USMLE-STEP-2 Exam Questions & Answers

Correct Answer: E

Sleep disturbance is a characteristic symptom associated with fibromyalgia. Patients awaken feeling tired. The examination, other than tenderness in 14 specific, symmetrical points, is usually normal. Fever, rash on the extremities, muscle weakness, and migratory joint inflammation point to Lyme disease or other rheumatologic disorders. Asedimentation rate should be normal. If elevated, it may point to another diagnosis. Lyme titers are not indicated unless the patient has symptoms or history suggestive of the disease. Electromyelography and spine radiographs are typically normal and unnecessary for help in establishing the diagnosis. Depression can be associated with pain, but screening for it early on does not make sense and might offend the patient. Low-dose antidepressants often help to correct the sleep pattern and result in relief of pain. Nonsteroidal anti-inflammatory agents can also be used as needed; low-dose steroid is not indicated. Exercise is also helpful, and patients should be encouraged to stay physically active. Amoxicillin is not used for fibromyalgia. Benzodiazepines have addictive potential and lose their effectiveness for sleep after a few weeks.

Correct Answer: A

Defense mechanisms provide a means for dealing with anxiety and affect. The mechanisms chosen range from the very narcissistic and immature to mature. In suppression, a person makes a conscious decision to put the conflict aside until it can be dealt with more appropriately. On the other hand, in acting out, there is little or no attempt to contain the affect, and it is directly expressed, as in name calling. Sublimation provides a channel for the indirect expression of a need or affect. Its use is positive and socially acceptable. In reaction formation, the person acts as if the strong need or affect did not exist and acts out the opposing feeling. In projection, unacceptable feelings and thoughts are denied as part of the self and instead are "put on" the other person.

Correct Answer: B

Prospective randomized trials have addressed the issue of locoregional control of breast cancer. Conservative management consisting of lumpectomy (with negative margins), irradiation, and axillary node dissection is equally effective as modified radical mastectomy in patients with clinical stage I or II breast carcinoma. Although radical mastectomy yields equivalent survival to modified radical mastectomy, it is disfiguring and disabling and is rarely employed for treatment of primary operable breast cancer. Lumpectomy without irradiation leads to unacceptably high local recurrence rates. Irradiation without surgery is not as effective as surgery in the presence of gross disease. Quadrantectomy removes excessive tissue and leads to an inferior cosmetic result as compared to lumpectomy. If quadrantectomy is thought to be required to gain negative margins, mastectomy with reconstruction should be entertained. The use of SLN biopsy to stage the axilla in breast cancer is gaining wider acceptance as experience with the procedure grows. Trials are ongoing that will answer numerous questions regarding the accuracy and efficacy of SLN biopsy for breast cancer. There are contraindications to SLN biopsy that include palpable adenopathy that is suspicious for metastatic disease, locally advanced disease or tumor size >5 cm, multicentric disease, pregnant or lactating patient, and use of preoperative chemotherapy. Therefore, in this patient with palpable suspicious adenopathy, SLN biopsy would be contraindicated. Although age may influence success of SLN biopsy, increasing age does not preclude the procedure.