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USMLE STEP2 Exam
Step2 (Page 2 )

Updated On: 19-Jan-2026
Page 2 of 149
PDF with 738 Questions

You evaluate a 38-year-old man who complains of muscle weakness. Her appearance is remarkable for a periorbital heliotrope rash with edema and erythema on his upper chest, neck, and face. Which of the following is the most likely diagnosis?

  1. polymyositis
  2. dermatomyositis
  3. spinocerebellar degeneration
  4. vasculitis
  5. rheumatoid arthritis

Answer(s): B

Explanation:

The heliotrope, purple periorbital rash is seen with dermatomyositis and may even precede the muscle involvement. On examination, these patients will usually show proximal muscle weakness and may complain of difficulty getting up from a chair, climbing stairs, and raising the arms over the head. Ataxia may be present with cerebellar lesions. Deep tendon reflexes should be normal and there is no joint inflammation. Polymyalgia rheumatica generally occurs in older people but is not associated with muscle weakness. Spinocerebellar degeneration, vasculitis, and rheumatoid arthritis are not associated with this rash. Creatine phosphokinase is usually markedly elevated and muscle biopsy will confirm the diagnosis.
Serum creatinine, sodium, and potassium should be normal, and the rheumatoid factor should not be elevated.



A 58-year-old woman with a history of chronic paranoid schizophrenia, who has been continuously treated with antipsychotics for the past 20 years, lives in a community-based residential facility. She has recently suffered an increase in auditory hallucinations, and her haloperidol dose has been increased from 2.5 to 10 mg/day. Four days later, she is brought by a visiting nurse to the emergency room, where she presents with confusion, marked flexor and extensor rigidity in her legs and arms, and a temperature of 103.5°F. Her blood pressure is160/120 mmHg, her pulse is 120/min and irregular. Which of the following is the most likely diagnosis that best describes this woman's current condition?

  1. neuroleptic malignant syndrome (NMS)
  2. metabolic syndrome
  3. extrapyramidal symptoms
  4. malingering
  5. alcohol withdrawal

Answer(s): A

Explanation:

NMS is a rare complication of neuroleptic therapy which involves symptoms of severe muscle rigidity, elevated temperature, and two or more of the following: diaphoresis, dysphagia, and tremor, and incontinence, changes in level of consciousness, tachycardia, mutism, leukocytosis, elevated CPK, or labile blood pressure. EPS would not explain the extensor rigidity, elevated temperature, and blood pressure.
Metabolic syndrome refers to another neuroleptc side effect where lipid levels are elevated and adult onset diabetes can develop. Malingering would not easily explain the elevated vital signs. Though alcohol withdrawal would be in the differential with the elevated vital signs, the pipe-like rigidity could not be explained.



A 58-year-old woman with a history of chronic paranoid schizophrenia, who has been continuously treated with antipsychotics for the past 20 years, lives in a community-based residential facility. She has recently suffered an increase in auditory hallucinations, and her haloperidol dose has been increased from 2.5 to 10 mg/day. Four days later, she is brought by a visiting nurse to the emergency room, where she presents with confusion, marked flexor and extensor rigidity in her legs and arms, and a temperature of 103.5°F. Her blood pressure is160/120 mmHg, her pulse is 120/min and irregular. Which of the following is the most important laboratory test to evaluate the possibility of the diagnosis?

  1. serum creatine phosphokinase (CPK) level
  2. serum sodium level
  3. serum potassium level
  4. serum glucose level
  5. serum calcium level

Answer(s): A

Explanation:

Patients with NMS typically demonstrate tachycardia, labile blood pressure, severe muscle rigidity, and severe fever. Serum CPK levels, which can be elevated to more than 100 times normal levels as a result of muscle damage, are the most consistently noted abnormalities in patients with NMS. Although the white blood cell count may be elevated, and blood levels of calcium, iron, and magnesium may be decreased in patients with the syndrome, serum CPK is the most important laboratory study to obtain in a patient with suspected NMS



A 58-year-old woman with a history of chronic paranoid schizophrenia, who has been continuously treated with antipsychotics for the past 20 years, lives in a community-based residential facility. She has recently suffered an increase in auditory hallucinations, and her haloperidol dose has been increased from 2.5 to 10 mg/day. Four days later, she is brought by a visiting nurse to the emergency room, where she presents with confusion, marked flexor and extensor rigidity in her legs and arms, and a temperature of 103.5°F. Her blood pressure is160/120 mmHg, her pulse is 120/min and irregular. Which of the following is most likely to be an effective treatment for this condition?

  1. intramuscular haloperidol
  2. oral bromocriptine
  3. intramuscular lorazepam
  4. intramuscular benztropine
  5. oral propranolol

Answer(s): B

Explanation:

The most effective treatments for the extremely serious, potentially fatal complication of antipsychotic treatment called NMS are oral bromocriptine, a dopaminergic agonist, and intravenous or oral dantrolene, a skeletal muscle relaxant. Afurther increase in the patient's haloperidol dose would likely worsen her NMS.
While the anticholinergic effects benztropine may alleviate some of the neuroleptic- induced muscular dystonia associated with the syndrome, and lorazepam may help relax the muscle rigidity, they are not likely to be life saving, and propranolol is not an effective medication in the treatment of NMS.



Narcolepsy is a primary sleep disorder with all of the following symptoms except which of the following?

  1. sleep paralysis
  2. sleep attacks with sleep onset REM (rapid eye movement)
  3. cataplexy
  4. hypnagogic hallucinations
  5. apnea

Answer(s): E

Explanation:

Narcolepsy is a rare dyssomnia (incidence of .07%) defined by the following four symptoms: sleep paralysis occurs upon falling asleep or waking, sleep attacks with sleep onset REM which are brief (1015 minutes) and occur in inappropriate situations (sleep attacks are effectively treated with stimulants), cataplexy which is a condition that involves sudden transient bilateral weakness or paralysis, and hypnagogic hallucinations. Apnea is the cessation of nasobuccal breathing for more than 10 seconds and is found in obstructive sleep apnea, central sleep apnea, and mixed sleep apnea.



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