A 55-year-old woman comes to the office due to vaginal bleeding.  The patient underwent menopause at age 49 but has had intermittent, light vaginal bleeding for the last 6 months.  She has no pelvic pain and otherwise feels well.  The patient has type 2 diabetes mellitus, which is managed with diet and exercise.  Vital signs are normal.  BMI is 38 kg/m².  Speculum examination shows dark red blood at the cervical os.  On bimanual examination, the uterus is small and nontender and there are no palpable adnexal masses.  Which of the following is the most likely underlying cause of this patient’s symptoms?

A 17-year-old boy comes to the office for evaluation of gynecomastia.  Examination shows sparse facial and pubic hair.  Laboratory studies show:

Semen analysis reveals severe oligospermia.  Which of the following mechanisms is the most likely cause of this patient’s condition?

A 14-year-old girl is brought to the office for evaluation of a bump on her chest just below the right breast.  The bump has been there for as long as she can remember, but it became a little larger 2-3 years ago.  The bump also becomes tender just before she starts her menses.  Menarche was at age 12.  Her menses occur every 28 days and last 4-5 days.  Examination shows Tanner stage 5 breasts.  Both breasts and axillae appear normal.  There is a soft, raised, hyperpigmented, 0.5-cm nontender lesion inferior to the right breast.  Which of the following is the cause of this patient’s presentation?

A 30-year-old woman comes to the office for evaluation of irregular menses.  The patient has had increasingly irregular menses over the past 6 months, and hot flashes and unintentional weight loss for the past few months.  She has also had intermittent lower abdominal pain that is usually worse after increased physical activity.  The patient has no chronic medical conditions and takes no daily medications.  On examination, the abdomen is nontender.  A pelvic examination shows a left adnexal mass and a small uterus.  TSH is low and a urine pregnancy test is negative.  Pelvic ultrasound reveals a 6-cm left ovarian mass.  The mass is surgically removed, and gross examination of the specimen shows a cystic lesion with an oily substance.  Which of the following cell types is the most likely source of the neoplasm in this patient?

A 37-year-old woman comes to the emergency department due to sudden-onset nausea and severe right lower quadrant pain.  The pain developed an hour ago after exercise and has become increasingly severe.  The patient has no chronic medical conditions and has had no prior surgeries.  She does not use contraception, and her last menstrual period was 3 weeks ago.  Blood pressure is 136/94 mm Hg and pulse is 104/min.  The abdomen is tender to palpation over the right lower quadrant.  Pelvic ultrasound shows a right ovarian mass with no blood flow to the ovary.  The specimen obtained from diagnostic laparoscopy and right oophorectomy is shown in the image below:

Which of the following is the most likely diagnosis?

A 28-year-old woman comes to the office due to discomfort during urination for the past 3 months.  Antibiotics for a urinary tract infection were prescribed at an urgent care center a few weeks ago, but her symptoms have persisted despite treatment.  The patient has also noticed increasing pain with the passage of stool for the last year, particularly during menses.  Bowel movements occur daily and are soft and not watery.  Examination shows suprapubic tenderness and an immobile, retroverted uterus.  Rectovaginal examination reveals nodularity in the posterior cul-de-sac.  Urinalysis and urine culture are normal.  Surgical biopsy of the pelvic nodules would most likely show which of the following?

A 45-year-old woman comes to the office due to unintentional loss of 6.8 kg (15 lb) over the past 6 months.  She used to enjoy dining with friends but now avoids it due to excessive lower abdominal pressure and feeling full very quickly.  She also has epigastric pain but no dysphagia, regurgitation, vomiting, or diarrhea.  Physical examination shows bilateral adnexal fullness.  A pelvic ultrasound shows bilateral complex ovarian masses with solid and cystic components.  Chest x-ray is normal.  CT scan shows stomach wall thickening in addition to the ovarian masses.  Which of the following is most likely to be seen on histologic evaluation of the ovaries?

A 33-year-old, previously healthy woman comes to the emergency department due to sudden-onset shortness of breath and left-sided chest pain.  The symptoms began an hour ago while she was doing yard work, and she nearly passed out at symptom onset.  The patient takes no medications or supplements other than ibuprofen for occasional headaches.  She does not use tobacco, alcohol, or illicit drugs.  Temperature is 37.1 C (98.8 F), blood pressure is 84/58 mm Hg, pulse is 122/min, and respirations are 24/min.  Pulse oximetry is 86% on room air.  On physical examination, the patient is in moderate distress.  The jugular veins are distended.  Heart sounds are rapid and regular with no murmurs.  Lungs are clear to auscultation bilaterally with no crackles or wheezes.  Arterial blood gas results are pH 7.52, PaCO₂ 28 mm Hg, and PaO₂ 54 mm Hg.  Which of the following is most likely to be seen on bedside echocardiography?

A 48-year-old woman comes to the office due to heavy menstrual bleeding for the last several months.  The patient has monthly menses with 5-6 days of heavy bleeding and passage of large blood clots and increased abdominal cramping.  She has no significant medical history and has had 2 vaginal deliveries.  Her family history is significant for endometrial cancer in her mother.  BMI is 24 kg/m².  Vital signs are normal.  Pelvic ultrasound shows a uterine mass.  The patient undergoes a total abdominal hysterectomy; gross examination of the uterus is shown below:

The abnormal region indicated by the arrow is most likely to display which of the following microscopic findings?

A 38-year-old woman, gravida 1 para 0, at 32 weeks gestation comes to the office due to a progressively worsening headache.  The patient also reports increased leg swelling and a 4.54-kg (10-lb) weight gain since her last visit 2 weeks ago.  She has no chronic medical conditions, and her pregnancy has been uncomplicated.  Review of medical records shows that blood pressure was 130/80 mm Hg at 30 weeks gestation.  Today, blood pressure is 165/100 mm Hg.  There is 2+ pitting edema to the knees.  Serum creatinine is 0.9 mg/dL.  Which of the following findings would most likely be present in this patient’s urinalysis?

A 17-year-old boy is brought to the office due to bilateral breast enlargement.  The patient first noticed it a few months ago and says that it is slightly painful.  His parents are concerned that the breast tissue is gradually becoming more prominent.  The patient is in special education classes due to a long history of learning disabilities.  Height is at the 95th percentile, and weight is at the 25th percentile.  Examination shows symmetric glandular tissue under both nipple-areolar complexes.  The lungs are clear bilaterally, and the abdomen is soft without organomegaly.  The testicles appear small and firm.  Neurologic examination is unremarkable.  Which of the following laboratory findings is most likely to be present in this patient?

A 73-year-old woman comes to the office due to increasing abdominal girth.  She also has constipation and decreased appetite that has worsened progressively for the last 6 months.  On physical examination, the abdomen is distended and nontender, and there is a palpable right adnexal mass.  The patient undergoes a right oophorectomy, and gross and microscopic examinations of the specimen are shown in the exhibit.  Which of the following markers is most likely to be elevated in this patient?

A 67-year-old man comes to the office for a routine health maintenance evaluation.  He feels well and has no specific symptoms.  Vital signs are within normal limits.  Digital rectal examination reveals a firm prostatic nodule.  The patient undergoes transrectal prostate biopsy, and microscopy reveals sheets of tumor cells infiltrating the stroma with no glandular differentiation; the tumor cells have large vesicular nuclei and prominent nucleoli.  Imaging shows enlargement of several iliac lymph nodes.  Which of the following is the best description of this patient’s tumor?

A 38-year-old woman comes to the emergency department for lower abdominal pain.  The patient has had some mild, cramping abdominal pain for the past few days, but today it became constant.  She has also had intermittent vaginal bleeding.  The patient has a history of irregular menses, and her last menstrual period was 8 weeks ago.  Physical examination shows a left adnexal mass.  The patient undergoes surgery and the resected specimen is shown in the image below:

Which of the following risk factors is most strongly associated with this patient’s condition?

A 34-year-old woman comes to the clinic due to a mass in her right breast.  The patient noticed the mass last week while in the shower.  She has no chronic medical conditions and takes no daily medications.  A 2-cm nodule is noted on examination of the right breast, and the patient is referred for biopsy.  Histologic evaluation of the tissue specimen is shown in the image below:

Which of the following is the most likely diagnosis?

A 59-year-old man is being evaluated for markedly elevated prostate-specific antigen levels.  He has no bone pain or urinary symptoms.  The patient has no chronic medical conditions or surgical history.  His father died of prostate cancer.  Vital signs are normal.  Digital rectal examination reveals an indurated prostate with no palpable nodules.  The remainder of the examination is normal.  Prostate biopsy is planned.  Which of the following is the best way to obtain a diagnosis in this patient?

A 31-year-old woman, gravida 3 para 2, at 28 weeks gestation comes to the office for a prenatal visit.  She has chronic hypertension that has been well controlled during this pregnancy.  At the patient’s previous prenatal visits, her blood pressure ranged from 120/70 to 130/80 mm Hg.  Today, her blood pressure is 150/100 mm Hg and repeat is 152/98 mm Hg.  Fundal height is 24 cm.  Urinalysis shows 2+ protein.  A transabdominal ultrasound reveals oligohydramnios and a fetus with growth restriction.  Compared to normal placental parameters, this patient most likely has which of the following hemodynamic changes?

A 66-year-old man comes to the office due to 2 episodes of hematuria over the past month.  Digital rectal examination reveals an indurated prostate with no palpable nodules.  An image from a transrectal prostate biopsy is shown in the exhibit.  Which of the following is the most likely underlying cause of this patient’s symptoms?

An 18-year-old man comes to the office due to a mass in his left scrotum.  He has no other symptoms.  The patient plays basketball regularly but does not recall any recent trauma to the testicle.  He is sexually active with 2 partners and does not use condoms.  Vital signs are within normal limits.  Physical examination shows a left intrascrotal nodule that is difficult to distinguish from the left testis.  The mass is nontender, does not change in size upon supine positioning, and does not transilluminate.  There is no inguinal lymphadenopathy.  Which of the following is the most likely diagnosis?

A 35-year-old man comes to the office for evaluation of an enlarged left testis.  He also reports decreased libido and erectile potency for the last 2 months.  The patient has no chronic medical conditions and takes no medications.  Physical examination is notable for significant enlargement of the left testis and bilateral gynecomastia.  His other secondary sexual characteristics are normal.  Serum β-hCG is markedly elevated and serum TSH is normal.  Scrotal ultrasound reveals a 3.1-cm, irregular testicular mass with cystic areas.  Which of the following is the most likely cause of this patient’s gynecomastia?

A 62-year-old woman comes to the office for follow-up a month after undergoing left mastectomy and axillary lymph node dissection for invasive ductal carcinoma.  Today, the patient feels well overall but reports continued burning and aching in her left upper arm, despite physical therapy.  Examination of the left chest wall shows a healing incision without erythema and mild but appropriate edema of the left chest wall and axillary soft tissues.  Sensation is diminished in the medial upper arm, near the axilla.  Shoulder range of motion is normal, and the rest of the physical examination is unremarkable.  Injury to which of the following nerves is most likely responsible for this patient’s symptoms?

A 16-year-old boy is brought to the emergency department due to severe right groin pain that has worsened over the past 12 hours.  During the last month, the patient has had several episodes of mild scrotal pain while walking between classes at school.  He has no history of traumatic injury and is sexually active.  Medical history is unremarkable except for an inguinal hernia repaired a year ago.  Temperature is 36.9 C (98.4 F), blood pressure is 116/78 mm Hg, and pulse is 86/min.  On examination, the right hemiscrotum is swollen and tender.  The bisected gross specimen from an orchiectomy is shown in the image below.

Which of the following is the most likely mechanism of this patient’s acute testicular pain?

A 38-year-old woman, gravida 4 para 3, at 18 weeks gestation comes to the office for a routine anatomy ultrasound.  The patient has had no vaginal bleeding, leakage of fluid, or contractions.  She has no chronic medical conditions and her 3 prior pregnancies resulted in uncomplicated cesarean deliveries.  Blood pressure is 118/66 mm Hg and pulse is 94/min.  Fundal height is appropriate for gestational age.  Transabdominal ultrasound reveals a fetus measuring 18 weeks gestation, an amniotic fluid index of 8 cm (normal: >5 cm), and an anterior placenta that covers the internal cervical os and penetrates the uterine myometrium.  This patient is at greatest risk of placental invasion into which of the following structures?

A 61-year-old woman comes to the office due to skin puckering on the right breast.  She first noticed the skin changes 3 months ago while on vacation and is concerned that they have not resolved.  The patient does not use tobacco, alcohol, or recreational drugs.  She exercises regularly and takes a daily multivitamin.  Her last menstrual period was 8 years ago.  Physical examination shows a prominent, nontender skin retraction without discoloration or swelling of the right breast.  There is also a 6-cm irregular, immobile, firm mass in the right upper outer quadrant of the breast.  The left breast appears normal.  This patient’s skin findings are likely due to malignant infiltration of which of the following structures?

A 48-year-old woman comes to the office due to painful, heavy menses for the past 6 months.  The patient has 4-5 days of heavy bleeding, often soaking through a tampon or sanitary napkin every few hours.  Menstrual periods occur every 28-30 days.  The patient is not on contraception and has no significant medical history.  Vital signs are normal.  Urine pregnancy test is negative.  After an appropriate workup, a hysterectomy is performed, and the surgical specimen is shown below:

Which of the following is the most likely diagnosis?

A 64-year-old woman comes to the office for evaluation of a vulvar lesion.  The patient has had a vulvar plaque for the past year that has slowly increased in size.  She underwent menopause at age 52 and has a 30-year smoking history.  Vital signs are normal.  Physical examination shows a 1-cm nonfriable, white plaque on the right labia majora.  The remainder of the physical examination is normal.  A biopsy of the lesion is performed and shows squamous cell carcinoma.  A sentinel lymph node biopsy is planned for cancer staging.  This procedure should target which of the following lymph nodes?

An 18-year-old primigravida at 27 weeks gestation comes to the emergency department due to severe right upper quadrant pain.  The pain started 2 hours ago, and the patient has also had nausea, vomiting, and irregular uterine contractions.  Temperature is 36.7 C (98.1 F), blood pressure is 172/118 mm Hg, and pulse is 110/min.  BMI is 34 kg/m².  On abdominal examination, tenderness to palpation is present over the right upper quadrant.  Aspartate aminotransferase (SGOT) is 220 U/L and alanine aminotransferase (SGPT) is 240 U/L.  Abdominal imaging reveals a hepatic subcapsular hematoma.  This patient is most at risk for which of the following complications?

A 66-year-old man comes to the emergency department due to a 3-day history of fever, chills, dysuria, and perineal pain.  The patient has never had similar symptoms before, although he has had occasional nocturia and urinary hesitancy over the last 2 years.  His other medical conditions include type 2 diabetes mellitus and hypertension.  The patient does not use tobacco, alcohol, or illicit drugs.  He has not traveled recently and is not sexually active.  Temperature is 39 C (102.2 F), blood pressure is 124/78 mm Hg, and pulse is 106/min.  The abdomen is soft and nontender with no costovertebral angle tenderness.  Digital rectal examination shows a smoothly enlarged and tender prostate.  External genitalia are normal with no scrotal tenderness.  There is no urethral discharge.  The remainder of the examination shows no abnormalities.  Urinalysis reveals bacteriuria and pyuria.  Which of the following pathogens is most likely responsible for this patient’s current symptoms?

A 53-year-old woman comes to the office due to an itchy rash she has had on her left breast for the past month.  The patient has applied over-the-counter corticosteroid ointment with no relief of symptoms.  The patient’s last menstrual period was 2 years ago.  She has a history of hypertension that has improved with weight loss and exercise, and she takes no prescription medications.  Physical examination shows an eczematous plaque on the left nipple and areola.  The remainder of the physical examination is unremarkable.  Histologic examination of the skin lesion would most likely show which of the following?

A 35-year-old man is seen in the office due to heaviness in his lower abdomen.  He has a history of bilateral cryptorchidism in childhood and underwent orchiopexy at age 14 months.  The patient is otherwise healthy and takes no medications.  Physical examination shows enlargement of both testicles.  Scrotal ultrasound reveals bilateral testicular masses consistent with testicular germ cell tumor.  CT scans of the chest, abdomen, and pelvis do not reveal any lymph node metastasis.  The patient undergoes bilateral orchiectomy.  Which of the following long-term physiologic changes are most likely to occur as a result of treatment in this patient?

A 32-year-old man is evaluated for bowel dysfunction.  The patient suffered multiple injuries during a motor vehicle collision 6 months ago.  He was hospitalized for several weeks and is currently undergoing treatment with physical therapy.  Since the injury, the patient has developed severe constipation with occasional fecal incontinence.  Evaluation reveals a large amount of stool in the distal colon due to impaired motor function.  Anal sphincter tone is decreased.  Injury to which of the following structures best explains this patient’s bowel dysfunction?