USMLE USMLE Certifications USMLE-STEP-2 Questions & Answers

• Question 671:

  A52-year-old woman has had diabetes mellitus since childhood. She has controlled her glucose well and kept her glycohemoglobin (HgbA1C) below 7% (normal, 26%). For which of the following complications is she still at risk, despite excellent glucose control? A. autonomic dysfunction

  A. coronary heart disease

  B. blindness

  C. peripheral neuropathy

  D. peripheral vascular disease

  Correct Answer: B

  Diabetes mellitus is associated with hyperglycemia, disease of the microvasculature (retinopathy, nephropathy, neuropathy), and macrovascular disease, including CAD and peripheral vascular disease, The Diabetes Control and Complications Trial and other studies have demonstrated that tight control can decrease complications of microvascular disease significantly, but it does not seem to reduce CAD mortality to the same extent.

• Question 672:

  A middle-aged White male presents to your office complaining of arthralgias, diarrhea, abdominal pain, and weight loss. On examination, you note generalized increased skin pigmentation.

  Which of the following is true regarding Whipple disease?

  A. Acute renal failure is a common complication.

  B. This disease usually strikes young adults before the third decade.

  C. It is predominantly a disease of women.

  D. Microscopic examination of duodenal biopsies show extensive periodic acid-Schiff (PAS) positive material in the lamina propria and villous atrophy.

  E. It is associated with gram-positive cocci.

  Correct Answer: D

  Whipple disease is a systemic illness characterized by arthralgias, diarrhea, abdominal pain, and weight loss. The usual patient is a middle-aged White male. Reported in 1907 by George Whipple, it has been associated with a gram-positive bacillus related to Actinomycetes. The disease can affect nearly every organ system, although it usually involves the GI tract, heart, and CNS. Renal failure is not a common complication.

• Question 673:

  A42-year-old patient suffering from alcoholism has advanced liver disease with ascites. He is hospitalized for agitation and bizarre behavior. Which of the following findings is most helpful in making the diagnosis of hepatic encephalopathy?

  A. jaundice

  B. asterixis of the hands

  C. spider angiomas on the face and chest

  D. heme-positive stool

  E. positive fluid wave on abdominal examination

  Correct Answer: B

  Hepatic encephalopathy is a syndrome of declining intellectual function, altered state of consciousness, and neurologic abnormalities in the setting of advanced liver disease. Other findings include hyperactivity, delirium, agitation, and personality changes, progressing to confusion, somnolence, and coma. Asterixis (lapses of sustained muscle contraction) or "flapping tremor" is common. Jaundice, spider angiomas, and ascites can be present in alcoholic liver disease without the presence of encephalopathy. Precipitating factors must be looked for and reversed if possible. GI bleeding (due to esophageal varices, gastritis, ulcer, and so forth) increases the nitrogen load in the gut and reduces cerebral perfusion. Excessive diuresis with prerenal azotemia increases extrahepatic circulation of urea and ammonia production, so noncompliance with diuretics would decrease ammonia levels. Lactulose acidifies the stool, traps ammonia and other nitrogenous substances, and decreases their absorption from the gut so excessive lactulose would decrease ammonia levels. Excessive protein intake is a common precipitant.

• Question 674:

  A24-year-old female is infected with HIV from an unprotected sexual exposure. What is the median time for this patient to develop clinical disease if she is not treated?

  A. 6 months

  B. 1 year

  C. 5 years

  D. 10 years

  E. 15 years

  Correct Answer: D

  The median time from initial infection with HIV to the development of clinical disease is 10 years. The rate of disease progression is highly variable and directly correlates with HIV RNA levels. With high levels of HIV RNA, the disease progresses faster. During the asymptomatic period of HIV infection, CD4+ cells decline at an average rate of 50 L per year. Some patients do not progress and show little if any decline in CD4+ counts over time.

• Question 675:

  A 45-year-old man with HIV is being evaluated in the clinic. His HIV diagnosis was made 6 months ago and he wants to know more about medication treatment options. Which of the following is an indication to initiate HIV medication treatment?

  A. CD4 count less than 700

  B. HIV viral load less than 55,000

  C. CD4 count greater than 700

  D. history of hepatitis A

  E. HIV viral load greater than 55,000

  Correct Answer: E

  Adherence to a drug regimen is critical to prevent antiretroviral drug resistance. Treatment usually should be offered to patients who are symptomatic from their HIV infection. Asymptomatic patients should have antiretroviral therapy offered if their CD4 counts are less than 350 or plasma HIV viral load is greater than 50,000 copies. A high viral load (>100,000 copies) correlates with poor prognosis and an increased likelihood of developing opportunistic infections.

• Question 676:

  Apreviously healthy 19-year-old woman has a sudden onset of headache, profound myalgias, profuse vomiting, and diarrhea. The woman is near the end of her menstrual period and is using tampons. She appears to be suffering from toxic shock syndrome (TSS). Which of the following is the most likely skin finding?

  Which of the following is another common finding in TSS and is part of the case definition?

  A. hypertension: systolic BP 160 mmHg

  B. hyperreflexia

  C. fever with temperature 102°F

  D. elevated platelet count 400,000

  E. hypercalcemia

  Correct Answer: C

  Toxin-producing S. aureus organisms have been implicated in the pathogenesis of TSS and are frequently cultured from the vagina and cervix of affected women. There is no diagnostic laboratory test, and diagnosis is based on the typical clinical findings. Diffuse macular erythroderma (sunburn-like rash) occurs in the first few days of illness, followed by desquamation, usually of the palms and soles 12 weeks later. Fever, hypotension, and multiorgan-system involvement (GI, CNS, muscular, renal, hepatic, hematologic) are also part of the case definition. Platelet counts are usually reduced below 100,000. Disorientation may occur but without such focal neurologic signs as hyperreflexia. Complications include shock, arrhythmias, renal failure, respiratory failure, and coagulopathy. Hypercalcemia is not a part of the picture

• Question 677:

  A 40-year-old patient of yours is planning to climb Mt. Everest. Which of the following is considered an important risk factor for highaltitude pulmonary edema?

  A. warm temperature

  B. history of asthma

  C. rate of ascent

  D. tall stature

  E. rate of descent

  Correct Answer: C

  Incidence of high-altitude pulmonary edema is related to the rate of ascent, altitude reached, and degree of exertion. Cold temperature increases pulmonary artery pressure through sympathetic stimulation and is an independent risk factor. Recurrence rate may be as high as 60% in persons with a previous history of highaltitude pulmonary edema. These individuals have reduced ventilatory response to hypoxia and an exaggerated pulmonary pressor response to exercise and hypoxia.

• Question 678:

  Apreviously healthy 19-year-old woman has a sudden onset of headache, profound myalgias, profuse vomiting, and diarrhea. The woman is near the end of her menstrual period and is using tampons. She appears to be suffering from toxic shock syndrome (TSS). Which of the following is the most likely skin finding?

  A. papular rash on the trunk

  B. scaly rash on the face

  C. pustular rash on the extremities

  D. macular erythroderma

  E. heliotrope facial rash

  Correct Answer: D

  Toxin-producing S. aureus organisms have been implicated in the pathogenesis of TSS and are frequently cultured from the vagina and cervix of affected women. There is no diagnostic laboratory test, and diagnosis is based on the typical clinical findings. Diffuse macular erythroderma (sunburn-like rash) occurs in the first few days of illness, followed by desquamation, usually of the palms and soles 12 weeks later. Fever, hypotension, and multiorgan-system involvement (GI, CNS, muscular, renal, hepatic, hematologic) are also part of the case definition.

  Platelet counts are usually reduced below 100,000. Disorientation may occur but without such focal neurologic signs as hyperreflexia. Complications include shock, arrhythmias, renal failure, respiratory failure, and coagulopathy. Hypercalcemia is not a part of the picture.

• Question 679:

  A34-year-old male presents to your clinic with an acute upper respiratory infection (URI). He has a nonproductive cough and no fever. This patient is immunocompetent and has no underlying heart or lung disease. Which of the following is the most appropriate treatment?

  A. 7 days of a macrolide antibiotic

  B. 7 days of a quinolone antibiotic

  C. 5 days of a macrolide antibiotic

  D. 5 days of a quinolone antibiotic

  E. rest and fluids

  Correct Answer: E

  Antibiotics have no role in the treatment of uncomplicated nonspecific URI. In the absence of clinical evidence of bacterial infection, treatment remains entirely symptom-based with use of decongestants and nonsteroidal anti-inflammatory drugs. Other therapies directed at specific symptoms are often useful, including dextromethorphan for cough and lozenges with topical anesthetic for sore throat. Clinical trials of zinc, vitamin C, echinacea, and other alternative remedies have revealed no consistent benefit for the treatment of nonspecific

• Question 680:

  For each antihypertensive agent listed below, select the set of undesirable side effects with which it is most commonly associated with amlodipine

  A. cough, hyperkalemia, angioedema

  B. positive Coombs test, hemolytic anemia, hepatitis

  C. hypokalemia, hyperuricemia, hyperglycemia

  D. peripheral edema, flushing, and constipation

  E. increased angina, tachycardia, systemic lupus erythematosus (SLE)

  Correct Answer: D

  All of the drugs used to treat hypertension can cause adverse reactions, ranging from trivial to life threatening. Thiazide diuretics are associated with hypokalemia, causing arrhythmias; hyperuricemia causing gout; and hyperglycemia due to insulin resistance. The vasodilator hydralazine can cause tachycardia with increased angina and a lupuslike syndrome. As many as 10% of patients on angiotensinconverting enzyme (ACE) inhibitors develop an annoying dry cough. Because they block aldosterone, they can lead to hyperkalemia. ACE inhibitors cause 1025% of all cases of angioedema. Peripheral edema is the most commonly reported side effect of calcium channel blockers, especially amlodipine and nifedipine. Constipation, flushing, and dizziness are also frequently reported. Coombs'-positive hemolytic anemia and hepatitis are idiosyncratic reactions to the central adrenergic-stimulant methyldopa.