{"id":3524,"date":"2023-10-18T12:22:00","date_gmt":"2023-10-18T12:22:00","guid":{"rendered":"https:\/\/www.osmosis.org\/blog\/?p=3524"},"modified":"2026-06-30T15:17:20","modified_gmt":"2026-06-30T23:17:20","slug":"usmle-step-2-question-of-the-day-focused-history","status":"publish","type":"post","link":"https:\/\/www.osmosis.org\/blog\/usmle-step-2-question-of-the-day-focused-history","title":{"rendered":"USMLE\u00ae Step 2 Question of the Day: Focused history"},"content":{"rendered":"<div id=\"ez-toc-container\" class=\"ez-toc-v2_0_80 ez-toc-wrap-center counter-hierarchy ez-toc-counter ez-toc-custom ez-toc-container-direction\">\n<div class=\"ez-toc-title-container\">\n<p class=\"ez-toc-title\" style=\"cursor:inherit\">In This Article<\/p>\n<span class=\"ez-toc-title-toggle\"><a href=\"#\" class=\"ez-toc-pull-right ez-toc-btn ez-toc-btn-xs ez-toc-btn-default ez-toc-toggle\" aria-label=\"Toggle Table of Content\"><span class=\"ez-toc-js-icon-con\"><span class=\"\"><span class=\"eztoc-hide\" style=\"display:none;\">Toggle<\/span><span class=\"ez-toc-icon-toggle-span\"><svg style=\"fill: #999;color:#999\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\" class=\"list-377408\" width=\"20px\" height=\"20px\" viewBox=\"0 0 24 24\" fill=\"none\"><path d=\"M6 6H4v2h2V6zm14 0H8v2h12V6zM4 11h2v2H4v-2zm16 0H8v2h12v-2zM4 16h2v2H4v-2zm16 0H8v2h12v-2z\" fill=\"currentColor\"><\/path><\/svg><svg style=\"fill: #999;color:#999\" class=\"arrow-unsorted-368013\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\" width=\"10px\" height=\"10px\" viewBox=\"0 0 24 24\" version=\"1.2\" baseProfile=\"tiny\"><path d=\"M18.2 9.3l-6.2-6.3-6.2 6.3c-.2.2-.3.4-.3.7s.1.5.3.7c.2.2.4.3.7.3h11c.3 0 .5-.1.7-.3.2-.2.3-.5.3-.7s-.1-.5-.3-.7zM5.8 14.7l6.2 6.3 6.2-6.3c.2-.2.3-.5.3-.7s-.1-.5-.3-.7c-.2-.2-.4-.3-.7-.3h-11c-.3 0-.5.1-.7.3-.2.2-.3.5-.3.7s.1.5.3.7z\"\/><\/svg><\/span><\/span><\/span><\/a><\/span><\/div>\n<nav><ul class='ez-toc-list ez-toc-list-level-1 ' ><li class='ez-toc-page-1 ez-toc-heading-level-2'><a class=\"ez-toc-link ez-toc-heading-1\" href=\"https:\/\/www.osmosis.org\/blog\/usmle-step-2-question-of-the-day-focused-history\/#The_correct_answer_to_todays_USMLE%C2%AE_Step_2_CK_Question_is%E2%80%A6\" >The correct answer to today&#8217;s USMLE\u00ae Step 2 CK Question is&#8230;<\/a><\/li><li class='ez-toc-page-1 ez-toc-heading-level-2'><a class=\"ez-toc-link ez-toc-heading-2\" href=\"https:\/\/www.osmosis.org\/blog\/usmle-step-2-question-of-the-day-focused-history\/#Incorrect_Answer_Explanations\" >Incorrect Answer Explanations<\/a><\/li><li class='ez-toc-page-1 ez-toc-heading-level-2'><a class=\"ez-toc-link ez-toc-heading-3\" href=\"https:\/\/www.osmosis.org\/blog\/usmle-step-2-question-of-the-day-focused-history\/#Main_Explanation\" >Main Explanation<\/a><\/li><li class='ez-toc-page-1 ez-toc-heading-level-2'><a class=\"ez-toc-link ez-toc-heading-4\" href=\"https:\/\/www.osmosis.org\/blog\/usmle-step-2-question-of-the-day-focused-history\/#Major_Takeaway\" >Major Takeaway<\/a><\/li><li class='ez-toc-page-1 ez-toc-heading-level-2'><a class=\"ez-toc-link ez-toc-heading-5\" href=\"https:\/\/www.osmosis.org\/blog\/usmle-step-2-question-of-the-day-focused-history\/#References\" >References<\/a><\/li><\/ul><\/nav><\/div>\n\n<p class=\"wp-block-paragraph\"><em><strong>We&#8217;re back with a USMLE\u00ae Step 2 CK Question of the Day!&nbsp;<em>Today&#8217;s case involves a patient who arrives at the emergency department with anxiety and two recent episodes of loss of consciousness. What&#8217;s the diagnosis? Let&#8217;s find out!<\/em><\/strong><\/em><\/p>\n\n\n\n<p class=\"wp-block-paragraph\">A <strong>38-year-old man<\/strong> presents to the emergency department for evaluation of <strong>anxiety <\/strong>and <strong>two episodes of<\/strong> <strong>loss of consciousness<\/strong> over the past 24 hours. The patient&#8217;s partner recounts that they found the patient <strong>facedown <\/strong>on the lawn last night with <strong>urinary incontinence<\/strong> and again in the kitchen this morning. The partner states that the patient has been <strong>feeling down<\/strong> and <strong>drinking more alcohol than usual<\/strong> since losing his job four months ago: up to <strong>five beers a night<\/strong>. <\/p>\n\n\n\n<p class=\"wp-block-paragraph\">The patient has <strong>no significant past medical history<\/strong>. <strong>Temperature is 36\u00b0C (96.8\u00b0F), blood pressure is 168\/60 mmHg, pulse is 110\/min, respiratory rate is 16\/min, oxygen saturation is 99% on room air. <\/strong>The patient is <strong>diaphoretic <\/strong>and <strong>anxious<\/strong>. He has evidence of <strong>tremor in the hands<\/strong> when the arms are <strong>outstretched <\/strong>and the <strong>fingers <\/strong>are <strong>spread<\/strong>. The underside of his <strong>tongue <\/strong>has a <strong>superficial laceration<\/strong>. <strong>Abdominal examination is unremarkable.<\/strong> IV access is established and the patient is given <strong>intravenous normal saline<\/strong>. <\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>Which of the following <em>additional historical elements<\/em> is most likely to be present?<\/strong><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>A. Recent cessation of alcohol use&nbsp;<\/strong><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>B. Recent cessation of cocaine use<\/strong><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>C. Anticholinergic ingestion<\/strong><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>D. Recent cessation of chronic opioids<\/strong><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>E. Isoniazid use<\/strong><\/p>\n\n\n\n<p class=\"has-text-align-center wp-block-paragraph\"><em>Scroll down for the correct answer!<\/em><\/p>\n\n\n\n<figure class=\"wp-block-embed is-type-video is-provider-youtube wp-block-embed-youtube wp-embed-aspect-16-9 wp-has-aspect-ratio\"><div class=\"wp-block-embed__wrapper\">\n<iframe loading=\"lazy\" title=\"Learn with Osmosis\" width=\"500\" height=\"281\" src=\"https:\/\/www.youtube.com\/embed\/iDxHtjjCMbU?feature=oembed\" frameborder=\"0\" allow=\"accelerometer; autoplay; clipboard-write; encrypted-media; gyroscope; picture-in-picture; web-share\" referrerpolicy=\"strict-origin-when-cross-origin\" allowfullscreen><\/iframe>\n<\/div><\/figure>\n\n\n\n<h2 class=\"wp-block-heading\"><span class=\"ez-toc-section\" id=\"The_correct_answer_to_todays_USMLE%C2%AE_Step_2_CK_Question_is%E2%80%A6\"><\/span>The correct answer to today&#8217;s USMLE\u00ae Step 2 CK Question is&#8230;<span class=\"ez-toc-section-end\"><\/span><\/h2>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>A. Recent cessation of alcohol use<\/strong><\/p>\n\n\n\n<p class=\"wp-block-paragraph\">Before we get to the&nbsp;<strong>Main Explanation<\/strong>, let&#8217;s see why the answer wasn&#8217;t B, C, D, or E. Skip to the bottom if you want to <strong>see the correct answer<\/strong> right away!<\/p>\n\n\n\n<h2 class=\"wp-block-heading\"><span class=\"ez-toc-section\" id=\"Incorrect_Answer_Explanations\"><\/span>Incorrect Answer Explanations<span class=\"ez-toc-section-end\"><\/span><\/h2>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>B. Recent cessation of cocaine use&nbsp;<\/strong><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>Incorrect:&nbsp;<\/strong>Cocaine withdrawal typically presents with symptoms similar to <strong>depression<\/strong>, including <strong>dysphoria, somnolence, <\/strong>and <strong>psychomotor retardation<\/strong>. Sympathetic hyperactivity and seizures are not usually present.<\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>C. Anticholinergic ingestion<\/strong><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>Incorrect:&nbsp;<\/strong>While <strong>anticholinergic overdose <\/strong>and <strong>alcohol withdrawal<\/strong> both present with symptoms of <strong>sympathetic hyperactivity<\/strong>, they can be distinguished by the <strong>presence or absence of diaphoresis<\/strong>. Anticholinergic effects result in <strong>anhidrosis<\/strong>.&nbsp;<\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>D. Recent cessation of chronic opioids<\/strong><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>Incorrect:&nbsp;<\/strong>Patients with <strong>opioid withdrawal <\/strong>can present similarly to patients with <strong>alcohol withdrawal<\/strong>. However, <strong>seizures <\/strong>are not typically seen in opioid withdrawal, and patients often have <strong>gastrointestinal symptoms<\/strong> (e.g. <strong>diarrhea, nausea, vomiting<\/strong>) with opioid withdrawal.&nbsp;<\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>E. Isoniazid use<\/strong><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>Incorrect:&nbsp;<\/strong>Isoniazid use can result in <strong>vitamin B6 deficiency<\/strong> and subsequent <strong>seizures<\/strong>. This patient has <strong>no historical features<\/strong> to suggest he has been taking isoniazid.<\/p>\n\n\n\n<h2 class=\"wp-block-heading\"><span class=\"ez-toc-section\" id=\"Main_Explanation\"><\/span>Main Explanation<span class=\"ez-toc-section-end\"><\/span><\/h2>\n\n\n\n<p class=\"wp-block-paragraph\">This patient presents with evidence of&nbsp;<strong>sympathetic hyperactivity<\/strong>&nbsp;on physical exam and likely&nbsp;<strong>seizure activity<\/strong>&nbsp;(loss of consciousness associated with urinary incontinence and tongue biting). Based on these findings and a history of heavy alcohol use,&nbsp;<strong>recent alcohol cessation<\/strong>&nbsp;with subsequent&nbsp;<strong>alcohol withdrawal syndrome<\/strong>&nbsp;is likely.&nbsp;<\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>Alcohol withdrawal<\/strong> refers to symptoms that develop in a patient with a <strong>history of heavy alcohol use<\/strong> when they either <strong>significantly reduce their alcohol intake or stop drinking entirely<\/strong>. Alcohol depresses the central nervous system. If alcohol intake drops after prolonged use, the patient will experience signs and symptoms due to&nbsp;<strong>hyperexcitability <\/strong>and <strong>hyperactivity of the central nervous system<\/strong>.&nbsp;<\/p>\n\n\n\n<p class=\"wp-block-paragraph\">Patients with <strong>moderate to severe alcohol withdrawal syndrome<\/strong> can have evidence of sympathetic hyperactivity, including&nbsp;<strong>tachycardia, hypertension, tremors, insomnia, anxiety, diaphoresis, nausea, and vomiting<\/strong>. The severity of symptoms is often reflective of the duration and quantity of alcohol used with heavy use increasing the risk of&nbsp;<strong>severe withdrawal symptoms<\/strong>, including&nbsp;<strong>seizures<\/strong>,&nbsp;<strong>delirium tremens<\/strong>, and&nbsp;<strong>death<\/strong>. The first withdrawal symptoms can occur <strong>anywhere from several hours to one day after the last drink<\/strong>. Severe manifestations, such as confusion, hallucinations, and generalized <strong>tonic-clonic seizures<\/strong>, can occur 24 to 48 hours after alcohol cessation.&nbsp;<\/p>\n\n\n\n<h2 class=\"wp-block-heading\"><span class=\"ez-toc-section\" id=\"Major_Takeaway\"><\/span>Major Takeaway<span class=\"ez-toc-section-end\"><\/span><\/h2>\n\n\n\n<p class=\"wp-block-paragraph\">Patients with <strong>alcohol withdrawal syndrome <\/strong>can present with signs and symptoms of <strong>sympathetic hyperactivity<\/strong>, such as <strong>insomnia, anxiety, palpitations, tachycardia, diaphoresis, <\/strong>and <strong>hypertension<\/strong>. <strong>Seizures <\/strong>and <strong>delirium tremens<\/strong> indicate severe alcohol withdrawal.<\/p>\n\n\n\n<h2 class=\"wp-block-heading\"><span class=\"ez-toc-section\" id=\"References\"><\/span>References<span class=\"ez-toc-section-end\"><\/span><\/h2>\n\n\n\n<ul class=\"wp-block-list\">\n<li>Wong, J., Saver, B. G., Scanlan, J., Gianutsos, L. P., Bhakta, Y., Walsh, J. J., Plawman, A. R., Sapienza, D., &amp; Rudolf, V. (2020). <strong>The ASAM Clinical Practice Guideline on Alcohol Withdrawal Management<\/strong>. Journal of Addiction Medicine,14(3S),1\u201372. https:\/\/doi.org\/10.1097\/adm.0000000000000668<\/li>\n\n\n\n<li>Mayo-Smith MF, Beecher LH, Fischer TL, et al. <strong>Management of Alcohol Withdrawal Delirium: An Evidence-Based Practice Guideline<\/strong>. Arch Intern Med.2004;164(13):1405\u20131412. doi:10.1001\/archinte.164.13.1405<\/li>\n\n\n\n<li>Bayard M, McIntyre J, Hill KR, Woodside J Jr.&nbsp;<a href=\"https:\/\/www.aafp.org\/pubs\/afp\/issues\/2004\/0315\/p1443.html\" target=\"_blank\" rel=\"noreferrer noopener\"><strong>Alcohol withdrawal syndrome.<\/strong><\/a>&nbsp;Am Fam Physician. 2004 Mar 15;69(6):1443-50. PMID: 15053409.<\/li>\n\n\n\n<li><a href=\"https:\/\/www.clinicalkey.com\/student\/content\/book\/3-s2.0-B9780323532662000308\" target=\"_blank\" rel=\"noreferrer noopener\">Alcohol Use Disorders &#8211; Goldman-Cecil Medicine &#8211; ClinicalKey Student<\/a><\/li>\n<\/ul>\n\n\n\n<figure class=\"wp-block-image size-large\"><a href=\"https:\/\/www.osmosis.org\/clinical-sciences\" target=\"_blank\" rel=\"noreferrer noopener\"><img loading=\"lazy\" decoding=\"async\" width=\"700\" height=\"250\" src=\"https:\/\/www.osmosis.org\/blog\/wp-content\/uploads\/sites\/2\/2020\/09\/Blog_Display_Ads_MD1_2023.png?w=700\" alt=\"\" class=\"wp-image-5904\" srcset=\"https:\/\/www.osmosis.org\/blog\/wp-content\/uploads\/sites\/2\/2020\/09\/Blog_Display_Ads_MD1_2023.png 700w, https:\/\/www.osmosis.org\/blog\/wp-content\/uploads\/sites\/2\/2020\/09\/Blog_Display_Ads_MD1_2023.png?resize=300,107 300w\" sizes=\"auto, (max-width: 700px) 100vw, 700px\" \/><\/a><\/figure>\n\n\n\n<p class=\"wp-block-paragraph\"><em>Want more<strong>&nbsp;USMLE\u00ae Step 2 CK practice questions<\/strong>?&nbsp;Try <strong>Osmosis by Elsevier<\/strong> today! Access your&nbsp;<a href=\"https:\/\/www.osmosis.org\/plans\" target=\"_blank\" rel=\"noreferrer noopener\"><strong>free trial<\/strong><\/a>&nbsp;and find out why millions of <strong>current and future clinicians and caregivers<\/strong> love <strong>learning by Osmosis<\/strong>.<\/em><\/p>\n","protected":false},"excerpt":{"rendered":"<p>A patient presents with anxiety and recent episodes of loss of consciousness. What is crucial to the patient&#8217;s diagnosis and treatment?<\/p>\n","protected":false},"author":202,"featured_media":3525,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"_jetpack_newsletter_access":"","_jetpack_dont_email_post_to_subs":false,"_jetpack_newsletter_tier_id":0,"_jetpack_memberships_contains_paywalled_content":false,"_jetpack_feature_clip_id":0,"_jetpack_memberships_contains_paid_content":false,"footnotes":"","jetpack_post_was_ever_published":false},"categories":[27,20,1366,1370,45],"tags":[176,343,369,1962,245,1963,1965,1964,1966,952],"class_list":["post-3524","post","type-post","status-publish","format-standard","has-post-thumbnail","hentry","category-medicine","category-exam-prep","category-questions","category-step-2-questions","category-step-2","tag-anxiety","tag-clinical-assessment","tag-emergency-nursing","tag-loss-of-consciousness","tag-nursing-education","tag-patient-history","tag-seizure-evaluation","tag-substance-withdrawal","tag-sympathetic-symptoms","tag-usmle-step-2-ck"],"yoast_head":"<!-- This site is optimized with the Yoast SEO plugin v23.6 - https:\/\/yoast.com\/wordpress\/plugins\/seo\/ -->\n<title>USMLE\u00ae Step 2 Question of the Day: Focused history - Osmosis Blog<\/title>\n<meta name=\"robots\" content=\"index, follow, max-snippet:-1, max-image-preview:large, max-video-preview:-1\" \/>\n<link rel=\"canonical\" href=\"https:\/\/www.osmosis.org\/blog\/usmle-step-2-question-of-the-day-focused-history\" \/>\n<meta property=\"og:locale\" content=\"en_US\" \/>\n<meta property=\"og:type\" content=\"article\" \/>\n<meta property=\"og:title\" content=\"USMLE\u00ae Step 2 Question of the Day: Focused history - Osmosis Blog\" \/>\n<meta property=\"og:description\" content=\"A patient presents with anxiety and recent episodes of loss of consciousness. 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Can you figure it out? A 31-year-old woman comes to her physician for evaluation of recurrent episodes of headache, palpitations, and anxiety. She works as a lawyer\u2026","rel":"","context":"In &quot;Allopathic Medicine (MD)&quot;","block_context":{"text":"Allopathic Medicine (MD)","link":"https:\/\/www.osmosis.org\/blog\/category\/medicine"},"img":{"alt_text":"","src":"https:\/\/www.osmosis.org\/blog\/wp-content\/uploads\/sites\/2\/2024\/09\/usmle-step-2-ck-question-of-the-day-pheochromocytoma.webp","width":350,"height":200,"srcset":"https:\/\/www.osmosis.org\/blog\/wp-content\/uploads\/sites\/2\/2024\/09\/usmle-step-2-ck-question-of-the-day-pheochromocytoma.webp 1x, https:\/\/www.osmosis.org\/blog\/wp-content\/uploads\/sites\/2\/2024\/09\/usmle-step-2-ck-question-of-the-day-pheochromocytoma.webp 1.5x, https:\/\/www.osmosis.org\/blog\/wp-content\/uploads\/sites\/2\/2024\/09\/usmle-step-2-ck-question-of-the-day-pheochromocytoma.webp 2x"},"classes":[]},{"id":822,"url":"https:\/\/www.osmosis.org\/blog\/usmle-step-2-ck-question-of-the-day-spinal-cord-injury","url_meta":{"origin":3524,"position":3},"title":"USMLE\u00ae Step 2 CK Question of the Day: Spinal cord injury","author":"Marina Horiates Kerekes, MD &amp; Team","date":"April 26, 2023","format":false,"excerpt":"Here's another USMLE\u00ae Step 2 CK Question of the Day!\u00a0Today's case involves a 32-year-old man who fell from a building. He did not suffer loss of consciousness. The patient has 2+ triceps and brachioradialis reflexes and 5\/5 strength of the upper extremities bilaterally. 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