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CNM Board Exam 2025 EXAM REAL EXAM
WITH DETAILED ANSWERS FULL LENGTH
EXAM WITH CLEAR IMAGE/DIAGRAM
GRADED A+
what is the gross appearance of the cervical transformation zone on colposcopy? application of acetic acid reveals transition zone as white what are the layers of cervical squamous epithelium? basal to apical:
- basal
- parabasal
- intermediate
- superficial
what are the normal histological appearances of the various layers of cervical squamous epithelium?
- basal: more cuboidal, dark blue, large nucleus
- parabasal: beginning to flatten out, more visible cytoplasm, still blue
- intermediate: flattened, squamous, shrunken nucleus, lighter blue
- superficial: very flat, nucleus disappearing, pink what is a koilocyte? what does one look like? A Koilocyte is a squamous epithelial cell that has undergone a number of structural changes, which occur as a result of infection of the cell by HPV:
- Nuclear enlargement
- Irregularity of the nuclear membrane contour
- A darker than normal nucleus (Hyperchromasia)
- A clear area around the nucleus (perinuclear halo)
- lymphocytes
- fibroblasts
- old blood what test should be done for a woman whose pap smear indicates LSIL?
- colposcopy how should a patient with a pap smear indicating HSIL be treated? either a) immediate loop electrosurgical excision, or b) colposcopy how do LSIL and HSIL appear on colposcopy and biopsy? what is the treatment for a woman with a biopsy indicating CIN 3?
excision! what proportion of CIN1 regress? what proportion of CIN 3 progress to cancer? CIN 1: 57% regress spontaneously CIN 3: >12% progress to cancer what is ASC-US? what test should automatically follow a pap smear indicating ASC-US? ASC-US: atypical squamous cells of undetermined significance (Borderline or atypical abnormalities on Pap smear that do not fit into normal, LSIL, HSIL, or cancer categories)
- follow up: HPV test what is the 2nd leading cause of death in women ages 20- 39 worldwide? invasive cervical carcinoma what is the purpose of the pap smear?
- to detect treatable precancerous lesions in the cervix
- used for screening and diagnosis (complementary to biopsy)
important points about the HPV vaccine
- goal: prevent HPV infection (6, 11, 16, 18) in unexposed girls/women & boys/men via induction of antibodies (cervical cancer prophylaxis)
- does not replace other prevention strategies (condoms, etc.)
- contains VLPs (virus-like particles)
- Gardasil protects against strains of HPV that can cause genital/anal warts
- NOT used as therapy for existing HPV infection
- DOES NOT change screening (pap smear) recommendations what are the most common causes of abnormal uterine bleeding? (mnemonic) mnemonic: PALM COEIN
- Polyp (endometrial)
- Adenomyosis
- Leiomyosis (fibroids)
- Malignancy (cancer)
- Coagulopathy
- Ovulatory dysfunction
- Endometrial
- Iatrogenic
- Not yet classified what are some uterine causes of abnormal uterine bleeding?
UTERUS:
- endometrial polyp
- pregnancy (normal, ectopic, spontaneous abortion)
- cancer
- trauma
- fibroids
- endometriosis what are some cervical causes of abnormal uterine bleeding? CERVIX:
- cervical cancer (SCC, adenocarcinoma)
- cervicitis
- trauma what are some vaginal causes of abnormal uterine bleeding? VAGINAL:
- trauma
- atrophic vaginitis (post-menopause)
- cancer what are some ovarian causes of abnormal uterine bleeding? OVARY:
- PCOS
- transverse vaginal septum (high, medium, low): a horizontal 'wall' of tissue that has formed during embryologic development and essentially creates a blockage of the vagina.
- imperforate hymen: a hymen that completely encloses the external orifice of the vagina what are some of the main defects of vertical fusion that can occur in the cervix?
- cervical agenesis
- cervical dysgenesis what is MRKH syndrome? what defect of vertical fusion in the female reproductive tract does it often cause? Mayer-Rokitansky-Küster-Hauser Syndrome
- a genetic disorder that causes Mullerian agenesis (vagina and uterus to be underdeveloped or absent)
what are the main defects of lateral fusion of the female reproductive tract?
- uterus didelphys
- bicornuate uterus
- septate uterus
- unicornuate uterus
- blind uterine horn
- blind, separate uterine horne
- uterus didelphys w/hemi-obstructed vagina what is a uterus didelphys? what does it look like? uterus didelphys: a double uterus with two separate cervices, and often a double vagina as well. Each uterus has a single horn linked to the ipsilateral fallopian tube that faces its ovary. what is a bicornuate uterus? what does it look like?
what are some important risk factors for developing breast cancer? what is the overall lifetime risk of a woman in the US?
- age
- family Hx
- reproductive factors (duration of exposure to estrogens)
- diet (alcohol), exercise lifetime risk of an American woman: 13% what are the 2 main genes that predispose women to breast cancer? in what population are these genes particularly prevalent?
- BRCA
- BRCA Ashkinazi Jews (BRCA genes were cloned in 1995) besides the BRCA genes, what dominant alleles have been associated with breast cancer in GWAS studies?
- FGFR2 (RR = 1.26)
- TNRC9 (RR = 1.20) these are risk modifiers for women who have the BRCA1/BRCA mutations
what exactly is the BRCA1 gene? how many mutations have been identified as being important?
- BRCA1 = tumor suppressor gene
- chromosome 17
- it's gene product plays key role in homologous DNA repair (necessary for genomic stability)
- many different mutations reported: 3 main founder mutations for a woman with a founder mutation in BRCA1 gene, what is the risk of developing breast cancer in her lifetime? ovarian cancer? what about for a man?
- breast cancer: 60-80%
- ovarian cancer: 50-60%
- man: breast = 1-5%, prostate = 2-3% for a woman with a founder mutation in BRCA2 gene, what is the risk of developing breast cancer in her lifetime? ovarian cancer? what about for a man?
- breast cancer: 60-80%
- ovarian cancer: 50%
- man: breast = 5-10%, prostate = 15-25%!!! who should be tested for the BRCA1/2 genes?
variant of uncertain significance = a missense mutation that might or might not affect the functionality of the gene product
- may just be a polymorphism what is the treatment plan for a patient who tests positive for a BRCA mutation? BRCA1/2+ possible options:
- increased surveillance
- changes in lifestyle
- chemo-preventive treatment (SERM)
- prophylactic surgery (mastectomy) PLUS possibly:
- annual mammogram + MRI beginning @ 25
- self/clinical breast exam 2x yearly
- oophorectomy what is RRSO? RRSO = risk-reducing salpingo-oophrectomy
- significantly reduces the risk of breast & ovarian CA in people with BRCA1 and/or BRCA2 mutations how do BRCA1 & BRCA2 mutations differ in the hormone- dependency status of the breast cancers they cause?
- BRCA1 mutation+ breast CA: 85% are estrogen receptor negative (E-independent)
- BRCA2 mutation+ breast CA: more like sporadic tumors (more often E-dependent) in vitro studies have shown BRCA1 mutation+ tumors to have reduced sensitivity to which type of chemo? increased sensitivity? BRCA1+:
- reduced sensitivity: taxanes (spindle poisons that disrupt microtubules/mitotic spindle formation)
- increased sensitivity: cisplatin (causes double-stranded DNA breaks) what are PARP inhibitors? how do they target BRCA mutation+ cancers?
- PARP = protein involved in repairing single stranded breaks in DNA, which is the 1st line mechanism by which cells (and tumor cells) repair DNA
- BRCA: normally, it performs double-stranded breaks that result when PARP fails and DNA replication turns a single stranded break into a double-stranded one
- in BRCA+ tumors, PARP remains the only way to repair broken DNA, so PARP inhibitors make the genome of tumor cells so unstable that they cannot replicate what is olaparib? olaparib = a PARP inhibitor used to Tx BRCA mutation tumors what does a mammography x-ray machine look like?
- to evaluate a patient with breast-related Sx (lump, pain, nipple discharge, etc.)
- to evaluate a patient with a past Hx of breast CA (e.g. monitoring breast cancer remission)
- to follow up on an abonormal screening mammogram what is spot compression on mammography? what is it's purpose? how does it work? spot compression: used to provide better compression over a small area of the breast in order to:
- (re)evaluate questionable areas
- evaluate masses (that might be obscured by overlapping tissue)
- include tissue in difficult areas (like upper inner quadrant) how does magnification work on breast imaging? why might it be indicated?
- magnification: elevation of breast from the detector in order to improve visualization of calcifications and mass margins what is ACR BI-RADS? what are the assessment categories
BI-RADS is an acronym for Breast Imaging-Reporting and Data System, a quality assurance tool originally designed for use with mammography to standardize reporting of findings. BI-RADS Assessment Categories are: 0: Incomplete 1: Negative 2: Benign finding(s) 3: Probably benign 4: Suspicious abnormality 5: Highly suggestive of malignancy 6: Known biopsy - proven malignancy what is the spectrum of breast tissue density?
- mainly fatty
- scattered fibroglandular densities
- heterogeneously dense
- extremely dense what is digital breast tomosynthesis? Breast imagers at Penn Medicine are now using digital breast tomosynthesis, or DBT, to perform three-dimensional mammography for breast cancer screening and diagnosis. The DBT system employs a digital X-ray that records a series of low-dose, high-resolution images of the breast while traversing a small (15°) arc around the compressed breast. As the projection angle changes, images are recorded at slightly different depths and thicknesses, from one surface of the breast to the other.
