USMLE USMLE Certifications USMLE-STEP-3 Questions & Answers

• Question 111:

  A full-term baby boy was noted in the immediate neonatal period to fail to pass meconium. Progressive

  abdominal distention was noted. Multiple laboratory and clinical tests lead to a decision to perform a rectal

  biopsy.

  What special stains would you use that would be helpful to confirm the finding of ganglion cells?

  A. periodic acid-Schiff (PAS)

  B. mucicarmine

  C. elastic stain

  D. trichrome stain

  E. acetylcholinesterase

  Correct Answer: E Section: (none)

  Explanation:

  Hirschsprung disease usually manifests in the immediate neonatal period by failure to pass meconium, followed by obstructive constipation. Abdominal distention develops and, in general, a large segment of the colon is involved and distended. The incidence of Hirschsprung disease is 1 in 5000 live births, with an 80% male predominance in nonfamilial cases. There is no apparent difference in occurrence among races. A number of abnormalities have been associated with Hirschsprung disease, including Down syndrome (23% of the cases), congenital heart disease, colonic atresia, and malrotation. The tissue diagnosis is made on the basis of an absence of ganglion cells in the submucosa and the myenteric plexus on a full-thickness rectal biopsy. Some surgeons prefer suction biopsy to full-thickness biopsy because it is easy to obtain the specimen and they can avoid scarring and fibrosis in the area. The other four choices are not applicable and can be ruled out on the basis of clinical history and an extremely low incidence of other pathologic conditions at the perinatal age. When suction biopsies are performed, the tissue sample for acetyl cholinesterase stain should be frozen as soon as possible. All of the other stains would not be helpful to identify ganglion cells. As soon as the diagnosis is confirmed with the rectal biopsy, a surgical procedure should be undertaken that consists of a resection of the aganglionic section of colon. All the other options are not the treatment of choice for this disease.

• Question 112:

  A third-year medicine resident has taken a trip to Guatemala to assist in a medical clinic for 2 weeks. After returning to work at the hospital, she faints during her grand rounds presentation of a case and is admitted to the teaching hospital where she works. She has a high temperature that cycles every few hours. The attending physician, a professor in her program, works her up for Dengue Fever and Malaria. Blood and urine laboratory tests are drawn and she receives many visitors from her concerned colleagues and coworkers. A fellow resident in her program, who is not directly involved in her care, reviews her chart and sees that her urine test came back positive for a pregnancy. Another resident sees him with the chart and asks, "So does she have Dengue or Malaria?" How should he respond to this request for information?

  A. Order another pregnancy test to confirm.

  B. Talk to the patient before sharing any information.

  C. Refrain from sharing the test results with the other resident.

  D. Share the information with the other resident in confidence.

  E. Only share the information with the attending physician.

  Correct Answer: C Section: (none)

  Explanation:

  The actions of the resident who reviewed the patient's chart were unethical. He is not involved in the case and the fact that he is a physician and colleague of the patient does not free him of the requirements that protect patient confidentiality, backed by federal regulations (see discussion of HIPAA above). He should not have pulled her chart. He would only be making matters worse by further violating the patient's right to confidentiality in sharing her results with the other resident. The attending clinicians involved in the case are the only people who should have privileged access to the patient's sensitive health information.

• Question 113:

  A full-term baby boy was noted in the immediate neonatal period to fail to pass meconium. Progressive

  abdominal distention was noted. Multiple laboratory and clinical tests lead to a decision to perform a rectal

  biopsy.

  What is the most important histologic finding that you expect to see in the rectal biopsy?

  A. ischemic necrosis of the bowel mucosa

  B. acute ulcerative colitis

  C. granulomatous inflammation

  D. absence of ganglion cells in the rectal mucosa and submucosa

  E. a malignant tumor

  Correct Answer: D Section: (none)

  Explanation:

  Hirschsprung disease usually manifests in the immediate neonatal period by failure to pass meconium, followed by obstructive constipation. Abdominal distention develops and, in general, a large segment of the colon is involved and distended. The incidence of Hirschsprung disease is 1 in 5000 live births, with an 80% male predominance in nonfamilial cases. There is no apparent difference in occurrence among races. A number of abnormalities have been associated with Hirschsprung disease, including Down syndrome (23% of the cases), congenital heart disease, colonic atresia, and malrotation. The tissue diagnosis is made on the basis of an absence of ganglion cells in the submucosa and the myenteric plexus on a full-thickness rectal biopsy. Some surgeons prefer suction biopsy to full-thickness biopsy because it is easy to obtain the specimen and they can avoid scarring and fibrosis in the area. The other four choices are not applicable and can be ruled out on the basis of clinical history and an extremely low incidence of other pathologic conditions at the perinatal age. When suction biopsies are performed, the tissue sample for acetyl cholinesterase stain should be frozen as soon as possible. All of the other stains would not be helpful to identify ganglion cells. As soon as the diagnosis is confirmed with the rectal biopsy, a surgical procedure should be undertaken that consists of a resection of the aganglionic section of colon. All the other options are not the treatment of choice for this disease.

• Question 114:

  One of your long-time patients, a 17-year-old with cystic fibrosis, after experiencing several hospital admissions in respiratory crisis requiring intubation, requests that she not be intubated again in the event of future respiratory crisis. She requests comfort care only. The patient lives with her mother, who is mildly mentally retarded and unable to understand or participate in her daughter's health decisions. Her father is deceased. After numerous discussions over several visits, you assist her in filling out an outpatient DNR form and request a bracelet with DNR instructions. Several weeks later, the young girl is at a friend's house and stops breathing. She is not wearing the DNR bracelet and the friends know nothing of her wishes. The ambulance is called and she is intubated en route to the hospital. You are called to the emergency room where she is being stabilized for transfer to pediatric intensive care unit (PICU). What is the most ethically justified next step in this case?

  A. Wait to see if the patient regains consciousness before extubating.

  B. Assist in the extubation of the patient per her request.

  C. Seek a consultation from the ethics committee.

  D. Approve the transfer to the PICU and proceed with stabilization.

  E. Write a DNR order.

  Correct Answer: B Section: (none)

  Explanation:

  Part of the care of terminally ill patients is to ameliorate suffering, prevent disability, or recognize the finitude of life. The SUPPORT study provides physicians with accurate predictive information on the functional ability of patients and survival probability for end-oflife care. This study revealed care provided to critically ill patients was often inconsistent with their preferences. Nearly half of the DNRs were written in the last 2 days of life. In this clinical situation, the patient makes an informed decision about her future treatment and clinical interventions. Despite her age, she exhibits maturity of thought and demonstrates sufficient capacity to make informed decisions. Such capacity can be assessed by the primary physician. If there are serious concerns about capacity, a psychiatric consultation can help determine ability to consent or refuse treatment. If she has sufficient capacity she may refuse even life-saving treatment. In early discussions about the Out-of-Hospital DNR, it would be important to inquire whether the patient's father is involved in her care and her life. In this case, the father was no longer alive and mother did not have sufficient capacity to understand even minor decisions regarding her daughter's care. She would qualify as a mature minor under most state statutes in the United States. Although the physician could support intubation, he is aware of the patient's preferences as documented in the DNR. Failure to extubate represents a violation of her clearly expressed wishes. The fact that intubation was started does not change the fact that intubation was an initial violation of the patient's wishes. Failure to extubate would further that violation. The sometimes asserted distinction between not starting an intervention and continuing the intervention once started is not appropriate in situations where the patient's wishes were clearly not to have the intervention in the first place. Ethical justifications for DNR orders include:

• Question 115:

  You have been the geriatrician for a 79-year-old patient with a 10-year history of Alzheimer's disease, diabetes mellitus, and coronary artery disease. His 75-year-old wife has been his caretaker in the home. In the last 3 months, he has become progressively more combative and violent toward his wife. He was recently discharged from the hospital after intravenous antibiotic therapy for pneumococcal pneumonia but had to be readmitted to the intensive care unit with resistant, pneumococcal bacteremia, altered mental status, renal insufficiency, hypotension, CHF, and hypoxemia. When he was first aware of his early loss of memory, he told a family friend and his wife he would not want to be kept alive under such conditions. However, he did not execute an advanced directive. He does not have any surviving blood relatives and has no children. His wife refuses to sign the consent form to intubate her husband. Which of the following is the most appropriate action to take at this time?

  A. Continue antibiotic therapy but don't intubate the patient.

  B. Send the wife home because of her emotional exhaustion.

  C. Intubate the patient.

  D. Request that a judge appoint a legal decision maker for the patient.

  E. Write a Do Not Attempt Resuscitation (DNR) order.

  Correct Answer: E Section: (none)

  Explanation:

  E. Medical care of the critically ill is focused on those individuals who, despite therapeutic interventions, may either recover with significant morbidity or die from their underlying illness. Part of the care of terminally ill patients is to ameliorate suffering, prevent disability, or recognize the finitude of life. The SUPPORT study provides physicians with accurate predictive information on the functional ability of patients and survival probability for end-oflife care. This study revealed that care provided to critically ill patients was often inconsistent with their preferences. Nearly half of the DNR orders were written in the last 2 days of life. In this clinical situation, the patient has multiple organ system failure with sepsis, acute respiratory failure, CHF, and altered mental status (coma). Although the physician could provide any of the medical interventions, he is aware of the patient's preferences as expressed by an appropriate proxy decision maker (wife). Ethical justifications for DNR orders include: These decisions require cultural sensitivity and awareness of the variety of beliefs surrounding death among patients, their families, physicians, hospital systems, and society. Although physicians are best qualified to identify possible outcomes, it is patients and their families who determine the significance of these outcomes.

• Question 116:

  The practice of confidentiality has roots in the Hippocratic Oath. However, the increasing use of health information technology has increased the efficiency of acquisition, manipulation, and dissemination of this potentially sensitive data. Federal laws have been adopted to safeguard health information privacy. Under the Health Insurance Portability and Accountability Act (HIPAA), which of the following is allowed?

  A. conducting teaching rounds at a table in the hospital cafeteria, as long as patient names are not used

  B. sharing a patient's diagnosis with any family member who requests the information

  C. discussing patient information with a consulting physician

  D. leaving an electronic medical record page with patient information open on a computer in the hallway of the ICU, to allow the nurse to have more rapid access to information

  E. sharing health information about a patient with his or her employer if the employer is paying for the patient's health insurance

  Correct Answer: C Section: (none)

  Explanation:

  In 1996, the U.S. Congress recognized the need for comprehensive national health information privacy standards, which required full compliance by April 14, 2004. This rule provided the first systematic privacy protection for health information and is grounded in the principle of protecting the confidentiality of information about patients while protecting the legitimate interests of third parties (e.g., proxy and surrogate decision makers, health care providers, health care institutions, teaching situations). This legislation provides mechanisms to release information for payment of health care services, and consumer access to medical records. HIPAA does not restrict the normal exchange of clinical information between consulting physicians or nurses on the patient's case. However, this normal exchange of information must occur in a medical context, not in elevators, public hallways, or the cafeteria. Health care providers must obtain the individual's written consent prior to disclosure of health information except in the management of emergencies or if the consent can be inferred from a patient with impaired communication. Procedures must be developed to prevent open access to patient information via computers or documents which can be easily accessed, including paper medical records. The privacy legislation also protects the release of medical information to an employer without the patient's consent.

• Question 117:

  You are contacted by the regional Federal Bureau of Investigations (FBI) field office to evaluate a prisoner in custody. The prisoner has confessed to crimes for which he could receive the death penalty. The FBI believes that he has information that could lead to the arrest of multiple co-conspirators and end an ongoing criminal enterprise. For which of the following actions is physician participation ethical?

  A. providing medical clearance for verbal interrogation

  B. providing medical treatment for sustained physical interrogation

  C. starting intravenous access and administering medications to sedate a prisoner prior to execution

  D. certifying the death of an executed prisoner

  E. continuing medical treatment based only on medical record documentation

  Correct Answer: D Section: (none)

  Explanation:

  The United Nations Standard Minimum Rules for the Treatment of Prisoners offers ethical guidelines for physicians working with prisoners. Physicians must not participate in the use of torture, cruel, or unusual punishment, disciplinary activities, or abuse of human rights. This includes medicating individuals to facilitate interrogation or providing supportive medical services in order to facilitate additional torture. Physicians have the ethical responsibility to provide independent medical judgments and must act as advocates for their individual care. Incarceration does not change a patient's ethical right to health care or permit a physician to ignore these rights. Under no circumstances are physicians to be used as an instrument of governments, even in legally sanctioned death penalty scenarios. They can, however, certify death. Furthermore, when completing a death certificate in military environments, the physician cannot leave out the role of torture (if applicable). Even if these concepts are not adopted by incarceration facilities or in the field of war, noncompliance with these standards has significant consequences for physicians, patients, and society.

• Question 118:

  As an intern on a medical consultation service, you are providing a cardiology consultation for a patient who developed a myocardial infarction while undergoing an elective cholecystectomy. Although not described in the medical record, the cardiology consultant attending stated the patient experienced the myocardial infarction because of prolonged general anesthesia. The surgical attending did not make the initial incision until the patient had been sedated for more than 1 hour. As you review the medical record, you realize the patient is the father of your college roommate. When you walk in the room, the family is very happy to see you and asks, "What happened? What went wrong?"

  Which of the following is a commonly used mechanism for reducing medical errors in hospitals?

  A. confidential peer review

  B. national hospital accreditation

  C. departmental grand rounds

  D. longer work shifts for employees to promote continuity of patient care

  E. random drug testing

  Correct Answer: A Section: (none)

  Explanation:

  Disclosure of unanticipated outcomes is one of the most challenging communications that can occur in the physician-patient relationship. Determining which events require disclosure and the appropriate mechanism to provide this information is part of the professional behavior inherent in our roles as physicians. Concepts for effective disclosure include: Many institutions have already developed policies and mechanisms to provide this communication. The attending physician is the most appropriate person to lead this process. Your knowledge of the clinical circumstances is hearsay. It is not appropriate for you to provide unsubstantiated information to the patient or to the friend. Appropriate documentation in the medical record provides the facts surrounding the primary event. It is inappropriate to document opinions, accusations, or arguments. Medical errors are responsible for more than 98,000 excessive patient deaths per year. In order for medical errors to be reduced, there need to be mechanisms for accountability which occur within a supportive environment. Peer review, morbidity and mortality rounds, shorter work weeks, and root cause analysis are all mechanisms to prevent future errors from fatigue, impaired system processes, and inadequate knowledge. Frequently when medical errors occur, the families want to know what is being done to prevent this from happening again. Although the peer review process is confidential and not subject to subpoena, it provides an effective mechanism to honestly evaluate our colleagues and enforce necessary discipline to improve patient safety. Random drug testing is not a systemic solution.

• Question 119:

  As an intern on a medical consultation service, you are providing a cardiology consultation for a patient who developed a myocardial infarction while undergoing an elective cholecystectomy. Although not described in the medical record, the cardiology consultant attending stated the patient experienced the myocardial infarction because of prolonged general anesthesia. The surgical attending did not make the initial incision until the patient had been sedated for more than 1 hour. As you review the medical record, you realize the patient is the father of your college roommate. When you walk in the room, the family is very happy to see you and asks, "What happened? What went wrong?" What is your ethical responsibility?

  A. disclosure of your knowledge of the clinical circumstances to the patient

  B. disclosure of your knowledge of the clinical circumstances to your college roommate

  C. disclosure of the family's questions to the attending physician

  D. documentation in the medical record of your assessment of the iatrogenic patient injury

  E. request a random drug test of the surgeon

  Correct Answer: C Section: (none)

  Explanation:

  Disclosure of unanticipated outcomes is one of the most challenging communications that can occur in the physician-patient relationship. Determining which events require disclosure and the appropriate mechanism to provide this information is part of the professional behavior inherent in our roles as physicians. Concepts for effective disclosure include: Many institutions have already developed policies and mechanisms to provide this communication. The attending physician is the most appropriate person to lead this process. Your knowledge of the clinical circumstances is hearsay. It is not appropriate for you to provide unsubstantiated information to the patient or to the friend. Appropriate documentation in the medical record provides the facts surrounding the primary event. It is inappropriate to document opinions, accusations, or arguments. Medical errors are responsible for more than 98,000 excessive patient deaths per year. In order for medical errors to be reduced, there need to be mechanisms for accountability which occur within a supportive environment. Peer review, morbidity and mortality rounds, shorter work weeks, and root cause analysis are all mechanisms to prevent future errors from fatigue, impaired system processes, and inadequate knowledge. Frequently when medical errors occur, the families want to know what is being done to prevent this from happening again. Although the peer review process is confidential and not subject to subpoena, it provides an effective mechanism to honestly evaluate our colleagues and enforce necessary discipline to improve patient safety. Random drug testing is not a systemic solution.

• Question 120:

  Mr. Jones is a 34-year-old married businessman. He and his wife are both patients in your practice. As part of his annual physical, you screen for high-risk behaviors and he admits to receiving confidential treatment at a public health clinic for gonorrhea and genital herpes. He has not revealed this information to his wife even though they are planning to have a baby. He did not return for the results of HIV screening at the public health clinic. On physical examination, you note that he has cervical and axillary lymphadenopathy, oral thrush, and seborrheic dermatitis. Mr. Jones returns to your office for a follow-up visit. He adamantly refuses to discuss his HIV status with his wife and threatens to sue if you reveal the test results. What is your role as a physician?

  A. Respect Mr. Jones' patient autonomy.

  B. Protect Mr. Jones' confidentiality.

  C. Contact Mrs. Jones and ask her to come in for an annual examination.

  D. Advise Mr. Jones you have a responsibility to notify his wife.

  E. Refer Mr. Jones to an HIV specialist.

  Correct Answer: D Section: (none)

  Explanation:

  Although Mycelex troches would be appropriate in the management of his oral candidiasis and the Lotrisone would treat his seborrheic dermatitis, the patient has previously described risk factors for HIV infection and physical symptoms of immunodeficiency. Accurate knowledge of his HIV status is essential in the appropriate long-term management of this patient. In fact, his current physical examination suggests long-standing HIV infection. A lymph node biopsy is not warranted. His wife will eventually need screening for STDs since active STDs increase her risk of cotransmission of HIV. The patient's refusal to discuss his situation with his wife raises many controversial issues with no simple solution. There are multiple arguments which support the ethical guidelines for supporting patient confidentiality. These include: · An appeal to consequences (potential patient discrimination secondary to health information; importance of trust) · Appeal to virtue (physician fidelity) · Respect (awareness and compassion for patient vulnerability) · Do no harm (breach of medical information may lead to discrimination) Respect for patient autonomy incorporates the patient in the treatment process and is based on mutual trust. Referring Mr. Jones to another physician doesn't address the concerns involved in the care of Mrs. Jones. The Tarasoff case (1976) established the following precedent: Patient confidentiality must be upheld as part of the protected clinicianpatient relationship but the physician has a duty to warn specific, innocent third parties of potential harm threatened or posed by the patient. In fact, failure to warn by the physician may constitute negligence. This is not the law in all states. Some states interpret the standard as a strict duty to warn; other states permit physicians to warn affected third parties but not require it. If the physician unilaterally discloses the HIV status, it would represent a breach of confidentiality. However, their marital status may allow this disclosure. Even if the patient is adamant in his refusal, the physician needs to determine the reasons for his reticence. As his physician, you can provide additional information about HIV prevention and treatment. It would be highly unusual for Mr. Jones to ultimately refuse notification of his spouse once he has been urged to do so by his physician. The mechanism for how these complex issues are addressed has potential ramifications for his future trust of physicians, consent to HAART (highly active antiretroviral therapy) treatment, and medication compliance. If these barriers to disclosure cannot be addressed within the physician-patient relationship, the health department can provide a mechanism for contact testing. Although you could ask Mrs. Jones to come in for a physical examination, she might refuse to have STD tests performed, especially if she perceives herself to be at minimal risk. Ideally, this assessment should be performed prior to a pregnancy. If she is currently HIV negative, then protective measures against future infection can be introduced.