A43-year-old morbidly obese woman presents to your office with a 3-week history of increasing vulvar burning. She has had no new sexual partners or practices. She has not noticed any change in her vaginal discharge. She has attempted to medicate herself with over-thecounter antifungals, herbal creams, and old antibiotics, none of which have provided relief. On examination, her entire labia majora and minora are markedly erythematous and tender to the touch. Her vaginal mucosa appears to have normal rugae. Her vaginal pH is normal and whiff test is negative. The wet mount shows a few WBCs and normal squamous cells.
What is the most likely diagnosis?
A. chemical dermatitis
B. bacterial vaginosis
C. PID disease
D. atrophic vaginitis
E. lichens sclerosis et atrophicus
Correct Answer: A Section: (none)
Explanation: History is critical in the evaluation and management of vulvar diseases. Given the fact that this patient has had exposures to numerous topical medications, it is likely that she has contact dermatitis of the vulva. Given the lack of hyphae on her wet mount and no apparent abnormal vaginal discharge, a candidal infection is less likely. She is obese and not in the average age range for menopause, thus atrophic findings are unlikely. The wet mount lacks clue cells that establish the diagnosis of bacterial vaginosis
Question 342:
A 22-year-old White female (gravida 2, para 1, abortus 1) comes to your office with a 3-week history of lower abdominal pain and increased vaginal discharge. She has a prior history of an ectopic pregnancy at age 16. Her last menstrual period (LMP) was 7 days ago, and she has had unprotected vaginal intercourse with a new sexual partner several times over the past few weeks. Her temperature is 38.0°C; her vital signs are stable. She has bilateral lower quadrant tenderness but no peritoneal signs. On speculum examination, she has foul smelling green discharge emanating from her cervix. She has cervical motion tenderness on bimanual examination and is tender in both adnexae. Her wet mount shows copious white cells. Her urine hCG is (-).
A. gonorrhea alone
B. chlamydia alone
C. Candida albicans
D. herpes simplex virus
E. polymicrobial aerobic and anaerobic bacteria from the lower genital tract
Correct Answer: E Section: (none)
Explanation:
PID is actually a spectrum of inflammatory disorders of the upper female genital tract. It includes endometritis, salpingitis, tubo-ovarian abscess, and pelvic peritonitis. While the sexually transmitted bacteria N. gonorrhea and C. trachomatis are often implicated, vaginal flora, including anaerobes, G. vaginalis, H. influenzae, gram-negative rods, and others, are also associated with PID. The clinical diagnosis of acute PID can be difficult and imprecise. There is a wide range of variation in signs and symptoms, and many women have very mild or subtle symptoms only. Because of the difficulty with diagnosis and the potential for damage to reproductive health with even mild PID, one must keep a low threshold for the diagnosis. Empiric treatment for PID should be considered in sexually active young women, or other women at risk for STDs, if there is uterine, adnexal, or cervical motion tenderness, and no other cause of illness can be identified. Additional criteria that support a diagnosis of PID include temperature >101°F, mucopurulent cervical or vagina l discharge, presence of WBCs on wet prep of vaginal secretions, elevated ESR, elevated C-reactive protein, and documentation of infection with gonorrhea or chlamydia.
Question 343:
A 22-year-old White female (gravida 2, para 1, abortus 1) comes to your office with a 3-week history of lower abdominal pain and increased vaginal discharge. She has a prior history of an ectopic pregnancy at age 16. Her last menstrual period (LMP) was 7 days ago, and she has had unprotected vaginal intercourse with a new sexual partner several times over the past few weeks. Her temperature is 38.0°C; her vital signs are stable. She has bilateral lower quadrant tenderness but no peritoneal signs. On speculum examination, she has foul smelling green discharge emanating from her cervix. She has cervical motion tenderness on bimanual examination and is tender in both adnexae. Her wet mount shows copious white cells. Her urine hCG is (-).
Which of the following would be the most appropriate treatment regimen for this patient?
A. metronidazole PO for 5 days
B. gentamicin IV × one dose
C. ceftriaxone intramuscular (IM) plus doxycycline PO for 14 days
D. Diflucan PO × one dose
E. ampicillin PO qid × 14 days 44. Most cases of PID are associated with which of the following?
Correct Answer: C Section: (none)
Explanation:
PID is actually a spectrum of inflammatory disorders of the upper female genital tract. It includes endometritis, salpingitis, tubo-ovarian abscess, and pelvic peritonitis. While the sexually transmitted bacteria N. gonorrhea and C. trachomatis are often implicated, vaginal flora, including anaerobes, G. vaginalis, H. influenzae, gram-negative rods, and others, are also associated with PID. The clinical diagnosis of acute PID can be difficult and imprecise. There is a wide range of variation in signs and symptoms, and many women have very mild or subtle symptoms only. Because of the difficulty with diagnosis and the potential for damage to reproductive health with even mild PID, one must keep a low threshold for the diagnosis. Empiric treatment for PID should be considered in sexually active young women, or other women at risk for STDs, if there is uterine, adnexal, or cervical motion tenderness, and no other cause of illness can be identified. Additional criteria that support a diagnosis of PID include temperature >101°F, mucopurulent cervical or vagina l discharge, presence of WBCs on wet prep of vaginal secretions, elevated ESR, elevated C-reactive protein, and documentation of infection with gonorrhea or chlamydia.
Question 344:
A 14-year-old nulligravid female is brought to the ER by her parents with a 12-hour history of severe, intermittent left lower quadrant pain. She has had nausea and vomiting for the past 2 hours. On history, the patient experienced menarche at age 12 and denies past or current contact with a sexual partner. Her last normal menstrual period was 3 weeks ago. On examination, she is afebrile, pulse 100, BP 110/70, respiratory rate (RR) 20. She is visibly uncomfortable. She has no costovertebral tenderness, has diminished bowel sounds, her abdomen is nondistended, and exhibits rebound and guarding in both lower quadrants. She is unable to tolerate a pelvic examination due to pain. Laboratory values are as follows: WBC 13, HCT 39, -hCG (-), UA (-). Apelvic ultrasound shows a normal nonpregnant uterus, normal right adnexa, and an 8-cm left adnexal mass with a 3-cm solid component
The most likely etiology of this patient's pain is which of the following?
A. ectopic pregnancy
B. acute appendicitis
C. ovarian torsion
D. pancreatitis
E. somatization disorder
Correct Answer: C Section: (none)
Explanation:
This patient is demonstrating acute peritoneal signs that require surgical intervention. Adding additional testing, either with radiology or more laboratory assessment would not alter the management at this point in time. Although some patients with chronic pelvic pain have a history of sexual or physical abuse, an assessment in the acute emergent setting does not take initial priority. Although ovarian torsion can be enigmatic in its presentation, this patient demonstrates classic signs of intermittent pelvic pain and an ovarian cyst with a solid component. The 8-cm increase in ovarian size is likely due to vascular congestion from occlusion of the blood supply. Early intervention is more likely to result in salvaging viable tissue before the onset of irreversible tissue necrosis. The absence of fever and other GI symptoms, along with a left lower quadrant mass on ultrasound goes against the possibility of appendicitis or pancreatitis. Her pregnancy test is negative which generally excludes an ectopic pregnancy.
Question 345:
A 14-year-old nulligravid female is brought to the ER by her parents with a 12-hour history of severe, intermittent left lower quadrant pain. She has had nausea and vomiting for the past 2 hours. On history, the patient experienced menarche at age 12 and denies past or current contact with a sexual partner. Her last normal menstrual period was 3 weeks ago. On examination, she is afebrile, pulse 100, BP 110/70, respiratory rate (RR) 20. She is visibly uncomfortable. She has no costovertebral tenderness, has diminished bowel sounds, her abdomen is nondistended, and exhibits rebound and guarding in both lower quadrants. She is unable to tolerate a pelvic examination due to pain. Laboratory values are as follows: WBC 13, HCT 39, -hCG (-), UA (-). Apelvic ultrasound shows a normal nonpregnant uterus, normal right adnexa, and an 8-cm left adnexal mass with a 3-cm solid component.
Which of the following would be the next appropriate step in managing this patient?
A. abdominal and pelvic CT scan
B. social work referral for possible sexual abuse
C. obtain liver enzymes, amylase, and lipase
D. consultation for immediate surgical intervention
E. discharge to home with pain medications
Correct Answer: D Section: (none)
Explanation:
This patient is demonstrating acute peritoneal signs that require surgical intervention. Adding additional testing, either with radiology or more laboratory assessment would not alter the management at this point in time. Although some patients with chronic pelvic pain have a history of sexual or physical abuse, an assessment in the acute emergent setting does not take initial priority. Although ovarian torsion can be enigmatic in its presentation, this patient demonstrates classic signs of intermittent pelvic pain and an ovarian cyst with a solid component. The 8-cm increase in ovarian size is likely due to vascular congestion from occlusion of the blood supply. Early intervention is more likely to result in salvaging viable tissue before the onset of irreversible tissue necrosis. The absence of fever and other GI symptoms, along with a left lower quadrant mass on ultrasound goes against the possibility of appendicitis or pancreatitis. Her pregnancy test is negative which generally excludes an ectopic pregnancy.
Question 346:
A76 year old White female presents to her family practitioner complaining of vaginal pressure, dyspareunia, urinary incontinence, and difficulty emptying her bladder for the past 4 weeks. Seven years ago she had a prolapsed "bladder tacking" procedure. Her postvoid residual urine in the office measures 250 mL. The most notable finding on pelvic examination is seen in Figure .
Which of the following would be the most appropriate action to take at this time?
A. referral for immediate surgery
B. abdominal and pelvic CT scan
C. urinalysis (UA) with culture and sensitivity
D. prescription for oxybutynin (Ditropan)
E. urodynamic studies
Correct Answer: C Section: (none)
Explanation:
When pelvic organs prolapse occurs beyond the level of the hymen, anatomic obstruction of urine occurs in approximately 30% of patients. Over time, urinary stasis from obstruction can lead to UTIs. Detrusor hypocontractility, not overactivity, can be another long-term sequela of chronic urinary retention, enhanced by a stretch injury to the postsynaptic parasympathetics in the bladder wall. Menopause alone is not a risk factor for retention, and a spinal cord tumor is not likely in this patient without specific neurologic complaints or findings on physical examination. Due to urinary stasis, she is at risk for a UTI. Left untreated, she could develop obstructive uropathy and/or pyelonephritis. Surgery is an option, but not without the prior consideration of nonsurgical options such as a pessary or intermittent clean, selfcatheterization (if the problem were to persist). In the event of chronic retention, radiographic imaging would help to assess for upper tract obstruction (i.e., hydronephrosis). Oxybutynin is not appropriate, as it could compound urinary retention. Urodynamic studies could be helpful in the future to ascertain the exact cause of her retention (obstruction from the prolapse vs. chronic detrusor insufficiency vs. neurogenic bladder), but is not the first action to consider.
Question 347:
A76 year old White female presents to her family practitioner complaining of vaginal pressure, dyspareunia, urinary incontinence, and difficulty emptying her bladder for the past 4 weeks. Seven years ago she had a prolapsed "bladder tacking" procedure. Her postvoid residual urine in the office measures 250 mL. The most notable finding on pelvic examination is seen in Figure .
What is the most likely etiology of her urinary retention?
A. detrusor overactivity
B. bladder outlet obstruction
C. urinary tract infection (UTI)
D. menopause
E. spinal cord tumor
Correct Answer: B Section: (none)
Explanation:
When pelvic organs prolapse occurs beyond the level of the hymen, anatomic obstruction of urine occurs in approximately 30% of patients. Over time, urinary stasis from obstruction can lead to UTIs. Detrusor hypocontractility, not overactivity, can be another long-term sequela of chronic urinary retention, enhanced by a stretch injury to the postsynaptic parasympathetics in the bladder wall. Menopause alone is not a risk factor for retention, and a spinal cord tumor is not likely in this patient without specific neurologic complaints or findings on physical examination. Due to urinary stasis, she is at risk for a UTI. Left untreated, she could develop obstructive uropathy and/or pyelonephritis. Surgery is an option, but not without the prior consideration of nonsurgical options such as a pessary or intermittent clean, selfcatheterization (if the problem were to persist). In the event of chronic retention, radiographic imaging would help to assess for upper tract obstruction (i.e., hydronephrosis). Oxybutynin is not appropriate, as it could compound urinary retention. Urodynamic studies could be helpful in the future to ascertain the exact cause of her retention (obstruction from the prolapse vs. chronic detrusor insufficiency vs. neurogenic bladder), but is not the first action to consider.
Question 348:
A43-year-old Black female (gravida 3, para 3) with a previous tubal ligation, presents to your office complaining of increasing menorrhagia, dysmenorrhea, and fatigue over the past 6 months. On examination, her vital signs are normal, and on abdominal examination you palpate a firm, mobile mass just below the umbilicus. On pelvic examination, there is a moderate amount of old blood coming from the cervical os. A urine pregnancy test is negative, her last pap smear was normal and her spun HCT today is 28%. Which pharmacologic agent would potentially result in an improvement in her HCT and help to decrease uterine size?
A. oral contraceptive pills (OCPs)
B. medroxyprogesterone
C. nonsteroidal anti-inflammatory agents
D. narcotics
E. GnRH agonists
Correct Answer: E Section: (none)
Explanation:
Pelvic ultrasound is the least invasive and most cost-effective test to diagnose uterine fibroids. MRI is useful but not always readily available and much more expensive. Plain radiographs would not be helpful, and office laparoscopy is impractical and potentially dangerous given the presumed size of her uterus. A hysterosalpingogram would only note filling defects within the uterine cavity and miss intramural or subserosal fibroids.
GnRH agonists have been used widely for preoperative treatment of uterine fibroids. They work by inducing amenorrhea, which improves hematologic parameters and decreases uterine volume. Although nonsteroidal anti-inflammatory drugs (NSAIDs) may help decrease bleeding for some patients with fibroids, they have not been reliably shown to decrease fibroid size. The other agents (OCPs, progesterone, and narcotics) do not have these effects and generally are not effective in treating dysfunctional uterine bleeding caused by anatomic lesions such as fibroids
Question 349:
A43-year-old Black female (gravida 3, para 3) with a previous tubal ligation, presents to your office complaining of increasing menorrhagia, dysmenorrhea, and fatigue over the past 6 months. On examination, her vital signs are normal, and on abdominal examination you palpate a firm, mobile mass just below the umbilicus. On pelvic examination, there is a moderate amount of old blood coming from the cervical os. A urine pregnancy test is negative, her last pap smear was normal and her spun HCT today is 28%.
Which diagnostic test would be most costeffective in confirming a diagnosis?
A. pelvic MRI
B. abdominal plain films
C. pelvic ultrasound
D. hysterosalpingogram
E. office laparoscopy
Correct Answer: C Section: (none)
Explanation:
Pelvic ultrasound is the least invasive and most cost-effective test to diagnose uterine fibroids. MRI is useful but not always readily available and much more expensive. Plain radiographs would not be helpful, and office laparoscopy is impractical and potentially dangerous given the presumed size of her uterus. A hysterosalpingogram would only note filling defects within the uterine cavity and miss intramural or subserosal fibroids.
GnRH agonists have been used widely for preoperative treatment of uterine fibroids. They work by inducing amenorrhea, which improves hematologic parameters and decreases uterine volume. Although nonsteroidal anti-inflammatory drugs (NSAIDs) may help decrease bleeding for some patients with fibroids, they have not been reliably shown to decrease fibroid size. The other agents (OCPs, progesterone, and narcotics) do not have these effects and generally are not effective in treating dysfunctional uterine bleeding caused by anatomic lesions such as fibroids
Question 350:
A 56-year-old thin, White woman, who has recently undergone a total abdominal hysterectomy, bilateral salpingo-oophorectomy, and pelvic lymphadenectomy for a stage IB, grade 1, endometrioid tumor of the uterus, presents to your office complaining of hot flashes and vaginal dryness. She wants advice about the use of estrogen replacement in women treated for endometrial cancer.
Which of the following is the best treatment for this woman?
A. psychotherapy
B. estrogen replacement therapy
C. increased soy intake
D. combination hormone replacement therapy
E. referral to an endometrial cancer support group
Correct Answer: B Section: (none)
Explanation:
The use of estrogen replacement in women previously treated for endometrial cancer represents a recent change in practice. For many women, the improvement in quality of life and the reduction in osteoporosis outweigh the possible risks of stimulating tumor growth. Most patients are diagnosed early with endometrial cancer and successfully treated with surgery. As a result, the risk-benefit ratio of estrogen replacement in these women has been reexamined. In a recent survey of the Society of Gynecologic Oncologists, 83% of
the respondents approved estrogen replacement in stage I, grade 1 endometrial cancer.
Data on the use of estrogen replacement therapy in women with endometrial cancer are limited primarily to retrospective studies. Three retrospective studies have concluded that estrogen replacement therapy is not detrimental to patients after treatment for endometrial cancer. There exists no data on which to base specific recommendations about estrogen replacement in these patients. The decision must involve a candid discussion about risks and benefits to the patients and be individualized to each patient, taking into consideration the stage, grade, and histology of the tumor and their current hypoestrogenic symptoms and risk factors for osteoporosis. The delivery method of estrogen is also not clear. Some patients may want to use more natural products like soy, although the relief of symptoms with soy varies considerably. Others may complain more of vaginal dryness, and a vaginal estrogen cream may be more appropriate. The benefit of adding progesterone and giving patients combined hormone replacement therapy is also unclear.
Nowadays, the certification exams become more and more important and required by more and more enterprises when applying for a job. But how to prepare for the exam effectively? How to prepare for the exam in a short time with less efforts? How to get a ideal result and how to find the most reliable resources? Here on Vcedump.com, you will find all the answers. Vcedump.com provide not only USMLE exam questions, answers and explanations but also complete assistance on your exam preparation and certification application. If you are confused on your USMLE-STEP-3 exam preparations and USMLE certification application, do not hesitate to visit our Vcedump.com to find your solutions here.
