Pathology Exam 9

D (begin pap screening at age 21 for women)

The following patients are presenting for a routine check up and have not received medical care in the past 5 years. Cervical cancer screening with a Pap smear should be performed in all of the following women EXCEPT A. 35-year-old woman B. 60-year-old woman C. 28-year-old woman who has been vaccinated against human papillomavirus D. 19-year-old who is sexually active E. 25-year-old homosexual

B (this is vitiligo, a loss of melanocytes common in African American populations)

An African American teenage boy presents for evaluation of skin discoloration shown. He reports that the discoloration had grown more noticeable over time and that it seems to get worse with prolonged sun exposure. He notes a similar pattern of discoloration in his left hand and reports that his mother has a similar appearing lesion on her skin. What is the cause of the skin discoloration in this patient? A. Tinea versicolor B. Destruction of melanocytes C. Postinflammatory hypopigmentation D. Impaired wound healing E. Post-surgical scarring

C (the cure for pre-eclampsia is delivery, not DiGiorno)

A 25-year-old pregnant woman of 28 weeks gestation presents with a severe persistent headache and visual changes. On physical exam her blood pressure was noted to be 175/112 and a spot urine dipstick shows 4+ protein. Which of the following interventions is most definitive treatment? A. Start IV lisinopril B. Observe expectantly and deliver only if the patient shows signs of seizure C. Deliver promptly D. Start sumatriptan E. Start IV magnesium

C (a drug reaction with epidermal sloughing and severe systemic rash is either Steven Johnson or TEN, depending on the fraction of affected tissue - over 30% makes it TEN rather than Steven Johnson)

A 13-year-old boy re-presents to his pediatrician with a new onset rash that began a few days after his initial visit. He initially presented with complaints of sore throat but was found to have a negative strep test. His mother demanded that he be placed on antibiotics, but this was refused by his pediatrician. The boy's father, a neurologist, therefore, started him on penicillin. Shortly after starting the drug, the boy developed a fever and a rash . The patient is admitted and his symptoms worsen. His skin begins to slough off, and the rash covers over 30% of his body. His oropharynx and corneal membranes are also affected. You examine him at the bedside and note a positive Nikolsky's sign. What is the most likely diagnosis? A. Erythema Multiforme B. Stevens-Johnson Syndrome C. Toxic Epidermal Necrolysis D. Rocky Mounted Spotted Fever E. Pemphigus Vulgaris

E (gynecomastia is common [2/3] in developing adolescent boys and is often benign and transient - red flag gynecomastia occurs in those with cancer risks, liver disease, drug or hormone use, or chromosomal abnormalities)

A 14-year-old boy is accompanied by his mother to general pediatrics clinic for a routine visit. The boy has no complaints. He is doing well in school and has no medical illnesses. However, his mother reports that she is concerned about the growth in his chest. She states that over the past several months he has been developing what seem to be breasts. Vital signs are stable. The left growth is larger than the right one. Both are soft to palpation and nontender. What is the next step in management? A. Order serum testosterone B. Order serum estrogens C. Order a mammogram of both breasts D. Biopsy the left, larger breast E. Reassurance

C (the case is most likely a left testicular torsion, which is a surgical emergency, and rushing the patient to the OR to save the testicle bypasses all other imaging and diagnostic studies - infection is unlikely due to the state of the vital signs)

A 15-year-old boy presents to the emergency room with severe lower abdominal pain that awoke him from sleep about 3 hours ago. The pain is sharp and radiates to the left thigh. While in the emergency room, the patient experiences one episode of vomiting. He denies any fever, dysuria or chills. Physical examination reveals normal vitals with blood pressure 100/60 and temperature of 98.6F. Abdominal examination is relatively benign. Scrotal examination reveals an elevated left testis that is diffusely tender. The cremasteric reflex is absent. What is the next step in the management of this patient? A. CT scan of abdomen and pelvis B. Testicular doppler ultrasound C. Surgical exploration D. IV antibiotics E. X-ray

D (the diagnosis is contact dermatitis from poison ivy - the tissue becomes spongiotic, the vesicles rupture, ooze, and crust - this is a type 4 hypersensitivity because it is mediated by T cells)

A 16-year-old boy presents to general pediatrics clinic with a rash. He is in an outdoor club and was camping with his father several days ago. He has no other complaints and no past medical history. He does not take any medications. His vital signs are stable. His physical exam is significant for the following rash as depicted. It is localized to his left forearm. The pathophysiology of this condition is described as a A. Type I hypersensitivity reaction B. Type II hypersensitivity reaction C. Type III hypersensitivity reaction D. Type IV hypersensitivity reaction E. This is not a hypersensitivity reaction

A (the sexual history is a distractor - imaging study shows decreased blood flow, which is diagnostic for testicular torsion - get this guy into surgery pronto)

A 16-year-old male presents to the emergency room with a 6-hour history of scrotal pain of sudden onset. The patient's past medical history is insignificant, though upon questioning he reports sleeping with several women in the prior three month period. On physical examination the testes appear to have a horizontal lie and the scrotum is neither swollen nor discolored. Doppler ultrasonography shows decreased blood flow to the affected testicle. Which of the following is the most likely diagnosis? A. Testicular torsion B. Epididymitis C. Seminoma D. Orchitis E. Traumatic urethral injury

E (the descent of the testes has two phases - the intraabdominal descent is mediated by anti-Mullerian hormone, which gets the testes down to the inguinal canal, after which testosterone takes over to complete the inguinosacral descent - testes lodged in the inguinal canal have completed the first phase and been unable to begin the second phase, indicating a lack of testosterone) (orchiopexy is the corrective surgery) (conditions caused by cryptorchidism include tubular atrophy, sexual infertility, and increased risk of testicular cancer)

A 2-year-old male is brought to his pediatrician by his parents because of a lack of testes in his scrotum. Physical examination confirms that testes are absent from the scrotal sac and palpable masses are found bilaterally around the inguinal canal. Deficiency of which of the following substances best explains this child's presentation? A. Luteinizing hormone B. Follicle-stimulating hormone C. Inhibin D. Anti-Mullerian hormone E. Testosterone

A (the patient has pelvic inflammatory disease, based on history, physical exam findings, and labs - the CT shows a cysic dilation of the left ovary and uterine tube, a serious complication of PID that can lead to secondary ovarian failure and infertility) (however, all the listed answer choices are potential complications of PID, among others)

A 20-year-old G0 female presents with 4 days of fever, pelvic pain, and left-sided adnexal tenderness. Physical examination reveals cervical motion tenderness and left adnexal fullness. Erythrocyte sedimentation rate (ESR) is elevated. Complete blood count values are as follows: White blood cell count: 17,000/mm^3 Hemoglobin: 12 g/dL Hematocrit: 36% Platelet count: 200,000/mm^3 A CT scan of the pelvis is shown. Which of the following complications of the disease is the patient experiencing? A. Tubo-ovarian abscess B. Broad ligament inflammation C. Pelvic adhesions D. Fallopian stricture E. Infective endocarditis

D (this is genital herpes, HSV2, which shows multinucleated giant cells on Tzanck smear, which is a scraping from the base of a vesicular herpetic lesion)

A 20-year-old college student presents to her OB/GYN complaining of a painful rash that has recently erupted on her labia. She is a college freshman and she states that she does not use condoms because her companion does not like them. On physical exam a thin young woman in no distress is observed. Which of the following is most likely to be found in this patient upon further diagnostic testing? A. Gram-negative diplococci B. Intracellular bacteria C. Bacteria coated vaginal epithelial cells D. Multinucleated giant cells E. Hyphae and pseudohyphae

A (poison ivy causes a contact dermatitis, which appears on histology as sponge-like tissue due to the production of vesicles and papules)

A 20-year-old male presents to his primary care physician complaining of intense itching on the back of his left calf. He states that he noticed a red, blistering rash this morning and does not recall experiencing a similar rash in the past. His past medical history is non-remarkable. His social history is notable for a job in wildlife biology. He states that he walks through open brush on a daily basis. His physical exam is notable for an erythematous skin rash on his upper extremity with tiny blisters that appears as shown. What would you expect to see on histology? A. Spongiosis B. Caseating granulomas C. Acanthosis D. Langerhans giant cells E. Intraepidermal vesicles with keratinocytes

D (ichthyosis is a scaling skin disease that is autosomal dominant usually over the extensor surfaces and trunk - it leads to an inability to sweat, increased predisposition to skin infections, and decreased sensation and joint motion)

A 20-year-old man presents to his primary care doctor complaining that his skin looks "scaly." He notes that his skin has become progressively dry and itchy over the past several years, and he is embarrassed about its appearance and doesn't want his skin to progress to the "lizard skin" his father had. Past medical history is significant for asthma and keratosis pilaris. On exam, he is well-appearing with normal vital signs His neck and back appear as shown. What is his most likely diagnosis? A. Atopic dermatitis B. Psoriasis C. Contact dermatitis D. Ichthyosis vulgaris E. Lichen planus

E (these are hydatidiform moles, caused by hydropic swelling of empty ova - the karyotype suggests that two sperm cells fertilized it rather than 1 - the buzzword is "grape like" cluster of chorionic villi in the ultrasound)

A 21-year-old Korean female in her 12th week of pregnancy presents with abdominal pain, vaginal bleeding, and excessive vomiting. A transvaginal ultrasound shows what appears to look like a cluster of grapes. Serology demonstrates a significantly increased beta-HCG, and physical exam reveals an abnormally large uterus for the gestational age of the pregnancy. Subsequent genetic analysis reveals a karyotype of 46,XX. Which of the following is the most likely pathogenesis? A. Ovum fertilized by one sperm and implanted in fallopian tubes B. Ovum fertilized by one sperm and implanted in the uterus C. Ovum fertilized by two sperm D. Ovum fertilized by one sperm with duplication of the sperm E. Empty ovum feritilized by two sperm

D (the diagnosis is erythema nodosum - the patient has signs of inflammatory bowel disease, which is highly associated with erythema nodosum)

A 21-year-old college student presents to the student health center complaining of persistent swollen, red, painful, hard "pimples" on his lower legs. He also reports intermittent stomach cramps and diarrhea, which he believes might be an allergy to spicy foods. He says that when he last visited home, his primary care doctor had referred him to a GI specialist, but he failed to make the appointment. Which of the following is the most likely diagnosis? A. Acne vulgaris B. Eczema C. Contact dermatitis D. Erythema nodosum E. Bed bugs

E (in a female fetus, the mesonephric ducts degenerate and the paramesonephric ducts form the reproductive anatomy - so no malformation would be expected, unless you believe that being female is a malformation)

A 22-year-old G2P1 female presents to the clinic at the beginning of her third trimester for a fetal ultrasound. The sonographer is unable to visualize any of the structures arising from the mesonephric duct. This infant is at risk for malformation of which of the following? A. Fallopian tubes B. Uterus C. Upper 1/3 of vagina D. Lower 2/3 of vagina E. No malformation would be expected

A (the patient presents with findings suggestive of an ectopic pregnancy - the location of the ectopic pregnancy is likely in the Fallopian tubes, which grow to accomodate the fetus, until they rupture and hemorrhage in the abdomen) (confirm with transvaginal ultrasound, treat with methotrexate or surgery)

A 23-year-old female with a history of pelvic inflammatory disease presents with uterine bleeding and unilateral pelvic pain. Her last menstrual period was 6 weeks ago. Testing reveals high levels of hCG. Which of the following is the most likely complication of her condition? A. Hematoperitoneum B. Breech presentation C. Eclampsia D. Primary ovarian insufficiency E. Endometrial hyperplasia

D (know the ABCDE of melanoma - asymmetry, border, color, diameter, and evolution)

A 23-year-old medical student presents to the university health clinic requesting a complete skin exam. He just sat through his first week of dermatology lectures and is very worried that he has not had proper skin surveillance. He is particularly concerned about a "mole" on the back of his neck that his girlfriend brought to his attention three months ago. Which of the following characteristics is least concerning for malignancy? A. Asymmetric shape B. Hatched, scalloped borders C. Fast-growing D. Solid black color E. Pruritis and bleeding

A (these are the 'fried egg' appearances of seminomas) (B; present in yolk sac tumors, the most common pediatric tumor) (C; present in Leydig cell tumors) (D; present in embryonal carcinomas, usually as part of mixed germ cell tumors) (E; present in teratomas, which are benign and children and considered malignant in post-pubertal males)

A 24 year-old male presented to his physician with a homogenous, painless testicular swelling that he noticed for the past two weeks. After ultrasound and blood tests, he subsequently underwent a radical inguinal orchiectomy and pathology was consistent with seminoma. Which of the following would you expect to see in a tissue sample from the patient's orchiectomy? A. Lobules of large cells with prominent nuclei and watery cytoplasm B. Schiller-Duval bodies C. Reinke crystals D. Tubular papillary architecture with necrosis E. Mature derivatives of endoderm, mesoderm, and ectoderm

B (this is psoriasis, as shown by the Auspitz sign, pitting in the nails, and presence on the elbows and knees - the stratum granulosum would actually be thinner in the expect psoriasis histology)

A 24-year-old male presents to his family physician with complaints of dry, scaly lesions on his bilateral elbows. He reports that these lesions developed approximately 3 years ago and have been growing in size since that time. He also reports similar lesions on the anterior portion of his bilateral knees. The lesions itch, and they bleed when he scratches them. He denies any additional past medical history. Additional significant findings include notable pitting of the fingernails and pin-point bleeding when a portion of the overlying scale is removed. Which of the following is NOT on the expected histology? A. Acanthosis B. Thickened stratum granulosum C. Vascular dilation D. Munro's microabscesses E. Spongiform vesicules

D (clue cell + vaginal odor + KOH whiff test positive = Gardnerella vaginalis) (this is a vaginOSIS, not a vaginITIS, because there is no inflammation)

A 24-year-old woman presents complaining of a new onset vaginal odor. She reports that she is sexually active in a monogamous relationship with the same partner for two years. You perform a KOH prep, and notice an abnormal smell. On microscopy in your office, you observe the findings shown. What is the most likely causative organism? A. Trichomonas vaginalis B. Candida albicans C. Escherichia coli D. Gardnerella vaginalis E. Neisseria gonorrhoeae

A (disordered epithelial growth most often occurs at the junctional zone between cell types [same principle as Barrett's esophagus] and starts in the basal layer of the cells)

A 27-year-old female presents to her gynecologist for her annual examination. A Pap smear reveals a low-grade squamous intraepithelial lesion. histological examination reveals cellular immaturity, disorganization, nuclear abnormalities and an increased mitotic index. Where are these changes mos likely to begin? A. Basal layer of the squamocolumnar junction B. Endocervical canal C. External cervical os D. Squamos epithelial layer of the ectocervix E. The upper vagina

A (this is a varicocele caused by nutcracker syndrome - this can also be caused by renal cell carcinoma invading or compressing the left renal vein) (B describes hydrocele) (C describes epididymitis) (D describes cryptorchidism) (E describes testicular torsion)

A 27-year-old male presents with primary complaints of a palpable mass in his scrotum and mild testicular pain. Physical exam reveals an abnormal appearing scrotum around the left testis, as depicted. Which of the following is the most likely etiology of this presentation? A. Compression of the left renal vein at the aortic origin of the superior mesenteric artery B. Patent processus vaginalis allowing fluid entry into the scrotum C. Neisseria gonorrhoeae infection of the left testis leading to epididymitis D. Unilateral failure of the left testis to descend into the scrotum E. Twisting of the spermatic cord secondary to rotation of the left testis

B (with endometriosis, oral contraceptive pills can be great treatment assuming they are not just estrogen - this can cause proliferation of the endometrium and make symptoms worse) (the other drugs will, by some way or another, reduce endometrial proliferation)

A 27-year-old nulligravida female presents to her primary care doctor with heavy, painful periods and dyspareunia. She notes that she is recently divorced, but she did not become pregnant after having unprotected sex for two years with her ex-husband. She has a significant family history of painful periods and believes her mother underwent surgery for her condition. Which of the following is LEAST likely to be effective in treatment for this patient's pain? A. Combined oral contraceptive pill B. Estrogen-only oral contraceptive pill C. Danazol D. Gonadotropin-releasing hormone agonists E. Non-steroidal anti-inflammatory medications

B (the patient has endometriosis - a long term complication of endometriosis is infertility) (C; endomtriosis may cause an increased risk of clear cell carcinoma of the ovary, but it does not have any effect on breast cancer risk)

A 27-year-old woman presents with pain during sexual intercourse. She also reports severe menstrual-related pain. Around the time of her periods, she complains of pain with bowel movements or urination. She has no significant past medical history. Vital signs are stable. Physical exam reveals no palpable masses and a pelvic exam which is within normal limits. Which of the following is true about this woman's condition? A. This condition is associated with insulin resistance B. The patient is at a greater risk of infertility C. The patient is at a greater risk of ovarian and breast cancer D. This patient should be referred for a hysterectomy E. Having multiple children is a risk factor for this illness

D (this is placenta accreta, where the placenta implants directly into myometrium without any decidua - this manifests as incomplete placental separation, profuse postpartum hemorrhage, and removal of the placenta manually and in chunks - previous Caesarean sections are a risk factor due to the scar being a site of implantation for the new placenta)

A 28-year-old G3P2 female is in the labor and delivery floor due to being in active labor. The patient is 10 centimeters dilated and preparations are made for delivery of the newborn. A male neonate is born with appropriate Apgar scores and without any perinatal complications. After an attempt at manual placental separation, there is profuse bleeding. Obstetric history is significant for previous cesarean delivery. The placenta is likely implanted A. Normally B. Over the cervical canal C. Over the Fallopian tube D. Over the Caesarean section scar E. Over preexisting placental tissue

A (fibrocystic change in a young female is normal, benign, and not associated with any increased cancer risk)

A 28-year-old female recently discovered a lump in her right breast. She has no family history of breast cancer, and her menstrual cycle began at 13 years of age. On exam you find a 1-cm movable mass in the right outer/upper quadrant. There is no skin dimpling. Biopsy is consistent with fibrocystic change. What is this patient's risk of cancer development? A. The same as the background cancer risk B. Twice the background risk C. Four to five times the background risk D. Ten to fifteen times the background risk

B (Trichimonas vaginalis can causes a fiery-red mucosa of the vagina and cervix, which is sometimes called a 'strawberry' cervix - other symptoms are yellow-gray vaginal discharge, discomfort, dysuria, and dyspareunia)

A 28-year-old female with no past medical history presents to your clinic with complaints of several days pale green frothy vaginal discharge. A sample of the discharge reveals pear-shaped motile cells. Which of the following is an expected finding in this patient? A. Pseudomembranes on the vaginal wall B. Inflamed cervix C. Abnormal menstruation D. Vulval ulceration E. History of spontaneous abortion

D (mastitis patients must be counseled to continue breasfeeding from the infected breast - this allows the milk to let down better and prevents the formation of an abscess) (A, B, C; mastitis is NOT a contraindication to breastfeeding) (E; there is currently no evidence to support that nursing infants gain immunity from feeding from an infected breast)

A 28-year-old woman who has been breastfeeding her 1 month old newborn since birth visits her physician complaining of breast tenderness and fevers. After assessing the patient, the physician believes that she is experiencing mastitis. The patient is started on analgesics and antibiotics. What should the physician recommend in terms of breastfeeding from the affected breast? A. Discontinue breastfeeding to allow time for proper healing B. Discontinue breastfeeding to decrease bacterial spread to the infant C. Discontinue breastfeeding to decrease bacterial spread within the mother D. Continue breastfeeding to decrease the chance of the mastitis progressing to a breast abscess E. Continue breastfeeding since the small bacterial load can help develop the infant's immune system

A (for a premenopausal woman with multiple precancerous lesions, suspect a BRCA mutation [BRCA 2 is more associated with breast cancer in males] - 10% of breast cancers are familial)

A 29-year old woman presents for a mammogram which shows multiple calcifiations and masses throughout the tissue. A biopsy of one of the lesions shows atypical hyperplasia. She does not know her family history for breast cancer. Which of the following genes would be most likely mutated in this patient? A. BRCA-1 B. Estrogen receptor C. Progesterone receptor D. Her2/neu receptor E. E-cadherin

B (the thing about preeclampsia is that it can progress to eclampsia, and all eclampsia is is preeclampsia + convulsions or seizures)

A 29-year-old G2P1 in her 22nd week of pregnancy presents with a primary complaint of peripheral edema. Her first pregnancy was without any major complications. Evaluation reveals a blood pressure of 160/90 and urinalysis demonstrates elevated levels of protein; both of these values were within normal limits at the patient's last well check-up 1 year ago. Further progression of this patient's condition would immediately place her at greatest risk for developing which of the following? A. Diabetes mellitus B. Seizures C. Myocardial infarction D. Crohn's Disease E. Tubulointerstitial nephritis

A (the diagnosis is a fibroadenoma, consistent with change in estrogen - this is a common and benign change in women under 35)

A 29-year-old female presents to her physician with a small, well-demarcated mass in her left breast. A biopsy of the lesion is taken and shown. Which of the following is associated with the patient's condition? A. Estrogen related variation in mass size and tenderness B. Serous nipple discharge C. Malignancy D. Caseous necrosis E. Overexpression of HER-2 receptors

C (this is a partial hydatidiform mole, which has mixed histology and mixed ultrasound results, due to the ability of some but not all chorionic villi to form fetal tissue - these are associated with triploid fertilizations)

A 29-year-old female reports having a positive home pregnancy test result 9 weeks ago. She presents today with vaginal bleeding and complains of recent onset abdominal pain. Ultrasound of the patient's uterus reveals mixed results - fetal tissue is present, but partially obstructed by a snowstorm appearance. Subsequent histologic analysis reveals regions of both normal as well as enlarged trophoblastic villi. Which of the following is the most likely karyotype associated with this pregnancy? A. 46 XX, both of maternal origin B. 46 XY, both of paternal origin C. 69 XXY D. 47 XXY E. 45 XO

B (the patient has a classic presentation of endometriosis, the first line of treatment for which is hormonal therapy in the form of estrogen suppressive agents, found in birth control pills - the other answer options are either extreme 2nd or 3rd line treatments or not helpful to the diagnosis or treatment of endometriosis)

A 29-year-old nulligravida complains of severe pain with menses and inability to conceive after 24 months of unprotected intercourse. She says she feels pain with defecation and intercourse. The first step of management for this patient would be a A. Colonoscopy B. Birth control pills C. Hysterectomy D. Bilateral oophorectomy E. Biopsy of the uterine wall

C (the patient's history and presentation are consistent with a molar pregnancy, which may progress to a choriocarcinoma - this tumor is highly malignant and metastasizes hematogenously - a chest radiograph is done to check for lung metastases - this tumor also produces betaHCG, so that needs to be done as well)

A 30-year-old G3P2 female at 17 weeks' gestation visits your office complaining of vaginal bleeding. The patient's pregnancy has thus far been complicated by severe nausea and vomiting. The patient has no known medical problems and does not smoke or use alcohol. Fetal heart tones are not heard on Doppler. Ultrasonography demonstrates a snowstorm pattern. Which of the following is the most appropriate initial step in management of this patient? A. Observation B. Laparotomy C. Chest radiograph and beta-HCG levels D. Suction dilation and curettage E. Methotrexate

D (the placenta has overgrown the cervical canal, which bleeds 'normally' without hemorrhage or early labor - this is an abnormal implantation of the placenta)

A 30-year-old G3P2 presents at 30 weeks gestation for a routine prenatal visit. Past gynecological history is notable for myomectomy for uterine fibroids. You explain to the patient that she is at increased risk for placenta previa. Which of the following is characteristic of placenta previa? A. Second trimester hemorrhage B. Firm, tender uterus C. Vaginal bleeding with painful contractions D. Painless vaginal bleeding E. Severe abdominal pain of sudden onset

C (Peyronie's disease is an idiopathic fibrous tissue proliferation in the shaft of the penis causing abnormal curvature - this is associated with other fibromatous diseases such as Dupuytren's contracture of the upper extremity - don't confuse this with chordee which is a curvature of the glans) (treatment for Peyronie's is collagenase injections or surgery if severe) (A, B; these are patterns of penile cancer) (D; this is an HPV infection)

A 30-year-old gentleman presents complaining of an abnormal curvature in his penile shaft particularly when he has an erection. He denies symptoms of dysuria and is otherwise in good health. He states that engaging in intercourse has been painful for his wife. Which of the following is a potential associated condition in this patient? A. Bowen disease B. Bowenoid papulosis C. Dupuytren's disease D. Condyloma acuminatum E. Chordee

E (this is an allergic dermatitis in response to an earring - the most common metal that causes this reaction for jewelery specifically is nickel - this can also happen with new soaps, dyes or fabrics of new clothes, and topical ointments used to treat preexisting conditions)

A 30-year-old otherwise healthy woman presents clinic with a rash as shown. She has no history of atopic dermatitis, other forms of eczema, or asthma. She has no allergies and denies any recent medications. Her vital signs are within normal limits. On physical exam, there is an erythematous rash on her ears bilaterally. There are no other appreciable skin lesions. Which of the following is the most likely causative agent of this patient's presentation? A. Platinum B. Gold C. Latex D. Cosmetics E. Nickel

A (a primagravida with a history of hypertension and antepartum hemorrhage with no ultrasound abnormalities sounds like an abrupted placenta - high risk for fetal distress, maternal DIC, and recurrence in future pregnancies)

A 31-year-old G1P0 woman with a history of hypertension presents to the emergency department because she believes that she is in labor. She is in her 38th week of pregnancy and her course has thus far been uncomplicated. This morning she began feeling painful contractions and noted vaginal bleeding. She is experiencing lower abdominal and pelvic pain between contractions as well. On exam, she is afebrile, blood pressure is 145/85 mmHg, heart rate is 102 bpm, and respiratory rate is 16 rpm. You note a gravid, hypertonic uterus on exam and moderate blood in the vaginal vault. Ultrasound reveals no abnormalities. Which of the following is the most likely diagnosis? A. Abruptio placentae B. Vasa previa C. Placenta previa D. Chorioamnionitis E. Onset of normal labor

A (in younger men who are sexually active, the most common cause of epididymitis is likely chlamydia or gonorrhea through retrograde ascending infection - the empiric treatment for this is ceftriaxone and doxycycline) (in older males, treat for Gram-negative rods)

A 31-year-old man with no significant past medical history presents to his primary care provider complaining of right scrotal pain. He states that the pain began 2 days ago and has gradually worsened. He denies burning on urination. On further questioning, he reports two new sexual partners in the past 6 months. Vital signs T 99.8 F, HR 75 bpm, BP 125/80 mmHg, RR 12 rpm. Exam demonstrates a swollen right scrotum that is painful to the touch. Urinalysis is positive for white blood cells. Of the following choices, which is the next best step? A. Ceftriaxone and doxycycline B. Levofloxacin C. Supportive care and MMR vaccine D. Referral to urologist E. CT abdomen and pelvis

D (the Pap smear shows koilocytes - clear vacuoles, containing HPV virions, is a clear sign of HPV infection, especially in high risk areas such as the cervix and in exophytic verrucous warts)

A 31-year-old woman presents to her gynecologist for a routine well-visit. She is sexually active with multiple male partners and uses an intrauterine device for contraception. Her last menstrual period was two weeks ago. She denies abnormal vaginal discharge or sensations of burning or itching. Pelvic exam is normal. Routine Pap smear shows the following. Which organism is most likely responsible for her abnormal Pap smear? A. Treponema pallidum B. Chlamydia trachomatis C. Herpes simplex virus 1 D. Human papillomavirus E. Trichomonas vaginalis

B (the diagnosis is polycystic ovarian syndrome, which is a leading cause of infertility and increases the risk of endometrial cancer)

A 32-year-old female complains to her gynecologist that she has had irregular periods for several years. She has severe facial acne and dense black hairs on her upper lip, beneath her hairline anterior to her ears, and the back of her neck. Ultrasound reveals bilateral enlarged ovaries with multiple cysts. The patient is at increased risk of A. Hypothyroidism B. Endometrial carcinoma C. Addison's disease D. Wegener's granulomatosus E. Eclampsia

C (the stem indicates that the infection is diffuse, likely spreading, and has features of cellulitis - these features indicate Streptococcus over the other common pathogen, S. aureus, which causes the abscessing form of mastitis more often)

A 33-year-old G2P2 woman presents with fever, chills, and acute onset pain of her left breast. She recently had her second child and has been breastfeeding exclusively for about 1 month. She reports having had this type of pain before with her first child. The pain resolved with antibiotics. On physical exam, her left breast is noted to be engorged and diffusely tender to palpation with some edema , induration, and warmth. There is no sign of an abscess. She is given antibiotics and told to continue breastfeeding. Which of the following is the most likely infectious agent? A. Staphylococcus epidermidis B. Staphylococcus aureus C. Streptococcus species D. Peptostreptococcus species E. Lactobacillus species

C (targetoid lesions occur in erythema multiforme due to a central CD8+ T cell mediated necrosis, and a rim of erythema caused by CD4+ T cells and Langerhans cells - this is more associated with infection, while Stevens Johnson is more associated with drug reaction and is far more severe)

A 33-year-old male presents to his physician complaining of several red lesions on his palms, back of hands, and on his lips. His past medical history is significant for recurrent herpes. The most likely diagnosis is A. Erythema migrans B. Erythema nodosum C. Eythema multiforme D. Stevens-Johnson syndrome E. Allergic urticaria

D (any time the pap smear is adequate and with any dysplasia that isn't of "uncertain significance", you proceed to colposcopy)

A 36-year-old female presents to her gynecologist for a check-up. She has had normal Pap smears as recommended every 3 years since she turned 30 years old. The physician conducts a pelvic examination that is without abnormality and obtains a cervical Pap smear. The results of the patient's Pap smear from the visit return as high grade squamous intraepithelial lesion (HGSIL). Which of the following is the best next step in the management of this patient? A. Repeat Pap smear in 12 months B. Repeat Pap smear in 3 years C. Obtain HPV DNA test D. Perform colposcopy E. Radical hysterectomy

C (woman in her first pregnancy, third trimester, has high blood pressure, and proteinuria = preeclampsia, which can progress to HELLP syndrome, and the H stands for hemolysis [EL stands for elevated liver enzymes and LP stands for low platelets])

A 36-year-old primigravida woman visits her gynecologist during the 28th week of her pregnancy. Physical examination reveals pitting edema around her ankles and elevated systolic blood pressure. 24-hour urine collection yields 4 grams of protein. If left untreated, the patient is at increased risk for which of the following? A. Urethral infection B. Hypovolemic shock C. Hemolysis D. Gestational diabetes E. Placenta accreta

D (this is acanthosis nigricans in an overweight 40-year old female - insulin resistance is extremely likely, which predisposes to polycystic ovarian syndrome, with further consequences such as infertility and endometrial carcinoma)

A 40-year-old female presents to her family physician for a check-up. On examination, she is 5'2", weighs 210 pounds, and has a dark and velvety skin discoloration on the back of her neck and in her axilla. She is not taking any medications and is otherwise healthy; however, she notes that she has struggled with her weight since college. Given her history and physical exam findings, for what is this patient at risk? A. Pellagra B. Adenocarcinoma C. Adrenal insufficiency D. Insulin resistance E. Melasma

D (so, yeah, just memorize that Meigs syndrome is an ovarian fibroma with ascites and pleural effusion, I guess...there wasn't much on this one)

A 40-year-old nulliparous woman with no significant medical history presents to your office with shortness of breath and increased abdominal girth over the past month. The initial assessment demonstrates that the patient has a right-sided hydrothorax, ascites, and a large ovarian mass. Surgery is performed to remove the ovarian mass, and the patient's ascites and pleural effusion resolve promptly. What is the most likely diagnosis? A. Metastatic colon cancer B. Metastatic lung cancer C. Metastatic ovarian cancer D. Meigs syndrome E. Nephrotic syndrome

A (VIN has an increased risk for carcinoma, 90% of which are squamos cell - risk factors are HPV, smoking, and immunosuppression - the treatment is a vulvectomy with good prognosis)

A 42-year-old women, gravida 4, para 4, complains of vulvar itching and a raised lesion. The lesion is confirmed to be a vulvar intraepithelial neoplasia of moderate grade. Which of the following would this most likely progress to? A. Squamos cell carcinoma B. Paget's disease C. Extramammary adenocarcinoma D. Malignant melanoma E. Basal cell carcinoma

A (this is pemphigus vulgaris, which is an autoimmune bullous disease where antibodies attack the desmogleins holding together the skin - fatalities occur from fluid loss and infection)

A 43-year-old woman presents to her primary care physician complaining of persistent blisters that she has had now for several weeks. She reports that the blisters started on her lips and then developed on the skin and have since began to slough, resulting in open ulcers that are painful. What is the target of the autoantibodies associated with this condition? A. Desmoglein 3 B. Desmopenetrin C. Gap junctions D. Intermediate junctions E. Tight junction

B (despite normal blood work, the ultrasound reveals what should be highly concerning for testicular cancer, which is treated with radical orchiectomy - biopsy is inappropriate for these tumors as it might induce metastasis) (D, E; testicular cancer is often asymptomatic and requires treatment upon detection)

A 45-year-old man presents to his primary care provider for his yearly physical. On exam, the physician discovers a hard, testicular mass on the right testis. On further questioning, the patient remarks that he first noticed it 6 months ago, but did not think he needed to have it examined since it wasn't painful. Transillumination of the scrotum does not reveal translucency. The ultrasound of his right testis shows a well-defined lesion without cystic areas. Blood work reveals normal AFP and beta-hCG. Chest radiograph and CT scan do not show positive lymph nodes or distant metastases. Which of the following is the most appropriate next step? A. Biopsy B. Radical orchiectomy C. Chemotherapy D. Three month re-imaging E. No further workup, instruct patient to return if symptomatic

A (this is lichen planus - the 6Ps are purple plaques and papules that are pruritic, planar and polygonal) (Wickham striae are another name for the mucosal lesions)

A 49-year-old woman with chronic hepatitis C infection develops a very itchy rash on her forearms, calves, and buccal mucosa. On exam, multiple polygonal, purple papules are found on the skin. The buccal mucosa shows a lacy, reticulated pattern. Which histologic pattern best describes her lesion? A. Sawtooth infiltrate of lymphocytes at dermal-epidermal junction B. Subcorneal spongiosis C. Suprabasal Paget cells D. Prominent vesiculosis with high mitotic index in the basal cells E. No abnormalities would be seen on histology

C (honey colored crusting vesicular rash on a pediatric patient? BAM, impetigo)

A 5-year-old boy is brought to his pediatrician by his mother, who reports that the child has had a skin infection on his face for the last several days which has been enlarging. He complains that the "rash" is very itchy. Which of the following is the most likely diagnosis? A. Folliculitis B. Acne vulgaris C. Impetigo D. Erysipelas E. Tinea capitus

A (the diagnosis is bullous pemphigoid - note that the bullae are tense and not present in the oral mucosa, to separate this from pemphigus vulgaris)

A 50-year-old female presents to her physician with vesicles and tense blisters across her chest, arms, and the back of her shoulders. Physical examination reveals that blistering is not present in her oral mucosa, and the epidermis does NOT separate upon light stroking of the skin. The patient most likely suffers from a hypersensitivity reaction located: A. Linearly along the epidermal basement membrane B. In net-like patterns around epidermal cells C. In granular deposits at the tips of dermal papillae D. In fat cells beneath the skin E. In nuclei within epidermal cells

E (this is a subtype of ductal carcinoma in situ - it is more likely to be aggressive and invasive)

A 52-year-old female was found upon mammography to have branching calcifications in the right lower breast. Physical exam revealed a palpable nodularity in the same location. A tissue biopsy was taken from the lesion, and the pathology report diagnosed the lesion as comedocarcinoma. Which of the following histological findings is most likely present in the lesion? A. Orderly rows of cells surrounding lobules B. Disordered glandular cells invading the ductal basement membrane C. Extensive lymphocytic infiltrate D. Halo cells in epidermal tissue E. Pleomorphic cells surrounding areas of caseous necrosis

C (you're looking at a granulosa cell tumor - note "gland-like structures with eosinophilic material", or Call-Exner bodies - this tumor occurs 66% of the time post-menopause, is potentially malignant, and produces inhibin - it also produces estrogen, which can cause precocious puberty in younger patients, and endometrial hyperplasia in all of them)

A 52-year-old patient undergoes a biopsy of the ovary, with the results shown. Which of the following additional findings would you most expect to see in this patient? A. Mature teratoma B. Increased CA 19-9 tumor marker C. Endometrial hyperplasia D. Vaginal atrophy E. Pregnancy

B (this is Paget's disease of the nipple [not related to Paget's disease of the vulva] - the underlying problem is a ductal carcinoma in situ, where the neoplasm is unable to penetrate the basement membrane and instead grows out of nipple and onto the surrounding skin - this patient would need a skin biopsy and a mammogram)

A 58 year-old woman presents to her primary care physician complaining of an itchy rash on her right breast. Upon further questioning, she notes that she's noticed an itchy red rash with flaking around her right nipple for several months. She originally attributed it to dry skin, as it was winter, but is concerned that it has not improved, even with application of moisturizing cream several times a day. Recently, she also has noticed occasional yellowish discharge from the right nipple. Her exam is within normal limits, with the exception of her right nipple and areola, which appear as shown. This presentation is most indicative of an underlying A. Fat necrosis B. Ductal carcinoma in situ C. Lobular carcinoma in situ D. Triple negative invasive ductal carcinoma E. Anterior pituitary tumor

B (this is dandruff, AKA seborrheic dermatitis - there is an increased risk of disease in Parkinson's because dopamine promotes sebum production)

A 58-year-old male presents to your office complaining of a rash on his forehead and scalp. His scalp is presented. This patient's cutaneous presentation is associated with which systemic disease? A. Rheumatoid arthritis B. Parkinson's disease C. Alzheimer's disease D. Sjogren's syndrome E. Systemic lupus erythematosus

B (the diagnosis is hypospadias, which is more common than epispadias which has the opening on the dorsal surface - associated with cryptorchidism and other urinary tract malformations, predisposure to UTIs and possible reproductive dysfunction) (epispadias is usually accompanied by bladder extrosphy)

A newborn male is found to have the urethral opening on the ventral side of his penis. The image demonstrates this defect in an adult. This abnormality is a result of which of the following? A. Incomplete fusion of the urachal duct B. Incomplete fusion of the urethral folds C. Incomplete fusion of the labioscrotal swellings D. Dysgenesis of the genital tubercle E. Vitelline fistula

C (this is inflammatory breast carcinoma - the neoplasm infiltrates and blocks the breast lymphatics, causing swelling and edema - the prognosis is poor with a 10% survival after 5 years, and is made worse by the presence of axillary lymphadenopathy)

A 58-year-old women presents with a rapidly enlarging, painful breast mass. The overlying skin exhibits edema, warmth, erythema. There is non painful adenopathy in the ipsilateral axila. Initially suspecting a case of acute masitis, you perscribe a course of antibiotics. One week later, the patient returns, having completed their antibiotics, and with no improvement in the breast. Which of the following does this patient likely have? A. Linear infilrations of lobular epithelia B. Keratin plugging C. Lymphatic infiltration D. Estrogen depletion E. High-grade fibrosis

B (transillumination is diagnostic test of hydrocele, which is described in the stem as being an accumulation of serous fluid accumulating in the scrotum)

A 6-month-old male presents with a painless, enlarged left scrotum. After examining the patient, you suspect this enlargement is secondary to serous fluid entering and accumulating in the scrotum through a patent processus vaginalis. Which of the following would be the most useful next step in confirming the diagnosis of this patient's condition? A. Measurement of AFP and hCG levels B. Transillumination test followed by scrotal ultrasound C. Evaluation of cremasteric reflex on physical exam D. Measurement of serum testosterone levels E. Standard urinalysis

C (this is basal cell carcinoma) (A; false, it can metastasize, but it very rarely does so) (B; this is a better description for squamous cell carcinoma) (D; sun exposure is the most important risk factor) (E; this is more true for squamous cell carcinoma)

A 62-year-old man presents to his primary care physician complaining of a skin lesion on his nose. He retired last year after working on a farm for 20 years. A biopsy of the lesion is performed and is shown. Which of the following is most likely true regarding this lesion? A. It cannot metastasize B. It appears as an ulcerative, hyperkeratotic red nodule C. It appears pearly and papular with overlying telangiectasia D. Smoking is the most important risk factor for its development E. The lower lip is its most common location

B (this is actinic/solar keratosis, a precancerous lesion to squamous cell carcinoma - treatment is to remove the lesion and reduce sun exposure)

A 65-year-old Caucasian male presents to his primary care physician for evaluation of several skin lesions. He has been a farmer for most of his adult life and this is the first time he is seeing a physician in many years. Distributed on his hands, arms, face, and lower legs, there are several discrete, rough, and hypertrophic papules with ill-defined borders. Several have overlying yellow scales. The patient indicates that these have been present for several years and began as rough patches that were difficult to see. Based on the presence of these lesions, what is this patient at risk for developing? A. Basal cell carcinoma B. Squamous cell carcinoma C. Melanoma D. Systemic lupus erythematosus E. Seborrheic keratosis

B (UV exposure is the most important risk factor for squamous cell carcinoma - actinic or solar keratoiss are precancerous lesions to this type of cancer)

A 67-year-old landscaper presents to his primary care physician for a routine visit. On exam, the physician notes a 2x2 cm rash on his lower lip, shown. Upon further questioning, the patient states the rash has been there for weeks, but it hasn't really bothered him. It is not painful or pruritic. He does not recall any recent bug bites. Which of the following is the most important risk factor for this type of lesion? A. Increasing age B. Sun exposure C. Immunosuppression D. Smoking E. History of eczema

C (in younger males, STDs are the likely cause of epididymitis/orchitis - in older men, think enteric Gram-negative rods like E coli)

A 68-year-old male presents with pain and tenderness of his right testicle. These symptoms started gradually over the last day. Vital signs are as follows: T 99.8 F, HR 75, BP 125/80 mmHg, RR 12. On physical exam, he has severe pain when the testicle is palpated which is lessened with elevation of the involved testicle. Doppler ultrasound shows normal blood flow in both testes. Which of the following organisms is the most likely pathogen in this patient's condition? A. N. gonorrhoeae B. C. trachomatis C. E. coli D. S. aureus E. S. epidermidis

D (the most important prognostic factor for melanoma is the depth/lesion thickness)

A 70-year-old male presents with the lesion shown. Which of the following factors will most impact his prognosis? A. Gender B. Lesion location C. Histology D. Lesion thickness E. Presence of ulceration

E (this is seborrheic keratosis, which is a benign proliferation of basal cells due to growth factors, and require no therapy)

A 71-year-old man presents to a dermatologist concerned that he has "skin cancer." He was watching a television report about skin cancer awareness and is now concerned that a "mole" he has on his chest is cancer. On dermatologic exam, the lesion is as shown. What is the most appropriate next step in the management of this patient's "mole"? A. Incisional biopsy B. Excisional biopsy C. Cryoablation D. Microsurgery E. No therapy

B (this is squamous cell carcinoma - well differentiated keratin pearls are diagnostic - treatment is excision with clear margins)

A 71-year-old man presents to his primary care physician with the lesion shown. He states that it has been present for several months. He has no significant past medical history and is a retired construction worker. What would be the expected pathology on biopsy? A. Palisading basal cells B. Keratin pearls C. S-100 postive staining cells D. Parakeratosis E. Hyperkeratosis

B (of the options, only nulliparity is a risk for ovarian carcinoma)

A G0 57-year-old female presents to her gynecologist complaining of lower abdominal pain, early satiety, and urinary frequency of 2 weeks duration. She used oral contraceptive pills for several years during her twenties and thirties, and entered menopause at age 45. Surgical history is notable for a myomectomy 20 years ago. Family history reveals that her mother died of lung cancer. Laboratory results demonstrate markedly elevated CA-125. A pelvic CT scan reveals a massive ovarian neoplasm. Which of the following in this woman's history is a risk factor for ovarian carcinoma? A. Family history of lung cancer B. Nulliparity C. Oral contraceptive use D. Myomectomy E. Early menopause

D (the Phyllodes tumor is a potentially malignant fibroadenoma of older women - it histologically appears as a "more adeno than fibro" fibroadenoma and is "leaf shaped" - because it is a type of fibroadenoma, it is well circumscribed, mobile, and smooth - breast enlargement can occur with hormonal fluctuation since these tumors are sensitive to hormones)

An incisional biopsy was performed which showed the following histology. The pathologist looked at the patient history and diagnosed the specimen as a Phyllodes tumor. Which of the following is the most likely patient history? A. Middle-aged male with cirrhosis B. Premenopausal woman with exquisite breast tenderness C. Postmenopausal woman with incidental finding on an annual mammogram D. Postmenopausal woman with enlarged breast and a mobile smooth palpable mass E. Premenopausal woman with bloody nipple discharge

That's cool man, play ball

I just put a picture of a smiling baby as the first card of the set because otherwise it was gonna be a deformed penis on the class page and that seemed untoward.

C (the diagnosis is phimosis - in childhood, this is an anomalous development but in adulthood it may be secondary to inflammation or scarring - phimosis is risk factor for infection and carcinoma, so circumcision is the best course of action)

On your OB/GYN rotation, a male neonate presents with a congenital anomaly of the penis - you note on an initial exam that the prepuce is too tight to be retracted over the glans. What is the best course of treatment for this patient? A. None; this is normal and resolves spontaneously B. Observation C. Circumcision D. Corticosteroids E. Advise the parents that the child will require above-average hygiene maintenance

D (there is a risk factor for penile cancer with HPV infection, but only of the high risk strains, which are 16 and 18 - 6 and 11 are the high risk strains for condyloma acuminatum)

Which of the following is not a risk factor for the development of squamos cell carcinoma of the penis? A. Smoking B. Lack of circumcision C. Chronic inflammation D. Infection with HPV strains 6 or 11 E. Phimosis