If you’re preparing for the United States Medical Licensing Examination® (USMLE®) Step 2 exam, you might want to know which questions are most often missed by test-prep takers. Check out this example from Kaplan Medical, and read an expert explanation of the answer. Also check out all posts in this series

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A 58-year-old woman comes to the physician for a follow-up examination two weeks after undergoing a barium enema. She denies fever, weight loss, rectal bleeding, or fatigue. She has a four-year history of hypertension controlled with hydrochlorothiazide. Examination shows no abnormalities. The barium enema shows four to five polyps scattered throughout her colon, ranging in size from 4 mm to 1.1 cm.

Which of the following is the most appropriate next step in management?

A. Colonoscopy.

B. Fecal DNA testing.

C. Repeat barium enema in six months.

D. Screening colonoscopy for her 25-year-old son.

E. Upper gastrointestinal barium study.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

The correct answer is A.

This patient underwent a screening barium enema for colorectal cancer and was found to have multiple polyps. The next best step is for her to undergo evaluation via colonoscopy to assess the appearance of the polyps for premalignant or malignant lesions and intervene if necessary.

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Choices B and C: Additional screening tests such as a fecal DNA test (Cologuard) or a repeat barium enema would not be helpful. A fecal DNA test looks for DNA in the stool shed by polyps or cancers. Abnormal screening tests for colorectal cancer need to be followed up with evaluation by colonoscopy, assuming colonoscopy was not done initially.

Choice D: Screening her 25-year-old son would not be necessary, because she does not have a family history of colon cancer, nor does she have innumerable polyps to warrant screening for a familial syndrome. Primary relatives of individuals who have colon cancer should undergo colon cancer screening 10 years before the diagnosis of colon cancer was made or at age 40.

Choice E: Upper gastrointestinal (UGI) imaging may be reasonable for a familial polyposis syndrome or for UGI symptoms; however, there is no such history given for this patient.

  • The current colon cancer screening recommendation is colonoscopy every 10 years for individuals at average risk older than age 50 years. 
  • Individuals who have a history of colon cancer in a first-degree relative should undergo colonoscopy 10 years before the age of the relative with the diagnosis of colon cancer or at age 40, whichever comes first.

For more prep questions on USMLE Steps 1, 2 and 3, view other posts in this series.

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