USMLE USMLE Certifications USMLE-STEP-3 Questions & Answers

• Question 281:

  A 40-year-old male is returning to the office for a follow-up visit. He is told about his blood work results, which are consistent with leukemia. He is informed that he should receive a bone marrow biopsy for further clarification. While being presented with this information, he remains silent, peering, and staring intensely. When finished, he comments, "Doctors think they are so smart!" He then explains that he has been mistreated by physicians in the past and, in fact, has several malpractice suits pending. He feels that the biopsy was recommended only "because you want to use me in order to publish and further your career."

  When interacting with this patient, which of the following approaches would be most effective?

  A. defend the recommendation by citing professional credentials

  B. encourage him to speak with a psychiatrist to provide added support

  C. interpret his anger as a defense against his fears of having leukemia

  D. provide detailed information regarding his differential diagnosis

  E. refer him to a colleague to avoid litigation

  Correct Answer: D Section: (none)

  Explanation:

  This patient clearly presents with a paranoid stance, although he is not overtly psychotic. Individuals with antisocial personality disorder are usually more dishonest, aggressive, and exploitative in their attitudes. Narcissistic patients may become easily offended by interactions when not feeling as though they are being treated as "special," but they do not display as much overt mistrust. Patients with schizoid and schizotypal personality disorders appear indifferent or odd, usually with a detached attitude. Patients with paranoid personality disorder display a pervasive suspiciousness toward others, continuously feeling slighted and bearing grudges, not unusually in the form of litigiousness

• Question 282:

  A 40-year-old male is returning to the office for a follow-up visit. He is told about his blood work results, which are consistent with leukemia. He is informed that he should receive a bone marrow biopsy for further clarification. While being presented with this information, he remains silent, peering, and staring intensely. When finished, he comments, "Doctors think they are so smart!" He then explains that he has been mistreated by physicians in the past and, in fact, has several malpractice suits pending. He feels that the biopsy was recommended only "because you want to use me in order to publish and further your career."

  Based on the above, what is his most likely diagnosis?

  A. antisocial personality disorder

  B. narcissistic personality disorder

  C. paranoid personality disorder

  D. schizoid personality disorder

  E. schizotypal personality disorder

  Correct Answer: C Section: (none)

  Explanation:

  This patient clearly presents with a paranoid stance, although he is not overtly psychotic. Individuals with antisocial personality disorder are usually more dishonest, aggressive, and exploitative in their attitudes. Narcissistic patients may become easily offended by interactions when not feeling as though they are being treated as "special," but they do not display as much overt mistrust. Patients with schizoid and schizotypal personality disorders appear indifferent or odd, usually with a detached attitude. Patients with paranoid personality disorder display a pervasive suspiciousness toward others, continuously feeling slighted and bearing grudges, not unusually in the form of litigiousness

• Question 283:

  The patient is a 28-year-old divorced female who presents in the emergency room complaining of insomnia. Further history reveals that she has been depressed since the divorce settlement 3 months ago. She also has anergia, poor concentration, decreased appetite with a 15-lb weight loss, anhedonia, and guilt surrounding her "failed marriage." She reluctantly admits to pervasive thoughts of killing herself, with a plan to overdose on two bottles of Tylenol as "I heard it can kill you." She has purchased the medicine and written a suicide note. She asks to leave to go home, and when discussion of admission is brought up, she becomes angry and demands to be discharged from the emergency room.

  The above decision is based on which of the following ethical principles?

  A. autonomy

  B. beneficence

  C. confidentiality

  D. justice

  E. nonmaleficence

  Correct Answer: B Section: (none)

  Explanation:

  This patient appears to be suffering from a major depressive episode and is exhibiting acute suicidal ideation with a definitive plan and intent to overdose on a potentially lethal substance. She clearly poses an increased risk of self-harm and requires immediate hospitalization. As she refuses a voluntary admission, involuntary admission (commitment) is warranted. Autonomy is the right of a patient to self-determination. Confidentiality is not a core ethical principle. Nonmaleficence is the duty to "first, do no harm." The concept of justice involves social, political, legal, and religious considerations. The important code of beneficence (preventing harm) is illustrated in the above case, where an immediately suicidal patient is admitted involuntarily.

• Question 284:

  The patient is a 28-year-old divorced female who presents in the emergency room complaining of insomnia. Further history reveals that she has been depressed since the divorce settlement 3 months ago. She also has anergia, poor concentration, decreased appetite with a 15-lb weight loss, anhedonia, and guilt surrounding her "failed marriage." She reluctantly admits to pervasive thoughts of killing herself, with a plan to overdose on two bottles of Tylenol as "I heard it can kill you." She has purchased the medicine and written a suicide note. She asks to leave to go home, and when discussion of admission is brought up, she becomes angry and demands to be discharged from the emergency room.

  What is the next most appropriate course of action?

  A. admit her to the hospital involuntarily

  B. admit her to the hospital voluntarily

  C. discharge her against medical advice

  D. discharge her with instructions to return in the morning

  E. prescribe a selective serotonin reuptake inhibitor (SSRI) and provide outpatient follow-up

  Correct Answer: A Section: (none)

  Explanation:

  This patient appears to be suffering from a major depressive episode and is exhibiting acute suicidal ideation with a definitive plan and intent to overdose on a potentially lethal substance. She clearly poses an increased risk of self-harm and requires immediate hospitalization. As she refuses a voluntary admission, involuntary admission (commitment) is warranted. Autonomy is the right of a patient to self-determination. Confidentiality is not a core ethical principle. Nonmaleficence is the duty to "first, do no harm." The concept of justice involves social, political, legal, and religious considerations. The important code of beneficence (preventing harm) is illustrated in the above case, where an immediately suicidal patient is admitted involuntarily.

• Question 285:

  A 29-year-old woman presents to the primary care clinic complaining of frequent headaches for several months. During the interview she appears tearful and withdrawn, with minimal eye contact and reluctance to answer questions. With further encouragement and support, she is able to describe intense feelings of sadness, along with significant insomnia, poor concentration, fatigue, anhedonia, and little appetite with a 20-lb weight loss It is decided to begin treatment for her depressive symptoms with pharmacotherapy. Regarding the selection of the specific class of medication, a family history of what would be crucial?

  A. allergies

  B. depressive symptoms

  C. manic symptoms

  D. medical illnesses

  E. substance abuse

  Correct Answer: C Section: (none)

  Explanation: This woman likely suffers from a major depressive episode. While asking about substance abuse, current medications, medical problems, and a past history of depression are very important in a complete psychiatric evaluation, assessment of suicidality is essential. The risk of suicide in patients with major depressive disorder is about 20 times higher than those without the illness. The estimated lifetime risk of suicide is approximately 15% in those individuals with major depressive disorder. The choice of a specific antidepressant may be influenced by many factors, including prior response in the patient or a family member and comorbid medical problems or substance abuse in the family (and, therefore, potentially the patient). If a patient or family member has a history of manic symptoms or bipolar disorder, consideration should be given to beginning a mood stabilizer prior to initiating antidepressant therapy, as antidepressants can cause a switch into mania in those individuals.

• Question 286:

  A 29-year-old woman presents to the primary care clinic complaining of frequent headaches for several months. During the interview she appears tearful and withdrawn, with minimal eye contact and reluctance to answer questions. With further encouragement and support, she is able to describe intense feelings of sadness, along with significant insomnia, poor concentration, fatigue, anhedonia, and little appetite with a 20-lb weight loss. Before she leaves the office, what is the most important question to ask her?

  A. "Have you been drinking alcohol or using illicit drugs recently?"

  B. "Have you been taking any over-thecounter medications?"

  C. "Have you been treated for any medical conditions?"

  D. "Have you ever felt like this before?"

  E. "Have you had thoughts of hurting yourself?"

  Correct Answer: E Section: (none)

  Explanation:

  This woman likely suffers from a major depressive episode. While asking about substance abuse, current medications, medical problems, and a past history of depression are very important in a complete psychiatric evaluation, assessment of suicidality is essential. The risk of suicide in patients with major depressive disorder is about 20 times higher than those without the illness. The estimated lifetime risk of suicide is approximately 15% in those individuals with major depressive disorder. The choice of a specific antidepressant may be influenced by many factors, including prior response in the patient or a family member and comorbid medical problems or substance abuse in the family (and, therefore, potentially the patient). If a patient or family member has a history of manic symptoms or bipolar disorder, consideration should be given to beginning a mood stabilizer prior to initiating antidepressant therapy, as antidepressants can cause a switch into mania in those individuals.

• Question 287:

  You are asked to see an inpatient for a gynecologic consultation. The patient is an 85-year-old female who was admitted s/p her third stroke. She has a history of dementia, coronary artery disease, insulin-dependent diabetes, and hypertension. She resides in a local nursing home and normally requires extensive nursing assistance as she is unable to care for herself. While in the hospital, the nursing staff observed a small amount of new vaginal bleeding. Her past OB/GYN history is unknown and no family members are immediately available for clarification. On physical examination, she is lying comfortably in bed, awake but not oriented to person, place, or time. She is unable to speak coherently, and becomes combative when you attempt to examine her abdomen. She quiets down when you step out of the room.

  You then receive a telephone call from someone who says she is the patient's granddaughter, inquiring as to the patient's status and your recommendations. What should be yor response?

  A. "Your grandmother is very sick. We will be taking her to the operating room this afternoon. Would you please give us permission to do that over the telephone?"

  B. "In order to respect patient confidentiality and privacy, I am unable to discuss patient-related issues without explicit permission from her or her designated decision maker."

  C. "In her current condition, I believe that she has too many other medical problems to workup her vaginal bleeding. I will not be seeing her again unless something changes."

  D. "Please call back later after we have completed her examination."

  E. "I cannot give you information over the phone but could give you any information that you want if you come to the hospital and can prove to us that you are related to the patient."

  Correct Answer: B Section: (none)

  Explanation:

  At this point in time, the patient would appear to be incapacitated, and unable to provide informed consent for herself. Given her baseline medical conditions, one would hope that the patient has a durable power of attorney for health care, with a designated surrogate decision maker. All attempts should be made to contact that person prior to initiating any procedures or surgery. It is unclear at this point in time as to whether or not this patient's dementia is being impacted by delirium. Restraints and/or additional sedation would not be appropriate unless the patient is posing harm to herself or others.

  In 1996, Congress enacted the Health Insurance Portability and Accountability Act (HIPAA). It provides standards for health information transactions and security of patient data. Under the HIPAA regulations, Health care providers must obtain the individual's written consent prior to disclosure of health information except in the management of emergencies or if the consent can be inferred from a patient with impaired communication. In this situation, where the patient is not capable of giving this consent, efforts should be made to identify a surrogate decision maker. As that person has not yet been identified, it would be appropriate to ask the caller if she could assist in identifying a previously designated decision maker. However, it would not be appropriate to disclose protected information to her at this time.

• Question 288:

  You are asked to see an inpatient for a gynecologic consultation. The patient is an 85-year-old female who was admitted s/p her third stroke. She has a history of dementia, coronary artery disease, insulin-dependent diabetes, and hypertension. She resides in a local nursing home and normally requires extensive nursing assistance as she is unable to care for herself. While in the hospital, the nursing staff observed a small amount of new vaginal bleeding. Her past OB/GYN history is unknown and no family members are immediately available for clarification. On physical examination, she is lying comfortably in bed, awake but not oriented to person, place, or time. She is unable to speak coherently, and becomes combative when you attempt to examine her abdomen. She quiets down when you step out of the room.

  Which of the following would be the most appropriate next step?

  A. Request that the nursing staff place her in restraints.

  B. Administer intravenous sedation.

  C. Take her to the operating room to perform an examination under anesthesia.

  D. Attempt to contact her family to assist in further decision making.

  E. Contact her primary attending physician and tell her that no further workup should be done in a patient in this condition.

  Correct Answer: D Section: (none)

  Explanation:

  At this point in time, the patient would appear to be incapacitated, and unable to provide informed consent for herself. Given her baseline medical conditions, one would hope that the patient has a durable power of attorney for health care, with a designated surrogate decision maker. All attempts should be made to contact that person prior to initiating any procedures or surgery. It is unclear at this point in time as to whether or not this patient's dementia is being impacted by delirium. Restraints and/or additional sedation would not be appropriate unless the patient is posing a harm to herself or others.

  In 1996, Congress enacted the Health Insurance Portability and Accountability Act (HIPAA). It provides standards for health information transactions and security of patient data. Under the HIPAA regulations, Health care providers must obtain the individual's written consent prior to disclosure of health information except in the management of emergencies or if the consent can be inferred from a patient with impaired communication. In this situation, where the patient is not capable of giving this consent, efforts should be made to identify a surrogate decision maker. As that person has not yet been identified, it would be appropriate to ask the caller if she could assist in identifying a previously designated decision maker. However, it would not be appropriate to disclose protected information to her at this time.

• Question 289:

  A 16-year-old nulligravid high school student is on your afternoon office schedule for a "talk visit." She was seen last year by one of your colleagues for an initial GYN evaluation. She is healthy and has no medical problems. Today she tells you that she and her new boyfriend had intercourse the night before, and the condom they were using broke

  She tells you that earlier in the day she had called her family doctor, who wouldn't call in a prescription because it was "against his personal beliefs." Your response should be which of the following?

  A. Prescribing health care providers must always prescribe it upon patient demand.

  B. It is within his right to decline giving treatments he deems outside his belief system, but he is ethically obliged to help her find a provider who does dispensePlan B.

  C. Plan B is available over the counter for all patients.

  D. You will report him to the state medical board.

  E. In situations regarding pregnancy, the physician is entitled to follow his personal ethical beliefs and has no obligation to assist a patient in seeking care that is outside of these beliefs.

  Correct Answer: B Section: (none)

  Explanation:

  Discussing the potential implications of her sexual activity is warranted, both in terms of potential pregnancy and risk of acquiring sexually transmitted infections. Making assumptions about her decision making (choices B and D) would breach the ethical principles of autonomy and confidentiality. In August 2006, the FDA approved emergency oral contraception (Plan B) to be available over the counter for women ages 18 and older. Younger women must have a prescription from a health care provider. Plan B contains 0.75 mg of levonorgestrel in two doses taken 12 hours apart. It is to be used within 72 hours of unprotected intercourse. The mechanisms of action include delay in ovulation, insufficient corpus luteum function, and interference with sperm transport. It is not an abortifacient. A physician is not obligated to provide treatments which conflict with his or her own personal belief system. Nonetheless, using ethical principles of autonomy, beneficience, nonmaleficence, veracity, and justice, physicians should discuss patients' requests for treatments in an attempt to reach common ground. If that is not possible, the physician should provide an alternative resource to address a patient's request.

• Question 290:

  A 16-year-old nulligravid high school student is on your afternoon office schedule for a "talk visit." She was seen last year by one of your colleagues for an initial GYN evaluation. She is healthy and has no medical problems. Today she tells you that she and her new boyfriend had intercourse the night before, and the condom they were using broke.

  The patient requests a prescription for "Plan B" emergency contraception. You tell her which of the following?

  A. The medication is not effective after 24 hours.

  B. Your office does not dispense prescriptions as such to minors.

  C. She should first seek permission from her parents.

  D. The first dose must be taken within72 hours of intercourse.

  E. The medication will cause an abortion.

  Correct Answer: D Section: (none)

  Explanation:

  Discussing the potential implications of her sexual activity is warranted, both in terms of potential pregnancy and risk of acquiring sexually transmitted infections. Making assumptions about her decision making (choices B and D) would breach the ethical principles of autonomy and confidentiality. In August 2006, the FDA approved emergency oral contraception (Plan B) to be available over the counter for women ages 18 and older. Younger women must have a prescription from a health care provider. Plan B contains 0.75 mg of levonorgestrel in two doses taken 12 hours apart. It is to be used within 72 hours of unprotected intercourse. The mechanisms of action include delay in ovulation, insufficient corpus luteum function, and interference with sperm transport. It is not an abortifacient. A physician is not obligated to provide treatments which conflict with his or her own personal belief system. Nonetheless, using ethical principles of autonomy, beneficience, nonmaleficence, veracity, and justice, physicians should discuss patients' requests for treatments in an attempt to reach common ground. If that is not possible, the physician should provide an alternative resource to address a patient's request.