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Elsevier
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CRUSH STEP 1: THE ULTIMATE USMLE STEP 1 REVIEW, ISBN: 978-0-323- 87886-9
THIRD EDITION
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 REVIEW BOARD

Zahir Basrai, MD
Assistant Clinical Professor of Emergency Medicine
David Geffen School of Medicine at UCLA
VA Greater Los Angeles Healthcare System
Los Angeles, California

Pranay Bonagiri, DO
Resident Physician, Department of Medicine
Scripps Mercy Hospital San Diego
San Diego, California

Manuel Celedon, MD
Assistant Clinical Professor of Emergency Medicine
David Geffen School of Medicine at UCLA
VA Greater Los Angeles Healthcare System
Los Angeles, California

Michelle W. Cheng, MD
Resident Physician
Department of Dermatology
UCLA Medical Center
Los Angeles, California

Matthew J. Christensen, MD
Resident Physician
Department of Emergency Medicine
Naval Medical Center San Diego
San Diego, California

Patricia Fermin, MD
Assistant Clinical Professor of Emergency Medicine
David Geffen School of Medicine at UCLA
VA Greater Los Angeles Healthcare System
Los Angeles, California

Jonie J. Hsiao, MD
Faculty, Division of Emergency Medicine
VA Greater Los Angeles Healthcare System
Assistant Clinical Professor of Emergency Medicine
David Geffen School of Medicine at UCLA
Los Angeles, California
vi REVIEW BOARD

Carol Lee, MD
Assistant Clinical Professor of Emergency Medicine
David Geffen School of Medicine at UCLA
VA Greater Los Angeles Healthcare System
Los Angeles, California

Miguel Lemus, MD
Assistant Clinical Professor of Emergency Medicine
David Geffen School of Medicine at UCLA
VA Greater Los Angeles Healthcare System
Los Angeles, California

Kian Preston-Suni, MD, MPH

Assistant Chief of Emergency Medicine
VA Greater Los Angeles Healthcare System
Assistant Clinical Professor of Emergency Medicine
David Geffen School of Medicine at UCLA
Los Angeles, California

Manpreet Singh, MD, MBE, FACEP

Director, Undergraduate Medical Education
Department of Emergency Medicine
Harbor-UCLA Medical Center
Assistant Professor of Emergency Medicine
David Geffen School of Medicine at UCLA
Los Angeles, California

Tina R. Storage, MD
Assistant Clinical Professor
Division of Digestive Diseases
David Geffen School of Medicine at UCLA
Los Angeles, California

Sabrina M. Tom, MD
VA Greater Los Angeles Healthcare System
Olive View-UCLA Medical Center
Assistant Clinical Professor of Emergency Medicine
David Geffen School of Medicine at UCLA
Los Angeles, California

Kathleen Yip, MD
Faculty, Division of Emergency Medicine
VA Greater Los Angeles Healthcare System
Assistant Clinical Professor of Emergency Medicine
David Geffen School of Medicine at UCLA
Los Angeles, California

Lisa F. Zhao, MD
Assistant Clinical Professor of Emergency Medicine
David Geffen School of Medicine at UCLA
VA Greater Los Angeles Healthcare System
Olive View-UCLA Medical Center
Los Angeles, California
 CONTRIBUTORS

Thomas E. Blair, MD
Deputy Chief of Emergency Medicine
VA Greater Los Angeles Healthcare System
Los Angeles, California
Assistant Clinical Professor of Emergency Medicine
David Geffen School of Medicine at UCLA
Los Angeles, California

William B. Babbitt, MD
Department of Pediatrics
Kaiser Permanente South Sacramento
Daly City, California

John H. Baird, MD
Assistant Professor
Division of Lymphoma
Department of Hematology and Hematopoietic Cell Transplant
City of Hope National Medical Center
Duarte, California

Brenton Bauer, MD
Internist and Cardiologist
COR Healthcare Medical Associates
Los Angeles, California
Torrance Memorial Medical Center
Torrance, California

Manuel Celedon, MD
Assistant Chief, Department of Emergency Medicine
VA Greater Los Angeles Healthcare System
Health Sciences Assistant Clinical Professor of Emergency Medicine
David Geffen School of Medicine at UCLA
Los Angeles, California

Michelle W. Cheng, MD
Resident Physician
Department of Dermatology
UCLA Medical Center
Los Angeles, California
viii CONTRIBUTORS

Jonie J. Hsiao, MD
Faculty, Division of Emergency Medicine
VA Greater Los Angeles Healthcare System
Assistant Clinical Professor of Emergency Medicine
David Geffen School of Medicine at UCLA
Los Angeles, California

Edwin Li, MD
Associate Physician
Department of Pediatrics
Kaiser Permanente San Jose
San Jose, California

Masood Memarzadeh, MD
Assistant Chief of Anesthesiology - Diablo Service Area
The Permanente Medical Group
Walnut Creek, California

Theodore X. O’Connell, MD
Founding Program Director
Family Medicine Residency Program
Kaiser Permanente Napa-Solano
Napa, California
Chief, Department of Family and Community Medicine
Kaiser Permanente Vallejo
Vallejo, California
Associate Clinical Professor
Department of Community and Family Medicine
University of California
San Francisco School of Medicine
San Francisco, California

Gwen E. Owens, MD, PhD

Clinical Fellow in Pediatric Anesthesia
Boston Children’s Hospital
Boston, Massachusetts

Ryan A. Pedigo, MD, MHPE

Associate Residency Program Director
Department of Emergency Medicine
Harbor-UCLA Medical Center
Torrance, California
Associate Professor of Emergency Medicine
David Geffen School of Medicine at UCLA
Los Angeles, California

Tiffany Pedigo, MD
Division of Pediatric Critical Care Medicine
Harbor-UCLA Medical Center
Torrance, California
 CONTRIBUTORS ix

Kian Preston-Suni, MD, MPH

Assistant Chief of Emergency Medicine
VA Greater Los Angeles Healthcare System
Assistant Clinical Professor of Emergency Medicine
David Geffen School of Medicine at UCLA
Los Angeles, California

Lauren Sanchez, MD
Assistant Professor, Pediatrics
University of California, San Francisco, School of Medicine
San Francisco, California

Manpreet Singh, MD, MBE, FACEP

Director, Undergraduate Medical Education
Department of Emergency Medicine
Harbor-UCLA Medical Center
Assistant Professor of Emergency Medicine
David Geffen School of Medicine at UCLA
Los Angeles, California

Tina R. Storage, MD
Assistant Clinical Professor
Division of Digestive Diseases
David Geffen School of Medicine at UCLA
Los Angeles, California

Natalie M. Villa, MD
Assistant Professor of Dermatology
Dartmouth Hitchcock Medical Center
Lebanon, New Hampshire

Kathleen Yip, MD
Faculty, Division of Emergency Medicine
VA Greater Los Angeles Healthcare System
Assistant Clinical Professor of Emergency Medicine
David Geffen School of Medicine at UCLA
Los Angeles, California

Andrew T. Yu, MD
Neurologist
UCSF Health – UCSF Medical Center
San Francisco, California
Zuckerberg San Francisco General Hospital and Trauma Center
San Francisco, California

Lisa F. Zhao, MD
Assistant Clinical Professor of Emergency Medicine
David Geffen School of Medicine at UCLA
VA Greater Los Angeles Healthcare System
Olive View-UCLA Medical Center
Los Angeles, California
This page intentionally left blank
 INTRODUCTION

The rst edition of Crush Step 1 was conceptualized, designed, and created by
medical students, then edited by experts in their eld, with the goal of being the best
resource on the market for truly understanding the material that is tested on the
USMLE Step 1. Our research showed that students were frustrated because review
books were either too in-depth for the purposes of the test or too focused on mem-
orization rather than understanding. We asked students like you before and after the
test what they wish they would have had during their own preparation, and we
sought to provide that for future students. The second edition built on this concept,
adding numerous updates and additional high-yield content. This book has always
been driven by what those preparing for the USMLE Step 1 want, and this concept
has not changed as we took your feedback into account for this third edition. The
response to the rst two editions has been great, and we are truly privileged to be
able to bring you a third edition of this text and take into account all of your feed-
back and requests as well as direct input from students and residents who did very
well on the USMLE Step 1 examination.
When students understand the concepts of how anatomy, physiology, pathol-
ogy, and pharmacology interact with one another, medicine becomes less about
memorization and more about truly learning how the body works—and doesn’t
work! The third edition builds on the careful analysis and planning that went into
creating and updating the rst two editions, adding improved explanations, new
information important for the USMLE Step 1, updated pharmacology, and many
more changes.
We sincerely hope you enjoy this third edition of Crush Step 1. Continued feed-
back is always important to us. This is your book, and we want to make sure every-
thing is clear, precise, and up to date and serves your needs. Although we have a
rigorous editing process, it is possible that errors occur within the text. Please help
us with our goal to make this text the best resource available for medical students by
submitting any comments, suggestions, or corrections at www.BookRevision.com or
directly to Dr. O’Connell through his website at www.tedxoconnell.com. You will
also nd useful information about USMLE preparation, clinical rotations, and the
residency application process there.
Thanks again, and best of luck to you on your journey toward becoming an out-
standing physician.

Sincerely,
The Crush Step 1 Team
This page intentionally left blank
 A NOTE FROM
THE AUTHORS

On the USMLE examinations, and throughout medical education, associations are often made
between disease processes and certain racial and ethnic groups or even socioeconomic status. These
associations become linked with individual groups and can perpetuate stereotypes, misinformation,
and racism. In essence, physicians in training are taught to link keywords, phrases, and ideas for the
purposes of making associations on examinations and in clinical contexts.
Associations made with certain terms or disease processes, without qualications or explanation,
can cause those of us in healthcare to believe that being part of a particular group causes one to have
a predilection for health problems and disease process. The reasons a disease process is more prevalent
in certain racial, ethnic, and socioeconomic groups may be due in large part to long-standing social
inequities, health disparities, structural racism, oppression, adverse childhood experiences (ACEs),
politics, environment, and likely many other factors. It is vitally important to remember that an in-
creased prevalence should not be assumed to be intrinsically linked to being part of any particular
group.
We have attempted to remove these keywords and linkages in Crush Step 1 wherever possible while
acknowledging that some linkages may remain on standardized exams. If you nd any inappropriate
or outdated associations in this book, please let us know so we can remove them. We encourage you to
consider the broader social issues outlined above and work within the healthcare system to call out and
try to eliminate inappropriate associations between disease processes and individual groups of people.
We owe it to our patients and to society to do this and to be better going forward.

Ted O’Connell, MD
This page intentionally left blank
 TABLE OF
CONTENTS

1 Biostatistics 1
Thomas E. Blair and Kian Preston-Suni

2 Biochemistry 22
Gwen Owens and Theodore X. O’Connell

3 Dermatology 64
Thomas E. Blair, Lisa F. Zhao, and Michelle W. Cheng

4 Embryology 86
Thomas E. Blair and Ryan A. Pedigo

5 Microbiology 118
Lauren Sanchez, William B. Babbitt, and John H. Baird

6 Immunology 214
Brenton Bauer

7 Pharmacology and Toxicology 228

Ryan A. Pedigo

8 Cardiology 249
Ryan A. Pedigo

9 Endocrinology 298
Ryan A. Pedigo

10 Gastroenterology 343
Thomas E. Blair and Jonie J. Hsiao

11 Hematology and Oncology 381

Manuel Celedon and Theodore X. O’Connell

12 Musculoskeletal/Rheumatology 449
Thomas E. Blair and Kathleen Yip

13 Neurology 483
Manpreet Singh

14 Psychiatry 540
Natalie Villa, Edwin Li, Andrew Yu, and Tiffany Pedigo
xvi TABLE OF CONTENTS

15 Nephrology 566
Ryan A. Pedigo

16 Reproductive System 610

Theodore X. O’Connell and Tina Roosta Storage

17 Pulmonology 631
Theodore X. O’Connell and Masood Memarzadeh

Answers 667

Index 701
 1 BIOSTATISTICS
Thomas E. Blair and Kian Preston-Suni

MEAN, MEDIAN, AND MODE

m Sample value set: 1, 1, 2, 4, 5, 7, 7, 25, where n 5 8

m Mean: The average of a sample. It is calculated by adding all values, then dividing by the number
of values (n). In the sample set just given, (1 1 1 1 2 1 4 1 5 1 7 1 7 1 25)/8 5 6.5. The mean
is sensitive to extreme values.
m Median: The middle value of a sample. It is equivalent to the 50th percentile such that half the
sample values are above and half are below. It is identied by arranging the values in ascending
order, then nding the middle-most number. If n is odd, the median is the [(n 1 1)/2]th largest
observation. If n is even, the median is the average of the (n/2)th and the (n/2 1 1)th largest
observations. In this example, there is an even number of values, so the median is the average of the
two middle-most numbers, that is, for 1, 1, 2, 4, 5, 7, 7, 25, the median 5 (4 1 5)/2 5 4.5. An
advantage of the median is that it is not sensitive to extreme values. You may notice that in this
sample the mean is greater than the median. This indicates that the distribution has a positive skew
(see later discussion).
m Mode: The most frequently occurring value in a sample. In this example, both 1 and 7 are modes Mean: average
because they both appear twice. Therefore, this data set can be said to be bimodal. value
m Standard deviation (SD): A measure of the spread and variability of a data set, calculated as the Median: middle
value
square root of the variance. It represents the average deviation from the mean. The closer the values
remain to the mean, the smaller the SD (Fig. 1.1). The concept, not the mathematics, may be tested Mode: most
frequent value
on Step 1.
● Example: Normal body temperature will have a small SD because an individual’s anterior and Standard
posterior hypothalamus maintains temperature homeostasis within a very limited range. Blood deviation
sugars, on the other hand, will have a larger SD because glycemic loads change throughout represents the
the day. average
deviation from
the mean.

DEFINITIONS

m Normal distribution: This is also known as a Gaussian distribution or bell-shaped curve. A prob-
ability function in which values are symmetrically distributed around a central value, and the mean,
median, and mode are equal. In a normal distribution, 1 SD accounts for 68% of all values, 2 SDs
account for 95% of all values, and 3 SDs account for 99.7% of all values—the 68-95-99 rule
(Fig. 1.2). The area under the curve (AUC) is 1 (100%).
● Example: The intelligence quotient (IQ) test is constructed to follow a normal distribution with In a normal
distribution,
a mean of 100 and SD of 15. That means 95% of the population (2 SDs) will have an IQ
mean 5 median
between 70 and 130. Of clinical importance, intellectual disability is dened as an IQ of ,70. 5 mode.
m Bimodal distribution: A distribution with two modes.
● Example: The incidence of Crohn disease displays a bimodal distribution with the rst peak
between 15 and 30 years of age and the second peak between 60 and 80 years of age.
m Negative skew: An asymmetric distribution in which a tail on the left indicates that mean ,
median , mode. The tail is due to outliers on the left side of the curve.