USMLE Step 1 Question Types: Two-Step Questions

USMLE two-step (also called double-jump) questions require several cognitive steps to arrive at a correct answer. Finding the correct answer requires you to formulate a proper diagnosis and then select the most appropriate pharmacologic treatment. Note that you get no credit for the intermediate step of diagnosis. The correct answer is found only by reasoning all the way through to the treatment.

Two-Step Practice Question 1

A 46-year-old, bright, energetic, and overweight man loves to talk and to give his opinion on the world around him. He is always quick with a joke and seems to love a good laugh. Yet, whenever he has to talk in front of more than three or four people, he reports sweating, heart palpitations, and trembling hands. “My mind just goes blank,” he says, “and I feel that I’m going to say something so stupid that I would rather die.” The most appropriate treatment for this man would be
(A) Alprazolam
(B) Atenolol
(C) Clonidine
(D) Diazepam
(E) Phenelzine

The correct answer is B, atenolol.

Two-Step Practice Question 2

In this next question, you must reason your way to the additional characteristics of the organism in mind by first correctly identifying what the organism is based on the laboratory data. Again, you get no credit for identifying the correct organism but only for “two-stepping” to the additional characteristic.

A 71-year-old man was admitted from his extended care facility because of recent aggravation of an exfoliative skin condition that has plagued him for several years. He had been receiving a variety of antibiotic regimens, including many topical preparations over the last year or two. He now has a temperature of 38.9 C (102 F). The skin of upper chest, extremities, and neck shows erythema with diffuse epidermal peeling and many pustular lesions. Cultures obtained from these lesions are reported back from the laboratory as yielding a gram-positive organism that is highly salt (NaCl) tolerant. This organism is also most likely
(A) bacitracin sensitive
(B) bile soluble
(C) coagulase positive
(D) optochin sensitive
(E) novobiocin sensitive

The correct answer is C, coagulase positive.

Note that you need to make two correct decisions to arrive at the correct answer, hence the name “two-step.” The goal is to guide you away from simple memorization in your learning. Instead, the exam wants you to be able to use the information you have memorized to reason through to a correct answer.
The correct process for answering these questions is not “read, answer,” but “read, think, answer.” You’ll definitely see your share of these two-step (and even three-step) questions on the Step 1 exam.
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