia of cervix [uteri],
abnormal Pap smear of cervix)
Vagina/Vulva (eg, vaginitis and vulvovaginitis, prolapse of vaginal walls, imperforate
hymen, vaginismus)
Menstrual Disorders (eg, dysmenorrhea, premenstrual tension syndrome, irregular
menstrual cycle, ovulation bleeding)
Menopause (eg, postmenopausal hormone replacement therapy, premenopausal
menorrhagia, postmenopausal bleeding, postmenopausal atrophic vaginitis)
Pelvic Relaxation and Urinary Disorders (eg, stress incontinence, uterine prolapse,
prolapse of vaginal walls, cystocele/rectocele)
Female Fertility/Infertility (eg, contraception, pre-pregnancy counseling, dyspareunia,
female infertility)
Neoplasms (eg, malignant neoplasm of breast, uterus, ovary, vagina/vulva; cervical
cancer)
Infections (eg, human papillomavirus, sexually transmitted diseases, pelvic
inflammatory disease, salpingitis and oophoritis)
Trauma and Toxic Effects (eg, injuries, wounds, toxic effects, or burns affecting the
female reproductive system)

12. Pregnancy/Labor and Delivery/Fetus and Newborn
Pregnancy: Complicated (eg, gestational diabetes, ectopic/tubal pregnancy,
preeclampsia or eclampsia, cervical incompetence)
Pregnancy: Uncomplicated (eg, supervision of normal pregnancy, examination of
liveborn before admission to hospital)
Labor, Delivery, & Postpartum (including placenta abnormalities) (eg, premature
rupture of membranes, infections complicating childbirth, cesarean delivery,
immediate postpartum hemorrhage)
Fetus & Newborn (eg, congenital anomalies, Down syndrome, neonatal
hypoglycemia, feeding problems in newborn [breast-feeding])
Perinatal Infections (eg, congenital cytomegalovirus infection, neonatal conjunctivitis
and dacryocystitis, neonatal sepsis, herpes simplex virus)

13. Disorders of Blood
Splenic Disorders (eg, traumatic and nontraumatic diseases of spleen)
Anemias and Cytopenias (eg, iron deficiency anemia, hereditary spherocytosis,
hemoglobinopathies, thrombocytopenic purpura and ITP)
Bleeding Disorders (eg, coagulation defects, congenital factor VIII
disorder/hemophilia, von Willebrand disease, disseminated intravascular coagulation)
Reactions to Blood Components (eg, transfusion reaction, ABO incompatibility
reaction, Rh incompatibility reaction)
Malignant Neoplasias (eg, Hodgkin disease, lymphomas, multiple myeloma,
leukemia)
Infections (eg, infectious mononucleosis, cat-scratch disease, septicemia,
lymphadenitis)
Toxic Effects (eg, heparin-induced thrombocytopenia)

14. Disorders of the Male Reproductive System
Male Reproductive System (eg, neoplasm of male breast/prostate/testes, prostatitis,
torsion of testes, orchitis/epididymitis)
Infections (eg, human papillomavirus, sexually transmitted diseases)
Trauma and Toxic Effects (eg, injuries, wounds, toxic effects, or burns affecting the
male reproductive system)

15. Disorders of the Immune System
Immune Deficiency Disorders (eg, hypogammaglobulinemia, IgA deficiency)
HIV (eg, AIDS, AIDS-related complex, pneumocystosis, Kaposi sarcoma)
Vascular/Arterial Disorders (eg, Wegener granulomatosis, arteritis)
MSK/Connective Tissue Disorders (eg, dermatomyositis, polymyositis, polymyalgia
rheumatica, systemic lupus erythematosus)
Vaccinations/Chemotherapy (eg, routine and nonroutine, including travel
vaccinations, prophylactic and maintenance chemotherapy)
Anaphylaxis/Immunologic Reactions (eg, anaphylaxis, reactions to venomous bites,
desensitization to allergens)
Infections (eg, scarlet fever, toxic shock syndrome, Rocky Mountain spotted fever,
retrovirus)


Step 3 consists of multiple-choice questions with only one best answer and computer-based
case simulations, distributed according to the content blueprint.
Multiple Choice Questions
Multiple choice items present detailed clinical situations, usually from the patient's
perspective. The presentation may be supplemented by one or more pictorials, or audio or
video. The response options for all questions are lettered (eg, A, B, C, D, E). Some response
options will be partially correct, but only one option will be the best and correct answer.

Strategies for Answering the Multiple-choice Questions
Read each patient vignette and question carefully. It is important to understand what is
being asked.
Alternatively, read each option carefully, eliminating those that are clearly incorrect.

Multiple Choice - Single Item Questions
A single patient-centered vignette is associated with one question about the information
presented and followed by four or more response options. This is the traditional, most
frequently used multiple-choice question format on the exam.
Example Question
A 45-year-old African-American man comes to the office for the first time because he
says, "I had blood in my urine when I went to the bathroom this morning." He reports
no other symptoms. On physical examination his kidneys are palpable bilaterally and
he has mild hypertension. Specific additional history should be obtained regarding
which of the following?
A. Chronic use of analgesics
B. Cigarette smoking
C. A family history of renal disease
D. Occupational exposure to carbon tetrachloride
E. Recent sore throats
(Answer: C)

Multiple Choice - Multiple Item Sets
questions about the information presented. Each question within these sets is associated with
the patient vignette and is independent of the other question(s) in the set. The items within
this type of format are designed to be answered in any order.
Example Questions (set of 2)
A 38-year-old white woman, who is a part-time teacher and the mother of three
children, comes to the office for evaluation of hypertension. You have been her
physician since the birth of her first child 8 years ago. One week ago, an elevated
blood pressure was detected during a regularly scheduled examination for entrance
into graduate school. Vital signs on examination today are temperature 37.0C (98.6F),
pulse 100/min, respirations 22/min, and blood pressure 164/100 mm Hg (right arm,
supine).
1. The physical examination is most likely to show which of the following?
A. An abdominal bruit
B. Cardiac enlargement
C. Decreased femoral pulses
D. Thyroid enlargement
E. Normal retinas
(Answer: E)
2. To assess this patient's risk factors for atherogenesis, the most appropriate test is
determination of which of the following?
A. Plasma renin activity
B. Serum cholesterol concentration
C. Serum triglycerides concentration
D. Urinary aldosterone excretion
E. Urinary metanephrine excretion
(Answer: B)
End Set

Multiple Choice - Sequential Item Sets
questions about the information presented. Each question is associated with the initial patient
order. You are required to select the one best answer to each question. You must click
"Proceed to Next Item" to view the next item in the set; once you click on this button, you will
not be able to add or change an answer to the displayed (previous) item.

Example Questions (set of 3)
A 24-year-old man comes to the office because of intermittent chest pain that
began a few weeks ago. You have been his physician for the past 2 years and he has
been in otherwise good health. He says he is not having pain currently. A review of his
medical record shows that his serum cholesterol concentration was normal at a pre-
employment physical examination 1 year ago. You have not seen him since that visit
and he says he has had no other complaints or problems in the interim. He reminds
you that he smokes 1 pack of cigarettes per day. When you question him further, he
says that he does not use any alcohol or illicit drugs. Although the details are vague,
he describes the chest pain as a substernal tightness that is definitely not related to
exertion.
1. Which of the following findings on physical examination would be most consistent
with costochondritis as the cause of his chest pain?
A. Crepitation over the second and third ribs anteriorly
B. Deep tenderness to hand pressure on the sternum
C. Localized point tenderness in the parasternal area
D. Pain on deep inspiration
E. Normal physical examination
(Answer: C)
2. In light of the patient's original denial of drug use, which of the following is the most
appropriate next step to confirm a diagnosis of cocaine use?
A. Ask the laboratory if serum is available for toxicologic screening on a previous blood
sample
B. Call his family to obtain corroborative history
C. Obtain a plasma catecholamine concentration
D. Obtain a urine sample for routine analysis but also request toxicologic screening
E. Present your findings to the patient and confront him with the suspected diagnosis
(Answer E)
3. Cocaine use is confirmed. The patient admits a possible temporal relationship
between his cocaine use and his chest pain and expresses concern about long-term
health risks. The patient should be counseled regarding which of the following?
A. Cocaine-induced myocardial ischemia can be treated with blocking agents
B. Death can occur from cocaine-induced myocardial infarction or arrhythmia
C. The presence of neuropsychiatric sequelae from drug use indicates those at risk for
sudden death associated with cocaine use
D. Q wave myocardial infarction occurs only with smoked "crack" or intravenous cocaine
use
E. Underlying coronary artery disease is the principal risk for sudden death associated with
cocaine use
(Answer B)
End of Case

Pharmaceutical Advertisement (Drug Ad) Format
The pharmaceutical advertisement item format includes an advertisement presented in a
manner commonly encountered by a physician (eg, a printed advertisement in a medical
journal). Examinees must interpret the presented material in order to answer questions on
various topics, including
Development and approval of drugs and dietary supplements
Medical ethics

Abstract Format
The abstract item format includes a summary of an experiment or clinical investigation
presented in a manner commonly encountered by a physician (eg, an abstract that
accompanies a research report in a medical journal). Examinees must interpret the abstract
in order to answer questions on various topics, including
Use of diagnostic studies
Primum Computer-based Case Simulations (CCS)
You will manage one case at a time. Free-text entry of patient orders is the primary means for
interacting with the format. Buttons and check boxes are used for advancing the clock,
changing the patient's location, reviewing previously displayed information, and obtaining
updates on the patient.
At the beginning of each case, you will see the clinical setting, simulated case time, and
introductory patient information. Photographs and sounds will not be provided. Normal or
reference laboratory values will be provided with each report; some tests will be
accompanied by a clinical interpretation. To manage patients using the Primum CCS
software, it is essential that you complete the Primum tutorial and sample cases provided. A
brief description of the interface is provided in the Primum Tutorial.

Feedback for Step 3 CCS Practice Cases (2012-
2013 practice materials)

The information below provides feedback on diagnostic and management steps for the
sample Step 3 Computer-Based Case Simulations. These also appear at the end of the
practice cases.
The computer-based case simulation database contains thousands of possible tests and
treatments. Therefore, it is not feasible to list every action that might affect an examinee's
score. The descriptions are meant to serve as examples of actions that would add to,
subtract from, or have no effect on an examinee's score for each case.

Orientation Feedback for Tension Pneumothorax (10-
minute case)

In evaluating case performance, the domains of diagnosis (including physical examination
and appropriate diagnostic tests), therapy, monitoring, timing, sequencing, and location are
considered.
In this case, a 65-year-old man is brought to the emergency department by ambulance
because of acute chest pain and respiratory distress. Initially the presentation and reason for
visit suggest a broad differential diagnosis, but the limited available history narrows the
differential. The patient had an acute onset of right-sided chest pain 10 minutes before the
ambulance arrived. He rates the pain as 8 on a 10-point scale. The pain is excruciating, sharp,
and increases with respiration.
The patient appears pale and in marked respiratory distress. He is moaning and holding his
hands over the right side of his chest. Vital signs show tachypnea, tachycardia, and low
blood pressure. Physical examination shows no breath sounds and hyperresonance to
percussion on the right side of the chest, faint heart sounds, and weak peripheral pulses. The
skin is pale, cool, and diaphoretic. The remainder of the physical examination is
unremarkable. The patient's illness, at this point, seems most consistent with a pulmonary
process.
score. The following descriptions are meant to serve as examples of actions that would add
to, subtract from, or have no effect on an examinee's score for this case.
Timely diagnosis and management is essential in this case. An optimal, efficient diagnostic
approach would include quickly performing a targeted physical examination that includes
chest/lung and cardiovascular examination, cardiac monitoring, and assessing oxygen
saturation with a pulse oximetry. Treatment should be initiated immediately before the
patients condition worsens. Ordering anything that might delay treatment (eg, a 12-lead
ECG, an arterial blood gas, or a stat, portable chest x-ray) would be suboptimal in this case if
ordered before the patients condition is stabilized.
As soon as the absent breath sounds are discovered, optimal treatment would include
inserting a needle thoracostomy followed by a chest tube insertion or a surgical consultation.
A chest x-ray should be ordered to confirm appropriate tube placement and lung re-
inflation. The patients blood pressure and respiratory rate should be closely monitored until
the patients condition has stabilized.
Ordering analgesics or intravenous fluids is appropriate but optional during the time frame of
the simulation if appropriate primary management is quickly instituted. Examples of additional
tests and treatments that could be ordered but would be neither useful nor harmful to the
patient include:
Angiography after treating the pneumothorax
Bronchodilators
Cardiac enzymes after treating the pneumothorax
Complete blood count
Electrolytes
Examples of suboptimal management of this case would include ordering a complete
physical examination and delay in expansion of the lung. Examples of poor management
would include failure to examine the chest, admission before treatment, failure to order a
chest x-ray after inserting the chest tube and or needle, and long delay in treatment.
In this acute presentation, timing is critically important. An optimal approach would include
completing the above diagnostic and management actions as quickly as possible. Delaying
diagnosis or treatment and pursuing alternate diagnoses with tests such as a lung scan will
waste valuable time and could be harmful or even fatal to the patient. Other examples of
treatments that would waste time, subject the patient to unnecessary discomfort or risk, and
add no real benefit to this patient include:
Angiography before treating the pneumothorax
Cardiac enzymes before treating the pneumothorax
CT before lung reinflation
Intubation
Pulmonary function testing
Thrombolytic therapy

Orientation Feedback for Rheumatoid Arthritis (20-minute
case)

considered.
In this case, a 32-year-old woman comes to the office because of knee pain and swelling.
From the chief complaint, the differential diagnosis is broad. It includes osteoarthritis,
infectious arthritis, rheumatoid arthritis, systemic lupus erythematosus (SLE), gout, and psoriatic
arthritis. The comprehensive history, however, narrows the differential. The patient has
experienced increasing fatigue and generalized weakness during the past 4 months. She
developed generalized aches and morning joint stiffness during the past 8 weeks and, more
recently, pain and intermittent swelling in both wrists, proximal metacarpophalangeal joints,
as well as bilateral knee swelling. These signs and symptoms are highly suggestive of a chronic
systemic inflammatory process.
Physical examination shows bilateral swollen, warm, and tender wrist, proximal
metacarpophalangeal, and knee joints. Other physical findings are unremarkable. In the
absence of other findings, the patients illness, at this point, seems most consistent with
rheumatoid arthritis. While the presence of certain clinical features is helpful in excluding
other connective tissue disease and degenerative joint disease (osteoarthritis), further
diagnostic evaluation is appropriate to confirm the presumptive diagnosis and establish the
severity of the disease.
An optimal, efficient approach to diagnosis would include performing an appropriate
physical examination (including extremities, chest, cardiovascular, abdominal, skin,
HEENT/neck, and lymph node examinations). A rheumatoid factor test or a cyclic citrullinated
peptide antibody (Anti-CCP) test would support the diagnosis of rheumatoid arthritis. The
diagnostic workup would also include a complete blood count (CBC), arthrocentesis with
relevant synovial fluid studies (cell count, crystals, and bacterial culture), an antinuclear
antibody (ANA) test, and an erythrocyte sedimentation rate or C-reactive protein test. These
tests serve to assess the severity of the disease and consider the likelihood of SLE, gout, an
infectious process, or reactive arthritis. In addition, joint x-rays would provide a baseline
assessment.
In adult patients, an optimal approach to treatment would focus on relieving pain, reducing
inflammation, preventing or slowing joint damage, and improving function. It is important to
manage the acute phase of the disease and to address the long-term care of the patient in
this case. To prevent deformity and loss of joint function, the patient would be advised to
exercise appropriately, or a referral would be made for physical or occupational therapy. A
nonsteroidal anti-inflammatory drug (NSAID) or corticosteroid is considered first-line therapy
for relieving pain and reducing inflammation. Concomitant administration of a disease-
modifying antirheumatic drug (DMARDs) (eg, methotrexate or etanercept), is considered
optimal in preventing or slowing joint damage, and improving joint function. Initial NSAID or
corticosteroid treatment is essential to provide interim symptom relief while the selected
DMARD takes effect.
In this case simulation, when NSAID or corticosteroid treatment is initiated, the patient
regularly reports both joint and systemic improvements. Therefore, ordering a rheumatology
consult or additional monitoring is appropriate but optional during the timeframe of this
simulation.
Examples of additional tests and treatments that could be ordered but would be neither
useful nor harmful to the patient include:
Chlamydia trachomatis tests
Neisseria gonorrhoeae tests
Antibody, anti-single-stranded DNA
Thyroid studies
Urinalysis
Uric acid, serum
Examples of suboptimal management of this case would include delay in diagnosis or
treatment, or treatment with NSAIDS or corticosteroids alone. Treatment with salicylates would
also be considered suboptimal management in this case. Although they would temporarily
relieve pain when administered in high doses, there are other agents with fewer toxic side
effects that would be better treatment options. Examples of poor management would
include failure to order any physical examination or failure to treat rheumatoid arthritis.
Examples of invasive tests that would subject the patient to unnecessary discomfort or risk
and add no useful information to that available through history, physical examination, and
other relatively noninvasive laboratory tests include:
Arthroscopy
Synovial biopsy
While many case scenarios run for a relatively short period of simulated time, a matter of
hours or days, this scenario runs for a longer period of time, weeks. This illustrates the
importance of allowing sufficient time for the patient to respond to treatment and
emphasizes monitoring and long-term management.

Orientation Feedback for Ascending Aortic Dissection
(20-minute case)

considered.
In this case, a 65-year-old woman comes to the emergency department complaining of
chest pain. From the chief complaint, the differential diagnosis is broad; however, the
comprehensive history narrows the differential. The patient is experiencing sharp, left-sided
chest pain that radiates to her left jaw and to her back. The pain began abruptly 45 minutes
before coming to the hospital. She is now short of breath and mildly nauseated. She has a
history of hypertension for the past 5 years that is being appropriately treated with
medication. There is no history of any previous episodes of chest pain either at rest or on
exertion. The absence of fever, chills, cough, or pleural rub suggests that the problem is not
an infectious pulmonary process.
Physical examination shows hypertension and tachycardia with bounding central and
peripheral pulses. The patient is anxious, diaphoretic, and in mild distress from chest pain.
Cardiovascular examination reveals a prominent and sustained apical impulse, and an
indistinct S2 with S4 audible at the apex, and a grade 2/6 diastolic decrescendo murmur
heard best at the left sternal border. HEENT/neck examination shows grade II arteriovenous
nicking on funduscopic examination. The remainder of the physical examination is
unremarkable. The patient's illness, at this point, would seem most consistent with a coronary
or aortic abnormality with associated aortic regurgitation. In this case, the sudden onset of
radiating chest pain along with the bounding pulses, widened pulse pressure, aortic murmur,
and long history of hypertension are highly suggestive of the diagnosis of ascending aortic
dissection.
An optimal, efficient approach would include performing a targeted physical examination
(including cardiovascular and chest/lung examinations), ordering a 12-lead
electrocardiogram and a portable chest x-ray. Stabilizing the patient with intravenous (IV)
beta blocker or an IV antihypertensive agent administration to reduce blood pressure, and IV
narcotic analgesic administration to alleviate pain is important. The patients cardiovascular
status should be monitored with a cardiac monitor or by ordering repeat vital signs. Some
measure of oxygen saturation is also indicated.
Once stable, some form of chest imaging that would reveal an aortic dissection (including CT
of the chest with contrast, CT of the chest without contrast, cardiac CTA with contrast,
echocardiogram, transesophageal echocardiogram (TEE), MRI of the chest, or cardiac MRI
with gadolinium) is needed. The diagnostic workup should also include blood tests for serum
creatinine (basic metabolic profile or complete metabolic profile) to assess kidney function,
electrolytes to check sodium and potassium levels, a complete blood count (CBC) to look for
signs of anemia and infection, serum creatine phosphokinase or serum troponin I (cardiac
enzymes) to rule out myocardial compromise, a d-Dimer to rule out a pulmonary embolus,
and a blood type and crossmatch. Some measure of oxygen saturation is also indicated.
Once the ascending aortic dissection is discovered and aortic root involvement confirmed,
optimal treatment should include either open heart surgery, thoracotomy or thoracic surgery,
or general surgery consult.
completing the above diagnostic and management actions as quickly as possible (ie, during
the first 2 hours of simulated time).
Examples of additional tests, treatments, or actions that could be ordered but would be
neither useful nor harmful to the patient include:
Admitting the patient to the inpatient ward or intensive care unit
Angiocardiography, right and left heart
Antibiotics
Suboptimal management of this case would include ordering a complete physical
examination or additional PE components that would add no relevant information,
administering an IV antihypertensive without a beta blocker, neglecting to order indicated
blood tests, or a delay in diagnosis or treatment. It would be suboptimal to order anything
unnecessary that would waste time, even if the test or procedure is not invasive or risky (eg,
lung scan).
Examples of poor management would include failure to order any physical examination,
failure to order an imaging study that would reveal the dissection, failure to administer an
antihypertensive agent, or failure to order surgical intervention.
Examples of invasive and noninvasive actions that would subject the patient to unnecessary
discomfort or risk, or would add no useful information to that available through safer or less
invasive means, include:
Changing the location to the outpatient office or sending the patient home
Chest tube
Exercise electrocardiogram
Heparin
Laparotomy
Needle thoracostomy
Stress echocardiogram
Thrombolytics
Warfarin

Orientation Feedback for Asthma (20-minute case)

considered.
In this case, a 4-year-old boy is brought to the office because of increasing shortness of
breath during the past 3 days. From the chief complaint, the differential diagnosis is broad;
however, the comprehensive history narrows it. The patient has been wheezing and has a
cough that has been worsening. The mother says that the wheezing seems to get worse after
the patient plays outside but resolves shortly after coming inside. The patient has a history of
frequent episodes of wheezy bronchitis and ear infections. When the patient was 2 years
old, he was hospitalized for 1 week for similar symptoms and treated with intravenous
antibiotics and oxygen. At age 18 months, the patient had pressure equalization tubes
inserted. The patient also has a history of allergy to pollen and atopic dermatitis.
Physical examination shows slight tachycardia. Chest/lung examination reveals bilateral, mild,
intercostal retractions, hyperresonance on percussion, and bilateral expiratory wheezes with
prolonged expiratory phase, and no crackles. HEENT/neck examination shows pale, boggy,
edematous nasal mucosa without nasal flaring. Skin examination reveals dry scaly patches in
the antecubital areas. The remainder of the physical examination is unremarkable. The
patient's illness, at this point, would seem most consistent with an obstructive pulmonary
disease process. In this case, the increased coughing and wheezing, as well as the history of
frequent respiratory and ear infections, are highly suggestive of the diagnosis of asthma.
(including HEENT/neck, chest/lung, cardiovascular, and abdominal examinations) and
addressing oxygen status by ordering pulse oximetry or oxygen therapy. Treating the patients
respiratory distress with optimal inhalation (IN) bronchodilators (such as albuterol or
levalbuterol), as well as optimal oral (PO) steroids, is essential.
The diagnostic workup should also include counseling the patient/family about asthma care
or the side effects of medication. Monitoring the patients respiratory status by ordering a
chest/lung examination after treatment is also important.
In this acute presentation, timing is important. An optimal approach would include
the first 12 hours of simulated time).
Antihistamines
Antitussives or expectorants
Pulmonary function tests
Vaccines
Suboptimal management of this case would include administering a bronchodilator by a
suboptimal route (such as intramuscular (IM), PO, or subcutaneous (SQ)); or administering a
suboptimal bronchodilator (such as atropine or aminophylline); monitoring the patient by
ordering arterial blood gas analysis instead of a chest/lung examination after treatment;
failing to counsel the patient/family; or a delay in diagnosis or treatment.
Examples of poor management would include failure to order a physical examination, failure
to administer a bronchodilator, and failure to address the patients oxygen status.
Antibiotics
Bronchoscopy
Chest CT
Endotracheal intubation
Intravenous sympathomimetics

Orientation Feedback for Diabetes with ketoacidosis;
E. coli sepsis (20-minute case)

considered.
In this case, a 31-year-old woman is brought to the emergency department by her
roommate because of lethargy, nausea, and vomiting. From the chief complaints, the
differential diagnosis is broad and includes the many causes of acutely altered mental status.
However, the comprehensive history narrows the possible differential diagnoses, making
uncontrolled diabetes very likely. The patient has been experiencing nausea and vomiting for
the past 24 hours and has been unable to eat during that time. During the past hour, she has
become drowsy and lethargic. She has a history of type 1 diabetes mellitus for which she
normally takes a 70/30 insulin suspension twice daily. However, she has had no insulin during
the past 24 hours. The patients roommate says that the patient experienced some chills
yesterday.
The patient appears drowsy, lethargic, and acutely ill. Physical examination reveals elevated
temperature, tachypnea, tachycardia, and hypotension. Cardiovascular examination shows
thready central and peripheral pulses. Skin examination reveals poor turgor. HEENT/neck
examination shows dry mucous membranes. Abdominal examination reveals diffuse mild
tenderness without guarding, rebound, or masses. Neurologic/psychiatric examination shows
that the patient is lethargic but oriented. Taken together, the history and physical
examination findings support the initial impression of complications of type 1 diabetes
mellitus. In this particular patient, the history of type 1 diabetes mellitus presenting with
prolonged nausea and vomiting and lethargy and drowsiness, combined with the physical
examination findings of fever, thready pulses, tachycardia, signs of dehydration, and diffuse
abdominal tenderness are highly suggestive of the diagnosis of diabetic ketoacidosis due to
infection and inadequate insulin.
(including chest/lung, cardiovascular, abdominal, and neurologic/psychiatric examinations),
and ordering a serum glucose test using a glucometer and a urinalysis or complete blood
count (CBC) to check for signs of infection. Stabilizing the patient with optimal intravenous
(IV) fluids (eg, lactated ringer solution or normal saline solution) to improve hydration, and
treating the patient empirically with a broad-spectrum IV or intramuscular (IM) antibiotics (eg,
aminoglycosides plus -lactam agents, second or third generation cephalosporins, or
fluoroquinolones) to cover the most likely sources of infection are important. Once the serum
glucose result is obtained, starting IV insulin to treat the hyperglycemia is critical. The patients
cardiovascular status should be monitored by ordering repeat vital signs or by changing the
patients location to the inpatient unit or intensive care unit.
The diagnostic workup should also include arterial blood gas analysis to assess acidosis,
bacterial blood culture to identify the organism, and serum electrolyte measurements to
assess the severity of dehydration. Serum creatinine or urea nitrogen measurements (basic
metabolic profile or complete metabolic profile) to assess kidney function are indicated.
Continued monitoring of the patients serum glucose, electrolytes, and arterial blood pH after
treatment is also important.
the first hour of simulated time).
Antiemetics
Proton-pump inhibitors
Lumbar puncture
Abdominal imaging
Antipyretics
Oxygen
12-lead or rhythm electrocardiography
Suboptimal management of this case would include ordering a complete physical
examination or additional PE components that would add no relevant information; delay in
diagnosis or treatment; administering suboptimal IV fluids (eg, hypotonic saline solutions,
dextrose in water, or lactated ringer); initial treatment with subcutaneous (SQ) insulin;
suboptimal IV or IM antibiotics (eg, first generation cephalosporins, penicillins, or
tetracyclines); or neglecting to order indicated blood tests. It would be suboptimal to order
unnecessary tests or procedures that would serve no clear diagnostic or therapeutic purpose
even if those actions are low-risk.
Examples of poor management would include failure to order any physical examination;
failure to order a serum glucose test; failure to order a blood culture to determine the cause
of the infection; failure to treat with IV fluids, antibiotics, and insulin; or failure to monitor the
patient after treatment.
discomfort or risk or would add no useful information to that available through safer or less
invasive means include:
Gastric lavage
Upper gastrointestinal endoscopy

Orientation Feedback for Eclampsia; Fetal Distress (10-
minute case)

considered.
In this case, a 25-year-old woman at 38 weeks gestation comes to the emergency
department after suffering a seizure with loss of consciousness about 10 minutes earlier. From
the chief complaint, the differential diagnosis is broad; however, the comprehensive history
narrows it. The patient is gravida 1, para 0, has been receiving routine prenatal care. The
pregnancy has been uncomplicated so far. She has had a severe headache for the past 3
days, and her feet have appeared swollen during the past 2 to 3 weeks. She has never had a
seizure, and there is no history of hypertension or renal or neurologic disease. The patient is
conscious but appears confused.
Physical examination shows tachycardia, a low-grade fever, and elevated blood pressure.
Cardiovascular examination shows a loud S4 and bounding central and peripheral pulses.
There is a grade 2/6 systolic ejection murmur at the left sternal border without radiation. There
is marked vasospasm on funduscopic examination with normal disc margins and a minor
tongue laceration. Abdominal examination shows a gravid uterus with a fundal height of 37
cm. Estimated fetal weight is 2700 g (6 lb). The fetus is cephalic by palpation with a fetal heart
rate of 144 beats/min, showing signs of compromise. Genital examination reveals an
edematous vulva. The cervix is dilated to 1 cm and 50% effaced. Extremities/spine
examination shows 4+ pitting edema in both lower extremities to the midthigh region.
Neurologic/psychiatric examination shows that the patient is conscious but oriented to
person and place only. Deep tendon reflexes are 4+ with bilateral clonus at the ankles. The
remainder of the physical examination is unremarkable. The patient's illness, at this point,
would seem most consistent with a neurologic or cardiovascular abnormality, possibly
pregnancy-associated. In this pregnant patient, the new onset of seizure, elevated blood
pressure, lower extremity edema, and hyperactive reflexes are highly suggestive of the
diagnosis of eclampsia.
An optimal, efficient approach would include performing a complete or targeted physical
examination (including skin, HEENT/neck, chest/lung, cardiovascular, abdominal, genital,
extremities, and neurologic/psychologic examinations) and ordering a complete blood
count (CBC) to rule out hemolysis. Stabilizing the patient with intravenous (IV) magnesium
sulfate to prevent another seizure, plus an IV optimal antihypertensive (hydralazine or
betablockers) to reduce blood pressure, is important. Once the patients condition is
stabilized, it is imperative to deliver the fetus quickly either by stimulating contractions (using
oxytocin, misoprostol, dinoprostone, or alprostadil), by performing a cesarean delivery, or by
consulting obstetrics/gynecology. The fetal heart rate should be watched until delivery by
ordering a fetal monitor. Some measure of patients urine output is also indicated.
The diagnostic workup should also include a urinalysis and blood tests for the following: serum
creatinine or blood urea nitrogen (basic metabolic profile or complete metabolic profile) to
assess kidney function; electrolytes to check sodium and potassium levels; liver enzymes;
PT/PTT; and platelet count to rule out disseminated intravascular coagulation.
the first hour of simulated time).
Arterial blood gases or Pulse oximetry
Fibrin breakdown products
Thrombin time, plasma
Appropriate isotonic intravenous fluids
Head CT
Suboptimal management of this case would include: ordering a peripheral smear instead of
a complete blood count to rule out hemolysis; administering intramuscular or IV
phenobarbital or benzodiazepine instead of IV magnesium sulfate; administering any IV
antihypertensive other than IV hydralazine or an IV beta blocker; stimulating contractions
using carboprost; failing to monitor the patients urine output; or a delay in diagnosis or
treatment.
Examples of poor management would include failure to order a neurologic/psychiatric
examination, failure to administer an antihypertensive agent, failure to monitor the fetus or
mother after delivery, or administering a suboptimal seizure medication (phenobarbital).
Changing the location to the outpatient office or sending the patient home
Mifepristone

Content Outline 2014 Usmle Changed To Final

Încărcat de

Informații document

Descriere originală:

Titlu original

Drepturi de autor

Formate disponibile

Partajați acest document

Partajați sau inserați document

Opțiuni de partajare

Vi se pare util acest document?

Este necorespunzător acest conținut?

Drepturi de autor:

Formate disponibile

Content Outline 2014 Usmle Changed To Final

Încărcat de

Drepturi de autor:

Formate disponibile

Introduction

S-ar putea să vă placă și