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.

A 59-year-old man comes to the physician because of severe perianal pain for the past five days. He has always been healthy and exercises three times a week. His regular diet consists mainly of fruits, vegetables, and fish. His temperature is 37.0 degrees celsius (98.6 degrees fahrenheit). Physical examination shows a very tender, purple, thrombosed, external hemorrhoid. He has been trying sitz baths at home, but gets only temporary relief. He needs to go on a business trip five days from now, and wants to make sure that he is comfortable by then.

Which of the following is the best course of action at this time?  

A. Continue with conservative measures.

B. Incision and drainage.

C. Laser fulguration.

D. Rubber band ligation.

E. Surgical excision. 









The correct answer is A.

Thrombosed external hemorrhoids have a timetable that marks the best time to intervene versus the best time to let nature take its course. That dividing line is three days. Intervention is appropriate within the first three days. This man has been symptomatic for five days. In a few more days the process will subside. If intervention is chosen now, the pain from the procedure will last longer than the pain from the disease.  

Choice B: Incision and drainage will provide the quickest resolution of the problem if done within the first 3 days.

Choice C and E: Laser fulguration and surgical excision are acceptable ways to provide a permanent solution, but at this particular time they would not render the patient pain-free within the desired time frame.

Choice D: Rubber band ligation is done for internal hemorrhoids only, not for external hemorrhoids.

  • Best time to treat thrombosed external hemorrhoids = first 3 days of symptoms.
  • After 3 days, pain from the procedure will last longer than the pain from the disease.
  • Rubber band ligation is only used in the treatment of internal hemorrhoids. 

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

The AMA selected Kaplan as a preferred provider to support you in reaching your goal of passing the USMLE® or COMLEX-USA®. AMA members can save 30 percent on access to additional study resources, such as Kaplan’s Qbank and High-yield courses. Learn more.

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