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. Check out this example from Kaplan Medical, and read an expert explanation of the answer. Also check out all posts in this series.  

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A 19-year-old woman is brought to the emergency department by her friends after a week of “bizarre behavior.” The friends say that she has been “talking a mile a minute” and stating that she has special powers from God. The patient has not slept in the past three days and yet has been “running all over the place and spending to the limit on her credit cards.”

On mental status examination, the patient is distracted and shows pressured speech and flight of ideas. When asked about her mood, the patient replies that she has never felt this good before. She denies any suicidal or homicidal intent, ideation, or plan. She notes that she has never been depressed in her life. Physical examination is unremarkable. There is no history of substance use disorder and urinary toxicology is negative.

Which of the following is the most likely diagnosis?

A. Bipolar I disorder.

B. Bipolar II disorder.

C. Cyclothymic disorder.

D. Schizophrenia.

E. Schizoaffective disorder.

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The correct answer is A.

Bipolar I disorder is the most likely diagnosis for this patient as she currently meets the criteria for a classic manic episode given her weeklong episode of distractibility, decreased need for sleep, and flight of ideas.

Choice B: Bipolar II disorder is characterized by hypomania (not mania) and major depression. This patient is manic now, so she cannot be diagnosed with bipolar II disorder.

Choice C: Cyclothymic disorder is characterized by hypomania and low-grade depression over a two-year period. This patient meets the criteria for a manic episode, not a hypomanic episode, and so would be diagnosed with bipolar I disorder.

Choice D: This patient's symptoms are consistent with a manic episode with possible psychotic features. The patient, however, is not demonstrating a clinical history of a degenerative psychotic illness continuing for at least six months, making schizophrenia incorrect.

Choice E: Patients with schizoaffective disorder present with a major mood episode (major depression or mania) with delusions or hallucinations. Additionally, at some point during the illness, psychotic symptoms must be present for at least two weeks without a major mood episode. This does not agree with the history given for this patient.

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  • A manic episode presents with at least seven days of symptoms of elevated mood that negatively affects function.
  • Symptoms of mania include flight of ideas, pressured speech, decreased need for sleep, indiscretions, and grandiosity.
  • One episode of mania defines bipolar I disorder.

For more prep questions on USMLE Steps 1, 2 and 3, view other posts in this series.

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