USMLE USMLE-STEP-2 Online Practice Questions and Exam Preparation

USMLE USMLE-STEP-2 Online Questions & Answers

• Question 221:

  A40-year-old man has a history of severe alcohol dependence and is very interested in whatever help he can get to avoid relapsing in his alcohol use. According to the clinical vignette, select the pharmacotherapeutic agent which is most likely to be helpful to the patient.

  A. buspirone
  B. sertraline
  C. risperidone
  D. lithium carbonate
  E. acamprosate
  F. dextroamphetamine
  E. acamprosate

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  Explanation

  Lithium carbonate is an effective treatment for manic and depressive episodes due to bipolar I disorder, as well as for the prophylaxis of manic and depressive episodes in patients with bipolar I disorder. It can impede the release of thyroid hormone from the thyroid, and it can reduce the ability of the kidneys to concentrate urine; its use requires regular blood levels to ensure the avoidance of toxic blood levels that could cause tremor, dysarthria, ataxia, or death. Acamprosate (Campral) is gabanergic and decreases the craving for alcohol in patients with alcohol dependence. Sertraline (Zoloft) is a SSRI which is effective in the treatment of major depressive disorder, as well as in the treatment of panic disorder, obsessive-compulsive disorder, and PTSD. Risperidone is an atypical antipsychotic that is effective in the treatment of psychotic conditions, including schizophrenia, and is associated with fewer serious longterm side effects, such as tardive dyskinesia, than traditional neuroleptics. Risperidone is a potent blocker of both 5-HT2 serotonin receptors and D2 dopamine receptors. Buspirone, a nonaddictive azapirone, acts as an agonist or partial agonist of 5-HT1 serotonin receptors, and is effective in the treatment of generalized anxiety disorder. Dextroamphetamine is a stimulant and is an effective treatment for ADHD.

• Question 222:

  Which of the following delusions would most likely be observed in a psychotically depressed person?

  A. "My mind's eye is perfused with a radiance of the gods."
  B. "I've been targeted by the FBI."
  C. "My body is rotting inside out."
  D. "I have been hand-picked to be the world's leader; I am awaiting the signal to bring the masses together."
  E. "All I need to do is clutch the book to myself and all the knowledge pours into me."
  C. "My body is rotting inside out."

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  Explanation

  Patients with severe psychotic depression will often have delusions that are mood congruent and reflect the depth of their despair and self-abhorrence. Patients with mania are more likely to have delusions that are mood congruent that would reflect their grandiosity, paranoid feelings, inflated self-esteem, and feelings of having special powers.

• Question 223:

  A 45-year-old woman reports a 6-month history of free-floating anxiety, which makes her feel tense most of the time on most days. According to the clinical vignette, select the pharmacotherapeutic agent which is most likely to be helpful to the patient.

  A. buspirone
  B. sertraline
  C. risperidone
  D. lithium carbonate
  E. acamprosate
  F. dextroamphetamine
  A. buspirone

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  Explanation

  Lithium carbonate is an effective treatment for manic and depressive episodes due to bipolar I disorder, as well as for the prophylaxis of manic and depressive episodes in patients with bipolar I disorder. It can impede the release of thyroid hormone from the thyroid, and it can reduce the ability of the kidneys to concentrate urine; its use requires regular blood levels to ensure the avoidance of toxic blood levels that could cause tremor, dysarthria, ataxia, or death. Acamprosate (Campral) is gabanergic and decreases the craving for alcohol in patients with alcohol dependence. Sertraline (Zoloft) is a SSRI which is effective in the treatment of major depressive disorder, as well as in the treatment of panic disorder, obsessive-compulsive disorder, and PTSD. Risperidone is an atypical antipsychotic that is effective in the treatment of psychotic conditions, including schizophrenia, and is associated with fewer serious longterm side effects, such as tardive dyskinesia, than traditional neuroleptics. Risperidone is a potent blocker of both 5-HT2 serotonin receptors and D2 dopamine receptors. Buspirone, a nonaddictive azapirone, acts as an agonist or partial agonist of 5-HT1 serotonin receptors, and is effective in the treatment of generalized anxiety disorder. Dextroamphetamine is a stimulant and is an effective treatment for ADHD.

• Question 224:

  A 17-year-old girl notes an enlarging lump in her neck. On examination, her thyroid gland is twice the normal size, firm to rubbery, multilobular, nontender, and freely mobile. There is no adenopathy. Family history is positive for both hypo- and hyperthyroidism. Her serum triiodothyronine (T3) and thyroxine (T4) levels are low normal, and serum thyroid-stimulating hormone (TSH) is high normal. Technetium scan shows nonuniform uptake. Serum and antithyroglobulin titer is strongly positive.

  What will thyroid biopsy of this patient most likely disclose?

  A. giant cell granulomas and necrosis
  B. polymorphonuclear cells and bacteria
  C. diffuse fibrous replacement
  D. lymphocytic infiltration
  E. parafollicular cells
  D. lymphocytic infiltration

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  Explanation

  The patient described in the question most likely has Hashimoto's thyroiditis, also called autoimmune or chronic lymphocytic thyroiditis. It is the most common cause of thyroiditis in the United States and is encountered more frequently in women than in men. Patients note progressive thyromegaly but are usually euthyroid at the outset. Hypothyroidism may appear years later, often heralded by an elevated serum TSH level. Diagnosis is based on the history, examination, heterogeneous uptake on thyroid scan, and the presence of antithyroid and antithyroglobulin antibodies. If the diagnosis is still in doubt, needle biopsy will demonstrate lymphocyte infiltration, sometimes in sheets or forming germinal centers. Subacute (de Quervain, granulomatous) thyroiditis will show polymorphonuclear cells, necrosis, and giant cells. Bacteria may not be present in acute suppurative thyroiditis. Thyroid infiltration and replacement by rock-hard, woody, fibrous tissue is typical of Riedel's struma. C-cell hyperplasia is associated with medullary thyroid carcinoma. Hashimoto's thyroiditis is treated with thyroid hormone. Lower doses (0.100.15 mg/day) of levothyroxine are used to treat hypothyroidism alone; whereas, higher doses (0.150.30 mg/day) suppress TSH release and diminish goiter size. Partial resection may result in enlargement of the remaining gland. Steroids, antibiotics, and radioiodine have no role in therapy.

• Question 225:

  For the screening tests listed below, select the screening schedule that is appropriate for women (as per the U.S. Preventive Services Task Force [USPSTF], The Guide to Clinical Preventive Services, 2006) Palpation, ultrasound, or serologic testing of the abdomen to screen for cancer of the pancreas

  A. do not routinely screen
  B. yearly over age 50
  C. at first prenatal visit
  D. every 12 years at age 40 and older
  E. every 12 years at age 50 and older
  F. every 3 years following an initial examination, but not after age 65
  G. every 3 years at age 50 and older
  A. do not routinely screen

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  Explanation

  The USPSTF recommends against routine screening for pancreatic cancer in asymptomatic adults

• Question 226:

  A 17-year-old girl is brought in by her parents because of their concerns about her weight loss. She is petite, and a normal weight for someone her height is 100 lbs, but she weighs 78 lbs. She reports menstrual irregularity. The patient believes she is obese. She does not believe she has a problem. Her mother reports that she found laxatives on her daughter's nightstand, and heard her vomiting in the bathroom yesterday after dinner.

  Which of the following is the most likely diagnosis?

  A. bulimia nervosa
  B. pregnancy
  C. anorexia nervosa
  D. no diagnosis, normal presentation
  E. obesity
  C. anorexia nervosa

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  Explanation

  Anorexia nervosa is an eating disorder that predominantly affects women in their teens and in early adulthood. It is defined as refusal to maintain a minimal normal weight, at least 85% of that weight considered normal for that person's age and height, and a morbid preoccupation with feeling obese. Common strategies to lose weight include avoidance of all fats and carbohydrates, self-induced vomiting, obsessive physical activity, and abuse of laxatives or diuretics or both. Despite apparent aversion to gaining weight, anorectics frequently take very special care in preparation and consumption of food and may delight in preparing gourmet feasts for others. Menstrual irregularity and amenorrhea are also commonly reported but are not essential factors in making the diagnosis. It is not yet clear whether such menstrual problems are simply secondary to starvation or whether they reflect a more pervasive endocrine dysfunction. Perhaps the most striking clinical feature of this disorder is the misperception of body image. Regardless of the method of confrontation, including use of mirrors or photographs, sufferers see themselves as overweight. The patient often refuses to agree that there is any problem whatsoever. Numerous factors, including developmental, family, endocrine, and gastrointestinal disturbances have been implicated in anorexia nervosa, but the etiology has yet to be clearly established. Most commonly, the course consists of a single episode followed by remission. Some patients may suffer a series of relapses and remissions. Mortality rates have been estimated to be as high as 20%.

• Question 227:

  A21-year-old male college student reports a 1- month period of intensely depressed mood, with marked anxiety, sleep disturbance, and weight loss. He has never before experienced an episode of a mood disorder.

  According to the clinical vignette, select the pharmacotherapeutic agent which is most likely to be helpful to the patient.

  A. buspirone
  B. sertraline
  C. risperidone
  D. lithium carbonate
  E. acamprosate
  F. dextroamphetamine
  B. sertraline

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  Explanation

  Lithium carbonate is an effective treatment for manic and depressive episodes due to bipolar I disorder, as well as for the prophylaxis of manic and depressive episodes in patients with bipolar I disorder. It can impede the release of thyroid hormone from the thyroid, and it can reduce the ability of the kidneys to concentrate urine; its use requires regular blood levels to ensure the avoidance of toxic blood levels that could cause tremor, dysarthria, ataxia, or death. Acamprosate (Campral) is gabanergic and decreases the craving for alcohol in patients with alcohol dependence. Sertraline (Zoloft) is a SSRI which is effective in the treatment of major depressive disorder, as well as in the treatment of panic disorder, obsessive-compulsive disorder, and PTSD. Risperidone is an atypical antipsychotic that is effective in the treatment of psychotic conditions, including schizophrenia, and is associated with fewer serious longterm side effects, such as tardive dyskinesia, than traditional neuroleptics. Risperidone is a potent blocker of both 5-HT2 serotonin receptors and D2 dopamine receptors. Buspirone, a nonaddictive azapirone, acts as an agonist or partial agonist of 5-HT1 serotonin receptors, and is effective in the treatment of generalized anxiety disorder. Dextroamphetamine is a stimulant and is an effective treatment for ADHD.

• Question 228:

  Which regulatory agency enforces standards in the sale of meat?

  A. Food and Drug Administration (FDA)
  B. United States Department of Agriculture (USDA)
  C. Environmental Protection Agency (EPA)
  D. United Nations Food and Agriculture Organization (FAO)
  E. World Health Organization (WHO)
  B. United States Department of Agriculture (USDA)

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  Explanation

  In the United States, the organization of food and water control is complex. Among the federal control agencies, the EPA is the most recent, and in many ways the most active and powerful. This agency has now set up an elaborate system of regulation and control of the use of pesticides (which until 1970 was the responsibility of the USDA) and has banned the marketing of chlorphenothane (DDT) for use in the home. The FDA has authority to remove food from the market if it contains pesticides (e.g., PCBs in fish) in excess of the action levels set by the EPA. The FDA also retains the authority to remove from the market any food with inappropriate additives, that contains substances harmful to human health, that is stored in unsanitary conditions, that has decomposed, or that is not fit for consumption.

  The USDAenforces wholesomeness standards that it sets for the production and sale of meat. International control is assisted by the WHO. This agency has mounted control programs for the eradication of communicable disease with conspicuous success in the case of smallpox. It also publishes the International Statistical Classification of Disease (ICD-9).

• Question 229:

  Select the organism associated with the following clinical findings:

  Aparent of a 4-year-old child who goes to nursery school develops a chronic cough and lowgrade fever.

  A. aureus
  B. beta-hemolytic Streptococcus
  C. perfringens
  D. Mycoplasma pneumoniae
  E. Haemophilus pertussis
  F. Helicobacter pylori
  G. Escherichia coli
  H. Rickettsia prowazekii
  I. Giardia lamblia
  D. Mycoplasma pneumoniae

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  Explanation

  Giardiasis may cause cramping and a chronic diarrheal syndrome, with malabsorption and weight loss. Its distribution is worldwide, particularly where hygienic standards are not high. It also occurs sporadically in high-risk individuals. Streptococcal pyoderma, including erysipelas and impetigo, has been demonstrated to precede acute glomerulonephritis. Even when appropriate antibiotics are given in adequate dosage and duration for these conditions, renal damage may still result. Prevention thus consists of wound care, including cleaning wounds well and removal of crust. Mycoplasma infections are particularly common in families with younger children. They are frequently imported to the family by school-aged children, leading to a low-grade fever and persisting tracheobronchitis in the parents, or more acutely, an atypical pneumonia. G. lamblia is found in up to 20% of homosexual males, and may cause chronic diarrhea, although in these patients it tends to be asymptomatic. E. coli was first reported as a cause of watery diarrhea in nurseries in the 1940s. Although nursery epidemics with enteropathogenic serotypes had decreased in recent years in the United States, the increase of infant- child day care centers has resulted in their relatively frequent occurrence. Furunculosis is most frequently caused by coagulase-positive staphylococcal infections. The public health significance of this largely relates to the hazards of skin infections in food handlers and subsequent staphylococcal toxin in the food, leading to staphylococcal intoxication food-borne disease. H. pylori has been associated with gastric ulcers, but not with duodenal ulcers. Otitis media, whether acute or with effusion, commonly results from viral infection, such as by RSV. Various other organisms may be responsible including Streptococcu pneumoniae, H. influenzae, and others. C. perfringens, with rare exceptions, is transmitted in a meat dish prepared in bulk. Under propitious circumstances for the organism, especially on cooling of the food, bacterial multiplication can be very rapid. Symptoms begin to occur in the affected population in about 12 hours. Epidemic typhus is a rickettsial illness. Man is the host and long-term reservoir. The vectors are body lice (P. humanus corporis). The rickettsia are not present in human excretions and cannot be transmitted by person-to-person contact.

• Question 230:

  A 3-year-old boy spends hours rocking in a chair or spinning the blades of a toy windmill; his parents say he never cries when he falls.

  Select the diagnosis with which it is most likely to be associated.

  A. childhood depression
  B. childhood schizophrenia
  C. conduct disorder
  D. ADHD
  E. infantile autism
  E. infantile autism

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  Explanation

  Infantile autism, called a pervasive developmental disorder in DSM-IV, typically is diagnosed when children do not demonstrate the acquisition of communication skills. Ability to form interpersonal relationships also is grossly impaired. Other behavioral manifestations of infantile autism include unusual repetitive mannerisms (e.g., spinning), marked anxiety during environmental changes, and high pain threshold. As to be expected, school performance is poor, though autistic children may display isolated areas (islands) of normal or superior intellectual functioning. Behavioral manipulation is useful in trying to contain the behavior of autistic children. Unlike infantile autism, childhood schizophrenia usually develops later in childhood and follows an intermittent course. Deterioration in social or school functioning is a characteristic presenting feature, along with hallucinations, delusions, and other manifestations of psychosis. Phenothiazine drugs offer effective treatment. Symptoms and signs of depression in children are similar to those in adults. However, children may not be able to recognize depressed feelings. Persistence of puzzling physical problems in association with apathetic, withdrawn behavior is a common presentation. The use of antidepressants is controversial; family and individual counseling often can be quite helpful. ADHD once was called hyperactivity and minimal brain dysfunction. Characteristic signs include impulsivity, distractibility, inattention in school, and (usually but not universally) hyperactivity.

  A variety of pharmacologic agents, including imipramine, dextroamphetamine, and methylphenidate (Ritalin), have been recommended for treatment of ADHD.