USMLE USMLE Certifications USMLE-STEP-3 Questions & Answers

• Question 61:

  A54-year-old Asian female with no significant medical history presents with frontal headache, eye pain, nausea, and vomiting. Her abdominal examination shows mild diffuse tenderness but no rebound or guarding. Her mucous membranes are dry. Her vision is blurry in both eyes, her eyes are injected but her extraocular muscles are intact. Her pupils are mid-dilated and fixed

  What other finding is this patient most likely to have?

  A. cloudy corneas

  B. anemia

  C. anorexia

  D. dizziness or vertigo

  E. polyuria and polydipsia

  Correct Answer: A Section: (none)

  Explanation:

  The presence of headache, eye pain, nausea, and vomiting should prompt the consideration of the diagnosis of acute angle closure glaucoma. This is a rare but serious condition in which the aqueous outflow is obstructed, and the intraocular pressure abruptly rises. Susceptible eyes have a narrow anterior chamber and when the pupil becomes dilated, the peripheral iris blocks the outflow via the anterior chamber angle. Edema of the cornea occurs, resulting in cloudiness on examination. Diagnosis is made by measuring the intraocular pressure during an acute attack. Treatment includes medications to induce miosis in an effort to relieve the blockage or, if that fails, surgical intervention. In some patients, the headache or GI symptoms can overshadow the ocular symptoms, resulting in a delay in diagnosis and unnecessary workup for other conditions. In this case, the lack of findings on abdominal examination makes appendicitis or perforated bowel unlikely. DKA can present with primary GI symptoms, but would not explain the ocular symptoms. Similarly, cerebellar or other brain tumors may cause headache, nausea, and vomiting, but would not be causes of a painful, red eye.

• Question 62:

  A54-year-old Asian female with no significant medical history presents with frontal headache, eye pain, nausea, and vomiting. Her abdominal examination shows mild diffuse tenderness but no rebound or guarding. Her mucous membranes are dry. Her vision is blurry in both eyes, her eyes are injected but her extraocular muscles are intact. Her pupils are mid-dilated and fixed.

  Which of the following is most likely to provide a diagnosis?

  A. abdominal ultrasound

  B. emergency exploratory laparoscopy

  C. MRI of the brain

  D. arterial blood gas

  E. ocular tonometry

  Correct Answer: E Section: (none)

  Explanation:

  The presence of headache, eye pain, nausea, and vomiting should prompt the consideration of the diagnosis of acute angle closure glaucoma. This is a rare but serious condition in which the aqueous outflow is obstructed, and the intraocular pressure abruptly rises. Susceptible eyes have a narrow anterior chamber and when the pupil becomes dilated, the peripheral iris blocks the outflow via the anterior chamber angle. Edema of the cornea occurs, resulting in cloudiness on examination. Diagnosis is made by measuring the intraocular pressure during an acute attack. Treatment includes medications to induce miosis in an effort to relieve the blockage or, if that fails, surgical intervention. In some patients, the headache or GI symptoms can overshadow the ocular symptoms, resulting in a delay in diagnosis and unnecessary workup for other conditions. In this case, the lack of findings on abdominal examination makes appendicitis or perforated bowel unlikely. DKA can present with primary GI symptoms, but would not explain the ocular symptoms. Similarly, cerebellar or other brain tumors may cause headache, nausea, and vomiting, but would not be causes of a painful, red eye.

• Question 63:

  A 64-year-old Hispanic female with type II DM and hypertension for 15 years comes to your office after not seeing a physician for 5 years. The HgbA1C is 9. She reports that her vision has been deteriorating but new glasses from the optometrist have helped.

  Your examination findings include all of the above. These form which of the following diagnoses?

  A. nonproliferative diabetic retinopathy

  B. proliferative retinopathy

  C. central serous chorioretinopathy

  D. microangiopathy of the retina

  E. hypertensive retinopathy

  Correct Answer: B Section: (none)

  Explanation:

  Persons with DM are 25 times more likely to become legally blind than persons without diabetes. Blindness is primarily the result of progressive diabetic retinopathy and clinically significant macular edema. The presence of retinal vascular microaneurysms, blot hemorrhages, and cotton wool spots mark the presence of nonproliferative diabetic retinopathy. Increased retinal vascular permeability, alterations in blood flow, and abnormal microvasculature lead to retinal ischemia. In response to the ischemia, new blood vessels may form at the optic nerve and/or macula (neovascularization). This marks the presence of proliferative diabetic retinopathy. These new vessels rupture easily and may lead to vitreous hemorrhage, fibrosis, and retinal detachment.

• Question 64:

  A 64-year-old Hispanic female with type II DM and hypertension for 15 years comes to your office after not seeing a physician for 5 years. The HgbA1C is 9. She reports that her vision has been deteriorating but new glasses from the optometrist have helped.

  Which of the following findings during your examination would represent the highest risk for blindness in this patient?

  A. microaneurysms

  B. neovascularization at the optic nerve

  C. arteriovenous nicking

  D. cotton wool spots or focal infarcts

  E. hard exudates or lipid deposits

  Correct Answer: B Section: (none)

  Explanation:

  Persons with DM are 25 times more likely to become legally blind than persons without diabetes. Blindness is primarily the result of progressive diabetic retinopathy and clinically significant macular edema. The presence of retinal vascular microaneurysms, blot hemorrhages, and cotton wool spots mark the presence of nonproliferative diabetic retinopathy. Increased retinal vascular permeability, alterations in blood flow, and abnormal microvasculature lead to retinal ischemia. In response to the ischemia, new blood vessels may form at the optic nerve and/or macula (neovascularization). This marks the presence of proliferative diabetic retinopathy. These new vessels rupture easily and may lead to vitreous hemorrhage, fibrosis, and retinal detachment.

• Question 65:

  A 23-year-old female graduate student with acne and asthma presents to you with a chief complaint of headaches. She has noted a gradual increase in the intensity and frequency of the headaches to the point where they are interfering with her daily activities and studies. Your examination shows an obese young lady with papilledema. The remainder of your physical examination is normal

  Which of the following interventions is most appropriate initially for the patient's suspected diagnosis?

  A. this condition is self-limited

  B. ventricular-peritoneal shunt placement

  C. optic nerve fenestration

  D. serial lumbar punctures

  E. acetazolamide therapy

  Correct Answer: E Section: (none)

  Explanation:

  Papilledema is optic disc swelling and implies raised intracranial pressure. Headache is a common associated symptom. The initial evaluation of papilledema should involve imaging, either by MRI or CT scan with and without contrast, to exclude mass lesions. If these studies are negative, then the subarachnoid opening pressure should be measured by lumbar puncture. An ESR is unlikely to be diagnostic in this case. It would be more important in the evaluation of vision loss or headache in a person over the age of 50. Neither a pregnancy test nor a glucose tolerance test would provide information on the cause of increased intracranial pressure. Pseudotumor cerebri is a condition of idiopathic intracranial hypertension. It is a diagnosis of exclusion that would be made in the presence of papilledema, normal imaging studies, and elevated opening pressure on lumbar puncture with normal CSF studies. The majority of patients with pseudotumor cerbri are young, female, and obese. This condition is treated with a carbonic anhydrase inhibitor, such as acetazolamide, which lowers intracranial pressure by reducing the production of CSF. Weight reduction, while important, is often unsuccessful in improving the condition by itself. Steroids, tetracycline, pregnancy, and oral contraceptives are not associated with the development of pseudotumor cerbri. Pseudotumor cerebri may ultimately resolve spontaneously, but there is a significant risk for development of impaired vision or even blindness if left untreated. The goal of treatment is the reduction of intracranial pressure. This may be accomplished in a number of ways. Use of medications such as acetazolamide or furosemide is considered a first-line therapy, with the aim of reducing CSF production. If pharmacologic treatment proves unsuccessful, alternative treatment options include surgical options such as optic nerve fenestration or creation of a ventricular-peritoneal shunt. Performing serial lumbar punctures is also possible but carries a number of associated risks including development of infections or headaches

• Question 66:

  A 23-year-old female graduate student with acne and asthma presents to you with a chief complaint of headaches. She has noted a gradual increase in the intensity and frequency of the headaches to the point where they are interfering with her daily activities and studies. Your examination shows an obese young lady with papilledema. The remainder of your physical examination is normal The test ordered above was negative. Which of the following is your most appropriate next step?

  A. instruct the patient on a weight loss program and follow-up in 3 months

  B. begin diuretic therapy

  C. start the patient on sumatriptan for migraine headaches

  D. perform a lumbar puncture to measure opening pressure

  E. obtain an MRI of the brain and orbits, with and without contrast

  Correct Answer: D Section: (none)

  Explanation: Papilledema is optic disc swelling and implies raised intracranial pressure. Headache is a common associated symptom. The initial evaluation of papilledema should involve imaging, either by MRI or CT scan with and without contrast, to exclude mass lesions. If these studies are negative, then the subarachnoid opening pressure should be measured by lumbar puncture. An ESR is unlikely to be diagnostic in this case. It would be more important in the evaluation of vision loss or headache in a person over the age of 50. Neither a pregnancy test nor a glucose tolerance test would provide information on the cause of increased intracranial pressure. Pseudotumor cerebri is a condition of idiopathic intracranial hypertension. It is a diagnosis of exclusion that would be made in the presence of papilledema, normal imaging studies, and elevated opening pressure on lumbar puncture with normal CSF studies. The majority of patients with pseudotumor cerbri are young, female, and obese. This condition is treated with a carbonic anhydrase inhibitor, such as acetazolamide, which lowers intracranial pressure by reducing the production of CSF. Weight reduction, while important, is often unsuccessful in improving the condition by itself. Steroids, tetracycline, pregnancy, and oral contraceptives are not associated with the development of pseudotumor cerbri. Pseudotumor cerebri may ultimately resolve spontaneously, but there is a significant risk for development of impaired vision or even blindness if left untreated. The goal of treatment is the reduction of intracranial pressure. This may be accomplished in a number of ways. Use of medications such as acetazolamide or furosemide is considered a first-line therapy, with the aim of reducing CSF production. If pharmacologic treatment proves unsuccessful, alternative treatment options include surgical options such as optic nerve fenestration or creation of a ventricular-peritoneal shunt. Performing serial lumbar punctures is also possible but carries a number of associated risks including development of infections or headaches

• Question 67:

  A 23-year-old female graduate student with acne and asthma presents to you with a chief complaint of headaches. She has noted a gradual increase in the intensity and frequency of the headaches to the point where they are interfering with her daily activities and studies. Your examination shows an obese young lady with papilledema. The remainder of your physical examination is normal. Which of the following is the most appropriate management at this time?

  A. order an erythrocyte sedimentation rate (ESR)

  B. order a glucose tolerance test

  C. urine pregnancy test

  D. obtain a lumbar puncture to measure opening pressure

  E. obtain an MRI of the brain and orbits, with and without contrast

  Correct Answer: E Section: (none)

  Explanation:

  Papilledema is optic disc swelling and implies raised intracranial pressure. Headache is a common associated symptom. The initial evaluation of papilledema should involve imaging, either by MRI or CT scan with and without contrast, to exclude mass lesions. If these studies are negative, then the subarachnoid opening pressure should be measured by lumbar puncture. An ESR is unlikely to be diagnostic in this case. It would be more important in the evaluation of vision loss or headache in a person over the age of 50. Neither a pregnancy test nor a glucose tolerance test would provide information on the cause of increased intracranial pressure. Pseudotumor cerebri is a condition of idiopathic intracranial hypertension. It is a diagnosis of exclusion that would be made in the presence of papilledema, normal imaging studies, and elevated opening pressure on lumbar puncture with normal CSF studies. The majority of patients with pseudotumor cerbri are young, female, and obese. This condition is treated with a carbonic anhydrase inhibitor, such as acetazolamide, which lowers intracranial pressure by reducing the production of CSF. Weight reduction, while important, is often unsuccessful in improving the condition by itself. Steroids, tetracycline, pregnancy, and oral contraceptives are not associated with the development of pseudotumor cerbri. Pseudotumor cerebri may ultimately resolve spontaneously, but there is a significant risk for development of impaired vision or even blindness if left untreated. The goal of treatment is the reduction of intracranial pressure. This may be accomplished in a number of ways. Use of medications such as acetazolamide or furosemide is considered a first-line therapy, with the aim of reducing CSF production. If pharmacologic treatment proves unsuccessful, alternative treatment options include surgical options such as optic nerve fenestration or creation of a ventricular-peritoneal shunt. Performing serial lumbar punctures is also possible but carries a number of associated risks including development of infections or headaches

• Question 68:

  Which of the following produces the greatest increase in bone mineral density (BMD) in patients with osteoporosis?

  A. estrogen

  B. calcitonin

  C. alendronate

  D. teriparatide

  E. raloxifene

  Correct Answer: D Section: (none)

  Explanation:

  Teriparatide is a recently approved recombinant form of parathyroid hormone that stimulates bone formation, rather than inhibiting resorption, and which is associated with a marked reduction in the incidence of bone fractures. Estrogen and the estrogen receptor modulator raloxifene, alendronate, and calcitonin all inhibit bone resorption and increase BMD, but the percent increase in bone density is less than occurs with teriparatide

• Question 69:

  A 42-year-old man presents to your clinic with a 1-week history of pain and inflammation involving his right first metatarsophalangeal (MTP) joint. He describes the pain as sudden in onset and worse at night. He denies experiencing any fever or traumatic injury to the joint and states that he has never had this type of pain before. He denies any chronic medical conditions, any prior surgery, and any current medication use. Besides an erythematous and exquisitely tender right first MTP joint, the remainder of his physical examination is unremarkable.

  After 1 week of treatment, your patient states that his pain and inflammation have resolved. You measure a serum urate level and find it elevated. Urinary urate excretion is high. Which of the following interventions is now most appropriate?

  A. no further treatment is necessary

  B. daily oral allopurinol

  C. daily oral probenecid

  D. daily oral colchicine with allopurinol

  E. daily oral colchicine with probenecid

  Correct Answer: D Section: (none)

  Explanation:

  This patient's presentation is consistent with gout. Aspiration of his first MTP joint is likely to reveal the presence of needle-shaped, negatively birefringent crystals. Rhomboid-shaped, positively birefringent crystals are characteristic of calcium pyrophosphate deposition disease, or pseudogout, with the knee being the joint most commonly affected. Nonbirefringent crystals are found in hydroxyapatite crystal deposition disease. The synovial fluid from joints affected by gout typically show evidence of inflammation in the form of leukocytosis with a predominance of polymorphonuclear neutrophils. The presence of bacteria in synovial fluid is characteristic of infection rather than gout, although gout and infectious arthritis may coexist. (Cecil Textbook of Medicine, pp. 17031708) Acute gouty arthritis usually presents in a monoarticular or oligoarticular distribution, with the first MTP joint most commonly affected. The diagnostic gold standard is detection of urate crystals within the synovial fluid of affected joints. It most commonly affects adult men with a peak incidence in the fifth decade of life. While patients with gout typically also have hyperuricemia, only a small fraction of the people with hyperuricemia actually have or will develop gout.

  Tophi are primarily seen in patients with long-standing hyperuricemia and is considered a finding of chronic gouty arthritis. As the disease progresses, acute attacks become more frequent and last longer if left untreated. Indomethacin inhibits the prostaglandin synthesis that facilitates the inflammation of acute gout and inhibits the phagocytosis of urate crystals by leukocytes. This inhibits the cell lysis and release of cytotoxic factors that initiate the inflammatory cascade. Allopurinol (an inhibitor of urate synthesis) and probenecid and sulfinpyrazone (promoters of urate excretion) are useful for preventing gout but are not effective during an acute gout attack. Aspirin is inappropriate in the treatment of gout since it can inhibit urate elimination and, therefore, increase hyperuricemia.

• Question 70:

  A 42-year-old man presents to your clinic with a 1-week history of pain and inflammation involving his right first metatarsophalangeal (MTP) joint. He describes the pain as sudden in onset and worse at night. He denies experiencing any fever or traumatic injury to the joint and states that he has never had this type of pain before. He denies any chronic medical conditions, any prior surgery, and any current medication use. Besides an erythematous and exquisitely tender right first MTP joint, the remainder of his physical examination is unremarkable.

  What is a potential long-term complication of this patient's condition?

  A. CHF

  B. nephrolithiasis

  C. anemia of chronic disease

  D. recurrent urinary tract infection (UTI)

  E. rheumatoid arthritis (RA)

  Correct Answer: B Section: (none)

  Explanation:

  This patient's presentation is consistent with gout. Aspiration of his first MTP joint is likely to reveal the presence of needle-shaped, negatively birefringent crystals. Rhomboid-shaped, positively birefringent crystals are characteristic of calcium pyrophosphate deposition disease, or pseudogout, with the knee being the joint most commonly affected. Nonbirefringent crystals are found in hydroxyapatite crystal deposition disease. The synovial fluid from joints affected by gout typically show evidence of inflammation in the form of leukocytosis with a predominance of polymorphonuclear neutrophils. The presence of bacteria in synovial fluid is characteristic of infection rather than gout, although gout and infectious arthritis may coexist. (Cecil Textbook of Medicine, pp. 17031708) Acute gouty arthritis usually presents in a monoarticular or oligoarticular distribution, with the first MTP joint most commonly affected. The diagnostic gold standard is detection of urate crystals within the synovial fluid of affected joints. It most commonly affects adult men with a peak incidence in the fifth decade of life. While patients with gout typically also have hyperuricemia, only a small fraction of the people with hyperuricemia actually have or will develop gout.

  Tophi are primarily seen in patients with long-standing hyperuricemia and is considered a finding of chronic gouty arthritis. As the disease progresses, acute attacks become more frequent and last longer if left untreated. Indomethacin inhibits the prostaglandin synthesis that facilitates the inflammation of acute gout and inhibits the phagocytosis of urate crystals by leukocytes. This inhibits the cell lysis and release of cytotoxic factors that initiate the inflammatory cascade. Allopurinol (an inhibitor of urate synthesis) and probenecid and sulfinpyrazone (promoters of urate excretion) are useful for preventing gout but are not effective during an acute gout attack. Aspirin is inappropriate in the treatment of gout since it can inhibit urate elimination and, therefore, increase hyperuricemia.