Kaplan USMLE Step 2 prep: 6 stumpers on middle-aged patients

Over the years, the AMA has run dozens of example questions from Kaplan Medical. If you’re preparing for the United States Medical Licensing Examination®​​​​​​ (USMLE®) Step 2 exam, you might want to know which questions are most often missed by test-prep takers. We’ve compiled six cases from Kaplan Medical involving middle-aged adult patients—those between 36 and 65 years old. Each question comes with an expert explanation of the answer. You can check out all posts in this series.

The AMA and Kaplan have teamed up to support you in reaching your goal of passing the USMLE® or COMLEX-USA®. If you're looking for additional resources, Kaplan provides free access to tools for pre-clinical studies, including Kaplan’s Lecture Notes series, Integrated Vignettes, Shelf Prep and more.

Think you can answer these questions involving middle-aged adult patients? Find out now.

1. Dyspnea, wheezing and cough

   1. A 40-year-old woman with a nine-year history of scleroderma comes to the physician because of shortness of breath and a dry cough for four months. She has had weakness, dyspnea with minimal exertion, arthralgias, and difficulty with swallowing. Her temperature is 36.8 °C (98.2 °F), blood pressure is 135/75 mm Hg, pulse is 112 beats per minute, and respirations are 26 per minute. What is the most appropriate next step in diagnosis?

2. Next step for patient with groin pain

   1. A 55-year-old man comes to the urgent care clinic because of groin pain. He describes the pain as intense, constant and dull. He also thinks he noticed a new bulge in his groin. Past medical history is significant for hypertension. There is no surgical history. His temperature is 38 ºC (100.4 ºF), pulse is 98 beats a minute, respirations are 16 breaths per minute, and blood pressure is 138/80 mm Hg.
   2. Examination of the groin shows mild right-sided erythema, and a mildly tender mass can be felt when the examiner's finger is placed in the internal inguinal ring. The size and presence of the mass are unaffected by cough or strain. The remainder of the examination is otherwise unremarkable. What is the most appropriate next step in the management of this patient? 

   3. Related Coverage

      Kaplan USMLE Step 2 prep: Abdominal pain drives these 6 stumpers

3. Woman seeks long-term weight loss

   1. A 40-year-old woman with obesity has made multiple attempts to lose weight for the past five years with no lasting success. She says she can’t resist sweets. She has, at times, lost up to 18 kilograms (40 pounds), which she has always regained. Her body mass index is 42 kg/m². She is moderately hypertensive and is on a diuretic and an angiotensin-converting enzyme inhibitor.
   2. She has osteoarthritis of both knees. She also has severe obstructive sleep apnea and uses continuous positive airway pressure nightly during sleep. What is the best option for her to achieve long-term weight loss and morbidity reduction? 

4. Patient says his skin is crawling

   1. A 50-year-old man comes to the emergency department because of bilateral hand tremor, diaphoresis, anxiety, nausea, headache and the sensation that “my skin is crawling.” His medical history is significant for hypertension that is treated with hydrochlorothiazide and enalapril. He also has bipolar disorder and anxiety, which is treated with three medications prescribed by his psychiatrist. He ran out of these three medications three days ago. Physical examination is notable for diaphoresis and tremulousness. What is the most appropriate initial step in this patient's care?  

5. Treating burning sensation in legs

   1. A 56-year-old woman comes to the physician because of a two-year history of a burning sensation in her legs. She has occasional sharp, lancinating pains that shoot up her legs, for which hydrocodone and acetaminophen provide some relief. She has had no weakness, headaches, confusion or memory loss. 
   2. She has a 22-year history of hypertension, chronic kidney disease and type 2 diabetes mellitus with retinopathy and diabetic gastroparesis. Current medications include insulin, metformin, lisinopril and hydrochlorothiazide. She had a myocardial infarction four years ago. Serum creatinine is 2.8 mg/dL and hemoglobin A1c level is 11.6%. What’s the most appropriate pharmacotherapy for this patient's leg pain?  

   3. Related Coverage

      Kaplan USMLE Step 2 prep: 6 stumpers involving senior patients

6. Barium enema reveals multiple polyps 

   1. A 58-year-old woman comes to the physician for a follow-up examination two weeks after undergoing a barium enema. She denies fever, weight loss, rectal bleeding, or fatigue. She has a four-year history of hypertension controlled with hydrochlorothiazide. Examination shows no abnormalities. The barium enema shows four to five polyps scattered throughout her colon, ranging in size from 4 mm to 1.1 cm. What is the most appropriate next step in management? 

For more prep questions on USMLE Steps 1 and 2, view other posts in this series.