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3.
A 66-year-old postmenopausal woman comes to the office for her periodic health evaluation. During the visit she says she has had continuous vaginal bleeding for the past 3 months. Her uterus and ovaries have been normal to palpation on previous yearly examinations, and she is taking cyclic hormone replacement therapy with estrogen and progesterone. Physical examination today, including pelvic examination, discloses no abnormalities. Which of the following is the most appropriate next step?
A) Do endometrial sampling
B) Order a serum estrogen concentration
C) Order serum follicle-stimulating hormone (FSH) and serum luteinizing hormone (LH) concentrations
D) Order ultrasonography of the pelvis
E) Schedule colposcopy
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Ans: A
The mcc of postmenopausal bleeding is vaginal or endometrial atrophy, but the most important diagnosis to rule out is Endometrial Carcinoma (the mc gynecologic malignancy).
Endometrial Biopsy is the 1st step in management of any patient with postmenopausal bleeding.
Master the Boards: USMLE Step 3 (Kindle Locations 10740-10742)
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4.
An 84-year-old hospital volunteer comes to the office for follow-up after receiving evaluation in the emergency department for weakness and dizziness. The symptoms had developed suddenly while the patient was walking to the bathroom. She has mild hypertension treated with metoprolol. She takes no other medications. On arrival in the emergency department, the patient stated that she was still weak and dizzy. She had not had any previous episodes or other symptoms. Vital signs were normal and pulse oximetry on room air showed a normal oxygen saturation. Physical examination disclosed no abnormalities. Results of laboratory studies obtained at the emergency department are shown:
Blood
Hematocrit 56%
Hemoglobin 17 g/dL
WBC 6000/mm3
Results of subsequent bone marrow testing disclose no abnormalities. Red blood cell mass is elevated. CT scan of the abdomen shows no evidence of any tumors. Which of the following is the most appropriate treatment for this patient?
A) Aspirin and dipyridamole
B) Chlorambucil
C) Enoxaparin therapy
D) Fludarabine
E) Routine phlebotomy
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D , after starting HRT patients may have bleeding upto 6-12 moths , if the bleeding continues beyond that , endometrial sampling should be done . In this particular case , ultrasound tomeasure the endometrial thichness should be done . Thicknes > 5mm needs sampling
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I marked that one too D) for question 3) ..... but I took the nbme with feedback and it was wrong for D 
Reading again, it's everywhere, get a bite of that endometrium, even Fischer keeps saying that on his videos So, based on that I think it's A
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4.
An 84-year-old hospital volunteer comes to the office for follow-up after receiving evaluation in the emergency department for weakness and dizziness. The symptoms had developed suddenly while the patient was walking to the bathroom. She has mild hypertension treated with metoprolol. She takes no other medications. On arrival in the emergency department, the patient stated that she was still weak and dizzy. She had not had any previous episodes or other symptoms. Vital signs were normal and pulse oximetry on room air showed a normal oxygen saturation. Physical examination disclosed no abnormalities. Results of laboratory studies obtained at the emergency department are shown:
Blood
Hematocrit 56%
Hemoglobin 17 g/dL
WBC 6000/mm3
Results of subsequent bone marrow testing disclose no abnormalities. Red blood cell mass is elevated. CT scan of the abdomen shows no evidence of any tumors. Which of the following is the most appropriate treatment for this patient?
A) Aspirin and dipyridamole
B) Chlorambucil
C) Enoxaparin therapy
D) Fludarabine
E) Routine phlebotomy
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In my exam, E) was the right answer
Polycythemia Vera (Pvera)
Presents with headache, blurred vision, dizziness, and fatigue. Pruritus, described as happening after a hot bath or shower, also occurs from the release of histamine from basophils. Splenomegaly is common.
The key to the diagnosis is a markedly high hematocrit in the absence of hypoxia with a low MCV. The erythropoietin level will be low. The white cell count and platelet count can also be elevated. The high hematocrit can lead to thrombosis. The B12 and LAP levels are elevated in Pvera.
Diagnostic Testing
After the CBC shows a high hematocrit, order an arterial blood gas to exclude hypoxia as a cause of erythrocytosis. If the case is a CCS, order an erythropoietin level, which should be low; hematology consultation; and nuclear red cell mass test. Test for JAK2 mutation. The B12 and LAP levels are elevated in Pvera. JAK2 mutation is found in Pvera and ET.
Treatment
Phlebotomy is the best initial therapy. Hydroxyurea is also used to lower the cell count. Daily aspirin should also be given.
Anagrelide is used in the context of thrombocythemia.
CCS: Order a B12 level and LAP in addition to the CBC. If the question is a “single best answer” question, these tests would not be the single “best initial” or “most accurate” tests.
Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kindle Locations 4176-4192)
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