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Question 1 of 200

1. A 32-year-old welder complains of weakness and fever. His illness initially presented as tonsillitis one month earlier. On examination: body temperature - 38,9oC, RR24/min., HR- 100/min., BP- 100/70 mm Hg, hemorrhages on the legs, enlargement of the lymph nodes. Complete blood count: Hb- 70 g/l, RBC- 2, 2 · 1012/l, WBC- 3, 0 · 109/l with 32% of blasts, 1% of eosinophils, 3% of band neutrophils, 36% of segments, 20% of lymphocytes, and 8% of monocytes, ESR- 47 mm/hour. What is the cause of anemia?

Explanation

Blast cells are immature WBC. Presence of 32% of Blast cells in the analysis indicates an acute form of leukemia. Less than 10% of blast cells will indicate a chronic form. This patient also has an anemia (post hemorrhagic form) indicated by the low level of RBC. N/B, when there is leukemia, most of the immature cells will be recruited to produce the cancer cells which will cause a reduction in most of the other cell types especially RBC’s.

Megaloblastic anemia is seen in vitamin B12 deficiency while chronic hemolytic anemia will show reticulocytes ( immature RBCs) on blood film unlike leukemia that show immature wbc.
2. A 54-year-old woman takes antihypertensive drugs for hypertension. Having discovered that her son was arrested and is under investigation, became agitated and extremely anxious. She lost her orientation in place, stopped recognizing her relatives, started hearing ”voices” threatening her and her son with violence. She had opened her window (on the 8th floor) and tried to jump out, resisted the people, who were holding her back. What drugs should be administered to terminate such condition of the patient?

Explanation

 

Antipsychotic drugs (neuroleptics) are a group of medications used in patients with psychosis ( hallucination, disorder in thought, paranoia or delusions). This patient is agitated and is having auditory hallucinations therefore an antipsychotic therapy is needed. Tranquilizers are used in anxiety disorders, fear, tension etc. Nootropics are drugs used in boosting memory and creativity.

3. A 43-year-old man, who has been abusing alcohol and suffering from pulmonary tuberculosis, in the course of two weeks gradually developed general weakness, headache, diplopia, vomiting. Objectively: ptosis on the left, anisocoria S>D, exotropia of the left eye, neck stiffness; Kernig’s and Brudzinski’s signs are positive. In cerebrospinal fluid: lymphocytic pleocytosis, low glucose, precipitation of cerebrospinal fluid resulted in production of fibrin film. What is the most likely diagnosis?

Explanation

Meningitis is an acute infectious disease with involvement of the arachnoid and pia of the brain and spinal cord by pathogenic microorganisms. Etiologically, the various forms include; bacterial, viral. Fungal and tuberculous meningitis. The tuberculous form occurs as a secondary infection ( from anamnesis, the patient already suffers from pulmonary tuberculosis); The CSF is under increased pressure, is clear or slightly cloudy, and contains a predominance of mononuclear cells (usually >400/mm3), increased protein (100 to 400 mg/dL), and a decreased glucose content
4. A 32-year-old woman complains of episodes of intense fear that occur without visible cause and last for 10-20 minutes; the episodes are characterized by rapid pulse, sweating, labored breathing, and vertigo. Specify the likely diagnosis:

Explanation

The essential features of Panic Disorder are recurrent attacks of severe anxiety (panic attacks) which are not restricted to any particular situation or set of circumstances.

Typical symptoms are palpitations, chest pain, choking sensations, dizziness, and feelings of unreality (depersonalisation or derealization). Individual attacks usually last for minutes only. 

Manic syndrome is characterised by an elevated, expansive or irritable mood, an increased psychomotor, speech and thought activities coupled with an unusual alertness, trying to do many things at one time.

 

Paranoid personality disorder is a personality disorder characterized by intense mistrust and suspicion of others.

5. A resuscitation unit received a 46-yearold woman, who has been suffering from diabetes mellitus type 1 for approximately 30 years. Objectively: the skin is pale, heart sounds are weakened, BP is 170/100 mm Hg, lower limbs are markedly swollen. Blood creatinine - 1125 mcmol/l, urea - 49,6 mmol/l, potassium - 6.3 mmol/l, glucose - 7,6 mmol/l, glomerular filtration rate - 5 ml/min. What treatment is indicated for the patient in the first place?

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 ( in this patient, the GFR is 5ml/min ( norm 90-120 ml/min). Notice that his blood values are not normal; K- 6.3mmol/L ( norm- 3.5-5.5), urea 49.6mmol/l (3.33 - 8.32 mmol/L),Creatinine - 1125 mcmol/ (53 - 106 mcmol/L ) glucose level is also high. Recall that the kidney has three basic functions; filtration, reabsorption and secretion, and a distortion in these values indicates a kidney related issue. After hemodialysis, a kidney transplant should be considered as a permanent solution for the failed kidneys.
6. A woman is on the 32nd week of her second pregnancy. She complains of fever, chills, nausea, vomiting, lumbar pain, and dysuria. Costovertebral angle tenderness is present on both sides. Urine analysis: pyuria, bacteriuria. Blood test: leukocytosis. What is the most likely diagnosis?

Explanation

Gestational pyelonephritis is a urinary tract infection that occurs in pregnant women. It is caused by bacteria that is why on blood analysis, we see leukocyturia. It is also accompanied by signs of pyelonephritis which include dysuria, lumbar pain, fever etc

 

Cystitis is an inflammation of the bladder, characterised by frequent urge to urinate, blood in urine, pain during intercourse etc. Pyelitis is an inflammation of the renal pelvis.

7. A 19-year-old young man complains of cough with expectoration of purulent sputum in amount of 100 ml per day, hemoptysis, dyspnea, increased body temperature up to 37,8oC, general weakness, weight loss. The patient’s condition lasts for 4 years. Exacerbations occur 2-3 times a year. The patient presents with malnutrition, pale skin, cyanosis of the lips, drumstick (clubbed) fingers. Tympanic percussion sound in the lungs, weakened respiration, various numerous moist crackles in the lower pulmonary segments on the left can be observed. In blood: erythrocytes - 3, 2 · 1012/l, leukocytes - 8, 4 · 109/l, ESR- 56 mm/hour. On X-ray: lung fields are emphysematous, the left pulmonary root is deformed and dilated. What is the most likely diagnosis?

Explanation

Bronchiectasis is a chronic necrotizing infection of the bronchi and bronchioles leading to or associated with abnormal dilation of these airways. Symptoms include  cough and daily  mucopurulent sputum production, often lasting for months; blood-streaked sputum (hemoptysis), dyspnea, low grade fever, pleuritic chest pain, wheezing, fever, weakness, fatigue and weight loss. Presence of moist crackles on auscultation indicates an infectious or inflammatory process; digital clubbing is seen in 2-3% of patients. A dilated and deformed left pulmonary root confirms bronchiectasis of the left lung.

 

Lung abscesses are characterized by large cavities filled with suppurative debris.

8. A 37-year-old man working as a typesetter in a print shop complains of rapid fatigability, paroxysmal attacks of stomachache, weak drooping hands. Examination of neurological status revealed hypotrophy of the forearm muscles. Carporadial reflexes are sharply weakened. Sensitivity is not disturbed. Gums present with dark blue border. What neurological pathology is it?

Explanation

The patient presents with weak dropping hands and a weakened carporadial reflex; this sign is often seen in individuals poisoned by lead ( wrist and foot drop). Other major signs are ’ Lead lines’ on gingiva/gums ( Burton's line),abdominal colic, encephalopathy and sideroblastic anemia.

Guillain-Barre syndrome is an autoimmune condition that destroys schwann cells via inflammation and demyelination of nerve fibres. It occurs as a result of molecular mimicry and triggered by infections, stress etc. major signs include Bilateral facial paralysis and respiratory failure.

 

Shingles is gotten from varicella zoster virus infection.

9. A 48-year-old woman has been hospitalized due to development of tachysystolic atrial fibrillation. She has lost 5 kg of body weight within 2 months. On palpation there is a node in the left lobe of the thyroid gland. What pathology resulted in the development of this condition?

Explanation

 

A toxic goiter refers to goiters which cause Hyperthyroidism eg. diffuse toxic goiter. A non toxic goiter does not cause hyperthyroidism - it refers to a diffuse or nodular enlargement of the thyroid gland that does not result from an inflammatory or neoplastic process and is not associated with abnormal thyroid function.. Notice that this patient shows symptoms of hyperthyroidism (loss of weight, tachycardia); this rules out the option of a non-toxic goiter. Nodular goiter is palpated as painless tumour with regular contours, smooth surface, not connected with adjacent tissues and displaced during swallowing. In this patient, the node on the left lobe coupled with signs of hyperthyroidism indicates a nodular goiter.

10. On the 9th day after childbirth the obstetric patient developed high fever up to 38oC. She complains of pain in the right mammary gland. On examination a sharply painful infiltrate can be palpated in the right mammary gland, the skin over the infiltrate is red, subareolar area and nipple are swollen and painful. What is your diagnosis?

Explanation

 

A breast abscess is a localised collection of pus in the breast tissue. It is usually caused by a bacterial infection. It is characterised by the presence of a lump on palpation (painful infiltrate can be palpated), swollen and painful nipple.

In mastopathy, we observe changes such as swellings, nodules, cysts etc, it is hormone dependent. In cancer, there will be increased proliferation of atypical tissues.

11. A 36-year-old woman complains of pain in her lumbar area, which irradiates to her lower right limb and increases during movements, and sensation of numbness in her limb. Objectively: palpation of the shin and thigh muscles is painful, positive stretch symptom on the right. MRI scan: herniation of intervertebral disk L5-S1 4 mm in size. What is the most likely diagnosis?

Explanation

12. During routine medical examination a 35-year-old woman presents with enlarged cervical and mediastinal lymph nodes. Her overall health is satisfactory. ESR is 30 mm/hour. Cervical node biopsy was performed. In the specimen there are granulomas composed of epithelial and giant cells, no caseous necrosis detected. What is the most likely diagnosis?

Explanation

 

Sarcoidosis is an inflammatory disease in which granulomas, or clumps of inflammatory cells, form in various organs. This causes organ inflammation. The lungs and lymph nodes are the most affected areas. The absence of caseous necrosis, rules out the option of lymph node tuberculosis while in Lymphogranulomatosis, we see Reed-sternberg cells which are a different type of giant cell from these granulomas. Infectious mononucleosis is characterized by Atypical lymphocytes.

13. A 39-year-old woman complains of violent pain in her left lumbar area with irradiation to the right iliac area. Several years ago she was diagnosed with cholelithiasis and urolithiasis. The patient’s condition is moderately severe, the skin is dry. Ortner’s symptom is negative; costovertebral angle tenderness is observed on the right. The most reasonable treatment tactics would be:

Explanation

 

Biliary and renal colic refer to pain that occur as a result of the blockage(most especially by stones) of the biliary or urinary tract respectively. This severe pain is due to continuous spasms (involuntary contraction) against these stones. To salvage this situation, the patient should be prescribed a spasmolytic (to stop the spasms) and an analgesic ( for pain relief).

14. An 18-year-old patient complains of skin rash. The patient has been suffering from this condition for 5 years. The first instance of this disease occurred after a car accident. Objectively: the patient presents with papular rash covered in silvery scales, ”thimble” symptom (small pits on the nails), affected joints. What is the most likely diagnosis?

Explanation

Psoriasis is a common skin disorder characterised by the presence of papules and plaques with silvery scaling especially on the knees and elbows. Other characteristics include acanthosis, parakeratosis and pinpoint bleeding ( Auspitz sign). The patient presents with a thimble symptom which translates into a pitting or a psoriatic nail.

 

A Panaritium or Whitlow is an acute purulent inflammation of the tissues of the finger or toes. Onychomycosis is a fungal infection of the nails; signs are white or yellow nail discoloration, thickening of the nail, and separation of the nail from the nail bed; it is also known as  tinea unguium.

15. A woman complains of frequent, liquid stool (up to 9-10 times per day) with mucus and blood admixtures, dull pain in the hypogastrium, weight loss of 4 kg within the last year. Objectively: malnutrition, dry skin, low turgor, aphthous stomatitis. The stomach is soft, the sigmoid colon is spastic and painful on palpation. Occult blood test is positive. Fibrocolonoscopy: edema, hyperemia, mucosal granulation, pseudopolyps, small ulcers with irregular edges. Make the diagnosis:

Explanation

Occult blood in stool is indicative of a hemorrhagic process from the colon, while the results from the colonoscopy indicates the pathology is located in the colon.

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

Distinguishing Ulcerative Colitis from Crohn Disease

 

Ulcerative Colitis

Crohn Disease

Only colon involved

Panintestinal

Continuous inflammation extending proximally

 from rectum

Skip-lesions with intervening normal mucosa

Inflammation in mucosa and submucosa only

Transmural inflammation

No granulomas

Noncaseating granulomas

Perinuclear ANCA (pANCA) positive

ASCA positive

Bleeding (common)

Bleeding (uncommon)

Fistulae (rare)

Fistulae (common)

16. A 26-year-old woman came to a gynecologist for a regular check-up. She has no complaints. Per vaginum: the uterus lies in anteflexion, not enlarged, dense, mobile, painless. On the left from the uterus in the area of uterine appendages there is a mobile painless outgrowth that can be moved independently from the uterus. On the right the appendages cannot be detected. What additional investigation would be informative for diagnosis clarification?

Explanation

An ultrasound of the lesser pelvis is used to examine the organs of the pelvis; in females these include the uterus, cervix, vagina, fallopian tubes and ovaries. The above patient has issues with the uterine appendages and this diagnostic method will be the most informative among all listed. 

 

A colposcopy is a simple procedure used to look at the cervix, the lower part of the womb at the top of the vagina.

17. A 57-year-old patient complains of dyspnea at rest. The patient presents with orthopnea, acrocyanosis, bulging cervical veins. On percussion: dull sound over the lower lung segments; on auscultation: no respiratory murmurs. Heart rate is 92/min. Right-sided cardiac dilatation is observed. The liver is enlarged by 7 cm. Shins are swollen. Pleural effusion is suspected. What indicator would confirm the presence of transudate in this case?

Explanation

 

In the case of a pleural effusion, there can be different types of fluids; Transudate and Exudate. 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.

18. A 28-year-old woman complains of girdle pain in her epigastric and left subcostal areas with irradiation to the back, nausea, and vomiting without relief. On examination a surgeon observes stomach distension and meteorism. There are positive Mondor’s, Mayo-Robson’s, and Cullen’s symptoms. What is the most likely diagnosis?

Explanation

 

Mondor’s sign refers to the presence of violet spot on face and trunk; Cullen’s sign refers to the yellow coloring of skin around the umbilicus; Mayo-Robson sign is the feeling of pain when pressure is applied by the fingers in the left costo-vertebral angle. These signs are seen in an individual with pancreatitis. Also notice that the patient experiences pain in  her epigastric and left subcostal areas with irradiation to the back; this rules out the option of cholecystitis in which the pain is present in the right upper quadrant.

19. A 57-year-old patient complains of sensation of dryness and pain during swallowing, frequent unbearable cough, the voice is hoarse. Disease onset was abrupt. On laryngoscopy: laryngeal mucosa is hyperemic, vocal folds are swollen, laryngeal lumen contains viscous secretion. What diagnosis is it?

Explanation

Acute laryngitis is catarrhal inflammation of mucous membrane, sub mucous layer and internal muscles of larynx. Clinical picture involves  Feeling of dryness, burning, tickling sensation, A dry, then moist cough, Hoarse voice. The above patient presents with a dry sensation, pain while swallowing, a hyperemic larynx and viscous (purulent ) secretion which confirms an acute laryngitis ( chronic form typically lasts more than 3 weeks).

Acute laryngotracheitis (croup) is a common viral infection which generally affects children younger than 5 years of age. Causative agents include Parainfluenza, influenza, rhinovirus etc. Stridor and steeple sign ( subglottic narrowing) are common signs.

Laryngeal diphtheria is characterised by  a thick, gray green, plaque-like membranous exudate over the tonsils, pharynx, and larynx;  the exudate is difficult to dislodge, and it bleeds when it is removed.
20. A 24-year-old pregnant woman on her 37th week of pregnancy has been delivered to a maternity obstetric service with complaints of weak fetal movements. Fetal heartbeats are 95/min. On vaginal examination the uterine cervix is tilted backwards, 2 cm long, external orifice allows inserting a fingertip. Biophysical profile of the fetus equals 4 points. What tactics of pregnancy management should be chosen?

Explanation

A biophysical profile is a prenatal test used to check the well being of a baby. It involves using an ultrasound in evaluating the fetal heart rate, breathing, movement ,muscle tone and amniotic fluid level combined with a non-stress test for checking the fetal heart rate. Points are allocated for every measurement taken. This test is recommended for pregnant women at high risk of complications and a tendency of pregnancy loss. In most cases, a low biophysical profile score might indicate an early or immediate child delivery. 

 

Note that the score of the above profile is 4 (indicating an immediate delivery).

21. During regular preventive gynecological examination a 30-year-old woman was detected to have dark blue punctulated ”perforations” on the vaginal portion of the uterine cervix. The doctor suspects endometriosis of the vaginal portion of the uterine cervix. What investigation method would be most informative for diagnosis confirmation?

Explanation

A colposcopy is a simple procedure used to look at the cervix, the lower part of the womb at the top of the vagina ( Colposcopy is like a microscope put near the vagina to allow more detailed examination of the cervix). It's often done if cervical screening finds abnormal cells in your cervix. Under the guidance of colposcopy, a piece of the lesion will be removed (called a biopsy) and sent to the laboratory for detailed examination.

 

A hysteroscopy is used in detecting pathologies involving the Uterus. Curettage is a procedure used in removing tissues from the uterine cavity.

22. A 55-year-old woman came to a gynecologist with complaints of leukorrhea and bloody discharge from the vagina after 5 years of menopause. Anamnesis states no pregnancies. Bimanual examination: the uterus and uterine appendages are without changes. During diagnostic curettage of the uterine cavity the physician scraped off enchephaloid matter. What is the most likely diagnosis in this case?

Explanation

Basically, there are three forms of cancer of the uterus (endometrium): 

      1. Fibrous carcinoma or scirrhous, hard cancer

      2. Medullary or encephaloid, or soft cancer 

      3. epithelioma, or chancroid.

 

Observe that on curettage of the uterine cavity, an encephaloid matter was found thereby indicating the presence of an endometrial (uterine) carcinoma.

Adenomyosis is a condition that involves the encroachment, or movement, of the endometrial tissue that lines the uterus into the muscles of the uterus. This makes the uterine walls grow thicker. It may lead to heavy or longer-than-usual menstrual bleeding, as well as pain during your menstrual cycle or intercourse.

23. A 10-year-old boy is delivered into a polytrauma unit after he received a blunt trauma of the thorax, having fallen from the bicycle. Upon hospitalization his blood pressure is 110/80 mm Hg, heart rate is 96/min. Chest X-ray is noncontributive to the diagnosis. Echocardiogram shows free liquid in the pericardial cavity, in the amount of up to 100 ml. In an hour after the hospitalization the patient started to develop increasing signs of heart failure: jugular venous distention, decreased blood pressure down to 90/70 mm Hg, tachycardia up to 120/min. On auscultation muffled heart sounds. What would be the primary tactics of a physician?

Explanation

Notice that the result from the echocardiogram shows the accumulation of fluid in the pericardium thereby indicating a pericardial effusion. As a result of this, the intrapericardial pressure will be increased leading to an adverse effect on the heart. In order to remove the accumulated fluid, a Pericardiocentesis (pericardial puncture) is carried out. This is a medical procedure in which a needle is used in aspirating (removing) the excess pericardial fluid.
24. After the celebratory feast that took place the day before, a 35-year-old man was hospitalized with complaints of marked pain within the I metatarsophalangeal articulation on the right, which developed late in the night, and impaired walking. Objectively: the metatarsophalangeal articulation is swollen, hyperemic, hot to touch, painful on movement. In blood: erythrocytes - 5, 1·1012/l, Нb- 155 g/l, leukocytes- 13, 0·109/l, ESR- 50 mm/hour, CRP- 46 mg/dl, uric acid - 720 mcmol/l. X-ray of feet articulations: osteoporosis, narrowing of interarticular spaces, numerous punched-out erosions. Make the preliminary diagnosis:

Explanation

Gout is an inflammatory arthritis characterized by self-limiting  but excruciatingly painful acute attacks. These  are a consequence of monosodium urate (MSU) crystal deposition within articular or periarticular tissue. Uric acid ------►Crystals------►Crystals deposits in joint------►Joint inflammation; the metatarsophalangeal are mostly affected. Hyperuricemia is a key finding in gout; notice that the patient’s uric acid level is 720mcmol/l ( norm: Male: 0.12-0.38 mcmol/L, Female: 0.12-0.46 mcmol/L).

 

Osteoarthritis is characterised by both degeneration of articular cartilage and simultaneous proliferation of new bone, cartilage and connective tissue.

25. A woman in her early- to mid-thirties has lost her consciousness 3-5 minutes ago. On examination: the skin is pale, no pulse over the carotid arteries, no spontaneous respiration, pupils are dilated; the patient is nonresponsive, presents with atony. The patient’s condition can be determined as:

Explanation

26. A 32-year-old woman complains of body weight loss despite her increased appetite, nervousness, and tremor of the extremities. Objectively: the skin is moist; the thyroid gland is diffusely enlarged, painless, soft, and mobile. Blood test: increased level of T3, T4, and thyroid-stimulating hormone (THS). What is the most likely diagnosis?

Explanation

Diffuse toxic goiter or grave’s disease is an autoimmune disease characterised by an increased amount of thyroid hormones ( T3- triiodothyronine and T4- thyroxine). Symptoms include; loss of weight, increased sweating,tachycardia, tremors of extremities, increased appetite etc.

Hashimoto’s thyroiditis is a destructive autoimmune thyroiditis leading to hypothyroidism.

A nontoxic goiter is a diffuse or nodular enlargement of the thyroid gland that does not result from an inflammatory or neoplastic process and is not associated with abnormal thyroid function.

 

27. A 74-year-old man visited an 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: the abdomen is soft and painful above the pubis; dullness of percussion sound is observed above the pubis. Murphy’s punch sign (costovertebral angle tenderness) is negative on 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 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.

28. During preventive examination a 58-yearold man on chest X-ray presents with multiple globular pale shadows 3 cm in diameter within parenchyma of the both lungs. Examination in the oncologic hospital: the primary focus is not found; transbronchial biopsy with cytologic investigation detected cells of glandular neoplasm. What tactics should the physician choose?

Explanation

 

After the x-ray was carried out with an uncertain result, a transbronchial biopsy with cytologic investigation was carried out and the result was a glandular neoplasm ( a tumor from the glands). With this known, a chemotherapeutic approach should be taken  ( ie, drugs targeted at killing fast differentiating cells in the body).

29. A 36-year-old man developed a disease with acute onset 6 hours ago. The patient presents with pain in the epigastric, ileocecal, and paraumbilical areas, vomiting, weakness, nausea, and body temperature of 38,5oC. Stool is liquid, profuse, frequent, retains fecal nature, foul-smelling, frothy, colored dark green. The stomach is moderately distended and painful on palpation. The patient attributes his disease to eating raw chicken eggs one day before the clinical signs of the disease appeared. What is the most likely diagnosis?

Explanation

30. A 14-year-old girl came to a general practitioner with complaints of weakness, loss of appetite, headache, rapid fatigability. Her last menstruation was profuse and lasted for 14 days after previous delay of 2 months. Objectively: the skin is pale, heart rate is 90/min., BP is 110/70 mm Hg, Hb is 88 g/l. Rectal examination: the uterus and its appendages are without changes, no discharge from the genital tracts. What complication occurred in the patient?

Explanation

From anamnesis, we see that the patient experienced a prolonged Menstrual cycle characterized by profuse blood discharge; 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.

 

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.

31. A postpartum woman on the 12th day after the normal delivery complains of pain localized in her left gastrocnemius muscle. Body temperature is 37,2oC; pulse is 85/min, rhythmic; blood pressure is 128/80 mm Hg. Mammary glands are soft and painless. The uterus is behind the pubis. The left leg in the area of gastrocnemius muscle is by 3 cm larger than the right leg in the diameter. Internal organs present no pathologies. What complication can be suspected?

Explanation

 

Deep vein thrombosis is observed when a clot is formed in a blood vessel located deep in the body ( not a superficial vessel). 3  factors (virchow’s Triad) that are critically important in the development of venous thrombosis: (1) venous stasis, (2) activation of blood coagulation, and (3) vein damage. Signs include throbbing or cramping pain, swelling, warm skin around the painful area, red or darkened skin, swollen veins etc. Note that in varicose veins, it is the superficial veins that are being affected (caused mainly due to an increased venous pressure) and can be clearly visible on the surface of the skin as twisted and enlarged.

32. Examination of a Rh-negative pregnant woman at 32 weeks of gestation revealed a four-time rise of Rh-antibody titer within 2 last weeks; the titer is 1:64. The first two pregnancies resulted in antenatal fetal death due to hemolytic disease. What is the optimal tactics of pregnancy management?

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.

33. During last several weeks an 11-yearold girl has been complaining of dyspnea and edema of shins and feet after physical exercise. After a long rest or sleep through the night her edemas diminish significantly. On clinical examination there are enlarged liver and rasping systolic murmur over the cardiac area. Blood and urine analyses are without changes. What is the most likely cause of the child’s edema?

Explanation

Congestive heart failure can cause both peripheral, pulmonary and abdominal edema (ascites). This is because the heart is too weak to pump blood around the body properly, so the blood gathers in front of the heart. Because of this, and due to the increased blood pressure in the veins, fluid seeps out into the surrounding tissue. This may cause swelling in the legs or a build-up of fluid in the abdomen. A rasping systolic murmur also indicates an organic heart pathology.

Nephrotic syndrome also leads to edema but will be characterised by severe proteinuria and an increased depletion in albumin levels.

Angioneurotic edema is seen in individuals with deficiency in C1 esterase inhibitor deficiency. It is also referred to as quinke’s edema.

 

Edema as a result of hepatocirhosis will be seen in an individual with a chronic alcohol abuse history or one with a liver related pathology.

34. 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.
35. A full-term newborn (born with the body weight of 3900 g at gestational age of 39 weeks) on the first day of his life developed respiratory disturbances: dyspnea, arrhythmic respiration, cyanosis attacks. On examination there is paradoxical respiration observed and left side of the chest lags behind in the act of breathing. On auscultation the respiration is weakened in the lungs on the left. Neurologist diagnosed the patient with left-sided ErbDuchenne palsy. Complete blood count shows no changes. What is the most likely diagnosis?

Explanation

ErbDuchenne palsy is the paralysis of the arm caused by the injury to the nerves C5-C6. Paradoxical respiration is a term used to refer to distressed breathing. Notice that this patient's left lung lags behind during respiration and respiration is also weakened on this side; a paresis ( muscular weakness due to nerve damage) of the diaphragm (the main respiratory muscle) can lead to this situation.

 

No changes in CBC rules out the option of an infection ( congenital pneumonia) and respiratory distress is often seen in preterm babies with lack of sufficient surfactant.

36. A 12-year-old child had three attacks of acute rheumatic fever accompanied by carditis. Examination revealed the symptoms of chronic tonsillitis, mitral insufficiency, and carious teeth. What is the optimal method of secondary prophylaxis?

Explanation

Primary prophylaxis involves the treatment of streptococcal pharyngitis with antimicrobial therapy. 

 

Secondary prophylaxis involves Continuous prophylaxis in patients with well-documented histories of rheumatic fever and in those with evidence of rheumatic heart disease. The table below gives the guideline:

Type

Duration after last attack

Evidence rating*

Rheumatic fever with carditis and residual heart disease (persistent valvular disease†)

10 years or until age 40 years (whichever is longer); lifetime prophylaxis may be needed

1C

Rheumatic fever with carditis but no residual heart disease (no valvular disease†)

10 years or until age 21 years (whichever is longer)

1C

Rheumatic fever without carditis

5 years or until age 21 years (whichever is longer)

1C

37. A 24-year-old patient had been delivered to a thoracic department with a chest injury, fracture of the IV, V, VI ribs on the right. Plan radiography showed the fluid level in the pleural cavity to be reaching the III rib on the right. Puncture contained blood clots. What is the optimal treatment tactics?

Explanation

The above patient presents with a major trauma to the right side of the chest which is confirmed by a collapsed right lung on x ray. Thoracotomy is a surgical procedure carried out inorder to have access to thoracic organs such as the lungs, heart or esophagus. This procedure is the first step in gaining access to the thoracic cavity and thus is indicated in cases of a lobectomy, major trauma of the chest, pneumonectomy. In the case of this patient, an urgent thoracotomy should be carried out in order to take out the blood clots. Thoracocentesis is indicated in pleural effusion and is also referred to as a pleural puncture.
38. A 3-year-old child has been delivered to a hospital with complaints of pain in the legs, fever, loss of appetite. Objectively: pale skin and mucosa, hemorrhagic rash. Lymph nodes are enlarged, painless, dense and elastic, not matted together. Bones, joints, and abdomen are painful. The liver and spleen are enlarged. Hemogram: Hb- 88 g/l, color index - 1,3, platelets - 80 · 109/l, leukocytes - 25, 8 · 109/l, lymphoblasts - 70%, ESR- 52 mm/hour. Make the provisional diagnosis:

Explanation

Pay attention to the Hemogram and notice that the lymphoblast level is highly elevated. Leukemia is a cancer of the marrow and blood. The major forms of leukemia are divided into four categories. The terms myelogenous or lymphocytic denote the cell type involved. Myelogenous and lymphocytic leukemia each have an acute or chronic form. Thus, the four major types of leukemia are acute or chronic myelogenous and acute or chronic lymphocytic leukemia. Acute leukemia is a rapidly progressing disease that affects mostly cells that are unformed or immature (Blast cells). These immature cells cannot carry out their normal functions. Chronic leukemia progresses slowly and permits the growth of greater numbers of more developed cells.

In  thrombocytopenic purpura  there will be a decreased number of circulating platelets (thrombocytopenia), easy bruising (purpura), or extravasation of blood from capillaries into skin and mucous membranes (petechiae).

Note that Atypical lymphocytes are mostly associated with Infectious Mononucleosis, an infection obtained from the epstein barr virus (EBV).
39. Heart X-ray of a 31-year-old man has revealed the following: with tightly filled opacified esophagus there is a marginal filling defect in its middle third on the posterior wall; the defect is 1,8x1,3 cm in size with clear oval border. Mucosal folds are retained and envelop the defect; wall peristalsis and elasticity are not affected. There are no complaints regarding the condition of the patient’s alimentary canal. Make the provisional diagnosis:

Explanation

Notice that mucosal walls are retained and wall peristalsis and elasticity are not affected- these rule out the options of achalasia cardia, Esophageal burns and barrett's esophagus ( because in these pathologies, one or more of the above listed is/are affected). The result from the x-ray shows a mass with clear oval borders thereby indicating a tumour.

Achalasia Cardia is a rare neurodegenerative disorder of esophagus resulting in defective peristalsis and impaired relaxation of lower esophageal sphincter. In Barrett's esophagus, the mucosal lining transforms from normal stratified squamous epithelium to simple columnar epithelium.

 
40. A patient with signs of general overexposure to cold presenting with local frostbites of fingers has been delivered into an admission room. Objectively: conscious, inert, speech is slow, the skin of the face is cold, body temperature is 34oC, heart rate is 68/min. What would be the actions of a doctor on call?

Explanation

Notice that the patient has local frostbites of the fingers; this patient should be admitted into the surgical department for estimation of degree of frost and possibly amputation of the fingers.
41. A 22-day-old infant developed subcutaneous red nodes from 1,0 to 1,5 cm in size on the scalp; later the nodes suppurated. Temperature increased up to 37,7oC, intoxication symptoms appeared, regional lymph nodes enlarged. Complete blood count: anemia, leukocytosis, neutrocytosis, increased ESR. What diagnosis will you make?

Explanation

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

 

Vesiculopustulosis is a widespread purulent disease, which appears in the first years of life. In the ostium of the sweat glands numerous pustules appear, filled with white yellow matter, the size of a pin head to a small pea, they do not merge with each other and are surrounded by bright edematous circles

42. During examination of a healthy infant, the child takes a toy into his hands, turns from the back to the side; when lying on the stomach he can firmly prop himself up on his forearms; the child laughs and makes joyful exclamations. The age of the child is:

Explanation

43. After significant physical exertion a 66- year-old man with deep vein thrombosis of the extremities developed shortness of breath, intense pain in the chest on the left, marked palpitations. The patient’s condition is grave, his face is cyanotic, the cervical veins are swollen, BP is 60/40 mm Hg. What investigation method would be the most advisable in this case?

Explanation

 

The patient presents with deep vein thrombosis, swollen cervical veins; this implies that we have to use an investigative method that will help us visualize inside the blood vessels. Selective angio pneumography is a diagnostic method that helps visualize the  lumen of blood vessels and organs. I.e., veins, arteries, chambers of the heart.

44. A 32-year-old woman complains of general fatigue, low-grade fever persisting for 4 months, lumbar pain, and dysuria. Anamnesis includes frequent acute respiratory diseases, overexposure to cold, lowcalorie diet, a case of pulmonary tuberculosis in childhood. Clinical urine analysis: pH4,8, leukocyturia, hematuria. Complete blood count: leukocytosis, lymphocytosis, increased ESR. Urography concludes: dilatation of renal pelvis and calyceal system of both kidneys, foci of calcification in the projection of right kidney parenchyma. What is the most likely diagnosis?

Explanation

45. An 9-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 was characterised by increased opening pressure, was transparent, with the cell count of 450 cells per 1 mcL (mainly lymphocytes - 90%), glucose level of 3,6 mmol/l. What agent could 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.

46. A 25-year-old woman has a self-detected tumor in the upper outer quadrant of her right breast. On palpation there is a painless firm mobile lump up to 2 cm in diameter, peripheral lymph nodes are without alterations. In the upper outer quadrant of the right breast ultrasound revealed a massive neoplasm with increased echogenicity sized 21x18 mm. What is the most likely diagnosis?

Explanation

 

An adenoma is a benign epithelial tumor from the epithelium of the glands and glandular organs e.g. breast, thyroid gland, ovaries etc. A fibroadenoma is a benign nodular proliferation and not a true neoplasm (cancer); it presents as a mobile lump in the breast of young women.

Lactocele are breast cysts that develop during or after lactation and are characterised by the accumulation of milk.

Diffuse mastopathy is a Fibrocystic change of the breast (also known as diffuse cystic mastopathy) is a benign alteration in the terminal ductal lobular unit of the breast with or without associated fibrosis.

47. A 68-year-old man complains of inability to urinate for a day. On attempt of urinary bladder catheterization there was detected a rough stricture in the membranous portion of the urethra. What first aid tactics should be applied in this case?

Explanation

 

A Troacar cystostomy or suprapubic catheter is a surgical connection made between the urinary bladder and the skin, it is carried out in individuals experiencing urinary blockade  even after the use of a catheter.

Optical Internal Urethrotomy is used to treat urethral strictures, a medical condition when the urethra (the tube that drains urine from the bladder) becomes narrow. In this surgical process, the body tissues in the urethra are removed, to release it.

48. A 3-month-old child presents with saffron-yellow coloring of the skin, sclera, and mucous membranes. The abdomen is enlarged, hepatomegaly and splenomegaly are observed. In blood there is conjugated bilirubin-induced hyperbilirubinemia. On intravenous cholangiocholecystography: opacified bile is discharged into the intestine. Transaminase activity is normal. What is the most likely diagnosis?

Explanation

49. A 51-year-old woman complains of headache, trembling, paresthesiae, palpitations, increased blood pressure up to 280/160 mm Hg. The day before she experienced exhausting headache, vascular pulsation, palpitations, asphyxia, stomachache, unbearable fear of coming death. The patient paled and broke out in cold sweat. In urine there is increased content of vanillylmandelic acid. What disease causes such clinical presentation in the patient?

Explanation

 

Pheochromocytoma is a tumor of the adrenal medulla; it stimulates the increased production of catecholamines. vanillylmandelic acid is an end stage metabolite of catecholamines and is typically elevated in patients with catecholamine-secreting tumors (eg, neuroblastoma, pheochromocytoma, and other neural crest tumors)......

50. A 52-year-old patient suffers from marked dyspnea during physical exertion, non-productive cough. The patient’s condition has been persisting for 8 months. The patient has been a smoker for 30 years. In the lungs there are cellophane-type crackles auscultated on both sides. Respiration rate is 26/min., oxygen saturation of blood is 92%. On spirometry: moderate restrictive-type disturbance of external respiration. What is the most likely diagnosis

Explanation

 

The function of the alveoli is dependent on the alveolar wall which is a thin membrane, allowing for oxygen and carbon dioxide to move freely across it. Notice that on auscultation, the patient presents with cellophane-type crackles which indicates an interstitial lung disease. Results from spirometry show a restrictive lung disease which rules out the options of COPD and chronic bronchitis ( which are obstructive lung diseases). IFA is a disease affecting both the walls and the interior of alveoli. It causes fibrosis of the alveolar walls, which impairs gas exchange.

51. 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 would be most effective in this case?

Explanation

 

A neuroleptic is an antipsychotic drug used that targets a patient's cognition and behaviour.  In psychotic patients, neuroleptic drugs cause a reduction in confusion and agitation and tend to normalize psychomotor activity. This patient also has a reduced need for sleep therefore, he should also be given a neuroleptic that can assist in sleeping (with sedative effect). Tranquilizers are used in anxiety disorders, fear, tension etc. Nootropics are drugs used in boosting memory and creativity.

52. A 19-year-old patient complains of dyspnea on exertion. He often has bronchitis and pneumonia. Since childhood the patient presents with cardiac murmur. Auscultation revealed splitting of the II sound above the pulmonary artery, systolic murmur in the 3rd intercostal space at the left sternal border. ECG detected right bundle branch block. What is the provisional diagnosis?

Explanation

53. 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

 

Our first approach should be to stop the bleeding which is done by applying a tourniquet above the injury.

54. A 25-year-old patient has been admitted to the hospital with the following problems: weakness, sweating, itching, weight loss, enlarged submandibular, cervical, axillary, inguinal lymph nodes. Objectively: hepatomegaly. Lymph node biopsy revealed giant Berezovsky-Reed-Sternberg cells, polymorphocellular granuloma composed of lymphocytes, reticular cells, neutrophils, eosinophils, fibrous tissue, and plasma cells. What is the most likely 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).

Lymph node tuberculosis is one of the extra pulmonary forms of Tb. The lymph node TB usually causes a painful swelling of one or more lymph nodes. Most often, the disease is localized to the anterior or posterior cervical chains (70-90%) or supra clavicular. It is often bilateral and non-contiguous lymph nodes can be involved

55. A 22-year-old man suddenly developed extreme weakness, nausea, vomiting with traces of blood. The patient is known to suffer from peptiv ulcer disease of duodenum and hemophilia A. Objectively: heart rate - 102/min., BP- 100/60 mm Hg. Complete blood count: erythrocytes - 3, 2 · 1012/l, Hb- 98 g/l, color index - 0,92, leukocytes - 7, 4 · 109/l, platelets - 240 · 109/l, ESR- 11 mm/hour. What measure would most effectively decrease hemorrhaging in this case?

Explanation

Cryoprecipitate is also known as cryoprecipitated antihemophilic factor. It is prepared from plasma and contains fibrinogen, von Willebrand factor, factor VIII, factor XIII and fibronectin. Used to prevent or control bleeding in people whose own blood does not clot properly. This includes patients with serious but rare hereditary conditions such as Hemophilia A (who lack factor VIII) and von Willebrand disease (who lack von Willebrand factor.

 

Fresh frozen plasma contains all factors of the soluble coagulation system, including the labile factors V and VIII. FFP is indicated when a patient has Multiple factor deficiencies and is Bleeding.

56. A 22-year-old woman complains of amenorrhea for 8 months. Anamnesis states that menarche occured at the age of 12,5. Since the age of 18 the patient has a history of irregular menstruation. The patient is nulligravida. The mammary glands are developed properly, nipples discharge drops of milk when pressed. Hormone test: prolactin level is 2 times higher than normal. CT reveals a bulky formation with diameter of 4 mm in the region of sella. What is the most likely diagnosis?

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.

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).

57. A 13-year-old girl complains of fatigability, frequent headaches, cardialgia. Eight years ago she had a case of pyelonephritis. Urine analyses periodically revealed leukocyturia. The child has undergone no further treatment. On examination: increased BP up to 150/100 mm Hg. Ultrasound investigation revealed significant reduction of the right kidney. What process is leading in arterial hypertension pathogenesis in this case?

Explanation

 

From ultrasound, we observe the reduction in size of the right kidney; this may be due to a reduction in blood flow or a chronic infection ( as earlier stated, she previously had a case of pyelonephritis). Due to the constriction of the renal artery, the kidney releases Renin (from juxtaglomerular cells). This renin converts angiotensinogen (produced in the liver) to angiotensin I; Angiotensin I is then converted to angiotensin II by angiotensin converting enzyme, ACE ( an enzyme produced in the vascular endothelial cells of the lungs). Angiotensin II then stimulates the secretion of aldosterone from the adrenal cortex. In this system, angiotensin II is a potent vasoconstrictor that assists in the Increase of blood pressure.

58. ECG revealed the following in a 10- year-old child: sharp acceleration of the heart rate - 240/min., P wave overlaps with T wave and deforms it, moderate lengthening of PQ interval, QRS complex is without alterations. What pathology does this child have?

Explanation

59. 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 hospitalization jaundice was severely progressed. Liver cannot be palpated. Gallbladder is enlarged and painless. Blood bilirubin is 190 mcmol/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.

60. During hemotransfusion the patient developed nausea, tremor, lumbar and retrosternal pain. On examination the skin is hyperemic, later developed pallor; the patient presents with hyperhidrosis, labored respiration, pulse is 110/min., BP is 70/40 mm Hg. Urine is black colored. What complication developed in the patient?

Explanation

 

Realise that the above symptoms began after the hemotransfusion. These signs are related to an acute hemolytic reaction which occurs due to ABO incompatibility. This is further proven by the presence of dark urine which is as a result of the broken down RBCs. An acute hemolytic reaction is one of the leading paths to the development of a post transfusion shock.

An anaphylactic shock during hemotransfusion will mostly occur in individuals with IgA deficiency.

Acute renal failure refers to a significant reduction in renal function occurring over hours or days clinically manifesting as an abrupt and sustained rise in serum urea and creatinine levels.

61. A 25-year-old patient is not married and has sexual relations with several partners. During the last 3 months he noticed a small amount of mucoserous discharge from the urethra. Subjectively: periodical itching or burning pain in the urethra. Two months ago pain in the knee joint 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 made?

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.  

Rheumatoid Arthritis is an autoimmune inflammation of the joints; it is usually symmetric,accompanied by pain, swelling, morning stiffness lasting greater than 1 hour and improves with continuous use.

62. A 19-year-old woman complains of severe pain in the axillary crease. Condition onset occurred a week ago after her swimming in a cold river and epilation. The next day a painful ”boil” appeared. The ”boil” was increasing in size every day and became a plum-sized tumor. Upon examination there are nodular conical growths joined together detected, the skin covering them is bluish-red in color. Some nodules have fistulous openings producing thick purulent mass. Body temperature is 38, 5oC, general malaise. What is the most likely diagnosis?

Explanation

63. A woman complains of weight gain, chills, edema, xeroderma, somnolence, diffi- culties with focusing. Objectively: height is 165 cm; weight is 90 kg; body proportions are of female type, to- 35,8oC, heart rate - 58/min, BP- 105/60 mm Hg. Heart sounds are weakened, bradycardia is observed. Other internal organs have no alterations. Thyroid gland cannot be palpated. Milk secretion from mammary glands is observed. Hormone test revealed increased levels of thyroidstimulating hormone (TSH) and prolactin, and decreased level of thyroxine (4). What is the cause of 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.

64. A 37-year-old patient complains of pain in the spinal column, reduced mobility. The condition persists for 7 years. ”Sway back” is observed, there is no movement in all spinal regions. On X-ray: ”bamboo spine” is detected. What is the most likely diagnosis?

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.

Spondylitis deformans is characterised by degeneration in the intervertebral discs followed by the presence of bony spurs or osteophytes along the edges of the bones of the spine.

65. 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.

 
66. A 64-year-old patient has been hospitalized with complaints of progressive jaundice that developed over 3 weeks without pain syndrome and is accompanied by general weakness and 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 by these symptoms?

Explanation

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). Note that Cholecystitis usually presents with tenderness (peritoneal irritation) 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.
67. A 6-year-old girl came to 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. Anti-fungal treatment such as Nystatin, Fluconazole are very effective in this case.
68. Anamnesis of a 30-year-old patient includes closed thoracic injury. Lately the patient has been suffering from increasing dyspnea, sensation of heaviness in the right subcostal area, and heart rate disturbances. Objectively: acrocyanosis, bulging cervical veins, ascites, edema of the lower extremities. Heart auscultation reveals muffled heart sounds, additional III heart sound is detected. Provisional diagnosis of constrictive pericarditis was made. What diagnostic technique would NOT confirm the diagnosis?

Explanation

 

The above patient has a pathology regarding the organs of the thoracic cavity. A diagnostic procedure involving an ultrasound of the abdomen will not help in confirming the diagnosis.

69. A 72-year-old woman suffers from diabetes mellitus type 2, concomitant diseases are stage 2 hypertension and stage 2B heart failure. She takes metformin. Hypertensic crisis had occurred the day before, after which the patient developed extreme weakness, myalgias, thirst, dry mouth, polyuria. BP is 140/95 mm Hg, heart rate is 98/min., no edemas or smell of acetone detected. What measures should be taken to prevent development of comatose state in the patient?

Explanation

 

Note that after the hypertensive crisis, the patient is presenting with symptoms that shows she is progressing into a comatose state. The absence of edemas or smell of acetone shows the patient is still in a stable condition; inorder to prevent the development of a diabetic coma, metformin should be replaced by short acting insulin such as Aspart, lispro etc.

Metformin (Glucophage) is an oral diabetic drug indicated for the treatment of type 2 diabetes and polycystic ovarian syndrome. It is a biguanide which prevents the further production of sugar from the liver and improves the body's sensitivity to insulin.

70. The body of a 24-year-old woman with probable signs of poisoning has been found on the street. Forensic medical examination was requested by an investigator during examination of the site and the body. According to the Criminal Procedure Code currently in force in Ukraine, forensic medical examination is required when it is necessary to determine the:

Explanation

 

According to the Criminal Procedure Code currently in force in Ukraine, forensic medical examination is required to determine the cause of death.

71. It is the 3rd day after the normal term labor; the infant is rooming-in with the mother and is on breastfeeding. Objectively: the mother’s general condition is satisfactory. Temperature is 36,4oC, heart rate is 80/min., BP is 120/80 mm Hg. Mammary glands are soft and painless; lactation is moderate, unrestricted milk flow. The uterus is dense, the uterine fundus is located by 3 fingers width below the navel. Lochia are sanguino-serous, moderate in volume. Assess the dynamics of uterine involution:

Explanation

Involution is the term used to describe the physical reduction in size of the uterus and cervix after parturition (childbirth). This process begins immediately after expulsion of the placenta with contraction of the uterine smooth muscle. The uterus, which at full term weighs approximately 11 times its prepregnancy weight, involutes to approximately 500 g by 1 week after birth and to 350 g by 2 weeks after birth. At 6 weeks it weighs 50-60 g.

Subinvolution is the failure of the uterus to return to a nonpregnant state. The most common causes of subinvolution are retained placental fragments and infection.

 
72. Survey radiograph of a 52-year-old worker of an agglomeration plant (28-yearlong record of service, the concentration of metal dust is 22-37 mg/m3) shows mildly pronounced interstitial fibrosis with diffused contrasting 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).
73. 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 at Mayo-Robson’s point. Biochemical blood analysis: glucose - 3,2 mmol/l, bilirubin - 16,5 mcmol/l, crude protein - 56,4 g/l. Urine diastase/amylase - 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).

Irritable bowel syndrome is a disorder of the large intestine related to defecation, change in  stool frequency and form. Patients with IBS will present with no structural abnormality, but will experience changes in the pattern of bowel movements.

74. A multigravida at 39 weeks of gestation presenting with regular labour activity for 8 hours has been delivered to a hospital; the waters broke an hour ago. She complains of headache, seeing spots. BP is 180/100 mm Hg. Urine test results: protein - 3,3 g/l, hyaline cylinders. Fetal heart rate is 140/min, rhythmical. Vaginal examination reveals complete cervical dilatation, the fetal head is on the pelvic floor, sagittal suture is in line with obstetric conjugate, the occipital fontanel is under the pubis. What is the optimal tactics of labour management?

Explanation

An outlet forceps is used in assisting delivery when there is full cervical dilation with the fetal head reaching the perineal floor and the scalp is visible between contractions. This type of assisted delivery is performed only when the fetal head is in a straight forward or backward vertex position or in slight rotation (less than 45 degrees to the right or left) from one of these positions.

The patient in question is manifesting signs and symptoms of pre-eclampsia already: proteinuria 3.3g/L; elevated blood pressure 180/100mmHg; headache and seeing spots; pregnancy is already beyond 20 weeks of gestation. The fetus is still stable judging from the fetal heart rate of 140beats per min. So, with a full cervical dilation, the best option is to assist the delivery using an outlet forceps.

Full cervical dilatation indicates completion of the first stage of labor and if the head of the fetus has descended, then an assisted vaginal delivery can be pursued without much risk to both the mother and fetus.

With a full cervical dilatation (completion of the first stage of labor) and in the absence of fetal distress, a cesarean section will be unnecessary. Cavity forceps and Vacuum extraction can be used when the head of the fetus is still high up in the uterus (i.e. yet to descend) or in the case of a retained second twin in multiple gestation.

We can’t go for the option of conservative labor management in this condition because the patient is already showing signs of pre-eclampsia and delivery should be done promptly.

75. After the contact with chemicals a plant worker has suddenly developed stridor, voice hoarseness, barking cough, progressing dyspnea. Objective examination reveals acrocyanosis. What is the 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/.

76. An 18-year-old woman complains of pain in her lower abdomen, profuse purulent discharge from the vagina, temperature rise up to 37,8oC. Anamnesis states that she had a random sexual contact the day before the signs appeared. She was diagnosed with acute bilateral adnexitis. On additional examination: leukocytes are present throughout all vision field, bacteria, diplococci with intracellular and extracellular position. What is the most likely agent in the given case?

Explanation

 

The options of Neisseria gonorrhoeae, Staphylococcus aureus , Trichomonas vaginalis and chlamydia trachomatis can all lead to an Adnexitis which refers to a disease of the female genital organs that causes inflammation of the uterus, ovaries and fallopian tubes. But notice that on further examination, diplococci with intracellular and extracellular position were found- this characteristic is typical for Neisseria gonorrhoeae which is a gram negative diplococci.

77. A 58-year-old man complains of general weakness, loss of 10 kg of weight within 1,5 months, progressive pain in the lumbar region, increased blood pressure up to 220/160 mm Hg, low grade fever. Objectively: in the right hypochondrium deep palpation reveals a formation with uneven surface and low mobility; veins of the spermatic cord and scrotum are dilated. Blood test results: Hb- 86 g/l, ESR- 44 mm/h. Urine test results: specific gravity - 1020, protein - 0,99 g/l, RBC cover the whole field of vision, WBC- 4-6 in the field of vision. What is the provisional diagnosis?

Explanation

The fact that the patient lost a lot of weight in a short period of time 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; the dilated veins of the spermatic cord and scrotum (varices) is due to disrupted blood flow  caused by increased pressure from the tumour.

A patient with urolithiasis will also experience flank pain, change in quantity of urine and can be differentiated by results from ultrasound. Glomerulonephritis will present with either a nephritic ( hematuria, slight proteinuria and hypertension) or nephrotic syndrome ( increased proteinuria accompanied by presence of edema).

 
78. A 12-year-old girl after a case of respiratory infection developed dyspnea at rest, paleness of skin. Heart rate is 110/min., BP is 90/55 mm Hg. Heart sounds are muffled. Borders of relative heart dullness: right - the parasternal line, upper - the III rib, left - 1,0 cm outwards from the midclavicular line. Make the provisional diagnosis:

Explanation

 

Myocarditis is an inflammation of the myocardium, it presents with a disruption in heart conduction and abnormal heart rhythms (arrhythmia). Notice that the above patient experiences an arrhythmia and the results from  auscultation and percussion indicates an inflamed portion of the heart. From anamnesis, the patient has a respiratory infection; many infectious, metabolic, toxic, inflammatory processes can lead to a myocarditis- the infectious form is mostly caused by a viral infection.

Hypertrophic cardiomyopathy (HCM) is a disease in which the heart muscle becomes abnormally thick (hypertrophied). The thickened heart muscle can make it harder for the heart to pump blood.

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.

79. A 48-year-old man complains of fatigue, excessive sweating, severe skin itching, undulant fever, enlarged cervical and supraclavicular lymph nodes. Objectively: paleness of skin and mucosa, cervical lymph nodes are mobile, dense, elastic, walnut-sized, painless, not attached to the skin. Complete blood count: erythrocytes - 3, 0 · 1012/l, Hb100 g/l, leukocytes - 14 · 109/l, eosinophils - 6%, basophils - 3%, band neutrophils - 11%, segmented neutrophils - 69%, lymphocytes - 7, monocytes - 4%, platelets - 280 · 109/l, ESR 37 mm/hour. What method should be applied to verify the diagnosis?

Explanation

The patient appears with enlarged cervical and supraclavicular lymph nodes; these lymph nodes are said to be mobile, dense, elastic, walnut-sized, painless, not attached to the skin; To verify diagnosis, a lymph node biopsy should be taken and examined.
80. A patient after a blow to the head developed general symptoms of cerebral disturbance, nausea, vomiting, focal signs - hemi-hyperreflexia S>D, hemihyperesthesia on the left, marked meningeal syndrome. Neither cranial X-ray nor computer tomography revealed any pathologies. What examination method would allow making and clarification of the diagnosis?

Explanation

 

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

A lumbar puncture, also known as a spinal tap, is a medical procedure in which a needle is inserted into the spinal canal, most commonly to collect cerebrospinal fluid for diagnostic testing. The main reason for a lumbar puncture is to help diagnose diseases of the central nervous system, including the brain and spine.

81. A 72-year-old man complains of lower extremity edema, sensation of heaviness in the right subcostal area, dyspnea of rest. For over 25 years he has been suffering from COPD. Objectively: orthopnea, jugular venous distention, diffuse cyanosis, acrocyanosis. Barrel chest is observed, on percussion there is vesiculotympanitic (bandbox) resonance, sharply weakened vesicular respiration on both sides, moist crepitant crackles in the lower segments of the lungs. Heart sounds are weakened, the II heart sound is accentuated over the pulmonary artery. The liver is +3 cm. What complicated the clinical course of COPD in this patient?

Explanation

82. A patient complains of painless ”sores” on his penis and inguinal lymph nodes enlargement. Synthomycin emulsion that the patient have been applying to the ”sores” was ineffective. Objectively: on the inner leaf of the foreskin there are three closely situated rounded erosions, 0,5 cm in diameter, with dense infiltration that can be palpated at their bases. Make the preliminary diagnosis:

Explanation

Syphilis is a sexually transmitted disease caused by the spirochete Treponema Pallidum. It has three stages namely:

  • Primary

  • Secondary

  • Tertiary

 

        Primary stage is characterised by the presence of Hard Chancre which are firm, painless genital ulcers/ sores. Lymphadenitis and Lymphagitis are also seen in this stage.

Herpes simplex viruses are enveloped double stranded linear viruses. HSV-1 is also known as oral herpes ( gingivostomatitis, keratoconjunctivitis etc) while HSV-2 is known as genital or neonatal herpes. The clinical presentation of genital herpes include  pain, itching, dysuria, vaginal and urethral discharge, tender lymphadenopathy, appearance of herpes vesicles on the  external genitalia, labia majora, labia minora, vaginal vestibule - for women and glans penis, the prepuce, the shaft of the penis, and sometimes on the scrotum, thighs, and buttocks- for men.

Candidiasis 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

83. A 1,5-month-old child on breasfeeding presents from birth with daily vomiting, irregular liquid foamy feces, and meteorism, which are resistant to antibacterial and probiotic therapy; no increase of body mass is observed. The child’s condition improved, when breastmilk was substituted with ”NAN low lactose” formula. What pathology is it?

Explanation

Note that the above symptoms were developed after breastfeeding and the child’s conditions improved after a change of diet . Recall that the main carbohydrate constituent of breast milk is lactose and the child fared well when the level was lowered. This child is said to have a lactose intolerance and is due to the deficiency in the enzyme  Lactase; an enzyme responsible for the breakdown of lactose. Functional dyspepsia is a chronic disorder of sensation and movement (peristalsis) in the upper digestive tract. Peristalsis is the normal downward pumping and squeezing of the esophagus, stomach, and small intestine, which begins after swallowing. We call this disorder functional because there are no observable or measurable structural abnormalities found to explain persistent symptoms. You might hear other terms used to describe this condition, such as non-ulcer dyspepsia, pseudo-ulcer syndrome, pyloro-duodenal irritability, nervous dyspepsia, or gastritis.
84. 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.

85. 10 days after birth a newborn developed sudden fever up to 38,1oC. Objectively: the skin in the region of navel, abdomen and chest is erythematous; there are multiple peasized blisters with no infiltration at the base; isolated bright red moist erosions with epidermal fragments are observed on the periphery. What is the provisional diagnosis?

Explanation

86. A man came to an urologist with complains of painful urination, discharge from urethra. The patient has been suffering from this condition for a week. Objectively: hyperemic urinary meatus, edema, purulent discharge. Microscopy of smears detected gram-negative bacteria. Specify the diagnosis:

Explanation

 

Results from the microscopy of smears coupled with the complaints of painful urination and discharge indicates an infection by Neisseria gonorrhoeae ( a gram negative diplococci). The result from the bacteria smear presentation rules out the options of Chlamydia, candida and trichomonas. The infection is an acute one since the individual has only experienced it for about a week.

87. A patient is 28 years old. He has been suffering from mental disorder since he was 22. His current condition has changed acutely: for 3 days the patient has been refusing to leave his home. He claims that there is a ”telepathy” occurring between him and the other people, through which he receives ”thoughts of strangers” and transmits his own thoughts for everyone to hear. He is convinced that his thoughts and actions are being manipulated through this ”telepathy”. Make the preliminary diagnosis:

Explanation

Schizophrenia is a mental disorder characterised by disturbances in thought and verbal behaviour,perception, motor behaviour and relationship to the external world. The different clinical types include; Paranoid, disorganised/ hebephrenic, Catatonic, residual or latent, undifferentiated schizophrenia. The described patient is said to have a paranoid schizophrenia; it is characterised by having delusions ( an unrealistic belief) of persecution, reference, control. These delusions are usually well connected and also have no disturbance  of speech and motor behaviour.

A catatonic episode is characterised by a marked disturbance of motor behaviour.

 

Organic delirium is characterised by clouding of consciousness and disorientation.

88. A 35-year-old woman has gained 20 kg weight within a year with the normal diet. She complains of chills, sleepiness, shortness of breath. 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. HR- 56/min, BP- 140/100 mm Hg. The patient has been suffering from amenorrhea for 5 months, has constipations. TSH- 28 mcIU/l (norm is 0,32-5). Craniogram shows no pathology. What is the etiology of obesity?

Explanation

 

An increase in weight, bradycardia, obesity, constipation are signs indicating hypothyroidism. Note that the absence of abdominal striaes rules out the option of cushing’s disease (hypercorticoidism). The increased TSH levels implies an activation of the feedback mechanism signalling  the body to produce more thyroid hormones; T3 and T4.

89. A 23-year-old woman has been suffering from a mental disease since the age of 18, the course of disease has no remission periods. At a hospital the patient mostly presents with non-purposeful foolish excitation: she makes stereotypic grimaces, exposes herself, publicly masturbates with a loud laughter, repeates stereotypical abusive shouts. The patient should be prescribed:

Explanation

Neuroleptics are antipsychotic drugs indicated for cases such as schizophrenia, bipolar disorders. They are used in managing psychosis and related symptoms such as delusions, hallucinations, paranoia or disordered thought. Tranquilizers are used in anxiety disorders, fear, tension etc. Nootropics are drugs used in boosting memory and creativity.
90. A 14-year-old patient complains of alopecia foci on his scalp. The patient has been presenting with this condition for 2 weeks. Objectively: on the scalp there are several small oval foci with blurred margins. The skin in the foci is pink-red, the hairs are broken off at 4-5 mm length or at skin level. Under Wood’s lamp there are no foci of green luminescence detected. What disease is it?

Explanation

91. A 38-year-old patient has been delivered by an ambulance to a surgical department with complaints of general weakness, indisposition, black stool. On examination the patient is pale, there are dotted hemorrhages on the skin of his torso and extremities. On digital investigation there are black feces on the glove. Blood test: Hb- 108 g/l, thrombocytopenia. Anamnesis states that similar condition was observed 1 year ago. Make the diagnosis:

Explanation

Immune thrombocytopenic purpura (ITP) is a clinical syndrome in which a decreased number of circulating platelets (thrombocytopenia) present as a bleeding tendency, easy bruising (purpura), or extravasation of blood from capillaries into skin and mucous membranes (petechiae). Recall that the patient presents with dotted hemorrhages on the skin (petechiae) and on analysis, thrombocytopenia. Caused by the binding of an autoantibody (specifically IgG) to platelets leading to platelet destruction.

 

In Hemophilia, patients will present with bleeding from joints (heathroses), easy bruising or a case of bleeding after surgery, dental procedure. Has three forms; Hemophilia A ( Factor VIII deficient), Hemophilia B ( factor IX deficient), C ( factor XI def.).

92. A 35-year-old patient developed an epileptic attack with tonoclonic spasms that lasted for 3 minutes. After the attack the patient fell asleep but in 5 minutes the second attack occurred. The first step of emergency aid would be to:

Explanation

If you are with someone having a tonic-clonic seizure (where the body stiffens, followed by general muscle jerking), try to: 

  • Stay calm and remain with the person.

  • If they have food or fluid in their mouth, roll them onto their side immediately.

  • Keep them safe and protect them from injury.

  • Place something soft under their head and loosen any tight clothing.

  • Reassure the person until they recover.

  • Time the seizure, if you can.

  • Gently roll the person onto their side after the jerking stops.

Do not put anything into their mouth or restrain or move the person, unless they are in danger. The major step is to ensure the airway is clear, to keep them breathing until the seizure stops.

 
93. A 14-year-old girl has been delivered to a gynecological department with complaints of profuse blood discharge from her genital tract for 2 weeks. Anamnesis: menstruation since 13, irregular, painful, profuse; the last one was 2 months ago. Objectively: pale skin and mucosa, BP- 100/60 mm Hg, Hb- 108 g/l. The abdomen is soft and painless on palpation. Rectal examination revealed no pathologies of reproductive organs. What condition is it?

Explanation

Notice that the patient above experiences abnormal blood discharge with no reproductive organ pathology; this indicates a case of Dysfunctional Uterine bleeding ( juvenile form- since it occurs at child age and in period of pubescence). A dysfunctional uterine bleeding (DUB) is the bleeding not associated with any organic diseases of women’s genitals, interrupted pregnancy or systemic diseases of the organism. In hypo menstrual syndrome, light or scanty menstrual flow is experienced.
94. An infant cries during urination, the foreskin swells and urine is excreted in drops. What approach to treatment should be chosen?

Explanation

95. A 20-year-old patient complains of pain in the left lumbar region, arterial pressure rise up to 160/110 mm Hg. US revealed that the structure and size of the right kidney were within age norms, there were signs of the 3rd degree hydronephrotic transformation of the left kidney. Doppler examination revealed an additional artery running to the lower pole of the kidney. Excretory urogram shows a narrowing in the region of ureteropelvic junction. Specify the treatment tactics:

Explanation

It is stated that there is a 3rd degree hydronephrotic change in the left kidney;  Hydronephrosis is swelling of one or both kidneys (dilation of the renal pelvis and calyces). Kidney swelling happens when urine can't drain from a kidney and builds up in the kidney as a result. There are three degrees of Hydronephrosis: 

 
  • 1st degree (mild)-   moderate renal pelvis dilation with few calyces

  • 2nd degree (moderate)- full renal pelvis dilation involving all calyces

  • 3rd degree (severe)- includes the above signs coupled with thinning of the parenchyma. In severe hydronephrosis, surgery is recommended.

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

Explanation

97. A 15-year-old girl complains of dizziness and sensation of lack of air that she develops in emotionally straining situations. Relief occurs after she takes corvalol. Objectively: hyperhidrosis and marble-like pattern of the skin of her palms and feet. Clinical and instrumental examination revealed no organic alterations of the central nervous, cardiovascular, and respiratory systems. What provisional diagnosis can be made?

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. Notice that this patient experiences these symptoms only during emotional stress, Clinical and instrumental examination revealed no organic alterations in any system therefore indicating a somatoform autonomic dysfunction.
98. A patient with chronic pancreatitis complains of diarrhea occurring up to 5 times per day (no blood traces), loss of body weight, abdominal distention, dryness of skin, loss of hair, thirst, bleeding gums, convulsions. Complete blood count: leukocytes - 5, 8 · 109/l; Hb- 86 g/l; ESR- 15 mm/g; Blood protein test: protein - 48 g/l; albumins - 28 g/l. What indicators of coprological analysis would accompany this syndrom?

Explanation

The pancreas plays a major role in digestion ( its exocrine function). It produces digestive enzymes such as; trypsin and chymotrypsinogen ( for protein digestion), Amylase (for carbohydrate digestion), lipase ( for breakdown of fats). In pathologies relating to the pancreas such as pancreatitis, this function is affected leading to a digestion and absorption issue. For example, due to a disruption in the release of lipase, fat breakdown is negatively affected leading to not enough absorption and its appearance in stool ( steatorrhea). Likewise a disruption in chymotrypsin and trypsin secretion will lead to an abnormal excretion of muscle fibres in faeces (creatorrhea).
99. A 35-year-old patient complains of heartburn, gasseous and sour eructation, burning constricting pain behind the sternum and along the esophagus, developing when bowing the torso to the front. No previous examination; the patient takes almagel at his own discretion, after which he notes improvement of his general state. Make the provisional diagnosis:

Explanation

 

Heartburn, gaseous and sour eructation, burning constricting pain behind the sternum and along the esophagus are signs of a reflux disease, these symptoms are observed due to the backflow of gastric acidic content into the esophagus. One main reason is the inefficient constriction/closing of the lower esophageal sphincter or an overproduction of gastric acid. Note that the patient takes Amagel, an antacid which helps in neutralizing the acidic content.

ulcers occur when the acid in the digestive tract eats away at the lining of the stomach or small intestine, creating irritated or raw spots that can become painful open, bleeding sores.  Some of the symptoms of peptic ulcer disease include burning stomach pain, feeling full quickly, bloating, intolerance to fatty foods, heartburn, and nausea.

100. The left hand of a newborn is extended in all its joints, stretched along the torso, and pronated in the forearm. Active movements of the shoulder joint are retained. The hand is flattened, atrophied, cold to touch, hangs passively. Grasping and Babkin’s reflexes are absent at the affected side. Hemogram indicators are normal. Make the most likely diagnosis:

Explanation

 

An obstetrical paralysis is a form of paralysis that occurs during birth due to an injury to the nerves of the brachial plexus. Observe that the proximal parts of the baby’s arm are with no defect and this pathology affects the distal arm ‘The hand is flattened, atrophied, cold to touch, hangs passively. Grasping and Babkin’s reflexes are absent at the affected side’. This indicates an obstetrical paralysis affecting the distal area of the arm.

Proximal type will affect the proximal muscles of the arm while the complete form will affect all muscles innervated by the brachial plexus.

101. A 34-year-old man is being treated for schizophrenia exacerbation in a psychiatric unit. Objectively: the patient remains in bed, is sluggishly mobile, unresponsive, does not react to questions. His position is unvaried, hypomimic, snout reflex and Dupre’s symptom are present, muscles exhibit waxy flexibility. He has been remaining in this state for approximately a week. Feeding is parenteral. Determine the neuromotor disturbance:

Explanation

 

Schizophrenia is a mental disorder characterised by disturbances in thought and verbal behaviour,perception, motor behaviour and relationship to the external world. The different clinical types include; Paranoid, disorganised/ hebephrenic, Catatonic, residual or latent, undifferentiated schizophrenia. Catatonic schizophrenia is further divided into an excited form and stuporous form. The patient above is said to have a catatonic stupor; this state is characterised by inability to speak, rigidity, maintenance of weird postures; maintained for a long period of time metc. Snout reflex  involves puckering or protrusion of the lips with percussion.

In depressive stupor, the patient will mostly be in a sleepy state, motionless, quiet and have no appetite.

102. A 43-year-old man has undergone a surgery for osteomyelitis of the left thigh. On the 6th day the patient’s condition was complicated with sepsis. Despite complex therapy of sepsis on the 9th day the patient persistently presents with temperature up to 40oC, heart rate is 110/min., respiration rate is 23/min., BP is 100/60 mm Hg. Blood test: leukocytes - 16 · 109/l, band neutrophils - 16%. What phase of clinical course is it?

Explanation

103. A 23-year-old woman presents with diabetes mellitus type 1. She complains of weakness, headache, nausea, and vomiting. Objectively: temperature is 37,6oC, heart rate is 98/min., BP is 95/65 mm Hg, respiration rate is 32/min., loud. Smell of acetone is detected, heart sounds are muffled, pulse is rhythmic. The stomach is sensitive in the epigastrium. Costovertebral angle tenderness (Murphy’s punch sign) is present. Blood glucose is 28,5 mmol/l; blood leukocytes - 16, 5 · 109/l. In urine: acetone ++, leukocytes - 25-40 in the vision field. Blood pH is 7,1. What correction method would be the most advisable?

Explanation

Diabetic ketoacidosis is an emergency medical condition that can be life-threatening if not treated properly. Diabetic ketoacidosis occurs most often in patients with type 1 diabetes (formerly called insulin-dependent diabetes mellitus). Realise that the patient’s blood glucose level is at 28.5 and acetone level is at a high; The major treatment of this condition is initial rehydration (using isotonic saline) with subsequent potassium replacement and low-dose insulin therapy. The use of bicarbonate is not recommended in most patients.
104. A 57-year-old woman complains of a sensation of esophageal compression, palpitations, difficult breathing 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, Ps76/min, BP- 120/80 mm Hg. X-ray study revealed considerable dilation of esophagus and its constriction in the cardial part. What pathology is the 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.
105. A 47-year-old man is employed at the weaving workshop, has 15-year-long record of service at this factory; his work conditions are associated with high-frequency and high-intensity noise. During periodical examination he was diagnosed with occupational deafness. What are the grounds for making such a diagnosis?

Explanation

An audiometry focuses on measuring the hearing acuity ( sharpness), check for variations in pitch, intensity, tones and frequencies.The above patient is diagnosed with occupational deafness ( loss of hearing ability due to work hazards), to put up such diagnosis, an audiometry test is to be carried out coupled with assessing hygienic conditions of his workplace.
106. A 37-year-old woman complains of acute pain in the genital area, swelling of the labia, pain when walking. Objectively: body temperature is 38,7oC, Ps- 98/min. In the interior of the right labia there is a dense, painful tumor-like formation 5,0x4,5 cm in size, the skin and mucous membrane of genitals are hyperemic, there is profuse foul-smelling discharge. What is the most likely diagnosis?

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 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.
107. A woman undergoing in-patient treatment for viral hepatitis type B developed headache, nausea, recurrent vomiting, memory lapses, flapping tremor of her hands, rapid pulse. Sweet smell from the mouth is detected. Body temperature is 37,6oC, heart rate is 89/min. What complication developed in the patient?

Explanation

Acute liver failure is a state of hepatic cells dysfunction, caused by unknown earlier liver disease, resulting in general intoxication, coagulation violations, neurological and mental disorders. Its etiology is usually connected with: viral hepatitis (hepatitis B virus, hepatitis A virus), poisonings (mushrooms, dichloroethane, phosphorus, carbon tetrachloride, arsenic), eclampsia, burn disease, anaesthetic gas, antibiotics, sulfanilamides, massive bacterial pneumonia, cirrhosis, hepatic tumours and metastasis.

 

Advanced liver failure manifests as coma due to the effects of accumulated metabolites on the brain. The patient in question presents with viral hepatitis B ( the probable cause of the liver failure) and a list of other symptoms which indicate neurological and intoxication disorder.

108. A 42-year-old man was delivered to a surgical in-patient department with complaints of icteric skin, pain in the right subcostal area. Biochemical blood analysis: total bilirubin - 140 mcmol/l, direct bilirubin - 112 mcmol/l. On US: choledoch duct - 1,4 cm, a concrement is detected in the distal area. Gallbladder is 40 cm, no concrements. What treatment tactics should be chosen?

Explanation

The above patient presents with signs of liver/ gallbladder pathology. From ultrasound results, we can conclude that a stone is present in the bile duct (distal part) and NOT the gallbladder. With this result, a cholecystectomy is ruled out and the preferred treatment tactics is Endoscopic papilla sphincterotomy which is a procedure used for the removal of bile duct stones. Endoscopic papilla sphincterotomy is a procedure indicated to treat of disorders of the papilla of Vater ( sphincter of oddi) or to facilitate diagnostic and therapeutic procedures in patients with biliary diseases.  
109. 4 weeks after myocardial infarction a 56- year-old patient developed acute heart pain, marked dyspnea. Objectively: the patient’s condition is extremely grave, there is marked cyanosis of face, swelling and throbbing of neck veins, peripheral pulse is absent, the carotid artery pulse is rhythmic, 130/min., BP is 60/20 mm Hg. Auscultation of the heart reveals extremely muffled sounds, percussion reveals heart border extension in both directions. What is the optimal treatment tactics for this patient?

Explanation

 

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

A thoracotomy can be carried out to gain access to the pleural cavity.

110. A 44-year-old patient with postinfarction cardiosclerosis presents with frequent heart rate disorders and lower extremity edema. Objectively: Ps- 95/min., irregular, 10-12 extrasystoles per minute. BP- 135/90 mm Hg. The 1st heart sound at the apex is weakened. Pulmonary respiration is rough. The liver is enlarged +2 cm. ECG: irregular sinus rhythm, heart rate - 95/min, frequent polytopic ventricular extrasystoles.What antiarrhythmic drug is advisable in this case for treatment and prevention of extrasystole?

Explanation

 Realize that the patient experiences about 10-12 extrasystoles per minute, irregular sinus rhythm with a heart rate of 95bpm, frequent polytopic ventricular extrasystoles. 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.

 

Lidocaine,mexiletine, novocaine and quinidine are all class I drugs ( sodium channel blockers) They basically affect conduction ( QRS complex) and have little or no effect on sinus rhythm.

111. A 60 year-old woman has been suffering from weakness, dizziness, and fatigue over the last year. Recently she has also developed dyspnea, paresthesia. Objectively: the skin and mucous membranes are pale and slightly icteric. The tongue is smooth due to the loss of lingual papillae. Liver and spleen are located at the costal margin. Blood count: Hb- 70 g/l, RBC- 1, 7·1012/l, color index - 1,2, macrocytes. Administer the patient a pathogenetically justified drug:

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.

 

Ascorbic acid or vitamin C deficiency will lead to scurvy, petechial bleeding or bruises are common in this case.

112. After excessive consumption of fatty food a 60-year-old woman suddenly developed pain in her right subcostal area, nausea, bile vomiting, sharp bitter taste in her mouth. In 2 days she developed jaundice, her urine darkened. Objectively: sclera and skin are icteric, the abdomen is distended, the liver is enlarged by 3 cm, soft and painful on palpation, Ortner’s, Murphy’s, Kehr’s, Zakharyin’s, Mayo-Robson’s signs are positive. What diagnostic technique should be used in the first place?

Explanation

Ortner’s sign- tenderness on light percussion on right costal margin by the edge of the palm

Murphy’s sign- a delay of breathing during palpation of gallbladder on inspiration

Kehr’s point- acute pain at the tip of the shoulder

Coupled with the positive result and the above stated signs, the patient also  experienced bile vomiting, sharp bitter taste in her mouth, jaundice etc. These are signs specific for pathologies relating to either the gallbladder or liver.Therefore to confirm, the individual should undergo an ultrasound.

 

A fibrogastrodudenoscopy will be the preferred choice of diagnostic method if it was a Gastrointestinal tract related issue.

113. A 42-year-old woman working at a poultry farm complains of dyspnea, thoracic pain on the left, increased body temperature up to 38- 39oC in the evening, and cough. The patient suffers from essential hypertension. Objectively: vesicular respiration in the lungs, vesicular resonance without alterations. X-ray of both lungs reveals numerous small lowintensity foci, 2-3 mm in size, located in a row along the blood vessels. ESR- 32 mm/hour. What is the most likely diagnosis?

Explanation

Disseminated lung tuberculosis is a clinical form of tuberculosis that arises as a result of lympho-haematogenous spreading of infection and is characterized by bilateral, symmetric nidal injury with predominant localization in upper, subcortical lung sections.

 

Observe that on X-ray examination of both lungs there presented numerous small low intensity foci, 2-3 mm in size, located in a row along the blood vessels.

114. A 65-year-old patient has been suffering from liver cirrhosis associated with hepatitis C virus for 7 years. During the last 3 weeks the patient developed severe edema of the lower extremities, the abdomen is significantly distended with fluid. Ultrasound: signs of liver cirrhosis, portal hypertension, lymph nodes are in the area of hepatic portal. Concentration of α-fetoprotein in blood serum is 285 ng/ml. What complication could have developed in this case?

Explanation

 

Note that hepatocellular carcinoma is the most common primary liver cancer. It usually occurs in patients with liver cirrhosis problems usually caused by hepatitis B or C. Alpha fetoprotein is a  tumor marker; it’s elevation indicates tumors such as: Hepatocellular carcinoma, Metastatic disease affecting the liver, Nonseminomatous germ cell tumors, Yolk sac tumor. In pregnant women, it also helps in diagnosing abnormal development such as aneuploidy, neural tube defects etc.

Hepatocellular insufficiency is also termed acute liver failure. In this pathology, lots of metabolites are accumulated in the body ( due to liver's failure in neutralizing them). A key finding can be hepatic encephalopathy ( caused by the toxic effect of such metabolites eg. ammonia on the brain).

115. A 46-year-old woman has been hospitalized with open fracture of the left thigh in its middle third. She underwent the surgery - fixation with extraosseous osteosynthesis plates. On the 4th day after the surgery she developed pain in the wound, body temperature rose over 39oC. What measures should be taken in this case?

Explanation

The Presence of an increased body temperature and pain a few days after the wound closure indicates ‘An Infection’ - most likely a bacterial form. To correct this, the sutures/wound dressing should be undone,  drained ( if there be any purulent process), an antiseptic should be used in cleaning the affected area coupled with the administration of an antibiotic therapy to the patient.
116. A multigravida on the 38th week of her pregnancy complains of increased BP up to 140/90 mm Hg, edema of the shins for 2 weeks. In the last month she gained 3,5 kg of weight. Urine analysis: protein - 0,033 g/l. Make the diagnosis:

Explanation

Preeclampsia, a pregnancy-specific condition in which hypertension develops after 20 weeks of gestation in a previously normotensive woman. It is characterized by hemoconcentration, hypertension, and proteinuria. The following are the differences between a mild and severe Preeclampsia:  

MIld Preeclampsia

Severe Preeclampsia

BP reading of 140/90 mm Hg twice, 4-6 hr apart

Proteinuria of 0.3 g/L in a 24 hr specimen or >0.1 g/L in a random day-time specimen on two or more occasions 6 hr apart

Dependent edema, some puffiness of eyes, face, fingers; pulmonary edema absent

Output matching intake, ≥30 ml/hr or <650 ml/24 hr

Rise to >160/110 mm Hg on two separate occasions 4-6 hr apart with pregnant woman on bed rest

Proteinuria of >0.5 g/L in 24 hr

Generalized edema, noticeable puffiness; eyes, face, fingers; pulmonary edema possibly present

<20 ml/hr or <400 ml to 500 ml/24 hr

 
117. A 28-year-old woman complains of increased intervals between menstruations, up to 2 months, and hirsutism. Gynecological examination revealed the following: ovaries are enlarged, painless, and dense; no alterations of the uterus. US of the lesser pelvis: ovaries are 4-5 cm in diameter, with numerous enlarged follicles on the periphery. X-ray of the skull base: sellar region is widened. What is the most likely diagnosis?

Explanation

Polycystic ovarian syndrome is a disorder found in women of reproductive age commonly due to hormonal disorder (high level of androgens). This disorder is characterised by infrequent menstrual cycle, pelvic pain, weight gain 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.

118. Posture of an 11-year-old boy was determined during preventive examination. The child presents with curled forward rounded shoulders, the head is bowed forward, the thorax is flattened, the stomach is bulging. In the vertebral column there are deepened cervical and lumbar flexures. What posture does the child have?

Explanation

 

Lordosis, kyphosis, and scoliosis refer to curvatures of the spine. Lordosis refers to the excessive inward curvatures of the spine at the cervical and lumbar regions, while kyphosis refers to the excessive outward curvature of the spine specifically at the thoracic region. Scoliosis refers to the abnormal sideways curves of the spine.

119. A patient has the second and third degree burns of the 15% of the body surface. On the 20th day after the trauma the patient presents with sharp increase of body temperature, general weakness, rapid vesicular respiration; facial features are sharpened, BP is 90/50 mm Hg, heart rate is 112/min. What complication is it?

Explanation

Sepsis is a life-threatening organ dysfunction caused by a dysregulated host response to infection. 

It can be clinically assessed when there is Fever (>38*C); Respiratory rate >22cpm; Tachycardia >100bpm; Systolic BP <100mmHg; altered consciousness.

 

Sepsis is a common complication when there is overwhelming infection. In this case, it is a complication of burns injury (presents 20th day after the trauma).

120. A 30-year-old woman complains of amenorrhea that lasts for 2 years after she has given birth, loss of hair and body weight. The labor was complicated with hemorrhage caused by uterine hypotonia. Objectively the patient is of asthenic type, her external genitalia are hypoplastic, the uterine body is small in size and painless. No uterine appendages can be detected. What is the most likely 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. 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.

121. On laboratory investigation of a pork sample there is 1 dead trichinella detected in 24 sections. This meat should be:

Explanation

 

The meat is infected by Trichinella and should be properly disposed. consumption of this meat will lead to trichinosis.

122. Examination of a 43-year-old man objectively revealed pallor of skin and mucous membranes, loss of tongue papillae, transverse striation of fingernails, cracks in the mouth corners, tachycardia. Blood test results: Hb- 90 g/l, anisocytosis, poikilocytosis. The most likely causative factor of this condition is the inadequate intake of:

Explanation

 

A person with insufficient iron in the blood will experience symptoms such as; fatigue, headaches, temperature sensitivity, heart palpitations, cold hands and feet, pallor of mucous membrane, cracks on the side of the mouth, inflammation of the tongue, brittle nails etc. These patients also experience an iron deficiency anemia which is characterised by a reduction in hemoglobin level and color index.

123. A 52-year-old woman presents with affected mucosa in the mouth angles where fissures, erosions, and ulcers develop; vertical fissures appear on the lips during their closing (cheilosis); there are tongue alterations (glossitis), angular stomatitis, seborrheic dermatitis around the mouth and wings of the nose, and pericorneal injection. The listed symptoms are characteristic of:

Explanation

The signs and symptoms of riboflavin (vitamin B2) deficiency typically include sore throat with redness and swelling of the mouth and throat mucosa, cheilosis and angular stomatitis (cracking of the lips and corners of the mouth), glossitis, seborrheic dermatitis or pseudo-syphilis, and a decreased red blood cell count with normal cell size and hemoglobin content (normochromic normocytic anemia).

 

Thiamine (vit B1) deficiency is known an as Beri-beri, Vitamin C - Scurvy , Vitamin A - night blindness.

124. Two days ago a woman fell from the height of 1,5 m. She complains of severe thoracic pain on the left and dyspnea. Chest X-ray reveals hydropneumothorax on the left with fluid level at the 7th rib and the lung collapsed by 1/3. The 6th-7th ribs are fractured along the scapular line. Serohemorrhagic fluid was obtained during thoracic puncture. What treatment tactics should be chosen?

Explanation

Thoracocentesis is a procedure in which a needle is inserted into the pleural space to remove fluid or air. The Chest X-ray reveals hydropneumothorax on the left with fluid level at the 7th rib; therefore a thoracocentesis should be carried out here to evacuate the air and fluid.

 
125. A patient complains of suppuration from the ear and impaired hearing of the left ear, which have been observed for the past 6 years. The patient had periodical headaches, general indisposition, fever. Objectively: otoscopy of the external auditory meatus revealed mucopurulent odorless substance. The eardrum is of normal color, with central perforation. What is the most likely diagnosis?

Explanation

126. In 2 hours after a traffic accident a 28-yearold man in grave condition was delivered to a hospital. The patient complains of abdominal pain. He received a blow to the abdomen with the steering wheel. Objective examination revealed the following: the abdomen does not participate in respiration, is tense and acutely painful on palpation; the abdominal muscles are defensively tense, peritoneal irritation signs are positive, hepatic dullness is absent. BP is 90/60 mm Hg, heart rate is 120/min. What further treatment tactics should be chosen?

Explanation

Laparotomy: is a surgical incision of the abdominal cavity performed to examine the abdominal organs and aid diagnosis. Indications include: abdominal hemorrhage or hemoperitoneum, blunt chest trauma, peritonitis, intestinal obstruction etc and is contraindicated in cases of severe sepsis and malignancy.

Laparoscopy: A surgical procedure in which the abdominal organs are observed with the use of a laparoscope (a camera). Unlike a laparotomy, it uses small incisions. It is also known as a keyhole surgery or minimal invasive surgery. Indications include: Cholecystectomy, gastric bypass. 

Laparocentesis: is simply the puncture of the peritoneal cavity to obtain its fluid.

 

Realize that the above patient received a blow to the abdomen with the steering wheel- which indicates a blunt trauma; peritoneal irritation signs are positive- an indication for peritonitis.

127. From urine of a 14-year-old boy with the exacerbation of secondary obstructive pyelonephritis Pseudomonas aeruginosa was isolated with a titer of 1000000 microbes per 1 ml. What antibiotic is the most advisable in this case?

Explanation

Pseudomonas aeruginosa , an encapsulated, Gram-negative, rod-shaped bacterium is resistant to a wide range of antibiotics; from the listed drugs, Ciprofloxacin ( a quinolone) is the best choice. Other possible drugs include gentamicin, carbenicillin, carbapenems etc.
128. A 20-year-old woman on the 10th day after her discharge from the maternity ward developed fever up to 39oC and pain in her left mammary gland. On examination the mammary gland is enlarged, in its upper outer quadrant there is a hyperemic area. In this area a dense spot with blurred margins can be palpated. The patient presents with lactostasis and no fluctuation. Lymph nodes in the right axillary crease are enlarged and painful. Specify the correct diagnosis:

Explanation

Realise that the patient’s breasts are swollen, hyperemic and painful on palpation and this occurs a few days after discharge from the maternity ward; this is a case of lactational mastitis which refers to a woman’s breast becoming swollen, red and painful during lactation. It occurs due to breast trauma, poor milk drainage (as seen in this case ‘lactostasis’) etc.
129. A 3-year-old girl is being treated at a resuscitation unit with diagnosis ”acute kidney failure, oligoanuric stage”. ECG: high T wave, extended QRS complex, displacement of S-T interval downwards below the isoline. What electrolyte imbalance is it?

Explanation

On ECG, hyperkalemia is characterised by a tall, peaked T wave, ST segment depression, shortened QT interval, widening of QRS. For Hypokalemia, we observe; flat or inverted T wave,prolongation of QT interval, appearance of a U wave in some cases ets. Patients with blood calcium level changes will experience a change in heart rate; Tachychardia in Hypercalcemia and Bradycardia in hypocalcemia.
130. Mother of an 8-year-old girl complains that the child is too short and has excessive body weight. Objectively: obesity with fat deposits on the torso and face (round moonlike face), acne, striae on the thighs and lower abdomen, hirsutism. What hormone can cause such symptoms, when in excess?

Explanation

“A round moon-like Face” is a term used to describe an individual with Cushing’s syndrome. Occurs when the body produces an increased amount of cortisol ( a hormone produced from the zona fasciculata of the adrenal cortex). Symptoms include;  abdominal obesity but with thin arms and legs, reddish stretch marks, a round red face, a fat lump between the shoulders ( buffalo hump), weak muscles, weak bones, acne, hirsutism.
131. A 9-year-old girl complains of fever up to 37,5oC, headache, inertness, weakness, loss of appetite, stomachache, and frequent painful urination. Provisional diagnosis of acute pyelonephritis is made. Clinical urine analysis: specific gravity - 1018, no protein, leukocytes - 10-15 in the vision field. What investigation method can verify the diagnosis of urinary system infection?

Explanation

Pyelonephritis is a Urinary tract infection mostly caused by bacteria and leads to an inflammatory process in the kidneys. Can be caused by E.coli, klebsiella, pseudomonas and is being accompanied by symptoms such as fever, frequent urination and pain during urination etc. In the patient described above, for confirmation of the causative agent, a sample of the patient’s urine is collected; a bacteria specimen is obtained from it ( unknown bacteria). It is then introduced into a culture ( inoculation) where they can grow and multiply. N/B various microorganisms have specific culture mediums.
132. During assessment of work conditions at the mercury thermometer manufacture, content of mercury vapors in the air of working area is revealed to exceed maximum concentration limit. Specify the main way of mercury penetration into the body:

Explanation

Realize that the question indicates “content of mercury vapors in the air of the working area”. Since the mercury is in vaporized form, the route of entry will be through the respiratory organs.
133. During health assessment of car drivers and police officers on point duty, the physicians detected carboxyhemoglobin in the blood of the patients, weakened reflex responses, disturbed activity of a number of enzymes. Revealed professional health disorders are most likely to be associated with the effect of:

Explanation

Hemoglobin is responsible for the transport of oxygen in blood. It binds to oxygen molecules forming Oxyhemoglobin. In the presence of carbon monoxide CO, carbon attaches to hemoglobin (dissociates oxygen) forming carboxyhemoglobin thereby leading to a reduction in oxygen transport. In CO2 poisoning, Carbhemoglobin will be the complex formed.
134. On the 3rd day of life a newborn, who had suffered birth asphyxia, developed hemorrhage from the umbilical wound. Laboratory analysis reveals hypocoagulation, thrombocytopenia, and hypothrombinemia. What is the cause of such clinical developments?

Explanation

Disseminated intravascular coagulation is a pathology that involves the widespread activation of clotting factors leading to a deficiency in clotting factors and a bleeding state. Notice that the newborn experiences  hypocoagulation, thrombocytopenia, and hypothrombinemia which are classical signs found in DIC. This pathology can be triggered by sepsis, acute pancreatitis etc. thrombocytopenic purpura is a clinical syndrome in which a decreased number of circulating platelets (thrombocytopenia) present as a bleeding tendency, easy bruising (purpura), or extravasation of blood from capillaries into skin and mucous membranes (petechiae)
135. A 46-year-old woman came to a maternity clinic with complaints of moderate blood discharge from the vagina, which developed after the menstruation delay of 1,5 months. On vaginal examination: the cervix is clean; the uterus is not enlarged, mobile, painless; appendages without changes. Make the diagnosis:

Explanation

A dysfunctional uterine bleeding (DUB) is the bleeding, not associated with organic diseases of women’s genitals, interrupted pregnancy or systemic diseases of the organism.

 

The dysfunctional uterine bleeding can appear at any age. Depending on the time of their onset, juvenile bleeding (at child age and in period of pubescence), bleeding of reproductive period, climacteric bleeding are classified. DUB are the manifestations of initial stages of neuroendocrinological diseases, especially of blood diseases. Realise that from physical examination the cervix is clean, the uterus is not enlarged and shows no pathologic changes.

136. An infant is 2,5 months old. The onset of the disease was gradual, the child had normal body temperature but presented with slight cough. Within a week the cough intensified, especially at night; on the 12th day the child developed cough fits occurring up to 20 times per day and followed by vomiting. There was one instance of respiratory arrest. Make the diagnosis:

Explanation

The prostate is the largest accessory gland in the male reproductive system.

It secretes proteolytic enzymes into the semen, which act to break down clotting factors in the ejaculate. This allows the semen to remain in a fluid state, moving throughout the female reproductive tract for potential fertilisation.

Anatomically, it is positioned inferiorly to the neck of the bladder and superiorly to the external urethral sphincter. Therefore, an enlarged prostate gland will cause urinary retention and disturb the outflow of urine (weak flow of urine and usually painful).

Prostate cancer is most common in adult males and usually asymptomatic until advanced stage. Patients with prostate cancer commonly presented with symptoms that included urinary complaints or retention, back pain, and hematuria.

The findings on digital rectal examination (DRE) indicates malignancy - enlarged; asymmetrical; central fissure is smoothed out. These points to prostate cancer.

Prostate Specific Antigen (PSA) is a useful tumor maker. 

PSA > 10ng/dL is worrisome at any age

1-4: norm

 

5-10: borderline

137. Vaginal examination reveals the head of the fetus, which fills the posterior surface of symphysis pubis and hollow of the sacrum. The lower edge of symphysis pubis, ischiadic spines, and sacrococcygeal joint can be palpated. Where in the lesser pelvis is the fetal head situated?

Explanation

138. A man works in casting of nonferrous metals and alloys for 12 years. In the air of working area there was registered high content of heavy metals, carbon monoxide, and nitrogen. During periodic health examination the patient presents with asthenovegetative syndrome, sharp pains in the stomach, constipations, pain in the hepatic area. In urine: aminolevulinic acid and coproporphyrin are detected. In blood: reticulocytosis, low hemoglobin level. Such intoxication is caused by:

Explanation

Aminolevulinic acid and coproporphyrin are amino acids necessary for the synthesis of Heme. The excretion of these constituents in urine indicates either an inherited or secondary Porphyria. One of the most frequent causes of the secondary form of this disease is Lead poisoning. An increased degradation of porphyrin will lead to a decrease in Hemoglobin synthesis. Also note that the patient experiences Asthenovegetative syndrome ( physical and nervous fatigue), pain in the hepatic area and stomach; these are classical signs of Lead poisoning.

 

Carbon monoxide poisoning will be characterised by headache, lethargy, dizziness, loss of consciousness etc.

139. A 30-year-old multigravida has been in labour for 18 hours. 2 hours ago the pushing stage began. Fetal heart rate is clear, rhythmic, 136/min. Vaginal examination reveals complete cervical dilatation, the fetal head in the pelvic outlet plane. Sagittal suture is in line with obstetric conjugate, the occipital fontanel is near the pubis. The patient has been diagnosed with primary uterine inertia. What is the further tactics of labour management?

Explanation

UTERINE INERTIA  (“Failure to progress”, hypotonic uterine dysfunction) describes lack of progressive cervical dilatation and/or descent of the fetus.  It is such a condition in which uterine contractions strength, duration and frequency are inadequate, that’s why cervical effacement, dilation and fetal descending is slower than in normal labor. Since the baby’s head is already in the pelvic outlet plane and cant proceed further due to inadequate contractions, an outlet forceps is used in assisting delivery.

 

Labour stimulation will occur in situations such as preeclampsia, eclampsia, diabetes, premature rupture of membranes etc. Cesarean session in cases of breech or fetal distress.

140. A patient, who had eaten canned mushrooms (honey agaric) three days ago, developed vision impairment (diplopia, mydriasis), speech disorder, disturbed swallowing. What type of food poisoning occurred in the patient?

Explanation

 

Botulism is an illness caused by Botulinum toxin , a toxin produced by Clostridium Botulinum ( a gram positive, spore forming, anaerobic bacteria). Foodborne botulism is gotten from eating infected food especially canned food. Symptoms include; disturbed vision (diplopia), flaccid paralysis, dysphagia, dyspnea etc. It is treated with Botulinum antitoxin.

141. An infant is 3 weeks old. Since birth there has been observed periodical vomiting within a few minutes after feeding. The amount of vomitive masses does not exceed the volume of previous feeding. The infant has age-appropriate body weight. What is the most likely cause of this symptom?

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.

142. A newborn with gestational age of 31 weeks presents with hypotonia and depressed consciousness. Hematocrit is 35%, general cerebrospinal fluid analysis shows increased content of erythrocytes and protein, and low glucose. These data correspond with the clinical presentation of:

Explanation

 

An increased content of Erythrocytes in CSF findings indicates “ intracranial hemorrhage”. Presence of protein and low glucose in CSF are not specific and can indicate pathologies such as an infarct, meningitis, sepsis etc.  Hypertonia and depressed consciousness are also general signs and can be found in any of the above pathology.

143. A 50-year-old patient was delivered to a hospital with complaints of blood traces in urine. Urination is painless and undisturbed. Macrohematuria had been observed for 3 days. Objectively: kidneys cannot be palpated, suprapubic area is without alterations, external genitalia are non-pathologic. On rectal investigation: prostate is not enlarged, painless, has normal structure. Cystoscopy revealed no alterations. What is the most likely diagnosis?

Explanation

Renal Cell Carcinoma is most common in men 50-70 years old. It manifests clinically with the classic triad of flank pain, hematuria, and flank mass. There could also be secondary polycythemia; fever and weight loss.

From the question stem:

Supra public area is without alteration and no abnormal findings on cystoscopy (i.e. no problem with the urinary bladder).

External genitalia and prostate - no abnormal findings.

So the best option here associated with hematuria (blood traces in urine) is Renal carcinoma.

144. A man complains of constant dull pain in the perineum and suprapubic area, weak flow of urine, frequent difficult painful urination, nocturia. The patient has been suffering from this condition for several months, during which urination was becoming increasingly difficult, and pain in the perineum has developed. On rectal examination: the prostate is enlarged (mainly its right lobe), dense, asymmetrical, central fissure is smoothed out, the right lobe is of stony density, painless, tuberous. What disease is it?

Explanation

The prostate is the largest accessory gland in the male reproductive system.

It secretes proteolytic enzymes into the semen, which act to break down clotting factors in the ejaculate. This allows the semen to remain in a fluid state, moving throughout the female reproductive tract for potential fertilisation.

Anatomically, it is positioned inferiorly to the neck of the bladder and superiorly to the external urethral sphincter. Therefore, an enlarged prostate gland will cause urinary retention and disturb the outflow of urine (weak flow of urine and usually painful).

Prostate cancer is most common in adult males and usually asymptomatic until advanced stage. Patients with prostate cancer commonly presented with symptoms that included urinary complaints or retention, back pain, and hematuria.

The findings on digital rectal examination (DRE) indicates malignancy - enlarged; asymmetrical; central fissure is smoothed out. These points to prostate cancer.

Prostate Specific Antigen (PSA) is a useful tumor maker. 

PSA > 10ng/dL is worrisome at any age

1-4: norm

 

5-10: borderline

145. A boy was born at 32 weeks of gestation. 2 hours after the birth he developed respiratory distress (RD). The RD severity assessed by Silverman score was 5. The respiratory disorders progressed, respiratory failure could not be eliminated by Martin-Bouyer CPAP (continuous positive airway pressure). X-ray of lungs shows reticular and nodular pattern, air bronchogram. What is the most likely cause of respiratory distress syndrome?

Explanation

Hyaline membrane disease is observed in Respiratory distress disorder. Usually found in premature infants, a membrane made up of proteins and dead cells lines the alveoli, making gas exchange difficult.
146. An 8-year-old child with a 3-year-long history of diabetes was hospitalized in hyperglycemic coma. Specify the initial dose of insulin to be administered:

Explanation

Initial intravenous administration of 10 to 14 units of short-acting insulin has to be prescribed for the patient during the first hour. Continuous intravenous infusion of insulin in a dose 0,1 unit/kg/hour in 0,9 % sodium chloride infusion has to be given after that.
147. A 17-year-old young man complains of general weakness, trismus, twitching of the muscles in his left shin. 7 days ago he pierced his foot with a nail. Objectively: at the sole of the foot there is a wound, 0,3х0,2 mm in size, with small amount of serous-purulent discharge, the skin around the wound is hyperemic. What is the most likely diagnosis?

Explanation

 

The injury from 7 days ago has been infected by clostridium tetani; the causative agent of tetanus. Notice that the patient experiences Trismus (lockjaw) which is a major indication of a tetanus infection.

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.

148. A patient with trauma of the lower third of the forearm volar surface caused by a glass shard came to a first-aid center. Objectively: flexion of the IV and V fingers is impaired, sensitivity of the inner dorsal and palmar surfaces of the hand and IV finger is decreased. What nerve is damaged?

Explanation

 Ulnar Nerve: Sensory innervation to the Fifth and medial half of the fourth digits; Motor innervation: flexion, adduction and abduction of 4th and 5th digits. Injury to this nerve causes Claw hand 

Median Nerve: innervates the skin of the palmar side of the index finger, thumb, middle finger, and half the ring finger, and the nail bed; motor innervation: flexion of lateral fingers, thumb opposition, lumbricals of index and middle fingers. Injured in Carpal Tunnel syndrome and leads to ape’s hand.

 

Radial Nerve: Sensory innervation to the dorsum (back) of the hand except the little finger (supplied  by ulnar). Motor innervation to the dorsum of the hand. Injury leads to loss of grip strength, wrist drop.

149. A 58-year-old patient complains of pain in the lower left extremity, which aggravates during walking, sensation of cold and numbness in the both feet. The patient has been suffering from this condition for 6 years. Objectively: the skin is pale and dry, with hyperkeratosis. On the left shin hair is scarce, ”furrow” symptom of inflamed inguinal lymph nodes is positive. Pulse cannot be detected over the pedal and popliteal arteries and is weakened over the femoral artery. In the right limb popliteal artery pulsation is retained. What is the most likely diagnosis?

Explanation

Notice that, there was no pulse detected over the pedal and popliteal arteries. This is a classic sign of ‘atherosclerosis obliterans’ a peripheral artery disease caused by occlusion of a major,medium or small sized artery ( in this case of the lower left extremity). 

Obliterating endarteritis is an inflammation that takes place in the inner lining of an artery (intima); it is seen in complications in relation to infections such as tuberculous meningitis, syphilis or in severe radiation poisoning.

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

Explanation

Pneumonia is a form of acute respiratory infection that affects the lungs. Pneumonia is caused by a number of infectious agents, including viruses, bacteria and fungi. Often characterized with cough; difficulty in breathing (dyspnea) and fever.

The lungs are made up of small sacs called alveoli, which fill with air when a healthy person breathes. When an individual has pneumonia, the alveoli are filled with pus and fluid, which makes breathing painful and limits oxygen intake.

A healthy lung will produce a tympanic sound on percussion as a result of the air in the alveoli. However, there will be percussion dullness when the alveoli is filled with pus and fluid. Crackles on auscultation of the lung also indicates fluid in the alveoli.

151. The mother of a 3-month-old child came to a family doctor with complaints of her child being physically underdeveloped and suffering from cough attacks and dyspnea. Anamnesis: the child is the result of the second full-term pregnancy with the risk of miscarriage (the first child died of pulmonary pathology at the age of 4 months, according to the mother). Body mass at birth is 2500 g. Cough attacks were observed from the fi- rst days of life, twice the child was treated for bronchitis. Considering the severity of the child’s condition the doctor made the referral for hospitalization. What diagnosis was most likely stated in the referral?

Explanation

Cystic fibrosis (Mucoviscidosis) is an inherited disorder that results in a buildup of thick and sticky mucus in the lungs, airways, and other organs. Excess mucus in the lungs can lead to coughing, breathing problems, scarring (fibrosis), and an increased risk of lung infections. There is no cure, but treatments can improve both the length and quality of life for people with the disease.

Cystic fibrosis is caused by mutations in the gene that encodes the cystic fibrosis transmembrane conductance regulator (CFTR). This protein functions as a channel across the membrane of cells that produce mucus, sweat, saliva, tears, and digestive enzymes. 

From the history, the mother already had a child that died of a pulmonary pathology (inherited disorder) and the recurrent infections (bronchitis) all points to Cystic Fibrosis.

 

All other options given are not hereditary.

152. A 46-year-old man notes swollen legs, weakness, sensation of fullness and heaviness in the right subcostal area; it is the first occurrence of these signs in the patient. The patient has 20-year-long history of rheumatoid arthritis. The liver and spleen are enlarged and dense. Blood creatinine - 0,23 mmol/l, proteinemia - 68 g/l, cholesterol - 4,2 mmol/l, urine specific gravity - 1012, proteinuria - 3,3 g/l, isolated wax-like cylinders, leached erythrocytes in the vision field, leukocytes - 5-6 in the vision field. What is the most likely complication?

Explanation

Amyloidosis refers to a number of protein deposition diseases in which normal or variant forms of proteins aggregate and form insoluble fibrils.The most common clinical manifestations of amyloidosis is nephrotic syndrome with or without renal impairment, heart failure, sensomotor and / or peripheral neuropathy and hepatomegaly. The special features of renal amyloidosis include rare hematuria and leukocyturia. Notice that the patient experiences proteinuria, hematuria and leukocyturia on the background of rheumatoid arthritis which are signs of a secondary renal amyloidosis ( specifically known as a Reactive Amyloid A Amyloidosis).

 
153. A 23-year-old man had taken 1 g of aspirin to treat acute respiratory infection. After that he developed an asthmatic fit with labored expiration that was arrested by introduction of aminophylline. The patient has no medical history of allergies. The patient has undergone two surgeries for nasal polyposis in the past. What is the most likely diagnosis?

Explanation

 

Note that the patient has no history of allergy, no infection or strenuous activity were mentioned; these rule out the options of atopic, infectious allergic and exercise induced asthma respectively. Aspirin induced asthma presents with three Keys; An Asthmatic reaction, intake of aspirin  or a NSAIDs and presence of nasal polyps (all of which are present in the above case). The disorder is thought to be caused by an anomaly in the arachidonic acid metabolizing cascade. When medications such as NSAIDs or aspirin block the COX-1 enzyme, production of thromboxane and some anti-inflammatory prostaglandins is decreased, and in patients with aspirin-induced asthma, this results in the overproduction of pro-inflammatory leukotrienes ( especially cysteinyl leukotrienes), which can cause severe exacerbations of asthma and allergy-like symptoms.

154. 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: the 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 by 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.
155. For three years a 31-year-old woman has been complaining of pain and swelling of her radiocarpal and metacarpophalangeal articulations, their reduced mobility in the morning, which persisted up to 1,5 hours. Two weeks ago she developed pain, swelling, and reddening of her knee joints, her body temperature increased up to 37,5oC. The treatment was belated. Examination of the internal organs revealed no pathologic alterations. Diagnosis of rheumatoid arthritis was made. What alterations are the most likely to be visible on the arthrogram?

Explanation

The question stem clearly states that the patient has been diagnosed with Rheumatoid Arthritis.

So basically, we need to differentiate Rheumatoid Arthritis and Osteoarthritis so that we can arrive at the correct answer specific for Rheumatoid Arthritis.

 

RA: autoimmune which erodes articulated cartilage and bone. The inflammatory cells and cytokines then induce pannus (proliferative granulation tissue) formation, deep usurations.

Associated with pain, swelling and morning stiffness, lasting >1hr and the pain improves with use.

Joint findings: joint space narrowing; erosions; juxtaarticular osteopenia; soft tissue swelling; subchondral cysts

Involves Metacarpophalangeal joints; wrist; proximal interphalangeal joints. Does not affect distal interphalangeal joints on the hands

 

OA: mechanical wear and tear - it’s a degenerative joint disease.

Associated with Pain in weight bearing joints after use (i.e. at the end of the day), and the pain improves with rest.

Joint findings: joint space narrowing; osteophytes (bone spurs); subchondral sclerosis and cysts.

Involves distal interphalangeal joints on the hands (heberden nodes) and Proximal interphalangeal joints (Bouchard nodes); does not affect Metacarpophalangeal joints.

 

So let’s answer the question:

From the question stem - Radiocarpal (wrist joints); metacarpophalangeal joints were affected with morning stiffness lasting >1.5hrs

These are clearly signs and symptoms of Rheumatoid Arthritis...

 

From the options it is clear that the only option talking about RA is joint space narrowing; usuration 

 

The other options are talking about Osteoarthritis.

 
156. 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. Ps- 100/min, BP110/70 mm Hg. There are no alterations of internal organs. Blood test results: RBC3, 0 · 1012/l, Нb- 92 g/l, color index - 0,9, anisocytosis, poikilocytosis, WBC- 10 · 109/l, eosinophils - 2%, stab neutrophils - 12%, segmented neutrophils - 68%, lymphocytes - 11%, monocytes - 7%, ESR- 12 mm/h. What laboratory test should be performed additionally to make the 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.

157. After tonsillectomy a woman with systemic lupus erythematosus, who has been taking prednisolone for a year, developed acute weakness, nausea, vomiting, pain in the right iliac area, watery stool up to 5 times per day. Ps- 96/min., BP- 80/50 mm Hg. What preventive therapy should have been administered prior to the surgery?

Explanation

 

The above patient is experiencing Postoperative nausea and vomiting; since she is already on prednisolone medication, an increased dose of this drug would be the best possible means of prevention. Note that prednisolone is a glucocorticoid and has immunosuppressive,antipyretic and antiinflammatory effects; it also possesses a direct antiemetic ( stops vomiting ) effect.

158. A 45-year-old woman complains of paroxysmal intolerable facial pain on the left with attacks that last for 1-2 minutes. Attacks are provoked by chewing. The disease onset was two month ago after overexposure to cold. Objectively: pain at the exit points of the trigeminal nerve on the left. Touching near the wing of nose on the left induces new pain attack with tonic spasm of the facial muscles. What is the most likely diagnosis among those listed?

Explanation

Trigeminal Neuralgia is a condition which produces repetitive,unilateral, shooting/shot-like pain in the areas innervated by the trigeminal nerve ( the face). It is triggered by chewing, talking or touching certain parts of the face. Typically lasts for seconds to minutes but episodes often increase in intensity and frequency over time.

Recall that the trigeminal nerve, CV is a mixed type of nerve, has 3 major branches;

V1 (ophthalmic), V2( Maxillar), V3(mandibular). This nerve is responsible for mastication, facial sensation, somatosensation from anterior ⅔ of the tongue, and innervates the tensor tympani.

 
159. A 28-year-old man complains of skin rash and itching on the both of his hands. The condition persists for 1,5 years. The exacerbation of his condition he ascribes to the occupational contact with formaldehyde resins. Objectively: lesion foci are symmetrically localized on both hands. Against the background of erythema with blurred margins there are papulae, vesicles, erosions, crusts, and scales. What is the most likely pathology?

Explanation

Eczema (dermatitis ) is a chronic inflammatory disease of the skin characterized by the presence of red, itchy, dry scaly rashes. Occupational eczema (dermatitis) is gotten from contact with certain chemicals in the course of working (in this case due to contact with formaldehyde). Allergic dermatitis is a form of contact dermatitis that results from immune reactions towards certain irritants.
160. A 10-year-old boy with symptoms of arthritis and myocarditis was delivered into a hospital. Based on clinical examination the preliminary diagnosis of juvenile rheumatoid arthritis was made. What symptom is the most contributive for the diagnostics of this disease?

Explanation

Rheumatoid  Arthritis is an autoimmune form of inflammation and is different from osteoarthritis which is due to mechanical wear and tear ( continuous use ). N/B in RA, the inflammation is always symmetrical ( on both sides of the body) and the patient always presents with the complaint of joint stiffness in the morning that lasts for more than an hour.
161. A 25-year-old patient was delivered to an infectious diseases unit on the 3rd day of illness with complaints of headache, pain in the lumbar spine and gastrocnemius muscles, high fever, chills. Objectively: condition is 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 color. Feces are normal in color. What is the most likely diagnosis?

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

 
162. A 28-year-old woman complains of skin hemorrhages after minor traumas and spontaneous appearance of hemorrhages on the front of her torso and extremities. On examination: the skin is variegated (old and new hemorrhages), bleeding gums. Blood platelets - 20·109/l; in the bone marrow there is increased number of megakaryocytes and no platelet production. Treatment with steroid hormones was effective. What disease is it?

Explanation

idiopathic thrombocytopenic purpura is also known as Immune thrombocytopenic purpura.It is a clinical syndrome in which a decreased number of circulating platelets (thrombocytopenia) present as a bleeding tendency, easy bruising (purpura), or extravasation of blood from capillaries into skin and mucous membranes (petechiae). The patient in review presents with thrombocytopenia ( low platelet levels );- 20 x 10^9/L ( norm = 150 − 400 · 10^9/L ) and also bleeding gums.

In Hemophilia, patients will present with bleeding from joints (heathroses), easy bruising or a case of bleeding after surgery, dental procedure. Has three forms; Hemophilia A ( Factor VIII deficient), Hemophilia B ( factor IX deficient), C ( factor XI def.).

Osler weber syndrome is a genetic condition characterized by abnormal vessel formation in the skin and mucous membrane of organs eg lungs, brain etc

 

disseminated coagulation syndrome presents with; widespread clotting factor activation, deficiencies in clotting factors leading to bleeding state.

163. A 74-year-old patient was delivered into admission room with clinical presentations of acute deep vein thrombosis of the shin. What symptom is the most typical of this pathology?

Explanation

 Homans’ sign test is a physical examination procedure which appears positive in cases of Deep vein Thrombosis (DVT). It is also referred to as the dorsiflexion sign test.

Rovsing’s sign indicates appendicitis; a positive sign is observed when pain is felt in the right lower quadrant during palpation of the left lower quadrant.

Courvoisier’s sign is seen in an enlarged palpable gallbladder.

Mayo-Robson’s sign is an indicator for pancreatitis.

Grey Turner’s sign indicates a retroperitoneal hemorrhage.
164. A 45-year-old man complains of cough fits and tickling in his nasopharynx. He had been staying for 10 days in the polluted area created by the Chornobyl nuclear power plant accident. Rhinoscopy shows signs of severe nasopharynx irritation. What radionuclide is the cause of this irritation?

Explanation

 

Amongst the listed radioactive substances, an exposure to radioactive iodine  will result in the irritation of the nasopharynx, increased tear production, swelling of the neck, loss or a change in taste etc. Note that radioactive iodine is mostly used in the treatment of thyroid cancers and is readily absorbed by the thyroid gland. Majority of the other listed radioactive substances will lead to acute radiation sickness, skin burns etc.

165. A 20-year-old patient complains of severe headache, double vision, weakness, fever, irritability. Objectively: body temperature is 38,1oC, the patient is reluctant to contact, sensitive to stimuli. There are ptosis of the left eyelid, exotropia, anisocoria S>D, pronounced meningeal syndrome. On lumbar puncture the cerebrospinal fluid flowed out under a pressure of 300 mm Hg, the fluid is clear, slightly opalescent. 24 hours later there appeared fibrin film. Protein - 1,4 g/l, lymphocytes - 600/3 per mm3, sugar - 0,3 mmol/l. What is the provisional diagnosis?

Explanation

Meningitis is an acute infectious disease with involvement of the arachnoid and pia of the brain and spinal cord by pathogenic microorganisms. Etiologically, the various forms include; bacterial, viral. Fungal and tuberculous meningitis. The tuberculous form occurs as a secondary infection; The CSF is under increased pressure, is clear or slightly cloudy, and contains a predominance of mononuclear cells (usually >400/mm3), increased protein (100 to 400 mg/dL), and a decreased glucose content.
166. A 37-year-old worker during a fire ended up in the area of high CO concentration. He was delivered to a hospital in unconscious state. Objectively: the skin of his face and hands is crimson. Respiration rate is 20/min. ECG: alterations specific for hypoxic myocardium. Hourly diuresis is 40 ml. Blood test: erythrocytes - 4, 5 · 1012/l, Нb- 136 g/l, color index - 0,89, ESR- 3 mm/hour, carboxyhemoglobin - 5%. What criterion allows determining the severity of the patient’s condition?

Explanation

 

When CO gets into the body, it attaches to hemoglobin ( responsible for oxygen transport) since it possesses higher affinity to Hb than Oxygen. This leads to the formation of carboxyhemoglobin. To estimate the severity of this state, the blood carboxyhemoglobin level should be checked.  In non smokers, the carboxyhemoglobin level is normally 2-3% and 7-9% for smokers.

167. After a case of purulent otitis a 1-year-old boy has developed pain in the upper third of the left thigh, body temperature up to 39oC. Objectively: swelling of the thigh in its upper third and smoothed out inguinal fold. The limb is in semiflexed position. Active and passive movements are impossible due to severe pain. What diagnosis is the most likely?

Explanation

 

Acute hematogenous osteomyelitis is an infection of the bone usually caused by a bacteria and common in children less than 5 years; typically affects the metaphysis of long tubular bones. Children present with fever, localized pain, swelling, and rarely erythema around a long bone, limited range of motion, and limping or refusal to bear weight or use an extremity (pseudoparalysis).

168. A patient with suspected pheochromocytoma has normal blood pressure in the periods between the atacks and a tendency towards tachycardia. Urine test revealed no pathologies. It was decided to use a provocative test with histamine. What medication should be prepared to provide emergency care in case of positive test result?

Explanation

 

It is important to note that certain drugs can be used for the diagnosis of Pheochromocytoma ( a tumor of the adrenal medulla). The Histamine test was the first test introduced and later on drugs such as  piperoxan, tetraethylammonium bromide, methacholine chloride  and phentolamine hydrochloride (Regitine) were added. Histamine, tetraethylammonium bromide, and methacholine chloride (Mecholyl) stimulate the discharge of the pressor substances from the tumor. Thus, tests with these drugs are useful in cases of paroxysmal hypertension to produce attacks similar to those that occur spontaneously. Phentolamine (Regitine) and piperoxan (Benzodioxane), on the other hand, lower blood pressure by blocking the pressor effect of epinephrine and norepinephrine in the blood if a pheochromocytoma is present.

169. A 42-year-old woman complains of severe pulsing headache in the frontoparietal area, vertigo, palpitations. She has been suffering from hypertension for 3 years. Significant increase of BP occurs 2-3 times per month and lasts for 3-8 hours. The left ventricle is enlarged, heart sounds are clear, heart rate - 105/min., BP- 225/115 mm Hg. ECG: signs of left ventricular hypertrophy. What drug would be the most effective for termination of cerebral crisis attack?

Explanation

 

Realise that the patient is in a state of hypertensive crisis (BP- 225/115 mm Hg). For emergency remedy, the patient should be administered Labetalol, Torasemide, magnesium sulfate ( in their right doses)  in combination with fluid therapy.

170. A woman came to a doctor with complaints of increased body temperature up to 37,8oC and moderately sore throat for the last 3 days. Objectively: mandibular lymph nodes are enlarged up to 3 cm. Palatine tonsils are hypertrophied, with gray coating that spreads to the uvula and anterior pillars of the fauces. What is the most likely diagnosis?

Explanation

Diphtheria is an acute toxic infection caused by toxigenic strains of Corynebacterium diphtheria. Affected areas are characterised by the formation of a grayish membrane over their surfaces; in this case the oropharynx. N/B this membrane is likely to bleed when detached. 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. The posterior pharynx of patients with Infectious Mononucleosis (EBV infection)  is often uniformly erythematous.
171. A primigravida at the term of 20 weeks complains of pain in her lower abdomen, smearing blood-streaked discharge from the genital tracts. Uterine tone is increased, fetus is mobile. On vaginal examination: the uterus is enlarged according to the term, uterine cervix is shortened to 0,5 cm, external cervical orifice is open by 2 cm. What is the most likely diagnosis?

Explanation

 

Abortion refers to the termination of a pregnancy before 22 weeks of gestation or before 500 grams of fetal weight. Early arbortion occurs before 12 weeks of gestation while late abortion takes place between 12-22 weeks. The above patient experiences an increased uterine tone, pain, bleeding, shortened cervix all of which are indicating a risk of abortion accompanied with hemmorhage. An incomplete abortion is observed when there is retention of some of the products of conception in  the uterus eg. the placenta.

172. A 65-year-old man was diagnosed with B12-deficient anemia and the treatment was prescribed. A week later control blood test was performed. What would be the early indicator of the therapy effectiveness?

Explanation

A B-12 deficiency anemia is characterised by the presence of megaloblastic cells (very large immature rbcs). After treatment, the CBC will show an increased level of reticulocytes; which are immature red blood cells and indicate the process of erythropoiesis.
173. A 35-year-old woman complains of heart pain (”aching and drilling”) occurring mainly in the morning in autumn and spring and irradiating to the neck, back and abdomen; rapid heartbeat; low vitality. Occurrence of this condition is not associated with physical activity. In the evening, the patient’s condition improves. Study of somatic and neurological status and ECG reveal no pathology. What pathology is most likely to have caused these clinical presentations?

Explanation

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

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

 
174. On the 4th day after recovery from a cold a patient was hospitalized with complaints of solitary spittings of mucoid sputum. On the 2nd day there was a single discharge of about 250 ml of purulent blood-streaked sputum. Objectively: the patient’s condition is moderately severe. Respiratory rate - 28-30/min., Ps- 96/min., BP- 110/70 mm Hg. Respiration over the left lung is vesicular, over the right lung - weakened. There are various moist crackles over the lower lobe and amphoric breath sounds near the angle of scapula. What is the most likely diagnosis?

Explanation

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

It is commonly characterized by a productive cough; chest pain; dyspnea.

 

On examination - One can perceive a foul-smell from the mouth when the patient coughs. The amount of sputum as a result of the productive cough is small initially, with a rusty tone (rusty as a result of RBCs that are broken down). 

 

If not properly treated, the abscess progresses by draining the destructive cavities through the bronchus with the daily quantity of the sputum increasing and even reaching 500 ml and more. At this time it is possible for the sputum to be associated with hemoptysis (coughing up of blood).

Acute abscesses are less than 4-6 weeks old, whereas chronic abscesses are of longer duration.

 
175. A 65-year-old woman on abdominal palpation presents with a tumor in the umbilical region and above it; the tumor is 13x8 cm in size, moderately painful, non-mobile, pulsing. On auscultation systolic murmur can be observed. What is the most likely diagnosis?

Explanation

 

Due to the presence of the tumour, the pressure over the abdominal aorta is increased leading to the bulging out or ballooning of the affected part of the aorta; this theory is further proved by the presence of a systolic murmur over the affected region indicating an aneurysm of the abdominal aorta.

176. For a week a 42-year-old patient has been suffering from fever attacks followed by high temperature, which occur each 48 hours. Body temperature raises up to 40oC and decreases in 3-4 hours with excessive sweating. The patient presents with loss of appetite and general fatigue. The skin is pale and sallow. The liver and spleen are enlarged and dense on palpation. What method of diagnosis verifi- cation would be most efficient?

Explanation

 

This pattern of fever is specific for malaria. The symptom stated above refers to ‘Paroxysm’ ( a cyclical occurrence of sudden coldness followed by shivering and then fever and sweating, occurring every two days (tertian fever) in P. vivax and P. ovale infections, and every three days (quartan fever) for P. malariae. P. falciparum infection can cause recurrent fever every 36–48 hours. For diagnosis, microscopy of blood smear and thick blood film is used (to detect plasmodium).

177. A 28-year-old patient is a drug addict. He has been sick for a year, when noticed general weakness, increased sweating, and weight loss. He often had cases of respiratory diseases. Within the last 2 days he demonstrates intermittent fever with profuse night sweating, increased general weakness, developed diarrhea with mucus and blood admixtures. On examination: polylymphadenopathy, herpetic rashes in the oral cavity; on abdominal palpation: the liver and spleen are enlarged. What is the most likely diagnosis?

Explanation

The patient being a drug addict raises strong suspicion for the HIV infection. The presence of poly lymphadenopathy, herpetic rashes in the oral cavity; on abdominal palpation: the liver and spleen are enlarged are all signs indicating an HIV infection.

Herpetic stomatitis is seen in individuals with herpes infection (oral herpes) and poly lymphadenopathy are not usually seen.

 
178. A 40-year-old patient has acute onset of disease caused by overexposure to cold. Temperature has increased up to 39oC. Foul-smelling sputum is expectorated during coughig. Various moist crackles can be auscultated above the 3rd segment on the right. Blood test: leukocytes - 15, 0 · 109/l, stab neutrophils - 12%, ESR- 52 mm/hour. On Xray: in the 3rd segment on the right there is a focus of shadow 3 cm in diameter, low density, with fuzzy smooth margins and a clearing in its center. What disease is most likely in the given case?

Explanation

 

Pneumonia is an infection of the lungs ( viral, bacterial or fungal) characterised by the presence of fluid filled air sacs or alveoli. From the analysis, the increased leukocyte number indicates a bacterial infection and the result from auscultation shows the lungs are affected. The results from the x-ray confirms the presence of an abscess (a pus filled cavity) which causes the foul smelling sputum. Lung abscesses are one of the various complications of pneumonia; others include; bacteremia, septic shock. Pleural effusion etc.

179. A 48-year-old patient was found to have diffuse enlargement of the thyroid gland, exophthalmia, weight loss of 4 kg in 2 months, sweating. Objectively: HR- 105/min, BP140/70 mm Hg. Defecation act is normal. What kind of therapy is recommended in this 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.
180. A 26-year-old woman is suspected to suffer from systemic lupus erythematosus due to systemic lesions of skin, vessels, joints, serous tunics, and heart that developed after photosensitization. The following is detected: LE cells, antibodies to native DNA, isolated anti-centromere antibodies, rheumatoid factor is 1:100, Wassermann reaction is positive, circulating immune complex is 120 units. What immunological indicators are considered to be specific to this disease?

Explanation

Systemic Lupus erythematosus is an autoimmune disease characterised by appearance of a butterfly rash ( malar rash), arthritis,oral ulcers, endocarditis etc.Organ damage is due to type III hypersensitivity ( immune complex) and type II (to a lesser extent). For diagnosis, Antinuclear antibodies are tested for. Subtypes of antinuclear antibodies specific for SLE include: Anti Smith and anti double stranded DNA antibodies (ds-DNA antibodies).
181. A 39-year-old man complains of morning headaches, appetite loss, nausea, morning vomiting, periodic nasal hemorrhages. The patient had a case of acute glomerulonephritis at the age of 15. Examination revealed rise of arterial pressure up to 220/130 mm Hg, skin hemorrhages 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. The Other test includes the checking of the glomerular filtration rate.
182. A worker of a glass-blowing workshop complains of headache, irritability, visual impairment - he sees everything as if through a ”net”. Objectively: hyperemic sclera, thickened cornea, decreased opacity of pupils, visual acuity is 0,8 in the left eye, 0,7 in the right eye. The worker uses no means of personal protection. What is the most likely diagnosis?

Explanation

Cataract is the opacification ( clouding ) of the lens which leads to a decrease in vision ( visual acuity). The visual acuity in adults is 60/60 or 6/6 which equals 1. Note that the patient in view has reduced visual acuity in both eyes and has a net like vision ( cloudy); these signs indicate presence of cataract.

In conjunctivitis, we see red eyes ( inflammation of the transparent membrane- conjunctiva), it doesn't affect visual acuity.

Keratitis is an inflammation of the Cornea. Symptoms include; eye redness, photophobia, eye pain coupled with a reduced visual acuity.
183. An infant has been born at the 41st week of gestation. The pregnancy was complicated with severe gestosis of the second semester. The weight of the baby is 2400 g, the height is 50 cm. Objectively: the skin is flabby, the layer of subcutaneous fat is thin, hypomyotonia is observed, neonatal reflexes are weak. The internal organs are without pathologic alterations. This newborn can be assessed as a:

Explanation

Norms;  gestation period- 280 days or 40 weeks up to 42 weeks

              birth weight- 3-3.5kg ( 3000-3500g)

             Body length- 45-55cm

The baby in question underwent a full term gestation period (41 weeks) but is underweight ( 2400g). This underweight is due to complications that occurred during gestation as stated “The pregnancy was complicated with severe gestosis in the second semester”. We can therefore conclude that the baby who had a full term gestation had some intrauterine growth restrictions.

A premature infant is one which is born before 37 weeks of gestation.

 

A post mature infant is one born after 42 weeks of gestation

184. A patient suffering from infiltrative pulmonary tuberculosis was prescribed streptomycin, rifampicin, isoniazid, pyrazinamide, vitamin C. One month after the beginning of the treatment the patient started complaining of reduced hearing and tinnitus. What drug has such a side effect?

Explanation

Tuberculosis is a disease caused by an acid fast bacteria, Mycobacterium tuberculosis. Streptomycin, Rifampicin, Isoniazid, pyrazinamide and ethambutol are very active drugs chosen for its treatment. The following are lists of side effects associated with these drugs:

Streptomycin- vestibular and auditory ( ototoxicity) dysfunction, non oliguric renal failure 

Rifampicin- red/ orange discoloration of body fluids e.g. tears, urine; flu-like symptoms, hepatitis, diarrhea, thrombocytopenia.

Isoniazid- hepatitis, peripheral neuropathies

Pyrazinamide- asymptomatic hyperuricemia, joint pain, rash

 

Ethambutol- retrobulbar optic neuritis

185. A 9-year-old boy has been suffering from multiple bronchiectasis since he was 3 years old. Exacerbations occur frequently (3- 4 times a year), after conservative therapy there are short remission periods. The disease progresses, the child is physically underdeveloped, presents with pale skin, acrocyanosis, deformed nail plates in the shape of ”clock-face”. Bronchography reveals saccular bronchiectases in the lower lobe of the right lung. What further treatment tactics should be chosen?

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.
186. 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 an infectious disease caused by the complex interaction of caries-causing bacteria ( eg. streptococci mutans) with carbohydrates (i.e., sugars) on the tooth surface over time. Cariogenic bacteria metabolize carbohydrates for energy and produce organic acids as byproducts which reduce oral pH leading to demineralization of the teeth.  One of the most effective methods to prevent caries is by promoting remineralization and slowing down demineralization. This can be accomplished with fluoride therapy. It is widely accepted that the regular use of fluoride, such as in drinking water, is extremely effective at preventing dental caries. The fluorine content in the community’s water supply is 0.1 mg/L which is low ( norm >0.5 mg/L). Water fluorination should be used to prevent dental caries.

187. A patient received flame burns of both hands. On the dorsal and palmar surface of the hands there are blisters filled with serous fluid. The wrist joint region is hyperemic. The forearms were not injured. What is the provisional diagnosis?

Explanation

rule of “nines” – area of different areas of the body is proportional: anterior surface of the trunk – 18 %, posterior – 18 %, lower limb – 18 %, external genitals – 1 %)

" rule of  “palm”. It is used if burns are limited and located on different areas of the body. According to the rule of palm takes 1 % of the skin surface.

Division of the burns on superficial (I, II, III A st.) and deep (III B-IV st.)

I stage – hyperemia of the skin

II stage – separation of epidermis with formation of bullas

III A stage – necrosis of superficial layers of the skin with saving of bulbs hair, sweat glands and sebaceous glands.

III B stage – necrosis of all the derma

IV stage – necrosis of the skin and underlying tissues. Notice that the patient has suffered burns affecting just the surface with the appearance of blisters ( bulla)  
188. During the periodic medical examination an assembly fitter (works on soldering details) didn’t report any health problems. Closer examination revealed signs of asthenicvegetative syndrome. Blood included red blood cells with basophilic aggregations and a somewhat higher number of reticulocytes, urine had a high concentration of delta-aminolevulinic acid. The complex of symptoms indicates the initial stage of chronic intoxication with:

Explanation

 

Delta-aminolevulinic acid dehydratase is an enzyme necessary for the synthesis of heme. In lead poisoning, this enzyme is inhibited leading to anemia and an increased delta aminolevulinic acid content in urine. N/B a high reticulocyte number means an increase in RBC production ( new cells) and is observed in cases such as bleeding, high altitude or anemia. The above patient presents with signs of asthenic vegetative syndrome coupled with the above stated reasons confirming a case of lead poisoning.

189. A 29-year-old woman came to a gynecologist with complaints of irritability, tearfulness, headache, nausea, occasional vomiting, pain in the heart area, tachycardia attacks, memory impairment, meteorism. These signs appear 6 days before menstruation and disappear the day before menstruation or during its first 2 days. On vaginal examination: the uterus and uterine appendages are without alterations. What diagnosis is the most likely?

Explanation

Premenstrual syndrome is a wide variety of signs and symptoms that affects a woman’s emotion, physical health, and behavior during certain days of the menstrual cycle, generally just before her menses. Symptoms start five to 11 days before menstruation and typically go away once menstruation begins. Signs include abdominal pain and bloating, vomiting ,meteorism, change in sleep patterns, emotional instability etc. 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.
190. Examination of a group of persons living on the same territory revealed the following common symptoms: dark-yellow pigmentation of the tooth enamel, diffuse osteoporosis of bone apparatus, ossification of ligaments and joints, functional disorders of the central nervous system. This condition may be caused by the excessive concentration of the following microelement in food or drinking water:

Explanation

Presence of dark-yellow pigmentation of the tooth enamel, diffuse osteoporosis of bone apparatus, ossification of ligaments and joints are specific symptoms that indicate Fluorosis. This is a condition that occurs as a result of excessive intake of fluorine.
191. A 52-year-old patient, who has been suffering from angina pectoris, for 2 weeks has increasingly frequent pain attacks in the area behind his sternum and his need for nitroglycerine has increased. Objectively: the condition is of moderate severity. The skin is pale. Heart sounds are weakened, rhythmic. Heart rate is 84/min. ECG shows no signs of focal myocardial injury. 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.

 
192. 5 weeks after hypothermia a 22-yearold patient developed fever, weakness, muscle pain, inability to move independently. Objectively: tenderness, induration of shoulder and shin muscles, restricted active movements, erythema on the anterior surface of the chest. There is a periorbital edema with heliotropic erythema. Gottron’s sign is present. What investigation is required for the diagnosis verification?

Explanation

Gottron’s sign refers to erythematous macules/papules present on the elbows ( sometimes also on the knees) and are specific signs in diagnosis of dermatomyositis.

Dermatomyositis is a muscle disease, a long term inflammatory myopathy (muscle disorder) characterised by progressive proximal muscle weakness, Gotron papules and heliotrope rash. For diagnosis, a muscle biopsy is obtained and observed under the microscope; signs such as mononuclear antibodies, abnormal cell degeneration and regeneration  etc are observed.

 
193. A 37-year-old woman complains of headaches, nausea, vomiting, spasms. The onset of the disease occurred the day before due to her overexposure to cold. Objectively: fever up to 40oC; somnolence; rigid neck; Kernig’s symptom is positive on the both sides; general hyperesthesia. Blood test: leucocytosis, increased ESR. Cerebrospinal fluid is turbid, yellow-tinted. What changes of the cerebrospinal fluid are most likely?

Explanation

A positive kernig sign indicates a form of meningitis or subarachnoid hemorrhage; for more information CSF findings are taken; the analysis shows no sign of hemorrhage,  but appears turbid and yellow tinted which are signs of a bacterial meningitis. Examination of the CSF in patients with acute bacterial meningitis reveals the characteristic neutrophilic pleocytosis ( a neutrophil count in the CNS greater than 50%). Lymphocytic pleocytosis is found in viral encephalitis.
194. A 44-year-old patient complains of diffi- cult urination, sensation of incomplete urinary bladder emptying. Sonographic examination of the urinary bladder near the urethra entrance revealed an oval welldefined hyperechogenic formation 2x3 cm large that was changing its position during the examination. What conclusion can be made?

Explanation

Echogenicity of the tissue refers to the ability to reflect or transmit Ultrasound waves waves. Based on echogenicity, a structure can be characterized as hyperechoic (white on the screen), hypoechoic (gray on the screen) and anechoic (black on the screen). Stones are examples of hyperechoic materials and can be responsible for the blockage of the urinary tract. Tumors are hypoechoic.
195. 4 days after a patient received a gunshot wound to the soft tissues of middle third of the thigh, his condition suddenly began deteriorating. There are complaints of bursting pain in the wound; pain has been increasing 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 color, have dirty-gray coating, and fall apart when 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.

196. A 35-year-old patient has been suffering from an illness for 3 days. 5 days ago he returned from a trip to Africa. The onset of disease was accompanied by fever up to 40oC, chills, acute headache, myalgia. In the axillary region the lymph node enlarged up to 3x6 cm can be palpated. The lymph node is dense, intensely painful, slightly mobile, without clear margins; the skin over the node is hyperenic and tight. Tachycardia is present. Make the preliminary diagnosis:

Explanation

A plague is a bacterial disease spread from one rodent to another by flea parasites and to humans by an infested flea; caused by Yersinia pestis possible signs include severe intoxication, fever, affection of lymphatic system and lungs. Various forms include the Bubonic, septicemic and pneumonic plague; the bubonic form is characterised by spread via the lymphatic system, severe lymphadenitis. Notice that the patient recently returned from africa, which presents a high probability of being bitten by an infected flea.
197. A parturient woman complains of pain in her mammary gland. In the painful area there is an infiltration 3x4 cm in size with softened center. Body temperature is 38,5oC. What is the most likely diagnosis?

Explanation

Acute suppurative mastitis is a bacterial infection of the mammary gland. It occurs mostly in pregnant or postpartum women; due to lactation, the nipples present with some erosions and are increased in size making it easier for bacterial entrance. This infection is characterised by the production of purulent exudates.
198. After a 5-day-long celebration of his daughter’s wedding a 65-year-old patient ”saw” in his yard many cats, chickens, and rats. He tried to chase them away, but was scared off when the animals started to scold him and tried to harm him. Make the diagnosis:

Explanation

 

Delirium tremens also known as Alcohol withdrawal delirium is the most severe form of alcohol withdrawal, it is characterised by an altered mental status and hyperactivity of the autonomic nervous system. Remember from the question stem, the patient attended a 5-day long celebration; most likely he has been stressed within these days and stayed without alcohol consumption leading to delirium tremens. Senile psychosis is  brain degenration due to old age.

199. An 8-year-old boy developed a temperature of 37, 5oC two days after his recovery from the case of URTI. He complains of suffocation, heart pain. Objectively: the skin is pale, tachycardia, the I heart sound is weakened, short systolyc murmur in the 4th intercostal area near the left edge of the breastbone. What heart disorder such clincal presentation is characteristic of?

Explanation

Rheumatic Fever:

Etiology: Group A Beta hemolytic Streptococci (Streptococcus pyogenes)

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

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

Note, the question stem says the 8 year old developed fever, suffocation and heart pain 2 days after an URTI. These are symptoms of Myocarditis but it is non-rheumatic because they developed 2 days after an URTI and not up to 2-3weeks.

 

Diagnosis is based on Jones Criteria:

Joint (migratory arthritis)

Carditis

Nodules in skin (subcutaneous)

Erythema marginatum

Sydenham chorea

 

ADDITIONAL NOTE: 

 

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

 
200. A 28-year-old woman has been delivered to a hospital with acute pain in the lower abdomen. There was a brief syncope. The delay of menstruation is 2 months. Objectively: the patient has pale skin, BP- 90/50 mm Hg, Ps- 110/min. Lower abdomen is extremely painful. Vaginal examination reveals uterus enlargement. Promtov’s sign (pain during bimanual gynecological examination) is positive. Right uterine appendages are enlarged and very painful. Posterior vault hangs over. What is the most likely diagnosis?

Explanation

An ectopic pregnancy occurs when implantation takes place outside the walls of the uterus; in most cases it occurs in the fallopian tubes ( tubal pregnancy). The patient presents with a history of missed periods for about 2 months ( an early sign of pregnancy). Typical signs include pelvic and severe lower abdominal pain, mass present in the uterine appendage ( adnexa). Notice that on examination, the patient presents with enlarged and very painful uterine appendages on the right side which confirms a right-sided tubal pregnancy. Right ovary apoplexy refers to the rupture of the ovary, it presents with severe pain, bleeding into the abdominal cavity and signs of irritation of the peritoneum.

The inflammation of the uterine appendage, particularly on the fallopian tubes is the disease called Salpingo-Oophoritis. It develops when staphylococci, streptococci, colon bacilli, gonococci, tubercle bacilli or other pathogens enter into fallopian tubes and the ovaries.