USMLE USMLE Certifications USMLE-STEP-2 Questions & Answers

• Question 221:

  A35-year-old man comes into the hospital with deep sadness and suicidal thoughts. He reports having experienced similar episodes in the past; he says he has also experienced two periods of extremely elated moods, during which he talked nonstop, went without sleep, and believed he was God. Identify the diagnosis below that best describes the situation.

  A. major depressive disorder, recurrent

  B. bipolar I disorder

  C. bipolar II disorder

  D. cyclothymia

  E. dysthymic disorder

  F. mood disorder due to a general medical condition

  G. substance-induced mood disorder

  Correct Answer: B

  The criteria for mood disorders depend on the presence or absence and duration of depressive and hypomanic or manic symptoms as well as on their severity, and also on the presence or absence of a causative general medical condition or the ingestion of substances. Major depressive disorder, recurrent, is marked by the lifetime occurrence of two or more major depressive episodes without intervening hypomanic or manic episodes. A major depressive episode is a severe depression which has lasted at least 2 weeks. Bipolar I disorder is characterized by a history of at least one full-blown manic episode, during which the patient's mood has been abnormally and persistently elevated, expansive or irritable for at least 1 week with marked impairment in occupational functioning. Bipolar II disorder, on the other hand, is marked by a history of at least one major depressive episode and at least one hypomanic episode, during which a patient's mood has been elevated, but not to the extent of causing marked impairment in social or occupational functioning. Apatient with bipolar II disorder may not, by definition, have had a full-blown manic episode.

  Cyclothymia is marked by periods of hypomanic symptoms alternating with depressive symptoms that do not meet the criteria for a major depressive episode. Dysthymic disorder is marked by a persistent, low-grade depression occurring more days than not for at least 2 years. Amood disorder due to a general medical condition is a prominent and persistent disturbance in mood that is judged to be the direct physiologic effect of a general medical condition, such as hyperthyroidism. A substance-induced mood disorder is a prominent and persistent disturbance in mood that is judged to be due to the direct effects of a substance, but which continues beyond the usual period of intoxication or withdrawal from a substance.

• Question 222:

  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

  Correct Answer: E

  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.

• Question 223:

  A5-year-old boy is reported by his kindergarten teacher to be easily distracted, impulsive, in need of continual supervision, but not hyperactive 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

  Correct Answer: D

  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.

• Question 224:

  An 11-year-old girl has become markedly withdrawn in the past 8 months and has complained of persisting abdominal pain and constipation, for which no organic cause has been found. 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

  Correct Answer: A

  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.

• Question 225:

  An 11-year-old girl has become uncharacteristically and markedly withdrawn in the past 8 months, staying in her room so that she can "talk to the ghosts in the attic." 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

  Correct Answer: B

  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.

• Question 226:

  A 9-year-old boy has had persisting difficulties in language and interpersonal relationships since the age of

  2 years, and, although he can barely read, he is able to perform arithmetic calculations at the fifth-grade

  level.

  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

  Correct Answer: E

  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.

• Question 227:

  A 42-year-old married woman reports being raped in an elevator 1 year ago. Her arms were fractured in the assault but have healed nicely. Still she reports difficulty sleeping, having nightmares of the attack several times per week ever since the assault. She avoids using the elevator and does not want to talk about the incident with anyone. She has been unable to return to work. Her husband feels she has been hypervigilant and irritable, and has been resistive to going out socially. She has a depressed mood. Her husband is encouraging her to seek disability. Which of the following is the most likely diagnosis?

  A. major depression

  B. adjustment disorder with anxious and depressed features

  C. acute stress disorder

  D. malingering E. PTSD

  Correct Answer: E

  The lifetime prevalence of PTSD is approximately 8%. For PTSD to be diagnosed, the trauma has to be where serious injury or death were threatened or involved, and the traumatized individual experienced a sense of helplessness, fear, or horror, and has at least one reliving symptom (nightmares of the trauma, recurrent intrusive thoughts of the event, intense psychological stress or physiologic reactivity to internal or external cues that symbolize or resemble an aspect of the trauma, or flashbacks), two or more symptoms of increased arousal (difficulty falling to or staying asleep, irritability, difficulty concentrating, hypervigilance, and exaggerated startle response), and three or more avoidance symptoms (efforts to avoid thoughts, feelings, or conversations about the trauma, efforts to avoid people, things or places that remind one of the trauma, inability to remember an important aspect of the trauma, diminished participation in activities, feeling detached or estranged from others, restricted range of affect, and/or sense of foreshortened future). The symptoms have to be recurring for at least a month.

• Question 228:

  Of the following, which is considered a cortical dementia?

  A. Huntington's disease

  B. Pick's disease

  C. Parkinson's disease

  D. occult hydrocephalus (normal pressure)

  E. none of the above

  Correct Answer: B

  Pick's disease is considered a cortical dementia, with the preponderance of pathologic findings found in the frontotemporal area. Aphasia, apraxia, and agnosia are signs sometimes seen in these patients. Huntington's and Parkinson's diseases are caused by pathologic changes in the basal ganglia. Pathologic changes are seen in the ventricles in occult hydrocephalus. Signs seen in subcortical dementia more characteristically involve motor disorders: rigidity, tics, gait difficulties, and incoordination.

• Question 229:

  A 35-year-old woman is seen by her primary care physician for a physical examination. She tells him she has a twin brother who has bipolar disorder and has been worried that she will develop it. Which of the following would be most helpful for her to hear?

  A. "You're past the age when bipolar disorder develops, so don't worry about it."

  B. "There is no clear evidence that a bipolar disorder is genetically determined."

  C. "The concordance rate for bipolar disorder for dizygotic twins is 19%."

  D. "The concordance rate for bipolar disorder for dizygotic twins is 79%."

  E. "Prophylactic treatment with lithium is advisable."

  Correct Answer: C

  There is strong evidence for a genetic predisposition to bipolar disorder. Some of the evidence comes from twin studies. The concordance rate for monozygotic twin is 79%, but for dizygotic twin it is 19%. Advising the patient that she is past the age when bipolar disorders develop, using lithium to prevent the disorder, or saying that no genetic link has been determined is very misleading and clinically incorrect.

• Question 230:

  Which of the following medications may be appropriate for treating children with attention deficit disorder?

  A. lithium

  B. bupropion

  C. alprazolam

  D. propranolol

  E. perphenazine

  Correct Answer: B

  The antidepressant bupropion has been found effective for treating some cases of attention deficit disorder and offers help to those children not responsive to the usual treatment with stimulants (methylphenidate, pemoline). The remaining choices have not been found useful in treating this condition. They are lithium, a mood stabilizer; alprazolam, a benzodiazepine anxiolytic; propranolol, a betablocker; and perphenazine, an antipsychotic.