USMLE题库Genitourinary11-20

Genitourinary题库Q11A25-year-oldsexuallyactivewomancomplainsofabnormalvaginalbleeding,nauseaandvagueabdominaldiscomfort.Dilationandcurettageisperformedandmaterialresemblingabunchofgrapesisevacuatedfromtheuterus.Thelevelofwhichofthefollowinghormonesshouldbecloselymonitoredinthispatientoverthenextyear?A.Alpha-fetoprotein(AFP)B.Humanchorionicgonadotropin(β-hCG)C.ProgesteroneD.Lactatedehydrogenase(LDH)E.EstradiolF.Carcinoembryonicantigen(CEA)A11Correctanswer:BHydatidiformmolescharacteristicallyhavethemacroscopicappearanceofaUbunchofgrapes.11Hydatidiformmolesaretheresultoftrophoblastproliferation.Microscopicexaminationofacompletemolewouldreveallargevilliwithdecreasedvillousbloodvesselsandproliferationofthevilloustrophoblasticlining.Fetaltissueisabsent.Acompletemolewillcausevaginalbleedingduringthefirsttrimesterofpregnancy.Thesizeofuterusmaybeoutofproportiontothegestationalage.SomepatientshaveseverenauseaandvomitingastheresultofincreasedhCGsecretionbytheproliferatingtrophoblast.ExcessivehCGalsostimulatesovariangrowthandcancausetheformationoftheca-luteincysts.Inthemajorityofpatientswithacompletemole,evacuationleadstorecovery.Insome,however,aninvasivemole(penetratestheuterinewall)orchoriocarcinoma(malignancyoftrophoblasticcells)maydevelop.Aninvasivemolewouldconsistofhydropicvilliandproliferatedtrophoblast,whilechoriocarcinomawouldcontainatypicalcytotrophoblasticandsyncytiotrophoblasticcellswithfociofhemorrhageandnecrosis.InvasivemolesandchoriocarcinomascanbedetectedbyserialmeasurementsofhCGlevelsandaretreatedwithchemotherapy.(ChoiceA)Anelevatedalpha-fetoprotein(AFP)levelinapregnantwomanmaysuggestthepresenceofafetalneuraltubedefect.OtherpossiblecausesofanelevatedAFPlevelincludeunderestimationofthegestationalage,twingestation,andabdominalwalldefects.AFPisalsoamarkerofyolksactumorsoftheovariesandtestes.(ChoicesC,DandE)Estrogen,progesteroneandLDHlevelsarenothelpfulinthefollow-upofamolarpregnancy.(ChoiceF)Carcinoembryonicantigen(CEA)isamarkerfollowedinpatientswithcolorectalcarcinoma.Q12A35-year-oldwomancomestothephysicianbecauseofanindurated,painlessnoduleonhervulva.Shehasbeencomplainingofoccasionalheadachesandmemorylossrecently.Shehasahistoryofintravenousdrugabuseandmultiplesexualpartners.Cervicalculturesarenegativeforgonorrhea,butaserumVDRLtestispositive.LumbarpuncturerevealsmildpleocytosisandapositiveVDRL.Whichofthefollowingbestdescribesthispatient’svulvarlesion?A.CondylomalataB.GranulomainguinaleC.ChancreD.GummaE.CondylomataacuminataA12Correctanswer:DTheclinicalpresentationofsyphilisoccursinwell-definedstagesasfollows:1.Primarysyphilismanifestsasapainlessulcerationwithraised,induratedbordersknownasachancre.ThechancredevelopsatthesiteofinoculationofTreponemapallidum,mostcommonlyonthepenisorvulva,onetothreeweeksaftercontactandresolvesinthreetosixweeks.Theorganismcommonlydisseminatessystemicallyduringthisprimarystage.2.Secondarysyphilisrepresentsabacteremicstageofinfectionanddevelopsfivetotenweeksfollowingresolutionofthechancre.Itpresentswithadiffusemacularrashthatincludesthepalmsandsoles.Condylomatalataarelargegraywart-likegrowthsthattypicallyoccurinthegenitalandperinealregion;theseareanothertypicalmanifestationofsecondarysyphilis.3.Latentsyphilisisanasymptomaticperioddividedintoearlylatent(withinoneyearafterresolutionofsymptomsofsecondarysyphilis),andlatelatent(morethanoneyearofasymptomaticstate).4.Tertiarysyphilisdevelopsmanyyearsafterinfectioninuntreatedindividualsandincludesneurosyphilis,whichmaybeasymptomaticorcausesubacutemeningoencephalitis,tabesdorsalis,orotherneurologicsequelae.Tertiarysyphiliscanalsocauseascendingaorticaneurysmsandresultantaorticvalveinsufficiency.Gummasarealsocharacteristicoftertiarysyphilis.Gummasoftenbeginaspainless,induratedgranulomatouslesionsthatprogresstowhite-grayrubberylesionsandmayulcerate.Theyaremostcommonlycutaneous,butalsoappearinthesubcutaneoustissue,bones,liver,andotherorgans.(ChoiceD)PLEASENOTE:ApositiveVDRLandpleocytosisinthecerebrospinalfluidarediagnosticofneurosyphilis,notprimarysyphilis!Neurosyphilisisacomponentoftertiarysyphilis,sothispatient'svulvarlesionismostlikelyagumma,NOTachancre!(ChoiceA)Condylomalataisawart-likegenitallesionthatoccursduringsecondarysyphilis.(ChoiceB)GranulomainguinaleisasexuallytransmitteddiseasecausedbyKlebsiellagranu/omatis(previouslyCalymmatobacteriumgranulomatis).Patientswiththisdiseasepresentwithinguinalswelling,ulcers,abscesses,andfistulas.Gramstainofthelesionsrevealcellswithrod-shapedintracytoplasmicinclusions(Donovanbodies).(ChoiceC)Achancreistheonlymanifestationofprimarysyphilis.Itisapainlessulcerationwithinduratedbordersmostcommonlylocatedonthepenisorvulvaatthesiteof厂inoculation.(ChoiceE)Condylomataacuminataareanogenitalwartscausedbyhumanpapillomavirus(HPV),thecausativeagentofcervicalcancer.ThemostcommonstrainsofthevirusassociatedwithcondylomataacuminataareHPV6and11,whichhavelowoncogenicpotentialQ13A32-year-oldfemalecomestoyourofficeforevaluationofinfertility.Sherevealsthathermenstrualperiodsoccur2-3timesperyear.Physicalexaminationreveals