USMLE PRACTICE QUESTION #88
TOPIC: Reproductive/endocrine physiology
Today’s question will test your understanding of a commonly tested concept associated with reproductive & endocrine physiology.
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A 29-year-old female is unable to breastfeed her newborn son 24 hours after giving birth. The infant can latch onto his mother’s breast, but no milk can be obtained. Twenty hours before giving birth, she required three units of packed red blood cells. Her current vital signs include a temperature of 98.9°F (37.2°C), pulse of 90/minute, respiratory rate of 15/minute, and blood pressure of 95/69 mmHg. Which of the following will most likely be revealed upon further evaluation?
A. Primary adrenal insufficiency
B. Secondary adrenal insufficiency
C. Primary hyperaldosteronism
D. Secondary hyperaldosteronism
E. Secondary hypercortisolism
Detailed Breakdown of Answers + Correct Answer Below ⏬
ANSWER + QUESTION BREAKDOWN
The MENTAL MODEL used to answer this question comes from our detailed test-taking skills masterclass (check it out if you want to elevate your skills). Here’s how to think through this question:
Step 1. Read the last line to get to the heart of the question: “Which of the following will most likely be revealed upon further evaluation?”
Step 2: Is this a first-, second-, or third-order question?
Answer: 2nd order. 1st: Diagnose the problem, and 2nd: Understand what else will be seen upon further evaluation (based on the given problem).
Step 3: Read the vignette carefully and ask yourself: “What else do I expect to see in this scenario?”
Step 4. Look at the answer choices and select the option most closely resembling your final thought from “Step 3” above.
GENERAL ANALYSIS
A 29-year-old female is unable to breastfeed her newborn son. Combined with her history of significant blood loss during childbirth and the need for a transfusion, it suggests a condition related to postpartum hemorrhage. The most likely cause of her inability to produce milk is Sheehan's syndrome, which results from ischemic necrosis of the pituitary gland due to severe blood loss and hypoperfusion during childbirth.
ANSWER CHOICES:
CHOICE A: Primary adrenal insufficiency
Explanation: Primary adrenal insufficiency (e.g., Addison's disease) occurs when the adrenal glands are damaged and cannot produce cortisol or aldosterone. In this case, the problem lies with the pituitary gland (secondary adrenal insufficiency), not the adrenal glands proper.
CHOICE B: Secondary adrenal insufficiency
Explanation: The patient’s inability to breastfeed is due to a lack of prolactin secretion from the damaged anterior pituitary. Additionally, secondary adrenal insufficiency occurs because the damaged pituitary cannot produce sufficient ACTH, leading to reduced cortisol production.
CHOICE C: Primary hyperaldosteronism
Explanation: This condition involves excessive secretion of aldosterone by the adrenal glands, leading to hypertension and hypokalemia. There are no signs or symptoms of hyperaldosteronism in this patient, and it does not explain her inability to lactate.
CHOICE D: Secondary hyperaldosteronism
Explanation: Secondary hyperaldosteronism is caused by increased renin production, usually due to conditions like heart failure or renal artery stenosis. This condition does not explain the patient's inability to breastfeed or her history of postpartum hemorrhage.
CHOICE E: Secondary hypercortisolism
Explanation: This refers to excessive ACTH production by the pituitary gland, leading to increased cortisol production (e.g., Cushing’s disease). The patient’s presentation suggests a deficiency in ACTH due to pituitary damage, not an excess.
FINAL VERDICT…
The most likely cause of this patient's inability to breastfeed and her symptoms is secondary adrenal insufficiency, resulting from Sheehan's syndrome due to significant postpartum hemorrhage. This condition leads to a deficiency in various anterior pituitary hormones, including prolactin (affecting lactation) and ACTH (leading to secondary adrenal insufficiency).
CORRECT ANSWER: B) Secondary adrenal insufficiency
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That’s it for question 88!
See ya tomorrow 👋