repro II all Flashcards

Question

benign — proliferative breast w atypia !!

Answer 1

having clonal proliferation - atypical ductal hyperplasia: **increase risk of carcinoma (4-5 fold)**, duct fill w mixed population of cell โดย neoplastic cell (at central portion) ส่วน non-neoplastic cell (อยู่ peripheral, irregular and slit-like)

Answer 2

- fibroadenoma น่ารักฟูฟู **most common benign tumor of female breast** - มาด้วย palpable mass, increase size during preg or mentrual cycle - frequent multiple and bilat - gross: well-circumscribe, rubbery, grayish white nodule that bulge above surrounding tissue - micro: stroma → delicate and myxoid resemble normal intralobular stroma / epith → may surround by stroma (pericanalicular pattern) or compressed and distorted (intracanalicular pattern) - phyllodes tumor น่าเกลียด ขี้เดียด🍃 - arise from intralobular stroma - ass w clonal acquired chromosomal change (MED12 mutation) - **leaflike architecture** due to presence of nodule of proliferating stroma covered by epith

Answer 3

- ductal carcinoma in situ (DCIS): mammogram found calcification, แบ่งเป็น 3 grade ตาม nuclear grade of tumor, แบ่งตาม architectural ได้ 2 แบบดังนี้ - comedo: tumor cell w pleomorphic, ass w high nuclear-grade, area of central expansive necrosis - non-comedo: lack of central expansive necrosis, มีหลาย pattern มากก ∼ cribiform or micropapillary or solid - lobular carcinoma in situ (LCIS): expand but not distorted so lobular architecture is preserved, grow in **discohesive fashion** due to **loss of adhesion protein E-cadherin**, in micro commonly found mucin-positive signet-ring cell - invasive (infiltrating) carcinoma **น่าจะเน้น** - type: invasive (breast) carcinoma of no special type (IBC NST) - gross: infiltrating tan-white mass w irregular margin, hard consistency - micro: well-diff, mod, poorly ก้ตามความอุบาด - type: invasive lobular carcinoma (ILC): biallelic loss of CDH1 expression which is the gene that encode **E-cadherin** - gross: irregular thicken of fibrous parenchyma - micro: discohesive infiltrating tumor cell, signet-ring cell containing intracytoplasmic mucin droplet - etiology: familial caused by single gene ∼ BRCA1 BRCA2 TP53 CHEK2 / sporadic related to hormone exposure and most common mutated gene is **TP53**

Answer 4

- nipple adenoma (florid papillomatosis of nipple duct): benign proliferation of gland embedded in fibrotic stroma / มาด้วย nipple appear eroded, accompany by serous or bloody discharge, unilat / micro → papillary lesion w dual population of epith and myoepith, epith oval nuc shape, lack of atypia, forming **adenosquamous nest** - paget’s disease of nipple: rare manifest of breast CA / มาด้วย erythematous eruption w scale crust, pruritus, unilat / pathophysio → paget cell extend from **DCIS** via lactiferous sinus into nipple skin **without crossing basement membrane** นั่นแหละขรั่บ มันจะไป **disrupt normal tight squamous epith cell barrier** / prognosis depend on underlying carcinoma

Answer 5

gynecomastia: button like / micro found dense collagenous connective tissue ass w epith hyperplasia “tapering micropapillae” / caused by androgen-estrogen imbalance ∼ ass w cirrhosis

Answer 6

- **epispadias**: urethral opening on dorsal surface of penis; often ass w bladder exstrophy - **hypospadias**: urethral opening on ventral surface; may affect urination and sexual function. - **phimosis**: inability to retract the foreskin; may cause infection or obstructed urination / management → circumcision or steroid creams if symptomatic - **paraphimosis**: foreskin trapped behind the glans; a urological emergency due to risk of ischemia / management → manual reduction or emergency surgery if necessary - **condyloma acuminata (genital wart)**: benign, wart-like lesions; treated with topical or surgical method / cause **→** HPV infection, typically types 6 and 11 - **carcinoma in situ** - **bowen disease**: clinical name; red plaques, can progress to scc - **bowenoid papulosis**: seen in younger patients; self-limiting, but histologically similar to bowen disease - **squamous cell carcinoma (SCC)**: invasive cancer, often ulcerative or exophytic; more common in uncircumcised men / cause **→** linked to HPV infection and poor hygiene / management **→** surgical excision or radiation therapy based on extent

Answer 7

- **testicular descent (cryptorchidism)**: failure of testicular descent; increases risk of infertility and testicular cancer / management → orchidopexy if not descended by 1 year - **testicular torsion**: twisting of spermatic cord, cutting off blood supply; a surgical emergency / symptom **→** sudden severe pain and scrotal swelling / management **→** manual detorsion or surgery to prevent loss of testis - **testicular tumor**: - **type** - **seminoma**: most common germ cell tumor; radiosensitive with good prognosis - **embryonal carcinoma**: aggressive and poorly differentiated - **yolk sac tumor (endodermal sinus tumor)**: common in young children; produces AFP as a tumor marker - **choriocarcinoma**: highly malignant, often with metastasis; produces hCG as a marker - **cystic teratoma**: can contain various tissue types; often benign in children but malignant in adults - **germ cell tumors**: includes seminomas, non-seminomas, mixed germ cell tumors

Answer 8

- **inguinal hernia:** protrusion of abdominal contents into scrotum via inguinal canal - **hydrocele**: fluid accumulation in tunica vaginalis; can be transilluminated / management → aspiration or surgery if symptomatic - **hematocele**: blood accumulation in tunica vaginalis, often due to trauma; does not transilluminate

Answer 9

- **spermatocele**: cystic swelling from the epididymis; usually asymptomatic - **varicocele** หนอน : dilation of pampiniform plexus veins; may cause infertility due to testicular temperature increase / management → surgical repair if symptomatic or causing infertility.

Answer 10

- **"Get Above the Swelling" test**: determine origin of swelling within scrotum - **fluctuation test**: indicates presence of fluid within mass - **transillumination test**: differentiate btw cystic (transilluminate) and solid mass (does not transilluminate)

Answer 11

- **benign prostatic hyperplasia (BPH)**: non-cancerous enlargement of prostate, common in older men / symptom → urinary frequency, urgency, nocturia, weak stream / management → medications (e.g., alpha-blockers, 5-alpha-reductase inh) or surgery (TURP) - **prostate cancer**: often adenocarcinoma; common in older men, typically asymptomatic in early stage / diagnosis → elevated PSA levels and biopsy; graded using Gleason score / management → surgery, radiation, active surveillance, depending on stage and grade

Answer 12

- agent: Neisseria gonorrhoeae - incubation period: 1-14 days (≈2-5 days) - cause urethritis, epididymitis, prostatitis, endocervical infection (50% asymp), PID, serious sequelae is ectopic preg and infertility, bartholinitis, proctitis, pharyngitis, ophthalmia neonatorum (permanent injury to eye, blindness), adult conjunctivitis, DGI - disseminated gonococcal infection (DGI): penetrate across endothelium and go to bloodstream / clinical presentation → dermatitis-arthritis syndrome, septic joint w effusion, endocarditis or meningitis / risk: individual w C’ def neisseria gonorrhoeae - aerobic gram-negative diplococci (found intracellular in PMN), oxidase and catalase positive, nonmotile, grow on enriched media and require 3-7% CO2, suscept to temp change & drying & uv light - transmission via sexual, newborn - antigenic structure: pili → adherence, antigenic and phase variation / lipooligosaccharide (LOS) → inflam response / peptidoglycan → activate alternative C’ pathway / porin protein → attach, invasin provoke phagocytic ingest by host cell / opacity → attach, invasin, phase variation / reduction modifiable protein → complex w porin and LOS - pathogenesis: IgA protease - culture: chocolate agar / thayer-martin medium (TM) / modified thayer-martin medium (MTM) for inh proteus swarming - colony: beige to gray-brown

Answer 13

- agent: treponema pallidum - primary stage: hard chancre, nonpainful, heals after 2-6wk secondary stage: immune มะรุมมะตุ้ม mucocutaneous rash, wart-like lesion called condylomata lata latency — ยาวได้ถึงเปนสิบปีอะ แล้วแต่คน tertiary syphilis: granulomatous lesion, gumma - แทรกอาการน่าจำ neurosyphilis (tabes dorsalis, partial paralysis, dementia / congenital syphilis (hutchinson’s teeth) **treponema pallidum** - spirochete ~ screw-like - rare transmembrane protein → ไม่ค่อยมี specific Ab ไปจับ / แต่มี lipoprotein เยอะ → induce inflam - CANNOT BE CULTURED IN VITRO (can do in rabbit’s testicular) - tx: just penicillin - lab dx — เน้น serology - microscopic exam: darkfield microscope - serology

Answer 14

- NGU: less dysuria and purulent ถ้าเทียบกับ gonorrhea / มาด้วย epididymitis, proctitis, bartholinitis, PID ได้หมดเลยย - lymphogranuloma venereum: painless, lymph node swelling //painless lesion -> after 2-4 wk จะตามด้วย suppurative lymphadenopathy - ocular infection: trachoma ริดสีดวงที่ตา ทำให้ blindness ได้, inclusion conjunctivitis - rs infection: pneumonia of newborn **chlamydia trachomatis** - developmental cycle: elementary bodies (EB) vs reticulate bodies (RB) reticulate is reproductive form - transmission via sexual and newborn - pathogenesis: hemagglutinin → phogocyte ingest → intracellular persistence → tissue inflam - sample collection: epith cell must be collected / swab using dacron and nylon / transport medium → 2SP (sucrose phosphate) at 4°c - lab dx: direct exam ~ iodine stained specimen / culture ~ detection of infected McCoy cells by iodine stain

Answer 15

- agent: haemophilus ducreyi - papule → pustular → eroded and ulcerated - inguinal lymphadenopathy **haemophilus ducreyi** - gram-negative coccobacilli, school of fish arrangement - pathogenesis: adherence, cytotoxin - lab dx: specimen (taken from base of ulcer) → ulcer swab, bubo aspirate - fastidious bacteria as well, require X factor

Answer 16

- prenatal: syphilis / CMV, HBV, HIV, HSV, Rubella, VZV - perinatal: group B strep, N.gonorrhoeae (ophthalmia neonatorum), C.trachomatis (pneumonia) / candida / HSV, HPV, HIV, HBV - postnatal: caused by inhaled bowel or vaginal flora or other pathogens e.g. staph, gram-negative bacilli, viruses

Answer 17

- gardnerella vaginalis: small gram-negative to gram-variable pleomorphic rod or coccobacilli ไซส์แวรี่สีแวรี่ ครับ - mobiluncus: gram-variable or curved bacilli - bacteriodes: gram-negative bacilli - lab dx: discharge → thin, milky, pH>4.5 / whiff test → mixed w 10% KOH will give fishy ador / clue cell → squamous epith cell covered w small gram variable rods and coccobacilli - nugent scoring: 0-3 normal / 4-6 intermediate / 7-10 BV

Answer 18

- nugent scoring: นับแบครอบ ๆ clue cell ถ้า lactobacillus น้อย ละพวก gardnerella bacteroides mobiluncus เยอะ ก้ยิ่ง score สูง - neisseria gonorrhoeae: chocolate agar โคโลนีเหมือนทรายเร้ก ๆ biochem น่าจำ ๆๆ “gram-negative, kidney bean-shaped diplococci within polymorphonuclear leukocytes” - N.**g**onorrhoeae: **g**lucose+ N.meningitidis: glucose+ maltose+

Answer 19

- Toxoplasmosis - Others: Syphilis, VZV, B19V, LCMV, ZIKV - Rubella - CMV (cytomegalovirus) - Herpes simplex routine antenatal screening: rubella IgG, VDRL, HBs Ag, anti-HIV

Answer 20

- ยิ่งอายุครรภ์มาก โอกาสติดจะน้อยลง โอกาสพิการน้อยลงเช่นกัน - congenital rubella syndrome (triad + mental retard) - cardio: PDA, pulmonary artery stenosis - ocular: cataract, glaucoma, retinitis - sensorineural hearing loss - mental retard - another clinical manifest (not pathog na): blueberry muffin rash, celery stalk (radiolucent band at metaphysis) - lab dx - serology (**recommend**): IgM persist for at least 6mo (ไม่ดู IgG เพราะอาจ cross มาจากของแม่) - viral culture: NP swab, urine, (conjucntival swab, feces, CSF, blood)

Answer 21

- transmission rate: ถ้า primary maternal infection จะ 40-50% เลย ส่วนถ้าแม่ reactivation เฉย ๆ ก้จะ <1% - cytomegalic inclusion disease ~ triad ! - microcephaly ถ้าดู imaging จะเจอ intracranial calcification (มักเกาะที่ cell lining at ventricle) - sensorineural hearing loss - chorioretinitis จอประสาทตาอักเสบ - another clinical manifest: also has blueberry muffin - lab dx - serology: IgM within 3wks of delivery - viral culture or PCR: urine, saliva, NP swab, blood which obtain within 1st wk of life

Answer 22

- rare - triad - skin vesicle and scarring (vesicle widespread not localized เหมือนผุ้ใหย่) - chorioretinitis, microphthalmia - microcephaly, hydraencephaly - lab dx - viral culture: vesicular lesion, conjunctiva, NP, CSF, blood - PCR: CSF (if CNS involvement) - serology: IgM

Answer 23

- defects - cicatricial skin lesion รอยแผลเป็นตาม dermatome - limb hypoplasia ข้างใดข้างนึง มักเป็นข้างเดียวกับรอยแผล dermatome - chorioretinitis, cataract, microphthalmia - microcephaly, hydraencephaly, cerebellar aplasia, horner, urethral or anal sphincter dysfx - lab dx - serology (recommend): IgM - PCR: tissue biopsy

Answer 24

congenital parvovirus B19 (fifth disease) - เพราะ attack erythroid progenitor cells in BM เลยทำให้เกิด hydrops fetalis — อาการหลัก ๆ คือ fetal anemia +/- fetal myocarditis - lab dx - serology: IgM - prenatal dx ~ PCR: เจาะ fetal blood, amniotic fluid congenital LCMV 🐭🪤 - defects: chorioretinitis, hydrocephalus or microcephaly w intracranial calcification - lab dx (both) - serology: IgM - RT-PCR: blood, urine, CSF, NP congenital zika syndrome - defects: severe microcephaly แทบจะไม่มีสมองละ, subcortical calcification, macular scarring, congenital contracture, marked early hypertonia - lab dx (both) - RT-PCR: serum+urine, (CSF) - serology: serum, (CSF) — IgM (PRNT)

Answer 25

neonatal herpes - 75% caused by HSV-2 - 3 categories of manifest - localized skin, eye, mouth infection (SEM) - encephalitis - disseminated infection พวกนี้ก้ด้วย แต่ไม่ได้พูดละเอียด neonatal chickenpox HIV vertical transmission HBV vertical transmission HCV vertical transmission: viral load ต้องสูงจริงถึงติด

Answer 26

- high in milk & high risk of transmission (ห้ามกินนมแม่): HIV, HTLV-1 - low in milk & high risk (กินได้): CMV, HSV-1 (ถ้ามี lesion แถว breast ไม่ควรให้กิน) - low in milk & low risk: HBV, HCV, rubella, zika

Answer 27

- ดู size, shape, margin - benign: well-circumscribed round/oval → cyst - circumscribed lobular shape → fibroadenoma - invasive ~ indistinct/stellate shape → carcinoma - โตช้า → maybe cell proliferation (~6mo) / โตเร็วหลักวัน → maybe cyst - ถ้าเจอในคนอายุน้อย มีโอาสเป็น benign>malig

Answer 28

- w or w/o mass lesion - may caused by inflam - cyclic → maybe physiologic (esp 40-50yo) / non-cyclic → ปวดตลอดเวลา หรือปวดตอนโดนกระแทก - unilat / bilat

Answer 29

- cyclic change: อาจเป็น fibrocystic change (benign) - predominant quadrant: upper-outer เกิดโรคเพราะเนื้อนมเย้ออ

Answer 30

mammogram - calcification - macrocalcification: popcorn appearance → from old fibroadenoma, benign / scattered (powderish) → from fibrocystic or น้ำนมค้าง, benign - microcalcification (more serious💥): ดูการกระจายของ linear, ductal, lobular จะพอบอกชนิดของ cancer ได้ / coarse or pleomorphic character น่ากังวลกว่า fine or punctate - mammographic lesion: โอกาสเป็น malig เพิ่มขึ้นตามอายุ ultrasound - hypoechoic lesion → mammary duct - ถ้าเจอ duct โตต้องติดตามต่อไปเรื่อย ๆ ถ้าหลายปีละไซส์เท่าเดิมแปลว่า benign

Answer 31

- ออกมาจากรูเดียว single duct orifice → pathologic !! / ออกจากหลายรู multi-duct → physiologic kubbb - discharge character? pain or not? - pathologic discharge: bloody, single duct w mass - investigation: ultrasound, ductogram ฉีดสีย้อนเข้าไป

Answer 32

- congenital → benign / acquired → more serious if in inner mass - palpable mass? - erythema / eczema / paget disease

Answer 33

- mastitis - granulomatous mastitis - abscess - inflam carcinoma → ต้อง r/o โดย FNA

Answer 34

1. non-invasive carcinoma - DCIS: prognosis is good, may progress to invasive cancer 2. invasive carcinoma - no special type - character: spiculate border (indicate ความ aggressive) - grade 1-3 3. invasive carcinoma - special type - invasive lobular carcinoma: diffuse, thickening, indistinct mass, grow in a single-file pattern, good prognosis - tubular carcinoma: tear-drop shape, excellent prognosis - mucinous carcinoma: circumscribe, abundant extracellular mucin, good prognosis - invasive breast carcinoma with medullary feature: circumscribe, high-grade cell w syncytium and lymphocyte

Answer 35

1. hormonal type (ER+) — aka luminal A&B - **marker**: **Estrogen Receptor (ER)** positive. - **meaning**: cancer cells express estrogen receptors, meaning they rely on estrogen for growth. - **tx**: **hormone therapy** (e.g., tamoxifen, aromatase inh) to block estrogen and slow cancer progression - **prognosis**: generally better, as hormone receptor-positive cancers are less aggressive and respond well to hormone therapies. 2. HER2+ - **marker**: **Human Epidermal Growth Factor Receptor 2 (HER2)** positive. - **meaning**: cancer cells overexpress HER2 protein, which promotes cancer cell growth. - **tx**: **targeted therapy** (e.g., trastuzumab/Herceptin) to block the HER2 receptor and slow cancer growth - **prognosis**: ass w more aggressive disease, but w HER2-targeted treatments, the prognosis has improved significantly 3. triple negative (ER-, PR-, HER2-) - **marker**: negative for **Estrogen Receptor (ER)**, **Progesterone Receptor (PR)**, and **HER2**. - **meaning**: cancer cells do not express the three main markers that are targeted by current treatments. - **tx**: not respond to hormone therapies or HER2-targeted therapies. Treatment generally involves **chemotherapy**. - **prognosis**: more aggressive and poorer prognosis due to the lack of targeted treatment options, though may respond well to chemotherapy.

Answer 36

1. **luminal A — ER+**, **PgR+**, **HER2-**, low Ki-67 (<20%) - **facts**: invasive ductal carcinoma grade 1, small size tumor, node negative, LV1 negative - **form**: tubular, mucinous, invasive cribiform carcinoma - **prognosis**: **best prognosis**, high survival rate, low recurrent rate - **tx**: **hormonal therapy**. chemotherapy is not always necessary, esp for early-stage 2. **luminal B (HER2-) —** ER+, HER2- and at least one of high Ki-67, PgR- or low - **facts**: younger age, invasive ductal carcinoma grade 1-2, tumor size bigger, node positive, no tubular formation - **prognosis**: more aggressive and poorer prognosis than luminal A - **tx**: hormonal therapy (tamoxifen, aromatase inhibitors), chemotherapy if high risk. 3. **luminal B (HER2+) —** ER+, HER2+ or amplified, any Ki-67, any PgR - **facts**: younger age, invasive ductal carcinoma grade 2-3, tumor size bigger, node positive, no tubular formation - **prognosis**: more aggressive than luminal A and luminal B HER2-, but HER2 targeted therapy improves prognosis. - **tx**: hormonal therapy, HER2-targeted therapy (trastuzumab), chemotherapy if high risk. 4. **HER2 overexpress (non-luminal) —** **HER2+**, ****ER-, PgR- - **facts**: invasive ductal carcinoma grade 2-3, tumor can be small size, node positive but can be negative - **prognosis**: historically poor, prone to early and frequent recurrent and metas, but **targeted therapies** (e.g., trastuzumab) have significantly improved prognosis - **tx**: **targeted therapies** like **trastuzumab** (Herceptin) or **pertuzumab** are used in combination with chemotherapy 5. **Basal-Like — triple-negative** (ER-, PR-, HER2-) - facts: must be exclude adenoid cystic, secretory, low-grade adenosquamous, typical medullary (ทุกอันตามด้วย carcinoma) //if basal type marker positive (EGFR+) will called it “basal-like breast carcinoma” - **prognosis**: **aggressive**, with a higher tendency for early metastasis. **poorer prognosis** than other subtypes due to lack of targeted therapies. - **tx**: **chemotherapy**, Newer treatments like **PARP inh** or **immunotherapy** may be used.

Answer 37

1. HER2/*neu —* also called ErbB2 - cell membrane marker (ตัวอื่นเป็น nuc protein), กก chromosome 17 - EGFR family - เป็น protein ที่ promote cell cancer growth / if **high HER2 → poor survival** :(( - มี targeted therapy: anti-HER2R 2. Ki-67 - ย้อมติดใน rapidly multiplying cells (proliferative Ag) - ย้อมติด nuc ด้วย - **high Ki-67 → aggressive tumor** (เพราะแบ่งตัวอย่างบ้าคลั่ง)

Answer 38

- type - spontaneous abortion: threatened, incomplete แท้งไม่หมด เหลือแขนเหลือรกไรเง้, complete, inevitable ปากมดลูกเปิดละ แท้งชัวร์ - induced abortion: legal, illegal - pathology: 80% occur in first 12wk, hemorrhage into decidua basalis ละก้เกิด necrotic - etiology: fetal → abnormal zygotic development (blighted ovum), aneuploidy / maternal → infect, drug use, chronic debilitating disease, endocrine abnormal, immune (SLE งี้), nutrition, cervical incompetent ปากมดลูกหลวม, physical trauma, laparotomy / paternal factors → chromosome abnormality - s&s: missed period, abnormal bleeding, pain, passage of conceptus, BP and pulse change

Answer 39

- risk factor: PID, previous pelvic surgery, previous ectopic preg, การใช้ยาคุมกำเนิดทุกแบบ, sterilization, - sequelae: rupture, hemorrhage.. - s&s: lower abdomen pain, missed period, abnormal uterine bleeding, abdominal and pelvic tenderness, BP and pulse change, pelvic mass, ถ้าปล่อยไปเรื่อย ๆ ละ rupture เด็กจะลอยใน bowel - dx - hx: **triad → pain, amenorrhea, vaginal bleed** - PE: abdominal non-tender or mild tender, +/- cervical motion tenderness - lab: quantitative β-human chorionic gonadotropin (hCG จะขึ้นเกิน 48hrs ต่างจากคนปกติที่จะขึ้นลง) - ultrasound - tx: methotrexate, surgical

Answer 40

- classification, pathogenesis - complete (46,XX): no fetal tissue ก็ไข่เปล่า, gross hydropic swelling, 25-30% have theca-lutein cyst, high malig risk, large uterine size, high hCH level - partial (69,XXX): some fetal tissue present มีไข่แต่สปิร์มเข้าสองตัวเยย, focal swelling - s&s: hyperemesis gravidum ↔ hyperthyroid, HT disorder in early preg, absent internal ballotment, no fetal heart beat, cardiac failure - sonographic: multiple vesicle in uterus - management: surgical (suction curettage, hysterectomy) / มา follow up เรื่อย ๆ ด้วย เพราะอาจเกิด malig

Answer 41

- etiology: abnormal trophoblastic invasion, immunological intolerance, maternal maladaptation, dietary def, genetic - **dx** - HT: BP≥140/90 - preeclampsia: HT+proteinuria - eclampsia: seizure - pathogenesis: involve แทบทุก organ รู้ไว้แค่นิ้ - management: termination of pregnancy การรักษาเดียวของ preeclampsia

Answer 42

- definition: before 37wk preterm / 34-36wk late preterm / ต่ำกว่านั้นก็ early preterm kub - threshold of viability: 23wk+ ดูแลดี ๆ ในรพก้รอดอยู่ - preterm premature rupture of membrane (PPROM): fetal membrane rupture before 37wk, เชื่อกันว่า intrauterine infection เป็น major predisposing event - antecedent and contributing factor **เน้น** 1. threatened abortion: vaginal bleeding in early preg 2. lifestyle factor: smoking, maternal น้ำหนักน้อยเกิน, illicit drug use, young or advance maternal age, short stature, vitC def, psychologic disorder 3. genetic 4. periodontal disease เหงือกอักเสบ 5. interval btw pregnancies: <18mo เร็วเกินไม่ดี ท้องติดกันเกิน or >59mo (5yrs) นานเกินก้ไม่ดี 6. prior preterm birth: เกือบ 50% แน่ะ sig มากกกก 7. infection: bacterial vaginosis ass w spontaneous abortion, preterm labor, PPROM, chorioamnionitis, amniotic fluid infection / ตัวเชื้อจะไปกระตุ้น inflam cytokine ซึ่งจะไป stimulate **prostaglandin** (cause uterine contract) & **degradation of extracellular matrix** (cause PPROM) - dx - symptom: regular contraction before 37wks - cervical dilate, length≈35mm - ambulatory uterine monitor & fetal fibronectin not recommend - management: corticosteroid for fetal lung development / ABX for GBS prophylaxis / tocolytic ~ beta agonist (terbutaline)

Answer 43

- definition: excessive bleeding after childbirth, typically >500 mL for vaginal birth and >1000 mL for cesarean - classification: immediate within 24hrs vs delayed can be 24hrs-6wks - etiology (4T): **tone** (abnormal uterine contraction), **trauma** (genital tract trauma), **tissue** (retained placenta), **thrombin** (coagulation disorder) - risk factor PPH — เอา 4 T มาขยายความ เดาได้อยู่อะ - management: เยอะมากก แก้ตาม cause อะ ;-; ถ้าเค้าออกค่อยมาอ่านละกัน

Answer 44

- postpartum uterine infection or puerperal sepsis → endometritis, endomyometritis, endoparametritis - predisposing factor - vagina delivery: from membrane rupture, prolong labor, multiple cervical examination - cesarean (most common): from membrane rupture, prolong labor, multiple cervical examination, internal fetal monitor [so single-dose perioperative ABX prophylaxis is recommend - pathogenesis: พอมีแผล normal flora ก้เข้าไปได้สบาย - clinical course: fever (38-39°c), leukocyte พุ่งถึง 15-30k //fever>38°c, uterine tenderness, foul smell or purulent vaginal discharge, tachycardia - tx: nonsevere metritis → oral ABX / moderate to severe → IV broad-spectrum ABX [clinda+genta]

Answer 45

- indication: 1 ปีไม่มีลูก / 6 เดือนไม่มีลูก เมื่อผญอายุ 35-40 / เร็วกว่านั้นหากผญอายุ>40 - specimen collection - specimen characteristic: seminal vesicle สร้าง fructose, prostate สร้าง liquefaction enz and acidity, bulbourethral สร้าง viscous and mucus — ถ้าคาแรคเต้อไหนหายไป ก้สงสัยส่วนที่สร้างได้เลย - patient prep and collection: daily ejaculation 2-3 days then **stop for 2-7 days** before test / หยุดยาพวก alpha blocker, SSRIs เพราะ affect vas def motility / use wide mouth sterile container อย่าใช้ condom จ้าาามันฆ่าสเปิร์ม / keep 37°, send to lab within 1hr

Answer 46

**macroscopic** - coagulation immediately then liquefraction within 5-60mins //if gelatinous clump is presence น่าจะ prostate พัง - volume≥2mL, pH 7.2-7.8 - appearance→homogenous white grey opacity - viscous→drop from thread shouldnt access 2cm **microscopic** - sperm conc >20x10^6 sperm/mL — ถ้า <5x10^6 ให้ไปตรวจ abnormal of sex chromosome - aggregation (random clumping) มีได้บ้าง แต่ถ้าเยอะนี่ abnormal ละ / agglutination: มี anti-sperm Ab - cellular element: มีหนองหรือ rbc มั้ย หรือมี epith cell, debris, bacteria and protozoa อ้ะเปล่า - motility: normal range is 50%+ w progressive motility or 25%+ w rapid progressive motility — if motility <50% ให้ไปตรวจ viability - viability: using supravital stain ถ้าติดสีคือตายละ, normal≥75% - morphology: using papanicolaou stain, ควรมี normal form ≥4%

Answer 47

- TSH: untreated thyroid disease can have an adverse effect on fertility //TRH สูง จะไปกระตุ้นทั้ง TSH & PRL → PRL ไปกด FSH LH !! - FSH: low FSH with azoospermia suggest obstructive azoospermia - FSH LH: high FSH and LH suggest abnormalities of spermatogenesis - FSH LH TT: low conc of FSH, LH, TT suggest hypogonadotropic hypogonadism (pitui พัง) //TT testing required fasting - PRL: prolactinemia cause low level of FSH LH making low testosterone level ตามลำดับ “secondary hypogonadism” - karyotyping: klinefelter syndrome, recommed testing in recurrent pregnancy loss - Y chromosome microdeletion: recommended if there is azoospermia or severe oligospermia with an elevated FSH, testicular atrophy, suspected impaired sperm production

Answer 48

“absence of menstrual flow by age 16yo, or by age 14yo if no breast development occurs” 1. measure hCG: for exclude pregnancy, can be dx trophoblastic disease or hCG secreting tumor 2. measure PRL TSH FT4: for exclude hyperprolactinemia (PRL high), hypothyroidism (PRL high TSH FT4 low), hyperthyroidism (stimulate SHBG) 3. progestin withdrawal test: for evaluate endogenous estrogen status — if no bleed go to step 4 , if bleed go to step 5 4. measure FSH LH vs imaging for outlet obstruction: FSH LH high → primary ovarian failure / FSH LH low or normal → secondary ovarian failure / imaging ว่าตันเพราะอะไร 5. androgen excess should be evaluated: TT high → PCOS or ovarian tumor / DHEA high → adrenal tumor / 17-OH progesterone → adrenal hyperplasia

Answer 49

- indication: confirm uterine preg, eva ectopic preg, monitor in vitro fertilization and embryo transfer - dx and f/u for: gestational trophoblastic disease e.g. hydatidiform mole, invasive mole, choriocarcinoma - estimate day of expected menses: measure hCG 5-7 days after expected mense / using quantitative serum testing can detected 3-4 days before expected mense - 1st tri: hCG increase from < 5 mIU/mL to 100,000 mIU/mL and **doubling** every 2-3 days for the first 6 weeks - serum vs urine hCG: serum ดีกว่าทุกตรงจบปิ๊ง - quantitative ดีกว่ายังไง: ประยุกต์ใช้ใน gestational trophoblastic disease and germ cell tumor ได้, อย่าง complete hydatidiform mole นี่ค่าพุ่งได้เปนล้านอะ, ectopic preg no doubling, monitor methotrexate for tx ectopic preg - high dose hook effect, macro β-hCG, heterophile Ab: ระวังค่าเยอะมาก ๆๆ ไม่ใช่ไม่เปน แต่เยอะจนเกิด hook effect kaaa

Answer 50

typical presentation (2 out of 3) 1. androgen excess: hirsutism, male pattern hair loss, acne, anger or irritation 2. ovulatory: anovulation, oligomenorrhea, fertility challenge 3. polycystic ovary morphology (น่าจะจากการทำ u/s)

Answer 51

- **Morphology**: - **Trophozoite**: - **Size**: 7-30 µm in length, 5-12 µm in width - **Appearance**: **Pear-shaped with a single nucleus, four anterior flagella**, and an undulating membrane running along one side of the body. Lacks a cyst stage. - **Host**: - **Definitive Host**: Humans (both men and women) - **Habitat**: - Trophozoites reside primarily in the urogenital tract (vagina, urethra, and prostate in men). - **Diagnostic Stage**: - Trophozoites in vaginal or urethral secretions, urine, or prostatic secretions. - **Infective Stage**: - Trophozoites (transmitted directly, no cyst form). - **Transmission**: - Sexual transmission (unprotected vaginal intercourse) - Rarely, non-sexual transmission via contaminated objects (e.g., shared towels or instruments)

Answer 52

- **Clinical Manifestations**: - **Women**: *ต้อง treat - Often asymptomatic - Symptomatic cases: **Vaginal discharge** (frothy leucorrhea, **greenish-yellow**), **vaginal** **pruritus**, dysuria, dyspareunia, and vulvar irritation. - "**Strawberry cervix**" (punctate hemorrhages on the cervix) / patchy vaginal erythema - discomfort during intercourse - **Men**: may self-limiting - Often **asymptomatic carriers** - Symptomatic cases: Urethritis, prostatitis, or mild discharge. - **Complications**: - **Women**: Increased risk of preterm delivery and low birth weight in pregnancy, and pelvic inflammatory disease (PID). - **Men**: Prostatitis and potential infertility.

Answer 53

- **Diagnosis**: - **Microscopic examination** of vaginal or urethral discharge for motile trophozoites (wet mount preparation) //also giemsa stain - **Culture**: cultivate in CPLM medium - direct IFA - DNA (PCR) - **Nucleic Acid Amplification Tests (NAATs)** (most sensitive) //อจไม่ได้สอน - **Initial Treatment**: - **Metronidazole** (single oral dose or 7-day regimen) - **Tinidazole** (alternative option) - **Remarks**: - **Prevention**: Consistent and correct use of condoms reduces transmission. - Trichomoniasis increases the risk of acquiring and transmitting HIV. - Routine screening is recommended for sexually active women, particularly those at higher risk (e.g., multiple sexual partners, history of STIs). - Treatment of both partners is recommended to prevent reinfection.

Answer 54

- **Morphology**: **jummmm** - **Tachyzoite**: แบ่งตัวเร็ว //พบในช่วง early stage of infection, asexual or **endodyogeny** - **Size**: 4-8 µm in length, crescent-shaped with a pointed anterior end and a rounded posterior end. - **Appearance**: Actively replicating form found during acute infection. - **Bradyzoite**: แบ่งตัวช้า - **Size**: Similar to tachyzoites but **found in tissue cysts** during the chronic phase. - **Appearance**: Slow-replicating form within tissue cysts in various organs (brain, muscle). - **Oocyst**: - **Size**: 10-12 µm in diameter. - **Appearance**: Found in cat feces, containing sporozoites which are infectious after sporulation // oocyst → sporoblast → sporocyte → sporulated oocyst [sporulated oocyst มี 8 sporozoite]

Answer 55

- **Host**: - **Definitive Host**: **Domestic cats and other felines** (sexual reproduction occurs in their intestines). oocyst** - **Intermediate Host**: Humans, birds, rodents, pigs, sheep, and etc. (asexual reproduction occurs in tissues). - **Habitat**: - Tachyzoites and bradyzoites reside in various tissues, especially the brain, muscle, and eyes in intermediate hosts. - Oocysts are shed in the feces of infected cats. - **Diagnostic Stage**: - **Tissue cysts** containing bradyzoites (chronic infection). - **Tachyzoites** in acute infection (found in blood, cerebrospinal fluid (CSF), or tissues). - **Infective Stage: all stage are infectious** - **Oocysts** (from contaminated **cat feces or soil**). - **Tissue cysts** (from **consumption of undercooked or raw meat**). - **Transmission**: - **Ingestion** of oocysts from soil, water, or vegetables contaminated by cat feces. - Ingestion of tissue cysts from undercooked meat (pork, lamb, beef). - **Congenital transmission** from mother to fetus during acute infection. - **Blood transfusion** or **organ transplantation** (rare).

Answer 56

- **Clinical Manifestations**: - **Immunocompetent individuals**: - Mostly asymptomatic. - Symptomatic cases: Flu-like illness with fever, lymphadenopathy, fatigue, and muscle pain (self-limiting). - **Congenital toxoplasmosis**: - If infected during pregnancy, the fetus may develop severe complications: chorioretinitis (**retinochoroiditis**?), **hydrocephalus**, **intracranial calcifications**, seizures, developmental delays. - **Immunocompromised individuals** (HIV/AIDS, organ transplant recipients): - **Reactivation of chronic infection** can lead to **toxoplasmic encephalitis**: fever, headache, confusion, seizures, and focal neurological deficits. - Eye involvement (chorioretinitis) can lead to visual disturbances. - **Complications**: - **Congenital toxoplasmosis**: May result in stillbirth, miscarriage, or long-term neurologic sequelae in infants. - **CNS toxoplasmosis**: Can cause brain abscesses in immunocompromised patients.

Answer 57

- **Diagnosis**: - **vital dye-staining** เชื้อเป็น - **Serological testing**: - IgM antibodies (acute infection) //within 3-6mo - IgG antibodies (chronic or past infection). - **PCR** for T. gondii DNA in blood, CSF, or amniotic fluid (for congenital cases). - **CT or MRI of the brain**: May show characteristic ring-enhancing lesions in toxoplasmic encephalitis. - **Histopathology**: Demonstration of tachyzoites or bradyzoites in tissue biopsy. - **Initial Treatment**: - **Immunocompetent, asymptomatic**: Usually no treatment required. - **Symptomatic or immunocompromised**: - **Pyrimethamine** + **Sulfadiazine** (plus leucovorin to prevent folate deficiency). - **Alternative**: Pyrimethamine + clindamycin. - **Congenital infection**: Same combination, adjusted for fetal or neonatal management. - **Remarks**: - **Prevention**: Avoid handling cat litter during pregnancy, thoroughly wash vegetables, cook meat thoroughly, and avoid consuming raw meat. - **Immunocompromised patients** (especially HIV/AIDS): Prophylaxis with trimethoprim-sulfamethoxazole (TMP-SMX) if CD4 count is <100 cells/mm³. - In areas of high endemicity, public health measures focus on food safety and hygiene to prevent the spread of T. gondii.

repro II all Flashcards

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