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USMLE STEP2 Exam
Step2 (Page 10 )

Updated On: 19-Jan-2026
Page 10 of 149
PDF with 738 Questions

You are called to the ICU to see a 65-year-old female who is 2 days status post hip surgery. The medical team is concerned because the patient is having visual hallucinations and did not sleep last night. She scored 21/30 on a Mini-Mental Status Examination (MMSE) with 5 points off for disorientation and 2 off for both concentration and shortterm memory. The patient is restrained because she pulled out her IV last night. Records indicate she has no previous psychiatric history and that her cognitive functioning presurgery was normal.
Which of the following is not a predisposing factor for the above condition?

  1. cancer
  2. advanced age
  3. female gender
  4. dementia
  5. alcohol dependence

Answer(s): C

Explanation:

Advanced age is a major risk factor for the development of delirium. Other predisposing risk factors include preexisting brain damage, a history of previous delirium, alcohol dependence, diabetes, cancer, dementia, sensory impairment, and malnutrition. Male gender is also an independent risk factor.



A 56-year-old man with a dual diagnosis of schizophrenia and alcohol dependency was arrested for "driving under the influence." After 2 days in jail, he was noted to be acting agitated and "crazy," claiming that the guards were going to kill him that night. When questioned about his profuse sweating, he claimed that he had just come in from his job working in the heat and humidity. He was distracted by various noises, claiming that these were made by people watching him and waiting for him. He appeared to watch things that seemed to be moving on the walls. On further examination, it was noted that he was very tremulous, unable to follow an object with his eyes only, and quite ataxic. The working diagnosis at this point is most likely which of the following?

  1. acute exacerbation of schizophrenia
  2. alcohol withdrawal delirium
  3. alcohol-induced persisting dementia
  4. alcohol intoxication
  5. malingering

Answer(s): B

Explanation:

According to the case study, this man can be presumed to have been without alcohol for at least the 2 days he has been in jail, and, therefore, the emerging symptoms would be most attributable to withdrawal and delirium. Withdrawal symptoms include autonomic hyperactivity, hand tremor, hallucinations, illusions, and agitation. Added to these are the signs of delirium, disorientation, irritability, agitation, disorganized thought, inability to focus and concentrate, and development of symptoms over a short time. Adiagnosis of exacerbation of schizophrenia does not adequately explain these symptoms and their development shortly after the withdrawal of alcohol. The signs and symptoms are not consistent with dementia, in which one would expect a longer period for symptom development and a clouding of consciousness. Although malingering might be considered, especially for an incarcerated individual, the history of recent alcohol intoxication with abrupt withdrawal makes alcohol withdrawal delirium a more consistent diagnosis.



A 56-year-old man with a dual diagnosis of schizophrenia and alcohol dependency was arrested for "driving under the influence." After 2 days in jail, he was noted to be acting agitated and "crazy," claiming that the guards were going to kill him that night. When questioned about his profuse sweating, he claimed that he had just come in from his job working in the heat and humidity. He was distracted by various noises, claiming that these were made by people watching him and waiting for him. He appeared to watch things that seemed to be moving on the walls. On further examination, it was noted that he was very tremulous, unable to follow an object with his eyes only, and quite ataxic. Which of the following benzodiazepines can reliably be given intramuscularly to this patient to help control his symptoms?

  1. diazepam
  2. chlordiazepoxide
  3. lorazepam
  4. alprazolam
  5. clonazepam

Answer(s): C

Explanation:

Diazepam, chlordiazepoxide, and lorazepam can all be given parenterally, but only lorazepam is reliably absorbed after intramuscular injection. Alprazolam and clonazepam are not available in parenteral form in the United States.



A 60-year-old man disappears from his home and travels 100 miles to a small town, where he opens a small grocery store using a different name. Six weeks later, he awakens in some agitation, uses his original name, and asks to know where he is. He wishes to return to his home. Which of the following is the most likely diagnosis?

  1. dissociative amnesia
  2. dissociative fugue
  3. dissociative identity disorder
  4. depersonalization disorder
  5. dissociative disorder not otherwise specified

Answer(s): B

Explanation:

Dissociative fugue is classically typified by a person's suddenly and unexpectedly traveling away from his or her home, assuming a new identity, and eventually recovering from the fugue or flight, unable to recall the events that took place during the episode. Dissociative amnesia is a more generalized term given to an inability to recall significant personal information. Dissociative identity disorder is the current diagnostic term for what was classically called multiple personality disorder. Depersonalization disorder is an alteration of experience in which an individual feels like an outside observer of his or her body or mental processes.
Dissociative disorder not otherwise specified is a name given to other dissociative illnesses not specifically listed in DSM-IV-TR, such as dissociative states occurring in individuals subjected to brainwashing or indoctrination while held captive by terrorists.



A 44-year-old man presents with fears that his mathematical abilities have been slowly sucked out of his brain for the last 4 years. He believes an "alien force disguised as a human being" is responsible. To avoid contacting this being, he has isolated himself in a room in a boarding house. His wife divorced him and left with their children. After 10 years teaching math at a local high school, he resigned about 3 years ago. He supports himself by "collecting cans." His affect is blunted. His appearance is disheveled, unshaven, and unwashed.
Which of the following hypotheses is the leading hypothesis to explain the patient's psychotic symptoms?

  1. serotonin hypothesis
  2. biogenic amine hypothesis
  3. acetylcholine hypothesis
  4. dopamine hypothesis
  5. gamma aminobutyric acid (GABA) hypothesis

Answer(s): D

Explanation:

The dopamine hypothesis of schizophrenia grew from the observations that medications that block dopamine receptors have antipsychotic activity and medications that stimulate dopamine receptors (amphetamines) can induce psychosis. Serotonin abnormalities have been implicated in mood and anxiety disorders. The biogenic amine hypothesis of mood disorders was based on the finding that tricyclic and MAOI drugs are effective in alleviating the symptoms of depression. The GABAergic system has been implicated in anxiety disorders because benzodiazepines which are GABAergic have antianxiety effects.
Acetylcholine abnormalities have been associated with dementia.



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