Urinary	
  incon*nence	
  
USMLE	
  prep	
  #2	
  
10.3.2016	
  
Klára	
  Valešová	
  (394587@mail.muni.cz)	
  	
  
Šimon	
  Hajda	
  (395098@mail.muni.cz)	
  
What	
  is	
  the	
  defini*on?	
  
•  involuntary	
  leakage	
  of	
  urine	
  
What	
  are	
  the	
  risk	
  factors?	
  
•  age:	
  diminished	
  size	
  of	
  bladder,	
  postmenopausal	
  
genitourinary	
  atrophy	
  
•  recurrent	
  urinary	
  tract	
  infec*ons	
  
•  DM,	
  CHF	
  
•  mul*parity,	
  history	
  of	
  prolonged	
  labor	
  
•  pelvic	
  floor	
  dysfunc*on	
  in	
  women,	
  BPH,	
  and	
  prostate	
  
cancer	
  in	
  in	
  men	
  
What	
  is	
  the	
  innerva*on	
  of	
  bladder?	
  
•  Relaxa*on	
  –	
  β2	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  Contrac*on	
  –	
  M3	
  
•  Sphincter	
  contrac*on	
  –	
  α1	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  Sphincter	
  relaxa*on	
  –	
  M3	
  
	
  	
  	
  	
  	
  Sympathe)c	
  effect	
   	
  	
  	
  	
  	
  	
  	
  	
  Parasympathe)c	
  effect	
  
Types	
  of	
  urinary	
  incon*nence	
  
1.  Urge	
  incon*nence	
  
2.  Stress	
  incon*nence	
  
3.  Overflow	
  incon*nence	
  
1.	
  Urge	
  incon*nence	
  
•  most	
  common	
  in	
  elderly	
  pa*ents	
  
•  causes:	
  idiopathic,	
  CNS	
  lesions	
  (demen*a,	
  strokes)	
  
•  mechanism:	
  involuntary	
  and	
  uninhibited	
  detrusor	
  
contrac*ons	
  -­‐>	
  loss	
  of	
  urine	
  
•  clinical	
  features:	
  sudden	
  urge	
  to	
  urinate,	
  loss	
  of	
  large	
  
volumes	
  of	
  urine	
  with	
  small	
  postvoid	
  residual,	
  and	
  
nocturnal	
  wejng	
  
•  diagnosis:	
  urodynamic	
  study	
  
•  management:	
  ini*ally	
  bladder-­‐training	
  exercises,	
  if	
  
unsuccessful	
  an*cholinergics	
  (oxybu*nin),	
  and	
  TCAs	
  
(imipramine)	
  
2.	
  Stress	
  incon*nence	
  
•  mostly	
  in	
  women	
  (aler	
  mul*ple	
  deliveries	
  of	
  children)	
  
•  mechanism:	
  weakness	
  of	
  the	
  pelvic	
  floor	
  allows	
  bladder	
  
neck	
  and	
  urethra	
  to	
  descend	
  with	
  increased	
  intra-­‐
abdominal	
  pressure	
  
•  clinical	
  features:	
  involuntary	
  urine	
  loss	
  during	
  increased	
  
intra-­‐abdominal	
  pressure	
  (cough,	
  laugh,	
  sneeze,	
  
exercise);	
  small	
  postvoid	
  volume	
  
•  management:	
  Kegel	
  exercises	
  (to	
  strengthen	
  pelvic	
  
floor	
  musculature);	
  estrogen	
  replacement	
  therapy;	
  
surgery	
  	
  
hnp://www.pcdsupport.org.uk/index.php/what_is_pcd/raising_a_family_30_years/
what_is_stress_incon*nence/	
  
3.	
  Overflow	
  incon*nence	
  I	
  
•  common	
  in	
  diabe*c	
  pa*ents	
  and	
  pa*ents	
  with	
  
neurologic	
  disorders	
  
•  mechanism:	
  inadequate	
  bladder	
  contrac*on	
  (due	
  to	
  
impaired	
  detrusor	
  contrac*lity)	
  or	
  a	
  bladder	
  outlet	
  
obstruc*on	
  -­‐>	
  urinary	
  reten*on	
  and	
  subsequent	
  
overdisten*on	
  of	
  the	
  bladder.	
  Bladder	
  pressure	
  
increases	
  un*l	
  it	
  exceeds	
  urethral	
  resistance-­‐>	
  urine	
  
leakage	
  
•  causes:	
  neurogenic	
  bladder	
  (diabe*c	
  pa*ents,	
  lower	
  
motor	
  neuron	
  lesions),	
  medica*ons	
  (an*cholinergics,	
  α-­‐
agonists),	
  obstruc)on	
  to	
  urine	
  flow	
  (BPH,	
  prostate	
  
cancer,	
  urethral	
  strictures)	
  	
  	
  
3.	
  Overflow	
  incon*nence	
  II	
  
•  clinical	
  features:	
  	
  nocturnal	
  wejng,	
  frequent	
  loss	
  of	
  
small	
  amount	
  of	
  urine;	
  large	
  postvoid	
  residual	
  
•  management:	
  interminent	
  self-­‐catheteriza*on	
  is	
  the	
  
best	
  management;	
  cholinergic	
  agents	
  (bethanechol);	
  
α-­‐blockers	
  (terazosin,	
  doxazosin)	
  	
  
Pujng	
  it	
  all	
  together	
  I	
  
Pujng	
  it	
  all	
  together	
  II	
  
hnp://dilipraja.com/urinary-­‐incon.htm	
  
Literature:	
  
1.  AGABEGI,	
  Steven	
  S.	
  and	
  AGABEGI,	
  Elizabeth	
  
D.	
  Step-­‐up	
  to	
  medicine.	
  Third	
  edi*on.	
  
Philadelphia:	
  Lippincon	
  Williams	
  and	
  Wilkins,	
  
c2013.	
  ISBN	
  978-­‐1609133603.	
  
2.  VOJVODIC,	
  Miliana	
  and	
  YOUNG,	
  Ann.	
  
Essen8al	
  Med	
  Notes	
  2014.	
  Thir*eth	
  edi*on.	
  
ISBN:	
  978-­‐1-­‐92736307-­‐2	
  
2.	
  Ques*ons	
  
Q1:	
  A	
  70-­‐year-­‐old	
  woman	
  is	
  evaluated	
  for	
  urinary	
  
incon*nence.	
  She	
  reports	
  frequent	
  urge	
  to	
  urinate.	
  
She	
  also	
  says,	
  that	
  „when	
  she	
  needs	
  to	
  go	
  she	
  has	
  to	
  
go	
  immediately“,	
  because	
  she	
  can´t	
  control	
  urinary	
  
flow	
  and	
  has	
  problems	
  with	
  urinary	
  leakage.	
  She	
  
started	
  using	
  pads	
  during	
  day	
  and	
  at	
  night,	
  because	
  her	
  
symptoms	
  worsened	
  since	
  her	
  last	
  visit.	
  Physical	
  
examina*on	
  is	
  insignificant,	
  pelvic	
  examina*on	
  reveals	
  
vaginal	
  atrophy	
  and	
  urinanalysis	
  is	
  normal.	
  Which	
  of	
  
the	
  following	
  is	
  the	
  most	
  appropriate	
  next	
  step?	
  
(A)	
  Begin	
  oral	
  estrogen	
  replacement	
  therapy	
  
(B)	
  Begin	
  oxybu*nin	
  
(C)	
  Begin	
  bethanechol	
  
(D)	
  Perform	
  cystoscopy	
  
(E)	
  	
  Surgical	
  management	
  
The	
  correct	
  answer	
  is	
  (B):	
  The	
  pa*ent	
  presents	
  with	
  typical	
  symptoms	
  of	
  
urge	
  incon*nence.	
  This	
  type	
  of	
  incon*nence	
  is	
  typical	
  in	
  older,	
  
postmenopausal	
  woman.	
  The	
  underlying	
  detrusor	
  instability	
  or	
  
hyperreflexia	
  leads	
  to	
  involuntary	
  detrusor	
  contrac*on	
  and	
  involuntary	
  
urine	
  leakage	
  accompanied	
  by	
  urgency	
  of	
  micturi)on.	
  The	
  next	
  step	
  in	
  
this	
  case	
  is	
  begin	
  an*cholinergic	
  treatment	
  (oxybu*nin,	
  tolterodin).	
  	
  
The	
  major	
  pa*ent	
  complain	
  is	
  incon*nence,	
  replacement	
  of	
  estrogen	
  (A)	
  
would	
  not	
  help	
  and	
  put	
  the	
  pa*ent	
  to	
  the	
  greater	
  risk	
  of	
  developement	
  of	
  
neoplasia.	
  
(B)	
  Bethanechol,	
  cholinergic	
  agent,	
  is	
  used	
  in	
  treatment	
  of	
  urinary	
  
overflow	
  incon*nence.	
  Bethanechol	
  would	
  not	
  improve	
  urge	
  
incon*nence.	
  
There	
  is	
  no	
  need	
  to	
  perform	
  cystoscopy	
  (D),	
  which	
  is,	
  in	
  this	
  case,	
  
unnecessary	
  invasive	
  procedure.	
  	
  
Surgerical	
  management	
  (E)	
  is	
  not	
  indicated	
  in	
  urge	
  urinary	
  incon*nence	
  
and	
  would	
  not	
  help	
  pa*ent	
  relieve	
  symptoms.	
  	
  
Q2:	
  A	
  78-­‐year-­‐old	
  man	
  comes	
  to	
  the	
  physician	
  for	
  evalua*on	
  aler	
  
falling	
  fi	
  ve	
  *mes	
  in	
  2	
  months.	
  An	
  x-­‐ray	
  skeletal	
  survey	
  reveals	
  no	
  
fractures,	
  but	
  the	
  pa*ent	
  admits	
  to	
  worsening	
  urinary	
  incon*nence	
  
over	
  the	
  previous	
  4	
  months.	
  His	
  wife	
  states	
  that	
  his	
  memory	
  and	
  
concentra*on	
  have	
  deteriorated	
  recently.	
  The	
  pa*ent’s	
  vital	
  signs	
  
are	
  normal,	
  and	
  his	
  physical	
  examina*on	
  is	
  notable	
  for	
  a	
  wide-­‐
based	
  gait	
  with	
  short	
  steps.	
  A	
  Mini-­‐Mental	
  State	
  Examina*on	
  
results	
  in	
  a	
  score	
  of	
  26/30.	
  His	
  funduscopic	
  examina*on	
  is	
  normal,	
  
and	
  his	
  neurologic	
  examina*on	
  is	
  notable	
  for	
  slight	
  bradykinesia	
  
without	
  tremor.	
  Laboratory	
  tests,	
  including	
  serum	
  vitamin	
  B12,	
  
folate,	
  and	
  TSH,	
  are	
  normal.	
  What	
  is	
  the	
  most	
  likely	
  e*ology	
  of	
  this	
  
pa*ent’s	
  recent	
  decline?	
  	
  
(A)  Alzheimer’s	
  disease	
  	
  
(B)  Hypothyroidism	
  	
  
(C)  Mul*-­‐infarct	
  demen*a	
  	
  
(D)  Normal	
  pressure	
  hydrocephalus	
  	
  
(E)	
  Parkinson’s	
  disease	
  
LE,	
  Tao,	
  Karen	
  A	
  ADLER	
  a	
  Seth	
  K	
  BECHIS	
  (eds.).	
  First	
  aid	
  Q&A	
  for	
  the	
  USMLE	
  Step	
  1.	
  2nd	
  ed.	
  New	
  York:	
  McGraw-­‐Hill	
  Medical,	
  c2009.	
  ISBN	
  978-­‐0-­‐07-­‐159794-­‐4	
  
	
  The	
  correct	
  answer	
  is	
  D.	
  This	
  pa*ent	
  has	
  a	
  poten*ally	
  reversible	
  case	
  of	
  demen*a:	
  
normal	
  pressure	
  hydrocephalus	
  (NPH),	
  with	
  the	
  classic	
  triad	
  of	
  incon)nence,	
  gait	
  
difficulty,	
  and	
  mental	
  decline	
  (“wet,	
  wobbly,	
  and	
  wacky”).	
  The	
  score	
  of	
  26/30	
  on	
  
the	
  MiniMental	
  State	
  Examina*on	
  indicates	
  only	
  that	
  some	
  mild	
  abnormality	
  is	
  
present.	
  The	
  pathophysiology	
  of	
  NPH	
  is	
  not	
  well	
  understood,	
  but	
  it	
  is	
  thought	
  that	
  
neurons	
  are	
  stretched	
  secondary	
  to	
  ventricular	
  dila*on	
  caused	
  by	
  excessive	
  
cerebrospinal	
  fluid	
  produc*on,	
  decreased	
  absorp*on,	
  or	
  both.	
  	
  
Answer	
  A	
  is	
  incorrect.	
  Alzheimer’s	
  disease	
  can	
  present	
  with	
  some	
  of	
  the	
  symptoms	
  
in	
  this	
  case.	
  However,	
  significant	
  physical	
  impairment	
  tends	
  to	
  occur	
  later	
  in	
  the	
  
Alzheimer’s	
  disease	
  process	
  and	
  would	
  thus	
  correlate	
  with	
  a	
  much	
  lower	
  score	
  on	
  
the	
  Mini-­‐Mental	
  State	
  Examina*on.	
  The	
  *me	
  course	
  and	
  the	
  rela*vely	
  rapid	
  
progression	
  in	
  symptoms	
  are	
  not	
  consistent	
  with	
  this	
  diagnosis.	
  	
  
Answer	
  B	
  is	
  incorrect.	
  Hypothyroidism,	
  another	
  poten*al	
  cause	
  of	
  reversible	
  
demen)a	
  in	
  the	
  elderly,	
  should	
  be	
  ruled	
  out	
  early	
  in	
  the	
  work-­‐up.	
  This	
  pa*ent’s	
  
TSH	
  level	
  is	
  normal,	
  indica*ng	
  euthyroidism.	
  
Answer	
  C	
  is	
  incorrect.	
  Mul*-­‐infarct	
  demen*a	
  is	
  the	
  most	
  common	
  cause	
  of	
  
cogni)ve	
  decline	
  with	
  a	
  stepwise	
  drop	
  in	
  func*on	
  in	
  the	
  sejng	
  of	
  prior	
  
cerebrovascular	
  disease	
  and	
  stroke.	
  In	
  this	
  case,	
  the	
  decline	
  has	
  been	
  steadily	
  
progressive	
  in	
  a	
  pa*ent	
  with	
  no	
  history	
  of	
  vascular	
  disease.	
  
	
  Answer	
  E	
  is	
  incorrect.	
  Parkinson’s	
  disease	
  classically	
  presents	
  with	
  bradykinesia,	
  
masklike	
  facies,	
  shuffling	
  gait,	
  tremor,	
  and	
  rigidity.	
  This	
  pa*ent	
  has	
  mild	
  
bradykinesia	
  and	
  no	
  rigidity	
  or	
  tremor,	
  so	
  this	
  diagnosis	
  is	
  a	
  less	
  likely	
  possibility.	
  
LE,	
  Tao,	
  Karen	
  A	
  ADLER	
  a	
  Seth	
  K	
  BECHIS	
  (eds.).	
  First	
  aid	
  Q&A	
  for	
  the	
  USMLE	
  Step	
  1.	
  2nd	
  ed.	
  New	
  York:	
  McGraw-­‐Hill	
  Medical,	
  c2009.	
  ISBN	
  978-­‐0-­‐07-­‐159794-­‐4	
  
Q3:	
  A	
  newborn	
  infant	
  is	
  found	
  to	
  have	
  a	
  
congenital	
  urethral	
  abnormality	
  in	
  which	
  the	
  
urethral	
  meatus	
  opens	
  on	
  the	
  ventral	
  side	
  of	
  the	
  
penis,	
  resul*ng	
  in	
  difficulty	
  direc*ng	
  the	
  urine	
  
stream	
  and	
  ventral	
  curvature	
  of	
  the	
  penis.	
  Which	
  
of	
  the	
  following	
  is	
  the	
  cause	
  of	
  this	
  
malforma*on?	
  	
  
(A) Failure	
  of	
  urethral	
  fold	
  fusion	
  	
  
(B) Failure	
  of	
  urethrorectal	
  septum	
  forma*on	
  	
  
(C) Maldevelopment	
  of	
  the	
  urinary	
  sphincters	
  	
  
(D) Short	
  urethra	
  	
  
(E) Urethral	
  stricture	
  
LE,	
  Tao,	
  Karen	
  A	
  ADLER	
  a	
  Seth	
  K	
  BECHIS	
  (eds.).	
  First	
  aid	
  Q&A	
  for	
  the	
  USMLE	
  Step	
  1.	
  2nd	
  ed.	
  New	
  York:	
  McGraw-­‐Hill	
  Medical,	
  c2009.	
  ISBN	
  978-­‐0-­‐07-­‐159794-­‐4	
  
The	
  correct	
  answer	
  is	
  A.	
  The	
  malforma*on	
  described	
  is	
  
hypospadias,	
  resul*ng	
  from	
  incomplete	
  union	
  of	
  the	
  urethral	
  
folds.	
  In	
  the	
  male,	
  the	
  urethral	
  folds	
  form	
  the	
  ventral	
  aspect	
  of	
  the	
  
penis.	
  In	
  the	
  female,	
  the	
  urethral	
  folds	
  develop	
  into	
  the	
  labia	
  
minora.	
  	
  
Answer	
  B	
  is	
  incorrect.	
  Congenital	
  failure	
  of	
  urethrorectal	
  septum	
  
forma*on	
  results	
  in	
  an	
  abnormal	
  communica*on	
  between	
  the	
  
urethra	
  and	
  the	
  rectum.	
  Clinical	
  signs	
  include	
  feces	
  in	
  the	
  urine.	
  
This	
  is	
  not	
  a	
  cause	
  of	
  hypospadias.	
  	
  
Answer	
  C	
  is	
  incorrect.	
  In	
  males,	
  the	
  proximal	
  por*on	
  of	
  the	
  urethra	
  
forms	
  from	
  the	
  urogenital	
  sinus.	
  The	
  distal	
  urethra	
  is	
  formed	
  by	
  
ectoderm	
  that	
  is	
  canalized	
  to	
  form	
  the	
  navicular	
  fossa.	
  If	
  the	
  
sphincters	
  do	
  not	
  form	
  properly,	
  urethral	
  incompetence	
  and	
  
incon)nence	
  result.	
  	
  
Answer	
  D	
  is	
  incorrect.	
  A	
  short	
  urethra	
  causes	
  chordee,	
  or	
  poorly	
  
developed	
  penis	
  with	
  ventral	
  curvature,	
  without	
  hypospadias.	
  	
  
Answer	
  E	
  is	
  incorrect.	
  Urethral	
  stricture	
  causes	
  urethral	
  
obstruc)on	
  and	
  is	
  the	
  second	
  most	
  common	
  cause	
  of	
  
incon)nence	
  in	
  older	
  men.	
  It	
  is	
  not	
  a	
  cause	
  of	
  hypospadias.	
  
LE,	
  Tao,	
  Karen	
  A	
  ADLER	
  a	
  Seth	
  K	
  BECHIS	
  (eds.).	
  First	
  aid	
  Q&A	
  for	
  the	
  USMLE	
  Step	
  1.	
  2nd	
  ed.	
  New	
  York:	
  McGraw-­‐Hill	
  Medical,	
  c2009.	
  ISBN	
  978-­‐0-­‐07-­‐159794-­‐4	
  
Q4:	
  A	
  74-­‐year-­‐old	
  man	
  comes	
  to	
  the	
  physician	
  complaining	
  
of	
  increased	
  urinary	
  frequency	
  along	
  with	
  difficulty	
  star*ng	
  
and	
  stopping	
  urina*on.	
  Assuming	
  a	
  benign	
  underlying	
  
cause,	
  which	
  of	
  the	
  following	
  is	
  the	
  mechanism	
  of	
  ac*on	
  of	
  
a	
  common	
  medica*on	
  used	
  to	
  treat	
  this	
  condi*on?	
  	
  
(A)	
  Forma*on	
  of	
  superoxide	
  radicals	
  that	
  anack	
  DNA	
  bonds	
  	
  
(B)	
  Gonadotropin-­‐releasing	
  hormone	
  analog	
  	
  
(C)	
  Inhibi*on	
  of	
  cyclic	
  guanosine	
  monophosphate–specific	
  
phosphodiesterase	
  type	
  5	
  	
  
(D)	
  Inhibi*on	
  of	
  cytochrome	
  P450	
  enzymes	
  	
  
(E)	
  Inhibi*on	
  of	
  5α-­‐reductase	
  	
  
(F)	
  Inhibi*on	
  of	
  testosterone’s	
  nega*ve	
  feedback	
  on	
  
gonadotropin	
  secre*on	
  
LE,	
  Tao,	
  Karen	
  A	
  ADLER	
  a	
  Seth	
  K	
  BECHIS	
  (eds.).	
  First	
  aid	
  Q&A	
  for	
  the	
  USMLE	
  Step	
  1.	
  2nd	
  ed.	
  New	
  York:	
  McGraw-­‐Hill	
  Medical,	
  c2009.	
  ISBN	
  978-­‐0-­‐07-­‐159794-­‐4	
  
The	
  correct	
  answer	
  is	
  E.	
  This	
  man	
  has	
  the	
  symptoms	
  of	
  benign	
  prosta)c	
  hypertrophy,	
  which	
  
include	
  difficulty	
  star*ng	
  and	
  maintaining	
  a	
  urine	
  stream,	
  feeling	
  as	
  though	
  the	
  bladder	
  is	
  never	
  
emp*ed,	
  having	
  the	
  urge	
  to	
  urinate	
  again	
  soon	
  aler	
  voiding,	
  and	
  pain	
  on	
  urina*on	
  or	
  dysuria.	
  
Finasteride	
  is	
  most	
  commonly	
  used	
  to	
  treat	
  this	
  condi*on.	
  Finasteride	
  acts	
  by	
  inhibi*ng	
  the	
  
conversion	
  of	
  testosterone	
  to	
  dihydrotestosterone	
  by	
  inhibi)ng	
  5α-­‐reductase.	
  This	
  leads	
  to	
  a	
  
reduc*on	
  in	
  the	
  size	
  of	
  the	
  prostate,	
  providing	
  symptoma*c	
  relief.	
  	
  
Answer	
  A	
  is	
  incorrect.	
  Bleomycin	
  acts	
  by	
  chela*ng	
  mechanisms	
  to	
  anack	
  the	
  phosphodiester	
  
bonds	
  of	
  DNA.	
  It	
  is	
  used	
  to	
  treat	
  tes)cular	
  tumors	
  and	
  lymphomas	
  (especially	
  Hodgkin’s),	
  not	
  
benign	
  prosta*c	
  hypertrophy.	
  	
  
Answer	
  B	
  is	
  incorrect.	
  Leuprolide	
  is	
  a	
  gonadotropin-­‐releasing	
  hormone	
  analog	
  that	
  binds	
  the	
  
luteinizing	
  hormone-­‐releasing	
  hormone	
  receptor	
  in	
  the	
  pituitary.	
  This	
  leads	
  to	
  reduced	
  release	
  
of	
  luteinizing	
  hormone.	
  Leuprolide	
  is	
  used	
  to	
  treat	
  metasta)c	
  carcinoma	
  of	
  the	
  prostate,	
  not	
  
benign	
  prosta*c	
  hypertrophy.	
  	
  
Answer	
  C	
  is	
  incorrect.	
  Sildenafil	
  inhibits	
  cGMP-­‐specific	
  phosphodiesterase	
  type	
  5,	
  resul*ng	
  in	
  
increased	
  concentra*ons	
  of	
  cGMP,	
  which	
  increases	
  vasodila*on	
  leading	
  to	
  increased	
  blood	
  fl	
  ow	
  
to	
  the	
  corpus	
  cavernosum.	
  Sildenafi	
  l	
  is	
  used	
  primarily	
  to	
  treat	
  erec)le	
  dysfunc)on.	
  	
  
Answer	
  D	
  is	
  incorrect.	
  Ketoconazole	
  is	
  an	
  that	
  acts	
  by	
  inhibi*ng	
  cytochrome	
  P450	
  enzymes.	
  It	
  is	
  
not	
  used	
  in	
  the	
  treatment	
  of	
  benian*fungal	
  with	
  an*androgenic	
  proper*es	
  gn	
  prosta*c	
  
hypertrophy.	
  	
  
Answer	
  F	
  is	
  incorrect.	
  Flutamide	
  is	
  a	
  potent	
  androgen	
  receptor	
  antagonist.	
  This	
  drug	
  is	
  used	
  
primarily	
  in	
  conjunc*on	
  with	
  a	
  gonadotropin-­‐releasing	
  hormone	
  analog	
  in	
  the	
  treatment	
  of	
  
metasta)c	
  prostate	
  cancer.	
  
LE,	
  Tao,	
  Karen	
  A	
  ADLER	
  a	
  Seth	
  K	
  BECHIS	
  (eds.).	
  First	
  aid	
  Q&A	
  for	
  the	
  USMLE	
  Step	
  1.	
  2nd	
  ed.	
  New	
  York:	
  McGraw-­‐Hill	
  Medical,	
  c2009.	
  ISBN	
  978-­‐0-­‐07-­‐159794-­‐4	
  
Q5:	
  A	
  73-­‐year-­‐old	
  pa*ent	
  has	
  been	
  hospitalized	
  for	
  6	
  days	
  due	
  to	
  
complica*ons	
  from	
  surgery.	
  The	
  pa*ent	
  had	
  a	
  urinary	
  catheter	
  in	
  
place,	
  which	
  was	
  removed	
  on	
  the	
  fourth	
  hospital	
  day.	
  Now	
  she	
  is	
  
complaining	
  of	
  painful	
  and	
  frequent	
  urina*on	
  and	
  has	
  a	
  fever	
  of	
  
38.9°	
  C	
  (102°	
  F).	
  Urinalysis	
  results	
  are	
  posi*ve	
  for	
  nitrites	
  and	
  
leukocyte	
  esterase.	
  A	
  urine	
  culture	
  grows	
  a	
  gram-­‐nega*ve	
  rod	
  that	
  
produces	
  a	
  red	
  pigment.	
  Which	
  of	
  the	
  following	
  organisms	
  is	
  the	
  
most	
  likely	
  cause	
  of	
  this	
  pa*ent’s	
  symptoms?	
  	
  
(A)	
  Candida	
  albicans	
  	
  
(B)	
  Escherichia	
  coli	
  	
  
(C)	
  Klebsiella	
  pneumoniae	
  	
  
(D)	
  Proteus	
  mirabilis	
  	
  
(E)	
  Pseudomonas	
  aeruginosa	
  	
  
(F)	
  Serra*a	
  marcescens	
  	
  
(G)	
  Staphylococcus	
  saprophy*cus	
  
LE,	
  Tao,	
  Karen	
  A	
  ADLER	
  a	
  Seth	
  K	
  BECHIS	
  (eds.).	
  First	
  aid	
  Q&A	
  for	
  the	
  USMLE	
  Step	
  1.	
  2nd	
  ed.	
  New	
  York:	
  McGraw-­‐Hill	
  Medical,	
  c2009.	
  ISBN	
  978-­‐0-­‐07-­‐159794-­‐4	
  
The	
  correct	
  answer	
  is	
  F.	
  This	
  pa*ent	
  presents	
  with	
  symptoms	
  of	
  a	
  UTI,	
  most	
  likely	
  caused	
  by	
  
prolonged	
  urethral	
  catheteriza*on.	
  Nosocomial	
  UTI	
  is	
  most	
  olen	
  associated	
  with	
  Escherichia	
  
coli,	
  Proteus	
  mirabilis,	
  Pseudomonas	
  aeruginosa,	
  Klebsiella	
  pneumoniae,	
  Serra)a	
  marcescens,	
  
staphylococci,	
  enterococci,	
  and	
  Candida	
  albicans.	
  Although	
  the	
  pa*ent’s	
  symptoms	
  are	
  not	
  
specific	
  for	
  any	
  of	
  these	
  organisms,	
  the	
  urine	
  culture	
  tells	
  us	
  that	
  (1)	
  the	
  organism	
  is	
  a	
  gram-­‐
nega*ve	
  rod,	
  and	
  (2)	
  the	
  organism	
  produces	
  a	
  red	
  pigment.	
  S.	
  marcescens	
  is	
  a	
  gram-­‐nega*ve	
  
rod	
  that	
  produces	
  a	
  red	
  pigment	
  called	
  prodigiosin.	
  
Answer	
  A	
  is	
  incorrect.	
  The	
  presence	
  of	
  Candida	
  albicans	
  in	
  an	
  otherwise	
  normal	
  female	
  usually	
  
represents	
  coloniza*on	
  rather	
  than	
  infec*on.	
  UTI	
  with	
  Candida	
  usually	
  can	
  be	
  anributed	
  to	
  
structural	
  abnormali*es,	
  metabolic	
  or	
  hormonal	
  abnormali*es.	
  
	
  Answer	
  B	
  is	
  incorrect.	
  Escherichia	
  coli	
  is	
  the	
  most	
  common	
  cause	
  of	
  UTI.	
  Although	
  it	
  is	
  a	
  gram-­‐
nega*ve	
  rod,	
  it	
  does	
  not	
  produce	
  any	
  pigments.	
  	
  
Answer	
  C	
  is	
  incorrect.	
  Klebsiella	
  pneumoniae	
  is	
  a	
  gram-­‐nega*ve	
  rod	
  and	
  is	
  responsible	
  for	
  
approximately	
  8%	
  of	
  nosocomial	
  infec*ons.	
  It	
  is	
  a	
  significant	
  cause	
  of	
  UTI	
  and	
  pneumonia	
  in	
  
hospitalized	
  and	
  ambulatory	
  pa*ents.	
  K.	
  pneumoniae	
  does	
  not	
  produce	
  any	
  pigments.	
  	
  
Answer	
  D	
  is	
  incorrect.	
  Proteus	
  mirabilis	
  is	
  a	
  gram-­‐nega*ve	
  bacillus	
  and	
  is	
  a	
  frequent	
  cause	
  of	
  
nosocomial	
  UTI.	
  It	
  produces	
  the	
  enzyme	
  urease,	
  which	
  serves	
  to	
  create	
  a	
  more	
  alkaline	
  
environment	
  for	
  itself	
  (urea	
  →	
  ammonia	
  +	
  carbon	
  dioxide)	
  but	
  does	
  not	
  produce	
  any	
  pigments.	
  	
  
Answer	
  E	
  is	
  incorrect.	
  Pseudomonas	
  aeruginosa	
  has	
  been	
  known	
  to	
  cause	
  catheter-­‐associated	
  
UTI.	
  Although	
  it	
  is	
  a	
  gram-­‐nega*ve	
  rod,	
  it	
  produces	
  a	
  blue-­‐green	
  pigment	
  called	
  pyocyanin.	
  	
  
Answer	
  G	
  is	
  incorrect.	
  Staphylococcus	
  saprophy*cus	
  is	
  the	
  second	
  most	
  common	
  cause	
  of	
  UTI	
  in	
  
young	
  women.	
  It	
  is	
  a	
  gram-­‐posi*ve	
  coccus	
  and	
  does	
  not	
  produce	
  any	
  pigments.	
  
LE,	
  Tao,	
  Karen	
  A	
  ADLER	
  a	
  Seth	
  K	
  BECHIS	
  (eds.).	
  First	
  aid	
  Q&A	
  for	
  the	
  USMLE	
  Step	
  1.	
  2nd	
  ed.	
  New	
  York:	
  McGraw-­‐Hill	
  Medical,	
  c2009.	
  ISBN	
  978-­‐0-­‐07-­‐159794-­‐4	
  
Q6:	
  A	
  20-­‐year-­‐old	
  woman	
  presents	
  with	
  a	
  2-­‐day	
  history	
  
of	
  dysuria	
  and	
  increased	
  urinary	
  frequency.	
  She	
  states	
  
that	
  she	
  was	
  recently	
  married	
  and	
  was	
  not	
  sexually	
  
ac*ve	
  prior	
  to	
  the	
  marriage.	
  Physical	
  examina*on	
  
reveals	
  a	
  temperature	
  of	
  38.2°C	
  with	
  normal	
  vital	
  
signs.	
  Gynecologic	
  examina*on	
  reveals	
  no	
  evidence	
  of	
  
discharge,	
  vagini*s,	
  or	
  cervici*s.	
  Urinalysis	
  reveals	
  14	
  
white	
  blood	
  cells	
  per	
  high-­‐powered	
  field	
  with	
  many	
  
gram-­‐nega*ve	
  rods.	
  Which	
  of	
  the	
  following	
  is	
  the	
  most	
  
appropriate	
  pharmacotherapy?	
  
(A)  Celriaxone	
  
(B)  Fluconazole	
  
(C)  Gentamicin	
  
(D) Metronidazole	
  
(E)  Trimethoprim-­‐sulfamethoxazole	
  
USMLE	
  step	
  1	
  Qbook.	
  Seventh	
  edi*on.	
  New	
  York	
  :	
  Kaplan	
  Publishing,	
  2015.	
  ISBN:	
  978-­‐1625232632	
  
The	
  correct	
  answer	
  is	
  E.	
  The	
  pa*ent’s	
  presenta*on	
  is	
  consistent	
  with	
  a	
  simple	
  
urinary	
  tract	
  infec*on;	
  there	
  is	
  a	
  short	
  history	
  of	
  dysuria,	
  increased	
  urinary	
  
frequency,	
  and	
  the	
  appearance	
  of	
  white	
  blood	
  cells	
  and	
  gram-­‐nega*ve	
  rods	
  
in	
  the	
  urine.	
  Urinary	
  tract	
  infec*ons	
  are	
  common	
  in	
  women	
  aler	
  they	
  
become	
  sexually	
  ac*ve.	
  The	
  infec*on	
  is	
  likely	
  caused	
  by	
  urethral	
  trauma	
  
during	
  intercourse,	
  which	
  leads	
  to	
  bacterial	
  contamina*on	
  of	
  the	
  bladder.	
  
Since	
  most	
  of	
  these	
  infec*ons	
  are	
  caused	
  by	
  Escherichia	
  coli	
  (a	
  gram-­‐
nega*ve	
  rod),	
  the	
  most	
  appropriate	
  therapy	
  would	
  be	
  trimethoprim-­‐
sulfamethoxazole	
  (TMP-­‐SMX)	
  for	
  around	
  3	
  days.	
  
Celriaxone	
  (choice	
  A)	
  is	
  the	
  treatment	
  of	
  choice	
  for	
  uncomplicated	
  infec*ons	
  
with	
  Neisseria	
  gonorrhoeae,	
  now	
  that	
  most	
  strains	
  are	
  resistant	
  to	
  
penicillin.	
  
Fluconazole	
  (choice	
  B)	
  is	
  indicated	
  for	
  the	
  treatment	
  of	
  vaginal	
  candidiasis.	
  
Since	
  there	
  is	
  no	
  vaginal	
  discharge	
  and	
  the	
  pa*ent	
  has	
  gram	
  nega*ve	
  rods	
  
in	
  the	
  urine,	
  a	
  diagnosis	
  of	
  vaginal	
  candidiasis	
  can	
  be	
  excluded.	
  
Gentamicin	
  (choice	
  C)	
  would	
  be	
  an	
  inappropriate	
  choice.	
  Most	
  urinary	
  
infec*ons	
  caused	
  by	
  gram-­‐nega*ve	
  rods	
  are	
  sensi*ve	
  to	
  TMP-­‐SMX,	
  and	
  the	
  
poten*al	
  for	
  toxicity	
  secondary	
  to	
  gentamicin	
  is	
  great.	
  	
  
Metronidazole	
  (choice	
  E)	
  is	
  an	
  an*bio*c	
  typically	
  used	
  in	
  the	
  treatment	
  of	
  
vaginal	
  Trichomonas	
  and	
  Gardnerelli	
  infec*ons,	
  as	
  well	
  as	
  serious	
  infec*ons	
  
believed	
  to	
  be	
  caused	
  by	
  anaerobic	
  bacteria.	
  Since	
  there	
  is	
  no	
  vaginal	
  
discharge	
  and	
  the	
  pa*ent	
  has	
  gram-­‐nega*ve	
  rods	
  in	
  the	
  urine,	
  this	
  is	
  not	
  
the	
  best	
  choice	
  for	
  the	
  treatment.	
  	
  
Most	
  common	
  urinary	
  tract	
  infec*ons	
  
bugs	
  
•  Escherichia	
  coli	
  
– leading	
  cause	
  of	
  UTI.	
  Collonies	
  show	
  green	
  metalic	
  
sheen	
  on	
  EMB	
  agar.	
  
•  Staphylococcus	
  saprophy8cus	
  
– 2nd	
  leading	
  cause	
  of	
  UTI	
  in	
  sexually	
  ac*ve	
  women	
  
•  Klebsiella	
  pneumoniae	
  
– 3rd	
  leading	
  cause	
  of	
  UTI.	
  Large	
  mucoid	
  capsule	
  and	
  
viscous	
  colonies	
  
Tao	
  Le,	
  Vikas	
  Bhushan:	
  First	
  Aid	
  for	
  the	
  USMLE	
  Step	
  1	
  2014,	
  McGraw	
  Hill	
  Professional,	
  
2014,	
  ISBN	
  0071831436.	
  
Q7:	
  A	
  76-­‐year-­‐old	
  man	
  presents	
  to	
  his	
  physician	
  complaining	
  
of	
  an	
  inability	
  to	
  empty	
  his	
  bladder	
  for	
  the	
  past	
  3	
  days	
  and	
  
a	
  con*nual	
  leakage	
  of	
  urine	
  for	
  the	
  past	
  2	
  days.	
  A	
  
cystometrogram	
  reveals	
  that	
  his	
  bladder	
  has	
  an	
  
abnormally	
  large	
  capacity,	
  and	
  a	
  MRI	
  reveals	
  a	
  lesion	
  
limited	
  to	
  the	
  sacral	
  spinal	
  cord.	
  Which	
  of	
  the	
  following	
  is	
  
the	
  most	
  likely	
  diagnosis?	
  
(A) Automa*c	
  neurogenic	
  bladder	
  
(B)  Autonomous	
  neurogenic	
  bladder	
  
(C)  Motor	
  neurogenic	
  bladder	
  
(D) Sensory	
  neurogenic	
  bladder	
  
(E)  Uninhibited	
  neurogenic	
  bladder	
  
USMLE	
  step	
  1	
  Qbook.	
  Seventh	
  edi*on.	
  New	
  York	
  :	
  Kaplan	
  Publishing,	
  2015.	
  ISBN:	
  978-­‐1625232632	
  
The	
  correct	
  answer	
  is	
  B.	
  This	
  pa*ent	
  has	
  an	
  autonomous	
  
neurogenic	
  bladder,	
  which	
  is	
  a	
  type	
  of	
  “lower	
  motor	
  
neuron”	
  bladder.	
  There	
  are	
  three	
  types	
  of	
  lower	
  motor	
  
neuron	
  bladders:	
  an	
  autonomous	
  neurogenic	
  bladder	
  
(lesion	
  to	
  the	
  sacral	
  spinal	
  cord	
  centers	
  involved	
  in	
  bladder	
  
func*on),	
  a	
  motor	
  neurogenic	
  bladder	
  (choice	
  C;	
  lesion	
  of	
  
motor	
  and	
  visceral	
  efferents	
  to	
  the	
  bladder),	
  and	
  a	
  sensory	
  
neurogenic	
  bladder	
  (choice	
  D;	
  lesion	
  of	
  sensory	
  afferents	
  
from	
  the	
  bladder).	
  All	
  these	
  condi*ons	
  are	
  associated	
  with	
  a	
  
flaccid	
  bladder	
  that	
  fills	
  to	
  capacity.	
  Whereas	
  a	
  normal	
  
bladder	
  typically	
  emp*es	
  at	
  300	
  mL,	
  these	
  bladder	
  fill	
  to	
  
about	
  1000	
  mL.	
  These	
  pa*ents	
  have	
  overflow	
  incon*nence,	
  
which	
  means	
  the	
  bladder	
  expands	
  completely.	
  Because	
  they	
  
cannot	
  void,	
  these	
  pa*ents	
  dribble	
  urine.	
  These	
  are	
  the	
  
most	
  dangerous	
  neurogenic	
  bladders,	
  because	
  urinary	
  stasis	
  
predisposes	
  pa*ents	
  to	
  lower	
  urinary	
  tract	
  infec*ons,	
  which	
  
may	
  ascend	
  to	
  the	
  kidneys,	
  producing	
  pyelonephri*s.	
  
An	
  automa*c	
  neurogenic	
  bladder	
  (choice	
  A)	
  is	
  a	
  type	
  of	
  “upper	
  
motor	
  neuron”	
  bladder.	
  This	
  condi*on	
  is	
  caused	
  by	
  a	
  lesion	
  
that	
  disconnects	
  the	
  pon*ne	
  micturi*on	
  center	
  (the	
  center	
  
that	
  is	
  responsible	
  for	
  producing	
  coordinated	
  voiding)	
  from	
  
the	
  sacral	
  spinal	
  cord	
  centers.	
  The	
  bladder	
  is	
  s*ll	
  able	
  to	
  void	
  
to	
  some	
  degree,	
  but	
  func*ons	
  “on	
  its	
  own”	
  without	
  input	
  
from	
  the	
  brainstem	
  center.	
  As	
  a	
  result,	
  the	
  urethral	
  sphincter	
  
does	
  not	
  relax	
  when	
  the	
  detrusor	
  muscle	
  contracts,	
  leading	
  
to	
  urinary	
  reten*on.	
  	
  
An	
  uninhibited	
  neurogenic	
  bladder	
  (choice	
  E)	
  is	
  another	
  type	
  of	
  
“upper	
  motor	
  neuron”	
  bladder.	
  Normal	
  adults	
  have	
  cor*cal	
  
control	
  over	
  their	
  pon*ne	
  micturi*on	
  center,	
  but	
  when	
  the	
  
cor*copon*ne	
  pathways	
  are	
  not	
  func*oning	
  properly,	
  the	
  
pa*ent	
  develops	
  an	
  uninhibited	
  neurogenic	
  bladder.	
  In	
  these	
  
pa*ents,	
  the	
  act	
  of	
  voiding	
  is	
  well	
  coordinated,	
  but	
  not	
  under	
  
conscious	
  control.	
  This	
  is	
  seen	
  in	
  pa*ents	
  with	
  frontal	
  lobe	
  
lesions	
  and	
  in	
  normal	
  children	
  prior	
  to	
  toilet	
  training.	
  	
  
Q8:	
  A	
  70-­‐year-­‐old	
  woman	
  presents	
  to	
  her	
  physician	
  prior	
  to	
  
beginning	
  chemotherapy	
  for	
  newly	
  diagnosed	
  small	
  cell	
  
lung	
  carcinoma.	
  her	
  examina*on	
  is	
  notable	
  for	
  obesity,	
  
blood	
  pressure	
  of	
  180/110	
  mmHg,	
  facial	
  hair,	
  abdominal	
  
striae,	
  and	
  an	
  acneiform	
  rash	
  on	
  her	
  chest	
  and	
  back.	
  
Laboratory	
  values	
  are	
  normal	
  except	
  for	
  a	
  serum	
  glucose	
  
of	
  250	
  mg/dL	
  (normal	
  range:	
  70	
  –	
  110	
  mg/dL).	
  Her	
  chest	
  
x-­‐ray	
  film	
  shows	
  a	
  right	
  perihilar	
  mass	
  and	
  severe	
  diffuse	
  
osteoporosis.	
  Which	
  of	
  the	
  following	
  most	
  likely	
  
accounts	
  for	
  her	
  physical	
  examina*on,	
  laboratory,	
  and	
  x-­‐
ray	
  findings?	
  
(A)  Adrenal	
  gland	
  destruc*on	
  by	
  metastases	
  
(B)  Anterior	
  pituitary	
  gland	
  disrup*on	
  by	
  metastases	
  
(C)  Ectopic	
  produc*on	
  of	
  cor*cotropin	
  (ACTH)	
  
(D)  Ectopic	
  produc*on	
  of	
  gastrin	
  
(E)  Ectopic	
  produc*on	
  of	
  parathyroid	
  hormone	
  (PTH)	
  
USMLE	
  step	
  1	
  Qbook.	
  Seventh	
  edi*on.	
  New	
  York	
  :	
  Kaplan	
  Publishing,	
  2015.	
  ISBN:	
  978-­‐1625232632	
  
The	
  correct	
  answer	
  is	
  C.	
  This	
  woman	
  has	
  all	
  the	
  classic	
  findings	
  of	
  
Cushing	
  syndrome:	
  obesity,	
  hypertension,	
  hirsu*sm,	
  acne,	
  
striae,	
  glucose	
  intolerance,	
  and	
  osteoporosis.	
  Cushing	
  
syndrome	
  may	
  be	
  caused	
  by	
  excess	
  produc*on	
  of	
  cor*sol	
  due	
  
to	
  bilateral	
  adrenal	
  hyperplasia	
  or	
  an	
  adrenal	
  neoplasm;	
  by	
  
excess	
  produc*on	
  of	
  cor*cotropin	
  (ACTH)	
  by	
  a	
  pituitary	
  
adenoma;	
  or	
  by	
  ectopic	
  produc*on	
  of	
  ACTH	
  by	
  a	
  tumor,	
  most	
  
commonly	
  a	
  small	
  cell	
  lung	
  carcinoma	
  (major	
  clue	
  in	
  the	
  
ques*on	
  stem!	
  
Destruc*on	
  of	
  the	
  adrenal	
  glands	
  bilaterally	
  (choice	
  A)	
  or	
  of	
  the	
  
anterior	
  pituitary	
  by	
  metastases	
  (choice	
  B)	
  would	
  cause	
  a	
  
deficiency	
  of	
  cor*sol	
  and	
  ACTH,	
  respec*vely,	
  and	
  would	
  lead	
  
to	
  a	
  syndrome	
  of	
  cor*sol	
  deficiency	
  with	
  ortosta*c	
  
hypotension,	
  malaise,	
  nausea,	
  and	
  weight	
  loss.	
  	
  
Ectopic	
  produc*on	
  of	
  gastrin	
  (choice	
  D),	
  as	
  seen	
  in	
  Zollinger-­‐
Ellison	
  syndrome,	
  causes	
  severe	
  refractory	
  pep*c	
  ulcer	
  
disease.	
  	
  
Ectopic	
  produc*on	
  of	
  parathyroid	
  hormone	
  (PTH;	
  choice	
  E),	
  
which	
  can	
  be	
  seen	
  in	
  squamous	
  cell	
  lung	
  carcinoma,	
  would	
  
result	
  in	
  hypercalcemia.	
  
Taelr 9-8 Paraneoplastic Syndrome Endocrinopathies
Cushing syndrome
Gynecomastia
Hypercalcemia
Hypocalcemia
Hypoglycemra
Hyponatremia
Secondary polycythemia
Small cell carcinoma of lung, medullary
carcinoma of thyroid, pancreatic cancer
Choriocarcinoma (testis), semrnoma
Renal cell carcinoma, primary squamous cell
carcinoma of lung, breast carcinoma, adult
T-cell leukemia/lymphoma
Malignant lymphomas (contain
1 or-hydroxylase)
Medullary carcjnoma of thyroid
Hepatocellular carcinoma, ovarian carcinoma,
fibrosarcoma
Small cell carcinoma of lung
Renal cell carcrnoma, hepatocellular
carcinoma, cerebellar hemanqioma
ACrH, Adrenocorticotropic hormone; hCG, human chorionic gonadotropin; prH, parathyroid hormone.
Taelr 9-9 Tumor Markers and Associated Cancers
ACTH
hCG
PTH-related protein
Calcitriol (vitamjn D
Calcitonin
lnsulin-like factor
Antidiuretic hormor
Erythropoietin
AFP
Bence Jones protein
cA 15-3
cA19-9
Hepatocellular carcinoma, yolk sac tumor (endodermal sinus tumor) of ovary or testis
Multiple myeloma, waldenstrom macroglobulinemia (represent light chains rn urine)
Breast cancer
GOLJAN,	
  Edward	
  F.	
  Rapid	
  review	
  pathology.	
  Fourth	
  edi8on.	
  Philadelphia,	
  PA:	
  Elsevier/Saunders,	
  2014.	
  ISBN	
  
03-­‐230-­‐8787-­‐6.	
  
Q9:	
  A	
  35-­‐year-­‐old,	
  sexually	
  ac*ve	
  woman	
  visits	
  her	
  
gynecologist	
  complaining	
  of	
  mild,	
  right-­‐sided,	
  lower	
  
abdominal	
  pain	
  but	
  no	
  other	
  symptoms.	
  There	
  are	
  
no	
  peritoneal	
  signs.	
  Her	
  surgical	
  history	
  is	
  significant	
  
for	
  an	
  appendectomy	
  at	
  age	
  10.	
  Her	
  last	
  period	
  
occurred	
  14	
  days	
  ago.	
  Which	
  of	
  the	
  following	
  
endometrial	
  changes	
  corresponds	
  to	
  this	
  stage	
  of	
  the	
  
pa*ent’s	
  menstrual	
  cycle?	
  
(A) Apical	
  movement	
  of	
  secre*ons	
  in	
  the	
  glandular	
  cells	
  
(B)  Degenera*on	
  of	
  the	
  glandular	
  structures	
  
(C)  Glandular	
  glycogen	
  accumula*on	
  in	
  the	
  func*onalis	
  
(D) Growth	
  of	
  the	
  spiral	
  arteries	
  
(E)  Tissue	
  expansion	
  by	
  cellular	
  hypertrophy	
  
USMLE	
  step	
  1	
  Qbook.	
  Seventh	
  edi*on.	
  New	
  York	
  :	
  Kaplan	
  Publishing,	
  2015.	
  ISBN:	
  978-­‐1625232632	
  
The	
  correct	
  answer	
  is	
  D.	
  This	
  pa*ent	
  appears	
  to	
  be	
  experiencing	
  
miXelschmerz,	
  abdominal	
  pain	
  occuring	
  at	
  the	
  *me	
  of	
  ovula*on	
  that	
  can	
  
mimic	
  acute	
  appendici*s	
  (which	
  is	
  rule	
  out	
  because	
  of	
  the	
  pa*ent’s	
  surgical	
  
history).	
  If	
  this	
  informa*on	
  didn’t	
  clue	
  you	
  into	
  the	
  stage	
  of	
  the	
  menstrual	
  
cycle,	
  you	
  are	
  told	
  explicitly	
  that	
  the	
  pa*ent’s	
  last	
  menstrual	
  period	
  was	
  14	
  
days	
  ago.	
  Therefore,	
  she	
  is	
  at	
  the	
  conclusion	
  of	
  the	
  prolifera*ve	
  
(estrogenic)	
  phase.	
  This	
  stage	
  begins	
  during	
  the	
  laner	
  period	
  of	
  menstrual	
  
flow	
  and	
  con*nues	
  through	
  the	
  thirteenth	
  to	
  fourteenth	
  day	
  of	
  typical	
  28-­‐
day-­‐cycle;	
  it	
  is	
  characterized	
  by	
  regrowth	
  of	
  the	
  endometrium.	
  The	
  
epithelial	
  cells	
  of	
  the	
  glandular	
  structures	
  remaining	
  aler	
  menstrua*on	
  
migrate	
  and	
  proliferate	
  to	
  cover	
  the	
  new	
  mucosal	
  surface.	
  Also,	
  the	
  spiral	
  
arteries	
  grow	
  into	
  the	
  regenera*ng	
  endometrium	
  (this	
  process	
  con*nues	
  
through	
  the	
  secretory	
  stage	
  as	
  well).	
  Significant	
  edema	
  develops	
  by	
  the	
  end	
  
of	
  the	
  prolifera*ve	
  stage	
  and	
  con*nues	
  to	
  develop	
  during	
  the	
  secretory	
  
phase.	
  
Apical	
  movement	
  of	
  secretons	
  in	
  the	
  glandular	
  cells	
  (choice	
  A)	
  occurs	
  during	
  
the	
  secretory	
  phase.	
  
Degenera*on	
  of	
  the	
  glandular	
  structures	
  (choice	
  B)	
  occurs	
  during	
  the	
  
premenstrual	
  stage	
  of	
  the	
  cycle.	
  	
  
Glandular	
  glycogen	
  accumula*on	
  in	
  the	
  func*onalis	
  (choice	
  C)	
  occurs	
  during	
  
the	
  secretory	
  phase	
  (luteal	
  phase).	
  
Tissue	
  expansion	
  by	
  cellular	
  hypertrophy	
  (choice	
  E)	
  occurs	
  during	
  the	
  
secretory	
  phase	
  since	
  mitosis	
  of	
  the	
  endometrial	
  *ssue	
  has	
  ceased	
  at	
  this	
  
point.	
  	
  
Q10:	
  A	
  29-­‐year-­‐old	
  woman	
  with	
  a	
  history	
  of	
  pelvic	
  
inflammatory	
  disease	
  presents	
  to	
  the	
  emergency	
  
department	
  with	
  severe	
  lel	
  quadrant	
  crampy	
  pain	
  and	
  
spojng,	
  and	
  amenorrhea	
  for	
  the	
  past	
  two	
  cycles.	
  
Physical	
  examina*on	
  reveals	
  a	
  lel	
  adnexal	
  mass	
  with	
  
tenderness	
  to	
  palpa*on.	
  The	
  beta-­‐human	
  chorionic	
  
gonadotropin	
  (hcG)	
  level	
  is	
  elevated.	
  Further	
  studies	
  
would	
  most	
  likely	
  reveal	
  an	
  implanta*on	
  at	
  which	
  of	
  the	
  
following	
  loca*ons	
  in	
  the	
  fallopian	
  tube?	
  
(A) Ampulla	
  
(B)  Fimbriae	
  
(C)  Infundibulum	
  
(D) Isthmus	
  
(E)  Uterine	
  segment	
  
USMLE	
  step	
  1	
  Qbook.	
  Seventh	
  edi*on.	
  New	
  York	
  :	
  Kaplan	
  Publishing,	
  2015.	
  ISBN:	
  978-­‐1625232632	
  
The	
  correct	
  answer	
  is	
  A.	
  This	
  pa*ent	
  has	
  an	
  ectopic	
  (tubal)	
  
pregnancy.	
  Pa*ents	
  with	
  a	
  history	
  of	
  pelvic	
  inflammatory	
  disease	
  
are	
  more	
  suscep*ble	
  to	
  this	
  disorder.	
  The	
  ampulla	
  is	
  the	
  most	
  
common	
  site	
  of	
  fer*liza*on	
  within	
  the	
  fallopian	
  tube,	
  as	
  well	
  as	
  
the	
  most	
  common	
  site	
  for	
  tubal	
  pregnancy.	
  It	
  is	
  the	
  longest	
  region	
  
of	
  the	
  tube	
  and	
  has	
  thin	
  walls.	
  
The	
  fimbriae	
  (choice	
  B)	
  of	
  the	
  fallopian	
  tubes	
  are	
  highly	
  unlikely	
  
loca*ons	
  for	
  tubal	
  pregnancy.	
  They	
  are	
  mucosal	
  ridges	
  located	
  at	
  
the	
  funnel-­‐shaped	
  end	
  of	
  the	
  oviduct	
  that	
  are	
  covered	
  with	
  
ciliated	
  cells.	
  They	
  beat	
  toward	
  the	
  mouth	
  of	
  the	
  tube,	
  “brushing”	
  
the	
  ovum	
  released	
  from	
  the	
  ovary	
  into	
  the	
  fallopian	
  tube.	
  
The	
  infundibulum	
  (choice	
  C)	
  is	
  the	
  technical	
  term	
  for	
  the	
  “funnel-­‐
shaped	
  end	
  of	
  the	
  fallopian	
  tube.”	
  it	
  opens	
  to	
  the	
  peritoneal	
  
cavity.	
  
The	
  isthmus	
  (choice	
  D)	
  is	
  the	
  narrow,	
  thick-­‐walled	
  segment	
  of	
  the	
  
fallopian	
  tube	
  nearest	
  to	
  the	
  uterine	
  wall.	
  
The	
  uterine	
  (inters**al)	
  segment	
  (choice	
  E)	
  is	
  the	
  por*on	
  of	
  the	
  tube	
  
that	
  traverses	
  the	
  uterine	
  wall.	
  Ectopic	
  pregnancies	
  occurring	
  here	
  
at	
  par*cularly	
  high	
  risk	
  for	
  catastrophic	
  rupture.	
  
Anatomy	
  of	
  fallopian	
  tube	
  	
  
hnp://www.nccrm.com/wp-­‐content/uploads/2012/12/fallopian.png	
  
Sources:	
  
1.  LE,	
  Tao,	
  Karen	
  A	
  ADLER	
  a	
  Seth	
  K	
  BECHIS	
  
(eds.).	
  First	
  aid	
  Q&A	
  for	
  the	
  USMLE	
  Step	
  1.	
  
2nd	
  ed.	
  New	
  York:	
  McGraw-­‐Hill	
  Medical,	
  
c2009.	
  ISBN	
  978-­‐0-­‐07-­‐159794-­‐4	
  
2. USMLE	
  step	
  1	
  Qbook.	
  Seventh	
  edi*on.	
  New	
  
York	
  :	
  Kaplan	
  Publishing,	
  2015.	
  ISBN:	
  
978-­‐1625232632	
  
If	
  you	
  have	
  any	
  ques*ons	
  don’t	
  hesitate	
  to	
  
contact	
  us.	
  	
  
See	
  you	
  at	
  USMLE	
  @	
  Masaryk	
  J	
  	
  
Klára	
  Valešová	
  394587@mail.muni.cz	
  	
  
Šimon	
  Hajda	
  395098@mail.muni.cz