Repro CASES only

34 year old female comes to office concerned of thick vaginal discharge. She recently had a bacterial infection that was treated with antibiotics. Her genital area is itchy and painful. Wet prep shows a treelike branching pattern. Treatment?

(ANTIBIOTICS CAN MESS WITH THE VAGINAL FLORA AND CAUSE YEAST OVERGROWTH) Budding yeast seen candida infection (yeast) Yeast vaginitis! single dose of fluconazole (azole) oral or vaginal no need to treat partner

19 year old female presents with lower abdominal pain. She has had one sexual partner her whole life. She states that they do not use protection, and that he has only ever had sex with her. Exam notes purulent cervical discharge, chandelier sign (cervical motion tenderness). Name the 2 most likely infections we suspect

1. Chlamydia trachomatis 2. Neisseria gonorrhea

34 year old female with history of cyclic pelvic pain, dysmenorrhea presents with an ovarian mass causing pain, fullness and urinary frequency. Histology reveals malignant tissue that ressembles endometrial tissue. What else does the doctor need to look for

15% of endometrioid carcinomas of the ovary also present with endometrial carcinoma look at the endometrium!

Premenopausal woman presents with a benign pappilary tumor in her lactiferous duct. What symptom do we expect? What is her chance of developing cancer?

2x increased risk intraductal papilloma

45 year old female presents with vulvar carcinoma. What do you predict is the cause?

40-50 year old probably got HPV in 20's, became carcinoma older postmenopausal women could get it from longstanding lichen scleroisis

15 year old girl with short stature, webbed neck, broad shield chest. Breast development is absent. External genetalia are infantile appearing. She has primary amenorrhea. Lab finds elevated FSH. Ultrasound finds streak ovaries. What is her karyotype?

45XO no barr body

34 year old female presents with bilateral breast lumps. They are more painful before menstruation. There are increased numbers of cell layers in the terminal duct lobule. Cellular atypia noted. Cancer risk?

5x increased cancer risk proliferative breast disease: atypical ductal hyperplasia presents in women over 30

3 year old boy presents with a testicular mass. Grossly, mass is yellow and hemorrhagic. Schiller duval bodies are noted. What tumor marker is likely present?

AFP endodermal sinus tumor AKA yolk sac tumor

Female who has had an IUD for 2 years presents with lower abdominal pain, fever, purulent cervical discharge, chandelier sign. Name a likely pathogen

Actinomyces israelii IUD + PID

24 year old female has a dilation and curettage after presenting with abnormal uterine bleeding. 3 months later she comes in with secondary amenorrhea. Dx?

Asherman syndrome loss of basalis layer of endometrium basalis layer can no longer regenerate functionalis layer

60 year old male presents with elevated BUN and SCr. Renal ultrasound reveals hydronephrosis. His bladder is distended, and he has not urinated in 2 days. After taking his history you find that he has had nocturia, painful urination, difficulty initiating urination, frequent urination getting worse for the past 2 years. His free PSA is elevated. Dx and treatment?

BPH alpha 1 antagonists: prazosin, tamsulosin, terazosin) (relaxes smooth muscle) finasteride (5 alpha reductase inhibitors)

69 year old man has nocturia and difficulty initiating his stream. PSA is 6, and free PSA is elevated. Dx?

BPH free PSA is only elevated in BPH PSA may be elevated in BPH, prostatitis, prostate cancer

55 year old man has nocturia, difficulty initiating his stream. He has had frequent urination for the past 2 years. free PSA is slightly elevated. Describe pertinent anatomy

BPH middle and lateral lobes (periurethral) are enlarged smooth, elastic, firm enlargement

62 year old man presents with a UTI and high free PSA. Nocturia, dysuria is noted in history. Explain why the doctor prescribed him prazosin after treating the UTI

BPH prazosin (alpha 1 antagonist) relaxes smooth muscle to ease urinary flow

78 year old man comes to ER because of inability to urinate for the past 2 days, and lower abdominal pain. He admits to urinary difficulties over the past two years, including difficulty initiating his stream, weak stream, nocturia, dribbling after voiding. PSA is high-normal (3.8), BUN is elevated. Renal pelves are enlarged on ultrasound. Dx?

BPH leading to acute urinary retention PSA level of over 4 would suggest prostate cancer

22 year old female patient has 2 family members with breast cancer and 3 family members with ovarian cancer. What genetic test may be appropriate in determining her risk for ovarian cancer

BRCA testing BRCA 1: 45% Lifetime risk of ovarian cancer BRCA2: 25% lifetime risk of ovarian cancer

69 year old female presents with fullness, urinary frequency and mild pelvic pain. A mass if found and removed. Histology reveals urothelial cells (transitional epithelium). Prognosis?

Brenner tumor benign

9 year old female with precocious puberty presents with an ovarian mass. Histology reveals _______. Granulosa cell tumor is diagnosed.

Call exner bodies coffee bean nuclei elevated estrogen or progesterone!

33 year old man presents with a painless testicular mas that does not transilluminate. His hCG is elevated. Symptoms of hyperthyroidism and gynecomastia are noted. Exam reveals a small testicular tumor and many, enlarged metastases all over the body. Explain the hyperthyroidism and gynecomastia

Choriocarcinoma elevated beta hCG mimmicks TSH, LH, FSH TSH causes hyperthyroidism FSH/LH cause gynecomastia

28 year old male presents with a testicular mass and elevated hCG. Hemoptysis, hemorrhagic stroke occured. Dx?

Choriocarcinoma most aggressive testicular germ cell tumor hematogenous spread to brain and lungs

32 year old female presents with hemoptysis after her baby is born. A small primary tumor in the ovary is found along with metastases to the lungs. treatment?

Choriocarcinoma pregnancy path responds well to chemotherapy

25 year old male comes to the ER complaining of hemoptysis. Physical exam reveals gynecomastia. Serum hCG is elevated. Free T4 is elevated. 3 days later he suffers a hemorrhagic stroke. What did the ER doc miss on physical examination?

Choriocarcinoma (germ cell tumor of testis)

27 year old female with history of gonorrhea tried to have kids years ago but has given up. She presents with abnormal uterine bleeding and pelvic pain. Histological analysis reveals lymphocytes and plasma cells in the endometrium. Dx?

Chronic endometritis must be diagnosed by presence of plasma cells

29 year old obese female presents with recent history of complaining that her feet are swollen. Her skin is flushed and sweaty and she is tachycardic. She states that her apetite has increased significantly in the last month. Physical exam finds systolic heart murmur. Dx?

Could be pregnant do a pregnancy test

69 year old female presents for a routine mammogram. Microcalcifications are noted in the ducts. A biopsy shows neoplastic cells confined to the basement membrane, filling the ducts. Dx?

DCIS arises from ductal atypia

80 year old female presents with microcalcifications in her breast duct on a routine mammogram. Histology shows intact basement membrane of ducts, but ducts are filled with hyperplastic cells. Necrosis, calcification in the middle of the ducts. What causes the calcification?

DCIS, comedocarcinoma remember that epithelia don't have blood supply. The center of the duct dies from decreased blood flow, undergoes DYSTROPHIC CALCIFICATION

female presents with columnar epithelium in the upper 1/3 of her vagina. What likely caused this? What should the patient be worried about?

DES exposure in utero caused it increased risk for clear cell adenocarcinoma (of the columnar cells)

Female presents with erythematous, pruritic itchy lesion on her vulva. Malignant epidermal cells are noted on histology. What is the next step?

Do a stain to distinguish between melanoma and carcinoma melanoma: PAS negative, keratin negative, S100 positive carcinoma (paget) = opposite

78 year old female presents with hyperplastic, discohesive cells in her acini (breast) that are found as an incidental finding of a biopsy. Cells are discohesive and lack E cadherin. Basement membrane intact. Treatment?

Do not remove: LCIS is often bilateral and multifocal: you would have to remove too much tissue. Additionally, this is not a precancerous lesion. It just increases the risk for other cancers. Give tamoxifen to decrease invasive progression Followup closely LCIS is more of a risk factor than a premalignancy

33 year old female presents with bilateral breast lumps. She experiences premenstrual breast pain, and large fluctuation of the size and mass of breasts. Histology reveals an increase in layers in the ducts. No cellular atypia noted. Cancer risk?

Dx = breast proliferative disease -Typical ductal hyperplasia 2x increased risk of cancer

27 year old bicyclist presents with a painful mass in his left testicle that has been growing for the last 2 months. It does not transilluminate. Histopathology reveals papillae full of pleomorphic cells. hCG is elevated. Dx?

Embryonal carcinoma lance armstrong worse prognosis than seminoma

4 year old female presents with vaginal bleeding. A vaginal mass is biopsied. It stains desmin positive and myoglobin positive. Dx?

Embryone rhabdomyosarcoma Sarcoma botryoides

20 year old man presents with a painful, hemorhagic testicular mass with glandular morphology. hCG levels are elevated. After chemotherapy, the tumor is found to have skin, hair and teeth. What happened?

Emrbyonal carcinoma differentiated into a teratoma after exposure to chemotherapy

30 year old female presents with irregular breast tissue that is diffusely lumpy. There is not one marked lump, it is vague. Blue dome cyst on gross pathology. Pathophys

Fibrocystic change cysts form, fibrosis forms around it: ducts or lobules

29 year old female presents with irregular breast tissue that is lumpy with no definite mass present in the upper outer quadrant of the breast. The pathology is a blue domed cyst. Dx?

Fibrocystic change variant of normal

5 year old boy presents with a testicular mass that does not transilluminate. AFP level is elevated. Malignant tumor is present. Describe a histological feature you expect

Glomeruloid structure called schiller duval body Yolk sac tumor

55 year old female (postmenopausal) presents with abnormal uterine bleeding and breast tenderness. Pathology reveals call-exner bodies and coffee bean nuclei Dx?

Granulosa cell tumor (secretes estrogen)

84 year old female presents with a breast mass. Biopsy reveals desmoplastic stroma, with small, near normal looking tubules that lack myoepithelial cells. Prognosis?

Great prognosis Tubular subtype of invasive carcinoma in situ giveaway is the desmoplastic stroma

Pregnant woman with type 1 diabetes in her 30th week of gestation presents with swollen face, BP of 170/110, RUQ pain, headache. Explain the following findings -thrombocytopenia -elevated liver enzymes -anemia -schistocytes on blood smear

HELLP syndrome in presence of pre-eclampsia hemolysis, elevated liver enzymes, low platelets thrombi form in liver (use up platelets) RBC's shear going thru the blockage (anemia + schistocytes) elevated liver enymes from liver infarction (low blood supply)

1 year old presents with condyloma acuminata on the genitals. What is the most likely mode of transmission/pathogen causing it?

HPV 6,11 Perinatal transmission!

24 year old female with multiple unprotected sexual partners presents with a cluster of painful vulvar genital vessicles. She had flu like symptoms a few days prior. Histology notes multinucleation, molding with eosinophilic intranuclear viral inclusions. She is very worried about other viral complications, and pregnancy complications from the virus. What do you tell her?

HSV 1 or HSV 2 genital herpes Pregnancy will be fine, but if she has active vessicles at the time of delivery she will need a C section Other complications include aseptic meningitis, distal skin manifestations, urinary bladder retention (sacral autonomic dysfunction)

A 35 year old couple present to a fertility doctor after unsuccessful attempts at getting pregnant after 3 years. Her workup is normal. His workup reveals tall stature, long arms, triangular shaped pubic hair, normal penis, small testicular volume. FSH, LH are high. T is low. Estrogen is elevated. What do you tell the couple about the likelihood of getting pregnant?

He has Klinefelter syndrome he is infertile because of seminiferous tubule atrophy If he were very young, you could extract spermatozoa for IVF

32 year old with 3 prior C sections has a confirmed diagnosis of placenta accreta. She is very worried for the health of her baby. What do you tell her?

Her baby is not at risk. Mom is at risk because of massive hemorrhage

27 year old female presents with fever, purulent cervical discharge, chandelier sign (cervical motion tenderness) and ____. Her doctor is concerned and tells her that her infection spread to her liver, creating adhesions between her liver and peritoneum. Name the complication and fill in the blank

Hugh-Fitz-Curtis syndrome presents with RUQ pain

24 y.o. man who has not gone through puberty. No secondary sexual hair, genitalia almost prepubertal. Testes 10 ml. volume. all pituitary tests normal FSH low LH low T low Your patient is married and desperately wants children. Treatment?

Hypogonadotropic hypogonadism (may be Kallman syndrome) Treat with pulsatile Leuprolide (GnRH agonist) this may restore fertility if you administer just T, he will not become fertile

32 year old female was previously treated for Chlamydia with doxycycline, and was also given cephalosporins for potential gonorrhea. She wants to talk about having an IUD because she can never remember to take her birth control pill. What do you tell her?

IUDs are contraindicated in patients with previous PID make it easier for more infections

30 year old female with hypertension and diabetes in the 32nd week of gestation presents with proteinuria and severe HT. Her headache worsens, and she experiences a seizure. Treatment?

Immediate delivery IV magnesium sulfate (seizure prophylaxis) antihypertensives (no ACEi or ARB) steroids if we need to improve fetal lung maturity

67 year old female presents with features of acute mastitis but does not respond to dicloxycycline. On biopsy you see her dermal lymphatics are blocked. Prognosis?

Inflammatory subtype of invasive ductal carcinoma neoplastic cells block lymph drainage poor prognosis because it has already reached lymphatics

15 year old boy with normal height a high voice, no pubic hair, no facial hair is unable to smell his own farts. He fails a colorblind test. Explain the pathophysiology of his delayed puberty and anosmia

Kallman syndrome Anosmia: lack of olfactory neurons in the brain Hypo hypo: genetic condition causing lack of GnRH neurons in the hypothalamus

15 year old boy states that his classmates make fun of him for his high voice and lack of facial hair. They saw in the locker room that his penis and testicles are smaller than normal. He is colorblind and unable to smell his farts. He cannot understand the stigma behind farting, so he gets bullied for farting a lot. What are his LH levels?

Kallman syndrome anosmia, color blindness, delayed puberty LH, FSH, GnRH and T are low

19 year old male who has not gone through puberty presents for a consult on family planning. He is worried that his penis and testicles are small for his age. He states that he never wants children. He wants a vasectomy, as he is sexually active. Exam notes lack of facial hair, high voice, small testis, colorblindness, anosmia. What should you tell his about his vasectomy?

Kallman syndrome no need for vasectomy, just treat with T and he will be infertile but will develop secondary sex characteristics

23 y.o. man with very small testes and no health problems comes for a checkup. He is 6'2'', 190 lbs with a normal penis gynecomastia, female (triangular) pubic hair distribution. All labs are normal except FSH is hig, LH is high, T is low. Explain FSH level

Klinefelter syndrome 47XXY phenotype dysgenisis of seminiferous tubules cause low inhibin and increased FSH

21 year old male with long arms, eunuchoid body shape, triangle shape of pubic hair, small testicles, High FSH, high LH, low testosterone, gynecomastia asks you why his arms are really long. What do you tell him?

Klinefelter syndrome Abnormal leydig cell function leads to decreased T, increased LH, increased estrogen. Decreased T delays closure of epiphyseal plates

28 year old male with a eunuchoid body shape and normal penis presents complaining of his long standing gynecomastia. Physical exam reveals triangular shaped pubic hair, very small testicles, long arms and tall stature. Explain his gynecomastia and FSH levels.

Klinefelter syndrome FSH is elevated because seminiferous tubules, and sertoli cells are damaged resulting in decreased inhibin abberant leydig cell function leads to decresed T and increased Estrogen (leydig cells have aromatase) increased Estrogen causes gynecomastia

78 year old female with stomach cancer presents with bilateral ovarian tumors. What tumor do we expect to find? Descibe it histologically

Kruckenberg tumor Signet ring cells mucinous adenocarcinoma

49 year old female with calcification in the breast (due to fibrocystic change) has a biopsy. Proliferation of small uniform cells within acini (lobules is noted). Cells in acini are discohesive. No necrosis. Basement membrane is intact. Dx?

LCIS discohesive cells because they lack E cadherin not precancerous, but increases risk of developing cancer by 10x LCIS is usually detected incidentally

65 year old woman presents with a benign breast calcification that is biopsied. ____ is found incidentally. Basement membrane intace. Acini filled with cells that are discohesive with one another. No necrosis or calcification. What causes the discohesion on these cells?

LCIS lack of E cadherin

80 year old female receives a breast biopsy for a benign calcification. Acini are found to be filled with discohesive cells because they lack ____. Cells do not havenecrosis or calcification. What is the likely distribution of this non invasive lesion in her breast?

LCIS lacks E Cadherin likely multifocal and bilateral we don't remove it

49 year old presents for a routine mammogram. LCIS is detected on physical exam. Biopsy shows intact lobular basement membrane with proliferation of uniform cells in acini. The cells are discohesive, and lack E-cadherin. She is told that it is not a precancerous lesion so it does not need to be removed. It does increase the risk for cancer. What is wrong with this story?

LCIS is an incidental finding you wouldn't detect it and do a mammogram no necrosis, no calcification

A 49 year old female presents with a recent onset of sleep disturbances, hot flashes accompanied by irregular periods she has been having hot flashes and her vagina is atrophying. Dx

Let's give menopause a round of menoplause

30 year old man with gynecomastia has a testicular mass removed. Gross pathology reveals a golden brown mass. Histology reveals Reinke crystals. Explain the gynecomastia.

Leydig cell tumor benign androgen producing (aromatization)

female with hirsutism presents with an ovarian mass that has Reinke crystals on histology. Dx?

Leydig/sertoli cell tumor

59 year old postmenopausal woman comes to see you because she is worried about her vulvar skin. It has white patches on it (leukoplakia) and feels very thin. She is curious about how this is happening. What do you tell her?

Lichen sclerosis atrophy of the epithelium over time underlying dermis undergoes fibrosis benign, but increases risk for SCC

2 postmenopausal women come into your clinic with vulvar leukoplakia. One patient's vulvar skin feels very thin, the other's feels thick and leathery. What do you tell them about their risk of cancer

Lichen sclerosis = thinning of epidermis: benign condition with increased risk for squamous cell carcinoma Lichen simplex chronicus = hyperplasia of vulvar squamous epithelium, totally benign, no increased risk for cancer

69 year old female with chronic itching in her genital region comes in worried about white patches on her vulva. On physical exam you notice a thick, leathery vulvar epithelium. Pathogenisis?

Lichen simplex chronicus benign hyperplasia of vulvar epithelium due to chronic irritation (scratching) Totally benign, no risk of carcinoma

39 year old BRCA1 positive female with invasive breast cancer presents with a high grade tumor with inflammatory cells (lymphocytes and plasma cells). Dx?

Medullary carcinoma fleshy, cellular lymphocytic infiltrate good prognosis

20 year old female presents with ascites, pleural effusion and an ovarian tumor. Dx?

Meigs syndrome

female presents with a pulling sensation in the groin, an ovarian mass with bundles of spindle shaped fibroblasts. She has a swollen abdomen from ascites. Additionally she has pleural effusion (hydrothorax). Dx?

Meigs syndrome with fibroma of ovary Meigs syndrome is usually R sided

Child presents with smooth papules on the belly. They contain a central cheesy plug. They cannot be popped like pimples. Dx?

Molluscum contagiosum

35 year old female presents with ovarian mass lined by a single, smooth layer of columnar epithelium with clear cytoplasm. The mass is multiloculated and large. Diagnosis?

Mucinous cystadenoma

36 year old female presents with bilateral ovarian masses. They are filled with fluid. Gross histology reveals thin walled multilocular cysts lined with a single layer of columnar epithelium. The columnar epithelium has lots of clear cytoplasm. Dx?

Mucinous cystadenoma benign neoplasm of the ovary the most common is serous

35 year old female and a 70 year old female present with adnexal masses. They are both highly prevalent. The premenopausal woman's gross pathology is cystic, with a single layer of columnar cells with clear cytoplasm. The postmenopausal woman's gross pathology has an irregular carpet like lining. Both tumors are filled with mucous fluid. Dx?

Mucinous cystadenoma (premenopausal) Mucinous cystadenocarcinoma

66 year old female with primary colon cancer has bilateral ovarian masses. Name the tumor and describe its histology

Mucinous signet cell (signet ring) adenocarcinoma Kruckenberg tumor

15 year old boy presents to the ER with nuchal rigitidy, headache and tender testicles. He reports his testicles started to hurt a few days after his cheeks swelled up. Should he be worried about his ability to have children

Mumps POM parotitis meningitis orchitis could cause sterility, especially post pubertally

6 year old boy presents with swollen neck, parotitis. 4 days later he develops painful orchitis ad aseptic meningitis. Dx?

Mumps makes your parotid glands and testes as big as POM poms Parotitis orchitis Meningitis may cause sterility

3 year old male child presents with teratoma. Is it malignant?

No teratomas in male children are benign All post pubertal teratomas are malignant in males

41 year old female notes breast masses on both sides that grow and shrink cyclically. Biopsy finds non clonal proliferation of the inner epithelial layer of the ducts. Irregular slit like spaces are seen in the ducts. No cellular atypia noted. Is this cancer?

No typical ductal hyperplasia 2x increased RISK for cancer, but this condition is benign

17 year old boy presents worried that he has not began puberty. He is worried that his penis and testicles are smaller than children his age. Ddx?

No female genetalia, so rule out 5 alpha reductase deficiency of any pseudohermaphrotidisms DDX: constitutional delay/family hx of delayed puberty malnutrition hypopituitarism Kallman syndrome

19 year old female presents with oligomenorrhea, hirsutism, obesity, acanthosis nigricans, acne, and bilaterally enlarged ovaries. Dx?

PCOS

34 year old female with history BMI of 34 and a history of lifelong irregular menses and menorrhagia

PCOS

24 year old obese woman with severe acne and hirsutism presents with oligomenorrhea. Her androgen and estrogen levels are elevated. What do we expect from her FSH and LH levels?

PCOS LH:FSH ratio = 3:1 this causes excess androgen

17 year old female presents with elevated Testosterone, estrogen, and an LH:FSH ratio of 3:1. She has acanthosis nigricans in her axilla, obesity, amenorrhea. She is worried about cancer because she notes that her ovaries are enlarged bilaterally, she is worried about ovarian cancer. What do you tell her?

PCOS don't worry about ovarian cancer, worry about endometrial cancer from the high levels of estrogen (aromatized from androgen)

26 year old female with history of obesity presents with complaints of acne, unwanted facial hair and oligomenorrhea. Physical exam reveals bilaterally enlarged ovaries, and a dark, thick pigmented area of skin behind her neck. Dx?

PCOS AKA Stein Leventhal syndrome Acne, hirsutism caused by increased androgen secreted by deranged theca cells acanthosis nigricans is from hyperinsulinemia (insulin resistance)

21 year old obese female with severe acne and deep voice presents compaining of a "weird, dark rash" on her armpit. History/physical reveals recent amenorrhea, hyperinsulinemia, bilaterally enlarged ovaries. What do we expect to find on ultrasound?

PCOS AKA Stein Leventhal syndrome expect to find multiple enlarged follicles (string of pearls) on ultrasound

28 year old female presents with chandelier sign, fever, abnormal uterine bleeding, vaginal discharge. What do you suspect?

PID

33 year old female with history of gonorrhea has lower abdominal pain. The surgeon removes an ectopic pregnancy. What is the relationship between gonorrhea and ectopic pregnancy

PID can scar and occlude the fallopian tubes

23 year old female presents with fever, purulent cervical discharge, chandelier sign, lower abdominal pain, acute onset of R knee pain/swelling. History is negative for recent trauma to the joint. Dx?

PID due to Neisseria gonorrhea often causes septic arthritis if it disseminates

26 year old female prevents with fever, pelvic pain unrelated to menstrual cycle. She has multiple sex partners. Exam reveals purulent cervical discharge and postitive chandelier sign. What is the most likely dx?

PID secondary to Chlamydia trachomatis infection

32 year old female presents with severe, sharp RUQ pain, which radiates to her R shoulder. It has been severe for the past 6 hours, and less severe over the last couple days. Pregnancy test is negative. She has had many sexual partners, has chandelier sign, and right lower quadrant pain of less severity. Dx?

PID secondary to infection causing Hugh-Fitz-Curtis syndrome

68 year old female presents with a firm mass in her breast. It has leaf like projections and lots of connective tissue overgrowth. Dx?

Phyllodes tumor benign, but may become malignant seen in postmenopausal women fibrous component grows out of control, giving it a leaflike architecture

60 year old female presents with a large bulky mass of connective tissue and cysts in her breast. Leaf like projections are noted on histology. What is her risk for cancer?

Phyllodes tumor may become malignant! presents in postmenopausal women

28 year old woman in her 33rd week of pregnancy is complaining of increased fatigue and swelling in her hands and face. Urine dipstick shows 2+ proteinuria and her BP is 150/110 (elevated from before). Brisk deep tendon reflexes are noted. Pathophysiology?

Pre-eclampsia (mild) caused by abnormal spiral arteries. results in maternal endothelial dysfunction, vasoconstriction, hyperreflexia

38 year old man presents with painful, frequent urination, fever, urinary urgency, and lower back pain. Prostate is tender on digital rectal exam. Dx?

Prostatitis could be acute or chronic

66 year old female presents with intraperitoneal accumulation of mucinous material. What is this called? What causes it?

Pseudomycoma peritonei mucinous adenocarcinoma from APPENDIX or OVARY

26 year old male presents with hard, painless mass in his testicle that does not transilluminate. For some reason you have no time to do a workup and you have to treat that instant. What is your best bet?

Radical orchiectomy and radiotherapy seminoma (which are usually not mixed) respond extremely well to radiotherapy and have an excellent prognosis. (this is just based on prevalence)

A 55 year old white nulliparous woman presents with postmenopausal bleeding. She has a past medical history of morbid obesity and asthma. She smoked 1 pack of cigarettes per day for the past 30 years. She previously used oral contraceptive pills for 10 years. An office endometrial biopsy reveals grade 1 endometrioid endometrial cancer. Which of the following is a risk factor for developing endometrial cancer? Asthma Obesity Smoking Oral contraceptive pill use Which of the following decreases the risk of developing endometrial cancer? White race Nulliparity Oral contraceptive pill use Age over 50 years

Risk factor: obesity decreases risk: OCP use

29 year old female presents with bilateral breast lumps that fluctuate with her menstrual cycle. They are painful premenstrually. Calcifications are seen on mammogram so she has a biopsy. Histology reveals increased numbers of acini (proliferation of lobules). Dx?

Sclerosing adenosis 2x increased risk for cancer calcification! Adenosis = increased number of glands

33 year old male with Klinefelter syndrome presents with a firm painless testicular mass that does not transilluminate. The testicle is removed (remember they don't biopsy testicular cancers). Gross pathology reveals a homogenous mass with no hemorrhage and no necrosis. Histology reveals large cells with clear cytoplasm and central nuclei. What is the prognosis?

Seminoma good prognosis because of late metastasis and good response to radiotherapy this is the most common testicular tumor

35 year old male with history of cryptorchidism presents with a firm painless testicular mass that does not transilluminate. A higher power tells you its a malignancy. If you had to guess, what histology would you expect to see

Seminoma is the most common testicular tumor fried egg appearance large cells with clear cytoplasm and central nuclei good prognosis

35 year old female with a BRCA1 mutation presents with an ovarian tumor that is removed. Histology notes cuboidal epithelium and psammoma bodies. Dx?

Serous cystadenocarcinoma

39 year old female with a strong family history of cancer presents with fullness, pelvic pain, urinary frequency. A malignant tumor is found in her ovary and fallopian tube. Which tumor is it most likely?

Serous cystadenocarcinoma BRCA1

25 year old pregnant woman in the first trimester presents with heavy vaginal bleeding. Physical exam reveals enlarged uterus. Ultrasound notes snowstorm pattern. She is worried she has cancer from internet reading. What do you tell her?

She has a molar pregnancy which is not cancerous in itself, but there is a risk of malignancy if the pregnancy is a complete mole (90% of molar pregnancies), there is a 20% risk of having an invasive mole (does not metastasize beyond myometrium) and a choriocarcinoma (highly metastatic)

15 year old girl with short stature, webbed neck, broad shield chest. Breast development is absent. External genetalia are infantile appearing. She has primary amenorrhea. Lab finds elevated FSH. Describe a finding we would see on ultrasound.

Streak ovaries

34 year old presents to the doctor's office with a painless chancre on her vulva. The doctor is worried it will progress to a stage characterized by condyloma lata, rash on palms, back, fever, rash on soles. How could he confirm this diagnosis?

Suspects primary syphilis, which presents with a painless chancre on the genitals. Should do darkfield microscopy. Confirmed by presence of spirochetes (little dark spirals) syphilis is caused by treponema pallidum, a spirochete

19 year old boy presents with a testicular mass. It is removed. Pathologic examination shows connective tissue, muscle tissue and mesothelial tissue in the testicle. Dx?

Teratoma. malignant in post pubertal males

44 year old man with gynecomastia presents with a testicular tumor. Crystals are found in the interstitium of the testis. Gross pathology shows a golden brown testicular mass. Prognosis?

Testicular non germ cell tumor leydig cell tumor Benign

35 year old diabetic female presents with thick vaginal discharge, erythema, itchiness and pain. Vaginal pH is normal. After a wet mount shows budding yeast she is treated with fluconazole (her partner is not treated). Somehow, using her omnipotence she finds out that after treatment ends she still has yeast in her vaginal canal. Why is that?

The goal of treatment is to stop symptoms. Candida are normally present in the vaginal canal. We don't want to eradicate the yeast.

23 year old female with a molar pregnancy has multiple bilateral masses in her ovaries that resolve within 3 months of dilatation and curettage of the molar preganncy. What was causing the bilateral cysts?

Theca-lutein cysts due to elevated hCG multiple and bilateral

20 year old female presents with a fishy vaginal odor accompanied by a white, milky vaginal discharge. Whiff test positive, vaginal pH above 4.5. She tells her boyfriend, who freaks out. What do you tell him?

There is no need to treat the male partner for bacterial vaginosis. Relax! Treat female partner with oral of intravaginal metronidazole or clindamycin

29 year old male presents with a painless testicular mass. Radical orchiectomy is performed. Histopathology shows large, fried egg cells with clear demarcations. Lymphocytes are present. The oncologist wants to begin chemotherapy. What do you tell him?

This is a seminoma germ cell tumor treat with radiotherapy!! not chemo chemo is for non seminomatous germ cell tumors

16 year old female with menarche at 12 presents. She recalls that, beginning about 18 months ago, her menses became irregular, occurring every 42 days and lasting for up to 12 days. Following this, she became completely amenorrheic.Recently she has been stressed about her body image: she began to diet and exercise intensely. What are some tests we should do to evaluate her?

Thyroid function Prolactin TSH, LH Estrogen hCG (slight chance of pregnancy)

29 year old female presents with vaginal discharge with itching. Colposcopy notes a strawberry red cervix. The discharge is foul smelling. Both her and her partner are prescribed oral metronidazole (acts like disulfiram with alcohol). Explain the diagnosis.

Trichomonas sexually transmitted infection due to motile flagellate protozoan

A 20 year old gravida 2 para 2 female comes to the office concerned about a vaginal discharge. She states that she has a profuse discharge associated with itching and pain. Colposcopy shows a strawberry red cervix (reddish appearance). On wet mount, small organisms with tails are visible. Treatment?

Trichomonas, STD Both partners need Oral metronidazole (disulfiram like reaction when taken with alcohol) Oral tinidazole

Normal 19 year old male comes to the dermatologist with severe acne. Physical exam reveals healthy, 6'5'' male. Patient reveals history of aggressive, antisocial behavior. He one time murdered someone for calling him "bitch." What is his Karyotype

XYY males are douches with acne

19 year old male with a eunuchoid body shape and normal penis presents complaining of his long standing gynecomastia. Physical exam reveals triangular shaped pubic hair, very small testicles, long arms and tall stature. He just took a biology class in college and wants to know if he has a Barr body.

Yes, he has a barr body

4 year old boy presents with a testicular mass that does not transilluminate. AFP is elevated and histology reveals glomeruloid structures. Dx?

Yolk sac tumor

2 year old boy presents with a solid testicular mass. What is the most likely diagnosis?

Yolk sac tumor (endodermal sinus tumor) most common testicular tumor in boys under 3 years old

29 year old male presents with a painless testicular mass that does not transilluminate. You order a biopsy to identify the testicular tumor. What is the next step.

You get yelled at testicular tumors are never biopsied unlike many cancers you could seed cancer cells in the scrotum

33 year old mother with prior endometritis and C section delivers a healthy baby. Upon delivery the doctors are unable to deliver her placenta and she dies of massive hemorrhage. What is the pathophysiology

abnormal connection of decidual layer to myometrium, cannot separate after birth placenta accreta: connection to myometrium with no penetration of myomtrium placenta increta: penetrates myometrium placenta percreta: penetrates serosa, possible bladder and rectal attachments

28 year old sexually active female presents with foul smelling vaginal discharge. Her genital area is itchy and painful. On colposcopy, bright red cervix is noted. On wet mount, flaggelated motile protozoa are noted. Her and her partner are treated with oral metronidazole, which acts like disulfiram with alcohol. What is her vaginal pH?

above 4.5 Trichomonas

23 year old woman who gave birth to her first child 1 week ago presents with fever, abnormal uterine bleeding and pelvic pain. A higher power tells you there is a bacterial infection present. Dx?

acute endometritis due to retained products of conception

Breastfeeding mother presents with a warm erythematous breast with purulent discharge. Dx? Pathogen? Treatment

acute mastitis staph aureus is able to enter breast through cracks in skin Dicloxacillin, continued breast feeding

22 year old man comes to the office complaining of painful urination, fever and chills. WBCs and bacteria are found in prostatic secretions. The prostate is tender and boggy. Dx?

acute prostatitis older adults: E coli or pseudomonas young adults: chlamydia/gonorrhea

55 year old man presents with dysuria, fever, chills. Prostate is boggy and tender on DRE. WBCs and bacteria are present in prostatic secretions. Identify the pathogen responsible.

acute prostatitis older adults: E coli or pseudomonas young adults: chlamydia/gonorrhea acute prostatitis is bacterial!!

39 year old female with a history of ER + breast cancer is prescribed ______. Later she develops abnormal uterine bleeding. Some higher power tells us she has a polyp stretching out from her endometrium. Explain the diagnosis and its interaction with the mystery drug

adenomyoma = polyp of the endometrium. Tamoxifen is a SERM that decreases E at the breast and increases E at the endometrium. Increases risk for polyps

16 year old boy presents to the doctor because he has not yet gone through puberty. He has small genitals for his age. He has had poor smell for his whole life and he is color blind. What are his levels of LH, FSH and T

all low Kallman syndrome, hypogonadotropic hypogonadism

29 year old female presents with a cluster of painful vesicular lesions on her vulva. Histology notes multinucleated, molded cells with eosinophilic viral inclusions (Cowdry A). Treatment?

antiviral -clovir drugs acyclovir famciclovir valacyclovir

59 year old female with history of PCOS presents with vaginal bleeding. Histological section of uterus shows endometrial tissue with simple glands and no atypia. Gland:stroma ratio is increased. How is PCOS relevant to her diagnosis?

any cause of anovulation will increase risk of endometrial hyperplasia

33 year old female presents with a mass that is removed. It is blue domed. On histology, large pink cells (apocrine) are found. What is her risk of cancer

apocrine metaplasia + fibrocystic change no increase in cancer risk *metaplasia usually increases cancer risk, but not in this case

41 year old female notes breast masses on both sides that grow and shrink cyclically. Biopsy finds clonal proliferation of the inner epithelial layer of the ducts. Round open spaces are noted between the proliferating cells. Is this cancer?

atypical ductal hyperplasia clonal 5x increased risk for cancer in both breasts, even if its only found in one breast

34 year old female presents with creamy, homogenous milky vaginal discharge, elevated vaginal pH, clue cells on wet mount. No pain. Fishy smell to discharge. Dx?

bacterial vaginosis

30 year old female presents with a milky vaginal discharge. Whiff test positive, clue cells seen on wet mount. Treatment?

bacterial vaginosis metronidazole or clindamycin vaginally or orally no need to treat partner

20 year old female presents with a fishy vaginal odor accompanied by a white, milky vaginal discharge. Whiff test positive, vaginal pH above 4.5. Your patient wants to know what caused this. What do you tell her?

bacterial vaginosis, caused by a shift in the natural flora of the vagina. Anything that disrupted the flora such as douching agents, intercourse, infection introduced etc. The normal population of lactobaccilus species decreased leading to a pH of above 4.5

26 year old weight lifter presents with a slow growing painful mass in his R testicle. No transillumination. Histopathology shows a glandular pattern with pleomorphic nuclei. hCG and AFP are elevated. Prognosis?

bad, seminoma is way better this is embryonal carcinoma hCG and AFP reveals it is likely a mixed cancer, as most embryonal carcinomas are

28 year old female presents with a unilateral lesion at the lower part of the vestibule of the vaginal canal. Lesion is painful. Dx?

bartholin cyst

10 year old boy presents with precocious puberty and a testicular mass containing Reinke crystals. What is his prognosis

benign tumor Leydig cell tumor

A 28 year old female nurse with a history of surgically removed fallopian tube tumor presents to the ER certain she has appendicitis. History reveals she is sexually active and does not use contraception. What test should be ordered?

beta hCG see if she has ectopic pregnancy

17 year old nulliparid Female presents with tiny primary ovarian tumor and multiple large metastases in the lungs. treatment?

choriocarcinoma germ cell variant does not respond to chemotherapy pregnancy version responds well to chemotherapy

33 year old female presents to the ER with hemoptysis and SOB. hCG is elevated and theca lutein cysts are noted. History reveals she was treated for a molar pregnancy 3 weeks ago. Treatment?

choriocarcinoma, pregnancy pathway, has spread hematogenously to lungs responds well to chemo they should have monitored the hCG more closely

39 year old man presents with dysuria, pelvic pain and back pain. DRE is unremarkable. Prostatic secretions are negative for bacteria but positive for white blood cells. Dx?

chronic prostatitis

female presents with a vaginal pathology with the following characteristics: sheets of cells with cleared out cytoplasm Hobnail cells Cysts lined by flat cells What precursor lesion is often seen in this primary vaginal cancer?

clear cell adenocarcinoma preceded by adenosis caused by in utero DES exposure

25 year old female presents with a milky, homogenous vaginal discharge. Her whiff test is positive (added KOH). vaginal pH is 5.2. What would we expect to see on wet mount?

clue cells this is bacterial vaginosis

34 year old obese female with hirsutism and oligomenorrhea and string of pearls ovaries on ultrasound is concerned about her infertility. Name 2 other high yield complications she should be concerned with

dB2 from insulin resistance endometrial carcinoma from increased estrone

69 year old obese female presents with a swollen erythematous breast and a peau d'orange skin finding. She does not respond to antibiotics so acute mastitis is ruled out. A biopsy finds _______. You inform her of a poor prognosis. Fill in the blank

dermal lymphatics are blocked by malignant cells

27 year old female with multiple sexual partners complains of fever and pelvic pain. Exam reveals cervical motion tenderness and purulent cervical discharge. She also had acute onset of knee pain and swelling absent of any trauma. Dx and treatment

dx = gonorrhea (PID) with septic arthritis ceftriaxone (cephalosporin) treats gonorrhea also give doxycycline or azithromycin for potential chlamydia

18 year old female presents with an ovarian tumor. Histology notes sheets of fried egg cells. Markers lactate dehydrogenase and hCG are present dx?

dysgerminoma malignant germ cell neoplasm

20 year old female presents with a malignant ovarian mass. Histology reveals large cells with clear cytoplasm and central nuclei. Marker lactate dehydrogenase is present. What is her treatment?

dysgerminoma respond well to radiotherapy

30 year old female with a history of PID secondary to chlamydia presents with intense R lower quadrant pain 2 weeks after a postive home pregnancy test. The date of conception was determined to be 4 weeks ago. beta HCG levels are elevated, but are not doubling every 48 hours as expected. dx?

ectopic pregnancy: higher risk with history of salpingitis from PID presents with apendicitis-like pain often confused with appendicitis

29 year old female in 35th week of pregnancy presents with pre-eclampsia. She complains of swelling in her legs and face. Explain the swelling

edema proteinuria, decreased osmotic pressure in the blood, causing edema

26 year old with 1st trimester vaginal bleeding, higher than normal hCG, hyperthyroidism, hyperemesis and snowstorm appearance on ultrasound is baffled by her diagnosis. She asks you, "How did this happen?"

either complete (90%) or partial (10%) complete: empty egg + 2 sperm 46 chromosomes no fetal tissue, completely molar higher malignancy risk partial: 1 egg + 2 sperm 69 chomosomes fetal tissue + mole smaller malignancy risk

1 year old boy presents with a malignant testicular tumor that is yellow and mucinous (gross appearance). What serum lab value anomalies do you expect to see?

elevated AFP yolk sac tumor (endodermal sinus tumor)

24 year old G1P0 woman who states she is 1 month pregnant complains of heavy vaginal bleeding. She has not been to clinic yet, but knows she is pregnant form a home urine pregancy test. She has been having severe nausea and vomiting which she thought was morning sickness. Ultrasound revealed a "snowstorm" pattern with no discernible fetus. Her hCG levels are likely _____

elevated way beyond what we would expect for her based on her last period the moles are made of trophoblast cells

29 year old male presents with a painful mass in his testicle that has been growing for the past 5 months. His hCG and AFP are elevated. Histology reveals glandular/pappilary pattern. Dx?

embryonal carcinoma

3 year old female presents with a grape like mass protruding from her vagina. Biopsy performed. Describe pertinent features of histology of the biopsy

embryonal rhabdomyosarcoma - immature malignant tumor of the skeletal muscle cytoplasmic cross striations visible stains positive for desmin and myoglobin

2 year old girl presents with ovarian mass. Glomeruloid structures noted. AFP elevated. Dx?

endodermal sinus tumor (yolk sac tumor)

65 year old nulliparous female presents with history of breast cancer treated with tamoxifien presents with vaginal bleeding. Histological section of uterus shows a malignancy with a largely increased gland: stroma ratio. The tissue ressembles endometrium. Pathophysiology

endometrial carcinoma caused by proliferation Estrogen driven endomterial hyperplasia become endometrial carcinoma

55 year old female with a history of anovulation presents with a 2 week history of vaginal bleeding. Histological section of uterine tissue shows benign changes: increased gland:stromal ratio and cellular atypia. The glands are complex. She is worried about getting endometrial cancer, like her mother. What do you tell her?

endometrial hyperplasia may progress to endometrial carcinoma, especially if it is showing cellular atypia

57 year old obese postmenopausal woman presents with uterine bleeding. Histological section of the uterus is remarkable for increased gland:stroma ratio. dx?

endometrial hyperplasia, estrogen driven aromatization (obesity) could increase estrogen

22 year old female presents with dysuria, cyclic pelvic pain, abnormal uterine bleeding. Her uterus is normal sized. After doing some reading on the internet, she has become worried about cancer. What do you tell her?

endometriosis increases the risk for cancer. She should be most concerned if she has endometrial tissue in the ovaries. This will increase the risk for cancer more than any other location.

34 year old african american female has regular periods but they are heavy and she has bleeding in between periods. Physical examination reveals an enlarged uterus with hardened nodules. Pelvic ultrasound reveals several tumorous growth within the myometrium. She wishes to start birth control pills to avoid pregnancy. What do you tell her?

exogenous estrogen in OCP would increase the size of her uterine fibroids

Female presents with a erythematous itchy prurutic skin on her vulva. Histology reveals malignant epithelium: a few scattered epidermal cells have a halo surrounding them. The cells stain positive for keratin, PAS. Negative for S100. Your patient is worried this is caused by another cancer somewhere else in her body. What do you tell her?

extramammary paget disease when it affect the vulva, there is usually no underlying cancer when it affects the nipple, there is usually cancer somewhere else in the breast`

33 year old female presents with a painless mass. Mammogram shows calcification. Biopsy shows necrotic tissue and giant cells. What caused the mass?

fat necrosis causes saponification of fat which causes a mass usually caused by trauma

A man and a woman both present with gonadal masses containing skin, hair and teeth. They are both worried about dying of cancer. What do you tell them

females: teratomas are benign males: teratomas are malignant

33 year old pregnant patient with pre-eclampsia is given an ACE inhibitor for her hypertension. What happens next?

fetal renal failure possible fetal death do not give pregnant women ACE inhibitors or angiotensin receptor blockers ARB

23 year old female presents with a small marble like firm mass that is mobile with clear demarcations. Explain another imporant clinical feature that would come up while taking history

fibroadenoma estrogen sensitive grows during cycle grows during pregnancy shrinks during menopause

30 year old female presents with irregular breast tissue that is diffusely lumpy. There is not one marked lump, it is vague. Blue dome cyst on gross pathology. Patient is worried about cancer. What do you tell her?

fibrocystic change is not associated with an increased risk of cancer, but we may find other features associated with it that increase risk for cancer

55 year old male presents with nocturia, dribbling stream, difficulty initiating stream, PSA of 8, Hypertension, hypertrophy of the bladder wall. Treatment?

finasteride (5 alpha reductase inhibitor) prazosin or other non selective alpha 1 antagonists: treats HT and BPH do no prescribe tamsulosin, it is too selective!

55 year old male presents with nocturia, dribbling stream, difficulty initiating stream, PSA of 8, hypertrophy of the bladder wall. Treatment?

finasteride (5 alpha reductase inhibitor, takes a while to work) tamsulosin: selective alpha 1 A antagonist: no vascular effects needed!

56 year old man presents with fever due to UTI. For the past 7 months he has hadnocturia, dribbling at the end of urination, weak stream, urinary frequency. He is prescribed prazosin and finasteride. What is a lab serum lab value that is elevated in only his condition?

free PSA elevated BPH

A 23-year old nulligravid woman presents to her gynecologist with a 4-day history of painful genital ulcer. One week earlier she had a low grade fever and generalized malaise, which has since resolved. She denies any history of genital ulcers. She has had five new sexual partners in the last year and uses oral contraceptives. She reports using condoms inconsistently.On pelvic examination, several 1 to 2 mm painful vesicles are noted on the left labia minora. There is no inguinal lymphadenopathy.

genital herpes HSV1 or 2

16 year old presents with an ovarian tumor. What is at the top of your ddx? (which general type of ovarian tumor)

germ cell tumors

Pregnant woman with no past history of HT presents in the 32nd week with a BP of 145/110. No other abnormalities. Dx and treatment

gestational HT deliver at 39 weeks antihypertensive drugs alpha methyldopa labetalol hydrlazine nifedipine

Patient presents with a chlamydia. You give them doxycycline and a cephalosporin. Your patient wants to know why she is getting 2 different antibiotics when she has chlamydia

gonorrhea is treated empirically in someone with a chlamydial infection

60 year old diabetic patient takes sildenafil for erectile dysfunction and dies. What happened?

he was probably on nitrates for chest pain life threatening hypotension with drug interaction

22 year old pregnant woman comes in to your office with heavy vaginal bleeding. She says she got pregnant 3 weeks ago, as her home pregnancy tested positive recently. She has had severe nausea and vomiting and attributed it to motion sickness. ddx?

heavy vaginal bleeding in the first trimester: ectopic pregnancy molar preganncy spontaneous abortion postcoital bleeding non pregnancy related trauma

68 year old female presents with white patches on her vulva. Physical exam notes thin epidermis on the vulva. It feels like parchment paper. Your patient is worried about cancer. What do you tell her?

her condition, call lichen sclerosis (thinning of epidermis and fibrosis of underlying dermis), is benign. But it increases the risk of squamous cell carcinoma

59 year old female who refused to see a gynecologist in the past presents with vaginal bleeding. Pap smear is abnormal and biopsy reveals a transformation zone that is 2/3 fillled with dysplastic cells and mitoses. Identify the pathogens that may have caused this

high risk HPV low risk won't advance to CIN 2 33% change of regression HPV 16, 18, 31, 33

18 y/o female with normal development presents with weight loss, intense dieting, amenorrhea. her FSH, LH, estrogen are on the low end of normal. Dx?

hypogonadotropic hypogonadism

19 year old female who had menarche as 13 develops anorexia nervosa. Her periods stop. She asks you if she can get pregnant. What do you tell her

hypogonadotropic hypogonadism probably not low LH, FSH, estrogen lack of fat inhibits GnRH pulsatility

17 year old girl with menarche at 12 and normal secondary sexual development presents with irregular bleeding followed by amenorrhea (past 3 months). She has become stressed with school lately and has started dieting intensely. Her FSH, LH, estrogen levels are low-normal. Normal prolactin, thyroid, hCG. Dx? Treatment?

hypogonadotropic hypogonadism, due to stress/anorexia get her on OCP

42 year old woman with secondary amenorrhea for 6 months presents with hypercholesterolemia, fatigue and a new, stressful job. What do you suspect?

hypothyroidism TRH increases prolactin causing amenorrhea

29 year old female presents with menorrhagia, dysmenorrhea and a uniformly enlarged, soft globular uterus. Your attending diagnoses endometriosis and prescribes NSAIDs. What treatment do you suggest?

hysterectomy to treat adenomyosis. the uterus would not be enlarged in endometriosis. this is likely adenomyosis because of the menorrhagia and enlarged uterus

34 year old diabetic, overweight, hypertensive pregnant woman in the 29th week of gestation has a BP of 170/112, headache, scotoma. She develops a seizure and goes untreated. The next day she dies of intracranial hemorrhage. How should she have been treated?

immediate delivery antihypertensives magnesium sulfate to prevent further seizures

77 year old man presents with a testicular mass. What do you suspect?

in older men, we do no suspect germ cell tumors. We suspect secondary tumors arising from aggressive lymphoma these are usually bilateral, diffuse large B cell lymphoma

30 year old man presents with scrotal enlargement, which he noticed a few months ago. Occasionally he experiences scrotal aching and heaviness. Ddx?

indirect inguinal hernia varicocele hydrocele hematocele testicular cancer infection (such as epididymitis) testicular torsion and trauma are ruled out because they are acute

Premenopausal woman presents with bloody nipple discharge. Discuss her risk of cancer?

intraductal papilloma 2x increased risk for cancer

82 year old nulliparous woman with late menopause and obesity presents with a firm, fibrous, rock solid mass in her breast. It has sharp margins. What gross pathology do we expect from this very common breast cancer

invasive ductal carcinoma stellate appearance

60 year old man with Klinefelter syndrome and a known BRCA2 mutation presents with subareolar mass and nipple discharge. What do we suspect?

invasive ductal carcinoma the male breast tissue has ducts but barely any lobules

80 year old female presents with an invasive carcinoma that lacks E cadherin, and arranges itself in a line. Describe the presentation in the breasts (uni lateral, bi, ...)

invasive lobular carcinoma bilateral with multicentric the physical exam reveals multiple ill defined firm areas

130 year old woman dies of cervical squamous carcinoma. What likely killed her?

it took sooooo long to metastasize locally to bladder, causing post renal failure with hydronephrosis no distant mets!

65 year old obese female with diabetes and hypertension presents with a 6 month history of uterine bleeding. She is obese, never had children and had late menopause. She turns to you and says "why are you asking me about my menopause? Just find out what this bleeding is all about!" What do you tell her?

late menopause increases the amount of cycling she had during her lifetime. It increases the risk of endometrial carcinoma

75 year old female presents with vulvar carcinoma. What do you predict is the cause?

longstanding lichen sclerosis the HPV type occurs in women in their 40's or 50's remember they get HPV during secxual activity (20's) then 20 years later it turns to cancer. The lichen sclerosis is seen in elderly

66 year old female present with granulosa cell tumor (ovary). Clinicians should be sure to look for _____ because ______

look for endometrial carcinoma which is present in 5% of these women caused by granulosa cell unopposed estrogen

44 year old male has low energy, reduced muscle mass, increased body fat, low bone mineral density, reduced sexual activity, fewer erections, depressed mood. Dx

low Testosterone

5 year old female presents with ovarian mass. It is removed, and is yellow and hemorrhagic. AFP is noted, along with Schiller duvall bodies microscopically. Dx?

malignant endodermal sinus tumor

66 year old multiparous female presents with green-brown nipple discharge and a breast mass. Pathophys?

mammary duct ectasia inflammation/dilatation of the duct inflammatory debris in the duct come sout of the nipple

69 year old multiparous female presents with a breast mass and green-brown nipple discharge. Describe the biopsy?

mammary duct ectasia not cancer, mass its caused by inflammation chronic inflammation: plasma cells!!

79 year old patient presents with bilateral mucinous tumors in her ovaries. What is the likely source (be general)

metastatic primaries are usually unilateral

26 year old female in 32nd week of pregnancy presents with 2+ proteinuria and a BP of 140/100. Treatment?

mild pre-eclampsia Deliver at 37 weeks bed rest until then steroids to enhance fetal lung maturity in case of premature labor

23 year old female patient notices this little umbilicated bump in skin close to her genitals and mentions it to you at annual physical exam. Histology notes cells filled with glassy pink material. Dx?

molluscum contagiosum STI in adults poxvirus

32 year old presents with a painless mass on her breast. She reports that she was hit in the breast with a softball 2 years earlier. Describe the biopsy

necrotic fat giant cells totally benign mass caused by abnormal calcification (saponification of necrotic fat)

65 year old black male with PSA of 12 has a digital rectal exam with irregular size and shape on screening. He has a strong family history of prostate cancer. Dx?

need a biopsy to confirm prostate cancer!

48 year old female has HPV 6. Should she worry about cancer?

no High risk HPV's are 16, 18, 31, 33`

29 year old female presents with fibrocystic change accompanied by apocrine metaplasia (cells are fat and pink) in her R breast. She is worried she will get cancer in her R breast. What do you tell her?

no increased risk of cancer in this condition if it were another condition with increased risk, it would be equally of both breasts!

23 year old female with no prior medical history presents to the doctor with malaise, nausea, fever. She is sent home. 5 days later she returns with a painful cluster of small vessicles on her labia minora. She has had one unprotected sexual partner in her life. She is embarassed and asks, "can you cure me?" What do you tell her?

no. HSV 1 or HSV 2 causing genital herpes When the symptoms reactivate they will be milder (genital vessicles lasting about a week) HSV 2 activates more often than HSV 1

19 year old female presents complaining of recurrent abdominal pain. She has painful menstruation, abnormal bleeding, painful intercourse, painful defecation. Physical exam reveals _____ sized uterus

normal endometriosis

67 year old female presents with eczematous patches on her nipple. No breast mass seen, but small calcifications noted on mammography. What diagnosis is likely

paget disease of nipple arising from DCIS in the duct clear halo cells seen in histology

29 year old female presents with bloody nipple discharge. What is the most likely dx/pathophys?

pappilary benign tumor in the lactiferous duct has fibrovascular core that bleeds often seen in pre menopausal women. In postmenopausal women may be pappilary carcinoma

32 year old smoker presents with nipple retraction, skin dimpling and a subareolar mass. What is the most likely dx?

periductal mastitis squamous metaplasia of the lactiferous ducts

33 year old mother begins delivery of her 4th pregnancy. Her last 2 pregnancies were C sections. She worries that she is at risk for placenta previa, which her great grandmother died of. She experiences no bleeding prior to delivery. She delivers a healthy happy baby, but the doctors are unable to remover her placenta. Dx, treatment?

placenta accretia/increta/percreta hysterectomy to avoid hemorhage this is life threatening for mom

40 year old female is in the third trimester of her 5th pregnancy. Her last 2 pregnancies were C sections. She experiences vaginal bleeding starting in her third trimester. Upon delivery there is no difficulty delivering the placenta. Dx?

placenta previa risk factors are similar to placenta accretia, but there is no difficulty delivering the placenta

25 year old pregnant woman with a history of cocaine addiction, obesity and smoking presents with painful third trimester bleeding after a getting in a fight with her drug dealer. In the ambulance, mom goes into hypotensive shock. Emergency C section results in stillbirth. Explain the pathophysiology

placental abruption classic risk factors and trauma hemorrhage separates the placenta from the uterine wall, which can causes some of the placenta to be nonfunctional (contributes to fetal distress)

After developing a longstanding cocaine addiction, Nurse Elkins becomes pregnant with Dr. Thackery's child. During the third trimester Nurse Elkins' cocaine use increases. She develops proteinuria and extremely elevated blood pressure. She trips and falls on the wards during her third trimester. She begins bleeding vaginally and goes into shock. List the risk factors for her diagnosis?

placental abruption risk factors: trauma, cocaine use, smoking, HT, pre-eclampsia

A 20 year old obese woman in her third trimester of pregnancy suffers a skydiving accident. She lit a cigarette after deploying her parachute and got distracted. After the accident she experienced acute pain accompanied. After going into shock, she dies. Her baby does not survive. Explain the pathophysiology of the baby's death?

placental abruption with concealed hemorhage does not always have to bleed! the hemorrhage disrupted part of the placenta resulting in improper fetal perfusion

29 year old female presents with abnormal uterine bleeding, pelvic pain. She has been unable to get pregnant after trying for the last 2 years. She had an IUD implanted after deciding she no longer wanted children. As a third year medical student you suspect chronic endometritis. How will you confirm?

plasma cells must be found in histology

80 year old nulliparous female with peau d'orange finding on her breast presents with a breast mass. On biopsy we see blockage of dermal lymphatics. Prognosis?

poor prognosis because it has already spread to lymphatics Inflammatory subtype of invasive ductal carcinoma 50% survive 5 years

33 year old female with chronic renal disease is 33 weeks pregnant. BP 155/110, proteinuria 2+, headache, scotoma. List the possible complications of _____

pre-eclampsia HELLP syndrome placental abruption eclampsia uteroplacental insufficiency

29 year old female with history of hypertension and diabetes mellitus type 1 presents in her 32nd week of preganncy with a BP of 165/110. She reports a severe headache and recurrent "floaters" in her vision. List the possible complications _______

pre-eclampsia (severe) placental abruption coagulopathy renal failure uteroplacental insufficiency eclampsia

Pregnant woman with a history of renal insufficiency, in her 32nd week of gestation presents with proteinuria, severe HT, scotoma, oliguria and headache. 4 days later her HT gets worse, she experiences RUQ pain, anemia, elevated liver enzymes. Treatment?

pre-eclampsia with HELLP syndrome IMMEDIATE DELIVERY!!!! MgSO4 for seizure prophylaxis steroids to improve fetal lung maturity

24 year old female with no past medical treatment comes in for her first checkup. She has a webbed neck, short stature and shield chest. Her nipples are far apart, and she has no secondary sex characteristics. Labs show elevated LH and FSH and low estrogen. BP (taken on her arm) is very elevated. What other findings do we suspect with the condition that is causing her HT?

preductal coarctation of the aorta BP in the arms/head > BP in the legs notched ribs from large collateral circulation (chest X raY)

19 year old female with webbed neck, short stature, shield chest, no secondary sex characteristics, normal uterus, low estrogen, hi FSH has elevated BP in her arm and lowered BP in her leg. Explain the pathophysiology of the BP difference

preductal coarctation of the aorta underperfusion of the kidneys results in Renin-angiotensin response resulting in higher BP HT will be found in cerebral and brachial vessels. CXR finds rib notching from collateral flow through vertebral arteries.

12 year old female presents with no secondary sexual characteristics, short stature, webbed neck, hi FSH low estrogen and streak ovaries. List 5 complications associated with this disorder

preductal coarctation of the aorta (femoral pulse > brachial pulse) lymphatic defects (results in cystic hygroma, lymphedema in feet/hands) horseshoe kidney hypothyroidism

33 year old female has regular periods but they are heavy and she has bleeding in between periods. Intercourse is somewhat painful. Physical examination reveals an enlarged uterus with hardened nodules. Pelvic ultrasound reveals several tumorous growth within the myometrium. She wishes to get pregnant. What do you tell her?

pregancy will increase the size of the fibroids because of estrogen! it may be difficult

37 year old woman presents with abnormal uterine bleeding. ddx?

premenopausal abnormal uterine bleeding adenomyosis endometriosis endometrial polyps uterine fibroids endometrial hyperplasia endometrial carcinoma

75 year old male comes for a routine checkup. He notes his lower back pain has been getting worse in the past couple months. PSA is greater than 4, but free PSA is low. Digital rectal exam is abnormal. Needle core biopsy notes small neoplastic glands with prominent nucleoli and sparse stromal tissue. PAP and serum ALP are elevated. Dx?

prostate adenocarcinoma with osteoblastic bone metastases (lower back pain, elevated ALP)

78 year old male comes in for a routine checkup. He has not complaints. PSA is greater than 10 and free PSA is low. His DRE is abnormal. Needle core biopsy confirms _____. Treatment?

prostatectomy is an option flutamide with continuous leuprolide (decrease androgens) chemotherapy if that doesn't work monitor with PSA levels

26 year old female with first trimester vaginal bleeding presents with vomiting, hypertension and proteinuria. Her uterus is elarged beyond what we expect and her hCG is extremely high. Explain the proteinuria and why she feels extremely hot and hungry all the time.

proteinuria + HT is pre eclampsia caused by a hydatidiform mole hyperthyroidism is because hCG mimmicks TSH

An 50 year old asian, black and white man walk into a bar. They're all worried about prostate cancer from watching TV. If you had to bet, who do you think would have it?

racist black > white > asian opposite of IgA black people have large .... prostates asians have small .... prostates

3 year old girl presents with a vaginal tumor. Cells are spindle shaped and stain positive for desmin. Dx?

sarcoma botryoides Rhadbomyosarcoma

An obese pregnant woman with type 1 diabetes, long standing HT, andwith pre-eclampsia has a worstening of HT accompanied by right upper quadrant pain. Her lab tests reveal anemia, thrombocytopenia, elevated liver enzymes and _____ found in blood smear

schistocytes HELLP syndrome

33 year old female presents with fever, rash on her palms and soles. She has a large fleshy grouping of bumps on her vulva. She had a painless vaginal sore on her labia minora a few weeks ago that went away. Dx?

secondary syphilis fleshy bumps on vulva = condyloma lata caused by spirochete treponema pallidum

A 27 year old bicyclist presents with a nonpainful mass in his left testicle that has been growing for the past 2 months. It does not transilluminate. Histopathology reveals large, distinct nuclei with clear cytoplasm and clearly demarcated cell borders. Placental ALP is elevated. Dx?

seminoma

34 year old male with history of cryptorchidism presents with a painless testicular mass that does not transilluminate. Gross pathology reveals a homogenous mass with no necrosis of hemorrhage. Histology reveal large cells with clear cytoplasm and central nuclei (fried egg appearance). What is his prognosis

seminoma late metastasis great response to radiotherapy great prognosis this is the most common testicular germ cell tumor its female variant is a dysgerminoma

75 year old female presents with an ovarian mass. Gross pathology reveals a large tumor with multiple cysts and a shaggy carpet like lining. The tumor forms a large cyst. Psammoma bodies are noted. What is the most likely diagnosis

serous cystadenocarcinoma

41 year old female presents with bilateral unilocular cystic enlargements in her ovaries. They are lined with a single layer of endothelium, consisting of cuboidal, dark cells. Patient is worried about cancer. What do you tell her?

serous cystadenoma, the most common ovarian neoplasm because it is lined with a single epithelial layer, it is totally benign

29 year old woman who is in week 10 of her pregancy experiences vaginal bleeding, cramping pain and passes dark, red tissue. Her ______ could have been caused by chromosomal abnormalities, teratogens, hypercoaguable state, congenital infections.

spontaneous abortion

75 year old female presents with vaginal bleeding. Histological section of uterus shows pappillary serous malignancy with fibrovascular cores and psammoma bodies. Pathophys?

sporatic endometrial carcinoma caused by p53 tumor suppressor gene mutation

27 year old obese female presents with oligomenorrhea, infertility, hirsutism. Her ovaries are enlarged and reveal string of pearls on ultrasound. Explain the pathophysiology

start with LH being too high (LH:FSH > 2) LH stimulates androgen synthesis in theca cells androgen goes to fat tissue and gets converted to estrone estrone inhibits FSH release from the pituitary low FSH, granulosa cells won't convert androgen to estrogen for the follicle to mature follicles degenerate and become cystic because of lack of ovarian estrogen

46 year old patient who has not had a pap in years comes in for an evaluation of post-coital bleeding. On physical exam you notice a small 8 mm lesion on her cervix. What is your next step? A) Perform a pap smear B) Peform a LEEP in the office C) Schedule her for a cold knife cone D) Take a biopsy of the lesion

take a biopsy of the lesion

3 year old boy presents with a testicular mass, elevated hCG and elevvated AFP. The cells have a meso/endo/ectodermal origin. What is his prognosis?

teratomas are always benign in males in the prepubertal age

13 year old boy presents with sudden testicular pain. Cremasteric reflex is absent. Pathophysiolog

testicular torsion spermatic cord twists venous occlusion, arterial patency blood can come in but cannot escape this causes hemorrhagic infarction

A 30 year old man and a 70 year old man present with hard, painless testicular masses. What do you tell them.

testicular tumor between age 15-40: probably germ cell tumor over age 60: probably metastasis from lymphoma

79 year old female presents with an invasive breast cancer with cells arranged in an "indian line" (orderly line). Physical exam reveals bilateral ill defined firm areas Why are they in a line?

they lack E cadherin invasive lobular carcinoma

44 year old female presents with an ovarian tumor. Transitional cell epithelium is noted. Prognosis?

this is a Brenner tumor of the surface epithelium mostly benign

22 year old female presents with bilateral ovarian cystic tumors. After removal, pathologist notes hair, bone, skin tissue. What is her prognosis

this is a cystic teratoma dermoid cyst the tissue is mature so it is benign

23 year old woman presents with a firm marble like mass in her breast. It is mobile and has clear demarcations. She is wondering if she should be worried about cancer

totally benign fibroadenoma no increased risk for canceer super common

25 year old pregnant hippie presents with first trimester bleeding, higher than normal hCG, enlarged uterus (larger than we would expect) and snowstorm appearance. Treatment is refused. During her second trimester she comes in complaining of ______.

treatment is dilation and curettage to remove tissue she would come in during the second trimester passing grape like abnormal, dilated villi surrounded by trophoblast

34 year old female with a history of infertility and appendectomy presents with excruciating lower R quadrant pain, vaginal bleeding. History reveals that she does not take birth control due to her infertility. Blood test confirms elevated levels of beta hCG. What test should you do to confirm your suspicion?

ultrasound to confirm ectopic pregnancy

25 year old pregnant woman in the first trimester presents with heavy vaginal bleeding. Ultrasound notes snowstorm pattern. What findings do you expect on physical exam?

uterus is larger than we would expect for that gestation similar idea to hCG

Eighteen months after undergoing hysterectomy BSO and staging for Stage I Grade 1 endometrial cancer, a 55 yo woman presents to the office with a complaint of vaginal spotting. General examination is unremarkable, and no masses are palpated on abdominal or pelvic exam. However, the speculum exam reveals a friable, erythematous, polypoid lesion at the vaginal apex. Which of the following diagnostic tests would you obtain? Pap smear Brain MRI Upper endoscopy Vaginal biopsy

vaginal biopsy vaginal cuff is a common site of recurrence of endometrial cancer

24 year old male presents with intermittent, nonpainful scrotal enlargement which he noticed a few months ago. His left scrotum is enlarged, but is less pronounced when he is lying down. He has been unable to have children. Scrotum does not transilluminate. What are the treatment options

varicocele varicocelectomy embolization by interventional radiologist

42 year old male comes to the doctor worried about his enlarged scrotal sac, which he says looks like a bag of worms. He is worried about his fertility. What do you tell him

varicocele can threaten fertility if untreated due to increasing testicular temperature

89 year old female presents with a breast mass. She is terrified she is going to die. Histology reveals malignant cells floating in pools of mucous. What is her prognosis?

very good the malignant cells are stuck in the mucous, can't go hurt her this is a subtype of invasive ductal carcinoma

26 year old G0P1 comes in during her first trimester, terrified as she is having heavy vaginal bleeding. After finding higher than normal hCG, enlarged uterus and snowstorm appearance on ultrasound, you inform her of her diagnosis. She is devastated, as it took her 2 years to get pregnant. She refuses the treatment you explained, and wants to go home. She says, "that is barbaric, you can't do that to me." What do you tell her?

we assume she has a complete mole based on prevalence After some very thoughtful ICMing, you explain that the mole itself is benign but could become invasive of the myometrium (20% risk) (with no metastases). There is also a 2% risk of converting to choriocarcinoma, a highly metastatic cancer that responds well to chemotherapy. Even though the dilation and curettage seems brutal, it is very necessary for her safety.

33 year old man presents with a painful testicular mass that does not transilluminate. The tumor is removed, and is hemorrhagic and necrotic. hCG is elevated. Histology reveals glandular pattern. What is the prognosis?

worse than seminoma this is embryonal carcinoma (Lance armstrong) it's aggressive with early hematogenous spread this makes sense because embryonal tissue is aggressive and go all over the place Chemotherapy may cause differentiation into a teratoma

2 year old boy presents with a testicular mass. Elevated AFP. Schiller-duval bodies found on histological section. Dx

yolk sac tumor aggressive malignancy of testis

26 year old with 1st trimester vaginal bleeding, higher than normal hCG and snowstorm appearance is treated with dilation and curettage. She is confused at why you want to measure hCG months after pregnancy. What do you tell her

you are monitoring for presence of choriocarcinoma