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Question 1 of 200

1. Head of a department and a trade-union group have appealed to the head of a hospital about dismissal of the senior nurse who has 17-year record of service. The facts of charge were confirmed and recognized by the nurse herself. The nurse lives with a daughter (who is divorced and unemployed) and a 9-month-old grandson. Make an administrative decision:

Explanation

2. A 50-year-old female patient complains of aching pain in the lower abdomen. She has a history of normal menstrual cycle. At the age of 40, the patient underwent a surgery for gastric ulcer. Examination findings: abdomen is soft, in the hypogastrium there is a well defined nodular tumor of limited mobility. Vaginal examination findings: the cervix is clean, of cylindrical shape. Body of the uterus cannot be palpated separately. On both sides of the uterus palpation reveals tight tumors with an uneven surface. The tumors are immobile and fill the whole pelvic cavity. What is the most likely diagnosis?

Explanation

Krukenberg tumor (also referred to as carcinoma mucocellulare) is a form of metastatic tumor that occurs in females. It is a malignancy present in the ovary that metastasized from the stomach ( primary site). Notice that from anamnesis, this woman underwent a surgery for gastric ulcer and on examination, a well defined tumor of limited mobility is found in the hypogastrium; these findings indicate a tumor in relation to the stomach. This tumor has likely travelled ( metastasised) to the region of the uterine cavity forming a krukenberg tumor. Note that the primary site of this malignancy can also be the colon, lungs and breast.
3. A 38-year-old male patient complains of marked dyspnea that escalates with physical exertion. The problems, namely acute chest pain on the left and cough, arose unexpectedly 2 hours before at work. The pain abated, but there were progressing dyspnea, dizziness, pallor, cold sweat, cyanosis. Auscultation reveals the absence of vesicular breath sounds, radiograph shows a shadow on the left. What pathology can be suspected?

Explanation

 

Pneumothorax develops when air enters the pleural space as the result of disease or injury. This leads to a loss of negative pressure between the two pleural membranes, which can result in the partial or complete collapse of the lung. Pneumothorax is classified as spontaneous or traumatic. Spontaneous pneumothorax can be further classified as primary (i.e., no underlying lung disease) or secondary (i.e., due to underlying lung disease). Any type of pneumothorax can progress to tension pneumothorax. Symptoms include;  dyspnea, ipsilateral chest pain, diminished breath sounds, and hyper-resonant percussion on the affected side. The result from the chest x-ray helps confirm the diagnosis- ‘shadows on the left’ proves the presence of air in the left lungs.

4. A 2-year-old boy has been admitted to the casualty department for the pain and deformity of his right thigh. Radiograph shows a femoral fracture with longitudinal displacement. What method of treatment is indicated for the patient?

Explanation

5. What juice should be included in a complex drug and dietary therapy for patients with gastric ulcer or duodenal ulcer and increased gastric juice acidity in order to accelerate the ulcer healing?

Explanation

 

Potato juice  helps eliminate  gastric acidity thereby, relieving ulcer pain.  Apple juice is rich in vitamin A and is recommended in individuals with poor sight, it also helps in reducing the risk of dementia in old individuals.

6. A 7-year-old child complains of itching, papular erythematous rash, dry skin. Objectively: there is lichenification in the popliteal fossae and antecubital spaces. What immunologic indicator if found in the blood serum will verify the diagnosis (atopic dermatitis)?

Explanation

 

Atopic dermatitis is a chronic disease that affects the skin. The word "dermatitis" means inflammation of the skin. "Atopic" refers to a form of allergy in which a hypersensitivity reaction such as eczema or asthma may occur in a part of the body not in contact with the allergen. In atopic dermatitis, the skin becomes extremely itchy and inflamed, causing redness, swelling, cracking, weeping, crusting, and scaling. For allergy related diseases, total IgE is increased in blood. Recall That these diseases are classified under Type 1 hypersensitivity reaction ( IgE mediated). IgM indicates a recent/acute infection while IgG is seen in chronic phases of an infection.

7. A 7-year-old patient presents with body temperature rise up to 39oC, dry cough, pain in the lateral abdomen. Objectively: there is cyanosis of the nasolabial triangle, inspiratory dyspnea with accessory muscle recruitment. Percussion reveals pulmonary dullness; among auscultation findings there are diminished breath sounds, crepitant rales. Respiratory rate is of 50/min, HR- 120/min. Evaluate the grade of respiratory failure in the patient:

Explanation

8. A 43-year-old alcohol abuser had not consumed alcohol for the last two days. In the evening he claimed to see rats and feel like they bite his feet. The patient is disoriented, agitated, all the time attempts to run somewhere. Specify the psychopathological syndrome

Explanation

Delirium tremens also known as Alcohol withdrawal delirium is the most severe form of alcohol withdrawal, it is characterised by an altered mental status and hyperactivity of the autonomic nervous system. From the question stem, we observe that this patient is a chronic alcoholic and has been without alcohol for 2 days leading to the described symptoms.

Amentia: this is a rough obscured consciousness with incoherent thought, complete unavailability for contact, isolated deception of perception and signs of sudden physical exhaustion. Patients in amentia generally lie in spite of having chaotic excitements. 

 

Oneiroid: it is also called dreamlike state and is defined by fantastic psychological suffering. It is characterized by ambivalent/contradictory speech, criminal action, senses global changing, catastrophe, and celebration simultaneously.

9. A 67-year-old male patient complains of rash, severe pain in the subscapular region on the right. Objectively: skin in the right subscapular region is covered with linearly arranged pink red edematous lesions that are somewhat infiltrated, and have  clear boundaries. On the lesion surface there are vesicles with transparent exudate. What is the most likely diagnosis?

Explanation

Herpes zoster is a viral disease that is caused by the Varicella-Zoster virus, it is characterized by inflammation of intervertebral or cranial nerves nodes and is shown up by a vesicular rash (with transparent exudate)on a skin along the nerves and symptoms of intoxication. The rash elements are macule - papule - vesicle - crust polymorphism which is often accompanied by hyperthermia. 

Dermatitis herpetiformis (also known as ‘DH’ or Duhring disease) is a rare but persistent blistering skin condition related to coeliac disease. Dermatitis herpetiformis is characterised by extremely itchy bumps (prurigo papules) and blisters (vesicles), which arise on normal or reddened skin. They tend to be distributed symmetrically and are most often found on the scalp, shoulders, buttocks, elbows and knees.

 

As the blisters are so itchy, they are often immediately scratched, resulting in erosions and crusting. Older lesions may leave pale or dark marks (hypopigmentation and hyperpigmentation).

10. An 8-year-old boy was brought to the admission department by his parents. Parents report that he has had pain in the right knee for the last 9 months, recently mother has noticed some limitation of motion in his right leg, and morning stiffness that doesn’t last till the evening. What is the most likely diagnosis?

Explanation

Juvenile rheumatoid arthritis is the most common cause of arthritis in children. The most common features of JRA are: joint inflammation, joint contracture (stiff, bent joint), joint damage and/or alteration or change in growth.

Other symptoms include joint stiffness following rest or decreased activity level (also referred to morning stiffness or gelling), and weakness in muscles and other soft tissues around involved joints. Coupled with the presented signs, the age of the patient helps us put the diagnosis of juvenile rheumatoid arthritis.

Reactive arthritis is an autoimmune condition that develops in response to an infection in another part of the body. Coming into contact with bacteria and developing an infection can trigger reactive arthritis. It has symptoms similar to various other conditions collectively known as \"arthritis,\".

11. A 13-year-old girl was admitted to the gynecology department for having a significant bleeding from the genital tract for 10 days. The patient has a history of irregular menstrual cycle since menarche. Menarche occurred at the age of 11. Recto abdominal examination revealed no pathology. What is the provisional diagnosis?

Explanation

Notice that the patient above experiences abnormal blood discharge with no reproductive organ ( recto-abdominal) pathology; this indicates a case of Dysfunctional Uterine bleeding ( juvenile form- since it occurs at child age and in period of pubescence). A dysfunctional uterine bleeding (DUB) is the bleeding, not associated with organic diseases of women’s genitals, interrupted pregnancy or systemic diseases of the organism.

Adenomyosis is a condition in which the inner lining of the uterus (the endometrium) breaks through the muscle wall of the uterus (the myometrium). Adenomyosis can cause menstrual cramps, lower abdominal pressure, and bloating before menstrual periods and can result in heavy periods.

Werlhof’s disease is also known as immune thrombocytopenic purpura.

 
12. A 64-year-old male patient has a 35 year history of chronic pancreatitis. In the last 5 years, he claims to observe the pain abatement, bloating, frequent bowel movements up to 3-4 times a day, grayish, glossy stool with undigested food rests, the progressive loss of body weight. Change of symptoms in the patient is due to over lay of:

Explanation

The pancreas plays a major role in digestion ( its exocrine function). It produces digestive enzymes such as; trypsin and chymotrypsinogen ( for protein digestion), Amylase (for carbohydrate digestion), lipase ( for breakdown of fats). In pathologies relating to the pancreas such as pancreatitis, this function is affected leading to a digestion and absorption issue. For example, due to a disruption in the release of lipase, fat breakdown is negatively affected leading to not enough absorption and its appearance in stool ( steatorrhea). Likewise a disruption in chymotrypsin and trypsin secretion will lead to an abnormal excretion of muscle fibres in faeces (creatorrhea). Irritable bowel syndrome is an inflammatory bowel disease characterised by recurrent abdominal cramps/spasms (pain), change in form (consistency) and frequency of stool, constipation etc. . This condition is common in middle aged women and is associated with underlying conditions such as stress, anxiety, depression or a previous case of intestinal infection.   
13. During the doctor’s round, a 56 year old male patient with decompensated cirrhosis complains of dizziness, palpitations, moving black specks seen before the eyes, general weakness. The patient is pale, Ps- 110/min, AP- 90/50 mm Hg. What complication is  most likely to have occurred in the patient?

Explanation

 

Usually seen in individuals with serious liver diseases, Esophageal varices refers to enlarged or swollen veins on the lining of the esophagus. Most likely complications are severe internal bleeding, hypovolemic shock and cardiac arrest. Notice that this patient has  decompensated cirrhosis of the liver ( the cause of these varices); an absence of neurological signs rules out the option of hepatic encephalopathy.

14. A 57-year-old female patient complains of intense pain in the right hypochondrium irradiating to the right supraclavicular region. Skin and sclerae are icteric. There is tension and tenderness in the right hypochondrium on palpation. Body temperature is 38, 8oC. Blood test results: WBC- 11, 2 · 109/l, total bilirubin - 112 mmol/l (conjugated - 86 mmol/l, unconjugated - 26 mmol/l). What is the most likely diagnosis?

Explanation

 

Intense pain in the right hypochondrium should signal the presence of a pathology in relation to the liver or gallbladder. This can be further proven by the presence of  icteric skin and sclera ( due to the deposition of bilirubin on the skin and sclera).  The results from palpation ( tenderness in right hypochondrium) and biochemical analysis ( increased bilirubin levels) helps confirm this. Cholangitis is an inflammation of the biliary system mostly as a result of bacterial infection. Of all the listed options, only cholangitis is in relation to gallbladder or liver pathology.

15. A 3-year-old girl has had an increase in body temperature up to 38, 5oC for four days. The child refuses to eat. Over the last two days, nose and mouth breathing has become difficult. Mesopharyngoscopy reveals hyperthermia and enlargement of tonsils, as well as hyperemia and bulging of the posterior wall of the oropharynx, which significantly narrows the oropharyngeal lumen. What complication of quinsy occurred in the patient?

Explanation

The term ‘quinsy’ also known as peritonsillar abscess refers to an inflammation of the throat, especially an abscess ( pus filled cavity) in the region of the tonsils. Notice that results from Mesopharyngoscopy shows hyperemia and bulging of the posterior wall of the oropharynx. One major complication of Quinsy is Retropharyngeal abscess which refers to the accumulation of pus behind the pharynx (as seen from the Mesopharyngoscopy ). Other possible  complications include sepsis, pneumonitis etc.
16. Within a year, in a maternity hospital there were 616 livebirths, one stillbirth, one infant died on the 5th day of life. What index can most accurately describe this situation?

Explanation

Perinatal mortality refers to the number of stillbirths and deaths in the first week of life (early neonatal mortality)

 

The infant mortality rate is defined as the number of deaths of children under one year of age

17. In one of the surgical departments the quality assurance testing of sterilization of surgical instruments was performed. After an instrument had been treated with 1% phenolphthalein, the solution turned pink. This indicates that the instrument has:

Explanation

18. A 21-year-old female patient consulted a gynecologist about itching, burning, watery vaginal discharges with a fish like smell. Speculum examination revealed that the cervical and vaginal mucosa was of a normal pink color. Vaginal examination revealed no alterations of the uterus and appendages. Gram stained smears included clue cells. What is the most likely pathology?

Explanation

 

Clue cells are certain cells in the vagina (vaginal epithelial cells) that appear fuzzy without sharp edges under a microscope. Clue cells change to this fuzzy look when they are coated with bacteria. If clue cells are seen, it means bacterial vaginosis is present.

19. A 9-year-old patient has measles. On the 6th day after the rash appeared, the boy developed a condition manifested by dyspnea, barking cough, stenotic respiration. Objectively: the rash on the face, neck and torso turned brown. There is a branny desquamation. Respiratory rate is 22/min. What complication should be diagnosed?

Explanation

The above symptoms manifested i.e dyspnea, barking cough, stenotic respiration is a sign of croup that is manifested in Laryngotracheitis, which itself is one of the complications of Measles.

Bronchitis will present with productive cough, along with wheezing sound during respiration

Pneumonia- for the above question they didn’t mention any characteristic symptoms involving lower respiratory tract like dyspnea on exertion, sputum with green or yellow colour/ rusty sputum

 

Quinsy : comes with throat pain, trouble opening mouth, change of voice but not with barking cough or dyspnea normally.

20. A 26-year-old secundipara at 40 weeks of gestation arrived at the maternity ward after the beginning of labor activity. 2 hours before, bursting of waters occurred. The fetus was in a longitudinal lie with cephalic presentation. Abdominal circumference was 100 cm, fundal height - 42 cm. Contractions occurred every 4-5 minutes and lasted 25 seconds each. Internal obstetric examination revealed cervical effacement, opening by 4 cm. Fetal bladder was absent. Fetal head was pressed against the pelvic inlet. What complication arose in childbirth?

Explanation

Recall that labour physiologically is divided into 3 stages; 

In the first stage the cervix opens to full dilation to allow the head to pass through  The second stage is from full dilation to delivery of the fetus. The third stage lasts from delivery of the fetus to delivery of the placenta. Labor often lasts between 12 and 14 hours – or longer – for first-time mothers, but is usually shorter in subsequent births.

The 1st stage—is the longest stage of labor, and is divided into three separate phases:

The early ( latent) phase-  averaging 8 1 ⁄2 h in nulliparas and 5 h in multiparas; duration is considered abnormal if it lasts > 20 h in nulliparas or > 12 h in multiparas.

Active labor (the active phase)-  here, the cervix dilates to 7cm.  On average, the active phase lasts 5 to 7 h in nulliparas and 2 to 4 h in multiparas. The cervix should dilate 1.2 cm/h in nulliparas and 1.5 cm/h in multiparas.

Transition. The cervix dilates from 7 centimeters to 10 centimeters. This is usually the shortest stage of labor, but is often the most unpleasant. 

If a woman's “water ―breaking” occurs in the first stage before/ until the active phase, it is called early amniorrhea. 

 

In Primary uterine inertia, uterine contractions fail to be initiated while in the secondary form, uterine inertia ceases in between labor ( before completion)

21. Examination of a 35-year-old patient with rheumatism revealed that the right heart border was 1 cm displaced outwards from the right parasternal line, the upper border was on the level with inferior margin of the 1st rib, the left border was 1 cm in from the left midclavicular line. Auscultation revealed atrial fibrillation, loud apical first sound, diastolic shock above the pulmonary artery. Echocardiocopy revealed abnormal pattern of the mitral valve motion. What heart disease is characterized by these symptoms?

Explanation

22. A 54-year-old male patient works as an engineer. At the age of 35, he got infected with syphilis and treated it with \\\"traditional remedies\\\". About 5 years ago, he became forgetful, unable to cope with work, told cynical jokes, bought useless things, collected cigarette butts in the street. Objectively: the patient is indifferent, has slow speech, dysarthria, can make only primitive judgments, is unabe to perform simple arithmetic operations or explain simple metaphors. The patient is untidy, takes no interest in anything, passive. Considers himself to be completely healthy. Qualify mental condition of the patient:

Explanation

This is a classical case of Neurosyphilis. Neurosyphilis is a bacterial ( syphilitic) infection of the brain and spinal cord; it occurs on the background of a chronic syphilitic infection (notice that this patient has a long history of syphilis infection not properly treated). 

Dementia is a brain related disorder characterized by progressive impairment of memory, thinking and behaviour that affects one’s everyday activities ( a decline in one’s mental and cognitive function that does not correspond to the age of the patient).

Lacunar dementia is also known as Binswanger disorder or Subcortical arteriosclerotic encephalopathy. Typically presents with Gait,urinary incontinence, parkinsonian features, pseudobulbar palsy etc. 

Korsakoff’s ( amnestic ) syndrome is characterised by thiamine deficiency ( beri-beri) on the background of chronic alcoholism.

In Somnolentia, the individual experiences incomplete sleep/ drowsiness which resembles a state of drunkenness.
23. A 13-year-old boy with hypertrophic cardiomyopathy complains of dyspnea on minimal exertion. EhoCG reveals asymmetric left ventricular hypertrophy, signs of pulmonary hypertension, dilatation of the left atrium. EF is 64%. The revealed alterations are indicative of:

Explanation

 

Recall that the normal ejection fraction ranges from about 50-70%. A diastolic heart failure usually occurs due to the stiffness of the Left ventricle and its inability to relax properly. In this type of HF, the ejection fraction is usually preserved as opposed to a systolic heart failure  which has a reduced ejection fraction due to the inability of the left ventricle to contract properly. Note that Systolic Heart failure is also referred to as Heart failure with reduced ejection fraction (HFrEF) while the  diastolic form is also referred to as Heart Failure with preserved ejection Fraction ( HFpEF).

24. Study of natural illumination for a workplace in a secondary school classroom revealed that the angle of sunlight incidence was 25o, window opening angle - 3o, window to floor area ratio - 1:4, daylight ratio - 0,5%, depth ratio - 2. What indicators do not meet hygienic standards?
25. Bakers at bread production work in conditions of high temperature and high heat radiation. What is used to increase the body’s resistance to the unfavorable effects of these harmful work environment factors?

Explanation

Vitamin preparations such as vitamin D helps against radiation; vitamin E acts as an antioxidant which destroys free radicals ( reactive oxygen species)
26. A 24-year-old male patient got a puncture injury below the Poupart’s ligament, which was accompanied by intense arterial bleeding. The best method to temporarily stop the bleeding in the patient would be:

Explanation

 

Poupart ligament refers to the inguinal or groin ligament. Compression bands are also known as pressure bandages;  are used to control bleeding and encourage blood clotting without constricting normal blood circulation. Esmarch tourniquet is used to stop bleeding located on the limbs.

27. 5 days before, a 26-year-old female patient developed an acute condition. Objectively: marked headache, vomiting, weakness, poor appetite, temperature up to 39oC. Objectively: the patient is in a moderately grave condition, excited. The face is hyperemic, sclerae are injected. The tongue is coated with brown fur. The trunk and limbs are covered with plentiful roseolous and petechial rash. Hepatosplenomegaly is present. Complement binding reaction with Rickettsia prowazekii is positive with the titer of 1:640. What drug should be administered?

Explanation

 

The results from the complement binding reaction  is positive for Rickettsia Prowazekii which is the causative agent for Epidemic typhus. Epidemic typhus is an infectious disease transmitted via Body lice ( note that other variants of the typhus disease can be transmitted by fleas). It is characterised by fever,  petechial rashes  which begins on the trunk and spreads to the extremities, and flu-like symptoms. Note that for treatment, Doxycycline is administered. 

28. A 39-year-old female patient complains of dyspnea when walking, palpitation, edemata in the evening. The patient’s height is 164 cm, weight - 104 kg. Objectively: overnutrition. Heart sounds are weak, and tachycardia is present. The menstrual cycle is not broken. Blood sugar is 5,6 mmol/l, ACTH-response tests revealed no alterations. X-ray of the Turkish saddle revealed no pathology. What disease is it?

Explanation

 

Notice that on X Ray, no pathology was found in the Turkish saddle ( the location of the Pituitary gland on the sphenoid bone) - this finding rules out the option of Pituitary obesity. The blood glucose level is within normal range  and the adrenocorticotropic hormone revealed no alteration- these rule out the options of diabetes mellitus and cushing’s syndrome. Alimentary obesity occurs as a result of an increased intake of food (overnutrition). Overnutrition is the major criteria in putting the diagnosis of this  patient.

29. A 26-year-old male patient complains of a rash on the upper lip skin, which arose on a background of influenza with high-grade fever and is accompanied by pain and burning. The rash has been present for 3 days. Objectively: the skin of the upper lip is edematic and erythematous, grouped vesicles are filled with serous fluid and have a rough surface. What is the most likely diagnosis?

Explanation

Herpetic vesicular dermatitis (herpes simplex dermatitis)  occurs as a result of an infection by HSV 1 ( human simplex virus 1) and is characterised by the presence of grouped vesicles ( blisters), erythematous in nature. These blisters are usually very painful and itchy. Notice that; From objective examination of this patient, erythematous grouped vesicles are found. 

Dermatitis herpetiformis (duhring’s disease) is an autoimmune skin disease that targets those with gluten intolerance or celiac disease. People with celiac disease are unable to digest the gluten protein that is present in grains such as wheat, rye and barley. Itchy blisters and hives will form commonly on a person’s back or buttocks; this disorder is handled by removing all gluten containing products from a person's lifestyle. People with hypothyroidism, Sjogren’s disease or rheumatoid arthritis are also known to get this skin condition. 

 
30. A 6-year-old boy complains of paroxysmal pain that occurs after a mental stress, consuming cold drinks or ice cream. After clinical and instrumental examination the boy has been diagnosed with hypertensive biliary dyskinesia. The drugs of the following groups should be administered in the first place:

Explanation

 

Biliary dyskinesia is a disorder of the biliary tract in which the motility of bile is affected and is mostly due to ineffective peristaltic contractions. Two main signs of this disorder are; a right upper quadrant pain and Indigestion ( most fatty foods). To tackle this symptomatically, Antispasmodic/spasmolytic drugs should be administered to tackle the pain caused by spasms while choleretics/cholagogues i.e. drugs that help in the secretion or release of bile should also be given.

31. A15-year-old patient consulted a dermatologist about a painful lump in the armpit. Objectively: there is a walnut sized node, lymphadenitis, infiltration of the surrounding tissues. The patient has bee n dignosed with hidradenitis. What is the most likely causative agent of this disease ?

Explanation

32. A 36 year old female has a 7 year history of pollen allergy. Over the last 2 years in August and September (during ragweed flowering), the patient has had 2-3 asthma attacks that could be treated with one dose of salbutamol. Objectively: body temperature - 36, 5oC, respiratory rate - 18/min, Ps- 78/min, AP- 115/70 mm Hg. There is vesicular breathing above the lungs. Cardiac sounds are sonorous, of regular rhythm. What drug would be most effective to prevent asthma attacks during the critical season for the patient?

Explanation

This patient has a history of allergy (asthmatic attacks); recall that an allergy is a type 1 hypersensitivity disorder - B cells are stimulated by  CD4+TH2 cells which leads to the production of IgE antibodies against the trigger antigen. Recall that these IgE antibodies bind to specific receptors on mast cells and basophils. On further exposure to the same trigger ( allergen), these mast cells release mediators ( histamine, prostaglandins, leukotrienes etc). These mediators are responsible for the changes observed in allergic attacks.

Italum inhalation ( Cromolyn sodium) is a mast cell stabilizer. They block the early and late responses in asthmatic attacks, control inflammation in asthma and are used for prophylaxis in allergic asthma. 

Berotec Inhalation (fenoterol) -β2 agonist; Atrovent Inhalation - Ipratropium (muscarinic antagonist).

 
33. A study of the structure of death causes in the urban population revealed that cardiovascular diseases accounted for 55,0% of all deaths. What statistic value represents these data?

Explanation

The extensive statistical indicator is used to determine a structure of a disease ( in this case, how many percent ( the proportion) of the total diseased fall under cardiovascular cases) ie., it shows, what part from the general number of all diseases is made with this or that disease which enters into total.

The intensive parameter characterizes frequency or distribution. It shows how frequently the given phenomenon occurs in the given environment. Examples of Intensive parameters include morbidity rate, mortality rate, lethality rate etc.
34. A 25 year old female patient complains of marked weakness, sleepiness, blackouts, di zziness, taste disorder. The patient has a history of menorrhagia. Objectively: the patient has marked weakness, pale skin, cracks in the corners of mouth, peeling nails, systolic apical murmur. Blood test results: RBC 3, 4 · 1012/l, Hb- 70 g/l, color index - 0,75, platelets - 140 · 109/l, WBC- 6, 2 · 109/l. What is the most likely diagnosis?

Explanation

 

From anamnesis, we see that the patient has a history of menorrhagia; the current state of the patient (pale skin, fatigue etc) is due to the amount of blood already lost. A post hemorrhagic anemia is a condition in which a person loses lots of hemoglobin and RBCs due to blood loss. It is usually seen in cases of trauma, severe injuries etc. A chronic form is seen in patients with moderate or prolonged occurrence of bleeding eg, gastric ulcers, menorrhagia, hemophilia etc while an acute form is seen in short term events such as trauma.

35. A 51-year-old female is a weaving factory worker with 15 years of service record. During a regular preventive examination she complained of frequent headaches, poor sleep, tingling in the heart, irritability, rapid fatigability, hearing impairment. For years, the noise level has exceeded the maximum allowable concentration by 10-15 dB. A year ago, the patient underwent a course of treatment for essential hypertension. Specify the most likely diagnosis:

Explanation

From anamnesis, it is stated that the patient has worked for a very long time in an environment in which the noise level exceeds the maximum allowable concentration. The complaints presented on preventive examination are as a result of prolonged exposure to noise over a long period of time. 

Asthenovegetative syndrome: weakness, severe fatigue, poor performance and mood, anxiety, depressive mood, hypochondria.

 

Neurasthenia: a condition that is characterized especially by physical and mental exhaustion usually with accompanying symptoms (such as headache and irritability), is of unknown cause but is often associated with depression or emotional stress, and is sometimes considered similar to or identical with chronic fatigue syndrome.

36. A 49-year-old male patient who had been scheduled for a surgery for gastric cancer underwent preoperative infusion therapy. Up to 3,0 liters of liquid was introduced into the right cubital vein. The following day, he felt a dragging pain in the right shoulder. Objectively: on the inner surface of the shoulder there is a longitudinal hyperemic zone, edema of skin, a tender cord. What complication occurred in the patient?

Explanation

Acute thrombophlebitis refers to the inflammation of a vein due to the formation of a blood clot (thrombus). Key findings include; pain, hyperemia , edema, tenderness and Veins being hard and cord-like

 

Paravenous tissue necrosis is ruled out due to the absence of necrosis on examination; a phlegmon refers to the inflammation of soft tissue due to an infection and is characterised by the production of pus ( this helps rule out tissue phlegmon). 

37. Some of the population of a city district have uneven teeth color. The individuals have white spots, transverse brown stripes on the incisors. Occurrence of these symptoms is associated with the quality of drinking water from a deep well. Which of the following components of water can be the cause of the disease?

Explanation

These individuals are experiencing Dental fluorosis which is a condition caused by excess fluorine in drinking water leading to inadequate enamel formation. Key signs include brown and white stripes on the teeth. Water fluoridation should be carried out in order to correct the amount of fluorine.
38. A 22-year-old female patient has been delivered by an ambulance team to a surgical clinic with symptoms of acute intestinal obstruction. It is known from the past history that 2 years ago she was operated for acute destructive appendicitis. For two years, she has repeatedly complained of bloating and abdominal pain. Which of the following etiological factors has led to the intestinal obstruction in the patient?

Explanation

Abdominal adhesions refer to bands of scar tissues that form between abdominal tissues and organs causing them to  stick together; These are one of the major causes of intestinal obstructions. Notice that this patient underwent an operation for acute destructive appendicitis  and since then has had complaints of bloating and abdominal pains; fibrous bands of scar tissue that formed after this procedure are the most likely cause of the intestinal obstruction. 

Ileal diverticulum (meckel's diverticulum) refers to the bulging out of the lower part of the small intestine. It can be a major cause of intestinal obstruction, but not in this case. 

 

Dolichosigma refers to an abnormal increase in the length of the sigmoid colon and its mesentery, leading to impaired motility and emptying of the large intestine. Dolichosigmoid is manifested by chronic constipation, flatulence, recurrent abdominal pain. 

39. Mother of a 10-month-old baby reports significant pallor, poor appetite, enlarged abdomen in the baby. As a neonate, the child underwent treatment in the in-patient hospital for jaundice and anemia. Objectively: the skin is pale and jaundiced, teeth are absent, abdomen is enlarged, spleen is palpable. Blood test results: Hb- 90 g/l, RBC- 3, 0·1012/l, c olor index - 0,9, microspherocytosis, reticulocytosis up to 20%, serum bilirubin - 37 mmol/l, unconjugated bilirubin - 28 mmol/l. What type of anemia has occurred in the patient?

Explanation

40. A lumbar puncture was performed for a newborn suspected of having an intracranial birth injury. Bloody cerebrospinal fluid was obtained. What hemorrhage occurred in this case?

Explanation

The term subarachnoid hemorrhage (SAH) refers to extravasation of blood into the subarachnoid space i.e. the space between the pia and arachnoid membranes.

The subarachnoid space is the space where the cerebrospinal fluid (CSF) circulates, therefore, hemorrhage into this space will result in bloody CSF as mentioned in the question or CSF liquor with high content of erythrocytes. The CSF is responsible for protecting your brain from injury by serving as a cushion. A hemorrhage in this space can cause a coma, paralysis, and even death. It is often characterized by a severe headache in adults (often referred to as ‘worst headache of my life’).

In newborns, subarachnoid hemorrhages can result from either birth trauma (excessive mechanical force on the baby during birth) or hypoxic-ischemic injury - HIE, (lack of oxygenated blood flow to the brain). The former (birth trauma) is a more common cause in term infants, and the latter (HIE) in preterm infants. 

 

Recall that Cerebrospinal fluid is produced by the ependymal cells in the choroid plexus of the third, fourth and lateral ventricles in the brain. It occupies the subarachnoid space i.e., the space between the arachnoid mater and the pia mater; including the ventricular system of the brain and spinal cord.

41. A 36-year-old female patient complains of intense pain in the knee joints and neck. In the morning she experiences pain in the interscapular region and leg joints; pain subsides after warm-up gymnastics. The patient is overnourished, there is a clicking sound in the knees when squatting, the knees are some what disfigured, painful on palpation. Blood test results: ESR- 18 mm/h, WBC- 8, 0·109/l. Radiography reveals subchondral sclerosis in the left knee. What is the basis of this pathology?

Explanation

Subchondral sclerosis is a condition common in people with osteoarthritis. It refers to the hardening/ stiffening of the bone just below the cartilage. Note that “Chondra” is another word for cartilage, so subchondral means “beneath the cartilage.” “Sclerosis” means hardening. Subchondral sclerosis appears in the later stages of osteoarthritis, when there’s a degeneration of cartilage.

 

Deposition of urates (tophi)in the articular tissues will be seen in Gout while Hemarthroses refers to bleeding into the joint cavity.

42. A 35-year-old female reports heart pain (aching and drilling) occurring mainly in the morning in autumn and spring and irradiating to the neck, back and abdomen; rapid heartbeat; low vitality. Occurrence of this condition is not associated with physical activity. In the evening, the patient’s condition improves. Study of somatic and neurological status, and ECG reveal no pathology. What pathology is most likely to have caused these clinical presentations?

Explanation

Somatoform disorders - multiple, recurrent and frequent somatic complaints requiring medical attention without association with any physical disorder. The above patient’s heart ache is not related to any physical activity and occurs at a particular period of the year, 

 

Hypochondriacal Disorder is characterized by a persistent preoccupation and a fear of developing or having one or more serious and progressive physical disorders. Physician physical examination does not reveal any disorder, but the fear and convictions persist despite the reassurance.

43. An hour before an elective surgery, a 56 year old patient of the surgical department got a dramatic increase in blood pressure, tachycardia, hand tremor. The patient is confused, anxious, depressed, fearful, is pessimistic about the operation outcome, refuses the surgery. What tactics should be chosen by a surgeon?

Explanation

 

Having hypertension, increases the risk of the surgery - for this patient, the blood pressure should be corrected before the surgery can be carried out.

44. A 33-year-old female complains of escalating spastic pain in the abdomen after the psycho-emotional stress. The patient has intermittent bowel movements, that is 2-3 bowel movements after waking up alternate with constipation lasting for 1-2 days. Objectively: body weight is unchanged, there is moderate pain on palpation of the sigmoid colon. Hb- 130 g/l, WBC- 5, 2 · 109/l, ESR- 9 mm/h. Proctosigmoidoscopy causes pain due to spastic bowel condition, intestinal mucosa is not changed. In the lumen there is a lot of mucus. What is the most likely diagnosis?

Explanation

One major difference between Irritable bowel syndrome  and inflammatory bowel disease is that intestinal mucosa is not affected in IBS while IBDs ( crohn’s disease and ulcerative colitis) have their mucosa affected. 

 Irritable bowel syndrome is an inflammatory bowel disease characterised by recurrent abdominal cramps/spasms (pain), change in form (consistency) and frequency of stool, constipation etc. . This condition is common in middle aged women and is associated with underlying conditions such as stress, anxiety, depression or a previous case of intestinal infection. 

Notice that in this patient, on endoscopic examination, painful spasm occurred while intestinal mucosa is not changed- this is indicative of Irritable bowel syndrome. 

 

In malabsorption syndrome, the small intestine is unable to absorb certain nutrients eg carbohydrates, proteins etc. can be caused by certain diseases such as celiac disease, lactose intolerance etc. 

45. An infant is 2 days old. He was born full-term with signs of intrauterine infection, and therefore receives antibiotics. Neonates should be given antibiotics at longer intervals and lower doses compared to older children and adults because:

Explanation

Note that the glomerular filtration rate of the kidneys is much lower in neonates than in adults. This implies that if a drug is given, the clearance rate will be much slower in neonates. Due to this fact, antibiotics should be given at longer intervals ( spaced between doses) and at lower doses.
46. After a holiday in the Crimea, a 36-year- old female patient presents with severe pain in the elbow joints, dyspnea and weakness. The body temperature is of 37, 6oC, the skin is pale, there is erythema of cheeks and nose, lower lip ulceration. Visual inspection reveals no changes in the joints, the right elbow movement is limited. There is murmur and pleural friction in the lungs below the right angle of the scapula. Cardiac sounds are muffled, there is tachycardia, gallop rhythm, Ps- 114/min. AP- 100/60. What is the most li kely diagnosis?

Explanation

The key finding here is the erythema on the cheeks and bridge of nose which describes a malar/ butterfly rash classically seen in patients with Systemic lupus erythematosus.

SLE is a chronic inflammatory disease of unknown cause which can affect the skin, joints, kidneys, lungs, nervous system, serous membranes and/or other organs of the body. Distinct immunologic abnormalities, especially the production of a number of antinuclear antibodies, other signs include, arthralgia, myalgia, nephritis, systolic murmurs in about 30% of patients, dry pleurisy in the lungs etc. The dry pleurisy is characterised by an abnormal sound on auscultation called a pleural friction rub

 

Rheumatic carditis and arthritis will be observe in a case of rheumatic fever ( prior infection by group A beta hemolytic streptococci infection)

47. A 63-year-old male patient complains of cough with expectoration of mucous blood streaked sputum, asthma, low-grade fever, general weakness. These presentations have been observed for 3 months. The patient has been a smoker since childhood. Objectively: t o- 37, 4oC, respiratory rate is 26/min, Ps- 82/min, rhythmic. AP- 130/85 mm Hg. There is limited breathing movement in the right side of chest cavity, as well as percussive dullness and diminished breath sounds. Radiograph shows a homogeneous opacity of the pulmonary field on the right with the mediastinum displacement to the affected side. What is the most likely diagnosis?

Explanation

48. A 33-year-old male patient developed a condition that had a stormy clinical course: chills, fever up to 39oC, vomiting, epigastric pain, diarrhea with watery smelly feces. 6 hours before, he ate a raw egg, fried potatoes with stewed meat, drank some juice. What pathogen is likely to have caused this condition?

Explanation

49. Chief physician of a polyclinic encharged a district doctor with a task to determine the pathological prevalence of disease N in his district. What document allows to estimate the disease prevalence in the population of a medical district?

Explanation

50. A 76-year-old male consulted a therapist about slow discharge of urine with a small jet. The patient reported no cardiac problems. Examination revealed atrial fibrillation with a heart rate of 72/min and without pulse deficit. There are no signs of heart failure. ECG confirms the presence of atrial fibrillation. From history we know that the arrhythmia was detected three years ago. What tactics for the treatment of atrial fibrillation in the patient should be chosen?

Explanation

 

Note that from anamnesis, the patient reported no cardiac problems. The heart rate revealed 72 beats per minute without pulse deficits - this finding debunks the claim of an atrial fibrillation. Also take note that there are no signs of Heart failure therefore, this patient does not require any form of treatment.

51. A 53-year-old male has been admitted to a hospital for an attack of renal colic which has repeatedly occurred throughout the year. Objectively: in the region of auricles and the right elbow some nodules can be seen that are covered with thin shiny skin. Ps- 88/min, AP- 170/100 mm Hg. There is bilateral costovertebral angle tenderness (positive Pasternatsky’s symptom). The patient has been scheduled for examination. What laboratory value would be most helpful for making a diagnosis?

Explanation

This patient has a history of repeated renal colic over the past one year. Renal colic refers to a form of abdominal pain that occurs as a result of urinary stones blocking the urinary tract ( bladders, ureters, urethra). This kidney pathology can be supported by a positive pasternetsky’s sign ( costovertebral angle tenderness). One basic component excreted by the kidneys via urine is uric acid. Due to the blockage of the urinary tract, these products are not excreted and remain accumulated in the blood system. Amongst the listed options,  An elevated uric acid level is the most helpful in putting a diagnosis. 

 

Elevated rheumatoid factor is helpful in the diagnosis of autoimmune conditions such as rheumatoid arthritis, sjogren's syndrome etc.

52. A 58-year-old female patient complains of spontaneous bruises, weakness, bleeding gums, dizziness. Objectively: the mucous membranes and skin are pale with numerous hemorrhages of various time of origin. Lymph nodes are not enlarged. Ps- 100/min, AP- 110/70 mm Hg. There are no changes of internal organs. Blood test results: RBC - 3,0·1012/l, Нb - 92 g/l, colour index - 0,9, anisocytosis, poikilocytosis, WBC - 10·109/l, eosinophils - 2%, stab neutrophils - 12%, segmented neutrophils - 68%, lymphocytes -11%, monocytes - 7%, ESR - 12 mm/h. What laboratory test is to be determined next for making a diagnosis?

Explanation

 

Since the patient complains about spontaneous bruises, bleeding gums, numerous hemorrhages of various time of origin, the blood platelet level should be checked. Platelets/ thrombocytes help in blood clot formation.

53. A 48-year-old male in-patient undergoes treatment for essential hypertension of II - B stage. It is known from history that he works in a design engineering office. His job involves neuro-emotional stress. Which of these foodstuffs do not stimulate the central nervous system and can be recommended for the patient?

Explanation

54. In an urban settlement situated on the riverbank, an outbreak of hepatitis A was registered. The disease might have water origin. This assumption can be confirmed by growth of the following values of water quality:

Explanation

 

Coliphage is a type of bacteriophage ( a virus) that infects coliform bacteria such as E. coli. Coliphages are microbial indicators specified in the Ground Water Rule (GWR) that can be used to monitor for potential fecal contamination of drinking water.

55. A 48-year-old male patient complains of pain in the lower extremities, especially when walking, intermittent claudication, numbness in the fingers, cold extremities, inability to walk more than 100 meters. Sleeps with his leg lowered. The patient has been a smoker

Explanation

Obliterating Endarteritis is also known as Buerger’s disease and vasculitis. The condition is thought to occur as a result of tobacco use and more common in males. The disease is characterized by inflammation and thrombosis of small and medium arteries of the legs and feet which recurs and progresses in stages. During the ischemic period, the veins of the lower leg are inflamed, skin has ulceration, and there is gangrene with intermittent claudication. During the nutritional disorder period there is persistent pain and muscle atrophy. During the necrosis period, the pain becomes worse as infection leads to the development of ulcers and gangrene. Pains usually persist; In addition, the patient usually complains of coldness and numbness. Burning sensations is another disturbing symptom.

Treatment usually has to do with smoking cessation.

Raynaud disease is a condition in which some areas of the body feel numb and cool in certain circumstances. In Raynaud's phenomenon, smaller arteries that supply blood to the skin constrict excessively in response to cold, limiting blood supply to the affected area. The fingers, toes, ears and tip of the nose are commonly involved and feel numb and cool in response to cold temperatures or stress.

 

Leriche Syndrome, also commonly referred to as aortoiliac occlusive disease, is a product of atherosclerosis affecting the distal abdominal aorta, iliac arteries, and femoral popliteal vessels. Its triad include; claudication, erectile dysfunction and decreased distal pulse.

56. A 38-year-old male complains of tonic tension of the masticatory muscles, so that he cannot open his mouth. 12 days before, he was bitten by an unknown dog. Objectively: there is pronounced tension and twitching of the masticatory muscles. What is the most likely diagnosis?

Explanation

Notice that this patient has tonic tension of the masticatory muscles and cannot open the mouth ( TRISMUS); tension and twitching of the muscles ( Tetany). These two findings occurred in the background of an unknown dog bite which helps indicate a Tetanus infection ( lockjaw). 

Tetanus (lockjaw) is an acute disease caused by neurotoxins (tetanospasmin) from the bacterium Clostridium tetani. C. tetani enters the body through broken skin (e.g., deep puncture wounds).

 

Rabies is a neurotropic virus contracted from the bite of an infected animal. The virus enters the patient's skin from the saliva of the animal and migrates along the peripheral nerves to the central nervous system (CNS). An incubation period of 4–12 weeks typically precedes the clinical appearance of the disease, which manifests with a prodrome of nonspecific flu-like symptoms, followed by acute rabies encephalitis. Clinical findings include fever, hydrophobia, hypersalivation, and stupor alternating with mania. 

57. A 72-year-old male had had a moderate headache. Two days later, he developed the progressing speech disorders and weakness in the right extremities. The patient has a history of myocardial infarction, arrhythmia. Study of the neurologic status revealed elements of motor aphasia, central paresis of the VII and XII cranial nerves on the right, central hemiparesis on the same side and hyperaesthesia. What is the most likely diagnosis?

Explanation

Ischemic stroke: cerebral infarction due to insufficient cerebral blood flow (hypoperfusion), which results in ischemia and neuronal injury 

Transient ischemic attack: temporary, focal cerebral ischemia; that results in neurologic deficits without acute infarction or permanent loss of function (previously defined as lasting < 24 hours).

 

Hemorrhagic stroke: cerebral infarction due to hemorrhage. 

58. A 28-year-old female patient has been admitted to the gynecology department for abdominal pain, spotting before and after menstruation for 5 days. The disease is associated with the abortion which she had 2 years ago. Anti-inflammatory treatment had no effect. Bimanual examination findings: the uterus is enlarged, tight, painful, smooth. Hysteroscopy reveals dark red holes in the fundus with dark blood coming out of them. What diagnosis can be made on the grounds of these clinical presentations?

Explanation

59. 2 weeks after having quinsy, a 26-year-old male patient got facial edemata, moderate pain in the sacrum. Objectively: body temperature is 37, 5oC, AP- 100/80 mm Hg. Urinalysis results: RBC- up to 100 fresh cells in per HPF, protein - 2,2 g/l, hyaline cylinders - up to 10 per HPF, relative density 1002. What is the most likely diagnosis?

Explanation

Quinsy: Peritonsillar abscess which occurs due to  Bacterial infection ( mostly streptococcal). 

Glomerulonephritis are a group of disorders where the damage to the glomerular filtration apparatus causes a leak of protein +/- blood into the urine, depending on the form. Patients may be asymptomatic or present with hematuria ( red cell casts), proteinuria, edema or hypertension.  Acute glomerulonephritis has a sudden onset while the chronic form has a gradual onset. Note that these changes occurred after the infection two weeks ago. 

Pyelonephritis refers to the bacterial infection of the renal pelvis. Symptoms include fever, oliguria, vomiting, pain. 

 

Urolithiasis refers to the lodging of stone in the urinary tract.

60. Examination of a full-term 6 day old infant revealed that different areas of skin had erythemas, flaccid bubbles, eroded surface, cracks, peeling of the epidermis looking like being scalded with boiling water. There was positive Nikolsky’s symptom. General condition of the child was serious. The child was restless, hypersensitive, febrile. What is the most likely diagnosis in this case?

Explanation

Nikolsky’s sign is a skin finding in which the top layers of the skin slips away from the top layers when rubbed. It is usually positive in Pemphigus Vulgaris, Scalded skin syndrome (Ritter’s exfoliative dermatitis, lyell’s disease), impetigo neonatorum and erythema multi form. 

Ritter’s Exfoliative dermatitis is widespread erythema and scaling of the skin caused by preexisting skin disorders, drugs, cancer, or unknown causes. Symptoms and signs are pruritus, diffuse erythema, and epidermal sloughing.

pseudofurunculosis, is observed in neonates and infants. The disease begins with the appearance of superficial pustules in the ostium of sweat glands (periporitis). Caused by staphylococcus aureus, which penetrates in the depth of the sweat gland and causes the forming of deep indurated painful nodules. The nodules are very similar to furuncles, but they have not got core in the center (hence the name pseudofurunculosis).

Neonatal pemphigus is characterised by  cutaneous, mucosal or mucocutaneous erosions. It results from transplacental passage of IgG maternal autoantibodies.
61. A 39-year-old female patient complains of rapid fatigability, drowsiness, dry skin, hair loss, swelling of the face. A month ago, she underwent a surgery for thyrotoxicosis. The patient has the following gland dysfunction:

Explanation

 

In hypothyroidism, there is reduced production of thyroid hormones ( T3 and T4) leading to findings such as; reduced metabolic rate,  fatigue, cold intolerance, weight gain, and periorbital edema. Notice that this patient underwent a thyroid surgery due to thyrotoxicosis (clinical manifestation of hyperthyroidism); she currently presents with signs of hypothyroidism ( post surgery).

62. A 27-year-old patient has a severe headache, nausea and vomiting. Objectively: body temperature is 38, 9oC, there is a haemorrhagic stellate rash on the legs. The patient takes meningeal pose in bed. Meningeal symptoms are strongly positive. Deep reflexes are brisk, uniform. Pathological reflexes are absent. It has been suspected that the patient has epidemic cerebrospinal meningitis. Which of additional tests should be performed in the first place to verify the diagnosis?

Explanation

 

It is well noted that on examination, the patient presents with Meningeal Symptoms (stiff neck, sensitivity to light etc) with the suspicion of cerebrospinal meningitis. To understand the cause of these meningeal signs and prove the diagnosis, a lumbar puncture is carried out inorder to obtain the cerebrospinal fluid for analysis.

63. 3 hours before, a 68-year-old male patient got a searing chest pain radiating to the neck and left forearm, escalating dyspnea. Nitroglycerin failed to relieve pain but somewhat reduced dyspnea. Objectively: there is crimson cyanosis of face. Respiratory rate is 28/min. The patient has vesicular breathing with isolated sibilant rales. Heart sounds are muffled, with a gallop rhythm. Ps- 100/min, AP- 100/65 mm Hg. ECG shows negative T- wave in V 2 − V 6 leads. What drug can reduce the heart’s need for oxygen without aggravating the disease?

Explanation

64. A 5-year-old girl has had thirst, polyuria, increased appetite for two months. At the same time, there is a 3 kg decrease in body weight. During the last week, these presentations got accompanied by nocturnal enuresis. Examination revealed hyperglycemia at the rate of 14 mmol/l. The child has been diagnosed with type I diabetes. What is the most likely genesis of this disease?

Explanation

 

Recall that diabetes mellitus is a group of metabolic disorders characterized by elevated glucose levels ( hyperglycemia). Type 1 (insulin dependent) and type 2 ( non insulin dependent) are the major forms. Type 1 is the result of an autoimmune response that triggers the destruction of insulin-producing β cells in the pancreas and results in an absolute insulin deficiency. Type 2, which is much more common, has a strong genetic component as well as a significant association with obesity and sedentary lifestyles. Type 2 diabetes is characterized by insulin resistance (insufficient response of peripheral cells to insulin) and pancreatic β cell dysfunction (impaired insulin secretion), resulting in relative insulin deficiency.

65. An 8-year-old child with a 3-year history of diabetes was hospitalized in hyperglycemic coma. Specify the initial dose of insulin to be administered:

Explanation

Initial intravenous administration of 10 to 14 units of short-acting insulin has to be prescribed for the patient during the first hour. Continuous intravenous infusion of insulin in a dose 0,1 unit/kg/hour in 0,9 % sodium chloride infusion has to be given after that.
66. A 12-year-old girl undergoes regular gastroenterological check-ups for duodenal ulcer, biliary dyskinesia. What is the recommended frequency of anti-relapse treatment?

Explanation

67. On the 2nd day of disease a 27-year-old patient complains of unbearable headache, repeated vomiting. Objectively: the patient is in a grave condition. He is conscious but adynamic. Lies in a forced position with his head thrown back. There is no skin rash. Nuchal muscles are evidently rigid, there are Kernig’s and Brudzinski’s signs. t o - 39, 5oC, Ps- 120/min, AP- 130/80 mm Hg. The leading syndrome of this disease is caused by:

Explanation

 

This patient presents with intracranial hypertension. This is a condition in which the pressure of the fluid that surrounds the brain (cerebrospinal fluid or CSF or liquor) is too high. There are two categories of IH: primary intracranial hypertension and secondary intracranial hypertension. Primary intracranial hypertension, now known as idiopathic intracranial hypertension (IIH), occurs without known cause.  Secondary intracranial hypertension has an identifiable, causative agent, including drugs (such as tetracycline, lithium, Vitamin A-derived oral acne medications or excessive ingestion of Vitamin A, and oral or intrathecal steroids, growth hormone treatments), sleep apnea and certain systemic diseases such as lupus, leukemia, kidney failure (uremia), meningitis and dural venous sinus thrombosis. The most common symptom is often an unbearably painful or frequent headache, sometimes associated with nausea and vomiting that is not relieved by medication.

68. Two years ago, a 46-year-old patient was diagnosed with stage I silicosis. Currently the patient complains of escalating dyspnea, pain in the infrascapular regions. Radiograph shows a diffuse enhancement and distortion of lung markings, as well as multiple nodular shadows 2-4 mm in diameter. There is interlobar pleural density on the right. Dense shadows are found in the hilar regions. Specify the form of radiographic pulmonary fibrosis in this case:

Explanation

69. A 63-year-old female complains of general weakness, a feeling of heaviness, compressi on in the epigastrium, postprandial fullness, nausea, belching after meals. These symptoms have been observed for about 15 years. Objectively: body temperature is 36, 4oC, respiratory rate - 20/min, Ps - 88/min, blood pressure - 115/75 mm Hg. Skin and mucous membranes are pale. Blood test results: RBC - 2,0·1012/l, Hb - 100 g/l. Tests revealed parietal cell antibodies. What is the most likely reason for the development of anemia in this patient?

Explanation

Histologically, the stomach is made up of parietal and chief cells. The parietal cells secrete Hydrochloric acid responsible for the stomach’s acidity(intrinsic factor) which helps in digestion and Vitamin B12 absorption. Gastric chief cells secrete Pepsinogen which is converted into pepsin and helps in protein digestion. Notice that  the RBC level is low and the test result revealed parietal cell antibodies which helps suggest that this patient has Vitamin B12 anemia ( pernicious anemia). As earlier stated, Gastric acidity( intrinsic factor ) is necessary for the absorption of vitamin B12, its absence due to parietal cells destruction by antibodies will lead to vitamin B12 deficiency.
70. During dressing of a poorly granulating wound Pseudomonas aeruginosa infection was revealed. What medication would be optimal for the wound d-bridement?

Explanation

  1. Boric acid Medical uses include; 

 
  • antiseptic in burns, cuts and dressing.

  • Vaginal douche in bacterial vaginosis and candidiasis.

  • Prevention of athlete’s foot, otitis externa.

71. A 39-year-old male patient complains of moderate pain and weakness in the shoulder, back and pelvic girdle muscles, that has been progressing for the last 3 weeks; great difficulty in getting out of bed, going up and down the stairs, shaving. Dermatomyositis has been suspected. Blood test results: Hb- 114 g/l, WBC- 10, 8 · 109/l, eosinophils - 9%, ESR -22 mm/h, C-reactive protein (++). The alteration in the following laboratory value wil be of decisive diagnostic significance:

Explanation

Dermatomyositis is a long term inflammatory disorder of the skin and muscles characterised by progressive proximal muscle weakness, Gottron papules and heliotrope rash. Since it is a muscular disorder, on laboratory examination, Muscle enzyme levels will be elevated (eg, creatine kinase, aldolase, aspartate aminotransferase, lactic dehydrogenase). 

Double stranded DNA (dsDNA) is seen in Systemic Lupus Erythematosus

 

Ceruloplasmin is needed for the transportation of copper and is deficient in Wilson’s disease. 

72. A 60-year-old female patient complains of recurrent pain in the proximal interphalangeal and wrist joints, their periodic swelling and reddening that have been observed for 4 years. X-ray picture represents changes in form of osteoporosis, joint space narrowing and single usuras. What is the most likely diagnosis?

Explanation

73. A 30-year-old female patient has been delivered to a hospital for sudden dyspnea progessing to asthma, sensation of having a \"lump in the throat\", hand tremor, fear of death. The attack has developed for the first time and is associated with a strong emotion. There is no previous history. Objectvely: respiratory rate - 28/min, Ps- 104/min, rhythmic, AP- 150/85 mm Hg. The patient has rapid superficial vesicular breathing with extended expiration. Percussion findings: heart borders are not changed. Cardiac sounds are loud, rhythmic. What is the most likely diagnosis?

Explanation

Neurocirculatory asthenia is a circulatory and a form of anxiety disorder that is characterised by breathing difficulties, heart palpitations,shortness of breath, dizziness and insomnia on the bases of neurological or psychiatric disturbance.

In this case, let's try to rule out all other options.

Bronchial Asthma will present earlier, most likely during childhood. It's not going to present for the first time at 30 years of age.

Cardiac asthma often results as a consequence of left heart failure leading to pulmonary congestion and the patient will present with other symptoms like cough, inability to lie flat on bed at night etc.

Thyrotoxic crisis will present with other symptoms of hyperthyroidism like heat intolerance, weight loss, etc.

Hypertensive crisis will likely not present with a sensation of lump in the throat and we might expect a higher blood pressure up to like 180/120mmHg.

 
74. A 42-year-old male patient wth essential hypertension presents with headache, palpitations, unexplained fear. Objectively: Ps- 100/min, AP- 200/100 mm Hg, the left border of cardiac dullness is displaced by 1,5 cm to the left, vesicular breathing is present. ECG shows sinus tachycardia, signs of left ventricular hypertrophy. What drug should be administered as an emergency?

Explanation

Obzidan is also known as Propranolol, inderal is a drug indicated for the treatment of high blood pressure, a number of types of irregular heart rate, thyrotoxicosis, capillary hemangiomas, performance anxiety, and essential tremors. It is classified as a beta blocker (non- selective);  weak indirect α1-adrenoceptor agonist in addition to potent β-adrenoceptor antagonist.

 

Reserpine is an adrenergic blocking agent used to treat mild to moderate hypertension via the disruption of norepinephrine vesicular storage. The antihypertensive actions of Reserpine are a result of its ability to deplete catecholamines from peripheral sympathetic nerve endings. These substances are normally involved in controlling heart rate, force of cardiac contraction and peripheral resistance. 

75. A 37-year-old male patient has a history of diabetes of moderate severity. On the left side of face the patient has a carbuncle. What severe complication might have occurred in the patient?

Explanation

 

Cavernous sinus thrombosis is usually a late complication of an infection of the central face or paranasal sinuses. In cavernous sinus thrombosis, a blood clot blocks a vein that runs through a hollow space underneath the brain and behind the eye sockets ( the cavernous sinus). Notice that this patient has a carbuncle located on the side of the face; this infection is most likely to spread via the sinuses. Cavernous sinus thrombosis can be a complication of this infectious process.

76. A 42-year-old female patient complains of a dull pain in her left side, low-grade fever, accelerated painful urination in small portions. These presentations have been observed for three years. For a long time, the patient has had cystitis with frequent exacerbations, there is pulmonary tuberculosis in the past history. Urinalysis results: microscopic hematuria, leukocyturia. What is the most likely provisional diagnosis?

Explanation

Notice that this patient has a history of pulmonary tuberculosis. Renal tuberculosis occurs due to hematogenous spread of Mycobacterium Tuberculosis to the kidneys. It is the  second most frequent kind of extrapulmonary tuberculosis. Key findings include increased frequency, dysuria ( painful urination), back pain, hematuria ( blood in urine) etc.

Urolithiasis refers to stones in the urinary tract. Dysuria, hematuria are also found in this condition. 

Glomerulonephritis are a group of disorders where the damage to the glomerular filtration apparatus causes a leak of protein +/- blood into the urine, depending on the form. Patients may be asymptomatic or present with hematuria ( red cell casts), proteinuria, edema or hypertension.  The chronic form has a gradual onset.

 

In Chronic cystitis ( inflammation of the bladder), there will be a burning sensation in the pelvic region with the frequent urge to urinate.

77. A woman at 30 weeks pregnant has had an attack of eclampsia at home. On admission to the maternity ward AP- 150/100 mm Hg. Predicted fetal weight is 1500 g. There is face and shin pastosity. Urine potein is 0, 66o/oo. Parturient canal is not ready for delivery. An intensive complex therapy has been started. What is the correct tactics of this case management?

Explanation

A Cesarean Section is a surgical procedure whereby an incision is made on the anterior abdominal wall and uterus to affect the delivery of fetus(es), placenta and membranes after the age of viability. It can be an Emergency or Elective Cesarean Section. The major difference between both is Emergency - Unplanned, while Elective - Planned during the antenatal period.

Indications for Emergency CS:

 
  • Maternal Indications: Eclampsia; Cephalopelvic disproportion; prolonged obstructed labour

  • Fetal Indications: Fetal distress in first stage of labour; Abruptio placenta; Cord prolapse; Multiple gestation with malpresentation of the leading twin.

78. Examination of a dead man who died from hanging revealed that cadaver spots disappeared when pressed upon and restored after 50 seconds, rigor mortis was moderately expressed only in the masticatory muscles and the muscles of neck and fingers. Body temperature was 31oC. Specify the time of death:

Explanation

Forensic pathologists are essentially required to estimate the time since death (TSD) to assist in death investigation. The early post-mortem phase is most frequently estimated using the classical triad of post-mortem changes – rigor mortis, livor mortis, and algor mortis.

Rigor mortis is the post-mortem stiffening of muscles, caused by the depletion of adenosine triphosphate (ATP) from the muscles, which is necessary for the breakdown of actin-myosin filaments in the muscle fibers.

 

Fully developed rigor mortis is an easily identifiable and reliable indicator that death has occurred. The time of onset is variable but it is usually considered to appear between 1 and 6 hours after death. Smaller muscles over the face – around the eyes, around the mouth (masticatory muscles), etc. are the muscles where rigor mortis first appears, followed by rigor mortis of the muscles in the hands and upper limbs and finally appears in the large muscles of the lower limbs. Rigor mortis appears approximately 2 hours after death in the muscles of the face, progresses to the limbs over the next few hours, completing between 6 to 8 hours after death.

79. A 65-year-old male patient complains of dyspnea that is getting worse with exertion, morning cough with expectoration of mucous sputum. For about 15 years, he has been subject to regular medical check-up for chronic bronchitis. The patient takes berodual (16 inhaled doses per day). Objectively: body temperature is 36, 8oC, RR- 24/min, Ps- 110/min, AP- 145/90 mm Hg. Auscultation reveals a lot of dry rales above the lungs. FEV1- 65%. What is the optimal tactics of further management of the patient?

Explanation

From the complaints of this patient ( dyspnea on exertion, cough accompanied by mucus production etc) we understand that this patient has been having exacerbations of COPD ( chronic obstructive pulmonary disease) - Chronic bronchitis. Berodual ( Ipratropium Bromide) is a Short acting Muscarinic agent ( anticholinergic drug) with a bronchodilatory effect and is one of the drugs indicated for the management of COPDs. Note that for The management of acute exacerbation of COPDs, an Inhaled Corticosteroid plus a Long acting Beta 2 Agonist should be administered.
80. A 49-year-old countryman got an itching papule on the dorsum of his right hand. In the centre there is a vesicle with serosanginous exudate. Within the next 2 days the patient developed a painless edema of hand and forearm. On the 4th day the temperature rose to 38, 5oC, in the right axillary region a large painful lymph node was found. One day before the onset of the disease the patient had examined a dead calf. What is the most likely diagnosis?

Explanation

Bacillus anthracis is an aerobic, non-motile, spore forming, large non-hemolytic Gram-positive rod that grows well on blood agar. The clinical manifestations of human anthrax - Cutaneous and Inhalation. 

Cutaneous anthrax, the most common form of naturally occurring disease, begins as a small, painless, pruritic papule that within 2 days enlarges, develops vesicles, and ulcerates to form an eschar. Inhalational anthrax follows inhalation of infectious doses of anthrax spores. 

When anthrax spores get into the skin, usually through a cut or scrape, a person can develop cutaneous anthrax. Human cases may follow contact with contaminated carcasses (dead calf) or animal products. This can happen when a person handles infected animals or contaminated animal products like wool, hides, or hair. Cutaneous anthrax is most common on the head, neck, forearms, and hands. It affects the skin and tissue around the site of infection.

 

Bubonic plague is caused by bacteria called Yersinia pestis. It’s usually spread by fleas. These bugs pick up the germs when they bite infected animals like rats, mice, or squirrels.

81. An employee of a petrol station with 15 years of service record having contact with ethylated gasoline presents with memory impairment, bradycardia, sensation of having a hair in the mouth, skin paresthesia. In this case, one can assume intoxication with the following substance:

Explanation

From anamnesis, this patient has been exposed to Ethylated gasoline from the nature of his Job. Tetraethyl Lead is a lead compound found in Ethylated gasoline. On chronic exposure, individuals present with memory loss, neurological problems, insomnia, psychosis, tremors etc.

Patients with organophosphate poisoning usually present with  Salivation, Lacrimation, Urination, Defecation, Gastric cramps, Emesis (SLUDGE) symptoms.

82. A 38-year-old female suddenly developed acute inflammatory rash in form of roseolas, papules, vesicles that are scattered on the skin of trunk in irregular and predominantly focal manner. The rash appeared a few hours after visiting a restaurant. The patient complains of itching skin. What is the most likely diagnosis?

Explanation

Toxicodermatosis is a disease of the skin caused by a poison or by an allergen. The causative agents may be such chemical substances as antibiotics, sulfanilamides, and bromine, iodine, arsenic, and mercury compounds, or such food products as berries, cheese, or fish. As described in this scenario, the rash appeared after visiting a restaurant. Toxicoderma can also occur as a metabolic disorder or an occupational disease.

The causative agent enters the body through the respiratory organs or the digestive tract, during injections, or by direct contact with the skin. The primary manifestation of toxicoderma is a rash, which is generally symmetrical; it can take the form of inflamed or hemorrhagic maculae, papule, or vesicles (blisters). In severe cases, widespread areas of the skin are affected (erythroderma) and the patient manifests fever, cardiovascular disorders, or symptoms of anaphylactic shock.

With the removal of the allergen the symptoms of toxicoderma rapidly disappear, although relapses (usually severe) may occur with subsequent repeated exposure to the causative agent. Treatment consists in avoiding contact with the suspected allergen or toxic agent, as well as in the use of desensitizing agents and of expectant treatment.

Atopic dermatitis is a chronic condition that requires symptom management. It’s characterized by an itchy, red rash that usually appears at joints in your body, such as knees or elbows, and even around the neck. This condition occurs in flare-ups or bouts, meaning that it gets worse and improves in irregular cycles.

Many doctors use the terms “atopic dermatitis” and “eczema” interchangeably. They are both generic terms for “inflammation of the skin.” Eczema usually starts in early infancy, but also affects a substantial number of adults. It is commonly associated with elevated levels of immunoglobulin E (IgE) and a series of allergic diseases—including food allergy, asthma, and allergic rhinitis.

Contact Dermatitis occurs when your skin has a reaction to something it’s come in contact with. This can include bleach, soap, poison ivy, certain metals, or other irritants. The rash is typically red and may itch or burn.

83. The institutions which take part in medical examinations can be prevention and treatment facilities, medical board of Ministry of Defense, medical board of Ministry of Home Affairs, medico-social expert commissions, forensic medical boards etc. What institutions are responsible for temporary disability examination?

Explanation

84. After lifting a load, a 36-year-old male patient has experienced a severe pain in the lumbar region, which spread to the right leg and was getting worse when he moved his foot or coughed. Objectively: the long back muscles on the right are strained. Achilles jerk is reduced on the right. There is a pronounced tenderness of paravertebral points in the lumbar region. The straight leg raise (Lasegue’s sign) is positive on the right. What additional tests should be performed in the first place?

Explanation

 

A positive Lasegue’s sign - Straight leg raise test refers to the sensation of pain by applying pressure to the piriformis muscle and its tendons , particularly when the hip is flexed at the angle of 90° and the knee extended. A positive straight leg raise test usually indicates S1 or L5 root irritation. To support this diagnosis, a radiography of the spinal column should be carried out.

85. A 17-year-old male patient consulted a therapist about malaise, chills, runny nose, aching muscles and joints, nausea and diarrhea. The patient asks to prescribe him a lot of painkillers and sedatives (tramadol orsolpadein that help the best, and diazepam). Pharyngeal mucosa is pale pink, clean. Auscultation reveals vesicular breathing. Tachycardia is present. The pupils are dilated, there is sluggish response to light. There are injection marks on the forearm skin. During examination, the patient’s manner is vulgar, irritable, rude and untruthful. Make a diagnosis:

Explanation

Opioids, sometimes called narcotics, are a type of drug. They include strong prescription pain relievers, such as oxycodone, hydrocodone, fentanyl, and tramadol. The illegal drug heroin is also an opioid. They are commonly used to treat moderate to severe or refractory pain. Examples of opioids include:

-Full agonist: Morphine, Heroin, Meperidine, Methadone, Codeine, Fentanyl

-Partial agonists: Buprenorphine

-Mixed agonist/antagonist: Pentazocine

-Antagonist: Naloxone, Naltrexone

Treat toxicity with Naloxone (competitive opioid receptor antagonist) and prevent relapse with Naltrexone.

 

The risks of using prescription opioids include dependence and addiction. Dependence means feeling withdrawal symptoms when not taking the drug. Addiction is a chronic brain disease that causes a person to compulsively seek out drugs, even though they cause harm. 

 

Common Signs of Opioid Addiction: The inability to control opioid use; Uncontrollable cravings; Drowsiness; Frequent flu-like symptoms; Isolation from family or friends; Stealing from family, friends or businesses; New financial difficulties. 

This patient has injection marks on the forearms and cravings for Tramadol in addition to showing signs of opioid withdrawal - sweating, dilated pupils, rhinorrhea, lacrimation, nausea, stomach cramps, diarrhea (“flu-like” symptoms), piloerection (“cold turkey”). Flu-like symptoms here include - malaise, chills, runny nose, aching muscles and joints.

Even though Solpadein contains both Paracetamol and Caffeine which are Pain killers, the best choice here is Opioid addiction due to the signs of withdrawal manifested by this patient.

   
86. A 4-year-old boy had untimely vaccination. He complains of painful swallowing, headache, inertness, fever. Objectively: the child is pale, has enlarged anterior cervical lymph nodes, swollen tonsils with cyanotic hyperemia, tonsils are covered with gray white pellicles which cannot be easily removed. When the pellicles are forcibly removed, the tonsils bleed. What is the most likely diagnosis?

Explanation

Diphtheria is an infectious disease caused by the bacterium Corynebacterium diphtheria, which primarily infects the throat and upper airways. The key finding here are the grey white coatings on the tonsils that cannot be easily removed (or bleeds when forcibly removed); these are the main findings of a diphtheria infection (causative agent -Corynebacterium Diphtheriae which produces an Exotoxin ie.,diphtheria toxin).

 

The grey matter covers the back of the throat, making breathing hard. Symptoms include sore throat, fever, swollen lymph nodes and weakness.

87. Public nurseries are designed as a single or several one- or two-storey buildings linked by covered walkways. Planning the structure of preschool instiutions is based upon the following principle:

Explanation

88. A city somatic hospital with 300 beds has a main building which houses the therapeutic and surgical departments. Several separate buildings house the maternity, pediatric and radiologic departments that are connected to the main building by underground walkways and above-ground covered skybridges. Specify the building system of the hospital:

Explanation

89. A 43-year-old female patient complains of dyspnea, swelling of legs, abdomen enlargement, pricking heart pain. She has a history of tuberculous bronchadenitis, quinsies. The patient’s condition deteriorated 6 months ago. Objectively: cyanosis, bulging neck veins, vesicular breathing. Heart borders are not displaced. Heart sounds are muffled, Ps- 106/min, liver is +4 cm, ascites is present. Low voltage on the ECG has been revealed. Radiograph shows a thin layer of calcium deposits along the left contour of heart. What treatment should be recommended to the patient?

Explanation

The 43 year old female patient with signs of edema (swelling of legs), dyspnea, ascites (abdomen enlargement), pricking heart pain, bulging neck veins (increased pressure in jugular veins), muffled heart sounds with history of Tuberculous bronchoadenitis most likely has Tuberculous pericarditis.

Tuberculous pericarditis is an important complication of tuberculosis (TB); the diagnosis can be difficult to establish and is often delayed or missed, resulting in late complications such as constrictive pericarditis as seen in this patient with bulging neck veins and pricking heart pain.

The management is therefore aimed at antituberculous medications for six months, drain fluid from the pericardium if the patient has heart failure, and sometimes remove the pericardium if it is thick and making the patient ill (this will require the skill of a cardiac surgeon); and sometimes give corticosteroids to reduce the effects of the inflammation.

 

The major complaints here that necessitated presentation to the hospital are the symptoms of heart failure and management of this patient’s cardiac condition will require the expertise of a cardiac surgeon.

90. A 26-year-old female patient has an 11 year history of rheumatism. Four years ago she suffered 2 rheumatic attacks. Over the last 6 months there have been paroxysms of atrial fibrillation every 2-3 months. What option of antiarrhythmic therapy or tactics should be proposed?

Explanation

The question is asking for the best antiarrhythmic medication or tactic to be employed in managing this patient’s atrial fibrillation.

Cordarone is in the same class as Amiodarone, an antiarrhythmic drug Class III - Potassium channel blocker. Other medications in this class include Ibutilide, Sotalol, Dofetilide. Indications - Atrial fibrillation, atrial flutter, ventricular tachycardia.

Lidocaine is an antiarrhythmic drug Class IB - Sodium channel blocker used to treat Acute ventricular arrhythmias especially Post Myocardial Infarction.

Defibrillation is commonly used in cases of ventricular fibrillation or pulseless ventricular tachycardia.

 

Heparin is an anticoagulant. It is not an antiarrhythmic medication.

91. Blood typing resulted in positive isohemagglutination reaction with standard sera of A(II) and B(III) groups and negative reaction with sera of 0(I) and AB(IV) groups. What is this result indicative of?

Explanation

Recall that different blood groups present with different antigens and antibodies. 

Group I (O) presents with anti A and anti B antibodies but no antigen.

Group II (A) presents with anti B antibody and A-antigen.

Group III (B) presents with anti A antibody and B- antigen

Group IV (AV) presents with no antibodies and antigen A and antigen B. Note that the presented antigen determines the blood group.

 In terms of compatibility, Group IV (AB) is a universal recipient while Group I (O) is a universal donor; Group II (A) can receive from A and O but can donate to A and AB; Group III(B) can receive from B and O but can donate to B and AB. 

 

From the question stem, a positive reaction with Group II (A) and III(B) shows that anti A and B antibodies are present in the sample blood ( indicating group I (O)) - but also notice that when the blood sample was tested with group I (O), a positive reaction (Clumping) also occurs. This proves that the standard sera used in testing is faulty and is currently giving inaccurate results.

92. A 9-year-old girl has been admitted to a hospital for an elevated body temperature (39, 8oC), painful dry cough, abdominal pain on the right. Examination reveals dullness on percussion on the right, diminished breath sounds, crepitus. What study is required to make a diagnosis?

Explanation

 

This patient presents with symptoms that indicates a pathology regarding the pulmonary system. These symptoms include: painful dry cough, diminished breath sounds, crepitus and dullness on percussion. To make a diagnosis, a simple chest x-ray (radiography of the chest cavity ) should be carried out.

93. A newborn has purulent discharges from the umbilical wound, the skin around the navel is swollen. The baby’s skin is pale, with a yellow-gray tint, generalized hemorrhagic rash is present. What is the most likely diagnosis?

Explanation

Sepsis is a medical condition caused by the body’s reaction to an infection. Neonatal sepsis can be caused by organisms such as E. coli, listeria, Group B streptococcus, Herpes simplex virus etc. Conditions that increase the risk of neonatal sepsis include: Preterm birth, early rupture of membrane, chorioamnionitis etc.Key signs include: Fever, vomiting, diarrhea, pale skin with yellow and white tint ( jaundice), irritability, difficulty in breathing and feeding etc. 

Hemorrhagic disease of  newborn occurs as a result of deficiency in vitamin K or essential blood clotting factors, trauma. It is characterised by excessive bleeding.

 

Hemolytic disease of newborn occurs due to ABO incompatibility or Rhesus Incompatibility between mother and child ( mother -ve, child +ve). 

94. A pregnant 26-year-old woman was admitted to a hospital for abdominal pain and Bleeding from the genital tract. Bimanual examination revealed that uterus was the size of 9 weeks of pregnancy, the cervical canal let a finger through. Fetal tissues could be Palpated in the orifice. There was moderate vaginal bleeding. What is the tactics of choice?

Explanation

This patient is most likely experiencing a Missed Abortion which is defined as the retention of dead product of conception for 4 weeks or more. Notice that the size of the uterus resembles that of a 9 week pregnancy and fetal tissues can be palpated from the cervical orifice accompanied by bleeding.  The appropriate tactics of choice is to evacuate the fetal tissue through vaginal or suction evacuation.
95. On the second day of the disease a 22- Year-old male patient complains of high-grade Fever, headache in the region of forehead and Superciliary arches, and during eye movement; Aching muscles and joints. Objectively: body Temperature is 39oC. Face is hyperemic, Sclerae are injected. The mucous membrane Of the soft palate and posterior pharyngeal wall is bright hyperemic and has petechial Hemorrhages. What changes in the hemogram Are typical for this disease?

Explanation

96. A 44-year-old male patient complains of severe non-localized abdominal pain, pain in the right shoulder girdle, repeated vomiting, red urine. The onset of the disease is associated with alcohol consumption. The face is hyperemic. AP- 70/40 mm Hg. Abdominal radiography reveals no pathological shadows. Hemodiastase is 54 mg/h/l. Prothrombin is 46%. What is the provisional diagnosis?

Explanation

Acute Pancreatitis refers to the inflammation of the pancreas usually caused by alcohol consumption or biliary tract disorders. Acute pancreatitis usually presents with epigastric pain radiating to the back, nausea and vomiting, and epigastric tenderness on palpation. These signs are accompanied by the release of proteolytic enzymes from the pancreas that cause autodigestion. Notice that the patient’s diastase level is high, diastase refers to groups of enzymes that catalyze the breakdown of starch to maltose; these enzymes include α,β and γ amylase (especially α). The diastase level is useful in the diagnosing of diseases such as pancreatitis, jaundice, gall stones etc.

 

In Acute myocardial infarction Biomarkers such as Troponin, Creatinine phosphokinase (MB isoform) and myoglobins will be elevated on biochemical analysis.

97. A 41-year-old male patient was delivered to a hospital unconscious. During the previous 7 days he had been taking large doses of biseptolum for a cold. The night before, he began complaining of dyspnea, especially when lying down, swollen legs, 2-day urinary retention. In the morning he had seizures and lost consciousness. Objctively: noisy breathing at the rate of 30/min, edematous legs and lumbar region, Ps- 50/min. Plasma creatinine is 0,586 mmol/l, plasma potassium - 7,2 mmol/l. What treatment is necessary for this patient ?

Explanation

 

This Patient presents with Acute Kidney Failure which is defined as a significant reduction in renal function occurring over hours or days clinically manifesting as an abrupt and sustained rise in serum urea and creatinine. It might be asymptomatic but oliguria is common. Life threatening consequences include volume overload ( presents as edema), increased potassium levels and metabolic acidosis. Note that plasma potassium levels > 7 mmol/l is an indication for Dialysis. Hemodialysis is a procedure used for removal of waste materials from the blood through filtration.

98. A 10-year-old child with a history of nonrheumatic carditis has periodic attacks manifested by heart pain, dyspnea, pallor, high blood pressure, a dramatic increase in heart rate up to 180/min. What drug would be most effective to treat this patient?

Explanation

 

Propranolol (Obsidan) is a drug indicated for the treatment of high blood pressure, a number of types of irregular heart rate, thyrotoxicosis, capillary hemangiomas, performance anxiety, and essential tremors. It is classified as a beta blocker (non- selective);  weak indirect α1-adrenoceptor agonist in addition to potent β-adrenoceptor antagonist. Procainamide and lidocaine are Na channel blockers  used to treat Acute ventricular arrhythmias especially Post Myocardial Infarction.

99. A 45-year-old male patient with acute abscess of the left lung has suddenly developed acute chest pain and dyspnea while coughing, tachycardia has increased. The control Ro-gram  shows left lung collapse, the air in the left pleural cavity and a horizontal fluid level. What is the mechanism of this complication?

Explanation

Lung abscess is a type of liquefactive necrosis of the lung tissue and formation of cavities (more than 2 cm) containing necrotic debris or fluid caused by microbial infection. It can also be caused by aspiration, which may occur during altered consciousness and it usually causes a pus-filled cavity.

Recall that An abscess is a cavity filled with Purulent content found within body tissue. This patient presents with an acute abscess of the left lung and can be easily identified on X-ray fluid as a cavity with air-fluid level. 

 

One major complication of an abscess is the rupture and release of its content into surrounding tissues. This is a serious medical concern. Potential complications following rupture of an abscess could lead to Empyema - this is a large collection of infected fluid around the lung that occurs where the abscess is. As seen in this patient with air and horizontal fluid level in the pleural cavity.

100. A 24-year-old male patient had been diagnosed with class III diffuse toxic goiter. There is moderate hyperthyroidism. A surgery was suggested, and the patient agreed to it. What preoperative measures should be taken for prevention of thyrotoxic crisis in the postoperative period?

Explanation

 

The patient in question already has diffuse toxic goiter with clinical manifestation of hyperthyroidism. Thyroid storm, also referred to as thyrotoxic crisis, is an acute, life-threatening, hypermetabolic state induced by excessive release of thyroid hormones in individuals with thyrotoxicosis. During a thyroid storm, an individual’s heart rate, blood pressure, and body temperature can soar to dangerously high levels. Without prompt, aggressive treatment, thyroid storm is often fatal. Thyroid storm may be precipitated by the stress of surgery, anesthesia, or thyroid manipulation and may be prevented by pretreatment with antithyroid drugs.

101. A 26-year-old male patient complains of pain in the right knee, which is getting worse in the morning. Two weeks before, he consulted an urologist about prostatitis. Objectively: conjunctivitis is present. There is also periarticular edema of the knee joint, redness of the overlying skin. Rheumatoid factor was not detected. Until further diagnosis is specified, it would be reason able to start treatment with the following antibiotic:

Explanation

A 26 year old male patient that presented with arthritis, prostatitis and conjunctivitis raised strong suspicion for a sexually transmitted infection with Chlamydia or Reactive Arthritis in which Chlamydia is also a culprit. 

Chlamydia is a common sexually transmitted infection caused by bacteria. In men, it can manifest with urethritis which can spread to the prostate causing Prostatitis; conjunctivitis; Arthritis and commonly cause pelvic inflammatory disease (PID) in women. Chlamydia is an obligate intracellular organism and often treated with macrolides (Azithromycin) or Tetracyclines. Drugs’ ability to accumulate intracellularly makes them very effective against Chlamydia. 

 

Penicillin is the drug of choice in the case of Syphilis; Cephalosporin (Ceftriaxone) in the case of Gonorrhea.

102. A 66-year-old female patient has been admitted to a hospital for massive gross hematuria with release of shapeless blood clots, frequent painful urination. The patient also reports a moderate weight loss within 3-4 months. Gross hematuria that was not accompanied by pain and dysuria first occurred three months ago for no apparent reason, and after a few days the bleeding subsided independently. What is the most likely diagnosis?

Explanation

People with bladder cancer may experience the following symptoms or signs: Blood or blood clots in the urine (Hematuria) which is usually painless; Pain or burning sensation during urination; Frequent urination; Feeling the need to urinate many times throughout the night (Nocturia); Feeling the need to urinate, but not being able to pass urine etc.

Most often, bladder cancer is diagnosed after a person tells his or her doctor about blood in the urine, also called hematuria. "Gross hematuria" means that enough blood is present in the urine that the patient can see it. It is also possible that there are small amounts of blood in the urine that cannot be seen. This is called "microscopic hematuria," and it can only be found with a urine test.

 

Renal tumor will present with hematuria, flank pain and palpable mass which is absent in this patient. Urolithiasis will also present with colicky flank pain (lumboabdominal pain), hematuria, vomiting, which are also not present in this patient. Hematuria is not usually associated with Acute or Chronic Cystitis, suprapubic pain is more common with these conditions.

103. A 36-year-old female pesented to a gynecological hospital with a significant bleeding from the genital tract and a 1-month delay of menstruation. Bimanual examination revealed soft barrel-shaped cervix. Uterus was of normal size, somewhat softened. Appendages were unremarkable on both sides. Speculum examination revealed that the cervix was cyanotic, enlarged, with the the external orifice disclosed up to 0,5 cm. Urine hCG test was positive. What is the most likely diagnosis?

Explanation

hCG is positive plus amenorrhea (absent menses for 1 month) in a woman of reproductive age clearly indicates pregnancy. hCG can be detected as early as 1-2 weeks of gestation - this is what is tested in urine pregnancy test kits.

 

On Bimanual examination, Uterus (womb) is without changes, appendages (i.e. fallopian tubes, ovaries) are also unremarkable but the question clearly states that the cervix is barrel-shaped, cyanotic, and enlarged. This shows that the embryo was probably implanted in the cervix, hence, Cervical pregnancy.

104. A 47-year-old female patient has an 8- year history of ulcerative colitis, has been treated with glucocorticoids. She complains of cramping pain in the umbilical region and left iliac region which has significantly increased during the past 2 weeks, diarrhea with mucus and blood 4-6 times a day, elevated body temperature up to 38 − 39oC, headache and pain in the knee joints. Objectively: the patient is in moderate condition, Ps- 108/min, AP- 90/60 mm Hg; heart and lungs are unremarkable; the tongue is moist; abdominal muscle tone is significantly decreased; peristaltic noises are absent. What complication developed in the patient?

Explanation

The term inflammatory bowel disease describes a group of disorders in which the intestines become inflamed. Two major types of inflammatory bowel disease are Ulcerative colitis and Crohn’s disease. Ulcerative colitis is limited to the colon or large intestine. Crohn’s disease, on the other hand, can involve any part of the gastrointestinal tract from the mouth to the anus. 

The patient in question suffers from Ulcerative colitis. Common complications include; Toxic megacolon (toxic dilatation of the colon), or fulminant colitis. If Ulcerative colitis attack is severe, the colon might burst, or infection could spread through your body. Your intestines stop moving waste, and your belly swells. However, if a toxic megacolon is not urgently attended to, it could further lead to perforation.

 

Fistulas, abscess, and strictures are commonly associated with Crohn’s disease.

105. A 10-year-old child has been admitted to a hospital with a closed craniocerebral injury with a suspected cerebral edema. The patient is in grave condition, unconscious. The dyspnea, tachycardia, hypertension are present. Muscle tone is increased, there is nystagmus, pupillary and oculomotor reactions are impaired. The mandatory component of intensive care is dehydration. What diuretic is adequate in this case?

Explanation

By definition cerebral edema is the excess accumulation of water in the intra-and/or extracellular spaces of the brain. The most rapid and effective means of decreasing tissue water and brain bulk is osmotherapy. Osmotic therapy is intended to draw water out of the brain by an osmotic gradient and to decrease blood viscosity. These changes would decrease ICP and increase cerebral blood flow (CBF). 

Mannitol is the most popular osmotic agent. However, prolonged administration of Mannitol results in an electrolyte imbalance that may override its benefits and that must be carefully monitored. Nursing care of the patient receiving Mannitol requires vigilant monitoring of electrolytes and overall fluid balance and observation for the development of cardiopulmonary complications in addition to neurological assessment.

 

Therefore, the best choice is to go for diuretics to prevent some of the complications associated with Mannitol. Furosemide is a loop diuretic with a strong osmotic effect. It has been shown to prolong the reversal of blood brain osmotic gradient established with the osmotic agents by preferentially excreting water over solute. Furosemide is a strong diuretic and acts fast.

106. For 3 days, a 28-year-old emale patient had had the body temperature increase up to 38oC, weakness, poor appetite, nausea, a single vomiting. On the 4th day the temperature was normal, the condition improved, but the jaundice developed. Objectively: moderate ictericity of skin, +3 cm enlarged liver of elastic consistency. Ortner’s, Kehr’s and Voznesensky’s symptoms are negative. What test will verify the diagnosis?

Explanation

This patient’s illness of an acute infection that lasted for 3 days with fever, hepatomegaly, jaundice and resolved on its own is consistent with Acute Hepatitis. Hepatitis B, C and D commonly manifest as chronic illnesses, while Hepatitis E is commonly associated with pregnant women. Hepatitis A on the other hand is transmitted fecal-orally and can produce an acute hepatitis infection in which the patient can recover completely with or without treatment.

Hepatitis A is a highly contagious liver infection caused by the hepatitis A virus. You're most likely to get hepatitis A from contaminated food or water or from close contact with a person or object that's infected. Mild cases of hepatitis A don't require treatment. Most people who are infected recover completely with no permanent liver damage.

IgM indicates an Acute Infectious process (IgM Anti-HAV - IgM Antibody to hepatitis A virus). IgG indicates a Chronic Infectious Process and it can be seen in immunized patients.

 

Of all the options listed, only IgM Anti-HAV will verify the diagnosis. Complete Blood Count will show increased Lymphocytes (shows an active viral infection) but will not verify which particular virus. Other options will tell us there is a pathology somewhere in the liver but none will verify the particular virus.

107. An 11-year-old girl has been immunized according to her age and in compliance with the calendar dates. What vaccinations should the children receive at this age?

Explanation

It is recommended that diphtheria, tetanus, and acellular pertussis vaccination be administered across the lifespan. Children younger than 7 years of age receive DTaP or DT, while older children and adults receive Td. 

D- Diphtheria; T- Tetanus; P- Pertussis (Whooping cough); aP- acellular pertussis vaccine.

 
  • Give infants and children 5 doses of DTaP. Give one dose at each of these ages: 2 months, 4 months, 6 months, 15 through 18 months, and 4 through 6 years.

  • Give adolescents a single dose of Tdap, preferably at 11 to 12 years of age.

  • Give pregnant women a single dose of Tdap during every pregnancy, preferably during the early part of gestational weeks 27 through 36. 

  • Give adults who have never received Tdap a single dose of Tdap. This can be given at any time, regardless of when they last got Td. This should be followed by either a Td booster every 10 years. 

108. A 40-year-old male patient has had heaviness in the epigastric region for the last 6 months. He has not undergone any examinations. The night before, he abused vodka. In the morning there was vomiting, and 30 minutes after physical activity the patient experienced dizziness and profuse hematemesis. What pathology should be suspected in the first place?

Explanation

The patient abused Vodka the night before he presented to the hospital with dizziness, profuse hematemesis (bloody vomit). Heavy alcohol ingestion is considered to be one of the most important predisposing factors as about 50% to 70% of the patients diagnosed with Mallory-Weiss syndrome have a history of the same.

Mallory-Weiss syndrome (MWS) is one of the common causes of acute upper gastrointestinal (GI) bleeding, characterized by the presence of longitudinal superficial mucosal lacerations (Mallory-Weiss tears). These tears occur primarily at the gastroesophageal junction; they may extend proximally to involve the lower or even mid esophagus and at times extend distally to involve the proximal portion of the stomach.

 

It is a lower esophageal lacerations (not ulcerations) happening to patients with repetitive forceful retching and vomiting following excessive alcohol intake.

109. A 55-year-old patient complains of severe itching, burning and pain in the eyes, skin redness in the outer corners of the palpebral fissure. Objectively: skin around the outer corners of the palpebral fissure is macerated, eczematous, there are single moist cracks. Palpebral conjunctiva is hyperemic, quaggy. There are minor discharges in form of stringing mucus. What is the most likely diagnosis?

Explanation

The conjunctiva is a thin, translucent, relatively elastic tissue layer with both bulbar and palpebral portions. The bulbar portion of the conjunctiva lines the outer aspect of the globe, while the palpebral portion covers the inside of the eyelids. 

Conjunctivitis refers to any inflammatory condition of the membrane that lines the eyelids and covers the exposed surface of the sclera. It is the most common cause of “red eye.”

Chronic conjunctivitis is most commonly caused by Staphylococcus species, although other bacteria are occasionally involved. This type of conjunctivitis often develops in association with blepharitis - bacterial colonization of the eyelid margins (palpebral conjunctiva is hyperemic and quaggy). The symptoms of chronic conjunctivitis include itching, burning, a foreign-body sensation and morning eyelash crusting, flaky debris, erythema and warmth along the lid margins, as well as eyelash loss and bulbar conjunctival injection (red eye).

 

Acute bacterial conjunctivitis typically presents with burning, irritation, tearing and, usually, a mucopurulent or purulent discharge and usually self-limited.

110. A 3-month-old infant has occipital alopecia, restless sleep, excessive sweating. What disease can you think of?

Explanation

Rickets (Rachitis) is a metabolic disease of growing bone that is unique to children (especially of the first 2 years) and adolescents often associated with Vitamin D deficiency. Vitamin D deficiency results in Rickets in Children and Osteomalacia in adults. Apart from the decreased bone mineralization in Rickets, there are also some non specific symptoms commonly found in patients with this condition.

  • Occipital Alopecia: occurs in about 30%.

  • Muscular Hypotonia: generalized muscular hypotonia; “floppy baby syndrome” or “slinky baby” 

  • Neurologic abnormalities: observed in all cases and revealed at initial period of disease as irritability, interrupted sleep, sweating.

 

Rachitic rosary; Craniotabes; occipital alopecia and enlargement of the wrists were four most common physical examination findings for the age group 0 - 6 months.

111. A 50-year-old male in a grave condition has been admitted to the intensive care unit. It is known from life history that the patient works in agriculture, and 3 hours ago was engaged into insecticide treatment of crops for control of colorado potato beetle. Condition on admission: acrocyanosis, bronchorrhea, tachypnea, AP- 100/60 mm Hg, Ps- 44/min. What method of efferent therapy would be most appropriate at this stage?

Explanation

Hemosorbtion: Removal of toxins or metabolites from the circulation by the passing of blood, within a suitable extracorporeal circuit, over semipermeable microcapsules containing adsorbents (e.g., activated charcoal) or enzymes, or other adsorbents (e.g., various resins, albumin-conjugated agarose).

Hemodialysis: A medical procedure to remove fluid and waste products from the blood and to correct electrolyte imbalances. This is accomplished using a machine and a dialyzer, also referred to as an \"artificial kidney.\"

Hemodialysis is used to treat both acute (temporary) and chronic (permanent) kidney failure.

Plasmapheresis (PP) is the removal of whole blood from the patient, its separation by machine into component parts, and then the return of certain of those components to the patient.  Indications include Gulliane barre syndrome, good pasture syndrome, chronic demyelinating disorders , Thrombotic thrombocytopenic purpura etc.

112. An 80-year-old patient complains of constantly urinating small amounts, a feeling of pressure in the lower abdomen. Objectively: there is a suprapubic spherical bulging with percussion dullness over it. What syndrome occurred in the patient?

Explanation

Paradoxical Ischuria is also known as urinary retention which refers to the inability to completely empty the bladder. It results from either a blockage that partially or fully prevents the flow of urine, or your bladder not being able to maintain a strong enough force to expel all the urine. Note that Urinary Incontinence and Urinary retention are completely opposite terms. Urinary Incontinence refers to the inability to hold urine and occurs when the control of the urinary sphincter is lost or weakened.

Notice that there is a suprapubic spherical bulging with percussion dullness - this is indicative of a full bladder which implies that this person is unable to empty the bladder ( paradoxical ischuria/ urinary retention).

113. Carpathian region is characterized by permanently high (over 80%) air humidity. In the cold season the population of this region feels very cold at moderately low temperatures. This is due to an increase in the heat transfe by:

Explanation

Convection refers to the transfers of heat via the movement of fluids and gases. Note that relative humidity also has a direct effect on convective heat transfer. Higher humidity will raise the amount for convective heat transfer coefficient and subsequently the rate of heat transfer increases.

Conduction involves the direct transfer of heat from one molecule to another. 

 

Radiation. Radiation involves the transfer of heat through the air or a vacuum. Heat from the sun is carried by radiation. The human body radiates heat in all directions. The ability to dissipate body heat by radiation depends on the temperature of the environment. Environmental temperature must be less than that of the body for heat loss to occur.

114. An 18-year-old girl complains of breast pain and engorgement, headaches, irritability, swelling of the lower extremities. These symptoms have been observed since menarche and occur 3-4 days before the regular menstruation. Gynecological examination revealed no pathology. Make a diagnosis:

Explanation

Premenstrual syndrome is a wide variety of signs and symptoms that affects a woman’s emotion, physical health, and behavior during certain days of the menstrual cycle, generally just before her menses. Symptoms start five to 11 days before menstruation and typically go away once menstruation begins. Signs include abdominal pain and bloating, vomiting ,meteorism, change in sleep patterns, emotional instability etc. 

 

Neurasthenia is a condition that is characterized especially by physical and mental exhaustion usually with accompanying symptoms (such as headache and irritability), is of unknown cause but is often associated with depression or emotional stress, and is sometimes considered similar to or identical with chronic fatigue syndrome.

115. A 56-year-old male patient has been delivered to the emergency department with frostbite on both feet. What aid should be rendered to the victim?

Explanation

A person who has frostbite should be covered with a warm blanket ( a warm bandage on the affected area). The frostbitten area should be warmed slowly and should not be warmed in front of a fire nor rubbed with snow. A vasodilatory injection such as Reserpine can be administered to improve blood flow to the affected area. Antibiotic therapy can also be given.
116. A 21-year-old male patient got a deep cut wound in his right thigh. In the emergency room a surgeon on duty performed primary debridement of the wound and primary wound closure with a suture. After 4 days, there appeared pain, redness, edema, purulent discharge from the wound gap, body temperature rose up to 39oC. What kind of wound complication can you think of and what actions should be taken?

Explanation

Recall that an abscess is a purulent filled cavity found within the body tissue. A wound abscess occurred in this process mainly due to an infection before or during the closure of the wound. This is confirmed by the presence of edema and purulent content from the wound gap 4 days after the closure. The sutures of this wound should be removed and the purulent content should be drained followed by an antibiotic therapy.
117. A general practitioner visited a 2-year-old child and diagnosed him with measles. The child attends a nursery, has a 5-year-old sister. What document must be filled in for the effective antiepidemic measures in the given health locality?

Explanation

 

This Patient has a measles infection ( an infectious disease).  A form that will notify the infectious disease department and provide the necessary information to help curtail the spread should be filled .

118. An employee has been diseased for 4 months, further treatment is necessary, the patient is incapacitated. Who is authorized to provide further disability examination of this patient?

Explanation

119. It has been suspected that a newborn has congenital diaphragmatic hernia (asphyctic incarceration). What study will allow to confirm the diagnosis?

Explanation

 

A diaphragmatic hernia is a congenital defect characterized by the protrusion of abdominal cavity contents into the thoracic cavity. This occurs due to the presence of a defective hole in the diaphragm. Recall that the diaphragm is one of the major muscles of respiration and separates the thoracic cavity from the abdominal cavity;  a defective hole will allow the passage of abdominal organs into the thoracic cage. This pathology is usually diagnosed by a chest X-ray ( plain radiography of the chest).

120. A 25-year-old female presented to a women’s welfare clinic and reported the inability to get pregnant within 3 years of regular sexual activity. Examination revealed. increased body weight, male pattern of pubic hair growth, excessive pilosis of thighs, dense enlarged ovaries, monophasic basal temperature. What is the most likely diagnosis?

Explanation

Polycystic ovarian syndrome is a disorder found in women of reproductive age commonly due to hormonal disorder (high level of androgens). This disorder is characterised by infrequent menstrual cycle, pelvic pain, weight gain male pattern pubic hair growth, excessive hair on the thighs etc. The ovaries mostly develop follicles (collection of fluids). Realise that the patient is of a reproductive age and experiences infrequent menstruation; 

Premenstrual syndrome is a wide variety of signs and symptoms that affects a woman’s emotion, physical health, and behavior during certain days of the menstrual cycle, generally just before her menses. Symptoms start five to 11 days before menstruation and typically go away once menstruation begins. Signs include abdominal pain and bloating, vomiting ,meteorism, change in sleep patterns, emotional instability etc.
121. A factory’s sectorial doctor selects a group of persons who often fall ill for thorough monitoring. At the same time he takes into consideration the number of etiologically related cases with temporary disability in each of the employees over the last year. An employee falls into this group if the number of sickness cases is:

Explanation

122. A 23-year-old female consulted a gynecologist on the 20th day postpartum period about pain in the left breast, purulent discharge from the nipple. Objectively: Ps-120/min, t-39C. The left breast is painful, larger than the right one, hyperemic. In the upper quadrant there is an infiltrate sized 10x15 cm with a softening inside. Blood test results: ESR- 50 mm/h, WBC- 15, 0 · 109/l. What is the tactics of choice?

Explanation

This patient who is 20 days postpartum most likely has Postpartum or Puerperal Mastitis. It is an inflammation of breast tissue that sometimes involves an infection. The inflammation results in breast pain, swelling, warmth and redness. You might also have fever and chills. Mastitis most commonly affects women who are breast-feeding (lactation mastitis). Milk that is trapped in the breast is the main cause of mastitis. Also, Bacteria from your skin's surface and baby's mouth can enter the milk ducts through a crack in the skin of your nipple or through a milk duct opening. Stagnant milk in a breast that isn't emptied provides a breeding ground for the bacteria.

 

From the question stem, In the upper quadrant of the left breast, there is an infiltrate sized 10 X 15cm with a softening inside. This case will require an incision and drainage which will be done by the surgical team followed by antibiotic treatment.

123. A family lives in the town situated within the zone of radiation pollution. A 6-year-old child had been ill with ARVI for 19 days. The child was undergoing outpatient treatment and was nursed by his mother, a cafe worker. Specify the order of disability examination:

Explanation

Employees are entitled to emergency time off (sick leave) to care for a dependant. A dependant includes:

  • spouse/partner,

  • child/grandchild,

  • parent/grandparent or

  • someone else who depends on you for their care.

 

Your employer may ask for evidence that you are entitled to parental leave. A birth certificate will usually do the trick and you’re entitled to return to the same job after taking parental leave.

124. A 49-year-old female patient with schizophrenia is all the time listening to something, insists that \\\"there is a phone in her head\\\"as she hears the voice of her brother who tells her to go home. The patient is anxious, suspicious, looks around all the time. Specify the psychopathological syndrome:

Explanation

This patient clearly shows signs of auditory hallucination which is very often seen in patients with Schizophrenia. Auditory hallucinations, or hearing voices, is a common symptom in people living with Schizophrenia. These voices can call your name, argue with you, threaten you, come from inside your head or via outside sources, and can begin suddenly and grow stronger over time.

 

Hallucinations: perceptions in the absence of external stimuli e.g. seeing a light that is not actually present; hearing or talking to someone when no one is actually there. Types: Auditory (common in Psychiatry illnesses like Schizophrenia); Visual (common with delirium, drug intoxication); Olfactory; Tactile (e.g. ‘Cocaine crawlies’) etc.

125. During the first home visit to a full-term boy after his discharge from the maternity hospital a pediatrician revealed a symmetrical swelling of mammae without skin changes over them, swelling of the scrotum. The body temperature was of 36, 5oC. The baby was calm, sucked the mother’s breast actively. What condition should you think of?

Explanation

Under the influence of maternal hormones during pregnancy a newborn may exhibit signs of hormone exposure after birth. Hormones from the mother (maternal hormones) are some of the chemicals that pass through the placenta into the baby's blood during pregnancy. These hormones can affect the baby.

For example, pregnant women produce high levels of the hormone estrogen. This causes breast enlargement in the mother. By the third day after birth, breast swelling may also be seen in newborn boys and girls. Such newborn breast swelling does not last, but it is a common concern among new parents. The breast swelling should go away by the second week after birth as the hormones leave the newborn's body. 

Hormones from the mother may also cause some fluid to leak from the infant's nipples. This is called witch's milk. It is common and most often goes away within 2 weeks.

Newborn girls may also have temporary changes in the vaginal area.

  • The skin tissue around the vaginal area, called the labia, may look puffy as a result of estrogen exposure.

  • There may be a white fluid (discharge) from the vagina. This is called physiologic leukorrhea.

  • There may also be a small amount of bleeding from the vagina.

 

These changes are common and should slowly go away without any intervention.

126. A 30-year-old male patient complains of inertness, low-grade fever, bleeding gums, frequent quinsies, aching bones. Objectively: the patient has pale skin and mucous membranes, sternalgia, +2 cm liver, +5 cm painless spleen. Blood test results: RBC- 2, 7 · 1012/l, Нb- 80 g/l, WBC- 3 · 109/l, eosinophils - 4%, basophils - 5%, blasts - 4 segmented neutrophils - 17%, lymphocytes -29%, myelocytes - 25%, promyelocytes - 12%, monocytes - 2%, platelets - 80 · 109/l, ESR -57 mm/h. What test should be performed to verify the diagnosis?

Explanation

Normal Rbc level in the blood ranges from about Male: 4.3 − 5.9 · 1012/L Female: 3.5 − 5.5 · 1012/L and hemoglobin level: Male: 135-175 g/L; Female: 120-160 g/L. A reduction in these values in the blood test indicates Anemia. Red blood cells are produced in the bone marrow of large bones and a bone marrow biopsy is needed for diagnosis. Platelets and White Blood Cells are also markedly decreased in this case. We are actually looking at a case of Pancytopenia.

Pancytopenia occurs when a person has a decrease in all three blood cell types. This happens when something is wrong with the bone marrow, where blood cells are formed. Pancytopenia has many possible causes: Diseases such as cancer, lupus or bone marrow disorders. Sternal puncture which is a type of bone marrow biopsy is indicated to verify the diagnosis.

[caption id="attachment_1376" align="alignnone" width="300"]Complete Blood Count Complete Blood Count[/caption]
127. A 46-year-old male patient complains of periodic epigastric pain that occurs at night. Objectively: HR- 70/min, AP- 125/75 mm Hg, tenderness in the epigastric region is present. EGD confirms duodenal ulcer of 0,6 cm in diameter. Test for H. Pylori is positive. Which of the given antisecretory drugs will be a compulsory element of the treatment regimen?

Explanation

Infection with H pylori is associated with the development of peptic ulcer disease, gastric cancer, and mucosa-associated lymphoid tissue lymphoma. Treatment Regimens for Eradication of H. pylori are omeprazole, amoxicillin, and clarithromycin (OAC) for 10 days; bismuth subsalicylate, metronidazole, and tetracycline (BMT) for 14 days; and lansoprazole, amoxicillin, and clarithromycin (LAC), which has been approved for either 10 days or 14 days of treatment. 

Proton Pump Inhibitors (PPI) are the first line antisecretory agents used in treating H. Pylori associated Peptic Ulcer Disease. Examples of PPI’s include: Omeprazole; Lansoprazole; Esomeprazole; Pantoprazole. They irreversibly inhibit H+/K+ ATPase in stomach parietal cells.

 

Famotidine, Cimetidine are examples of H2-Histamine receptor blockers. This class of antisecretory agents are older than Proton Pump Inhibitors and no longer first line antisecretory agents due to their adverse effect profile such as multiple drug interactions, antiandrogenic effects etc.

128. A 47-year-old male patient has been lately complaining of compressing chest pain that occurs when he walks a distane of 700-800 m. Once a week, he drinks 2 liters of beer. Rise in arterial pressure has been observed for the last 7 years. Objectively: Ps- 74/min, AP- 120/80 mm Hg. The bicycle ergometry performed at workload of 75 watts shows 2 mm ST-segment depression in V 4 − V 6 leads. What is the most likely diagnosis?

Explanation

An angina refers to chest pain due to an ischemic myocardium secondary to coronary artery narrowing or spasms. Canadian Cardiovascular Society grading of angina pectoris is a classification used to grade the severity of Angina.

Class 0: Asymptomatic Angina- Mild myocardial ischemia with no symptoms.

Class I: Angina only with strenuous exertion- Presence of angina during strenuous, rapid, or prolonged ordinary activity (walking or climbing the stairs).

Class II:Angina with moderate exertion- Slight limitation of ordinary activities when they are performed rapidly, after meals, in cold, in wind, under emotional stress, during the first few hours after waking up, but also walking uphill, climbing more than one flight of ordinary stairs at a normal pace and in normal conditions.

Class III: Angina with mild exertion- Having difficulties walking one or two blocks or climbing one flight of stairs at normal pace and conditions e.g walking short distances (20 - 100m)

Class IV: Angina at rest- No exertion needed to trigger angina.

 

The patient in perspective experiences anginal symptoms after he walks about 700 - 800m (a short distance and normal activity).

 

The New York Heart Association (NYHA) also classifies the extent of heart failure. It classifies patients in one of the four categories based on their limitations during physical activity.

CLASS I: No symptoms and no limitation in ordinary physical activity

CLASS II: Mild symptoms (mild shortness of breath and/or angina) and slight limitation during ordinary activity.

CLASS III: Marked limitation in activity due to symptoms, even during less than ordinary activity e.g. walking short distances (20 - 100m). Comfortable only at rest.

 

CLASS IV: Severe limitations. Experiences symptoms even while at rest.

 
129. A puerperant is 28 years old. It’s the 3rd day post-partum after a second, normal, term delivery. The body temperature is of 36, 8oC, Ps 72/min, AP- 120/80 mm Hg. Mammary glands are moderately engorged, the nipples are clean. Abdomen is soft, painless. The fundus is 3 fingers’ breadth below the navel. Moderate bloody lochia are present. What diagnosis can be made?

Explanation

The postpartum physiological changes are those expected changes that occur to the woman's body after childbirth, in the postpartum period. These changes mark the beginning of the return of pre-pregnancy physiology and of breastfeeding.

Involution, a part of postpartum physiology, is the term given to the process of reproductive organs returning to their prepregnant state. Immediately following the delivery, the uterus, and the placental site contracts rapidly to prevent further blood loss. 

After birth, the fundus of the uterus contracts downward into the pelvis one centimeter each day. After two weeks the uterus will have contracted and returned into the pelvis. Hence, the 3 finger’s breadth below the navel on the 3rd day postpartum.

The lochia is the vaginal discharge that originates from the uterus, cervix, and vagina. The lochia is initially red and consists of blood and fragments of decidua, endometrial tissues, and mucus and lasts 1 to 4 days. The lochia then changes color to yellowish or pale brown, lasting 5 to 9 days, and is composed mainly of blood, mucus, and leukocytes. Finally, the lochia is white and contains mostly mucus, lasting up to 10 to 14 days.

The lactogenesis or milk secretion starts the third or fourth day postpartum making the mammary glands engorged.

 

Subinvolution of the uterus is seen after childbirth, when the uterus does not return to its normal size. But a fundus 3 finger’s breadth below the navel on the 3rd day postpartum clearly indicates a physiologic process taking place.

130. A 29-year-old unconscious patient has been delivered to a hospital. Objectively: skin and mucous membranes are pale, cyanotic, breath sounds are dramatically diminished on the right and cannot be auscultated in thelower parts, at the level of the 6 rib along the interior axillary line there is a wound hole with moderate bleeding and passage of air during inspiration. Radiography reveals a bullet in the pleural cavity. What is the medical tactics of choice?

Explanation

Many patients with penetrating thoracic injuries do not survive to the Emergency Department (ED), and those that do survive to the ED often require immediate interventions such as tube thoracostomy, intubation, and thoracotomy. Thus, the emergency clinician must be able to rapidly diagnose and treat injuries that are immediately life-threatening as in this case that presented with a Gunshot injury.

The above patient presents with a major trauma to the right side of the chest which is confirmed by a hemothorax and pneumothorax (Hemopneumothorax). Thoracotomy is a surgical procedure carried out inorder to have access to thoracic organs such as the lungs, heart or esophagus. This procedure is the first step in gaining access to the thoracic cavity and thus is indicated in cases of a lobectomy, major trauma of the chest, pneumonectomy. In the case of this patient, an urgent thoracotomy should be carried out in order to take out the bullet and prevent eventual collapse of the lungs.

Thoracentesis or Pleural puncture is a procedure in which a needle is inserted into the pleural space between the lungs and the chest wall. This procedure is done to remove excess fluid, known as a pleural effusion, from the pleural space to help you breathe easier. In this case, it’s not just fluid, there are blood clots. So, an incision (thoracotomy) should be made and arrest the bleeding, then drain. This patient needs this to be done as soon as possible, that’s why the best answer choice is the Emergency Thoracotomy.

It’s not enough to use hemostatic therapy, the clots must be removed and blood drained. Thoracoscopy is an imaging technique and the X-ray has given enough information at this point.

131. A patient had four generalized convulsive seizures within a day. Between the seizures the patient did not come to waking consciousness (was in a coma or stupor). Specify his state:

Explanation

Status epilepticus (SE) is a common, life-threatening neurologic disorder that is essentially an acute, prolonged epileptic crisis. Status epilepticus is defined as a continuous seizure lasting more than 30 min, or two or more seizures without full recovery of consciousness between any of them. Based on recent understanding of pathophysiology, it is now considered that any seizure that lasts more than 5 min probably needs to be treated as SE.

It can also be defined as a seizure that persists for a sufficient length of time or is repeated frequently enough that recovery between attacks does not occur. Therefore, the key phrase here is “recovery between attacks does not occur.” The question puts it this way - ‘between the seizures the patient did not come to waking consciousness.’

Prolonged Status epilepticus can lead to cardiac dysrhythmia, metabolic derangements, autonomic dysfunction, neurogenic pulmonary edema, hyperthermia, rhabdomyolysis, and pulmonary aspiration. Permanent neurologic damage can occur with prolonged SE.
132. A 12-year-old boy presents with nausea, frequent repeated vomiting that first occurred after eating canned vegetables. Objectively: the patient has dry mucous membranes, muscular hypotonia, anisocoria, mydriasis, dysphagia and dysarthria. What is the most likely diagnosis?

Explanation

Botulism is an illness caused by Botulinum toxin , a toxin produced by Clostridium Botulinum ( a gram positive, spore forming, anaerobic bacteria). Foodborne botulism is gotten from eating infected food especially canned food. It is treated with Botulinum antitoxin.

The germ is found in soil and can survive, grow, and produce a toxin in certain conditions, such as when food is improperly canned. The toxin can affect your nerves, paralyze you, and even kill you.

 

Symptoms may include the following: Double vision (diplopia; anisocoria); Blurred vision; Drooping eyelids (ptosis); Slurred speech (dysarthria); Difficulty swallowing (dysphagia); A thick-feeling tongue; Dry mouth; Muscle weakness (flaccid paralysis) etc.

133. A full-term neonate weighing 4500 g was born asphyxiated with Apgar score of 4-6 points. During the delivery shoulder dystocia occurred. Neurologic assessment revealed non focal neurologic symptoms, total flaccid paresis of the upper extremities since the arm was atonic and pronated. Grasping, Babkin’s and Moro’s reflexes were absent. What segments of spinal cord had been affected?

Explanation

Shoulder dystocia refers to a situation where, after delivery of the head, the anterior shoulder of the fetus becomes impacted on the maternal pubic symphysis, or (less commonly) the posterior shoulder becomes impacted on the sacral promontory. One major complication of this state is an injury to the brachial plexus.

The brachial plexus is a network of nerves made up the anterior rami of the lowest four cervical nerves and the first thoracic nerve ( C5-C8 & Th1). The brachial plexus provides nerve supply to the skin and muscles of the arms ( except the trapezius and an area close to the axilla ; an injury to the brachial plexus affects the sensation and movement of different parts of the arm.

The Moro reflex is an infantile reflex that develops between 28–32 weeks of gestation and disappears between 3–6 months of age. It is a response to a sudden loss of support and involves three distinct components.: spreading out the arms (abduction), pulling the arms in (adduction), crying (usually).

 

Notice that this reflex is absent coupled with flaccid paresis of the upper extremities- these are key signs that indicate an injury to the brachial plexus ( C5-TH1).

134. A newborn (mother’s I pregnancy) weighing 3500 g has been found to have jaundice, lethargy, reduced reflexes. Objectively: second grade jaundice of skin with saffron tint, liver - +2 cm, spleen - +1 cm. Urine and feces are yellow. Blood count: Hb- 100 g/l, RBC-3, 2 · 1012/l, WBC- 18, 7 · 109/l, mother’s blood type - 0(I) Rh(+), baby’s blood type - A(II) Rh(-), bilirubin - 170 mmol/l, indirect fraction. ALT, AST rates are normal. What is the most likely disease in the child?

Explanation

Hemolytic disease of the newborn is a disease characterised by the increased breakdown of RBCs in the newborn. Hemolytic disease of the newborn occurs when the immune system of the mother sees a baby\'s RBCs as foreign. Antibodies then develop against the baby\'s RBCs. These antibodies attack the RBCs in the baby\'s blood and cause them to break down too early. Two major ways the child’s and mother’s blood may differ are: ABO incompatibility and rhesus incompatibility ( Mother Rhesus -ve and child Rhesus +ve).

In this case, The fetus and mother present with ABO incompatibility; Notice that the mother’s blood type is 0(I) while the newborn’s A (II). Antibodies are formed against the newborn’s RBCs leading to its increased destruction. It is not Rhesus incompatibility because the mother is Rhesus positive while the baby is negative. Rhesus incompatibility occurs when a Rhesus negative (Rh-) mother marries a Rh+ Man and they conceive a Rh+ child. Note: the mother must be Rh- and the child Rh+. The first child with Rh+ usually survives, but subsequently Rh+ fetus will be attacked by Rh antibodies in the mother which crosses the placenta to attack the fetal red blood cells causing hemolysis.

 
135. As a result of a road accident a 45-year-old male patient got multiple injuries, namely closed fractures of the right humerus and the left antebrachial bones with a displacement of bone fragments, a closed blunt abdominal injury. The patient was delivered to the emergency department 30 minutes after the injury. Objectively: the skin is pale. AP-90/20 mm Hg, there is pain and deformation at the fracture sites. Abdomen is tense, palpation causes severe pain, there is rebound tenderness (positive Blumberg’s sign). What is the treatment tactics of choice?

Explanation

Blumberg sign refers to the presence of pain upon removal of pressure on the abdomen. It is a clinical sign that indicates Peritonitis ( inflammation of the peritoneum).

 

A laparotomy is a surgical incision into the abdominal cavity done to examine the abdominal organs and aid diagnosis. From the listed options, an urgent diagnostic laparotomy procedure should be carried out to  confirm the incidence of Peritonitis.

136. A 34-year-old male visited Tajikistan. After return, he complains of fever up to 40oC which occurs every second day and is accompanied by chills, sweating. Hepatosplenomegaly is present. Blood test results: RBC- 3 · 1012/l, Нb- 80 g/l, WBC- 4 ·109/l, eosinophils - 1%, stab neutrophils - 5%, segmented neutrophils - 60%, lymphocytes 24%, monocytes - 10%, ESR - 25 mm/h. What is the provisional diagnosis?

Explanation

From anamnesis, we understand that the patient has just returned from Tajikistan (asia) , this should prompt the idea of a malarial infection. Malaria is caused by a plasmodium infection (P.vivax, P.falciparum, P.malariae, P.ovale. In its life cycle, various stages are involved ( see image). 

The initial symptoms of malaria infection are nonspecific and can include headache, nausea, vomiting, photophobia and muscle aches. A malarial paroxysm is marked by onset of a sudden shaking chill which may last from 10 to 15 minutes or perhaps longer. Elevated temperature accompanies the paroxysm and may be sustained for typically 10 hours or more. This cycle repeats itself every 36 to 72 hours depending on which species the human host has been infected with. The phase of erythrocytic schizogony takes place within  day 6-15 of the disease ; it is characterised by the production of merozoites which are released into the bloodstream.
137. A 23-year-old male patient consulted a doctor about pain occurring in the lower third of the thigh with weight bearing activities and unloaded. The patient denies any injuries to the region. Objectively: the skin is of normal color, deep palpation reveals pastosity and tenderness, movements of the knee joint are limited. Radiograph of the distal femoral metaepiphyseal region shows a zone of degradation and spicules. In blood: immature cells are present, there are no signs of inflammation. What is the most likely diagnosis?

Explanation

Osteosarcoma is a type of cancer that produces immature bone. It is the most common type of cancer that arises in bones, and it is usually found at the end of long bones, often around the knee. Presents as a painful enlarging mass or pathologic fractures. A codman Triangle ( from elevation of the periosteum)  or sunburst pattern are classical findings on radiography. Note that in the blood immature cells were found. The absence of signs of inflammation rules out the option of Chronic osteomyelitis ( which is an infection of the bone tissue) . 

Multiple myeloma is also known as B-cell myeloma. It is a form of cancer that affects the plasma cells. Bence Jones proteins are a key finding in this pathology. 

 

Marble bone disease is also called Osteopetrosis or Albers-Schonberg disease. It is a rare inherited disorder in which the bone hardens and becomes denser ( stone bone). It is the opposite of osteoporosis and osteomalacia.

138. It is planned to organize a rural outpatient clinic. The patients will be able to visit the doctors of the following specialities:

Explanation

139. A 12-year-old girls has minor functional and morphological abnormalities: 1,0 D myopia, reduced body resistance. The patient has no history of chronic diseases. Over the last year, there were 4 cases of respiratory diseases. The girl belongs to the following health group:

Explanation

140. 4 weeks after a myocardial infarction, a 56-year-old male patient developed acute heart pain, pronounced dyspnea. Objectively: the patient’s condition is extremely grave, there is marked cyanosis of face, swelling and throbbing of neck veins, peripheral pulse is absent, the carotid artery pulse is rhythmic, 130 bpm, AP- 60/20 mm Hg. Auscultation of heart reveals extremely muffled sounds, percussion reveals heart border extension in both directions. What is the optimal treatment tactis for this patient?

Explanation

 

Ventricular rupture is a known complication of Myocardial infarction and this patient currently presents with signs and symptoms of cardiac tamponade - extravasation of blood into the pericardial cavity preventing the heart from pumping properly.

We can pick out: Extended heart borders, low b.p and an increased pulse . These three signs are known as Beck’s triad. They indicate a Cardiac Tamponade ( the impaired pumping ability of the heart due to accumulation of fluid in the pericardium). Note that percussion reveals heart border extension in both directions. The most suitable approach  should be a pericardial puncture ( pericardiocentesis) to remove the fluid in the pericardium. A thoracotomy can be carried out to gain access to the pleural cavity.

141. A puerperant is 32 years old, it’s her first childbirth, term precipitate labor, the III period is unremarkable, the uterus is contracted, tight. Examination of the birth canal revealed a rupture in the left posterior vaginal wall that was closed with catgut. Two hours later, the patient complained of a feeling of pressure on the anus, pain in the perineum, minor vaginal discharges, edema of the vulva. These clinical presentations are indicative most likely of:

Explanation

Precipitate labor  occurs when the duration of the entire labor process is below 3 hours. It involves the rapid and spontaneous expulsion of the fetus. Major complication of this case involves laceration of the cervix, vagina and/or the perineum. These lacerations can lead to hemorrhaging and further hematoma of the cervix, vagina or perineum. Notice that this patient experienced the rupture of the posterior vaginal wall that led to bleeding. Although this rupture was closed by catgut, the collection of blood (  hematoma ) in the pelvic cavity led to the presented symptoms of pressure on the anus, pain in the perineum, vaginal discharge etc.  
142. .A hospital nutrition unit received a batch of beef. Sanitation physician examined the meat and revealed the presence of 5 bladder worms per 40 cm2 of meat. Give the hygienic assessment of meat:

Explanation

 

Due to the presence of bladder worms ( parasitic worms) in the meat, the meat should not be consumed. It should be technically ( properly) disposed of.

143. A 47-year-old female patient complains of having pain on swallowing and difficult passing of solid food for two months. The patient has taken to the liquid and semi liquid food. During the last week the liquid food has barely passed through. General condition is satisfactory, the patient is undernourished, the appetite is preserved, there is a fear of eating. What is the provisional diagnosis?

Explanation

Esophageal cancer refers to a malignant tumor of the esophagus. The esophagus is the tube that connects the throat with the stomach. The two main subtypes of esophageal cancer are:

  • Squamous cell carcinoma: This arises from the cells lining the upper part of the esophagus.

  • Adenocarcinoma of the esophagus: This occurs due to changes in the glandular cells that exist at the junction of the esophagus and the stomach.

The junction between the stomach and esophagus (Gastroesophageal junction) is already narrower than other parts of the esophagus. So, having a cancer develop at this junction or close to it just exacerbates the condition and prevents free passage of food starting with solids.

People often experience no symptoms during the initial stages of this cancer. The majority of esophageal cancer diagnoses occur when the cancer has advanced.

 

When symptoms are present, they may include and usually the first noticeable symptom: Dysphagia (difficulty in swallowing). As the tumor narrows the passage in the esophagus, pushing food through becomes harder. And eventually, if the growth goes on unchecked, it begins to become narrower and affects semi-solids and then at the terminal stage, liquids.

144. A 31-year-old female patient complains of infertility, amenorrhea for 2 years after the artificial abortion that was complicated by endometritis. Objectively: examination of the external genitalia revals no pathology, there is female pattern of hair distribution. According to the functional tests, the patient has biphasic ovulatory cycle. What form of infertility is the case?

Explanation

This patient has had a previous abortion that was complicated by Endometritis. Endometritis is inflammation of the inner lining (endometrial layer) of the uterus. But she is presently bothered about her inability to conceive and the question is concerned about the origin/organ of primary focus.

Amenorrhea is the absence of menstruation. If a woman doesn’t see her menses, she can’t conceive (infertility). 

On examination: 

  • ‘the external genitalia reveals no pathology’ i.e. the vagina, cervix are normal.

  • ‘there is a female pattern of hair distribution’ - this is a function of Estrogen and this shows her secondary sexual characteristics are present. Estrogen is produced primarily in the ovaries, and adipose tissue. This indicates that the ovary is functioning normally.

  • ‘the patient has biphasic ovulatory cycle’ - biphasic ovulatory cycle is possible due to the effects of Progesterone and Estrogen. (NB: a monophasic ovulatory cycle indicates a problem with the ovary or the Hypothalamic-Pituitary Axis). These two hormones are elevated at different times during the normal ovulatory cycle and they indicate an adequate functioning of the Hypothalamus-Pituitary-Ovarian Axis. The Hypothalamus releases Gonadotropin Releasing Hormone to stimulate the Pituitary to release Follicle Stimulating Hormone (FSH) and Luteinizing Hormone (LH) - FSH and LH then act on the Ovary to produce Estrogen and Progesterone respectively producing the effect of the biphasic ovulatory cycle.

Therefore, since all other pathways and organs involved are functioning properly, we can conclude that the primary focus is the Uterus.

 
145. A 49-year-old male patient consulted a doctor about difficult swallowing, voice hoarseness, weight loss. These symptoms have been gradually progressing for the last 3 months. Objectively: the patient is exhausted, supraclavicular lymph nodes are enlarged. Esophagoscopy revealed no esophageal pathology. Which of the following studies is most appropriate in this case?

Explanation

A CT scan of the chest can help find problems such as infection, lung cancer, blocked blood flow in the lung (pulmonary embolism), and other lung problems. It also can be used to see if cancer has spread into the chest from another area of the body. Note that this patient most likely has cancer since there has been loss of weight over 3 months, progressing symptoms coupled with enlarged lymph nodes around this area. A lung x-ray gives a pictorial view of the heart, lungs, airways, blood vessels and the bones of the spine and chest but a CT scan is more detailed. Because it is able to detect very small nodules in the lung, chest CT is especially effective for diagnosing lung cancer at its earliest, most curable stage. Imaging of the esophagus is not needed as the question clearly stated that the esophagus revealed no pathology.
146. A 36-year-old male patient complains of having headache, obstructed nasal breathing, purulent nasal discharge for 2 weeks. A month before, he had his right maxillary premolar filled. Radiolography revealed an intense opacity of the right maxillary sinus. Diagnostic puncture revealed a large amount of thick malodorous crumbly pus. What is the most likely diagnosis?

Explanation

The first point to take note of here is that the patient had his right maxillary premolar filled a month ago.

Sinusitis is the inflammation of one or multiple sinuses. Your sinuses are hollow air-filled cavities (like pouches) behind your forehead, cheeks and eyes. Odontogenic sinusitis is any inflammation of a dental origin and of your sinuses. It’s almost always one of the maxillary sinuses that are affected. These can be found to the right and left of your nose, behind the cheeks.

This condition occurs when a dental infection caused by lack of oral hygiene or dental surgery, such as tooth implants, a tooth removal or a sinus lift, reaches the maxillary sinus. Your teeth project up towards the maxillary sinus, and sometimes directly into it. There is a membrane called the Schneiderian membrane that protects your sinuses from teeth and teeth infections, but if surgery or a tooth’s root disrupts the membrane, the infection can spread.

 

Odontogenic sinusitis accounts for the majority of cases of chronic maxillary sinusitis. It is the most common cause of unilateral maxillary sinusitis

147. A 5-year-old boy has a history of repeated pneumonia, frequent acute respiratory viral diseases. Objectively: exertional dyspnea, minor fatigabilty. There is a systolic murmur having its epicenter in the IV intercostal space on the left. Left relative dullness is found along the midclavicular line. According to the findings of instrumental methods of examination (electrocardiography, echocardiography), the patient has been diagnosed with ventricular septal defect, subcompensation stage. What is the main method of treatment?

Explanation

 Many babies born with a small ventricular septal defect (VSD) won't need surgery to close the hole. After birth, the doctor may want to observe the baby and treat symptoms while waiting to see if the defect closes on its own. 

Babies who need surgical repair often have the procedure in their first year. Children and adults who have a medium or large ventricular septal defect or one that's causing significant symptoms may need surgery to close the defect.

With this 5 year old boy already having exertional dyspnea, fatigability and in the sub compensation stage, it is an indication for Surgery in order to close the defect. Surgical treatment for ventricular septal defects involves plugging or patching the abnormal opening between the ventricles.

 

In the sub compensation stage and with the child already showing symptoms of dyspnea, conservative treatment is no longer indicated. Indomethacin is used in the case of patent ductus arteriosus due to its inhibitory effect on Prostaglandin E2 which helps in closing the ductus arteriosus immediately after birth.

148. A patient with autoimmune thyroiditis accompanied by multinodular goiter underwent the right lobe ectomy and subtotal resection of the left lobe. What drug should be administered to prevent postoperative hypothyroidism?

Explanation

 Lobectomy has been generally recommended as an optimal surgical approach for symptomatic unilateral goiter, toxic adenoma, and low-risk differentiated thyroid cancer. Although patients are expected to maintain normal thyroid function after lobectomy or subtotal resection since not all the thyroid tissue was resected, some patients develop hypothyroidism that requires thyroid-hormone replacement. Routine levothyroxine (L-Thyroxine) supplementation is commonly prescribed for prophylaxis of postoperative hypothyroidism. 

Merkazolil and Iodomarin can be used in case of Hyperthyroidism. They are anti-thyroid medications. Lithium is commonly used in Psychiatry cases for Bipolar conditions but it is commonly associated with Hypothyroidism and will not be useful in this case.

 
149. A 49-year-old female patient has type 1 diabetes of moderate severity. The disease is complicated by retinopathy and polyneuropathy. Besides that, repeated analyses of the daily urinary excretion of albumin revealed microalbuminuria (200-300 mg/day). Glomerular filtration rate is 105 ml/min. Blood pressure is within normal range. Normalization of the following indicator should be the first-priority task in the secondary prevention of diabetic nephropathy:

Explanation

The glycated hemoglobin (HbA1c) test is an important blood test that determines how well you are managing your diabetes. The hemoglobin A1c test tells you your average level of blood sugar over the past 2 to 3 months.

 

Diabetes mellitus (DM) is the leading cause of chronic kidney disease (CKD) worldwide. Measuring glycated hemoglobin (HbA1c) has been suggested as a means of assessing glycemic control in patients with diabetes. Current guidelines recommend a target HbA1c of approximately 7% for preventing or delaying microvascular complications, including diabetic kidney disease (Diabetic Nephropathy). 

150. 10 days after birth, a newborn developed a sudden fever up to 38, 1oC. Objectively: the skin in the region of navel, abdomen and chest is erythematous; there are multiple pea-sized blisters with no infiltration at the base; single bright red moist erosions with epidermal fragments on the periphery. What is your provisional diagnosis?

Explanation

Epidemic pemphigus of newborn or Pemphigus Neonatorum is a disease of the newborn, in which vesicles or blebs, usually flat on the top, appear with or without fever, on a perfectly normal or reddened skin with pin-head size vesicle elevation, which rapidly develops into a large bleb. As the disease progresses, relapses may occur, yet the infant may recover promptly after a single outbreak of but few blebs. In some cases these blebs show a marked tendency to peripheral extension, which finally dry, leaving a thin brown crust. Staphylococcus aureus have been implicated as the causative agent.

The distinction between Pemphigus and syphilis in the newborn may be determined by the localization of the eruption. Syphilis will be localized to the palms of the hands and soles of the feet, as well as by the associating symptoms of syphilis.

Impetigo commonly presents with honey crusted vesicles and papules. Atopic dermatitis is an allergic reaction and patient most often have other allergic conditions or family history of asthma, allergic rhinitis, eczema etc.

151. An emergency physician arrived to provide medical care for a hangman taken out of the loop by his relatives. The doctor revealed no pulse in the carotid arteries, lack of consciousness, spontaneous breathing and corneal reflexes; cadaver spots on the back and posterior parts of extremities. A person can be declared dead if the following sign is present:

Explanation

Forensic pathologists are essentially required to estimate the time since death (TSD) to assist in death investigation. The early post-mortem phase is most frequently estimated using the classical triad of post-mortem changes – rigor mortis, algor mortis and livor mortis. 

Algor Mortis: Humans are warm-blooded organisms, which means that we maintain a constant internal temperature, regardless of the outside environment. The brain is our thermostat and the circulatory system is the main heat dissipator. However, within seconds of death, the brain cells begin to die and the heart stops pumping blood. Without the brain and and the blood distributing heat, the corpse eventually starts to match the outside temperature.

Rigor mortis is the post-mortem stiffening of muscles, caused by the depletion of adenosine triphosphate (ATP) from the muscles.

 

Livor Mortis: This is the final stage of death. When the heart stops beating, the blood is now at the mercy of gravity. It tends to collect at certain parts of the body. Depending on the position of the body, these parts would vary. For instance, if the person was flat on their back when they died, the blood would collect in the parts that are touching the ground (just as in this patient - cadaver spots were on the back and posterior parts of the extremities). If the person was hanging, it would collect in their fingertips, toes, and earlobes. Lividity starts with the skin where the blood has settled developing a bright red color. After a few hours, the color changes from red to bluish-purple. The bluish coloring of the skin is called livor mortis or cadaver spots.

152. A 69-year-old male patient has been hospitalized with hypothermia. Objectively: the patient is pale, has shallow breathing. AP-100/60 mm Hg, Ps- 60/min. Palpation of the abdomen and chest reveals no pathological signs. The body temperature is of 34, 8oC. The patient’s breath smells of alcohol. Give treatment recommendations:

Explanation

Hypothermia is a severe condition in which the body temperature drops to an abnormally low level. It occurs when the body is unable to produce enough heat to counter the heat that it is losing. Under healthy conditions, the body maintains a relatively stable temperature of around 98.6˚F or 37˚C. 

The following techniques can help treat hypothermia:

Passive external rewarming: This uses the individual’s heat-generating ability. It involves removing their cold, wet clothing, ideally replacing it with adequately insulated, dry clothing, and moving them to a warm environment. 

Active external rewarming: This involves applying warming devices, such as hot-water bottles or warmed forced air, externally to truncal areas of the body. For example, the individual could hold a hot-water bottle under each arm.

Active core rewarming: This uses warmed, intravenous fluids to irrigate body cavities, including the thorax, peritoneum, stomach, and bladder. Other options include getting the individual to inhale warm, humidified air, or applying extracorporeal rewarming by using a heart-lung machine.

Do not give a person alcohol if they have signs of hypothermia, and avoid giving any drinks to an unconscious person.

 

Considering the critical condition of this patient, active core warming by using warmed intravenous fluids which gets into the system immediately and will bring the most desired result at the shortest time possible is by far the best treatment recommendation.

153. A 26-year-old male patient consulted a doctor abut sore throat, fever up to 38, 2oC. A week before, the patient had quinsy, didn’t follow medical recommendations. On examination, the patient had forced position of his head, trismus of chewing muscles. Left peritonsillar region is markedly hyperemic, swollen. What is the provisional diagnosis?

Explanation

Extension of a tonsil infection can take place in the surrounding tissue and is referred to as  a Peritonsillar abscess or quinsy. The 26 year old man had previously had quinsy but didn’t follow medical advice. This complication of tonsillitis is usually caused by a B-hemolytic streptococcal infection and are characterised by an extremely sore throat and high fever ( as seen in the patient) . 

A peritonsillar abscess forms in the tissues of the throat next to one of the tonsils. An abscess is a collection of pus that forms near an area of infected skin or other soft tissue. The abscess can cause pain, swelling, and, if severe, blockage of the throat. If the throat is blocked, swallowing, speaking, and even breathing become difficult.

 

The key sign that distinguishes quinsy/peritonsillar abscess from ordinary tonsillitis is the presentation of trismus. Trismus is usually absent in any form of tonsillitis but would be seen in a Peritonsillar abscess.

154. A 21-year-old female patient has been hospitalized on an emergency basis because of severe dyspnea, pain in the left side of chest. Body temperature is 38, 8oC. The condition developed three days ago. Respiratory rate is 42/min, auscultation reveals shallow breathing. There is percussive dullness on the right starting from the middle of the blade, breath sounds cannot be heard. The left border of heart is 3 cm displaced outwards. Embryocardia is present, HR is 110/min. The right hypochondrium is painful on palpation. What urgent therapeutic measures should be taken in this situation?

Explanation

Embryocardia is a symptom of heart disease in which the heart sounds resemble that of the fetal heart. In this condition, S1 and S2 sound cannot be distinguished and are equally spaced. This condition is usually seen in myocarditis. This patient presents with a tension Pneumothorax of the right lung indicated by the absence of breath sound on the right. 

 

A tension Pneumothorax is a medical emergency in which air is drawn into the pleural space during inspiration and has no route of escape during expiration.  Respiratory distress, tachycardia, hypotension, distended neck veins and deviation of trachea from the affected side are key findings. Unless the air is rapidly removed, cardiorespiratory arrest will occur. To evacuate the air, a pleural puncture ( Pleural tap, thoracocentesis) is carried out. 

155. A 77-year-old male patient complains of inability to urinate, bursting pain above the pubis. The patient developed acute condition 12 hours before. Objectively: full urinary bladder is palpable above the pubis. Rectal prostate is enlarged, dense and elastic, well-defined, with no nodes. Interlobular sulcus is distinct. Ultrasonography results: prostate volume is 120 cm3, it projects into the bladder cavity, has homogeneous parenchyma. Prostate-specific antigen rate is of 5 ng/ml. What is the most likely disease that caused acute urinary retention?

Explanation

 

Benign prostatic Hyperplasia is a non carcinogenic pathology that occurs mostly in men above 40. It presents with symptoms similar to Prostate cancer. These include frequency of urination, hesitancy, dribbling, and frequent nighttime urination. To differentiate between these two pathologies, an objective examination is carried out (  a digital rectal examination ). In this case, the prostate is dense, enlarged, elastic  and well defined with no nodes - these findings support the initial diagnosis of BPH because on digital rectal examination, prostatic carcinoma will not be well defined and will present with nodes. To further prove this diagnosis, the Prostate specific antigen is measured ( normal <4). A marginal increase is going to support the diagnosis of BPH while PSA of 10 and above will indicate prostate cancer. 

156. At the first minute of life a full-term infant born with umbilical cord entangled around his neck has total cyanosis, apnea, HR- 80/min, hypotonia and areflexia. There are no signs of meconium aspiration. After the airway suctioning the newborn did not start breathing. What is the next action of the doctor?

Explanation

For resuscitation of the baby, the CAB approach should be used ( circulation, airway and breathing). From the question, we see that the baby’s circulation is present although reduced ( HR- 80 bpm; should be above 100); to assist the baby in breathing, An ALV ( assisted lung ventilation should be used). An intubation is only done if there is a restriction or obstruction in the upper airways.
157. Examination of an 11-year-old boy revealed frequent nosebleeds, fatigue when walking, underdevelopment of the lower half of the body, increased blood pressure in the upper extremities and decreased pressure in the lower ones, extension of the left heart border, blowing systolic murmur in the interscapular region. ECG shows the horizontal axis of heart. Radiography reveals left cardiomegaly, costal usuration. What is the most likely diagnosis?

Explanation

Key points to note here: underdevelopment of the lower half of the body, increased blood pressure in the upper extremities and decreased blood pressure in the lower extremities - these are pointers to coarctation of the Aorta/Aortarctia (narrowing of the aorta). 

The aorta is the largest artery in your body. It moves oxygen-rich blood from your heart to the rest of your body. Narrowing of the aorta (aortic coarctation) forces your heart to pump harder to move blood through the aorta.

Coarctation of the aorta is generally present at birth (congenital). Although the condition can affect any part of the aorta, the defect is most often located near and after the left subclavian artery. From the image, you will discover that the 3 branches coming off the aortic arch supplies the head, and upper limbs and these branches come off the aorta before the narrowing, therefore the upper limbs will have normal/increased blood pressure while the branches that come off after/beyond the narrowing supplying the lower part of the body will have a lower blood pressure as compared to the upper part of the body.

From the question there is also left cardiomegaly. Coarctation of the aorta usually occurs beyond the blood vessels that branch off to your upper body and before the blood vessels that lead to your lower body. This can often lead to high blood pressure in your arms but low blood pressure in your legs and ankles.

Furthermore, with coarctation of the aorta, the lower left heart chamber (left ventricle) of your heart works harder to pump blood through the narrowed aorta, and blood pressure increases in the left ventricle. This may cause the wall of the left ventricle to thicken (hypertrophy).

 

Aortic stenosis can also lead to left cardiomegaly but there won't be any disparity between the blood pressures in the upper and lower part of the body. None of the other options listed will produce the same symptoms seen in this patient.

[caption id="attachment_1385" align="alignnone" width="300"]Coarctation of Aorta Coarctation of Aorta[/caption]
158. During the preventive examination a 17-year-old young man reports no health problems. Objectively: the patient is undernourished, asthenic; blood pressure is 110/70 mm Hg, Ps- 80/min. Heart borders are within normal range. Auscultation reveals three apical heart sounds, murmurs are absent. ECG shows no pathological changes, PCG registers the S3 occurring 0,15 seconds after the S2. How can you interpret these changes?

Explanation

A physiological third heart sound (S3) is common in youth but allegedly very rare after the age of 40 years. A physiological third heart sound (S3) can be heard in practically all healthy children and adolescents but rarely in individuals after the age of 40 years. After age 40, a third heart sound is usually abnormal and correlates with dysfunction or volume overload of the ventricles. 

The third heart sound (S3) is a low-frequency, brief vibration occurring in early diastole at the end of the rapid diastolic filling period of the right or left ventricle. It is physiologic because it is not related to any pathology at any age before 40 years. Patient is 17years, has no health problems, murmurs are absent and ECG shows no pathological changes.

 

There is no physiologic S4 and all other options listed are signs of different heart pathologies.

159. After having the flu, a 39-year-old male patient with a history of Addison’s disease developed a condition manifested by weakness, depression, nausea, vomiting, diarrhea, hypoglycemia. AP- 75/50 mm Hg. Blood test results: low corticosterone and cortisol, 13-oxycorticosteroids, 17-oxycorticosteroids levels. What condition developed in the patient?

Explanation

An Addisonian crisis most often occurs in a patient with known adrenal insufficiency (this patient has a history of Addison’s disease), either primary or secondary. Primary adrenal insufficiency (Addison Disease) is characterized by low cortisol and high ACTH from the destruction of the adrenal glands. Chronic, stable primary adrenal insufficiency is called Addison's disease, which is a  chronic condition controlled with long-term glucocorticoid therapy.

Addisonian crisis, also known as adrenal crisis or acute adrenal insufficiency is an endocrinologic emergency commonly seen in patients with known adrenal insufficiency. It is characterized as an acute change in physiologic status, quickly progression from nonspecific symptoms of fatigue, weakness, nausea, vomiting, abdominal pain, back pain, diarrhea, dizziness, hypotension, syncope, eventually to obtundation, metabolic encephalopathy, and shock. 

 

Most cases are patients with known adrenal insufficiency who experience an acute stress event (patient had flu), who do not adjust their usual dose of glucocorticoid therapy and their body's cortisol stores are quickly depleted leading to an Addisonian crisis as these patients cannot produce their own cortisol. Roughly half of the patients have undiagnosed Addison's disease and present to the emergency room in acute crisis and shock after an acute stress event.

160. A female patient complains of being unable to get pregnant for 5 years. A complete clinical examination brought the following results: hormonal function is not impaired, urogenital infection hasn’t been found, on hysterosalpingography both tubes were filled with the contrast medium up to the isthmic segment, abdominal contrast was not visualized. The patient’s husband is healthy. What tactics will be most effective?

Explanation

In vitro fertilization (IVF) is a complex series of procedures used to help with fertility or prevent genetic problems and assist with the conception of a child. During IVF, mature eggs are collected (retrieved) from ovaries and fertilized by sperm in a lab. Then the fertilized egg (embryo) or eggs (embryos) are transferred to a uterus. One full cycle of IVF takes about three weeks. IVF is the most effective form of assisted reproductive technology. The procedure can be done using your own eggs and your partner's sperm. Or IVF may involve eggs, sperm or embryos from a known or anonymous donor. 

IVF is the best option if the woman has Fallopian tube damage or blockage. Fallopian tube damage or blockage makes it difficult for an egg to be fertilized or for an embryo to travel to the uterus. This is the case with this patient. The contrast medium got to the isthmic segment of the fallopian tube and wasn’t visualized in the abdominal cavity. This clearly indicates a blockage somewhere beyond the isthmic segment.

 

With this pathology, insemination with husband’s semen will not yield any result because the oocyte can’t travel to the uterus due to the blockage in the fallopian tube. In artificial insemination, sperm is placed in the uterus and conception happens otherwise normally. IVF involves combining eggs and sperm outside the body in a laboratory. Once an embryo or embryos form, they are then placed in the uterus. Research shows that IVF is just as effective as the ICSI (Intracytoplasmic sperm injection) procedure, where sperm is injected directly into an egg, when there is no male infertility factor.

161. A 19-year-old primiparous woman with a body weight of 54,5 kg gave birth at 38 weeks gestation to a full-term live girl after a normal vaginal delivery. The girl’s weight was 2180,0 g, body length - 48 cm. It is known from history that the woman has been a smoker for 8 years, and kept smoking during pregnancy. Pregnancy was complicated by moderate vomiting of pregnancy from 9 to 12 weeks pregnant, edemata of pregnancy from 32 to 38 weeks. What is the most likely cause of low birth weight?

Explanation

Cigarette smoke contains about 4000 toxic chemical compounds that exert direct effect on cell proliferation and differentiation in the placenta and the fetus. Maternal smoking may lead to intrauterine growth restriction, spontaneous abortion, premature descent of placenta, premature rupture of membranes, premature birth, and sudden death syndrome in the newborn.

 

The abnormal development of placental vascularization leads to placental insufficiency, which further reduces the nutrient and trace exchange between maternal circulation and fetal circulation. These changes cause maternal and fetal complications which can result in intrauterine growth restriction manifesting as low birth weight. Low birth weight, according to the World Health Organization is any birth weight of an infant less than 2,500g regardless of gestational age.

 

Vomiting in the first trimester between 9 - 12 weeks of pregnancy and 3rd trimester edema are fairly normal and physiological changes during pregnancy. There are no signs of proteinuria or elevated blood pressure so we can rule out Preeclampsia. The woman’s age and weight has nothing to do with the birth weight as long as the baby gets the necessary nutrient. Moreso, the weight of 54.5kg is okay for the woman.

162. In a cold weather, the emergency room admitted a patient pulled out of the open water. There was no respiratory contact with the water. The patient is excited, pale, complains of pain, numbness of hands and feet, cold shiver. Respiratory rate is 22/min, AP- 120/90 mm Hg, Ps- 110/min, rectal temperature is 34, 5oC. What kind of warming is indicated for this patient?

Explanation

Hypothermia is a severe condition in which the body temperature drops to an abnormally low level. It occurs when the body is unable to produce enough heat to counter the heat that it is losing. Under healthy conditions, the body maintains a relatively stable temperature of around 98.6˚F or 37˚C. 

The following techniques can help treat hypothermia:

Passive external rewarming: This uses the individual’s heat-generating ability. It involves removing their cold, wet clothing, ideally replacing it with adequately insulated, dry clothing, and moving them to a warm environment. 

Active external rewarming: This involves applying warming devices, such as hot-water bottles or warmed forced air, externally to truncal areas of the body. For example, the individual could hold a hot-water bottle under each arm.

Active core rewarming: This uses warmed, intravenous fluids to irrigate body cavities, including the thorax, peritoneum, stomach, and bladder. Other options include getting the individual to inhale warm, humidified air, or applying extracorporeal rewarming by using a heart-lung machine.

Do not give a person alcohol if they have signs of hypothermia, and avoid giving any drinks to an unconscious person.

 

From the vitals given, this patient is fairly stable except for the tachycardia (110bpm) and low body temperature, therefore passive warming will suffice. The patient was pulled out of the open water in a cold weather so removing the wet clothing, and replacing it with adequately insulated, dry clothing, and moving them to a warm environment will keep the patient warm.

163. A week before, a 65-year-old male patient suffered an acute myocardial infarction. His general condition has deteriorated: he complains of dyspnea at rest, pronounced weakness. Objectively: edema of the lower extremities, ascites is present. Heart borders are extended, paradoxical pulse is 2 cm displaced from the apex beat to the left. What is the most likely diagnosis?

Explanation

One of the most common complications occurring post-infarction is a ventricular aneurysm. Almost 85% to 90% of the ventricular aneurysms occur in the setting of acute anterior wall myocardial infarction. Left ventricular aneurysm is defined as a localized area of myocardium with abnormal outward bulging and deformation during systole and diastole. The natural course leading to the formation of a ventricular aneurysm involves a full-thickness infarct that has been replaced by fibrous tissue. This inert portion cannot take part in the contraction and herniates outward during systole.

A week before presenting to the hospital, he had an acute myocardial infarction. A true left ventricular aneurysm following acute myocardial infarction can occur as early as within 48 hours or two weeks post-infarction. 

 

Common symptoms associated with the ventricular aneurysm include: Fatigue; Shortness of breath (dyspnea); Chest pain; Palpitations; Syncope; Fluid retention causing swelling of ankles, feet, or abdomen (ascites); Stroke; Limb or visceral ischemia.

164. A 41-year-old patient consulted a dermatologist about discoloration, thickening, brittleness of toenails. These symptoms have been present for about five years. Objectively: nail plates in all toes are thickened, of dirty yellow color, lustreless, crumble over the edge. Microscopy of the nail plate material treated with alkali revealed mycelial filaments. Material inoculation onto Sabouraud medium resulted in growth of the Trichophyton rubrum colony. What is the most likely diagnosis?

Explanation

Dermatophyte infections, also known as tinea, are the most common fungal infections of the skin, hair, and nails.The term "Dermatophyte" refers to fungal species that infect keratinized tissue, and includes members of the Trichophyton, Microsporum, and Epidermophyton genera. 

Trichophyton rubrum is a dermatophytic fungus. It colonizes the upper layers of dead skin, and is the most common cause of athlete's foot, fungal infection of nail, jock itch, and ringworm worldwide. T. rubrum colony shows Partial yellow-green fluorescence under wood-lamp.

T. rubrum is now the most common cause of invasive fungal nail disease (called onychomycosis or tinea unguium). Nail invasion by T. rubrum tends to be restricted to the underside of the nail plate and is characterized by the formation of white plaques on the lunula that can spread to the entire nail. The nail often thickens and becomes brittle, turns brown or black.

 

The question clearly states that inoculation onto Sabouraud medium resulted in growth of T. rubrum colony which makes Rubromycosis the correct answer and rules out Epidermophytosis and Psoriasis (patient must have psoriasis first before a diagnosis of Psoriasis of the nails can be made). 

165. Examination of an electric welder with 15 years of service record revealed dry rales in the lower lung fields. Radiograph shows diffuse nodules sized 3-4 mm in the middle and lower lung fields. What disease can be suspected?

Explanation

The term coniosis refers to a group of diseases ( conditions) caused by the inhalation of dust ( of different forms). For Example Anthracosis ( pneumoconiosis) also called coal miners lung occurs as a result of inhalation of coal or carbon. Silicosis ( grinder’s disease) -  inhalation of crystalline silica dust.  Siderosis- Iron inhalation. Berylliosis- Beryllium, Byssinosis - cotton etc. These mineral dusts when inhaled over time accumulate and deposit in the lung tissues forming infiltrates and fibrotic changes. 

 

This patient presents with a condition known as Pneumosiderosis ( welder’s lung) a chronic condition  caused by long term inhalation of iron dust; this condition is usually seen in welders.

166. A 12-year-old boy periodically has short episodes (10-15 seconds) of a brief loss of awareness with a dazed look and eyes stare in an upright position, blank expression of face, absence of motions and subsequent amnesia. Specify the described state:

Explanation

Absence or Petit mal seizures are a form of generalised seizures usually less than 15 seconds in duration and commonly seen in children. It is characterised by sudden lapses of consciousness which involves an absence of motion and a state of forgetfulness. 

Obnubilation is a state of clouding of consciousness and stupor. 

 

fugue state or psychogenic fugue, is a dissociative disorder and a rare psychiatric disorder characterized by reversible amnesia for personal identity, including the memories, personality, and other identifying characteristics of individuality. 

167. Evaluation results of sanitary and hygiene conditions in a 4-bed ward were as follows: ward area - 30 m2, height - 3,2 m, temperature- 20oC, humidity - 55%, air velocity - 0,1 m/s, window-to-floor area ratio - 1:5, daylight ratio- 0,6%, concentration of carbon dioxide in the air - 0,1%. Which of the given indicators does not meet hygienic requirements?

Explanation

168. A 25-year-old patient works as a tractor driver. Four days ago, he got pain in the left axillary region, general weakness, fever up to 38oC. He hadn’t sought medical help until a painful solid lump appeared in this region. Objectively: in the left axilla there is a very painful cone-shaped mass sized 3x2,5 cm, with a destruction in the center of the pointed vertex. The surrounding skin is hyperemic, there are purulent discharges. What is the most likely diagnosis?

Explanation

Hidradenitis refers to small painful lumps that form under the skin usually in areas of friction such as: axilla, groin, buttocks and breast.  

Carbuncle: clusters of boil; an area of subcutaneous necrosis which discharges itself unto the surface through multiple sinuses. 

Furuncle ( boil) - forms under the hair follicle and associated glands which contains pus.
169. A 19-year-old male patient complains of intense pain in the left knee joint. Objectively: the left knee joint is enlarged, the overlying skin is hyperemic, the joint is painful on palpation. Blood test results: RBC- 3, 8·1012/l, Hb- 122 g/l, lymphocytes - 7, 4 · 109/l, platelets - 183 · 109/l. ESR- 10 mm/h. Duke bleeding time is 4 minutes, Lee-White clotting time - 24 minutes. A-PTT is 89 sec. Rheumatoid factor is negative. What is the most likely diagnosis?

Explanation

Partial Thromboplastin Time (PTT): <28seconds (normal)

PTT in this patient is 89seconds.

Defect in the Intrinsic coagulation pathway results in an Increased Partial Thromboplastin Time (PTT).

Intrinsic pathway coagulation defect:

Hemophilia A: deficiency of Factor VIII

Hemophilia B: deficiency of Factor IX

Hemophilia C: deficiency of Factor XI

Hemophilia is usually an inherited bleeding disorder in which the blood doesn't clot properly. This can lead to spontaneous bleeding as well as bleeding following injuries or surgery. Blood contains many proteins called clotting factors that can help to stop bleeding. People with hemophilia have low levels of any of factor VIII (8); factor IX (9) or factor XI (11).

 

Hemophilia commonly presents as hemarthrosis (bleeding into joints e.g. knee); easy bruising; bleeding after trauma or surgery (e.g. dental procedures).

170. A 29-year-old female patient complains of dyspnea and palpitations on exertion. According to her mother, as a child she had heart murmur, did not undergo any examinations. Objectively: the patient has pale skin, Ps- 94/min, rhythmic. AP- 120/60 mm Hg. In the II intercostal space on the left auscultation reveals a continuous rasping systolodiastolic murmur, diastolic shock above the pulmonary artery. Blood and urine are unremarkable. What is the most likely diagnosis?

Explanation

Patent ductus arteriosus is a congenital heart anomaly in which the ductus arteriosus fails to close at birth. PDA is normal in utero and normally closes only after birth. Due to the failure of the ductus arteriosus ( a connection between the aorta and pulmonary artery), oxygenated blood flows from the aorta into the pulmonary artery then back to the lungs for more oxygenation. Key signs include: dyspnea, tachycardia, cyanosis of the lower extremities etc. On objective examination, we observe increased systolic pressure, left subclavicular thrill, a continuous rasping systo diastolic murmur in the 2nd intercostal space on the left; this murmur can also be termed like “a machine gun” or “rolling thunder”. Echocardiogram and normal chest x-ray are used in the diagnosis. One major finding on chest x-ray is the cardiac Silhouette (loss of normal borders between thoracic structures).

Tetralogy of Fallot is caused by the anterosuperior displacement of the infundibular septum and is the most common cause of cyanosis in early childhood. It consists of 4 anomalies: Ventricular septal defect, Right ventricular hypertrophy, pulmonary valve stenosis and a misplaced (overriding) aorta. A systolic ejection murmur is common in this anomaly.

171. A 6-year-old boy had had a quinsy. 9 days later, there appeared edemata of the face, extremities and trunk, general health condition deteriorated. Urine became turbid. Objectively: expressive edemata, ascites. AP-100/55 mm Hg, diuresis - 0,2 l of urine per day. Results of the biochemical blood analysis: total protein - 50 g/l, cholesterol - 11,28 mmol/l, urea - 7,15 mmol/l, creatinine - 0,08 mmol/l. Urinalysis results: leukocytes - 3-5 per HPF, red blood cells are absent. What is the provisional diagnosis?

Explanation

Glomerulonephritis is a group of Disorders where damage to the glomerular filtration apparatus causes a leak of protein +/- blood into urine depending on the disease. Patients may be asymptomatic or present with hematuria, proteinuria, edemas, hypertension etc. 

This patient has a post streptococcal form of glomerulonephritis. Notice That few days ago, he suffered from Quinsy also known as peritonsillar abscess, a condition mostly caused by streptococcal infection. A deposition of the immune formed complex (between the streptococcal antigen and antibodies ) on the kidney’s glomerular membrane  leads to its inflammation ( glomerulonephritis) .

Chronic Glomerulonephritis involves long term inflammation and scarring of the glomeruli. This condition progresses over the years. 

Acute Pyelonephritis is an inflammation of the Renal pelvis due to an infection. High fever,     rigor, vomiting, pain and tenderness of the lumbar region  are key findings.  

 

In acute renal failure, there is a significant decrease in renal function that occurs over hours or days. This manifests as an abrupt and sustained  rise in serum urea and creatinine levels coupled with oliguria / anuria.

172. A 13-year-old boy has had abdominal pain, bloating, nausea, liquid fatty gray stool with putrid smell for the last 3 years. Palpation reveals epigastric tenderness, as well as tenderness in the Desjardins’ pancreatic point, Chauffard’s triangle; there is positive Mayo Robson’s sign. Failure of exocrine pancreatic function has been suspected. What is the most informative method for evaluating the state of exocrine pancreatic function?

Explanation

Apart from the endocrine function of the pancreas ( production of hormones such as insulin, glucagon, somatostatin etc), the Pancreas also possess exocrine function ie, it produces enzymes that aid in in food digestion eg amylase for the digestion of carbohydrate, lipase for the breakdown of fats and trypsin and chymotrypsin for proteins, elastase. Notice that this patient has an issue with digestion revealed by the presence of bloating, liquid, gray and smelly stool. 

 

Pancreatic fecal elastase-1 (FE-1) has become the first-line test of pancreatic function. FE-1 is well documented in quantitative studies to be stable during intestinal transit and studies demonstrate significant correlation between fecal elastase and levels of other pancreatic enzymes such as duodenal lipase, amylase, trypsin, and bicarbonate concentration. Fecal elastase is concentrated in human feces compared with pancreatic juice and is a simple, non-invasive and inexpensive test.

173. Explosion of a tank with benzene at a chemical plant has killed and wounded a large number of people. There are over 50 victims with burns, mechanical injuries and intoxication. Specify the main elements of medical care and evacuation of population in this situation:

Explanation

In this case, A Triage system is to be followed. Triage is a procedure followed in a medical emergency. It involves the sorting of and allocation of treatment to patients and especially battle and disaster victims according to a system of priorities designed to maximize the number of survivors

 These individuals should be allocated into categories such as: Minor, Deceased, Immediate and delayed. Those in the immediate category require instant medical assistance. Lastly, all 50 victims should be evacuated from the site of explosion.
174. A 36-year-old injured has been taken to the emergency station with open tibial fractures. Examination reveals bleeding: pulsating blood spurts out of the wound. What medical manipulations are required at this stage of medical care?

Explanation

175. The outpatient department of a city hospital works also as a 60-bed day hospital for somatic patients. The department operates in a single-shift mode. What specialist selects patients for admission to the day hospital?

Explanation

176. A 67-year-old female patient with hypertensive crisis has asthma, cough with expectoration of frothy pink sputum, moist rales in the lungs. The patient stays in sitting position, respiratory rate is 40/min, AP-214/136 mm Hg, heart rate - 102/min. What is the most rational tactics of this patient management?

Explanation

177. A 23-year-old primigravida at 39 weeks gestation has been admitted to the maternity ward with irregular contractions. The intensity of uterine contractions is not changing, the intervals between them stay long. Bimanual examination reveals that the cervix is centered, soft, up to 1,5 cm long. There is no cervical dilatation. What diagnosis should be made?

Explanation

The Preliminary stage of labor is characterized by: 

  • Irregular contractions

  • No structural changes in the uterus

  • Usually lasts 6-8 hours 

The first stage of labor is considered to last from the onset of regular uterine contractions to full dilation of the cervix. The first stage is much longer than the second and third combined. The first stage of labor has been divided into three phases: a latent phase, an active phase, and a transition phase. During the latent phase there is more progress in effacement ( stretching and thinning) of the cervix and little increase in descent. During the active phase and the transition phase there is more rapid dilation of the cervix and increased rate of descent of the presenting part.

The second stage of labor lasts from the time the cervix is fully dilated to the birth of the fetus. The second stage takes an average of 20 minutes for a multiparous woman and 50 minutes for a nulliparous woman.

The third stage of labor lasts from the birth of the fetus until the placenta is delivered. The placenta normally separates with the third or fourth strong uterine contraction after the infant has been born.The duration of the third stage may be as short as 3 to 5 minutes, although up to 1 hour is considered within normal limits

The fourth stage of labor arbitrarily lasts approximately 2 hours after delivery of the placenta. It is the period of immediate recovery, when homeostasis is reestablished. It serves as an important period of observation for complications, such as abnormal bleeding. 

 

Notice that this patient presents with irregular contraction and no cervical dilation.

178. A 49-year-old male patient complains of retrosternal pain, heartburn, weight loss of 8 kg over the last year, constipation, weakness. The patient has been a smoker for 20 years, and has a 10-year history of gastroesophageal reflux disease. The patient is asthenic, has dry skin. EGD revealed an ulcer in the lower third of the esophagus and esophageal stricture accompanied by edema, hyperemia and multiple erosions of the mucosa. What study is required for more accurate diagnosis?

Explanation

 

From anamnesis, this patient has a history of Gastroesophageal reflux disease; a condition that occurs as a result of weakening of the lower esophageal sphincter. Due to the weakening of the LES, gastric contents flow back into the esophagus leading to symptoms such as heartburns, retrosternal pain, constipation etc. The result from Esophagoduodenoscopy shows the presence of ulcers, stricture and edema at the lower end of the esophagus. For more accurate diagnosis, during the EGD, a biopsy of the esophageal mucosa should be obtained. This biopsy is used to check for an abnormal growth, pre existing infection etc. 

179. A 63-year-old male patient with persistent atria fibrillation complains of moderate dyspnea. Objectively: peripheral edemata are absent, vesicular breathing is present, heart rate - 72/min, AP- 140/90 mm Hg. What combination of drugs will be most effective for the secondary prevention of heart failure?

Explanation

The absence of peripheral edema in this patient helps rule out the use of diuretics - this group of drugs will be in the first line of action if the patient presents with any forms of edema. The groups of Drugs indicated for the secondary prevention of heart failure include: Angiotensin Converting enzyme inhibitor ( ACE inhibitors) or Angiotensin Receptor blockers ( ARBs), Beta blockers, Calcium channel blockers, Diuretics etc. Amongst these, a combination between ACE inhibitors and Beta blockers has proved to be more effective than monotherapy.
180. A 57-year-old male patient had an attack of retrosternal pain that lasted more than 1,5 hours. Objectively: the patient is inert, adynamic, has pale skin, cold extremities, poor volume pulse, heart rate - 120/min, AP- 70/40 mm Hg. ECG shows ST elevation in II, III, aVF leads. What condition are these changes typical for?

Explanation

 

The results from the ECG ( ST elevation in II, III and AVF) indicates an acute myocardial infarction of the inferior wall. Myocardial infarction is the leading cause of cardiogenic shock. Others include; arrhythmias, heart failure, cardiac trauma, mitral valve regurgitation etc. Cardiogenic shock is a medical emergency in which the heart is unable to pump adequate blood to vital organs.

181. During an exam, a 22-year-old female student fainted. She grew up in a family with many children, has a history of frequent acute respiratory infections. Objectively: the patient has pale skin and mucous membranes, splitend hair, brittle nails. Blood test results: RBC-2, 7 · 1012/l, Hb- 75 g/l, color index - 0,7, WBC-3, 2·109/l, platelets - 210·109/l, ESR- 30 mm/h. Blood serum iron is 6 mmol/l. What is the most likely diagnosis?

Explanation

Anemia is a condition characterised by too few RBCs . In iron deficiency anemia, we observe the presence of low hemoglobin levels coupled with a low color index; recall that iron is responsible for the characteristic red color in Rbc and a deficiency in Iron content in blood will lead to a decreased color index. In this patient, together with the RBC level, the color index and hemoglobin levels are also low ( norm Color index 0.85- 1.05,  Hemoglobin, blood Male: 135-175 g/L Female: 120-160 g/L); Characteristics of individuals with iron deficiency anemia include; brittle hair and nails, pale skin and mucous membrane  etc.

 

B12 deficiency will lead to the presence of megaloblasts in blood smear with the patient experiencing some neurological disturbances.

182. During the ultrasound study of carotid and vertebral arteries a 74-year-old patient developed a condition manifested by dizziness, weakness, nausea, transient loss of consciousness. Objectively: pale skin, AP-80/60 mm Hg, Ps- 96/min of poor volume. ECG shows sinus tachycardia, left ventricular hypertrophy. Focal neurological symptoms were not found. What is the provisional diagnosis

Explanation

Anatomically, the carotid sinus is located at the proximal end of the internal carotid artery just  above the bifurcation of the common carotid artery into the internal and external carotid artery. The carotid sinus houses baroreceptors (stretch receptors); The carotid sinus baroreceptor functions as a sensor responding to the mechanical stretch that occurs to the carotid artery as the arterial blood pressure increases. Notice that the above stated changes occurred on the background of an ultrasound study of the carotid and vertebral bodies.

Carotid sinus syncope (hypersensitivity) refers to an  exaggerated response to carotid sinus baroreceptor stimulation. It is characterised by a drop in blood pressure with or without accompanying bradycardia. 

Orthostatic syncope refers to the loss of consciousness resulting from the postural decrease in blood pressure ( change in position).

Morganani Adams stokes attack refers to periodic loss of consciousness due to a significant loss of cardiac output. 

 

Absence of focal neurological signs rules out the options of acute cerebrovascular accident.

183. On the 10th day postpartum a puerperant woman complains of pain and heaviness in the left breast. Body temperature is 38, 8oC, Ps- 94 bpm. The left breast is edematic, the supero-external quadrant of skin is hyperemic. Fluctuation symptom is absent. The nipples discharge drops of milk when pressed. What is a doctor’s further tactics?

Explanation

 

This patient most likely has an infection around the left mammary gland; this expresses itself by the increased temperature, hyperemia in this region and edema. The doctor’s tactics should be to firstly administer an antibiotic  to curl the infection. Recall that this woman is currently breastfeeding; expression of breastmilk refers to manually squeezing out the breast milk for storage and to feed the baby later. This procedure should be carried out in order to prevent the baby from coming in contact with the infected area. The option of opening and drainage of the mammary gland will be carried out in case of purulent discharge from the breast.

184. During the breast self-exam a 37-year-old female patient revealed a lump in the lower inner quadrant of her left breast. Palpation confirms presence of a mobile well-defined neoplasm up to 2 cm large. Peripheral lymph nodes are not changed. What is the way of further management?

Explanation

Since physical examination revealed a neoplastic formation on the left breast, further investigation ought to be carried out in order to know the specific type of formation. These investigations include an ultrasound and a needle aspiration biopsy. Only after confirming the specific diagnosis can we begin to administer the right procedure to follow ( therapeutic or surgical).
185. An 8-year-old child was hospitalized for fever up to 39, 8oC, inertness, moderate headache, vomiting. Examination revealed meningeal symptoms. Lumbar puncture was performed. The obtained fluid had raised opening pressure, it was transparent, with the cell count of 450 cells per 1 mcL (mainly lymphocytes - 90%), glucose level of 2,6mmol/l. What causative agent might have caused the disease in the child?

Explanation

 

Enterovirus infections (ECНO and Coxsackie’s infections) a group of an acute diseases caused by ECНO and Coxsackie’s enteroviruses, that  are characterized by the variety of clinical displays from the mild fever and simple carrying of virus to protracted meningoencephalitis, myocarditis, myalgia and other. Notice that the cell count in the CSF is 90% lymphocytes which indicates a viral cause;  for bacterial origin, the cell count will be mainly neutrophils. Enterovirus is the only viral cause amongst the listed agents.

186. A 25-year-old female has a self detected tumor in the upper outer quadrant of her right breast. On palpation there is a painless, firm, mobile lump up to 2 cm in diameter, peripheral lymph nodes are not changed. In the upper outer quadrant of the right breast ultrasound revealed a massive neoplasm with increased echogenicity sized 21x18 mm. What is the most likely diagnosis?

Explanation

 

An adenoma is a benign epithelial tumor from the epithelium of the glands and glandular organs e.g. breast, thyroid gland, ovaries etc. A fibroadenoma is a benign nodular proliferation and not a true neoplasm (cancer); it presents as a mobile lump in the breast of young women. Lactocele are breast cysts that develop during or after lactation and are characterised by the accumulation of milk.

187. A 49-year-old female patient complains of itching, burning in the external genitals, frequent urination. The symptoms have been present for the last 7 months. The patient has irregular menstruation, once every 3-4 months. Over the last two years she has had hot flashes, sweating, sleep disturbance. Examination revealed no pathological changes of the internal reproductive organs. Complete blood count and urinalysis showed no pathological changes. Vaginal smear contained 20-25 leukocytes per HPF, mixed flora. What is the most likely diagnosis?

Explanation

This patient actually presents with Climacteric syndrome; one of the neuroendocrine syndrome in gynaecology that occurs during the transitional period ( starts before menopause); it occurs as a result of the gradual decrease in ovarian function and is characterised by; hot flashes, insomnia, nervousness, irregular menstruation , sleep disturbance etc. The term Climacteric syndrome is usually used interchangeably with Menopausal syndrome  but note that, Menopausal syndrome refers to the cessation of menstruation for 12 straight months

 

The result from the examinations carried out  revealed no pathological  changes - this rules out the option of  cystitis, trichomonas colpitis, vulvitis and bacterial vaginosis. 

188. A 45-year-old male patient complains of acute pain in his right side irradiating to the right thigh and crotch. The patient claims also to have frequent urination with urine which resembles a meat slops. The patient has no previous history of this condition. There is costovertebral angle tenderness on the right (positive Pasternatsky’s symptom). What is the most likely diagnosis?

Explanation

A positive pasternestky’s sign indicates kidney related pathology ruling out the option of Acute appendicitis, cholecystitis and pancreatitis. Urolithiasis and pyelonephritis ( infection of the kidney tubules mostly by bacteria)  have many symptoms in common (eg, hematuria, flank pain, shaking chills, anorexia). Urolithiasis ( stones in the urinary tract) is usually not associated with fever, except in patients with concomitant pyelonephritis. The best way to differentiate these diseases is by conducting a renal ultrasonography.
189. After a holiday in the Crimea, a 49-year-old male patient with a history of lung tuberculosis felt increased weakness, periodic dizziness, easing bowel movements with abdominal pain, the need for additional salting his meals. The patient has noted that his condition improves after some sweet tea and validol taken sublingually. Objectively: there is an intense darkening of skin, AP- 70/50 mm Hg, glycemia is 3,0 mmol/l. What is the possible cause of health deterioration:

Explanation

 

Note that Tuberculosis is the most common cause of Addisson’s disease ( primary adrenal insufficiency). Adrenal insufficiency is the decreased production of adrenocortical hormones (glucocorticoids, mineralocorticoids, and adrenal androgens) and can be primary, secondary, or tertiary. Primary adrenal insufficiency (Addison disease) is caused by a disorder of the adrenal glands. Patients with long-standing adrenal insufficiency can present with postural hypotension, nausea, vomiting, weight loss, anorexia, lethargy, depression, and/or chronic hyponatremia. Patients can also present with loss of libido as a result of hypoandrogenism. Patients with primary adrenal insufficiency also tend to develop hyperpigmentation of the skin, mild hyperkalemia, and metabolic acidosis. The glycemic level of 3.0 mmol/l rules out the option of diabetes mellitus. 

190. A 42-year-old male patient has been delivered to a hospital in a grave condition with dyspnea, cough with expectoration of purulent sputum, fever up to 39, 5oC. The first symptoms appeared 3 weeks ago. Two weeks ago, a local therapist diagnosed him with acute right-sided pneumonia. Over the last 3 days, the patient’s condition deteriorated: there was a progress of dyspnea, weakness, lack of appetite. Chest radiography confirms a rounded shadow in the lower lobe of the right lung with a horizontal fluid level, the right sinus is not clearly visualized. What is the most likely diagnosis?

Explanation

Recall that an abscess refers to a pus filled cavity found within tissues. The result from the chest radiography confirms a rounded shadow ( a cavity) in the lower lobe of the right lung with a horizontal fluid level ( purulent content).  This patient presents with a primary abscess which occurs on the background of a pneumonia infection. 

In Pleuropneumonia, the inflammation of the lung is accompanied by the inflammation of the pleura ( pneumonia plus Pleurisy).

In pulmonary empyema and pleural effusion, purulent contents build up within the pleural space and also occurs as a complication of bacterial pneumonia. 

Atelectasis is a loss of lung volume that may be caused by a variety of ventilation disorders, for instance, bronchial injury or an obstructive mass such as a tumor. 

 
191. An 11-year-old boy complains of general weakness, fever up to 38, 2oC, pain and swelling of the knee joints, feeling of irregular heartbeat. 3 weeks ago, the child had quinsy. Knee joints are swollen, the overlying skin and skin of the knee region is reddened, local temperature is increased, movements are limited. Heart sounds are muffled, extrasystole is present, auscultation reveals apical systolicmL murmur that is not conducted to the left inguinal region. ESR is 38 mm/h. CRP is 2+, anti streptolysin O titre - 400. What is the most likely diagnosis?

Explanation

Rheumatic Fever:

Etiology: Group A Beta hemolytic Streptococci (Streptococcus pyogenes)

This commonly presents as Pharyngitis - upper respiratory tract infection (URTI) accompanied with fever.

The common complications are myocarditis and post Streptococcal glomerulonephritis. However, these symptoms only present about 1-5 weeks (average of 20 days which is 2-3 weeks) after a Group A Streptococcal infection.

Note, the question stem says the 11 year old had quinsy ( peritonsillar abscess) from group A Strept infection

 

Diagnosis is based on Jones Criteria:

Joint (migratory arthritis)

Carditis

Nodules in skin (subcutaneous)

Erythema marginatum

Sydenham chorea

 

ADDITIONAL NOTE: 

 

Mediated by Type II hypersensitivity reaction and ASSOCIATED WITH ASCHOFF BODIES AND ANTISCHKOW CELLS; increased anti-streptolysin O titers.

 
192. A 28-year-old male patient complains of sour regurgitation, cough and heartburn that occurs every day after having meals, when bending forward or lying down. These problems have been observed for 4 years. Objective status and laboratory values are normal. FEGDS revealed endoesophagitis. What is the leading factor in the development of this disease?

Explanation

 

Sour regurgitation, cough, heartburns after meals are key findings in Gastroesophageal reflux disease. In this disorder, there occurs a backflow of acidic content of the stomach into the lower end of the esophagus leading to inflammation and formation of erosions. This disorder occurs due to the failure of the lower esophageal sphincter to function properly; its inability to close properly allows for the backflow of gastric content.  A Fibroesophagogastroduedenoscopy is usually carried to confirm diagnosis- in this case we observe an endo esophagitis which helps confirm this diagnosis. 

193. On admission a 35-year-old female reports acute abdominal pain, fever up to 38, 8oC, mucopurulent discharges. The patient is nulliparous, has a history of 2 artificial abortions. The patient is unmarried, has sexual contacts. Gynecological examination reveals no uterus changes. Appendages are enlarged, vilaterally painful. There is profuse purulent vaginal discharge. What study is required to confirm the diagnosis?

Explanation

The absence of uterine changes on gynecological examination helps rule out the option of Hysteroscopy and curettage of the uterine cavity. Notice the presence of profuse purulent discharge from the vagina coupled with acute abdominal pain and fever- these are indicative of an infectious process; a bacterioscopic and a bacteriological examination of the purulent discharge should be carried out inorder to identify the causative agent and administer the right treatment.
194. A 20-year-old female consulted a gynecologist about not having menstrual period for 7 months. History abstracts: early childhood infections and frequent tonsillitis, menarche since 13 years, regular monthly menstrual cycle of 28 days, painless menstruation lasts 5-6 days. 7 months ago the patient had an emotional stress. Gynecological examination revealed no alterations in the uterus. What is the most likely diagnosis?

Explanation

195. A 48-year-old female has been admitted to the gynecology department for pain in the lower right abdomen and low back pain, constipations. Bimanual examination findings: the uterus is immobile, the size of a 10-week pregnancy, has uneven surface. Aspirate from the uterine cavity contains atypical cells. What diagnosis can be made?

Explanation

196. A 27-year-old male patient consulted a doctor about pain in the lower third of the thigh with weight bearing activities and unloaded. Two years ago, the patient underwent treatment in the casualty depatment for the open fracture of the lower third of femur. The fracture healed slowly, the healing process was accompanied by prulent inflammation. Objectively: edema of the lower third of the thigh, elevated local temperature. Radiograph shows signs of destruction and sequestration. What is the most likely diagnosis?

Explanation

 From anamnesis, we observe that this patient had an open fracture (trauma) of the lower third of the femur 2 years ago. The healing process was slow and accompanied by purulent inflammation. Osteomyelitis is a serious bone inflammation that can result from a previous trauma, puncture wound, surgery, bone fracture, abscessed tooth, or infection of soft tissue, the ear or sinus. Chronic osteomyelitis usually occurs after an acute episode of osteomyelitis when the infection has not been totally cured. Purulent discharge, bone pain, redness, swelling and elevation of temperature in the affected area are key findings.

Hematogenous Osteomyelitis usually occurs in Children and takes place on the background of a spreading infection via the blood. 

 

Multiple myeloma is a cancer of the plasma cells and is  characterised by the presence of bence jones proteins.

197. A 30-year-old male patient had been admitted to the TB hospital because of the following changes detected by fluorography: an ill-defined shadow of low intensity up to 1 cm in diameter in the S1 of the right lung. CT scan showed a destruction area in the center of the shadow. Sputum analysis revealed MTB. The patient was diagnosed with focal tuberculosis. What phases of tuberculosis are the identified changes typical for?

Explanation

198. A 43-year-old female complains of significant weakness, sore throat, occurrence of multiple unexplained bruises on her skin. These symptoms have been present for a week, the disease is associated with quinsy which she had some time before. Objectively: body temperature - 38, 9oC, respiratory rate -24/min, Ps- 110/min, AP- 100/65 mm Hg. The patient has pale skin, petechial rash on the extremities, enlarged lymph nodes. Blood test results: Hb- 80 g/l, RBC- 2, 2 · 1012/l; WBC-3, 5 · 109/l; blasts - 52%; eosinophils - 2%; stab neutrophils - 3%; segmented neutrophils 19%; lymphocytes - 13%; monocytes - 1%; platelets - 35 · 109/l. ESR - 47 mm/h. What test is required to specify the diagnosis?

Explanation

Immunophenotyping is an analysis of heterogeneous ( various) populations of cells for the purpose of identifying the presence and proportions of the various populations ( identifying how much of each cell type is present). This technique works on the basis of identifying different cell markers or antigens peculiar for each cell type. 

This patient presents with low RBC, WBC and platelets coupled with an increased blast cell level; the result from the general blood analysis suggests a leukemia or a lymphoma. Immunophenotyping will help specify the diagnosis. 

Cytogenetic study is used to analyse the structure of chromosome material and the study of diseases caused by structural and numerical abnormalities of chromosomes.
199. A 47-year-old male patient complains of compressive chest pain that occurs both at rest and during light physical activity; irregular heartbeat. These problems arose 3 months ago. The patient’s brother died suddenly at the age of 30. Objectively: Ps- 84/min, arrhythmic, AP- 130/80 mm Hg. ECG confirms signs of left ventricular hypertrophy, abnormal Q-waves in V 4 − V 6 leads. EchoCG reveals that interventricular septum is 1,7 cm, left ventricular wall thickness is 1,2 cm. What is the most likely diagnosis?

Explanation

The key findings here are the results from the ECG and the echocardiogram. Notice that the left ventricle has undergone a hypertrophy and the interventricular septum is increased in size ( norm 0.6-1.1cm). Hypertrophic cardiomyopathy is a condition in which the heart becomes enlarged without any underlying disease/pathology; this reduces the heart’s pumping ability leading to  cardiac irregularities, dizziness, dyspnea etc.

 

Aortic stenosis is the narrowing of the walls of the aorta thereby restricting blood flow through the aorta. Chest pain, lightheadedness, difficulty walking are key symptoms

200. Within the structure of the region’s population the share of persons aged 0 to 14 years is 25%, the share of persons aged 50 years and older is 30%. What concept most accurately describes this demographic situation?

Explanation

A regressive type of population is one in  which the percentage of older individuals is higher than that of the early aged ( younger). In the Progressive type, the younger ones are more in the population. Notice that in this analysis, the percentage of persons aged 50 and above is greater than the percentage of the individuals aged 0-14