USMLE USMLE Certifications USMLE-STEP-2 Questions & Answers

• Question 251:

  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 the most important laboratory test to evaluate the possibility of the diagnosis?

  A. serum creatine phosphokinase (CPK) level

  B. serum sodium level

  C. serum potassium level

  D. serum glucose level

  E. serum calcium level

  Correct Answer: A

  Patients with NMS typically demonstrate tachycardia, labile blood pressure, severe muscle rigidity, and severe fever. Serum CPK levels, which can be elevated to more than 100 times normal levels as a result of muscle damage, are the most consistently noted abnormalities in patients with NMS. Although the white blood cell count may be elevated, and blood levels of calcium, iron, and magnesium may be decreased in patients with the syndrome, serum CPK is the most important laboratory study to obtain in a patient with suspected NMS

• Question 252:

  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 the most likely diagnosis that best describes this woman's current condition?

  A. neuroleptic malignant syndrome (NMS)

  B. metabolic syndrome

  C. extrapyramidal symptoms

  D. malingering

  E. alcohol withdrawal

  Correct Answer: A

  NMS is a rare complication of neuroleptic therapy which involves symptoms of severe muscle rigidity, elevated temperature, and two or more of the following: diaphoresis, dysphagia, and tremor, and incontinence, changes in level of consciousness, tachycardia, mutism, leukocytosis, elevated CPK, or labile blood pressure. EPS would not explain the extensor rigidity, elevated temperature, and blood pressure. Metabolic syndrome refers to another neuroleptc side effect where lipid levels are elevated and adult onset diabetes can develop. Malingering would not easily explain the elevated vital signs. Though alcohol withdrawal would be in the differential with the elevated vital signs, the pipe-like rigidity could not be explained.

• Question 253:

  A 35-year-old woman comes into the ER after cutting her wrists for the 10th time. She did this after her boyfriend of 2 weeks left her yesterday. She reports a history of unstable interpersonal relationships, chronic feelings of emptiness, impulsive sexual relationships, and problems with her sense of identity. The one psychotherapeutic technique to avoid would be:

  A. therapeutic physical holding sessions to help the patient feel in control

  B. clear roles and responsibilities of patient and therapist are established

  C. therapist conveys empathic validation

  D. flexibility

  E. patient and therapist mutually develop a hierarchy of priorities

  Correct Answer: A

  Physically holding a patient would be a boundary violation. Conveying empathic validation, having clear roles and responsibilities, being flexible, and developing a hierarchy of priorities are all common features of recommended psychotherapy for a patient with borderline personality disorder.

• Question 254:

  A 35-year-old woman comes into the ER after cutting her wrists for the 10th time. She did this after her boyfriend of 2 weeks left her yesterday. She reports a history of unstable interpersonal relationships, chronic feelings of emptiness, impulsive sexual relationships, and problems with her sense of identity.

  Which of the following is the most likely axis II diagnosis?

  A. histrionic personality disorder

  B. borderline personality disorder

  C. antisocial personality disorder

  D. dependent personality disorder

  E. avoidant personality disorder

  Correct Answer: B

  Recurrent suicidal behaviors, affective instability, unstable interpersonal relationships, chronic feelings of emptiness, and rejection sensitivity are all traits of borderline personality disorder.

• Question 255:

  A 60-year-old man disappears from his home and travels 100 miles to a small town, where he opens a small grocery store using a different name. Six weeks later, he awakens in some agitation, uses his original name, and asks to know where he is. He wishes to return to his home. Which of the following is the most likely diagnosis?

  A. dissociative amnesia

  B. dissociative fugue

  C. dissociative identity disorder

  D. depersonalization disorder

  E. dissociative disorder not otherwise specified

  Correct Answer: B

  Dissociative fugue is classically typified by a person's suddenly and unexpectedly traveling away from his or her home, assuming a new identity, and eventually recovering from the fugue or flight, unable to recall the events that took place during the episode. Dissociative amnesia is a more generalized term given to an inability to recall significant personal information. Dissociative identity disorder is the current diagnostic term for what was classically called multiple personality disorder. Depersonalization disorder is an alteration of experience in which an individual feels like an outside observer of his or her body or mental processes. Dissociative disorder not otherwise specified is a name given to other dissociative illnesses not specifically listed in DSM-IV-TR, such as dissociative states occurring in individuals subjected to brainwashing or indoctrination while held captive by terrorists.

• Question 256:

  A 25-year-old woman presents with a recurrent depression, and says she has taken many antidepressant medications from several different classes of drugs in the past. Which of the following atypical antidepressants is a presynaptic alpha-2 receptor noradrenergic antagonist and a 5-HT2 and 5-HT3 receptor serotonergic antagonist?

  A. bupropion

  B. trazodone

  C. nefazodone

  D. venlafaxine

  E. mirtazapine

  Correct Answer: E

  Mirtazapine is a tetracyclic antidepressant that has both presynaptic alpha-2 receptor noradrenergic antagonist properties and 5-HT2 and 5-HT3 receptor serotonergic antagonist properties, which, taken together, result in a net increase in both noradrenergic and serotonergic neurotransmission. Bupropion may exert its antidepressant effects by acting on the noradrenergic system, but its method of action is currently being investigated. Trazodone and nefazodone are combined serotonin reuptake inhibitors and 5- HT2 serotonin antagonists. Venlafaxine is a combined norepinephrine and serotonin reuptake inhibitor

• Question 257:

  A 56-year-old man with a dual diagnosis of schizophrenia and alcohol dependency was arrested for "driving under the influence." After 2 days in jail, he was noted to be acting agitated and "crazy," claiming that the guards were going to kill him that night. When questioned about his profuse sweating, he claimed that he had just come in from his job working in the heat and humidity. He was distracted by various noises, claiming that these were made by people watching him and waiting for him. He appeared to watch things that seemed to be moving on the walls. On further examination, it was noted that he was very tremulous, unable to follow an object with his eyes only, and quite ataxic. Which of the following benzodiazepines can reliably be given intramuscularly to this patient to help control his symptoms?

  A. diazepam

  B. chlordiazepoxide

  C. lorazepam

  D. alprazolam

  E. clonazepam

  Correct Answer: C

  Diazepam, chlordiazepoxide, and lorazepam can all be given parenterally, but only lorazepam is reliably absorbed after intramuscular injection. Alprazolam and clonazepam are not available in parenteral form in the United States.

• Question 258:

  A 56-year-old man with a dual diagnosis of schizophrenia and alcohol dependency was arrested for "driving under the influence." After 2 days in jail, he was noted to be acting agitated and "crazy," claiming that the guards were going to kill him that night. When questioned about his profuse sweating, he claimed that he had just come in from his job working in the heat and humidity. He was distracted by various noises, claiming that these were made by people watching him and waiting for him. He appeared to watch things that seemed to be moving on the walls. On further examination, it was noted that he was very tremulous, unable to follow an object with his eyes only, and quite ataxic. The working diagnosis at this point is most likely which of the following?

  A. acute exacerbation of schizophrenia

  B. alcohol withdrawal delirium

  C. alcohol-induced persisting dementia

  D. alcohol intoxication

  E. malingering

  Correct Answer: B

  According to the case study, this man can be presumed to have been without alcohol for at least the 2 days he has been in jail, and, therefore, the emerging symptoms would be most attributable to withdrawal and delirium. Withdrawal symptoms include autonomic hyperactivity, hand tremor, hallucinations, illusions, and agitation. Added to these are the signs of delirium, disorientation, irritability, agitation, disorganized thought, inability to focus and concentrate, and development of symptoms over a short time. Adiagnosis of exacerbation of schizophrenia does not adequately explain these symptoms and their development shortly after the withdrawal of alcohol. The signs and symptoms are not consistent with dementia, in which one would expect a longer period for symptom development and a clouding of consciousness. Although malingering might be considered, especially for an incarcerated individual, the history of recent alcohol intoxication with abrupt withdrawal makes alcohol withdrawal delirium a more consistent diagnosis.

• Question 259:

  You are called to the ICU to see a 65-year-old female who is 2 days status post hip surgery. The medical team is concerned because the patient is having visual hallucinations and did not sleep last night. She scored 21/30 on a Mini-Mental Status Examination (MMSE) with 5 points off for disorientation and 2 off for both concentration and shortterm memory. The patient is restrained because she pulled out her IV last night. Records indicate she has no previous psychiatric history and that her cognitive functioning presurgery was normal. Which of the following is not a predisposing factor for the above condition?

  A. cancer

  B. advanced age

  C. female gender

  D. dementia

  E. alcohol dependence

  Correct Answer: C

  Advanced age is a major risk factor for the development of delirium. Other predisposing risk factors include preexisting brain damage, a history of previous delirium, alcohol dependence, diabetes, cancer, dementia, sensory impairment, and malnutrition. Male gender is also an independent risk factor.

• Question 260:

  You are called to the ICU to see a 65-year-old female who is 2 days status post hip surgery. The medical team is concerned because the patient is having visual hallucinations and did not sleep last night. She scored 21/30 on a Mini-Mental Status Examination (MMSE) with 5 points off for disorientation and 2 off for both concentration and shortterm memory. The patient is restrained because she pulled out her IV last night. Records indicate she has no previous psychiatric history and that her cognitive functioning presurgery was normal. Which of the following is the most likely axis I diagnosis?

  A. bipolar disorder manic phase

  B. schizophrenia, undifferentiated

  C. dementia NOS (not otherwise specified)

  D. delirium NOS

  E. psychosis NOS

  Correct Answer: D

  The hallmark of delirium is fluctuation in level of consciousness. Periods of lucency may be interspersed with periods of clouding and unresponsiveness. Impaired judgment, impaired memory, and disorientation are seen in both delirium and dementia. Disordered thought is seen in both and tends to be disorganized in delirium and impoverished in dementia. Another distinguishing feature is that the onset of delirium usually occurs within hours or days, whereas, the onset of dementia may be insidious throughout a period of weeks to months.