USMLE Application Materials

 

Examination

Type of Applicant

Registration Entity to Contact

Step 1
or
Step 2

Students and graduates of LCME- and AOA-accredited medical schools in the United States, Puerto Rico, and Canada

NBME®
Applicant Services
3750 Market St.
Philadelphia, PA 19104-3190
(215) 590-9700
Fax: (215) 590-9457
Website: http://www.nbme.org
2002 Step 1 and Step 2 application materials: click here.

Step 1
or
Step 2

Students and graduates of medical schools outside the United States, Puerto Rico, and Canada

ECFMG®
3624 Market St.
Philadelphia, PA 19104-2685
Application materials:
  Visit the ECFMG website at www.ecfmg.org
  Telephone (215) 375-1913
  Telephone (800) 500-8249 toll-free within North America
Other inquiries: (215) 386-5900
Fax: (215) 387-9963

Step 3

All medical school graduates who have passed Step 1 and Step 2

FSMB
Department of Examination Services
400 Fuller Wiser Road, Suite 300
Euless, TX 76039-3855
(817) 868-4041
Website: http://www.fsmb.org
or
Medical licensing authority

 

Home Pages for ECFMG, FSMB, NBME

 

 

 Table 1. USMLE Step 1 Specifications*

System**

 

40%-50%

General principles

50%-60%

Individual organ systems

  • cardiovascular
  • hematopoietic / lymphoreticular
  • gastrointestinal
  • nervous / special senses
  • renal / urinary
  • skin / connective tissue
  • reproductive
  • musculoskeletal
  • endocrine
  • pulmonary / respiratory

Process

 

30%-50%

Normal structure and function

30%-50%

Abnormal processes

15%-25%

Principles of therapeutics

10%-20%

Psychosocial, cultural, occupational and environmental considerations

*Percentages may be changed without notice.
**The general principles category includes test questions concerning those normal and abnormal processes that are not limited to specific organ systems. Categories for individual organ systems include test questions concerning those normal and abnormal processes that are system specific.

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STEP 1 Content Outline (U1D)

General Principles

Biochemistry and molecular biology

# gene expression: DNA structure, replication, and exchange

– DNA structure: single- and double-stranded DNA, stabilizing forces, supercoiling

– analysis of DNA: sequencing, restriction analysis, PCR amplification, hybridization

– DNA replication, mutation, repair, degradation, and inactivation

– gene structure and organization; chromosomes; centromere, telomere

– recombination, insertion sequences, transposons

– mechanisms of genetic exchange (transformation, transduction, conjugation) cross-over, recombination,

linkage

– plasmids and bacteriophages

# gene expression: transcription (including defects)

– transcription of DNA into RNA, enzymatic reactions, RNA, RNA degradation

– regulation: cis-regulatory elements, transcription factors, enhancers, promoters, silencers,

repressants, splicing

# gene expression: translation (including defects)

– the genetic code

– structure and function of tRNA

– structure and function of ribosomes

– protein synthesis

– regulation of translation

– post-translational modifications (phosphorylation, addition of CHO units)

– protein degradation

# structure and function of proteins

– principles of protein structure and folding

– enzymes: kinetics, reaction mechanisms

– structural and regulatory proteins: ligand binding, self-assembly

– regulatory properties

# energy metabolism (metabolic sequences and regulation) and disorders

– generation of energy from carbohydrates, fatty acids, and essential amino acids; glycolysis, pentose

phosphate pathway, tricarboxylic acid cycle, ketogenesis, electron transport and oxidative

phosphorylation, glycogenolysis

– storage of energy: gluconeogenesis, glycogenesis, fatty acid and triglyceride synthesis

– thermodynamics: free energy, chemical equilibria and group transfer potential, energetics of ATP and

other high-energy compounds

# metabolic pathways of small molecules and associated diseases

– biosynthesis and degradation of amino acids (eg, homocystinuria)

– biosynthesis and degradation of purine and pyrimidine nucleotides (eg, gout, Lesch-Nyhan

syndrome)

– biosynthesis and degradation of lipids (eg, dyslipidemias, carnitine deficiency, adrenogenital

syndromes)

– biosynthesis and degradation of porphyrins

# biosynthesis and degradation of other macromolecules and associated abnormalities, complex carbohydrates

(eg, lysosomal storage disease), glycoproteins, and proteoglycans

Biology of cells

# signal transduction: second messenger systems – voltage- and ligand-gated channels and receptors

# cell components (eg, endoplasmic reticulum, plasma membrane, nucleus)

# cytoskeleton (including cell movement and intracellular transport)

# secretion and exocytosis, endocytosis, transcytosis

# cell cycle, mitosis, meiosis, structure and regulation of spindle apparatus, control points

# epithelial cells (including surface specialization, intercellular junctions, gap junctions, and desmosomes)

# fibroblasts, endothelial cells, and mesenchymal cells: basement membrane, extracellular matrix,

proteoglycans, fibronectins, adhesion molecules, annexins

# muscle cells (cardiac, smooth, skeletal): structure and regulation of contractile elements, excitationcontraction

coupling

# adaptive cell response to injury (eg, hypertrophy, metaplasia)

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# mechanisms of cell injury and necrosis (including free radical mediated cell injury)

# apoptosis (programmed cell death)

Human development and genetics

# embryogenesis: programmed gene expression, tissue differentiation and morphogenesis, homeotic genes

# congenital abnormalities: principles, patterns of anomalies, dysmorphogenesis

# principles of pedigree analysis (inheritance patterns, occurrence and recurrence risk)

# population genetics: Hardy-Weinberg law, founder effects, mutation-selection equilibrium

# genetic mechanisms: chromosomal abnormalities, mendelian inheritance, multifactorial diseases

# clinical genetics (including genetic testing, prenatal diagnosis, newborn screening, genetic counseling/

ethics, gene therapy)

Biology of tissue response to disease

# inflammation (cells and mediators)

– acute inflammation and mediator systems

– vascular response to injury (including mediators)

– inflammatory cell recruitment (adherence and cell migration) and phagocytosis

– bactericidal mechanisms and tissue injury

– clinical manifestations (including pain, fever, leukocytosis, leukemoid reaction, and chills)

– chronic inflammation

# reparative processes

– wound healing, hemostasis, and repair: thrombosis, granulation tissue, angiogenesis, fibrosis,

scar/keloid formation

– regenerative processes

# neoplasia

– classification, histologic diagnosis

– grading, and staging of neoplasms

– cell biology, biochemistry, and molecular biology of neoplastic cells: transformation, oncogenes,

altered cell differentiation, and proliferation

– hereditary neoplastic disorders

– invasion and metastasis

– tumor immunology

– paraneoplastic manifestations of cancer

– cancer epidemiology and prevention

Gender, ethnic, and behavioral considerations affecting disease treatment and prevention (including psychosocial,

cultural, occupational, and environmental)

# progression through the life cycle (birth through senescence)

– cognitive, language, motor skills, and social and interpersonal development

– sexual development (eg, puberty, menopause)

– influence of developmental stage on physician/patient interview

# psychologic and social factors influencing patient behavior

– personality traits or coping style (coping mechanisms)

– psychodynamic and behavioral factors, related past experience

– family and cultural factors, including socioeconomic status, ethnicity, and gender

– adaptive and maladaptive behavioral responses to stress and illness (eg, drug-seeking behavior,

sleep deprivation)

– interactions between the patient and the physician or the health care system (eg, transference)

– patient adherence (general and adolescent)

# patient interviewing, consultation, and interactions with the family

– establishing and maintaining rapport

– data gathering

– approaches to patient education

– enticing patients to make life style changes

– communicating bad news

– “difficult” interviews (eg, anxious or angry patients)

– multicultural ethnic characteristics

# medical ethics, jurisprudence, and professional behavior

– consent and informed consent to treatment

– physician-patient relationships (eg, ethical conduct, confidentiality)

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– death and dying

– birth-related issues

– issues related to patient participation in research

– interactions with other health professionals (eg, referral)

– sexuality and the profession, other “boundary” issues

– ethics of managed care

– organization and cost of health-care delivery

Multisystem processes

# nutrition

– generation, expenditure, and storage of energy at the whole-body level

– assessment of nutritional status across the life span (eg, calories, protein, essential nutrients,

hypoalimentation

– functions of nutrients (essential, transfatty acids, cholesterol)

– protein-calorie malnutrition

– vitamin deficiencies and/or toxicities

– mineral deficiencies and toxicities

– eating disorders (eg, obesity, anorexia, bulimia)

# temperature regulation

# adaptation to environmental extremes (including occupational exposures)

– physical and associated disorders (eg, temperature; radiation; burns; decreased atmospheric

pressure; high altitude sickness; increased water pressure)

– chemical (eg, gases, vapors; smoke inhalation; agricultural hazards, volatile organic solvents, heavy

metals; principles of poisoning and therapy)

# fluid, electrolyte, and acid-base balance and disorders (eg, dehydration, acidosis, alkalosis)

Pharmacodynamic and pharmacokinetic processes

# general principles

– pharmacokinetics: absorption, distribution, metabolism, excretion, dosage intervals

– mechanisms of drug action, structure-activity relationships, receptors, signal transduction

– concentration- and dose-effect relationships (eg, efficacy, potency), types of agonists and antagonists

and their actions

– individual factors altering pharmacokinetics and pharmacodynamics (eg, age, gender, disease,

tolerance, compliance, body weight, metabolic proficiency, pharmacogenetics)

– drug side effects, overdosage, toxicology

– drug interactions

– regulatory issues (eg, drug development, approval, scheduling)

# general properties of autacoids (including peptides and analogs, biogenic amines, prostanoids and their

inhibitors, and smooth muscle/endothelial autacoids)

# general principles of autonomic pharmacology

# general properties of antimicrobials (including mechanisms of action and resistance)

# general properties of antineoplastic agents and immunosuppressants, drug effects on rapidly dividing

mammalian cells

Microbial biology and infection

# microbial classification and its basis

# bacteria and bacterial diseases

– structure and composition

– metabolism, physiology, and regulation

– genetics

– nature and mechanisms of action of virulence factors

– pathophysiology of infection

– epidemiology and ecology

– principles of cultivation, assay, and laboratory diagnosis

# viruses and viral diseases

– physical and chemical properties

– replication

– genetics

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– principles of cultivation, assay, and laboratory diagnosis

– molecular basis of pathogenesis

– pathophysiology of infection

– latent and persistent infections

– epidemiology

– oncogenic viruses

# fungi and fungal infections

– structure, physiology, cultivation, and laboratory diagnosis

– pathogenesis and epidemiology

# parasites and parasitic diseases

– structure, physiology, and laboratory diagnosis

– pathogenesis and epidemiology

# principles of sterilization and pure culture technique

Immune responses

# production and function of granulocytes, natural killer cells, macrophages

# production and function of T lymphocytes, T lymphocyte receptors

# production and function of B lymphocytes and plasma cells; immunoglobulin and antibodies: structure

and biologic properties

# antigenicity and immunogenicity; antigen presentation; cell activation and regulation; tolerance and

clonal deletion

# immunologic mediators: chemistry, function, molecular biology, classic and alternative complement

pathways, cytokines, chemokines

# immunogenetics; MHC structure and function, class I, II molecules; erythrocyte antigens; transplantation

# immunizations: vaccines, protective immunity

# alterations in immunologic function

– T or B lymphocyte deficiencies

– deficiencies of phagocytic cells

– combined immunodeficiency disease

– HIV infection/AIDS and other acquired disorders of immune responsiveness

– drug-induced alterations in immune responses, immunopharmacology

# immunologically mediated disorders

– hypersensitivity (types I–IV)

– transplant rejection

– autoimmune disorders

– risks of transplantation, transfusion (eg, graft-versus-host disease)

– isoimmunization, hemolytic disease of the newborn

– immunopathogenesis

# immunologic principles underlying diagnostic laboratory tests (eg, ELISA, complement fixation, RIA,

agglutination)

Quantitative methods

# fundamental concepts of measurement

– scales of measurement

– distribution, central tendency, variability, probability

– disease prevalence and incidence

– disease outcomes (eg, fatality rates)

– associations (correlation or covariance)

– health impact (eg, risk differences and ratios)

– sensitivity, specificity, predictive values

# fundamental concepts of study design

– types of experimental studies (eg, clinical trials, community intervention trials)

– types of observational studies (eg, cohort, case-control, cross-sectional, case series, community

surveys)

– sampling and sample size

– subject selection and exposure allocation (eg, randomization, stratification, self-selection, systematic

assignment)

– outcome assessment

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– internal and external validity

# fundamental concepts of hypothesis testing and statistical inference

– confidence intervals

– statistical significance and type I error

– statistical power and type II error

Hematopoietic and lymphoreticular systems

Normal processes

# embryonic development, fetal maturation, and perinatal changes

# organ structure and function

# cell/tissue structure and function

– production and function of erythrocytes, hemoglobin, O2 and CO2 transport, transport proteins

– production and function of leukocytes and the lymphoreticular system

– production and function of platelets

– production and function of coagulation and fibrinolytic factors

# repair, regeneration, and changes associated with stage of life

Abnormal processes

# infectious, inflammatory, and immunologic disorders

– infections of the blood, reticuloendothelial system, and lymphatics

– allergic and anaphylactic reactions and other immunopathologic mechanisms

– acquired disorders of immune deficiency

– autoimmunity and autoimmune diseases (eg, Coombs’ positive hemolytic anemia, pernicious anemia,

cryoglobulinemias, ITP)

– anemia of chronic disease

– transfusion complications, transplant rejection

# traumatic and mechanical injury (eg, mechanical injury to erythrocytes, splenic rupture)

# neoplastic disorders (eg, lymphoma, leukemia, multiple myeloma)

# metabolic and regulatory disorders (acquired and congenital)

– anemias and cytopenias (eg, iron deficiency anemia, hemoglobinopathies, hereditary spherocytosis)

– cythemia

– hemorrhagic and hemostatic disorders (eg, coagulopathies, DIC)

– bleeding secondary to platelet disorders (von Willebrand's)

# vascular and endothelial disorders (eg, effects and complications of splenectomy, hypersplenism, TTP,

hemolytic-uremic syndrome)

# systemic disorders affecting the hematopoietic and lymphoreticular system (eg, nutritional deficiencies,

systemic lupus erythematosus)

# idiopathic disorders

Principles of therapeutics

# mechanisms of action, use, and adverse effects of drugs for treatment of disorders of the hematopoietic

system

– blood and blood products

– treatment of anemia, drugs stimulating erythrocyte production (eg, erythropoietin)

– drugs stimulating leukocyte production (eg, G-CSF, GM-CSF)

– anticoagulants, thrombolytic drugs

– antiplatelet drugs

– antimicrobials (eg, antimalarials, anti-HIV)

– antineoplastic and immunosuppressive drugs

– drugs used to treat acquired disorders of immune responsiveness

# other therapeutic modalities (eg, splenectomy, chelating agents, radiation therapy for lymphomas,

plasmapheresis)

Gender, ethnic, and behavioral considerations affecting disease treatment and prevention (including psychosocial,

cultural, occupational, and environmental)

# emotional and behavioral factors (eg, diet, depression and immune responses, “blood doping” among

athletes)

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# influence on person, family, and society (eg, childhood leukemia)

# occupational and other environmental risk factors (eg, heavy metals, hydrocarbons, lead)

# gender and ethnic factors (eg, herbal treatments with bone marrow depression)

Central and peripheral nervous systems

Normal processes

# embryonic development, fetal maturation, and perinatal changes (eg, neural tube derivatives, cerebral

ventricles, neural crest derivatives)

# organ structure and function

– spinal cord (including gross anatomy, blood supply, and spinal reflexes)

– brain stem (including cranial nerves and nuclei, reticular formation, gross anatomy, and blood

supply)

– brain (including gross anatomy and blood supply; cognition, language, memory; hypothalamic

function; limbic system and emotional behavior; circadian rhythms and sleep; and control of eye

movement)

– sensory systems (including proprioception, pain, vision, hearing, balance, taste, and olfaction)

– motor systems (brain and spinal cord, basal ganglia and cerebellum)

– autonomic nervous system

– peripheral nerves

# cell/tissue structure and function

– axonal transport

– excitable properties of neurons, axons and dendrites, including channels

– synthesis, storage, release, reuptake, and degradation of neurotransmitters and neuromodulators

– pre- and postsynaptic receptor interactions, trophic and growth factors

– brain metabolism

– glia, myelin

– brain homeostasis: blood-brain barrier; cerebrospinal fluid formation and flow, choroid plexus

# repair, regeneration and changes associated with stage of life

Abnormal processes

# infectious, inflammatory, and immunologic disorders (eg, meningitis, multiple sclerosis, myasthenia

gravis)

# traumatic and mechanical disorders (subdural and epidural hematomas, cord compression, peripheral

nerve injury)

# neoplastic disorders (primary and metastatic)

# acquired metabolic and regulatory disorders (eg, delirium, Reye’s syndrome)

# vascular disorders (eg, cerebrovascular occlusion, venous sinus thrombosis, arterial aneurysms,

hemorrhage)

# systemic disorders affecting the nervous system (eg, lupus, diabetic neuropathy)

# idiopathic disorders affecting the nervous system

# congenital disorders, including metabolic (eg, neural tube defects, cerebral palsy, mental retardation,

Down’s syndrome)

# degenerative disorders (eg, peripheral neuropathy, Alzheimer's dementia, Parkinson*s disease, Huntington's

disease, amyotrophic lateral sclerosis)

# paroxysmal disorders (eg, epilepsy, headache, pain syndromes, and sleep disorders including narcolepsy,

restless legs syndrome/periodic limb movement, circadian rhythm disorders, parasomnias)

# disorders of special senses (eg, blindness, deafness)

# psychopathologic disorders, processes and their evaluation

– early-onset disorders (eg, learning disorders)

– disorders related to substance use

– schizophrenia and other psychotic disorders

– mood disorders

– anxiety disorders

– somatoform disorders

– personality disorders

– physical and sexual abuse of children, adults, and elders

– other disorders (eg, dissociative, impulse control, posttraumatic stress disorder)

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Principles of therapeutics

# mechanisms of action, use, and adverse effects of drugs for treatment of disorders of the nervous system

– anesthetics

– hypnotics

– psychopharmacologic agents (eg, anxiolytics, antidepressants, antipsychotic agents, moodstabilizing

agents)

– anticonvulsants

– analgesics

– stimulants, amphetamines

– antiparkinsonian drugs

– skeletal muscle relaxants, botulinum toxin

– neuromuscular junction blocking agents

– antiglaucoma drugs

– drugs used to decrease intracranial pressure (eg, mannitol, high-dose glucocorticoids)

– antimigraine agents

– drugs affecting autonomic nervous system (eg, anticholinesterases)

# other therapeutic modalities (eg, radiation, CFS shunting, surgery)

Gender, ethnic, and behavioral considerations affecting disease treatment and prevention (including psychosocial,

cultural, occupational, and environmental)

# emotional and behavioral factors (eg, drug abuse, dementia, sleep deprivation, accident prevention, pets)

# influence on person, family, and society (eg, developmental disabilities, dementia, generational reversal,

nutrition, seizures, sleep disorders)

# occupational and other environmental risk factors (eg, boxing, carbon monoxide exposure)

# gender and ethnic factors

Skin and related connective tissue

Normal processes

# embryonic development, fetal maturation, and perinatal changes

# organ structure and function

# cell/tissue structure and function (eg, barrier functions, thermal regulation, eccrine function)

# repair, regeneration, and changes associated with stage of life or ethnicity (eg, senile purpura, male

pattern baldness, postmenopausal hair changes)

# skin defense mechanisms and normal flora

Abnormal processes

# infectious, inflammatory, and immunologic disorders

– bacterial infections, (eg, acne, cellulitis, carbuncle, abscess, necrotizing fasciitis, gangrene)

– viral infections (eg, herpes infections, chickenpox, rubella, measles, roseola, verrucae)

– fungal infections, including mycoses, dermatophytosis (eg, tinea)

– parasitic infections (eg, scabies, lice)

– immune and autoimmune disorders (eg, discoid lupus erythematosus, scleroderma, dermatomyositis,

alopecia, psoriasis, urticaria, allergic dermatosis)

# traumatic and mechanical disorders (eg, thermal injury, decubitus ulcers, effects of ultraviolet light and

radiation)

# neoplastic disorders

– keratinocytes (eg, seborrheic keratosis, actinic keratosis, basal cell carcinoma, squamous cell

carcinoma)

– melanocytes (eg, nevi, melanoma, ichthyosis)

– vascular neoplasms (eg, hemangiomas, Kaposi’s sarcoma)

– other (eg, T-cell lymphoma, skin appendage tumors)

# metabolic, regulatory, and structural disorders (eg, vitamin deficiencies, hypervitaminosis, hyperhidrosis)

# vascular disorders (eg, vasculitis, Raynaud's disease)

# systemic disorders affecting the skin (eg, Ehlers-Danlos syndrome, Marfan’s syndrome)

Principles of therapeutics

# mechanisms of action, use, and adverse effects of drugs for treatment of disorders of the skin and

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connective tissue (including anti-inflammatory agents (eg, steroids, antihistamines), emollients,

sunscreen, retin-A, antimicrobial agents, cytotoxic therapy (eg, methotrexate, PUVA, keratinolytics)

# other therapeutic modalities (eg, laser, tattoo removal, cryotherapy)

Gender, ethnic, and behavioral considerations affecting disease treatment and prevention (including psychosocial,

cultural, occupational, and environmental)

# emotional and behavioral factors (eg, sun exposure, acne)

# influence on person, family, and society (eg, psoriasis)

# occupational and other environmental risk factors

# gender and ethnic factors (eg, keloid)

Musculoskeletal system

Normal processes

# embryonic development, fetal maturation, and perinatal changes

# organ structure and function

# cell/tissue structure and function

– biology of bones, joints, tendons, skeletal muscle

– exercise and physical conditioning

# repair, regeneration, and changes associated with stage of life

Abnormal processes

# infectious, inflammatory, and immunologic disorders

– infectious disorders (eg, septic arthritis, Lyme disease, osteomyelitis)

– inflammatory disorders (eg, fibrositis, synovitis, tenosynovitis)

– immunologic disorders (eg, rheumatoid arthritis, ankylosing spondylitis, polymyositis, systemic

lupus erythematosus, dermatomyositis, polymyalgia rheumatica)

# traumatic and mechanical disorders (eg, fractures, sprains, strains, dislocations, repetitive motion injuries)

# neoplastic disorders (eg, osteosarcoma, metastatic disease)

# metabolic, regulatory, and structural disorders (eg, dwarfism, osteogenesis imperfecta, osteomalacia,

osteoporosis, osteodystrophy, gout)

# vascular disorders (eg, polyarteritis nodosa, bone infarcts)

# systemic disorders affecting the musculoskeletal system (eg, diabetes mellitus)

# idiopathic disorders (eg, Dupuytren's contracture, scoliosis, Paget's disease)

# degenerative disorders (eg, disc disease, osteoarthritis)

Principles of therapeutics

# mechanisms of action, use, and adverse effects of drugs for treatment of disorders of the musculoskeletal

system

– nonsteroidal anti-inflammatory drugs

– muscle relaxants

– antigout therapy (eg, allopurinol, colchicine, uricosuric drugs)

– immunosuppressive drugs (eg, glucocorticoids, gold, cytotoxic agents)

– drugs affecting bone mineralization (eg, diphosphonates, calcitonin, estrogen analogs)

# other therapeutic modalities (eg, radiation, surgery, casts, rehabilitation)

Gender, ethnic, and behavioral considerations affecting disease treatment and prevention (including psychosocial,

cultural, occupational, and environmental)

# emotional and behavioral factors (eg, diet, exercise, seat belts, bicycle helmets)

# influence on person, family, and society (eg, osteoporosis, fractures in elderly, alcohol abuse, fractures)

# occupational and other environmental risk factors (eg, athletes, musicians)

# gender and ethnic factors (eg, bone mass)

Respiratory system

Normal processes

# embryonic development, fetal maturation, and perinatal changes

# organ structure and function

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– airways (eg, mechanics and regulation of breathing)

– lung parenchyma (eg, ventilation, perfusion, gas exchange)

– pleura

# cell/tissue structure and function (eg, surfactant formation, alveolar structure)

# repair, regeneration, and changes associated with stage of life

# pulmonary defense mechanisms and normal flora

Abnormal processes

# infectious, inflammatory, and immunologic disorders

– infectious diseases of the upper and lower respiratory tract and pleura and their complications (eg,

bronchiectasis, abscess, empyema)

– immunologic disorders

– allergic and hypersensitivity disorders (eg, asthma)

– autoimmune disorders (eg, Wegener’s granulomatosis, Goodpasture’s syndrome)

– inflammatory disorders

– pneumoconioses

– acute and chronic alveolar injury (eg, adult respiratory distress syndrome, chlorine gas/smoke

inhalation)

– obstructive pulmonary disease

– restrictive pulmonary disease (eg, sarcoidosis, idiopathic fibrosis)

# traumatic and mechanical disorders (eg, aspiration, pneumothorax, atelectasis, sleep apnea)

# neoplastic disorders (eg, polyps, bronchogenic carcinoma, mesothelioma, metastatic tumors)

# metabolic, regulatory, and structural disorders (eg, hypoventilation, disorders of gas exchange,

ventilation-perfusion imbalance, neonatal respiratory distress syndrome)

# vascular and circulatory disorders (eg, thromboembolic disease, pulmonary hypertension, pulmonary

edema, pleural effusion)

# systemic disorders affecting the respiratory system

Principles of therapeutics

# mechanisms of action, use, and adverse effects of drugs for treatment of disorders of the respiratory

system (eg, decongestants, cough suppressants, expectorants, mucolytics

bronchodilator drugs, anti-inflammatory and cytotoxic drugs, antimicrobial agents, antineoplastic agents)

# other therapeutic modalities (eg, oxygen therapy, nasal CPAP, mechanical ventilation, physical therapy,

surgical procedures, including transplantation)

Gender, ethnic, and behavioral considerations affecting disease treatment and prevention (including psychosocial,

cultural, occupational, and environmental)

# emotional and behavioral factors (eg, smoking, substance abuse, pets, allergies)

# influence on person, family, and society (eg, tuberculosis, asthma, chronic obstructive pulmonary

disease, school issues, protective parents, family smoking)

# occupational and other environmental risk factors

# gender and ethnic factors (eg, sarcoidosis, lung cancer)

Cardiovascular system

Normal processes

# embryonic development, fetal maturation, and perinatal changes

# organ structure and function

– chambers, valves

– cardiac cycle, mechanics, heart sounds, cardiac output

– hemodynamics (systemic, pulmonary, coronary) and blood volume

– circulation in specific vascular beds

# cell/tissue structure and function

– heart muscle, metabolism, oxygen consumption, biochemistry, and secretory function (eg, atrial

natriuretic peptide)

– endothelium and secretory function, vascular smooth muscle, microcirculation, and lymph flow

– mechanisms of atherosclerosis

– neural and hormonal regulation of the heart, blood vessels, and blood volume, including responses

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to change in posture, exercise, and tissue metabolism

# repair, regeneration, and changes associated with stage of life

Abnormal processes

# infectious, inflammatory, and immunologic disorders

– infectious disorders (eg, endocarditis, myocarditis, pericarditis )

– inflammatory and immunologic disorders (eg, acute rheumatic fever, systemic lupus erythematosus,

transplant rejection, vasculitis, temporal arteritis)

# traumatic and mechanical disorders (eg, tamponade, valvular disease, subaortic stenosis)

# neoplastic disorders

# metabolic and regulatory disorders (eg, dysrhythmias, systolic and diastolic dysfunction, low- and highoutput

heart failure, cor pulmonale, systemic hypertension, ischemic heart disease, myocardial infarction,

systemic hypotension, shock)

# vascular disorders (eg, aneurysms, occlusions, varicosities, atherosclerosis)

# systemic diseases affecting the cardiovascular system (eg, amyloidosis, aortic dissection with Marfan

syndrome, hemochromatosis, scleroderma)

# congenital disorders of the heart and central vessels

Principles of therapeutics

# mechanisms of action, use, and adverse effects of drugs for treatment of disorders of the cardiovascular

system

– coronary and peripheral vasodilators

– antiarrhythmic drugs

– antihypertensive drugs

– measures used to combat hypotension and shock

– drugs affecting cholesterol and lipid metabolism

– drugs affecting blood coagulation, thrombolytic agents

– inotropic agents and treatment of heart failure

– immunosuppressive and antimicrobial drugs

– drugs to treat peripheral arterial disease

# other therapeutic modalities (eg, pacemakers, angioplasty, valves, grafts, other surgical procedures)

Gender, ethnic, and behavioral considerations affecting disease treatment and prevention (including psychosocial,

cultural, occupational, and environmental)

# emotional and behavioral factors (eg, smoking, alcohol, ischemic heart disease, obesity, exercise, diet)

# influence on person, family, and society (eg, altered lifestyle)

# occupational and other environmental risk factors (eg, stress)

# gender and ethnic factors (eg, hypertension)

Gastrointestinal system

Normal processes

# embryonic development, fetal maturation, and perinatal changes

# organ structure and function (eg, alimentary canal, liver and biliary system, salivary glands and exocrine

pancreas, motility, digestion and absorption)

# cell/tissue structure and function

– endocrine and neural regulatory functions, including GI hormones)

– salivary, gastrointestinal, pancreatic, hepatic secretory products (eg, enzymes, proteins, bile salts)

and processes

– synthetic and metabolic functions of hepatocytes

# repair, regeneration, and changes associated with stage of life

# gastrointestinal defense mechanisms and normal flora

Abnormal processes

# infectious, inflammatory, and immunologic disorders

– infectious disorders (eg, peritonitis, hepatitis, gingivostomatitis, peptic ulcer, gastritis, esophagitis,

traveler’s diarrhea, food poisoning)

– inflammatory disorders (eg, cholecystitis, pancreatitis)

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– immunologic disorders (eg, Crohn's disease, ulcerative colitis)

# traumatic and mechanical disorders

– malocclusion

– hiatus hernia

– obstruction (eg, volvulus, intussusception, esophageal atresia, annular pancreas, post-surgical

obstruction)

– perforation of hollow viscus and blunt trauma

– inguinal, femoral, and abdominal wall hernias

– esophageal and colonic diverticula (eg, Meckel's diverticulum)

# neoplastic disorders (benign and malignant)

# metabolic and regulatory disorders (eg, motility disorders, malabsorption, hepatic failure, cholelithiasis)

# vascular disorders (eg, portal hypertension, hemorrhoids, ischemia, angiodysplasia)

# systemic disorders affecting the gastrointestinal system

Principles of therapeutics

# mechanisms of action, use, and adverse effects of drugs for treatment of disorders of the gastrointestinal

system

– treatment and prophylaxis of peptic ulcer disease and gastroesophageal reflux (eg, antacids,

antisecretory drugs, motility drugs, mucosal protective agents, antibiotics)

– drugs to alter gastrointestinal motility (eg, cathartics, antidiarrheal drugs, antiemetic drugs, prokinetic

drugs)

– fluid replacement (eg, oral rehydration)

– pancreatic replacement therapy and treatment of pancreatitis

– drugs for treatment of hepatic failure (eg, lactulose) and biliary disease (eg, drugs to dissolve

gallstones)

– anti-inflammatory, immunosuppressive, antineoplastic, and antimicrobial drugs

# other therapeutic modalities (eg, surgical procedures, stents, feeding tubes)

Gender, ethnic, and behavioral considerations affecting disease treatment and prevention (including psychosocial,

cultural, occupational, and environmental)

# emotional and behavioral factors (eg, peptic ulcer, encopresis, Monday morning stomach)

# influence on person, family, and society (eg, inflammatory bowel disease, irritable bowel disease,

pancreatitis and alcohol, chronic laxative abuse)

# occupational and other environmental risk factors

# gender and ethnic factors (eg, diets)

Renal/urinary system

Normal processes

# embryonic development, fetal maturation, and perinatal changes

# organ structure and function

– kidneys, ureters, bladder, urethra

– glomerular filtration and hemodynamics

– tubular reabsorption and secretion, including transport processes and proteins

– urinary concentration and dilution

– renal mechanisms in acid-base balance

– renal mechanisms in body fluid homeostasis

– micturition

# cell/tissue structure and function (eg, renal metabolism and oxygen consumption, hormones produced by

or acting on the kidney)

# repair, regeneration, and changes associated with stage of life

Abnormal processes

# infectious, inflammatory, and immunologic disorders

– infectious disorders

– upper urinary tract (eg, pyelonephritis, papillary necrosis)

– lower urinary tract (eg, cystitis, urethritis)

– inflammatory and immunologic disorders

17

– glomerular disorders (eg, glomerulonephritis, nephrotic syndrome)

– tubular interstitial disease (eg, interstitial nephritis, transplant rejection, IgA nephropathy)

# traumatic and mechanical disorders (eg, obstructive uropathy)

# neoplastic disorders (eg, renal, urinary bladder and collecting system, metastases)

# metabolic and regulatory disorders

– renal failure, acute and chronic (acute tubular necrosis)

– tubular and collecting duct disorders (eg, Fanconi’s syndrome, renal tubular acidosis, nephrogenic

diabetes insipidus)

– renal calculi

# vascular disorders (eg, renal artery stenosis)

# systemic diseases affecting the renal system (eg, diabetes mellitus, hepatitis, amyloidosis, systemic lupus

erythematosus, Wegener's granulomatosis)

Principles of therapeutics

# mechanisms of action, use, and adverse effects of drugs for treatment of disorders of the renal and

urinary system

– diuretics, antidiuretic drugs

– drugs and fluids used to treat volume, electrolyte, and acid-base disorders

– drugs used to enhance renal perfusion (eg, dopamine)

– anti-inflammatory, antimicrobial, immunosuppressive, and antineoplastic drugs

# other therapeutic modalities (eg, dialysis, renal transplantation)

Gender, ethnic, and behavioral considerations affecting disease treatment and prevention (including psychosocial,

cultural, occupational, and environmental)

# emotional and behavioral factors (eg, drug-induced interstitial nephritis, diet)

# influence on person, family, and society (eg, hemodialysis, living related kidney donation, transplants)

# occupational and other environmental risk factors (eg, heavy metals)

# gender and ethnic factors (eg, disease progression, urinary tract infections)

Reproductive system

Normal processes

# embryonic development, fetal maturation, and perinatal changes

# organ structure and function

– female structure (including breast)

– female function (eg, menstrual cycle, puberty, menopause)

– male structure

– male function (eg, spermatogenesis, puberty)

– intercourse, orgasm (male and female)

– pregnancy (including 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 (eg, toxic shock syndrome, breast abscess, orchitis,

sexually transmitted diseases, autoimmune hypogonadism, cystic mastitis)

# traumatic and mechanical disorders (eg, female incontinence, torsion of testis, varicocele)

# neoplastic disorders (eg, female reproductive, male reproductive, breast [male and female, including

fibrocystic disease], trophoblastic disease)

# metabolic and regulatory processes

– female (eg, anovulation, infertility, polycystic ovaries, endometriosis, orgasmic dysfunction, delayed

and premature puberty)

– menopausal syndrome

– male (eg, infertility, impotence, gynecomastia, delayed and premature puberty)

– benign prostatic hyperplasia

# systemic disorders affecting reproductive function (eg, obesity, myotonic dystrophy, cirrhosis, renal

failure)

18

# disorders relating to pregnancy, the puerperium, and the postpartum period

– obstetric problems (eg, ectopic pregnancy, third trimester bleeding)

– complications affecting other organ systems (eg, eclampsia, gestational diabetes, thyroid disorders)

– disorders associated with the puerperium (eg, postpartum hemorrhage, sepsis, depression)

– antepartum, intrapartum, postpartum disorders of the fetus (eg, prematurity, postmaturity, cord

compression, macrosomia,)

Principles of therapeutics

# mechanisms of action, use, and adverse effects of drugs for treatment of disorders of the reproductive

system and management of normal reproductive function

– female reproductive tract

– fertility drugs

– oral contraception, other methods of contraception (eg, condoms)

– estrogen, progestogen replacement

– stimulants and inhibitors of labor

– estrogen and progesterone antagonists, treatment of menopause

– stimulators and inhibitors of lactation

– male reproductive tract

– fertility drugs

– androgen replacement and antagonists

– gonadotropin-releasing hormone and gonadotropin replacement

– abortifacients

– antimicrobials

– antineoplastics

– restoration of potency

# other therapeutic modalities affecting the reproductive system (eg, tampons, anabolic steroids)

Gender, ethnic, and behavioral considerations affecting disease treatment and prevention (including psychosocial,

cultural, occupational, and environmental)

# emotional and behavioral factors(eg, sexually transmitted diseases)

# influence on person, family, and society (eg, infertility)

# occupational and other environmental risk factors (eg, radiation)

# family planning and pregnancy (eg, unwanted)

# gender identity, sexual orientation, sexuality, libido

# effects of traumatic stress syndrome, violence, rape, child abuse

Endocrine system

Normal processes

# embryonic development, fetal maturation, and perinatal changes

# organ structure and function

– hypothalamus, posterior and anterior pituitary gland

– thyroid gland

– parathyroid glands

– adrenal cortex, adrenal medulla

– pancreatic islets

– ovary and testis

– adipose tissue

# cell/tissue structure and function (eg, hormone synthesis, secretion, action, and metabolism)

– peptide hormones

– steroid hormones, including vitamin D

– thyroid hormones

– catecholamine hormones

– renin-angiotensin system

# repair, regeneration, and changes associated with stage of life

Abnormal processes

# infectious, inflammatory, and immunologic disorders (eg, subacute thyroiditis, Graves’ disease,

19

sarcoidosis)

# traumatic and mechanical disorders

# neoplastic disorders (eg, pituitary, thyroid, parathyroid, adrenal cortex, pancreatic islets, neural crest,

pheochromocytoma)

# metabolic and regulatory processes (eg, diabetes mellitus, pituitary, hypothalamus, thyroid, parathyroid,

pancreatic islet disorders, adrenal disorders)

# vascular disorders (eg, pituitary apoplexy)

# systemic disorders affecting the endocrine system (eg, hemochromatosis)

# idiopathic disorders (eg, hirsutism)

Principles of therapeutics

# mechanisms of action, use, and adverse effects of drugs for treatment of disorders of the endocrine

system

– hormones and hormone analogs

– stimulators of hormone production (eg, sulfonylureas)

– inhibitors of hormone production (eg, thiouracils)

– hormone antagonists

– potentiators of hormone action (eg, thiazolidinediones, demeclocycline)

– antiobesity agents (eg, dexfenfluramine)

# other therapeutic modalities (eg, surgery, radiation)

Gender, ethnic, and behavioral considerations affecting disease treatment and prevention (including psychosocial,

cultural, occupational, and environmental)

# emotional and behavioral factors (eg, compliance in diabetes mellitus, factitious use of insulin, psychogenic

polydipsia)

# influence on person, family, and society

# occupational and other environmental risk factors (eg, radiation exposure, iodine deficiency)

# gender and ethnic factors

 

 

Table 2. USMLE Step 2 Specifications*

Normal Conditions and Disease Categories

  • Normal growth and development and general principles of care
  • Individual organ systems or types of disorders
    • immunologic disorders
    • diseases of the blood and blood-forming organs
    • mental disorders
    • diseases of the nervous system and special senses
    • cardiovascular disorders
    • diseases of the respiratory system
    • nutritional and digestive disorders
    • gynecologic disorders
    • renal, urinary, and male reproductive systems
    • disorders of pregnancy, childbirth, and the puerperium
    • disorders of the skin and subcutaneous tissue
    • diseases of the musculoskeletal system and connective tissue
    • endocrine and metabolic disorders

Physician Task

15%-20%

Promoting preventive medicine and health maintenance

20%-35%

Understanding mechanisms of disease

25%-40%

Establishing a diagnosis

15%-25%

Applying principles of management

·         Percentages may be changed without notice

 

 

7

1. General Principles

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) and research issues (eg, consent, placebos, conflict of interest, vulnerable

populations)

Physician-patient relationship (eg, truth-telling, confidentiality, privacy, autonomy, public

reporting)

Death and dying (eg, diagnosing death, life-support, autopsy, organ donation, euthanasia,

suicide) and birth-related issues (eg, prenatal diagnosis, abortion, maternal-fetal conflict)

Applied Biostatistics and Clinical Epidemiology

Understanding statistical concepts of measurement in medical practice

Interpretation of the medical literature

2. Infectious and Parasitic Diseases

(Topic covered under each organ system)

3. Neoplasms

(Topic covered under each organ system)

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

8

4. Immunologic Disorders (continued)

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

Health and Health Maintenance

Anemia (iron deficiency, vitamin-related, drug-induced, sickle cell)

Infection (systemic)

Mechanisms of Disease

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 associated with chronic disease; aplastic anemia, pancytopenia; thalassemia; methemoglobinemia,

sickle cell disease; polycythemia vera; hemochromatosis)

Bleeding disorders, coagulopathies, thrombocytopenia (eg, hemophilia, von Willebrand’s

disease; qualitative and quantitative platelet deficiencies; disseminated intravascular coagulation;

hypofibrinogenemia; idiopathic thrombocytopenic purpura; hemolytic-uremic syndrome)

Leukopenic disorders, agranulocytosis

Neoplastic disorders (eg, Hodgkin’s disease, non-Hodgkin’s 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

Infection (eg, sepsis, malaria, mononucleosis)

Principles of Management

(With emphasis on topics covered in Diagnosis)

Pharmacotherapy only

Management decision (treatment/diagnosis steps)

Treatment only

9

6. Mental Disorders

Health and Health Maintenance

Early identification and intervention (eg, suicide potential, depression, alcohol/substance abuse,

family involvement in schizophrenia)

Mechanisms of Disease

Biologic markers of mental retardation syndromes

Biologic markers of mental disorders

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; attentiondeficit/

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 disorder s; 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)

Principles of Management

(With emphasis on topics covered in Diagnosis)

Pharmacotherapy only

Management decision (treatment/diagnosis steps)

Treatment only

7. Diseases of the Nervous System and Special Senses

Health and Health Maintenance

Cerebrovascular disease, cerebral infarction

Toxic injuries, occupational disorders and nutritional deficiencies (affecting the nervous system,

eyes, and ears, including lead poisoning, carbon monoxide, and organophosphate)

Infection involving the nervous system, eyes, or ears

Degenerative and demyelinating disorders, including Alzheimer’s disease and multiple sclerosis

10

7. Diseases of the Nervous System and Special Senses (continued)

Mechanisms of Disease

Localizing anatomy:

- brain and special senses

- brain stem

- spinal cord

- 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; toxic

damage; vertigo, tinnitus, Meniere’s disease; acoustic neuroma; traumatic, toxic injury)

Disorders of the nervous system:

- paroxysmal disorders (eg, headache; trigeminal neuralgia; epilepsy; syncope)

- cerebrovascular disease (eg, intracerebral hemorrhage; ischemic disorders; aneurysm,

subarachnoid hemorrhage; cavernous sinus thrombosis)

- traumatic, toxic injury (including lead, carbon monoxide, organophosphate)

- infections (eg, bacterial, fungal, viral, opportunistic infection in immunocompromised

patients; Lyme disease; abscess; neurosyphilis; Guillain-Barré syndrome)

- neoplasms (eg, primary; metastatic; neurofibromatosis)

- metabolic disorders (eg, metabolic encephalopathy, vitamin B12 [cyanocobalamin]

deficiency, vitamin B1 [thiamine] deficiency; coma, confusion, delirium, dementia)

- degenerative and developmental disorders (eg, Alzheimer’s disease; Huntington’s disease;

parkinsonism; amyotrophic lateral sclerosis; Tay-Sachs disease; multiple sclerosis; cerebral

palsy; dyslexia)

- 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)

- sleep disorders

Principles of Management

(With emphasis on topics covered in Diagnosis)

Pharmacotherapy only

Management decision (treatment/diagnosis steps)

Treatment only

11

8. Cardiovascular Disorders

Health and Health Maintenance

Arterial hypertension

Atherosclerosis and coronary artery disease; hyperlipidemia

Prevention of rheumatic heart disease, thromboembolic disease, pulmonary emboli, bacterial

endocarditis

Mechanisms of Disease

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

Principles of Management

(With emphasis on topics covered in Diagnosis)

Pharmacotherapy only

Management decision (treatment/diagnosis steps)

Treatment only

12

9. Diseases of the Respiratory System

Health and Health Maintenance

Chronic bronchitis, asthma, emphysema, carcinoma of the larynx, carcinoma of the lung;

pulmonary aspiration, atelectasis; tuberculosis

Mechanisms of Disease

• Ventilatory dysfunction (eg, obstructive disorders: asthma, chronic obstructive pulmonary

disease, cystic fibrosis, bronchitis, bronchiectasis, emphysema)

• Respiratory 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, obstruction, trauma; tracheoesophageal fistula)

Infections of the lung (eg, acute bronchiolitis; pneumonia; tuberculosis)

Obstructive airways disease (eg, chronic bronchitis, bronchiectasis; asthma, bronchospasm,

wheezing; emphysema, a1-antitrypsin deficiency; cystic fibrosis)

Atelectasis, aspiration

Pneumothorax, hemothorax, traumatic injury to the lungs

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)

Disorders involving the pleura (eg, pleurisy; pleural effusion)

Neoplastic disorders of the lungs and pleura (eg, primary tumors; metastatic tumors)

Principles of Management

(With emphasis on topics covered in Diagnosis)

Pharmacotherapy only

Management decision (treatment/diagnosis steps)

Treatment only

13

10. Nutritional and Digestive Disorders

Health and Health Maintenance

Screening (eg, cancer)

Viral hepatitis and alcohol-related hepatopathy

Mechanisms of Disease

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)

Principles of Management

(With emphasis on topics covered in Diagnosis)

Pharmacotherapy only

Management decision (treatment/diagnosis steps)

Treatment only

14

11. Gynecologic Disorders

Health and Health Maintenance

Postmenarchal/reproductive

Peri/postmenopausal

Mechanisms of Disease

• Infections (eg, vulvovaginitis; pelvic inflammatory disease; toxic shock; sexually transmitted

disease; endometritis; urethritis; Bartholin’s gland abscess; abscess of the breast; mastitis)

Urinary incontinence and obstruction

Neoplasms

Menstrual and endocrinologic disorders; infertility

Diagnosis

Pelvic relaxation and urinary incontinence (eg, UTI; 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 disease])

Sexual abuse and rape

Principles of Management

(With emphasis on topics covered in Diagnosis)

Pharmacotherapy only

Management decision (treatment/diagnosis steps)

Treatment only

12. Renal, Urinary, and Male Reproductive Systems

Health and Health Maintenance

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)

Mechanisms of Disease

Disorders of the male reproductive system

Urinary incontinence and obstruction, enuresis

Renal insufficiency/failure

Electrolyte and water metabolism and acid-base balance

15

12. Renal, Urinary, and Male Reproductive Systems (continued)

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, 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

Principles of Management

(With emphasis on topics covered in Diagnosis)

Pharmacotherapy only

Management decision (treatment/diagnosis steps)

Treatment only

13. Disorders of Pregnancy, Childbirth, and the Puerperium

Health and Health Maintenance

Prenatal care (eg, nutrition; prevention of iron deficiency; prevention of vitamin deficiency; Rh

immunoglobulin prophylaxis; prenatal diagnosis; teratology, diabetes mellitus, urinary tract

infection, a-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

Mechanisms of Disease

Placenta, placental dysfunction

Pregnancy and labor including infection

Postpartum disorders including infection

Fetus and newborn

16

13. Disorders of Pregnancy, Childbirth, and the Puerperium (continued)

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)

Principles of Management

(With emphasis on topics covered in Diagnosis)

Pharmacotherapy only

Management decision (treatment/diagnosis steps)

Treatment only

14. Disorders of the Skin and Subcutaneous Tissues

Health and Health Maintenance

Epidemiology and prevention of skin disorders secondary to exposure to the sun; contact

dermatitis and drug reactions; decubitus ulcers; dermatophytic skin disorders

Mechanisms of Disease

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)

Principles of Management

(With emphasis on topics covered in Diagnosis)

Pharmacotherapy only

Management decision (treatment/diagnosis steps)

Treatment only

17

15. Diseases of the Musculoskeletal System and Connective Tissue

Health and Health Maintenance

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)

Mechanisms of Disease

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’s contracture; Paget’s

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)

Principles of Management

(With emphasis on topics covered in Diagnosis)

Pharmacotherapy only

Management decision (treatment/diagnosis steps)

Treatment only

16. Endocrine and Metabolic Disorders

Health and Health Maintenance

Diabetes mellitus, including prevention of morbidity and mortality due to complications

Screening (eg, cancer)

Mechanisms of Disease

Thyroid function

Diabetes mellitus and carbohydrate metabolism

Parathyroid and calcium metabolism

Pituitary and hypothalamic function

Adrenal function

16. Endocrine and Metabolic Disorders (continued)

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)

Hypoglycemia; hyperinsulinism and parathyroid disorders (eg, iatrogenic; insulinoma)

Parathyroid and calcium (eg, hyperparathyroidism; hypoparathyroidism)

Pituitary, hypothalamic disorders (eg, diabetes insipidus; inappropriate ADH secretion;

panhypopituitarism; acromegaly)

Adrenal disorders (eg, corticoadrenal insufficiency; Cushing’s syndrome; adrenogenital

syndrome; hyperaldosteronism; pheochromocytoma)

Heat-related illness

Principles of Management

(With emphasis on topics covered in Diagnosis)

Pharmacotherapy only

Management decision (treatment/diagnosis steps)

Treatment only

17. Congenital Anomalies

(Topic covered under each organ system)

18. Conditions Originating in the Perinatal Period

(Topic covered under Disorders of Pregnancy, Childbirth, and the Puerperium [category 13])

19. Symptoms, Signs, and Ill-defined Conditions

(Topic covered under each organ system)

20. Injury and Poisoning

(Topic covered under each organ system)

 

Table 3. USMLE Step 3 Specifications*

Clinical Encounter Frame

20%-30%

Initial care

55%-65%

Continued care

10%-20%

Emergency care

 

Physician Task

8%-12%

Obtaining history and performing physical examination

8%-12%

Using laboratory and diagnostic studies

8%-12%

Formulating most likely diagnosis

8%-12%

Evaluating severity of patient's problems

8%-12%

Applying scientific concepts and mechanisms of disease

45%-55%

Managing the patient

  • health maintenance
  • clinical intervention
  • clinical therapeutics
  • legal and ethical issues

* Percentages may be changed without notice.

7

Step 3 Clinical Encounter Frames

INITIAL WORK-UPS CONTINUING CARE URGENT INTERVENTION

1 2 3

Patient encounters characterized

by initial assessment and

management of clinical problems

among patients seen principally in

ambulatory settings for the first

time. These encounters may also

include new problems arising in

patients for whom a history is

available.

Clinical problems include ill-defined

signs and symptoms; behavioralemotional;

acute limited; initial

manifestation and presentation of

chronic illness.

Physician tasks emphasized

include data gathering and initial

clinical intervention. Assessment

of patients may lead to urgent

intervention.

Patient encounters 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.

Clinical problems include

frequently-occurring chronic

diseases and behavioral-emotional

problems. Periodic health

evaluations of established patients

are included here.

Physician tasks emphasized include

recognition of new problems in an

existing condition, assessment of

severity, establishing prognosis,

monitoring therapy, and long-term

management.

Patient encounters 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 severe

life-threatening and organthreatening

conditions and

exacerbations of chronic illness.

Physician tasks emphasized

include rapid assessment of

complex presentations,

assessment of patients'

deteriorating condition, and

prompt decision-making.

8

Figure 2: Step 3 Physician Tasks

Obtaining history

and performing

physical exam

! Objectives focus on interpreting the patient’s history, knowing

pertinent factors in the patient’s history, and interpreting the history in

terms of risk factors for the patient.

! Objectives focus on the physical exam, such as recognizing and

interpreting pertinent physical findings and knowing required

techniques in the physical exam.

Using 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 test findings; knowing the value of and indications for

screening tests; and predicting the most likely test result.

Formulating most

likely 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.

Evaluating

severity of

patient’s problems

! 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.

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; e.g.,

anatomic structure.

! Objectives focus on interpreting results of experimental or biometric

data, including knowing design features of clinical studies,

understanding issues regarding validity of research protocols, knowing

sensitivity and specificity of selected tests, and recognizing potential

bias in clinical studies.

9

Figure 3 shows how frames and tasks intersect to create the Step 3 blueprint which specifies the broad content

allocations for constructing Step 3. Estimates of approximate percentages are provided for the marginal totals.

Figure 3: Step 3 Blueprint

PHYSICIAN TASKS

CLINICAL ENCOUNTER FRAMES

Initial Work-up Continued Care Urgent Intervention

1 2 3 TOTAL

History & Physical 8-12%

Diagnostic Studies 8-12%

Diagnosis 8-12%

Prognosis 8-12%

Managing Patients

Health Maintenance 5-9%

Clinical Intervention 18-22%

Clinical Therapeutics 12-16%

Legal & Ethical Issues 4-8%

Applying Basic Concepts 8-12%

TOTAL 20-30% 50-60% 15-25% 100%

10 10

Problem/Disease List

The Step 3 Problem/Disease List provided here is organized at the system level according to the International

Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM). It is subdivided according to presentation

categories and includes disorders, health problems, and issues relating to health maintenance. This list has been

prepared from empirical data drawn from several sources; including, for example, the National Ambulatory Medical

Care Survey and the National Hospital Discharge Survey. The aggregated frequency listings have been subjected to

extensive review. Although the Problem/Disease List is not comprehensive, it does serve as a primary reference for

identifying the clinical problems the generalist physician should be prepared to encounter in one or more of the frames

cited.

DISEASES/DISORDERS OF THE CENTRAL NERVOUS SYSTEM

Infectious Diseases of CNS

Tetanus

Acute Poliomyelitis

Rabies

Meningitis

Encephalitis

Brain Abscess

Degenerative/Hereditary Diseases of CNS

Alzheimer/Cerebral Atrophy

Parkinson Disease

Multiple Sclerosis

Amyotrophic Lateral Sclerosis (ALS)

Other Diseases of CNS

Mental Retardation

Seizure Disorder

Brain Death

Cerebral Palsy

Neoplasms

Intracranial Neoplasm

Malignant Neoplasm of CNS

Diseases of Peripheral Nerves

Myasthenia Gravis

Neuropathies

Neuralgia/Neuritis

Vascular Diseases of CNS

Cerebral Hemorrhage

Transient Cerebral Ischemia

Cerebrovascular Disease

Cerebral Embolism and Thrombosis

Ill-defined CNS Symptoms

Reye Syndrome

Migraine

Convulsions

Headache

Psychalgia

Syncope and Collapse, Ataxia

Abnormal Involuntary Movement

Sleep Disturbances

Aphasia

Coma

DISEASES/DISORDERS OF THE EYE

Eye

Ophthalmologic Manifestations of Diabetes

Retinal Detachments, Defects and Disorders

Chorioretinitis

Glaucoma

Cataract

Visual Disturbances

Diplopia

Visual Field Defects

Pterygium

Acute Conjunctivitis

Disorders of Eyelids/Lacrimal System

Orbital Cellulitis

Diseases of Optic Nerve/Visual Pathways

Strabismus

Anomalies of Pupillary Function

Nystagmus

Corneal Abrasion

Degeneration of Macula

11

DISEASES/DISORDERS OF THE EAR/NOSE/MOUTH/THROAT

Ear

Diseases of Ear and Mastoid Process

Otitis Media

Vertiginous Syndromes

Otalgia

Hearing Loss

Nose/Throat

Streptococcal Sore Throat

Acute Upper Respiratory Tract Infection

Chronic Rhinitis

Peritonsillar Abscess

Allergic Rhinitis

Diseases of Nasal Cavity; e.g., Abscess

Sinuses

Acute Sinusitis

Chronic Sinusitis

Mouth/Tongue

Herpetic Gingivostomatitis

Herpes Simplex Fever Blister

Disorders of Teeth/Jaw

Neoplasms

Malignant Neoplasm of Larynx

Malignant Neoplasm of Lip, Oral Cavity,

Pharynx

DISEASES/DISORDERS OF THE RESPIRATORY SYSTEM

Pneumonia/Influenza

Croup

Acute Bronchitis

Acute Bronchiolitis

Bronchopneumonia

Pneumonia

Influenza with Other Respiratory

Manifestations

Chronic Obstructive Pulmonary Disease

Bronchitis

Obstructive Chronic Bronchitis

Emphysema

Asthma

Chronic Airway Obstruction

Pneumoconioses

Malignant Neoplasm of Bronchus and Lung,

Primary and Secondary

Other Diseases of the Respiratory System

Pulmonary Tuberculosis

Sarcoidosis

Cystic Fibrosis

Pulmonary Embolism and Infarction

Pulmonary Hypertension

Pleurisy without Effusion

Spontaneous Tension Pneumothorax

Mediastinitis

Pertussis

Ill-defined Symptoms of the Respiratory System

Dyspnea

Cough

Hemoptysis

Stridor

Hoarseness

DISEASES/DISORDERS OF THE CIRCULATORY SYSTEM

Essential Hypertension

Hypertensive Disease

Hypertensive Heart Disease

Hypertensive Renal Disease

Secondary Hypertension

Ischemic Heart Disease

Congestive Heart Failure

Pericarditis

Cardiomyopathy

Congestive Heart Failure

Arrhythmias/Conduction Disorders

Peripheral Vascular Disease

Aortic Aneurysm

Peripheral Vascular Disease

Arterial Embolism/Thrombosis

Phlebitis/Thrombophlebitis

Venous Embolism/Thrombosis

Varicose Veins

General Arteriosclerosis

Arteriosclerotic Disease

Atherosclerosis

12

Valvular Heart Disease

Rheumatic Heart Disease

Valve Disorders

Endocarditis

Congenital Anomalies of the Heart

Ill-defined Symptoms of the Circulatory System

Tachycardia

Palpitations

Murmurs

Elevated Blood Pressure without Diagnosis of

Hypertension

DISEASES/DISORDERS OF THE DIGESTIVE SYSTEM

Ill-defined Symptoms of Digestive System

Dyspepsia

Constipation

Diarrhea

Hemorrhage of Rectum and Anus

Gastrointestinal Hemorrhage

Nausea and Vomiting

Abdominal Pain

Abnormal Stool Contents

Indigestion

Heartburn

Ascites

Hepatomegaly

Splenomegaly

Dysphagia

Esophagus

Malignant Neoplasm of Esophagus

Esophageal Varices

Achalasia/Esophagitis

Stomach

Malignant Neoplasm of Stomach

Benign Neoplasm of Stomach

Gastric Ulcer

Duodenal Ulcer

Peptic Ulcer

Gastritis/Duodenitis

Gallbladder

Calculus of Gallbladder

Cholecystitis

Liver

Malignant Neoplasm of Liver

Cirrhosis of Liver

Stricture of Common Bile Duct

Small Intestine/Colon

Malignant Neoplasm of Colon

Benign Neoplasm of Duodenum, Jejunum,

Ileum

Appendicitis

Other Noninfectious Gastroenteritis

Intestinal Obstruction

Diverticula of Small Intestine

Diverticula of Colon

Irritable Colon/Irritable Bowel Syndrome

Peritonitis

Intestinal Abscess

Hernia

Inguinal Hernia

Other Hernias with Obstruction

Ventral Hernia

Diaphragmatic Hernia

Rectum

Malignant Neoplasm of Rectosigmoid

Junction

Malignant Neoplasm of Rectum

Benign Neoplasm of Rectum

Hemorrhoids

Anal Fissure

Anal Abscess

Rectal Prolapse

Pancreas

Malignant Neoplasm of Pancreas

Benign Neoplasm of Pancreas

Pancreatitis

BEHAVIORAL/EMOTIONAL DISORDERS

Psychotic Disorders

Schizophrenia

Paranoid States

Disorders Originating in Childhood

Conduct Disturbance

Attention-Deficit/Hyperactivity Disorder

Autistic Disorder

13

Anxiety Disorders/Adjustment Disorders

Phobic Disorders

Obsessive-compulsive Disorder

Post-traumatic Stress Disorder

Bereavement

Mood Disorders

Depressive Disorders

Bipolar Disorders

Psychological-Medical Interactive Disorders

Somatoform Disorders

Eating Disorders

Psychological Factors Associated with Other

Medical Conditions

Cognitive Disorders

Confusion States

Dementia

Substance Abuse Disorders

Alcohol Related Disorders

Chemical/Drug Abuse

Drug Dependence

Psychosocial Problems/Personality Disorders

Abuse of Other Person

Sexual Dysfunction

Personality Disorders

DISEASES/DISORDERS OF THE MUSCULOSKELETAL SYSTEM

General Musculoskeletal Problems

Internal Derangement of Knee

Effusion of Joint

Affections of Shoulder Region

Synovitis/Tenosynovitis

Bursitis

Ganglion and Cyst of

Synovium/Tendon/Bursa

Muscular Wasting and Disuse Atrophy

Infective Myositis

Myositis Ossificans

Myalgia/Myositis

Disorders of Bone and Cartilage

Developmental Problems

Congenital Anomalies of Limbs

Muscular Dystrophy

Disorders of Back/Spine

Spinal Enthesopathy

Intravertebral Disc Disorders

Disc Displacement

Spinal Stenosis

Lumbago, Sciatica

Kyphoscoliosis and Scoliosis

Sprains and Strains of Back

Contusion of Back

Cervicalgia

Malignancy

Secondary Malignant Neoplasm of

Bone/Marrow

Pathologic Fracture

Contusions

Fractures/Dislocations

Closed Fracture of Facial Bones

Fracture of Vertebral Column

Fracture of Ribs

Closed Fracture, Upper Extremity

Fracture of Neck of Femur

Various Fractures, Lower Limbs

Dislocations/Separations

Sprains/Strains

Temporomandibular Joint Disorders

Rotator Cuff Syndrome

Enthesopathy of Elbow or Ankle

Various Sprains and Strains

Rheumatoid Conditions

Collagen Diseases

Rheumatoid Arthritis

Nonarticular Rheumatism

Osteoarthritis and Arthropathies

Infective Arthritis

Osteoarthritis

Monoarthritis

Arthropathy

Polyarthritis

Ill-defined Symptoms of the Musculoskeletal System

Pain in Joint

Stiffness of Joint

Pain in Limb

Cramp, Swelling

14

DISEASES/DISORDERS OF THE SKIN/SUBCUTANEOUS TISSUE

Skin Eruptions

Scabies

Contact Dermatitis

Psoriasis

Acne

Urticaria

Seborrhea

Nails/Hair

Ingrowing Nail

Diseases of Hair and Follicle

Other

Cauliflower Ear

Decubitus Ulcer

Keloid Scar

Lumps/Tumors of Skin

Viral Warts

Malignant Neoplasm of Skin

Benign Neoplasm of Skin

Keratoderma

Sebaceous Cyst

Neurofibromatosis

Lipoma

Ill-defined Symptoms, Skin and Integumentary

Rash, Edema

Localized Swelling, Mass, or Lump

Enlarged Lymph Nodes

DISEASES/DISORDERS OF ENDOCRINE/NUTRITION/METABOLISM

Diseases of the Thyroid Gland

Malignant Neoplasm of Thyroid Gland

Goiter, Hyperthyroidism, Hypothyroidism

Hyperparathyroidism

Diabetes Mellitus

Diabetes Mellitus

Hypoglycemia

Hyperglycemia

Nutritional Deficiencies/Avitaminosis

Disorders of Adrenal and Pituitary Glands

Other Endocrine/Metabolic/Immunity Disorders

Pure Hypercholesterolemia

Hyperlipidemia

Gout

Electrolyte Disorders

Immunity Deficiency

SIADH, Phenylketonuria

DISEASES/DISORDERS OF THE KIDNEYS AND URINARY TRACT

Lower

Malignant Neoplasm of Prostate

Malignant Neoplasm of Bladder

Urethritis

Hyperplasia of Prostate

Enuresis

Hematuria, Urethral Stricture

Upper

Malignant Neoplasm of Kidney

Nephrotic Syndrome/Nephritis

Chronic Renal Failure

Acute Renal Failure

Calculus of Kidney

Calculus of Ureter

Ill-defined Symptoms of the Genitourinary System

Abnormalities of Urination

Stress Incontinence, Female

15

DISEASES/DISORDERS OF THE MALE REPRODUCTIVE SYSTEM

Testes

Testicular Feminization

Torsion of Testes

Testicular Mass

Malignant Neoplasm of Testes

Benign Neoplasm of Testes

Other Male Reproductive

Male Infertility

Disorders of Male Genital Organs

Orchitis/Epididymitis

DISEASES/DISORDERS OF THE FEMALE REPRODUCTIVE SYSTEM

Uterus

Malignant Neoplasm of Uterus

Leiomyoma of Uterus

Disorders of Uterus

Uterine Prolapse

Endometriosis of Uterus

Ovary

Malignant Neoplasm of Ovary

Benign Neoplasm of Ovary

Ovarian Cysts

Cervix

Malignant Neoplasm of Cervix

Cervicitis/Endocervicitis

Dysplasia of Cervix Uteri

Abnormal Pap Smear

Vagina/Vulva

Malignant Neoplasm of Vagina

Malignant Neoplasm of Vulva

Vaginitis/Vulvovaginitis

Prolapse of Vaginal Walls

Imperforate Hymen

Vaginal Discharge

Menstrual Disorders

Dysmenorrhea

Premenstrual Tension

Amenorrhea, Excess Menstruation

Irregular Menstrual Cycle

Menopause

Climacteric States

Atrophic Vaginitis

Breast

Malignant Neoplasm of Breast

Benign Neoplasm of Breast

Breast-Related Problems, e.g., Fibrocystic

Breasts

Signs and Symptoms in Breast

Female Infertility

Acute Parametritis and Pelvic Cellulitis

Pelvic Inflammatory Disease

Salpingitis and Oophoritis

16

PREGNANCY/CHILDBIRTH/NEONATES

Pregnancy, Complicated

Adolescent Pregnancy

Supervision of At-Risk Pregnancy

Ectopic Pregnancy

Spontaneous, Induced, or Septic Abortion

Hemorrhage in Early Pregnancy

Placenta Previa

Abruptio Placentae

Antepartum Hemorrhage

Preeclampsia

Eclampsia

Premature Labor

Complication of Labor or Delivery

Other Viral Disease in Pregnancy

Incompetent Cervix

CNS Malformation in Fetus

Suspected Fetal Abnormality Affecting

Management of Mother

Rh Incompatibility

Infection, Amniotic Cavity

Obstruction, Malposition of Fetus

Cesarean Delivery

Chromosomal Anomalies

Multiple Fetuses

Pregnancy, Uncomplicated

Delivery and Labor with Minor or No

Complications

Supervision of Normal Pregnancy

Single Liveborn Before Admission to

Hospital

Conditions Originating in the Perinatal Period

Congenital Anomalies of the Digestive

System

Birth Trauma

Birth Asphyxia

Respiratory Distress Syndrome

Other Respiratory Problems After Birth

Hypocalcemia

Infections Specific to the Perinatal Period

Hemolytic Disease Due to

Rh-Isoimmunization

Perinatal Jaundice

DISEASES/DISORDERS OF BLOOD/BLOOD-FORMING ORGANS

Malignant Neoplasias

Leukemias

Multiple Myeloma

Lymphomas

Anemias

Pernicious Anemia

Thalassemias

Sickle-Cell Trait

Other Hemoglobinopathies

Iron-Deficiency Anemia

Other

Septicemia

Pancytopenias

Coagulation Disorder

Disseminated Intravascular Coagulation

Polycythemia

Viremia

Transfusion Reaction

Thrombocytopenic Purpura

INFECTIOUS/PARASITIC DISEASES

Intestinal Infectious Diseases

Enteric Infections

Infections of Skin and Subcutaneous Tissue

Cellulitis and Abscess

Impetigo

Other Local Skin Infection

Other Bacterial Diseases

Streptococcal Infection

Staphylococcal Infection

Pneumococcal Infection

Escherichia coli Infection

Hemophilus influenzae Infection

Other Bacterial Infections

17

HIV Infection

AIDS, HIV Status

Viral Diseases Accompanied by Exanthem

Chickenpox

Herpes Zoster

Measles

Rubella and Roseola

Erythema Infectiosum

Kawasaki Syndrome

Arthropod-borne Diseases

Rocky Mountain Spotted Fever

Lyme Disease

Sexually Transmitted Diseases

Syphilis

Gonococcal Infections

Other STDs; e.g., Genital Herpes,

Trichomoniasis

Mycoses

Dermatophytosis

Candidiasis

Mycoses

Infections Involving Bone

Acute and Chronic Osteomyelitis

Other Diseases Due to Viruses and Chlamydiae

Hepatitis

Mumps

Herpangina

Infectious Mononucleosis

Inclusion Conjunctivitis

Molluscum Contagiosum

Cat-scratch Disease

Foot and Mouth Disease

Cytomegalic Inclusion Disease

Echovirus

Coxsackievirus

Rhinovirus

Toxoplasmosis

Infectious Diseases of Urinary System

Infections of Kidney

Acute Cystitis

Infectious Diseases Complicating Pregnancy

Infection of Genitourinary Tract During

Pregnancy

Other Infections Complicating

Pregnancy

INJURIES/WOUNDS/TOXIC EFFECTS/BURNS

Eye Injury

Foreign Body in Eye

Eye Burn

Ocular Injuries

Various Toxins

Food Poisoning

Poisoning by Drugs and Medicinal Substances

Toxic Effects of Nonmedicinal Substances

Adverse Effects of Drugs, Medicinals and

Biological Substances

Trauma

Rape/Crisis Adjustment

Concussion, No Loss of Consciousness

Concussion, Brief Loss of Consciousness

CNS Trauma

Cranial Injuries

Chest Trauma

Internal Injuries, Abdomen and Pelvis

Other Trauma; e.g., Traumatic Shock

Post-operative Complications

CNS Complications

Respiratory Complications

GI Complications

Hemorrhage Complicating Surgery

Post-operative Infections

Complications of Medical Care, Infection

Other Complications of Device/Graft

Wounds

Foreign Body

Foreign Body in Ear

Foreign Body in Nose

Foreign Body in Trachea/Aspiration

Swallowed Foreign Body

Other

Epistaxis

Burns

Frostbite

Heat Stroke

18

HEALTH MAINTENANCE

General Checks

Community-Related Prevention

Routine Child/Infant Health Check

Other After-Care Follow-up

Other Counseling

Follow-up Examinations

General Medical Exam

Laboratory Examination

Child Behavioral/Developmental Disorders

Targeted Checks, Gynecology

Counseling for Contraception

Sterilization

Surveillance of Prescribed

Contraception

Contraceptive Management

Genetic Counseling

Antenatal Screening

Gynecologic Examination

Routine Cervical Pap Smear

Post-Partum Follow-up

Breast Cancer Screening

Targeted Checks, Cardiovascular Risk

Dietary Surveillance

Cardiovascular Risk Screening

Exercise

Vaccinations/Other Chemotherapy

Influenza Vaccination

DTP and Polio Vaccination

Vaccinations

Desensitization to Allergens

Prophylactic Chemotherapy

Skin Sensitization Tests

Non-dependent Abuse of Drugs

Alcohol Abuse

Tobacco Use Disorder

Cannabis Abuse

Hallucinogen Abuse

Sedative, Hypnotic, or Anxiolytic Abuse

Opioid Abuse

Cocaine Abuse

Amphetamine Abuse

Antidepressant Type Abuse

Other Mixed, Unspecified Drug Abuse

ILL-DEFINED SYMPTOM COMPLEXES

Symptoms Referable to Nutrition

Abnormal Weight Gain

Abnormal Weight Loss

Loss of Appetite

Ill-defined Causes of Morbidity

Malignant Neoplasm, Unspecified Site

Secondary Malignant Neoplasm, Other Sites

Ill-defined Presentations

Chest Pain

Pyrexia of Unknown Origin

Malaise and Fatigue

Lack of Normal Physiologic Development

Septic Shock

Allergy

Abnormal Test Results

Chronic Pain

19

Evaluative Objectives

A complete listing of Step 3 Evaluative Objectives follows. These objectives are categorized according to the

physician tasks and they serve to guide writing and classification of test items. They can be read as more detailed

descriptions of the kinds of issues that will be posed to physicians taking Step 3.

Step 3 Evaluative Objectives

Obtaining History and Performing

Physical Exam

# Knows signs/symptoms of selected

disorders.

# Interprets elicited history.

# Knows individual’s risk factors for

development of condition leading to

encounter.

# Interprets patient's habitus, posture, and

facial expression.

# Knows commonly associated pertinent

history.

# Associates current complaints with

presented history and identifies pertinent

factor.

# Knows appropriate directed physical

examination or required technique.

# Recognizes pertinent physical findings.

# Interprets particular physical finding in order

to differentiate one disorder from another.

# Performs or interprets mental status and

neurologic exams.

# Recognizes new physical signs and

symptoms in a patient with an established

disease.

Objectives Related to Using Laboratory

and Diagnostic Studies

# Knows when NO diagnostic or laboratory

studies are indicated.

# Selects appropriate routine or initial laboratory

or diagnostic studies.

# Interprets the clinical impact of laboratory or

diagnostic test findings.

# Knows appropriate invasive, special,

non-routine, or follow-up studies.

# Knows appropriate diagnostic

studies/procedures in terms of

cost-effectiveness.

# Knows appropriate common screening tests

for conditions related to an encounter or

complaint.

# Identifies study/procedure most likely to

establish the diagnosis or distinguish one

diagnosis from another.

# Predicts the most likely laboratory or

diagnostic test result.

20

Objectives Related to Formulating the

Most Likely Diagnosis

# Identifies diagnosis when given a criterion

finding.

# Selects the most likely diagnosis or evaluates

differential in light of history and/or physical

and/or diagnostic test findings.

# Knows the most likely cause or preliminary

diagnosis associated with the presented

signs and symptoms or physical findings.

Objectives Related to Evaluating the Severity

of Patient’s Problems (Prognosis)

# Evaluates severity of patient condition and

identifies indications for consultation or

diagnostic assessment.

# Evaluates appropriateness of available data

or therapies.

# Assesses severity of patient condition and

makes judgment as to current status,

prognosis, or need for further action.

# Recognizes factors in the history (given

symptoms) that affect patient prognosis.

# Evaluates patient data in light of

management plan.

# Recognizes iatrogenic complications, not

drug-related.

# Knows clinically relevant implications of

specifically referenced treatment.

# Interprets laboratory or diagnostic results

and identifies current status of patient.

Objectives Related to Managing the Patient

Management of Health Maintenance

and Disease Prevention

# Recognizes physician’s best choice of words

in eliciting history or further description from

the patient; knows statements that facilitate

communication with the patient.

# Knows risk factors for conditions amenable to

prevention or detection in an asymptomatic

patient.

# Knows pertinent incidence statistics and identifies

patient groups at risk; knows incidence

of symptomless/dangerous disorders among

various groups.

# Identifies organ/system at greatest risk in the

patient.

# Knows appropriate directed physical exam in

screening an asymptomatic patient during a

well-care visit.

# Knows common screening tests for conditions

amenable to prevention or detection in an

asymptomatic patient or population.

# Knows range and timing of diagnostic study in

monitoring for prevention.

# Selects appropriate preventive, therapeutic

agent/technique.

# Selects appropriate follow-up management

when first plan is not effective.

21

Clinical Intervention

# Identifies appropriate cost-effective management.

# Evaluates severity of patient condition in

terms of need for referral for surgical

treatments/procedures versus other

nonsurgical options.

# Knows appropriate next step in patient care.

# Knows priority in management, specifically

in emergency or acute cases.

# Knows immediate management or medical

intervention in emergency situations.

# Knows appropriate present management of

selected conditions.

# Knows appropriate long-term treatment or

management goals.

# Knows appropriate surgical management

among surgical options.

# Knows post-surgical or post-procedural

management.

# Knows indications for hospital admission or

other appropriate setting.

# Knows appropriate follow-up schedule or

monitoring approach regarding the general

management plan.

# Knows appropriate discharge planning; e.g.,

focusing priorities on maximizing benefits of

hospitalization.

# Knows components of rehabilitation

program.

# Knows various therapeutic modalities for

selected behavioral/affective disorders.

# Knows appropriate counseling of patient or

family regarding current and future

problems, including risk factors related to

present encounter.

# Knows importance of educating patient or

family regarding self-care.

# Knows relevant roles of allied health

personnel.

# Knows issues surrounding management of

chronic pain, especially in terminally ill

patients.

# Recognizes/manages patient’s expression of

fear of injury or death.

Clinical Therapeutics

# Selects appropriate preliminary steps to ensure

effectiveness of intended therapy.

# Knows appropriate management in terms of

cost-effectiveness.

# Selects most appropriate pharmacotherapy.

# Knows appropriate follow-up schedule or

monitoring approach regarding therapeutic

regimen.

# Assesses patient compliance with treatment

regimen by recognizing techniques to increase

compliance or understanding of the disease

state and how therapy may affect compliance

with instructions.

# Applies knowledge of drugs to the safe and

effective selection and administration of drugs.

# Recognizes factors that alter drug

requirements for a patient.

# Recognizes signs and symptoms of drug

interactions resulting from polypharmacy in the

therapeutic regimen.

# Knows adverse effects of various drugs.

# Knows actions in response to acute, specific

drug toxicity.

# Knows contraindications of various drugs.

# Recognizes new signs and symptoms in a

patient with an established medication regimen

within the context of continuing care.

# Modifies therapeutic regimen within the

context of continuing care.

# Knows importance of educating patient or

family specifically about medication regimen.

# Applies results of experimental data or

biometric studies to the treatment of a patient.

Legal/Ethical and Health Care Systems

# Knows informed consent.

# Recognizes patient’s right to refuse

treatment or testing (patient autonomy).

# Knows guidelines for treatment of minors

with or without notification of parent.

# Knows guidelines for confidentiality of

medical records.

# Recognizes opportunities for cost

containment.

# Knows guidelines for physician/patient

relationship.

# Assesses quality of life decisions.

# Recognizes priorities in decisions to allocate

transplant organs and/or other scarce

resources.

# Knows use of unorthodox/experimental or

folk/alternative therapies.

# Recognizes physician error vs. negligence.

# Knows Good Samaritan laws.

# Knows guidelines for reporting findings to

proper authorities.

# Recognizes need for third-party permission

for treatment in medical emergencies.

# Assesses degree of disclosure to terminally

ill patients.

# Knows definitions of competence and

sanity.

# Knows guidelines for commitment.

# Recognizes impaired physician.

# Knows appropriate prescriptive practices.

# Knows definition of and legal issues

regarding brain death.

Objectives Related to Applying Scientific

Concepts

# Identifies the cause/causal agent or

predisposing factor(s); or, given an effect,

what is the cause.

# Predicts the effect; given a particular cause,

identifies what effects may be expected.

Given an anatomic, pathologic, or physiologic

abnormality, predicts the effect on function,

including compensatory effects.

# Recognizes associated disease conditions,

including complications, or indicators for

potential disease complications, of a given

disease (excludes iatrogenic

complications).

# Identifies the underlying processes/pathways

that account for, or contribute to, the

expression or resolution of a given condition.

# Recognizes characteristics of disease relating

to natural history or course of disease,

including progression, severity, duration, and

transmission of disease.

# Evaluates given clinical or physical findings to

identify the underlying anatomic structure or

physical location.

# Interprets laboratory or diagnostic studies as to

the underlying pathophysiology; predicts

expected diagnostic test findings for a given

disease.

# Recognizes appropriate methods and

techniques related to procedures, artifacts of

instrumentation, technical errors/problems

contributing to misinformation.

# Interprets results of experimental data or

biometric studies.

# Knows design features of clinical studies.

# Knows issues regarding validity of research

protocols.

# Recognizes potential bias in clinical studies

including the extent to which bias accounts

for study results.

# Interprets results of clinical studies.

# Distinguishes clinical importance from

statistical significance.

# Knows sensitivity and specificity of

selected test.

Links

Federation of State Medical Boards (FSMB)

National Board of Medical Examiners®(NBME®)

Educational Commission for Foreign Medical Graduates (ECFMG®)

Association of American Medical Colleges

National Resident Matching Program

Liaison Committee on Medical Education (LCME)

Prometric, Inc.®, a subsidiary of Thomson Learning
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