USMLE USMLE Certifications USMLE-STEP-3 Questions & Answers

• Question 211:

  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 medications would be most helpful in decreasing her future cravings for alcohol?

  A. disulfiram (Antabuse)

  B. fluoxetine (Prozac)

  C. lithium

  D. naltrexone (ReVia)

  E. risperidone (Risperdal)

  Correct Answer: D 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.

• Question 212:

  The patient is a 52-year-old male presenting to the emergency room with complaints of severe leg pain. The patient states he has had ongoing left knee pain of 6 months' duration, unrelieved by NSAIDs but improved with vicodin. He denies any trauma but claims to have arthritis. His vital signs are stable. Physical examination of his knee demonstrates no significant findings except for decreased range of motion but with little effort. There is no swelling, erythema, or signs of trauma. An x-ray is obtained which is read as "normal," without evidence of arthritis. He asks for narcotic analgesics, but when he is offered a trial of NSAIDs and a referral to a specialty clinic, he becomes angry and walks out of the emergency room. Which of the following would be the most appropriate management should this patient return?

  A. accusation regarding drug-seeking behavior

  B. admission to a psychiatric facility

  C. confrontation and further evaluation

  D. notification of the police

  E. referral to a psychiatrist

  Correct Answer: C Section: (none)

  Explanation: Explanations: This case is a characteristic presentation for malingering. Consciously producing symptoms in order to assume the sick role is the motivation behind factitious disorder. There is no evidence of psychotic symptoms as would be seen in delusional disorder. Hypochondriasis involves the preoccupation with fears of having a serious illness rather than the focus on complaints of pain. The unconscious production of symptoms due to unconscious conflict is the hallmark of conversion disorder, which presents with a neurologic deficit. Malingering, which is not considered a mental illness, is defined as the intentional production of symptoms motivated by external incentives. These incentives may include such things as avoidance of work, military duty, and jail, or the acquisition of drugs (which is seen in the above case) (DSM IV-TR). In cases of suspected malingering, accusations or law enforcement involvement will likely result in further hostility and harm to any therapeutic alliance. Referral for admission to a mental health facility or to a psychiatrist may also have the same effect and is not warranted unless another mental illness or safety concerns are present. While limit setting is absolutely necessary with these individuals, a professional demeanor must be maintained. Gentle confrontation coupled\ with a focus on understanding their underlying problems (leading to their feigning illness) are the most helpful approaches. Amore complete evaluation may be necessary to determine whether or not there is an additional mental illness or substance dependence that will need to be treated.

• Question 213:

  An 8-year-old boy is brought in for evaluation by his parents, who are worried about his behavior in school. Recently, he has become increasingly upset about attending school. Whereas he had always enjoyed being read to as a small child, he has appeared easily frustrated when reading or being asked to write. During those times, he will often disrupt the class, and this has led to his parents being asked to remove him from the school.

  Which of the following additional diagnoses most likely would be present in this patient?

  A. ADHD

  B. autistic disorder

  C. major depressive disorder

  D. mental retardation

  E. tic disorder

  Correct Answer: A Section: (none)

  Explanation: Explanations: This child may have reading disorder, a type of learning disorder characterized by reading achievement below expected given measured intelligence and age (DSM IV-TR). The Bender Visual Motor Gestalt Test is not a diagnostic test, but it may be used to identify perceptual performance difficulties. Projective psychological tests, such as the Children's Apperception Test and the Rorschach, are not useful for intelligence testing. The Reitan-Indiana Neuro-psychological Test is helpful for children with suspected brain damage. In diagnosing learning disorders, it is essential to measure intelligence in order to compare the results with any discrepancies in achievement. The Wechsler Intelligence Scale for Children is one of the most widely used for this purpose. Many patients with learning disorders, such as reading disorder, have comorbid axis I disorders. It is not uncommon to find other learning disorders, such as mathematics disorder, present as well. Conditions such as autistic disorder and mental retardation make it difficult to diagnose a learning disorder. If another deficit in functioning is present, the learning difficulties must be in excess of those assoiated with it (DSM IV-TR). Depressive symptoms are not unusual in individuals with learning disorders, given the problems with school performance and peer relationships. Tic disorders are not significantly increased in those with reading disorder. There is a high level of correlation between ADHD and reading disorder, with figures up to 25%; there may also be a relationship between the etiologies associated with each.

• Question 214:

  The patient is a 52-year-old male presenting to the emergency room with complaints of severe leg pain. The patient states he has had ongoing left knee pain of 6 months' duration, unrelieved by NSAIDs but improved with vicodin. He denies any trauma but claims to have arthritis. His vital signs are stable. Physical examination of his knee demonstrates no significant findings except for decreased range of motion but with little effort. There is no swelling, erythema, or signs of trauma. An x-ray is obtained which is read as "normal," without evidence of arthritis. He asks for narcotic analgesics, but when he is offered a trial of NSAIDs and a referral to a specialty clinic, he becomes angry and walks out of the emergency room.

  Which of the following is the most likely motivation for this patient's presentation?

  A. conscious production of symptoms to assume the sick role

  B. conscious production of symptoms to obtain secondary gain

  C. false belief that he has arthritis

  D. fear that he is suffering from a serious disease

  E. unconscious production of symptoms due to unconscious conflict

  Correct Answer: B Section: (none)

  Explanation: Explanations: This case is a characteristic presentation for malingering. Consciously producing symptoms in order to assume the sick role is the motivation behind factitious disorder. There is no evidence of psychotic symptoms as would be seen in delusional disorder. Hypochondriasis involves the preoccupation with fears of having a serious illness rather than the focus on complaints of pain. The unconscious production of symptoms due to unconscious conflict is the hallmark of conversion disorder, which presents with a neurologic deficit. Malingering, which is not considered a mental illness, is defined as the intentional production of symptoms motivated by external incentives. These incentives may include such things as avoidance of work, military duty, and jail, or the acquisition of drugs (which is seen in the above case) (DSM IV-TR). In cases of suspected malingering, accusations or law enforcement involvement will likely result in further hostility and harm to any therapeutic alliance. Referral for admission to a mental health facility or to a psychiatrist may also have the same effect and is not warranted unless another mental illness or safety concerns are present. While limit setting is absolutely necessary with these individuals, a professional demeanor must be maintained. Gentle confrontation coupled\ with a focus on understanding their underlying problems (leading to their feigning illness) are the most helpful approaches. Amore complete evaluation may be necessary to determine whether or not there is an additional mental illness or substance dependence that will need to be treated.

• Question 215:

  An 8-year-old boy is brought in for evaluation by his parents, who are worried about his behavior in school. Recently, he has become increasingly upset about attending school. Whereas he had always enjoyed being read to as a small child, he has appeared easily frustrated when reading or being asked to write. During those times, he will often disrupt the class, and this has led to his parents being asked to remove him from the school.

  Which of the following tests would be the most useful in the evaluation of this child?

  A. Bender Visual Motor Gestalt Test

  B. Children's Apperception Test

  C. Reitan-Indiana Neuropsychological Test

  D. Rorschach Inkblots Test

  E. Wechsler Intelligence Scale for Children

  Correct Answer: E Section: (none)

  Explanation: Explanations: This child may have reading disorder, a type of learning disorder characterized by reading achievement below expected given measured intelligence and age (DSM IV-TR). The Bender Visual Motor Gestalt Test is not a diagnostic test, but it may be used to identify perceptual performance difficulties. Projective psychological tests, such as the Children's Apperception Test and the Rorschach, are not useful for intelligence testing. The Reitan-Indiana Neuro-psychological Test is helpful for children with suspected brain damage. In diagnosing learning disorders, it is essential to measure intelligence in order to compare the results with any discrepancies in achievement. The Wechsler Intelligence Scale for Children is one of the most widely used for this purpose. Many patients with learning disorders, such as reading disorder, have comorbid axis I disorders. It is not uncommon to find other learning disorders, such as mathematics disorder, present as well. Conditions such as autistic disorder and mental retardation make it difficult to diagnose a learning disorder. If another deficit in functioning is present, the learning difficulties must be in excess of those assoiated with it (DSM IV-TR). Depressive symptoms are not unusual in individuals with learning disorders, given the problems with school performance and peer relationships. Tic disorders are not significantly increased in those with reading disorder.

  There is a high level of correlation between ADHD and reading disorder, with figures up to 25%; there may also be a relationship between the etiologies associated with each.

• Question 216:

  A38-year-old married woman presents to her urgent care clinic complaining of "crying spells" for several weeks since the termination of her employment. She admits to feeling "down all the time." She also has difficulty falling asleep, poor energy, decreased appetite, and is "not able to enjoy anything." She fears that her condition will never improve. She has begun to feel that "it wouldn't matter if I died," but she denies any suicidal plan or intent. She drinks one to two mixed drinks per week and denies any drug use. It is decided to begin antidepressant therapy with paroxetine (Paxil) 20 mg at bedtime.

  Which of the following side effects would be most likely to emerge after several months of treatment?

  A. headache

  B. inhibited orgasm

  C. loose stools

  D. nausea

  E. vivid dreams

  Correct Answer: B Section: (none)

  Explanation:

  This woman likely suffers from major depressive disorder. Treatment with a SSRI is considered to be first-line therapy. Although the neurovegetative symptoms of depression (e.g., insomnia, change in appetite, anergia, poor concentration) can sometimes improve after several days of initiating pharmacotherapy, the feelings of depression and hopelessness may take up to 46 weeks to significantly improve. As long as she is tolerating the SSRI, the urge to quickly increase the dose should be avoided so as to minimize side effects. Upon initiation of a SSRI, education and reassurance should be provided to the patient regarding the expected time until remission. Although there are characteristic side effects, most patients tolerate treatment with SSRIs. Many of these side effects, such as headaches, gastrointestinal disturbances, and vivid dreams, transpire at the start of treatment and may resolve over days to weeks. Sexual dysfunction, such as impotence or inhibited orgasm, not uncommonly occurs after several weeks to months of treatment with SSRIs and can continue with ongoing treatment.

• Question 217:

  A 17-year-old boy is reluctantly taken to the family medicine clinic by his mother, who is upset as "he is hanging out with the wrong crowd." She strongly believes that he has been smoking marijuana every day after school and on weekends with his friends. The patient appears irritated about the appointment but denies using any drugs or alcohol. His mother would like him to be counseled about the potential dangers of "smoking pot."

  Which of the following would be the most serious potential long-term consequence of smoking cannabis in this individual?

  A. amotivational syndrome

  B. cerebral atrophy

  C. chromosomal damage

  D. lung cancer

  E. seizures

  Correct Answer: D Section: (none)

  Explanation:

  Cannabis is one of the few substances of abuse that does not affect the respiratory rate. Consuming marijuana classically produces symptoms of a dry mouth and increased appetite (the munchies). Contrary to what is sometimes claimed, intoxication with cannabis does significantly impair motor function and, therefore, interferes with driving ability. It also can cause tachycardia (DSM IV-TR). Amotivational syndrome is a potential, but controversial, long-term effect of heavy cannabis use. It is characterized by apathy and boredom. Cerebral atrophy, chromosomal damage, and seizures have also been reported, but not confirmed, in individuals with chronic cannabis use. The most concerning medical consequences of smoking cannabis over the long term are similar to those from smoking tobacco, such as lung cancer and respiratory disease.

• Question 218:

  A38-year-old married woman presents to her urgent care clinic complaining of "crying spells" for several weeks since the termination of her employment. She admits to feeling "down all the time." She also has difficulty falling asleep, poor energy, decreased appetite, and is "not able to enjoy anything." She fears that her condition will never improve. She has begun to feel that "it wouldn't matter if I died," but she denies any suicidal plan or intent. She drinks one to two mixed drinks per week and denies any drug use. It is decided to begin antidepressant therapy with paroxetine (Paxil) 20 mg at bedtime.

  If there is no significant improvement in her symptoms, but the medication is tolerated, after what length of time should a dosage increase be considered?

  A. 4 days

  B. 1 week

  C. 2 weeks

  D. 4 weeks

  E. 7 weeks

  Correct Answer: D Section: (none)

  Explanation:

  This woman likely suffers from major depressive disorder. Treatment with a SSRI is considered to be first-line therapy. Although the neurovegetative symptoms of depression (e.g., insomnia, change in appetite, anergia, poor concentration) can sometimes improve after several days of initiating pharmacotherapy, the feelings of depression and hopelessness may take up to 46 weeks to significantly improve. As long as she is tolerating the SSRI, the urge to quickly increase the dose should be avoided so as to minimize side effects. Upon initiation of a SSRI, education and reassurance should be provided to the patient regarding the expected time until remission. Although there are characteristic side effects, most patients tolerate treatment with SSRIs. Many of these side effects, such as headaches, gastrointestinal disturbances, and vivid dreams, transpire at the start of treatment and may resolve over days to weeks. Sexual dysfunction, such as impotence or inhibited orgasm, not uncommonly occurs after several weeks to months of treatment with SSRIs and can continue with ongoing treatment.

• Question 219:

  A 17-year-old boy is reluctantly taken to the family medicine clinic by his mother, who is upset as "he is hanging out with the wrong crowd." She strongly believes that he has been smoking marijuana every day after school and on weekends with his friends. The patient appears irritated about the appointment but denies using any drugs or alcohol. His mother would like him to be counseled about the potential dangers of "smoking pot."

  Which of the following physical effects would be most consistent with cannabis intoxication?

  A. decreased respiration

  B. increased salivation

  C. decreased appetite

  D. normal motor function

  E. tachycardia

  Correct Answer: E Section: (none)

  Explanation:

  Cannabis is one of the few substances of abuse that does not affect the respiratory rate. Consuming marijuana classically produces symptoms of a dry mouth and increased appetite (the munchies). Contrary to what is sometimes claimed, intoxication with cannabis does significantly impair motor function and, therefore, interferes with driving ability. It also can cause tachycardia (DSM IV-TR). Amotivational syndrome is a potential, but controversial, long-term effect of heavy cannabis use. It is characterized by apathy and boredom. Cerebral atrophy, chromosomal damage, and seizures have also been reported, but not confirmed, in individuals with chronic cannabis use. The most concerning medical consequences of smoking cannabis over the long term are similar to those from smoking tobacco, such as lung cancer and respiratory disease.

• Question 220:

  A 6-year-old girl is brought in to the primary care clinic for evaluation by her foster parents, who are concerned that "something is wrong with her." They have noticed odd behavior, with repetitive words and phrases, and difficulty following directions. Her vital signs are normal. Her physical examination is remarkable for a head circumference greater than the 90th percentile but a height less than the 30th percentile, large-appearing ears, and significant flexibility in the joints.

  Which of the following is the most likely comorbid diagnosis in this patient?

  A. anorexia nervosa

  B. ADHD

  C. OCD

  D. oppositional defiant disorder

  E. Tourette disorder

  Correct Answer: B Section: (none)

  Explanation:

  This patient displays the classic phenotype for fragile X syndrome: a large, long head, long ears, short stature, hyperextensible joints, and macro-orchidism (in males). Cri du chat syndrome involves a deletion affecting chromosome 5 and is characterized by microcephaly, low-set ears, and severe mental retardation. Chromosome 21 is involved in Down syndrome, the most common single cause of mental retardation. Patients with Down syndrome exhibit slanted eyes, epicanthal folds, and a flat nose. Fragile X syndrome results from a mutation on the X chromosome. Fragile X syndrome is the second most common single cause of mental retardation, with affected individuals having mild-to-severe mental retardation. It is also associated with various comorbid diagnoses, including learning disorders, autism, and approximately a 75% rate of ADHD.