USMLE USMLE Certifications USMLE-STEP-2 Questions & Answers

• Question 291:

  A 35-year-old man with no previous psychiatric history is referred by his family physician for psychiatric evaluation. The family physician has been following the man for mild hyperlipidemia, which is currently being successfully treated with dietary changes alone. The man reports that he has been happily married for 10 years and has two children. He has been working as an accountant and has generally enjoyed his job. About 2 months ago, with no obvious precipitating event, he says, the man began to feel very blue, with a drop in his desire to play with his children and to compete in his usual volleyball league games. He reports that he has lost most of his libido and is having difficulty sleeping, with earlymorning wakening. He reports that his appetite has become very poor over the past 2 months, and he estimates that he has lost 10 lbs over that time. Which of the following is the most likely diagnosis?

  A. Alzheimer's disease

  B. schizophrenia

  C. major depressive disorder

  D. metastatic cancer to the brain

  E. systemic lupus erythematosus

  Correct Answer: C

  The essential feature of a major depressive disorder is the development of a major depressive episode without a history of mania or hypomania. The hallmarks of a major depressive episode are a subjective sense of dysphoria and a loss of interest in previously enjoyed activities, also called anhedonia. Depressed patients often report decreased libido, sleep disturbance, and appetite disturbance. It would be important to rule out organic causes for this man's disorder, such as hypothyroidism or the relatively rare phenomenon of metastatic cancer to the brain in a 35-year-old. Given the patient's age and recent onset of symptoms, Alzheimer's disease is unlikely. Schizophrenia generally has a gradual onset and is accompanied by psychotic symptoms such as hallucinations and delusions

• Question 292:

  A28-year-old woman with a 7-year history of chronic undifferentiated schizophrenia is hospitalized for an exacerbation of her schizophrenia, with an increase in auditory hallucinations. She has also developed the delusion that she is controlled by aliens from Mars. She has always been very sensitive to the extrapyramidal side effects (EPS) of antipsychotic medications.

  She developed an acute restlessness in her legs and arms which her psychiatrist diagnosed as akathisia. Which of the following is the preferred treatment option?

  A. benztropine

  B. propranolol

  C. haldoperidol

  D. dantrolene

  E. fluoxetine

  Correct Answer: B

  Typical neuroleptic antipsychotic medications frequently cause unpleasant side effects, which occur at various times during treatment. The extrapyramidal side effect most likely to occur in the first few days of treatment is an acute dystonia, such as a muscle spasm in the neck. A pill-rolling tremor of the hands and masked facies are signs of Parkinsonian EPS, which tend to have their onset several weeks after treatment is begun; whereas severe restlessness of the arms and legs is caused by an unpleasant sensation called "akathisia," which also tends to have its onset several weeks after treatment is begun. Involuntary lip smacking is a sign of tardive dyskinesia, a sometimes irreversible motor syndrome that tends to occur after months or years of treatment with typical antipsychotics. Anticholinergic medications such as benztropine are effective in treating dystonias and pill-rolling tremors. Propranolol is effective in treating akathisia. Haldoperidol would worsen EPS. Dantrolene uncouples muscle contractions and is used occasionally in severe NMS. L-Dopa would decrease the Parkinsonian EPS, but would worsen the psychosis and therefore is not used. Fluoxetine is an SSRI.

• Question 293:

  A28-year-old woman with a 7-year history of chronic undifferentiated schizophrenia is hospitalized for an exacerbation of her schizophrenia, with an increase in auditory hallucinations. She has also developed the delusion that she is controlled by aliens from Mars. She has always been very sensitive to the extrapyramidal side effects (EPS) of antipsychotic medications.

  This woman develops cogwheel rigidity and a pill-rolling tremor. Which of the following is the most appropriate treatment choice?

  A. benztropine

  B. propranolol

  C. haldoperidol

  D. dantrolene

  E. fluoxetine

  Correct Answer: A

  Typical neuroleptic antipsychotic medications frequently cause unpleasant side effects, which occur at various times during treatment. The extrapyramidal side effect most likely to occur in the first few days of treatment is an acute dystonia, such as a muscle spasm in the neck. A pill-rolling tremor of the hands and masked facies are signs of Parkinsonian EPS, which tend to have their onset several weeks after treatment is begun; whereas severe restlessness of the arms and legs is caused by an unpleasant sensation called "akathisia," which also tends to have its onset several weeks after treatment is begun. Involuntary lip smacking is a sign of tardive dyskinesia, a sometimes irreversible motor syndrome that tends to occur after months or years of treatment with typical antipsychotics. Anticholinergic medications such as benztropine are effective in treating dystonias and pill-rolling tremors. Propranolol is effective in treating akathisia. Haldoperidol would worsen EPS. Dantrolene uncouples muscle contractions and is used occasionally in severe NMS. L-Dopa would decrease the Parkinsonian EPS, but would worsen the psychosis and therefore is not used. Fluoxetine is an SSRI

• Question 294:

  A28-year-old woman with a 7-year history of chronic undifferentiated schizophrenia is hospitalized for an exacerbation of her schizophrenia, with an increase in auditory hallucinations. She has also developed the delusion that she is controlled by aliens from Mars. She has always been very sensitive to the extrapyramidal side effects (EPS) of antipsychotic medications.

  Which of the following is an extrapyramidal side effect of antipsychotic medications most likely to be seen in the first few days of treatment with typical neuroleptic antipsychotics?

  A. pill-rolling tremor of the hands

  B. severe restlessness of the arms and legs

  C. involuntary lip smacking

  D. muscle spasm in the neck

  E. masked facies

  Correct Answer: D

  Typical neuroleptic antipsychotic medications frequently cause unpleasant side effects, which occur at various times during treatment. The extrapyramidal side effect most likely to occur in the first few days of treatment is an acute dystonia, such as a muscle spasm in the neck. A pill-rolling tremor of the hands and masked facies are signs of Parkinsonian EPS, which tend to have their onset several weeks after treatment is begun; whereas severe restlessness of the arms and legs is caused by an unpleasant sensation called "akathisia," which also tends to have its onset several weeks after treatment is begun. Involuntary lip smacking is a sign of tardive dyskinesia, a sometimes irreversible motor syndrome that tends to occur after months or years of treatment with typical antipsychotics. Anticholinergic medications such as benztropine are effective in treating dystonias and pill-rolling tremors. Propranolol is effective in treating akathisia. Haldoperidol would worsen EPS. Dantrolene uncouples muscle contractions and is used occasionally in severe NMS. L-Dopa would decrease the Parkinsonian EPS, but would worsen the psychosis and therefore is not used. Fluoxetine is an SSRI.

• Question 295:

  Astudy that has been stratified for age finds a statistically significant association between alcohol use and socioeconomic status (SES). In reviewing the data, the investigators find that the relationship between alcohol and SES is greatest for those in the 40- to 50-year age group. In this scenario, age plays which of the following roles in the relationship between alcohol use and SES?

  A. bias

  B. confounder

  C. effect modifier

  D. chance

  E. distractor

  Correct Answer: C

  An effect modifier changes the relationship between a risk factor and an outcome. In this example, the overall relationship between alcohol and SES has not changed, but its effects are greatest in a particular age group, and thus age is modifying the effect of the association between alcohol and SES. In this example, the study was stratified based on age, which would control for confounding effect based on age. Bias is seen when there is a systematic error in the manner in which age is distributed between the risk factor and outcome categories. Bias occurs when there is a systematic error in the design or conduct of a study. There is not enough information provided to determine whether bias may be present. Because the findings have been stratified and have been found to be statistically significant at each stratum, there is less of a possibility that chance is playing a role in the relationship between age and the exposure or outcome. Distractor is not a term commonly used to describe a variable's relationship to an outcome.

• Question 296:

  The National Center for Health Statistics collects information on chronic disease risk factors such as obesity, treatment for blood pressure, exercise, and alcohol use. These data are best captured using which of the following tools?

  A. health survey

  B. hospital records

  C. registries

  D. physician-based reports

  Correct Answer: A

  The Behavioral Risk Factor Surveillance System is a health survey that uses telephone interviews to collect information about chronic disease risk factors such as obesity, treatment for blood pressure, alcohol use, and exercise. Review of hospital records may capture some of this information, but is not an efficient method of capturing information on multiple risk factors for chronic disease. Registries are primarily used to track clinical information regarding particular diseases or conditions. They do not tend to capture a large body of information on behavioral risk factors. Physician-based reports are usually generated as a consequence of state or federal mandates regarding the reporting of communicable disease, rather than behavioral risk factors for chronic disease.

• Question 297:

  There is public alarm over the possible foodborne transmission of bovine spongiform encephalitis in your community. You decide to institute an active surveillance system to gather information on possible cases. In order to do this you should do which of the following?

  A. Collect information by gathering voluntary data reports from health care providers, laboratories, and others.

  B. Conduct a case-control study of individuals in your community with and without the disease.

  C. Organize the systematic calling of pathologists and neurologists from surrounding areas in an attempt to identify cases.

  D. Monitor disease in animal flocks.

  E. Collect billing reports to identify from where the cattle were purchased.

  Correct Answer: C

  Active surveillance is used in urgent situations, such as active and ongoing epidemics. Health agencies contact those data sources most likely to have current information regarding cases. The collection of data which has been voluntarily submitted is referred to as passive surveillance. Case-control studies are a form of investigation and represent a "next step" after surveillance. These studies seek to identify further information regarding the health problem y studying individuals with the disease. Surveillance systems on the other hand are used primarily to identify whether or not a problem exists and how it is changing through time. Monitoring disease in animal population or in other specific populations that are higher or earlier risk is referred to as sentinel data collection or surveillance. Identifying where cattle were purchased may help to identify the extent of disease spread in animals, but does not describe active surveillance of human cases.

• Question 298:

  In order to allocate health care resources in your community, you compare the health status of subpopulations by comparing infant mortality rates. Which of the following most accurately compares the infant mortality rates for children born to White mothers and for children born to Black or African- American mothers in 2004 in the United States?

  A. The infant mortality rate for children born to Black or African-American mothers was one-third the infant mortality rate for children born to White mothers.

  B. The infant mortality rate for children born to Black or African-American mothers was one-half the infant mortality rate for children born to White mothers.

  C. The infant mortality rate for children born to Black or African-American mothers was between one and two times the infant mortality rate for children born to White mothers.

  D. The infant mortality rate for children born to African-American mothers was between two and three times the infant mortality rate for children born to White mothers.

  E. The infant mortality rate for children born to Black or African-American mothers was six times the mortality rate for children born to White mothers.

  Correct Answer: D

  In 2004, the infant mortality rate for children born to White mothers was 5.7 infant deaths/1000 live births. The infant mortality rate for children born to Black or African- American mothers was 13.8 infant deaths/1000 live births.

• Question 299:

  The USPSTF made recommendations for screening mammography and clinical breast examination every 12 years for women aged 40 years and older. Which of the following is the best explanation for why routine screening mammography was not recommended for women in the general population under 40 years of age?

  A. Screening mammography in women less than 40 is not as sensitive as in those over 40.

  B. Screening mammography in women less than 40 is more difficult due to tissue density.

  C. Women under the age of 40 are still likely to have high estrogen levels.

  D. Breast self-examination in the younger group is more sensitive in detecting cancers than mammography.

  E. The benefit of detecting cancers in the younger age group was outweighed by the risks screening caused in that age group.

  Correct Answer: E

  It is true that mammography for detection of breast cancer in older women is technically easier and probably more sensitive than in younger women. However, the burden of cost and mortality resulting from screening women less than 40 was the real reason that screening them was not recommended. For first mammograms of women aged 4049, cancers were diagnosed at half the rate of women aged 50 59 years old, yet twice as many follow-up diagnostic tests were performed. Simply put, the cost in terms of dollars, mortality from testing, and mortality from radiation exposure for women under 40 were not considered to be worth the benefit.

• Question 300:

  An HMO has its annual medical directors, meeting, and new treatments are discussed. A recent study has just clearly demonstrated that a new drug can lower blood pressure significantly, although monitoring tests for renal function are required. The directors consider adding the treatment to their list of approved treatments but feel handicapped. Which of the following is one of the real disadvantages of making treatment decisions based on clinical outcomes alone?

  A. Clinical tests cannot reliably tell which treatment works best.

  B. Clinical trials ignore the difference in costs between treatments.

  C. Results of clinical trials cannot possibly be applied to real-world situations.

  D. Effects noted in the study population will not show up in the general population.

  E. The advantages of improvement in clinical outcomes are always too significant to ignore.

  Correct Answer: B

  Although clinical trials can determine which treatment works best, they cannot determine the cost of this success. Unfortunately, they do not take into account costs and ultimate benefits, which would be the role of a costbenefit study. If properly constructed, with study and control groups randomly drawn from the general population, the results should be applicable to the general population. In addition, they usually determine what works best by measurement of a clinical endpoint. In many cases, the treatment may achieve its objective, but the change in parameters may not be significant. It is worthy of note that the USPSTF is now taking cost-effectiveness into account when making recommendations.