Name:_______________________________
Brown Medical School
The Integrated Final Exam
April 21, 2006
Bio Med 351 Human Reproduction, Growth and Development
Richard Moore, MD
Zeev Harel, MD
Bio Med 351Pharmacology
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:
1. ______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.
2. _______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.
3. ________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.
4. _________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.
5. _______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.
6. __________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.
You observe a breastfeeding session and assess that there is proper latch.
36. ______In addition to the history, exam, and session observed above, which of the
following would reassure you that Lechitta is receiving adequate breast milk?
a. Lechita’s weight today is 6 lbs 14 oz (3118gms) (10.9% loss)
b. Mom feels that her breasts are full (all of the time).
c. Audible and frequent swallowing is heard throughout the breastfeeding session.
d. None of the above
37. _______The mother then states that she initially had a lot of nipple pain with nursing
in the hospital, but that it now has stopped. She wants to know why she was having pain.
You congratulate her on working through this difficult time, and state that you may not
be able to tell her exactly why she was having nipple pain but that the most likely
explanation is that.
a. “All breastfeeding is painful at first”
b. “You were most likely breastfeeding for too long”
c. “You most likely had an infection or mastitis”
d. “Pain is often caused by improper position or latch”
38. _______The mother then tells you that her doctor wants her to start on a
medication for post partum depression called “Goodmood”. She asks you if this is safe
while breastfeeding. You look “Goodmood” up in the PDR and consult with your
pharmacist and determine that “Goodmood” has the following characteristics. Which of
the followings would raise your concern that this medication is unsafe in breastfeeding
mothers?
a. It is hydrophilic
b. It has a low molecular weight
c. It has a Milk: Plasma ratio that is 0.05
d. It has a short half-life
Case Vignette 12
Drug use during pregnancy is a major problem for health care providers due to the
relatively limited information available about drugs used during pregnancy, and the high
frequency of unplanned pregnancies.
39. ________The most important factor in determining transport of a drug from the
mother to the fetus is:
a. Increases in maternal cardiac output promoting enhanced delivery of the drug to the
placenta
b. The surface area of the placenta available for gas exchange
c. The maternal fetal osmotic gradient
d. The maternal steady state concentration of the drug
40. ________Which of the following is not correct regarding the effects of alcohol
exposure during pregnancy:
a. The characteristic triad of effects from fetal alcohol syndrome includes pre/post-natal
growth deficiency, cranial facial abnormalities, and central nervous system
dysfunction
b. Alcohol represents the most common major teratogen to which fetuses are exposed
c. The diagnosis of fetal alcohol syndrome can be easily established shortly after birth
and is amenable to early intervention
d. The major neurologic morbidities of fetal alcohol syndrome include problems with
attention, impulse control, judgment, and memory
e. 20% of women continue to drink alcohol during pregnancy
41. _______Thalidomide exposure during pregnancy is associated with the
development of Phocomelia/Amelia, cranial facial abnormalities, congenital heart
disease, and intestinal atresias. The time of exposure for such malformations to occur is:
a.
b.
c.
d.
e.
Second trimester
Days 2-6
Days 9-14
Days 21-36
Days 28-42
42. _________The following are correct statements regarding selective serotonin reuptake inhibitors (SSRIs) except for:
a. SSRIs are infrequently used during pregnancy due to their known teratogenic potential
b. SSRIs readily cross the placenta
c. SSRIs are associated with a neonatal withdrawal syndrome
d. SSRIs have been associated with persistent pulmonary artery hypertension of the
newborn
Case Vignette 13
A 36-year-old G2P1 was offered a Quad screen test at 15 weeks gestational age to
evaluate for possible fetal congenital anomalies. She is married to her first cousin. Her
prior pregnancy 7 years ago ended with the delivery of a full term male infant with no
abnormalities. She was diagnosed with Gestational diabetes during this pregnancy. She
reported using marijuana before and during pregnancy. Her current Quad screen results
are as follows:
Alpha Feto Protein = 0.5 MoM; Estriol = 0.4 MoM; HCG = 0.25 MoM; Inhibin A = 0.5
MoM.
(MoM=Multiples of Median)
She then underwent an amniocentesis at 20 weeks gestation and cytogenetic studies
revealed a 47, XY fetal karyotype. Following genetic counseling the mother elected to
terminate this pregnancy. On pathologic examination the fetus showed multiple
congenital anomalies including clenched fists with overlapping of second and fifth digits
over third and fourth. See photo.
43 ._________What is the most probable diagnosis?
a. Trisomy 13 (Patau syndrome)
b. Trisomy 18 (Edward’s syndrome)
c. Trisomy 21 (Down’s syndrome)
d. Monosomy X (Turner’s syndrome)
44. __________Apart from classical karyotype analysis, what other genetic test is
commonly used to detect this abnormality on fetal cells obtained trough amniocentesis?
a. DNA microarray
b. Preimplantation genetic diagnosis
c. Fluorescent in Situ Hybridization (FISH)
d. Comparative genomic hybridization
45. _________What risk factor was most probably associated with this abnormality.
a. Maternal diabetes
b. Advanced maternal age
c. Maternal use of marijuana
d. Consanguinity
46. _________What is the estimated risk associated with amniocentesis?
a. 0.5%
b. 1.5%
c. 10%
d. 20%
Case Vignette 14
You see a patient in your office with the chief complaint of a prior miscarriage. In the
course of taking care of her, you counsel her as to the following:
47. _______The single most likely contributing reason for her miscarriage was:
a. An infection
b. Her smoking
c. Her young reproductive age
d. Her advanced reproductive age
e. A structural problem
48. _______You state that her miscarriage was very typical in its characteristics
manifested by the fact that it:
a. Was associated with exposure to chemicals at her workplace
b. Was due to recurrent Herpes infection
c. Occurred in the first trimester
d. Led to a life threatening hemorrhage
e. Occurred despite progesterone treatment
49. ________Which of the following is likely to happen with her next pregnancy, if her
miscarriage was due to an infection with Toxoplasmosis?
a. Normal outcome with no related repercussions
b. Miscarriage again in first trimester
c. Inability to conceive because of the prior miscarriage
d. Miscarriage again in second trimester
50. _______Several months later, she presents requesting a termination of unintended
pregnancy. Of the following emotions, the most common one felt following a
termination is:
a. Joy
b. Stress
c. Guilt
d. Anger
e. Relief
Case Vignette 15
You are giving a lecture on puberty and the menstrual cycle to premed college students.
During this lecture, you discuss:
51. ________True precocious puberty:
a. Is more common in boys
b. Is a benign presentation in girls and should not be evaluated or treated
c. Is associated with an advanced bone age and may impair final height
d. Pulses of GnRH are used in the treatment of precocious puberty
52. ________Increasing levels of a hormone leading to decreasing amounts of the
stimulating substance is an example of:
a. Positive feedback
b. Negative feedback
c. Hyper synthesis of proteins
d. Apoptosis
53 .______Irregular & painless menstrual periods are common during the first three years
post menarche because of:
a. High consumption of seafood by adolescents
b. Inactivity of the cyclooxygenase enzyme during this time period
c. Immaturity of the positive estrogen - LH feedback mechanism and lack of LH surge at
around mid cycle
d. High level of progesterone during the luteal phase
54. ______If a woman’s menstrual cycle is 32 days, her luteal phase is:
a. 7 days
b. 14 days
c. 16 days
d. 18 days
e. 20 days
Case Vignette 16
A woman presents with amenorrhea. After an evaluation you diagnose her as having
hypothalamic amenorrhea (hypogonadotropic hypogonadism).
55. ______Which of the following laboratory tests is most consistent and diagnostic for
her condition?
a. Elevated serum LH
b. Low to normal serum FSH
c. Elevated serum progesterone
d. Elevated serum estrogen
e. Normal serum testosterone
56. ______Which of the options below is the theoretical best way to treat the patient
to restore her fertility?
a. Hormone replacement therapy
b. Continuous birth control pills
c. Cyclic birth control pills
d. Pulsatile GnRH treatment
e. High dose progesterone therapy
57. ______Which of the sentences below is a true statement in this patient?
a. She is likely to go through an early menopause
b. Her brain is very sensitive to changes in estrogen
c. Her condition is likely due to a tumor
d. She can never have a baby despite treatment
e. Her ovaries can still respond to gonadotropins (FSH, LH)
Case Vignette 17
A term newborn infant 3 hours old has tachypnea without obvious distress and is pink
and well perfused in room air. Delivery was normal.
58. _________The tachypnea is most likely due to:
a. Cyanotic heart disease
b. Surfactant deficiency
c. Unabsorbed retained lung fluid
d. Hypoxic - ischemic brain injury
59. ________If this were a 29 week premature infant with an oxygen requirement to stay
pink, the more likely cause of the respiratory distress would be:
a. Surfactant deficiency
b. Heart disease
c. Meconium aspiration
d. Bacterial pneumonia
60. ______If the mother had a fever, and the baby has a low blood pressure and a low
neutrophil count, you must also consider:
a. Hypothermia
b. Persistence of a right to left cardiac shunt
c. Retained lung fluid
d. Bacterial sepsis
61. _________If you do an arterial blood gas and the baby' s PaO2 is 70 mm Hg, that
value is:
a. Too high for a newborn
b. Too low
c. Just right
d. Irrelevant to your decision about giving oxygen
Case Vignette 18
A 28 year-old Gravida 3 para 1, with a history of preterm delivery in her previous
pregnancy, and now at 29 weeks gestation (by reliable dates), calls you at 11 pm and
describes painful, rhythmic tightening of her belly. She normally sees your partner in the
office, and is scheduled for a routine visit the day after tomorrow; you have never met the
patient. The contractions remind her of her labor pains from her last pregnancy, and are
occurring every 3 minutes for about an hour now.
62. _______By dating conventions, how long ago did she conceive this pregnancy?
a. 25 weeks
b. 27 weeks
c. 29 weeks
d. 39 weeks
63. ________She is:
a. In preterm labor, again
b. In latent phase labor
c. Having Braxton-Hicks contractions
d. Experiencing an infection of the amniotic membranes, resulting in prostaglandin
release
e. Don’t know yet
64. ________The best course of action for you is:
a. Reassure the patient that the majority of patients delivering early in their first
pregnancy deliver at term in their second
b. Arrange for the patient to be evaluated within the next 24 hours by her usual
obstetrician
c. Instruct the patient to present immediately for obstetrical evaluation
d. Instruct the patient to take an ibuprofen to block the prostaglandins that are probably
responsible for her contractions
65. ________Whatever your advice, she demands to be evaluated right away. The
nurse examines the patient and finds her cervix to be 3 cm dilated and 50% effaced.
There are no signs of infection or fetal compromise. As you complete your assessment of
mother and baby, options you can consider for treatment include all of the following
EXCEPT:
a. Magnesium sulfate
b. Synthetic Oxytocin
c. Beta-adrenergic agonist
d. Cyclo-oxygenase inhibitors
e. Calcium channel blockers
Case Vignette 19
A healthy nullipara at 40 weeks and 5 days gestation comes to labor and delivery
complaining of painful contractions; she also thinks her waters may have broken last
night. Her contractions are observed to occur every 2-3 minutes, lasting for 60 seconds.
The midwife checks her cervix, and reports that it is 2 cm dilated and 50% effaced.
66. ________She is:
a. Experiencing Braxton-Hicks contractions
b. In the quiescent stage of uterine activity, where 95% of pregnancy is spent
c. In the First stage of Labor, latent phase
d. In the First stage of Labor, active phase
e. In the Second stage of labor
67. ________She asks to be placed on Electronic Fetal Monitoring (EFM), and the
following tracing is observed:
How would you characterize these changes?
a. Early decelerations, suggestive of head compression
b. Variable decelerations, suggestive of cord compression but intact fetal neurologic
systems
c. Late decelerations, suggestive of fetal acidosis
d. Fetal tachycardia, suggestive of maternal cocaine use
68. ______Looking more closely at this deceleration, which of the following can be
inferred?
Time points:
A
B
C
D
E
a. Time point C represents the compression of the umbilical vein
b. Time point B represents the release of the umbilical artery
c. From Time point C to D, fetal circulation is halted
d. From Time point B to D, flow of oxygenated blood to the fetus is impaired
e. From Time point A to E, the fetus has become acidotic
Case Vignette 20
A 20-year-old female college freshman with a history of latex allergy has recently
initiated sexual activity and reports severe vaginal itching and discomfort after having
protected sex.
69. _____Which of the following condoms has she used?
a. Durex, Avanti male condom
b. Trojan Supra male condom
c. Ramses male condom
d. Reality female condom
You switched her to a condom made of polyurethane and the itching and discomfort after
intercourse have resolved. Three months later she reports that the polyurethane condom
she was using during sex 3-4 days ago broke. Her LMP was 2 weeks ago. The student is
concerned that a pregnancy at this time will mess up her life and asks for your help.
70. _____The right approach will be:
a. Advise her that it is too late for emergency contraception
b. No intervention is needed since the risk of pregnancy at this stage is very low
c. Perform a pregnancy test and if negative prescribe emergency contraception such as
Plan B
d. Intravaginal application of nonoxynol 9 while at your office, with a second intavaginal
application of nonoxynol 9 at home 12 hours later
Five months later she presents to your office during her menstrual period with a request
to initiate transdermal contraception.
71. _________Which of the following is true regarding the contraceptive patch
Ortho-Evra?
a. It contains etonogestrel, the primary metabolite of desogestrel
b. It is very effective in obese (> 198 pounds) women
c. Although peak concentrations of ethinyl estradiol are 25% lower in users of Ortho Evra
compared with the peak levels in users of OCP (with 35 mcg of ethinyl estradiol), area
under the curve and average steady state concentration of ethinyl estradiol are about
60% higher in users of Ortho Evra than in users of OCP (with 35 mcg of ethinyl
estradiol).
d. A woman may write on the patch reminders such as the patch change day or love notes
She used the patch for two months but was compelled to discontinue its use because of
application site reactions. She is now interested in Depo Provera.
72. _____Which of the following is not a side effect of Depo Provera?
a. Irregular menstrual periods
b. Weight gain
c. Dysmenorrhea
d. Decreased bone mineral density
Case Vignette 21
You are a reproductive endocrinologist working in a successful IVF program and a
couple present to you for help in conceiving. The male partner has cystic fibrosis.
Related to his cystic fibrosis, he has congenital bilateral absence of the vas deferens. In
order to assist this couple, you recommend In Vitro Fertilization (IVF), a testicular
biopsy for testicular sperm extraction (TESE), and fertilization of the woman’s eggs by
intracytoplasmic sperm injection (ICSI) using TESE-derived sperm, as illustrated in the
diagram below.
73. ______The structure that the arrows are pointing to, at 12 o’clock in the oocyte, is:
a. A cumulus cell
b. The first polar body
c. The germinal vesicle
d. The second polar body
e. The zona pellucida
74. _______Whether by ICSI, by IVF, or by intercourse, oocytes must be fertilized by
sperm in order to undergo:
a. Germinal vesicle breakdown (Metaphase I)
b. Separation of chromatids with formation of the first polar body and formation of a
Metaphase II oocyte
c. Separation of chromatids with formation of the second polar body and completion of
Meiosis II
d. Separation of homologous chromosome pairs with formation of the first polar body
and formation of a Metaphase II oocyte
e. Separation of homologous chromosome pairs with formation of the second polar body
and completion of Meiosis II
75. ________Which statement regarding the gametes present in a testicular biopsy for
TESE is true?
a. All gametes present will contain a haploid chromosome complement
b. Cytoplasmic bridges between gametes derived from the same spermatogonium are
maintained until advanced stages of maturation
c. Gametes lose physical contact with Sertoli cells upon entering Meiosis I
d. Most gametes will be mature
e. Tails and acrosomes develop once the gamete reaches the epididymis
76. ______The adluminal compartment of the seminiferous tubule:
a. Contains Type A spermatogonium
b. Contains Type B spermatogonium
c. Is separated from the basal compartment by tight junctions between Sertoli Cells and
Leydig Cells
d. Is separated from the basal compartment by tight junctions between adjacent Sertoli
cells
e. Is the site for germ cell mitosis in the male gonad
Case Vignette 22
The next couple that you see during your morning office session met in 2003 while
training for the Summer Olympics in Athens. She is a long-distance runner with a low
Body Mass Index and minimal body fat, who has not had a period in seven years. He is
on the weight-lifting team, and admits to ingesting a designer anabolic testosterone-like
steroid that is not detectable by current doping assays. Your evaluation reveals very low
levels of FSH, LH and estradiol in the woman. The man has very low levels of FSH, LH
and testosterone. A semen analysis reveals azoospermia. You diagnose hypothalamic,
hypogonadotropic amenorrhea in the woman because of her excessive physical activity
and low body fat. You diagnose hypogonadal hypogonadism in the man, secondary to
his excess anabolic/androgenic steroid intake.
77. _______Low gonadotropins in the woman:
a. Cause accelerated follicle and oocyte atresia
b. Inhibit germ cell mitosis
c. Prevent the initiation of germ cell meiosis
d. Result in the arrest of oocyte maturation at Prophase I
e. Result in the arrest of oocyte maturation at Metaphase II
78. _________Low gonadotropins in the man:
a. Inhibit the initiation of germ cell meiosis
b. Lead to spermatogenesis arrest at Meiosis I (Primary Spermatocyte)
c. Lead to spermatogenesis arrest at Meiosis II (Secondary Spermatocyte)
d. Result in diminished Sertoli cell testosterone production
e. Result in a compensatory increase in Sertoli cell production of Androgen Binding
Protein
79. ________Low levels of LH:
a. Inhibit both testosterone and inhibin synthesis by Leydig cells in the male and theca
cells in the female
b. Inhibit testosterone synthesis by Leydig cells in the male and theca cells in the female
c. Inhibit testosterone synthesis by Leydig cells in the male and granulosa cells in the
female
d. Inhibit testosterone synthesis by Sertoli cells in the male and theca cells in the female
e. Inhibit testosterone synthesis by Sertoli cells in the male and granulosa cells in the
female
80. ________Low levels of FSH:
a. Lead to failure of primordial germ cell migration from the yolk sac to the genital ridges
in utero.
b. Are associated with impaired erasure and re-establishment of imprinting in primordial
germ cells in utero.
c. Decrease inhibin secretion by Sertoli cells in males and estrogen secretion by granulosa
cells in females
d. Decrease inhibin secretion by Leydig cells in males and theca cells in females
e. Lead to compensatory increases in Sertoli cell production of Androgen Binding Protein
in the male and a compensatory increase in granulosa cell conversion of testosterone to
estradiol in the female.
Case Vignette 23
Failure to attain key developmental milestones by critical times suggests serious and
potentially life-long neuro-developmental problems.
At which of these well-child visits would you begin to worry if this milestone has not
been achieved?
81._________ Reaching with a raking grasp with both hands
a. 2 months
b. 4 months
c. 6 months
d. 9 months
e. 12 months
82._______ Sitting well alone
a. 2 months
b. 4 months
c. 6 months
d. 9 months
e. 12 months
83._________ Smiling responsively
a. Birth/newborn
b. 2 months
c. 4 months
d. 6 months
e. 9 months
84.________ Symmetric tone and movements of extremities, face, eyes
a. Birth/newborn
b. 2 months
c. 4 months
d. 6 months
e. 9 months