USMLE USMLE Certifications USMLE-STEP-2 Questions & Answers

• Question 641:

  Select the ONE best lettered option that is most closely associated with the question below. A40-year- old male with purulent, bloody sinus drainage, hemoptysis, and rising creatinine

  A. rheumatoid arthritis

  B. SLE

  C. Wegener's granulomatosus

  D. polyarteritis nodosa

  E. Goodpasture syndrome

  F. fibromyalgia

  G. osteoarthritis (OA)

  H. giant cell arteritis

  I. sarcoidosis

  Correct Answer: C

  Wegener granulomatosis affects males and females equally, can occur at any age, and is extremely rare in African Americans. Patients typically present with severe upper respiratory tract symptoms. Nasal perforation and saddle nose deformity may occur. Pulmonary involvement (cough, hemoptysis, or dyspnea are common presenting symptoms/signs) is present in 8590% of patients, renal disease in 7080% of patients, eye involvement in 5055%, and skin lesions in 4050%. Antineutrophil cytoplasmic antibodies (CANCA) is positive in 90% of patients. ESR typically is high.

• Question 642:

  Select the ONE best lettered option that is most closely associated with the question below. A 32-year-old White female with anemia, arthralgia, alopecia, and RBC casts on urinalysis.

  A. rheumatoid arthritis

  B. SLE

  C. Wegener's granulomatosus

  D. polyarteritis nodosa

  E. Goodpasture syndrome

  F. fibromyalgia

  G. osteoarthritis (OA)

  H. giant cell arteritis

  I. sarcoidosis

  Correct Answer: B

  SLE is characterized by tissue and cell damage from pathogenic autoantibodies and immune complexes. Ninety percent of patients are women in childbearing years and the disease is more common in African Americans. Multiple organ system manifestations can occur, including musculoskeletal (arthralgias, myalgias), cutaneous (malar rash, photosensitivity, hair loss), renal (nephritis, nephritic syndrome), nervous (seizures, headaches), cardiopulmonary (pericarditis, pleuritis), hematologic (anemia, leukopenia)

• Question 643:

  Select the ONE best lettered option that is most closely associated with it. Each lettered option may be selected once, more than once, or not at all.

  A 70-year-old female with headaches and fevers notices visual changes. Her erythrocyte sedimentation rate (ESR) is 125. Most likely she is the victim of

  A. rheumatoid arthritis

  B. SLE

  C. Wegener's granulomatosus

  D. polyarteritis nodosa

  E. Goodpasture syndrome

  F. fibromyalgia

  G. osteoarthritis (OA)

  H. giant cell arteritis

  I. sarcoidosis

  Correct Answer: H

  Giant cell arteritis (aka temporal arteritis) occurs almost exclusively in patients over 55 years of age. The classic clinical findings are fever, anemia, high ESR, and headache. Other anifestations may include malaise, fatigue, anorexia, weight loss, sweat, and arthralgias. Headache may be associated with a tender, thickened, or nodular temporal artery. Diagnosis often is made clinically and can be confirmed by a temporal artery biopsy. Patients respond well to glucocorticoid therapy.

• Question 644:

  A56-year-old man complains of fatigue, dyspnea on exertion, and palpitations. He has had a murmur since childhood. Examination reveals a lift at the left sternal border, split S1, and fixed splitting of S2. There is a grade 3/6 midsystolic pulmonic murmur and a 1/6 middiastolic tricuspid murmur at the lower left sternal border. CXR shows right ventricular enlargement and prominent pulmonary arteries. An ECG demonstrates atrial fibrillation with a RBBB. Which of the following is the most likely diagnosis?

  A. coarctation of the aorta

  B. ASD

  C. patent ductus arteriosus

  D. tetralogy of Fallot

  E. VSD

  Correct Answer: B

  ASD is the second most common form of congenital heart disease in adults, after a bicuspid aortic valve. The murmur heard in childhood is often considered innocent, and symptoms do not appear until adulthood. A left-to-right shunt of blood between the atria causes right ventricular overload and increased pulmonary circulation. These result in the classic findings of a pulmonic systolic ejection murmur, late pulmonic valve closure with wide splitting of S2, and a tricuspid flow murmur. CXR has signs of cardiomegaly and pulmonary overcirculation. Characteristic ECG changes are atrial fibrillation and an incomplete or complete RBBB. In the more common ostium secundum type of ASD, there is often right axis deviation; whereas, the ostium primum type has a left axis deviation pattern.

  Coarctation of the aorta, patent ductus arteriosus, and VSDs are not associated with the findings of the patient described in the question, and tetralogy of Fallot would not present in adulthood.

• Question 645:

  A55-year-old man is being evaluated for gradually increasing shortness of breath. He does not smoke and does not have any significant environmental exposures. Cardiac workup is unremarkable and pulmonary function tests reveal decreased lung volumes and decreased total lung capacity (TLC) and vital capacity. Which of the following is the most likely diagnosis?

  A. chronic pulmonary emboli

  B. obstructive lung disease

  C. adult-onset asthma

  D. tuberculosis

  E. interstitial lung disease (ILD)

  Correct Answer: E

  ILD is characterized by decreased lung volumes including decreased TLC, forced expiratory volume in 1 second (FEV1), and forced vital capacity (FVC). Such patients also have reduced diffusing capacity (DLCO) due to alveolar damage. Causes of ILD include pulmonary diseases such as idiopathic pulmonary fibrosis, connective tissue disorders, and drugs. Extrapulmonary issues from poor breathing mechanics such as scoliosis or myasthenia gravis may also result in a restrictive pattern on PFT testing, however DLCO is normal. Obstructive lung disease is characterized by decreased FEV1 and TLC that is normal or increased.

• Question 646:

  A 24-year-old man is found to be seropositive for HIV on a military induction screening test. Which of the following opportunistic infections is most likely to develop in this patient?

  A. Pneumocystis carinii pneumonia

  B. Candida albicans fungemia

  C. disseminated Mycobacterium aviumintracellulare infection

  D. cryptococcal meningitis

  E. cytomegalovirus retinitis

  Correct Answer: A

  Although thrush and esophagitis attributable to C. albicans are common manifestations of AIDS-related immunodeficiency, fungal dissemination and sepsis are extremely rare. Although not uncommon, opportunistic infections in these patients, disseminated M. aviumintracellulare, cryptococcal meningitis, and cytomegalovirus retinitis, are less common than P. carinii pneumonia. Prior to the HAART (highly active antiretroviral therapy) era, PCP (phencyclidine) was the AIDS defining illness in about 50% of AIDS patients not on PCP prophylaxis. While the number of deaths from PCP has decreased dramatically, it is still a leading cause of death in AIDS

• Question 647:

  A 33-year-old woman complains of generalized, throbbing headache that is worse in the morning and with coughing. She occasionally feels dizzy and nauseated. Examination is significant only for obesity and bilateral papilledema. ACT scan of the head is normal. At lumbar puncture, the opening pressure is 220 mmH2O; CSF is clear, with protein of 12 mg/100 mL (normal, 1545), glucose of 68 mg/100 mL (normal, 4580), and no cells are seen. Which of the following is the most likely diagnosis?

  A. migraine headache

  B. multiple sclerosis

  C. malignant carcinomatosis

  D. pseudotumor cerebri

  E. glaucoma

  Correct Answer: D

  Pseudotumor cerebri is a disorder of increased intracranial pressure that has no obvious cause. The typical patient is an obese young woman who complains of headache and is found to have papilledema. Slight decrease in visual fields and enlargement of blind spots may also be observed. Neurologic examination is otherwise normal, and the patient appears to be healthy. CSF is under increased pressure and may have slightly low protein concentration, but is otherwise normal. CT scan, arteriogram, and other x-ray studies are usually normal. The most serious complication is severe visual loss, which occurs in about 10% of affected persons. Treatment with a carbonic anhydrase inhibitor decreases intracranial pressure by decreasing production of CSF. Weight loss is important but often unsuccessful. If the carbonic anhydrase inhibitor and weight loss fail, or if visual loss develops, lumboperitoneal shunting or optic nerve sheath fenestration are important maneuvers to prevent blindness.

• Question 648:

  A62-year-old man presents with weakness and aching in his hips and shoulders which has progressed over the last few months. He reports generalized fatigue and malaise. Workup includes a normal complete blood count, kidney and liver tests, and a sedimentation rate of 102. Which of the following is the most likely diagnosis?

  A. SLE

  B. diabetes

  C. Wegener's granulomatosis

  D. polymyalgia rheumatica

  E. Graves' disease

  Correct Answer: D

  Polymyalgia rheumatica is characterized by bilateral aching and stiffness of the proximal parts of the arms and thighs with associated weakness and generalized fatigue. The sedimentation rate typically is significantly elevated. This condition can coexist with the syndrome of temporal arteritis (aka giant cell arteritis) which is a chronic vasculitis of largeand medium-sized vessels, usually including cranial branches of the aortic arch arteries. Common symptoms among patients with overlapping temporal arteritis are headache and sudden loss of vision. Graves' disease is an autoimmune thyroid disease and Wegner granulomatosis typically involves the sinuses, lungs, and/or kidneys.

• Question 649:

  A54-year-old woman is brought to the ER with palpitations and dizziness. She has a history of arrhythmia. Adenosine is given and the patient converts to a sinus rhythm. With which of the following rhythms did this patient most likely present to the ER?

  A. ventricular tachycardia

  B. atrial fibrillation

  C. atrial flutter

  D. paroxysmal supraventricular tachycardia

  E. ventricular fibrillation

  Correct Answer: D

  The majority of paroxysmal supraventricular tachycardias respond to adenosine, because they involve a re- entrant circuit including the atrioventricular node. Adenosine is ineffective in the termination of the majority of other atrial or ventricular tachycardias that do not involve the AV node, although it may slow the ventricular response to an atrial tachycardia

• Question 650:

  A 48-year-old man complains of fatigue and shortness of breath. His hematocrit is 32% and hemoglobin is

  10.3 g/100 mL. Peripheral blood smear reveals macrocytosis. His serum vitamin B12 level is 90 pg/mL (normal, 170940); serum folate level is 6 ng/mL (normal, 214). Which of the following is the most likely cause of this patient's symptoms?

  A. poor dietary habits

  B. colonic diverticulosis

  C. regional enteritis

  D. chronic constipation

  E. vagotomy

  Correct Answer: C

  The most common causes of megaloblastic anemia are folate and vitamin B12 deficiencies. Vitamin B12 deficiency rarely results from inadequate intake, but has been associated with strict vegetarianism. Decreased absorption may be due to insufficient intrinsic factor (as in pernicious anemia and after gastrectomy), malabsorption of the intrinsic factor-vitamin B12 complex in the terminal ileum (as in regional enteritis, sprue, pancreatitis, and after ileectomy), or competition for vitamin B12 by gut bacteria (as in the blind loop syndrome and Diphyllobothrium latum infections). Because diverticulosis and constipation do not interfere with stomach or small-bowel functioning, they are not causes of vitamin B12 deficiency.