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FIRST AID FOR
THE I

USMLE
STEP 2 CK
Clinical Knowledge
Eleventh Edition
ASTUDENT-TO-
STUDENT GUIDE
J
Focuses on exactly what you need to know to succeed on the USMLE Step 2 CK
Case vignettes included to test your application of knowledge
Key facts and mnemonics reinforce key information
Rapid review section for last minute cramming
Includes hundreds of color clinical images and illustrations

TAOT. LE VIKAS BHUSHAN DANIEL 0. GRIFFIN MARINA BOUSHRA

 FIRST AIDS
USMLE Step 2 CK
Eleventh Edition
TAO LE, MD, MHS VIKAS BHUSHAN, MD
Founder, ScholarRx Founder, lint Aid for the IISMl .i . Step I
Associate Clinical Professor, Department of Medicine Boracay, Philippines
University of I ouisville School of Medicine

MONAASCHA , MD ABHISHEK BHARDWAJ, MD

Fcllosv, Department of Plastic Singers
Johns Hopkins University
Pulmonologist and Inlensivlst
Coast Pulmonary Associates, Orange County, California
.
Assistant Clinical Professor Health Sciences
University of California, Riverside

MARINA BOUSHRA, MD DANIEL GRIFFIN, DO

Emergency Medicine and ( Critical ('are Medicine Inlensivist, Saint Francis Medical Center
Cleveland Clinic Foundation, Cleveland, Ohio

CAROLINE COLEMAN, MD STEPHANIE JONES, PhD

Resident , Department of Medicine Emory ldiversity I «mey Graduate School
Emory University School of Medicine

KIMBERLY KALLIANOS, MD
Assistant Professor, Department of Radiologs and Biomedical Imaging
.
lInivcrsily of California San Francisco School of Medicine

New York Chicago San Francisco Athens London Madrid Mcsico Cits
Milan New Delhi Singapore Sydney Toronto
Copyright © 2023, 2019, 2016, 2012, 2010, 2007, by Tao Le. All rights reserved. Except as
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 DEDICATION

To the contributors to this and past editions, who took

time to share their knowledge, insight, and humor for
the benefit of students and physicians everywhere.
Contents
Contributing Authors
Faculty Reviewers
Preface
Acknowledgments
How to Contribute
How to Use This Book

SECTION 1: GUIDE TO EFFICIENT EXAM PREPARATION

Introduction
USMLE Step 2 CK—Computer-Based Testing Basics
Defining Your Goal
Study Resources
Test-Day Checklist
Testing Agencies

SECTION 2: DATABASE OF HIGH-YIELD FACTS

How to Use the Database
Cardiovascular
Dermatology
Endocrinology
Epidemiology
Health Systems Science
Gastrointestinal
Hematology/Oncology
Musculoskeletal
Neurology
Obstetrics
Gynecology
Pediatrics
Psychiatry
Pulmonary
Renal/Genitourinary
Multisystem
Rapid Review

SECTION 3: TOP-RATED REVIEW RESOURCES

How to Use the Database
Comprehensive
Question Banks
Internal Medicine, Emergency Medicine, Family Medicine
Neurology
OB/GYN
Pediatrics
Psychiatry
Surgery
Commercial Review Courses
Appendix I: Acronyms and Abbreviations
Appendix II: Common Laboratory Values
Index
About the Authors
 CONTRIBUTING AUTHORS

Manik Aggarwal, MD, MBBS

Fellow, Gastroenterology and Hepatology
Mayo Clinic, Rochester, Minnesota

John Carl Barba II, MPH

MD Candidate
Ohio State University College of Medicine

Anup Chalise, MBBS, MS

Nepal

Paola Ghanem, MD
Physician, Department of Internal Medicine
Johns Hopkins University

Myles Mowery, DO, MBA

Resident, Diagnostic and Interventional Radiology
Spectrum Health/Michigan State University
Grand Rapids, Michigan

Waneeza Mughees, MD
Resident, Obstetrics and Gynecology
Drexel University College of Medicine, Philadelphia

Christian Cuvillier Padilla, MD

Chief Resident, Internal Medicine
Cleveland Clinic and Cleveland Veterans Affairs Medical Center, Cleveland, Ohio

Vivek Podder, MBBS

Intern
BIRDEM General Hospital, Bangladesh

Vikram Shee, MBBS, MSc

Physician Case Manager
Teladoc Health, Inc.

Collin Andrew Weintraub, MD

Resident, General Surgery
State University of New York Upstate Medical University
 IMAGE AND ILLUSTRATION TEAM

Yoree Grace Chung

MD/PhD Candidate
Emory University School of Medicine

Nikitha Crasta, MBBS

Mangalore, India

Sean Evans, MD
Resident, Internal Medicine
Emory University School of Medicine

Victor Jose Martinez Leon, MD

Resident, Internal Medicine
Einstein Medical Center, Philadelphia

Angel Xiao, MD, MSE

Resident, Orthopedic Surgery
University of California–San Francisco
 ASSOCIATE AUTHORS

Aparna Savitri Bhat, MD

Fellow, Pulmonary and Critical Care Medicine
Cleveland Clinic, Cleveland, Ohio

Naveena Daram, MD
Resident, Obstetrics and Gynecology
Wright State University

Ifrah Fatima, MBBS

Resident, Internal Medicine
University of Missouri–Kansas City School of Medicine

Lindsay Friedman, MD, MS

Resident, General Surgery
Rush University Medical Center

Luise Josefine Froessl, MD

Resident
Université d’Aix-Marseille, Faculté de Medecine

Izhan Hamza, MBBS

Resident
University of Texas Medical Branch, Internal Medicine

Abdul Rehman Mustafa, MBBS

Alfaisal University College of Medicine, Saudi Arabia

Aaron Panicker, MD
Resident, Emergency Medicine
University of Florida College of Medicine

Austin Patrick, DO
Resident
Franciscan Health Olympia Fields

Faateh Ahmad Rauf, MBBS

CMH Lahore Medical College and Institute of Dentistry, Pakistan

Jaimie Rogner, MD, MPH

Resident, Internal Medicine/Pediatrics
University of Rochester Medical Center/Strong Memorial Hospital

Kyle Robert Wagner

MD Candidate
University of Illinois College of Medicine, Peoria
 FACULTY REVIEWERS

Brooks D. Cash, MD
Professor, Department of Medicine
Chief, Gastroenterology, Hepatology, and Nutrition
University of Texas Health Science Center at Houston

Dimitri Cassimatis, MD
Associate Professor, Department of Medicine
Emory University School of Medicine

Bradley Cole, MD
Assistant Professor of Neurology
Loma Linda University School of Medicine

Meredith K. Greer, MD
Assistant Professor, Department of Medicine
Emory University School of Medicine

Jennifer O. Howell, MD
Associate Professor, Department of Obstetrics and Gynecology
Duke University Medical Center

Matthew Kraybill, PhD

Clinical Neuropsychologist
Cottage Health, Santa Barbara, California

Patrick M. Lank, MD, MS

Assistant Professor, Department of Emergency Medicine
Northwestern University, Feinberg School of Medicine

Kachiu C. Lee, MD, MPH

Assistant Professor (Adjunct), Department of Dermatology
Lewis Katz School of Medicine at Temple University

Carl Marfurt, PhD

Professor Emeritus, Department of Anatomy, Cell Biology and Physiology
Indiana University School of Medicine–Northwest, Gary

Peter Marks, MD, PhD

Center for Biologics Evaluation and Research
US Food and Drug Administration

Kristen L. Pagel, MD, MPH

Assistant Professor, Department of Psychiatry
University of Utah School of Medicine

Mahesh Patel, MD
Professor, Department of Medicine
University of Illinois at Chicago College of Medicine

Diane Payne, MD, MPT

Orthopedic, Hand and Microvascular Surgery
OrthoAtlanta Newnan, Georgia

Soroush Rais-Bahrami, MD
Professor of Urology and Radiology and Interim Chair, Department of Urology
University of Alabama at Birmingham School of Medicine

Keisha Ray, PhD

Assistant Professor, McGovern Center for Humanities and Ethics
University of Texas Health Science Center at Houston

Rachel Marie E. Salas, MD, MEd

Professor, Neurology and Nursing
Johns Hopkins Medicine

Sarah Schimansky, MB BCh BAO

Resident, Department of Ophthalmology
Bristol Eye Hospital

Shireen Madani Sims, MD

Associate Professor and Vice Chair for Education, Obstetrics and Gynecology
University of Florida College of Medicine

Nathan Wm. Skelley, MD

Associate Professor, Medical Director of Orthopaedic Surgery
Sanford Health–University of South Dakota School of Medicine

Matthew Sochat, MD
Physician, Hematology/Oncology
Southeastern Medical Oncology Center

Lorrel Toft, MD
Associate Professor of Cardiology, Department of Medicine
University of Nevada, Reno School of Medicine

Tisha Wang, MD
Professor of Clinical Medicine, Department of Medicine
David Geffen School of Medicine at UCLA

Sylvia Wassertheil-Smoller, PhD

Professor Emerita, Department of Epidemiology and Population Health
Albert Einstein College of Medicine

Adam Weinstein, MD
Associate Professor of Medical Sciences and Pediatrics
Frank H. Netter MD School of Medicine at Quinnipiac University
James S. Yeh, MD, MPH
Department of Medicine
Massachusetts General Hospital, Harvard Medical School

Kristal Young, MD
Clinical Instructor, Department of Cardiology
Huntington Hospital, Pasadena, California
Preface
With the 11th edition of First Aid for the USMLE Step 2 CK, we continue our commitment to
providing students with the most high-yield and up-to-date preparation guide for the USMLE
Step 2 CK exam. Preparation for and performance on the Step 2 CK exam are more important
than ever with the transition of the Step 1 exam to a pass/fail scoring system in 2022. With
this in mind, we have greatly expanded the content and depth for the 11th edition. This
revision includes:

Over 200 additional pages of content incorporating the most current evidence-based
reviews and recommendations to help students on the Step 2 CK exam and in clinical
practice.
163 new and revised diagrams and illustrations, including more than 40 new diagnostic
and management algorithms, to further drive home the next best diagnostic and
management options.
140 new and revised photos/images to help visualize various disorders, descriptive
findings, and clinical content tie-ins.
Extensive text revisions, new mnemonics, and clarifications curated by a team of 26
medical student and resident physician authors who excelled on their USMLE exams and
verified by a team of expert faculty advisors and nationally recognized USMLE
instructors.
Continued focus on clinical presentation and the best initial step in diagnosis and
management, mirroring the content outline and blueprint of Step 2 CK.
Vignette-style flash cards embedded in the margins to reinforce key concepts.
Heavily updated and revised Rapid Review section for last-minute preparation.
Revised rating of current high-yield review resources, with clear explanations of their
relevance to Step 2 CK exam review.
Improved organization and integrations of text, illustrations, clinical images, tables, and
algorithms throughout for focused review of high-yield topics.

The 11th edition of First Aid for the USMLE Step 2 CK truly is a completely revised, in-
depth, student-to-student guide for preparation for the Step 2 CK exam. The 11th edition
would not have been possible without the help from hundreds of students and faculty
members who contributed their feedback and suggestions. We invite students and faculty to
continue sharing their thoughts and ideas to help us improve First Aid for the USMLE Step 2
CK (see How to Contribute, p. xi).

Tao Le
Louisville

Vikas Bhushan
Boracay

Mona Ascha
Baltimore
 Abhishek Bhardwaj
Orange County

Marina Boushra
Cleveland

Daniel Griffin
Cape Girardeau, Missouri

Caroline Coleman
Atlanta

Stephanie Jones
Tumwater, Washington

Kimberly Kallianos
San Francisco
Acknowledgments
This has been a collaborative project from the start. We gratefully acknowledge the
thoughtful comments, corrections, and advice of the many medical students, international
medical graduates, and faculty who have supported the authors in the continuing
development of First Aid for the USMLE Step 2 CK.

Thanks to our publisher, McGraw Hill, for the valuable assistance of its staff, including Bob
Boehringer, Christina Thomas, and Jeffrey Herzich. For outstanding editorial work, we thank
Megan Chandler and Lisa Nahach. We are also grateful to our medical illustrator, Rachael
Williams, and illustration manager, Susan Mazik. For administrative support we thank
Miranda Carter, Katherine Knight, and Louise Petersen. A special thanks to GW, Inc. for
remarkable production work.

For contributions and corrections, we thank Ataa Ahmed, Arjun Basnet, Jeffrey Beach,
Monica I. Burgos Claudio, Fiorella B. Castillo, Mallory Castillo, Christian Casteel, Anthony
Chung, Jonathan Daou, Karanpal Dhaliwal, Fadi Dib, Celia Escamilla, Arber Frakulli,
Mohan Bharadwaj Gudivada, Jacqueline Hairston, Nathaniel Hayward, Lydia Kaotzani,
Panagiotis Kaparaliotis, Alex Lu, Juliana Maya, Austin McCullough, Nupur Mishra,
Mounika Mukherjee Peethala, Majd Oteibi, Shannon D. Powell, Aubtin Saedi, Tanjot Saini,
Angelica Maria Sanchez Ruiz, Charles Sanky, Maida Sarfraz Chaudhry, Neetu Scariya, Ryan
Schusler, Tarif Shaaban, Tomonari Shimoda, Biraj Singh Karki, Colton Southall, Charles
Starling, Ari Stone, Erica Stratton, Jennifer Tram, Nicholas Ting, Vivekanand Tiwari, Sheela
Vaswani, and Earl Vialpando.

Tao Le
Louisville

Vikas Bhushan
Boracay

Mona Ascha
Baltimore

Abhishek Bhardwaj
Orange County

Marina Boushra
Cleveland

Daniel Griffin
Cape Girardeau, Missouri

Caroline Coleman
Atlanta

Stephanie Jones
Tumwater, Washington

Kimberly Kallianos
San Francisco
How to Contribute
In our effort to continue to produce a high-yield review source for the Step 2 CK exam, we
invite you to submit any suggestions or corrections. We also offer paid internships in medical
education and publishing ranging from three months to one year (see below for details).
Please send us your suggestions for the following:

Study and test-taking strategies for the Step 2 CK exam

New high-yield facts, mnemonics, diagrams, and illustrations
Low-yield topics to remove

For each entry incorporated into the next edition, you will receive up to a $20 gift certificate
to Amazon as well as personal acknowledgment in the next edition. Diagrams, tables, partial
entries, updates, corrections, and study hints are also appreciated, and significant
contributions will be compensated at the discretion of the authors. Also let us know about
material in this edition that you feel is low yield and should be deleted.

The preferred way to submit entries, suggestions, or corrections is via our blog:

www.firstaidteam.com

We are also reachable by e-mail at firstaid@scholarrx.com.

 NOTE TO CONTRIBUTORS

All entries become property of the authors and are subject to editing and reviewing. Please
verify all data and spellings carefully. If similar or duplicate entries are received, only the
first entry received will be used. Include a reference to a standard textbook to facilitate
verification of the fact. Please follow the style, punctuation, and format of this edition if
possible.
 INTERNSHIP OPPORTUNITIES

The author team is pleased to offer part-time and full-time paid internships in medical
education and publishing to motivated physicians. Internships may range from three months
(eg, a summer) up to a full year. Participants will have an opportunity to author, edit, and
earn academic credit on a wide variety of projects, including the popular First Aid series.
Writing/editing experience, familiarity with Microsoft Word and Google Docs, and
illustration skills are highly desired. For more information, e-mail a résumé or a short
description of your experience along with a cover letter to firstaidteam@usmle-rx.com.
How to Use This Book
We have made many improvements and added several new features to this edition of First
Aid for the USMLE Step 2 CK. In particular, we have added more than two hundred pages of
content and hundreds of new illustrations and images throughout the text to facilitate
studying. We encourage you to read all aspects of the text to learn the material in context. We
have also included comments in the margins and vignette questions to periodically test your
knowledge of key concepts. These questions are located in the lower corner of certain pages.
To prevent peeking at the answers, you’ll find the answer on the back of the same page in the
lower corner. These questions are not always representative of test questions.

To practice for the exam and simulate the actual test day, you can use the USMLE-Rx Step 2
CK Qmax question test bank (www.usmle-rx.com). If you are constantly on the move, use the
USMLE-Rx Step 2 CK app. The question bank and this text are more than enough to allow
many students to ace the exam.

Good luck!
SECTION 1
GUIDE TO EFFICIENT EXAM
PREPARATION
Introduction

USMLE Step 2 CK—Computer-Based Testing Basics

WHO CAN REGISTER FOR THE EXAM?
HOW WILL THE CBT BE STRUCTURED?
TESTING CONDITIONS: WHAT WILL THE CBT BE LIKE?
WHAT DOES THE CBT FORMAT MEAN FOR ME?
HOW DO I REGISTER TO TAKE THE EXAMINATION?
WHAT IF I NEED TO RESCHEDULE THE EXAMINATION?
WHAT ABOUT TIME?
SECURITY MEASURES
IF I LEAVE DURING THE EXAMINATION, WHAT HAPPENS TO MY SCORE?
WHAT TYPES OF QUESTIONS ARE ASKED?
HOW LONG WILL I HAVE TO WAIT BEFORE I GET MY SCORES?
HOW ARE THE SCORES REPORTED?

Defining Your Goal

WHEN TO TAKE THE EXAM
HOW WILL THE STEP 2 CK SCORE AFFECT MY MATCH?

Study Resources
QUALITY CONSIDERATIONS
CLINICAL REVIEW BOOKS
TEST BANKS
TEXTS AND NOTES
COMMERCIAL COURSES
NBME/USMLE PUBLICATIONS

Test-Day Checklist
THINGS TO BRING WITH YOU TO THE EXAM

Testing Agencies

INTRODUCTION
The United States Medical Licensing Examination (USMLE) Step 2 allows you to pull
together your clinical experience on the wards with the numerous “factoids” and classical
disease presentations that you have memorized over the years. Where Step 1 stresses basic
disease mechanisms and principles, Step 2 places more emphasis on clinical diagnosis and
management, disease pathogenesis, and preventive medicine. Previously, the Step 2
examination consisted of the Step 2 Clinical Knowledge examination (Step 2 CK), and the
Step 2 Clinical Skills examination (Step 2 CS). However, recent changes have removed the
Step 2 CS exam as a requirement for ECFMG certification after the onset of the pandemic,
and this change has been recorded as permanent by the ECFMG.
The USMLE Step 2 CK is the second of three examinations that you must pass to become
a licensed physician in the United States. The computerized Step 2 CK is a 1-day (9-hour)
multiple-choice examination.

KEY FACT
The goal of the Step 2 CK is to apply your knowledge of medical facts to clinical scenarios
that you may encounter as a resident.

USMLE STEP 2 CK—COMPUTER-BASED TESTING

BASICS

WHO CAN REGISTER FOR THE EXAM?

The eligibility requirement for USMLE Step 2 CK exam is same as that of USMLE Step 1
and can be taken either before or after the Step 1 exam. This means that you should be:

Officially enrolled in, or be a graduate of, a US or Canadian medical school leading to the
MD degree (LCME accredited), or
Officially enrolled in, or be a graduate of, a US medical school leading to the DO degree
(COCA accredited), or
Officially enrolled in, or be a graduate of, a medical school outside the US and Canada and
listed in the World Directory of Medical Schools as meeting ECFMG eligibility
requirements and meet other ECFMG criteria.

These criteria should be met at the time of application and on the test day.

HOW WILL THE CBT BE STRUCTURED?

The Step 2 CK exam is a computer-based test (CBT) administered by Prometric, Inc. It is a 1-

day examination with a maximum of 318 items divided into eight 1-hour blocks that are
administered during a single 9-hour testing session. The number of items in a block are
displayed at the beginning of each block. This number may vary from block to block but will
not exceed 40 items per block.
Two question styles predominate throughout. The most common format is the single one-
best-answer question. This is the traditional multiple-choice format in which you are tasked
with selecting the “most correct” answer. Sequential item sets comprises the second
question style. These are sets of multiple-choice questions that are related and must all be
answered in sequence without skipping a question in the set. As you answer questions in a
set, the previous answers become locked and cannot be changed. These are the only questions
on the USMLE examination that are locked in such a way. There are no more than five
sequential item sets within each USMLE Step 2 CK exam.

KEY FACT
Sometimes the answer to the previous question in a sequential question set is provided to
you once you lock your answer. Do not be disheartened if you got it wrong. Simply
understand that you now have an opportunity to get at least one answer correct in the
sequence.

During the time allotted for each block in the USMLE Step 2 CK exam, you can answer
test questions in any order and can also review responses and change your answers (except
for responses within the sequential item sets described earlier). However, under no
circumstances can you return to previous blocks and change your answers. Once you have
finished a block, you must click on a screen icon to continue to the next block. Time not used
during a testing block will be added to your overall break time (45 minutes total at start of
exam), but it cannot be used to complete other testing blocks. Also note that a short tutorial
(shorter than the one available at the USMLE website) is present at the start of the exam,
which if you choose to skip, can add 15 minutes to your total break time.

KEY FACT
Expect to spend up to 9 hours at the test center.

TESTING CONDITIONS: WHAT WILL THE CBT BE LIKE?

Even if you are familiar with CBT and the Prometric test centers, you should still access the
latest practice software from the USMLE Web site (http://www.usmle.org) and try out prior
to the examination.
For security reasons, you are not allowed to bring personal equipment (except those
needed for medical reasons and soft-foam earplugs as detailed later) into the testing area—
which means that writing implements, outerwear, watches (even analog), cellular telephones,
and electronic paging devices are all prohibited. Food and beverages are prohibited as well.
The proctor will assign you a small locker to store your belongings and any food you bring
for the day. You will also be given two 8 cm × 11 cm laminated writing surfaces, pens, and
erasers for note taking and for recording your test Candidate Identification Number (CIN).
You must return these materials after the examination. Note that you are not allowed to write
on these until you enter the CIN number in the computer. Testing centers are monitored by
audio and video surveillance equipment, and minimum of 2 surveillance rounds by the exam
monitor per hour. Each time you enter the testing room, you will have to undergo a screening
process to ensure that you are not bringing in personal items.
You should become familiar with a typical question screen. A window to the left displays
all the questions in the block and shows you the unanswered questions (marked with an “i”).
Some questions will contain figures, color illustrations, audio, or video adjacent to the
question. Although the contrast and brightness of the screen can be adjusted, there are no
other ways to manipulate the picture (eg, zooming or panning). Larger images are accessed
with an “exhibit” button. You can also call up a window displaying normal lab values. You
may mark questions to review at a later time by clicking the check mark at the top of the
screen. The annotation feature functions like the provided dry-erase sheets and allows you to
jot down notes during the examination. Play with the highlighting/strike-out and annotation
features with the vignettes and multiple answers.
You should also do a few practice blocks to determine which tools will help you process
questions more efficiently and accurately. If you find that you are not using the marking,
annotation, or highlighting tools, then keyboard shortcuts can be quicker than using a
mouse. Headphones are provided for listening to audio and blocking outside noise.
Alternatively, you can bring soft earplugs to block excess noise. These earplugs must be
examined by Prometric staff before you can take them into the testing area.

KEY FACT
Keyboard shortcuts:
A–E—Letter choices.
Enter or space bar—Move to the next question.
Esc—Exit pop-up Lab and Exhibit windows.
Alt-T—Countdown and time-elapsed clocks for current session and overall test.

WHAT DOES THE CBT FORMAT MEAN FOR ME?

The CBT format is the same format as that used on the USMLE Step 1. If you are
uncomfortable with this testing format, spend some time playing with a Windows-based
system and pointing and clicking icons or buttons with a mouse.
The USMLE also offers students an opportunity to take a simulated test, or practice
session, at a Prometric center. The session is divided into three 1-hour blocks of up to 50
questions each. The approximately 127 Step 2 CK sample test items that are available on the
USMLE Web site (http://www.usmle.org) are the same as those used at CBT practice
sessions. No new items are presented. The cost is about $75 for US and Canadian students
but is higher for international students. Students receive a printed percent-correct score after
completing the session. No explanations of questions are provided. You may register for a
practice session online at http://www.usmle.org.
The National Board of Medical Examiners (NBME) provides another option for students
to assess their Step 2 CK knowledge with the Comprehensive Clinical Science Self-
Assessment (CCSSA) test. This test is available on the NBME Web site for $60, which will
display at the end of the exam all of the questions that you answered incorrectly. The current
versions of the test also have answer explanations. The content of the CCSSA items
resembles that of the USMLE Step 2 CK. After you complete the CCSSA, you will be given
a performance profile indicating your strengths and weaknesses. This feedback is intended
for use as a study tool only and is not necessarily an indicator of Step 2 CK performance. For
more information on the CCSSA examination, visit the NBME’s Web site at
http://www.nbme.org, and click on the link for “Students and Residents.”

HOW DO I REGISTER TO TAKE THE EXAMINATION?

Information on the Step 2 CK exam’s format, content, and registration requirements are
found on the USMLE Web site. To register for the examination, students/graduates of
accredited schools in the United States and Canada can apply online at the NBME Web site
(http://www.nbme.org), whereas students/graduates of non-US/Canadian schools should
apply through the Educational Commission for Foreign Medical Graduates (ECFMG)
(https://iwa2.ecfmg.org). A printable version of the application is also available on these
sites.
The preliminary registration process for the USMLE Step 2 CK exam is as follows:
 Complete a registration form and send your examination fees to the NBME (online) for
students in US/Canada medical schools, and to the ECFMG (online) for international
medical students. The fees payable are outlined in Table 1.1.

TABLE 1.1 Exam Fees for the USMLE Step 2 CK

Select a 3-month block in which you wish to be tested (eg, June/July/August).

Attach a passport-type photo to your completed application form.
Complete a Certification of Identification and Authorization form. This form must be
signed by an official at your medical school such as from the registrar’s office (if you are a
student) or a notary public (if you have graduated) to verify your identity. It is valid for 5
years, allowing you to use only your USMLE identification number for future
transactions.
Send your certified application form to the NBME for processing. Applications may be
submitted more than 6 months before the test date, but examinees will not receive their
scheduling permits until 6 months prior to the eligibility period.
The NBME will process your application within 4–6 weeks and will send you a slip of
paper that will serve as your scheduling permit.
Once you have received your scheduling permit, decide when and where you would like to
take the examination. For a list of Prometric locations nearest you, visit
https://www.prometric.com.
Call Prometric’s toll-free number or visit https://www.prometric.com to arrange a time to
take the examination.
The Step 2 CK is offered on a year-round basis except for the first 2 weeks in January. For
the most up-to-date information on available testing days at your preferred testing location,
refer to http://www.usmle.org.
The scheduling permit you receive from the NBME will contain the following important
information:

Your USMLE identification number.

The eligibility period during which you may take the examination.
Your “scheduling number,” which you will need to make your examination appointment
with Prometric.
Your CIN, which you must enter at your Prometric workstation in order to access the
examination.

Prometric has no access to the codes and will not be able to supply these numbers, so do
not lose your permit! You will not be allowed to take the Step 2 CK unless you present your
permit along with an unexpired, government-issued photo identification that contains your
signature (eg, driver’s license, passport). Make sure the name on your photo ID exactly
matches the name that appears on your scheduling permit.

KEY FACT
Because the Step 2 CK examination is scheduled on a “first-come, first-served” basis, you
should be sure to call Prometric as soon as you receive your scheduling permit.

WHAT IF I NEED TO RESCHEDULE THE EXAMINATION?

You can change your date and/or center within your 3-month period by contacting Prometric
if space is available. When you reschedule, a fee may apply (Table 1.2).

TABLE 1.2 Rescheduling Fees Payable to Prometric for USMLE Step 2 CK (1 Jan, 2022)

If you need to reschedule outside your initial 3-month period, you can apply for a single 3-
month extension (eg, April/May/June can be extended through July/August/September) after
your eligibility period has begun. For other rescheduling needs, you must submit a new
application along with another application fee.

WHAT ABOUT TIME?

Time is of special interest on the CBT examination. The following is a breakdown of the
examination schedule:

The computer will keep track of how much time has elapsed during the examination.
However, the computer will show you only how much time you have remaining in a block.
Therefore, it is up to you to determine if you are pacing yourself properly.
The computer will not warn you if you are spending more than the 45 minutes allotted for
break time. The break time includes not only the usual concept of a break—when you leave
the testing area—but also the time it takes for you to make the transition to the next block,
such as entering your CIN or even taking a quick stretch. If you do exceed the 45-minute
break time, the time to complete the last block of the test will be reduced. However, you
can elect not to use all of your break time, or you can gain extra break time either by skipping
the tutorial or by finishing a block ahead of the allotted time.

SECURITY MEASURES

Smile! The USMLE uses a check-in/check-out process that includes electronic capture of
your fingerprints and photograph. Fingerprints from a finger on each hand will be used for
this process. These measures are intended to increase security by preventing fraud, thereby
safeguarding the integrity of the examination. These procedures also decrease the amount of
time needed to check in and out of the examination throughout the day, thereby maximizing
your break time. However, you still need to sign out and sign in with the Test Center Log
when exiting and entering the testing area.

IF I LEAVE DURING THE EXAMINATION, WHAT HAPPENS TO MY

SCORE?

You are considered to have started the examination once you have entered your CIN onto the
computer screen, but to receive an official score, you must finish the entire examination. This
means that you must start and either finish or run out of time for each block of the
examination. If you do not complete all of the question blocks, your examination will be
documented on your USMLE score transcript as an incomplete attempt, but no actual score
will be reported.
The examination ends when all blocks have been completed or time has expired. As you
leave the testing center, you will receive a written test completion notice to document your
completion of the examination.

WHAT TYPES OF QUESTIONS ARE ASKED?

The Step 2 CK is an integrated examination that tests understanding of normal conditions,

disease categories, and physician tasks. Almost all questions on the examination are case
based. Some questions will involve interpreting a study or drug advertisement. A substantial
amount of extraneous information may be given, or a clinical scenario may be followed by a
question that could be answered without actually requiring that you read the case. It is your
job to determine which information is superfluous and which is pertinent to the case at hand.
Content areas include internal medicine, OB/GYN, pediatrics, preventive services,
psychiatry, surgery, and other areas relevant to the provision of care under supervision (see
Tables 1.3, 1.4, and 1.5).

TABLE 1.3 Exam Content Specification per Discipline

TABLE 1.4 Exam Content Specification per System
TABLE 1.5 Exam Content Specification per Physician Tasks/Competencies
 Most questions on the examination have a single best-answer format. The part of the
vignette that actually asks the question—the stem—is usually found at the end of the scenario
and generally relates to the physician task. From student experience, there are a few stems
that are consistently addressed throughout the examination:

What is the most likely diagnosis? (40%)

Which of the following is the most appropriate initial step in management? (20%)
Which of the following is the most appropriate next step in management? (20%)
Which of the following is the most likely cause of…? (5%)
Which of the following is the most likely pathogen…? (3%)
Which of the following would most likely prevent…? (2%)
Other (10%)

Additional examination tips are as follows:

Note the age and race of the patient in each clinical scenario. When ethnicity is given, it is
often relevant. Know these well (see high-yield facts), especially for more common
diagnoses.
 Be able to recognize key facts that distinguish major diagnoses.
Questions often describe clinical findings rather than naming eponyms (eg, they cite
“audible hip click” instead of “positive Ortolani sign”).
Questions about acute patient management (eg, trauma) in an emergency setting are
common.

The cruel reality of the Step 2 CK examination is that no matter how much you study,
there will still be questions you will not be able to answer with confidence. If you recognize
that a question cannot be solved in a reasonable amount of time, make an educated guess and
move on; you will not be penalized for guessing. Also bear in mind that some of the USMLE
questions are “experimental” and will not count toward your score.

HOW LONG WILL I HAVE TO WAIT BEFORE I GET MY SCORES?

The USMLE reports scores 3–4 weeks after the examinee’s test date. During peak periods,
however, as many as 6 weeks may pass before reports are scored. This usually includes
scheduled delays after the first two weeks of the year in January when the scores may get
delayed up to March. Official information concerning the time required for score reporting is
posted on the USMLE Web site, http://www.usmle.org and recent changes may need to be
checked every testing session.

HOW ARE THE SCORES REPORTED?

Like the Step 1 score report, your Step 2 CK report includes your pass/fail status, a numeric
score, and a performance profile organized by discipline and disease process (see Fig. 1.1).
The score is a 3-digit scaled score based on a predefined proficiency standard. The current
required passing score is 214. This score requires answering 60–70% of questions correctly.
Any adjustments in the required passing score will be available on the USMLE Web site.
FIGURE 1-1. Sample score report—front page.
FIGURE 1-1. Sample score report—back page.

DEFINING YOUR GOAL

Step 2 CK scores are becoming increasingly used for residency selection. The amount of time
spent in preparation for this examination varies widely among medical students. Possible
goals include the following:

Beating the mean. This signifies an ability to integrate your clinical and factual
knowledge to an extent that is superior to that of your peers (around 247 for recent
examination administrations). Others redefine this goal as achieving a score 1 standard
 deviation above the mean (usually in the range of 250–260). Highly competitive residency
programs may use your Step 1 and Step 2 scores (if available) as a screening tool or as a
selection requirement. International medical graduates should aim to beat the mean, as
USMLE scores are likely to be a selection factor even for less competitive US residency
programs.
Acing the exam. Perhaps you are one of those individuals for whom nothing less than the
best will do—and for whom excelling on standardized examinations is a source of pride
and satisfaction.
Evaluating your clinical knowledge. In many ways, this goal should serve as the ultimate
rationale for taking the Step 2 CK, as it is technically the reason the examination was
initially designed. The case-based nature of the Step 2 CK differs significantly from the
more fact-based Step 1 examination in that it more thoroughly assesses your ability to
recognize classic clinical presentations, deal with emergent situations, and follow the step-
by-step thought processes involved in the treatment of particular diseases.
Preparing for internship. Studying for the USMLE Step 2 CK is an excellent way to
review and consolidate all of the information you have learned in preparation for
internship.

Matching statistics, including examination scores related to various specialties, are available
at the National Resident Matching Program Web site at https://www.nrmp.org under “Data
and Reports.”

WHEN TO TAKE THE EXAM

The second most important thing to do in your exam preparation is to decide when to take the
examination. With the CBT, you now have a wide variety of options regarding when to take
the Step 2 CK. Here are a few factors to consider:

The nature of your objectives, as defined earlier.

The specialty to which you are applying. An increasing number of residency programs
are viewing the Step 2 CK as an integral part of the residency application process. Several
research publications demonstrate the increasing importance placed on this examination
by residency directors. Some programs are now requiring the Step 2 CK score in order to
rank candidates for a residency position. It is therefore in the best interest of candidates to
have this examination done in time for scores to be available for the residency application.
Taking the examination in June or July ensures that scores will be available for the Match
period that begins in September. Some programs, however, will accept scores after the
application process starts. Check with programs in your desired specialty to determine
when to take the exam.
Prerequisite to graduation. If passing the USMLE Step 2 CK is a prerequisite to
graduation at your medical school, you will need to take the examination in the fall or
winter at the latest.
Proximity to clerkships. Many students feel that the core clerkship material is fresher in
their minds early in the fourth year, making a good argument for taking the Step 2 CK
earlier in the fall.
The nature of your schedule.
Considerations for MD/PhD students. The dates of passing the Step 1, Step 2, and Step
3 examinations should occur within a 7-year period. However, the typical pathway for
MD/PhD students consists of 2–3 years of preclinical (and sometimes clinical) work in
 medical school, 3–4 years of graduate work with research, and finally returning to medical
school for clinical work. MD/PhD students typically exceed the 7-year limit. Depending
on the state in which licensure is sought, such students may need to petition their licensure
body for an exception to this rule.
Considerations for International Medical Graduates. A passing score on the Step 2 CK
is required to qualify for ECFMG certification which is necessary to match. It is generally
recommended to take the Step 2 CK early enough to obtain ECFMG certification before
interview season is completed, ideally even before applications are reviewed by programs.

KEY FACT
The Step 2 CK is an opportunity to consolidate your clinical knowledge and prepare for
internship.

HOW WILL THE STEP 2 CK SCORE AFFECT MY MATCH?

Since Step 1 is now being reported as pass or fail, it is expected that the Step 2 CK score may
take on more importance. Programs receive hundreds if not thousands of applications yearly,
and they rely on certain objective metrics to select applicants to interview. Having a
competitive Step 2 CK score will not guarantee a match at a top choice program but it will
strengthen your application. It is one of many elements that programs will consider.

STUDY RESOURCES

QUALITY CONSIDERATIONS

Although an ever-increasing number of USMLE Step 2 CK review books and software

packages are available on the market, the quality of these materials is highly variable (see
Section 3). Some common problems include the following:

Some review books are too detailed to be reviewed in a reasonable amount of time or
cover subtopics that are not emphasized on the examination (eg, a 400-page
anesthesiology book).
Many sample question books have not been updated to reflect current trends on the Step 2
CK.
Many sample question books use poorly written questions, contain factual errors in their
explanations, give overly detailed explanations, or offer no explanations at all.
Software for boards review is of highly variable quality, may be difficult to install, and
may be fraught with bugs.

CLINICAL REVIEW BOOKS

Many review books are available, so you must decide which ones to buy by carefully
evaluating their relative merits. Toward this goal, you should compare different opinions
from other medical students; read the reviews and ratings in Section 3 of this guide, and
examine the various books closely in the bookstore. Do not worry about finding the “perfect”
book, as many subjects simply do not have one.
 KEY FACT
The best review book for you reflects the way you like to learn. If a given review book is not
working for you, stop using it no matter how highly rated it may be.

There are two types of review books: those that are stand-alone titles and those that are
part of a series. Books in a series generally have the same style, and you must decide if that
style is helpful for you and optimal for a given subject.

TEST BANKS

A test bank can serve multiple functions, including the following:

Provide information about strengths and weaknesses in your fund of knowledge.

Add variety to your study schedule.
Serve as the main form of study.
Improve test-taking skills.
Familiarize examinees with the style of the USMLE Step 2 CK examination.

Students report that some test banks have questions that are, on average, shorter and less
clinically oriented than those on the current Step 2 CK exam. Step 2 CK questions demand
fast reading skills and the application of clinical facts in a problem-solving format. Approach
sample examinations critically, and do not waste time with low-quality test bank questions
until you have exhausted better sources.

KEY FACT
Use test banks to identify concepts and areas of weakness, not just facts that you missed.

After you have taken a practice test, try to identify concepts and areas of weakness, not
just the facts that you missed. Use this experience to motivate your study and to prioritize the
areas in which you need the most work. Analyze the pattern of your responses to questions to
determine if you have made systematic errors in answering questions. Common mistakes
include reading too much into the question, second-guessing your initial impression, and
misinterpreting the question.

TEXTS AND NOTES

Most textbooks are too detailed for high-yield boards review and should be avoided. When
using texts or notes, engage in active learning by making tables, diagrams, new mnemonics,
and conceptual associations whenever possible. If you already have your own mnemonics, do
not bother trying to memorize someone else’s. Textbooks are useful; however, they are best
used to supplement incomplete or unclear material.

COMMERCIAL COURSES

Commercial preparation courses can be helpful for some students, as they offer an effective
way to organize study material. However, multiweek courses are costly and require
significant time commitment, leaving limited time for independent study. Also note that some
commercial courses are designed for first-time test takers, students who are repeating the
examination, or international medical graduates.

NBME/USMLE PUBLICATIONS

We strongly encourage students to use the free materials provided by the testing agencies and
to study the following NBME publications:

USMLE Step 2 Clinical Knowledge (CK): Content Description and General

Information. This publication provides you with nuts-and-bolts details about the
examination (included on the Web site http://www.usmle.org; free to all examinees).
USMLE Step 2 Clinical Knowledge (CK): Sample Test Questions. This is a PDF version
of the test questions and test content also found at http://www.usmle.org under “Prepare
for your exam”.
USMLE Web site (http://www.usmle.org). In addition to allowing you to become familiar
with the CBT format, the sample items on the USMLE Web site provide the only
questions that are available directly from the test makers. Student feedback varies as to the
similarity of these questions to those on the actual exam, but they are nonetheless
worthwhile to know.

TEST-DAY CHECKLIST

THINGS TO BRING WITH YOU TO THE EXAM

Be sure to bring your scheduling permit as a hard copy and a photo ID with signature.
(You will not be admitted to the examination if you fail to bring your permit, and
Prometric will charge a rescheduling fee.)
Remember to bring lunch, snacks (for a little “sugar rush” on breaks), and fluids
(including a caffeine-containing drink if needed).
Bring clothes to layer to accommodate temperature variations at the testing center.
Earplugs will be provided at the Prometric center.
Remove all jewelry (eg, earrings, necklaces) before entering the testing center.
Bring acetaminophen/ibuprofen, in case you develop a headache during the exam.
Check the USMLE Web site (http://www.usmle.org/test-accommodations/PIEs.html) for
the personal item exception list to see if a medical device or personal item that you need is
allowed into the testing facility without submitting a special request.
If you have a medical condition that requires use of an item NOT on the above list,
contact the NBME personal item exception (PIE) coordinator at
disabilityservices@NBME.org or (215) 590-9700 for additional information on how to
request a personal item exception.
If you need test accommodation for one of the following reasons: assistance with keyboard
tasks, audio rendition, extended testing time, additional break time, you need to fill in a
request by going to the website https://www.usmle.org/step-exams/test-accommodations

TESTING AGENCIES
National Board of Medical Examiners (NBME)
Department of Licensing Examination Services
3750 Market Street
Philadelphia, PA 19104-3102
Customer Service: (215) 590-9700, Front Desk: (215) 590-9500
Fax: (215) 590-9460
http://www.nbme.org/contact/
e-mail: webmail@nbme.org

USMLE Secretariat
3750 Market Street
Philadelphia, PA 19104-3190
(215) 590-9700
Fax: (215) 590-9460
http://www.usmle.org
e-mail: webmail@nbme.org

Educational Commission for Foreign Medical Graduates (ECFMG)

3624 Market Street
Philadelphia, PA 19104-2685
(215) 386-5900
Fax: (215) 386-9196
http://www.ecfmg.org/contact.html
e-mail: info@ecfmg.org

Federation of State Medical Boards (FSMB)

400 Fuller Wiser Road, Suite 300
Euless, TX 76039
(817) 868-4041
Fax: (817) 868-4098
http://www.fsmb.org/contact-us
e-mail: usmle@fsmb.org
SECTION 2
DATABASE OF HIGH-YIELD FACTS
Cardiovascular

Dermatology

Endocrinology

Epidemiology

Health Systems Science

Gastrointestinal

Hematology

Musculoskeletal

Neurology

Obstetrics

Gynecology

Pediatrics

Psychiatry

Pulmonary

Renal/Genitourinary

Multisystem

Rapid Review

HOW TO USE THE DATABASE

The 11th edition of First Aid for the USMLE Step 2 CK contains a revised and expanded
database of clinical material that student authors and faculty have identified as high yield for
boards review. We have organized information according to subject matter, whether medical
specialty (eg, Cardiovascular, Renal) or high-yield topic (eg, Health Systems Science). Each
subject then branches out into smaller subsections of related facts.
Individual facts appear in a logical fashion, from basic definitions and epidemiology to
history/physical exam, diagnosis, and treatment. Lists, mnemonics, pull quotes, vignette flash
cards, and tables help the reader form key associations. In addition, we have interspersed
color and black-and-white photos throughout the text. At the end of Section 2, we also feature
a Rapid Review chapter consisting of key facts and classic associations that can be studied a
day or two before the exam.
 The content contained herein is useful primarily for the purpose of reviewing material
already learned. The information presented is not ideal for learning complex or highly
conceptual material for the first time.
The Database of High-Yield Facts is not meant to be comprehensive. Use it to
complement your core study material, not as your primary study source. We have condensed
and edited the facts and notes to emphasize essential material. Work with the material, add
your own notes and mnemonics, and recognize that not all memory techniques work for all
students.
We update material to keep current with new trends in boards content, as well as to expand
our database of high-yield information. However, we must note that our database inevitably
does not include many other high-yield entries and topics.
We actively encourage medical students and faculty to submit entries and mnemonics so
that we may enhance the database for future students. We also solicit recommendations for
additional study tools that may be useful in preparing for the exam, such as diagrams, charts,
and computer-based tutorials (see How to Contribute, p. xi).

DISCLAIMER

The entries in this section reflect student opinions of what is high yield. Owing to the diverse
sources of material, we have made no attempt to trace or reference origins of individual
entries. We have regarded mnemonics as essentially in the public domain. We will gladly
correct errors and omissions if brought to the attention of the authors, either through the
publisher or directly by email.
HIGH-YIELD FACTS IN
CARDIOVASCULAR
Electrocardiogram

Cardiac Physical Exam

Arrhythmias
BRADYARRHYTHMIAS AND CONDUCTION ABNORMALITIES
TACHYARRHYTHMIAS

Cardiac Life Support Basics

Congestive Heart Failure

CLASSIFICATION
SYSTOLIC DYSFUNCTION/HEART FAILURE WITH REDUCED EJECTION FRACTION
HEART FAILURE WITH PRESERVED EJECTION FRACTION

Cardiomyopathy
DILATED CARDIOMYOPATHY
HYPERTROPHIC CARDIOMYOPATHY
ARRHYTHMOGENIC RIGHT VENTRICULAR DYSPLASIA
RESTRICTIVE CARDIOMYOPATHY
SECONDARY CARDIOMYOPATHY
OTHER CARDIOMYOPATHIES

Coronary Artery Disease

ANGINA PECTORIS
PRINZMETAL (VARIANT) ANGINA

Acute Coronary Syndromes

UNSTABLE ANGINA/NON-ST-SEGMENT ELEVATION MYOCARDIAL INFARCTION
ST-SEGMENT ELEVATION MYOCARDIAL INFARCTION
CAROTID ARTERY STENOSIS

Dyslipidemia

Hypertension
PRIMARY (ESSENTIAL) HYPERTENSION
SECONDARY HYPERTENSION
HYPERTENSIVE EMERGENCY/URGENCY

Pericardial Disease
ACUTE PERICARDITIS
CONSTRICTIVE PERICARDITIS
PERICARDIAL EFFUSION
CARDIAC TAMPONADE

Endocarditis
Another random document with
no related content on Scribd:
 CHAPTER XIII
THE AMERICAN COLLEGE AT ASYUT

At Asyut up the Nile valley about as far south of the Mediterranean

as Washington is south of Buffalo, the United Presbyterians of the
United States have established a training college for young
Egyptians which is doing a wonderful work. I came from Cairo to see
it, winding my way in and out along the great river. The valley is
narrow above Cairo, being only from three to nine miles in width, so
that from the railroad I could see the yellow sand on both sides of the
green, watered strip. We were sometimes far out in the desert, and
sometimes moving in and out of the irrigated lands. We passed mud
villages which border the river and the larger canals. The date trees
hanging over them were loaded with honey-coloured fruit. Upper
Egypt has vast numbers of dates. There are in the whole country
something like eight million of these palms, which, at a rough
estimate, bring in one dollar annually for every tree.
Asyut is the largest city in Egypt south of Cairo. It is the capital of
this part of the Nile valley and the chief centre of its commerce and
trade. Before the railroad was built, caravans from the Sudan
brought great quantities of merchandise from Central Africa to Asyut
and transferred it to other camel trains bound for Tripoli, Cairo, or
Suez. The railroad now carries this trade, and the iron tracks have
been extended southward beyond the city of Khartum. The gap in
the railroad between Shellal and Wady Halfa is filled by steamers on
the river.
Asyut itself has many good buildings. Not far from the railroad
station are brick houses of two and three stories which would be
considered fine anywhere. They are owned by Copts, who started
life poor and have become millionaires. Most of the houses of the
city are Egyptian in character, flat-roofed buildings of one, two, and
three stories, facing the street. Many of them are new and
substantially built. The bazaars are far better than when first I visited
Asyut, and the town, which has now over fifty thousand people, is
double the size it was then.
The Asyut Training College is a missionary institution, but it gives
a good general education. It is run upon broad lines and has among
its students Mohammedans, Copts, and other Christians. This is
about the only one of our Protestant denominations that is working
here, the other sects having apparently given up Egypt to it. This
Church has mission stations scattered throughout the Nile valley,
and schools not only in Lower and Upper Egypt but also in the
Sudan, and even on the borders of Abyssinia. There are more than
fifteen thousand boys now being taught in its various institutions. It is
surprising that a large part of the money that the mission is spending
upon education comes from the natives themselves. In one year
over one hundred thousand dollars was spent, of which almost
eighty thousand was subscribed by the Egyptians. Of the fifteen
thousand in the schools, more than thirteen thousand are paying for
tuition, so that the institutions are largely self-supporting. The
Egyptians of to-day have learned the value of modern school training
and are anxious to have their sons go to college. They want them
taught English and are willing to pay something in order that they
may get a good education.
I went through the college with its president, John Alexander, D.D.,
who has been in charge for almost a generation. To him it is largely
due that it is the most successful institution of its kind in northern
Africa. Dr. Alexander is by birth an Ohioan. He was educated at
Wooster University and shortly after he left there he came to Egypt.
He has lived here ever since and he knows the people and their
wants as well as any man. He says that the natives are thoroughly
alive to the advantages of modern education and that they could use
more schools and better facilities than either the government or the
mission can supply. He tells me that he has to refuse many
applications for entrance to the training school for lack of room and
that the college stands ready to erect new buildings as soon as it can
raise the money. It has already bought twenty acres of land at the
junction of the Nile and the great irrigating canal which runs from
here to the Faiyum, and it now needs only an appropriation for
additional buildings. My examination shows me that the institution is
ably and economically managed, and I know of no place where any
one of our rich men can better invest his surplus and have it pay big
dividends in a charitable way than right here.
This college is conducted on the dormitory plan. The majority of its
students live in the buildings and are continually under the eyes of
their professors. The training partakes somewhat of a military
character. The boys not only go to classrooms, but they have to
attend chapel, weekly prayer meeting, and Sunday-school. They are
also compelled to take part in college athletics. Twice a week they
must engage in football and tennis and every effort is made to
develop them as our boys are being developed. They study well and
do good work on track and football field.
I should like to show you these Egyptian boys as I saw them to-
day. There were seven hundred and thirty of them in the campus
when I went through—bright-eyed, dark-faced young fellows, ranging
in age from ten to twenty years and coming from every class of
Egyptian life. Some were Mohammedans, the fatalistic, sober
followers of the Prophet; others were Copts, having the bronze
faces, the high cheekbones, and the black eyes which mark them as
the descendants of those who oppressed the Israelites when
Pharaoh ruled. All the students wear red fezzes that extend about
eight inches above their heads and are kept on both in classroom
and chapel. They wear long gowns, often belted in at the waist, and
look more dignified than the college boy of America.
The students are of all classes and conditions. Many are working
their way through school. There are three scales of expense,
graduated according to the tables at which the boys eat. One class
has a table where all have knives and forks and the food furnished is
as good and as varied as can be found anywhere. This is for the
rich, who can pay as much as one hundred dollars a year for room
and board. The second table is filled by students who can afford to
pay only fifty dollars a year, and the third by those who cannot spare
more than thirty-five dollars a year. Of the students of the first class
only two or three live in one room, and of the second from four to
eight, while those of the third are lodged in large rooms
accommodating twenty or thirty, each of whom has his own bed,
which he furnishes himself.
The boys of the second class have simpler food than those of the
first and eat with their fingers in native style. Those of the third class
have still cheaper food, but in all cases it is as good as or better than
the boys get at home, for here they have wheat bread and meat at
least once a week.
A pupil must pay a minimum fee of one dollar a session in money,
but as far as is possible he may work out the rest of his expenses.
The average tuition is only ten dollars a year.
This big American college is doing so much good for Egypt that it
is commended by the government and by every tourist who learns
anything of Egyptian affairs. It was founded in 1865 and its first work
was done in a donkey stable with five students. Dr. Hogg, a Scotch
missionary, then constituted the entire faculty. It has now seven large
buildings, which cover two acres, built around a campus shaded by
date palms, and among its professors are graduates from the best of
our colleges, including men from Princeton and Yale. It has not far
from one thousand students, who come from all parts of Egypt and
even from the Sudan and the other countries of northern Africa.
These youths represent more than one hundred towns throughout
the Nile valley and the graduates are scattered all over Egypt. Many
of them are influential business men; some are lawyers, doctors, and
teachers, and others are government officials. The graduates of the
school are anxiously sought by the government as clerks. Their
training is considered better than that of the Mohammedan colleges,
where little except the Koranic law is taught, and they are found to
be trustworthy and of high moral character.
 From Asyut come the famous metal shawls of silver or gold on black or white.
The bazaar is over a mile long, and before the days of railroads was the trading
place of caravan merchants from the south and buyers from the north.
 The Egyptian complained that under British rule not enough of his tax money
was spent on native schools. Only twelve per cent of the men and less than two
per cent of the women can read and write.
 CHAPTER XIV
THE CHRISTIAN COPTS

Many of the students of the Asyut Training College are Copts.

They belong to that class of natives who are said to be the only
direct descendants of the ancient Egyptians. The Copts are more
intelligent than the Mohammedans. They take naturally to education,
and about four Copts go to school to every one Moslem. They are
also shrewd clerks and, many of them being educated men, they
have a large number of the minor government appointments. The
British, however, tried to be partial to the Mohammedans because
they form the great majority of the population, and to give them
offices in preference to the Copts. During Lord Cromer’s
administration, a committee of Copts objected to his crowding out
these native Christians and giving their places to the followers of the
Prophet. Applicants for any government posts or for training schools
have to give their names, and the Copts can thus be easily
distinguished from the Mohammedans. The Christian boys get their
names from the characters of the Bible, while the names of the
Mohammedan boys come from the Koran. When the examination
papers were turned in, the judges were said to have been instructed
to mark down all those bearing such names as Moses and Jacob,
Peter and Paul, and to recommend for appointment the
Mohammeds, the Alis, and the Hassans. The British governing class
considered that the Copt and the Mussulman, being alike natives,
were generally not capable of holding any responsible position. And
now it is said also that it would be bad policy to put the Christian
Egyptian over the Moslem.
The Copts are the sharpest business men of Egypt. It is a
common saying here that no Jew can compete with them and they
have driven the Jews out of the upper part of the Nile valley. In Asyut
there are a number of rich Copts who have become Protestant
Christians, and some of these men are very charitable. One, for
instance, built a Protestant native church, after a visit to England,
where he was much impressed by Westminster Abbey. Upon his
return he said he was going to build a church for Asyut on the plan of
Westminster. The missionaries advised him to make his building
rectangular instead. But no! it must be Westminster Abbey or
nothing; and the result is a great T-shaped structure of wood with a
long hall in the centre and wings at the end. The church cost about
twenty thousand dollars and will seat one thousand five hundred
people. I attended it last Sunday and found the main hall filled with
dark-faced men in gowns and fezzes. The wings were shut off by
curtains, but I was seated in front and so near one side that I could
look through the cracks. Each wing was filled with women clad in
black balloon-like garments and veiled so as to conceal all but their
eyes. Yet a few women wore European clothes and French hats,
showing how the new civilization is coming in.
Another rich Copt established two large primary schools at Asyut,
one for boys and the other for girls. In the boys’ school there are five
hundred and fifty pupils, and in that for the girls more than two
hundred. These schools are taught by native Protestants, and not
one cent of American money is spent upon them.
I am much interested in the Copts. There are about eight hundred
and fifty thousand of them in the country. They look very much like
the Egyptians and dress in about the same fashion. The women veil
their faces, both in public and private, and until about a generation
ago the unmarried women wore white veils.
These people believe in the ancient form of Christianity. They are
indeed the same Christians that Egypt had in Roman times. They
claim St. Mark as their first patriarch and say that he preached the
Gospel at Alexandria and started the sect there. They have a
patriarch to-day, with twelve bishops and a large number of priests
and deacons under him. They have their monks and nuns, who lead
rigorous lives; they fast and pray, wear shirts of rough wool, and live
upon vegetables.
 The Copts believe in God the Father, and in the Lord Jesus Christ
as his Son. They believe in prayer, and like the Mohammedans, pray
five or six times a day. They begin their devotions at daybreak and
are supposed to make five separate petitions before dark and to
close with a final prayer at midnight. As they pray they recite a Psalm
or chapter from the Gospel, and some have rosaries of beads on
which they count forty-one times, saying the words:
“Oh! my Lord, have mercy.”
After this they end with a short petition. They wash before praying,
and worship with their faces turned toward the east. They believe in
baptism and think that an unbaptized child will be blind in the next
life. They have fixed times for baptism, a boy baby being baptized at
forty days and a girl baby at eighty days after birth.
There are Coptic churches all over Egypt, and I find several here
at Asyut. The church usually consists of four or five buildings
surrounding a court, and includes a chapel, a hall of worship, the
residence of the bishop, and other rooms. The sanctuary proper
contains an altar separated from the rest of the rooms by a screen,
covered by a curtain with a cross worked upon it. Before this curtain
stand the priest, the choir, and the more influential members of the
congregation. Beyond them is a lattice work, on the other side of
which are the less important men, with the women in the rear.
Everyone is expected to take off his shoes when he comes in, and in
many of the halls of worship, as there are no seats, the people lean
upon sticks while the sermon is preached. The service begins at
daybreak and often lasts four or five hours, so that it is no wonder
that some of the members of the congregation fall to chatting during
the preaching, and discuss business and social matters.
I am told that the Copts do not trust their wives any too much.
Each has but one, but he does not make her his confidante, never
tells her his business secrets, and pays her much less respect than
the native Protestant Christians show their wives. He seldom sees
his wife until he is married and is forbidden by his religion to marry
any one but a Copt. As among the Mohammedans, marriages are
usually a matter of business, with a dowry bargained for beforehand.
The favourite wedding time is Saturday night, and the marriage
feasts last through the following week. When the marriage contract is
made all the parties to it say the Lord’s Prayer three times. Before
the ceremonies are completed the bride and the bridegroom go
separately to church where the Eucharist is administered to them.
Just before her marriage, the bride is given a steam bath, and her
finger nails and toe nails are stained red with henna. Immediately
before the ceremony she sends the groom a suit of clothing, and a
woman from her house goes to him to see that it is delivered
properly and that he is taken to the bath. This provision ensures that
both start the married life comparatively clean.
 CHAPTER XV
OLD THEBES AND THE VALLEY OF THE KINGS

All day long I have been wandering about through the tombs of the
kings who ruled Egypt three or four thousand years ago. I have gone
into the subterranean chambers which the Pharaohs dug out of the
solid rocks for their burial vaults, and I have visited the tombs of
kings older than they. The last resting places of more than fifty of
these monarchs of early Egypt have been discovered, and the work
is still going on. Some of the best work of excavation all along the
Nile valley is being done by Americans. While at Cairo I found the
money of Harvard College and the Boston Museum uncovering the
cemeteries of the nabobs and paupers who were buried at the time
of King Cheops under the shadow of the Great Pyramid of Gizeh.
The Egyptian Exploration Fund, which is supported by Great Britain,
Canada, and the United States, has a small army of workmen
operating near Luxor, the University of Pennsylvania has made
important discoveries, and a large part of the uncovering of the
valley in which these royal tombs lie has been done by the
Americans.
The Egyptologists of the Metropolitan Museum in New York and
Lord Carnarvon of England are responsible for some of the most
remarkable finds of this generation. During my trip of to-day I met a
young archæologist, in charge of the American operations, who
showed me through the tombs of the kings and explained the
symbols and pictures on the walls. I went to that part of the valley
where the excavation is now going on and took pictures of a gang of
one hundred and fifty Egyptian men and boys who are working there.
Let me describe the place that the ancient Egyptian monarchs
selected for their burials, the Valley of the Kings. They wanted to
hide their remains so that posterity could never find them, and to
cover them so that future generations would have no idea that they
and their treasures lay beneath. Our cemeteries are chosen for the
beauty of their surroundings. We like to turn up our toes to the
daisies and to have leafy trees whisper a requiem over our heads.
The old Egyptian kings wanted to lie under the sterile desert waste
and chose a region about as far up the Nile valley as Cleveland is
inland from the Atlantic, and fully six miles back from the fertile strip
on which their people lived. I can imagine no place more dreary. At
this point the Nile is walled on the west by limestone mountains. As
far as the moisture reaches, the valley is the greenest of green, but
beyond lies a desert as brown as any part of the Sahara. There is
not a blade of grass, nor a sprig of vegetation of any kind. There is
nothing but sand and arid mountains, the latter almost as ragged in
outline as the wildest parts of the Rockies. Some of their stony sides
are built up in great precipices while in other places there are fort-like
bluffs and similar convulsions of nature.
 Rameses II, the greatest egoist of Egyptian history, covered his dominions with
his monuments and inscriptions. Standing against the colossal leg of this statue is
the figure of his sister, Nefertari, who was also his favourite wife.
 Hatshepsut, the Queen Elizabeth of Egypt, reserved for herself the best space in
the splendid temple-tomb at Deir-el-Bahari, tucking away in small quarters the
bodies of her male relatives. A brother later retaliated by removing her name from
the inscriptions.

Every great temple in ancient Egypt had its sacred lake, where the worshippers
performed their ablutions and the religious processions of boats took place. The
banks of this lake at Karnak were originally lined with smooth-cut stone.

To visit this valley one first comes to Luxor, which is very nearly on
the site of Old Thebes, the capital of Egypt in the days of its most
brilliant past. The ancient city lay on both sides of the Nile, but Luxor
is on the east bank. Crossing the river in a ferry boat, I rode for an
hour or more through the desert before I came into the Valley of the
Kings. My donkey boy was a good one and his donkeys were young.
His name was Joseph, and the brute I bestrode was called
“Gingerbread.”
We traversed green fields, winding in and out along the canals,
until we came to the desert and entered a gorge walled with rocks of
yellow limestone and a conglomerate mixture of flint and limestone
of curious formation. The gorge shows evidences of having been cut
out by some mighty stream of the past. There are masses of débris
along the sides, and the way is rough except on the road which has
been made by the explorers.
Looking at the valley from the Nile one would not suppose it to be
anything other than a desert ravine, so I did not at first realize that it
was a cemetery. There are neither gravestones nor monuments, for
the kings obliterated every sign that might indicate their burial
places. They dug out great chambers under the bed of this dried-up
river and built cisterns for their proper drainage, but when they had
finished they did all they could to make the spot look as it was in
nature. For this reason their tombs remained for ages untouched and
unknown.
From time to time, however, one or another was discovered.
Strabo, the Greek geographer, who was alive when Christ was born,
speaks of forty of them as being worthy of a visit, and others are
mentioned by subsequent writers. Later they were again lost, and
not until in our generation when some Arabs began to sell curious
antiquities was it learned that the tombs had been rediscovered and
were being rifled by these vandals. The archæologists then went to
work on their explorations which resulted in the opening up of tomb
after tomb, until we now have what might almost be called a
subterranean city of the dead in the heart of the desert.
 The tombs are nothing like our burial vaults. They are large rooms
cut out of the solid rock, with walls straight and smooth. They are
reached by many steps, going down inclined planes until they bring
one far below the surface of the valley and deep under the
mountains. Each king had his own tomb, which he decorated with
sketches and paintings representing the life of his time and the
achievements of his reign. The ceilings are beautiful. From some of
them the figures of gods and goddesses look down upon us. Others
are decorated with geometric designs in beautiful colours. In some,
men and women are carved in bas-relief out of the solid rock and
then coloured. Many of the scenes are religious, so that from them
the Egyptologist is able to learn what the people of that day believed.
The carvings show, too, how they lived when our remotest ancestors
were savages in the wilds of Europe and Asia.
The Americans have had remarkably good luck in their finds. One
of them was the tomb of the parents of Queen Tiy in which all the
objects were in as good condition as if they had been in a house just
closed for the summer. There were armchairs beautifully carved and
decorated with gold. The cushion on one of them was stuffed with
down and covered with linen perfectly preserved. In another part of
the chamber were two beds decorated with gold, while a light chariot
stood in a corner. But most wonderful of all was the discovery in this
tomb of a jar of honey, still liquid and still fragrant after thirty-three
hundred years.
In some of the tombs I saw the massive stone boxes in which lay
the mummies of the dead kings. I measured one ten feet long, six
feet wide, and eight feet high. It was hollowed out of a block of
granite, and would weigh many tons. That mighty burial casket was
cut out of the quarries of Aswan far above here, on the banks of the
Nile. It must have been brought down the river on a barge and
carried to this place. When it was finally on the ground it had to be
lowered into the vault. All these feats were done without modern
machinery. As I went through the tombs I saw several such caskets,
and the archæologist who guided me showed me the holes in the
stone walls of the entrance ways where beams had been put across
in order that ropes might be used to prevent these stone masses
from sliding too far when let down. It is a difficult job for us to handle
safes. One of these stone boxes would weigh as much as several
safes, yet the old Egyptians moved them about as they pleased.
Indeed, I venture to say that the civil engineers of the Pharaohs
could teach us much. All through this region there are enormous
monuments which it would puzzle the engineers of to-day to handle.
For instance, there are the Colossi of Memnon, the two mammoth
stone statues that sit upon pedestals in the Nile valley within a few
miles of where I am writing. Each is as high as a six-story building,
and the stone pedestals rise thirteen feet above the ground. As I
rode by them on my way home from the Valley of the Kings I climbed
up and ran a tape measure over their legs. Each leg is nineteen feet
from sole to knee. The feet are each over three yards in length, so
long that one would fill the box of a farm wagon from end to end, and
so wide that it could hardly be fitted within it. Each arm from finger
tips to elbow measures five yards, and the middle finger of each
hand is a yard and a half long. As I stood beside the pedestal, with
my feet on Gingerbread’s saddle, I could not reach the top.
These two colossal figures sit side by side on the edge of the Nile
valley with the desert mountains at their backs. They were set up in
honour of an Egyptian king who lived more than thirty-five centuries
ago. The temple he constructed behind them has now entirely
disappeared. The statues overlook green fields, and as I gazed at
the giant shapes I thought how they had watched the people sowing
and reaping through all these centuries.
Not far from these monuments are the ruins of the temple of
Rameses II, according to some authorities the Pharaoh who “would
not let the people go.” Among them I saw the remains of a statue of
that old king, once part of a structure at least sixty feet high. There is
no granite nearer here than in the quarries of Aswan, so this mighty
monument must have been cut there and brought down the Nile to
Thebes, a distance of one hundred and thirty-five miles.
Consider the obelisks which the Egyptians made at those quarries
and carried down the Nile to Thebes, to Cairo, and to Alexandria.
There are two of them still at this place. You may see them in the
great Temple of Karnak, which is not more than a twenty-minute walk
from Luxor. They weigh something like four hundred tons each, and
if they were broken up and loaded upon wagons it would take one
thousand six hundred horses to haul them. Each is a single block of
granite, and each was carried in that shape to this place. There are
inscriptions on the Deir-el-Bahari Temple here which show that these
two shafts were dug out of the quarries, covered with hieroglyphic
carvings, brought here, and put up all in the space of seven months.
I doubt whether our engineers could do such a job as quickly or as
well.
We thought it a wonderful work to bring the Alexandria obelisk
from Egypt to New York in the hold of a steamer. To load it a hole
had to be cut in the bow of the vessel and the pillar dragged through.
The Egyptian obelisk at Paris was carried across the Mediterranean
on a barge, while that which now stands in London was taken there
in an iron watertight cylinder which was shipped to Alexandria in
pieces and built around the column as it lay upon the shore. When
the great stone was thoroughly encased, the whole was rolled into
the sea and thus towed to London. After the huge monoliths were
landed, the modern engineers had great trouble to get them where
they wanted them. The New York obelisk was rolled along upon iron
balls running in iron grooves laid down for the purpose, while that of
London was hauled over greased ways to the place where it now
stands on the banks of the Thames.
The oldest temple of Egypt by five hundred years was unearthed
here by the agents of the Egyptian Exploration Fund. This lies near
the famous temple of Deir-el-Bahari, and in a valley which is a
branch of that of the tombs of the kings. When I visited it to-day the
excavators were at work, and the men in charge told me they had
great hopes of making valuable discoveries. It was with the
American representative of the Exploration Fund, that I went over the
temple. I met him at the little one-story house which forms the
laboratory and home of the foreign explorers, and had a chat with
the other members as to the progress of the work. A number of
specialists from Canada, England, and the United States, supported
by the fund, are superintending the Egyptians, who do the hard
labour. They have quite an army of men at work and have been
successful. Of what they find one half goes to the museum at Cairo
and the rest to the countries which subscribe to the fund in
proportion to the amount of their subscriptions. The chief money
from America has come from Boston, New York, Baltimore, and
Washington, so that our share of what is now being unearthed will go
to the museums of those cities.
More famous than this ancient temple itself is its shrine of the cow
goddess, Hathor, from which the noted statue was excavated by the
Egyptian Exploration Fund and taken to Cairo. I saw the place
whence it came and talked to the men who dug it out of the earth.
The statue, which is life-sized, is a perfect likeness of a beautiful cow
carved out of stone. It is reddish-brown in colour, with spots shaped
like a four-leaved clover. Traces still remain of the gold that once
covered the head, neck, and horns. The head is crowned with lotus
flowers and lotus stalks hang down each side the neck almost to the
ground. Beneath the head stands the dead king whom Hathor
protects, while the living king, whom she nourishes, kneels beneath
her form. That image was probably worshipped at the time the
Israelites were working in the valley of the Nile, and it may have
been after one like her that they modelled their calf of gold.
Near the site of this oldest temple are the ruins of the great temple
of Hatshepsut, the Queen Elizabeth of Egypt, who ruled fifteen
hundred years before Christ was born. Her epitaph says that “Egypt
was made to labour with bowed head for her.” The temple is really a
tomb-chapel in memory of the royalties buried there—her father, her
two brothers, and herself. Hatshepsut took most of the space,
however, and put the bodies of her male relatives into as small
quarters as she could. She called her temple “most splendid of all”
and covered its walls with engravings and paintings showing her
principal acts. Hers is a long record of kingly deeds. She discarded
the dress of a woman, wore the crown, attached an artificial beard to
her chin, and let it be known that she liked to be addressed as His
Majesty by her courtiers and subjects. The New Woman is
apparently as old as civilization itself!
 It was the work of Americans, again, that unearthed here the tomb
of the first great pacifist, Pharaoh Akhnaton, who reigned from 1375
to 1358 b.c. When he came to the throne Egypt, in the height of her
power, was mistress of the chief parts of the civilized world. But the
country was then ridden by the priesthood of Amon with its hosts of
gods and its degraded worship. According to the inscriptions which
have been deciphered young Akhnaton defied the priests of Amon
and declared his belief in one God, a “tender and merciful Father
and Mother of all that He had made,” the “Lord of Love,” the
“Comforter of them that weep.” It is thought that he was the Pharaoh
in Egypt when the Children of Israel came into the land and that the
One Hundred and Fourth Psalm in our Bible was written by him. He
did not believe that warfare or military conquests were consistent
with his creed and when revolts broke out in his Syrian provinces he
refused to fight, though his soldiers tried desperately hard to hold the
different people of his empire faithful to their king.
Breaking entirely with the priests, Akhnaton left Thebes and set up
his capital at Aton, one hundred and sixty miles south of Cairo on the
eastern bank of the Nile. He died at the age of twenty-eight, leaving
only daughters to succeed him. They reëstablished the court at
Thebes, the city of Aton was abandoned, and its temples and
palaces were left to crumble and decay.
I had thought of the Pharaoh who forced the Israelites to make
bricks without straw as living at Memphis, near where Cairo now
stands. The truth is, he had a great city there, but his capital and
favourite home was at Thebes, over four hundred and fifty miles
farther up the Nile valley. Thebes was one of the greatest cities of
antiquity. It covered almost as much ground as Paris does now and
is said to have had more than a million people. The metropolis had
walls so thick that chariots drawn by half-a-dozen horses abreast
could easily pass as they galloped along them. It had one hundred
gates, and temples and residences which were the wonder of the
world. Some of the houses were five stories high, the skyscrapers of
those days. The riches of Thebes were increased by the successful
wars which the kings waged with other nations. The monarchs of
that day had mighty armies of infantry and cavalry. Some of the