USMLE USMLE Certifications USMLE-STEP-2 Questions & Answers

• Question 101:

  A 30-year-old man presents to the emergency department with sudden onset of severe epigastric pain and vomiting 3 hours ago. He reports a 6-month history of chronic epigastric pain occurring nearly every day and relieved by antacids. On examination, he appears sweaty and avoids movement. Vital signs reveal a temperature of 100°F, BP of 100/60 mmHg, pulse rate of 110/min, and respiratory rate of 12/min. The remainder of his examination reveals diminished bowel sounds and a markedly tender and rigid abdomen. A chest x-ray and abdominal films reveal pneumoperitoneum Which of the following is the most appropriate next step in management?

  A. immediate laparotomy

  B. nonoperative management with NG decompression and antibiotics

  C. fluid resuscitation

  D. administration of H2 blockers

  E. placement of a central venous line

  Correct Answer: C

  Perforated duodenal ulcer usually presents as a sudden onset of acute abdominal pain.Examination usually reveals severe abdominal tenderness with rigidity of the abdominal musculature (i.e., an acute abdomen). With a prior history of abdominal pain relieved by antacids, a chronic ulcer that has now perforated is strongly suggested. Perforated colon cancer occurs in an older age group, as well as gastric ulcer. Following plain radiographs that show pneumoperitoneum, no additional diagnostic tests are required and serve only to delay treatment. The treatment is laparotomy and either patch closure of the perforation or definitive operation, the latter being preferred, depending on operative findings. However, the patient must receive fluid resuscitation before laparotomy to avoid hypotension and its consequences. Although nonoperative management for contained perforations has been suggested by some authors, an acute abdomen is an indication for operative management.

• Question 102:

  A 30-year-old man presents to the emergency department with sudden onset of severe epigastric pain and vomiting 3 hours ago. He reports a 6-month history of chronic epigastric pain occurring nearly every day and relieved by antacids. On examination, he appears sweaty and avoids movement. Vital signs reveal a temperature of 100°F, BP of 100/60 mmHg, pulse rate of 110/min, and respiratory rate of 12/min. The remainder of his examination reveals diminished bowel sounds and a markedly tender and rigid abdomen.

  A chest x-ray and abdominal films reveal pneumoperitoneum

  Which of the following is the most appropriate next diagnostic test?

  A. CT scan

  B. UGI water-soluble contrast study

  C. lower GI water-soluble contrast study

  D. abdominal ultrasound

  E. none of the above

  Correct Answer: E

  Perforated duodenal ulcer usually presents as a sudden onset of acute abdominal pain. Examination usually reveals severe abdominal tenderness with rigidity of the abdominal musculature (i.e., an acute abdomen). With a prior history of abdominal pain relieved by antacids, a chronic ulcer that has now perforated is strongly suggested. Perforated colon cancer occurs in an older age group, as well as gastric ulcer. Following plain radiographs that show pneumoperitoneum, no additional diagnostic tests are required and serve only to delay treatment. The treatment is laparotomy and either patch closure of the perforation or definitive operation, the latter being preferred, depending on operative findings. However, the patient must receive fluid resuscitation before laparotomy to avoid hypotension and its consequences. Although nonoperative management for contained perforations has been suggested by some authors, an acute abdomen is an indication for operative management.

• Question 103:

  A 30-year-old man presents to the emergency department with sudden onset of severe epigastric pain and vomiting 3 hours ago. He reports a 6-month history of chronic epigastric pain occurring nearly every day and relieved by antacids. On examination, he appears sweaty and avoids movement. Vital signs reveal a temperature of 100°F, BP of 100/60 mmHg, pulse rate of 110/min, and respiratory rate of 12/min. The remainder of his examination reveals diminished bowel sounds and a markedly tender and rigid abdomen. A chest x-ray and abdominal films reveal pneumoperitoneum.

  Which of the following is the most likely diagnosis?

  A. small-bowel obstruction

  B. dead bowel

  C. perforated colon carcinoma

  D. perforated duodenal ulcer

  E. perforated gastric ulcer

  Correct Answer: D

  Perforated duodenal ulcer usually presents as a sudden onset of acute abdominal pain. Examination usually reveals severe abdominal tenderness with rigidity of the abdominal musculature (i.e., an acute abdomen). With a prior history of abdominal pain relieved by antacids, a chronic ulcer that has now perforated is strongly suggested. Perforated colon cancer occurs in an older age group, as well as gastric ulcer. Following plain radiographs that show pneumoperitoneum, no additional diagnostic tests are required and serve only to delay treatment. The treatment is laparotomy and either patch closure of the perforation or definitive operation, the latter being preferred, depending on operative findings. However, the patient must receive fluid resuscitation before laparotomy to avoid hypotension and its consequences. Although nonoperative management for contained perforations has been suggested by some authors, an acute abdomen is an indication for operative management.

• Question 104:

  A 68-year-old man presents to the physician's office complaining of progressive dysphagia over the last 3 months associated with mild chest discomfort. He reports a 15-lb weight loss, a 30 pack-year smoking history, and occasional alcohol intake. The physical examination, including vital signs, is unremarkable. A chest x-ray was normal, and a barium esophagogram shows an irregular filling defect in the distal third of the esophagus with distortion and narrowing of the lumen. Which of the following is the most appropriate next step in management?

  A. CT scan

  B. esophagoscopy

  C. MRI scan

  D. surgical resection

  E. bronchoscopy

  Correct Answer: B

  Progressive dysphagia in an older adult warrants evaluation, especially with associated symptoms of weight loss, chest pain, or hematemesis. A barium esophagogram is the first study that should be obtained. The typical carcinoma demonstrates an irregular, rigid narrowing of the esophageal wall with distortion of the lumen. Achalasia demonstrates a narrow, tapering bird's beak appearance of the distal esophagus. Development of an esophageal stricture causes slowly progressive dysphagia, usually after a long history of gastroesophageal reflux disease (GERD). Esophagoscopy and biopsy are mandatory for evaluation of esophageal stenosis and yield a diagnosis of carcinoma in 95% of patients with malignant strictures. CT scanning is the standard technique for staging, once the diagnosis has been made. Bronchoscopy is helpful in patients with upper and middle third carcinomas to exclude invasion of the trachea or bronchi before esophagectomy.

• Question 105:

  A 68-year-old man presents to the physician's office complaining of progressive dysphagia over the last 3 months associated with mild chest discomfort. He reports a 15-lb weight loss, a 30 pack-year smoking history, and occasional alcohol intake. The physical examination, including vital signs, is unremarkable. A chest x-ray was normal, and a barium esophagogram shows an irregular filling defect in the distal third of the esophagus with distortion and narrowing of the lumen. Which of the following is the most likely diagnosis?

  A. esophagitis with stricture

  B. esophageal carcinoma

  C. lung carcinoma with invasion into the esophagus

  D. lymphoma

  E. achalasia

  Correct Answer: B

  Progressive dysphagia in an older adult warrants evaluation, especially with associated symptoms of weight loss, chest pain, or hematemesis. A barium esophagogram is the first study that should be obtained. The typical carcinoma demonstrates an irregular, rigid narrowing of the esophageal wall with distortion of the lumen. Achalasia demonstrates a narrow, tapering bird's beak appearance of the distal esophagus. Development of an esophageal stricture causes slowly progressive dysphagia, usually after a long history of gastroesophageal reflux disease (GERD). Esophagoscopy and biopsy are mandatory for evaluation of esophageal stenosis and yield a diagnosis of carcinoma in 95% of patients with malignant strictures. CT scanning is the standard technique for staging, once the diagnosis has been made. Bronchoscopy is helpful in patients with upper and middle third carcinomas to exclude invasion of the trachea or bronchi before esophagectomy.

• Question 106:

  A 55-year-old man presents to the emergency department at 5 a.m. complaining of vomiting blood. After binge drinking last night, the patient began to vomit repeatedly. After a number of episodes, the patient noted blood in the vomitus, followed by a melanotic stool 5 hours later. His past history is pertinent for ethanol abuse and a 40 pack-year smoking history. Vital signs reveal a BP of 100/60 mmHg, pulse rate of 95/min, respiratory rate of 12/min, and temperature of 97°F. Examination reveals a thin man with norma l chest, cardiac, and abdominal findings. Rectal examination reveals heme-positive stool. Laboratory data show normal electrolytes and a hematocrit of 30. A chest x-ray is unremarkable. Volume resuscitation, gastric lavage, and NG tube decompression are initiated. Which of the following is the most appropriate diagnostic test?

  A. barium esophagogram

  B. water-soluble contrast esophagogram

  C. esophagoscopy

  D. CT scan

  E. angiogram

  Correct Answer: C

  Mallory--Weiss tear involves acute UGI hemorrhage that occurs after retching or vomiting and accounts for 515% of patients with UGI bleeding. The patient is often an alcoholic who vomits after binge drinking. Hematemesis follows vomiting without blood. After resuscitation, esophagoscopy is required to determine the source of bleeding and may be helpful in nonoperative management. Contrast studies are not helpful, and the use of barium would coat the stomach and preclude a diagnostic endoscopic examination. Most patients with Mallory--Weiss tears stop bleeding spontaneously. Angiography may be helpful in selected patients who continue to bleed and in whom the site of hemorrhage cannot be determined endoscopically.

• Question 107:

  A 49-year-old woman presents to her physician with dysphagia, regurgitation of undigested food eaten hours earlier, and coughing over the last 6 months. She was hospitalized 1 month ago for aspiration pneumonia and successfully treated with antibiotics. Examination reveals a thin-appearing woman with normal vital signs and unremarkable chest, heart, and abdominal examination. A UGI contrast study is performed and reveals a pharyngoesophageal (Zenker's) diverticulum. Which of the following is the most important aspect of treatment?

  A. resection of the diverticulum

  B. cricopharyngeal muscle myotomy

  C. H2 blockers

  D. elevation of the head of the bed

  E. diverticulopexy

  Correct Answer: B

  Pharyngoesophageal (Zenker's) diverticulum is the most common esophageal diverticulum and typically occurs in the 3050 age group and, therefore, is believed to be acquired. Its symptoms include cervical dysphagia, regurgitation of undigested food, and recurrent aspiration. It is categorized as a pulsion type, creating protrusion of mucosa, resulting in a false diverticulum. An underlying neuromotor abnormality exists, which is responsible for increased pharyngeal pressure. The most important aspect of treatment is a cricopharyngeal muscle myotomy, which can be combined with resection or diverticulopexy.

• Question 108:

  A 49-year-old woman presents to her physician with dysphagia, regurgitation of undigested food eaten hours earlier, and coughing over the last 6 months. She was hospitalized 1 month ago for aspiration pneumonia and successfully treated with antibiotics. Examination reveals a thin-appearing woman with normal vital signs and unremarkable chest, heart, and abdominal examination. A UGI contrast study is performed and reveals a pharyngoesophageal (Zenker's) diverticulum. Which of the following statements is true regarding Zenker's diverticula?

  A. Cervical dysphagia is related to the size of the diverticulum.

  B. Pharyngoesophageal diverticula are of the pulsion type.

  C. Pharyngoesophageal diverticula are true diverticula.

  D. Pharyngoesophageal diverticula are congenital in origin.

  E. Upper esophageal sphincter function is usually normal.

  Correct Answer: B

  Pharyngoesophageal (Zenker's) diverticulum is the most common esophageal diverticulum and typically occurs in the 3050 age group and, therefore, is believed to be acquired. Its symptoms include cervical dysphagia, regurgitation of undigested food, and recurrent aspiration. It is categorized as a pulsion type, creating protrusion of mucosa, resulting in a false diverticulum. An underlying neuromotor abnormality exists, which is responsible for increased pharyngeal pressure. The most important aspect of treatment is a cricopharyngeal muscle myotomy, which can be combined with resection or diverticulopexy.

• Question 109:

  A 45-year-old man presents to the physician's office complaining of dysphagia and retrosternal pressure and pain of 2-year duration. The symptoms have worsened over the last 3 months. He has a 30 packyear smoking history and drinks beer on weekends. Vital signs include a BP of 150/90 mmHg, pulse rate of 90/ min, and respiratory rate of 12/min, with a normal temperature. Examination reveals a thin man with a normal heart, lung, and abdomen examination. An esophagogram reveals a 6-cm, smooth, concave defect in the midesophagus with sharp borders. Esophagoscopy reveals intact overlying mucosa and a mobile tumor. Which of the following is the most appropriate next step?

  A. repeat esophagoscopy with biopsy

  B. thoracotomy with extramucosal resection

  C. thoracotomy with esophageal resection

  D. radiation therapy

  E. chemotherapy

  Correct Answer: B

  Leiomyomas are the most common benign tumors of the esophagus. They are intramural, occur between 20 and 50 years of age, and may be symptomatic when over 5 cm. Symptoms may include dysphagia and retrosternal pressure and pain. Esophagogram shows characteristic features of a smooth concave defect with sharp borders. Esophagoscopy is indicated to rule out carcinoma. These tumors are mobile, with intact overlying mucosa. Biopsy should not be performed so that subsequent extramural resection can be performed without complication. Excision is recommended for symptomatic leiomyomas or those greater than 5 cm.

• Question 110:

  A 39-year-old woman presents to the physician's office for evaluation of a palpable nodule in the neck of 2 years' duration. Her past history is pertinent for Hashimoto's disease diagnosed 5 years ago, for which she takes thyroid hormone. She has a history of low-dose chest irradiation for an enlarged thymus gland during infancy. On examination, a 2.5-cm nodule is palpable in the left lobe of the thyroid and is firm and nontender. Which of the following is the most appropriate next step in her management?

  A. ultrasound of the neck

  B. thyroid scintiscan

  C. MRI of the neck

  D. CT scan of the neck and chest

  E. FNA of the nodule

  Correct Answer: E

  Factors that increase the risk for carcinoma include exposure to low-dose irradiation, age under 20 or over 60, male gender (especially over age 40), and recent onset. An increased incidence of thyroid carcinoma in patients with Hashimoto's thyroiditis has not been substantiated. For diagnosis, FNA is highly accurate and has become the preferred diagnostic modality. FNA is the most important diagnostic test for selecting patients for operation, supplanting all other diagnostic tests.