Reproductive Question Set 2

A 56-year-old female presents to the physician with a lump in her left breast. On examination, bilateral small nodules are present which is further confirmed on mammography. Fine needle aspiration cytology of the lesions revealed malignant cells arranged in a row of cells. Which is the most likely cause of the present finding?

A 49-year-old female presents with an enlarged breast. On examination, it is characterized by diffuse erythema, gross edema, and negative for localized palpable mass. Which of the following is the most accurate statement regarding the above condition?

A 24-year-old female recently notices a left breast mass. Examination shows a 4 cm mass in the left upper quadrant. It is firm, mobile, and has well defined margins. She complains of occasional tenderness. There is no lymphatic involvement. Mammography showed a dense lesion. The most likely cause is?

A 40-year-old male presents with painless firm mass in the right breast. Examination shows retraction of the nipple and skin is fixed to the underlying mass. Axillary nodes are positive on palpation. Which of the following statement is true regarding the above condition?

A 55-year-old Caucasian woman is brought to your office for six months of anal discomfort and vaginal pruritus and soreness that have worsened in the last couple of months. Her past medical history is relevant for hypertension and smoking. Family history is negative for malignancies. Physical examination is unremarkable, except for the presence of white, atrophic papules merging into an ulcerated plaque, with some of the white lesions extending and surrounding the anus (see image). You order biopsies of the lesions and a follow up appointment. Two weeks later, the patient comes back with the histology evaluation, which reports hyperkeratosis, significant epidermal thinning, and plugging of infundibular follicles. Which of the following lesions is the patient at risk to develop?

A 19-year-old African American woman visits her local walk-in clinic after noticing a mass projecting from her vagina. The mass looked like “a bunch of grapes”. She also says she’s been having a intermenstrual mucosanguineous vaginal discharge for the past 6 months. Her family and personal history is not relevant for malignancies or inherited disorders. She states she has not initiated sexual intercourse. Her physical examination is unremarkable, except for the presence of soft nodules protruding from the vaginal canal. A tissue sample is taken to for histologic evaluation. Several weeks later, the patient returns to the walk-in clinic with a pathology that describes a polypoid mass beneath an epithelial surface with atypical stromal cells positive for polyclonal desmin. What is the most likely diagnosis in this patient?

A 47-year-old Caucasian woman visits your office because she has been presenting postcoital vaginal bleeding for the past 8 months, with occasional intermenstrual watery, blood-tinged vaginal discharge. Her family history is negative for malignancies and inherited disorders. She is the result of pregnancy complicated by attempted miscarriages, for which her mother received diethylstilbestrol in the late 1960s. During pelvic examination, you notice a polypoid mass on anterior wall of the vagina. Bimanual examination is negative for adnexal masses. You suspect the presence of a carcinoma, and therefore send tissue samples to pathology who report back confirming the presence of malignant cells. Which of the following is the most likely malignant tumor in this patient?

A 24-year-old Caucasian woman visits the health services of her university for vaginal itching, dysuria, pelvic discomfort and foul smelling vaginal discharge. She states this is the eighth time presenting such symptoms within the last year, for which she and her sexual partners have received multiple trials of doxycycline and ceftriaxone, and in other cases azithromycin and ceftriaxone. Pelvic examination shows a mucopurulent cervical discharge with cervical friability. A vaginal wet-mount shows an elevated number of polymorphonuclear leukocytes. What is the most likely cause of this patient cervicitis?

A 32-year-old Caucasian woman goes to her family physician for a routine checkup for her new job. Presently, she is asymptomatic, and the physical examination is unremarkable. Her family history is negative for malignancies and inherited disorders. During the visit, she presents to her family physician the results of a Pap smear taken last week, which reports the presence of atypical squamous cells of undetermined significance (ASC-US), along a test for HPV, which came back negative. The Pap smear before this one was normal (Negative for intraepithelial lesion or malignancy). When would you recommend her to take her next cervical test?

A 38-year-old Caucasian woman visits her family physician for a routine a checkup after being away for one-year travelling. She recently underwent a screening Pap smear which was negative for malignancy. Her past medical history is relevant for a Pap smear from two years ago that reported a low grade squamous intraepithelial lesion (LSIL), and subsequent colposcopy diagnosing a low grade cervical intraepithelial neoplasia CIN2. The patient is surprised by the differences on her diagnostic test. You explain to her the situation and reassure her. With this in mind, which of the following HPV serotypes is the most likely present in the patient?

A 56 year-old Caucasian female with a history of stage IIA cervical cancer presents to your office after her fifth episode of complicated urinary tract infection in the past 12 months. She complains of easy fatigability, weakness and has noted her shoes no longer fit. The physical examination is unremarkable except for a blood pressure of 165/90 mmHg and mild pitting lower extremity edema. Rectovaginal examination reveals no cancer-free space between the tumour and the pelvic sidewalls, while being negative for blood and fistulas.Given the patient’s medical history, you order abdominal and transvaginal ultrasounds and renal function tests. Which of the following findings would you most likely expect to be reported in the ultrasound?

A 40 year-old African-American female visits her gynecologist with concerns about recent changes in her menstrual cycle. Her last menstrual period was more than 12 months back. She has two children and used to have regular menstrual periods in the past. She also complains of difficulty in falling and staying asleep, occasional hot flashes, vaginal dryness and decreased libido. Her physical examination is unremarkable, her height and weight are 1.68 m and 70 kg, respectively. She has the following hormonal panel from 2 months ago when she first seeked help for her symptoms. Human Chorionic Gonadotropin: 4 IU/L (0.8 - 7.3 IU/L) Thyroid Stimulating Hormone: 2.5 mIU/L (0.4 - 4.2 mIU/L) Prolactin: 5 ng/mL (2-29 ng/mL) Follicle Stimulating Hormone: 45 mIU/mL (Follicular phase: 3.1-7.9 mIU/mL; Ovulation peak: 2.3-18.5 mIU/mL; Luteal phase: 1.4-5.5 mIU/mL) Estradiol: 5 pg/mL (Mid-follicular phase: 27-123 pg/mL; Periovulatory: 96-436 pg/mL; Mid-luteal phase: 49-294 pg/mL) Which of the following is the most likely diagnosis in this patient?

During a humanitarian mission in South East Asia, a 42-year-old male is brought to the outpatient clinic for a long history (more than two years) of progressive painless enlargement of his scrotum. His family history is negative for malignancies and inheritable diseases. His personal history is relevant for cigarette smoking for up to two packs per day for the last 20 years, and a couple of medical consultations for episodic fever that resolved spontaneously. Physical examination is unremarkable, except for an enlarged painless left hemiscrotum that transilluminates. Which of the following accounts for the underlying mechanism in this patient condition?

A 72-year-old man of Asian descent visits your office frustrated about the frequency he wakes up at night to urinate. He comments he is even avoiding to drink liquids at night, but the symptoms have progressively worsened. Physical examination is unremarkable, except for an enlarged, symmetrical prostate free of nodules. If you wish to intervene in the main factor contributing to the pathogenesis of this patient condition, which of the following should you prescribe?

A 10-year-old boy is brought to his pediatrician after discovering a painless mass in the left testicle. Results from tumor markers and a biopsy are available in the following table: AFP: 350 ng/mL (normal values <10 ng/mL) hCG: 0.4 IU/L (normal values <0.5 IU/L) Biopsy: Presence of glomeruli-like structures with a central capillary within a mesodermal core, lined by flattened layers of germ cells. What is the most likely diagnosis in this patient?

A 32-year-old Caucasian male is admitted to the ER for a generalized tonic-clonic seizure. After stabilization, the medical team found multiple contrast enhancing lesions in his brain, lungs and liver. The patient has lost several pounds according to his relatives. His medical history is relevant for cryptorchidism, with abdominal testes that were fixed to the scrotum when just before he turned 1-year old. Tumor markers show the following:

A 45-year-old Asian man visits your office with a history of two years of moderate to severe pelvic pain, irritative voiding urinary symptoms (mainly, hesitancy and terminal dribbling), and every now and then some frank blood in his semen with painful ejaculation. He has visited various practitioners, who have prescribed him antimicrobial therapy including ciprofloxacin, with no improvement at all, leading to emotional distress and sleep disturbances. Physical examination is unremarkable, except for a mild tender prostate, without masses or nodules. There are no testicular masses, hernias, or hemorrhoids. Additionally, to this health issue, you also have been following him for recurrent abdominal pain, associated with periods of constipation and diarrhea, and fatigability, with all tests ordered falling within normal range so far. A summary of recent tests is shown in the following table: Sample: Mid-stream urine, White cells: negative, Culture: negative Sample: Expressed prostatic secretion, White cells: positive, Culture: negative What is the most likely diagnosis in this patient?

A 40 year-old African-American female visits her gynecologist with concerns about recent changes in her menstrual cycle. Her last menstrual period was more than 12 months back. She has two children and used to have regular menstrual periods in the past. She also complains of difficulty in falling and staying asleep, occasional hot flashes, vaginal dryness and decreased libido. Her physical examination is unremarkable, her height and weight are 1.68 m and 70 kg, respectively. She has the following hormonal panel from 2 months ago when she first seeked help for her symptoms. Human chorionic gonadotropin:: 4 IU/L (0.8 - 7.3 IU/L) Thyroid stimulating hormone: 2.5 mIU/L (0.4 - 4.2 mIU/L) Prolactin: 5 ng/mL (2-29 ng/mL) Follicle stimulating hormone: 45 mIU/mL (follicular phase: 3.1-7.9 mIU/mL; Ovulation peak: 2.3-18.5 mIU/mL; luteal phase: 1.4-5.5 mIU/mL) Estradiol: 5 pg/mL (mid-follicular phase: 27-123 pg/mL; periovulatory: 96-436 pg/mL; mid-luteal phase: 49-294 pg/mL) Which of the following is the most likely diagnosis in this patient?

A 55-year-old woman of mediterranean descent comes to your office because she noticed the growth of unwanted hair on her upper lip, chin and chest as well as increase in blackheads and pimples on her skin. Her female partner has also recently brought to her attention the deepening of her voice, weight gain, and changes in her external genitalia which has generated some personal relationship issues. The patient is desperate as these changes have appeared in the course of last 8 months. She claims that she was doing completely normal before all this started. Physical examination shows dark coarse stubbles distributed along her upper lip, chin, chest and back, an oily skin and moderately inflamed acne. Pelvic examination reveals a clitoris measuring 12 mm long, a normal sized mobile retroverted uterus and a firm, enlarged left ovary. What is the most likely diagnosis of this patient?

A 27-year-old Caucasian female comes to the office with concerns about her long struggle with her physical appearance since adolescence. She says she has been always been "large" and she has been constantly bullied and targeted by her classmates and coworkers for being so. However, her main concern at the moment is the presence facial acne and unwanted body hair on her upper lip, for which she often visits a local spa. She has tried numerous diet plans, exercise regimes, and cosmetic products with little to no effect, and concomitantly has started to refrain from social activities and gatherings. Recently, she had a glucose tolerance test that showed a plasma glucose level of 160 mg/dL (8.9 mmol/L) after 2 hours of a 75 gm of oral glucose. She has a family history of type 2 diabetes mellitus and a menstrual cycle that lasts 45 days. Physical examination reveals that her height is 1.60 m and weight is 85 kg; pulse is 72/min, blood pressure is 138/80 mmHg, severe inflammatory acne over the cheeks and forehead and dark coarse hairs on the back. What is the most likely diagnosis of this patient?

A mother brings her 18-year-old daughter to your office because her daughter has not menstruated yet. They recently immigrated from a country in the Middle East and do not have any previous medical records. The adolescent girl looks relatively short but otherwise looks healthy She has no complaints except a mild cyclic lower abdominal pain for the past one years. On physical examination, vitals are within normal limits. There is the presence of axillary hair and breast development and pubic hair at Tanner stage 5. You explain to the mother and the patient that you need to perform a complete vaginal examination, however, both of them declined the procedure. You are able to run a priority hormonal test that shows: FSH: 7 mIU/mL, follicular phase: 3.1 - 7.9 mIU/mL; ovulation peak: 2.3 - 18.5 mIU/mL; luteal phase: 1.4 - 5.5 mIU/mL; postmenopausal: 30.6 - 106.3 mIU/mL Estradiol: 28 pg/mL, mid-follicular phase: 27 - 123 pg/mL; Periovulatory: 96 - 436 pg/mL; Mid-luteal phase: 49 - 294 pg/mL; Postmenopausal: 0 - 40 pg/mL Testosterone: 52 ng/dL, 40 - 60 ng/dL What is the most likely diagnosis of this patient?

A 34-year-old woman visits a fertility clinic with her husband with the concerns about their inability to conceive their first child. Originally from India, she met her present husband during a humanitarian mission in Nepal 10 years ago. In addition to this, she also complains about a long history of vague lower abdominal pain along with changes in her menstrual cycle such as spotting and irregular vaginal bleeding with passage of clots for the past few months. The patient denies pain during intercourse, postcoital bleeding, fouls smelling vaginal discharge, fever and weight loss. Her physical examination is unremarkable, with no signs of acute illness. During vaginal examination a healthy vagina and mild bleeding from the cervix are found. The patient is subjected to a hysterosalpingogram as part of her infertility evaluation, which shows sinus formation and peritubal adhesions. Subsequently, a sample of menstrual fluid is taken to the microbiology lab. Which of the following pathogens is more likely to be the cause of this patient complains?

A 40 year-old Caucasian woman visits your office after with her pathology report after being subjected to total abdominal hysterectomy a month ago. She explains that she went through this procedure after a long history of lower abdominal pain that worsened during menses and heavy menstrual bleeding. She’s a mother of 5 children, all delivered by caesarean section. The pathology gross and microscopic examination report from the specimen from surgery describes an enlarged, globular uterus with invading clusters of endometrial tissue within the myometrium. What is the most likely diagnosis for this patient?

A 32-year-old Asian-American woman visits her family physician for a routine health check-up. During the consult, she complains about a recent onset constipation, painful defecation, and occasional pain with micturition for the past few months. Her menstrual cycles have always been regular with moderate pelvic pain during menses that relieved by the use of pain medication. However, in the last 6 months, she has noticed that her menses are "heavier", with severe lower abdominal cramps that linger for 4-5 days after the last day of menstruation. She and her husband are trying to conceive a second child, but lately, she’s been unable to have sexual intercourse due to pain during sexual intercourse. During the physical examination, she has tenderness in the lower abdomen with no palpable mass. Pelvic examination reveals a healthy, left-deviated tender cervix, a tender retroverted uterus, and a left adnexal mass. During rectovaginal examination, the presence of nodules is noted. Which of the following is the most likely diagnosis for this patient?

A 38-year-old Caucasian woman undergoes a diagnostic hysteroscopy for a six-month history of small volume intermenstrual bleeding with no other complaints. There is no history of pelvic pain, painful intercourse or vaginal discharge other than blood. During the procedure, a red beefy pedunculated mass is seen arising from the endometrium of the anterior wall of the uterus which has well-demarcated borders. This mass is resected and sent for histopathological examination. Which of the following is the most likely diagnosis?

A 45-year-old African-American woman visits your office concerned about the recent changes in her menstrual cycle. She noticed that her menses have become longer and heavier, to the point of needing almost the double the number of sanitary pads than 6 months ago. She denies any abdominal or pelvic discomfort. She started menstruating at the age of 9. Her past medical history includes a negative Pap and HPV tests that were done 5 years ago. Physical examination is unremarkable, with no masses during abdominal palpation and pelvic examination is negative for vaginal lesions or tenderness. Bimanual examination reveals a mobile, nontender retroverted uterus with no masses noted in the adnexa. A transvaginal ultrasound performed 4 days after her last menses reported an endometrial thickness of 4 mm. Which of the following is the most likely cause of this patient's condition?

A 30-year-old African-American woman visits her local walk-in clinic with a week's history of lightheadedness and palpitations. She also complaints of fatigability and shortness of breath for the same duration. Her past medical history is significant for menarche at the age of 9, heavy menstrual bleeding for past several years and abdominal pain that worsens during menses. She stopped trying to conceive a child after 2 spontaneous abortions in the past four years and has been under iron oral supplementation for the last 2 years. She adds that she feels a dull pressure like discomfort in her pelvic region and constipation. Her physical examination is significant for pale mucous membranes and a grade II/VI ejection systolic murmur in the pulmonary area. Pelvic examination reveals an enlarged, mobile uterus with irregular contour during bimanual examination. Her hemoglobin level is found to be 10 gm/dl and hematocrit to be 27%. Based on these findings, which of the following is the most likely diagnosis?

A 22-year-old Caucasian woman visits her local walk-in clinic due to severe lower abdominal pain, vaginal discharge, and painful intercourse for the last couple of weeks. Her last day of menstruation was one week ago and since then the pain has only worsened. She’s an out of town college student engaged in an open relationship with a fellow classmate and another partner from her original town. Additional concerns include painful micturition and low-grade fever for the same duration. Physical examination reveals a heart rate of 120 /minute, a respiratory rate of 24/min, and temperature of 38.6 C. Pelvic examination shows an erythematous cervix with mucopurulent exudate. The cervix is prone to bleed when manipulated with a swab and is extremely tender upon mobilization. Based on the clinical findings which of the following causative agents is the most likely cause of her condition?

A 25-year-old African-American woman is brought to the emergency department by her flatmate due to severe right lower quadrant pain for the last 8 hours which is progressively getting worse and associated with vomiting. When you ask the patient about her last menstrual period, she tells you that although she stopped keeping note of her cycle after undergoing surgical sterilization one year ago, she recalls bleeding yesterday. A quick physical examination reveals a hemodynamically stable patient with a pulse of 90/min; respiratory rate of 14/min; blood pressure of 125/70 mmHg and Temperature of 37 °C). Her abdomen is tender to touch, more in the lower quadrant, McBurney's point tenderness is absent. Which of the following is the best next step in management of this patient?

A mother brings her 17-year-old daughter to your office because of recent onset dull unilateral pelvic pain since last week. In addition, the daughter also complains of constipation for which she increased her intake of fibers but that doesn't seem to help. She began menstruating at the age of 13 and her menstrual cycles are regular and of 28 days. You examine the patient and find a large non-tender, mobile adnexal mass in the left lower quadrant. Pelvic examination is normal except for the presence of the adnexal mass. You prescribe an ultrasound and ask the patient to come back next week. Two weeks later you find out, the patient had to visit the emergency department for sudden onset of abdominal pain, that required observation only after performing an abdominal ultrasound on the patient, which reported a large simple cystic mass with increased internal echoes, having a diameter of 10 cm and hyperechogenic vascular walls on the left ovary with a small intraperitoneal collection in the pouch of Douglas. What was the most likely diagnosis for this patient?

A 38-year-old Caucasian female is visits the Emergency Room for sudden onset of pain and swelling of her left leg since one day. Her family history is significant for breast cancer in her mother who was diagnosed at the age of 52 and bronchioloalveolar carcinoma of the lungs in her grandfather at the age of 45. When the patient was 13 years old she was diagnosed with osteosarcoma of the right distal femur treated successfully with surgery with no major sequela. Physical examination shows unilateral left leg edema, erythema, tender to touch and warm. Homan's sign is positive. During the abdominal examination you also notice a large mass in the left lower quadrant, firm, fixed with irregular borders. Proximal leg ultrasonography reveals a noncompressible femoral vein, and the presence of the thrombus after color flow Doppler evaluation. Concerned about the association between the palpable mass and the thrombotic event in this young patient, you order an abdominal CT scan with contrast that reports a left abdominopelvic large cystic mass with thick septae consistent with a high-grade serous ovarian cancer with several lymph nodes compromised and ascites. Which of the following genes is most likely mutated in this patient?

A 28-year-old African-American woman at her 30th week of gestation is rushed to the Emergency Room for sudden onset vaginal bleeding accompanied with intense abdominopelvic pain and uterine contractions since this morning. The intensity and frequency of her pain have increased in the past 2 hours. This is her first pregnancy and she was diagnosed with gestational diabetes a couple of weeks back. Her vital signs include a blood pressure of 124/68 mmHg, a pulse of 77/min, respiratory rate of 72/min and a temperature of 37° C. Abdominal examination is positive for a firm and tender uterus. An immediate cardiotocographic evaluation reveals a fetal heart rate of 150/min with prolonged and repetitive decelerations, and high frequency and low amplitude uterine contractions. Your attending warns you about delaying the vaginal physical examination until a quick sonographic evaluation is completed. Which of the following is the most likely diagnosis in this patient?

A 25-year old primigravida is rushed to the emergency room at her 35th week of gestation due to a severe headache for the past 5 hours. Her headache is severe and incapacitating showing no response to acetaminophen. In the ER, her blood pressure is found to be 150/100 mmHg, pulse is 88/min, respiratory rate is 30/min and temperature is 37 C. Her records show that her blood pressure was the same yesterday during her regular antenatal visit. Chest auscultation reveals bilateral crepitations along the lung base. Abdominal palpation reveals a gravid uterus with size consistent with a gestational age of 32 weeks and floating fetus with cephalic presentation. Pelvic examination is performed which shows a closed firm cervix. There is no bleeding or any discharge. Moderate pitting edema is noted and neuro exam shows generalized hyperreflexia. Blood tests show: Hemoglobin: 12.5 g/dL Platelets: 185,000 platelets/microL Serum creatinine: 0.4 mg/dL (35 micromol/L) Spot urine creatinine: 110 mg/dL Spot urine protein: 360 mg/dL AST: 40 IU/L Which of the following is the most likely diagnosis?

A 24-year-old Caucasian woman at her 6th week of gestation visits her local walk-in clinic because she has started noticing a clear, sticky discharge from her right nipple for the past one week. The discharge leaves a clear, sometimes pale yellow, stain on her innerwear. She doesn’t feel any pain in her breasts and denies changes in skin color or nipple shape. Her past medical history is significant major depressive disorder for which she is on fluoxetine. Her family history if negative for breast, endometrial and ovarian cancer. Physical examination is unremarkable. There are no palpable masses or tenderness on breast exam and no skin discoloration or ulcers. Both breasts look symmetrical. Nipple discharge on the right side is seen as a straw-colored secretion that is sticky, with no secretion on the left. Axillary lymph nodes are normal. Which of the following is the most likely diagnosis of this patient?

A 34-year-old Asian-American woman of visits and outpatient clinic with the complaint of pain in her left breast for the last few months. The pain worsens during her menstrual cycle and relieves once the cycle is over. She denies any nipple discharge, skins changes, warmth, erythema, or a palpable mass in the breast. Her family history is negative for breast, endometrial and ovarian cancer. There is no palpable mass or any abnormality in the physical examination of her breast. A mammogram is ordered which shows a cluster of microcalcifications with a radiolucent center. A breast biopsy is also performed which reveals a lobulocentric proliferation of epithelium and myoepithelium. Which of the following is the most likely diagnosis?

A 30-year-old Caucasian woman presents to the office with the complaints of pain in her right breast for five days. The pain is moderate to intense and is localized to the upper quadrants of her right breast and for the past 48 hours present mainly in the areola. She further adds that there is some nipple discharge on the same side and that her right breast looks red. She was diagnosed with Type 1 Diabetes at the age of 10 and is on insulin. Her family history is negative for breast, ovarian and endometrial disorders. She smokes half a pack of cigarettes everyday and binge drinks on weekends. Two weeks ago she got hit by a volleyball ball while playing at the beach. There is no history of fractures or surgical procedures in the past. Physical examination reveals a swollen, erythematous, and warm right breast with sharp periareolar tenderness and nipple discharge. There are no palpable masses or lymph nodes. Which of the following is the most important risk factor for the development of the condition that this patient has?

A 52-year-old Caucasian woman visits your office complaining about discharge from her left nipple for the past 3 months. The discharge looks like cottage cheese and its amount is progressively increasing. She appears to be anxious and extremely uncomfortable with this situation as it is embarrassing for her when it occurs outdoors. Past medical history is insignificant. Her family history is negative for breast and ovarian disorder. She tries to stay active by running for 30 minutes every day on a treadmill, staying away from smoking and eats a balanced diet. She drinks alcohol occasionally. During physical examination you find a firm, stable mass under an inverted nipple in her left breast; while on the right breast, dilated subareolar ducts can be noted. There is no lymphadenopathy and remaining of the physical exam is normal. A mammogram is performed which reveals tubular calcifications. Which of the following is the most likely diagnosis?

A 44-year-old woman of Latin American descent visits the clinic for her annual physical checkup. She expresses her concerns about a mass in her right breast that she noticed while taking shower 3 months back. Since then, it has progressively increased in size. She denies any changes in her nipples or nipple discharge. Her family history is negative for breast, ovarian, and endometrial cancer. Physical examination reveals a smooth, multi-nodular, firm mass on the right breast that is mobile and painless measuring approximately 5 x 5 cm. The skin over the mass appears to be stretched and shiny without ulcerations, erythema or vascular demarcation. There is no nipple retraction or active nipple discharge. An ultrasound of the breast is ordered and the patient is asked to come back after the reports are available. During the follow-up visit, the physician notes that the mass has increased in size, measuring 8 x 7 cm now, with the other characteristics same as before. The ultrasound report states the presence of a well circumscribed, hypoechoic mass, primarily solid but with some cystic components within the right breast tissue. A core needle biopsy is ordered. Which of the following is expected to be confirmed by the biopsy?

A 56-year-old Caucasian woman is referred to your office after her mammography showed a modest dense spiculated mass with clustered microcalcifications. Her family history is negative for breast, endometrial, and ovarian cancer. She used to be a flight attendant, and since her retirement, she started a strict Mediterranean diet because she was 'trying to compensate for her lack of physical activity'. She is a mother of two, whom she breastfed each for 18 months as recommended by her previous physician. Her only two surgical procedures have been a breast augmentation with implants and a tubal ligation. Her physical examination is unremarkable. There are no palpable masses and no other nipple or breast skin abnormalities. The patient is lacks of family history of breast cancer. Which of the following is the most significant risk factor for the development of breast cancer in this patient?

A 34-year-old African woman who recently moved to the United States visits a surgical outpatient clinic with the history of painful ulceration in her right breast for the last 2 months. She is worried as the ulcer is increasing in size. On further questioning, she says that she has discharge from her right nipple as well. She had her second child 4 months back and was breastfeeding the baby until the pain started getting worse in the past few weeks and became unbearable. According to her health records from Africa, her doctor prescribed antimicrobials multiple times with a diagnosis of mastitis but she did not improve much. Both her mother and aunt died of breast cancer, at 60 and 58 years of age, respectively. On examination, there is an enlarged firm right breast, and a thickened skin with diffuse erythema, edema, and an ulcer measuring 3 x 3 cm. A whitish gray active nipple discharge is present. The breast is tender and axillary and cervical adenopathy can be appreciated. A mammography is ordered which shows a mass with a large area of calcification, parenchymal distortion and extensive soft tissue and trabecular thickening in the affected breast. The patient is subsequently subjected to a core needle and full-thickness skin punch biopsies. The pathology report states a clear dermal lymphatic invasion by tumor cells. Which of the following is the most likely diagnosis?

A 39-year-old African American woman is admitted to the hospital after having seizure followed by a severe headache. She was diagnosed with breast cancer a year ago when she presented with a hard, rock like, immobile, mass with irregular borders accompanied by changes in the breast skin such as erythema and dimpling. She had an ipsilateral mobile axillary lymphadenopathy at that time. A biopsy confirmed the diagnosis of invasive breast cancer stage IIB. Her mother died at the age of 42 due to the same type of breast cancer. A CT scan done at this admission reveals multiple metastatic lesions in her brain and liver along with the involvement of supra and infraclavicular lymph nodes. Which of the following molecular profile most likely belongs to this patient?

A 60-year-old male is brought to your office by his daughter who noticed that her father has a progressive increase in his breast size in the past 6 months. The patient does not complain of anything else, except for easy fatigability and weakness. His daughter adds that he does not have a good appetite as before. He has occasional discomfort and nipple sensitivity when he puts on a tight shirt. Past medical history is significant for benign prostatic hyperplasia, for which he takes finasteride, and comments that he used to take antihypertensive medication but stopped them as his blood pressure 'normalized'. On physical examination, his pulse is regular and 78 beats per minute, he has a regular breathing pattern and blood pressure of 100/68 mm Hg with a temperature of 37 C. Chest examination reveals multiple vascular lesions consisting of a central pinpoint red spots with red streaks radiating from the central lesion and bilaterally enlarged breast tissue. You also notice lack of hair on the chest and axilla. There is no hepatosplenomegaly on abdominal palpation. What is the most likely cause of gynecomastia in this patient?

A 27 year old Caucasian female visits your office for 3 days of fever, malaise, myalgia, and headache associated with vulvar itching, vulvar soreness, dysuria, and urethral discharge. She comments the pain while urinating is so severe that she has started to avoid the use of the toilet. She just came back from a spring break in the tropics and explains she had multiple unprotected sexual encounters with men and women. Upon physical examination, you find a body core temperature of 38.7°C (101.6 F), heart rate of 90 beats per minute, and a regular respiratory rate. Pelvic examination reveals exquisitely vulvar ulcers, vulvar excoriations, erythema, edema in the vaginal mucosa, and ulcerative cervicitis after passing the speculum. With the above information, you make a clinical diagnosis and initiate treatment. Which of the following will best aid you in the identification of the specific organism causing the above symptoms?

A 62 year old African American visits his local walk-in clinic for intense mid-low back pain. He has tried different rehabilitation therapies and medication with no improvement so far. He was treated with pain medication and sent home. One week later, the patient presents with difficulty to walk and worsening of the back pain. He is admitted to the ER where he is found with hypoesthesia from T12 to S4-S5, significant muscle weakness in both lower limbs and reduced knee and ankle deep tendon reflexes. Digital rectal examination reveals an hypotonic anal sphincter with conserved deep anal pressure, as well as a multinodular, asymmetric prostate. Imaging studies show multiple sclerotic bone lesions along his spine. Subsequently, a prostatic core biopsy is taken, confirming diagnosis of prostate cancer. Which of the following characteristics would you expect in the evaluated specimen?

A 17 year old Caucasian male visits his family physician concerned about the size of his penis. He has started to feel extremely anxious during physical education (PE) class, as he has noticed the size of his penis is significantly smaller when compared to his peers. During physical examination a Tanner stage 1 is noted. Patient’s weight and height are 60 kg and 1.75 m, respectively. Cardiopulmonary examination is normal, however, the patient has difficulty sensing smells. Which of the following explains the pathophysiology behind this patient disorder:

A 35 year old Caucasian male visits your office for his annual checkup. He was diagnosed with general anxiety disorder 6 months ago which is being treated with citalopram. He comments his symptoms have improved since the initiating the prescribed therapy, however in the past two months he has been unable to have sexual intercourse due weak tumescence and low libido. Which of the following is the best next step in managing this patient?

A 28 year old Caucasion with a past history of type 1 diabetes patient presents to your office with a 2 week history of vaginal itching and soreness accompanied with a white, clumpy vaginal discharge which she comments resembles cheese curds. Her last HbA1c from a month ago was 7.8 %, and her last cervical cytology from 10 months ago was reported as normal. Pelvic examination reveals multiple small erythematous lesions in the inguinal and perineal area, vulvar erythema and excoriations. Inspection demonstrates a normal cervix, and a white, adherent, thick, non-malodorous vaginal discharge. Which of the following is most likely to show in a saline wet mount from the vaginal discharge of this patient?

A 27 year old Caucasian woman visits her family physician preoccupied for a recent onset of a unpleasant fish-like vaginal odor that has started to affect her sexual life. She recently was treated for Traveller’s diarrhea after a vacation trip to Thailand. External genitalia appear normal on pelvic examination, speculoscopy shows a gray, thin, homogenous and malodorous vaginal discharge; cervical mobilization is painless and no adnexal masses are identified. A sample of the vaginal discharge is taken for saline wet mount examination. Which of the following characteristics is most likely to show in the microscopic evaluation of the sample?

A 23 year old Caucasian female approaches her university health services after a 5 day history of burning sensation when urinating and a mucoid secretion she has only seen on her underwear when she wakes up in the morning. She comments than 2 weeks ago she engaged in unprotected sexual intercourse with both male and female classmates during a sorority party. During physical examination, the practitioner finds pain with mobilization of the cervix and a clear, mucoid secretion coming out of the urethra. The rest of the physical is normal. If you were to perform an urine exam for microscopic evaluation, which of the following would you expect to see?

A 12-year-old African American boy is brought to the Emergency Room due to a severely painful erection of the penis for the past 5 hours. He was attending a class at his school when his penis gained tumescence without sexual excitation. A complete blood count and a cavernous blood gas analysis shows: Hemoglobin (Hb): 11.5 g/dL; 14.5 g/dL (-2SD 13.0 g/dL) for 12-18 years males; Mean Corpuscular Volume (MCV): 95 fL; 80 - 96 fL; Platelet count: 250,000/mm^3, 150,000 - 400,000 /mm^3; pO2: 38 mmHg, 75 - 100 mmHg; pCO2: 65 mmHg, 35 - 45 mmHg; pH: 7.25, 7.38 - 7.42; So2 %: 60 %, 94 - 100 %; HCO3-: 10 mEq/L, 22 - 26 mEq/L. Peripheral blood film reveals Red blood cells with Howell-Jolly bodies. Rapid detumescence is achieved after aspiration of blood and administration of an adrenergic agonist and analgesia. Which of the following etiologies should be considered in this patient?

A couple brings their 1-year-old child to the office for a follow-up for a small empty scrotum of their boy. They say that it has been so since birth and the doctor asked them to follow up regularly with a pediatrician.There are no other complaints. Immunization history is up to date and his growth and development have been excellent. On examination, a playful active child with a left, non-retractable, nontender inguinal mass, with an empty and poorly rugated hemiscrotal sac; while the right testis is found in the right hemiscrotal sac. Which of the following hormones would be deficient in this patient by puberty if his condition is left untreated?

A 64-year-old Caucasian male visits the office with the complaints of scrotal pain and swelling for the past two weeks. The pain is so severe that he is now unable to even sit comfortably for more than 5 minutes. Additionally, he also complains of inability to hold urine when he has an urge to urinate and mild discomfort during urination. His past medical history is significant for hypertension that is well-controlled with Losartan. He smokes a pack of cigarette every day and has been doing so for the past 25 years. On physical examination, swelling and erythema of the right hemiscrotal sac are evident, accompanied by exquisite tenderness with palpation of an indurated epididymis. What is the most likely infectious agent responsible for this patient’s condition?

A 13-year-old boy is brought to the emergency department for severe groin pain for the past 4 hours. His symptoms began while he was participating a basketball game. On arrival to the ED, the resident on call notes a swollen, tender and elevated left testicle with an absence of the cremasteric reflex. A urology consult is requested and the patient is scheduled for surgery. Abnormality is which of the following anatomical structures is most likely responsible for this patient’s condition?

A 72-year-old man of Asian descent visits your office frustrated about the frequency he wakes up at night to urinate. He comments he is even avoiding to drink liquids at night, but the symptoms have progressively worsened. Physical examination is unremarkable, except for an enlarged, symmetrical prostate free of nodules. If you wish to intervene in the main factor contributing to the pathogenesis of this patient condition, which of the following should you prescribe?