My Score

After possibly one of the longest waiting periods in USMLE Step 1 history, I got my score back.

25X/99

I am very happy with my score and, of course, relieved that it's finally over.

Anki Flash Cards for the USMLE Step 1

I've always been a fan of flashcards. They're a great way to memorize facts that are hard to remember. While studying for the USMLE Step 1, I used Anki, a free flashcard program that works on Windows, Mac, and Linux. You can also get it for iPhone but you'd have to buy it from the app store. There is an android version that is free.

There are already some USMLE step 1 anki flashcards out there that you can download. I used some of these. Overall I think they were helpful at drilling some of this information into my memory.


Anki Program: http://ichi2.net/anki/index.html

Brenner’s Pharmacology Flashcards: click here

Micro Cards: click here

Performance, Progress, Prediction

I started studying for the USMLE Step 1 back in January while doing my last semester of Basic sciences. It was hard to balance board prep with classwork, so I really didn't get much done during those four months. My real prep started at the end of May. I had a good  7 weeks of pure Step 1 preparation. Here is my performance on the practice tests I took:


Free 150: 80% (6 weeks out)


UWSA-1: 247 (4 weeks out)

UWSA-2: 265 (2 days out)

Cumulative UW average: 82% (first few blocks were in the low 70's, last few blocks were in the high 80's)

I didn't take any NBME's. Why? Because after paying more than $850 to register for the USMLE (as an IMG), I didn't want to spend another penny that would go to the NBME. It should not cost that much to administer an exam! With all the money they suck out of us, you'd think they'd take the time to update the software they use for the NBME practice forms! They don't! They use outdated software that was used years ago and is different from the current FRED 2.0 software they use to adminster the USMLE. You also have to pay extra if you want to find out your answers on the NBME practice exams (If I remember correctly, an NBME is about $40 without the answers, and $60 with the answers).

I went with the UWSAs because when you buy USMLE World, you can get the package that gives you access to the Qbank, UWSA1, and UWSA2 for $130 (1 month subscription). If you consider that the subscription to the qbank by itself is $99, that's like $15 for each UWSA, including answers, explanations, and software that is almost exactly the same as the FRED 2.0 software. Anyways, that was my rant for the day.

According to my performance on UW and UWSAs, my predicted score should fall in the 250's. Crossing my fingers for this!

What I wrote down on my laminated board

I wrote down a few mnemonics and facts that would save me time later during my exam.

• The drug receptors mnemonic in first aid: QISS QIQ SIQ SQS
• The Standard deviation curve (including the value for each interval e.g. from 0-1 SD is 34%, from 1-2 SD is 13.5% etc)
• I drew several blank 2 x 2 tables (you can use these for a lot of different things so it's good to keep them blank)
• The PT vs. PTT diagram in Rapid Review Pathology (i.e. which factors are tested by each test)
• I also wrote down 4 equations that I always forget.
• Css = (Rate in x f) / Cl
• Cl = Vd x k
• VA = (VT - VD) x f
• VD = VT x (PaCO2 - PeCO2)/PaCO2

 Overall, I think it was worth it to write all of this down before starting my test.

Looking back, which review books were most useful?

First Aid for the USMLE Step 1, 2010 (First Aid USMLE): Most of the questions on my exam were covered in First Aid. I would say about 80% of the questions on my exam were covered in First Aid. The remaining 20% were were based on information I read in other review books and annotated into First aid.

Pathology: Most of the questions on my exam were either straight Pathology questions, or Pathology related questions that tested other subjects. I had a few questions that weren't in First Aid or USMLE World, but were covered in Rapid Review Pathology. During my exam, I remember saying "Thank God for Goljan" several times.

Physiology: The physiology questions on my exam were straight forward. I had a lot of endocrine questions and a lot of "up and down arrow" questions. Physiology has always been one of my stronger subjects, so I didn't struggle with any of the Physiology questions. I think First Aid was sufficient for the Physiology questions, however sometimes First Aid lacks enough depth in explaining concepts (rightfully so, wince it's a review book), so I would recommend using another Physiology review book alongside First Aid, at least in your first pass through the material to help you understand the concepts better (I used the Kaplan Physiology lecture notes for most chapters, and sometimes used BRS Physiology instead). The Physiology questions tested broad concepts rather than obscure details, so that was good.

Anatomy: the Anatomy questions on my exam were difficult. There were some really easy ones that tested basic nerve lesions, but there were a few difficult questions that tested nerve/artery branches for example that weren't in First Aid or the Kaplan Anatomy Lecture notes. 

Biochemistry: I killed the biochemistry on my exam. First Aid was good enough for the most part. However, I felt that the Kaplan Biochemistry lecture notes helped me grasp Biochem concepts better. Some of the diagrams in the Kaplan lecture notes are essential. There was one genetics question I got that wasn't in First Aid but was covered well in Kaplan.

Pharmacology: All of the drugs on my exam were in First Aid. There was only 1 Pharm question that was in the Kaplan notes but wasn't in First Aid. The drug in the question was in First Aid, but the question was asking for a side effect that wasn't in First Aid.

Microbiology and Immunology: I didn't have any trouble with the Micro an Immuno questions. They were all covered in First Aid. I really don't recommend using anything else for Micro and Immunology.

Behavioral Science: I had a good portion of Behavioral Science questions on my exam. Several ethics questions, several Biostatistics questions, only one Psych question I think. I think First Aid is a bit weak in the Biostatistics department. I would recommend High Yield Biostatistics or the Biostatistics chapter in Kaplan.

Exam Experience

Let me start by saying how great it feels to be done with Step 1! It’s like having a two ton load lifted off your back. These past 7 weeks were tough, and I’m so glad it’s over. Now let’s get to the juicy stuff. Here’s my exam experience:


I woke up at 7:00 a.m. ate a well balanced breakfast and had my first caffeine dose of the day. I had to fight off urges to grab my First Aid book and look through some of the pages I had previously marked but didn’t have time to look at. I was feeling a bit anxious to get through the day, but I was confident in my abilities and I knew that I had studied enough to do well on this test. I grabbed my bag and stuffed into it enough food for a picnic:
• 2 club sandwiches (roast beef and chicken)
• Container of fruit salad
• Container of canned corn kernels.
• Bottle of Diet Coke
• 2 small bottles of water
• 2 Snickers chocolate bars
• 1 can of Red Bull

I arrived at my test center at 8:30. I signed in, had my fingerprints taken, and put all of my belongings (including my wallet, cell phone, and watch) in a locker. I was given 2 laminated boards and 2 markers. I honestly think they should rethink the marker thing because writing stuff out with thick tipped markers like the ones they provided wasn’t very feasible, especially when I had to write down equations and solve them. They should at least try to provide markers with thinner tips.

I headed over to my computer and signed in with my candidate number (you also have to enter your candidate number each time you sign in after a break). I started the tutorial and just made sure that my headphones were working. I skipped the rest of the tutorial. I wrote down some mnemonics and facts on my board that would save me time later (I’ll share these in my next post). I then took a deep breath and started my first block. The first 5-10 questions on my exam were VERY clinically oriented, to the point that I honestly thought that they had made a mistake and had me doing the USMLE Step 2! I made educated guesses for these first 5-10 questions and moved on. As I discovered anatomy questions and biochemistry questions, I quickly realized that I was overreacting and that this definitely was the USMLE Step 1. As I progressed through the first block, I calmed down and regained my focus. Overall, the 1st block on my exam was the second hardest block in my exam. I finished my block with 5 minutes to spare so I decided to take a 5 minute break to eat half a sandwich.

After pulling my pockets inside out to prove to the proctor that I wasn’t bringing anything into the test area, I signed in and went back to my computer to start the 2nd block. The second block was definitely the easiest on my exam. I finished it with more than 10 minutes to spare. The 3rd, 4th, and 5th blocks were also fairly easy (compared to USMLE World at least) and I finished with 7-10 minutes to spare on each block. I used the extra time to take well deserved breaks during the blocks to eat and keep my energy up. I had a can of red bull after the 4th block to keep my brain from shutting down during the latter half of my exam.

The 6th block on my exam was brutal! It was by far the toughest block on my exam. For most blocks I marked about 5 questions. On this block I marked at least 14 questions. I had 10 minutes of break time left and used it all after the 6th block. At this point, I had only 1 block left. I was so glad that this was my last block. Freedom was just an hour away. The seventh block was easy, and I was glad because at this point, my brain could only perform simple tasks. After my last block, there was a short survey I had to fill out. After being in that room for 8 hours, I honestly just wanted to leave. I filled out the survey and left the test room for the last time ever. I headed home satisfied with my performance, and already feeling anxious as to how I scored.

Let me finish by saying that time was never a big issue for me on the exam. The questions were just as long as the ones in USMLE World. I even had some 1-2 line questions. I always had more than 5 minutes to spare on each block (except for the 6th block, which I finished with 2 minutes to spare). So for those of you worried about the new exam format, don't worry! If you're managing your time well on USMLE World timed blocks, then you won't have a problem on the actual exam. I generally tried to pace myself at 1 question per minute. Check every 10 minutes to make sure you're on track. Half way through each block, I would always check to make sure that I still had more than 30 minutes remaining. If you're having trouble finishing a full USMLE World block in an hour, practice practice practice!

DONE!

I just got home from my exam and I'm EXHAUSTED! Overall, I am pleased with my performance. I know I did my best. I marked 5-10 questions per block. Since my mind is completely drained at the moment I won't be able to type up my full experience, but you'll get all the gruesome details tomorrow so stay tuned!

UWSA 2

I did UWSA 2 today. While doing the test, I felt that it was a lot harder than the actual USMLE World Qbank. Surprisingly I scored a 265! I don't know how accurate this is, but it's still very encouraging to score so high. All of my blocks were in the mid to high 80's percentage-wise.


With 2 days left I'm focusing on First Aid and looking at high yield images. I also hope I'll have time to look at some Neuroanatomy images from the UofT Neuroanatomy program.

My Second Simulated USMLE Step 1 Exam Experience

This time around, I knew what to expect! I knew when I'd feel tired and need a break, I knew when I'd need a snack, and I knew how I'd feel during each part of the exam. This experience wasn't all that different from the first one except in that I feel more prepared now, which is always a good thing 3 days before your exam! Anyways, I'm done with USMLE World now, I probably won't have time to do another pass of the questions I got wrong because I'd like to focus on First Aid.

This past week I've been marking all the topics I need to review again the day before my exam, and I'm going to continue to do that with the few chapters I have left in First Aid. I feel that I need to do another full pass of First Aid, but since that's not going to be possible, I should just focus on the other things I want to get done. At this point, I wouldn't ever consider postponing my exam. Yes I could do better with more time, but I'm just too burnt out to keep going like this. Another 3 days and that's it! I can't wait to be done with Step 1! Good luck to anyone reading this who is taking their exam this week (I know of a few who have contacted me). Stay focused and before we know it, we'll be done!

Get your melanin straight

++ melanocytes = Lentigo

-- melanocytes = vitiligo

++ melanin = freckles

-- melanin = albinism

++ nevus cells (modified melanocytes): nevus or melanoma

Simulated USMLE Step 1 Exam Experience

AI just finished my simulated usmle exam. I tried to pace myself closely, making sure I don't run out of time on blocks. I took a total of 1 hour break time and divided it as follows:

1st block
1 minute breather
2nd block
5 minutes
3rd block
10 minutes
4th block
30 minutes for lunch
5th block
5 minutes
6th block
10 minutes
7th block

My lowest point was the 6th block, I felt so exhausted during that block. I'm probably going to experiment some more with how I divide my break time. I still have enough questions for another full simulated exam.

I consistently scored in the low to mid 80's in all the blocks. I'm pretty pleased with my performance. I'd be ecstatic to do this well on the real deal.

A couple of points I learned from this experience:

• Eat a light lunch. I probably ate more than I should have for lunch and ended up feeling too laid back during the next block of questions.
• Look at the timer every 10 questions or so to make sure you're on your track.
• Don't get bogged down if you're not doing well. Like I said before, I felt so tired during the 6th block; surprisingly, it was my 2nd highest score.
• Focus on doing one block at a time. Before I started the simulated exam, I was like, "Ugh, this is going to take forever." I decided to just focus on getting through one block at a time.

Simulating the Exam Experience

I want to make sure I'm mentally prepared for the experience of taking an 8-hour long exam. I'm going to set up a simulation for myself today and make it as close to the real deal as possible. Seven one-hour long blocks of questions with 1 hour of break time. I even have some snacks prepared for my breaks. While I'm not looking forward to spending 8 hours on my laptop, I need to find out how this is going to feel so I can be prepared for doomsday. Wish me luck! I'll report back in 8 hours.

Recombinant cytokines

Filgrastim: gra = granulocyte; stim = stimulating factor

Sargramostim: gra = granulocyte; mo = monocyte; stim = stimulating factor

10 Days to go

With 10 days left, I still have so much to do. I've done 2/3 of USMLE World and 1/2 of First Aid, so I still have a lot to cover in the next few days.

This is definitely the time when you fell the stress, a word of advice to those of you at this point is to just focus on what you want to get done and NOT worry.

Branchial Arches

A lot of people, myself included, have trouble memorizing the development of the branchial apparatus. Hopefully with these mnemonics, this process will be much easier for you. It definitely helped me. Along with congenital heart disease, this seems to be the highest yield topic in Embryology for the USMLE Step 1.

1st Arch: a Massive list of M’s

Nerve: Maxillary and Mandibular nerves

Artery: Maxillary artery

Cartilage: Meckel’s Cartilage
- Mandible + sphenoMandibular ligament
- Malleus + Incus

Muscles: MAT x 2
- Muscles of Mastication
- Mylohyoid
- Anterior belly of digastric
- Anterior 2/3 of tongue
- Tensor veli palatini
- Tensor tympani

PS: for every one you get right reward yourself with an M&M  :D



2nd arch: Second

Nerve: Seventh nerve (facial nerve)

Artery: Stapedial artery and hyoid artery

Cartilage:
- Stapes
- Styloid
- Stylohyoid ligament
- leSSer horn of hyoid

Muscles:
- Muscles of facial expression (Smiling)
- Stapedius
- Stylohyoid
- poSSSterior belly of digastric



3rd arch: think Glossopharyngeal nerve

Nerve:
- Glossopharyngeal nerve

Cartilage:
- Greater horn of hyoid

Muscle:
- Stylopharyngeus



4th Arch: Swallowing + The exceptions to the 6th arch below

Nerve: Superior Laryngeal (branch of vagus)

Cartilage:
- Thyroid cartilage

Muscles:
- Pharyngeal constrictors
- Levator veli palatini
- Cricothyroid


6th Arch: Speaking (Laryngeal)

Nerve: Recurrent laryngeal (branch of vagus)

Cartilage: All laryngeal cartilages except thyroid cartilage

Muscles:  All instrinsic laryngeal muscles except cricothyroid

First Aid Rapid Review

I've been doing the Rapid Review Section of First Aid these past few days. I do 3 pages per day after I'm done with everything else.

There are 3 sections to it:
1. Classic Findings
2. Most common associations
3. Equation Review

I personally found these VERY helpful because they are the highest yield facts in First Aid. "The biggest bang per buck" as some would say.

Each page is divided into 2 columns, questions on the left, answers on the right. I covered the right column with a cue card and tried to answer them all without uncovering the answers. If I didn't know something, I highlighted it. I'm going to go over the highlighted ones again next week. This is definitely something you should plan on doing during towards the end of your USMLE Step 1 preparation.

Progress

I'm a third of the way through USMLE World. I'm learning a lot! It's definitely something I would recommend to anyone taking the USMLE Step 1. So far my percantage is in the high 70's. I hope I can break 80 by the end.

Drug Induced Sexual Dysfunction

Statistical Tests

On the USMLE, you will most likely be presented with a research design and according to the variables, you will be asked which statistical test to use.

 

2 interval variables: Pearson's correlation

2 ordinal variables: Spearman correlation
2 nominal variables: Chi-square
Both nominal and interval variables:

• 2 groups: t-test
• more than 2 groups: ANOVA

A mnemonic for interval vs. nominal is PINK:
Pearson = Interval
Nominal = Khi square (Chi square)

USMLE World

I've been doing USMLE World questions for 3 days now, and I must say I love it! The questions are well thought up, the explanations are amazing, and the feedback you get on your performance is very useful. I'm actually having fun! Who know studying for the USMLE Step 1 could be fun? I try to do 3-4 blocks of 48 questions each per day. I then go over the explanations which takes 30 minutes to an hour for each block. So in total, each block takes 1.5-2 hours.
My plan was to finish USMLE World and read through First Aid again and Rapid Review Pathology in 14 days, but it looks like I may have to rethink it. I also do 3 pages of First Aid's Rapid Review Section per day. Today I was supposed to do the Behavioral Science and Psychiatry sections in First Aid, but I ended up doing only half of the BS section. I really need to rethink my schedule.

USMLE World Self Assessment Exam 1

I just did UWSA1. I thought the first block was just brutal! The rest of it was ok. I got 247, which I'm happy with. If you look back to my first post, you'll see that my goal is 240+, so if I do this well on the actual exam, I'll be happy. Now I'm off to review the questions I got wrong! I'm going to do UWSA2 a week before my exam, and I hope there'll be more improvement by that time.

Feeling the stress

It just hit me today that I have less than a month left until my exam! I have so much I want to do in these 4 weeks. I want to do the USMLE World Qbank, read First Aid twice, read Rapid Review Pathology once more, and go over images and radiographs among other things. I've created a hardcore schedule for the time I have left. I'm probably going to be studying 10-12 hours per day. I really hope that I can pushmyself to the limit. The USMLE Step 1 exam is infamous for being one of the toughest professional licensing examinations out there. I'm going to start with UWSA tomorrow, so we'll see how that turns out. It'll either give me a confidence boost, or will knock my confidence down like a wrecking ball. I'm hoping it'll be the former rather than the latter...Nervous!

Microbiology and Immunology

I'm finally done with Microbiology. I think overall, virology was the hardest for me. Having to learn which viruses are +ssRNA, which are -ssRNA, which are linear/circular, which are helical/icosahedral was a pain. I spent a lot of time working on the virology cheat sheet that I posted earlier. It helped me so much in that regard. Overall I found First Aid 2010 adequate for Microbiology and Immunology. I had the Kaplan lecture notes at one side and went through each section I finished in first aid. I honestly only made a few annotations here. The Kaplan lecture notes for Micro are disorganized and I didn't like their format at all. The Immunology part was okay.

I'm going to spend the day going over a few pages from First Aid that I marked to go over again. I'm also going to do the sections in the Robbins Review (Question) book for infectious diseases and Immunopathology.Tomorrow I'm going to start USMLE World, and I'm very excited about that!

Monoclonal Antibodies

The monoclonal antibodies have very hard to remember names. These probably aren't very high yield for the USMLE Step 1, but it may be useful to be able to identify them. Hopefully these mnemonics will help. There are so many monoclonal bodies that have clinical uses, however I'm only going to list the ones that are in the Kaplan Pharmacology Lecture Notes.

• ABciximab: antagonist of IIb/IIIa receptors (antiplatelet)
• INFliximab: binds TNF (Rheumatoid arthritis and Crohn disease)
• TASTtuzumab: ERB-B2 antagonist (breAST cancer)
• PaliVIzumab: blocks respiratory syntycial VIrus

 The 2 Mabs used in immunosuppression are: (no mnemonic for these)

• Dacliximab: transplants (IL-2 receptor antagonist)
• Muromonab: transplants (CD3 antagonist)

Interleukin-6

IL-6 increases the production of:

• acute phase reactants
• immunoglobulins

 Note that each has 6 syllables.

Virology Cheat Sheet

Virology has always been the most difficult to remember part of Microbiology for me. For my USMLE Step 1 prep, I created this guide to help me out with remembering all the viruses. Some of these mnemonics are the same as the ones in First Aid for the USMLE, but I'd added some more. I hope it helps you as much as it helped me.

 

Here are some mnemonics for the members of the various virus families:

Bunyaviruses: Bunyaviruses viciously destroy CHuRCHeS

• California encephalitis
• Hantavirus
• Rift valley fever virus
• Crimean-Congo Hemorrhagic fever
• Sandfly fever virus

Togaviruses: Early Romans Wore Togas

• EEE (Eastern equine encephalitis)
• Rubella
• WEE (Western equine encephalitis) 

Eosinophils

Answer quickly, which Interleukin increases eosinophils? Quickly now! If you didn't get it, simply ask yourself what letter does Eosinophils start with? E, the 5th letter of the alphabet...so IL-5

Catalase positive organisms

Here's one of my latest creations:

If you've got CGD, make SPACE for organisms with catalase!

1. Staphylococcus
2. Pseudomonas aeruginosa
3. Aspergillus
4. Candida
5. Enterobacteriaceae

Viruses...linear or circular?

All DNA viruses have linear DNA except:

1. the 2 "-oma" viruses: papillomavirus and polyomavirus (circular) [oma reminds you of tumors, which are generally round]
2. hePAdna virus (PArtially circular).

 All RNA viruses have linear RNA except for the following circular viruses:

1. Arenaviruses: an "arena" is round
2. Bunyavirus: "bunions" are round
3. Deltavirus: the greek letter delta "δ" is round

E. coli

Common associations of the different types of E. coli:

ETEC: Traveller's diarrhea
EPEC: Pediatric diarrhea
EHEC: HUS, Hamburger
EIEC: Invasive (dysentery)

Encapsulated Organisms

The mnemonic in the Kaplan Lecture Notes is better than the one in First Aid. Here it is: Some Killers Have Pretty Nice Capsules

1. Streptococcus pneumoniae
2. Klebsiella
3. Haemophilus influenzae
4. Pseudomonas aeruginosa
5. Neisseria meningitidis
6. Cryptococcus neoformans

 There are some others (not as important) including:

1. some E. coli
2. Streptococcus agalactiae
3. Yersinia pestis (F1 envelope)

Clubbing

The causes of clubbing (hypertrophic osteoarthropathy) are CLUBBING:

1. Cyanotic heart disease
2. Lung diseases (hypoxia, cancer, bronchiectasis, cystic fibrosis)
3. Ulcerative colitis
4. Biliary cirrhosis
5. Birth defect
6. Infective endocarditis
7. Neoplasms (e.g. Hodgkin's)
8. GI malabsorption

Myocardial Infarction

Myocardial Infarction is definitely a topic you're bound to run into on the USMLE step 1 exam. Here are 2 mnemonics that may help you out.

Sequence of Elevated Enzymes in Myocardial Infarction:  Time to CALL 911

 Troponin, CK-MB, AST, and LDH1-2

Complications of an MI:  ACT RAPID

1. Arrhythmia
2. CHF
3. Thromboembolism (from a ventricular aneurysm)
4. Rupture (of ventricular wall, papillary muscle, or IV septum)
5. Aneurysm (of ventricle) 
6. Pericarditis
7. Infarction (a second one)
8. Dressler syndrome

The Ultimate Study Guide for Gastrointestinal Hormones

A lot of people struggle with GI hormones during their Physiology course or during USMLE Step 1 Preparation. Hopefully this will help.

All together there are 8 major hormones in this table. We are going to group these into 3 groups:

1. Hormones that affect the stomach: the first 4 (Gastrin, CKK, Secretin, GIP)
2. The inhibitory hormone: Somatostatin
3. Hormones that affect intestinal motility: the bottom 3 (NO, VIP, and Motilin)

For the most part, the hormone's name will give away its function.
1. Gastrin: this is the only hormone that promotes GASTRIC functions (acid secretion and motility)
2. CKK: “cholecyst” means gallbladder, “kinin” means move. Therefore, this is the only hormone that causes gallbladder contraction. Remember that bile is important for lipid digestion (formation of micelles, etc.). What else is important for lipid digestion? Pancreatic lipase! Therefore, CKK also increases secretion of Pancreatic enzymes. The fact you need to memorize here is that CKK decreases gastric emptying.
3. Secretin: promotes pancreatic HCO3- secretions. Since this hormone promotes an alkaline pH in the duodenum, it also inhibits gastric acid secretion.
4. GIP: GIP stands for 2 things
     a. Gastric inhibitory polypeptide: referring to its function in reducing gastric acid secretion.
     b. Glucose dependent insulinotropic polypeptide.
5. Somatostatin: inhibits all secretions (acid, pepsinogen, HCO3-, pancreatic enzymes, insulin, glucagon). It does not affect motility.
6. NO: you know that nitric oxide is the ultimate smooth muscle relaxer, so it reduces motility and relaxes sphincters.
7. VIP: “active” indicates that it increases intestinal motility.
8. Motilin: you can tell from its name that this hormone also promotes intestinal motility.

Go over the actions one more time just to make sure you’ve got them. Then move on to Regulation:
1. Stomach distension increases motility of the stomach (via Gastrin) and intestine (via VIP). When the stomach’s full, you want the food to move along to the next part of the GIT.
2. Acidity: when the stomach is too acidic, you’ll want to bring the pH back to normal by decreasing acid secretion. This is done by decreasing Gastrin (which normally increases acid secretion), and increasing secretin and Somatostatin (which decrease acid secretion).
3. Glucose: when there’s glucose in your GIT, you’ll want to get ready for it by having insulin available. This is done via GIP. Note that GIP secretion is also stimulated by amino acids and fatty acids.
4. Fatty acids and amino acids each increase the secretion of 3 hormones.
     a. Both amino acids and fatty acids increase the secretion of CCK and GIP.
     b. Amino acids also increase secretion of Gastrin [think: proteins are digested by pepsin, which is derived from activation of pepsinogen by acid ].
     c. Fatty acids also increase secretion of Secretin [think fatty acids are digested by pancreatic lipases  which require an alkaline pH to function]
5. Vagal stimulation increases Gastrin and VIP. It also decreases Somatostatin.

Done with Physiology

I just finished Physiology today. It took me a bit longer than I had planned. Overall, physiology is one of my strengths. I found that First Aid for the USMLE Step 1 2010 was only decent for physiology. It did cover most of the high yield topics, however I found it a bit lacking in certain areas, especially Endocrine and Cardiovascular Physiology. For Cardiovascular Physiology, I made a lot of annotations and page references to the Kaplan lecture notes. For Endocrine physiology, what First Aid lacks, Rapid Review Pathology has. I actually ended up reading the whole endocrine chapter from Rapid Review Pathology. I'm probably going to do the practice questions in the Kaplan Qbook by the end of the day. Next in my USMLE Step 1 prep is Microbiology, my least favorite subject. I still haven't created a plan for Micro, but I'm going to work on that before going to bed. Wish me luck!

Hypoxemia Algorithm

This algorithm is important. The information it contains is not found in First Aid for the USMLE Step 1, so you should definitely copy it in there.
*FIO2 stands for fraction of inspired oxygen.

Biochemistry

I've just finished Biochemistry. I went through the Biochemistry section in First Aid and then annotated some extra information from the Kaplan Lecture notes. I honestly think First Aid covers Biochem sufficiently. I did the 2 Qbook practice tests with an average of 86% questions right, so I'm satisfied with myself for this subject.

 

In my opinion, the highest yield topic in First Aid Biochemistry is the Rate-limiting enzymes. I'm definitely going to review this page the day before my exam. Not as high yield but difficult to retain for me were the Lysosomal storage diseases and the Glycogen storage diseases, so I'm also going to review these 2 pages again the day before my exam.

 

My next step in USMLE Step 1 prep is Physiology! I'm going to try to get through it all in 6 days, and I'm going to have to work hard to achieve that!

 

Here is a list of the major Biochemistry annotations I added from the Kaplan lecture ntoes (I have the 2006-2007 edition):

• Comparison between Prokaryotic and Eukaryotic DNA Replication: Kaplan pg. 22
• Genetic regulation: Kaplan pg. 69-77
• Transcription: Kaplan pg. 35-38 + pg. 43
• Indirect Genetic Diagnosis: Kaplan pg. 385-388
• Gene mapping: Kaplan pg. 366-376
• Algorithm for the Modes of Inheritance of a disease: Kaplan pg. 298 (Figure II-I-11)
• Vitamins: I'm not going to study these from First Aid because I felt Rapid Review Pathology covered these better. So I crossed them out in First Aid and made a page reference to Rapid Review Pathology.
• SAM, B12, and Folate: Kaplan pg. 257-259
• Overview of Energy metabolism: Kaplan pg. 153-159
• Functions of NADPH: Kaplan pg. 205
• Transport of ammonium by glutamine: Kaplan pg. 250
• VOMIT Pathway and enzyme deficiencies: diagram in Kaplan pg. 186      VOMIT (Valine, odd chain fatty acids, methionine, isoleucine and leucine, and threonine are all gluconeogenic and enter this pathway)
• Ketogenesis and Ketolysis: Kaplan pg. 237-239
• Triglyceride synthesis: Kaplan pg. 214-215

Cofactors

Carboxylases require ABC: ATP, Biotin, and CO2

Pyruvate dehydrogenase, a-ketoglutarate dehydrogenase, and Branched chain amino acid dehydrogenase require 5 cofactors: "Tender Love & Care For Nancy"
1. TPP (from B1)
2. Lipoic acid
3. CoA (from B5)
4. FAD (from B2)
5. NAD (from B3)

Glycogen bonds

The point at which a glycogen branch forms is an α-1,6 bonds (BRANCH has 6 letters in it)

The rest of the glycogen molecule has α-1,4 bonds (REST has 4 letters)

Hyperbilirubinemia

This table is based on the one in Rapid Review Pathology. I've just added some of the extra information about the different types of jaundice to make it more complete.

Splenomegaly

Protein Synthesis Inhibitors: Never Mix Them Up Again!

Aminoglycosides: A is the 1st letter, thus aminoglycosides inhibit Initiation (the first step of translation) by preventing formation of the initiation complex.

ChloramPhenicol: the only one with a "P", thus the only one inhibiting Peptide bond formation (by peptidyltransferase)

Macrolides: prevent the Movement of ribosomes (translocation)

Clindamycin: makes ribosomes Cling to mRNA (prevents translocation)

Tetracyclines (TTC): tRNA Tries but Can't (prevents the aminoacyl-tRNA from attaching to the A site of the ribosome)

Lincomycin: Like erythromycin (prevents translocation)

Linezolid: Like an aminoglycoside (prevents initiation)

Developmental Milestones

This chart is a hybrid between the ones in Kaplan Lecture Notes, First Aid for the USMLE step 1, First aid for the basic sciences, and a few other resources. The bottom row of the table (the "others" row) has mnemonics for each age. The mnemonics cover a great deal of what's in the table, however there is still a lot of information that is not covered by the mnemonics, so you're still going to have to put in a lot of effort if you want to master this.

Need to get organized

As the number of posts grows, the lack of organization here is becoming more evident. I am going to work on this throughout these next few days. I'm going to create separate pages and hopefully re-organize my posts. This is going to be very GRADUAL since I don't have  alot of time to spare. I look forward to getting it done though and I'm sure it will make coming to my blog more enjoyable for you. :)

Intestinal Obstruction mnemonic

Here is a mnemonic I made up for the Causes of Intestinal Obstruction:

CHAGAS is Very Important in Hispanic Municipalities


Chagas disease can lead to Hirschprung's disease because the tryponosomas can destroy the ganglion cells in the rectum. Hirschsprung's is itself a cause of intestinal obstruction.
C= Crohn's disease
H= Hirschsprung's disease
A= Adhesions
G= Gallstone ileus
A= Atresia (duodenal)
S= pSeudoobstruction (neurogenic)

is Very= Volvulus

Important= Intussusception

in Hispanic= Hernia (Indirect)

Municipalities= Meconium ileus

My Greatest Fear

Imagine waking up one morning only to discover that you're trapped in your body! You open your eyes to frantically discover that you're still alive. You role your eyes down to look towards your legs and they're still there, but unable to move. You're completely paralyzed, can't speak, can't yell for help...all you can do is move your eyes up and down. The only movement you have left in your body consists of vertical movements of the eyes because the only 2 nerves spared in this state are the oculomotor and trochlear nerves. You can hear yourself think, you can hear people around you speak, you can even understand what they're saying, but you're trapped! A prisoner of your own body. You can't express to anyone around you that you're scared to death or want to cry.

This is what is experienced by thousands of unlucky people with "Locked in syndrome" or cerebromedullospinal disconnection. It is caused by a lesion at the base of the pons such as an infarct of the basilar artery.

Corticospinal tracts are lost, meaning you have no movement in your body.
Corticobulbar tracts are lost, meaning that you have no movement in your face and can't speak. All you have are the up and down movements that you can perform using the oculomotor nerve.

This is the scariest disease to me. I would probably prefer to have any other disease than this.

Hypothalamus (hunger vs. satiety)

The hypothalamus has both the hunger center (lateral area) and the satiety center (ventromedial area).
I honestly didn't like the mnemonic in first aid for this. The mnemonic I like is this:
Lat makes you fat (hunger center)
Ven makes you thin (satiety center)

Brain Stem Lesions Simplified

I've been going through Anatomy these past few days A(for the second time now). I'm almost done. Neuroanatomy was the hardest section for me and took the most time. I despise the Brainstem section in Kaplan. I created a table to summarize the Brain stem lesions. It includes information from Kaplan, First Aid, and HY Neuroanatomy. It took time to create but it was worth it in the end.

Extraordinary Measures

I decided to take some time off today to watch the movie Extraordinary Measures. I loved it! It is one of my favorite "medicine-based" movies.

It is about a family with 2 kids who have Pompe's disease and how their parents create a foundation that plays the major role in developing a drug for the disease (the drug is a replacement enzyme that can enter the cell and perform the functions of the deficient enzyme). What is amazing about this movie is that it is based on the true story behind the development of the drug "Myozyme" (alglucosidase alpha) by the company Genzyme which has been available since 2006. Go to http://www.myozyme.com/ to learn more about the drug. I strongly suggest you watch the movie Extaordinary Measures.

Cushing Ulcers and Curling Ulcers

These are peptic ulcers caused by CNS injury and burns respectively.

One possible explanation for the development of Cushing ulcers is the stimulation of vagal nuclei due to the increased intracranial pressure which leads to increased secretion of gastric acid.

Curling ulcers may be explained by a reduced plasma volume, which leads to sloughing of the gastric mucosa or secretion of burn toxins (necrotic and carbonaceous materials released from burned cells) by the stomach.

Dopamine and Serotonin

I prefer to study material in table format becaue I can easily find what I want and it provides a condensed version of the same material in text. I often create tables like the ones below and use them instead of material in First Aid or Kaplan. These 2 tables are for Dopamine and Serotonin Pharmacology. I will post more tables and notes like these soon.

Final Thoughts on Pharmacology

I'm finally done with Pharm! I'm very ecstatic, this was one of my worst subjects in school but I've come to enjoy it over the past few days.
My plan for Pharm was to use Kaplan and then go through first aid. That's exactly what I did at the beginning, but it was too time consuming. When I started going through first aid, I realized that everything I needed to know was in first aid! I realized that I wouldn't have time to go through Kaplan again before the exam, so I decided to annotate in First Aid anything that was written in Kaplan but not first aid (sometimes making page references if there was a diagram or a whole page that I didn't want to copy into first aid). I think this will save me so much time when it comes time to do my final reading. Having one source to study from is much more pragmatic than reading the same material from 2 different books.

The moral of the story: Don't underestimate First Aid!

Near the end of the Pharmacology section in First Aid, there's a 2 page list of the most important side effects and their drug associations. These 2 pages are PURE GOLD! I'd say that these 2 pages are the 2 most important pages in Pharm.
Now that I'm done with my first read for all subjects, I'm going to be starting my 2nd read, during which I plan on annotating everything from Kaplan into First Aid. This way, during the final week, I can go through first aid and now have to worry about going through all the kaplan books again. I'm scheduled to take the exam in late July, and I still have a lot to do!

Serotonin Syndrome and Hypertensive Crisis

Two highly tested drug interactions for CNS drugs are Serotonin syndrome and Hypertensive crisis.

The purpose of this diagram is to present these interactions in an "easily digestible" manner.

SSRI Can cause Serotonin syndrome
MAOI can cause Serotonin Syndrome
MAOI can cause Hypertensive Crisis

*Note that TCAs can cause all 3 of the above interactions.

The drug at the beginning of the arrow can cause the result at the end of the arrow with any 1 of the drugs above or below the arrow.

Print this diagram and stick it into the Pshchiatry-Pharmacology Section of First Aid.

Once Again

Conflict:

Kaplan says: Local anesthetics bind preferentially to activated Na channels.

First aid says: Local anesthetics bind preferentially to INactivated Na channels.

So who's right? Once again, both are correct! According to Katzung Basic and Clinical Pharmacology (LANGE), local anesthetics have an increased affinity for BOTH activated and inactivated states of Na channels, but they have a low affinity for resting Na channels. Remember that Na channels in the heart and neurons have 3 states according to their M and h gates (resting, activated, and inactivated). Neurons with higher rates of firing have more Na channels in the activated and inactivated states, and less in the resting/ready state.

Mannitol (First Aid VS Kaplan)

Conflict:

Kaplan says: Mannitol is used in anuric states

First Aid says: Mannitol is contraindicated in anuria
 
Which is right? They're both right. Huh? It depends on the cause of anuria. Here is what the ultimate encyclopedia of medicine (wikipedia) says:
 
"Mannitol is a medicine that is used to increase the amount of water removed from the blood and thus improve the blood flow to the kidneys. However, mannitol is contraindicated in anuria secondary to renal disease, severe dehydration, intracranial bleeding (unless during craniotomy), severe pulmonary congestion, or pulmonary edema."
http://en.wikipedia.org/wiki/Anuria

Antiarrhythmics

Each antiarrhythmic drug has a predominant use for certain types of arrhythmias. You need to be able to determine which antiarrhythmic is suitable for certain arrhythmias. Yes, this is more important for Step 2, however it is knowledge you are required to have some familiarity with for Step 1, especially since often the stem of the question may reveal the type of arrhythmia and ask you about the unkown drug being used. Unfortunately, in Kaplan and First Aid this information is scattered in a difficult to study manner.

THE SOLUTION: If you have Lippincott's Pharmacology, go to page 174 (figure 17.2). This is a full page sized reader-friendly figure showing the different arrhythmias and the anti-arrhythmics that can be used. It is very organized and I highly recommend you refer to this. If you don't have the book, email me and I will scan this page for you.

Reserpine

RESERpine acts by depleting RESERves of Norepinephrine in neurons.

People who took reserpine became severely DepRESsed

Speaking of Depression, here are the drugs that can induce depression:
PROMS:
Propranolol
Reserpine
Oral contraceptives
Methyldopa
Steroids

Bosentan

Bos-EN-t-AN is an ENdothelin receptor ANtagonoist.

Vasodilator Vessel Specificity

Vasodilators are commonly used in clinical practice, so make sure to get these facts straight.

Arteriolar Vasodilators: Calcium channel blockers, Potassium channel blockers, and Hydralazine. These cause reflex tachycardia and edema.

Venular dilators: Nitrates. These cause orthostatic hypotension.

Drugs that are Both Arteriolar and Venular dilators: all other vasodilators. These cause reflex tachycardia, edema, AND postural hypotension. A prime example would be alpha-1 blockers such as prazosin.

***There are 3 important dilators that act via increasing NO. These are Nitrates (venular), Hydralazine (arteriolar), and Nitroprusside (both).

Order of Subjects

Today I was asked a very good question on one of the usmle forums. The student asked me what the best order is to review the subjects for Step 1. The most logical method is to study them in the same order you took these classes in Med School. Start with subjects that don't need a lot of integrations with other subjects. For example, here is the order I am using:

1. Anatomy
2. Biochemistry
3. Physiology
4. Microbiology
5. Pathology
6. Pharmacology
7. Behavioral Sciences

Now, for the last 3 subjects, you may prefer to switch these around, and it would be okay. Please note that Pathology integrates almost all of the other subjects you've studied (makes sense since it's the main bulk of the USMLE step 1). You can do Pharm before Pathology if you want to take advantage of the Pharm integration in Rapid Review Pathology (however there aren't that many of them). I recommended Behavioral Sciences after Pharmacology because BS (lol) has a psychopharmacology section that requires you to have some background in Pharm.
I recently came across an excellent study guide for the USMLE by someone called Taus on SDN. I highly recommend it. It integrates several subjects well and is overall an excellent guide that you can mend to best fit you. Here is the link for it:
http://forums.studentdoctor.net/showthread.php?p=6192274#post6192274
If you guys have any further suggestions or questions, feel free to comment.

Bethanechol vs. Methacholine

As a med student, you have to make up ridiculous methods for memorizing certain facts. Bethanechol and Methacholine are both muscarinic receptor agonists, but Bethanechol only affects Muscarinic receptors, while Methacholine activates both muscarinic and nicotinic receptors.
To memorize this, think of AcetylCHOLINE. MethaCHOLINE has the whole "CHOLINE" in it, therefore, like Acetylcholine, it activates both M and N receptors. BethaneCHOL has only half what Acetylcholine has, therefore it only activates M receptors.
Now you won't ever again forget what these 2 drugs do!

The Sneeze Drug

Some drugs have wacky names! I was reviewing some Pharm today and I came across the drug Eptifibatide. It sounds like you're sneezing if you say it like this EPTI-fibatide!

I spent almost an hour laughing about this today. I don't know if it's the long stressful hours of studying that have induced a mania-like state, or perhaps I was stressing about memorizing this hard-to-remember drug that my ego decided to use humor as a defense mechanism...but wait, defense mechanisms are supposed to be unconscious...so if I'm thinking about it being a defense mechanism, then it probably isn't right? But does this statement hold for medical students and doctors, who are aware of the use of defense mechanisms? I'd like to know the answer to that.

Well, now that you've read about the drug that sounds like a sneeze, EPTI-fibatide, I might as well tell you what it is. It is an antiplatelet drug that acts as an antagonist on gp IIb/IIIa (receptors for fibrinogen, required for platelet adhesion). Note that this is the same receptor that is deficient in Glanzmann's disease.

I hope this helps!

Alright! Let's get the ball rolling! I'm going to be writing the USMLE step 1 in July 2010. My goal is to score 240/99 or higher. In this blog I will post updates on how my USMLE Step 1 prep is going and tips that will help you during YOUR USMLE Step 1 Prep. I will also post mnemonics and tables that I've created to help you study some of the high yield material for the USMLE Sep 1.