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USMLE STEP 2


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USMLE STEP 2
Fourth Edition
Theodore X. O’Connell, MD

Program Director, Family Medicine Residency Program
Kaiser Permanente Napa-Solano, California
Assistant Clinical Professor, Department of Community and Family Medicine
University of California, San Francisco School of Medicine, San Francisco, California
Assistant Clinical Professor, Department of Family Medicine
David Geffen School of Medicine at UCLA
Los Angeles, California

1600 John F. Kennedy Blvd.
Ste 1800
Philadelphia, PA 19103-2899
USMLE STEP 2 SECRETS, FOURTH EDITION
Copyright © 2014, 2010, 2004 by Saunders, an imprint of Elsevier Inc.

ISBN: 978-0-323-18814-2

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Library of Congress Cataloging-in-Publication Data
O’Connell, Theodore X., author
USMLE step 2 secrets : questions you will be asked / Theodore X. O’Connell. -- Fourth edition.
  p. ; cm. -- (Secrets series)
Preceded by USMLE step 2 secrets / Theodore X. O’Connell, Adam Brochert. 3rd edition. 2010.
Includes bibliographical references and index.
ISBN 978-0-323-18814-2 (alk. paper)
I. Title. II. Series: Secrets series.
[DNLM: 1. Clinical Medicine--Examination Questions. WB 18.2]
RC58
616.0076--dc232013021243

Senior Content Strategist: Jim Merritt
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Printed in the United States of America
Last digit is the print number: 9 8 7 6 5 4 3 2 1


To Nichole, Ryan, Sean, and Claire.
I love you.


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CONTENTS
100 Top Secrets................................................................................................................. 1
1.Acid-Base and Electrolytes............................................................................................17
2.Alcohol..........................................................................................................................24
3.Biostatistics...................................................................................................................28
4.Cardiology.....................................................................................................................35
5.Cholesterol....................................................................................................................51
6.Dermatology..................................................................................................................54
7.Diabetes Mellitus...........................................................................................................68
8.Ear, Nose, and Throat Surgery........................................................................................73
9.Emergency Medicine.....................................................................................................78
10.Endocrinology................................................................................................................81
11.Ethics............................................................................................................................89
12.Gastroenterology...........................................................................................................92
13.General Surgery..........................................................................................................112
14.Genetics......................................................................................................................124
15.Geriatrics.....................................................................................................................130
16.Gynecology..................................................................................................................132
17.Hematology.................................................................................................................144
18.Hypertension...............................................................................................................161
19.Immunology................................................................................................................165
20.Infectious Diseases......................................................................................................172
21.Laboratory Medicine....................................................................................................191
22.Nephrology..................................................................................................................193
23.Neurology....................................................................................................................199
24.Neurosurgery..............................................................................................................213
25.Obstetrics....................................................................................................................219

vii


viii CONTENTS

26.Oncology.....................................................................................................................240
27.Ophthalmology............................................................................................................262
28.Orthopedic Surgery.....................................................................................................269
29.Pediatrics....................................................................................................................277
30.Pharmacology.............................................................................................................285
31.Preventive Medicine....................................................................................................290
32.Psychiatry...................................................................................................................294
33.Pulmonology...............................................................................................................306
34.Radiology....................................................................................................................312
35.Rheumatology.............................................................................................................315
36.Shock..........................................................................................................................323
37.Smoking......................................................................................................................326
38.Urology........................................................................................................................327
39.Vascular Surgery.........................................................................................................332
40.Vitamins and Minerals.................................................................................................336


Plate 1.  Infant with fetal alcohol syndrome. Note short palpebral fissures, mild ptosis, nostrils, smooth philtrum, and
narrow vermillion of the upper lip. See Figure 2-1, p. 26. (From Gilbert-Barness E. Potter’s pathology of the fetus,
infant, and child, 2nd ed. Philadelphia: Elsevier, 2007, Fig. 4.1.12.)

Plate 2.  Xanthelasma. Multiple soft, yellow plaques involving the lower eyelid. Xanthelasma is usually a normal finding
with no significance but is classically seen on the USMLE because of its association with hypercholesterolemia. Screen
affected patients with a fasting lipid profile. See Figure 5-1, p. 52. (From Yanoff M, Duker JS. Ophthalmology, 3rd ed.
Philadelphia: Mosby, 2008, Fig. 12-9-18.)

Plate 3.  Allergic contact dermatitis of the leg caused by an elastic wrap. Notice the well-marginated distribution that
differentiates it from cellulitis. See Figure 6-1, p. 55. (From Auerbach PS. Wilderness medicine, 6th ed. Philadelphia:
Mosby, 2011.)

Plate 4.  Tinea corporis. Red ring-shaped lesions with
scaling and some central clearing. See Figure 6-2,
p. 56. (From ­Kliegman RM. Nelson textbook of pediatrics,
19th ed. Philadelphia: Saunders, 2011.)

Plate 5.  Pityriasis rosea. Small oval plaques as well
as multiple small papules are present. See Figure 6-3,
p. 59. (From Habif TP. Clinical dermatology, 5th ed. St.
Louis: Mosby, 2009.)


Plate 6.  Lichen planus. Flat-topped, purple polygonal papules of lichen planus. See Figure 6-4, p. 60. (From Kliegman RM.
Nelson textbook of pediatrics, 19th ed. Philadelphia: Saunders, 2011.)

Plate 7.  Erythema multiforme. “Bull’s-eye” annular lesions with central vesicles and bullae. See Figure 6-5, p. 60.
(From Goldman L. Goldman’s Cecil medicine, 24th ed. Philadelphia: Saunders, 2011.)

Plate 8.  Erythema nodosum on the legs of a young woman. See Figure 6-6, p. 61. (From Hochberg MC. Rheumatology,
5th ed. Philadelphia: Mosby, 2010.)


Plate 9.  Bullous pemphigoid. Tense subepidermal bullae on an erythematous base. See Figure 6-7, p. 61. (From
Goldman L. Goldman’s Cecil medicine, 24th ed. Philadelphia: Saunders, 2011.)

Plate 10.  Dermatitis herpetiformis is characterized by pruritus, urticarial papules, and small vesicles. See Figure 6-8,
p. 62. (From Feldman M. Sleisenger and Fordtran’s gastrointestinal and liver disease, 9th ed. Philadelphia: Saunders,
2010; Courtesy Dr. Timothy Berger, San Francisco, Calif.)

Plate 11.  Melanoma (superficial spreading type). See Figure 6-9, p. 63. (From Goldman L. Goldman’s Cecil medicine,
24th ed. Philadelphia: Saunders, 2011.)


Plate 12.  Keratoacanthoma on the right upper lid. Lesions are solitary, smooth, dome-shaped red papules or nodules with a central keratin plug. See Figure 6-10, p. 64. (From Albert DM. Albert & Jakobiec’s principles and practice
of ophthalmology, 3rd ed. Philadelphia: Saunders, 2008.)

Plate 13.  Keloid of the earlobe after piercing. See Figure 6-11, p. 64. (From Kliegman RM, Stanton BF, St. Geme JW III,
et al. Nelson textbook of pediatrics, 19th ed. Philadelphia: Saunders, 2011.)

Plate 14.  An ulcerated basal cell carcinoma with rolled borders on the posterior ear. See Figure 6-12, p. 65. (From
Abeloff DA, Armitage JO, Niederhuber JE, et al. Abeloff’s clinical oncology, 4th ed. Philadelphia: Churchill Livingstone,
2008.)


Plate 15.  Squamous cell carcinoma on the lower lip. See Figure 6-13, p. 65. (From Rakel RE, Rakel DP. Textbook of
family medicine, 8th ed. Philadelphia: Saunders, 2011. © Richard P. Usatine.)

Plate 16.  Multiple actinic keratoses visible as thin, red, scaly lesions. See Figure 6-14, p. 66. (From Goldberg DJ.
Procedures in cosmetic dermatology: lasers and lights, Vol 1, 2nd ed. Saunders, 2008.)

Plate 17.  Nailbed melanoma. See Figure 6-15, p. 67. (From Goldman L, Schafer AI. Goldman’s Cecil medicine, 24th ed.
Philadelphia: Saunders, 2011.)


Plate 18.  Paget disease of the nipple. Note the erythematous plaques around the nipple. See Figure 6-16, p. 67.

(From Lentz GM, Lobo RA, Gershenson DM, Katz VL. Comprehensive gynecology. 6th ed. Philadelphia: Mosby, 2011.
Originally from Callen JP. Dermatologic signs of systemic disease. In Bolognia JL, Jorizzo JL, Rapini RP [eds]. Dermatology. Edinburgh: Mosby, 2003, p 714.)

Plate 19.  Multiple patterned café au lait spots in a child with McCune-Albright syndrome. See Figure 10-2, p. 86.
(From Eichenfield LF, Frieden IJ, Esterly NB. Neonatal dermatology, 2nd ed. Philadelphia: Saunders, 2008, Fig. 22-3.)

Plate 20.  Colonoscopic photograph of a pale colon cancer easily seen against the dark background of pseudomelanosis
coli. See Figure 12-3, p. 95. (From Feldman M, Friedman LS, Brandt LJ, eds. Sleisenger and Fordtran’s gastrointestinal
and liver disease, 9th ed. Philadelphia: Saunders, 2010, Fig. 124-8. Courtesy Juergen Nord, MD, Tampa, Fla.)


3
1
4
5

2

A

B

Plate 21.  Mucosal pathology in celiac disease. A, Duodenal biopsy specimen of a patient with untreated celiac d­ isease.
The histologic features of severe villus atrophy (arrow 1), crypt hyperplasia (arrow 2), enterocyte disarray (arrow 3), and
intense inflammation of the lamina propria and epithelial cell layer (arrow 4) are evident. B, Repeat ­duodenal biopsy
after 6 months on a strict gluten-free diet. There is marked improvement, with well formed villi (arrow 5) and a return of
the mucosal architecture toward normal. See Figure 12-5, p. 97. (From Feldman M, Friedman LS, Brandt LJ. Sleisenger
and Fordtran’s gastrointestinal and liver disease, 9th ed. Philadelphia: Saunders, 2010, Fig. 104-2.)

Plate 22.  Chronic viral hepatitis. Portal-portal bridging fibrosis is seen in longstanding chronic hepatitis C. See Figure 12-8,

p. 102. (From Odze RD, Goldblum JR. Surgical pathology of the GI tract, liver, biliary tract, and pancreas, 2nd ed. Saunders,
2009, Fig. 38-10.)


Trachea

Proximal esophagus
Tracheoesophageal fistula

Bronchi
Distal esophagus

Plate 23.  Tracheoesophageal fistula. Diagram of the most common type of esophageal atresia and tracheoesophageal
fistula. See Figure 12-11, p. 108. (From Gilbert-Barness E. Potter’s pathology of the fetus, infant and child, 2nd ed.
Philadelphia: Mosby, 2007, Fig. 25.6.)

A

B

Plate 24.  Abdominal wall defects. A, Omphalocele with intact sac. B, Gastroschisis with eviscerated multiple bowel
loops to the right of the umbilical cord. See Figure 12-13, p. 110. (From Sabiston DC, Townsend CM. Sabiston textbook
of surgery: the biological basis of modern surgical practice, 19th ed. Philadelphia: Saunders, 2012, Fig. 67-20.)


Plate 25.  Henoch-Schönlein purpura in a 7-year-old child. Note typical red-purple rash on the lower extremities. See
Figure 12-14, p. 111. (From Marx JA, Hockberger RS, Walls RM. Rosen’s emergency medicine: concepts and clinical
practice, 7th ed. Mosby, 2009, Fig. 170-10. Courtesy Marianne Gausche-Hill, MD.)

A

B

Plate 26.  Edward syndrome. A, Note the small head, prominent occiput, and low-set, malformed ears. B, Clenched hand
with overlapping fingers. See Figure 14-2, p. 127. (Kanski JJ. Clinical diagnosis in ophthalmology, 1st ed. Philadelphia:
Mosby, 2006, Fig. 15.10. Courtesy BJ Zitelli and HW Davis).


Plate 27.  Turner syndrome. This 13-year-old female demonstrates the classic webbed neck and triangular facies
of Turner syndrome. She has sexual infantilism and short stature. See Figure 14-3, p. 128. (Moshang T, ed. Pediatric
endocrinology: the requisites in pediatrics, 1st ed. St. Louis: Mosby 2005, Plate 8-2.)

Plate 28.  Marfan syndrome. Arachnodactyly in a patient with Marfan syndrome. See Figure 14-4, p. 129. (Stamper RL,
Lieberman MF, Drake MV. Becker-Shaffer’s diagnosis and therapy of the glaucomas, 8th ed. Philadelphia: Mosby 2009,
Fig. 19.41.)


Plate 29.  Pigment gallstones within an otherwise unremarkable gallbladder are a marker for hemolytic anemia. See
Figure 17-1, p. 145. (From Kumar V, Abbas AK, Fausto N, Aster JC. Robbins and Kotran pathologic basis of disease,
professional edition, 8th ed. Philadelphia: Saunders, 2009, Fig. 18-53.)

Plate 30.  Sickle cells show a sickle or crescent shape resulting from the polymerization of hemoglobin S. This smear
also shows target cells and boat-shaped cells with a lesser degree of polymerization of hemoglobin S than in a classic
sickle cell. See Figure 17-2, p. 145. (From Goldman L, Schafer AI. Goldman’s Cecil medicine, 24th ed. Philadelphia:
Saunders, 2011, Fig. 160-7.)


Plate 31.  Megaloblastic changes of macrocytosis and
a hypersegmented neutrophil. See Figure 17-3, p. 146.
(From Rakel RE, Rakel DP. Textbook of family medicine,

8th ed. Philadelphia: Saunders, 2011, Fig. 39-4; The
American Society of Hematology Image Bank image
#2611. Copyright 1996 American Society of Hematology, used with permission.)

Plate 32.  Iron-deficiency anemia. Pale red blood cells
with enlarged central pallor. See Figure 17-4, p. 146.
(From McPherson R, Pincus M. Henry’s clinical diagnosis and management by laboratory methods, 21st ed.
Philadelphia: Saunders, 2006, Fig. 31-2.)

Plate 33.  Basophilic stippling. Irregular basophilic
granules in red blood cells; often associated with lead
poisoning and thalassemia. See Figure 17-5, p. 147.
(From McPherson R, Pincus M. Henry’s clinical diagnosis and management by laboratory methods, 21st ed.
Philadelphia: Saunders, 2006, Fig. 29-23.)

Plate 34.  Bite cells with Heinz bodies. See Figure 17-6,
p. 147. (Courtesy Dr. Robert W. McKenna, Department
of Pathology, University of Texas Southwestern Medical
School, Dallas, Texas.)

Plate 35.  Howell-Jolly bodies in peripheral blood
erythrocytes. These nuclear remnants indicate lack
of splenic filtrative function. See Figure 17-7, p. 148.
(From Orkin SH, et al. Nathan and Oski’s hematology of
infancy and childhood, 7th ed., Philadelphia: Saunders,
2009, Fig. 14-4.)

Plate 36.  Teardrop red blood cells, usually seen in
myelofibrosis. See Figure 17-8, p. 148. (From Goldman
L, Ausiello D. Cecil medicine, 23rd ed. Philadelphia:

Saunders, 2008, Fig. 161-13.)


Plate 37.  Schistocytes and helmet cells. Red blood
cell fragments seen with microangiopathic hemolytic
anemia and disseminated intravascular coagulation.
See Figure 17-9, p. 148. (From McPherson R, Pincus
M. Henry’s clinical diagnosis and management by
laboratory methods, 21st ed. Philadelphia: Saunders,
2006, Fig. 29-19.)

Plate 38.  Hereditary elliptocytosis. Blood film reveals
characteristic elliptical red blood cells. See Figure 17-10,
p. 149. (From ­McPherson RA, Pincus MR. Henry’s clinical
diagnosis and management by laboratory methods,
22nd ed. Saunders, 2011, Fig. 30-16.)

Plate 39.  Acanthocytes. Irregularly spiculated red
blood cells, frequently seen in abetalipoproteinemia
or liver disease. See Figure 17-11, p. 149. (From
McPherson R, Pincus M. Henry’s clinical diagnosis and
management by laboratory methods, 21st ed. Philadelphia: Saunders, 2006, Fig. 29-20.)

Plate 40.  Target cells are frequently seen in hemoglobin C disease and liver disease. See Figure 17-12,
p. 149. (From McPherson R, Pincus M. Henry’s clinical
diagnosis and management by laboratory methods,
21st ed. Philadelphia: Saunders, 2006, Fig. 29-18.)


Plate 41.  Echinocytes, or burr cells (arrows), are

the hallmark of uremia. See Figure 17-13, p. 150.
(Hoffman R, et al. Hematology: basic principles and
practice, 5th ed. Philadelphia: Churchill Livingstone,
2008, Fig. 156-1.)

Plate 42.  Microangiopathic hemolytic anemia
demonstrating red blood cell fragments, anisocytosis,
polychromasia, and decreased platelets. See Figure
17-14, p. 150. (From Tschudy MM, Arcara KM, editors.
The Harriet Lane handbook, 19th ed. Philadelphia:
Mosby, 2011, Plate 7.)

A
Plate 43.  Rouleaux formation of stacked red blood
cells seen in multiple myeloma. See Figure 17-15,
p. 150. (From Goldman L, Ausiello D. Cecil medicine,
23rd ed. Philadelphia: Saunders, 2008, Fig. 161-19.)

B

Plate 44.  Malaria. Peripheral blood film examples of
various stages of Plasmodium falciparum. A, Small
ring forms. B, A crescentic gametocyte with centrally
placed chromatin. See Figure 17-16, p. 151. (From
Hoffman R, et al. Hematology: basic principles and
practice, 5th ed. Philadelphia: Churchill Livingstone,
2008, Fig. 159-5.)

Plate 45.  Ringed sideroblasts seen in sideroblastic anemia. See Figure 17-17, p. 151. (From Goldman L, Ausiello D.
Cecil medicine, 23rd ed. Philadelphia: Saunders, 2008, Fig. 163-5.)