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Table of Contents
                            Contents
Authors
Preface
Acknowledgments
How to Contribute
Section I: General Principles
	Chapter 1 Behavioral Science
	Chapter 2 Biochemistry
	Chapter 3 Embryology
	Chapter 4 Microbiology
	Chapter 5 Immunology
	Chapter 6 Pathology
	Chapter 7 Pharmacology
Section II: Organ Systems
	Chapter 8 Cardiovascular
	Chapter 9 Endocrine
	Chapter 10 Gastrointestinal
	Chapter 11 Hematology-Oncology
	Chapter 12 Musculoskeletal
	Chapter 13 Neurology
	Chapter 14 Psychiatry
	Chapter 15 Renal
	Chapter 16 Reproductive
	Chapter 17 Respiratory
Section III: Full-Length Examinations
	Test Block 1
	Test Block 2
	Test Block 3
	Test Block 4
	Test Block 5
	Test Block 6
	Test Block 7
Appendix: Common Laboratory Values
Index
	A
	B
	C
	D
	E
	F
	G
	H
	I
	J
	K
	L
	M
	N
	O
	P
	Q
	R
	S
	T
	U
	V
	W
	X
	Y
	Z
About the Authors
                        
Document Text Contents
Page 2

FIRST AID
Q&A
USMLE
STEP 1
Third Edition



FOR THE



New York / Chicago / San Francisco / Lisbon / London / Madrid / Mexico City

Milan / New Delhi / San Juan / Seoul / Singapore / Sydney / Toronto

Tao Le, MD, MHS
Associate Clinical Professor
Chief, Section of Allergy and Clinical Immunology
Department of Medicine
University of Louisville

James A. Feinstein, MD
Clinical Instructor, Section of General Pediatrics
The Children's Hospital Colorado
Research Fellow
Primary Care Research Program
University of Colorado School of Medicine

Mark W. Ball, MD
Resident
The James Buchanan Brady Urological Institute
The Johns Hopkins Hospital

Annie Dude, MD
Resident
Department of Obstetrics and Gynecology
Duke University Medical Center

Rebecca L. Hoffman, MD
Resident
Department of General Surgery
Hospital of the University of Pennsylvania

Mark Robert Jensen
University of Rochester School of Medicine
Class of 2012

Kimberly Kallianos
Harvard Medical School
Class of 2012

Cesar Raudel Padilla
University of Rochester School of Medicine
Class of 2012

Lauren Rothkopf, MD
Masters in Public Health candidate
Temple University College of Health Professions and

Social Work

James Yeh, MD
Resident
Department of Medicine
Cambridge Hospital, Cambridge Health Alliance

SENIOR EDITORS

EDITORS

Page 392

376 Section II: Organ Systems • Answers

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Of note, MAO inhibitors, another class of anti-
depressants, do not have anticholinergic prop-
erties, but can cause adverse effects similar to
those of anticholinergic medications, includ-
ing dry mouth and urinary retention. MAO in-
hibitors often are associated with tyramine cri-
ses on the USMLE exam, especially when the
patient described has consumed tannin-rich
foods, such as red wines and aged cheeses.

Answer B is incorrect. Clonazepam is a ben-
zodiazepine sometimes prescribed as an anxio-
lytic at the initiation of anti-depressant therapy.
The most commonly reported adverse effects
are those associated with CNS depression,
such as sedation or respiratory depression at
higher doses. Dependence and rebound anxi-
ety can result from benzodiazepine abuse.

Answer C is incorrect. Lithium is a mood sta-
bilizer used to treat bipolar affective disorder.
It indirectly inhibits the reuptake of serotonin
and norepinephrine by inhibiting the phos-
phatidylinositol second messenger system.
Adverse effects include CNS depression, diz-
ziness, nephrogenic diabetes insipidus, acne,
edema, and hypothyroidism, as well as many
others.

Answer D is incorrect. Sertraline and other
SSRIs are associated with adverse effects re-
lated to CNS stimulation such as headache,
anxiety, tremor, insomnia, anorexia, nausea,
and vomiting. Weight gain and sexual dysfunc-
tion are also frequently reported with SSRI
use.

Answer E is incorrect. Venlafaxine is a sero-
tonin/norepinephrine reuptake inhibitor. It
has adverse effects similar to those of selective
serotonin reuptake inhibitors, plus additional
adverse effects due to the norepinephrine,
such as dizziness and diaphoresis. Venlafaxine
is also known to cause hypertension.

20. The correct answer is C. This patient has evi-
dence of benzodiazepine intoxication. This
is the most likely scenario given her recent
diagnosis and treatment for panic disorder, in
addition to the exclusion of other causes with
similar presentations. Benzodiazepines are
relatively safe in overdose; however, shorter-

sant; it is not typically used to manage anorexia
nervosa. MAO inhibitors are not known to in-
crease the risk of seizure in anorexic patients.

18. The correct answer is D. SSRIs block the
reuptake of serotonin (5-hydroxytryptamine [5-
HT]) by the serotonin transport protein (STP)
in presynaptic neurons; the result is an effec-
tive increase in serotonin within the synaptic
space. SSRIs act at the “X” in the image by
inhibiting the binding of 5-HT to STP. SSRIs
have demonstrated efficacy for numerous med-
ical and psychiatric conditions, most notably
depression, anxiety, obsessive-compulsive dis-
order, and eating disorders.

Answer A is incorrect. SSRIs are not first-line
treatment for bipolar disorder; a mood stabiliz-
ing agent (eg, lithium or valproic acid) would
be the treatment of choice.

Answer B is incorrect. SSRIs are not first-line
treatment for delirium tremens; a long-acting
benzodiazepine (eg, chlordiazepoxide) would
be the treatment of choice.

Answer C is incorrect. SSRIs are not first-line
treatment for multiple personality disorder; an
antipsychotic (eg, haloperidol or risperidone)
would be the treatment of choice.

Answer E is incorrect. SSRIs are not first-line
treatment for schizophrenia; an antipsychotic
(eg, haloperidol or risperidone) would be the
treatment of choice.

19. The correct answer is A. This patient is being
treated for depression. Amitriptyline, a tricyclic
anti-depressant, is as effective as the selective
serotonin reuptake inhibitors, but often is not
prescribed as a first-line agent because of its
many adverse effects. These include sedation,
a-blocking effects, and, most commonly, anti-
cholinergic effects such as dry mouth, blurry
vision, tachycardia, urinary retention, consti-
pation, confusion, and dry, hot skin. These
adverse effects can be remembered with the
following: red as a beet (flushing), dry as a
bone (anhidrosis), hot as a hare (overheating
secondary to anhidrosis), blind as a bat (blurry
vision), mad as a hatter (hallucinations or de-
lirium), and full as a flask (urinary retention).

Page 393

Chapter 14: Psychiatry • Answers 377

Psychiatry
HigH-Yield SYStem

S

Answer B is incorrect. Physostigmine is an
indirect-acting cholinomimetic that inhibits
the action of acetylcholinesterase, thereby am-
plifying the effect of endogenous acetylcholine.
It is indicated in cases of anticholinergic (but
not tricyclic) poisoning, which would present
with the classic picture described by the mne-
monic “red as a beet, blind as a bat, mad as a
hatter, dry as a bone, and hot as a hare.” One
would expect fever, flushing, delirium, dry mu-
cous membranes, and miosis on physical exam.

Answer D is incorrect. Ethanol is indicated
in cases of toxic alcohol ingestion (eg, metha-
nol or ethylene glycol). Toxic metabolites are
formed when alcohol dehydrogenase metabo-
lizes methanol or ethylene glycol. Ethanol
works by inhibiting the formation of these
harmful substances by competing for binding
sites on alcohol dehydrogenase.

Answer E is incorrect. Reserpine inhibits the
storage of norepinephrine in adrenergic nerve
terminals, thereby depleting the neuron of its
stores. It has been classified as a postganglionic
sympathetic nerve terminal blocker, and is
rarely used as an antihypertensive medication.

acting benzodiazepines such as temazepam,
triazolam, and alprazolam pose a greater risk
for morbidity and mortality. Competitive
antagonists work by displacing a drug from
its binding site. Flumazenil is a competi-
tive antagonist that can be used in the case of
benzodiazepine overdose, and naloxone is a
competitive antagonist that is used to reverse
symptoms of opiate overdose. When using flu-
mazenil, be aware that rapid reversal of benzo-
diazepine overdose may lead to rebound sei-
zure activity. In clinical practice flumazenil is
rarely used except in children.

Answer A is incorrect. Pralidoxime, a cholin-
esterase regenerator, is indicated in cases of or-
ganophosphate poisoning. Organophosphates
such as parathion and malathion are indirect-
acting cholinomimetics that inhibit acetylcho-
linesterase by forming a very stable bond with
it. This results in general cholinergic CNS
stimulation (incontinence, bronchoconstric-
tion, miosis, and bradycardia). Pralidoxime has
a greater affinity for binding to organophos-
phates than acetylcholinesterase. As such, it is
thought of as an organophosphate “chemical
antagonist.”

Page 784

Mark Robert Jensen Mark is a fourth-year student at the University of Rochester School of Medicine. He plays ice hockey
in his spare time and does his best to stay out of the penalty box. Off the ice, he tutors inner city stu-
dents in math and science and likes to travel when he can get away. He has always loved writing and
has published articles on bone sclerosis, dry eye disorder, the utility of CT in evaluation of the left
ventricular assist device, and the development of radical Islam in London. He plans to follow his fa-
ther and grandfather’s footsteps into anesthesia, and to hopefully, someday, publish a book of his
own.

Kimberly Kallianos Originally from Atlanta, Georgia, Kim attended the University of North Carolina at Chapel Hill where
she earned a Bachelor of Science degree in biology. She is currently a fifth-year student at Harvard
Medical School and will begin her radiology residency at the University of California, San Francisco in
2012.

Cesar Raudel Padilla Cesar was raised in the San Francisco Bay area and is a first-generation Mexican American. He
dropped out of high school but managed to get a scholarship to a community college and ultimately
graduated from the University of San Francisco with a degree in biological sciences. He plans to be-
come an anesthesiologist and specialize in critical care. Cesar hopes to serve the Latino community in
California as well as in Guadalajara, Mexico, where he has spent his summers since childhood. He
has helped the University of Rochester School of Medicine reach out to the local Latino community
by coordinating mock interviews with Spanish-speaking standardized patients. Cesar is an avid fútbol
fan and enjoys spending time with his wife and daughter Elena.

Lauren Rothkopf, MD Lauren attended Johns Hopkins University, earning a Bachelor of Arts degree in English with a minor
in psychology. She graduated from Temple University School of Medicine in 2007 and completed her
internship year in internal medicine at Beth Israel Deaconess Medical Center in Boston. She is cur-
rently pursuing a Master’s degree in public health while raising her 1-year-old son.

James Yeh, MD James is a clinical fellow in medicine at Harvard Medical School and a resident physician at the Cam-
bridge Hospital/Cambridge Health Alliance. He is a graduate of Boston University School of Medicine,
where he received the Henry J. Bakst Award in community medicine and was an Albert Schweitzer
Fellow. He completed his undergraduate and graduate degrees at the University of California, Berke-
ley and Harvard University. He has extensive basic science and clinical research background and has
received multiple grants and awards. James has wide-ranging experiences in tutoring and teaching,
and he has been working with First Aid and USMLERx since 2009. In his spare time, he enjoys travel-
ing around the world, exploring new places and museums, cooking/eating, playing guitar, riding his
bike, and photography.

ABouT THe AuTHoRS
Kirsten Austad
Kirsten graduated from the University of Wisconsin-Madison with degrees in English literature and medical microbiology & immunology. She is currently taking a year off after com-
pleting two years at Harvard Medical School to be a fellow at the Edmond J. Safra Center for Ethics at Harvard University. Her work looks at how to improve physician-pharmaceutical
industry interactions, and she will soon start her third year in Cambridge Hospital’s Integrated Clerkship. Kirsten plans to remain involved in medical education as well as practice
community-based primary care with underserved populations in the U.S. or abroad and work to link health care to poverty reduction and community empowerment.

eike Blohm
Eike grew up in Germany and came to the U.S. to study medicine. He worked as a paramedic and ICU tech before starting his studies at Johns Hopkins. Now at the end of his third
year in medical school, Eike is starting the application process for a residency seat in emergency medicine. In his free time, he is an avid marathoner, competing in five marathons
this year alone.

Benjamin Caplan, MD
Ben is a family medicine resident at Boston Medical Center. After earning his undergraduate degree in psychology at Williams College, Ben worked as a staff researcher at the
UCLA Brain Mapping Center, where he authored several neuroscience publications and helped launch the international Human Brain Project. Apart from the medical world, he is a
concert cellist of 25 years, a world traveler, and a performance magician of 18 years.

Po-Hao Chen
Po-Hao is completing his medical training at Harvard Medical School and is a joint-degree student at Harvard Business School to learn more about health policy and hospital ad-
ministration. After graduation, he would like to enter a radiology residency program while continuing to participate in medical education and research. Ultimately, Po-Hao wishes
to hold a leadership position at a hospital as well as be involved in medical innovation to develop ways physicians can organize increasing amounts of patient information more
effectively.

Lauren de Leon, MD
Lauren is a recent graduate of the Alpert Medical School of Brown University. She is finishing her internship year in internal medicine and loving it. She enjoys traveling, cooking,
and searching for the perfect dumpling. In terms of her medical career, Lauren is debating between gastroenterology and palliative/end of life care.

Philip eye
Philip grew up in Baldwin, New York. Four years after being accepted into Boston University’s seven-year medical program, he graduated with a Bachelor of Science degree in eco-
nomics and medical sciences. Phil is currently a Second Lieutenant in the United States Army and a medical student at Boston University School of Medicine. He plans to pursue a
residency in neurology upon graduation in 2012. In his spare time, Phil both studies and teaches kung fu.

Jim Griffin, MD
Jim is originally from Waynesboro, Georgia, and attended the University of Georgia, where he majored in biochemistry and molecular biology. After graduating from Johns Hopkins
School of Medicine in May 2011, he began a general surgery internship at the Johns Hopkins Hospital and plans to pursue a career in surgical oncology.

Page 785

John Hegde
John was born in Philadelphia and grew up in Carmel, Indiana. He graduated from Indiana University and is currently a third-year student at Harvard Medical School. He is still un-
decided about which medical specialty to pursue, although he is considering a career in either radiation oncology or radiology. John enjoys reading, watching movies, traveling,
and cheering on all Philly sports teams.

emily Heikamp
Emily is currently working in the MD/PhD program at Johns Hopkins. She is originally from New Orleans, Louisiana, and she attended Duke University as an undergraduate. Before
coming to Hopkins, Emily earned a Master’s degree in medical oncology from Oxford University. Her clinical and research interests include tumor immunology and autoimmunity.

Thomas Robert Hickey, MD
Originally from central New York, Tom recently graduated from Harvard Medical School and is currently pursuing an anesthesia residency at Brigham and Women’s Hospital.

Henry R. Kramer, MD
Henry attended Cornell University, where he studied biology and psychology. He earned his medical degree from the Johns Hopkins University School of Medicine. He is now a
resident in internal medicine at the Massachusetts General Hospital. Henry enjoys running with his dog, cooking, wine, craft beer, and bourbon.

Thomas Lardaro
Thomas is originally from Peace Dale, Rhode Island. After graduating summa cum laude from the University of Connecticut, he worked for two years researching molecular neuro-
biology at Harvard Medical School. Thomas has since enrolled at the Johns Hopkins University School of Medicine, where he has taken an additional year of study as part of a
funded clinical research training program. He will graduate with MD/MPH degrees in the spring of 2012. In his free time, Thomas enjoys playing soccer, traveling, and being out-
doors.

Katherine Latimer
Katherine is a third-year medical student at Johns Hopkins University School of Medicine. She is originally from Bethesda, Maryland, and earned her Bachelor of Science degree
from Georgetown University. She plans to pursue a career in obstetrics and gynecology.

Joseph Liao
Joey is from sunny Ventura, California. He earned a degree in biology from MIT and has been living in New England ever since. He is currently a third-year student at Boston Uni-
versity School of Medicine, and plans to go into radiology. As a second-year, Joey formed a rock band with two of his college buddies, proving that there is indeed time during
medical school to have fun. He also enjoys photography.

Jerry Loo
Jerry did his undergraduate studies in microbiology, immunology & molecular genetics at UCLA. He is currently finishing his fourth year at the USC Keck School of Medicine and
will be continuing his training there as a radiology resident in 2012. In his free time, Jerry enjoys playing piano, computer programming, basketball, and the occasional death
match on PlayStation 3.

Aya Michaels, MD
After graduating from Columbia University in 2007 with a Bachelor of Arts degree in biochemistry, Aya entered Harvard Medical School. She graduated in May 2011 and is excited
to start her training as a radiologist at Brigham and Women’s Hospital in Boston.

Somala Muhammed, MD
Somala recently graduated from Harvard Medical School and is excited to return to her hometown of Houston for a general surgery residency at Baylor College of Medicine. She
hopes to specialize in surgical oncology or pediatric surgery.

Behrouz namdari, MD
Behrouz earned his medical degree from Chicago Medical School and is currently a resident in psychiatry at Duke University. In his nonmedical time, he is often found on the golf
course or basketball court.

Tashera Perry, MD
Tashera hails from Westfield, New Jersey. She studied biology at Mary Baldwin College and completed a two-year postbaccalaureate Intramural Research Training fellowship at the
National Heart, Lung, and Blood Institute prior to attending the University of Chicago Pritzker School of Medicine. She began residency training in obstetrics and gynecology at the
University of Illinois at Chicago College of Medicine in June 2011. Aside from medicine, Tashera’s interests include art history, mountain biking, and bikram yoga.

Christopher Roxbury
Christopher is currently a third-year medical student at Johns Hopkins University. He hails from Bridgewater, New Jersey, and attended Johns Hopkins University as an undergradu-
ate, majoring in molecular and cellular biology and Spanish. After completing medical school, he plans to pursue a career in otolaryngology—head and neck surgery.

neepa Shah
Neepa is from Toronto, Canada and is a third-year medical student at Boston University. She plans to pursue a career in ophthalmology, with a focus on academics and teaching.
Her hobbies include traveling, baking, and Indian classical dance.

Bethany Strong
Bethany is originally from Oklahoma City, Oklahoma. She completed her undergraduate education at Spelman College, where she studied biology and biochemistry. As a partici-
pant in the five-year MD/PhD program at Harvard Medical School, she spent an additional year of training completing clinical rotations at McCord Hospital in Durban, South Africa
and conducting research at the Centers for Disease Control and Prevention in Atlanta. She plans to complete a residency program in general surgery, focusing her career on global
health and medical student education.

Seenu Susarla, MD, DMD, MPH
Seenu is from Vestal, New York, and graduated with a degree in chemistry from Princeton University. After graduating college, Seenu decided that being a degree-collector would
be an interesting career. As such, he earned his Master of Public Health, Doctor of Dental Medicine, and Doctor of Medicine degrees from Harvard University. He is currently a resi-
dent in the combined general surgery/oral & maxillofacial surgery residency program at Massachusetts General Hospital.

Jeffrey Tosoian
Jeff is originally from Farmington, Michigan, and attended the University of Michigan in Ann Arbor, where he majored in cellular and molecular biology. Jeff graduated from the
Johns Hopkins Bloomberg School of Public Health in May 2011 with a Master of Public Health degree in biostatistics and epidemiology. After completing medical school in 2012,
Jeff plans to pursue a career in urological surgery with a focus in genitourinary cancers.

Jackson Vane, MD
Jackson is from Whittier, California. He attended California State University, Los Angeles to earn his undergraduate degree in biology in 2005. He then ventured out of the sunny
confines of Southern California to Chicago, where he attended Rosalind Franklin University of Medicine and Science and earned his Master of Science degree in applied physiology
in 2006. He then attended Chicago Medical School and graduated in 2010. He is currently at the University of California, Irvine doing his residency in pediatrics. In his free time,
Jackson enjoys wandering aimlessly in his new surroundings, riding his bike, playing poker, trying all sorts of new restaurants, and catching up on the many movies he has missed
over the years.

Daniel J. Verdini, MD
After graduating Boston College with degrees in biology and economics, Dan worked as an investment analyst before deciding to embark on a career in medicine. After graduating
from Ross University, Dan spent a year at Massachusetts General Hospital as a research fellow in cardiac imaging and will be starting a radiology residency at the University of
Texas in San Antonio after completing a year in preliminary medicine at the University of Nevada School of Medicine in Reno.

Marc e. Walker
Marc is an MD/MBA student at Harvard Medical School and Harvard Business School. On the business side, Marc is interested in health care delivery systems development and in-
novation and entrepreneurship in medicine and surgery. He will be dedicating the upcoming year to the pursuit of his research interests in plastic surgery and plans to graduate in
May 2012 with the intent of entering a surgical residency thereafter.

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