Dissecting the USMLE Steps 1, 2, and 3

Second Edition
Copyright  2005

Authors:
Francis Ihejirika, M.D.
Terra C. Holdeman, M.D., M.S.

Editors:
Jamison Strahan, M.D.
Amer Raza, B.D.S.

Illustrations:
Lindsey Jackson, M.D.

All Rights Reserved. No part of this book may be reproduced in any form without permission in writing
from the author. This book is intended for use in the preparation of taking the United States Medical
Licensure Examinations, and is not meant to be used in the treatment of patients. Readers are encouraged
to corroborate with current resources regarding any knowledge used in the treatment of patients.

Acknowledgements:
Gina Bathurst: ANP mnemonic
Barabar de la Torre: Psychiatry mnemonic
Will Chaviz: Newborns, An/Catabolic, Comma bugs, p450 drugs mnemonics
Karina Franco: Homan vs. Hamman, Arnold Chiari vs. Budd-Chiari comparisons
Seunghee Oh: X-linked recessive diseases mnemonic
Stephen Rath: Managing ventilators, Acid-Base methods
Malaika Scott: Low C3 mnemonic
Jamison Strahan: Loop diuretics, Hb shift, Granulosa cell, Blots, Hypersensitivity
Kevin Woods: LITER mnemonic
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So how can you have one book for Steps 1, 2, and 3?

Step 1: Diagnosis
You do not need to know treatment options at this time. They are listed here for Step 2 and 3 students, and
so that you can review the same material again in a familiar format as you prepare for later examinations.
You also only need to know generic drug names, although some trade names are included here for
recognition's sake.

Step 2: Tests
You don't need to know biochemical pathways, but should know the diseases associated with these
pathways. The main focus of these exams is diagnostic workup and tests, showing that you can use basic
medical science and apply it clinically to pathologic situations.

Step 3: Treatment
For this test, you should focus on patient management, although you still need to remember important
diagnostic clues leading to your management decisions.

Please send all questions, corrections, or comments to:

terraholdeman@yahoo.com

For more info on how you can attend live USMLE lectures taught by Dr.
Francis, contact the PASS Program at:

Physician Assisted Student Success Program, Inc.

Mail: 116 N. Chestnut St. Suite 120; Champaign, IL 61820
Web: http://www.passprogram.net
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Phone: (217) 378-8018
Table of Contents:
Introduction: The PASS Program Theory.................................... 7

Chapter 1: Neurology................................................................. 13

Chapter 2: Psychiatry................................................................. 31

Chapter 3: Cardiology................................................................ 43

Chapter 4: Pulmonary.................................................................65

Chapter 5: Gastrointestinal......................................................... 81

Chapter 6: Renal.......................................................................103

Chapter 7: Hematology............................................................ 119

Chapter 8: Endocrinology.........................................................139

Chapter 9: Dermatology........................................................... 157

Chapter 10: Muscles.................................................................163

Chapter 11: Bones.................................................................... 171

Chapter 12: Rheumatology.......................................................177

Chapter 13: Gynecology...........................................................183

Chapter 14: Obstetrics.............................................................. 195

Chapter 15: Pediatrics.............................................................. 205

Chapter 16: Surgery................................................................. 213

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Chapter 17: Biochemistry (Step 1 Only) .................................221

Chapter 18: Genetics ............................................................... 245

Chapter 19: Microbiology ....................................................... 255

Chapter 20: Immunology .........................................................283

Chapter 21: Biostatistics ..........................................................295

Chapter 22: Step 2 Clinical Skills ............................................299

Chapter 23: The PP Clues ........................................................315

Outline: The Pass Program Outline .......................................... 383

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Neurology:
"Any man who reads too much and uses his own brain too little falls

into lazy habits of thinking"

– Albert Einstein
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Terminology:
Central nervous system = brain/ spinal cord (Cl- in hyperpolarizes) – Oligodendrocytes
Peripheral nervous system = everything else (K+ out depolarizes) – Schwann cells

Autonomic nervous system = automatic stuff

Somatic nervous system = moving your muscles

Parasympathetic: "sit and think" Sympathetic: "get up and go"

Function: Rest-and-Digest => slows stuff down Fight-or-Flight => speed stuff up
2nd Messenger: cGMP cAMP
Control: Craniosacral: brain + below the belt Thoracolumbar: above the belt
Preganglionic NT: ACh (nicotinic receptor) ACh (nicotinic receptor): except sweat
Postgangiolic NT: ACh (muscarinic receptor): NE (α or β receptor)
except skeletal mm, ganglia except sweat glands
Side Effects: "DUMBBELS": Opposite of Parasympathetics:
Diarrhea Constipation
Urination Urinary retention
Miosis "constrict" Mydriasis "eyes wide with fright"
Bradycardia Tachycardia
Bronchoconstrict Bronchodilate
Erection "point" Ejaculation "shoot"
Lacrimation Xerophthalmia (dry eyes)
Salivation Xerostomia (dry mouth)

Neuron Anatomy: peripheral nerves grow 1mm/day, requires Ca, ATP, microtubule "train tracks"
Soma – makes and transports all proteins, NT
Kinesin – anterograde transport
Actin – retrograde transport

Stimulatory NT: depolarize

Tyr  (Tyr OHase)  DOPA  DA  NE  MAO (pre-synaptic) + COMT (post-synaptic)
Trp  (Trp OHase)  5-HT (High: sleepy, Low: depression)  5-HIAA
AcetylCoA + Choline  (Choline Acetyltransferase)  ACh  (AChase)  Acetate + Choline

Inhibitory NT:
Spinal cord: Gly
Brain: GABA

GABA: bradycardia, lethargy, constipation, impotence, memory loss

NH3 + H+  NH4+ + α-KG  Glu  GABA

Stress Response: Cushing's triad:

1st response: Parasympathetic intracranial pressure
• Ex: Erection • HTN
• Bradycardia
• Irregular
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2nd response: Sympathetic
• Ejaculation, constipation, increased GI acid output
• Stress ulcer
• Curling's ulcer (burn pts) "Burn pts have a curling scream"
• Cushing's ulcer (intracranial pressure ulcer)
• IBS: constipation  diarrhea  repeat

Embryology:
Brain has developed by 8 wks  can direct other stuff now
Primitive streak  Notochord  Spinal cord (nucleus pulposus)
Spinal cord: plates are divided by sulcus limitans
• Basal plate (motor) => ventral spinal cord "boob side"
• Alar plate (sensory) => dorsal spinal cord "anus side"
Vertebral arch develops ventral  dorsal (fusion starts in cervical region, zips up bidirectionally)

Forebrain = Prosencephalon "Pro Die & Tell"

• Diencephalon => Thalamus, Basal ganglia
Budd-Chiari: Hepatic vein obstruction
• Telencephalon => Cerebrum
Arnold-Chiari: Foramen magnum obst.
Midbrain = Mesencephalon (CN 3-4)
Hindbrain = Rhombencephalon "Met My Rhomb"
• Metencephalon => Pons (CN 5-8), Cerebellum
• Myencephalon => Medulla (CN 9-12)

Brain Problems:
Anencephaly: notochord (day 17) did not make contact with brain => only have medulla => high AFP
Encephalocele: pocket at the base of the brain
Dandy Walker malformation: no cerebellum, distended 4th ventricle
Arnold-Chiari malformation: herniation of cerebellum through foramen magnum
• Type I: cerebellar tonsils (asymptomatic)
• Type II: cerbellar vermis/ medulla => hydrocephalus, syringomyelia (loss of pain/temp)

Sacral Problems:
Spina bifida occulta: covered by skin w/ tuft of hair Neural crest cells:
Spina bifida aperta: opening (high AFP) • Adrenal medulla
Meningocele: sacral pocket w/ meninges in it • Melanocytes
Meningomyelocele: sacral pocket w/ meninges and nerves in it • Odontoblasts – teeth
• Tracheal cartilage (C-shaped)
• Laryngeal cartilage
CN Sensory/Motor Function:
"Some Say Money Matters, But My Brother Says • Parafollicular cells
Big Brains Matter Most" • Ganglia
CN 1: Sensory • Schwann cells
CN 2: Sensory • Aorticopulmonary septum
CN 3: Motor • Pseudounipolar cells =>
CN 4: Motor dorsal root ganglia

Neuroepithelial cells:
• Astrocytes
• Oligodendrocytes
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CN 5: Both sensory and motor
CN 6: Motor
CN 7: Both sensory and motor
CN 8: Sensory
CN 9: Both sensory and motor
CN 10: Both sensory and motor
CN 11: Motor
CN 12: Motor

Cranial Nerve Lesions: Put the lesion at the level of the highest CN affected…
"On Old Olympus' Towering Top, A Fin And German Viewed Some Hops"
CN 1: Olfactory => can't smell
CN 2: Optic => blind
CN 3: Occulomotor => no response to light, ptosis, look down and out
CN 4: Trochlear => see double when they look down
CN 5: Trigeminal => can't chew
Eye Reflexes:
CN 6: Abducens => eye points toward nose
Blink reflex: CN 5  7  3
CN 7: Facial => facial paralysis
Pupillary light reflex: CN 2  3
CN 8: Acoustic => can't hear
CN 9: Glossopharyngeal => dry mouth, dysphagia, ↓gag
CN 10: Vagus => hoarse voice, uvula deviation, palate does not rise with "ahh"
CN 11: Spinal Accessory => can't shrug shoulders or turn head
CN 12: Hypoglossal => tounge deviates to weak side, difficulty speaking

Sleep Waves:
Increased by: ACh, 5-HT
Decreased by: DA, NE

"BATs Drink Blood"

Wide awake: β waves
Eyes closed awake: αwaves
Light sleep: θ waves "Stage 1-2"/ K-complexes
Deep sleep: δ (huge) waves "Stage 3-4"
o teeth grinding, sleepwalking
o BZ, Imipramine inhibit this
REM sleep: β waves – every 90 min
Watershed Areas:
o dreams, penile erections
First to lose, last to recover
o NE, EtOH, Barbs, Age inhibit this
Brain: Hippocampus
o 5-HT, ACh increase this GI: Splenic flexure

Sleep Disorders:
Nightmare: remember dreams, occurs in REM sleep
Sleep Terror: don't remember dreams, occurs in non-REM sleep
Dysomnia: quality of sleep
Parasomnia: sleep behavior (nightmares)
Narcolepsy: fall asleep during day, sleep paralysis, cataplexy
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Kleine-Levin syndrome: teenage boys eat and sleep a lot

I) Cerebellum: depth perception, balance

• Romberg – lose unconscious proprioception (signal doesn't go to cortex)
• EtOH: attacks vermis => ataxia
• All else: attacks hemispheres => intention tremor, dysmetria, dysdiodokinesis, pronator drift

II) Brainstem:
1) Midbrain CNS Infections:
2) Pons: most sensitive to shifts in osmolarity Frontal Lobe: Rubella
3) Medulla: sets stuff Temporal Lobe: HSV
Parietal Lobe: Toxoplasma
Limbic Lobe: deep inside temporal lobe Hippocampus: Rabies
• Emotion, drive-related behavior Posterior Fossa: TB
DCML: Treponema pallidum
Frontal Lobe:
• Abstract reasoning => Schizophrenia (test: interpret proverbs)
• Personality => Pick's disease (inhibition loss)
• Broca's area (expressive aphasia) => can't speak or write "Broken speech: say babababa"
• Hippocampus (short-term memory) => Alzheimer's, drowning victims

Parietal Lobe:
Dominant Lobe: (99% population: left side -- regardless of what hand you write with)
• Everything you learned in kindergarden: all long-term memory => Alzheimer's
Non-dominant lobe:
• Apraxia: finger function (test: trace a letter)
• Hemineglect => not recognize 1 side of body (usually left side)

Corpus Collosum: fibers cross from right to left side of brain (and vice versa)
• L handed people: ipsilateral connections
• R handed people: contralateral connections
• Absent corpus collusum: ipsilateral connections => ambidextrous

Temporal Lobe: includes hippocampus, amygdala, and limbic lobes

• Hearing
• Balance
• Hallucinations
o Temporal lobe "partial complex" seizures: have olfactory hallucinations before seizure
o Hypnopompic hallucinations: occur when waking up
o Hypnogogic hallucinations: occur when going to sleep
• Wernicke's area (receptive aphasia) => can't understand speech or writing "Wordy"
• Wernicke's encephalopathy: due to thiamin deficiency => ataxia, nystagmus, psychosis
• Korsakoff psychosis: mamillary bodies hurt by EtOH => confabulation, anterograde amnesia

Occipital Lobe: Make sure and flip ALL the words in eye lesion problems…
Vision: light must hit retina by 3mo or child is permanently blind => look for red reflex
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• No red reflex: Cataracts – hard lens (may be caused by rubella virus)
o Newborns: sporadic
o Adults: sunlight, any disease with high sugar
• White reflex: Retinoblastoma => osteosarcoma
Eye Diseases:
Amblyopia: difference in visual acuity (baby's head tilts toward bad eye)
Anisocoria: unequal pupils
• Newborns: genetic (AD)
• Adults: intracranial pressure
Astigmatism: defect in the shape of cornea
Esotropia: cross-eyed
• Newborns: weak eye mm. for 1st 6mo (common) Tx: patch the good eye (3 y/o)
• >1y/o: eye turns in => intracranial pressure
Hyperopia: farsighted – need convex lens
Myopia: nearsighted – need concave lens
Presbyopia: loss of accommodation w/ aging (hold book at arm's length to read)
Strabismus: squint
Marcus-Gunn pupil: dilates with light (instead of constricting; CN 2 defect)
Pterygium: skin growth from conjunctiva to nasal side of cornea
Pinguecula: yellow nodule on cornea
Blepharitis: eyelash inflammation
Chalazion: inner eyelid tumor

Visual Acuity:
20/20 => can see bottom line of Snell chart 20ft away
20/100 => enlarge chart 5x to see bottom line of chart => legally blind

Glaucoma:
Open-angle: overproduction of fluid
• Sx: Painless, ipsilateral dilated pupil, gradual tunnel vision, optic disc cupping
• Tx: Control intraocular pressure
Closed-angle: obstruction of canal of Schlemm
• Sx: Sudden onset, pain
• Tx:
• 1) Induce miosis: Pilocarpine, α-agonist
• 2) Decrease aqueous production: β-blocker, Acetazolamide (CA inhibitor)
• 3) Laser iridotomy

Eye Clues:
Yellow color: Bilirubin
Yellow vision: Digoxin toxicity
Blue sclera: Osteogenesis imperfecta
Opaque: Cataract
Roth spot: Endocarditis
Cherry-red macula: Tay-Sachs, Neimann-Pick
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Brown macula: Malignant melanoma

Vision Lesions: "SO4LR6"

• Nasal fibers – cross over
• Temporal fibers – go straight back

1) Ipsilateral blindness: Optic nerve lesion

Newborns: cataract or Rb
Kids: optic nerve glioma
Adults: emboli
• TIA: blind in one eye for <24 hrs
• Temporal arteritis: HA, blind in one eye (Tx: steroids)
• Optic neuritis: painful, blind in one eye, change in color perception (Tx: steroids)
• Central retinal artery occlusion => pale retina and cherry red macula (Tx: thrombolytics)
• Central retinal vein occlusion => blue retina

2) Bitemporal Hemianopsia: Optic chiasm lesion

• Pituitary tumor => high PRL
• Pineal tumor => precocious puberty

3) Homonymous Hemianopsia: Optic tract lesion

Lose nasal same side, temporal other side

4) Quadranopsia: Calcarine fissure lesion

Lose opposite side

5) Central Scotoma: Macula lesion

6) Acute Loss:
• Retinal detachment: flashes of light (Tx: surgery)
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• Vitreous hemorrhage: floaters (Tx: photocoagulate)

7) Amaurosis Fugax: Retinal emboli => painless loss of vision, looks like a "curtain falling down"

Hypertensive Retinopathy: neovascularization => DM

• Grade I – arteriole narrowing, copper wiring
• Grade II – A-V nicking
• Grade III – hemorrhage
• Grage IV – papilledema

Thalamus:
Epithalamus: no known fxn
Thalamus: "The Secretary" All sensory info must stop here
• Medial: Leg fibers
• Lateral: Arm fibers
Hypothalamus:
• Anterior nucleus: Temp regulation (dissipates heat) "AC: Anterior Cools"  Acetaminophen
• Posterior nucleus: Temp regulation (conserves heat), parasympathetics
• Lateral nucleus: Hunger
• Medial nucleus: Satiety
• Suprachiasmatic nucleus: Circadian rhythms "the timekeeper"
• Supraoptic nucleus: ADH production
• Paraventricular nucleus: Thirst center

Basal Ganglia: lateral wall of internal capsule, controls gross movement

1) Caudate nucleus
• Huntington's: triplet repeats, anticipation, no GABA, choreiform movements
• Cause of death: suicide (30 y/o), insurance will drop them upon diagnosis

2) Globus Pallidus: inhibits movement (send Ach or GABA to substantia nigra)

Movement Disorders:
Tick: involuntary movement of one muscle
Dystonia: sustained contraction of muscle groups
Tardive Dyskinesia: facial grimace, tongue thrusting
Akathesia: non-stop restless movements
Tourette's Syndrome:
• Motor ticks (Tx: Clonidine or Haloperidol)
• Vocal ticks
• Echolalia: repeats everything
• Coprolalia: constant swearing

3) Putamen: most common site of HTN hemorrhage

Wilson's: ceruloplasmin def. => Cu deposits in liver, eye (KF rings), brain (lenticular nucleus)
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4) Substantia Nigra: med wall of internal capsule => initiates movements (sends DA to basal ganglia)
Parkinson's: can't initiate movement (no DA)

5) Subthalamic Nucleus: "The Final Relay Station for Fine Motor Coordination" => ballismus

Basal Ganglia Nomenclature:

Striatum = caudate nucleus + putamen
Corpus striatum = globus pallidus + striatum
Lenticular nucleus = globus pallidus + putamen

Internal Capsule: All info going in & out of brain must come through here
Reticular Activating System: "Gatekeeper of the Internal Capsule", maintains your focus (NE, 5-HT)
• Attention Deficit Disorder: low NE, 5-HT => can't ignore any thought coming in or out of brain

Brain Tracts:
Fasciculus = few fibers
Tractus = lots of fibers
Gracilus = legs "graceful legs"
Cuneatus = arms

Uppper vs. Lower Motor Neuron Lesions:

UMN: "upper" LMN: "downer"
CS tract non-CS tracts Glasgow Coma Scale:
<8=severe
Spasticity Flaccid paralysis
Hyperreflexia Hyporeflexia • Eye opening (max=4)
Clonus Atrophy • Verbal response (max=5)
Babinski reflex Fasiculations/ fibrillations • Motor response (max=6)

1) Descending Tracts
Corticospinal (CS) tract: motion
Crosses in medulla => sx are contralateral, pyramidal decussation, use CN to find level of injury

Corticorubral tract: contains red nucleus, runs right below CN3 => flexion

Hypothalamospinal tract:
Lesion => ipsilateral Horner's syndrome: miosis, ptosis, anhydrosis, enopthalmos

2) Ascending Tracts
Dorsal Column Medial Lemniscus (DCML) tract: vibration, position, 2-point discrimination
Crosses in medulla
1st synapse: Dorsal root ganglion
2nd synapse: Nucleus cuneatus and nucleus gracilis (crosses here)
3rd synapse: Thalamus
4th synapse: Post-central gyrus
• Pernicious anemia: anti-IF Ab (affects DCML and ST)
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• Freidrich's ataxia: scoliosis, retinitis pigmentosa (attacks DCML and SC)
• 3° Syphilis: obliterative endarteritis, lancenating stabbing pain (attacks DCML)

Spinocerebellar (SC) tract: balance, depth perception

The only pathway that crosses twice => ipsilateral symptoms
Spinothalamic (ST) tract: pain & temp
Crosses in spinal cord (ant. white commisure) => lose stuff 2 levels lower on contralateral side
All sensory fibers come in through dorsal root ganglia, go up two dermatomes, then cross
• Anterior white commisure lesion: Syringomyelia => lose pain/temp in "cape" distribution
• Spinal cord lesions: pain & temp loss on opposite side of all other losses

↑ Intracranial pressure:
• Sx: Headache
• Signs:
1) Papilledema (check CT first)
• Mass => don't do a lumbar puncture!
• No Mass => do LP for meningitis
2) Esotropia/ Anisocoria (eye moves in due to CN6 compression)
3) Dilated pupils (due to CN3 compression) => 1st sign of herniation
4) Decorticate rigidity: herniation above red nuc. => flex arms => 2nd sign of herniation
5) Decerebrate rigidity: herniation below red nucleus => extend arms => dead

CPP = MAP - ICP

CPP = cerebral perfusion pressure (Ex: HTN + head injury => ↑CCP)
ICP = intracranial pressure (↓ w/ head injury) – No Nitroprusside! Treat ICP and BP will follow…
MAP = mean arterial pressure (↑ w/ HTN)

Head Injury Tx: "VMAB"

1) Ventilator (100% O2 to ↓CO2  ↓flow  ↓ICP)
2) Mannitol – suck fluid out of brain cells to shrink brain
3) Acetazolamide – inhibits CA (which makes CSF)
4) Burr a hole in top of head to relieve pressure, No LP!

LP Barriers: Skin  Ligaments  Dura  Arachnoid (Note: CSF is in subarachnoid space)

• Do LP at L4-L5 "L4-L5 keep the spinal cord alive"

CSF Production:
• Needs Vit A, carbonic anhydrase
• Drainage: subarachnoid dural sinuses  plasma
• Each ventricle has its own choroid plexus => CSF
• CO2 can diffuse into your brain
• Bicarb and H+ cannot diffuse into brain => resp. problems affect CSF (Not metabolic acidosis)
• Acid can make GABA
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Vomiting centers: responds to increased intracranial pressure, toxic smells

• Chemotactic Trigger Zone – on floor of 4th ventricle
• Area Postrema – in BBB
Ventricle Problems:
Non-communicating Hydrocephalalus: obstruction CSF: ↓Bicarb, ↑Cl
• Newborns: Sweat: ↑Bicarb, ↑K
#1: Aqueductal stenosis
#2: Dandy Walker Cyst (in 4th ventricle)
• Adults: Tumors (Ependymoma)

Communicating Hydrocephalus:↑CSF production

• Newborns: Intraventricular hemorrhage
• Kids: Pseudotumor cerebri (high Vit A)
• Elderly: Normal pressure hydrocephalus – due to cortical atrophy with age

Headaches:
Migraines: aura, photophobia, numbness and tingling  throbbing HA, nausea
• Tx: NSAIDs, Sumatriptan (5-HT agonist)
Tension Headache: "band-like" pain, worse as day progresses, sleep disturbance
• Tx: Aspirin, Amitriptyline prophylaxis
Cluster Headache: rhinorrhea, unilateral orbital pain, suicidal, facial flushing
• Tx: O2 inhalation, Methysergide (prophylaxis), Glucocorticoid, Sumatriptan
Temporal (Giant cell) Arteritis: pain with chewing, blind in one eye
• Tx: Prednisone
Trigeminal Neuralgia: sharp, shooting face pain
• Tx: Carbamazepine

Types of Hemorrhage:
Anterior cerebral artery => affects from waist down
Middle cerebral artery => affects from waist up
Posterior cerebral artery => affects eyes
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Basilar skull facture: trauma

• Bleed around eye "raccoon eyes"
• Bleed around mastoid "battle sign"
• Bleed behind eardrum "ebotympana"