USMLE USMLE Certifications USMLE-STEP-2 Questions & Answers

• Question 271:

  A 70-year-old man is brought to his primary care doctor by the man's son. According to his son, who had not seen his father for about a year, the father seemed to have some personality changes. He was no longer interested in his hobbies and seemed apathetic. He seemed to forget easily, and he repeatedly asked the same already answered questions. On at least two occasions, the father wandered out of the house and was found by neighbors, who thought he was confused. Considering the information learned thus far, which of the following medications would be the most appropriate treatment here?

  A. donepezil

  B. fluoxetine

  C. aspirin

  D. amitriptyline

  E. ginkgo biloba

  Correct Answer: A

  Donepezil is a cholinesterase inhibitor used for the treatment of mild-to-moderate impairment in Alzheimer's disease. Fluoxetine is an SSRI antidepressant. Aspirin would decrease clotting. Amitriptyline is a tricyclic antidepressant and with its anticholinergic properties, it would worsen cognition. Ginkgo is an herbal medicine.

• Question 272:

  A 70-year-old man is brought to his primary care doctor by the man's son. According to his son, who had not seen his father for about a year, the father seemed to have some personality changes. He was no longer interested in his hobbies and seemed apathetic. He seemed to forget easily, and he repeatedly asked the same already answered questions. On at least two occasions, the father wandered out of the house and was found by neighbors, who thought he was confused. Which of the following is the most common cause of dementia in a 70-year-old man?

  A. Alzheimer's disease

  B. Pick's disease

  C. Parkinson's disease

  D. vascular dementia

  E. subcortical dementia

  Correct Answer: A

  Alzheimer's disease is the most common form of dementia. Of persons with dementia, 5060% will have Alzheimer's. Vascular dementia is the second most common, accounting for about 1530% of dementias.

• Question 273:

  A 17-year-old girl is brought in by her parents because of their concerns about her weight loss. She is petite, and a normal weight for someone her height is 100 lbs, but she weighs 78 lbs. She reports menstrual irregularity. The patient believes she is obese. She does not believe she has a problem. Her mother reports that she found laxatives on her daughter's nightstand, and heard her vomiting in the bathroom yesterday after dinner. Which of the following is the best initial treatment?

  A. Have her return in 2 weeks for cognitive behavioral therapy.

  B. Initiate lithium as it often causes weight gain.

  C. Send her home telling her parents this is normal teen behavior.

  D. Start a prenatal vitamin.

  E. Admit her for inpatient psychiatric hospitalization.

  Correct Answer: E

  Generally speaking, anorexic patients who are 20% or more below their expected weight for their height are recommended for inpatient programs. Inpatient programs for anorexia nervosa usually use a combination of a behavioral management approach, individual psychotherapy, family education and therapy, and in some cases psychotropic medications.

• Question 274:

  A 17-year-old girl is brought in by her parents because of their concerns about her weight loss. She is petite, and a normal weight for someone her height is 100 lbs, but she weighs 78 lbs. She reports menstrual irregularity. The patient believes she is obese. She does not believe she has a problem. Her mother reports that she found laxatives on her daughter's nightstand, and heard her vomiting in the bathroom yesterday after dinner. Which of the following is the most likely diagnosis?

  A. bulimia nervosa

  B. pregnancy

  C. anorexia nervosa

  D. no diagnosis, normal presentation

  E. obesity

  Correct Answer: C

  Anorexia nervosa is an eating disorder that predominantly affects women in their teens and in early adulthood. It is defined as refusal to maintain a minimal normal weight, at least 85% of that weight considered normal for that person's age and height, and a morbid preoccupation with feeling obese. Common strategies to lose weight include avoidance of all fats and carbohydrates, self-induced vomiting, obsessive physical activity, and abuse of laxatives or diuretics or both. Despite apparent aversion to gaining weight, anorectics frequently take very special care in preparation and consumption of food and may delight in preparing gourmet feasts for others. Menstrual irregularity and amenorrhea are also commonly reported but are not essential factors in making the diagnosis. It is not yet clear whether such menstrual problems are simply secondary to starvation or whether they reflect a more pervasive endocrine dysfunction. Perhaps the most striking clinical feature of this disorder is the misperception of body image. Regardless of the method of confrontation, including use of mirrors or photographs, sufferers see themselves as overweight. The patient often refuses to agree that there is any problem whatsoever.

  Numerous factors, including developmental, family, endocrine, and gastrointestinal disturbances have been implicated in anorexia nervosa, but the etiology has yet to be clearly established. Most commonly, the course consists of a single episode followed by remission. Some patients may suffer a series of relapses and remissions. Mortality rates have been estimated to be as high as 20%.

• Question 275:

  A 44-year-old man presents with fears that his mathematical abilities have been slowly sucked out of his brain for the last 4 years. He believes an "alien force disguised as a human being" is responsible. To avoid contacting this being, he has isolated himself in a room in a boarding house. His wife divorced him and left with their children. After 10 years teaching math at a local high school, he resigned about 3 years ago. He supports himself by "collecting cans." His affect is blunted. His appearance is disheveled, unshaven, and unwashed. Considering the information learned thus far, which of the following would be an appropriate first-line treatment for this patient?

  A. thiamine

  B. olanzapine

  C. amitriptyline

  D. lithium carbonate

  E. fluoxetine

  Correct Answer: B

  The treatment of choice for patients with a schizophrenic disorder is an antipsychotic drug. Of the medications listed, only olanzapine is an antipsychotic drug. Olanzapine causes relatively fewer EPS than traditional neuroleptics, such as haloperidol, and seems to be substantially less likely to cause tardive dyskinesia than typical neuroleptics. Olanzapine blocks both dopamine D2 receptors and serotonin 5- HT2 receptors. Its use is often associated with some weight gain by patients.

• Question 276:

  A 44-year-old man presents with fears that his mathematical abilities have been slowly sucked out of his brain for the last 4 years. He believes an "alien force disguised as a human being" is responsible. To avoid contacting this being, he has isolated himself in a room in a boarding house. His wife divorced him and left with their children. After 10 years teaching math at a local high school, he resigned about 3 years ago. He supports himself by "collecting cans." His affect is blunted. His appearance is disheveled, unshaven, and unwashed. Which of the following hypotheses is the leading hypothesis to explain the patient's psychotic symptoms?

  A. serotonin hypothesis

  B. biogenic amine hypothesis

  C. acetylcholine hypothesis

  D. dopamine hypothesis

  E. gamma aminobutyric acid (GABA) hypothesis

  Correct Answer: D

  The dopamine hypothesis of schizophrenia grew from the observations that medications that block dopamine receptors have antipsychotic activity and medications that stimulate dopamine receptors (amphetamines) can induce psychosis. Serotonin abnormalities have been implicated in mood and anxiety disorders. The biogenic amine hypothesis of mood disorders was based on the finding that tricyclic and MAOI drugs are effective in alleviating the symptoms of depression. The GABAergic system has been implicated in anxiety disorders because benzodiazepines which are GABAergic have antianxiety effects. Acetylcholine abnormalities have been associated with dementia.

• Question 277:

  A 44-year-old man presents with fears that his mathematical abilities have been slowly sucked out of his brain for the last 4 years. He believes an "alien force disguised as a human being" is responsible. To avoid contacting this being, he has isolated himself in a room in a boarding house. His wife divorced him and left with their children. After 10 years teaching math at a local high school, he resigned about 3 years ago. He supports himself by "collecting cans." His affect is blunted. His appearance is disheveled, unshaven, and unwashed. Which of the following factors in this case would favor a more positive prognosis?

  A. presence of negative symptoms

  B. late onset

  C. being male

  D. being divorced

  E. experience in teaching mathematics

  Correct Answer: B

  Features that weigh toward a good prognosis in schizophrenia include late onset, obvious precipitating factors, good premorbid functioning, mood disorder symptoms, being married, a family history of mood disorders, good support systems, and having primarily positive symptoms.

• Question 278:

  A 44-year-old man presents with fears that his mathematical abilities have been slowly sucked out of his brain for the last 4 years. He believes an "alien force disguised as a human being" is responsible. To avoid contacting this being, he has isolated himself in a room in a boarding house. His wife divorced him and left with their children. After 10 years teaching math at a local high school, he resigned about 3 years ago. He supports himself by "collecting cans." His affect is blunted. His appearance is disheveled, unshaven, and unwashed. Which of the following is the most likely diagnosis?

  A. paranoid schizophrenia

  B. alcohol abuse and dependence

  C. major depression with psychotic features

  D. Alzheimer's disease E. Huntington's disease

  Correct Answer: A

  The preoccupation with a rather welldeveloped delusional system and later age at onset suggest paranoid schizophrenia. A case can be made for undifferentiated schizophrenia because of the apparent disorganization in personal habits and the flattening of affect. There is no history of alcohol abuse and dependence to support the diagnosis. The long period of symptoms, bizarreness of paranoid delusion, and decline in functioning are more characteristic of schizophrenia. The time course of a major depression is much shorter. Usually, in major depression there is not the profound decline in functioning. No symptoms of memory impairment or loss of cognitive functioning have occurred that would suggest Alzheimer or Huntington dementias. In addition, in Huntington dementia, one would expect a prominent movement disorder as seen in subcortical dementia.

• Question 279:

  A young mother seeks psychiatric help because she is unable to remember events surrounding her 3year-old son's death after being struck by a car 2 months ago. She is worried that maybe she did something that put him at risk. Except for this brief time period, she is able to recall other events both before and after the tragedy. Of the following treatments, which is the most appropriate to help this patient regain her memory?

  A. electroshock therapy

  B. individual psychotherapy

  C. chlordiazepoxide

  D. sertraline

  E. aripiprazole

  Correct Answer: B

  Individual therapy, which would include exploring the events recalled surrounding the incident, reactions to the child's death, feelings about motherhood, as well as other issues, is considered the most effective treatment for dissociative amnesia. If other symptoms indicate another disorder, then treatment would include appropriate drugs or ECT. In some cases, there is a role for hypnosis or sodium amobarbital interview to help recall. Benzodiazepines may be helpful to reduce anxiety. Integration through psychotherapy of the events of the traumatic episode into one's conscious state is important for recovery.

• Question 280:

  A young mother seeks psychiatric help because she is unable to remember events surrounding her 3year-old son's death after being struck by a car 2 months ago. She is worried that maybe she did something that put him at risk. Except for this brief time period, she is able to recall other events both before and after the tragedy.

  Given the information above, which of the following is the most likely diagnosis?

  A. depersonalization disorder

  B. posttraumatic stress disorder (PTSD)

  C. dissociative amnesia

  D. dissociative fugue

  E. major depression

  Correct Answer: C

  Dissociative amnesia is loss of ability to recall information occurring within a certain time period, usually related to a severely stressful event as occurred with this woman. In depersonalization disorder, a person feels detached from his or her own body or mental processes and feels as if he or she is standing apart and acting as observer. In PTSD, there is a persistent re-experiencing of the traumatic event in a variety of ways, persistent avoidance of stimuli associated with that event, and persistent symptoms of arousal. It is possible for the arousal to be a part of this larger symptom complex. In dissociative fugue, the person forgets his identity, travels, and may even establish a new identity. Symptoms of major depression involve mood, inability to experience pleasure, appetite and sleep disturbance, fatigue, and other disturbances of affect and mood.