USMLE USMLE-STEP-3 Exam Preparation Materials

Correct Answer: D Section: (none)

Explanation:

Retinal detachment is fairly uncommon but should be considered for any patient with visual loss. Risk factors for retinal detachment include advanced age, myopia, cataract surgery, focal retinal atrophy, congenital eye diseases, fibromuscular hyperplasia (FMH) retinal detachment, prematurity, uveitis, diabetic retinopathy, and hereditary vitreoretinopathy. Patients may be asymptomatic but usually present with sudden onset of flashes of light, new floaters, visual field defects, and a sensation of a "curtain" coming down over their visual field. Prompt ophthalmology evaluation, preferably by a retinal specialist, is warranted. Immediate care is paramount as often retinal tears can be managed so as to prevent retinal detachment. Symptomatic retinal tears can be managed with laser or cryo burns to create a chorioretinal scar that prevents fluid access to the subretinal space. This is effective 95% of the time to prevent progression to a retinal detachment. Retinal detachment can be surgically corrected with scleral buckling techniques (90% success rate) or posterior vitrectomy (7590% success rate).

Correct Answer: E Section: (none)

Explanation: Explanations: This woman is likely suffering from "baby blues," which is considered a normal reaction to the stress of the postpartum period. It occurs in up to 50% of women after delivery, usually beginning within several days. It is very important to distinguish this from a major depressive episode, postpartum onset, which requires antidepressant treatment and/or psychotherapy. Hospitalization would be indicated only if there were concerns over suicide, or, in cases of "postpartum psychosis," where psychotic symptoms put the infant in immediate danger. Mood stabilizers would be appropriate if the mood disorder were considered to be a bipolar illness. Baby blues are usually self-limiting and respond to reassurance and support.

Correct Answer: B Section: (none)

Explanation: Explanations: Primary care physicians are frequently called on to perform preparticipation examinations on young athletes. These types of encounters can be used to serve a number of purposes, including attempting to identify conditions that may adversely affect the athlete during participation, identify conditions that may predispose the athlete to injury, provide anticipatory guidance on high-risk behaviors common to the age group being addressed, and fulfill legal conditions of the institution involved. Fortunately, the rate of sudden death in young athletes is low. In those under the age of 35, the most common cause of sudden death is congenital cardiac anomalies. Hypertrophic cardiomyopathy (HCM) is responsible for about onethird of these deaths. Unfortunately, sudden death may be the presenting symptom of HCM. Apersonal or family history of congenital heart disease, symptoms of chest pain or tightness, palpitations, dyspnea, syncope or near-syncope are important. A family history of HCM or unexplained sudden death in someone under the age of 50 is significant as well. The murmur of HCM may not be present in all persons with this disorder.

To identify the murmur, dynamic auscultation is often necessary. The heart should be auscultated while the patient is lying and then standing. As this murmur is accentuated by maneuvers which reduce cardiac preload, the murmur will get louder when the patient stands or performs a Valsalva maneuver and will diminish as the patient lies or squats. As the patient in question 22 has the concerning historical point of exertional syncope and a family history of an unexplained, early death along with a characteristic murmur on examination, further evaluation is warranted. In the 26th Bethesda Conference report, the American College of Cardiology recommends that persons with HCM should be restricted from all, except possibly for the least strenuous, athletic activity. In this case, restriction of all athletic activity until the patient can be further evaluated by a cardiologist--preferably one with experience in dealing with the evaluation of athletes--would be the most appropriate option of the choices given.

Marfan syndrome is a connective tissue disorder that typically affects the eyes, skeletal system, and cardiovascular system. Persons with Marfan syndrome are typically tall and have arm spans that are greater than their height. Signs include long, slender digits, high-arched palates, and pectus deformities of the chest. Lens dislocations in the eye are common. Detecting Marfan syndrome during a preparticipation examination is important because of the occurrence of aortic\ root dilation and the risk of sudden death caused by aortic rupture. The patient in questions 23 and 24 has multiple signs of Marfan syndrome and further evaluation would be indicated. Of the options given, an echocardiogram to evaluate the aortic root and to look for other valvular abnormalities would be indicated. These persons usually require referral to an ophthalmologist as well for a dilated eye examination to evaluate for lens dislocations. Turner syndrome is a syndrome of gonadal dysgenesis, associated with a 45, X karyotype (or another defect of the X chromosome). This syndrome is typically associated with a short stature and multiple anomalies including a webbed neck and "shield" chest. The female athlete triad is a syndrome of disordered eating, amenorrhea, and osteoporosis. It is seen most often in participants in activities that emphasize low body weights, such as gymnastics or ballet. The presence of regular menstrual cycles makes this diagnosis unlikely. Atlantoaxial instability can be associated with Down syndrome.

Physicians performing preparticipation examinations on someone with Down syndrome must consider performing lateral cervical spine x-rays with flexion and extension views. This patient does not have any of the classic findings of Down syndrome. Similarly, she does not exhibit any of the classic symptoms of type 1 diabetes polydipsia, polyphagia, and polyuria. Performing serum glucose testing would therefore not be indicated. The patient in question 25 is the most typical type of patient who presents for a preparticipation examination--the healthy adolescent. This may be the only encounter that a physician will have with an adolescent, especially an adolescent male. It is in this population where a physician can use this encounter to address other age appropriate health maintenance issues. As the patient had a Td booster 3 years ago, another one at this point would not be indicated (although consideration could be given to providing a Tdap). Other vaccinations to consider would be hepatitis B and MMR, if he has not previously been adequately immunized. As he has had two MMR vaccines, he has completed the recommended series. There is no history given regarding hepatitis B vaccination and this would be something to address clinically. A nonjudgmental discussion of sexual behaviors, drug use, alcohol use, and other high-risk behaviors would also be appropriate. Screening athletes who have neither concerning symptoms nor signs with ECGs is not recommended because of the poor predictive values and significant costs involved with mass screening. ECGs should be performed without hesitation in any athlete who has a history, examination finding, or preexisting diagnosis of a potentially high-risk condition. Although some localities may require a urinalysis as part of a preparticipation examination, there is no evidence to recommend universal screening