Name:______
BrownMedicalSchool
The Integrated Final Exam
April 21, 2006
Bio Med 351 Human Reproduction, Growth and Development
Richard Moore, MD
Zeev Harel, MD
Bio Med351274 Organ System Pharmacology
Robert Patrick, Ph.D.
Wayne Bowen, Ph.D.
Bio 280 Systemic Pathology
Calvin Oyer, MD
Questions 1-84 (Case Vignettes)--Choose the one best answer
Case Vignette 1
A 27-year-old G0 married woman calls the office:
- ______Her period is 3 days late. You tell her:
a. That it is too early to get a pregnancy test because you have to wait until at least 1 week after her missed menses.
b. Her quantitative HCG level should be over 10,000.
c. Her blood can be tested for the presence of progesterone to see if she is pregnant.
d. She can do a home pregnancy test or come in to the office for a urine pregnancy test.
- ______She calls the office 2 weeks later and tells you she is bleeding and has some pain. She is now 6 weeks and 1 day from her last menstrual period.
a. You draw a serum estriol level to assess the pregnancy health. It is lower than you expected and you think she might be losing a twin.
b. You order an abdominal ultrasound to assess the fetal heart rate.
c. You are not concerned about the pregnancy health when you run serial quantitative HCG levels and the value went from 2500 to 3000 in 2 days.
d. She should be evaluated for a possible ectopic pregnancy.
- ______She continues to bleed over the next 2 weeks very lightly. She states that her heart is racing and she feels very jittery. Her HCG level is 140,000.
a. Her ultrasound might show a sac in the uterus with no fetus and possibly a snowstorm like appearance.
b. Her symptoms are probably due to pregnancy related anxiety.
c. She has probably been drinking too much coffee.
d. She should be tested for a pheochromocytoma.
- ______Her second pregnancy at age 29 is uncomplicated in the first trimester. You tell her:
a. A high alpha-fetoprotein level in the second trimester indicates that her fetus might have a urinary tract anomaly.
b. Her progesterone level will drop at about 10 weeks.
c. Human placental lactogen is important for fetal nutrition, particularly when she doesn’t eat well.
d. Her estriol value will drop from 15 weeks on.
Case Vignette 2
One of your obstetrical patients has concerns about pregnancy and sexuality. She is 8 weeks pregnant and has noticed some changes in her sexual function.
- ______You tell her:
a. Women in the first trimester often have decreased sexual drive.
b. Coitus is always fine during pregnancy.
c. During the second trimester, there is decreased desire and sexual responsiveness.
d. The third trimester often leads to increased coital frequency.
- ______Two weeks after delivery, she asks about sexual function. You tell her all of the below except:
a. Nursing women may experience some vaginal dryness
b. Her small episiotomy will heal quickly and she can initiate intercourse in 4-6 weeks.
c. Vaginal atrophy symptoms may be treated with lubricants.
d. She should see a therapist if her desire is decreased.
Case Vignette 3
7. ______A 37 y/o G1P0TAB1 comes in to your office requesting routine gyn care. She states she is not currently in a sexual relationship. After questioning, she states that she recently came out as a lesbian. Which of the following statements is correct?
a. You mark clearly on the chart that she is lesbian and disclose this to your staff at every visit.
b. She doesn’t need a pap smear.
c. You should question her about use of safer sex practices such as dental dams.
d. She is likely to have a very healthy lifestyle.
8. ______She returns 6 months later. She and her new partner are interested in having a child, and she would like to become pregnant. They should:
a. Be prepared to cover the costs of donor insemination since it is unlikely to be covered by insurance.
b. Choose a friend to be the sperm donor since he wouldn’t have to be tested.
c. Assume that the partner will be the legal parent.
d. Consider adopting a child because her pregnancy will be high risk.
Case Vignette 4
A 27-year-old male complains of erectile dysfunction. He is a non-smoker, has no known medical diseases, and exercises regularly.
9. ______He asks about the physiology and anatomy of normal erections. You explain to him that:
a. The dorsal artery of the penis is the main arterial supply of the corpora cavernosa.
b. The normal arterial supply that is important for erections comes from the erectile artery.
c. The normal arterial supply that is important for erections comes from the external iliac artery.
d. The normal arterial supply that is important for erections comes from the bulbourethral artery.
e. The normal arterial supply that is important for erections comes from the internal pudendal artery.
10. ______You further explain that to develop a rigid erection:
a. Smooth muscle in the corpora and arterioles of the penis must relax.
b. The contraction of the corporal tissue is due to skeletal muscle contraction.
c. The arteries to the penis must relax, while the smooth muscle in the corporal tissue must contract.
d. The smooth muscles in the walls of the veins draining the corpora contract causing trapping of blood in the corpora.
e. The blood pressure in the corpora must be higher that venous pressure, but must stay below systolic blood pressure.
11. ______The patient asks about detumescence and you explain that:
a. Detumescence is caused by active relaxation of the veins
that drain the corpora.
b. The parasympathetic nervous system is normally responsible for detumescence.
c. The injection of vasodilators into the corpora cavernosa will aid in detumescence.
d. The tunica albuginea actively expands by relaxation, causing detumescence.
e. The sympathetic nervous system is normally responsible for detumescence.
12. ______You discover that the patient has a testicular tumor. As part of his treatment he undergoes a retroperitoneal lymph node dissection for testicular cancer. The procedure removes lymph nodes as well as many of the sympathetic nerves.
Following the procedure the patient may suffer from:
a. Low libido
b. Persistent erections
c. Poorly moving sperm
d. Ejaculatory dysfunction
e. The patient is likely to develop inability to obtain erections by physical stimulation
Case Vignette 5
A 67-year-old male complains of erectile dysfunction with his 58-year-old wife. He reports gradually worsening erections over the last 4 years. His history is significant for coronary artery disease, hypertension and peripheral vascular disease. He reports normal libido and still describes his wife as “the most beautiful woman in Providence.”
13. ______After you perform a thorough history and physical exam, you explain to the patient that the most likely cause of his erectile dysfunction is:
a. Due to poor blood supply
b. Secondary to low testosterone
c. Psychogenic due to depression
d. A normal, inevitable consequence of aging
e. Neurogenic due to autonomic nerve dysfunction
14. ______The patient asks if erectile dysfunction is “normal.” You explain that:
a. Libido always decreases with age.
b. Erectile dysfunction is not an inevitable consequence of aging.
c. As men age it takes less physical stimulation to induce an erection.
d. Erectile dysfunction exists if a man cannot maintain an erection for 30 minutes.
e. The prevalence of erectile dysfunction increases with age and reaches 100% by
age 70 years old.
15. ______You explain various treatments to the patient. He does not take nitrates for angina and is interested in using a pill. You decide to try sildenafil and explain that this medication:
a. Acts on the central nervous system
b. Inhibits the breakdown of cyclic GMP
c. Works by directly relaxing smooth muscle cells
d. Requires cyclic AMP to be released by nerve endings
e. Requires the production of nitric oxide due to an increase in cyclic GMP levels
16. ______The patient tries all of the various pills available but none of them results in adequate erections. He is interested in surgery. You explain that:
a. Surgery has a risk of infection of 35%
b. Both malleable and inflatable penile prostheses are available
c. Surgery involves doing bypass surgery of the penile artery
d. Inflatable penile prosthesis are only used in men under 50 years old
e. Malleable prosthesis are no longer used because they cause erections that last too long
Case Vignette 6
A 29-year-old male and his 28-year-old wife complain of infertility for 2 years. She has one child from a prior relationship. Your evaluation reveals azoospermia and Sertoli Cell Only Syndrome.
17. ______You explain to the patient that:
a. FSH binds to Sertoli cells.
b. He can be treated with testosterone therapy.
c. All cell types are present but his sperm lack axonemes.
d. LH stimulates his spermatogonia but the Sertoli cells are not responding.
e. His seminiferous tubules are normal, but he has an absence of Sertoli cells in the tissue between seminiferous tubules.
18. ______During your discussion, the patient asks about normal spermatogenesis. You explain that:
a. Capacitation follows the acrosome reaction
b. The sperm acrosome is important for initiation of sperm motility
c. The sperm mitochondria are normally only present in the sperm head
d. Cross-overs between maternal and paternal chromosomes occur during the first meiotic division
e. Constant non-pulsatile stimulation of the pituitary by GnRH (gonadotropin releasing hormone) will increase FSH, LH, and sperm production
19. ______The patient asks about the blood: testis barrier. You tell him that:
a. It develops during puberty
b. It separates all germ cells from the interstitial tissue
c. It allows the immune system to be exposed to all germ cell types
d. This barrier involves tight junctions between Sertoli cells and germ cells
e. It separates the seminiferous tubule into a compartment that contains mature sperm and Leydig cells and a compartment that contains spermatogonia
20. ______You explain to the patient that his epididymis is normal. He asks you to explain what the epididymis does. You tell him that:
a. Capacitation occurs in the epididymis
b. Spermiogenesis occurs in the epididymis
c. The epididymis does nothing more than transport sperm
d. It transports sperm from the seminiferous tubules to the efferent ducts
e. Sperm that enter the epididymis have poor motility, but sperm that leave it have good motility
Case Vignette 7
The above couple are so happy with your explanations that they invite you to talk at an infertility support group. You are asked to give an overview of the reproductive system in the male.
21. ______The first topic the audience asks about is the seminal plasma. You tell them that:
a. The seminal vesicle secretions are alkaline
b. The prostate contributes the least volume of fluid
c. Most of the volume of the seminal plasma comes from the testis
d. Cowper’s glands and the periurethal glands make the most volume
e. The ejaculatory duct drains the seminal vesicle while the vas deferens drains directly into the urethra.
22. ______One audience member asks you to explain spermatogenesis. You tell them that:
a. All germ cells are haploid
b. The second meiotic division yields spermatids
c. The length of spermatogenesis in the human is approximately 34 days
d. Spermatogonia divide by meiosis while spermatocytes divide by mitosis
e. Spermatogenesis involves the production of mature spermatocytes from spermatids
23. ______You then proceed to explain spermiogenesis and tell them that this process involves:
a. The addition of cytoplasm to the spermatids
b. The development of motile sperm from immotile sperm
c. The formation of the axoneme and binding of sperm to the zona pellucida
d. The elongation of the nucleus and condensation of DNA (chromatin)
e. The creation of the acrosome that occurs in the secondary spermatocytes
24. ______Somebody asks you about the sperm tail. You explain that:
a. The midpiece contains mitochondria
b. The fibrous sheath covers the sperm acrosome
c. The tail has no plasma membrane over any part of it.
d. The axoneme is only present in the endpiece of the tail
e. The 9+2 microtubule doublet arrangement is present in cilia of the pulmonary system but is 9+3 in the sperm tail
Case Vignette 8
A couple, married for 10 years, is being seen in an infertility clinic. The female partner is otherwise healthy but complains of irregular menstrual periods. She mentions that her periods occur every 2-3 months with intermittent spotting in-between periods. She has not had a period in the past 45 days. She is slightly overweight and is not on any medication. Her male partner is healthy.
25. ______Her ovarian biopsy at this time is unlikely to show:
a. Maturing follicles
b. Corpus albicans
c. Corpus luteum
d. Thick ovarian cortical surface
e. Multiple follicular cysts in ovarian cortex
26. ______An endometrial biopsy would likely to show:
a. Prominent sub-nuclear vacuolation in the gland epithelium
b. Proliferative type endometrium with occasional dilated glands
c. Marked secretion within the gland lumen
d. Decidual stromal reaction
e. Prominent spiral arterioles
27. ______The underlying problem is likely to be related to:
a. Failure of ovulation
b. Increased level of progesterone in the blood
c. Increased levels of estrogen and progesterone in the blood
d. Secretory pattern of endometrium
e. Hypersecretory pattern of endometrium
28. ______In-vitro fertilization is planned and the endometrium is prepared for implantation of the blastocyst. The endometrium is most suitably prepared to receive implantation on the following days:
a. 16 – 17
b. 23 – 24
c. 19 – 20
d. 21 – 22
e. 14 - 15
Case Vignette 9
A 23-year-old woman who has never been pregnant began experiencing painful periods 2 years ago after being diagnosed and treated for acute pelvic inflammatory disease (PID). Her pain worsens after ovulation and culminates during her period. Over the counter painkillers, such as Naproxen, have not helped her. A physical exam by her family practice doctor was benign and revealed no palpable abnormalities. She was diagnosed with secondary dysmenorrhea.
29. ______The most compelling reason why primary dysmenorrhea in this patient is less likely is because:
a. The physical exam was normal
b. Naproxen is not helping her
c. She has a history of PID
d. She is too young
e. She clearly has endometriosis
30. ______Which one of the following scenarios would best support a diagnosis of secondary dysmenorrhea:
a. Further history taking reveals that she has always had somewhat painful periods
b. She has 2 older sisters who were diagnosed with endometriosis
c. The pelvic ultrasound is normal
d. Her menstrual cycle pattern is consistent with regular ovulation
e. She has no other symptoms such as dyspareunia (painful intercourse)
31. ______In primary dysmenorrhea, the first line of treatment usually involves:
a. A gonadotropin releasing hormone (GnRH) agonist such as leuprolide acetate
b. Surgery such as a laparoscopy
c. Androgenic therapy with Danazol
d. Non steroidal anti-inflammatory agents
e. An aromatase inhibitor
32. ______In secondary dysmenorrhea caused by endometriosis, a likely explanation for the associated symptoms is:
a. Excessive production of leukotrienes by the uterus at time of menses
b. Invasion of peritoneal surfaces of the ectopic endometrial cells with bleeding and inflammation resulting from response to circulating endogenous estrogen and progesterone
c. A lack of aromatase enzyme in the ectopic endometrial tissue
d. Abundance of progesterone receptors in normal eutopic endometrium
e. A decrease in cyclo-oxygenase type II (COX-II) activity in the uterus
Case Vignette 10
A 31-year-old woman has noted a change in her menstrual cycle over the last 2 to 3 years that has been characterized by an increase in pain and discomfort throughout the cycle that worsens during her menstrual flow. She is concerned because she never had painful periods and this is affecting her daily activities and especially her performances in the church choir. She has a history of gastritis. The rest of her history is unremarkable except for obesity. Her physical exam is limited due to her body habitus, but no obvious abnormalities are found. An ultrasound of the pelvis was within normal limits.
33. ______A reasonable approach to improving her symptoms is:
a. A prescription for narcotics for pain relief
b. A 3-month trial of oral contraceptives
c. Diagnostic surgery prior to any treatment
d. Observation and reassurance that this is expected as she becomes older
e. Six months of androgenic therapy with Danazol
34. ______The differential diagnosis for this patient includes pelvic endometriosis. She has never heard of endometriosis before, so you tell her that this condition is a(n):
a. Extremely rare condition found in less than 1% of symptomatic women her age
b. Only treated by surgical techniques
c. Common disease (found in >80% of women her age) and perfectly explained by Samson’s theory of retrograde menstruation
d. Possible explanation of her symptoms, but the definitive diagnosis may require surgery
e. Easily manageable, curable disease and rarely recurs after medical treatment
35. ______The treatment of endometriosis may include a GnRH agonist such as leuprolide acetate. The mechanism of action of this agent in the treatment of endometriosis is:
a. Through achieving a pseudomenopausal state
b. By preventing a pregnancy which could worsen the symptoms of endometriosis
c. Through an effective but yet unknown process
d. By balancing her hormones, which will help her cope with her symptoms
e. Through achieving a pseudopregnancy state
Case Vignette 11
The mother of a seven-day-old newborn baby “Lechita,” comes to your office with questions about breastfeeding. This first time mother is concerned that the baby is not getting enough to drink.
The baby was born at term by vaginal delivery after an uncomplicated pregnancy. You elicit from mom that the baby is voiding 6-8 times a day, and stooling 4-6 times a day. There is no emesis, diarrhea, or excessive fussiness. Feeding history reveals that the baby is at the breast for 10-15 minutes per side at the end of which she seems satisfied but ends up “crying for more” in 2 hours. There is no family history of major medical problems, and the father of the baby is supportive of the breastfeeding Lechita’s birth weight was 7 lbs 11 oz (3487 gms). Her anterior fontanel is open, soft, and flat, not bulging or sunken, her mucous membranes are moist, and she is alert and active.