USMLE USMLE Certifications USMLE-STEP-3 Questions & Answers

• Question 241:

  A 12-year-old boy is brought into the office by his mother, who states, "I can't deal with this anymore!" She appears exasperated, claiming that her son has been getting into more and more trouble over the past 15 months since the finalization of a particularly long and difficult divorce. He has been leaving the house at night without notifying his mother or telling her of his whereabouts. She suspects that he is responsible for the increased vandalism in the neighborhood. He has recently been caught shoplifting at a nearby store. His grades have always been poor, but he has just been suspended for missing classes and skipping school over the past year. He has often come home with evidence of having been in fights. She suspects that he may be hanging out with gang members. She is afraid of his ending up in jail and "becoming like his father."

  If untreated, which of the following diagnoses is most likely to transpire in this patient?

  A. alcohol dependence

  B. oppositional defiant disorder

  C. panic disorder

  D. schizoid personality disorder

  E. schizophrenia

  Correct Answer: A Section: (none)

  Explanation:

  This patient exhibits the criteria for conduct disorder. Antisocial personality disorder can only be diagnosed in a person who is over age 18. In fact, the diagnosis of antisocial personality disorder requires evidence of conduct disorder prior to age 15 (DSM IV-TR). Children with autism, schizophrenia, and mental retardation may display aggressive or disruptive behavior, but these illnesses do not necessarily predict future conduct disorder. Patients with ADHD and learning disorders are at an increased risk of developing conduct disorder as they get older.

  It is not uncommon for patients with conduct disorder to have a history of oppositional defiant disorder as a younger child. Indeed, the disorders are often thought of as being on a spectrum, with oppositional defiant disorder early on, followed by conduct disorder and eventually antisocial personality disorder. Having conduct disorder does not by itself predict panic disorder, schizoid personality disorder, or the development of schizophrenia. If left untreated, there is a significantly increased risk of developing a substance use disorder, which also predicts a worse prognosis

• Question 242:

  The patient is a 70-year-old man brought to the primary care clinic by his family over concerns that he has Alzheimer's disease. They have noticed a worsening of his memory over the past 6 months. He does not seem to want to get out of bed, and he appears to have difficulty providing for his basic needs such as cleaning, dressing, and cooking for himself. He is hesitant when talking, but it is unclear whether he is unable or unmotivated to speak. His family has also noticed that he appears depressed and is often seen crying. A MSE of the patient is performed to help determine whether he is suffering from a dementing illness or a depressive illness (pseudodementia).

  Further history, cognitive examinations, physical examination, and laboratory/radiographic studies are obtained. The results are consistent with Alzheimer's dementia. While the family had been able to take care of him initially, they have since returned to the clinic stating that they can no longer keep him at home. They feel that he is becoming much more agitated. He is staying up at night. Lately he has been rearranging the furniture, claiming to look for "the little people who are teasing me." They have noticed that he has difficulty walking, often moving slowly and dropping items. The family has pursued nursing home placement, but they wish to have something prescribed in order to help him sleep and keep him calm.

  Which of the following medications should be avoided in this patient?

  A. buspirone (Buspar)

  B. donepezil (Aricept)

  C. lorazepam (Ativan)

  D. trazodone (Desyrel)

  E. risperidone (Risperdal)

  Correct Answer: E Section: (none)

  Explanation:

  Older patients with cognitive decline due to depression, sometimes called pseudodementia, display characteristic findings on MSE. They usually are greatly concerned about their problems, even emphasizing their difficulties when compared with demented patients, who attempt to hide or minimize their deficits and appear unconcerned. Patients with pseudodementia are able to attend well to tasks despite their cognitive complaints. Individuals with dementias, however, have significant difficulty with attention and concentration. Patients with depression are more likely to demonstrate good insight into their presumed memory loss than those with dementia, who will commonly deny that there is anything wrong with them. On tests of cognition, those individuals with pseudodementia will show inconsistent results, performing better at some times and worse at others. Patients with dementia, however, will consistently perform poorly on various tests that address the same function. This patient displays characteristics of Lewy body disease, a dementia which may be related to Alzheimer's dementia. The classic triad of Lewy body dementia is a fluctuating course, peduncular hallucinations (visual hallucinations of small people, animals, or objects), and parkinsonian features. These patients tend to be very sensitive to extrapyramidal side effects and, therefore, antipsychotics such as risperidone should be avoided or sparingly used.

• Question 243:

  The patient is a 70-year-old man brought to the primary care clinic by his family over concerns that he has Alzheimer's disease. They have noticed a worsening of his memory over the past 6 months. He does not seem to want to get out of bed, and he appears to have difficulty providing for his basic needs such as cleaning, dressing, and cooking for himself. He is hesitant when talking, but it is unclear whether he is unable or unmotivated to speak. His family has also noticed that he appears depressed and is often seen crying. A MSE of the patient is performed to help determine whether he is suffering from a dementing illness or a depressive illness (pseudodementia).

  Which of the following characteristics on MSE is most consistent with pseudodementia?

  A. appears unconcerned during examination

  B. attends poorly to questions on MSE

  C. displays poor insight into symptoms

  D. gives "don't know" answers to questions

  E. consistently performs poorly to tasks

  Correct Answer: D Section: (none)

  Explanation:

  Older patients with cognitive decline due to depression, sometimes called pseudodementia, display characteristic findings on MSE. They usually are greatly concerned about their problems, even emphasizing their difficulties when compared with demented patients, who attempt to hide or minimize their deficits and appear unconcerned. Patients with pseudodementia are able to attend well to tasks despite their cognitive complaints. Individuals with dementias, however, have significant difficulty with attention and concentration. Patients with depression are more likely to demonstrate good insight into their presumed memory loss than those with dementia, who will commonly deny that there is anything wrong with them. On tests of cognition, those individuals with pseudodementia will show inconsistent results, performing better at some times and worse at others. Patients with dementia, however, will consistently perform poorly on various tests that address the same function. This patient displays characteristics of Lewy body disease, a dementia which may be related to Alzheimer's dementia. The classic triad of Lewy body dementia is a fluctuating course, peduncular hallucinations (visual hallucinations of small people, animals, or objects), and parkinsonian features. These patients tend to be very sensitive to extrapyramidal side effects and, therefore, antipsychotics such as risperidone should be avoided or sparingly used.

• Question 244:

  A30-year-old separated female with borderline personality disorder is brought in by her roommate after she admitted to feeling suicidal and taking several handfuls of "an old prescription" some hours ago. Her vitals demonstrate a slight fever, elevated BP, and tachycardia. On physical examination, her pupils are dilated, she has a tremor, and she complains of "seeing scary faces." She also has noticeably dry mucous membranes.

  Which of the following medications should be immediately administered in the above case?

  A. benztropine

  B. flumazenil

  C. naloxone

  D. phentolamine

  E. physostigmine

  Correct Answer: E Section: (none)

  Explanation:

  Overdose of benzodiazepines such as alprazolam would cause depressed rather than elevated vitals, as well as somnolence and ataxia. Opiates such as oxycodone, taken in large amounts, cause the classic triad of miosis, respiratory depression, and coma. Risperidone may cause excess sedation or orthostasis, but in high doses it may also cause extra-pyramidal symptoms including dystonic reactions. Monoamine oxidase inhibitors (MAOIs) such as tranylcypromine, when taken with tyraminerich foods, are likely to cause a hypertensive crisis consisting of hypertension, headache, stiff neck, sweating, and nausea/ vomiting. Tricyclic antidepressants such as amitryptyline have significant anticholinergic toxicity which can cause dry skin, dry mucous membranes, hyperpyrexia, tachycardia, mydriasis, restlessness, and psychotic symptoms such as hallucinations. Benztropine is indicated for the treatment of extra-pyramidal symptoms, such as acute dystonia. Flumazenil is used in benzodiazepine intoxication. Naloxone is the treatment of choice for opiate overdose. Phentolamine or other alpha-adrenergic blockers are employed to treat hypertensive crisis. Physostigmine is considered the treatment of choice for anticholinergic toxicity.

• Question 245:

  A30-year-old separated female with borderline personality disorder is brought in by her roommate after she admitted to feeling suicidal and taking several handfuls of "an old prescription" some hours ago. Her vitals demonstrate a slight fever, elevated BP, and tachycardia. On physical examination, her pupils are dilated, she has a tremor, and she complains of "seeing scary faces." She also has noticeably dry mucous membranes.

  Which of the following medications did this patient most likely ingest?

  A. alprazolam

  B. amitryptyline

  C. oxycodone

  D. risperidone

  E. tranylcypromine

  Correct Answer: B Section: (none)

  Explanation:

  Overdose of benzodiazepines such as alprazolam would cause depressed rather than elevated vitals, as well as somnolence and ataxia. Opiates such as oxycodone, taken in large amounts, cause the classic triad of miosis, respiratory depression, and coma. Risperidone may cause excess sedation or orthostasis, but in high doses it may also cause extra-pyramidal symptoms including dystonic reactions. Monoamine oxidase inhibitors (MAOIs) such as tranylcypromine, when taken with tyraminerich foods, are likely to cause a hypertensive crisis consisting of hypertension, headache, stiff neck, sweating, and nausea/ vomiting. Tricyclic antidepressants such as amitryptyline have significant anticholinergic toxicity which can cause dry skin, dry mucous membranes, hyperpyrexia, tachycardia, mydriasis, restlessness, and psychotic symptoms such as hallucinations. Benztropine is indicated for the treatment of extra-pyramidal symptoms, such as acute dystonia. Flumazenil is used in benzodiazepine intoxication. Naloxone is the treatment of choice for opiate overdose. Phentolamine or other alpha-adrenergic blockers are employed to treat hypertensive crisis. Physostigmine is considered the treatment of choice for anticholinergic toxicity.

• Question 246:

  A 29-year-old married male is seen in the emergency room with the chief complaint of, "I'm afraid I'm having a heart attack." He states a 2-month history of experiencing recurrent episodes of chest pain and shortness of breath that last 1020 minutes. He also describes associated tachypnea, lightheadedness, tingling in his extremities, nausea, diaphoresis, anxiety, and fears that he may die. These symptoms are now occurring almost daily but are not provoked by any situations or activities such as exertion or exercise. He is significantly worried about having future episodes and is genuinely concerned that he will suffer a myocardial infarction. He denies having any medical illnesses or taking any medications. He drinks three beers on the weekends only and does not use illicit drugs. His physical examination reveals a slightly elevated BP and pulse. An ECG demonstrates sinus tachycardia

  Which of the following medications would be most appropriate in the long-term management of this patient's symptoms?

  A. bupropion

  B. buspirone

  C. imipramine

  D. lorazepam

  E. paroxetine

  Correct Answer: E Section: (none)

  Explanation:

  This patient is most likely experiencing panic attacks as part of panic disorder. Dopaminergic antidepressants such as bupropion have not demonstrated significant efficacy in panic disorder. Buspirone is approved in the treatment of GAD but is not useful in panic disorder. While tricyclic antidepressants, such as imipramine, and SSRIs, such as paroxetine, are both effective in the treatment of panic disorder, therapeutic benefit for both may require several weeks. Benzodiazepines, such as lorazepam and alprazolam, have been shown to be effective in the treatment of panic disorder. Their more rapid onset of action (hours to days) make them ideally suited for the immediate and acute management of panic attacks. Neither bupropion nor buspirone are considered to be first-line treatments for panic disorder. Imipramine and other tricyclic antidepressants have demonstrated their efficacy in panic disorder. The disadvantages are several: the need to increase up to a therapeutic dose over time, a significant side effect profile, and lethality in overdose. While benzodiazepines such as alprazolam are also effective in the long-term treatment of panic disorder, their potential for abuse and withdrawal if/when tapered make them less than ideal overall. It is not unusual to initiate a benzodiazepine for more immediate relief of anxiety along with another agent that will require a longer time period until its benefits become apparent. Given their proven efficacy, reduced side effects, lack of abuse potential and safety in overdose, SSRIs such as paroxetine are the most suitable choice for the long-term pharmacotherapy of panic disorder.

• Question 247:

  A 55-year-old lawyer without past psychiatric history presents to her internist with complaints of insomnia. Since her husband suddenly passed away 5 weeks ago, she has had difficulty sleeping, frequently awakening throughout the evening. She subsequently finds herself tired during the day. When asked about her mood, she states that she is "sad" and will often break down in tears when thinking about her husband. Although she feels that her job occupies her mind, she describes being distracted and making minor mistakes at work. Her appetite has diminished, but her weight has not changed. While she feels "lost" and that her life is not enjoyable without him, she denies any suicidal ideation. She reluctantly admits to occasionally hearing her husband calling her name at nighttime. She understands that it is not real but still finds it comforting for her.

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

  A. hospitalize her for further evaluation and treatment

  B. initiate treatment with an antidepressant alone

  C. initiate treatment with an antidepressant and antipsychotic

  D. monitor her symptoms over the next several weeks

  E. refer her to a psychiatrist for medication management

  Correct Answer: D Section: (none)

  Explanation:

  This is a woman who is suffering from bereavement, which is not a diagnosable mental illness. Bereavement is considered to be a normal grief reaction to the death of a loved one. Hospitalization would only be indicated if the patient were imminently dangerous to herself (or others) or if she were unable to take care of herself. As she is not suicidal and is functioning adequately at work, hospitalization would be neither necessary nor helpful. Beginning an antidepressant would be appropriate if treating major depressive disorder. While she exhibits some symptoms consistent with MDD, it has been less than 2 months since the sudden death of her spouse and her complaints are not as pervasive as those seen in MDD (DSM IV-TR). Another factor favoring bereavement over major depressive disorder in this patient is the lack of a prior history of depression or current suicidality. Pharmacotherapy with both an antidepressant plus antipsychotic would be the treatment of choice if she were suffering from major depressive disorder with psychotic features.

  Although she does have occasional perceptual disturbances, this phenomenon is not unusual in uncomplicated bereavement. Her insight and lack of other psychotic symptoms, such as delusions or disorganization, are not consistent with a major psychotic illness. Individuals with bereavement do not usually require referral to a psychiatrist unless there is another existing mental disorder or complicating problem. Given the time-limited nature of bereavement, monitoring her symptoms over time is the most appropriate approach for this patient. Referral to grief therapy, either individual or group, may also be helpful. If the patient's symptoms worsen, persist for more than 8 weeks, impair her ability to function, or cause her to be dangerous, then referral to a psychiatrist or hospitalization may be warranted.

• Question 248:

  A 29-year-old married male is seen in the emergency room with the chief complaint of, "I'm afraid I'm having a heart attack." He states a 2-month history of experiencing recurrent episodes of chest pain and shortness of breath that last 1020 minutes. He also describes associated tachypnea, lightheadedness, tingling in his extremities, nausea, diaphoresis, anxiety, and fears that he may die. These symptoms are now occurring almost daily but are not provoked by any situations or activities such as exertion or exercise. He is significantly worried about having future episodes and is genuinely concerned that he will suffer a myocardial infarction. He denies having any medical illnesses or taking any medications. He drinks three beers on the weekends only and does not use illicit drugs. His physical examination reveals a slightly elevated BP and pulse. An ECG demonstrates sinus tachycardia.

  Which of the following medications would be most appropriate in the acute management of this patient's symptoms?

  A. bupropion (Wellbutrin)

  B. buspirone (Buspar)

  C. imipramine (Tofranil)

  D. lorazepam (Ativan)

  E. paroxetine (Paxil)

  Correct Answer: D Section: (none)

  Explanation:

  This patient is most likely experiencing panic attacks as part of panic disorder. Dopaminergic antidepressants such as bupropion have not demonstrated significant efficacy in panic disorder. Buspirone is approved in the treatment of GAD but is not useful in panic disorder. While tricyclic antidepressants, such as imipramine, and SSRIs, such as paroxetine, are both effective in the treatment of panic disorder, therapeutic benefit for both may require several weeks. Benzodiazepines, such as lorazepam and alprazolam, have been shown to be effective in the treatment of panic disorder. Their more rapid onset of action (hours to days) make them ideally suited for the immediate and acute management of panic attacks. Neither bupropion nor buspirone are considered to be first-line treatments for panic disorder. Imipramine and other tricyclic antidepressants have demonstrated their efficacy in panic disorder. The disadvantages are several: the need to increase up to a therapeutic dose over time, a significant side effect profile, and lethality in overdose. While benzodiazepines such as alprazolam are also effective in the long-term treatment of panic disorder, their potential for abuse and withdrawal if/when tapered make them less than ideal overall. It is not unusual to initiate a benzodiazepine for more immediate relief of anxiety along with another agent that will require a longer time period until its benefits become apparent. Given their proven efficacy, reduced side effects, lack of abuse potential and safety in overdose, SSRIs such as paroxetine are the most suitable choice for the long-term pharmacotherapy of panic disorder.

• Question 249:

  The patient is a 26-year-old male graduate student presenting to his health maintenance organization. He is having ongoing difficulty completing his thesis. When he is working on the computer, he finds it necessary to print out and save every draft of his paper. Even though he realizes that it is unnecessary to do so, he feels compelled to read and reread all of his versions in case he made a mistake. As a result, he has been unable to move forward with his dissertation. He is consumed with doubts about his thesis, but at the same time he cannot throw away discarded sections. In fact, his apartment contains stacks of paper spread throughout his rooms. He understands that these thoughts and behaviors are "not rational," and he is greatly distressed by them and the problems they have caused.

  The patient does not wish to take medication but is interested in psychotherapy. Which of the following would be the most efficacious in reducing his symptoms?

  A. behavioral therapy

  B. eye movement desensitization and reprocessing (EMDR)

  C. psychoanalysis

  D. psychodynamic psychotherapy

  E. supportive therapy

  Correct Answer: A Section: (none)

  Explanation:

  This patient has OCD. Benzodiazepines such as alprazolam may be helpful for the acute anxiety associated with OCD, but they are not a first-line medication to reduce the obsessions or compulsions. Although antipsychotics such as olanzapine are sometimes used in conjunction with other psychotropics in patients with severe, intractable OCD, they are not recommended as monotherapy given their significant side effects. Antidepressants that mostly affect norepinephrine, such as bupropion and desipramine, are not particularly effective in treating OCD. Serotonergic drugs, such as citalopram and the tricyclic clomipramine, have been proven to improve both obsessions and compulsions.

  Because of this fact, OCD is thought to involve the serotonergic system. EMDR is a treatment used specifically for posttraumatic stress disorder (PTSD). Although psychoanalysis and psychodynamic (or insight-oriented) psychotherapies may be beneficial for some individuals with OCD, there have not been enough studies to document their effectiveness. Supportive psychotherapy can be useful in helping the patients to cope with their severe anxiety and limitations, but it does not particularly address the obsessions and compulsions themselves. Behavioral therapy has consistently demonstrated success in treating OCD, and studies have shown it to be as efficacious as pharmacotherapy.

• Question 250:

  The patient is a 26-year-old male graduate student presenting to his health maintenance organization. He is having ongoing difficulty completing his thesis. When he is working on the computer, he finds it necessary to print out and save every draft of his paper. Even though he realizes that it is unnecessary to do so, he feels compelled to read and reread all of his versions in case he made a mistake. As a result, he has been unable to move forward with his dissertation. He is consumed with doubts about his thesis, but at the same time he cannot throw away discarded sections. In fact, his apartment contains stacks of paper spread throughout his rooms. He understands that these thoughts and behaviors are "not rational," and he is greatly distressed by them and the problems they have caused.

  Which of the following would be the most appropriate pharmacotherapy for his condition?

  A. alprazolam (Xanax)

  B. bupropion (Wellbutrin)

  C. citalopram (Celexa)

  D. desipramine (Norpramin)

  E. olanzapine (Zyprexa)

  Correct Answer: C Section: (none)

  Explanation:

  This patient has OCD. Benzodiazepines such as alprazolam may be helpful for the acute anxiety associated with OCD, but they are not a first-line medication to reduce the obsessions or compulsions. Although antipsychotics such as olanzapine are sometimes used in conjunction with other psychotropics in patients with severe, intractable OCD, they are not recommended as monotherapy given their significant side effects. Antidepressants that mostly affect norepinephrine, such as bupropion and desipramine, are not particularly effective in treating OCD. Serotonergic drugs, such as citalopram and the tricyclic clomipramine, have been proven to improve both obsessions and compulsions.

  Because of this fact, OCD is thought to involve the serotonergic system. EMDR is a treatment used specifically for posttraumatic stress disorder (PTSD). Although psychoanalysis and psychodynamic (or insight-oriented) psychotherapies may be beneficial for some individuals with OCD, there have not been enough studies to document their effectiveness. Supportive psychotherapy can be useful in helping the patients to cope with their severe anxiety and limitations, but it does not particularly address the obsessions and compulsions themselves. Behavioral therapy has consistently demonstrated success in treating OCD, and studies have shown it to be as efficacious as pharmacotherapy.