USMLE USMLE Certifications USMLE-STEP-2 Questions & Answers

• Question 531:

  Select the ONE best lettered option that is the most likely diagnosis of vaginal bleeding in pregnancy. Each lettered option may be selected once, more than once, or not at all.

  A 32-year-old pregnant woman has a low forceps vaginal delivery after a 3-hour second stage of labor. One hour later the nurse informs you she has excessive vaginal bleeding. On examination, her uterus is firm and nontender, and the uterine fundus is at the umbilicus.

  A. threatened abortion

  B. gestational trophoblastic disease

  C. cervicitis

  D. placenta previa

  E. placental abruption

  F. uterine rupture

  G. placenta accreta

  H. uterine inversion

  I. uterine atony

  J. vaginal laceration

  K. tubal pregnancy

  Correct Answer: J

  The use of forceps and the presence of a firm, nontender uterus of appropriate size suggest vaginal laceration as the cause of postpartum bleeding. The diagnosis is confirmed by a speculum examination. A cervical laceration should also be considered and the cervix carefully inspected at the time of the speculum examination

• Question 532:

  Select the ONE best lettered option that is the most likely diagnosis of vaginal bleeding in pregnancy. Each lettered option may be selected once, more than once, or not at all.

  A 39-year-old pregnant woman with chronic hypertension at 37 weeks' gestation presents with heavy vaginal bleeding and complains of lower abdominal pain. She also has noted diminished fetal movement since the bleeding began 3 hours previously. On physical examination her uterus is firm (rock hard) and very tender. Fetal heart tones are in the range of 160170 BPM.

  A. threatened abortion

  B. gestational trophoblastic disease

  C. cervicitis

  D. placenta previa

  E. placental abruption

  F. uterine rupture

  G. placenta accreta

  H. uterine inversion

  I. uterine atony

  J. vaginal laceration

  K. tubal pregnancy

  Correct Answer: E

  The features that make placental abruption the most likely diagnosis are the amount of bleeding, chronic hypertension, and an excessively firm (even titanic) uterus that is tender to palpation. Women with a placental abruption may have no bleeding if placental separation occurs only in the center of the placenta. The other signs of pain and tenderness will be present.

• Question 533:

  Select the ONE best lettered option that is the most likely diagnosis of vaginal bleeding in pregnancy. Each lettered option may be selected once, more than once, or not at all.

  A 15-year-old girl began her last menstrual period (LMP) 14 weeks ago. She had a positive pregnancy test 6 weeks ago. On examination, her uterine fundus is at the level of the umbilicus. Fetal heart tones are not heard and no fetus is seen by abdominal ultrasound.

  A. threatened abortion

  B. gestational trophoblastic disease

  C. cervicitis

  D. placenta previa

  E. placental abruption

  F. uterine rupture

  G. placenta accreta

  H. uterine inversion

  I. uterine atony

  J. vaginal laceration

  K. tubal pregnancy

  Correct Answer: B

  Gestational trophoblastic disease is more common in women at the extremes of reproductive age. Uterine size larger than her gestational age calculated from her last menses, the absence of fetal heart tones, and the absence of a fetus by ultrasound confirm the diagnosis. Treatment is evacuation of the uterus.

• Question 534:

  Select the ONE best lettered option that is the most likely diagnosis of vaginal bleeding in pregnancy. Each lettered option may be selected once, more than once, or not at all.

  A 23-year-old pregnant woman at 16 weeks' gestation begins to have light vaginal bleeding several hours after sexual intercourse. She has no abdominal discomfort. Her prenatal course has been uneventful and fetal heart tones were heard at 12 weeks. Her uterus is midway between her symphysis pubis and umbilicus, and is soft and nontender. Fetal heart tones are now 148 BPM. Her cervix is undilated.

  A. threatened abortion

  B. gestational trophoblastic disease

  C. cervicitis

  D. placenta previa

  E. placental abruption

  F. uterine rupture

  G. placenta accreta

  H. uterine inversion

  I. uterine atony

  J. vaginal laceration

  K. tubal pregnancy

  Correct Answer: C

  Light vaginal bleeding following sexual intercourse is likely of cervical origin because of the increased blood flow to the pelvic organs in pregnancy and eversion of the endocervix that occurs as a result of the increased estrogen production. The absence of abdominal pain and tenderness, the appropriate size of the uterus and the spotting rather than overt bleeding tend to exclude threatened abortion as the cause of this woman's bleeding.

• Question 535:

  A 16-year-old girl presents because she has not begun to menstruate. Also, breast development and pubic hair have not developed. She is 59 in. (150 cm) tall and weighs 115 lbs (52 kg). On examination, her vital signs are normal. She has skin folds on the lateral sides of her neck. She has evidence of cubitus valgus. Breasts are Tanner stage 1 and the nipples appear to be spaced wider than average. Pubic hair is Tanner stage 1. The external genitalia are normal. The vagina is of normal depth and a small cervix is seen on speculum examination. The uterus is present but small. There are no adnexal masses. Which of the following is the treatment of choice for this patient?

  A. estrogen replacement therapy

  B. estrogen plus progestin therapy

  C. clomiphene

  D. Follistim (recombinant FSH)

  E. gonadectomy

  Correct Answer: B

  The streak gonads of women with gonadal dysgenesis will never secrete sex hormones. Combined estrogen plus progestin is the correct choice to stimulate pubertal development. Estrogen alone,in long term, increases the risk that these women will develop endometrial adenocarcinoma. Clomiphene and Follistim are fertility-promoting agents used to stimulate ovulation in anovulatory women who have ovarian follicles. Women with Turner syndrome have few or no follicles and oocytes. Gonadectomy is necessary only when a Y chromosome is present in a woman with gonadal dysgenesis.

• Question 536:

  Select the ONE best lettered option that is the most likely diagnosis of vaginal bleeding in pregnancy. Each lettered option may be selected once, more than once, or not at all.

  A 28-year-old pregnant woman at 32 weeks' gestation suddenly begins profuse, painless vaginal bleeding. Her prenatal care began at 7 weeks and had been uncomplicated. She last had sexual intercourse 7 days ago. She denies abdominal trauma. Her uterus is soft and nontender, and the fetal heart rate is 132 BPM.

  A. threatened abortion

  B. gestational trophoblastic disease

  C. cervicitis

  D. placenta previa

  E. placental abruption

  F. uterine rupture

  G. placenta accreta

  H. uterine inversion

  I. uterine atony

  J. vaginal laceration

  K. tubal pregnancy

  Correct Answer: D

  Painless vaginal bleeding in the third trimester is most often due to a placenta previa. The diagnosis is easily confirmed by abdominal ultrasound. No vaginal/cervical examination or vaginal ultrasound should be done because these may damage the placenta and cause further bleeding and fetal compromise. Delivery is by cesarean section.

• Question 537:

  A 16-year-old girl presents because she has not begun to menstruate. Also, breast development and pubic hair have not developed. She is 59 in. (150 cm) tall and weighs 115 lbs (52 kg). On examination, her vital signs are normal. She has skin folds on the lateral sides of her neck. She has evidence of cubitus valgus. Breasts are Tanner stage 1 and the nipples appear to be spaced wider than average. Pubic hair is Tanner stage 1. The external genitalia are normal. The vagina is of normal depth and a small cervix is seen on speculum examination. The uterus is present but small. There are no adnexal masses.

  What is the most likely karyotype of this 16 year old?

  A. 46,XX

  B. 46,XY

  C. 45,X

  D. 47,XX trisomy 21

  E. 47,XXY

  Correct Answer: C

  The short stature and other features of Turner syndrome are strong presumptive evidence of a 45,X karyotype. A46,XX and a 46,XY karyotype may be found in women with gonadal dysgenesis. Their clinical presentation is absence of pubertal events, but lack of the physical features of Turner syndrome. Most helpful in excluding either of these karyotypes is the short stature: those with 46,XX or 46,XY gonadal dysgenesis are of normal height. There is nothing in the clinical presentation to suggest 47,XX trisomy 21. The phenotype of those with a 47,XXY karyotype is male, Klinefelter syndrome.

• Question 538:

  A 53-year-old woman with five adult children complains of losing urine shortly after coughing or jumping. She occasionally loses urine while lying in bed if she happens to cough vigorously. She is unable to stop the urine once it has begun to flow.

  Which of the following is the treatment of choice for this woman's urinary incontinence?

  A. a course of nitrofurantoin

  B. a selective serotonin reuptake inhibitor (SSRI)

  C. oxybutynin chloride (Ditropan)

  D. vaginal hysterectomy and anterior colporrhaphy

  E. a Marshall-Marchetti-Krantz urethropexy

  Correct Answer: C

  Antibiotics are useful only when there is evidence of cystitis. SSRIs are antidepressants that have not been shown to improve incontinence with detrusor dyssynergia. Surgery is of no value and may actually worsen incontinence in women with detrusor dyssynergia. Bladder retraining, in which the patient embarks on a programmed progressive lengthening of the interval of voiding, forms the basis of therapy. While such retraining is occurring, the use of anticholinergic drugs, such as oxybutynin chloride (Ditropan), propantheline (Pro-Banthine), or flavoxate (Urispas), seems to improve the results over use of any one alone.

• Question 539:

  A 16-year-old girl presents because she has not begun to menstruate. Also, breast development and pubic hair have not developed. She is 59 in. (150 cm) tall and weighs 115 lbs (52 kg). On examination, her vital signs are normal. She has skin folds on the lateral sides of her neck. She has evidence of cubitus valgus. Breasts are Tanner stage 1 and the nipples appear to be spaced wider than average. Pubic hair is Tanner stage 1. The external genitalia are normal. The vagina is of normal depth and a small cervix is seen on speculum examination. The uterus is present but small. There are no adnexal masses.

  Which of the following is the most likely diagnosis?

  A. anorexia nervosa

  B. androgen insensitivity syndrome

  C. Turner syndrome (gonadal dysgenesis)

  D. Müllerian agenesis

  E. premature ovarian failure

  Correct Answer: C

  The delayed puberty, short stature, web neck, increased carrying angle (cubitus valgus), widely spaced nipples are classic signs of Turner syndrome, gonadal dysgenesis. Women with anorexia nervosa are of normal height and have a history of weight loss below 15% of ideal body weight. Androgen insensitivity syndrome is not a consideration because these women lack a uterus and cervix, and have a short vagina. The Müllerian ducts develop to form the Fallopian tubes, uterus, cervix, and upper vagina. The presence of a cervix and uterus excludes this diagnosis. Strictly, gonadal dysgenesis is a type of premature ovarian failure, developing before the age of puberty to result in primary amenorrhea. However, premature ovarian failure is most often a postpubertal event and these women usually menstruate for a variable period of time.

• Question 540:

  A 53-year-old woman with five adult children complains of losing urine shortly after coughing or jumping. She occasionally loses urine while lying in bed if she happens to cough vigorously. She is unable to stop the urine once it has begun to flow.

  Which of the following is the most likely diagnosis?

  A. GSI

  B. a vesicovaginal fistula

  C. a urethrovaginal fistula

  D. an atonic bladder

  E. detrusor dyssynergia

  Correct Answer: E

  Two clues to the diagnosis of detrusor dyssynergia are loss of urine in the recumbent position and inability to stop the urine loss once the stream has begun. Generally, large volumes of urine are lost because of the inability to stop the flow of urine. With GSI, urine is lost only in the upright position when intra-abdominal and intravesical pressure exceeds urethral closing pressure, such as with coughing. Women with SI are able to stop the flow of urine voluntarily and, therefore, the volume of urine lost is small. With GSI, urine loss with coughing is immediate. Women with a vesicovaginal or urethrovaginal fistula will complain of a watery vaginal discharge. Women with an atonic bladder typically void small amounts and complain that the bladder still feels full (which it is). This is a disorder seen in women with neurologic dysfunction of the bladder, such as multiple sclerosis and diabetic neuropathy.