USMLE USMLE Certifications USMLE-STEP-2 Questions & Answers

• Question 241:

  During the course of psychotherapy with a woman who has a severe phobia of cars, it is discovered that her first sexual experience, which was a humiliating one for her, took place in an automobile. What is the defense mechanism illustrated by this phobia called?

  A. acting out

  B. reaction formation

  C. displacement

  D. sublimation

  E. repression

  Correct Answer: C

  In the defense mechanism of displacement, an emotion is severed from its original connection with a person or event and attached to a substitute person or object. With its origin thus disguised, the emotion may be more safely expressed. In the example described in the question, anxiety associated with sexual feelings is displaced on to the setting in which they occurred, with resulting phobic anxiety.

• Question 242:

  A45-year-old woman, seen by her medical internist, has been experiencing fears that she may have a serious illness. She complains that after eating she experiences "a lot of gas" and abdominal pain, followed by diarrhea on occasion. Her heart at times seems to be beating rapidly, and she feels faint at times, has chest "discomfort," and wonders if she is having a heart attack. Multiple tests have identified only a mild irritable bowel syndrome. The woman's fears are not allayed by this. She makes repeated calls to be seen by her doctors as well as seeking consultation from other specialists. She insists that "there's something there" and believes the doctors are not taking her seriously. Which of the following most appropriately describes this woman's disorder?

  A. more frequently seen in women than in men

  B. 2025% prevalence rate in a general medical practice

  C. course of disorder usually of short duration (23 months)

  D. associated with elevated erythrocyte sedimentation rate (ESR)

  E. absence of secondary gain is a favorable prognostic indicator

  Correct Answer: E

  Hypochondriasis is a somatoform disorder in which misperceptions or distortions of somatic signs and symptoms lead to preoccupation with fears of having a serious illness. In factitious disorders, one deliberately manufactures signs and symptoms to enter the sick role. The preoccupation with fear of serious illness is not part of factitious disorder. Major depression is characterized by symptoms of depression: sleep disturbance, appetite disturbance, and so forth.

  It may be complicated by hypochondriasis. In the case study, no supporting evidence for major depression (for which she would have been evaluated) is provided. This woman's symptoms as described are not of a psychotic level; thus, reactive psychosis would be inappropriate. In pain disorder, pain in a specific body site is the predominant focus, unlike the predominance of fear seen in hypochondriasis. Care of these patients is best managed supportively by developing a therapeutic alliance with them. Anticipating their needs by establishing regular office visits and physical examinations with them will help allay fears as well as reassure them of one's concern for them, and that if an occult condition becomes evident it will be diagnosed early. Certainly, regular consultation with other specialists is in order to manage these patients. Although the course of hypochondriasis tends to be chronic, there are indications that factor in for a good outcome. One of these is the absence of secondary gain. This disorder is seen equally in both men and women. The prevalence in a general medical practice is approximately 46%. There is no relationship between hypochondriasis and increased ESR.

• Question 243:

  A45-year-old woman, seen by her medical internist, has been experiencing fears that she may have a serious illness. She complains that after eating she experiences "a lot of gas" and abdominal pain, followed by diarrhea on occasion. Her heart at times seems to be beating rapidly, and she feels faint at times, has chest "discomfort," and wonders if she is having a heart attack. Multiple tests have identified only a mild irritable bowel syndrome. The woman's fears are not allayed by this. She makes repeated calls to be seen by her doctors as well as seeking consultation from other specialists. She insists that "there's something there" and believes the doctors are not taking her seriously.

  Which of the following is the most effective long-term management of this patient?

  A. Transfer her care to a psychiatrist.

  B. Prescribe alprazolam.

  C. Establish regular follow-up visits with regularly scheduled physical examinations.

  D. Refer for supportive group psychotherapy.

  E. Refer to a pain management clinic.

  Correct Answer: C

  Hypochondriasis is a somatoform disorder in which misperceptions or distortions of somatic signs and symptoms lead to preoccupation with fears of having a serious illness. In factitious disorders, one deliberately manufactures signs and symptoms to enter the sick role. The preoccupation with fear of serious illness is not part of factitious disorder. Major depression is characterized by symptoms of depression: sleep disturbance, appetite disturbance, and so forth.

  It may be complicated by hypochondriasis. In the case study, no supporting evidence for major depression (for which she would have been evaluated) is provided. This woman's symptoms as described are not of a psychotic level; thus, reactive psychosis would be inappropriate. In pain disorder, pain in a specific body site is the predominant focus, unlike the predominance of fear seen in hypochondriasis. Care of these patients is best managed supportively by developing a therapeutic alliance with them. Anticipating their needs by establishing regular office visits and physical examinations with them will help allay fears as well as reassure them of one's concern for them, and that if an occult condition becomes evident it will be diagnosed early. Certainly, regular consultation with other specialists is in order to manage these patients. Although the course of hypochondriasis tends to be chronic, there are indications that factor in for a good outcome. One of these is the absence of secondary gain. This disorder is seen equally in both men and women. The prevalence in a general medical practice is approximately 46%. There is no relationship between hypochondriasis and increased ESR.

• Question 244:

  A45-year-old woman, seen by her medical internist, has been experiencing fears that she may have a serious illness. She complains that after eating she experiences "a lot of gas" and abdominal pain, followed by diarrhea on occasion. Her heart at times seems to be beating rapidly, and she feels faint at times, has chest "discomfort," and wonders if she is having a heart attack. Multiple tests have identified only a mild irritable bowel syndrome. The woman's fears are not allayed by this. She makes repeated calls to be seen by her doctors as well as seeking consultation from other specialists. She insists that "there's something there" and believes the doctors are not taking her seriously.

  Which of the following is the most likely diagnosis?

  A. factitious disorder

  B. major depression

  C. reaction psychosis

  D. hypochondriasis

  E. pain disorder

  Correct Answer: D

  Hypochondriasis is a somatoform disorder in which misperceptions or distortions of somatic signs and symptoms lead to preoccupation with fears of having a serious illness. In factitious disorders, one deliberately manufactures signs and symptoms to enter the sick role. The preoccupation with fear of serious illness is not part of factitious disorder. Major depression is characterized by symptoms of depression: sleep disturbance, appetite disturbance, and so forth.

  It may be complicated by hypochondriasis. In the case study, no supporting evidence for major depression (for which she would have been evaluated) is provided. This woman's symptoms as described are not of a psychotic level; thus, reactive psychosis would be inappropriate. In pain disorder, pain in a specific body site is the predominant focus, unlike the predominance of fear seen in hypochondriasis. Care of these patients is best managed supportively by developing a therapeutic alliance with them. Anticipating their needs by establishing regular office visits and physical examinations with them will help allay fears as well as reassure them of one's concern for them, and that if an occult condition becomes evident it will be diagnosed early. Certainly, regular consultation with other specialists is in order to manage these patients. Although the course of hypochondriasis tends to be chronic, there are indications that factor in for a good outcome. One of these is the absence of secondary gain. This disorder is seen equally in both men and women. The prevalence in a general medical practice is approximately 46%. There is no relationship between hypochondriasis and increased ESR.

• Question 245:

  A 45-year-old homeless schizophrenic patient presents to you with suicidal ideation. You interview him and find out he is a divorced Roman Catholic. He recently lost his job after being caught a second time drinking on the job. He had attempted suicide impulsively 5 years previous by overdosing. He is not currently psychotic. He bought a handgun and ammunition recently and has been thinking about shooting himself in the head. He has gotten as close to acting on it as having loaded the gun and held it up to his head this morning. Someone walking by stopped him and convinced him to come and see you. He is ambivalent about seeking help Which of the following is the most appropriate immediate treatment recommendation?

  A. Start him on antidepressant medication.

  B. Send him home to live with his brother and ask the brother to keep the gun.

  C. Increase his antipsychotic medication.

  D. Prescribe a benzodiazepine to calm him down.

  E. Admit him to the inpatient psychiatric unit.

  Correct Answer: E

  Most suicides among psychiatric patients are felt to be preventable, as supported by the evidence that inadequate assessment or treatment is often associated with suicide. When to hospitalize patients with suicidal ideation is the most important clinical decision to be made. The absence of a strong support system, a history of past suicide attempt and impulsivity, and having a suicidal plan with intent would be indications for hospitalization.

• Question 246:

  A 45-year-old homeless schizophrenic patient presents to you with suicidal ideation. You interview him and find out he is a divorced Roman Catholic. He recently lost his job after being caught a second time drinking on the job. He had attempted suicide impulsively 5 years previous by overdosing. He is not currently psychotic. He bought a handgun and ammunition recently and has been thinking about shooting himself in the head. He has gotten as close to acting on it as having loaded the gun and held it up to his head this morning. Someone walking by stopped him and convinced him to come and see you. He is ambivalent about seeking help. Which of the following is not associated with an increased suicide risk?

  A. Roman Catholic religion

  B. male

  C. divorced

  D. previous suicide attempt

  E. schizophrenia

  Correct Answer: A

  Historically, suicide rates among Roman Catholics have been lower than among Jews and Protestants. Being divorced, being male, and having a previous suicide attempt all increase the risk for suicide. Up to 10% of schizophrenics die from suicide.

• Question 247:

  A 40-year old man has been treated for chronic paranoid schizophrenia for many years with a typical neuroleptic. To decrease his risk for tardive dyskinesia, his psychiatrist wants to change his medication to an atypical antipsychotic. Which of the following atypical antipsychotics is limited in its use by the risk of agranulocytosis, which occurs in 12% of all patients treated?

  A. aripiprazole

  B. clozapine

  C. risperidone

  D. quetiapine

  E. ziprasidone

  Correct Answer: B

  Aripiprazole, clozapine, risperidone, quetiapine, and ziprasidone are all atypical antipsychotic medications. The use of clozapine, however, is limited because of the risk of potentially fatal agranulocytosis in patients taking it. Because the agranulocytosis is reversible, monitoring the blood count of patients on clozapine is recommended, usually starting on a weekly basis at the beginning of treatment.

• Question 248:

  A 37-year-old woman telephones to alert her psychiatrist that she has developed a severe pain in her right eye that has persisted for about 5 hours. She has no history of migraine headaches. The psychiatrist is treating her with 150 mg imipramine for major depression. She denies any recent injury or infection in this eye. She wears corrective lenses for nearsightedness. Which of the following is the most appropriate step in management?

  A. Advise her to take an anti-inflammatory analgesic.

  B. Advise her to rest and call again in 8 hour if the pain has not subsided.

  C. Consult immediately with her ophthalmologist.

  D. Plan to evaluate her eye at her next psychiatric appointment in 2 weeks.

  E. Decrease imipramine to 125 mg/day.

  Correct Answer: C

  The onset of severe, persistent eye pain is always a cause for concern. In a patient medicated with a drug with anticholinergic side effects, such as imipramine, there is a potential for the development of narrow-angle glaucoma. Adelay in the diagnosis and treatment of this will lead to irreparable harm to the eye. In this case, the psychiatrist would act immediately to facilitate appropriate evaluation and treatment which would best be provided by her ophthalmologist.

• Question 249:

  Narcolepsy is a primary sleep disorder with all of the following symptoms except which of the following?

  A. sleep paralysis

  B. sleep attacks with sleep onset REM (rapid eye movement)

  C. cataplexy

  D. hypnagogic hallucinations

  E. apnea

  Correct Answer: E

  Narcolepsy is a rare dyssomnia (incidence of .07%) defined by the following four symptoms: sleep paralysis occurs upon falling asleep or waking, sleep attacks with sleep onset REM which are brief (1015 minutes) and occur in inappropriate situations (sleep attacks are effectively treated with stimulants), cataplexy which is a condition that involves sudden transient bilateral weakness or paralysis, and hypnagogic hallucinations. Apnea is the cessation of nasobuccal breathing for more than 10 seconds and is found in obstructive sleep apnea, central sleep apnea, and mixed sleep apnea.

• Question 250:

  A 58-year-old woman with a history of chronic paranoid schizophrenia, who has been continuously treated with antipsychotics for the past 20 years, lives in a community-based residential facility. She has recently suffered an increase in auditory hallucinations, and her haloperidol dose has been increased from 2.5 to 10 mg/day. Four days later, she is brought by a visiting nurse to the emergency room, where she presents with confusion, marked flexor and extensor rigidity in her legs and arms, and a temperature of 103.5°F. Her blood pressure is160/120 mmHg, her pulse is 120/min and irregular. Which of the following is most likely to be an effective treatment for this condition?

  A. intramuscular haloperidol

  B. oral bromocriptine

  C. intramuscular lorazepam

  D. intramuscular benztropine

  E. oral propranolol

  Correct Answer: B

  The most effective treatments for the extremely serious, potentially fatal complication of antipsychotic treatment called NMS are oral bromocriptine, a dopaminergic agonist, and intravenous or oral dantrolene, a skeletal muscle relaxant. Afurther increase in the patient's haloperidol dose would likely worsen her NMS. While the anticholinergic effects benztropine may alleviate some of the neuroleptic- induced muscular dystonia associated with the syndrome, and lorazepam may help relax the muscle rigidity, they are not likely to be life saving, and propranolol is not an effective medication in the treatment of NMS.