USMLE USMLE Certifications USMLE-STEP-2 Questions & Answers

• Question 281:

  Apatient reports that, on his way to the hospital, he saw a man feeding two squirrels in the park. He says that this means his future will be decided in 2 weeks. This man, he believes, is deliberately out to alarm him (the patient). One of the squirrels is scheming with the man; the other is innocent and trusting. Which of the following terms best describes what this man is experiencing?

  A. illusions

  B. hallucinations

  C. delusions

  D. loosened associations

  E. neologisms

  Correct Answer: C

  Delusions are false ideas that cannot be corrected by reasoning and that are not based on reality. Psychotic patients often experience ideas or delusions of reference and misinterpret incidents or events in the outside world as having direct personal reference to themselves. Delusions may occur in a variety of psychiatric disorders, including schizophrenia, paranoia, mania, depression, and organic brain syndromes. The bizarre nature of the delusion described in the question is more characteristic of schizophrenia than of other types of psychiatric ailments. Illusions are sensory misperceptions that occasionally may be experienced even by normal individuals. Psychotic persons may report hallucinations, which are sensory experiences that cannot be substantiated by normal observers. Loosened associations and neologisms are patterns of speech often noted in psychotic individuals.

• Question 282:

  A 25-year-old Caucasian man reports that he has got in trouble with the law as a result of his rubbing up against a woman he did not know in an elevator at work. Recurrent, intense sexually arousing fantasies, sexual urges, or behaviors involving touching and rubbing against a nonconsenting person, such as a stranger in an elevator, which occur for at least 6 months and which cause significant impairment in an individual's functioning are best characterized as which of the following?

  A. exhibitionism

  B. fetishism

  C. frotteurism

  D. pedophilia

  E. sexual masochism

  Correct Answer: C

  Frotteurism is the term given to obtaining sexual gratification by rubbing. It is usually the only source of sexual gratification for the man involved, who rubs his penis against the buttocks or other bodily part of a fully clothed woman to achieve orgasm. Exhibitionism is the exposure of one's genitals to an unsuspecting person. Fetishism is the term for intense sexual fantasies and behaviors involving the use of nonliving objects, such as female undergarments. Pedophilia is the term for intense sexual urges toward children 13 years of age or younger, and sexual masochism is the term for sexual arousal involving the real act of being humiliated, beaten, bound, or otherwise made to suffer.

• Question 283:

  A 70-year-old female with chronic paranoid schizophrenia presents to the ER acutely confused with visual hallucinations. Her skin is warm and dry and her heart rate is 110 beats per minute. Her group home nurse tells you that the patient had been complaining of having a dry mouth and having difficulty initiating urination this past week. Which of the following is the treatment of choice for this patient's acute condition?

  A. bethanechol

  B. haldoperidol

  C. physostigmine

  D. bromocriptine

  E. dantrolene

  Correct Answer: C

  Severe anticholinergic reactions, such as delirium, should be treated with intramuscular or intravenous injection of physostigmine, 12 mg IV (1 mg every 2 minutes) or IM every 3060 minutes. The first dose should be repeated in 1520 minutes if no improvement is seen. Such peripheral anticholinergic side effects as urinary retention can be treated with bethanechol. Dantrolene and bromocriptine, not effective in the treatment of anticholinergic reactions, are two drugs that have been tried in the treatment of NMS, a rare but extremely dangerous neuroleptic-induced disorder. Haldol, having anticholinergic effects, is contraindicated.

• Question 284:

  A 70-year-old female with chronic paranoid schizophrenia presents to the ER acutely confused with visual hallucinations. Her skin is warm and dry and her heart rate is 110 beats per minute. Her group home nurse tells you that the patient had been complaining of having a dry mouth and having difficulty initiating urination this past week. Which of the following is the most likely cause for this presentation?

  A. psychotic exacerbation of schizophrenia

  B. urinary tract infection

  C. Alzheimer dementia

  D. anticholinergic delirium

  E. myocardial infection

  Correct Answer: D

  Acute confusion with visual hallucinations would be characteristic of a delirium. Warm and dry skin, tachycardia, dry mouth, constipation, and urinary retention are anticholinergic side effects. Many antipsychotics are anticholinergic, and when Parkinsonian EPS present, anticholinergic medicines are often added to reverse these side effects. These anticholinergic effects can be additive and can cause delirium.

• Question 285:

  Identify the most likely diagnosis with the case descriptions below.

  A 40-year-old woman is brought to the emergency department after she had frantically called the paramedics because she thought she would die. She was experiencing sharp chest pain, shortness of breath, racing heartbeat, and cold, sweaty chills. Cardiac assessment proved negative for myocardial ischemia.

  A. body dysmorphic disorder

  B. conversion disorder

  C. factitious disorder

  D. hypochondriasis

  E. malingering

  F. pain disorder

  G. panic disorder

  H. somatization disorder

  Correct Answer: G

  Complaints involving both psychological and medical conditions are difficult to diagnose and treat. At times, medically identifiable causes are present, but the psychological factors contributing to the discomfort complicate the diagnosis and treatment and lead to frustration in both physician and patient. At other times, no identifiable cause for pain or other physical symptoms can be found; nevertheless, the patient still has the symptoms. Questions arise:

  Is the patient lying? Is there some deep psychological problem? Could there be a medical disorder in the early stages of development that gives rise to physical symptoms but no clear physical signs to make the diagnosis? One group of psychiatric disorders addresses some of these issues--the somatoform disorders. Somatization disorder is an axis I psychiatric disorder where a patient complains of multiple somatic complaints involving multiple organ systems, but which cannot be explained by physical and/or laboratory findings. Conversion disorder is another axis I disorder where there is a disturbance of bodily function that does not conform to anatomic or neurologic concepts, and it is due to psychological factors. Body dysmorphic disorder is a pervasive subjective feeling/belief that some aspect of the patient's appearance is ugly or deformed. Hypochondriasis is a persistent belief in the presence of one or two serious physical diseases despite medical assurance that one does not have the disease/illness. Pain disorder (somatoform pain disorder) is a disorder with the presence of severe, distressing and persistent pain which cannot be explained adequately by evidence of a physiologic process or physical disorder. Panic disorder is a kind of anxiety disorder. Discrete periods of extreme sympathetic nervous system symptoms occur, including tachycardia, sweating, shortness of breath, and others, during which time a person experiences extreme fear. Malingering is the deliberate manufacture of false or exaggerated symptoms for financial gain or to avoid an unpleasant situation such as jail time or military duty. In a factitious disorder, there is the deliberate production of signs and symptoms of illness in order to assume the sick role.

• Question 286:

  Identify the most likely diagnosis with the case descriptions below.

  A55-year-old man requests "some kind of pain medication that really works!" to relieve the "extreme" pain in his foot. He walks with a cane. He angrily claims that his previous employer did not care about what happened to him in an accident 1 year earlier in which his foot was struck by an iron rod. No fracture was found. He claims his doctor said he had a "severe contusion" and then states "the doctor didn't know anything."

  A. body dysmorphic disorder

  B. conversion disorder

  C. factitious disorder

  D. hypochondriasis

  E. malingering

  F. pain disorder

  G. panic disorder

  H. somatization disorder

  Correct Answer: E

  Complaints involving both psychological and medical conditions are difficult to diagnose and treat. At times, medically identifiable causes are present, but the psychological factors contributing to the discomfort complicate the diagnosis and treatment and lead to frustration in both physician and patient. At other times, no identifiable cause for pain or other physical symptoms can be found; nevertheless, the patient still has the symptoms. Questions arise:

  Is the patient lying? Is there some deep psychological problem? Could there be a medical disorder in the early stages of development that gives rise to physical symptoms but no clear physical signs to make the diagnosis? One group of psychiatric disorders addresses some of these issues--the somatoform disorders. Somatization disorder is an axis I psychiatric disorder where a patient complains of multiple somatic complaints involving multiple organ systems, but which cannot be explained by physical and/or laboratory findings. Conversion disorder is another axis I disorder where there is a disturbance of bodily function that does not conform to anatomic or neurologic concepts, and it is due to psychological factors. Body dysmorphic disorder is a pervasive subjective feeling/belief that some aspect of the patient's appearance is ugly or deformed. Hypochondriasis is a persistent belief in the presence of one or two serious physical diseases despite medical assurance that one does not have the disease/illness. Pain disorder (somatoform pain disorder) is a disorder with the presence of severe, distressing and persistent pain which cannot be explained adequately by evidence of a physiologic process or physical disorder. Panic disorder is a kind of anxiety disorder. Discrete periods of extreme sympathetic nervous system symptoms occur, including tachycardia, sweating, shortness of breath, and others, during which time a person experiences extreme fear. Malingering is the deliberate manufacture of false or exaggerated symptoms for financial gain or to avoid an unpleasant situation such as jail time or military duty. In a factitious disorder, there is the deliberate production of signs and symptoms of illness in order to assume the sick role.

• Question 287:

  Identify the most likely diagnosis with the case descriptions below.

  A 35-year-old woman complains that she has been to multiple doctors, none of whom have been able to effectively treat or even diagnose the cause of her chronic stomach pain and diarrhea, repeated problems swallowing, headache, and recurrent back pain. The symptoms have been present on and off for most of her adult life.

  A. body dysmorphic disorder

  B. conversion disorder

  C. factitious disorder

  D. hypochondriasis

  E. malingering

  F. pain disorder

  G. panic disorder

  H. somatization disorder

  Correct Answer: H

  Complaints involving both psychological and medical conditions are difficult to diagnose and treat. At times, medically identifiable causes are present, but the psychological factors contributing to the discomfort complicate the diagnosis and treatment and lead to frustration in both physician and patient. At other times, no identifiable cause for pain or other physical symptoms can be found; nevertheless, the patient still has the symptoms. Questions arise:

  Is the patient lying? Is there some deep psychological problem? Could there be a medical disorder in the early stages of development that gives rise to physical symptoms but no clear physical signs to make the diagnosis? One group of psychiatric disorders addresses some of these issues--the somatoform disorders. Somatization disorder is an axis I psychiatric disorder where a patient complains of multiple somatic complaints involving multiple organ systems, but which cannot be explained by physical and/or laboratory findings. Conversion disorder is another axis I disorder where there is a disturbance of bodily function that does not conform to anatomic or neurologic concepts, and it is due to psychological factors. Body dysmorphic disorder is a pervasive subjective feeling/belief that some aspect of the patient's appearance is ugly or deformed. Hypochondriasis is a persistent belief in the presence of one or two serious physical diseases despite medical assurance that one does not have the disease/illness. Pain disorder (somatoform pain disorder) is a disorder with the presence of severe, distressing and persistent pain which cannot be explained adequately by evidence of a physiologic process or physical disorder. Panic disorder is a kind of anxiety disorder. Discrete periods of extreme sympathetic nervous system symptoms occur, including tachycardia, sweating, shortness of breath, and others, during which time a person experiences extreme fear. Malingering is the deliberate manufacture of false or exaggerated symptoms for financial gain or to avoid an unpleasant situation such as jail time or military duty. In a factitious disorder, there is the deliberate production of signs and symptoms of illness in order to assume the sick role.

• Question 288:

  Identify the most likely diagnosis with the case descriptions below. A 23-year-old violinist reports to his neurologist that he thinks he has had a stroke. He is unable to feel anything with his left fingers and is barely able to hold down the violin strings with this same hand because of "paralysis." The numbness he describes reaches to his wrist only, and he "even feels a band" around the wrist delineating the sensitive from the insensitive areas.

  A. body dysmorphic disorder

  B. conversion disorder

  C. factitious disorder

  D. hypochondriasis

  E. malingering

  F. pain disorder

  G. panic disorder

  H. somatization disorder

  Correct Answer: B

  Complaints involving both psychological and medical conditions are difficult to diagnose and treat. At times, medically identifiable causes are present, but the psychological factors contributing to the discomfort complicate the diagnosis and treatment and lead to frustration in both physician and patient. At other times, no identifiable cause for pain or other physical symptoms can be found; nevertheless, the patient still has the symptoms. Questions arise:

  Is the patient lying? Is there some deep psychological problem? Could there be a medical disorder in the early stages of development that gives rise to physical symptoms but no clear physical signs to make the diagnosis? One group of psychiatric disorders addresses some of these issues--the somatoform disorders. Somatization disorder is an axis I psychiatric disorder where a patient complains of multiple somatic complaints involving multiple organ systems, but which cannot be explained by physical and/or laboratory findings. Conversion disorder is another axis I disorder where there is a disturbance of bodily function that does not conform to anatomic or neurologic concepts, and it is due to psychological factors. Body dysmorphic disorder is a pervasive subjective feeling/belief that some aspect of the patient's appearance is ugly or deformed. Hypochondriasis is a persistent belief in the presence of one or two serious physical diseases despite medical assurance that one does not have the disease/illness. Pain disorder (somatoform pain disorder) is a disorder with the presence of severe, distressing and persistent pain which cannot be explained adequately by evidence of a physiologic process or physical disorder. Panic disorder is a kind of anxiety disorder. Discrete periods of extreme sympathetic nervous system symptoms occur, including tachycardia, sweating, shortness of breath, and others, during which time a person experiences extreme fear. Malingering is the deliberate manufacture of false or exaggerated symptoms for financial gain or to avoid an unpleasant situation such as jail time or military duty. In a factitious disorder, there is the deliberate production of signs and symptoms of illness in order to assume the sick role.

• Question 289:

  Identify the most likely diagnosis with the case descriptions below.

  Despite repeated efforts to reassure a 40-yearold woman that the stomach pain she is experiencing is not cancerous, she continues to worry and fears that she will die.

  A. body dysmorphic disorder

  B. conversion disorder

  C. factitious disorder

  D. hypochondriasis

  E. malingering

  F. pain disorder

  G. panic disorder

  H. somatization disorder

  Correct Answer: D

  Complaints involving both psychological and medical conditions are difficult to diagnose and treat. At times, medically identifiable causes are present, but the psychological factors contributing to the discomfort complicate the diagnosis and treatment and lead to frustration in both physician and patient. At other times, no identifiable cause for pain or other physical symptoms can be found; nevertheless, the patient still has the symptoms. Questions arise:

  Is the patient lying? Is there some deep psychological problem? Could there be a medical disorder in the early stages of development that gives rise to physical symptoms but no clear physical signs to make the diagnosis? One group of psychiatric disorders addresses some of these issues--the somatoform disorders.

  Somatization disorder is an axis I psychiatric disorder where a patient complains of multiple somatic complaints involving multiple organ systems, but which cannot be explained by physical and/or laboratory findings. Conversion disorder is another axis I disorder where there is a disturbance of bodily function that does not conform to anatomic or neurologic concepts, and it is due to psychological factors. Body dysmorphic disorder is a pervasive subjective feeling/belief that some aspect of the patient's appearance is ugly or deformed. Hypochondriasis is a persistent belief in the presence of one or two serious physical diseases despite medical assurance that one does not have the disease/illness. Pain disorder (somatoform pain disorder) is a disorder with the presence of severe, distressing and persistent pain which cannot be explained adequately by evidence of a physiologic process or physical disorder. Panic disorder is a kind of anxiety disorder. Discrete periods of extreme sympathetic nervous system symptoms occur, including tachycardia, sweating, shortness of breath, and others, during which time a person experiences extreme fear. Malingering is the deliberate manufacture of false or exaggerated symptoms for financial gain or to avoid an unpleasant situation such as jail time or military duty. In a factitious disorder, there is the deliberate production of signs and symptoms of illness in order to assume the sick role.

• Question 290:

  A 35-year-old man with no previous psychiatric history is referred by his family physician for psychiatric evaluation. The family physician has been following the man for mild hyperlipidemia, which is currently being successfully treated with dietary changes alone. The man reports that he has been happily married for 10 years and has two children. He has been working as an accountant and has generally enjoyed his job. About 2 months ago, with no obvious precipitating event, he says, the man began to feel very blue, with a drop in his desire to play with his children and to compete in his usual volleyball league games. He reports that he has lost most of his libido and is having difficulty sleeping, with earlymorning wakening. He reports that his appetite has become very poor over the past 2 months, and he estimates that he has lost 10 lbs over that time. Of the following, which would be the most appropriate initial treatment for this patient?

  A. electroconvulsive therapy (ECT)

  B. clozapine

  C. diazepam

  D. fluoxetine

  E. buspirone

  Correct Answer: D

  The most appropriate initial therapy for this man would be antidepressant medication with a medication such as fluoxetine, an SSRI with a relatively benign side effect profile in most patients. SSRIs produce antidepressant response rates approaching 70%. The addition of psychotherapy to help the patient get through his depression would likely be helpful. Although ECT is the most dependably effective treatment for major depression, it has significant side effects, such as short-term memory loss. The absence of severe suicidal tendencies in this patient means that ECT should be reserved for possible later use, should two different antidepressant medications fail. Clozapine, diazepam, and buspirone do little by themselves to alleviate a depressive mood.