It's really not that bad. My test was like 25% slam dunks. If you were even half-asleep in the first two years, you should nail every single one of these questions. For example, my very first question on the real deal was classic bacterial pneumonia with gram stain results and the only cocci in the answer list was Strep pneumo. I had a question that straight-up asked me what inheritance mode is sickle cell disease.
I had no sequentials on my exam and from talking to like 25-30 kids at my school, only a very few had any sequentials. Even the huge Step 1 thread in the Step 1 forums says a paucity of sequentials.
Images were classic images that Pathoma or Goljan will show you. I did no extra studying for images and I never once said to myself "boy I wish I looked at more pictures". If they want you to diagnose AML, they will show Auer rods in up-close, gritty detail. No question will ask you whether or not a cervical biopsy is CIN I, II or III based on a picture.
The heart murmurs were, for the most part, concise and classic. Aortic stenosis will be absolutely silent everywhere except over the aortic region. Mitral regurg will be silent everywhere except over the mitral area. Often times, that's all you need because all the other answer choices won't even be in the right area. I had 4-5 murmur questions on the real deal and only one was like "here's the dude for his physical exam, what's his finding". The rest gave classic clinical vignettes (eg stenosis -> syncope on exertion).
Yes, the exam is difficult, but it's also placed on a pedestal by a lot of medical students. I had an upperclassman tell me that he had like 3 "recall questions" which was a blatant lie. The vast majority of the exam (>250 questions) are either 1-step or 2-step questions.
