USMLE USMLE Certifications USMLE-STEP-3 Questions & Answers

• Question 201:

  The patient is a 25-year-old woman recently released from the hospital after her first manic episode. She is currently taking lithium 1200 mg/day, and her lithium level is 1.1 meq/L. She has a slight, but tolerable, tremor and has gained 5 lbs, but she is otherwise olerating the medication. She claims her mood is "pretty good." She is sleeping approximately 7 hours per night. Her energy and concentration are adequate, and she denies racing thoughts, talkativeness, or increased activity. She has no major medical problems, and her only other medication is birth control pills. She does not consume alcohol or drugs. She wonders, "How long will I have to take medications for this problem?"

  This patient returns to the clinic 6 months later. She has continued to take the lithium and her level remains at 1.2 meq/L. She states that for the past several weeks, she has become increasingly sad. She is now sleeping over 10 hours per night but still feels tired. She is having difficulty focusing on her schoolwork, and she doesn't eat more than one meal a day. She has not enjoyed pursuing her usual hobbies and feels that "life is not worth living," although she denies any suicidal plan or intent.

  Which of the following would be the most appropriate next step in the management of this patient?

  A. add lamotrigine (Lamictal)

  B. add sertraline (Zoloft)

  C. add valproate (Depacon)

  D. decrease lithium

  E. increase lithium

  Correct Answer: A Section: (none)

  Explanation: Explanations: This woman has bipolar disorder, most recent episode manic, and she has been stabilized on lithium. Bipolar disorder is a chronic mental illness, with a high number of future episodes (mania and depression) likely. Because of this, after one episode of mania, it is generally recommended to continue on maintenance treatment indefinitely in order to minimize the risk of future recurrences. This woman has now developed an episode of bipolar disorder, depressed. While adding an antidepressant such as sertraline may help the depression, there is always a risk\ of provoking a manic episode. Adding another mood stabilizer in order to treat the depression has little data to support it. Decreasing the lithium will not help her depression, and it may make her more vulnerable to a switch into mania. As her lithium level is therapeutic, increasing the dose will likely only add to her side effects and may lead to toxicity. Lamotrigine has been found to be beneficial in treating bipolar depression and does not appear to increase the likelihood of causing a manic episode, as other antidepressants do. It is recommended as a first-line treatment for depressive episodes in bipolar patients. In fact, it has been shown to be useful in maintenance treatment of bipolar disorder by decreasing the likelihood that a patient experiences a depressive, manic, or mixed episode.

• Question 202:

  A 30-year-old man is seen in the primary care clinic. He complains of 3 months of "feeling down" that began soon after his job loss 6 months ago. His appetite has decreased, and he has noticed his clothes are baggy on him. He has felt extremely distracted and fatigued. He attributes this to waking up at approximately 3:00 a.m. every day and then not falling back to sleep. While he has felt "lower than I've ever been," he denies any suicidal ideation. He does not have any past psychiatric history or current medical problems. He is prescribed mirtazepine (Remeron) 15 mg at bedtime, but he asks, "how long does the medication take to work"?

  His illness is successfully treated and remits for 1 year. He returns to the clinic wishing to stop the medications. He asks whether he needs to take the medications "for the rest of my life." What should he be counseled regarding his approximate risk of recurrence if he discontinues the medication?

  A. 010%

  B. 1030%

  C. 3050%

  D. 5080%

  E. 80100%

  Correct Answer: D Section: (none)

  Explanation: Explanations: This patient presents with a major depressive episode. He is appropriately begun on an antidepressant, namely mirtazepine. With all antidepressants, the first symptoms to improve over days to weeks will be the neurovegetative symptoms such as insomnia, anergia, appetite, and concentration. Unfortunately, the depressed mood and hopelessness are often the last symptoms of depression to remit. Like many other psychiatric as well as medical illnesses, MDD tends to be a recurrent illness. While individual episodes are very treatable, there is a high risk of recurrence without continued treatment. After having a single episode of depression, studies indicate approximately 5085% of individuals will develop subsequent episodes of major depression.

• Question 203:

  The patient is a 25-year-old woman recently released from the hospital after her first manic episode. She is currently taking lithium 1200 mg/day, and her lithium level is 1.1 meq/L. She has a slight, but tolerable, tremor and has gained 5 lbs, but she is otherwise tolerating the medication. She claims her mood is "pretty good." She is sleeping approximately 7 hours per night. Her energy and concentration are adequate, and she denies racing thoughts, talkativeness, or increased activity. She has no major medical problems, and her only other medication is birth control pills. She does not consume alcohol or drugs. She wonders, "How long will I have to take medications for this problem?" How long should she be recommended to continue on maintenance therapy?

  A. 6 months

  B. 1 year

  C. 2 years

  D. 5 years

  E. lifelong

  Correct Answer: E Section: (none)

  Explanation: Explanations: This woman has bipolar disorder, most recent episode manic, and she has been stabilized on lithium. Bipolar disorder is a chronic mental illness, with a high number of future episodes (mania and depression) likely. Because of this, after one episode of mania, it is generally recommended to continue on maintenance treatment indefinitely in order to minimize the risk of future recurrences. This woman has now developed an episode of bipolar disorder, depressed. While adding an antidepressant such as sertraline may help the depression, there is always a risk\ of provoking a manic episode. Adding another mood stabilizer in order to treat the depression has little data to support it. Decreasing the lithium will not help her depression, and it may make her more vulnerable to a switch into mania. As her lithium level is therapeutic, increasing the dose will likely only add to her side effects and may lead to toxicity. Lamotrigine has been found to be beneficial in treating bipolar depression and does not appear to increase the likelihood of causing a manic episode, as other antidepressants do. It is recommended as a first-line treatment for depressive episodes in bipolar patients. In fact, it has been shown to be useful in maintenance treatment of bipolar disorder by decreasing the likelihood that a patient experiences a depressive, manic, or mixed episode.

• Question 204:

  A 30-year-old man is seen in the primary care clinic. He complains of 3 months of "feeling down" that began soon after his job loss 6 months ago. His appetite has decreased, and he has noticed his clothes are baggy on him. He has felt extremely distracted and fatigued. He attributes this to waking up at approximately 3:00 a.m. every day and then not falling back to sleep. While he has felt "lower than I've ever been," he denies any suicidal ideation. He does not have any past psychiatric history or current medical problems. He is prescribed mirtazepine (Remeron) 15 mg at bedtime, but he asks, "how long does the medication take to work"?

  Which of the following symptoms should he be told will most likely improve last?

  A. anergia

  B. hopelessness

  C. insomnia

  D. low concentration

  E. poor appetite

  Correct Answer: B Section: (none)

  Explanation: Explanations: This patient presents with a major depressive episode. He is appropriately begun on an antidepressant, namely mirtazepine. With all antidepressants, the first symptoms to improve over days to weeks will be the neurovegetative symptoms such as insomnia, anergia, appetite, and concentration. Unfortunately, the depressed mood and hopelessness are often the last symptoms of depression to remit. Like many other psychiatric as well as medical illnesses, MDD tends to be a recurrent illness. While individual episodes are very treatable, there is a high risk of recurrence without continued treatment. After having a single episode of depression, studies indicate approximately 5085% of individuals will develop subsequent episodes of major depression.

• Question 205:

  A25-year-old woman returns for her well-baby check 1 week after delivery. The baby has been gaining weight adequately and awakens several times per night to breast feed. Although the mother claims she enjoys being a mom overall, she looks sad and does reluctantly admit to feeling "down" quite a bit. While she feels a great deal of support by her husband, she finds herself crying when alone. Her sleep is erratic, and she often feels tired, but she is eating adequately. She denies significant guilt or any thoughts of suicide or infanticide. What is the appropriate treatment approach for this patient?

  A. antidepressant

  B. hospitalization

  C. mood stabilizer

  D. psychotherapy

  E. reassurance

  Correct Answer: E Section: (none)

  Explanation: Explanations: This woman is likely suffering from "baby blues," which is considered a normal reaction to the stress of the postpartum period. It occurs in up to 50% of women after delivery, usually beginning within several days. It is very important to distinguish this from a major depressive episode, postpartum onset, which requires antidepressant treatment and/or psychotherapy. Hospitalization would be indicated only if there were concerns over suicide, or, in cases of "postpartum psychosis," where psychotic symptoms put the infant in immediate danger. Mood stabilizers would be appropriate if the mood disorder were considered to be a bipolar illness. Baby blues are usually self-limiting and respond to reassurance and support.

• Question 206:

  A74 year-old widowed man presents for evaluation to his physician. He has a history of several episodes of major depression, with one prior hospitalization many years ago although he cannot remember the medication he was prescribed. He complains of 3 months of depression, crying spells, terminal insomnia, poor appetite with weight loss, anhedonia, and passive suicidal ideation without plan. His medical history is significant for hypertension, peripheral vascular disease, hypercholesterolemia, and unstable angina. He is currently prescribed diltiazem, aspirin, metoprolol, and simvastatin. Which of the following antidepressants would be the most appropriate treatment option?

  A. amitriptyline (Elavil)

  B. citalopram (Celexa)

  C. fluoxetine (Prozac)

  D. paroxetine (Paxil)

  E. phenelzine (Parnate)

  Correct Answer: B Section: (none)

  Explanation: Explanations: This patient is having a recurrence of his major depression. While all of the listed antidepressants are equally efficacious, the tricyclics such as amitriptyline and monoamine oxidase inhibitors such as phenelzine are not considered to be first-line treatments. This is especially true in the elderly considering medication side effects, dietary restrictions, druginteractions, and lethality in overdose. The remaining listed serotonin-specific reuptake inhibitors are also equally efficacious, but they inhibit the liver cytochrome P450 enzymes 2D6 and 3A4 to varying degrees. This is especially concerning in this elderly patient who is on a beta-blocker and calcium channel locker, both of which are metabolized by these hepatic enzymes; therefore, blood levels of each can increase appreciably and cause or exacerbate side effects. Fluoxetine inhibits both cytochrome P450 2D6 and 3A4, while paroxetine primarily inhibits cytochrome P450 2D6. Citalopram and sertraline are not believed to considerably inhibit P450 enzymes, so in this patient with polypharmacy, either would be appropriate first choices

• Question 207:

  A 26-year-old divorced woman is brought into the emergency room after being found wandering the streets aimlessly. She is a relatively good historian but gives few spontaneous answers to questions. She describes a 1-year history of the belief that she is being followed by "agents" of the Vatican, who watch her closely to "see if I'm a good Catholic." While they monitor her, they also use radio signals to tell her she is a "whore" and a "slut." Due to these experiences, she has been unable to work. She is afraid to associate with others for fears of being "judged." She denies any medical problems and takes no medications. Her parents were divorced when she was an infant. She does not know anything about her father, but her mother has "manic-depression" and is taking lithium. Her MSE is notable for significant psychomotor slowing, paucity of speech, and a flat affect.

  She is hospitalized and eventually stabilized on quetiapine 400 mg twice daily. As she nears discharge, she asks about her prognosis if she maintains medication compliance. What should she be told about her likelihood of leading a moderately well-functioning life?

  A. 020%

  B. 2040%

  C. 4060%

  D. 6080%

  E. 80100%

  Correct Answer: B Section: (none)

  Explanation: Explanations: This patient likely suffers from schizophrenia. While the paranoid and persecutory delusions, auditory hallucinations, disorganization, and negative symptoms (e.g., alogia) are all commonly seen in schizophrenia, none of these alone is necessary. Her occupational and social dysfunction, however, are necessary criteria when making the diagnosis of schizophrenia (DSM IV-TR). Even with appropriate antipsychotic treatment, the likelihood of maintaining a high level of functioning is low. Studies indicate that with treatment, approximately 50% of patients will still exhibit significant symptomatology and display poor functioning. Only 2040% of patients with schizophrenia will be able to lead somewhat unimpaired lives

• Question 208:

  A 26-year-old man is brought into the emergency room via ambulance, minimally responsive to questioning or examination. According to his girlfriend, he has a history of major depressive disorder as well as alcohol dependence. He was found unconscious with a suicide note and many empty beer bottles. She also believes that he had taken "some other drug" that he purchased from a local drug dealer. Which of the following substances found in urine toxicology would be the most dangerous in this patient?

  A. barbiturate

  B. cannabis

  C. cocaine

  D. opiate

  E. PCP

  Correct Answer: A Section: (none)

  Explanation: Explanations: Even large amounts of cannabis do not cause death. Cocaine, PCP, and opiates can certainly be lethal in overdose, particularly when combined with alcohol. However, because of their similar effects on the GABA (gammaaminobutyric acid) receptors in the brain, barbiturates (and benzodiazepines) are especially deadly when added to alcohol in an overdose

• Question 209:

  A 26-year-old divorced woman is brought into the emergency room after being found wandering the streets aimlessly. She is a relatively good historian but gives few spontaneous answers to questions. She describes a 1-year history of the belief that she is being followed by "agents" of the Vatican, who watch her closely to "see if I'm a good Catholic." While they monitor her, they also use radio signals to tell her she is a "whore" and a "slut." Due to these experiences, she has been unable to work. She is afraid to associate with others for fears of being "judged." She enies any medical problems and takes no medications. Her parents were divorced when she was an infant. She does not know anything about her father, but her mother has "manic-depression" and is taking lithium. Her MSE is notable for significant psychomotor slowing, paucity of speech, and a flat affect.

  Which of the above symptoms or signs is necessary in order to make a diagnosis of schizophrenia?

  A. belief of being followed by the Vatican

  B. inability to work and social dysfunction

  C. psychomotor slowing and paucity of speech

  D. radio signals transmitting curses

  E. wandering in the streets

  Correct Answer: B Section: (none)

  Explanation: Explanations: This patient likely suffers from schizophrenia. While the paranoid and persecutory delusions, auditory hallucinations, disorganization, and negative symptoms (e.g., alogia) are all commonly seen in schizophrenia, none of these alone is necessary. Her occupational and social dysfunction, however, are necessary criteria when making the diagnosis of schizophrenia (DSM IV-TR). Even with appropriate antipsychotic treatment, the likelihood of maintaining a high level of functioning is low. Studies indicate that with treatment, approximately 50% of patients will still exhibit significant symptomatology and display poor functioning. Only 2040% of patients with schizophrenia will be able to lead somewhat unimpaired lives

• Question 210:

  A 54-year-old woman is triaged in the emergency room for nausea and vomiting. Upon examination, she appears somewhat disheveled and anxious, smelling of alcohol. Her sclerae are injected, and she has moderate tenderness to palpation over her upper abdomen, without rebound or guarding. Although she initially denies alcohol use, she eventually concedes that she drinks daily, her last drink being "late last night."

  Which of the following signs or symptoms would most likely occur first in this patient?

  A. delirium

  B. delusions

  C. hallucinations

  D. seizures

  E. tremulousness

  Correct Answer: E Section: (none)

  Explanation:

  Explanations:

  This patient is at risk for alcohol withdrawal. Although the progression of withdrawal may vary, tremors are

  generally the first signs seen. These usually begin 68 hours after cessation of drinking. Psychotic

  symptoms, such as delusions or hallucinations, typically develop 812 hours after cessation. Seizures

  typically occur between 12 and 24 hours, and DTs takes place within 72 hours. (Synopsis, p. 403)

  Disulfiram is used in individuals with alcohol dependence. As it inhibits acetaldehyde dehydrogenase,

  thereby causing a deleterious reaction when combined with alcohol, it is used as a deterrent and not for

  cravings. Antidepressants, lithium, and antipsychotics have not been shown to reduce cravings.

  Naltrexone, an opiate antagonist, has shown small but positive results in promoting abstinence, reducing

  heavy drinking days, and blunting cravings. The presumed mechanism involves the blockade of opiate receptors, thereby interfering with the euphoric and rewarding effects of alcohol.