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A 32-year-old primigravid woman presents at 32 weeks' gestation because of sudden vaginal bleeding and painful abdominal cramps. She denies trauma. She has a 10-pack-year smoking history and admits to cocaine use during her pregnancy. Her blood pressure is 95/60 mm Hg, pulse is 112/min, and blood oxygen saturation is 97% on room air (normal: 95%-99%). Physical examination reveals a tense abdomen with a firm, tender uterus. Urinalysis shows no protein, leukocytes, or bacteria, with few RBCs. Pelvic examination reveals dark-red blood in the vaginal vault and a hypertonic uterus. Pelvic ultrasound shows a high posterior placenta with no abnormalities of placentation. Fetal heart tones indicate fetal distress. This patient is at increased risk for which of the following complications? A. Disseminated intravascular coagulation B. Infertility C. Postpartum bleeding D. Preeclampsia E. Sheehan syndrome

A The patient presents with sudden vaginal bleeding and painful abdominal cramps at 32 weeks' gestation without trauma. She has low blood pressure and rapid heart rate indicating a bleed. The fetus is in distress within a hypertonic uterus. The patient's history of smoking and cocaine use also point to a diagnosis of abruptio placentae, or placental abruption. Placental abruption is the partial or complete premature separation of placenta from the uterine wall. Risk factors include smoking and cocaine use as seen in this patient, as well as trauma, hypertension, and preeclampsia. Patients present with sudden painful bleeding in the third trimester, as seen in the vignette. Complications are life threatening and include DIC from tissue factor entering maternal circulation, maternal shock, and fetal distress or death. Postpartum hemorrhage and Sheehan syndrome are associated with placenta accreta/increta/percreta, where the maternal portion of the placenta, the desidua basalis, has abnormal attachment and separation after delivery. This condition would be visible on ultrasound, unlike what is seen in this patient. Preeclampsia is a condition of new-onset hypertension with either proteinuria or end-organ dysfunction after the 20th week of gestation. Abruptio placentae can be a complication of preeclampsia, but not a cause. This patient's condition also does not include infertility as a complication.

A 22-year-old woman is brought to the emergency department via ambulance because of sudden right lower quadrant (RLQ) pain. Vital signs are normal. The patient has diffuse lower abdominal tenderness with rebound and guarding in the RLQ. Psoas sign is negative. Her last menstrual period was 7 weeks ago. β-hCG levels are elevated. After obtaining appropriate imaging, an obstetrician is consulted to perform an emergent surgical procedure. Previous infection by which of the following agents most likely put this patient at higher risk for developing this complication? A. Chlamydia trachomatis B. Escherichia coli C. Human papillomavirus D. Treponema pallidum E. Trichomonas vaginalis

A This patient presents with sudden abdominal pain and tenderness with rebound and guarding. Diagnosis could point to appendicitis or appendix rupture; however, her history of amenorrhea, a negative psoas sign on examination, and elevated hCG levels points towards ectopic pregnancy. In this patient's case, hCG levels would be elevated, but they would be lower than expected to current gestational stage. Diagnosis is confirmed with ultrasound. Ectopic pregnancy most often occurs in the ampulla of the fallopian tube, but can also occur in the ovary, cervix, and abdominal cavity. It is often clinically mistaken for appendicitis but can be differentiated based on β-hCG and imaging. It can be complicated by rupture and develop into a life-threatening condition. Risk factors include prior ectopic pregnancy, history of pelvic inflammatory disease, endometriosis, postoperative adhesions, and chronic salpingitis. Chlamydia trachomatis, one of the most common sexually transmitted bacteria, can cause pelvic inflammatory disease leading to scarring of the fallopian tubes, especially if left untreated. These lesions can cause a recently fertilized egg to adhere to the fallopian tube wall or cervix, or improperly migrate to the peritoneal or pelvic cavity, resulting in ectopic pregnancy. Escherichia coli is one of the most common causes of urinary tract infection (UTI) in ambulatory young women, along with Staphylococcus saprophyticus. UTIs, however, are not associated with ectopic pregnancy. Trichomonas vaginalis is a sexually transmitted protozoa resulting in vaginitis, also not associated with ectopic pregnancy. Human papillomavirus is a DNA virus associated with genital and cutaneous warts, as well as cervical and anal carcinomas. Treponema pallidum is a spirochete causing syphilitic infection. None of these are associated with ectopic pregnancy.

A 36-year-old nulliparous woman presents to her primary care physician reporting breast pain of several days' duration. She denies a history of breast cancer in her family but is very worried about the possibility of malignancy. There is no warmth, swelling, or erythema; and there is no bleeding or discharge at the nipples. There is no cervical or axillary lymphadenopathy. Breast examination reveals several small, mobile lumps on both breasts. The patient states that she thinks she may have felt similar lumps before around the time of her periods. Which of the following would a biopsy of the breast lumps most likely reveal? A. Central necrosis B. Increase in number of acini and intralobular fibrosis C. Large cells with clear "halos" D. Lymphatic involvement E. Sheets of pleomorphic cells infiltrating adjacent stroma

B This patient presents with cyclic, menstruation-associated breast pain without any additional symptoms. On examination, she is found to have multiple bilateral small, mobile lumps. This is the classic presentation of fibrocystic changes of the breast. Fibrocystic disease is a benign condition and manifests with diffuse breast pain and multiple bilateral masses, commonly found in the upper outer quadrants of the breast. It is one of the most common causes of breast lumps in women from the age of 35 years to the onset of menopause. Common risk factors include nulliparity and being age 35 or older. Fibrocystic changes can be characterized histologically as fibrosis (fibrous stroma, indicated by the red arrow in the image) and cysts (indicated by the black arrow in the image). Fibrocystic changes can cause masses that fluctuate in size with menstruation and caffeine intake. Proliferation of the acini may be seen in patients with fibrocystic disease; if present, it may be associated with a low risk of carcinoma. Central necrosis is characteristic of comedocarcinoma, a subtype of ductal carcinoma in situ (DCIS). Comedocarcinoma would present with a palpable mass, nipple discharge, or Paget disease. This patient has no nipple discharge and no evidence of Paget disease. Large cells with clear ?halos? refer to Paget disease, which presents with unilateral eczematous nipple changes. This patient does not have any nipple or skin changes. Lymphatic involvement is indicative of inflammatory carcinoma, which results in a peau d'orange appearance of the skin. This patient does not have any erythema, swelling, warmth, or skin changes, making lymphatic involvement unlikely. Sheets of pleomorphic cells infiltrating adjacent stroma describes the histology of invasive ductal carcinoma. Invasive ductal carcinoma can present as a firm, irregular, and fixed mass; unilateral bloody nipple discharge; and skin changes; this patient has none of these findings.

A 15-year-old boy presents with a painless testicular mass. He is otherwise healthy and has been meeting normal developmental milestones. After surgical removal of the testicle, the parents are informed that the mass is a common germ cell tumor that is highly sensitive to radiotherapy. They are told their son has a good prognosis. Which of the following histologic findings was most likely present in this patient's tumor? A)An alveolar/papillary morphologic pattern B)Large cells in lobules with clear cytoplasm C)Reinke crystals D)Structures resembling primitive glomeruli E)Syncytiotrophoblastic and cytotrophoblastic cells with hemorrhage and necrosis

B) This otherwise healthy 15-year-old boy presents with a painless testicular mass. After orchiectomy, the mass is found to be a common germ cell tumor that is highly sensitive to radiotherapy. The patient most likely has a seminoma. Seminomas are the most common testicular neoplasms and are common in boys and men from 15 to 35 years of age. They typically have a painless presentation and are radiosensitive. As shown in the image, this patient has a testicular tumor characterized by large cells in lobules with watery cytoplasm and a "fried egg" appearance. Numerous lymphocytes may be seen in and around the tumor. The other histologic findings indicate the presence of other testicular pathologies. An alveolar or papillary pattern is seen in embryonal carcinoma, which is not radiosensitive and has a poor prognosis. These tumors are also painful. Syncytiotrophoblastic and cytotrophoblastic cells with hemorrhage and necrosis are consistent with choriocarcinoma, which normally presents with systemic symptoms due to the production of human chorionic gonadotropin and is highly sensitive to chemotherapy. Reinke crystals are seen in Leydig cell tumors, which produce androgens, leading to precocious puberty or gynecomastia. They are not radiosensitive. Structures resembling primitive glomeruli are seen in yolk sac tumors, which are most commonly seen in boys < 3 years of age.

A 28-year-old woman, G2P1, at 34 weeks' gestation presents to the emergency department saying that she is experiencing severe vaginal bleeding. She describes the passage of enough bright red blood to thoroughly soak through a few sanitary pads over the past few hours. She denies vaginal or abdominal trauma, passage of other fluids, uterine contractions, or any pain. She denies bleeding or complications during her previous pregnancy. She has no significant history of medical problems or surgeries. She denies use of illicit drugs, tobacco, or alcohol. Vital signs include: temperature, 98.6°F (37°C); blood pressure, 135/80 mm Hg; pulse, 90; and respiratory rate, 14. Her abdomen is gravid, soft, and nontender. Bimanual and speculum examinations are both deferred. She becomes more comforted when her physician tells her that the fetal heart rate is normal at about 130-140 beats/min. An ultrasound is scheduled to be performed. Without knowing the ultrasound results, what is the most likely diagnosis? A Abruptio placentae B. Placenta accreta C. Placenta previa D. Uterine rupture E. Vasa previa

C Antepartum hemorrhage refers to significant vaginal bleeding after 20 weeks' gestation that is unrelated to labor and delivery. The two major causes of third-trimester bleeding are placenta previa and abruptio placentae; uterine rupture and vasa previa are rarer causes. Placenta previa occurs when the placenta overlies the internal cervical os and can be further described as complete placenta previa, partial placenta previa, marginal placenta previa, or low-lying placenta, depending on the exact relationship to the os. Placenta previa generally presents with painless bleeding, making this the most likely diagnosis. Because this is the first episode of bleeding, this patient can be treated conservatively, with the goal of delaying delivery and maximizing fetal maturity. She will likely be observed during prescribed bed rest unless another bleeding episode occurs, at which time delivery may be necessary. Abruptio placentae refers to the premature separation of the placenta from the uterus, despite its implantation in a normal location. It is also associated with painful antepartum bleeding. The distinction between abruptio placentae and placenta previa is classically made based on the presence (abruptio placentae) or absence (placenta previa) of pain. The fetus may also show signs of distress when abruptio placentae has occurred; no signs of fetal distress have been detected in this patient. Uterine rupture and vasa previa are rarer causes of vaginal bleeding in pregnancy. A patient with uterine rupture will normally present during delivery and have a history of cesarean delivery. On physical examination, fetal parts will commonly be palpated. In a patient with vasa previa, vessels transverse the membrane over the the internal opening of the uterus. Vasa previa can lead to exsanguination and fetal death. In this patient, the fetus has a normal heart rate. In a patient with placenta accreta, the placental villi attach directly to the myometrium due to a defect in the decidua basalis layer, which leads to incomplete separation of the placenta after delivery. It can cause severe postpartum hemorrhage, rather than antepartum hemorrhage as seen in this patient.

A 32-year-old pregnant woman comes to the emergency department because of vaginal bleeding. She reports that her last menstrual period was 24 weeks ago and that she has been receiving routine prenatal care. She denies any pain or recent trauma. The patient's temperature is 99.2°F (37.3°C), blood pressure is 100/59 mm Hg, and pulse is 102/min. A transabdominal ultrasound is performed and confirms the presence of a gestational sac and an intrauterine fetal heartbeat. Transvaginal ultrasound is ordered and reveals a placenta that is encroaching on the cervical os. Discovery of which of the following factors in the patient's medical history would most likely increase the risk for her current complication? A. History of endometriosis B. History of pelvic inflammatory disease C. Prior cesarean section delivery D. Prior ectopic pregnancy E. Use of assisted reproductive technologies

C This patient presenting with vaginal bleeding and a placenta encroaching over the cervical os is most likely suffering from placenta previa, or the attachment of the placenta to the lower uterine segment. Placenta previa typically manifests with painless vaginal bleeding after 20 weeks of gestation. Risk factors include history of a prior cesarean section delivery, increased number of pregnancies, twin gestation, and history of curettage. Ectopic pregnancy, on the other hand, most commonly occurs in the first trimester and is characterized by vaginal bleeding and/or abdominal pain. This pregnancy also has evidence of a gestational sac and intrauterine heartbeat. History of endometriosis leads to increased risk of infertility and epithelial ovarian cancer. History of pelvic inflammatory disease (PID) leads to an increased risk of ectopic pregnancy and is often associated with infertility. Prior ectopic pregnancy leads to an increased risk for future ectopic pregnancies. Use of assisted reproductive technologies leads to an increased risk for multiple gestations.

A 52-year-old white woman who has never given birth comes to the physician for an annual check-up. She has a 10-pack-year smoking history and a family history significant for early mastectomies in her mother and grandmother. She has two glasses of wine every night with dinner and occasionally drinks three or more servings of alcohol on the weekends with friends. Vital signs are within normal limits. She has had a 14 kg (30 lb) weight gain over the past 5 years. Findings on physical examination are notable for a red scaly patch on her right nipple and palpable axillary nodes. Palpation reveals a firm mass in her right breast and discharge from the right nipple, which consists of blood and serum. Which of the following would most likely be seen on histologic examination of the scaly patch? A. Cells presenting in a linear pattern within breast stroma B. Extracellular mucus surrounding clusters of tumor cells C. Fibrovascular structures lined by ductal epithelium D. Large cells with clear "halos" E. Lymphocytic infiltration F. Proliferation of normal epithelial cells G. Solid pattern with an area of central necrosis

D The 52-year-old nulliparous white patient presents with a red scaly patch on her right nipple with serosanguinous discharge, palpable axillary nodes, and a firm mass in her right breast. This points to a diagnosis of Paget disease of the breast. Paget disease of the breast consists of an eczematous patch on the nipple or areola, often with underlying ductal carcinoma (ipsilateral ductal carcinoma in situ or invasive ductal carcinoma) that is palpable on breast examination. Histologic examination of the patch reveals large cells with prominent nucleoli and pale to clear ?halos? of cytoplasm in the epidermis, as shown in the image. Risk factors for breast cancer include nulliparity, early menarche, late menopause, obesity, high-fat diet, and a positive family history. Mucinous carcinomas are a rare form of invasive ductal carcinoma, which originate in the milk duct and have a gelatinous consistency due to extracellular mucus surrounding the tumor cells, unlike the firm mass seen in this patient Infiltrating lobular carcinomas have cells presenting in a linear pattern within breast stroma but are often bilateral with multiple lesions in the same location, unlike the single mass seen in this patient. Medullary carcinomas are often soft and fleshy, not firm like the mass seen in this patient, and they present with lymphocytic infiltration on histologic examination. Epithelial hyperplasia, the proliferation of normal epithelial cells, is a type of fibrocystic change that often occurs in women older than 30 years; it is benign and not associated with Paget disease. Intraductal papillomas are characterized histopathologically by the presence of fibrovascular structures lined by ductal epithelium. Intraductal papillomas may be felt as small lumps behind or next to the nipple, but they are not associated with a scaly patch on the nipple. Comedocarcinoma is a tumor with a ?cheesy? consistency and has a solid pattern with central necrosis; the duct will feel cord-like, and squeezing it will yield cheese-like material. It is not associated with Paget disease.

A 31-year-old man presents for his annual physical and reports noticing a nontender "lump" in his right testicle a few weeks earlier. He denies gynecomastia, changes in his voice, or recent trauma to the testicle. An ultrasound completed in the office reveals a nontender, homogenous right testicular enlargement. The physician orders an abdominal CT scan, which reveals enlarged, right-sided para-aortic lymph nodes. What testicular pathology does this patient most likely have? A) Embryonal carcinoma B) Epididymitis C)Leydig cell tumor D)Seminoma E) Torsion of the appendix testis F) Yolk sac tumor

D) This young man presents with a painless testicular lump that has no clear etiology. Taken in combination with findings of a nontender, homogenous right testicular enlargement on ultrasound and enlarged para-aortic lymph nodes on abdominal CT, the differential diagnosis includes testicular cancer with possible metastasis. Seminomas are the most common type, accounting for approximately 40% of testicular cancers. Seminomas are most often diagnosed in men between the ages of 25 and 40 years and do not occur in infancy. Because the testicles drain to the para-aortic lymph nodes, lymphatic spread of testicular cancers is often seen in the para-aortic chain. Patients with seminomas will typically have an elevated level of placental alkaline phosphatase (tumor marker). Epididymitis and torsion of the appendix testis would both present with pain and would not cause para-aortic lymphadenopathy. Leydig cell tumors present with signs of hyperandrogenism, which are not present in this patient, and yolk sac tumors are usually found in children under the age of 4 years. Embryonal carcinoma is another type of testicular tumor, which presents as a hemorrhagic mass with necrosis, but a "pure" embryonal carcinoma is rare.

A 58-year-old woman (gravida 2, para 2), who went through menopause 2 years ago, presents to her physician after discovering a lump in her left breast. She first noticed the lump about 4 weeks ago. She has no family history of breast cancer and has been otherwise healthy. Gynecologic history is unremarkable except for two uncomplicated vaginal deliveries. The physician examines the lump and finds it to be hard, nontender, and movable. Which of the following increases this woman's risk for breast cancer? A. Daily St. John's wort intake B. Excess caffeine intake C. History of a cyst with straw-colored fluid D. History of fibroadenoma in the right breast E. Late menopause F. Multiparity

E This patient presents with a hard, nontender, movable lump and a history of menopause at age 56. Late menopause (>55 years old) is a known risk factor for breast cancer. Because this patient went through menopause 2 years ago, at age 56, she has had an increased lifetime exposure to estrogen, which increases her risk for breast cancer. Other risk factors include female gender, older age, early menarche (<12 years old), delayed first pregnancy (>30 years old), and family history of a first-degree relative with breast cancer at a young age. Caffeine intake, history of a nonbloody cyst, St. John's Wort use, and multiparity do not increase lifetime exposure to estrogen and therefore do not increase the risk for breast cancer. A fibroadenoma only slightly increases the risk for breast cancer.

A 2-month-old boy is brought to the pediatrician by his mother for a well-baby visit for the first time since his birth. He was born 2 weeks prematurely and is at the 40th percentile for birth weight. On examination, the doctor palpates two small bilateral masses in the inguinal canal. The anus is patent, there is no evidence of hypospadias, and the testicles are not palpated in the scrotal sac. This patient is at increased risk for developing which of the following conditions? A. Extragonadal germ cell tumors B. Hypogonadotropic hypogonadism C. Low testosterone levels D. Spermatocele E. Testicular cancer

E) This 2-month-old boy has two small bilateral masses in the inguinal canal, and the testicles are not palpated in the scrotal sac. The testicles normally reside within the scrotum. When the testicles fail to drop from the abdomen into the scrotum during gestation, this is call cryptorchidism. Prematurity increases the risk of cryptorchidism. Normally, testicles need to be several degrees cooler than body temperature to produce sperm. Undescended testicles remain too warm, compromising spermatogenesis and reducing fertility. Patients with cryptorchid testicles are also at increased risk for testicular germ cell tumors. In a patient this young, the best management of cryptorchidism is watchful waiting, given the high likelihood that the testes will descend on their own. If this has not occurred after 4-6 months, then surgery to bring the testes into the scrotal sac (orchiopexy) is the gold standard of treatment. Spontaneous descent is rare after 6 months of age. Cryptorchidism increases the risk of testicular torsion and infertility, but testosterone levels are usually normal. Also, cryptorchidism is not associated with endocrine disorders such as hypogonadotropic hypogonadism, neoplasms outside of the gonads, or anatomic defects such as varicocele, hydrocele, or spermatocele.