USMLE USMLE Certifications USMLE-STEP-3 Questions & Answers

• Question 361:

  A38-year-old woman presents to the ER with heavy vaginal bleeding. A pelvic examination using a speculum to visualize the cervix reveals a large, friable, fungating cervical mass. On bimanual examination, the mass extends to the right pelvic sidewall. A biopsy from a recent gynecologic visit reveals invasive squamous cell carcinoma of the cervix. An abdominal/pelvic CT scan shows enlarged pelvic lymph nodes and right hydronephrosis. Her hematocrit (HCT) in the ER is 24%, but she is hemodynamically stable with a BP of 124/70 and a pulse of 73. The cervical mass is actively bleeding.

  Your initial treatment of the vaginal bleeding in the ER only partially controls the bleeding, and she is requiring frequent retreatment. The best definitive treatment to control the bleeding at this time is which of the following?

  A. emergency bilateral hypogastric artery ligation

  B. uterine artery embolization

  C. emergency high-dose radiation therapy

  D. emergency radical hysterectomy

  E. loop excision electrocautery procedure (LEEP)

  Correct Answer: C Section: (none)

  Explanation:

  A woman with advanced cervical cancer may present emergently with heavy vaginal bleeding. Often, the bleeding can be controlled for 24 hours by packing the vagina with a packing soaked in Monsel solution. The patient is kept on bedrest, and the packing is changed every 24 hours. If packing the vagina does not control the bleeding, then emergent radiation therapy is warranted if the patient has not had previous radiation treatment. Hemorrhage is usually controlled within 2448 hours of initiating external beam therapy. If radiation therapy fails, then the next best treatment is arterial embolization of either the uterine or hypogastric arteries. However, embolization may result in tumor hypoxia and decrease the sensitivity of the tumor to radiation. Arteriography with embolization may allow visualization of the bleeding vessel with direct embolization of the source. Arterial embolization has several risks including infarction of distal tissue, infection, and femoral artery thrombosis. If embolization is not available or not successful, bilateral hypogastric artery ligation is an option. In this patient, surgical therapy with radical hysterectomy is not an appropriate treatment because this patient's disease has spread beyond the cervix. This procedure would result in transection of the tumor and lead to further bleeding complications. This patient has at least a stage IIIB tumor, and the best treatment for her is chemoradiation

• Question 362:

  A38-year-old woman presents to the ER with heavy vaginal bleeding. A pelvic examination using a speculum to visualize the cervix reveals a large, friable, fungating cervical mass. On bimanual examination, the mass extends to the right pelvic sidewall. A biopsy from a recent gynecologic visit reveals invasive squamous cell carcinoma of the cervix. An abdominal/pelvic CT scan shows enlarged pelvic lymph nodes and right hydronephrosis. Her hematocrit (HCT) in the ER is 24%, but she is hemodynamically stable with a BP of 124/70 and a pulse of 73. The cervical mass is actively bleeding.

  Which of the following is the most appropriate immediate management of the vaginal bleeding in the ER?

  A. vaginal packing soaked with Monsel solution

  B. vitamin K

  C. transfusion of fresh frozen plasma (FFP)

  D. uterine massage

  E. supportive care with transfusion of packed red blood cells

  Correct Answer: A Section: (none)

  Explanation:

  A woman with advanced cervical cancer may present emergently with heavy vaginal bleeding. Often, the bleeding can be controlled for 24 hours by packing the vagina with a packing soaked in Monsel solution. The patient is kept on bedrest, and the packing is changed every 24 hours. If packing the vagina does not control the bleeding, then emergent radiation therapy is warranted if the patient has not had previous radiation treatment. Hemorrhage is usually controlled within 2448 hours of initiating external beam therapy. If radiation therapy fails, then the next best treatment is arterial embolization of either the uterine or hypogastric arteries. However, embolization may result in tumor hypoxia and decrease the sensitivity of the tumor to radiation. Arteriography with embolization may allow visualization of the bleeding vessel with direct embolization of the source. Arterial embolization has several risks including infarction of distal tissue, infection, and femoral artery thrombosis. If embolization is not available or not successful, bilateral hypogastric artery ligation is an option. In this patient, surgical therapy with radical hysterectomy is not an appropriate treatment because this patient's disease has spread beyond the cervix. This procedure would result in transection of the tumor and lead to further bleeding complications. This patient has at least a stage IIIB tumor, and the best treatment for her is chemoradiation.

• Question 363:

  A41-year-old woman, recently diagnosed with a 2-cm, stage IB1 cervical cancer, undergoes a radical hysterectomy, bilateral salpingooophorectomy, and retroperitoneal pelvic lymph node dissection. Her surgery and postoperative course are uncomplicated. Four weeks postoperatively, she presents to the ER complaining of left leg swelling and left lower quadrant abdominal pain. On physical examination, she is afebrile, has a normal WBC count, and you palpate a 5 4 cm mass in the left lower quadrant. You order a pelvic ultrasound that shows a 5 5 cm simple cyst in the left lower quadrant.

  Which of the following is the most likely diagnosis?

  A. deep venous thrombosis (DVT) B. pelvic abscess

  B. lymphocyst

  C. ovarian cyst

  D. diverticular abscess

  Correct Answer: C Section: (none)

  Explanation:

  The incidence of lymphocyst formation following radical hysterectomy and pelvic lymphadenectomy ranges as high as 30%, but is less than 5% if only symptomatic cysts are counted. Risks for lymphocyst formation include lymphadenectomy, radiation therapy, lymph node metastases, and closure of the pelvic peritoneum. From a surgical standpoint, closure of the pelvic peritoneum traps the lymph fluid in the retroperitoneal space and prevents absorption by the peritoneal membrane. Most lymphocysts are small, asymptomatic, and clinically insignificant. Large lymphocysts can produce serious consequences including venous obstruction with DVT, ureteral obstruction, leg edema, and pain. Bilateral lymphocysts can cause obstructive renal failure. The diagnosis is made most easily and accurately by pelvic ultrasound. Large or symptomatic pelvic lymphocysts can almost always be managed by percutaneous drainage with a pigtail catheter placed under CT or ultrasound guidance. A pelvic DVT following gynecologic surgery should be in the differential for this patient. Typically, DVT following pelvic surgery is asymptomatic, but the appearance of leg edema, pain, or tenderness in the calf, popliteal space, or inguinal triangle is highly suspicious. Erythema and fever are uncommon. A pelvic DVT is uncommon compared to a more distal DVT in the lower extremity venous system. Women with a pelvic DVT will not have the classic symptoms associated with a calf DVT. The diagnostic test to evaluate for a DVT would be a lower extremity venous duplex ultrasound.

• Question 364:

  A 63-year-old woman with a grade 2 endometrioid adenocarcinoma of the uterus diagnosed by endometrial biopsy is taken to the operating room for surgical treatment with a total abdominal hysterectomy, bilateral salpingooophorectomy, and pelvic and paraaortic lymphadenectomy. No complications are noted intraoperatively. On postoperative day 1, the patient complains of numbness in her medial thigh. Your neurologic examination suggests absence of cutaneous sensation to the medial thigh and an inability to adduct her hip.

  Which of the following is the most likely etiology for this clinical presentation?

  A. femoral nerve injury

  B. genitofemoral nerve injury

  C. pudendal nerve injury

  D. obturator nerve injury

  E. peroneal nerve injury

  Correct Answer: D Section: (none)

  Explanation: In gynecology, the obturator nerve (L2-L4) is most commonly injured during retroperitoneal surgery for gynecologic malignancies. In this case, a pelvic lymph node dissection for endometrial cancer involves a retroperitoneal dissection into the obturator fossa to remove the obturator lymph nodes. The nodal tissue of the obturator fossa obscures the location of the obturator nerve and predisposes it to injury. Postoperatively, patients with an injury to the obturator nerve will present with sensory loss to the upper medial thigh and motor weakness in the hip adductors. If an obturator nerve injury is recognized intraoperatively, immediate repair is the recommended treatment. However, with postoperative recognition, as in this case, treatment includes physiotherapy with neuromuscular electrical stimulation and electromyographic biofeedback, and exercise. Obturator nerve injury is a highly treatable condition, and complete recovery of motor strength is generally the result after physical therapy.

  The common peroneal nerve branches off the posterior tibial branch of the sciatic nerve just above the popliteal fossa and runs superficially across the lateral head of the fibula and down the lateral calf. This nerve can be compressed when patients are inappropriately placed in the lithotomy position with stirrups. Compression of the peroneal nerve results in a foot drop and lateral lower extremity numbness or paresthesia

• Question 365:

  Which of the following can induce menstrual bleeding in a 21-year-old anovulatory, amenorrheic woman with PCOS?

  A. administration of progestins

  B. administration of estrogens

  C. withdrawal of progestin therapy

  D. withdrawal of estrogen therapy

  E. danazol

  Correct Answer: C Section: (none)

  Explanation:

  Apatient who is anovulatory due to PCOS would be expected to have normal estrogen production. However, without corpus luteum formation following ovulation there is no significant progesterone production. Therefore, the discontinuation of a period of progestin therapy would initiate menstrual flow

• Question 366:

  The predicted length of the follicular phase of a patient with a consistent 34-day menstrual cycle is which of the following?

  A. 14 days

  B. depends on the length of the luteal phase

  C. 16 days

  D. 18 days

  E. 20 days

  Correct Answer: E Section: (none)

  Explanation:

  The luteal phase of the menstrual cycle, defined as beginning with the LH surge and ending with onset menses, is normally fixed at 14 + 2 days. Therefore, the length of the follicular phase can fairly accurately be determined by subtracting 14 days from the total length of the cycle. In this case, the length of the follicular phase is: 34 -14 = 20 days.

• Question 367:

  A 44-year-old female has a history of endometriosis resulting in chronic pelvic pain. She presents to you 6 months after her total abdominal hysterectomy and bilateral salpingooophorectomy. She reports continued pelvic pain. Which of the following would be your most appropriate recommendation for medical management?

  A. GnRH

  B. oral estrogens

  C. oral progestins

  D. tamoxifen

  E. GnRH antagonist

  Correct Answer: C Section: (none)

  Explanation:

  There are a number of effective medical therapies for pain due to endometriosis. These include GnRH agonists, danazol, progestins, and oral contraceptives. Surgical menopause requires the use of GnRH agonists or antagonists in order to suppress of ovarian function. Unopposed estrogen would be contraindicated in this patient because of its stimulatory effect on any remaining endometriosis. Tamoxifen has not demonstrated efficacy in the treatment of endometriosis. Progestins are effective at improving endometriosis symptoms due to their atrophic effect.

• Question 368:

  A patient with a persistent headache following a postpartum hemorrhage is diagnosed with Sheehan's syndrome. If the patient were subsequently amenorrheic and infertile, what treatment would you recommend to assist this patient to conceive?

  A. gonadotropin releasing hormone (GnRH) pump

  B. clomiphene citrate

  C. dopamine agonist

  D. in vitro fertilization

  E. gonadotropins (FSH and LH)

  Correct Answer: E Section: (none)

  Explanation:

  Sheehan syndrome describes damage to the pituitary gland classically resulting from hypotension following a postpartum hemorrhage. The clinical picture is variable due to the fact that the damage may involve one or more of the various cellular subtypes in the pituitary gland that secrete either adrenocorticotropic hormone (ACTH), GH, prolactin, TSH, or LH/FSH. An amenorrheic patient with a history of Sheehan's syndrome would not be expected to have functional pituitary gonadotropes so a GnRH pump or clomiphene citrate would not be useful because they both rely on a functional pituitary gland. Replacement of gonadotropins (LH and FSH) would be the best treatment option

• Question 369:

  A26-year-old female with recurrent pregnancy loss undergoes a laparoscopy and hysteroscopy. She is

  found to have a Müllerian anomaly with a heart-shaped uterus that has two uterine horns but one common

  cervix.

  What is the name of the uterine anomaly?

  A. didelphic

  B. septate

  C. unicornuate

  D. bicornuate

  E. Müllerian agenesis (Mayer-Rokitansky-Küster-Hauser syndrome)

  Correct Answer: D Section: (none)

  Explanation:

  Müllerian anomalies result from either the lack of proper fusion or resorption of the paramesonephric (Müllerian) ducts during organogenesis. Vertical abnormalities occur when the invaginating urogenital sinus--extending in a cranial direction from the introitus--and the Müllerian structures--extending caudally-fail to canalize appropriately. Longitudinal defects occur when the two paramesonephric ducts either do not fuse appropriately or following fusion the intervening tissue is not reabsorbed completely. A didelphic uterus represents lack of fusion, and the patient has a duplicated cervix and each cervix is connected to a separate uterine horn. Aunicornuate uterus results from aplasia of one of the paramesonephric ducts so that only one cervix connecting to a single uterine horn is found. A bicornuate uterus results from failure of the paramesonephric ducts to fuse cranially resulting in a single cervix but two separate uterine horns. A septate uterus occurs when fusion is completed but reabsorption of the intervening tissue is incomplete.

• Question 370:

  A 24-year-old G1 presents to you for initiation of obstetric care. She informs you that she is on a medication that was prescribed for acne. The drug is listed as category X in your pharmacy book.

  The patient reports that she is going to continue the medication because she would be too embarrassed to go to work if her acne were to return. You counsel the patient about the possible risks of this approach but she desires to proceed. You counsel the patient that her best option may be to terminate the pregnancy and continue the medication. Allowing her to make this decision is an example of which of the following?

  A. beneficence

  B. autonomy

  C. breach of confidentiality

  D. malfeasance

  E. justice

  Correct Answer: B Section: (none)

  Explanation:

  The pregnancy risk factor category assists the physician and patient to understand the safety of the use of a medication during pregnancy. The summary of the categories is as follows: category A--controlled human studies demonstrate no risk to a fetus. Category B--animal-reproduction studies have not demonstrated fetal risk but there are no controlled human studies to assess the risk. Category C--animalreproduction studies have demonstrated risk to a fetus and no controlled human studies are available. Category D--evidence of human teratogenic risk exists but in some cases the known risks may be outweighed in serious situations, such as lifethreatening disease. Class X--this drug should never be used by a pregnant female under any circumstances. The principle of autonomy states that the patient has the right and capability to control the course of her medical care and to participate in the decision-making process.