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USMLE STEP2 Exam
Step2 (Page 5 )

Updated On: 19-Jan-2026
Page 5 of 149
PDF with 738 Questions

A25-year-old man presents in the emergency department for a 2-week problem of worsening urinary hesitancy. He has had problems getting his urine stream started and has noted a decrease in the force of the stream. Now it seems to just "dribble out." He denies any pain or burning, any medical problems, and any exposure to sexually transmitted diseases. For approximately 1 month, he has been taking thioridazine, 200 mg bid, and benztropine, 2 mg qid, and "sometimes one or two benztropine" prn.Given the above information, which of the following is the most likely cause of this man's problem?

Which of the following is a safer choice of medication for this man?

  1. amitriptyline
  2. risperidone
  3. chlorpromazine
  4. mesoridazine
  5. imipramine

Answer(s): B

Explanation:

Given the temporal relationship in the start of two anticholinergic drugs and the onset of the urinary hesitancy in an otherwise healthy young male, it would be reasonable to conclude that he drugs are causing the problem. Certainly, a rapid assessment regarding the possibility of other causes (e.g., infection, trauma, stricture) is important. Careful, attentive listening for any hint of psychotic delusion involving urination is important to screen for. The manner in which the patient describes his symptoms is invaluable in facilitating diagnosis. Also remember that a real medical condition can be described in bizarre, distorted terms, making assessment more difficult and complicated. Drug-induced urinary hesitancy may be treated by discontinuing the causative medications. In addition, bethanechol, 1030 mg three to four times each day, may be administered. Bethanechol acts by stimulating the parasympathetic nervous system. The tone of the detrusor urinae muscle increases, producing a contraction strong enough to initiatemicturition and emptying of the bladder. Giving benztropine, an anticholinergic, would only heighten the problem.
Unfortunately, some patients understand that benztropine is "for the side effect" of their antipsychotic medication but do not understand the difference between the extrapyramidal effect and the anticholinergic effects. Increased thioridazine would also increase the urinary problem. Calling in a urologist would be indicated if the initial treatment failed to work or if the emergency department physician were not able to "get beyond" an extremely distorted, disorganized presentation by the patient. If the bladder were extremely distended and the patient very uncomfortable, insertion of a urinary catheter would be a reasonable course of action. In the patient described, the bladder is not distended.
Of the medications listed, risperidone is a reasonable and safe choice because its anticholinergic effects are low compared to the other drugs listed, and much lower than thioridazine. Chlorpromazine and mesoridazine have substantial anticholinergic effects. Amitriptyline and imipramine have substantial anticholinergic effects, and, in addition, they are tricyclic antidepressants, not antipsychotics.



A 78-year-old woman is seen by a psychiatrist for depression. She is fairly cooperative in responding to questions. She admits to feeling blue; she "catnaps" throughout the day and is up at night; and her appetite is very poor. She thinks of death frequently but denies feeling suicidal. There is no past psychiatric history. On the MMSE, she obtains a score of 14. Her depressive symptoms have been present for "several days." Which of the following is highly suggested by the findings?

  1. impaired cognitive functioning
  2. psychosis not otherwise specified
  3. bipolar disorder--manic
  4. dysthymia
  5. changes secondary to normal aging

Answer(s): A

Explanation:

One of the most significant findings here is that the woman, cooperative with the examination, has the score of 14 on the MMSE. Ascore of 2530 indicates no cognitive impairment, 2025 suggests possible mild impairment, and less than 20 is very strongly suggestive of cognitive impairment. This degree of change on the MMSE is not a normal sign of aging. In addition, there are no signs of psychosis or mania. Even if there were, in this woman with no previous sychiatric history, one would not likely consider psychosis not otherwise specified or mania. The time frame for dysthymia is not met by the "several days" length described here.



A 40-year-old man has been unsuccessfully treated for depression with two different medications for the past 3 months. He has a number of medical problems, and he recently was hospitalized after threatening suicide. His psychiatrist is considering the use of ECT for the patient. Which of the following is a relative contraindication to ECT?

  1. hypertension
  2. history of seizures
  3. clinically significant space-occupying cerebral lesion
  4. degenerative joint disease of the spine
  5. suicidality

Answer(s): C

Explanation:

ECT can be a life-saving tool in the treatment of depression, particularly in individuals who are very suicidal, because of its relatively quick onset of action. It is a relative contraindication to give patients with a clinically significant space-occupying cerebral lesion ECT because of the risk of brain stem herniation. ECT can be performed on patients with space-occupying lesions rarely, but the benefit needs to outweigh the risk, and it should be performed by experts. However, although hypertension and cardiovascular disease put patients at a higher risk for complications from ECT, they are not absolute contraindications to its use.
With the use of muscle relaxants as part of the electroconvulsive technique, patients with degenerative joint disease of the spine can generally safely receive ECT. Seizures actually would typically decrease in frequency with the application of ECT.



A 40-year-old man has been unsuccessfully treated for depression with two different medications for the past 3 months. He has a number of medical problems, and he recently was hospitalized after threatening suicide. His psychiatrist is considering the use of ECT for the patient.

The patient has consented to ECT, and the pre ECT workup has been completed. Which of the following medications could routinely be continued through a course of ECT?

  1. lithium
  2. divalproex
  3. bupropion
  4. clonazepam
  5. risperdal

Answer(s): E

Explanation:

Risperdal and high potency neuroleptics slightly decrease the seizure threshold and would enhance the seizure and can typically be continued through a course of ECT. Lithium can result in increased postictal delirium, divalproex and clonazepam would typically be withdrawn due to their anticonvulsant effect. If a benzodiazepine is required a short-acting medication should be used. Bupropion has been associated with late appearing seizures.



A 40-year-old woman with no previous psychiatric history seeks help from her internist for a sleep problem. Initially, she is able to fall asleep but then sleeps fitfully, and finally around 4:00 a.m. decides to stay up. She averages approximately 34 hours of sleep per night, and this has been occurring for the last 3 weeks. She finds herself quite tired and "blue" during the day but is unable to nap. Mornings are "the worst" for her, but she feels better toward the end of the day. There has been a 15-lb weight loss because "I'm just not hungry." She denies any physical problems except for constipation. As a gradeschool teacher, she feels extremely stressed but sees no way out and no way to improve the situation. At times, suicide seems like a possible option, and she admits to spending long hours brooding on how to do it. A physical examination is unremarkable.
Which of the following is the most likely diagnosis?

  1. borderline personality disorder
  2. major depression
  3. dysthymia
  4. Alzheimer's disease
  5. generalized anxiety disorder

Answer(s): B

Explanation:

This woman's symptoms meet the criteria for a major depressive episode. She has had a depressed (blue) mood for at least a 2-week period, a significant weight loss, insomnia, fatigue and loss of energy, and thoughts of suicide. Because her symptoms seem to be limited to 3 weeks, dysthymic disorder would most likely not be considered. There are no indications for an organic mental disorder that would suggest Alzheimer's disease. Generalized anxiety disorder is characterized by excessive anxiety and worry for about 6 months. For a diagnosis of borderline personality disorder, patterns of instability in relationships, selfimage, affect, and impulsivity would have been present in early adulthood. None of that is described here.



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