USMLE USMLE Certifications USMLE-STEP-2 Questions & Answers

• Question 581:

  On a routine annual examination, a 43-yearold woman is found to have a 2-cm mass in the lateral aspect of her right breast. Which of the following is the most appropriate next step in management?

  A. repeat the breast examination after her next menses

  B. mammography

  C. fine-needle aspiration

  D. open biopsy

  E. segmental resection

  Correct Answer: C

  The presence of a dominant mass requires immediate evaluation. While all women with a dominant mass should have a mammogram, this is a screening test. Afine-needle aspiration is a diagnostic tool that will resolve whether the mass is cystic or solid. Any fluid or tissue obtained should be sent for cytologic evaluation to further aid in the diagnosis. If clear or cloudy fluid is aspirated, and the mass disappears, the woman should have a repeat breast examination in 1 month. If the mass remains after aspiration, if the fluid is bloody, or if there is a residual mass on a follow-up visit in 1 month, an open biopsy should be done. A segmental resection is a therapeutic option for a circumscribed carcinoma, but is not an appropriate diagnostic tool.

• Question 582:

  A 69-year-old woman with diabetes mellitus complains of urinary incontinence. Her diabetesis well controlled with oral hypoglycemic agents. She has no complaints other than the wetness. Which of the following tests is most likely to demonstrate the cause?

  A. urinalysis

  B. urine culture and sensitivity

  C. intravesical instillation of methylene blue

  D. the Q-tip test

  E. measurement of residual urine volume

  Correct Answer: E

  The combination of aging and diabetes suggests the likelihood of a neurologic defect in the bladder, resulting in overflow incontinence. This occurs when the detrusor muscle becomes hypotonic or atonic. Such women complain of voiding small amounts but still having the feeling of a full bladder. In addition, these women are incontinent of small amounts of urine and are unable to stop the flow. This helps to distinguish those with overflow incontinence from those with GSI; the latter are able to voluntarily increase urethral pressure enough to stop urine flow. Cystitis commonly causes urgency and increased urinary frequency, but not incontinence. Urinalysis and urine culture are not likely to be revealing in this patient, but should be done routinely in all incontinent women. Instillation of methylene blue into the bladder after placement of a vaginal tampon should be done when a vesicovaginal fistula is suspected. This occurs most often following gynecologic surgery and should be suspected in women complaining of constant urine leakage. The Q- tip test is useful to demonstrate posterior urethral rotation found in women with GSI.

• Question 583:

  A 24-year-old woman lost her previous two pregnancies at approximately 20 weeks' gestation, without having noted any contractions. She is currently at 15 weeks' gestation and denies having uterine contractions. Her cervix is undilated and uneffaced. Which of the following is the most appropriate management of this patient?

  A. bed rest

  B. terbutaline

  C. hydroxyprogesterone

  D. DES

  E. a cervical cerclage

  Correct Answer: E

  The patient described in the question has a classic history of an incompetent cervix: expulsion of a fetus without labor. It is believed to be caused by previous cervical trauma, DES exposure, or, most commonly, a congenital defect in cervical stroma. In the absence of preterm labor, there is no indication for terbutaline or other tocolytic agents. DES is contraindicated in pregnancy, but was used in the past to treat repeated pregnancy loss. Hydroxyprogesterone is a progestational compound that is being used by some hospitals for patients in premature labor, but its use is controversial. Bed rest is occasionally encouraged by some practitioners for patients with a history of premature deliveries. The probability of a successful pregnancy after a cervical cerclage increases from 20% to approximately 80%. It is crucial to eliminate the possibility of preterm labor before placing a cerclage.

• Question 584:

  A 44-year-old woman had a normal Pap smear 3 years ago. Her menstrual periods occur monthly and last

  5 days. She has had intermenstrual and postcoital spotting intermittently for the past 6 months. The pelvic

  examination is normal.

  Which of the following is the most appropriate test to perform?

  A. an endometrial biopsy

  B. an endocervical curettage

  C. a conization of the cervix

  D. a Pap smear

  E. a hysteroscopy

  Correct Answer: D

  Postcoital spotting and intermenstrual spotting in a woman with cyclic menses is suggestive of a cervical abnormality, rather than an endometrial hormonal abnormality. In the absence of a visible lesion, a Pap smear that includes cells from both the ectocervix and endocervix is the preferred method of evaluation, especially when the woman has no history of cervical pathology or a normal Pap smear in the recent past. Endometrial biopsy and hysteroscopy assess the endometrium, not the cervix. A conization of the cervix should be reserved for women with documented cervical neoplasia when determination of the extent ofthe lesion is necessary. An endocervical curettage is usually reserved for women with unsatisfactory Pap smears and persistent abnormal bleeding.

• Question 585:

  A 44-year-old woman had a normal Pap smear 3 years ago. Her menstrual periods occur monthly and last 5 days. She has had intermenstrual and postcoital spotting intermittently for the past 6 months. The pelvic examination is normal. All tests performed on the woman were normal. She returns 1 year later for her annual gynecologic examination. On speculum examination, she has a visible 7-mm lesion on her cervix that bleeds on contact. Which of the following is the most appropriate procedure to perform?

  A. colposcopy

  B. cervical biopsy

  C. Pap smear

  D. conization of the cervix

  E. vaginal hysterectomy

  Correct Answer: B

  Pap smear and colposcopy are screening tests appropriate when there is no visible cervical pathology. In the presence of a lesion, pathologic evaluation is necessary to make a diagnosis. An office cervical biopsy is the procedure of choice to establish the diagnosis. If the diagnosis from the biopsy is cancer, a conization of the cervix is indicated to determine the extent of the disease surface spread as well as depth of stromal invasion. As a general principle, cytology is a screening tool, not a diagnostic test, and any visible lesion (vulvar, vaginal, or cervical) should be biopsied for a definitive diagnosis

• Question 586:

  A 35-year-old primigravid woman with a history of cyclic menses at 28- to 30-day intervals began her last menses on August 18. A home pregnancy test was positive on September 20. At her first prenatal visit, she asks you what the duration of pregnancy is and what her due date is. You tell her that the average number of days from the onset of menses to delivery is which of the following?

  A. 250

  B. 260

  C. 270

  D. 280

  E. 290

  Correct Answer: D

  The mean duration of human pregnancy is 266 days from conception. To this is added 14 days for the interval between the onset of the last menses and the conception date. Thus, it is important to ascertain the range of days for each woman's menstrual cycles. The more variable a woman's menstrual cycles are, the less certain is the estimated due date calculated from the LMP. The standard deviation of pregnancy duration is ?7 days. Thus, 95% of human pregnancies will deliver between 263 and 297 days after the onset of the LMP.

• Question 587:

  A19-year-old primigravid woman at 39 weeks' gestation is in active labor, and her cervix is 4 cm dilated, 90% effaced. Her amniotic membranes have been ruptured for 4 hours. Contractions are strong at 2- to 3minute intervals and of 60- to 70-second duration. For the past 30 minutes, repetitive variable decelerations of the fetal heart rate have occurred. They have lasted 6090 seconds, and the fetal heart rate has dropped as low as 60 beats per minute (BPM). You explain that there is a risk that the baby will become hypoxic and recommend a cesarean section. She refuses. Which of the following is the most appropriate course of action?

  A. obtain permission for the cesarean section from her mother

  B. perform a cesarean section as an emergency

  C. obtain a court order permitting a cesarean section

  D. counsel her carefully about the fetal risks but accede to her wishes

  E. assign her care to another obstetrician

  Correct Answer: D

  In many states, a pregnant woman under the age of 21 years is considered an emancipated minor and is the only person who may make legal decisions pertaining to the pregnancy. Although an immediate cesarean section is indicated because of the severe fetal heart rate decelerations, to perform it without her permission violates the ethical principle of autonomy. This is a principle that states that human beings should have their wishes respected as autonomous persons if they are capable of self- determination. Obtaining a court order may fulfill the ethical principle of beneficence, a physician acting to do no harm and to help the patient. In this situation, the ethical (moral) decision is complicated by a conflict between beneficence and autonomy. However, proceeding with a cesarean section exposes the obstetrician to a legal charge of battery. Assigning her care to another physician is a standard and accepted solution when there is a moral conflict between patient and physician. However, this is not an acceptable option in an emergency situation. The obstetrician is at risk for abandonment. Although not a satisfying choice, the choice most ethically sound is to counsel her carefully, but eventually accede to her wishes. Placing her in the lateral position, giving her oxygen by mask, and providing adequate intravenous hydration should be instituted to minimize the risk of fetal hypoxia.

• Question 588:

  You are seeing a 38-year-old woman for her annual gynecologic examination. She asks you for some information regarding the HPV vaccine and whether you think it would be appropriate for her 17-year- old daughter. Which of the following statements regarding the quadrivalent human papillomavirus vaccine and HPV is true?

  A. The vaccine is recommended for women ages 1126 but can be given as young as age 9.

  B. After vaccination, women no longer need routine Pap smears.

  C. The vaccine is given every month for 3 months.

  D. The vaccine is prepared from the proteins of four oncogenic (e.g., high-risk for cervical cancer) strains of HPV.

  E. Women with a prior history of abnormal Pap smears are not candidates for vaccination.

  Correct Answer: A

  The quadrivalent human papillomavirus (under the name Gardasil) was licensed for use in June 2006. It is currently recommended for routine vaccination of young women ages 1112 with "catch-up" vaccination for women 1326. It can be given as young as age 9. The vaccine is three separate 0.5-mL doses, given at 0, 2 and 6 months apart. If one dose is delayed, there is no need to restart the schedule. Rather, the doses should be given as soon as possible. The vaccine is targeted against the L1 proteins of HPV types 6, 11, 16, and 18. HPV 6 and 11 are "low-risk" strains causing genital condylomata, and HPV 16 and 18 are "high-risk" oncogenic strains responsible for 70% of all cervical cancer. Guidelines for screening for cervical cancer have not changed--patients should still be advised to have routine Pap smear screening and HPV screening as indicated. Women with a prior history of abnormal Pap smears are still candidates for the vaccine, as it is unlikely that they have been exposed to all four strains.

• Question 589:

  A 38-year-old G4P3013 woman is seeing you for her annual gynecologic examination. She has no specific complaints, but notes that her menses have gradually become heavier over the past 23 years. Your pelvic examination is normal aside from an enlarged uterus, which you estimate at 12 weeks' size. Office ultrasonography confirms that she has multiple uterine fibroids. Which of the following statements is true regarding leiomyomata?

  Your patient comes back 6 months later with a calendar demonstrating continued worsening of her menstrual bleeding, now 10 days in duration and requiring one pad hourly during her heaviest days. Which of the following statements are true regarding treatment of leiomyomata?

  A. Because fibroids are responsive to sex steroids, treatment with GnRH agonists (e.g., leuprolide) will produce up to a 50% reduction in volume.

  B. Treatment with leuprolide appears to be long lasting, making this an attractive alternative to hysterectomy or myomectomy.

  C. Myomectomy (i.e., removal of uterine fibroids without removal of the uterus) is replacing hysterectomy as it is associated with less complications and less blood loss.

  D. Because it requires no abdominal or uterine incisions, uterine artery embolization is the preferred method of treatment for women who desire future pregnancy.

  E. Any leiomyoma larger than 5 cm should be removed by either hysterectomy or myomectomy to rule out leiomyosarcoma.

  Correct Answer: A

  As mentioned, leiomyomata account for more hysterectomies than any other gynecologic disorder, but alternative treatments continue to be explored. Myomectomy (e.g., removal of uterine fibroids) can be performed via laparotomy, laparoscopy, hysteroscopy, or even vaginally. However, it is generally not considered a "simpler" or safer procedure than hysterectomy, and bleeding can be excessive. Uterine artery embolization is an angiographic procedure currently reserved for women who do not desire future pregnancy, as the effects of embolizing both uterine arteries and then allowing pregnancy is uncertain. GnRH agonists are useful in reducing uterine bleeding and reducing fibroid volume up to 50%, but this effect is short-lived and completely reversible. Therefore, this therapy is useful as an adjunct to surgery in improving hemoglobin or allowing a vaginal approach rather than abdominal. No specific size limit exists for removal of a single myoma.

• Question 590:

  A 38-year-old G4P3013 woman is seeing you for her annual gynecologic examination. She has no specific complaints, but notes that her menses have gradually become heavier over the past 23 years. Your pelvic examination is normal aside from an enlarged uterus, which you estimate at 12 weeks' size. Office ultrasonography confirms that she has multiple uterine fibroids. Which of the following statements is true regarding leiomyomata?

  A. OCs cause leiomyomata to grow more rapidly.

  B. Leiomyomata not removed by hysterectomy may eventually degenerate into malignant tumors (i.e., leiomyosarcoma).

  C. Submucosal fibroids are more likely to cause painful, heavy periods than are subserosal fibroids.

  D. Leiomyomata occur in up to 5% of all women.

  E. Typical bleeding abnormalities seen with uterine fibroids are heavy menstrual bleeding as well as frequent intermenstrual bleeding episodes.

  Correct Answer: C

  Leiomyomata lead to more hysterectomies than any other gynecologic condition and can be found in up to 50% of all women. Most are asymptomatic, but symptoms can include heavy menstrual bleeding, pelvic pain, "pressure symptoms," and even preterm birth. Symptoms depend on where the fibroids are located-those closest to the endometrial cavity cause more problems with bleeding and dysmenorrhea, while those closest to the serosa can be expected to cause more pressure symptoms such as bladder frequency or constipation. However, the typical bleeding disturbance associated with uterine fibroids is heavy regular bleeding as opposed to bleeding or spotting between periods, which deserves separate evaluation. Leiomyosarcomas are malignant tumors that appear very similar to benign leiomyomata-- however, they are now felt to arise de novo and not from degeneration of a benign fibroid. Leiomyomata do seem to respond to sex steroids but oral contraceptives do not cause more rapid growth or regression.