|
M2 Questions Webmaster: 2Lt David Lynch |
Find a mistake? Email dlynch@creighton.edu -Reproduction Questions-
Questions 1-5 1. The optimal temperature (in degrees Fahrenheit) for producing sperm is: A. 93.0 B. 94.6 C. 96.0 D. 98.6 E. 99.0
2. A developing sperm is in the rete testis. If the sperm is on the way out of the testis, where did it just come from, and where will it go next? A. vas deferens, epididymis B. epididymis, seminiferous tubule C. efferent ductules, epididymis D. efferent ductules, vas deferens E. seminiferous tubule, efferent ductules
3. Luteinizing hormone is inhibited primarily by a product of ________, and follicle stimulating hormone is inhibited primarily by a product of _________. A. Sertoli cells, Leydig cells B. Sertoli cells, Sertoli cells C. Leydig cells, Sertoli cells D. Leydig cells, Leydig cells
4. Testosterone is not involved in which of the following? A. Initiation of spermatogenesis B. Inhibition of GnRH C. Inhibition of LH D. Bone Growth E. Erythropoietin secretion F. Actually, all of the above are related to testosterone
5. Epispadias differ from hypospadius in that A. epispadias do not involve an abnormal location of urethral opening B. epispadias are always found with extrophy of the bladder C. epispadias occur earlier in development and are unrelated to the cause of hypospadius D. epispadias are derived from similar developmental abnormalities, and only differ in the location of the urethral opening
Answers 1-5 1. Answer A: The optimal temperature is 5.6 degrees below body temperature, according to Dr. Beisel's lecture. 98.6 - 5.6 = 93.0
2. Answer E: The correct path out of a testis is seminiferous tubule, rete testis, efferent ductules, epididymis, vas deferens. The only answer that follows this path is E.
3. Answer C: Sertoli cells make inhibin, which inhibits FSH. Leydig cells make testosterone which inhibits LH. Testosterone also inhibits GnRH, which is produced in the hypothalamus to promote production of the three glycoproteins LH, FSH, and TSH in the anterior pituitary
4. Answer F
5. Answer C: Hypospadius are related to deficiencies in testosterone. Epispadias occur earlier in development and are unrelated to hypospadius. Epispadias are associated with extrophy of the bladder, and hypospadius is not.
Questions 6-10 6. The earliest that the sex of a fetus can be determined by ultrasound is approximately: A. 8th week B. 12th week C. 16th week D. 20th week E. 24th week
7. Which of the following conditions would most be most likely to result in infertility? A. uterus bicornis B. uterus bicornis unicollis C. uterus arcuatus D. atresia of the cervix E. uterus didelphys with double vagina
8. The first polar body: A. is produced only in oogenesis after meiosis I B. is produced only in oogenesis after meiosis II C. is produced both in spermatogenesis and oogenesis after meiosis I D. is produced both in spermatogenesis and oogenesis after meiosis II E. is produced only in spermatogenesis after meiosis I F. is produced only in spermatogenesis after meiosis II
9. A deficiency in 5-alpha reductase would most likely result in: A. true hermaphrodite B. female pseudo-hermaphrodite from increased DHT levels C. a male pseudo-hermaphrodite from decreased DHT levels D. miscarriage E. extrophy of the bladder
10. A patient complains of painful erections. He admits to an upward bend in the shaft of his penis. The most likely cause for this abnormality is: A. condylmona acuminatum (genital warts) B. excessive fibrosis following trauma C. neoplasm D. incomplete closure of the urethral folds (hypospadius) E. chronic syphilis
Answers to questions 6-10 6. Answer B: Dr. Nichols said that a good guess can be made by the 9 week. However, 8 weeks is clearly too early, so A is incorrect. 12 weeks is the number given in his PowerPoint.
7. Answer D: Only D would completely prevent pregnancy from happening. All other answers would likely result in fertility issues but would still allow pregnancy to occur.
8. Answer A: Only oogenesis produces polar bodies. After completion of meiosis I, one polar body is produced. After meiosis II, either two or three polar bodies have been produced, depending on whether the first polar body replicated.
9. Answer C: Testosterone is converted into dihydrotestosterone (DHT) by 5-alpha reductase. DHT is crucial for proper male development. Failure to produce enough testosterone and/or DHT may result in male pseudohermaphrodism (male genotype with feminized phenotype).
10. Answer B: Peyronie's disease is a disorder of inappropriate fibrosis of the penis. This typically results in an upward bend of the erect penis, and may result in painful erections. Hypospadius also may cause a bend in the penis, but will typically cause a downward bend. Moreover, hypospadius would likely have been addressed soon after birth. None of the other conditions are likely to result in a bent shaft.
Questions 11-15 11. Which of the following is a common feature of benign prostatic hypertrophy and prostate cancer? A. symmetrical enlargement B. elastic consistency C. discrete palpable nodule D. indistinguishable median sulcus
12. The location and size (from side to side) of a normal prostate observed by a digital rectal exam is: A. anterior to rectal wall, 2.5 cm B. anterior to rectal wall, 5 cm C. anterior to rectal wall, 7cm D. posterior to rectal wall, 2.5 cm E. posterior to rectal wall, 5 cm
13. HPV, or Human Papilloma Virus, is a cause of genital warts. Which of the following types of HPV is most likely to cause benign disease? Which are associated with malignant disease? (There are two best answers to each question) A. HPV-5 B. HPV- 6 C. HPV-10 D. HPV-11 E. HPV- 12 F. HPV-16 G. HPV-18 H. HPV-19
14. A 55 year old patient presents with numerous wart-like lesions on his penis that have not healed over the past year. Some areas are bleeding and appear infected. Biopsy reveals hyperchromic, dysplastic epithelial cells that have broken through the basement membrane. After treatment of the primary lesions, what is the next appropriate step? A. Yearly follow-up to examine for recurrence B. Inguinal and iliac lymph node biopsy C. CT to look for local and distant metastasis D. Advise patient to improve hygiene and to be circumcised
15. A baby boy with microcephaly and rocker-bottom feet is born 4 weeks early. He is breathing on his own, but has difficulty eating. Additionally, his left testicle remains in the inguinal canal. Which of the following is best accounts for his condition? A. trisomy 13 B. 5-alpha reductase deficiency C. androgen insensitivity D. all of the baby boy's features are common in a premature baby
Answers to questions 11-15 11. Answer: D The features of benign hypertrophy include symmetrical enlargement, protusion into the rectal lumen, smooth, no nodules, as well as elastic or rubbery consistency. Prostate cancer is largely the opposite of this, including features such as hard consistency, asymmetry, and nodules. Both may have an unidentifiable median sulcus.
12. Answer: A
13. Answer: B,D HPV 6 and 11 are the most common cause of condyloma acuminatum, or benign genital warts, accounting for ~90% of all cases. Answer F,G HPV 16 and 18 are associated with carcinoma of the penis. The role of HPV in malignancy is unclear.
14. Answer: B Squamous cell carcinoma of the penis accounts for less than 1% of male cancer in the US. However, it is up to 20x more common in many other parts of the world. Risk factors include an uncircumcised penis, poor hygiene, HPV-16 and HPV-18, and cigarette smoking. Inguinal and iliac lymph nodes are highly susceptible to metastasis. Therefore, the next best step is to biopsy these lymph nodes.
15. Answer C: The testicles typically descent around the 7th or 8th month. It would not be uncommon to see undescended testes (aka cryptorchidism) at this stage. However, microcephaly and foot deformity should alert you to a more severe problem. Descent of the testes occurs in two distinct stages. First, the trans-abdominal stage depends on mullerian inhibiting substance, produced by Sertoli cells. The second stage, or trans-inguinal stage, is controlled by androgens. However, according to 7th Edition Robbins pg. 1038, cryptorchidism is only "rarely associated with hormonal disorders". Chromosomal disorders are more likely. Common features of trisomy 13 include microcephaly, cleft lip, heart defects, and rocker-bottom feet.
Questions 16-20 16. Circumcision does not significantly reduce the likelihood of which of the following: A. squamous cell carcinoma B. HIV C. urinary tract infection D. benign prostatic hyperplasia (BPH) E. actually, all of the above have reduced likelihood
17. Which of the following experimental approaches would be most likely to prevent benign prostatic hyperplasia (BPH)? A. 5-alpha reductase inhibitor targeted to stromal cells of the prostate B. 5-alpha reductase inhibitor targeted to epithelial cells of the prostate C. testosterone inhibitor targeted to stromal cells of the prostate D. testosterone inhibitor targeted to epithelial cells of the prostate
18. Which of the following is not a common feature of eunuchoidism? A. sitting height less than one-half of standing height B. osteoporosis C. diminished axillary and pubic hair D. small testes E. small prostate F. gynecomastia (male breasts) G. anosmia (no sense of smell) H. actually, all of the above are features of eunuchoidism
19. A 7 year old boy presents with Turner stage 4 genital and pubic hair development (significant enlargement of penis and scrotum, darkening of scrotal skin, and adult type pubic hair). Which of the following would you most likely find in a patient with adrenogenital syndrome? A. increased ACTH, increased cortisol, decreased aldosterone B. decreased ACTH, decreased cortisol, decreased alsosterone C. increased urinary 17-ketosteroids D. hyperglycemia E. anosmia
20. Which of the following features is common to both 21-beta-hydroxylase deficiency and 17-alpha hydroxylase deficiency? A. increased cortisol B. increased androgens C. early onset of puberty D. increased aldosterone E. increased ACTH
Answers 16-20 16. Answer: D There has been clear evidence to suggest that circumcision reduces the likelihood of HIV and UTIs, as well as squamous cell carcinoma. No such evidence exists for BPH.
17. Answer: A The proposed mechanism for BPH is that testosterone is converted to DHT by 5-alpha reductase in the stromal cells of the prostate. DHT then binds to androgen receptors in both stromal cells and epithelial cells, resulting in production of growth factors which produce hyperplasia. Other factors are likely important, since experiments with 5-alpha reductase inhibitors did not benefit all patients who took it. (Robbins 7th Ed, pg 1049). 5-alpha reductase is a better target than testosterone since DHT is 10x more potent at activating androgen receptors. Other appropriate targets for therapy may include the androgen receptors and growth factor receptors.
18. Answer: F Eunuchoidism is the failure of puberty to begin and proceed. There should be no hormonal increase that would result in gynecomastia. A less obvious feature is that these individuals tend to have long legs and therefore a sitting height less than half of their standing height. Anosmia is commonly seen in eunuchoids because there is often a problem in the pituitary which may affect the nearby olfactory system.
19. Answer: C Precocious sexual development can be the result of 21-beta-hydroxylase deficiency. This deficiency will reduce the output of both mineralocorticoids (from the zona glomerulosa) and glucocorticoids (zona fasciculata). The anterior pituitary responds by increasing ACTH. As a result, there is overproduction of androgens (zona reticularis), which can lead to early sexual development. The increase in androgens will be broken down into excretory metabolites such as 17-ketosteroids, leading to increased urinary levels. Hyperglycemia is more likely to be seen in cortisol excess, and anosmia is associated with eunuchoidism (failure to enter puberty).
20. Answer: E Both deficiencies result in a decrease in cortisol levels which results in an increase in ACTH. 21-beta-hydroxylase causes adrenogenital syndrome, where only androgens are increased. 17-alpha-hydroxylase deficiency results in decrease in all except mineralocorticoids. Here's a visual: 21-β-hydroxylase deficiency 17-α-hydroxylase deficiency
zona granulosa
zona fasciculata
zona reticularis
androgens
Questions 21-25 21. Which of the following is the most important prognostic factor in breast cancer? A. lymph node involvement B. distant metastasis C. size > 2cm D. tumor grade
22. A 12 year old boy suddenly doubles over in pain while watching TV, complaining of pain in his scrotum. Which of the following most accurately describes the situation? A. Earlier trauma resulted in an indolent hemorrhagic infarction B. He has cryptorchidism that has spontaneously resolved with the increase in androgens from puberty C. He has torsion of the testis, which requires prompt surgery D. He has a seminoma, a rare cancer affecting boys in puberty
23. In females, where would you most likely find the highest concentrations of aromatase, which catalyzes the production of estradiol? A. theca cells B. granulosa cells C. germinal epithelium D. aromatase is essentially absent in the female
24. A young couple comes to you asking about the benefits of tracking the woman's body temperature to predict fertile days. Which of the following statements is most accurate? A. Body temperature has been shown to be unrelated to fertility. B. Body temperature rises about 5 days prior to ovulation C. Body temperature is highest at the time of ovulation D. Body temperature follows a similar pattern to progesterone (baseline during the follicular phase and highest levels in the luteal phase) E. Body temperature is typically lowest during the luteal phase
25. During a normal menstrual cycle at the peak of LH, which of the following would you least expect? A. Peak of FSH B. Decreasing levels of 17-beta-estradiol C. Increasing levels of progesterone D. Ovulation E. Decrease in cervical mucus
Answers 21-25 21. Answer: A As reported in the MDC on Feb 6, 2009. 11min 40s
22. Answer: C Torsion of the testis primarily affects adolescent boys and is the result of an anatomic abnormality that allows for increased mobility of the testes. This is an emergency requiring treatment within 6 hours to preserve the testis. No other choice provides a reasonable explanation for the sudden onset of pain.
23. Answer: B In the female, theca cells produce testosterone which moves into the granulosa cells to be converted into 17-beta-estradiol by aromatase.
24. Answer: D Body temperature is lowest in the follicular phase and begins to rise roughly at the time of ovulation. It peaks during the luteal phase, similar to progesterone. In fact, progesterone is thought to act on the hypothalamus to cause this change. Costanzo has a nice image of these changes. Here's another.
25. Answer E:
The increase LH is the cause of ovulation. There is a concomitant
increase in FSH. Meanwhile, estrogen is decreasing and
progesterone is just starting to increase. If you were unsure, the
process of elimination should have left you with E as the only possible
answer. What typically happens is an increase in cervical mucus
which is more receptive to sperm, allowing for increased fertility.
Some family planning methods rely on observation of the cervical mucus.
Questions 26-30 26. The loss of the endometrium is caused predominantly by decreases in which two hormones? A. LH B. FSH C. 17-beta-estradiol D. Progesterone E. Testosterone
27. Ductal carcinoma in situ is most likely to be detected as which of the following? A. palpable mass B. irregular mammographic density C. mammographic calcification D. incidental finding on biopsy
28. You detect numerous calcifications on a routine mammography on a 40 year old woman. Which of the following is not on the differential? A. sclerosing adenosis B. hyalinized fibroadenoma C. apocrine cysts D. invasive carcinoma E. actually, all of the above are reasonable causes of calcification
29. A baby boy is delivered by caesarian section at 32 weeks because of oligohydraminos. Which of the following features are you least likely to find in the baby? A. renal agenesis B. pulmonary hypoplasia C. decreased alveolar phospholipid production D. birth weight of 2500 grams E. talipes equinovarus (club feet)
30. An autopsy is performed on a 4 month old baby that was found dead in his crib sleeping on his stomach. The baby was previously healthy, although he was born 3 week premature. Autopsy findings include periadrenal brown fat, hepatic hematopoiesis, congested lungs without edema, and petichiae on the parietal pleura. What was the cause of death? A. abuse B. SIDS (Sudden Infant Death Syndrom) C. bacterial infection D. congenital malformation of the heart E. IRDS (Infant Respiratory Distress Syndrome)
Answers 26-30 26. Answers: C & D. LH and FSH are not true since their levels peak 14 days before the onset of menses and are virtually at baseline levels 10-12 days before menses. Estradiol and progesterone, on the other hand, do not reach low levels until menses begins.
27. Answer: D Check Robbins 7th pg 1123 and 1124 DCIS is the most associated with calcifications.
28. Answer: E Robbins 7th 1124 Many things can cause calcifications: secretory material, necrotic debris, and hyalinized stroma. Of course, cancer, such as invasive carcinoma, is high on the list. Routine mammograms typically begin at age 40.
29. Answer: D The most common cause of oligohydraminos is an amniotic leak, although it often occurs from renal agenesis, obstructed ureters, cystic kidneys, etc. Oligohydraminos results in features from the baby being squeezed by the uterus: flattened face, low set ears, and club feet. Without sufficient amniotic fluid, the lungs do not develop properly. Hypoplasia and deficient surfactant production (made of phospholipids) will result. Answer D is correct because we would not expect a "normal" birth weight of 2500 grams (or about 5.5 pounds) at 32 weeks, even in the absence of oligohydraminos. Another good question would be "what is the most likely cause of death after a baby is delivered after an extended period of oligohydraminos"? The baby would die from IRDS.
30. Answer: B All of the findings listed in the question are common in SIDS. SIDS affects children within the first six months of life. It is associated with many factors, perhaps most importantly sleeping in the prone position. Other risk factors include second hand smoke, recent upper respiratory tract infection, prematurity, and low socioeconomic standing. Although many factors play a role, Robbins suggests that the fundamental abnormality is in the arcuate nucleus, which normally arouses the body if stressed during sleep (7th ed pg 497).
Questions 31-35 31. Which of the following is least likely to produce precocious puberty? A. Leydig cell tumor B. granulosa cell tumor C. 21-β-hydroxylase deficiency D. teratoma
32. Which of the following plays the largest role in maintaining the blood-testis barrier? A. myoid cell B. Leydig cell C. Sertoli cell D. spermatogonia E. connective tissue
33. Which of the following is not true regarding breast density in mammography? A. lower density tends to be found in fatty breast tissue B. lactating women tend to have lower density breast tissue C. breast density is a significant risk factor for breast cancer D. dense breasts are better imaged with digital mammography
34. Which of the following is not true about the BI-RADS (Breast Imaging Reporting and Data System) A. it standardizes breast imaging reporting B. it facilitates outcome monitoring C. it standardizing terminology and report organization D. applies to mammography, ultrasound, and MRI of the breast E. actually, all of the above are true
35. Primary spermatocytes are derived from: A. spermatogonia B. secondary spermatocytes C. spermatids D. myoid cells E. Sertoli cells
Answers 31-35 31. Answer: D Only teratomas are not associated with excessive hormone production. Teratomas are common germ cell tumors of the ovary that are usually benign.
32. Answer: C The occluding junctions between Sertoli cells play a crucial role in maintaining the barrier. Spermatogonia lie on the basal compartment below the blood-testis barrier. As divisions occur, cells move past the basal compartment and move into the adluminal compartment. (Junqueira et al. Basic Histology, 11th Ed pgs 426, 427)
33. Answer: B When lactating the breast is filled with fluid, which appears dense (white) in mammography. Fat appears black. Younger women and lactating women tend to have the densest breasts.
34. Answer: E The BI-RADS is a "quality assurance guide" that covers all of the features listed in the question. Source: frequently asked questions about BI-RADS on the American College of Radiology website
35. Answer: A The primary spermatocytes come from type B spermatogonia, and are undergoing the first meiotic division.
Questions 36-40 36. Where it is thinnest, the barrier between maternal blood and fetal blood consists of all except: A. synctiotrophoblasts B. basement membrane C. fetal capillary endothelium D. Hofbauer cells
37. Where is the male reproductive tract will you most likely find true cilia? A. seminiferous tubule B. rete testis C. efferent duct D. epididymis E. ductus deferens
38. What structure in the male reproductive tract provides secretions that allow sperm to be motile? A. seminiferous tubule B. rete testis C. efferent duct D. epididymis E. ductus deferens
39. Which of the following women has the greatest chance of developing
breast cancer? B. 35 year old woman with age of menarche of 11 C. 50 year old woman on post-menopausal estrogen D. 60 year old woman with a BMI of 35
40. Which of the following contains a secondary oocyte? (there may be more than one answer) A. primordial follicle B. primary follicle C. early primary follicle D. secondary follicle E. Graafian follicle
Answers 36-40 36. Answer D Synctiotrophoblasts provide the immunologic protection for the fetus by shrouding the villus in a placenta. The Hofbauer cell is essentially a macrophage in the villus.
37. Answer C Only the efferent duct expresses cilia. They are identified by their star-like shape. The epididymis and ductus deferens do exhibit stereocilia, but these are microvilli, not true cilia. The epididymis and ductus deferens moves sperm via peristalsis. Therefore, we expect to see more smooth muscle lining these structures than the efferent duct.
38. Answer D The epididymis provides the secretions that allow for the sperm to be motile. The epididymis is made of pseudostratified columnar epithelium with microvilli.
39. Answer: A The 75 year old woman has a 17 fold increased risk of developing cancer since she is over 70. The other three present with mild risk factors (~1.5x chance). These risks are age of menarche less than 12, post-menopausal estrogen, and BMI greater than 31.
40. Answer: E Seems like a good test question. Source: Dr. Nichols lecture on Histo of the Female slide 4. Although, after looking at slide 9 in his lecture it looks like D could also be correct.
Questions 41-45 41. Which of the following is an action shared by estrogen and progesterone? A. maintenance of pregnancy B. positive feedback on FSH and LH C. development of secondary sex characteristics
42. Which of the following glands does not contribute to semen? A. prostate B. epididymis C. seminal vesicles D. bulbourethral E. actually, all the above contribute fluid to semen
43. Histologically, which of the following appears the closest to normal prostate tissue? A. epididymis B. seminal vesicles C. ductus deferens D. rete testis E. seminiferous tubules
44. The structure in the center of the picture below is most likely:
A. primordial follicle B. early primary follicle C. late primary follicle D. Graafian follicle E. secondary follicle F. artery
45. This structure found in the cortex of an ovary is most likely in which stage of division:
A. mitosis B. prophase I C. metaphase I D. metaphase II E. the cell is not dividing since it just completed meiosis II
Answers 41-45 41. Answer: A Both estrogen and progesterone are involved in maintaining pregnancy, especially after HCG begins to drop in the second trimester. Estrogen can either have positive or negative feedback on LH and FSH. Progesterone has negative feedback on LH and FSH. Secondary sex characteristics are driven by estrogen.
42. Answer E
43. Answer B The seminal vesicles are in close proximity to the prostate, unlike any of the options listed. A crystal clear distinction between the two is that only the prostate will have concretions.
44. Answer B It is probably an early primary follicle since it has a single layer of cuboidal graulosa cells. The zona pelucida forms at this stage. A late primary follicle would likely have a granulosa layer many cells thick.
45. Answer C This is a primordial follicle, covered by flat epithelial cells. Primordial follicles are arrested in prophase I. Leading up to ovulation, 15 primordial follicles progress to metaphase II. One of these will be released from a Graafian follicle as a secondary oocyte.
Questions 46-50 46. A 25 year old man presents with gynecomastia. Which of the following tumors is most likely to produce this effect? A. Leydig cell tumor B. teratoma C. spermatocytic seminoma D. choriocarcinoma
47. Which of the following is not a feature of adenocarcinoma of the prostate? A. crowded glands B. bone metastasis C. perineural invasion D. absence of basal cells E. PSA > 4ng/mL F. actually, all of the above are true
48. You are advising a couple on ways to increase fertility. Which of the following would provide the highest likelihood of pregnancy? A. Intercourse 4-5 days before ovulation B. Intercourse 1-3 days before ovulation C. Intercourse on the day of ovulation D. Intercourse 1-3 days after ovulation
49. A patient comes to your office seeking birth control pills. She is in overall good heath but says she is currently being treated for epilepsy. Which of the following is appropriate to say to this patient? A. Anti-epileptic drugs do not affect birth control pills B. A birth control pill may be more because of her anti-epileptic medications C. A birth control pill may be less because of her anti-epileptic medications D. Birth control pills are unsafe with her condition. Natural family planning methods should be explored.
50. Which of the following is not an effect of monophasic birth control consisting of estrogen and progestin? A. inhibition of LH surge B. inhibition of FSH C. altered lipid profile D. induction of PTH E. decreased antithrombin III
Answers 46-50 46. Answer A. Leydig cell tumors are known for their hormonal effects. They can cause precocious puberty and gynecomastia, although the most common symptom is simply testicular swelling. Sertoli cell tumors can also produce these hormonal effects. Spermatocytic seminomas tend to occur in senior citizens. It is slow growing and prognosis is excellent. Neither choriocarcinoma or teratoma have hormonal effects.
47. Answer F Probably the most important ones for histology to remember are the "back to back" glands and the loss of basal cells. PSA is important in that its rate of change is helpful in guiding therapy. It is a sensitive, but not specific test for prostate cancer.
48. Answer B The sperm can live for about 3 to 5 days, while the egg is viable for less than one day. Therefore, the highest chance for conception occurs if the sperm is already present when ovulation occurs. This has been backed up in the literature (Barrett et al., Population Studies 1969). see slide 7 of Khandalavala's lecture on natural family planning.
49. Answer C St. John's Wort, rifampin, antiepileptic drugs, and anti-HIV drugs are known to induce the cytochrome P450 system in the liver. This results in an increased metabolism of drugs that go through this pathway, such as estrogens. Therefore, their effectiveness is decreased, and unwanted pregnancy may occur. Here's a link to the National Library of Medicine talking about the effects of St. John's Wort.
50. Answer D Estrogen tends to oppose the action of PTH, resulting in increased bone formation (or decreased resorption). Estrogens increases many clotting factors and decreases AT III. Lipid profiles often change, although estrogen tends to increase HDL, while progestins decrease HDL.
Questions 51-55 51. Which of the following conditions of a patient contraindicates the use of oral contraceptives? A. obesity B. smoking C. hypertension D. melanoma E. none of the above
52. Which of the following is incompatible with a female conceiving in the future? A. vasectomy in male partner B. bilateral salpingectomy C. intrauterine device D. 15 years of oral contraceptive use
53. A Pap smear reveals cervical intraepithelial neoplasia grade I (CIN I). Progression to carcinoma in situ (CIN III) is A. unlikely if the patient has HPV 11 B. almost certain if the patient has HPV 16 C. almost certain regardless of which HPV she has D. avoidable if vaccinated with Gardasil®
54. A 27 year old woman presents to the emergency room with extreme abdominal pain. The pain came on suddenly, beginning in the lower left quadrant. She has been in a monogamous sexual relationship for 2 years. She denies any trauma. She says her last menstrual period was about 6 weeks ago. She is afebrile, BP 90/50 and dropping, heart rate 100. Which of the following is the most likely diagnosis? A. pelvic inflammatory disease B. appendicitis C. toxemia of pregnancy D. fallopian tube rupture from ectopic pregnancy E. fibroma-thecoma
55. A 24 year old primipara woman is in her 35th week of pregnancy. She claims to have had a persistent headache for the last 5 days. She is afebrile, but is hypertensive and is found to have 2+ proteinuria and edema. Which of the following is not true of her condition? A. she is at risk for developing seizures B. her kidneys would likely show fibrin deposits C. this condition often occurs at any stage in pregnancy D. she is at risk for developing DIC E. she will likely improve upon delivering the baby
Answers 51-55 51. Answer E Conditions which contraindicate oral contraceptives include breast cancer, history of DVT or PE, coronary artery disease, liver disease, and (of course) pregnancy.
52. Answer B Removing both fallopian tubes is a bilateral salpingectomy. Dr. Khandalavala made sure to write in big bold letters that tubal ligation should not be done if a patient wants children in the future.
53. Answer A The low risk HPV include 6 and 11. The high risk HPV include 16 and 18. Patients often spontaneously regress from CIN I. Gardasil® only protects before infection of HPV 6, 11, 16, and 18.
54. Answer D The only option that fits all of the woman's symptoms is a ruptured ectopic pregnancy. One in every 150 pregnancies is an ectopic pregnancy, and 90% of those are in the fallopian tubes. Neisseria gonorrhoeae can cause pelvic inflammatory disease leading to scarring of the fallopian tubes, which predisposes to ectopic pregnancy. Appendicitis is possible, but the facts that she is afebrile with lower left pain make it less likely. Moreover, appendicitis tends to occur in adolescents and young adults. This woman's lowering blood pressure indicates that she is bleeding into the abdominal cavity. This is clearly a medical emergency.
55. Answer C Toxemia of pregnancy tends to occur in the third trimester in primiparas. It is diagnosed as preeclampsia by the gradual onset of hypertension, edema, and proteinuria. Upon CNS involvement (such as seizures), the condition is termed eclampsia. Toxemia resolves spontaneously after the birth of the baby.
Questions 56-60 56. Regarding the two layers of the endometrium, the functionalis differs from the basalis in that: A. the functionalis does not breakdown during menses B. the functionalis is largely unresponsive to estrogen C. the functionalis produces estrogen D. the functionalis is more responsive to estrogen
57. Endometrial hyperplasia and excessive bleeding during and between menses can be caused by anovulatory cycles. How do anovulatory cycles produce these effects? A. prolonged stimulation of the endometrium by estrogen B. prolonged stimulation of the endometrium by progesterone C. prolonged stimulation of the endometrium by estrogen and progesterone D. lack of stimulation of the endometrium
58. Compared to a 60 year old post-menopausal woman, how is a 30 year old woman different? A. increased HDL, increased LDL, increased lipoproteins B. increased HDL, increased LDL, decreased lipoproteins C. increased HDL, decreased LDL, decreased lipoproteins D. decreased HDL, decreased LDL, decreased lipoproteins E. decreased HDL, decreased LDL, increased lipoproteins
59. Teriparatide is a human recombinant parathyroid hormone (rhPTH) used to prevent bone loss. Which of the following explains why terparatide is given as a daily subcutaneous injection? A. PTH normally stimulates bone resorption, but intermittent PTH stimulates bone formation B. PTH normally stimulates bone formation, and daily injections keep plasma PTH levels continually elevated C. PTH normally stimulates bone resorption, but intermittent PTH causes inhibition of calcitonin D. PTH antagonizes vitamin D excretion, causing increased bone formation
60. The finding on a Pap smear which is most indicative of invasive squamous carcinoma is A. koilocytes with two nuclei B. hyperchromic nuclei with little cytoplasm C. CIN III on two consecutive Pap smears D. spindle cells in the presence of CIN III E. all of the above are highly indicative of invasive squamous carcinoma
Answers 56-60 56. Answer D The functionalis is the protion of the endometrium that varies throughout the menstrual cycle. It is built up in response to estrogen and sloughed off as both estrogen and progesterone are cut off (all from the corpus luteum). The basalis is essentially unaffected.
57. Answer A Normally, before ovulation, the corpus luteum produces only estrogen to prepare the uterus. After ovulation, the corpus luteum normally produces both estrogen and progesterone. If pregnancy occurs, human chorianic gonadotropin (HCG) from the placenta prevents the corpus luteum from atrophy. If pregnancy doesn't occur, the corpus luteum simply regresses and estrogen and progesterone production drop. In the anovulatory cycle, the corpus luteum continues to produce estrogen. This continued bath in estrogen causes the symptoms of menometrorrhagia (excessive bleeding at irregular intervals).
58. Answer C Estrogen has beneficial effects on both cholesterol and lipoproteins, so the 30 year old has increased HDL, with decreased LDLs and lipoproteins. This helps explain why women have a greater risk for cardiovascular disease after menopause. However, as illustrated in the Women's Health Initiative, estrogen plus progesterone may increase the risk of coronary heart disease if given to healthy postmenopausal women. Here's the NEJM article.
59. Answer A PTH is normally secreted in response to low ionized calcium levels in the plasma. PTH causes bone resorption to restore normal calcium levels. However, intermittent PTH causes the opposite effect.
60. Answer D Once the basement membrane has been broken (invasive squamous carcinoma) the Pap smear will show oddly shaped cells. These can be described as spindle cells or tadpole cells. The highly dysplastic CIN III cells will also be present since they immediately preceded the invasion of the basement membrane. Answers A and B are CIN I and II, respectively.
Questions 61-65 61. The single best area of the cervix to sample during a Pap smear is: A. the endocervix B. the ectocervix C. the squamo-columnar junction D. the junction between the cervix and vagina
62. Polycystic ovary syndrome (PCO) is associated with all of the following except: A. enlarged ovaries B. hirsutism C. amenorrhea D. obesity E. anovulation F. actually, PCO often displays all of these characteristics
63. Teratomas differ from other germ cell tumors (GCTs) in females in that they are: A. usually benign B. found in the ovary C. extremely rare D. actually, all of the above are true of all GCT
64. Hydatidiform moles occur at a rate of 1 per 1000 pregnancies in the US. A history of a hydatidiform mole (complete or partial) significantly raises the risk of: A. mature teratoma B. Paget disease C. embryonal rhabdomyosarcoma D. gestational choriocarcinoma
65. A 24 year old woman presents to your office complaining of "painful swelling near her hip bone". You find tender and enlarged inguinal lymph nodes that accentuate the ilioinguinal fold. She is afebrile, but otherwise appears normal. Upon questioning, she tells you that about 5 weeks ago she had painless lesions on her vagina. She has had 20 lifetime sexual partners. What is the most likely diagnosis? A. Chlamydia trachomatis B. poor hygiene C. Herpes Simplex Virus 2 D. Haemophilus ducreyi E. Neisseria gonorrhoeae
Answers 61-65 61. Answer C The initial changes following HPV infection occur in the transitional zone, which begins at the meeting of endo and ectocervix (aka the squamo-columnar junction).
62. Answer F
63. Answer A GCTs account for about 1 in 5 tumors in the ovary. Most GCTs are mature teratomas, which are are common and benign. Other GCTs include the dysgerminoma and yolk sac tumor. They tend to be rare and malignant. Dysgerminoma should recognized as the female equivalent to the seminoma. It is the most common malignant GCT.
64. Answer D Robbins states that 1 in 40 hydatidiform moles will give rise to choriocarcinoma (7th ed pg 1113). Choriocarcinomas are aggressive (local invasion and metastasis) but respond well to chemotherapy. They often appear as large hemorrhagic masses in the uterus. Answers A,B, and C are unrelated to hydatidiform moles in both origin and location. Mature teratomas (aka dermoid cysts) are germ cell tumors of the ovary that are both common and benign. They are all of karyotype 46,XX because they arise from a single ovum. Paget disease is a rare complication of ductal carcinoma in situ of the breast (and less frequently extramammary sites). The malignant cells push through to the surface of the nipple, allowing fluid to seep out and dry into a crust. Embryonal rhabdomyosarcoma is a vaginal tumor found in toddlers. It appears as a grape-like mass protruding from the vagina.
65. Answer A The L1, L2 and L3 serotypes of Chlamydia can cause Lymphogranuloma Venerum. This presents first as painless ulcers followed by lymphadenopathy with bubo formation and finally drainage of buboes. Treat with a macrolide. Since the ulcer was painless, answers C, D, and E can be ruled out. Syphilis would be a reasonable possibility in this case. VDRL, RPR, and FTA should be explored.
Questions 66-70 66. Which of the following cancers has the worst five year relative survival rate? A. uterine cervix cancer B. uterine corpus cancer C. ovarian cancer
67. This is a representative picture of a biopsy taken from a 30 year old man with a testicular mass. It is the most common germ cell tumor in males. What is the name of the similar tumor found in females?
A. dysgerminoma B. teratoma C. choriocarcinoma D. yolk sac tumor E. fibroma-thecoma
Questions 68 and 69 refer to the following picure:
68. Before being biopsied and stained with H&E, the cell indicated by the black arrow in this seminal vesicle was most likely: A. maintaining the blood-testis barrier B. producing testosterone C. producing inhibin D. producing primary spermatocytes E. none of the above
69. The cell indicated by the blue arrow has DNA content that is most likely: A. diploid, 1N B. diploid, 2N C. diploid, 4N C. haploid, 1N D. haploid, 2N E. haploid, 4N
70. Which of the following tumors is most likely to produce estrogen in amounts that would cause precocious puberty? A. dysgerminoma B. granulosa cell tumor C. teratoma D. leiomyoma E. Brenner tumor
Answers 66-70 66. Answer C Memorization from Casey's lecture. The other important fact is that uterine corpus cancer has decreasing 5 year survival rates.
67. Answer A The most common germ cell tumor in a man is a seminoma. It occurs in the third decade, and it appears as a uniform population of cells. A dysgerminoma occurs in the ovaries, and it parallels the seminoma.
68. Answer D This is most likely a spermatogonia, which divides to create primary spermatocytes. Sertoli cells maintain the blood-testis barrier as well as produce inhibin, and Leydig cells produce testosterone.
69. Answer C This cell is near the perimeter of the seminiferous tubule. It is most likely a primary spermatocyte, which is a differentiated spermatogonia. It's DNA content is diploid 4N. The primary spermatocytes go through the first meiotic division to produce secondary spermatocytes with haploid 2N DNA content. One more meiotic division produces haploid spermatids with 1N. If you thought the cell was a Sertoli cell, it would also be diploid with 2N. However, we wouldn't expect a Sertoli cell to have the DNA that looks like its dividing.
70. Answer B Only the granulosa cell tumor is associated with estrogen secretion. Leiomyomas, on the other hand, are estrogen sensitive, and may cause symptoms as estrogen levels normally go up. Therefore, they may cause menorrhagia and increase in size during pregnancy.+
Questions 71-75 71. Which station describes the baby that is closest to being born? A. -3 B. 0 C.+3
72. The expulsion of the fetus occurs at what stage? A. first B. second C. third D. fourth
73. Maintenace of the corpus luteum during the first trimester of pregnancy is due to the hormone production of what cell? A. cytotrophoblast B. syncytiotrophoblast C. blastocele D. decidual cells
74. A 38 year old G1P1 woman presents with severe ascites. She states that she never drinks, and has been healthy to date. Which tumor is most likely to cause this? A. endometrioid tumor B. serous cystadenocarcinoma C. Brenner tumor D. mucinious cystadenocarcinoma
75. A 34 year old female at 30 weeks gestation arrives at the ER with painful vaginal bleeding. She has had consistent prenatal care, but admits to using cocaine. Which of the following complication is most likely? A. ectopic pregnancy B. placenta previa C. abruptio placentae D. placenta accreta
Answers71-75 71. Answer C At the pelvic outlet, the baby is +3. At the ischial spines, 0. At the pelvic inlet, -3.
72. Answer B The first stage involves cervical effacement and dilatation and ends with complete dilation of the cervix. The second stage ends with the expulsion of the fetus. The third stage ends with the expulsion of the placenta. There is no fourth stage.
73. Answer B Syncytiotrophoblasts produce beta-HCG.
74. Answer D The presentation of intraperitoneal mucus is indicative of mucinous cystadenocarcinoma. Since the presentation is fairly unique, this makes for a good test question. All of the answers listed are the major surface-derived tumors of the ovary, but only the Brenner tumor is benign (think B as in Benign).
75. Answer C Painful vaginal bleeding is most indicative of abruptio placentae, or premature detachment of the placenta. This usually happens in the third trimester. Risk factors include advanced age, hypertention, smoking, and cocaine use. Remember that cocaine is a potent vasoconstrictor.
Fact Recall Questions In what age group is mammography most effective? 50-60 Lowest stage of breast cancer with lymph node involvement? Stage 2 What antibody against Her-2-Neu is given for breast cancer? Trastuzumab What is the incidence and death rate of breast cancer? Highest incidence (30%), 2nd highest death rate (15%) What is the incidence and death rate of prostate cancer? Highest incidence, 2nd highest death rate What is the source of HCG in the first trimester? syncytiotrophoblasts in the placenta What is the most common cystic fibrosis mutation? delta F508 Most common endocrine abnormality in male? DM, second most common is hypogonadism Most common cause of breast lump? fibrocystic changes, 2nd most common is no disease Most common cause of bloody discharge from nipple? intraductal papilloma (and piercings?) Lifetime risk of breast carcinoma? ~1 in 9 Chromosome of BRCA1? 17 Chromosome of BRCA2? 13 Recommended age for mammography screening to begin for high risk? 30, for normal population: 40 Most common HPV associated with penile malignancies? HPV-16 Serum markers used to stage testicular cancer? LDH, beta-hCG, AFP What hormones does the corpus luteum secrete? progesterone and estrogen Most common benign tumor of the breast? fibroadenoma Best test for diagnosing testicular mass? ultrasound Sharma L32 33:50 Most common penile carcinoma? squamous cell carcinoma Most common testicular tumor in child under 3? yolk sac tumor Most common prostatitis? Chronic abacterial Definition of infertility: 1 year without conception (with unprotected sex) Most common form of breast cancer? infiltrating ductal carcinoma Percent of pregnancies that end in spontaneous abortion? 15% Most common ovarian cancer? serous cystadenocarcinoma Most common benign tumor in females? leiomyoma Most common place to find endometriosis? ovaries Karyotype of benign ovarian teratoma? 46,XX Post-menopausal women most likely to die from? cardiovascular disease Most common STD worldwide? Chlamydia trachomatis The only gynecological cancer with decreasing survival rates? uterine corpus cancer
|
