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Question 1 of 200

1. A 38-year-old man works within the range of ionizing radiation. At a routine medical examination he presents no problems. In blood: RBCs - 4, 5 · 1012/l, Hb- 80 g/l, WBCs - 2, 8 · 109/l, thrombocytes - 30 · 109/l. Decide if this person can work with sources of ionizing radiation:

Explanation

Observe that the levels of WBC, hemoglobin and platelets are very low. This can be traced to the effect of radiation from around his workplace. Working in this environment should be prohibited for this individual because of the health effects.
2. A maternity patient breastfeeding for 1,5 weeks has attended a doctor. She considers the onset of her disease to be when proportional breast engorgement occurred. Mammary glands are painful. Body temperature is 36, 6oC. Expression of breast milk is hindered. The most likely diagnosis is:

Explanation

 

They key finding here is “ the expression of breastmilk is hindered” - this refers to a stagnation in the flow of milk in one or several lobes of the mammary gland leading to an enlarged and painful mammary gland; if not corrected, this leads to mastitis ( is an inflammation (most often one-sided) of the mammary gland caused by pathogenic coccal flora (most often by staphylococci)).

This patient is yet to develop mastitis, however, if Lactostasis is not properly managed, it can result in Mastitis. Mastitis will be accompanied with fever, redness on the affected breast and pain. Of which this patient is afebrile and no redness stated in the question. 

It is important to treat blocked milk ducts so they do not progress to mastitis. Options include: 

-Making sure the baby is feeding well on the affected breast – offering the affected breast first can help. 

-The application of heat for a few minutes before a feed, gentle massage of the affected area during feeding, and cold packs after a feed and between feeds for comfort. 

-A change in feeding position. 

-Frequent drainage of the breast through feeding and expressing. 

If the blockage does not clear within 8 to 12 hours or you start to feel unwell, see your doctor.

3. A 12-year-old girl complains of general weakness, rise of body temperature up to 38, 2oC, pain and swelling of knee joints, feeling of cardiac rhythm disruption. The child had tonsillitis 3 weeks ago. The knee joints are swollen, local raise of temperature is observed, mobility is reduced. Heart sounds are weakened, extrasystole is present; at the cardiac apex systolic noise can be auscultated, which is not conducted to the left axillary region. ESR is 38 mm/h. CRP 2+. AntistreptolysinO titers are 400. The most likely disease is:

Explanation

Acute rheumatic fever typically occurs 2-3 weeks after Group A streptococcal pharyngitis. Diagnosis depends on a set of clinical signs that result from this infection ( Jones criteria)- these include chorea, carditis, subcutaneous nodules, erythema marginatum, and migratory polyarthritis. For biochemical analysis, certain key markers are used in diagnosis; these include C reactive protein ( an inflammatory marker), antistreptolysin O titer ( a marker that indicates a group A streptococcal infection ), ESR ( a marker from general blood analysis). Using these criterias, we can observe that this patient has arthritis, carditis and results from the biochemical analysis all appear positive for an acute rheumatic fever.

 

Reactive arthritis is also known as reiter’s syndrome  and refers to the inflammation of joints as a result of  a urogenital, intestinal or respiratory infection.

4. A 60-year-old man has a diet consisting of unvaried food staples: mostly cereals, potato, pasta; few vegetables and little fats (especially animal fats). During medical examination he complains of deterioration of his twilight vision. This condition can be caused by lack of:

Explanation

Vitamin A (retinal, retinol, retinoic acid) is a constituent of visual pigment (retinal + opsin= rhodopsin). Rhodopsin is a visual pigment present in Rods ( responsible for dim light or night vision). It is also essential for the normal differentiation of epithelial cells into specialized tissue. Deficiency leads to night blindness, dry scaly skin etc.
5. A 45-year-old patient was hospitalised in surgical in-patient unit with intermuscular phlegmon of the right thigh on the 6th day from the onset of disease. Abscess formed under the fascia lata was diagnosed, lanced and widely drained, necrotic tissues were removed. Antibiotic therapy with cephalosporines and the III generation fluoroquinolones was prescribed, as well as immune corrective and detoxification infusion therapy (2,5 liters per day), diuresis stimulation, UV irradiation of blood and plasmapheresis. What is the main component of sepsis prevention?

Explanation

6. An Rh-negative woman with 32-weeklong term of pregnancy has been examined. It was observed that Rh-antibodies titer had increased four times within the last 2 weeks and was 1:64. First two pregnancies ended in antenatal death of fetus caused by hemolytic disease. What tactics of pregnancy management should be chosen?

Explanation

 

Rh Antibody Titre test is done to determine the type and quantity of antibodies in the blood. Rh antibodies are likely to rise during pregnancy. Depending on the level of other antibodies these antibodies could cause hemolytic problems in the baby and need to be monitored. It is usually repeated several times during pregnancy (at 32, 36, & 38 weeks). A low titer (less than 1:16) may not pose any problem for the baby.  any test from 1:64 or higher, is indicative of incompatibility. Notice that the patient has previously had 2 fetal deaths from this incompatibility, to save the current situation, an early delivery should be induced.

7. A 2-year-old child has been suffering since birth from recurring inflammatory diseases of lungs, purulent pansinusites, hearing deterioration, multiple cylindrical bronchiectases. Dextrocardia is observed. On biopsy  ultrastructural change of ciliated epithelium. What is the basis of the given syndrome?

Explanation

This patient presents with Kartengener’s Syndrome. This  is a rare, autosomal recessive genetic ciliary disorder comprising the triad of situs inversus, chronic sinusitis, and bronchiectasis. The basic problem lies in the defective movement of cilia, leading to recurrent chest infections, ear/nose/throat symptoms, and infertility.

If there are defects in the cilia lining the airways, the body is unable to expel foreign material and clear mucus. This can lead to pulmonary complications, including frequent infections of the lungs, ears, throat and sinuses.

Deficiency of surfactant is the primary cause of Respiratory distress syndrome which is usually seen in premature babies.

8. A newborn infant (the first labor, lasted for 26 hours) is 1-day-old, postmature; body weight is 3850 g; body length is 52 cm. Delivery was performed by applying obstetrical forceps in sincipital presentation, Apgar score is 1/3. The face is bluish-pale. The head is thrown back; severe birth trauma is present; the infant is excitable, shrill \"cerebral scream\" is present; the eyes are half-open; facial expression is attentive; hyperesthesia, hypersthenia and readiness for convulsions are present. Liquor has high content of erythrocytes, lymphocytic cytosis occurs. The most likely diagnosis is:

Explanation

The take home point from this question is this - “Liquor has high content of erythrocytes…”

The Liquor here is the Cerebrospinal Fluid (CSF). Presence of Red Blood Cells or Erythrocytes in CSF is a clear indication of a subarachnoid hemorrhage. Risk factors for the subarachnoid hemorrhage were listed in the question. 

  • Prolonged labour (26hrs)

  • Delivery by obstetric forceps

  • Severe birth trauma etc.

When it comes to infant brain hemorrhages, the cause is usually a birth injury that may have been caused by several elements. As mentioned, the use of birth-assisted tools, such as forceps, during the delivery can also result in hemorrhaging.

A newborn baby’s skull and head are very fragile, so doctors have to ensure that such tools are used with the utmost care. Forceful and improper pulling when using the birth-assisted tools can damage a baby’s brain, leading to a lifetime of trauma.

A subarachnoid hemorrhage occurs when there is bleeding into the subarachnoid space – the area that lies between the brain and the tissues that cover it. It is within the subarachnoid space that cerebrospinal fluid circulates and protects the brain from injury. A hemorrhage in the subarachnoid space can lead to paralysis, brain damage, and other long-lasting prognoses.

Subdural, Epidural hemorrhages can also result from birth trauma but the blood will not get to the CSF. The other options listed will not result in bloody CSF or Erythrocytes in Liquor as stated in the question.

9. A 74-year-old patient visited a urologist with complaints of pain above the pubis and inability to urinate for 8 hours. At home he had taken antispasmodics and had a warm bath but no improvement occurred. Objectively: abdomen is soft and painful above the pubis; dullness of percussion sound is observed above the pubis. Murphy’s (Pasternatski’s) punch sign is negative on the both sides. What condition does the patient have?

Explanation

Acute Urinary Retention is a Sudden inability to urinate. The patient experiences increasingly agonizing suprapubic pain associated with severe urgency and may dribble (release) only small amounts of urine. Urinary retention is characterised by poor urinary stream with intermittent flow, straining, a sense of incomplete voiding, and hesitancy (a delay between trying to urinate and the flow actually beginning). As the bladder remains full, it may lead to incontinence, nocturia (need to urinate at night), and high frequency. Notice that this patient has only had this for 8 hours (a short period); in the chronic form, it might last for days and also be recurrent.

 

Paradoxal Ischuria is a form of urinary incontinence that occurs when the bladder is so full that it continually leaks urine; often attributable to a blocked urethra (e.g., due to prostate enlargement) or weak bladder muscles or nerve damage.

10. A 37-year-old patient has been undergoing treatment of diskogenic lumbosacral radiculitis for a month. There is skin numbness observed at the lateral surface of the right lower extremity, Achilles jerk is absent. MRI of lumbar spine revealed intervertebral disk L5-S1 prolapse up to 8 mm. Choose the further tactics for patient treatment:

Explanation

 

Lumbosacral radiculitis refers to a condition  associated with neurogenic pain caused by the mechanical pressure or inflammation of one or more lumbar nerve roots. In this patient, we can see there is a prolapse of the intervertebral disc L5-S1 ( the reason for the neurogenic pain). Therefore for treatment of this patient, the prolapsed intervertebral disk should be surgically removed.

11. A 40-year-old patient complains of constant moderate pain in the lumbar spine and significantly reduced mobility. The patient has been suffering from this condition for the last 7 years since pain appeared first in the sacrum area. X-ray: ankylosis of sacroiliac articulation, significant narrowing of intervertebral joint fissures of lumbar vertebrae and calcification of spinal ligaments. What pathology is most likely to cause such X-ray image?

Explanation

Ankylosing spondylitis (AS) is a chronic, multisystem inflammatory disorder primarily involving the sacroiliac (SI) joints and the axial skeleton. Overtime, it results in the fusion of  the small bones in your spine (vertebrae) making the spine less flexible and can result in a hunched-forward posture. The term “swayback” is an inappropriate curve of the upper lumbar spine; And Bamboo spine is a radiographic feature seen in ankylosing spondylitis that occurs as a result of vertebral body fusion. Notice on xray 'ankylosis of sacroiliac articulation, significant narrowing of intervertebral joint fissures of lumbar vertebrae and calcification of spinal ligaments’.
12. A 7-year-old child became ill again 2 weeks after he had tonsillitis. There are the following complaints: temperature rise up to 38oC, hemorrhagic rash on the extremities, enlargement of the ankle joints. Blood test: hemoglobin is 120 g/l, platelets are 170 · 109/l, ESR is 30 mm/h. Urine test: proteinuria up to 0,7 g/l, cylinders - 5-6 in the field of vision, erythrocytes - 8-10 in the field of vision. What mechanism of hemorrhagic syndrome is present in the given case?

Explanation

From the description above, the patient is said to have an Immune complex Vasculitis. This is a form of vasculitis, which is characterized by the deposition of immunoglobulin and/or complement on the vessel wall. It affects mainly small vessels and the kidneys; we can confirm this by the presence of hemorrhagic rash and signs of a kidney related disorder ( proteinuria, erythrocytes and cylinders in blood).

 

Observe that the platelet levels is normal ( norm. 150-400 · 109/l); this rules out the option of a platelet dysfunction.

13. A 48-year-old patient was delivered to a hospital in-patient unit with uterine bleeding that occurred after the 2-week-long delay of menstruation. Anamnesis states single birth. Examination of the uterine cervix with mirrors revealed no pathologies. On bimanual examination: uterus is of normal size, painless, mobile; uterine appendages have no changes. Discharge is bloody and copious. What primary hemostatic measure should be taken in the given case?

Explanation

Indication for fractional curettage includes Abnormal uterine bleeding: irregular bleeding, menorrhagia, suspected malignant or premalignant condition, Retained material in the endometrial cavity, Evaluation of intracavitary findings from imaging procedures (abnormal endometrial appearance due to suspected polyps or fibroids), Evaluation and removal of retained fluid from the endometrial cavity (hematometra, pyometra) in conjunction with evaluating the endometrial cavity and relieving cervical stenosis etc. This patient presents with uterine bleeding, the word ‘copious’ means the discharge is abundant ( plenty in quantity).

14. A 30-year-old woman complains of irregular copious painful menstruations, pain irradiates to the rectum. Anamnesis states 10- year-long infertility. On bimanual examination: uterus is of normal size; uterine appendages on the both sides are corded, with rectricted mobility, painful; there are dense nodular painful growths detected in the posterior fornix. A doctor suspects endometriosis. What method allows to verify this diagnosis?

Explanation

15. A 14-year-old girl complains of tooth caries; the tooth should be filled. Anamnesis states that artificial mitral valve was installed 2 years ago due to mitral insifficiency. What antibacterial drug should be prescribed to prevent infective endocarditis?

Explanation

Infective endocarditis (IE) is an infectious inflammation of the endocardium that affects the heart valves. The condition is a result of bacteremia, which is most commonly caused by dental procedures, surgery, distant primary infections, and nonsterile injections. IE clinically presents with either an acute or subacute course. Clinical features include constitutional symptoms (fatigue, fever/chills, malaise) in combination with signs of pathological cardiac changes (e.g., new or changed heart murmur, heart failure signs) and possibly manifestations of subsequent damage to other organs (e.g., glomerulonephritis, septic embolic stroke). Diagnosis is made based on the Duke criteria, whose main features include positive blood cultures and evidence of endocardial involvement in echocardiography. To prevent Infective endocarditis, the patient should be given Amoxicillin PO one hour before the procedure.
16. A 30-year-old woman complains of infertility during her 10-year-long married life. Menstruations occur since she was 14 and are irregular, with delays up to a month and longer. Body mass is excessive. Hirsutism is observed. On bimanual examination: uterine body is decreased in size; ovaries are increased in size, dense, painless, and mobile. The most likely diagnosis is:

Explanation

 

Polycystic ovarian syndrome (Stein–Leventhal 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 etc. The ovaries mostly develop follicles (collection of fluids). Realise that the patient is of a reproductive age and experiences infrequent menstruation; the result of bimanual examination, confirms the polycystic ovary pathology.

17. A 22-year-old woman on a reduced diet, vegetarian, attended a hospital with complaints of distorted smell and taste perception and lesions in the angles of her mouth. Objectively: sclera is distinctly blue. Diagnosis: irondeficiency anemia. What clinical syndrome is expressed primarily?

Explanation

 

Lesion located at the angle of the mouth ( angular stomatitis) is the key finding here; coupled with other symptoms such as dysphagia, pain, atrophic glossitis- these are symptoms that indicate sideropenic syndrome ( usually found in individuals with iron deficiency anemia, sometimes referred to as Plummer- Vinson syndrome). Hemolytic syndrome will be characterised by an increased breakdown of cells and often seen in patients with sickle cells anemia. Hemorrhagic syndrome will be in a case of continuous bleeding due to deficiency of clotting factors or trauma.

18. A 15-year-old patient complains of excessive body weight, headache, irritability, rapid fatigability. Significant increase of body weight occurred at the age of 14. Objectively: weight is 90 kg; height is 160 sm, proportional body built. Fatty tissue is distributed evenly. There are thin pink striae (stretch marks) on the thighs, abdomen and mammary glands. BP - 145/90 mm Hg. Provisional diagnosis is:

Explanation

19. A 6-year-old girl attended a general practitioner with her mother. The child complains of burning pain and itching in her external genitalia. The girl was taking antibiotics the day before due to her suffering from acute bronchitis. On examination: external genitalia are swollen, hyperemic, there is white deposit accumulated in the folds. The most likely diagnosis is:

Explanation

Candidal vulvovaginitis is also known as vaginal thrush or vaginal yeast infection. It is characterised by very severe vaginal itching, burning sensation while urinating, pain during sex, hyperemic vagina and a thick white vaginal discharge. It occurs due to excessive growth of vaginal candida. Note that Trichomoniasis secretion is usually yellowish-green in colour.
20. A 44-year-old man complains of dyspnea with sensation of lack of air on inhale, palpitations occurring during slight physical exertion, and shin edemas that appear in evening and resolve in morning. His condition has been lasting for 5 months already, deterioration is gradual. What method of instrumental diagnostics allows to verify decrease of systolic function in this patient?

Explanation

An echocardiography is a procedure used in checking the live images of the heart. Information from this procedure shows: Changes in your heart size, Pumping strength, Damage to the heart muscle, Valve problems, Heart defects.

An electrocardiography is a procedure that  records electrical signals of the heart. It provides information about the heart rate, rhythm, Inadequate blood and oxygen supply to the heart, Heart attack and some structural abnormalities.

 

A phonocardiography is the recording of the sounds from the heart.

21. When playing in a kindergarten a 3- year-old child sudenly developed dyspnea, paroxysmal compulsive dry cough. The face is cyanotic, the eyes are tearful. Vomiting occurred several times. Breathing is weakened over the whole right side of the chest. The provisional diagnosis is:

Explanation

While playing, the child must have inserted into his nose a foreign object. Recall that  in most cases, a foreign body is going to be deposited in the right bronchial tree because of the size and position. This explains why Breathing is weakened over the whole right side of the chest.

 

Bronchial asthma is a chronic obstructive pulmonary disease that is characterised by the narrowing and swelling of the airways due to excess secretion of mucus.

22. A patient with otopyosis is in sharply deteriorating condition: he developed headache, vomiting, febrile temperature, general hyperesthesia. Meningeal symptoms and stagnant optic disks are observed. There is no focal symptoms. Liquor is turbid, blood pressure is high, albuminocytological dissociation occurs with neutrophils. What disease can be suspected?

Explanation

23. A 25-year-old patient is not married and has sexual relations with several partners. During the last 3 months he noticed small amount of mucoserous secretions produced from urethra. Subjectively: periodical itching or burning pain in urethra. Two months ago pain in knee join developed. Possibility of trauma or exposure to cold is denied by the patient. During the last week eye discomfort is noted - lacrimation and itching. What provisional diagnosis can be suggested?

Explanation

 

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,". It is caused by another infection and is thus "reactive". The symptoms of reactive arthritis very often include a combination of three seemingly unlinked symptoms—an inflammatory arthritis of large joints, inflammation of the eyes (conjunctivitis and uveitis), and urethritis. A useful mnemonic is "the patient can't see, can't pee and can't bend the knee" or "the patient can't see, can't pee and can't climb a tree". Also known as Reiter’s syndrome.

24. A 19-year-old patient complains of severe pain in axillary crease. Condition onset was a week ago after her swimming in cold river and epilation. The next day painful \"boil\"appeared that was becoming larger every day and became a plum-sized tumor. Upon examination nodular conical growths joined together are detected, the skin covering them is bluishred in colour. Some nodules have fistulous openings producing thick purulent mass. Body temperature is 38, 5Oc, general malaise. The most likely diagnosis is:

Explanation

25. A patient complains of weight gain, chill, edemas, xeroderma, somnolence, difficulties with focusing. Objectively: height is 165 cm; weight is 90 kg; body proportions are of female type, t o- 35, 8oC, heart rate - 58/min, BP - 105/60 mm Hg. Heart sounds are weakened, bradycardia is observed. Other internal organs have no changes. Thyroid gland cannot be palpated. Milk secretion from mammary glands is observed. Hormone investigation revealed increased levels of thyroid-stimulating hormone (TSH) and prolactin, and decreased level of thyroxine (T4). Which one is the cause for obesity?

Explanation

Hypothyroidism is an endocrine disorder in which the thyroid gland does not produce enough thyroid hormones. It is classified under congenital and acquired. The acquired form is further divided into Primary, secondary and tertiary forms.

Primary Hypothyroidism: Occurs due to thyroid gland disturbances. This can be as a result of environmental factors, autoimmune causes e.g. Hashimoto, radiation etc. Characterised by low levels of T3 triiodothyronine and T4 thyroxine.

Secondary hypothyroidism: occur due to pituitary gland disorders. In this form, thyroid stimulating hormone (TSH) is low.

Tertiary Hypothyroidism: Occurs due to hypothalamic related disorders. Characterised by a low level of thyroid releasing hormone.

Symptoms include intolerance to cold, hair loss, fatigue, brittle nails, weight gain, bradycardia etc. sometimes referred to as Myxedema.

The secretion of T3 and T4 by the thyroid is controlled by an endocrine feedback system involving the pituitary gland and the hypothalamus (structures in the brain). Lowered levels of these thyroid hormones result in increased levels of pituitary and hypothalamic hormones ( TSH, TRH, Prolactin)

26. A 54-year-old patient complains of weakness, jaundice, itching skin. Disease onset was 1,5 months ago: fever up to 39oC appeared at first, with progressive jaundice developed 2 weeks later. On hospitalisation jaundice was severely progressed. Liver cannot be palpated. Gallbladder is enlarged and painless. Blood bilirubin is 190 micromole/l (accounting for direct bilirubin). Stool is acholic. What is the most likely jaundice genesis in this patient?

Explanation

Prehepatic/ hemolytic - occurs due to increased breakdown of RBC eg, hemolytic disease of newborn. There is an increased level of unconjugated bilirubin. Stool and urine colour are normal.

Hepatic/ parenchymatous  - Occurs in diseases affecting the liver parenchyma eg, cirrhosis, hepatitis etc. There is an increase in both unconjugated and conjugated bilirubin. Urine appears dark and faeces pale.

Post hepatic/ obstructive/ mechanical jaundice - pathology lies after conjugation of bilirubin and is caused by obstruction of biliary path. Conjugated bilirubin is accumulated, Urine is dark and faeces pale or acholic. Seen in disease such as cholelithiasis
27. A 22-year-old patient complains of 8-months-long delay of menstruation. Anamnesis: menarche since the age of 12,5. Since the age of 18 menstruations are irregular. No pregnancies. Mammary glands have normal development; when the nipples are pressed, milk drops are discharged. On gynecological examination: moderate uterus hypoplasia. On hormonal examination: prolactin level exceeds the norm two times. On computed tomogram of the sellar region: a space-occupying lesion 4 mm in diameter is detected. The most likely diagnosis is:

Explanation

Notice that the result of the CT shows a bulky mass in the sella; anatomically, the pituitary gland is located in the sella turcica of the sphenoid bone and a bulky formation of such diameter in this location indicates the presence of a tumour. Furthermore, Prolactin levels are twice the normal; this hormone is produced from lactotrophs present in the anterior pituitary gland. The increased production is mostly as a result of the tumour.

Lactational amenorrhea is observed in breastfeeding mothers; the period after child birth in which the lactating mother doesn't menstruate.

 

Sheehan’s syndrome is one of the major causes of hypopituitarism in females; it is due to pituitary infarction as a result of postpartum hemorrhage.  fatigability, significant weight loss, weakness, and loss of appetite all include associated symptoms.

28. A 2-year-old child in a satisfactory condition periodically presents with moderate proteinuria, microhematuria. US results: the left kidney is undetectable, the right one is enlarged, there are signs of double pyelocaliceal system. What investigation is required to specify the diagnosis?

Explanation

 

Excretory Urography is also known as intravenous Pyelogram. It is an x-ray procedure that involves the intravenous administration of contrast material inorder to  verify and localize upper urinary tract diseases.  Retrograde pyelogram also uses a contrast agent for better visualization of the ureters and kidneys but note that: In intravenous pyelogram, the contrast dye is injected into  a vein while in retrograde pyelogram, it is injected directly into the ureters. Retrograde pyelogram is mostly done in cases where excretory urography does not give a clear image of the pathological area.

29. For the last 3 years a 12-year-old boy has been suffering from stomachache, abdominal distension, nausea, periodical liquid fatty stool, grey in color, with rotten smell. On palpation: pain in the epigastrium, Desjardins’ pancreatic point and Chauffard’s triangle; positive MayoRobson’s sign. Insufficiency of pancreas exocrine function is suspected. What method is the most informative for pancreas exocrine function assessment?

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). The exocrine pancreas is responsible for producing elastase .Human pancreatic elastase 1 (E1) remains undegraded during intestinal transit. Therefore, its concentration in feces reflects exocrine pancreatic function. Enzymes such as trypsin and amylase are used in testing for pancreatitis. Scatology is also known as coprology which is the study of faeces
30. A 34-year-old patient was delivered to a first-aid center with open fracture of the lower leg bones. Upon examination bleeding is stated: blood flows in pulsating bursts. What actions should be taken at this stage of medical aid?

Explanation

 

To control or stop the bleeding, a tourniquet should be applied PROXIMALLY to the site of bleeding before being delivered to the operating room.

31. A 26-year-old patient with affective bipolar disorder has developed a condition manifested by mood improvement, behavioural and sexual hyperactivity, verbosity, active body language, reduced need for sleep. Which of the following drugs are most effective in this case?

Explanation

 

Neuroleptics, also known as antipsychotic medications, are used to treat and manage symptoms of many psychiatric disorders. They fall into two classes: first-generation or "typical" antipsychotics and second-generation or "atypical" antipsychotics." They are Dopamine D2 receptor antagonists. Antipsychotics are drugs that have a specific sedative effect, and which improve the attitude and calm the behavior of psychotic patients.

Typical antipsychotics: Haloperidol, Chlorpromazine

Atypical antipsychotics: Risperidone, Clozapine, Aripiprazole

This patient is currently having a manic episode and it's best to use a Neuroleptic (antipsychotic) with sedative effect to calm the patient down.

A manic episode requires 3 or more of the following:

  • Decreased need for sleep

  • Distractibility

  • Impulsivity/Indiscretion: seeks pleasure without regard to consequences including sexual pleasure

  • Talkativeness or pressured speech

  • Grandiosity: inflated self esteem

  • Flight of ideas: racing thoughts

  • Increased goal oriented activity/psychomotor agitation

Antidepressants are used for Major Depressive Disorders; Tranquilizers are used for General Anxiety Disorder or Panic attacks. Mood stabilizers like Lithium, Valproic acid, Lamotrigine, Carbamazepine are commonly used in Bipolar disorders. Nootropics are used to enhance mental function not mania.

32. An emergency doctor has diagnosed a 32- year-old woman with generalized convulsive status epilepticus. The deterioration in the patient’s condition is caused by a sudden gap in the epilepsy treatment. Specify the doctor’s further tactics:

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.

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.
33. A 19-year-old patient complains of dyspnea during physical exertion. He often has bronchitis and pneumonia. Cardiac murmur has been observed since his childhood. On auscultation: there is splitting of II heart sound over pulmonary arteria, systolic murmur in the third intercostal space near the left sternum margin. ECG test shows right bundle-branch block. What is the provisional diagnosis?

Explanation

34. A 30-year-old patient was in a car accident. He is unconscious, pale, has thready pulse. In the middle third of the right thigh there is an extensive laceration with ongoing profuse external arterial bleeding. What urgent actions must be taken to save the life of the patient?

Explanation

35. A 75-year-old male patient complains of slight pain in the right iliac region. The abdominal pain arose 6 days ago and was accompanied by nausea. Surgical examination revealed moist tongue, heart rate - 76 bpm. BP - 130/80 mm Hg. Abdomen is soft, slightly painful in the right iliac region on deep palpation, the symptoms of the peritoneum irritation are doubtful. In blood: RBCs - 4, 0 · 1012/l, Hb135 g/l, WBCs - 9, 5 · 109/l, stab neutrophiles - 5%, segmentonuclear - 52%, lymphocytes - 38%, monocytes - 5%, ESR - 20 mm/h. Specify the doctor’s further tactics:

Explanation

36. On the 10th day postpartum a puerperant woman complains of pain and heaviness in the left mammary gland. Body temperature is 38, 8oC, Ps- 94 bpm. The left mammary gland 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.
37. 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 2,6 mmol/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.

38. A 25-year-old patient during selfexamination detected a tumor in the upper external quadrant of the right mammary gland. On palpation: painless, dense, mobile growth 2 cm in diameter is detected in the mammary gland; no changes in the peripheral lymph nodes are observed. On mammary glands US: in the upper external quadrant of the right mammary gland there is a space-occupying lesion of increased echogenicity 21х18 mm in size. The most likely diagnosis is:

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.
39. A 20-year-old woman complains of feeling of air shortage, lingering dull pain in the heart area, irritability. Objectively: general condition is satisfactory, heart rate lability, BP is 130/60 mm Hg. ECG reveals disruption of repolarization proceses. The patient is diagnosed with somatoform autonomic dysfunction of cardial type. Specify the conditions of the patient treatment:

Explanation

 

An inpatient is someone admitted into the hospital to stay overnight, days, weeks etc while an outpatient or ambulatory care  does not require hospitalization. Somatoform dysfunction is a mental disorder; In Somatoform Autonomic dysfunction, the symptoms are presented by the patient as if they were due to a physical disorder of a system or organ that is largely or completely under autonomic innervation and control. This patient should undergo an outpatient form of care since nothing is really wrong.

40. A 70-year-old patient consulted a doctor about arrhythmic cardiac activity, dyspnea. Objectively: BP - 150/90 mm Hg, extrasystole arrhythmia (10-12 beats per minute), left ventricular systolic dysfunction (ejection fraction at the rate of 42%). Which of antiarrhythmic drugs should be administered as initial therapy in this case?

Explanation

Realize that the patient experiences about 10-12 extrasystoles per minute. Amiodarone is a class III antiarrhythmic drug; a potassium blocker. It prolongs phase 3 of the cardiac action potential (in this phase, calcium permeability is decreased while potassium permeability is increased- it is also known as the repolarization phase). This drug is indicated in Supraventricular tachycardia, ventricular tachycardia, atrial fibrillation etc. N/B If phase 3 is prolonged, the heart rate slows down. Flecainide belongs to class 1c (sodium channel blockers) while encainamide is no longer in use.
41. 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\\\"in color. 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.

42. A 45-year-old patient (14-year-long work record as a house painter) upon the contact with synthetic paint develops skin reddening, edema, severe itching and oozing lesions on her face. Symptoms disappear after the contact with this chemical substance stops but even the smell of paint alone is enough to make them reappear each time. Each recurrence is characterised by increased severity of symptoms. What provisional diagnosis can be made?

Explanation

Eczema (dermatitis ) is a chronic inflammatory disease of the skin characterized by the presence of red, itchy, dry scaly rashes. Occupational or professional  eczema (dermatitis) is gotten from contact with certain chemicals in the course of working (in this case due to contact with the chemicals in paint ). Allergic dermatitis is a form of contact dermatitis that results from immune reactions towards certain irritants.
43. In cold season a patient was delivered to a hospital. He was rescued from drowning in a body of water. There was no contact of his airways with water. The patient is anxious, pale, complains of pain and numbness of limbs, has cold shivering. Breathing rate is 22/min, BP is 120/90 mm Hg, heart rate is 110/min, rectal temperature is 34, 5oC. What kind of warming should be prescribed to the 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.

44. Survey radiograph of a 52-year-old worker of an agglomeration plant (28 years of experience, the concentration of metal dust is 22-37 mg/m3) shows mildly pronounced interstitial fibrosis with diffused contrast well-defined small nodular shadows. The patient has no complaints. Pulmonary function is not compromised. What is the provisional diagnosis?

Explanation

Agglomeration plants are factories that work mainly with Iron ore materials together with other products, refining them into finished goods. This  patient has an accumulation of iron dust in his system as a result of long term exposure over the years. Pneumoconiosis is a restrictive lung disease  caused by the inhalation of dust leading to fibrosis. Depending on the type of dust inhaled, different types exist. They include; Siderosis (iron ore), byssinosis (cotton), anthracosis (coal), Asbestosis (asbestos), silicosis (silica dust).
45. 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

 An aneurysm refers to the bulging out of blood vessels; usually occurs in the aorta or vessels located at the base of the heart septum. In most cases, aneurysm occurs secondary to a myocardial infarction. When the heart muscle (cardiac muscle) partially dies during a heart attack, a layer of muscle may survive, and, being severely weakened, start to become an aneurysm. Blood may flow into the surrounding dead muscle and inflate the weakened flap of muscle into a bubble.
46. A 60-year-old patient complains of nearly permanent sensation of heaviness and fullness in the epigastrium, that increases after eating, foul-smelling eructation, occasional vomiting with food consumed 1-2 days ago, weight loss. 12 years ago he was first found to have an ulcer of pyloric channel. The patient has taken ranitidine for periodic hunger pain. The patient’s condition has been deteriorating over the last 3 months. Objectively: splashing sound in the epigastrium is present. What kind of complication is it?

Explanation

Recall that the complications of ulcers include Bleeding (hemorrhage), penetration, perforation, outlet obstruction (stenosis) and malignization.

Hemorrhage: Hemorrhage is the most common complication of pep­tic ulcer disease. Symptoms include hematemesis (vomiting of fresh blood or \"coffee ground\" material); passage of bloody or black tarry stools (hematochezia and melena, respectively); and weakness, orthostasis, syncope, thirst, and sweating caused by blood loss.

Penetration: A peptic ulcer may penetrate the wall of the stomach or duodenum and enter the adja­cent confined space (lesser sac) or organ (eg, pancreas, liver). Pain may be intense, persistent, referred to sites other than the abdomen (usually the back when caused by penetration of a posterior duode­nal ulcer into the pancreas), and modified by body position.

perforation: perforation usu­ally presents as an acute abdomen. Ulcers that perforate the peritoneal cavity are usu­ally located in the anterior wall of the duo­denum or, less commonly, in the stomach. The patient experiences sudden, intense, steady epigastric pain that spreads rapidly throughout the abdomen, often becoming prominent in the right lower quadrant and at times referred to one or both shoulders.

Gastric outlet obstruction/ Stenosis: This may be caused by scarring, spasm, or inflammation associated with an ulcer. Symptoms in­clude recurrent large volume vomiting, foul smell and often consist of food eaten days ago. Persistent bloating or fullness after eating and loss of appetite also suggest gas­tric outlet obstruction. Prolonged vomiting may cause weight loss, dehydration, and alkalosis.

Malignization/ Stomach cancer: H. pylori is associated with intestinal-type ad­enocarcinoma of the gastric body and an­trum but not cancer of the gastric cardia. Gastric lymphomas and mucosa-associated lym­phoid tissue (MALT) lymphomas have also been linked to this infection.

47. A 5-year-old child has body temperature risen up to febrile numbers, suffers from inertness, weakness. Examination revealed hemorrhage on the skin of limbs and torso. Enlargement of cervical and axillary lymph nodes can be detected. The liver is 4 cm below the costal arch; the spleen is 6 cm below the costal arch. Blood test: erythrocytes - 2, 3 · 1012/l, Hb- 60 g/l, platelets - 40 · 109/l, leukocytes - 32, 8 · 109/l, eosinophiles - 1%, band neutrophiles - 1%, segmented neutrophiles - 12%, lymphocytes - 46%, monocytes - 1%, blasts - 40%, Duke’s bleeding time test result is 9 min. What examination is necessary to make the diagnosis?

Explanation

Notice that from the above analysis, the platelet level is relatively low (150 − 400 · 109/L is the normal). This is confirmed in the result of the duke test being 9 minutes - prolonged ( normal is 2-5 ). The  Duke test is done to check the bleeding time , it is a platelet function test. An abnormality indicates diseases such as von Willebrand, thrombocytopenia, DIC etc.  Recall that platelets originate from large bone marrow cells  and a bone marrow biopsy will be most helpful in analysis amongst all the above listed.
48. A child from primipregnancy was born in a term labor and has body weight of 4000 g and body length of 57 cm. When born, he was nonresponsive to examination. Diagniosis is diffuse. Heart rate is 80/min. What resuscitation measures should be prescribed?

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 higher for babies); 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 or in cases.
49. A 20-year-old patient was delivered to a surgical unit complaining of an incised wound on his right forearm that has been bleeding for 1,5 days. Suffers from general weakness, vertigo, cold sweat, opplotentes. Skin and visible mucous membranes are pale. Heart rate is 110/min, BP is 100/70 mm Hg. Blood test: Hb is 100 g/l, erythrocytes 2, 5 · 1012/l. What is the cause for the paient’s general condition?

Explanation

Posthemorrhagic anemia is an anemia which develops after hemorrhage. There are two types of anemias of this group according to the character of hemorrhage: 1) acute posthemorrhagic and 2) chronic posthemorrhagic anemia.

Acute posthemorrhagic anemia arises after fast massive hemorrhage as a result of injury of vessels or their damage by pathological process.

Chronic posthemorrhagic anemia develops after repeated hemorrhages, caused by injury of blood vessels during number  diseases (dysmenorrhea, ulcer of  stomach, hemorrhoids etc.). From anamnesis, this patient has an injury that has been bleeding for 1,5 days- this helps us understand the reason behind the low amount of RBCs.

 

In Aplastic anemia, the body fails to produce enough blood cells; can be due to a pathology of the bone marrow, radiation etc.

50. A 20-year-old parturient woman has the I labor stage. The pregnancy is full-term. Labors occur every 3 minutes and last for 55 seconds. Fetus presentation is polar, the head is pressed to the small pelvis entrance. Heart rate of the fetus is 150/min, distinct and rhythmic. Vagina examination: uterus cervix is smoothed out; mouth of the womb is 2 cm open; fetal bladder is intact; the head is presented over the I plane of small pelvis; moderate mucous-bloody discharge is observed. What phase of the I labor stage is it?

Explanation

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.  the latent phase generally ranges from the onset of labor until 3 or 4 cm of dilation and is characterised by slow cervical changes. The Active phase follows the latent phase and expands until 10cm or more of dilation and is characterised by fast cervical changes.

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.

51. A 23-year-old woman after stress has developed thirst, polydipsia, polyuria, weight loss, increasing fatigue. Later she developed nausea and somnolence, lost consciousness and was hospitalised. Glycemia is 27 mmol/l, acetone in urine is sharply positive. Treatment for ketoacidotic coma was initiated. When would it be advisable to start preventive treatment of hypoglycemia by introduction of 5% glucose solution?

Explanation

 

While treating patients with Ketoacidosis, When glucose levels fall below 11-14 mmol/l, intravenous fluids should be switched to dextrose-containing 0.45% NaCl solution to prevent hypoglycemia, and/or insulin infusion rate should be decreased.

52. A 53-year-old woman complains of weight loss up to 10 kg within the last 2 years, liquid foul-smelling stool two times a day that poorly washes off the toilet, periodic bouts of nausea, girdle pain in the upper abdomen. Objectively: pain in Gubergrits zone (on the right from navel) and Mayo-Robson’s point. Biochemical blood analysis: glucose - 3,2 mmol/l, bilirubin - 16,5 micromole/l, crude protein - 56,4 g/l. Urine diastase - 426 g/h/l. D-xylose test (oral administration of 25 g of d-xylose) after 5 hours reveals 3 g of xylose in urine. The most likely diagnosis is:

Explanation

Notice that the patient’s diastase level is high (norm: 25-125 U/L), diastase refers to groups of enzymes that catalyze the 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.

 

D-xylose test is a medical test performed to diagnose conditions that present with malabsorption (defect in GIT mucosa). In an individual with intact GIT mucosa, a 25 g oral dose of D-xylose will be absorbed and excreted in the urine at approximately 4.5 g in 5 hours ( it is 3.5g in this patient indicating a malabsorption syndrome).

53. A 23-year-old patient after intake of brake fluid has developed anuria that has been lasting for 5 days already. Creatinine level increased up to 0,769 mmol/l. What treatment tactics should be chosen in the given case?

Explanation

 

Hemodialysis is a procedure used for removal of waste materials from the blood through filtration. It is carried out on people with renal failure. This patient experiences anuria ( production of only about 50-100ml of urine daily); creatinine levels are also rising; This procedure should be carried out to remove such waste products since the amount of urine being produced is inadequate.

54. A 15-year-old teenager has undergone medical examination in military recruitment center. The following was revealed: interval systolic murmur at the cardiac apex, accent of the II heart sound over the pulmonary artery, tachycardia. What additional examination method will be the most informative for determining diagnosis?

Explanation

An echocardiography is a procedure used in checking the live images of the heart. Information from this procedure shows: Changes in your heart size, Pumping strength, Damage to the heart muscle, Valve problems, Heart defects.

An electrocardiography is a procedure that  records electrical signals of the heart. It provides information about the heart rate, rhythm, Inadequate blood and oxygen supply to the heart, Heart attack and some structural abnormalities.

A phonocardiography is the recording of the sounds from the heart.

 
55. A 64-year-old patient has been hospitalised with complaints of progressive jaundice that developed over 3 weeks ago without pain syndrome, general weakness, loss of appetite. Objectively: temperature is 36, 8oC, heart rate is 78/min, abdomen is soft and painless, peritoneum irritation symptoms are not detected, palpation reveals sharply enlarged tense gallbladder. What disease can be characterised with these symptoms?

Explanation

The patient in question presents with obstructive/mechanical/post-hepatic jaundice. The gallbladder is enlarged and tense and the patient also presented with general weakness, poor appetite plus progressive jaundice.

Obstructive jaundice is a common clinical manifestation of pancreatic cancers, especially in patients with malignant tumors of the head of the pancreas. Obstructive Jaundice is a common surgical problem that occurs when there is an obstruction to the passage of conjugated bilirubin from liver cells to intestine.

Cancer of the head of the pancreas appears near the common bile duct. From an early stage,they tend to compress this duct leading to an obstruction in bile flow (causing an obstructive jaundice). 

Apart from Cancer of the head of pancreas, other causes of obstructive jaundice include: biliary stricture (narrowing of the bile duct); cholangitis (infection or inflammation of the common bile duct); cholelithiasis (gallstones); cysts of the bile duct; parasitic infection etc.

Note that Cholecystitis usually presents with pain in the right upper quadrant and signs of systemic infection (pyrexia, raised leukocyte count, raised C-reactive protein). The above patient presents with none of these symptoms thereby ruling out the options of cholecystitis.

56. During a surgical operation necessitated by the patient’s suffering from autoimmune thyroiditis with concomitant multinodular goiter the right lobe was removed and subtotal resection of the left lobe was performed. What should be prescribed to the patient for postoperative hypothyroidism prevention

Explanation

For the treatment of hypothyroidism, the patient should be given L-thyroxin also known as levothyroxine, a synthetic form of Thyroxine, T4. Mercazolil (thiamazole) is indicated in Hyperthyroidism.
57. A 54-year-old patient has been suffering from diabetes mellitus for 5 years, with diet being his only treatment. Within the last half a year he lost 7 kg of body weight, complains of thirst, vertigo when raising from bed, decrease of erectile function, frequent stool, especially at night. Objectively: malnutrition, dry skin. BP in lying position is 160/90 mm Hg; BP in standing position is 170/85 mm Hg. No edemas. Fasting plasma glucose level is 12 mmol/l. Glycated hemoglobin accounts for 11%. Albumin excreted with urine is 20 mg per day. The most likely diagnosis is:

Explanation

 

Neuropathy is one of the complications of diabetes mellitus. The various types of neuropathy include; Sensorimotor polyneuropathy, cranial neuropathy and autonomic. Recall that the autonomic nervous system gives innervation to the viscera ie., the heart, lungs, GIT, urinary tract etc One major sign of autonomic neuropathy is the presence of orthostatic hypotension ie significant difference in blood pressure while standing and in lying position. Note that type I diabetes mellitus usually develops from childhood while type II present can develop at any age but is usually seen in adults over 45 years ( just like in the presented patient).

Diabetic nephropathy will present with signs of chronic kidney failure while polyneuropathy will include the nerves of the fingers, foot etc.

58. A young woman suffering from seborrhea oleosa has numerous light-brown and white spots on the skin of her torso and shoulders. The spots have clear margins, branny desquamation, no itching. What provisional diagnosis can be made?

Explanation

The above description is typical for Tinea (pityriasis) versicolor which is caused by malassezia spp. A yeast like fungus. It is characterised by areas of hypopigmentation ‘white spots’. Hyperpigmentation can also occur due to inflammatory response - ‘areas of brown spots .’ It differs from dermatophytes because it is less pruritic (itchy).

Pityriasis rosea is a viral rash that resembles small oval red patches and are very itchy.

Seborrheic dermatitis is a common skin disease that causes an itchy rash with flaky scales and mainly affects the scalp, face and trunk. Vitiligo is a condition that is associated with pathological destruction of melanocytes.

59. 10 days after birth an infant developed a sudden fever up to 38, 1oC. Objectively: the skin 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

 

Pemphigus neonatorum is characterised by the presence of erythematous patches coupled with the presence of vesicles and small bullaes usually localised in the lower abdomen and on extremities. The bullaes later form crusts but pigmentation is absent.

Streptococcal impetigo is characterized by papules that evolve into pustules then thick crust which are golden or honey-coloured. These lesions are usually found on the face and extremities.

60. In a traffic accident two persons died. An appointed forensic medical expert was called on duty to another accident location; therefore, according to the crininal law in force in Ukraine, an investigator called in the following specialist for examination of the location and bodies:

Explanation

 

The nearest available doctor should cover up for the forensic specialist according to the law of ukraine.

61. A 35-year-old female patient has gained 20 kg weight within a year with the normal diet. She complains of chill, sleepiness, dyspnea. The patient’s mother and sister are corpulent. Objectively: height - 160 cm, weight - 92 kg, BMI - 35,9. Obesity is uniform, there are no striae. The face is amimic. The skin is dry. The tongue is thickened. Heart sounds are muffled. Heart rate - 56/min, BP - 140/100 mm Hg. The patient has constipations, amenorrhea for 5 months. TSH - 28 mkME/l (normal rate - 0,32- 5). Craniogram shows no pathology. What is the etiology of obesity?

Explanation

Your thyroid produces thyroid hormone, which controls many activities in your body, including how fast you burn calories and how fast your heart beats. Diseases of the thyroid cause it to make either too much or too little of the hormone. Depending on how much or how little hormone your thyroid makes, you may often feel restless or tired, or you may lose or gain weight. Women are more likely than men to have thyroid diseases, especially right after pregnancy and after menopause.

Hypothyroidism is when your thyroid does not make enough thyroid hormones. It is also called underactive thyroid. This slows down many of your body's functions, like your metabolism. Signs and symptoms include the following: Feeling cold when other people do not; Constipation; weight gain, even though you are not eating more food; Feeling sad or depressed; Feeling very tired; Pale, dry skin; Dry, thinning hair; Slow heart rate (bradycardia); puffy face;  hoarse voice; abnormal menstrual bleeding etc.

Note that the craniogram shows no pathology so we can rule out Hypothalamic-pituitary. Hypo-ovarian can present with amenorrhea, vaginal dryness, monophasic cycles etc but not with bradycardia or weight gain. Absence of abdominal striaes or skin hyperpigmentation and sometimes diabetes - rules out the option of cushing’s disease (hypercorticoidism). 

 

The increased TSH levels seen in this patient implies an activation of the feedback mechanism signalling  the body to produce more thyroid hormones; T3 and T4.

62. A 45-year-old patient has been suffering from essential hypertension for 10 years. After hot bath he suddenly developed sharp headache and recurrent vomiting. Objectively: pronounced meningeal symptoms; BP is 180/110 mm Hg. He was hospitalised in a neurology unit. What additional tests should be primarily prescribed?

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. A 77-years-old patient complains of inability to urinate and bursting pain above his pubis. Acute onset of his condition occurred 12 hours ago. Objectively: overfilled urinary bladder can be palpated above the pubis. On rectal examination: prostate is enlarged, denseelastic, with clear margins and no nodules. Interlobar sulcus is pronounced. US examination: prostate volume is 120 cm3, it protrudes into urinary bladder cavity, parenchyma is homogeneous. Prostate specific antigen is 5 ng/ml. What disease is the most likely to cause 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. 

64. A patient with uterine fibromyoma sized up to 8-9 weeks of pregnancy consulted a gynaecologist about acute pain in the lower abdomen. Examination revealed pronounced positive symptoms of peritoneal irritation, high leukocytosis. Vaginal examination revealed that the uterus was enlarged up to 9 weeks of pregnancy due to the fibromatous nodes, one of which was mobile and extremely painful. Appendages were not palpable. Discharges were mucous, coming in moderate amounts. What is the treatment tactics?

Explanation

From the vaginal examination, we observe the presence of a very large fibroid mass that causes the enlargement of the uterus and is responsible for the severe pain the woman is experiencing and the mucous discharge. Coupled with the positive symptom of peritoneal  irritation, this patient is in need of an urgent surgical procedure.

Uterine fibroids are noncancerous growths that grow in the wall of the uterus. When fibroids cause heavy bleeding or painful symptoms, and other treatments are ineffective, a doctor may recommend surgery. People with asymptomatic fibroids do not require surgery or other treatments. However, other people experience severe abdominal pain, pressure, bloating, pain during sex, frequent urination, and heavy or painful periods. These individuals may require surgery.

Myomectomy is a surgical procedure that removes fibroids. Depending on the location of these growths, a surgeon may also have to remove other tissue in the process. The traditional technique is quite invasive as it uses a relatively large cut (Laparotomy). This incision may go from the bellybutton to the bikini line or run horizontally along the bikini line. Some surgeons also perform laparoscopic surgeries, which use smaller incisions but require more skill. However, in this case, a fibroid as big as 9 weeks gestation will require a big incision and laparoscopic surgery will not be able to get the fibroid out.

65. A 4-month-old child was admitted to a surgical department 8 hours after the first attack of anxiety. The attacks happen every 10 minutes and last for 2-3 minutes, vomiting occurred once. Objectively: the child’s condition is grave. Abdomen is soft, palpation reveals a tumour-like formation in the right iliac area. After rectal examination the doctor’s finger was stained with blood. What is the most probable diagnosis?

Explanation

Ileocaecal invagination is also termed ileocaecal intussusception which makes up more than 70% of cases of intussusception in children. Note that the tumour-like formation is in the right iliac area ( the ileocaecal angle - the point at which the ileum and caecum meet). Intussusception is a medical condition in which one section of the intestine gets enclosed or enveloped by another part. Symptoms include, vomiting, abdominal pain, and rectal bleeding (red jelly-like stools).

Wilms tumor is also called nephroblastoma and is a rare tumor that occurs in children, also presents with abdominal pain, anorexia, vomiting, malaise but does not show any signs of rectal bleeding.

 
66. A 68-year-old patient complains of pain, slight swelling and creaking in the distal joints of her fingers and knee joints. She has been suffering from this condition for 4 years. Objectively: thickening of knee and interphalangeal joints, restricted mobility of these joints. Blood test: leukocytes - 5, 4 · 109/l, ESR - 12 mm/h, fibrinogen - 3,5 g/l; Rheumatoid factor - 1:32; anti-streptolysin O - 160 units; seromucoid - 0,20 units.; CRP+. What mechanism of development is likely for this condition?

Explanation

67. A 30-year-old male patient consulted a family doctor 2 months after he had been operated for an open fracture of brachial bone. Objectively: the patient’s condition is satisfactory; in the area of the operative wound there is a fistula with some purulent discharge, redness, fluctuation. X-ray image shows brachial bone destruction with sequestra. What complication arose in the postoperative period?

Explanation

Osteomyelitis is an infection of the bone tissue. Bone can get infected via several means majority are post operative, post traumatic or hematogenous means. From anamnesis, we can see that the patient had an open fracture of the brachial bone; through this portal, the infection was able to gain access and cause the above written bone disorder (sequestration, purulent discharge from this area). We can conclude that this patient has a post traumatic form of osteomyelitis since the bone infection happened via the open fracture.

Hematogenous osteomyelitis usually occurs in children; is a systemic infection that occurs due to bacteremia.

 
68. A 40-year-old female patient complains of having a bulge on the anterior surface of neck for 5 years. Objectively: Heart rate - 72 bpm, arterial pressure - 110/70 mm Hg, in the right lobe of thyroid gland palpation reveals a mobile 4x2 cm node, the left lobe is not palpable, the basal metabolic rate is 6%. What is the most likely diagnosis?

Explanation

 

Notice that the Blood pressure and heart rate are normal which indicates no case of hyperthyroidism or hypothyroidism. Recall that A goiter occurring in a hyperthyroid state is a Hyperthyroid goiter; one that occurs in a hypothyroid state is a hypothyroid goiter while a goiter that occurs in a normal environment  is an Euthyroid goiter. This is a nodular form because on palpation, a mobile node was palpated.

69. Estimation of community health level involved analysis of a report on diseases registered among the population of catchment area (reporting form 12). What index is calculated basing on this report?

Explanation

 

Common morbidity rate refers to the proportion or frequency at which a disease occurs in a population; from the report of registered diseases in a particular area, we can calculate the  morbidity rate.

70. A tractor driver with the record of service of 24 years has undergone palestesiometry test (Vibration Sensitivity Measurement). Test revealed increased vibration sensitivity threshold at the frequencies of 63-125-259 Hz to 25 dB. Dynamometry is 20 kg on the right and 16 kg on the left. Cold stimulus test is positive, time of hand temeperature restoration is 52 minutes. Blanching at pressure symptom is positive and equals 21. Hypesthesia of upper and lower limbs is observed and can be classified as \\\"gloves\\\"and \\\"socks\\\"polyneuritic pattern. Make the provisional diagnosis.

Explanation

According to the character of influence to the organism there is local, general and combined vibration. During the local vibration the transmission of mechanical oscillations to the body is realized through the arms. Most often this etiologic factor we can see among the face-workers, chasers, drillers. The sources of the general vibration are the vibro platform, the table vibrator, the forming and concrete-laying machines. The combined vibration is a combination of local and general.

According to the intensity’s degree of pathologic process symbolically mark out 4 stages of disease:

I – initial;

II – moderately expressed (dystrophic disorders);

III – expressed (irreversible organic changes);

 

IV – generalized

71. A patient’s X-ray image (anteroposterior projection) shows deformation of lung pattern, pneumofibrosis, reticular (honeycomb) lung pattern of lower pulmonary segments, cylindric and fusiform lumps. The most likely diagnosis is:

Explanation

72. A 41-year-old patient with Addison’s disease had influenza. After that he developed adynamia, depression, nausea, vomiting, diarrhea and hypoglycemia. BP is 75/50 mm Hg. Blood test: decreased content of corticosterone, hydrocortisone, 13-oxycorticosteroids, 17-oxycorticosteroids. What condition has 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.

73. After a contact with chemicals a plant worker has suddenly developed stridor, voice hoarseness, barking cough, progressing dyspnea. Objective examination reveals acrocyanosis. What is your provisional diagnosis?

Explanation

The contact with chemicals led to the edematic reaction in the worker’s larynx. Recall that the larynx is the voicebox; this is why the edematic reaction presents with symptoms such as stridor, voice hoarseness, barking cough etc
74. A 58-year-old patient complains of general weakness, weight loss up to 10 kg within the last 1,5 months, progressive pain in the small of the back, raise of blood pressure to 220/160 mm Hg, subfebrile body temperature. Objectively: tuberous slightly movable lump can be palpated in the right subcostal area; veins of spermatic cord and scrotum are dilated. Blood test: Hb - 86 g/l, ESR - 44 mm/h. Urine test: specific gravity - 1020, proteine - 0,99 g/l, erythrocytes - all field of vision, leukocytes - 4-6 in the field of vision. The provisional diagnosis is:

Explanation

The fact that the patient lost a lot of weight in a short period of time in the absence of any other pathology should signal a carcinogenic process. Key diagnostic features of this pathology include; blood in urine, presence of flank mass and pain accompanied with weight loss and high blood pressure. Note, most renal pathologies present with elevated blood pressure due to the Renin-Angiotensin-Aldosterone System (RAAS). The dilated veins of the spermatic cord and scrotum (varices) is due to disrupted venous blood flow caused by increased pressure from the obstruction caused by the tumour.

A patient with urolithiasis will also experience colicky (more like an attack with relieve period in between) flank pain, change in quantity of urine and can be differentiated by results from ultrasound which shows an obstruction in the ureter. 

Glomerulonephritis often follows an upper respiratory tract infection 2-3weeks prior to presentation and can also present with a nephrotic syndrome (increased proteinuria accompanied by presence of edema). Pyelonephritis is inflammation of the kidney parenchyma which can be as a result of infection via an ascending or hematogenous pathway.

75. A 58-year-old patient complains of headache in the occipital region, nausea, choking, opplotentes. The presentations appeared after a physical exertion. Objectively: the patient is excited. Face is hyperemic. Skin is pale. Heart sounds are regular, the 2nd aortic sound is accentuated. BP - 240/120 mm Hg, heart rate - 92/min. Auscultation reveals some fine moist rales (crackles) in the lower parts of the lungs. Liver is not enlarged. ECG shows signs of hypertrophy and left ventricular overload. What is the most likely diagnosis?

Explanation

 

A person is said to be in a state of hypertensive crisis if the blood pressure exceeds 180mmhg for systolic and 110mmhg for diastolic pressure. The above patient presents with signs of ventricular hypertrophy and overload which complicates his current state of a hypertensive emergency. Other complications of hypertensive crisis include pulmonary edema, a stroke, aneurysm, heart failure etc.

76. A 37-year-old patient complains of pain in the lumbar spine, which increases during walking, limited mobility, edema of the right side of abdomen. Focal tuberculosis is recorded in the anamnesis. X-ray shows destruction of adjacent surfaces of the bodies of the 1- 2 lumbar vertebrae, vertebral bodies height is decreased, intervertebral fissure cannot be detected. Abdominal US reveals a growth 15x20 cm in size in the retroperitoneal space and echo signs of liquid. What diagnosis can be suspected?

Explanation

 

Also known as Pott’s disease, lumbar tuberculous spondylitis is a medical condition caused by the hematogenous spread of tuberculosis mostly from the lungs; these spread contents are latter deposited in the spine- mostly the lower thoracic and upper lumbar vertebrae; they can also affect the intervertebral disc  and generally cause symptoms of arthritis. Observe that from anamnesis, this patient has a history of tuberculosis and the various results from tests carried out shows a disruption in the normal form/functioning of the spine. A fracture will occur in case of trauma while osteochondrosis occurs mostly in developing individuals eg children and adolescents and is characterised by an interrupted blood supply to the bone especially the epiphysis of the bone.

77. A 26-year-old woman has attended maternity center complaining of her inability to become pregnant despite 3 years of regular sex life. Examination revealed the following: increased body weight; male-type pubic hair; excessive pilosis of thighs; ovaries are dense and enlarged; basal body temperature is monophasic. The most likely diagnosis is:

Explanation

Also called Stein- Leventhal syndrome, Ovarian sclerocytosis is the process of ovarian regeneration, accompanied by the formation of small cystic formations up to 1 cm in size. It usually occurs in patients with polycystic ovarian syndrome. Key findings include; infertility, male pattern hair distribution, weight loss, hormonal disbalance, bilateral enlargement of the ovaries, violation of menstrual cycle etc. 

Adrenogenital syndrome ( congenital adrenal hyperplasia) is a condition characterized by the enlargement of the adrenal gland coupled with the excess production of androgens (sex hormones).

 

Premenstrual syndrome usually occurs just before a woman’s menses and is characterised by emotional, physical and behavioural changes.

78. A workshop resident doctor makes a list of workers, who are often ill, for special supervision. He takes into account the number of etiologically connected cases resulting in temporary disability that occurred in the span of a year for each worker. How many such cases should a worker have to be included in this group?

Explanation

79. A 28-year-old woman complains of increased intermenstrual periods up to 2 months, hirsutism. Gynaecological examination revealed that the ovaries were enlarged, painless, compact, uterus had no pecularities. Pelvic ultrasound revealed that the ovaries were 4-5 cm in diameter and had multiple enlarged follicles on periphery. X-ray of skull base showed that sellar region was dilated. What is the most probable 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 etc. The ovaries mostly develop follicles (collection of fluids). Realise that the patient is of a reproductive age and experiences infrequent menstruation; the result of ultrasound, confirms the polycystic ovary pathology.

Algodysmennhorhea is characterised by painful menstruation or menstrual cramps during menstruation.

 

Premenstrual syndrome is a group of symptoms females usually  experience a week or two before menstruation.

80. A woman consulted a therapeutist about fatigability, significant weight loss, weakness, loss of appetite. She has been having amenorrhea for 8 months. A year ago she born a full-term child. Haemorrhage during labour made up 2 l. She got blood and blood substitute transfusions. What is the most probable diagnosis?

Explanation

 

Notice that the woman in question gave birth about a year ago and experienced a severe blood loss during delivery; this is the leading cause of sheehan’s syndrome ( post partum hemorrhage). Sheehan’s syndrome is one of the major causes of hypopituitarism in females; it is due to pituitary infarction as a result of postpartum hemorrhage.  fatigability, significant weight loss, weakness, and loss of appetite all include associated symptoms.

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 etc. The ovaries mostly develop follicles (collection of fluids).

81. The correlation between service record and eosinophiles concentration in blood was studied in workers at dyeing shops of textile factories. What index will be the most informative for the analysis of this data?

Explanation

Correlation factor/ coefficient is a statistical measure that shows the relationship between two variables; in the case between service records and eosinophil concentration. Most common types include the Pearson’s correlation coefficient and Spearman rank coefficient.
82. A 39-year-old woman suffering from schizophrenia constantly strains to hear something insisting that \\\"there is a phone connection in her brain and she hears her brother’s voice demanding that she come back home\\\". The patient is anxious, suspicious, constantly looking around. Specify the psychopathologic 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.

83. A 3-month-old girl has rhinitis, dyspnea, dry cough. She has been sick for 2 days. Objectively: pale skin, acrocyanosis, hypopnoe; breathing rate is 80/min; over the whole pulmonary surface there is vesiculotympanitic (bandbox) resonance observed with numerous bubbling rales (crackles). The most likely diagnosis is:

Explanation

 

Note that acute bronchiolitis and Acute bronchitis are very similar and basically present with almost the same symptoms. One key difference is the age range of people affected ; Bronchitis is found in individuals of all age ranges although mostly seen in older children and adults  while bronchiolitis is only found in younger children especially below 2 years. From analysis, we hear vesicular tympanic sound and bubbling rales / crackles - these can  be found in both diseases; but the key difference here is the age of the child (3 months).

84. A 30-year-old patient was hospitalised in an intensive care unit with a diagnosis of multiple bee stings. Skin is pale and covered with cold sweat. Pulse can be palpated only at the carotid arteries and is 110/min; breating rate is 24/min, rhytmical, weakened. What drug must be administered immediately?

Explanation

 

A bee sting usually stimulates a reaction that leads to vasodilation, increased permeability, muscle spasms etc this is due to the release of mediators such as histamine, prostaglandin E2, leukotrienes etc. To counter this effect, a patient should be immediately administered adrenaline hydrochloride intravenously in order to reduce the body’s allergic response ( recall that adrenaline has a vasoconstrictive effect). Other treatments such as glucocorticoids and antihistamines can follow after this.

85. A 24-year-old patient complains of gaining body mass and increased appetite. Objectively: built of hypersthenic type, body mass index is 33,2 kg/m2, waist circumference is 100 cm. Waist to hips circumference ratio is 0,95. What is the provisional diagnosis?

Explanation

based on the body mass index, there are three classes of obesity;

 Class 1 (low-risk) obesity, if BMI is 30.0 to 34.9.

Class 2 (moderate-risk) obesity, if BMI is 35.0 to 39.9.

Class 3 (high-risk) obesity, if BMI is equal to or greater than 40.0. 

 

Alimentary obesity occurs as a result of an increased intake of food (overnutrition).

86. A parturient woman is 27 year old, it was her second labour, delivery was at full-term, normal course. On the 3rd day of postpartum period body temperature is 36, 8oC, heart rate - 72/min, BP - 120/80 mm Hg. Mammary glands are moderately swollen, nipples are clean. Abdomen is soft and painless. Fundus of uterus is 3 fingers below the umbilicus. Lochia are bloody, moderate. What is the most probable diagnosis?

Explanation

 

After childbirth, the female’s body undergoes some changes (physiologically), these include; Involution of the uterus ( return of the uterus to a nonpregnant state following birth), postpartum hemostasis, afterbirth pains, increased amount of oxytocin that leads to changes in the mammary glands and an increased production of breast milk, Postchildbirth uterine discharge, commonly called lochia, initially is bright red and changes later to a pinkish red or reddish brown etc In subinvolution of the uterus, the uterus fails to return to its normal size.

87. A 40-year-old patient suffers from influenza. On the 5th day of illness there are pain behind sternum, cough with sputum, inertness. Temperature is 39, 5oC. Face is pale. Mucosa of conjunctivas and pharynx is hyperemic. Heart rate is 120/min, breathing rate is 38/min. In the lower lung segments shortening of percussion sound and moist rales (crackles) can be detected. What additional investigation should be performed first of all to specify the diagnosis?

Explanation

 

Note that this patient already suffers from influenza ( a viral infection that mainly affects the respiratory tract). She also presents with symptoms that show the effect of this virus on the respiratory tract ie., cough with sputum, a hyperemic pharynx coupled with the results from auscultation. To confirm the rate of its spread and its full effect on the lungs, a chest x-ray should be carried out. This gives a pictorial view of the heart, lungs, airways, blood vessels and the bones of the spine and chest.

88. A 45-year-old patient complains of body temperature rise up to 40oC, general weakness, headache, painfulness and spastic muscle contractions around the wound in the shin. He received this wound 5 days ago when working in his garden. He requested no medical care back then. What wound infection can be suspected?

Explanation

Clostridium tetani is a gram positive, obligate anaerobic, spore forming bacillus that resembles a tennis racket or drumstick; it is the causative agent of tetanus (lockjaw). This pathology is characterised by the stiffness of muscles (spactic muscle), spasms that last for a few minutes, fever, trouble swallowing, increased blood pressure etc. This bacteria produces a toxin ( a neurotoxin called tetanospasmin) that has a potent effect in the brain leading to the above mentioned stiffness.

Anthrax is caused by a gram positive, spore forming bacteria called Bacillus Anthracis. It is usually associated with individuals in contact with infected livestocks eg cows

 
89. A 60-year-old woman started feeling weakness, vertigo, rapid fatigability during the last year. Recently there have been dyspnea and paresthesia observed. Objectively: skin and mucous membranes are pale and icteric. Lingual papillae are smoothed out. Liver and spleen are situated at the edge of costal arch. Blood test: Hb- 70 g/l, erythrocytes - 1, 7·1012/l, blood color index - 1,2, macrocytes. What drug  can be prescribed on pathogenetic grounds?

Explanation

Notice that from the blood analysis, Macrocytes are present- these refer to irregular large Rbcs. The erythrocyte level is also very low ( norm- Female: 3.5 − 5.5 · 1012/L) - this indicates an anemia . The major causes of macrocytic anemia include Vitamin b12 deficiency, Vitamin b9 deficiency or medications such as antiretroviral drugs. Symptoms include loss of appetite, brittle nails , pale skin, fatigue etc.

 To differentiate between B12 or Folic acid deficiency, Vit B12 deficiency is often associated with nervous system symptoms like paresthesias - subacute combined degeneration due to abnormal myelin synthesis. These nervous system symptoms are absent in Folic Acid Deficiencies.

With the symptoms listed in the question, and the presence of anemia and macrocytes - it safe to say Vitamin B12 deficiency is the best choice.

Ascorbic acid or vitamin C deficiency will lead to scurvy, petechial bleeding or bruises are common in this case. Vitamin B1 deficiency will lead to the development of Beri-Beri. Iron deficiency will result in Anemia but macrocytes will be absent on the blood film, instead we will see microcytes.

90. A 34-year-old patient complains of profuse sweating at night, skin itching, weight loss (9 kg within the last 3 months). Examination revealed malnutrition, skin pallor. Palpation of neck and inguinal areas revealed dense elastic lymph nodes of about 1 cm in diameter, nonmobile, non-adhering to skin. What is the most probable diagnosis?

Explanation

 

Berezovsky/Reed-Sternberg (RS) cells are giant cells that have more than one nucleus and appear large, eosinophilic, inclusion-like nuclei. The lineage of these cells is probably B-cell lymphocytes. RS cells and the accompanying mononuclear Hodgkin’s cells are the neoplastic cells in Hodgkin’s lymphoma (lymphogranulomatous), surrounded by a reactive cellular infiltrate. RS cells usually express CD15 and CD30 (Ki-1, an antigen that is also expressed in anaplastic large cell lymphoma).

91. A 57-year-old woman complains of having a sensation of esophageal compresion, palpitation, breathing difficulties when eating solid food, occasional vomiting with a full mouth, \\\"wet pillow\\\"sign at night for the last 6 months. Objectively: body tempearture - 39oC, height - 168 cm, weight - 72 kg, heart rate - 76/min, BP120/80 mm Hg. X-ray revealed considerable dilation of esophagus and its constriction in the cardial part. What pathology is most likely to have caused dysphagia in this patient?

Explanation

Esophageal achalasia is an esophageal motility disorder involving the smooth muscle layer of the esophagus and the lower esophageal sphincter (LES). It is characterised by an increased LES tone, incomplete LES relaxation and lack of esophageal peristalsis. The sign of wet pillow results from increased salivation and nocturnal discharge of saliva and mucus from the mouth and is observed in esophageal pathologies. Diagnosis is confirmed by x-ray examination and from the above patient, we see the dilation of esophagus and its constriction in the cardial part which confirms our diagnosis. Bird's beak sign on X-ray is a key finding.
92. A 25-year-old man complains of pain in the lower third of his left thigh, which occurs both with and without physical exertion. Possibility of trauma is denied by the patient. Objectively: skin colour is normal; pastosity and pain can be detected with deep palpation; knee joint mobility is reduced. X-ray of distal femoral metaphysis shows an area of destruction and spicule. Blood test: immature cells, no signs of inflammation. The most likely diagnosis is:

Explanation

 

Osteosarcomas are primary malignant tumors of bone that are characterized by the production of osteoid or immature bone by the malignant cells. Characteristics of osteogenic sarcoma include; the presence of osteoid-producing cells ( malignant osteoblasts- immature cells), present as painful enlarging mass . A major sign seen on x-ray is the Codman triangle ( a subperiosteal lesion), in some literature, it is described as ‘resembling melting sugar’ or ‘sunburst pattern’.

93. A 37-year-old woman complains of sharp pains in her external genitalia, edema of the vulvar lips, pain when walking. Objectively: body temperature is 38, 7oC, heart rate is 98/min. Inside the right vulvar lip there is a dense, painful, tumor-like growth 5,0х4,5 cm in size; skin and mucosa of the external genitalia are hyperemic, copious foul-smelling discharge is observed. The most likely diagnosis is

Explanation

 

Bartholinitis is an inflammation of Bartholin’s gland (large gland of vaginal vestibule). It may be caused by Staphylococcus, E.coli and N. gonorrhoeae.. There can be serous, serous-purulent, or purulent inflam­mation. Bartholin's glands are located at the openings of the vagina ( left and right sides). Bartholinitis and bartholin's cyst are used interchangeably but most cysts are caused by the blockade of the ductal path of the gland leading to an accumulation of its contents.

94. In a rural health care area there is a case of child dying during the first month of his life. To analyse this situation, among other measures, an expert assessment of medical records is performed. What medical document should be considered first?

Explanation

95. Examination of placenta revealed a defect. An obstetrician performed manual investigation of uterine cavity, uterine massage. Prophylaxis of endometritis in the postpartum period should involve the following actions:

Explanation

Endometritis is caused by an infection in the uterus. It can be due to chlamydia, gonorrhea, tuberculosis, or a mix of normal vaginal bacteria. It is more likely to occur after miscarriage or childbirth. It is also more common after a long labor or C-section. For prophylaxis, Antibacterial therapy such as metronidazole, methylergometrine are drugs indicated .
96. A 15-year-old boy has developed pain in the area of his left knee joint. Objectively: thigh soft tissues in the painful area are infiltrated, joint function is reduced. X-ray: there is a focus of destruction in the left distal femoral metaphysis, with periosteum detachment and formation of Codman triangle in the bone cortical layer at the margin of the defect. Chest X-ray reveals numerous microfocal metastases. What pathology is the most likely to cause such presentation?

Explanation

 

Osteosarcomas are primary malignant tumors of bone that are characterized by the production of osteoid or immature bone by the malignant cells. Characteristics of osteogenic sarcoma include; the presence of osteoid-producing cells ( malignant osteoblasts- immature cells), present as painful enlarging mass . A major sign seen on x-ray is the Codman triangle ( a subperiosteal lesion), in some literature, it is described as ‘resembling melting sugar’ or ‘sunburst pattern’.

97. A 74-year-old man complains of pain in the left foot and dark color of the 1st toe. He has been sick for 6 days. Objectively: heart rate is 84/min. Body temperature is 37, 8oC. The left foot resembles \\\"chicken claw\\\"due to soft tissues decreasing in volume, skin is dark red. The 1st toe is black, small amount of dark substance is being discharged from under the nail. Pulse over the peripheral arteries of extremity is absent. The most likely diagnosis is:

Explanation

Gangrene is a condition in which the tissue dies due to lack of blood supply or a bacterial infection. The most often examples of gangrene are; gangrene of the lower extremities, uterus, lungs etc. forms include; dry, wet and gas gangrene. In dry gangrene borders are properly demarcated while this is not the case in the Wet form. Note that the first toe of the above patient shows signs of necrosis ie, change in colour, texture and this is caused by the absence of blood flow to that particular area (confirmed by the absence of pulse over peripheral arteries)- these findings confirm the presence of gangrene.

 

A Phlegmon is simply a diffuse purulent inflammation while a panaritium is an acute inflammation of the side of the fingers.

98. Head circumference of a 1-month-old boy with signs of excitement is 37 cm, prefontanel is 2x2 cm large. After feeding the child regurgitates small portions of milk; stool is normal in its volume and composition. Muscle tone is within norm. What is the most likely diagnosis?

Explanation

One of the forms of stomach  dyskinesia of hypertonic type is pylorospasm. It is observed mainly in babies, especially in the first weeks and months of life. Pylorospasm in children is caused by functional disturbances of the nervous- muscular system of the stomach pyloric part. Pylorospasm is marked by weak development of muscles in cardial part of the stomach and its more expressed development in the area of the pylorus. It promotes development of vomiting and eructation. Symptomatically, the major difference between pylorospasm and pyloric stenosis is the presence of Projectile vomiting in stenosis.

 

In esophageal achalasia, the lower esophageal sphincter fails to open during swallowing leading to the build up food in the esophagus.

99. A 49-year-old patient complains of difficulties when swallowing food, hoarse voice, weight loss. The patient has been suffering from these symptoms for the last 3 months. The symptoms are gradually progressing. Objectively: the patient is emaciated, supraclavicular lymph nodes are enlarged. Esophagoscopy revealed no pathologies of esophagus. What investigation would be the most advisable in the given 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.

100. 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. X-ray 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

 

From anamnesis, we observe that the patient had his right maxillary premolar filled (a dental procedure); results from x-ray indicate an inflammatory state of the right maxillary sinus and results from the pleural puncture shows a suppurative form of inflammation ( inflammation accompanied by pus). An Odontogenic sinusitis is the inflammation of the paranasal sinuses that occur due to a dental (odontogenic) procedure.

101. A 52-year-old patient complains of pain in the right part of her chest, dyspnea, cough with a lot of albuminoid sputum emitting foul smell of \\\"meat slops\\\". Objectively: the patient’s condition is grave, cyanosis is observed, breathing rate is 31/min, percussion sound above the right lung is shortened, auscultation revealed various moist rales (crackles). What is the most probable diagnosis?

Explanation

Meat slops’ sputum is a specific term  used by Krok to  describe a lung gangrene. A lung gangrene is a diffuse purulent necrosis of the tissue without the tendency of a defined demarcation.

Pleural empyema is a purulent inflammation of its visceral and parietal membranes, which is associated with accumulation of pus in a pleural space.

 

Lung abscess is defined as necrosis of the pulmonary tissue and formation of cavities containing necrotic debris or fluid caused by microbial infection. 

102. A 15-year-old patient suffers from headache, nasal haemorrhages, sense of lower extremity coldness. Objectively: muscles of shoulder girdle are developed, lower extremities are hypotrophied. Pulsation on the pedal and femoral arteries is sharply dampened. BP is 150/90 mm Hg, 90/60 in the legs. Systolic murmur can be auscultated above carotid arteries. What is the most probable diagnosis?

Explanation

103. A patient with frostbite of both feet was delivered to an admission ward. What actions should be taken?

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.
104. A patient in a clinical death condition is being resuscitated through mouth-to-mouth artificial pulmonary ventilation and external cardiac massage. A doctor noticed that air does not flow into the patient’s airways and his head and torso are positioned at the same level. Why is artificial respiration not effective in the given case?

Explanation

 

During mouth-mouth pulmonary ventilation, the usual thing that blocks the airway is the tongue. This is because, in an unconscious state the tone of the tongue muscles is weak (lacks strength or force); making the tongue fall towards the back of the throat, blocking the airway.

105. Hygienic assessment of a sample taken from the batch of grain revealed 2% of grains infected with microscopic Fusarium fungi. On the grounds of laboratory analyses this batch of grain should be:

Explanation

0-7% – the seed may not need to be treated with a registered seed treatment.

8-14% – the seed should be treated with a registered seed treatment.

> 14% – the seed should not be planted.

 
106. Residents of an industrial community situated near a plant suffer from increased morbidity rate caused by nervous and endocrine system conditions and kidney diseases. Blood test: decrease of sulfhydric groups content in blood. The pathologies developed can be caused by environment being polluted by the following:

Explanation

Notice that the question states that there is a decrease in sulfhydryl groups in the blood. This points towards mercury toxicity because Methylmercury has a high affinity for sulfhydryl groups, which explains its effect on enzyme dysfunction. Mercury ions produce toxic effects by protein precipitation, enzyme inhibition, and generalized corrosive action. Mercury not only binds to sulfhydryl groups but also to phosphoryl, carboxyl, amide, and amine groups.  Lead toxicity is characterised by a high amount of delta aminolevulinic acid in urine.
107. Various population groups mortality has been studied for a long time; territorial distribution of population and resulting changes in mortality trends are considered. What statstical method can be applied?

Explanation

108. A 45-year-old patient with urolithiasis had an attack of renal colic. What is the mechanism of the attack development?

Explanation

 

In the presence of kidney stones (urolithiasis), urine builds up ( accumulates) in the urinary tract leading to the dilation, stretching and spasm of these tracts. These corresponding changes lead to the development of painful sensation that radiates towards the groin.

109. A 28-year-old woman has bursting pain in the lower abdomen during menstruation; chocolate-like discharges from vagina are observed. It is known from the anamnesis that the patient suffers from chronic adnexitis. Bimanual examination revealed a tumour-like formation of heterogenous consistency 7х7 cm large to the left from the uterus. The formation is restrictedly movable, painful when moved. What is the most probable diagnosis?

Explanation

 

Endometrial cyst or endometrioma also called chocolate-like cyst is a form of endometriosis ( a condition in which the lining of the uterus ie., the endometrium grows outside the uterus). They are characterised by fluid filled cavities usually dark brown or chocolate in color; this color feature is gotten from old menstrual blood. Recall that a cyst is a fluid formed cavity and from bimanual examination, the cavity was found from which the chocolate like discharge can be traced. Note that follicular cysts are painless and harmless and usually resolve on its own.

110. A 6-year-old child complains of frequent liquid stool and vomiting. On the 2nd day of desease the child presented with inertness, temperature rise up to 38, 2oC, heart rate - 150 bpm, scaphoid abdomen, palpatory painful sigmoid colon, defecation 10 times a day with liquid, scarce stool with mucus and streaks of green. What is a provisional diagnosis?

Explanation

111. A 65-year-old patient complains of pain in the lumbar spine, moderate disuria. He has been suffering from this condition for about half a year. Prostate volume is 45 cm3 (there are hypoechogenic nodes in both lobes, capsule invasion). Prostate-specific antigen is 60 ng/ml. Prostate biopsy revealed an adenocarcinoma. Which of the supplementary examination methods will allow to determine the stage of neoplastic process in this patient?

Explanation

 

From all the above listed options, a CT scan will provide the best information about the adenocarcinoma. It will use radiographic images in producing results that will help define the extent of the adenocarcinoma.

112. A 12-year-old child has been hit on the stomach. The patient is in moderately grave condition, has a forced position in bed. The skin is pale, heart rate - 122/min. Stress on the left costal arch causes a slight pain. Weinert and Kulenkampff symptoms are positive. Macroscopically the urine is unchanged. What is the most likely diagnosis?

Explanation

A positive Kulenkampff’s symptom refers to an acute pain during palpation of the stomach and an absent tension of muscles of the anterior abdominal wall. This sign helps in the diagnosis of abdominal bleeding. The main symptom of a ruptured spleen is pain located around the left costal arch. A kidney related pathology will present with pain in the lumbar region (since the kidney is a retroperitoneal organ) and also have an effect on urine. Pancreatic pathologies will present with belt-like pain. In peritonitis, the pain is dull and poorly localised.
113. Establishments participating in medical examinations include: medical and preventive treatment facility, hygiene and preventive treatment facility, sociomedical expert committees, Ministry of Defence medical committees, Ministry of Domestic Affairs medical committees, forensic medicine agency, etc. Specify what service deals with sociomedical assessment of temporary disability

Explanation

114. An unconscious 35-year-old patient has been delivered by an ambulance to the intensive care unit. Objectively: the patient is in semicoma. Moderate mydriasis is present. The reaction of pupils to light is reduced. The patient is non-responsive to verbal instructions. BP is150/100 mm Hg, tachycardia is present. Blood contains methanol. What antidote should be administered?

Explanation

 

The antidote of Methanol poisoning is Ethanol or fomepizole. This is because, compared to methanol, ethanol has a higher affinity to the enzyme that metabolizes alcohols (alcohol dehydrogenase). In doing this, metabolism of methanol is slowed down and excreted naturally or via dialysis. Naloxone is indicated in acute ethanol poisoning while unithiol is used for forced diuresis in cases of heavy metal poisoning.

115. 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.
116. A patient is active, lively, fussy. He resists the examination. His speech is fast and loud, his statements are spontaneous and inconsequent. Specify the psychopathological state of this patient:

Explanation

117. A 4-year-old boy was vaccinated in violation of his vaccination schedule. There are complaints of pain in the throat during swallowing, headache, inertness, fever. Objectively: the child is pale; anterior cervical lymph nodes are enlarged; tonsils are swollen, with cyanotic hyperemy, and covered with greywhite coating that cannot be removed; if it is forcibly removed, tonsils bleed. The most likely diagnosis is

Explanation

 

The key finding here are grey white coatings on the tonsils that cannot be removed ( or bleeds when removed); these are the main findings of a diphtheria infection ( causative agent -Corynebacterium Diphtheriae which produces an Exotoxin ie.,diphtheria toxin). The posterior pharynx of patients with Infectious Mononucleosis (EBV infection)  is often uniformly erythematous.

118. A 26-year-old male patient complains of piercing pain during breathing, cough, dyspnea. Objectively: t o- 37, 3oC, respiration rate is 19/min, heart rate is 92/min; BP is 120/80 mm Hg. Vesicular respiration is observed. In the inferolateral parts of chest auscultation in both inspiration and expiration phase revealed noise that was getting stronger at phonendoscope pressing and could be still heard after cough. ECG showed no pathological changes. What is the most likely diagnosis?

Explanation

A pleural friction rub is a medical sign mostly heard during auscultation of patients with pleuritis/pleurisy (inflammation of the lining of the lungs). Usually heard both on inspiration and expiration coupled with movements of the chest wall ( in this case while coughing). This sound is said to be like that of crushing or stepping on snow.

Spontaneous pneumothorax (collapsed lungs) is observed on the background of chest trauma or an underlying lung disease; on auscultation, there will be decreased or no breath sound on the affected area and on x-ray, air spaces around the lungs.

Pericarditis Sicca is known as a fibrinous pericarditis without pleural effusion

 
119. A child is 3-week-old. Since his birth periodical vomiting is observed occuring several minutes after feeding. Vomit mass does not exceed previous feeding volume. Body mass is appropriate to the child’s age. What is the most likely cause for the symptoms described?

Explanation

 

Pylorospasm is a condition in which the Pyloric sphincter fails to relax properly due to continuous contractions (spasms). The key finding here is that vomiting occurs a few minutes after eating and the volume does not exceed previous food content; this helps differentiate it from Pyloric stenosis which occurs due to the narrowing of the pyloric part of the stomach leading to improper digestion. Pyloric stenosis is characterized by splashing sound in the epigastrium, Projectile vomiting followed by an eagerness to take food. In esophageal achalasia, the patient will firstly experience Dysphagia ( difficulty in swallowing) followed by vomiting; this occurs due to failure in the relaxation of the lower esophageal sphincter and peristalsis.

120. A 30-year-old parturient woman was delivered to a maternity hospital with full-term pregnancy. She complains of severe lancinating pain in the uterus that started 1 hour ago, nausea, vomiting, cold sweat. Anamnesis states cesarean section 2 years ago. Uterine contractions stopped. Skin and mucous membranes are pale. Heart rate is 100/min, BP is 90/60 mm Hg. Uterus has no clear margins, is sharply painful. No heartbeat can be auscultated in the fetus. Moderate bloody discharge from the uterus can be observed. Uterus cervix is 4 cm open. Presenting part is not visible. The most likely diagnosis is:

Explanation

121. 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

Since the patient usually experiences paroxysms of atrial fibrillation every 2-3 months, she should be administered a drug with the aim of prevention (prophylactic measures). Codarorone also called amiodarone is an antiarrhythmic drug (class III - potassium blocker). Indicated for the prevention and treatment of irregular contractions ie., ventricular tachycardia, ventricular fibrillation, and wide complex tachycardia, as well as atrial fibrillation and paroxysmal supraventricular tachycardia. Defibrillation and immediate hospitalization are steps that should be taken in emergency cases.
122. A 47-year-old female patient complains of cough with purulent sputum, pain in the lower left chest, periodical body temperature rise. She has been suffering from this condition for about 10 years. Objectively: \"drumstick\"distal phalanges. What examination would be the most informative for making a diagnosis?

Explanation

123. A patient is 60-year-old, retired, worked as deputy director of a research institute. Behavioural changes appeared 2 years ago after the death of her husband: she stopped looking after herself and leaving the house; then she stopped to clean the apartment and cook. Mental status: temporal disorientation. The patient does not understand many of the questions, is confused; does not know how to cook soup or fasten a button. Her speech is characterized by stumbling and logoclonia. She does not recognize doctors, fellow patients. She cries a lot but can not explain the reason for tears. What is the mechanism of this pathology?

Explanation

 

Recall that the cerebral cortex is made up of different lobes, sulci and gyri that act as centres for various functions for example the occipital lobe for vision. The cerebral cortex can further be divided into brodmann's area with each area having a specific function eg area 44 & 45 ( broca’s area) - for motor activities in speech production etc. this patient presents with temporal disorientation, problems with understanding questions, repetition of syllables (logoclonia), long term memory defects- these signs are mostly due to a defect in the Temporal lobe ( responsible for long term memory, processing auditory and visual sensory input, language recognition and formation of new memories). Note that from anamnesis, since this patient does not have any underlying disease that can lead to an atherosclerotic formation, that option is ruled out. The above stated symptoms are most likely due to the atrophy of the cerebral cortex.

124. An 8-year-old girl periodically has sudden short-term heart pain, sensation of chest compression, epigastric pain, dizziness, vomiting. Objectively: the patient is pale, respiratory rate - 40/min, jugular pulse is present. Heart rate - 185 bpm, of poor volume. BP - 75/40 mm Hg. ECG taken during an attack shows ectopic P waves, QRS wave is not deformed. At the end of an attack a compensatory pause is observed. The most likely cause of the attack is:

Explanation

125. During examination a patient is unconscious, his skin is dry and hot, face hyperemia is present. The patient has Kussmaul’s respiration, there is also smell of acetone in the air. Symptoms of peritoneum irritation are positive. Blood sugar is 33 millimole/l. What emergency actions should be taken

Explanation

Kussmaul breathing pattern is a form of deep laboured breathing usually seen in patients with diabetes ketoacidosis. Observe the blood glucose level of the patient is very high; therefore to act quickly, the patient should be prescribed a short acting insulin. Always remember that only short acting insulin is used for the correction of hyperglycemia in diabetic ketoacidosis. Eg. Vesolin.
126. A patient complains of evaginations in the region of anus that appear during defecation and need resetting. Examination with anoscope revealed 1x1 cm large evaginations of mucosa above the pectineal line. What is the most probable diagnosis?

Explanation

 

Anatomically, the dentate line also refers to the pectineal line; a line that divides the anal canal into upper and lower segments. Hemorrhoids refer to the dilation of the rectal veins also referred to as Piles. Internal hemorrhoids lie above the pectineal/dentate line, covered by columnar epithelium and do not cause pain while External hemorrhoids lie below the dentate/ pectineal line, covered by squamous epithelium and are very painful.

127. During the newborn infant’s examination redness of the skin was detected, which occurred immediately after birth and became the most pronounced on the second day of the infant’s life. What provisional diagnosis can be made?

Explanation

Note that this baby is actually experiencing Erythema toxicum neonatorum (ETN); an erythemic process usually seen in full term infants. It starts on the first day after birth and usually fades away within a week.

Erythema nodosum is a type of skin inflammation that is located in a part of the fatty layer of skin. Erythema nodosum results in reddish, painful, tender lumps most commonly located in the front of the legs below the knees. The tender lumps, or nodules, of erythema nodosum range in size.

Transient erythema occurs as a result of loss of hair ( maybe due to exposure to radiation) and neurological changes.

128. A baby was born by a young smoker. The labour was complicated by uterine inertia, difficult delivery of the baby’s head and shoulders. The baby’s Apgar score was 4. Which of the following is a risk factor for a spinal cord injury?

Explanation

Recall that the spinal cord is connected to the brain via the brainstem. During delivery, injury to the spinal cord/brainstem is likely to occur during expulsion of the head and shoulders of the baby. Apgar score refers to  a rapid method for assessing a neonate immediately after birth and in response to resuscitation. Elements of the Apgar score include color, heart rate, reflexes, muscle tone, and respiration. Each element is scored 0 (zero), 1, or 2. The score is recorded at 1 minute and 5 minutes in all infants with expanded recording at 5-minute intervals for infants who score seven or less at 5 minutes, and in those requiring resuscitation as a method for monitoring response. Scores of 7 to 10 are considered great.
129. In order to study impact of microclimate on the human organism it is necessary to make systematic observation of air temperature during the period of 3 days. Choose a device that will allow to make the most precise temperature records

Explanation

 

A thermograph is a visual representation of temperature recordings of an area over a period of time. Thermometers are used to measure instant temperature while a psychrometer is used in measuring relative humidity.

130. Against the background of angina a patient has developed pain in tubular bones. Examination revealed generalized enlargement of lymph nodes, hepatolienal syndrome, sternalgia. In blood: RBCs - 3, 6 · 1012/l, Hb87 g/l, thrombocytes - 45 · 109/l, WBCs - 13 · 109/l, blasts - 87%, stab neutrophiles - 1%, segmented neutrophiles - 7%, lymphocytes - 5%, ESR - 55 mm/h. What is the most likely diagnosis?

Explanation

Leukemias are malignant neoplasms of the hematopoietic stem cells characterized by diffuse replacement of the bone marrow by neoplastic cells.

From the question stem, using the full blood count, we can denote that there is Leukemia due to the presence of immature blast cells. To distinguish between Acute and  Chronic leukemia, the blast count is always very important. Blasts are immature white blood cells.

 

In chronic Leukemia, the blood and bone marrow contain less than 10% blasts (blast - 2%). In Acute leukemia, blasts are usually more than 20%. Using the lab values given in the question, we have 87% of blast cells, which makes it Acute Leukemia..

131. For a long time to eradicate weeds on agricultural lands herbicides retaining in environment have been used. Point out the most probable way of herbicides reaching human organism from soil:

Explanation

 

Herbicides are chemicals ( a form of pesticides) used in killing unwanted plants; when applied, they come in contact with the soil and may affect food products (plants) which will cause harm to the consumer. ( soil-plants-humans).

132. A 47-year-old patient came to see a doctor on the 7th day of disease. The disease is acute: after the chill body temperature rose to 40oC and lasted up to 7 hours, then dropped abruptly, which caused profuse sweat. There were three such attacks occurring once every other day. Two days ago the patient arrived from Africa. Objectively: pale skin, subicteric sclera, significantly enlarged liver and spleen. What is the cause of fever attacks in this disease

Explanation

From anamnesis, we understand that the patient has just returned from africa , 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 ( patient arrives on Day 7); it is characterised by the production of merozoites which are released into the bloodstream.
133. A 49-year-old patient 2 years ago was diagnosed with stage 1 silicosis. He complains of increased dyspnea and pain in the infrascapular regions. X-ray shows diffuse intensification and distortion of lung pattern with numerous nodular shadows 2-4 mm in diameter. Hardening of right interlobar pleura is detected. Lung roots are hardened and expanded. What X-ray type of pneumosclerosis does the patient have?

Explanation

According to the X-ray pattern, the process can be consolidation, nodular, interstitial, nodular-interstitial or an atelectasis. Consolidation - any pathologic process that fills the alveoli with fluid, pus, blood, cells (including tumor cells) or other substances resulting in lobar, diffuse or multifocal ill-defined opacities.

Interstitial - involvement of the supporting tissue of the lung parenchyma resulting in fine or coarse reticular opacities or small nodules.

Nodule or mass - any space occupying lesion either solitary or multiple.

Atelectasis - collapse of a part of the lung due to a decrease in the amount of air in the alveoli resulting in volume loss and increased density.

 

From the patient above, we see numerous nodular shadows which indicates a nodular process.

134. A 24-year-old patient complains of general weakness, dizziness, body temperature rise up to 37, 5oC, sore throat, neck edema, enlargement of submaxillary lymph nodes. Objectively: mucous membrane of oropharynx is edematic and cyanotic, tonsils are enlarged and covered with films that spread beyond the tonsils and cannot be easily removed. What is the leading mechanism of this illness development?

Explanation

Note that the toxins are covered with films that ‘cannot be easily removed’ in another term, the examiner might say ‘bleeds when removed’; these phrases are characteristic of a corynebacterium diphtheria infection. This bacteria produces a Diptheria toxin  ( an Exotoxin).
135. A patient suffering from acute posttraumatic pain received an injection of morphine that brought him a significant relief. Which of the following mechanisms of action provided for antishock effect of morphine in this patient?

Explanation

 

Morphine is a phenanthrene opioid receptor agonist, κ-opioid receptor (KOR) and δ-opioid receptor (DOR) agonist. Morphine binds to opioid receptors, blocks transmission of nociceptive signals, signals pain-modulating neurons in the spinal cord, and inhibits primary afferent nociceptors to the dorsal horn sensory projection cells. used primarily to treat both acute and chronic severe pain.

136. A 9-month-old child presents with fever, cough, dyspnea. The symptoms appeared 5 days ago after a contact with a person having URTI. Objectively: the child is in grave condition. Temperature of 38oC, cyanosis of nasolabial triangle is present. Respiration rate - 54/min, nasal flaring while breathing. There was percussion dullness on the right below the scapula angle, and tympanic sound over the rest of lungs. Auscultation revealed bilateral fine moist rales (crackles) predominating on the right. What is the most likely diagnosis?

Explanation

 

The presence of percussion dullness on the right just below the scapula accompanied by the result from auscultation (presence of fine moist crackles) are common signs found in cases of pneumonia. Pneumonia is an inflammation of the pulmonary tissue that occurs as a result of an infection e.g. bacterial, viral etc.

laryngotracheitis is also termed Croup; it involves an infection of the larynx, trachea and lungs.

137. A 50-year-old patient complains about having pain attacks in the right subcostal area for about a year. The pain arises mainly after taking fatty food. Over the last week the attacks occurred daily and became more painful. On the 3rd day of hospitalization the patient presented with icteritiousness of skin and scleras, light-coloured feces and dark urine. In blood: neutrophilic leukocytosis - 13, 1 · 109/l, ESR - 28 mm/h. What is the most likely diagnosis?

Explanation

 

The main function of bile is for emulsification of fats; this function is mainly disturbed in pathologies relating to the gallbladder. Notice that the situation intensifies especially after eating fatty foods resulting in the body’s inability to emulsify fats. The differentials for this question can be based on the location of pain. Physical examination and analysis of blood, faeces and urine. Pain is located in the right upper quadrant which indicates a problem with either the liver or gallbladder; pancreatitis presents with an upper abdominal pain that radiates to the back. The presence of neutrophilic leukocytosis shows that an inflammatory process occurred.

138. A 40-year-old woman with a history of combined mitral valve disease with predominant stenosis complains of dyspnea, asthma attacks at night, heart problems. At present, she is unable to do even easy housework. What is the optimal tactics of the patient treatment?

Explanation

A commissurotomy is a surgical procedure used in people with narrowing/ stenosis of heart valves. It involves the removal of deposits on the valve leaflets such as calcium,scar etc An artificial valve replacement will be carried in situations of degenerative valve diseases, very low ejection fraction < 30%.
139. A 30-year-old woman with a long history of chronic pyelonephritis complains of considerable weakness, sleepiness, decrease in diuresis down to 100 ml per day. BP is 200/120 mm Hg. In blood: creatinine - 0,62 millimole/l, hypoproteinemia, albumines - 32 g/l, potassium - 6,8 millimole/l, hypochromic anemia, increased ESR. What is the first step in the patient treatment tactics?

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.

 
140. A 43-year-old patient had right-sided deep vein thrombosis of iliofemoral segment 3 years ago. Now he is suffering from the sense of heaviness, edema of the lower right extremity. Objectively: moderate edema of shin, brown induration of skin in the lower third of shin, varix dilatation of superficial shin veins are present. What is the most probable diagnosis?

Explanation

Post-thrombotic syndrome refers to symptoms and signs of chronic venous insufficiency that develop following deep vein thrombosis (DVT) and is a common, burdensome, and costly complication . The term "post-thrombotic" replaces the prior terminology "postphlebitic" syndrome. A combination of reflux due to valvular incompetence and venous hypertension due to thrombotic obstruction is thought to underlie the pathophysiology of post-thrombotic syndrome . Symptoms and signs of post-thrombotic syndrome may include leg pain, leg heaviness, vein dilation, edema, skin pigmentation, and venous ulcers.
141. A 59-year-old female patient attended a maternity welfare clinic with complains of bloody discharge from the genital tracts. Postmenopause is 12 years. Vaginal examination revealed that external genital organs had signs of age involution, uterus cervix was not erosive, small amount of bloody discharge came from the cervical canal. Uterus is of normal size, uterine appendages are unpalpable. Fornices were deep and painless. What method should be applied for the diagnosis specification?

Explanation

Diagnostic dilation and curettage is typically employed to assess endometrial histology. Indications include; Abnormal uterine bleeding, biopsy and sampling, Evaluation and removal of retained fluid from the endometrial cavity, etc.

For many gynecologic procedures, such as removal of an ectopic pregnancy, treatment of endometriosis, ,ovarian cystectomy and hysterectomy, laparoscopy has become the treatment of choice. Colposcopy is a procedure in which a colposcope is used in examining the vagina, cervix and vulva. Culdoscopy is used in examining the rectouterine pouch and organs of the pelvis.

 
142. A 41-year-old patient, a hunter, complains of heaviness in the right subcostal area. No other complaints recorded. Anamnesis states causeless urticaria and skin itching that occurred 1 year ago. Objectively: liver margin is rounded, painless, and can be palpated 3 cm below the costal arch. No other pathology was detected during physical examination of the patient. Body temperature is normal. X-ray reveals a hemispherical protrusion in the right cupula of the diaphragm. What disease can be suspected in the given case?

Explanation

143. A 14-year-old girl has been presenting with irritability and tearfulness for about a year. A year ago she was also found to have diffuse enlargement of the thyroid gland (II grade). This condition was regarded as a pubertal manifestation, the girl did not undergo any treatment. The girl’s irritability gradually gave place to a complete apathy. The girl got puffy face, soft tissues pastosity, bradycardia, constipations. Skin pallor and gland density progressed, the skin got a waxen hue. What disease may be assumed?

Explanation

 

Autoimmune thyroiditis (hashimoto’s thyroiditis) is a chronic disease in which the body creates antibodies which destroy the thyroid gland; it is characterised by symptoms of hypothyroidism ( bradycardia, increase in weight constipation etc). Notice that a year ago, she had a diffuse enlargement of the thyroid relatively due to a lymphocyte infiltration of the stroma. Diffuse toxic Goiter ( grave’s disease) also presents with an enlarged thyroid but is characterised by  signs of hyperthyroidism. Recall that a person with a cancer related issue in anamnesis, will present with an unexplained loss of weight within a short period.

144. A 26-year-old woman, who delivered a child 7 months ago, has been suffering from nausea, morning vomiting, sleepiness for the last 2 weeks. She breastfeeds the child, menstruation is absent. She has not applied any contraceptives. What method should be applied in order to specify her diagnosis

Explanation

 

For a breastfeeding mother, menstruation is meant to return 5-6 weeks after Childbirth; in the above patient , this has been absent for 7 months; for better examination, a non invasive method should be used. An Ultrasound diagnosis, uses sound waves to give an image of a person’s internal body structure; Among the listed options, it is the best possible choice ( a Transvaginal Ultrasound)

145. Over a current year among workers of an institution 10% have not been ill a single time, 30% have been ill once, 15% - twice, 5% - 4 times, the rest - 5 and more times. What is the percentage of workers belonging to the I health

Explanation

146. A 34-year-old patient after vacation in Crimea has developed severe pain in her elbow joints, dyspnea and weakness. Body temperature is 37, 6oC, skin pallor and erythema on the cheeks and bridge of nose are observed, lip mucosa is ulcerated. The joints are not visibly deformed, movement of the right elbow joint is restricted. Pleura friction sound is detected in the lungs on the right side below the angle of scapula. Heart sounds are dull, tachycardia, gallop rhythm, heart rate - 114/min, BP - 100/60 mm Hg. The most likely diagnosis is:

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)

147. Several hours before, a 28-year-old patient suddenly developed acute headache and repeated vomiting, then lost consciousness.Objectively: focal neurological symptoms were not found. Pronounced meningeal symptoms were revealed. BP - 120/80 mm Hg. According to clinical and liquorological findings the patient was diagnosed with subarachnoid haemorrhage. After administration of dehydrants the patient’s condition somewhat improved. What is the main component of further emergency care?

Explanation

 

The above patient presents with subarachnoid hemorrhage ( bleeding in the subarachnoid space). Coagulants should be prescribed to reduce or stop the bleeding ( form a clot / meshwork in the bleeding site) .

148. A 42-year-old man has undergone gastric analysis. Free hydrochloric acid is absent at all phases. On endoscopy: pallor, gastric mucosa loss, gastric folds are smoothed out. On microscopy: glands atrophy with intestinal metaplasia. What disease can be characterized by such presentation?

Explanation

The following types of chronic gastritis include;

Type A is caused by your immune system destroying stomach cells. And it can increase your risk of vitamin deficiencies, anemia, and cancer.

Type B, the most common type, is caused by Helicobacter pylori bacteria, and can cause stomach ulcers, intestinal ulcers, and cancer.

Type C is caused by chemical irritants like nonsteroidal anti-inflammatory drugs (NSAIDs), alcohol, or bile. And it can also cause stomach lining erosion and bleeding.

Observe that on examination, free HCL is absent and results from endoscopy and microscopy indicate the gastric cells have been destroyed - this occurs in Type A gastritis.

 

In menetrier's disease, we see an overgrowth of gastric cells ( foveola) found in the gastric lining which leads to the presence of large gastric folds.

149. A 24-year-old woman, teacher by profession, complains of dizziness and heart pain irradiating to the left nipple. Pain is not associated with physical activity and cannot be relieved by nitroglycerin, it abates after taking Valocordin and lasts for an hour or more. The patient has a nearly 2-year history of this disease. Objectively: Heart rate - 76 bpm. BP - 110/70 mm Hg. Heart borders are normal, heart sounds are clear. The ECG shows respiratory arrhythmia. X-ray of the cervicothoracic spine shows no pathology. Lungs, abdomen are unremarkable. What changes in blood formula can be expected?

Explanation

 

From the description of the above patient, we can deduce that the issue is more psychological/mental than physical. This can be proved by the fact that all diagnostic procedures are without any pathological changes. Note that the problem was resolved when the patient was prescribed  Valocordin (corvalol) a tranquilizer indicated for neuroses. Since it is a mental issue, the blood formula will show no changes.

150. Chief physician of a polyclinic tasked a district doctor with determining 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

151. A 32-year-old woman complains of dizziness, headache, palpitation, tremor. For the last several months she has been under outpatient monitoring for increased arterial pressure. Recently such attacks have become more frequent and severe. Objectively: skin is covered with clammy sweat, tremor of the extremities is present. Heart rate - 110/min, BP - 220/140 mm Hg. Heart sounds are weakened. In blood: WBCs - 9, 8 · 109/l, ESR - 22 mm/h. Blood glucose - 9,8 millimole/l. What disease is the most likely cause of this crisis?

Explanation

 

The woman not only shows signs of hypertension but also presents with changes relating to body metabolic activities ( tremors, tachycardia, dizziness, palpitations, sweating - these are signs relating to stress ( caused by the release of stress hormones ie, catecholamines). Pheochromocytoma is a tumor of the adrenal gland, it is characterised by the increased production of catecholamines ( adrenaline, noradrenaline) coupled with stress symptoms.

Essential hypertension is also called primary hypertension- a form of hypertension with no underlying disease as its cause.

Preeclampsia is a pregnancy-associated hypertension coupled with other signs.

Primary hyperaldosteronism  or Conn’s disease is also associated with the above stated signs , its other signs may include kidney related problems, excessive urination, low potassium content, flank pain etc.

152. A 45-year-old patient complains of pain in the epigastric region, left subcostal area, abdominal distension, diarrhea, loss of weight. He has been suffering from this condition for 5 years. Objectively: tongue is moist with white coating near the root; deep palpation of abdomen reveals slight pain in the epigastric region and Мауо-Robson’s point. Liver is painless and protrudes 1 cm from the costal arch. Spleen cannot be palpated. What disease can be primarily suspected?

Explanation

 

It is stated that the patient has had this condition for 5 years; this rules out the possibility of an Acute form of the disease. The presence of an epigastric pain also confirms the answer isn't a Chronic enteritis. Pain and tenderness in the Mayo robson’s point indicates a pancreatic disorder. N/B Mayo-Robson's point – a point on the border of inner 2/3 with the external 1/3 of the line that represents the bisection of the left upper abdominal quadrant. This is where the tail of the pancreas is located. 

153. A 58-year-old woman 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. Heart rate - 100/min, BP- 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, eosinophiles - 2%, stab neutrophiles - 12%, segmented neutrophiles - 68%, lymphocytes - 11%, monocytes - 7%, ESR - 12 mm/h. What laboratory test should be determined additionally to make 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.

154. After examination a 46-year-old patient was diagnosed with left breast cancer T2N2M0, clinical group II-a. What will be the treatment plan for this patient?

Explanation

155. In river-side urban community there was an outbreak of hepatitis type A possibly spread by water. What indexes of river water quality can confirm this theory?

Explanation

 

Coliphages are microbial indicators specified in the Ground Water Rule (GWR) that can be used to monitor for potential fecal contamination of drinking water. Number of bacteria of group of an intestinal rod (coli-index) in 1000 ml of water - no more than 3.Common microbial number in one ml of water - no more than 100.

156. A 25-year-old patient was delivered to an infectious diseases unit on the 3rd day of illness with complaints of headache, pain in lumbar spine and gastrocnemius muscles, high fever, chill. Objectively: condition of moderate severity. Scleras are icteric. Pharynx is hyperemic. Tongue is dry with dry brown coating. Abdomen is distended. Liver is enlarged by 2 cm. Spleen is not enlarged. Palpation of muscles, especially gastrocnemius muscles, is painful. Urine is dark in colour. Stool is normal in colour. The most likely diagnosis is:

Explanation

Leptospirosis is an acute generalized infectious disease, characterized by extensive vasculitis, caused by spirochetes of the genus Leptospira. It presents with flu-like symptoms, myalgias ( majorly calf muscles eg gastrocnemius ), jaundice. Photophobia, icteric scleras etc. The icterohemorrhagic form of leptospirosis presents with a severe form of jaundice and azotemia from the liver and kidney dysfunction coupled with anemia.

 

N/B Virus hepatitis has a gradual onset, without chills, the temperature rises at the pre-icteric period. Muscle pains, scleritis, conjunctivitis are not characteristic of it. There are no meningeal and renal syndromes.

157. A 52-year-old woman complains of face distortion. It appeared 2 days ago after exposure to cold. Objectively: body temperature is 38, 2oC. Face asymmetry is present. Frontal folds are flattened. Left eye is wider than the right one and cannot close. Left nasolabial fold is flattened, mouth corner is lowered. Examination revealed no other pathology. Blood count: leukocytes - 10 · 109/l, ESR - 20 mm/h. What is the most probable diagnosis?

Explanation

Facial (nerve) palsy is a neurological condition in which function of the facial nerve (cranial nerve VII) is partially or completely lost.  Key findings include; Sensory disturbances : Painful sensation around or behind the ear, Impairment of taste in the anterior tongue , Hyperacusis; dropping of the mouth, dry mouth, Bell's phenomenon: a physiologic, reflexive movement of the eye (upward and outward) that occurs when the eyelid is actively closed, Lagophthalmos: The patient cannot fully close the eyes (due to paralysis of the orbicularis oculi muscle). Decreased lacrimation. 

In neuropathy of the trigeminal nerve ( trigeminal neuralgia), the individual will feel excruciating pain at the slightest pressure applied on the face e.g. while brushing the teeth, yawning etc.
158. A 28-year-old female patient with a six-year history of Raynaud’s syndrome has recently developed pain in the small joints of hands, difficult movement of food down the esophagus. What disease can be suspected in this case?

Explanation

Systemic sclerosis (SSc) is a chronic multisystem disorder of unknown etiology characterized clinically by thickening of the skin caused by accumulation of connective tissue and by involvement of visceral organs, including the gastrointestinal tract, lungs, heart, and kidneys. Antibodies virtually specific for scleroderma include nucleolar autoantibodies, antibodies to ScL-70, a nonhistone nuclear protein, and anticentromere antibodies. The acronym CREST syndrome is used in describing this disease - (calcinosis of the digits, Raynaud's phenomenon, esophageal dysmotility, sclerodactyly, and telangiectasias). Periarteritis Nodosa is a blood vessel disease characterized by inflammation of small and medium-sized arteries (vasculitis), preventing them from bringing oxygen and food to organs.
159. An 8-year-old boy, who has been suffering from diabetes mellitus for 3 years, was delivered to a hospital in a condition of hyperglycemic coma. Primary dose of insulin should be prescribed basing on the following calculation:

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.
160. A 43-year-old female patient complains of rash on the skin of her right leg, pain, weakness, body temperature rise up to 38oC. The disease is acute. Objectively: there is an edema on the skin of her right leg in the foot area, a welldefined bright red spot in the irregular shape of flame tips, which is hot to touch. There are isolated vesicles in the focus. What is your provisional diagnosis?

Explanation

Erysipelas is a distinctive type of superficial border serous or serous-hemorrhagic inflammation of the skin with prominent lymphatic involvement with acute or chronic course of disease. due to group A b–hemolytic streptococci (uncommonly, group С or G). Group В streptococci have been found to produce erysipelas in the newborns. characterized by a raised, well-defined, tender, bright red rash typically on the face or legs, but can occur anywhere on the skin; this rash can be said to be very painful ( burning sensation) when touched. Also called St. Anthony’s fire.
161. A 9-year-old boy has been suffering from bronchoectasis since he was 3. Exacerbations occur quite often, 3-4 times a year. Conservative therapy results in short periods of remission. The disease is progressing, the child has physical retardation. The child’s skin is pale, acrocyanotic, he has \\\"watch glass\\\"nail deformation. Bronchography revealed saccular bronchiectases of the lower lobe of his right lung. What is the further treatment tactics?

Explanation

 

The patient has had this condition for about 3 years and conservative treatment is slowing down and less effective, a surgical intervention should be the next line of action.

162. A 29-year-old female patient complains of dyspnea, heaviness and chest pain on the right, body temperature rise up to 37, 2oC. The disease is associated with a chest trauma received 4 days ago. Objectively: skin is pale and moist. Heart rate is 90 bpm, regular. Palpation reveals a dull sound on the right, auscultation reveals significantly weakened vesicular breathing. In blood: RBCs - 2, 8 · 1012/l, colour index - 0,9, Hb- 100 g/l, WBCs - 8, 0·109/l, ESR - 17 mm/h. What results of diagnostic puncture of the pleural cavity can be expected?

Explanation

From anamnesis, the patient is said to have experienced a chest trauma which is the reason behind the presented symptoms. Observe that the RBC level is low ( norm Female - 3.5-5.5 x 10^12/l), this reduced amount is most likely as a result of bleeding from the chest trauma ( post hemorrhagic anemia). This implies that when the pleural puncture is taken, signs of hemorrhage are going to be found on the punctate ( a hemorrhagic punctate).

 

A transudate is due to high capillary pressure and has protein levels below 25g/l or 2.5g/dl while an exudate is mostly present in inflammatory processes and its protein content is above 25g/l or 2.5g/dl.

163. A 54-year-old man had been drowning at sea, when he was found and evacuated to the shore. Objectively: unconscious, pale face, no breathing can be auscultated, thready pulse. Resuscitation measures allowed to save the man. What complication can develop in him in the nearest future?

Explanation

If a lot of fluid gained access to his lungs (air sacs), he is most likely to get a pulmonary edema which disrupts gas exchange leading to a respiratory arrest and then a cardiac arrest due to hypoxia. Pulmonary edema is a condition in which fluid accumulates in the interstitium/tissues of the lungs thereby impairing gas exchange.
164. A 7-year-old child complains of cramping pain occuring after mental exertion, cold drinks and eating ice-cream. Instrumental examination allowed to diagnose biliary dyskinesia of hypertensive type. What group of drugs should be prescribed for treatment?

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.

165. Caries morbidity rate is 89% among residents of a community. It is determined that fluorine content in water is 0,1 mg/l. What preventive measures should be taken?

Explanation

Dental caries is a bacterial disease that begins with demineralization of the outermost dental enamel and progresses, if not halted, can lead to loss of tooth substance and infection of the dental pulp. Fluoride acts in several ways to prevent caries. The principal action is thought to be that fluoride in dental plaque inhibits the initial demineralization of enamel, and then promotes remineralization of early lesions. Fluorine is gotten from drinking water and food materials. Adequate amount of fluorine in water should be from 0.7-1.5mg/l
166. A 46-year-old patient once took part in elimination of breakdown at an atomic power plant. Currently he is being treated at an inpatient hospital unit. He was diagnosed with progressing somatoform autonomic dysfunction. This disease relates to the following group of ionizing radiation effects:

Explanation

 

Biological Effects of radiation are of two types a) 1.Deterministic Effect b) Stochastic Effect. Deterministic effects are also called non-stochastic effects. These effects depend on time of exposure, doses, type of Radiation.it has a threshold of doses below which the effect does not occur, the threshold may vary from person to person. They include acute and chronic graduation sickness. Stochastic effects are those effects which occur when a person receives a high dose of radiation. These effects have an increased probability of occurring with increased dose. The two types include a) somatic stochastic  effect eg., somatoform autonomic dysfunction, malignancies etc  B) Genetic or hereditary effects.

167. A patient complains of fatigue, lack of appetite, pain and burning sensation in the tongue, numbness of the distal limbs, diarrhea. Objectively: pale skin with lemon-yellow tint, face puffiness, brown pigmentation in the form of a \\\"butterfly\\\", bright red areas on the tongue. The liver is 3 cm below the costal margin, soft. Blood count: RBCs - 1, 5 · 1012/l, colour index - 1,2, WBCs - 3, 8·109/l, thrombocytes - 180·109/l, eosinophiles - 0%, stab neutrophiles - 1%, segmented neutrophiles - 58%, lymphocytes - 38% monocytes - 3%, RBC macrocytosis. ESR - 28 mm/h. What diagnosis are these presentations typical for?

Explanation

From the blood analysis given, Macrocytes are present- this refers to irregular large Red Blood cells. Also the color index is elevated. The erythrocyte level is also very low ( norm- Female: 3.5 − 5.5 · 1012/L) - this indicates an anemia . The major causes of macrocytic anemia include Vitamin B12 deficiency, Vitamin B9 (Folic Acid) deficiency or medications such as antiretroviral drugs. 

Symptoms include loss of appetite, brittle nails , pale skin, fatigue etc. To differentiate between B12 or Folic acid deficiency, Vit B12 deficiency is often associated with nervous system symptoms like paresthesias - subacute combined degeneration due to abnormal myelin synthesis. These nervous system symptoms are absent in Folic Acid Deficiencies.

With the symptoms listed in the question, and the presence of anemia and macrocytes - it safe to say Vitamin B12 deficiency is the best choice.

 

168. A 25-year-old female patient complains of marked weakness, sleepiness, blackouts, dizziness, taste disorder. The patient has a history of menorrhagia. Objectively: the patient has marked weakness, pale skin, cracks in the corners of her mouth, peeling nails, systolic apical murmur. Blood test results: RBC - 3, 4 · 1012/l, Hb- 70 g/l, colour 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.

169. A 39-year-old patient complains of morning headache, appetite loss, nausea, morning vomiting, periodic nasal haemorrhages. The patient had acute glomerulonephritis at the age of 15. Examination revealed rise of arterial pressure up to 220/130 mm Hg, skin haemorrhages on his arms and legs, pallor of skin and mucous membranes. What biochemical parameter is the most important for making diagnosis in this case?

Explanation

 

Creatinine clearance test is one of the tests done to check the Renal function. It involves the measurement of the amount of plasma cleared of creatinine per unit time.The above patient presents with an acute glomerulonephritis and for biochemical analysis, the blood creatinine level is most informative. Another important test is the checking of the glomerular filtration rate.

170. A child was taken to a hospital with focal changes in the skin folds. The child was anxious during examination, examination revealed dry skin with solitary papulous elements and ill-defined lichenification zones. Skin eruption was accompanied by strong itch. The child usually feels better in summer, his condition is getting worse in winter. The child has been on bottle feeding since he was 2 months old. He has a history of exudative diathesis. His grandmother on his mother’s side has bronchial asthma. What is the most likely diagnosis?

Explanation

Atopic dermatitis is a systemic chronic allergic disease that occurs in people with an inherited predisposition to atopy and characterized by typical morphological changes of the skin with itching, lesions of the central and autonomic nervous system, endocrine and immune systems with hyper Ig E.    Essential criteria for diagnosis: itch, rash elements`, typical morphology and localization ( flexor surface of extremities in adults (lichenification), extensor surfaces and face in children (eczema)), chronic recurrent course, atopic diseases in personal and family anamnesis (bronchial asthma, allergic rhinitis).

Contact dermatitis: a localized reaction that includes redness, itching, and burning where the skin has come into contact with an irritant such as an acid, a cleaning agent, or other chemical.

Allergic contact eczema (dermatitis): a red, itchy, weepy reaction where the skin has come into contact with a substance that the immune system recognizes as foreign.
171. An electro-gas welding operator working at a machine workshop performs welding and cutting of metal, which is accompanied by intense UV-radiation. His welding station is equipped with effective mechanical ventilation. What occupational disease is most likely to develop in the electro-gas welding operator?

Explanation

The main risk amongst welders is the inflammation of the cornea and conjunctiva, commonly known as 'arc eye' or 'flash'. This is caused by the irritation of the eyes by the ultraviolet rays produced. Other possible hazards include skin inflammation, cancer
172. 2 weeks after recovering from tonsillitis an 8-year-old boy developed edemas of face and lower limbs. Objectively: the patient is in grave condition, BP - 120/80 mm Hg. Urine is of dark brown colour. Oliguria is present. On urine analysis: specific gravity - 1,015, protein - 1,2 g/l, RBCs are leached and cover the whole vision field, granular casts - 1-2 in the vision field, salts are represented by urates (large quantity). What is the most likely diagnosis?

Explanation

 

Recall that Nephritic syndrome is a disorder characterised by mild Proteinuria ( less than 3g/l) and hematuria while nephrotic syndrome is characterised by massive Proteinuria (greater than 3g/l), hypoalbuminemia and edemas. Note that this patient presents with proteinuria of about 1.2g/l coupled with hematuria (Rbcs cover the whole vision field of the urine); these findings indicate Nephritic syndrome. The idea of hypertension is ruled out since the B.p is 120/80 mmHg.

173. A 48-year-old patient has the following symptoms: diffuse enlargement of thyroid gland, exophthalmus, weight loss up to 4 kg within 2 months, excessive sweating. Objectively: heart rate 105/min, BP - 180/70 mm Hg. Stool is normal. What therapy is advisable in the given case?

Explanation

 

The patient experiences an enlarged thyroid gland, tachycardia, loss of weight  and exophthalmos which are symptoms of Hyperthyroidism ( thyrotoxicosis). For treatment Mercazolil (thiamazole) is administered. Propranolol is a beta blocker and used in heart related issues while thyroxine is indicated for hypothyroidism.

174. A patient is on sick leave for 4 months continuously from the date of injury. The treatment is going to last for another 1-2 months. Who is authorised to extend the duration of medical certificate for this patient?

Explanation

  1. The right of prolongating a medical certificate (in this case a sick list) of invalidity alongside with the medical treatment by the doctor is granted by:

• Chief medical officer (assistant of the chief medical officer on expertise of ability for work);

• Manager of department;

• Medical-consulting commission also known as medical expertise committee

 

The medical-consulting commission (MCC) is formed in case the doctors staff is above 15 doctors.

175. A 30-year-old woman complains of pain in the heart area (\\\"aching, piercing pain\\\") that arises primarily in the morning hours in autumn and spring. Pain irradiates into the neck, back, abdomen and is attended by rapid heart rate and low vital tonus. This condition occurs independently from physical exertion. In the evening her condition improves. Somatic and neurologic state and ECG have no pathologies. What pathology is likely to result in such clinical presentation?

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.

 
176. What juice is recommended to be included in a complex drug and diet therapy for patients suffering from gastric or duodenal ulcer and high acidity of gastric juice to speed up 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.

177. A 40-year-old woman has been hospitalized for attacks of asphyxia, cough with phlegm. She has a 4-year history of the disease. The first attack of asphyxia occurred during her stay in the countryside. Further attacks occurred while cleaning the room. After 3 days of inpatient treatment the patient’s condition has significantly improved. What is the most likely etiological factor?

Explanation

 

The patient was admitted as a result of an allergic attack. From anamnesis, we find that these attacks mostly occurred while cleaning the room indicating that the causative factor is a household allergen.

178. A 13-year-old girl complains of periodic prickly pain in the heart region. Percussion revealed no changes of cardiac borders. Auscultation revealed arrhythmic enhanced heart sounds, extrasystole at the 20-25 cardiac impulse. ECG showed the sinus rhythm, impaired repolarization, single supraventricular extrasystoles at rest. What is the most likely diagnosis?

Explanation

In Somatoform Autonomic dysfunction, the symptoms are presented by the patient as if they were due to a physical disorder of a system or organ that is largely or completely under autonomic innervation and control, i.e. the cardiovascular, gastrointestinal, respiratory, and  urogenital systems. Clinical and instrumental examination revealed no specific organic alterations in any system therefore indicating a somatoform autonomic dysfunction.
179. A 24-year-old patient visited a doctor complaining of enlargement of his submaxillary lymph nodes. Objectively: submaxillary, axillary and inguinal lymph nodes are enlarged. Chest X-ray shows: enlarged lymph nodes of mediastinum. Blood test: erythrocytes - 3, 4 · 1012/l, Hb- 100 g/l, blood colour index - 0,88, platelets - 190 · 109/l, leucocytes - 7, 5 · 109/l, eosinophiles - 8%, band neutrophiles - 2%, segmented neutrophiles - 67%, lymphocytes - 23%, ESR - 22 mm/h. What test must be prescribed to verify the cause of lymphadenopathy?

Explanation

180. A 60-year-old woman has been suffering from arterial hypertension for 15 years. After recurrent stroke she started complaining about unmotivated bad mood, problems with attention concentration; she forgets to close the entrance door, cannot recall events of the past day. Computer tomography shows areas of postinfarction changes in the cortical postfrontal areas. What is the most probable diagnosis?

Explanation

Observe that the patient has a history of stroke which from the CT scan result created postinfarction changes in the cerebral cortex. This patient also presents with problems of reasoning, memory, decision and thought which are signs seen in patients with dementia (a chronic organic mental disorder characterised by impairment in intellectual function, memory and personality). We can conclude that the dementia is as a result of disturbed brain blood supply (vascular dementia).

Alzheimer's disease is a type of dementia that causes problems with memory, thinking and behavior. It is a progressive disorder that causes brain cells to waste away (degenerate) and die. Pick’s disease is also a type of dementia but it is specific because it affects mainly the Frontotemporal lobe.
181. Clinic of a research instutute for occupational diseases examined a worker who works at a concentration plant and diagnosed him with chronic dust bronchitis. The case is investigated by a commission including the representatives of: the plant, medical unit, territorial sanitation center, department of Social Insurance Fund, trade union. According to the \"regulation on investigation of. . . \", the commission should be headed by the representative of the following authority:

Explanation

182. 4 days after a patient received a gunshot wound of the middle third of the thigh soft tissues his condition suddenly began deteriorating. There are complaints of bursting pain in the wound; pain increases during the last 12 hours. Edema of skin and hypodermic tissue quickly grows. Body temperature is 38, 2oC, heart rate is 102/min. The wound edges gape, are dull in color; the muscles, viable as of day before, now protrude into the wound, look boiled, are dull in colour, have dirty-grey coating and fall apart when being held with forceps. What infection has developed in the wound?

Explanation

The patient presents with possible signs of an infection; fever, tachycardia and worsening of the wound. The physical appearance of the wound indicates an infection most like an anaerobic bacteria eg clostridium. 

Cl. Perfringens is a gram positive, rod shaped, spore forming anaerobic bacteria which is a major cause of food poisoning and gas gangrene.

183. Bacterial analysis of air in a living space in winter period by means of Krotov’s apparatus revealed that total number of microorganisms in 1m3 of air was 7200. What is the allowed number of microorganisms for the air to be characterized as \\\"pure\\\"?

Explanation

  1. Air cleanness estimation according to indexes of bacteriological research in different year periods.

 

Air estimation

Microorganisms Contents in 1m3 of air.

 

Generally

Streptococcus hemolyticus

Generally

Streptococcus hemolyticus

 

Summer period

Winter period

Clean

less 1500

less 16

less 4500

less 36

Moderately muddy

1500 - 2500

16-35

4500-7000

36-125

Muddy

more 2500

more 35

more 7000

more 125

184. Maximum permissible concentration of carbon dioxide in the air is considered to be a sanitary index of air purity in a classroom. What concentration of carbon dioxide in the air is accepted as a permissible maximum?

Explanation

CO2 maximum allowable concentration (MAC) for indoors is determined at the level 0.07%-0.1%. In industrial premises where CO2 is accumulated during manufacture processes- 1-1.5%. The indoor air is considered pure if the CO2 concentration does not exceed the maximum allowable concentration 0.07% by Pettencofer or 0.1% by Flugge
185. When examining the parameters of desk natural lighting in a school class it was determined that: light angle is 25o, window angle is 3o, window-to-floor area ratio is 1:4, daylight factor is 0,5%, and window-head-to-roomdepth ratio is 2. What parameter does not correspond to hygienic norms?

Explanation

  1. The natural lighting norms for different premises

 

The type of premises

The daylight factor (DF)

The lighting coefficient (LC)

The angle of incidence (a)

The aperture angle (g)

The depth coefficient of premises

not less than

not less than

not less than

not less than

1.Classrooms

1.25-1.5%

1:4 – 1:5

27°

2

2.Residential

1.0%

1:5 – 1:6

27°

2

3. Wards

0.5%

1: – 1:8

27°

2

4. Surgeries

2.0%

1:2 – 1:3

27°

2

186. A 29-year-old patient works as a motor mechanic. Anamnesis shows frequent exposure to cold, exacerbation of chronic bronchitis attended by cough with relativly small amount of mucopurulent sputum, subfebrility,sometimes joined by hemoptysis and pain in the right side of chest. Breathing is vesicular. X-ray shows darkening and sharp decrease in size of the lower lobe distinctly visible on the X-ray image as a streak 2-3 cm wide situated at the angle from lung root to the frontal costodiaphragmatic recess. The most likely diagnosis is:

Explanation

187. A 52-year-old patient, who has been suffering from angina pectoris for 2 weeks, has more and more frequent pain attacks in the area behind his sternum and his need for nitroglycerine increased. Objectively: the condition is of moderate severity. Skin is pale. Heart sounds are weakened, rhythmic. Heart rate is 84 per minute. ECG shows no signs of focal myocardial damage. What is the most likely diagnosis?

Explanation

No signs of focal myocardial injury on ECG rules out the option of acute cardiac infarction. Angina pectoris is a clinical syndrome due to myocardial ischemia characterised by episodes of precordial ( area behind the sternum, above the heart) discomfort or pressure, typically triggered by stress and relieved by rest or sublingual nitroglycerin. 3 forms are present, they include; 

Stable: pain follows a steady pattern, triggered by stress.

Unstable/Progressive: occurs at rest or during minimal exertion, follows a crescendo pattern ( prolonged, more severe and frequent), usually requires an increase in nitroglycerin dose as it progresses.

Variant/prinzmetal: occurs at rest usually between midnights and early morning.

188. An 8-year-old boy during preventive examination was determined to have changes in his spine curvature in frontal plane: the right shoulder is lowered and flat, scapulae angles are of different height due to the right scapula being shifted down. Waist triangles are pronounced on the both sides; longitudinal muscles of the back form muscle cushion on the left. What type of posture is detected in the child?

Explanation

Lordosis, kyphosis, and scoliosis refer to curvatures of the spine. Lordosis refers to the normal inward curvatures of the spine at the cervical and lumbar regions, while kyphosis refers to the normal outward curvature of the spine specifically at the thoracic region. Scoliosis which always refers to the abnormal sideways curves of the spine.
189. A patient with cardiac infarction is on sick leave with his medical certificate being continuously extended for 4 months according to a standard procedure. The disease is progressing. The issue is put forward to refer the patient to the industrial injury assessment board. Who among the medical staff of medical and preventive treatment facility is authorized to do this

Explanation

The right of prolongating a medical certificate of invalidity alongside with the medical treatment by the doctor is granted by:

• Chief medical officer (assistant of the chief medical officer on expertise of ability for work);

• Manager of department;

• Medical-consulting commission also known as medical expertise committee

 

The medical-consulting commission (MCC) is formed in case the doctors staff is above 15 doctors.

190. A baby was born at 36 weeks of gestation. Delivery was normal, by natural way. The baby has a large cephalohematoma. The results of blood count are: Hb- 120g/l, Er- 3, 5 · 1012/l, total serum bilirubin - 123 mmol/l, direct bilirubin - 11 mmol/l, indirect - 112 mmol/l. What are the causes of hyperbilirubinemia in this case?

Explanation

Notice that the total serum bilirubin, indirect and direct form of bilirubin levels are elevated ( norm total 2-17 mcmol/l); also recall that bilirubin is obtained from the breakdown of RBCs. An elevated amount of bilirubin in this case indicates an increased breakdown of RBCs; in newborns, this is termed Hemolysis of newborn or Erythroblastosis fetalis.

Intravascular hemolysis is seen when the RBCs rupture inside the blood vessels. It mostly occurs in the presence of parasites in the blood eg, plasmodium etc.

Disturbance of the conjugative function of liver is observed in the absence of the enzyme UDP glucuronyltransferase

 
191. A patient has been hospitalised. The onset of the disease was gradual: nausea, vomiting, dark urine, аcholic stool, yellowness of the skin and scleras. The liver is enlarged by 3 cm. Jaundice developed on the 14th day of the disease. The liver diminished in size. What complication of viral hepatitis caused deterioration of the patient’s condition?

Explanation

 

One major function of the liver is the detoxification of harmful substances e.g. ammonia, alcohol etc. In situations of a viral hepatitis, this function is disturbed leading to the accumulation of these harmful substances. In the patient above, bilirubin is accumulated in the bloodstream leading to the presented symptoms ie, jaundice, skin itching etc. This substance has the ability to cross the blood brain barrier leading to an encephalopathy etc This condition is termed a hepatic encephalopathy since the root condition is from the liver.

192. An 18-year-old patient was admitted to a hospital with complaints of headache, weakness, high fever, sore throat. Objectively: enlargement of all groups of lymph nodes was revealed. The liver is enlarged by 3 cm, spleen - by 1 cm. In blood: leukocytosis, atypical lymphocytes - 15%. What is the most probable diagnosis?

Explanation

Note that Atypical lymphocytes are mostly associated with Infectious Mononucleosis, an infection obtained from the epstein barr virus (EBV). These lymphocytes are termed atypical because they have a larger cytoplasm and nucleoli in their nuclei. All other symptoms are generalised and can indicate every other disease.
193. A 60-year-old woman, mother of 6 children, developed a sudden onset of upper abdominal pain radiating to the back, accompanied by nausea, vomiting, fever and chills. Subsequently, she noticed yellow discoloration of her sclera and skin. On physical examination the patient was found to be febrile with temperature of 38, 9oC, along with right upper quadrant tenderness. The most likely diagnosis is:

Explanation

 

The above patient presents with upper quadrant pain and tenderness, jaundice which are signs that indicate diseases such as cholecystitis, Choledocholithiasis (stones in the bile duct)  and other pathologies relating to the liver and gallbladder. Note that in most malignant diseases, the patient often presents with an unexplained loss of weight within a very short period ( with this in mind, the options of Malignant biliary stricture and Carcinoma of the head of the pancreas are ruled out). Benign biliary strictures are often experienced in chronic inflammatory diseases, and postoperative situations.

194. 13 months after the first labor a 24- year-old patient complained of amenorrhea. Pregnancy ended in Caesarian section because of premature detachment of normally positioned placenta which resulted in blood loss at the rate of 2000 ml due to disturbance of blood clotting. Choose the most suitable investigation:

Explanation

 

The menstrual cycle is regulated by a group of hormones namely; follicle stimulating hormones, luteinizing hormones (both referred to as the major gonadotropins); other hormones include the female sex hormones estrogen and progesterone. From the above listed options, estimation of the gonadotropin rate will be the suitable investigation in finding the reason behind the amenorrhea.

FSH- is activated by the gonadotropin releasing hormones from the hypothalamus. FSH is produced in the anterior lobe of the pituitary gland  and its production is increased in the first half of the menstrual cycle. It stimulates the recruitment and maturation of oocytes. 

LH- is also released by the anterior lobe of the pituitary and initiates ovulation.  Ovulation takes place 36 hours after the LH surge. 

195. A 24-year-old primipara was hospitalised with complaints of discharge of the amniotic waters. The uterus is tonic on palpation. The position of the fetus is longitudinal, it is pressed with the head to pelvic outlet. Palpitation of the fetus is rhythmical, 140 bpm, auscultated on the left below the navel. Internal examination: cervix of the uterus is 2,5 cm long, dense, the external opening is closed, light amniotic waters are discharged. Point out the correct component of the diagnosis:

Explanation

 

The above patient is experiencing a preterm/prelabor rupture of membrane. Refers to the escape/leakage of amniotic fluid from the ruptured fetal membrane. It can be Preterm (occurs after 28 weeks of gestational age and before 37 weeks) or Term ( occurs after 37 completed weeks of gestational age, including post-term cases occurring after 40 weeks). From the above listed signs, the antenatal discharge of amniotic fluid is the key in diagnosis because in this case, it indicates the woman is about to enter the first stage of labor.

196. A patient was delivered to a surgical department after a road accident with a closed trauma of chest and right-sided rib fracture. The patient was diagnosed with right-sided pneumothorax; it is indicated to perform drainage of pleural cavity. Pleural puncture should be made:

Explanation

A pleural puncture or thoracentesis is done along the midclavicular line or posterior axillary line, 1-2 intercostal spaces below the percussed upper border of the effusion. 
197. A primagravida with pregnancy of 37-38 weeks complains of headache, nausea, pain in epigastrium. Objectively: the skin is acyanotic. Face is hydropic, there is short fibrillar twitching of blepharons, muscles of the face and the inferior extremities. The stare is fixed. BP - 200/110 mm Hg; sphygmus is of 92 bpm, intense. Respiration rate is 32/min. Heart activity is rhythmical. Appreciable edemas of the inferior extremities are present. Urine is cloudy. What medication should be administered?

Explanation

 

The patient in perspective is pregnant and thus drug selection should be done carefully. Dibazolum is contraindicated in pregnant and lactating mothers while Papaverine has not been cleared as a safe drug to administer during pregnancy. Droperidol is a drug that has sedative, tranquilizing and antipsychotic effects and is marked safe to use during pregnancy. Notice that the patient experiences twitching of the facial muscles, Droperidol can act as a relaxant in this case coupled with having an anti nausea effect.

198. A patient with high temperature came to a first-aid post in the evening. The fact of temporary disability was established. Indicate the measure to be taken in this case:

Explanation

 

The physician on duty should issue a medical certificate ( a written statement from a physician or another medically qualified health care provider which attests to the result of a medical examination of a patient) indicating a temporary disability. This medical certificate will assist the patient in obtaining a sick list which is a document given to an individual exempting him/her from workday to an illness or disability.

199. A 10-year-old boy complains of pain in his left eye and strong photophobia after he has injured his left eye with a pencil at school. Left eye examination revealed: blepharospasm, ciliary and conjunctival congestion, cornea is transparent, other parts of eyeball have no changes. Visus 0,9. Right eye is healthy, Visus 1,0. What additional method would you choose first of all?

Explanation

A fluorescent eye stain test should be carried out to detect foreign bodies in the eye, abrasions or scratches on the cornea etc. Requires the use of a fluorescent dye and a blue light in examining the eyes especially the cornea.

Tonometry is used in detecting the ocular pressure of the eye. Gonioscopy is majorly done if glaucoma is suspected, it involves the inspection of the iridocorneal angle.

 
200. An infant was born with body mass 3 kg and body length 50 cm. Now he is 3 years old. His brother is 7 years old, suffers from rheumatic fever. Mother asked a doctor for a cardiac check up of the 3-year-old son. Where is the left relative heart border located?

Explanation

 

Border’s of hearts relative dullness:

 

 

age of child

Border

until 2 years

2-7 years

7-12 years

older 12 years

Right

right parasternal line

right parasternal line or something inward from right parasternal line

Between the right parasternal line and the right sternal line

the right sternal line

Upper

the II rib

the II intercostal space

the III rib

the III intercostal space

Left

2 cm outward from left midclavicular line

1 cm outward from left midclavicular line

0,5 cm outward from left midclavicular line

0,5 cm medialy from left midclavicular line

Transversal size

6-9 cm

8-12 cm

9-14 cm

9-14 cm