5/19/06

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Gender determination

occurs after 7wks gestation; presence or absence of Y chrom (and SRY) determines which gonads drive differentiation

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embryology - Day 0

fertilization by sperm; initiates embryogenesis

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embryology - within week 1

implantation as BLASTOCYST

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embryology - within week 2

bilaminar disk

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embryology - within week 3

gastrulation; primitive streak, notochord, and neural plate begin to form

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embryology - weeks 3-8

neural tube formed; organogenesis; most suscetible to teratogens

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embryology - week 4

heart begins to beat; upper and lower limb buds form (thalidomide damage)

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embryology - week 10

genetalia have male/female characteristics

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ectoderm categories

surface, neuroectoderm, neural crest cells

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surface ectoderm

adenohypophysis, lens of eye, epithelial linings epidermis

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neuroectoderm

neurohypophysis, CNS neurons, oligodendrocytes, astrocytes, pineal gland

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neural crest cells

ANS, dorsal root ganglia, melanocytes, chromaffin cells of adrenal medulla, enterochromaffin cells, pia, celiac ganglion, schwann cells, odontoblasts, parafollicular (C) cells of thyroid, laryngeal cartilage

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mesodermal derivatives

dura CT, muscle, bone, CV structures, lymphatics, blood, urogenital structrues, serous lining of body cavities (ex: peritoneum), spleen, adrenal cortex

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endodermal derivatives

gut tube epithelium and derivatives (lungs, liver, pancreas, thymus, thyroid, parathyroid

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notochord

induces ectoderm to form neuroectoderm (neural plate); its postnatal derivative is the nucleus pulposus of the intervertebral disk

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rules of 2s for 2nd week of embryogenesis

2 germ layers (bilaminar disk; epiblast & hypoblast); 2 cavities (amniotic, yolk sac); 2 components to placenta (cytotrophoblast, syncytiotrophoblast)

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epiblast

precursur to ectoderm; invaginates to form primitive streak; cells from primitive streak give rise to intraembryonic mesoderm and endoderm

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rule of 3s for 3rd week of embryogenesis

3 germ layers (gastrula): ectoderm, mesoderm, endoderm

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Teratogens: ACE inhibitor

renal damage

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Teratogen: Cocaine

abnormal fetal development and fetal addiction

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Teratogen: DES

vaginal clear cell adenocarcinoma

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Teratogen: Iodide

congenital goiter or hypothyroidism

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Teratogen: 13-cis-retinoic acid

extremely high risk for birth defects

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Teratogen: thalidomide

limb defects ("flipper" limbs)

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Teratogen: warfarin, xrays

multiple anomalies

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Monozygotic twinning

1 zygote splits evenly to form 2 amniotic sacs w/single common chorion and placenta

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Dizygotic (fraternal) or monozygotic twins

Dizygotes develop individual placentas, chorions, and amnions; Monozygotes develop 2 placentas (separate or fused), chorions and amniotic sacs

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Fetal erythropoiesis

Yolk sac (3-8wks), Liver (6-30wks), Spleen (9-28wks), Bone marrow (28wks onward); Fetal Hb = a2g2; Adult Hb a2b2; "Young Liver Synthesizes Blood"

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Branchial clefts, arches, pouches (CAP)

derived from ectoderm, mesoderm, endoderm, respectively

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Branchial arch 1 derivatives: "Ms"

Meckel's cartilage: mandible, malleus, incus, sphenoMandibular ligament; Muscles: Muscles of mastication (temporalis, Masseter, lateral/medial pterigoids; Mylohyoid, ant belly of digastric, tensor tympani, tensor veli palatini; CNV3

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Branchial arch 2 derivatives: "Ss"

Reichert's cartilage; Stapes, Styloid process, lesser horn of hyoid, Stylohyoid ligament; Muscles: facial expression, Stapedius, Stylohyoid, post belly of digastric; CNVII

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Branchial arch 3 derivatives

"think of pharynx" (styloPHARYNGEOUS innervated by glossoPHARYNGEAL nerve) Cartilage: greater horn of hyoid; Muscles: stylopharyngeus; CNIX

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Branchial arches 4-6

Cartilage: thyroid, criocoid, arytenoids, corniculate, cuneiform; Muscles (4th): most parhyngeal constrictors, cricothyroid, levator veli palatini; (6th): all intrinsic mm of larynx except cricothyroid; CNX (4th), recrurent laryngeal branch of CNX (6th)

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Branchial arch innervation: 1, 2, 3, 4, 6

V2 and V3; VII; IX; X; X (recurrent laryngeal)

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Branchial cleft 1 derivatives

external auditory meatus

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Branchial cleft 2-4 derivatives

temporary cervical sinuses, which are obliterated by proliferation of 2nd arch mesenchyme; peristance = branchial cyst in neck

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tongue development: 1st branchial arch

anterior 2/3; sensation via CNV3, taste via CNVII

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Tongue development: 3rd and 4th branchial arches

posterior 1/3; sensation and taste via CNIX; extreme posteior via CNX

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taste innervation

CNVII, IX, X

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tongue pain sensation

CNV3, IX, X

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tongue motor control

CNXII

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Ear derivatives from 1st branchial arch

incus, malleus, tensor tympani (V3)

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ear derivatives from 2nd branchial arch

stapes, stapedius (VII)

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ear derivatives from 1st branchial cleft

external auditory meatus

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ear derivatives from 1st pharyngeal membrane

eardrum, eustachian tube

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1st branchial pouch

middle ear, eustachian tubes, mastoid air cells; (endoderm-lined structures of ear)

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2nd branchial pouch

epithelial lining of palatine tonsil

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3rd branchial pouch

3 structures: thymus (ventral wings), left and right inferior parathyroids (dorsal wings)

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4th branchial pouch

superior parathyroids

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Aberrant development of 3rd and 4th branchial pouches

DiGeorge Syndrome; Tcell deficiency (thymic hypoplasia) and Hypocalcemia (parathyroid hypoplasia)

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Persistance of thyroglossal duct

connection btw tongue and thyroid; "pyramidal lobe" of thyroid; originated from thyroid diverticulum in floor of primitive pharynx

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most common site of ectopic thyroid tissue

tongue

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foramen cecum

normal remnant of thyroglossal duct

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cleft lip

failure of fusion of maxillary and medial nasal processes

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cleft palate

failure of fusion of lateral palatine process, nasal septum, and/or median palatine process

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Diaphragm is derived from: "Several Parts Build Diaphragm"

Septum transversum, Pleuroperitoneal folds, Body wall, Dorsal mesentery of esophagus; innervated by C3,4, 5

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Intramembranous Bone formation

spontaneous bone formation w/o preexisting cartilage

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Endochondral Bone formation

ossification of cartilaginous molds; long bones; 1* and 2* ossification centers

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Meckel's diverticulum

persistance of vitelline duct or yolk sac; a/w intussusception and volvulus, ectopic gastric and pancreatic tissue

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Omphalomesenteric cyst

cystic dilation of vitelline duct

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Pancreas

derived from foregut; ventral bud = head, uncinate process, main pancreatic duct; dorsal bud = body, tail, isthmus, accessory pancreatic duct

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Spleen

arises from dorsal mesentery BUT is supplied by celiac artery of foregut

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Mesonephric (wolffian) ducts; develops SEED

Seminal vesicles, Epididymis, Ejaculatory duct, Ductus deferens

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Paramesonephric (mullerian) duct

develops into fallopian tubes, uterus, part of vagina

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mullerian inhibiting peptide

secreted by testes to suppress development of mullerian/paramesonephric ducts

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Genital tubercle

forms either glans penis (DHT) or glans clitoris (estrogen)

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Urogenital sinus

forms corpus spongiosum, Cowper's bulbourethral glands, Prostate gland (DHT) or Vestibular bulbs, Bartholin vestibular glands, urethral/paraurethral skene's glands (estrogen)

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Urogenital folds

forms ventral shaft of penis/penile urethra (DHT) or Labia minora (estrogen)

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Labioscrotal swelling

forms scrotum (DHT) or Labia majora (estrogen

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Bicornuate uterus

d/t incomplete fusion of paramesonephric ducts (mullerian); a/w urinary tract abnormalities and INFERTILITY

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Hypospadias

more common; urethra opens on inferior (ventral) side of shaft d/t failure of urethral folds to close; fix to prevent UTIs

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Epispadias

a/w exstrophy of bladder; urethra opens on superior (dorsal) side of shaft d/t faulty positioning of genital tubercle

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Spermatogenesis

begins with spermatogonia (type A and B); full development takes 2 months; occurs in seminiferous tubules; type A forms both type A and B spermatogonia

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Spermatogonium

diploid, 2N

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1* spermatocyte

diploid, 4N

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2* spermatocyte

haploid, 2N

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Spermatid

haploid, N

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Blood testis barrier

a tight junction (junctional complex) between sertoli cells

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Derivation of sperm parts

Acrosome (golgi), Flagellum (centrioles), Neck (contains mitochondria); Food = Fructose

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Meiosis and ovulation

1* oocytes begin meiosis I during fetal life and complete meiosis I prior to ovulation

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Meiosis I

arrested in prOphase for years until Ovulation

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Meiosis II

arrested in METaphase until it has MET a sperm at fertilization

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Polyhydraminos

>1.5-2L of amniotic fluid; a/w esophageal/duodenal atresia causing inability to swallow amniotic fluid; and with anencephaly

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Oligohydraminos

<0.5L of amniotic fluid; a/w bilateral renal agenesis (Potter's syndrome) or posterior urethral valves (in males) and inability to excrete urine

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Potter's syndrome

bilateral renal agenesis d/t oligohydraminos, limb and facial deformities, pulmonary hypoplasia; d/t malformation of ureteric bud; (can't Pee in utero)

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Horseshoe kidney

INFERIOR poles of both kidneys fuse; they ascend from pelvis and get trapped under inferior mesenteric artery and remain in lower abdomen

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Left ovary/testis venous drainage

flows to left gonadal vein --> left renal vein --> IVC

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Right ovary/testis venous drainage

flows from right gonadal vein DIRECTLY to IVC

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Suspensory ligament of ovaries

contains ovarian vessels

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Transverse cervical (cardinal) ligament

contains uterine vessels

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Round ligament of uterus

contains no important structures

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Broad ligament of uterus

contains round ligaments of uterus and ovaries and the uterine tubules and vessels

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Autonomic innervation of male ERECTION, EMISSION, and EJACULATION

mediated by Parasympathetics, Sympathetics and Visceral/Somatic nerves, respectively (Point and Shoot before it hits the target)

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The course of the Ureters

they pass UNDER the UTERINE ARTERY and Ductus Deferens (retroperitoneal); "water (ureter) under the bridge (artery or ductus deferens)"

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Primordial follicles

contain PRIMARY oocytes (XX genotype) and follicular (granulosa) cells that form the ovaries

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Gubernaculum

assists in descent of ovaries toward perineum; it becomes the ovarian ligament and the round ligament of the uterus

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Paramesonephric (mullerian) ducts

develop into uterine tubes and eventually the uterus

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Breast development during fetal life

only the main lactiferous ducts form

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Breast development during puberty

glands enlarge d/t increased estrogen, progestins, prolcactin, and growth hormone

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Primary sex cords

contain primordial germ cells of XY genotype; Y chromosome contains testes-determining factor (TDF) which allows for male gonadal differentiation

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Mullerian inhibiting hormone

secreted by Sertoli cells to inhibit Mullerian/paramesonephric duct development and associated female structures

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Mesonephric (wolffian) ducts

are under influence of testosterone; form ductus deferens, seminal vesicles, ejaculatory ducts in male

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Undescended testis (cryptorchidism)

usu descend w/in 1yr; if undescended, it causes sterility or testicular cancer; may be a/w with congenital inguinal hernia

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Congenital inguinal hernia (indirect)

d/t communication btw TUNICA VAGINALIS (next to testis) and peritoneal cavity; a loop of intestine can become entrapped/obstructed; a/w cryptorchidism

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True Hermaphroditism

both testicular and ovarian tissue present; external genitals are ambiguous; usu 46XX

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Female psuedohermaphroditism

XX genotype w/VIRULIZATION of external genitals d/t EXCESS ANDROGEN EXPOSURE; a/w Congenital Adrenal Hyperplasia (21-hydroxylase deficiency; AR, low cortisol and high ACTH)

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Male pseudohermaphroditism

XY; varying ambiguities in external genitals; LACK of MIF and TESTOSTERONE

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Androgen Insensitivity Syndrome

testicular feminization; XY w/FEMALE PHENOTYPE; d/t defective androgen receptor; blind vagina, no female pubertal development

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Double Uterus

d/t failure of fusion of PARAMESONEPHRIC DUCTS; may be divided internally by a thin septum or only at the superior part (bicornuate)

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Kallmann's Syndrome

deficiency of GnRH = increased FSH and LH; no 2* sex traits; a/w HYPOPLASIA of OLFACTORY BULBS (anosmia)

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Fetal Genetic abnormalities

greatly increases with maternal age >35; pts need additional counseling and genetic testing

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Down's syndrome

Trisomy 21 (95%) or Robertsonial translocation of 14 and 21; MR (mcc in males), atrial septal defect; epicanthal folds, large tongue, simian crease, acute leukemia, Alzheimer's

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Edward's syndrome

Trisomy 18; MR; "Rocker bottom feet;" second digit overlaps 3rd/4th; congenital heart dz, micrognathia (small jaw)

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Patau's syndrome

Trisomy 13; MR, Microophthalmia, Polydactyly, Cleft lip/palate

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Cri-du-chat syndrome

Deletion of 5p; cat-like cry; MR, microcephay, hypertelorism

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Fragile X

second most common MR in males (behind Downs); MACRO-ORCHIDISM; long face, low-set large ears

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Turner's syndrome

45 XO; Monosomy of X chromosome; Absent Barr body; short stature, webbed neck; coarctation of aorta/bicuspid aortic valve; amenorrhea

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Klinefelter's syndrome

47, XXY; tall with long limbs; gynecomastia; hyalinization of seminiferous tubules & lack of spermatogenesis = sterility; One Barr Body

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XYY syndrome

normal appearing male with AGGRESSIVE tendencies; may be over-represented in population of incarcerated males

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XXX syndrome

usu asymptomatic; may be a/w Menstrual Irregularities and mild MR; 2 Barr Bodies

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Prader-Willi syndrome

15q12; Uniparental Disomy; maternal imprinting (no paternal contribution); Obesity, HYPERPHAGIA, HYPOGONADISM; short, MR

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Angelmans Sydrome

15q12 uniparental disomy; paternal imprinting (no maternal contribution); Ataxia, MR, INAPPROPRIATE LAUGHTER, "Happy Puppet"

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Breast surgery for girls with precocious puberty

should be avoided b/c excision of a "lump" in premature thelarche will cause loss of entire breast

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Menarche

final maturation of ovarian follicles; usu btw 11-14yo; follows thelarche by 2yrs

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Precocious puberty

pubertal changes before 9yo in boys, 8yo in girls;can be CENTRAL (inc FSH, LH) or PERIPHERAL (d/t inc sex steroids)

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True precocious puberty

early, but normal pubertal development; usu idiopathic; may cause emotional and social adjustment problems

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Incomplete precocious puberty

premature development of a single pubertal characteristic (thelarche - breast buds, adrenarche - axillary hair, pubarche - pubic hair); self-limiting

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regulates conversion of cholesterol to pregnenolone (1st step in estrogen synthesis) in THECA CELLS

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FSH

regulates the "final step" in estrogen synthesis in the GRANULOSA CELLS

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Estrogen

secreted by ovary; induces 2* sex development; stimulates growth of endometrial spiral aa; thickens vaginal mucosa, induces breast DUCTAL development; stimulates bone growth (inc osteoblastic activity)

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Progesterone

secreted by CORPUS LUTEUM; converts Proliferative endometrium to Secretory; induces endometrial proliferation; Inhibits uterine contractions; Increases viscosity of cervical mucus, body temp; induces breast GLANDULAR development

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Menses

days 1-4 of menstrual cycle; without fertilization the endometrium is sloughed off

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Follicular phase

days 5-14; after menses, FSH falls and ESTROGEN rises; by day 6-8, one recruited follicle is selected and the rest degenerate; Meiosis resumes (prophase I to metaphase II); formation of 1st polar body; uterine proliferation; LH surge

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Ovulation

day 15; occurs AFTER LH surge; oocyte expelled into fallopian tube; cervical mucus is increased and thinned; body temperature raises 1*C

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Luteal phase

days 15-28; corpus luteum makes progesterone and estrogen; rising estrogen inhibits FSH secretion; endometrial glands grow (secretory phase) creating spiral aa; endometrium is ready for potential implantation or menses

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Fertilization

days 16-21; one sperm penetrates oocyte; oocyte completes meiosis II; spermatocyte and oocyte fuse to form zygote

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Implantation

days 20-26 (1st week after fertilization); zygote embeds in endometrium; endometrial blood vessels infiltrate theca interna over 14 day period

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Pregnancy

the corpus luteum persists under the influence of hCG secreted by rapidly developing placenta

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Dysfunctional uterine bleeding

excessive bleeding during, or between, menstrual periods; mc gynocological prob in reproductive yrs d/t Leiomyoma, Anovulatory cycle, Organic lesions (tumor, polyp), Pregnancy complication, Endometrial hyperplasia, Corpus luteum cysts

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Polycystic ovarian syndrome (Stein-Leventhal)

Triad: 2* amenorrhea, obesity, hirsutism; Increased LH and Testosterone; Stromal fibrosis ans small follicular cysts in ovaries

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Endometriosis

non-neoplastic endometrial tissue outside of uterus; responds to hormonal cycle; usu bilateral in ovary; presents as pain and excessive bleeding during menstruation; large blood-filled sacs (chocolate cysts); may cause infertility

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Menopause

dec ovarian fxn = low estrogen, high FSH; early signs = hot flashes, anxiety, mood swings, irritability; Late signs = vaginal dryness, Osteoporosis, dec HDL w/inc risk of coronary artery dz; atrophy of breast tissue

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Normal pregnancy

always assume a childbearing aged woman could be pregnant; term is 40wks; signs = missed periods, fatigue, nausea, elevated b-hCG

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Hormonal regulation of pregnancy

Fertilization (b-hCG from placenta maintains corpus luteum); First trimester (corpus luteum makes E & P); 2nd/3rd trimester (PLACENTA makes P; fetal adrenals/liver/placenta make E); Lactation (E & P fall which permits prolactin to stimulate breast milk)

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Pudendal nerve block

can alleviate pain of childbirth; insert hand into vagina to locate ischial spine (landmark) and other hand inserts needle into skin lateral to vaginal opening

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The narrowest diameter of birth canal

pelvic outlet between the ischial spines (interspinous distance)

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Prenatal Amniocentesis

aspiration of amnion btw 10-14wks; AFP (neural tube defects), Spectrophotometry (hemolytic dz of newborn; Sex chromosomes (x-linked dzs); Cell culture (chromosomal abnormalities); Enzyme and DNA analysis

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Prenatal Maternal Serum AFP

ELEVATED in neural tube defects; DECREASED in Downs Syndrome

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Prenatal Chorionic Villi Sampling

done at 10wks; cells aspirated from villi and evaluated for genetic abnormalities

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Prenatal Ultrasound

done at 12 weeks; measures fetal size, determines sex, diagnoses fetal malformations

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Abruptio placentae

separation of placena from uterine wall prior to partuition; causes FETAL DEATH; may cause DIC in mom

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Placenta accreta

invasive direct connection of uterus wall to placenta; d/t prior surgery or trauma; improper separation results in massive HEMORRHAGE

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Placenta previa

placenta attaches to lower uterus and blocks cervical os; a/w BLEEDING

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Ectopic pregnancy

Risks (PID; chronic salpingitis; previous surgery; endometriosis; previous ectopic pregnancy); Clinical (amenorrhea; pelvic pain, cervical tenderness; tissue mass (tubal); elevated b-hCG)

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Preeclampsia

Triad: HTN, Albuminemia, Edema; mc in last trimester; can progress to eclampsia (seizures and DIC)

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HELLP and Eclampsia

HTN, Elevated Liver enzymes, Low Platelets

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Treatment for preeclampsia

Magnesium sulfate; but the only cure is with delivery of fetus

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Hydatidiform Mole

placental villi that enlarge abnormally early in pregnancy; "Cluster of Grapes" with MARKED inc in b-hCG; Manifests w/vaginal Bleeding and INC UTERINE SIZE (>expeted for gestational stage); usu precede choriocarcinoma (malignant trophoblastic cells)

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Complet hydatidiform mole

Diploid XX; NO EMBRYO; completely PATERNAL in origin

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Partial hydatidiform mole

Triploid (XXX or XXY); EMBRYO present ("make up of 3 or more parts w/fetal parts")

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Gestational Diabetes

insulin resistance occurs in normal pregnancy; mother may not be able to meet inc metabolic demands; 2 or more abnormal venous glucose values must be reached after 100g oral glucose (fasting >105, 1hr >190, 2hr >165, 3hr >145mg/dL)

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High blood glucose in mother

leads to hypoglycemia in INFANT when born; macrosomia (enlarged body), inc risk of trauma, inc likelihood of c-section d/t large fetus

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Infectious causes of birth defects: TORCH

Toxoplasmosis, other, Rubella, Cytomegalovirus, Herpes simplex

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Wet Mount Gynecologic Diagnostic Test

vaginal epithelial scrapings placed on glass slide w/saline; Detects Trichomonas (pear-shaped w/sporadic movement) or Bacterial vaginosis (clue cells = epithelium w/rough edges)

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Potassium hydroxide (KOH) gyno prep

addition of KOH to slide w/vaginal epithelium detects CANDIDIA (resistant to KOH, "budding cells w/short hyphae;" or BACTERIAL VAGINOSIS (KOH reacts w/bacterial amines = "Fishy odor")

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Pap Smear - microbes detected

cells from cervix are scraped onto glass slide; Detects HPV (KOILOCYTES - large epithelial cells w/perinuclear clearing) or CMV (intranuclear inclusions w/halo around them "owl's eye"), or HSV (multinucleated giant cells)

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Pap smear - Precancerous and Cancerous lesions

Precancerous cervical intraepithelial neoplasia (CIN 1, 2, 3); Cancerous INVASIVE SCC (mc) and Endometrial Adenocarcinoma

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Chlamydia

mc STD; mostly b/c it is undetected when pt is co-infected with gonorrhea; Tx for gonorrhea should be supplemented w/chlamydia therapy for both pt and partner (azithromycin or doxycycline (C) + injection of ceftriaxone OR cirpo/foxin fluoroquinolone (G))

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20-50% of pts with an STD

will be coinfected with another

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Calmmatobacterium granulomatis

Granuloma inguinale; Bx shows DONOVAN BODIES

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Chlamydia trachomatis

urethritis, acute PID from serotyps D-K; ulcerative lesions of genitalis w/ L1-L3 serotypes

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PID

can be diagnosed via bimanual pelvic exam by doing "chandelier sign" for cervical motion; salpingitis can lead to infertility

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Gardernella vaginalis

vulvovaginitis

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Haemophilus ducreyi

Chancroid; PAINFUL ulcerative lesion on genitalia

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HSV-2

genital herpes; PAINFUL vesicles - lesions on genitals

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HIV type 1 and 2

can lead to AIDS

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HPV types 6 and 11

condyloma acuminatum of vulva

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HPV types 16, 18, 31, 45

genital or anal warts, SQUAMOUS CELL CARCINOMA of cervix, vagina, anus, penis

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Neisseria gonorrheae

Urethritis; ACUTE PID; pharyngitis, MONOARTICULAR ARTHRITIS

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Treponema pallidum

Syphilis; PAINLESS ulcerative lesions on genitalia; 1* - hard chancres; 2* - gray wartlike lesions (condyloma lata), 3* - neurologic symptoms like TABES DORSALIS, acending aortic aneurysm

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Trichonomas vaginalis

Vulvovaginitis; male urethritis

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Non STD infections of GU tract

Candida albicans (vulvovaginitis), Staphylococcus aureus (TSS), E. coli and Staph saprophyticus (UTIs)

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Toxic Shock Syndrome

d/t S. aureus overgrowth on tampons; enterotoxin acts as a supertoxin causing excess activation of Thelper cells, resulting in increased cytokine production and septic shock

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Serous Cystadenoma of ovary

cystic; benign; usu bilateral

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Serous Cystadenocarcinoma

cystic; malignant; usu bilateral; most common ovarian neoplasm (50%)

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Mucinous cystadenoma

mucin-filled cyst; benign ovarian tumor

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Mucinous cystadenocarcinoma

mucin-filled ovarian cyst; malignant; PSEUDOMYXOMA PERITONEI (diffuse peritoneal metastasis secreting mucin)

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Endometrioid tumor

resembles endometrium in ovary; malignant

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Brenner tumor

resembles TRANSITIONAL epithelium in ovary; benign; rare

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Clear cell tumor of ovary

abundant CLEAR CYTOPLASM; usu unilateral; rare

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CA125 (cancer antigen 125)

elevated in over 80% of ovarian tumors

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75% of ovarian neoplasms

are epithelial in origin; usu seen in middle-aged to elderly women

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Germ cell tumors

only 25% of ovarian neoplasms, BUT they are the most common ovarian tumors found in women <20yo

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Ovarian Dysgerminoma

large cells w/clear cytoplasm; malignant; EQUIVALENT of seminoma; usu in KIDS

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Ovarian Endodermal Sinus (Yolk sac tumor)

resembles yolk sac; Malignant; produces AFP

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Ovarian Immature Teratoma

elements from multiple embryonic layers; poorly differentiated; resembles fetal or embryonic tissue; Malignant

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Ovarian Mature Teratoma/Dermoid Cyst

Elements from multiple embryonic layers, including hair, bone, tooth, nerves; Duplication of maternal genetics; resembles adult tissue; MOST COMMON germ cell neoplasm (90%); BENIGN (malignant in males)

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Ovarian Monodermal Teratoma

elements from one of teh embryonic germ layers; usu thyroid tissue (STRUMA OVARII); Benign, HYPERTHYROIDISM

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Ovarian Choriocarcinoma

usu seen in combo w/other germ cell tumors; Malignant; produces b-hCG

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Ovarian Granulosa-Theca tumor

lipid-laden cells; fibroblast proliferation; cuboidal cells in cords; eosinophilic follicles (Call-Exner Bodies); Benign; may secrete estrogen leading to precocious puberty or endometrial hyperplasia or carcinoma

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Ovarian Thecoma-Fibroma

Fibroblast proliferation; Benign; rare; a/w ascites and hydrothorax = "MEIG'S SYNDROME"

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Ovarian Sertoli-Leydig Cell Tumor

tubules containing testicular cells; produces testosterone and virulization

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Ovarian Metastasis tumors

most commonly d/t GI, breast or ovarian cancer; KRUENBERG TUMOR = stomach cancer signet rings bilaterally in ovaries; only 5% of ovarian tumors

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Cervical intraepithelial neoplacia

neoplastic changes beginning at SQUAMOCOLUMNAR junction

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Squamous cell carcinoma of cervix

evolves from a progression of CIN; inc incidence a/w EARLY sexual activity and MULTIPLE sex partners

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Leiomyoma of uterus

most common BENIGN tumor in women (versus mc malignancy = breast); usu multiple; size increases with estrogen from pregnancy and decreases with menopause

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Leiomyosarcoma of uterus

uncommon; arises de novo; bulky necrotic/hemorrhagic; blacks; aggressive; recurs; may protrude from cervix/bleed

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Endocervical carcinoma

MOST COMMMON MALIGNANCY of the female genital tract; a/w nulliparity i older women; EXOGENOUS ESTROGEN is a risk factor (as is diabetes, tamoxifen, HTN, obesity d/t adipose estrone); presents w/post-menopausal vaginal bleeding

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Papillary hidradenoma of vulva/vagina

MOST COMMON benign tumor of vulva; presents as ulcerative bleeding nodule; originates from sweat glands; easily removed

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Squamous cell carcinoma of vulva

OLDER women; preceded by vulvar dystrophy; a/w HPV 16, 18, 31, 33, 45

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Paget's disease of the vulva

histologically similar to dz of the breast, but not always a/w underlying adenocarcinoma unlike breast

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Malignant melanoma of vulva/vagina

similar to condition in skin; 10% of malignant vulvar tumors

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Squamous cell carcinoma of vagina

a rare site for primary cancer; usu an extension of cervical cancer

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Clear cell adenocarcinoma of vulva/vagina

rare malignant tumor; a/w fetal exposure to DES

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Sarcoma botryoides of vagina/vulva

a rhabdomyosarcoma; girls <5yo; "bunch of grapes" that protrude from vagina

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Risk factors for breast cancer

>45yo, nulliparity, early menarche, late menopause, high fat diet, HER-2/neu oncogene activation, 1st degree relative w/+ Hx; Hx of breast cancer in contralateral breast

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Breast cancer

MOST COMMON cancer in women, but 2ND cause of cancer death after lung cancer; mc location UPPER OUTER QUADRANT

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Presence of estrogen and/or progesterone receptors on breast cancer

indicates a good prognosis d/t ability to employ hormonal (anti-estrogen) therapy

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Acute mastitis

d/t entry of Staph aureus into nipple; causes abscesses; common in nursing moms and pts with eczema

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Fibrocystic breast changes

MOST COMMON breast disorder; tender BILATERAL mass; "blue-domed" cysts; non-neoplastic; predisposition to cancer only w/evidence of cellular atypia

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Fibroadenoma of breast

MOST COMMON breast tumor in women <25YO; painless benign rubbery mass

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Intraductal papilloma of breast

benign tumor of lactiferous ducts; may have bloody or serous discharge

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Phyllodes of breast

large mass, cysts, skin ulceration with malignant potential; may recur

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Invasive ductal carcinoma of breast

MOST COMMON CARCINOMA; firm mass forms glands w/fibrous stroma; Malignant

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Lobular carcinoma of breast

cancer cells fill ducts; BLOODY DISCHARGE, may be bilateral; "indian file" cells; malignant, may be progression of lobular carcinoma in situ

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Paget's disease of the breast

superficial lesion of nipple or areola; paget cells (large w/marginal clearing) in epidermis; Malignant; indicative of UNDERLYING DUCTAL CARCINOMA

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Medullary carcinoma of breast

soft, fleshy tumor w/LYMPHOCYTIC infiltrate; malignant

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Gynecomastia in males can be d/t:

alcoholism, cimetidine, ketoconazole, spironolactone, digitalis

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Male breast cancer

represents 1% of all breast cancer

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Prostatic carcinoma

mc male cancer; enlarged, firm nodular prostate on DRE; elevated serum PSA and alk phos; bone metastasis (spine); effects on POSTERIOR lobe; 2nd most common cancer death in men (behind lung)

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Benign prostatic hyperplasia

mc cause of male urinary obstruction; bladder distention or hypertrophy; UTIs; inc residual volume/frequency; nocturia, difficulty initiating stream; d/t age-related increase in testosterone and estrogen; common after 40yo; effects MIDDLE lobe

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Digital rectal exam

checks anal tone (S2-S4 innervation); anterior to posterior structures = lower border of prostate, posterior aspect of prostate, bladder if distended

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Hydrocele

serous fluid collects in tunica vaginalis; d/t patency btw peritoneal cavity and tunica vaginalis

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Hematocele

blood collects in tunica vaginalis; usu d/t TRAUMA

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Varicocele

engorgement of veins of spermatic cord; noticable when pt is standing; can cause infertility

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Spermatocele

epididymal cyst containing sperm

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Cryptorchidism

failure of 1 or both testes to descend; inc incidence of GERM CELL TESTICULAR CANCER (seminoma or embryonal carcinoma); failure to descend = atrophy and sterility

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Testicular torsion

twisting of spermatic cord; if untreated, necrosis occurs

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Orchitis

infxn & inflammation of testicle; may be viral or bacterial; can cause sterility if bilateral

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Epididymitis

inflammation and infxn; usu N. gonorrhea, Chlamydia, E. coli or Mycobacterium tubercuolsis

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Seminoma

MC germ cell tumor; lobules or nests; malignant; 35-40yo; similar to dysgerminoma of ovary; Radiosensitive and curable

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Embryonal carcinoma of testis

germ cell; papillary convolutions; malignant; 20yo; more aggressive than seminomas

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Yolk sac tumor (endodermal sinus) of testis

germ cell; anastomosing cords; malignant; inc AFP; presents with pain or metastasis; CHILDHOOD ~3yo

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Teratoma of testis

2+ embryonic layers w/cartilage, epithelium, liver, muscle tissue types; malignant; any age (more common in kids)

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Mixed germ cell tumor of testis

most common testicular tumor; malignant; AGGRESSIVE; >1 neoplastic pattern

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Leydig cell tumor (interstitial) of testis

testicular stroma w/ intracytoplasmic Reinke CRYSTALS; Benign; a/w PRECOCIOUS PUBERTY or gynecomastia d/t steroid, androgen, estrogen, ccsteroid production; similar to ovarian Sertoli-leydig tumor

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Sertoli cell tumor (androblastoma) of testis

testicular stroma w/cord-like structures; benign; minor endocrine abnormalities; similar to ovarian Sertoli-leydig tumor

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Choriocarcinoma of testis

Trophoblastic cells resembling placenal villi; malignant; HEMORRHAGIC; elevated b-hCG; early adulthood

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Needlestick transmission of HIV

low risk; 0.3%; hepatitis C is more common

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HIV infection pathology

infects CD4 Thelper cells via interaction with viral ptns gp120 and gp41 with eachother and the CD4 marker; it also infects MQs and monocytes (entry to CNS); viremia is a/w flu-like "acute retroviral syndrome"

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1st month of HIV infection

"window period" b/c p24 antigen is not yet detectable, but pt is contagious

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Chronic HIV infection

immune response lowers viral load, but activ replication persists; no clinical sx for ~10yrs (latent period); CD4 count steadily declines until pt has wt loss, fever, night sweats, adenopathy

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AIDS

<200 CD4 or opportunistic infxn (Pneumocystis pneumonia (80%); Kaposi's sarcoma; Bcell lymphoma (brain/BM); Toxoplasma gondii (brain abscess); CMV (retinitis); Cryptococcus (meningitis); MAI, TB, Candida (thrush, esophagitis), Cryptosporidium (diarrhea)

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Diagnosis of HIV

ELISA for antibodies leads to a presumptive dx; must be confirmed by Western blot for Antibodies to gp41 or p24 viral proteins

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Treatment of HIV

nucleoside analogues and protease inhibitors; combo HAART

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Preeclampsia pathophysiology

placental ischemia triggers release of thromboplastic substances, increases renin synthesis and reduces prostaglandin E levels

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Tremors, wt loss, heat intolerance, but low TSH levels (non-Grave's type hyperthyroid symptoms) and unilateral ovarian cystic mass

a/w monodermal teratomas that can develop mature thyroid tissue (struma ovarii) which produces excessive thyroid hormone

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