USMLE USMLE Certifications USMLE-STEP-3 Questions & Answers

• Question 331:

  You are asked to perform a high school physical examination for a 16-year-old female patient. She is on the track team. By history, she is healthy except for the fact that she has been amenorrheic for 4 months. She denies current or past sexual activity. On examination, she is 5 ft 9 in. tall and weighs 115 lbs. Her heart rate is 50 bpm. She has dry skin with lanugo. She has several sores in her mouth and obvious dental caries. She has several scratches on the backs of her hands. She is tanner stage III on breast examination. Her pelvic examination is remarkable for findings of urogenital atrophy. Her urine -hCG is negative. This patient is at risk for developing which of the following?

  A. schizophrenia

  B. renal failure

  C. morbid obesity

  D. osteoporosis

  E. cholecystitis

  Correct Answer: D Section: (none)

  Explanation:

  Menstrual disorders, primarily oligo-and amenorrhea, are particularly common among women with eating disorders and are thought to be the result of hypothalamic hypoestrogenism. This patient demonstrates estrogen deficiency (decreased breast size, urogenital atrophy). Her dental caries, oral sores, and hand sores might be a result of self-induced vomiting. Hyperthyroidism would be considered in the differential diagnosis of a young woman with weight loss and menstrual irregularities. In contrast to persons with a medical condition that causes weight loss, those with an eating disorder express a disordered body image and, often, a desire to be underweight. This patient requires additional investigation to assess for the possibility of inpatient admission. Patients with a prolonged, severe eating disorder are at risk for developing dehydration, electrolyte imbalance (especially hypokalemia), cardiac dysrhythmias, and hypothermia. Hospitalization would be considered for those who are severely dehydrated, who have marked electrolyte abnormalities who are <75% of their ideal body weight, or who have a comorbid condition that would require hospitalization, such as a severe psychiatric disorder. Although weight-bearing exercise favors bone formation, when excessive exercise and/or an eating disorder results in amenorrhea, estrogen levels fall. Subsequently, bone mineral density decreases. Persons with eating disorders are at increased risk for comorbid psychiatric conditions including depression, anxiety, obsessive-compulsive disorder, and personality disorders.

• Question 332:

  You are asked to perform a high school physical examination for a 16-year-old female patient. She is on the track team. By history, she is healthy except for the fact that she has been amenorrheic for 4 months. She denies current or past sexual activity. On examination, she is 5 ft 9 in. tall and weighs 115 lbs. Her heart rate is 50 bpm. She has dry skin with lanugo. She has several sores in her mouth and obvious dental caries. She has several scratches on the backs of her hands. She is tanner stage III on breast examination. Her pelvic examination is remarkable for findings of urogenital atrophy. Her urine -hCG is negative.

  At this point in time, appropriate management of this patient would include which of the following?

  A. laboratory assessment of electrolytes and an electrocardiogram

  B. intensive care unit (ICU) admission

  C. antipsychotic medication

  D. reassurance

  E. IM Depo-Provera injection

  Correct Answer: A Section: (none)

  Explanation:

  Menstrual disorders, primarily oligo-and amenorrhea, are particularly common among women with eating disorders and are thought to be the result of hypothalamic hypoestrogenism. This patient demonstrates estrogen deficiency (decreased breast size, urogenital atrophy). Her dental caries, oral sores, and hand sores might be a result of self-induced vomiting. Hyperthyroidism would be considered in the differential diagnosis of a young woman with weight loss and menstrual irregularities. In contrast to persons with a medical condition that causes weight loss, those with an eating disorder express a disordered body image and, often, a desire to be underweight. This patient requires additional investigation to assess for the possibility of inpatient admission. Patients with a prolonged, severe eating disorder are at risk for developing dehydration, electrolyte imbalance (especially hypokalemia), cardiac dysrhythmias, and hypothermia. Hospitalization would be considered for those who are severely dehydrated, who have marked electrolyte abnormalities who are <75% of their ideal body weight, or who have a comorbid condition that would require hospitalization, such as a severe psychiatric disorder. Although weight-bearing exercise favors bone formation, when excessive exercise and/or an eating disorder results in amenorrhea, estrogen levels fall. Subsequently, bone mineral density decreases. Persons with eating disorders are at increased risk for comorbid psychiatric conditions including depression, anxiety, obsessive-compulsive disorder, and personality disorders.

• Question 333:

  You are asked to perform a high school physical examination for a 16-year-old female patient. She is on the track team. By history, she is healthy except for the fact that she has been amenorrheic for 4 months. She denies current or past sexual activity. On examination, she is 5 ft 9 in. tall and weighs 115 lbs. Her heart rate is 50 bpm. She has dry skin with lanugo. She has several sores in her mouth and obvious dental caries. She has several scratches on the backs of her hands. She is tanner stage III on breast examination. Her pelvic examination is remarkable for findings of urogenital atrophy. Her urine -hCG is negative.

  Which of the following would be the most likely diagnosis for this patient?

  A. domestic abuse

  B. eating disorder

  C. hyperthyroidism

  D. herpes simplex virus serotype I

  E. congenital adrenal hyperplasia

  Correct Answer: B Section: (none)

  Explanation:

  Menstrual disorders, primarily oligo-and amenorrhea, are particularly common among women with eating disorders and are thought to be the result of hypothalamic hypoestrogenism. This patient demonstrates estrogen deficiency (decreased breast size, urogenital atrophy). Her dental caries, oral sores, and hand sores might be a result of self-induced vomiting. Hyperthyroidism would be considered in the differential diagnosis of a young woman with weight loss and menstrual irregularities. In contrast to persons with a medical condition that causes weight loss, those with an eating disorder express a disordered body image and, often, a desire to be underweight. This patient requires additional investigation to assess for the possibility of inpatient admission. Patients with a prolonged, severe eating disorder are at risk for developing dehydration, electrolyte imbalance (especially hypokalemia), cardiac dysrhythmias, and hypothermia. Hospitalization would be considered for those who are severely dehydrated, who have marked electrolyte abnormalities who are <75% of their ideal body weight, or who have a comorbid condition that would require hospitalization, such as a severe psychiatric disorder. Although weight-bearing exercise favors bone formation, when excessive exercise and/or an eating disorder results in amenorrhea, estrogen levels fall. Subsequently, bone mineral density decreases. Persons with eating disorders are at increased risk for comorbid psychiatric conditions including depression, anxiety, obsessive-compulsive disorder, and personality disorders.

• Question 334:

  A 63-year-old Black female presents to your office complaining of leaking urine. She gets up at night five times to urinate and occasionally loses urine en route to the toilet. During the daytime, she urinates every 45 minutes "to help prevent the leakage." She denies loss of urine with coughing or sneezing. She has not had dysuria or any other pelvic floor complaints. She has a family history of diabetes. She drinks several caffeinated beverages throughout the day. On examination, her postvoid residual urine is normal, and a urine dipstick shows 3+ glucose but is otherwise negative. Her abdominal and pelvic examinations are normal.

  Which of the following do you recommend?

  A. surgery for her incontinence

  B. antibiotics for a UTI

  C. diuretic therapy

  D. timed voids, decrease in caffeine intake, and screening for diabetes

  E. referral to a urologist for cystoscopy

  Correct Answer: D Section: (none)

  Explanation:

  Clinically, this patient is exhibiting signs and symptoms of overactive bladder syndrome, or urge incontinence. Her risk factors include her age, race, caffeine use, and potential abnormal glucose tolerance. Attention should first be directed toward treating any modifiable risk factors. She does not demonstrate findings or a history of stress urinary incontinence for which surgery might be appropriate. Diuretic therapy could worsen, rather than improve, her symptoms, and she does not have findings consistent with a UTI.

• Question 335:

  A 31-year-old (gravida 1, para 1) female had a forceps-assisted vaginal delivery 3 months ago. Her infant weighed 4250 g. During the delivery she sustained a fourth degree perineal injury that was repaired. She now complains of fecal incontinence and foul vaginal discharge when her stools are loose, which happens several days a week. The most likely etiology for her fecal incontinence and foul vaginal discharge would be which of the following?

  A. Crohn's disease

  B. a perianal abscess

  C. a vaginal hematoma

  D. a retained vaginal foreign body

  E. a rectovaginal fistula

  Correct Answer: E Section: (none)

  Explanation:

  Maternal obstetric injury remains a major cause of rectovaginal fistula in women. For this patient, it is imperative to determine the presence or absence of a concomitant injury to the anal sphincter complex along with the possibility of a fistula. Crohn's disease can be a cause of abdominal pain, diarrhea, anal abscess formation, and fecal incontinence. It would be very unlikely, and highly coincidental, for it to present in this manner. Perianal abscesses can lead to anal fistula formation and subsequent fecal incontinence, but most commonly present with exquisite pain. Fistulas and fecal incontinence would be later complications. Neither a vaginal hematoma nor a retained vaginal foreign body would result in fecal incontinence.

• Question 336:

  A 25-year-old nulligravid female, whose LMP was 4 weeks ago, is seen by her OB/GYN for a left breast mass. The patient discovered it 2 weeks ago while in the shower. Her maternal aunt died of breast cancer at age 60, and the patient is very worried about this new finding. On examination, a mobile, nonerythematous, 3-cm nonsolid feeling mass is palpated in the left upper outer quadrant of her left breast. There is no nipple discharge, and the axillary lymph nodes are nonpalpable. Her right breast examination is normal. The patient wants you to schedule a mammogram that same day.

  Your response is which of the following?

  A. A surgical biopsy should be performed instead.

  B. A needle core biopsy can be done at the same time of her mammogram.

  C. Ultrasound would be a better imaging modality for her situation.

  D. In-office cyst aspiration is reassuring i the fluid is bloody.

  E. Antibiotics can treat her mastitis.

  Correct Answer: C Section: (none)

  Explanation:

  By history and physical examination, this patient most likely has a breast cyst. Given her age, mammography is not helpful due to the density of her breast tissue. Ultrasound is more helpful in detecting fluid-filled breast masses. In-office aspiration would be both diagnostic and therapeutic if the fluid was not bloody.

• Question 337:

  A70-year-old White woman has been faithful about taking 1200 mg of calcium, 400 IU of vitamin D supplements, and performing weight-bearing exercise on a daily basis. Her hip T score from her current DEXA scan has changed from -2.0 SDs to -2.55 SDs compared with last year's test.

  Which of the following is associated with a reduced risk of osteoporotic fractures?

  A. family history of hip fractures

  B. estrogen deficiency

  C. body mass index of greater than 23

  D. tobacco use

  E. vision problems

  Correct Answer: C Section: (none)

  Explanation:

  This patient meets criteria for the diagnosis of osteoporosis, with a T score falling below -2.5 standard SD. AT score indicates the number of standard deviations below or above the average peak bone mass in young, healthy adults of the same gender. Bisphosphonate therapy has been shown to reduce vertebral and hip fracture risk in up to 50% of women with documented osteoporosis. GnRH therapy and discontinuation of her vitamin D therapy would worsen, not improve, this patient's bone density. Although testosterone may arrest further bone loss, the side effects of the medication are too great compared to any potential benefit. For women who have osteoporosis the serum calcium level is generally normal. In premenopausal osteoporosis, or more severe cases of bone loss/fractures, the presence of metabolic bone disease should be considered. In hyperparathyroidism the serum calcium is elevated. With renal failure, as with osteomalacia, serum calcium is low. The serum calcium level is normal, and the alkaline phosphatase level is elevated in patients with Paget disease. The use of tobacco, a family history of mother or maternal grandmother with hip fractures, postmenopausal state without estrogen replacement, vision problems, and a body mass index of less than 23 are all increased risks for fractures. Abody mass index of greater than 23 does not represent an increased risk for fracture.

• Question 338:

  A70-year-old White woman has been faithful about taking 1200 mg of calcium, 400 IU of vitamin D supplements, and performing weight-bearing exercise on a daily basis. Her hip T score from her current DEXA scan has changed from -2.0 SDs to -2.55 SDs compared with last year's test.

  Which of the following statements is correct?

  A. With osteoporosis, serum calcium is low.

  B. With hyperparathyroidism, serum calcium is normal.

  C. With Paget disease, serum calcium is low.

  D. With renal failure, serum calcium is low.

  E. With osteomalacia, serum calcium is high.

  Correct Answer: D Section: (none)

  Explanation: This patient meets criteria for the diagnosis of osteoporosis, with a T score falling below -2.5 standard SD. AT score indicates the number of standard deviations below or above the average peak bone mass in young, healthy adults of the same gender. Bisphosphonate therapy has been shown to reduce vertebral and hip fracture risk in up to 50% of women with documented osteoporosis. GnRH therapy and discontinuation of her vitamin D therapy would worsen, not improve, this patient's bone density. Although testosterone may arrest further bone loss, the side effects of the medication are too great compared to any potential benefit.

  For women who have osteoporosis the serum calcium level is generally normal. In premenopausal osteoporosis, or more severe cases of bone loss/fractures, the presence of metabolic bone disease should be considered. In hyperparathyroidism the serum calcium is elevated. With renal failure, as with osteomalacia, serum calcium is low. The serum calcium level is normal, and the alkaline phosphatase level is elevated in patients with Paget disease. The use of tobacco, a family history of mother or maternal grandmother with hip fractures, postmenopausal state without estrogen replacement, vision problems, and a body mass index of less than 23 are all increased risks for fractures. Abody mass index of greater than 23 does not represent an increased risk for fracture.

• Question 339:

  A70-year-old White woman has been faithful about taking 1200 mg of calcium, 400 IU of vitamin D supplements, and performing weight-bearing exercise on a daily basis. Her hip T score from her current DEXA scan has changed from -2.0 SDs to -2.55 SDs compared with last year's test.

  At this time, which of the following do you recommend?

  A. an oral bisphosphonate

  B. weekly GnRH injections

  C. discontinuation of her vitamin D

  D. glucocorticoid therapy

  E. IM testosterone

  Correct Answer: A Section: (none)

  Explanation:

  This patient meets criteria for the diagnosis of osteoporosis, with a T score falling below -2.5 standard SD. AT score indicates the number of standard deviations below or above the average peak bone mass in young, healthy adults of the same gender. Bisphosphonate therapy has been shown to reduce vertebral and hip fracture risk in up to 50% of women with documented osteoporosis. GnRH therapy and discontinuation of her vitamin D therapy would worsen, not improve, this patient's bone density. Although testosterone may arrest further bone loss, the side effects of the medication are too great compared to any potential benefit.

  For women who have osteoporosis the serum calcium level is generally normal. In premenopausal osteoporosis, or more severe cases of bone loss/fractures, the presence of metabolic bone disease should be considered. In hyperparathyroidism the serum calcium is elevated. With renal failure, as with osteomalacia, serum calcium is low. The serum calcium level is normal, and the alkaline phosphatase level is elevated in patients with Paget disease. The use of tobacco, a family history of mother or maternal grandmother with hip fractures, postmenopausal state without estrogen replacement, vision problems, and a body mass index of less than 23 are all increased risks for fractures. Abody mass index of greater than 23 does not represent an increased risk for fracture.

• Question 340:

  A concerned mother brings her 5-year-old daughter to the ER because she noticed redness around her daughter's genital region while bathing her last night. The child has not complained of any discomfort, itching, bleeding, or inappropriate contact with other adults. On external inspection of her labia, you see the fusion of the labia minora and generalized erythema. The most appropriate treatment would be which of the following?

  A. surgical excision

  B. vaginoscopy and biopsies

  C. ice packs and sitz baths

  D. lidocaine ointment

  E. topical estrogen cream

  Correct Answer: E Section: (none)

  Explanation:

  Labial agglutination is a clinical diagnosis, with a greater prevalence occurring in pediatric or elderly patients. Forced manipulations of the genital region are to be avoided, as the condition readily responds to topical estrogen therapy.