4120 1398
NOTEPAD

Notice: Trying to get property 'note' of non-object in /home/krushkro/public_html/wp-content/themes/krush/exam.php on line 189
Results
of 163 questions answered correctly

You have reached of 163 points, ( %)

Your time

Question 1 of 163

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

Explanation

Vegetative-vascular dysfunction is also referred to as Somatoform autonomic dysfunction. This  is a clinical syndrome that includes disorders of human systems and organs with various origin and manifestations. The vegetative (autonomous) nervous system that has two main branches, the sympathetic branch and the parasympathetic system, provides innervation of internal organs. These systems produce an opposite effect on a human body. Normal systems are balanced, whereas the somatoform autonomic dysfunction disturbs the balance and the effect of either sympathetic or parasympathetic system predominates.

In the case of rheumatism, the heart valves will be affected with an underlying streptococcal infection. The appearance of no changes in cardiac borders on percussion rules out the option of carditis.

2. A 7-year-old boy had complained of headache, nausea, fatigue for 3 weeks. His condition gradually deteriorated, headache and general weakness progressed. The boy had bronchitis at the age of 3. His father has a history of pulmonary tuberculosis. Objectively: body temperature 37,5oC, conscious, lies supine, with the hip and knee flexed to 90 degrees, nuchal rigidity +6 cm, partial ptosis of the right eyelid, the dilated right pupil. General hyperalgesia is present. Liquor: transparent, pressure - 400 mm of water column, protein - 1,5%, cytosis - 610/3 with predominant lymphocytes, sugar - 1,22 mmol/l, chlorides - 500 mmol/l. What is the most likely diagnosis?

Explanation

***
3. A 13-year-old girl has a 5-year histrory of pain in the right hypochondrium irradiating to the right shoulder blade. The pain attacks are usually associated with diet violations, they are short and can be easily relieved by antispasmodic drugs. During a pain attack, palpation of the abdomen is painful, the pain is most intensive in the projection of the gallbladder. What is the most likely diagnosis?

Explanation

***
4. A 12-year-old boy has a 6-year hi- story of insulin-dependent diabetes. The disease is labile. Since recently there have been periodical rises in blood pressure. Microalbuminuria test gave positive results. The patient’s condition corresponds with the following stage of diabetic nephropathy:

Explanation

  1. In Diabetes Mellitus, Mogensen identified 5 stages of renal dysfunction:
  •  Stage 1: Renal hypertrophy and hyperfiltration – glomerular filtration rate may be increased 20 - 40% 

  • Stage 2: Is clinically ‘silent’ but hyperfiltration persists and is correlated with mild hyperglycemia 

  • Stage 3: Microalbuminuria is present 

  • Stage 4: Overt nephropathy with proteinuria, hypertension and progressive renal failure 

  • Stage 5: End-stage renal failure develops

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

Explanation

The presence of percussion dullness on the right just below the scapula accompanied by the result from auscultation (presence of fine moist crackles) are common signs found in cases of pneumonia. Pneumonia is an inflammation of the pulmonary tissue that occurs as a result of an infection e.g. bacterial, viral etc. laryngotracheitis is also termed Croup; it involves an infection of the larynx, trachea and lungs.
6. An 8-year-old child complains of fever up to 38,8oC, throat pain when swallowing, skin rash. Objectively: lacunar tonsillitis, circumscribed hyperaemia and enanthema of soft palate, pinointsized skin rash, mostly in the folds and on the flexor surfaces of the extremities, pale nasolabial triangle. Which antibiotic should be administered in the first place?

Explanation

Notice that this patient has scarlet fever which is characterised by the presented symptoms; fever, difficulty swallowing, hyperemic soft palate/ tongue, skin rash on flexors and folds, pale nasolabial triangle. This disease is as a result of a Group A streptococcal  or streptococcus pyogenes infection. For its treatment an antibiotic regimen should be followed; the preferred choice of antibiotics is Penicillin or Amoxicillin.

7. A 16-year-old girl had had polyuria, polydipsia for 2 months. She had lost 8 kg with a good appetite. The patient was urgently hospitalized for abdominal pain and nausea. Examination revealed glycemia at the rate of 18 mmol/l, glycosuria at the rate of 24 g/l. Insulin and infusion of isotonic solutions of sodi- um chloride and glucose eliminated these problems, including thirst. What is the most likely diagnosis?

Explanation

The key point here is ‘ Insulin and infusion of isotonic solutions of sodium chloride and glucose eliminated these problems’ which confirms this patient has a type 1 diabetes mellitus ( insulin dependent). Recall that type 1 insulin diabetes mellitus is usually noticed at a young age whereas type 2 ( non- insulin dependent) is observed at the latter ages of life as well as in obesed individuals. Renal glucosuria is seen when the kidney excretes glucose with urine in individuals with normal or low blood glucose level. Diabetes insipidus is related to the antidiuretic hormone also called vasopressin. In this case, the individual excretes large volumes of urine.

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

Explanation

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

Explanation

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

Explanation

***
11. Examination of a 13-year-old girl revealed acute glomerulonephritis, nephritic syndrome at the initial stage without renal dysfunction. What is the main drug of choice for the basic therapy of this patient?

Explanation

Glomerulonephritis  is an immunologically mediated diffuse inflammatory disease which involves both kidneys symmetrically affecting mainly the glomerulus and associated with changes in tubules, interstitial tissue and vessels. The main etiological factor is an infection by group A beta hemolytic streptococcus. note that the question states that this disease is in its initial stage ‘without renal dysfunction’;  this implies that for the basic therapy, an antibiotic ( targeted at the causative agent) should be prescribed for the patient.  In a case where renal function has been affected, other approaches such as dialysis, transplant etc should be considered.
12. A 6-year-old child complains of frequent liquid stool and vomiting. On the 2nd day of desease the child presented with inertness, temperature rise up to 38, 2oC, Ps- 150 bpm, scaphoid abdomen, palpatory painful sigmoid colon, defecati- on 10 times a day with liquid, scarce stool with mucus and streaks of green. What is a provisional diagnosis?

Explanation

***
13. A 13-year-old boy complains of pain in the upper third of his left thigh, body temperature rise up to 39oC. There is a swelling in the upper third of thigh and inguinal fold smoothness. The extremity is in a half bent position. Active and passive movements are not possible because of the sharp pain. What is the most likely diagnosis?

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). Brodie's abscess is a sub-acute form of osteomyelitis, presenting as a collection of pus in bone.  Classically, this may present after progression to a draining abscess extending from the tibia out through the skin.

14. An 8-month-old baby has decreased appetite, pale skin, enlarged right side of abdomen. Palpation the right side of abdomen reveals a dense elastic tumour like formation 10x7 cm large. There is a positive ballotement sign. What is the most likely diagnosis?

Explanation

Apart from orthopedics where the ballotment sign indicates increased fluid in the suprapatellar pouch at the knee joint, the term ‘ballotment’ is also used in referring to an ascitic abdomen. Considering the age of the child, and the result from the palpation of the right side of the abdomen, we can narrow our option to wilms tumor ( nephroblastoma) which is the most common type of kidney tumour ( adrenal medulla) that affects children less than 4 years of age. The tumours in the area of the kidney affects its function leading to reduced fluid excretion via urine resulting in ascites ( accumulation of fluid in the abdomen)
15. 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 that of previous feeding. The infant has age appropriate body weight. What is the most likely cause of this symptom?

Explanation

Pylorospasm is a condition in which the Pyloric sphincter fails to relax properly due to continuous contractions (spasms). The key finding here is that vomiting occurs a few minutes after eating and the volume does not exceed previous food content; this helps differentiate it from Pyloric stenosis which occurs due to the narrowing of the pyloric part of the stomach leading to improper digestion. Pyloric stenosis is characterized by splashing sound in the epigastrium, Projectile vomiting followed by an eagerness to take food. In esophageal achalasia, the patient will firstly experience Dysphagia ( difficulty in swallowing) followed by vomiting; this occurs due to failure in the relaxation of the lower esophageal sphincter and peristalsis.
16. A 13-year-old girl complains of fever up to 37,4oC during the last 2 months after recovering from ARVI. Objectively: malnutrition, diffuse grade II enlargement of the thyroid gland feeling dense on palpation, exophthalmos, tachycardia. What kind of pathological syndrome is it?

Explanation

From observation, this patient presents with an enlarged thyroid gland,exophthalmos ( eyeballs bulging out), tachycardia. These are characteristic findings in a patient with hyperthyroidism ( thyrotoxicosis- excess circulating thyroid hormone). Tremors, weight loss and fatigue are other vital signs that can be seen in such patients. Hypothyroidism will present with the exact opposite symptoms ie., weight gain, slow metabolic rate, bradycardia etc. The parathyroid gland produces parathormone; a hormone responsible for regulating blood calcium and phosphorus level.

17. On the 2nd day of life a full-term boy developed mild jaundice of skin and mucous membranes, the general condition of the child is normal. Blood test results: indirect hyperbilirubinemia - 120 mmol/l. The child’s blood group is A(II) Rh(+), his mother’s blood group - B(III) Rh(+). What is the doctor’s tactics of choice?

Explanation

Notice that the Rh group of both mother and child are the same. This Proves that the increased unconjugated bilirubin is NOT due to Rh incompatibility. This baby is having PHYSIOLOGICAL JAUNDICE; a condition characterised by a high level of unconjugated bilirubin within the first week of life. Mild infant jaundice often disappears on its own within two or three weeks. Moderate and severe  cases are often treated with phototherapy, intravenous immunoglobulin etc. In this case, mild jaundice is experienced therefore, no  drug therapy is needed.
18. 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. Which antibiotic is most advisable to be administered 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, It inhibits DNA replication by inhibiting bacterial DNA topoisomerase and DNA-gyrase. Other possible drugs include gentamicin, carbenicillin, carbapenems etc.
19. A 14-year-old boy with a history of chronic tonsillitis and sinusitis has developed a feeling of heart irregularities and additional pulse. HR- 83/min. ECG results: regular impulses with no visible P wave that occur every two sinus contractions, QRS complex is dramatically deformed and prolonged to over 0,11 s, T wave is discordant followed by a complete compensatory pause. Specify the arrhythmia type:

Explanation

Note that from the results from ECG- regular impulses with no visible P wave that occur every two sinus contractions. This indicates a case of Premature ventricular contractions ( PVC); When this occurs in a three-beat pattern, it is called trigeminy. This pattern can be two normal (sinus) beats and one abnormal one. Another trigeminy pattern is two PVCs with one sinus beat. This rhythm is different from bigeminy, where the heart beats with one sinus beat and one PVC.
20. An 8-year-old girl periodically has sudden short-term heart pain, sensation of chest compression, epigastric pain, dizziness, vomiting. Objectively: the patient is pale, respiratory rate - 40/min, jugular pulse is present. Ps- 185 bpm, of poor volume. AP- 75/40 mm Hg. ECG taken during an attack shows ectopic P waves, QRS wave is not deformed. At the end of an attack a compensatory pause is observed. The most likely cause of the attack is:

Explanation

Paroxysmal means that the episode of arrhythmia begins and ends abruptly. Atrial means that arrhythmia starts in the upper chambers of the heart (atria). From ECG, we find the presence of ectopic p waves with QRS complex not affected which proves that this arrhythmia is of atrial origin.
21. A baby is 3 months old. The mother consulted a pediatrician about lack of breast milk. After several test weighings it was found that the child had to receive supplementary feeding. What is the opti- mal milk formula for this child?

Explanation

***
22. Examination of a newborn revealed skin redness that appeared immediately after birth and reached the maximum intensity on the second day of life. What is your provisional diagnosis?

Explanation

Note that this baby is actually experiencing Erythema toxicum neonatorum (ETN); an erythemic process usually seen in full term infants. It starts on the first day after birth and usually fades away within a week. Erythema nodosum is a type of skin inflammation that is located in a part of the fatty layer of skin. Erythema nodosum results in reddish, painful, tender lumps most commonly located in the front of the legs below the knees. The tender lumps, or nodules, of erythema nodosum range in size. Transient erythema occurs as a result of loss of hair ( maybe due to exposure to radiation) and neurological changes.

23. A  10-year-old patient has a history of mild bronchial asthma. During a regular check up the patient should be recommended:

Explanation

Bronchial asthma is a medical condition classified under type 1 hypersensitivity ( IgE mediated); it is a chronic inflammatory pulmonary disease that is characterized by periodic cough, wheezing, tachypnea, dyspnea, hypoxemia, increased production of mucus which blocks the airways. Triggers include stress, allergens, viral upper respiratory infections, cold air etc. On objective examination, Tachypnoe, audible wheezing, hyperinflated chest and hyper resonant sound on percussion are observed. Curshman’s spirals ( shed epithelium in mucus plugs) and Charcot leyden crystals ( broken down eosinophils) are key findings morphologically.
24. A 10-year-old child has been admitted to a hospital with a closed crani- ocerebral injury with suspected cerebral edema. The patient is in grave condition, unconscious. The dyspnea, tachycardia, hypertension are present. Muscle tone is increased, there is nystagmus, pupillary and oculomotor reactions are disturbed. The mandatory component of intensive care is dehydration. What diuretic is adequate in this case?

Explanation

By definition cerebral edema is the excess accumulation of water in the intra-and/or extracellular spaces of the brain. The most rapid and effective means of decreasing tissue water and brain bulk is osmotherapy. Osmotic therapy is intended to draw water out of the brain by an osmotic gradient and to decrease blood viscosity. These changes would decrease ICP and increase cerebral blood flow (CBF). Mannitol is the most popular osmotic agent. However, prolonged administration of Mannitol results in an electrolyte imbalance that may override its benefits and that must be carefully monitored. Nursing care of the patient receiving Mannitol requires vigilant monitoring of electrolytes and overall fluid balance and observation for the development of cardiopulmonary complications in addition to neurological assessment.

25. A baby born after fast labour has palsy of hand muscles. Grasp reflex is absent, as well as hand-to-mouth reflex. Hand sensitivity is absent. What is the most likely diagnosis?

Explanation

Dejerine Klumpke’s palsy occurs when there is a traction or tear of the lower trunk: C8-TH1 roots. In infants, it is caused as a result of upward force on the arm during delivery while in adults it occurs after trauma. This condition affects the intrinsic hand muscles ( lumbricals, interossei, thenar and hypothenar). This condition is characterised by a total claw hand ( see image ) because the lumbrical muscles normally flex the metacarpophalangeal joints and extend the Distal and proximal interphalangeal joints. In Duchenne Erb’s palsy ( waiter’s tip hand), there is a traction or tear to the upper trunk: C5-C6 roots. It is caused by the lateral traction of the neck during the delivery of infants. It affects the deltoid (abduction), Infraspinatus ( lateral rotation) and biceps brachii ( flexion and supination). Horner’s syndrome is characterised by Ptosis ( slight drooping of the eyelid), Anhidrosis ( absence of sweating) and Miosis ( pupil constriction)

26. A child is 12 years old. He complains of a dull aching pain in the epigastrium and right hypochondrium, that is getting worse after taking fatty or fried food, headache, weakness, nausea, low- grade fever. Abdominal palpation reveals a marked resistance of muscles in the right hypochondrium, positive Kerr’s, Ortner’s, Murphy’s symptoms. What is the most likely diagnosis?

Explanation

Kehr’s sign- pain in the left shoulder ( due to irritation of the under surface of the diaphragm). Murphy’s sign pain during inspiration while palpating the right subcostal region. Ortner\'s sign painfulness at the easy pushing on the right costal arch by the edge of the palm. These signs are positive in conditions related to the gallbladder eg cholecystitis, cholelithiasis etc.Chronic cholecystitis refers to a long term inflammation of the gallbladder. It is characterised by flatulence, abdominal distension and discomfort, nausea and fat intolerance. Diagnosed with the help of ultrasound. Acute Pancreatitis  will be accompanied by epigastric or central abdominal pain that radiates to the back and is relieved  when sitting forward. Periumbilical bruising ( Cullen’s sign) or on the flanks ( Grey turner’s sign) are key findings in this pathology.

27. A 3-month-old girl presents with rhinitis, dyspnea, dry cough. These manifestations has been observed for two days. Objectively: the child has pale skin, acrocyanosis, shallow respiration at the rate of 80/min. Percussion reveals handbox resonance over the whole surface of lungs, massive fine rales. What is the most likely diagnosis?

Explanation

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

28. A newborn (mother’s I pregnancy) weighing 3500 g presents with jaundice, lethargy, reduced reflexes. Objectively: second grade jaundice of skin with saffron tint, liver - +2cm, spleen - +1 cm. Urine andfecesareyellow.Bloodcount:Hb-100 g/l, RBCs - 3, 2 · 1012/l, WBCs - 18, 7 · 109/l, mother’s blood type - 0(I) Rh(+), baby’s blood type - А(II) Rh(-), bilirubin - 170 mmol/l, indirect fraction. ALT, AST rates are normal. What disease is the child most likely to have?

Explanation

Hemolytic disease of the newborn is a disease characterised by the increased breakdown of Red blood cells (RBC) in the newborn. Hemolytic disease of the newborn occurs when the immune system of the mother sees a baby's RBCs as foreign. Antibodies then develop against the baby's RBCs. These antibodies attack the RBCs in the baby's blood and cause them to break down too early. Two major hemolytic pathologies in pregnancy are: ABO incompatibility and rhesus incompatibility (Mother Rhesus -ve and child Rhesus +ve). In this case, the fetus and mother present with ABO incompatibility; Notice that the mother’s blood type is 0(I) while the newborn’s A (II). Antibodies are formed against the newborn’s RBCs leading to its increased destruction. It is not Rhesus incompatibility because the mother is Rhesus positive while the baby is negative. Rhesus incompatibility occurs when a Rhesus negative (Rh-) mother marries a Rh+ Man and they conceive a Rh+ child. Note: the mother must be Rh- and the child Rh+. The first child with Rh+ usually survives, but subsequently Rh+ fetus will be attacked by Rh antibodies in the mother which crosses the placenta to attack the fetal red blood cells causing hemolysis.
29. A 15-year-old boy feels pain in the region of the left knee joint. Objectively: the soft tissues in the affected region are infiltrated, the joint function is limited. Radiography reveals a focus of bone destruction in the distal metaepiphysial segment of the left femur. The destruction is accompanied by periosteal detachment and a defect formed within cortex of Codman triangle bone. X-ray of chest shows multiple microfocal metastases. What is the most likely pathology?

Explanation

Osteosarcoma is a metaphyseal bone tumor. It is the most common type of cancer that arises in bones, and it is usually found at the end of long bones, often around the knee. Presents as a painful enlarging mass or with pathologic fractures. A codman Triangle (elevation of the periosteum)  or sunburst pattern are pathognomonic and classical findings on radiography.
30. 10 days after birth a newborn developed a sudden fever up to 38,1oC. Objectively: the skin in the regi- on of navel, abdomen and chest is erythematous; there are multiple pea- sized blisters with no infiltration at the base; single bright red moist erosions wi- th epidermal fragments on the periphery. What is your provisional diagnosis?

Explanation

Epidemic pemphigus of newborn or Pemphigus Neonatorum is a disease of the newborn, in which vesicles or blebs, usually flat on the top, appear with or without fever, on a perfectly normal or reddened skin with pin-head size vesicle elevation, which rapidly develops into a large bleb. As the disease progresses, relapses may occur, yet the infant may recover promptly after a single outbreak of but few blebs. In some cases these blebs show a marked tendency to peripheral extension, which finally dry, leaving a thin brown crust. Staphylococcus aureus have been implicated as the causative agent. The distinction between Pemphigus and syphilis in the newborn may be determined by the localization of the eruption. Syphilis will be localized to the palms of the hands and soles of the feet, as well as by the associating symptoms of syphilis. Impetigo commonly presents with honey crusted vesicles and papules. Atopic dermatitis is an allergic reaction and patient most often have other allergic conditions or family history of asthma, allergic rhinitis, eczema etc.
31. A 13-year-old girl was admitted to the gynecological department with heavy bleeding, which appeared after a long delay of menstruation. Shortly before, the girl suffered a serious psychotrauma. Her menarche occurred at the age of 11, she has a 30-day cycle with 5 to 6 days of moderate, painless bleeding. The patient is somatically healthy, of normosthenic constitution with height of 160 cm, weight of 42 kg. The patient is pale. Rectoabdominal examination revealed that the uterus was of normal size and consistency, anteflexio-versio, the appendages were not changed. What is the most likely diagnosis?

Explanation

Menstrual cycles are often irregular during adolescence, particularly the interval from the first cycle to the second cycle. Most females bleed for 2–7 days during their first menses. Immaturity of the hypothalamic–pituitary–ovarian axis during the early years after menarche often results in anovulation and cycles may be somewhat long; although short cycles of less than 20 days and long cycles of more than 45 days may occur. For the first few years after menstruation begins, long cycles are common. However, menstrual cycles tend to shorten and become more regular as you age. As for this patient her menstrual cycle is yet to stabilize, so it is a case of Female Juvenile bleeding.
32. A 2-year-old child in a satisfactory condition periodically presents with moderate proteinuria, microhematuria. USI results: the left kidney is undetectable, the right one is enlarged, there are signs of double pyelocaliceal system. What study is required to specify the diagnosis?

Explanation

***
33. An 8-year-old boy has a 2-year hi- story of blotchy itchy rash appearing after eating citrus fruit. The first eruption occurred at the age of 6 months after the introduction of juices to the baby’s diet. Father has a history of bronchial asthma, mother that of allergic rhinitis. What is the most likely diagnosis?

Explanation

Chiefly, we can notice a trend of allergic diseases running in the family tree. Parental history of allergic conditions are strong risk factors for atopic dermatitis in the child. Atopic dermatitis is an inflammatory skin disease that is characterised by itching, redness, and scaling of the skin, predominantly in the skin creases. This patient is allergic to citrus fruits. Atopic dermatitis is a systemic chronic allergic disease that occurs in people with an inherited predisposition to atopy and characterized by typical morphological changes of the skin with itching, lesions of the central and autonomic nervous system, endocrine and immune systems with hyper IgE.    Essential criteria for diagnosis: itch, rash elements`, typical morphology and localization (flexor surface of extremities in adults (lichenification), extensor surfaces and face in children (eczema)), chronic recurrent course, atopic diseases in personal and family anamnesis (bronchial asthma, allergic rhinitis).

34. A  22-day-old infant had developed red subcutaneous nodules from 1,0 to 1,5 cm large on the scalp. Later the nodules suppurated, body temperature rose up to 37, 7oC, there appeared symptoms of intoxication, the regional lymph nodes grew bigger. Blood test results: anemia, leukocytosis, neutrophilia, accelerated ESR. What is the most likely diagnosis?

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.
35. A 10-year-old patient complains of skin itch that occurs at night. Objectively: multiple paired papules, burrow tracks in the interdigital skin folds, on the anterolateral surfaces of abdomen and buttocks. Specify the period of regular medical check-up for pupils of the class where the patient learns:

Explanation

Scabies is an itchy skin condition caused by a tiny burrowing mite called Sarcoptes scabiei. Intense itching occurs in the area where the mite burrows. The urge to scratch may be especially strong at night. The first time a person is exposed to the scabies mite, it can take upwards of 2 to 6 weeks for symptoms to develop. So, suspected contacts i.e. pupils of the class where the patient learns can be checked in 6 - 8 weeks (approximately 2 months) to see if they’ve manifested any symptom to the infection.
36. A 7- y e a r - o l d f e m a l e c h i l d h a s developed an acute condition. She complains of a headache, two onsets of vomiting. Objectively: deferred reactions, body temperature - 39, 3oC, pronounced hyperesthesia, nuchal rigidity, positive superior and inferior Brudzinski’s signs, symmetric Kernig’s sign. What is the provisional diagnosis?

Explanation

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

Explanation

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

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

Explanation

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

Explanation

Juvenile rheumatoid arthritis is the most common cause of arthritis in children. The most common features of JRA are: joint inflammation, joint contracture (stiff, bent joint), joint damage and/or alteration or change in growth. Other symptoms include joint stiffness following rest or decreased activity level (also referred to morning stiffness or gelling), and weakness in muscles and other soft tissues around involved joints. Coupled with the presented signs, the age of the patient helps us put the diagnosis of juvenile rheumatoid arthritis. Reactive arthritis is an autoimmune condition that develops in response to an infection in another part of the body. Coming into contact with bacteria and developing an infection can trigger reactive arthritis. It has symptoms similar to various other conditions collectively known as "arthritis,".

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

Explanation

Notice that the patient above experiences abnormal blood discharge with no reproductive organ ( recto-abdominal) pathology; this indicates a case of Dysfunctional Uterine bleeding ( juvenile form- since it occurs at child age and in period of pubescence). A dysfunctional uterine bleeding (DUB) is the bleeding, not associated with organic diseases of women’s genitals, interrupted pregnancy or systemic diseases of the organism. Adenomyosis is a condition in which the inner lining of the uterus (the endometrium) breaks through the muscle wall of the uterus (the myometrium). Adenomyosis can cause menstrual cramps, lower abdominal pressure, and bloating before menstrual periods and can result in heavy periods. Werlhof’s disease is also known as immune thrombocytopenic purpura.

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

Explanation

The term ‘quinsy’ also known as peritonsillar abscess refers to an inflammation of the throat, especially an abscess ( pus filled cavity) in the region of the tonsils. Notice that results from Mesopharyngoscopy shows hyperemia and bulging of the posterior wall of the oropharynx. One major complication of Quinsy is Retropharyngeal abscess which refers to the accumulation of pus behind the pharynx (as seen from the Mesopharyngoscopy ). Other possible  complications include sepsis, pneumonitis etc.

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

Explanation

The above symptoms manifested i.e dyspnea, barking cough, stenotic respiration is a sign of croup that is manifested in Laryngotracheitis, which itself is one of the complications of Measles. Bronchitis will present with productive cough, along with wheezing sound during respiration Pneumonia- for the above question they didn’t mention any characteristic symptoms involving lower respiratory tract like dyspnea on exertion, sputum with green or yellow colour/ rusty sputum Quinsy : comes with throat pain, trouble opening mouth, change of voice but not with barking cough or dyspnea normally.

43. A 13-year-old boy with hypertrophic cardiomyopathy complains of dyspnea on minimal exertion. EhoCG reveals asymmetric left ventricular hypertrophy, signs of pulmonary hypertension, dilatation of the left atrium. EF is 64%. The revealed alterations are indicative of:

Explanation

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

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

Explanation

***
45. A 15-year-old patient consulted a dermatologist about a painful lump in the armpit. Objectively: there is a walnut sized node, lymphadenitis, infiltration of the surrounding tissues. The patient has been diagnosed with hidradenitis. What is the most likely causative agent of this disease?

Explanation

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

Explanation

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

Explanation

The term subarachnoid hemorrhage (SAH) refers to extravasation of blood into the subarachnoid space i.e. the space between the pia and arachnoid membranes. The subarachnoid space is the space where the cerebrospinal fluid (CSF) circulates, therefore, hemorrhage into this space will result in bloody CSF as mentioned in the question or CSF liquor with high content of erythrocytes. The CSF is responsible for protecting your brain from injury by serving as a cushion. A hemorrhage in this space can cause a coma, paralysis, and even death. It is often characterized by a severe headache in adults (often referred to as ‘worst headache of my life’). In newborns, subarachnoid hemorrhages can result from either birth trauma (excessive mechanical force on the baby during birth) or hypoxic-ischemic injury - HIE, (lack of oxygenated blood flow to the brain). The former (birth trauma) is a more common cause in term infants, and the latter (HIE) in preterm infants. Recall that Cerebrospinal fluid is produced by the ependymal cells in the choroid plexus of the third, fourth and lateral ventricles in the brain. It occupies the subarachnoid space i.e., the space between the arachnoid mater and the pia mater; including the ventricular system of the brain and spinal cord.

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

Explanation

Note that the glomerular filtration rate of the kidneys is much lower in neonates than in adults. This implies that if a drug is given, the clearance rate will be much slower in neonates. Due to this fact, antibiotics should be given at longer intervals ( spaced between doses) and at lower doses.
49. Examination of a full-term 6-day-old infant revealed that different areas of skin had erythemas, flaccid bubbles, eroded surface, cracks, peeling of the epidermis looking like being scalded with boiling water. There was positive Nikolsky’s symptom. General condition of the child was serious. The child was restless, hypersensitive, febrile. What is the most likely diagnosis in this case?

Explanation

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

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

Explanation

Recall that diabetes mellitus is a group of metabolic disorders characterized by elevated glucose levels ( hyperglycemia). Type 1 (insulin dependent) and type 2 ( non insulin dependent) are the major forms. Type 1 is the result of an autoimmune response that triggers the destruction of insulin-producing β cells in the pancreas and results in an absolute insulin deficiency. Type 2, which is much more common, has a strong genetic component as well as a significant association with obesity and sedentary lifestyles. Type 2 diabetes is characterized by insulin resistance (insufficient response of peripheral cells to insulin) and pancreatic β cell dysfunction (impaired insulin secretion), resulting in relative insulin deficiency.
51. A 17-year-old male patient consulted a therapist about malaise, chills, runny nose, aching muscles and joints, nausea and diarrhea. The patient asks to prescribe him a lot of painkillers and sedatives (tramadol or solpadein that help the best, and diazepam). Pharyngeal mucosa is pale pink, clean. Auscultation reveals vesicular breathing. Tachycardia is present. The pupils are dilated, there is sluggish response to light. There are injection marks on the forearm skin. During examination, the patient’s manner is vulgar, irritable, rude and untruthful. Make a diagnosis:

Explanation

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

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

-Partial agonists: Buprenorphine

-Mixed agonist/antagonist: Pentazocine-Antagonist: Naloxone, Naltrexone

Treat toxicity with Naloxone (competitive opioid receptor antagonist) and prevent relapse with Naltrexone. The risks of using prescription opioids include dependence and addiction. Dependence means feeling withdrawal symptoms when not taking the drug. Addiction is a chronic brain disease that causes a person to compulsively seek out drugs, even though they cause harm. Common Signs of Opioid Addiction: The inability to control opioid use; Uncontrollable cravings; Drowsiness; Frequent flu-like symptoms; Isolation from family or friends; Stealing from family, friends or businesses; New financial difficulties. This patient has injection marks on the forearms and cravings for Tramadol in addition to showing signs of opioid withdrawal - sweating, dilated pupils, rhinorrhea, lacrimation, nausea, stomach cramps, diarrhea (“flu-like” symptoms), piloerection (“cold turkey”). Flu-like symptoms here include - malaise, chills, runny nose, aching muscles and joints. Even though Solpadein contains both Paracetamol and Caffeine which are Pain killers, the best choice here is Opioid addiction due to the signs of withdrawal manifested by this patient.

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

Explanation

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

Explanation

This patient presents with symptoms that indicates a pathology regarding the pulmonary system. These symptoms include: painful dry cough, diminished breath sounds, crepitus and dullness on percussion. To make a diagnosis, a simple chest x-ray (radiography of the chest cavity ) should be carried out.
54. A newborn has purulent discharges from the umbilical wound, the skin around the navel is swollen. The baby’s skin is pale, with a yellow-gray tint, generalized hemorrhagic rash is present. What is the most likely diagnosis?

Explanation

Sepsis is a medical condition caused by the body’s reaction to an infection. Neonatal sepsis can be caused by organisms such as E. coli, listeria, Group B streptococcus, Herpes simplex virus etc. Conditions that increase the risk of neonatal sepsis include: Preterm birth, early rupture of membrane, chorioamnionitis etc.Key signs include: Fever, vomiting, diarrhea, pale skin with yellow and white tint ( jaundice), irritability, difficulty in breathing and feeding etc. Hemorrhagic disease of  newborn occurs as a result of deficiency in vitamin K or essential blood clotting factors, trauma. It is characterised by excessive bleeding. Hemolytic disease of newborn occurs due to ABO incompatibility or Rhesus Incompatibility between mother and child ( mother -ve, child +ve).

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

Explanation

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

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

Explanation

By definition cerebral edema is the excess accumulation of water in the intra-and/or extracellular spaces of the brain. The most rapid and effective means of decreasing tissue water and brain bulk is osmotherapy. Osmotic therapy is intended to draw water out of the brain by an osmotic gradient and to decrease blood viscosity. These changes would decrease ICP and increase cerebral blood flow (CBF). Mannitol is the most popular osmotic agent. However, prolonged administration of Mannitol results in an electrolyte imbalance that may override its benefits and that must be carefully monitored. Nursing care of the patient receiving Mannitol requires vigilant monitoring of electrolytes and overall fluid balance and observation for the development of cardiopulmonary complications in addition to neurological assessment. Therefore, the best choice is to go for diuretics to prevent some of the complications associated with Mannitol. Furosemide is a loop diuretic with a strong osmotic effect. It has been shown to prolong the reversal of blood brain osmotic gradient established with the osmotic agents by preferentially excreting water over solute. Furosemide is a strong diuretic and acts fast.

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

Explanation

It is recommended that diphtheria, tetanus, and acellular pertussis vaccination be administered across the lifespan. Children younger than 7 years of age receive DTaP or DT, while older children and adults receive Td. D- Diphtheria; T- Tetanus; P- Pertussis (Whooping cough); aP- acellular pertussis vaccine.

  • Give infants and children 5 doses of DTaP. Give one dose at each of these ages: 2 months, 4 months, 6 months, 15 through 18 months, and 4 through 6 years. 
  • Give adolescents a single dose of Tdap, preferably at 11 to 12 years of age.

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

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

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

Explanation

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

Occipital Alopecia: occurs in about 30%.

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

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

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

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

Explanation

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

Explanation

Under the influence of maternal hormones during pregnancy a newborn may exhibit signs of hormone exposure after birth. Hormones from the mother (maternal hormones) are some of the chemicals that pass through the placenta into the baby's blood during pregnancy. These hormones can affect the baby. For example, pregnant women produce high levels of the hormone estrogen. This causes breast enlargement in the mother. By the third day after birth, breast swelling may also be seen in newborn boys and girls. Such newborn breast swelling does not last, but it is a common concern among new parents. The breast swelling should go away by the second week after birth as the hormones leave the newborn's body. Hormones from the mother may also cause some fluid to leak from the infant's nipples. This is called witch's milk. It is common and most often goes away within 2 weeks. Newborn girls may also have temporary changes in the vaginal area.

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

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

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

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

61. A 12-year-old boy presents with nausea, frequent repeated vomiting that first occurred after eating canned vegetables. Objectively: the patient has dry mucous membranes, muscular hypotonia, anisocoria, mydriasis, dysphagia and dysarthria. What is the most likely diagnosis?

Explanation

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

Explanation

Shoulder dystocia refers to a situation where, after delivery of the head, the anterior shoulder of the fetus becomes impacted on the maternal pubic symphysis, or (less commonly) the posterior shoulder becomes impacted on the sacral promontory. One major complication of this state is an injury to the brachial plexus. The brachial plexus is a network of nerves made up the anterior rami of the lowest four cervical nerves and the first thoracic nerve ( C5-C8 & Th1). The brachial plexus provides nerve supply to the skin and muscles of the arms ( except the trapezius and an area close to the axilla ; an injury to the brachial plexus affects the sensation and movement of different parts of the arm. The Moro reflex is an infantile reflex that develops between 28–32 weeks of gestation and disappears between 3–6 months of age. It is a response to a sudden loss of support and involves three distinct components.: spreading out the arms (abduction), pulling the arms in (adduction), crying (usually).

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

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

Explanation

Many babies born with a small ventricular septal defect (VSD) won't need surgery to close the hole. After birth, the doctor may want to observe the baby and treat symptoms while waiting to see if the defect closes on its own. Babies who need surgical repair often have the procedure in their first year. Children and adults who have a medium or large ventricular septal defect or one that's causing significant symptoms may need surgery to close the defect. With this 5 year old boy already having exertional dyspnea, fatigability and in the sub compensation stage, it is an indication for Surgery in order to close the defect. Surgical treatment for ventricular septal defects involves plugging or patching the abnormal opening between the ventricles.

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

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

Explanation

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

Explanation

***
66. During the preventive examination a 17-year-old young man reports no health problems. Objectively: the patient is undernourished, asthenic; blood pressure is 110/70 mm Hg, Ps- 80/min. Heart borders are within normal range. Auscultation reveals three apical heart sounds, murmurs are absent. ECG shows no pathological changes, PCG registers the S3 occurring 0,15 seconds after the S2. How can you interpret these changes?

Explanation

A physiological third heart sound (S3) is common in youth but allegedly very rare after the age of 40 years. A physiological third heart sound (S3) can be heard in practically all healthy children and adolescents but rarely in individuals after the age of 40 years. After age 40, a third heart sound is usually abnormal and correlates with dysfunction or volume overload of the ventricles. The third heart sound (S3) is a low-frequency, brief vibration occurring in early diastole at the end of the rapid diastolic filling period of the right or left ventricle. It is physiologic because it is not related to any pathology at any age before 40 years. Patient is 17years, has no health problems, murmurs are absent and ECG shows no pathological changes. There is no physiologic S4 and all other options listed are signs of different heart pathologies.

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

Explanation

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

Obnubilation is a state of clouding of consciousness and stupor. 

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

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

Explanation

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

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

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

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

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

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

Explanation

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

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

70. An 8-year-old child was hospitalized for fever up to 39, 8oC, inertness, moderate headache, vomiting. Examination revealed meningeal symptoms. Lumbar puncture was performed. The obtained fluid had raised opening pressure, it was transparent, with the cell count of 450 cells per 1 mcL (mainly lymphocytes - 90%), glucose level of 2,6mmol/l. What causative agent might have caused the disease in the child?

Explanation

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

Explanation

***
72. A 51-year-old man complains of vomiting with blood. He has been drinking alcohol excessively. Health disorder has been observed since he was 40, when he first developed jaundice. On examination the skin and visible mucosa are icteric, with a stellate vascular pattern. The patient is malnourished and presents with abdominal distension, umbilical hernia, and ascites. The edge of the liver is tapered and painless, +3 cm, the spleen is +2 cm. Blood test: Hb - 80 g/L, leukocytes -3∙109/L, platelets - 85∙109/L. What is the cause of portal hypertension in this patient?

Explanation

***
73. During an outdoors school event in hot weather, a 10-year-old girl lost her consciousness. Body temperature - 36.7°C. Objectively her skin is pale and cold to touch, her pupils are dilated. Blood pressure - 90/50 mm Hg. Heart rate - 58/min. What pathology occurred in this case?

Explanation

The Spearman's Rank Correlation Coefficient is used to discover the strength of a link between two sets of data. This example looks at the strength of the link between the immunization rate of children and measles incidence rate by district.

Correlation is a bivariate analysis that measures the strength of association between two variables and the direction of the relationship.  In terms of the strength of relationship, the value of the correlation coefficient varies between +1 and -1.  A value of ± 1 indicates a perfect degree of association between the two variables.  As the correlation coefficient value goes towards 0, the relationship between the two variables will be weaker.  A correlation coefficient of zero indicates that no relationship exists between the variables. The direction of the relationship is indicated by the sign of the coefficient; a + sign indicates a positive relationship and a – sign indicates a negative relationship.

An inverse correlation, also known as negative correlation, is a contrary relationship between two variables such that when the value of one variable is high then the value of the other variable is probably low. 

In this case, it is expected that as the immunization rate increases, measles incidence should decrease.

74. 10 hours after birth a child developed jaundice, hypotonia, hyporeflexia, and moderate hepatosplenomegaly. Feces and urine are of normal color. Umbilical cord blood bilirubin is 51cmol/L due to unconjugated bilirubin levels. In venous blood: erythrocytes - 3.5∙1012/L, Hb - 140g/L, reticulocytes - 1.5%, bilirubin - 111 mcmol/L, conjugated - 11 mcmol/L, ALT - 40 U/L, AST - 30U/L. Mother’s blood group is A(II) Rh(-), child’s blood group is A(II) Rh(+). What laboratory test can confirm the diagnosis?

Explanation

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

Associated with Pain in weight bearing joints commonly experienced after use (i.e. at the end of the day), and the pain improves with rest. The pain associated with OA could also be precipitated by trauma.

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. Rheumatoid Arthritis: 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.

75. 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 changes in the central nervous, cardiovascular, and respiratory systems. What provisional diagnosis can be made?

Explanation

76. The 5-year-old child has been ill for 2 weeks. Cough attacks developed first and were then followed by reprises. During coughing the child’s face turns red and cervical veins bulge. The cough attacks induce vomiting. X- ray shows intensified bronchial pattern. Blood test: leukocytes-16∙109/L , lymphocytes - 72%, erythrocyte sedimentation rate - 4 mm/hour. What is the most likely diagnosis?

Explanation

77. A 6-month-old child on breastfeeding is hospitalized in the inpatient department. After the child recovers, the doctor recommends the mother to start introducing solid food to the child’s diet. What products should be introduced to the child’s diet first?

Explanation

78. A 16-year-old girl has primary amenorrhea, no pubic hair growth, normally developed mammary glands; her genotype is 46 XY; uterus and vagina are absent. What is your diagnosis?

Explanation

79. A 17-year-old girl has made an appointment with the doctor. She plans to begin her sex life. No signs of gynecological pathology were detected. In the family history the patient’s grandmother had cervical cancer. The patient was consulted about the maintenance of her reproductive health. What recommendation will be the most helpful for prevention of invasive cervical cancer?

Explanation

80. An 11-year-old boy for a month has been presenting with increasing pain in the right femur. In the painful area there is a non mobile painful tumor with unclear margins. The child complains of general indisposition, weakness, increased body temperature up to 39°C. X-ray shows widened medullary cavity, small foci of cancellous bone destruction, and onion-like lamellar exfoliation of the cortical layer. What is the most likely pathology resulting in such clinical presentation?

Explanation

81. During medical examination of high and middle school students, the doctors vere assessing correlation between biological and calendar age of the school students based on the following criteria: height growth rate per year, ossification of the carpal bones, the number of permanent teeth. What additional development criterion should be assessed at this age?

Explanation

82. A 3-week-old infant developed large, flaccid vesicles with purulent contents on the skin of chest and abdomen. The vesicles rupture quickly. Make the provisional diagnosis:

Explanation

83. A child is 1 year old. After solid food was introduced into the diet, within the last several months the child developed loss of appetite, diarrhea with large amount of feces, and occasional vomiting. Body temperature remains normal. Body weight is 7 kg. The child is very pale, has leg edemas and extremely distended abdomen. Feces analysis detects high levels of fatty acids and soaps. Diagnosis of celiac disease was made and gluten-free diet was prescribed. What should be excluded from the diet in this case?

Explanation

84. A 10-year-old boy with symptoms of arthritis and myocarditis was brought to a hospital. Based on clinical examination the provisional diagnosis of juvenile rheumatoid arthritis was made. What symptom is the most contributive for the diagnostics of this disease?

Explanation

85. A 14-year-old girl came to the general practitioner with complaints of weakness, loss of appetite, headache, rapid fatigability. Her last menstruation was profuse and lasted for 14 days after the 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

86. A 7-year-old boy has severe pulmonary mucoviscidosis (cystic fibrosis). He complains of dyspnea and blood expectoration. Objectively he presents with lagging physical development, acrocyanosis, hepatomegaly, drumstick fingers, and nail plates resembling a ”clock face”. Provisional diagnosis of chronic pulmonary heart disease is made. What examination would be the most informative for diagnosis confirmation?

Explanation

A doppler echocardiography is a diagnostic method for heart related issues. It is a combination of an echocardiogram (which uses sound waves to create an image of the heart) and a doppler technology ( which shows the velocity ie, speed and direction of blood flow in cardiac tissues). An Electrocardiography shows the electrical activity of the heart. In patients with cystic fibrosis (CF), continuous pulmonary infection and inflammation with thickened secretions cause airways obstruction and hyperinflation. As the disease progresses, these patients develop disabling lung disease and eventually respiratory failure and pulmonary hypertension (PH). PH is considered to be a consequence of several mechanisms that either raise the pressure downstream of the pulmonary capillaries, induce vasoconstriction, increase blood flow to the lung, or obstruct the pulmonary vessels either by embolism or in situ fibrosis. The echocardiogram is an integral part of the evaluation of a patient with PH. Common echocardiographic findings in PH includes right atrial and right ventricular (RV) enlargement, reduced RV function, displacement of the intraventricular septum to the left, and tricuspid regurgitation that permits the estimation of the pulmonary artery systolic pressure (PASP). Therefore, Doppler echocardiography will be the best choice to evaluate a patient with a chronic pulmonary heart disease.

87. A 10-year-old boy, who was outdoors in windy and cold weather, developed moderate pain and tingling in his fingers and toes. When he had returned home, his parents noticed that the tips of his fingers and toes were white and their sensitivity was lost. The affected areas are warming up, the fingers are tingling and in pain. Skin pallor changed into redness, tingling stopped, slight itching and swelling of the fingers appeared. Determine the frostbite degree in this child

Explanation

Frostbite is an injury of the skin and underlying tissues that occur due to exposure to cold ( low temperature). There are 4 degrees of frostbite: I Degree: lasts for about 5-7 days; after warming, paleness changes to hyperemia (redness). Edema of tissues progresses for about 2 days and then it decreases to 6-7 days when shelling (peeling) of epidermis appears. Tactile and pain sensitiveness (sensation) are preserved but sometimes with disorders.  Pain in injured areas could be severe, itching also could be. II Degree: characterised by the spreading of edema, appearance of bullaes. The bottom of the opened bullaes are covered with fibrin. Cyanotic skin and difficulty of movement of phalanges. Necrosis of keratic and granular layers. N/B growth layer of the skin is not lost and regeneration appears after 2 weeks. Scars are not formed. III Degree: Necrosis of all skin layers or even fatty tissue appears. Inflammation develops: firstly aseptic and then on 5th- 7th day purulent . Bullas contain blood . Decrease of tactile and temperature sensation. Edema of tissues spreads on the proximal areas. Firstly skin has cyanotic color then dark brown and black crusts are formed. IV Degree: Necrosis of all skin, fat tissue and even bones and joints. Results in amputation of the affected area.

88. A 12-year-old boy with hypertrophic cardiomyopathy complains of dyspnea caused by the slightest physical exertion. Echocardiography detected asymmetrical left ventricularhM hypertrophy, signs of pulmonary hypertension,aM and left ventricular dilatation, its ejection fraction is 59%. These developments are indicative of

Explanation

Ejection fraction refers to how much blood the heart ( left ventricle) pumps at a single contraction.  It ranges from 55%-75%. Heart failure is observed when the heart is unable to meet up with the body's blood and oxygen demand. This is either due to inadequate contraction of the heart (weak heart muscles) or not enough filling of the heart during relaxation majorly as a result of stiffness of the walls. Heart failure due to weak heart muscles ( reduced contractility power) is referred to heart failure with reduced ejection fraction. Heart failure due to inadequate filling of the ventricle during relaxation but with normal heart contraction is referred to as a Heart failure with preserved ejection fraction.

89. A 9-month-old infant presents with delayed tooth eruption and fontanel closure, weakness, and excessive sweating. What type of hypovitaminosis is the most likely in this child?

Explanation

The symptom of delayed fontanelle closure and tooth eruption indicates the 9 month old baby has issues in relation to reduced calcium levels ( calcium is responsible for formation/modelling of bones and teeth). In relation to vitamins, vitamin D is responsible for the intestinal absorption of elements like calcium, magnesium etc. In humans, vit D₃- cholecalciferol and D₂- ergocalciferol are the most important. Deficiency of vitamin D will lead to Rickets (in children) and osteoporosis(in adults). Vitamin C deficiency will lead to scurvy characterised by bleeding gums, petechial bleeding ( small hemorrhages) Vitamin B1 deficiency leads to Beri-Beri, Vit A deficiency results in night blindness.

90. A 10-year-old girl exhibits high level of physical development ( + 3σ), her body length increased by 10 cm within a year (which is double the norm for her age group), the number of permanent teeth corresponds with the age norm (20), the development of her secondary sex characteristics is three years ahead of her age (Ма, Р, Ах, Menarche). Development rate ahead of her biological age can occur due to:

Explanation

Realise that the 10 year old girl experiences an acceleration in both physical development and sexual characteristics; this indicates that she has a high level of the growth hormone ( somatotropin) either due to increased production, increased receptors or decreased clearance. Somatotropin is a peptide hormone produced by the anterior pituitary gland. Hormones and glands make up the endocrine system.
91. 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 50cm. Objectively: the skin is flabby, the layer of subcutaneous fat is thin, hypomyotonia, neonatal reflexes are weak. The internal organs are without pathologic changes. 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 ( 2500g). This underweight is due to complications that occurred during gestation as stated “The pregnancy was complicated with severe gestosis of 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.

92. A 16-year-old adolescent living in a rural area has been bitten in the shin by a stray dog. The wound is superficial. Regular vaccination against tetanus was received 3 months ago. What treatment tactics would be the most advisable in this case?

Explanation

Rabies is a viral disease humans get via an infected dog’s bite. For its remedy, the anti rabies vaccine is used. It is a recombinant vaccine.

93. During examination a 4-month-old child with meningococcemia presents with acrocyanosis, cold extremities, tachypnea, and thready pulse, blood pressure of 30/0 mm Hg, anuria, and sopor. What clinical syndrome is it?

Explanation

Septic shock is a type of distributive shock, caused by generalized reaction of the organism to microorganisms and their toxins. Its etiology can be connected with gram positive and gram negative bacteria, rickettsia or fungi and any mucosa can be their entrance (intestine, abdominal cavity, urinary tracts, wound surface). When the toxins get to the blood flow tissue macrophages answer their appearance with production of cytokines. Cytokines are mediators of systemic inflammatory response; they trigger a whole number of immune reactions (both humoral and cellular immune response). This leads to circulation and microcirculation disorders and thus to tissue hypoperfusion and tissue anoxemia.

94. The right arm of a newborn is stretched along the torso with all its joints extended; the shoulder is rotated inwards, while the forearm is pronated, the hand is in the position of palmar flexion. Spontaneous movements are absent in the shoulder and elbow joints, passive movements are painless. What is the most likely diagnosis?

Explanation

Duchenne-Erb's palsy is a form of brachial plexus palsy. Erb's palsy leads to a weakness of a newborn baby's arm. It is caused by a stretch injury to the brachial plexus ( C5-C6). The brachial plexus is a network of nerves near the neck that give rise to all the nerves of the arm. These nerves provide movement and feeling to the arm, hand, and fingers (note that - Spontaneous movements are absent in the shoulder and elbow joints, passive movements are painless). Klumpke paralysis (C7-8, T1) results in weakness of the intrinsic muscles of the hand; grasp reflex is absent. If cervical sympathetic fibers of the first thoracic spinal nerve are involved, Horner syndrome is present.

95. A 1-year-old child with a case of URTI suddenly developed noisy respirations with difficult inspiration, intercostal retractions, and barking cough on the 2nd night after the disease onset. What is the most likely diagnosis?

Explanation

The patient presents with symptoms of croup also called laryngotracheobronchitis; classic symptoms include barking cough, noisy breathing (stridor), intercostal retraction (hoover’s sign). This can be caused by a virus ( parainfluenza, influenza A or B) or bacteria (corynebacterium diphtheriae, staph. Aureus, strep pneumonia etc). It is most commonly seen in children aged 6 months- 5years.

96. 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.

97. A 7-year-old boy has been an inpatient for 1.5 months. He had been delivered to the hospital with complaints of edemas all over his body, low urine output, and headache. Clinical urinalysis: proteins - 7.1 g/L, leukocytes - 1-2 in the vision field, erythrocytes - 3-4 in the vision fi- eld. During the course of treatment the edemas gradually dissipated, headache abated, diuresis normalized. Daily urine proteins - 3 g/L. Biochemical blood test: total protein - 43.2 g/L,urea - 5.2 mmol/L, cholesterol - 9.2 mmol/L. What glomerulonephritis syndrome is the most likely to be present in the patient?

Explanation

Nephrotic Syndrome - Massive proteinuria (> 3.5g/ day) with hypoalbuminemia, edema (due to decrease in oncotic pressure). Occurs due to podocyte damage, focal segmental glomerulosclerosis, membranous nephropathy, amyloidosis or diabetic glomerulonephropathy. Nephritic Syndrome- usually due to glomerular inflammation which further damages the glomerular basement membrane, loss of rbc into urine leading to hematuria. Occurs in acute post streptococcal glomerulonephritis, rapidly progressive glomerulonephritis, IgA nephropathy, Alport syndrome, membranoproliferative glomerulonephritis. Observe that the patient loses about 7.1g of protein per litre of urine daily  (> 3.5g/ day) and also presents with edema which indicates a nephrotic syndrome.

98. The mother of a 3-month-old child came to a family doctor with complaints of her child being physical 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 first 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 is an autosomal recessive defect in CFTR gene ( Cystic Fibrosis Transmembrane Regulator ). This gene encodes  an ATP gated Cl ion channel that secretes Cl in lungs and GI tract and reabsorbs Cl in sweat glands. The hallmarks of cystic fibrosis are salty tasting skin, normal appetite but poor growth and poor weight gain, excess mucus production, and coughing/shortness of breath……..

99. A 5-year-old child that contacts with viral hepatitis in the kindergarten presents with increased body temperature up to 38oC, weakness, low appetite, single case of vomiting, dull pain in the subcostal area on the right. The child is provisionally diagnosed with viral hepatitis. What examination would be the most informative for diagnosis confirmation?

Explanation

Alanine Transaminase (ALT) is a transaminase enzyme primarily found in the liver and kidneys. An Elevation in ALT (liver function test) levels is used in diagnosing liver pathologies such as cirrhosis, hepatitis, liver cancer etc.

100. 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

***
101. A 14-year-old boy presents with moderate bronchial asthma in its exacerbation period. What drug should be prescribed to stop an acute attack of expiratory dyspnea?

Explanation

The symptoms of Bronchial Asthma are as a result of bronchoconstriction - expiratory dyspnea, wheezing, shortness of breath etc. Salbutamol is a short-acting beta 2 agonist (another example is Albuterol) commonly used in clinical practice as an emergency antiasthmatic agent because of its fast acting quality. Beta 2 receptors are found in the bronchioles of lungs and the arteries of skeletal muscles. This drug dilates (opens up) the bronchi (bronchodilation). Short acting beta agonists are the same medications as those in your quick-acting inhaler. Other medications that can be used to treat emergency asthma attacks are Oral corticosteroids, Ipratropium, Oxygen. Cromolyn sodium is a mast cell stabilizer, it prevents the release of Histamine and other inflammatory mediators. Dexamethasone is a glucocorticoid, it has anti inflammatory, immunosuppressive and antipyretic effects.

102. 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.

103. A 16-year-old girl has primary amenorrhea, no pubic hair growth, normally developed mammary glands; her genotype is 46 ХY; uterus and vagina are absent. What is your diagnosis?

Explanation

Testicular Feminization syndrome also called Complete androgen insensitivity syndrome is a genetic anomaly in which an XY fetus has a defect in androgen receptors leading to a feminine appearance. Usually presents with an absent uterus and fallopian tubes, a rudimentary vagina, scanty or no pubic hair growth, normal and functioning testes etc Genotype 46XY. Mayer-Rokitansky-Kuster-Hauser syndrome is also called Mullerian Agenesis. A failure in the development of the mullerian duct which leads to uterus, cervix agenesis and vaginal hypoplasia. Secondary sexual characteristics are normal in such individuals because Ovaries do not develop from the mullerian duct.

104. 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 moon-like 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.

105. A 9-year-old girl complains of fever up to 38.5oC, headache, inertness, weakness, loss of appetite, stomachache, and frequent painful urination. Provisional diagnosis of acute pyelonephritis is made. Clinical urine analysis: specific gravity - 1016, no protein, leukocytes- 10-15 in the vision field. What investigation method can verify the diagnosis of urinary tract 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.

106. A newborn has Apgar score of 9. When should the infant be put to the breast?

Explanation

An apgar score is a test used in assessment of the health of a newborn child. In this test, the skin colour, pulse rate, irritability, muscle tone and respiration are checked and scored individually between 0-2. A score of 7 and above means the baby is normal, 4-6 is fairly low, 3 below refers to a critical condition; immediate actions to restore the child’s health should be taken. For a baby with normal response, he/she should be taken immediately to the mother to be breastfed.

107. A woman with blood group B(III) Rh(+) gave birth to a full-term healthy boy. Examination on the 3rd day of the infant’s life shows him to have icteric tint to his skin. The child has no problems with suckling, sleep is nondisturbed. The abdomen is soft, the liver protrudes by 2 cm from under the costal margin. Complete blood count: hemoglobin -200 g/L, erythrocytes - 5.5 · 1012/L, total bilirubin - 62 mcmol/L, indirect bilirubin - 52mcmol/L. What condition can be suspected?

Explanation

Due to the inability of the fetal liver to conjugate and quickly excrete the increased amount of bilirubin after birth, a buildup of bilirubin in the blood takes place in the newborn. These accumulated products are deposited in areas like mucous membrane, eyes, skin and in complicated cases- brain. This process is termed ‘Physiological Jaundice’; it occurs within the first 24hrs of birth and resolves without treatment in 1-2 weeks. Hemolytic disease of the newborn due to Rh incompatibility occurs when an Rh- mother presents with an Rh+ fetus. In the first pregnancy, the mother is exposed to fetal blood and forms a maternal anti-D IgG. In subsequent pregnancies, the anti-D IgG crosses the placenta, attacks fetal RBCs and leads to hemolysis in the fetus. Hemolytic disease of the newborn due to ABO incompatibility occurs when a type O mother presents with a type A or type B  fetus. Pre-existing maternal anti-A or anti-B IgG antibodies cross the placenta leading to hemolysis in the fetus.

108. A 3-day-old infant with hyperbilirubinemia (428 mcmol/L) developed disturbances manifesting as periodical excitation and convulsions against the background of inertness, hypotension, hypodynamia, and inhibition of unconditioned reflexes, convergent strabismus, rotational nystagmus, and setting sun eye phenomenon. What is the most likely cause of such symptoms?

Explanation

Newborns are at a high risk of developing encephalopathy caused by hyperbilirubinemia due to the fact that soon after birth, the infant’s liver gets busy in fetal hemoglobin breakdown (which is later replaced by the adult form) and as a result, the conjugation process of bilirubin  is slowed down leading to an accumulation of unconjugated bilirubin in the blood. Coupled with  a not too developed blood brain barrier, the accumulated bilirubin easily goes across the barrier leading to encephalopathy.

109. A 15-year-old adolescent girl came the gynecologist with complaints of painful menstruations that are accompanied by nausea, vomiting, and dizziness. Her menarche was at 12. Menstruations became painful since she was 14, remain regular. What treatment should be prescribed in this case?

Explanation

Menarche refers to the first menstrual cycle. Painful menstruation (dysmenorrhea) expresses as cramping pain in the abdomen, it is most times associated with symptoms such as lower back pain, nausea, diarrhea, and headaches. These muscle cramps occur as a result of increased prostaglandin levels produced from the uterus. These prostaglandins cause the uterus to continuously tighten and relax, leading to cramps. For treatment, the patient can be given NSAIDs - for pain and anti-inflammatory effect; Antispasmodics- for relaxation of muscles and antiprostaglandin therapy- to reduce the amount and effect of prostaglandins produced.

110. A 3-year-old child presents with sharp deterioration of his general condition. He has a history of purulent otitis. His temperature is now 38.5oC. The left leg is pressed to the torso, active movements are absent, the lower third of the thigh and knee joint are thickened, hyperemic, with localized fever. Axial load leads to acute discomfort of the patient. What is the most likely diagnosis?

Explanation

The patient has a history of purulent otitis ( a purulent inflammation of the middle ear) mostly as a result of an infection (confirmed by the increased temperature). From the description above, we can draw out that the patient has an infection around the knee joint ( knee joint is thickened, hyperemic, with localized fever). Osteomyelitis ( a rare infection of the bone) is the best possible choice.

111. A 1.5-month-old child on breastfeeding presents from birth with daily vomiting, irregular liquid foamy feces, and flatulence, which are resistant to antibacterial and probiotic therapy; no increase of body mass is observed. The child’s condition improved, when breastmilk was substituted. What pathology is it?

Explanation

The baby presented with the above stated symptoms only when  given breast milk. Meaning the symptoms are as a result of the constituents of the breast milk (lactose). This baby is termed ‘ lactose intolerant’ due to the inability to digest products containing lactose. This is due to the deficiency of the enzyme Lactase responsible for the breakdown of lactose into glucose and galactose.
112. During regular examination of a 2-year-old boy, he presents with enlarged left kidney, painless on palpation. The right kidney was undetectable on palpation. Excretory urography shows no contrast on the right. Cytoscopy detected hemiatrophy of the urinary bladder trigone, the right ureteral orifice is not detected. What pathology is it?

Explanation

An agenesis is the failure of an organ to develop. From the above analysis, we observe an undetected right kidney on palpation; an absent contrast on the right during excretory urography indicates no organ located ( supported by an incomplete bladder trigone) - coupled with the patient’s age, we can conclude that development of the right kidney never took place. A compensatory hypertrophy/ hyperplasia of the left kidney occured in order to meet the body’s requirement.

113. A 5-year-old child has body temperature risen up to febrile numbers, suffers from inertness, weakness. Examination revealed hemorrhage on the skin of limbs and torso. Enlargement of cervical and axillary lymph nodes can be detected. The liver is 4 cm below the costal arch; the spleen is 6 cm below the costal arch. Blood test: erythrocytes- 2.3 · 1012/L, Hb- 60 g/L, platelets - 40 · 109/L, leukocytes - 32.8 · 109/L, eosinophiles - 1%,band neutrophiles - 1%, segmented neutrophiles - 12%, lymphocytes - 46%, monocytes - 1%, blasts - 40%, Duke’s bleeding time test result is 9 min. What examination is necessary to make the diagnosis?

Explanation

Notice that from the above analysis, the platelet level is relatively low (150 − 400 · 109/L is the normal). This is confirmed in the result of the duke test being 9 minutes - prolonged ( normal is 2-5 ). The  Duke test is done to check the bleeding time , it is a platelet function test. An abnormality indicates diseases such as von wilirend,thrombocytopenia, DIC etc.  Recall that platelets originate from large bone marrow cells  and a bone marrow biopsy will be most helpful in analysis amongst all the above listed.

114. 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.

115. An 8-year-old girl with complaints of painful urination, frequent low volume urination, and leukocyturia was diagnosed with acute cystitis. 10 days before the disease onset she was treated by the gynecologist for acute vulvitis. 5 days ago she presented with mild catarrhal symptoms. Her mother ascribes the child’s disease to her overexposure to cold. Specify the most likely infection route:

Explanation

Notice that the patient presents with a history of vulvitis ( inflammation of the vulva) and a urinary tract infection. The more common mode of UTIs is through the ascending pathway, where fecal flora gain access to the urinary tract via colonization of the urethra. Descending infections are the result of hematogenous spread of bacteria from a primary source located elsewhere in the body.

116. A 5-year-old boy complains of severe dyspnea and sensation of lack of air. Objectively the child assumes orthopneic position, presents with marked peripheral cyanosis, drumstick fingers, nail plates resembling a \\\"clock face”, the borders of cardiac dullness are bilaterally extended; coarse systolic murmur can be detected over the whole surface of the heart and is especially pronounced in the II inter costal area on the left near the sternum. What disease can be characterized by such presentations?

Explanation

Tetralogy of fallot is a combination of four congenital heart defects; they include- pulmonary valve stenosis, ventricular septal defect,  hypertrophy of the right ventricle and an overriding aorta. Symptoms include; a heart murmur, clubbing of the fingers (drumstick fingers), cyanosis, prolonged crying, poor weight gain etc ; majority of which are seen in the described patient…………..

117. 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 100ml. 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 mmHg, 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.

118. An 8-year-old child presents with blood pressure up to 180/100 mm Hg in the upper limbs accompanied by headaches, tinnitus, occasional nosebleeds, and high fatigability. On examination there is no pulse over the leg arteries. ECG shows left ventricular hypertrophy. MRI-scan shows aortic narrowing to 5 mm in the typical place. Coarctation of aorta is diagnosed. What kind of treatment should be prescribed in this case?

Explanation

The patient is diagnosed with coarctation of the aorta which refers to the narrowing of the aorta leading to reduced  blood flow to various parts of the body. Treatment approaches usually consist of surgery or a procedure called balloon angioplasty or stent placement. The various types of surgery include; Bypass graft repair, Subclavian flap aortoplasty. Resection with end-to-end anastomosis etc. Medication/ conservative treatment isn't used to repair coarctation of the aorta, but it might be used to control blood pressure before and after stent or surgery.

119. A 6-year-old girl arrived to the in-patient unit with complaints of enlargement of the lower third of her right thigh. According to the case history, she has been stepping carefully on her right leg and limping for 6 months. Blood test detected anemia. X-ray of the right thigh shows a round bone defect with clear margins resembling melting sugar in the distal metaphysis. What provisional diagnosis can be made in this case?

Explanation

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

120. A 15-year-old girl suffers from systemic lupus erythematosus and has been receiving prednisolone therapy in the daily dosage of 2mg/kg for the last 6 weeks. The plans are made to gradually lower the dosage of the medicine. No clinical signs of her disease are observed.  Previously she has received no immunization against measles. Due to measles outbreak it is necessary to develop the immunity against this infection in the patient. When can she be vaccinated?

Explanation

For specific prevention of Measles, the MMR vaccine is used (measles, mumps and rubella). It is a live/attenuated vaccine administered at the age of 12 months, Revaccination at 4 to 6 years or at 10 to 11 years.After contact with measles, unvaccinated persons under 30 years of age without a history of measles or any contraindication for vaccination should be vaccinated  with measles vaccine not later than 72 hours after the contact.  Recall that the patient has no previous record of measles vaccination and due to the outbreak of measles, she should immediately be vaccinated ( or within the next 72 hours)

121. A healthy child 1 year and 5 months of age is being vaccinated against hepatitis B. The child did not receive the first dose of the vaccine previously, while in the maternity hospital. The doctor makes an individual vaccination schedule for this child and plans the administration of the next dose of the vaccine. What is the minimum interval between doses of vaccine in this case?

Explanation

A minimum interval is the shortest time between two doses in a vaccination series. The Hepatitis B vaccination is given in a three dose series; First dose at birth, second Between 1-2 months and the third dose is given between the 6th-15th month. Examples of the hepatitis B vaccines are Engerix-B and Recombivax HB; the minimum interval between the first and second doses is 4 weeks. An adult taking the Hepatitis B vaccine will take 3 doses one month apart. For example, as an adult, if you take the first dose 1st March, next dose will be 1st April and the last dose will be 1st May.

122. A 6-month-old infant is not vaccinated. The physician recommends a DPT (diphtheria, pertussis, tetanus) vaccination but the mother is absolutely against this procedure. Choose the most substantial argument in favor of vaccination:

Explanation

There are a variety of reasons behind vaccine opposition. Some people have to forgo different vaccinations due to a high risk of potential allergic reactions, religious beliefs, mistrust of pharmaceutical companies, post vaccination complications such as autism. As a medical personnel, it is important to explain to these individuals the risk of staying unvaccinated stressing on the fact that these individuals risk exposure and stay unprotected to a wide range of diseases which in a long run will cause more damages (lethal consequences).

123. During administration of planned DPT vaccination the child suddenly developed acute anxiety, signs of pain response, dyspnea, grunting respirations, cutis marmorata, cold sweat. Objectively the child’s consciousness is disturbed, heart rate is 150/min., blood pressure is 60/40 mm Hg, heart sounds are muffled. The child was diagnosed with anaphylactic shock. What drug should be administered first?

Explanation

Anaphylactic shock is a medical emergency that may require resuscitation measures such as airway management, supplemental oxygen, large volumes of intravenous fluids, and close monitoring. Administration of epinephrine is the treatment of choice with antihistamines and steroids often used as adjuncts. It is recommended that an epinephrine solution be given intramuscularly into the mid anterolateral thigh as soon as the diagnosis is suspected. The injection may be repeated every 5 to 15 minutes if there is insufficient response. A second dose is needed in 16-35% of episodes. with more than two doses rarely required. The intramuscular route is preferred over subcutaneous administration because the latter may have delayed absorption. Minor adverse effects from epinephrine include tremors, anxiety, headaches, and palpitations.

124. Among first-year schoolchildren there was a case of measles registered. A 7-year-old boy from the same group was not vaccinated against measles due to refusal of his parents. His clinical history has no cases of measles in the past and is not contraindicatory to immunobiological agents. Choose the most rational tactics of measles prevention in this schoolboy:

Explanation

The boy has not been vaccinated therefore, the most rational decision will be to vaccinate him after convincing his parents to carry out the procedure, MMR vaccine is a combined vaccine usually administered at the age of 12 months.

125. 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

***
126. 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.
127. 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

***
128. 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.

129. 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.

130. 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 per1 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.

131. 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.

132. 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)

133. 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 normal inward curvatures of the spine at the cervical and lumbar regions, while kyphosis refers to the normal outward curvature of the spine specifically at the thoracic region. Scoliosis which always refers to the abnormal sideways curves of the spine.

134. 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.
135. An infant cries during urination, the foreskin swells and urine is excreted in drops. What approach to treatment should be chosen?

Explanation

An opening should be created on the foreskin in order to evacuate the urine. A urine bladder catheterization is used to evacuate urine in cases of bladder pathologies.

136. 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

***
137. 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 pea sized 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

Neonatal impetigo (Impetigo Neonatorum), also known as neonatal Pemphigus (Pemphigus Neonatorum), occurred in a newborn as a suppurative acute infectious skin disease, rapid onset, infectious intensity. Primary lessons are bullae which progress into blisters, rupture and cause erosions.......

138. 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 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.
139. 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.

140. 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.

141. 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

Recall that on an ecg, P wave shows Atrial depolarization ( contraction), QRS- ventricular depolarization (contraction) and T wave- ventricular repolarization (relaxation).  The above patient presents with a tachycardia and a P and T wave overlap…………
142. 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 150/100mm 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.

143. 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

Children with biliary atresia often present with an absent or very tiny gallbladder, a nonvisual common bile duct; In this condition bile ducts in and out of the liver are either scarred or blocked…………
144. 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 per1 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.

145. 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

***
146. 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 Erb duchenne 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.

147. 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

***
148. 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. Blast cells are immature WBC. Presence of 70% of Blast cells in the analysis indicates an acute form of leukemia. Less than 10% of blast cells will indicate a chronic form. Ithrombocytopenic 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).

149. 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.

150. During last several weeks an 11-year-old 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 peripheral (lower extremity edema), pulmonary and abdominal edema (ascites). This is because the heart is too weak to pump blood around the body properly, so the blood accumulates in other parts of the body before getting to 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. Edema due to cardiac origin are commonly seen after stressful activities (physical exertion) or in the evening after the day’s work. This is because the heart has been overworked and cannot perform its normal duty of pumping blood around the body effectively. Cardiac edema generally resolves with rest.  Nephrotic syndrome also leads to edema but will be characterised by severe proteinuria and an increased depletion in albumin levels. Also it is characterized by generalized edema commonly seen in the morning when the patient wakes up in contrast to cardiac edema.  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 and associated with ascites, esophageal varices, caput medusa and rectal varices.

151. In a pre-school educational establishment the menu consists of the following dishes: milk porridge from buckwheat, pasta with minced meat, cucumber salad, kissel (thin berry jelly), rye bread. What dish should be excluded from the menu?

Explanation

***
152. A 10-year-old boy had a case of viral hepatitis type B four years ago. Currently the assumption was made about the formation of hepatic cirrhosis in the patient. What additional investigation can clarify the diagnosis?

Explanation

Individuals with liver cirrhosis, alcoholic hepatitis and other chronic liver diseases are most likely to develop hepatorenal syndrome. Hepatorenal syndrome is a medical condition in which the kidneys are progressively damaged  usually due to an increase in pressure in the portal vein, build up of toxins; these changes take place as a result liver insufficiency. A renal needle biopsy (percutaneous biopsy) is the most common method of obtaining a kidney specimen. In this procedure, a thin needle is used in obtaining kidney materials for microscopic examination. Note that the question asks about an ‘Additional investigation’- patients with liver cirrhosis are usually examined to rule out the development of hepatorenal syndrome.
153. A full term baby born from the 1st non complicated pregnancy with complicated labor was diagnosed with cephalohematoma. On the 2nd day of life the child developed jaundice; on the 3rd day of life there appeared neurological changes: nystagmus, Graefe syndrome. Urine is yellow, feces are golden-yellow. The mother’s blood group is А (II)Rh−, the child’s - А (II) Rh+. On the 3rd day the results of the child’s blood test are as follows: Hb- 200 g/l, erythrocytes - 6, 1 · 1012/l, blood bilirubin - 58 mcmol/l due to the presence of its unconjugated fraction, Ht- 0,57. In this case the jaundice is caused by:

Explanation

Although the Rh groups of the mother and child are different, the presence of normal erythrocyte and hemoglobin levels from the blood test rules out the option of hemolytic disease of the newborn. A cephalohematoma is a traumatic subperiosteal hematoma that occurs in the periosteum of an infant’s skull bone underneath the skin. Occurs mostly because of increased friction between infants cranium and maternal pelvis or forceps ( during assisted delivery). Infants with cephalohematoma are also at a heightened risk for developing jaundice, because as the blood breaks down, the levels of bilirubin increase. In these instances, and if the bilirubin is excessively high, treatment may include phototherapy.

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

Explanation

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

155. In a maternity hospital a newborn had been presenting with cough attacks after eating. The child was discharged from the hospital on the 18th day due to a case of pneumonia. During the further 1,5 months the child had 2 cases of pneumonia. Periodically there are cough attacks after eating, especially if the child lies on the left side. Objectively: the II degree hypotrophy, isolated moist crackles, dyspnea. Stool and diuresis are not disrupted. What diagnosis is most likely?

Explanation

Transesophageal fistula (TEF) is an abnormal connection between the esophagus and the trachea ie, the tube that leads to the stomach and that which leads to the lungs. It is characterised by continuous effusion of saliva from the mouth, choking and vomiting  with first feeding. Due to this abnormal connection, contents going to the stomach can easily get into the respiratory tract Mucoviscidosis ( cystic fibrosis of the pancreas) is a genetic disorder that occurs due to the mutation in CFTR gene. It is characterised by the production of thick and sticky mucus that can clog the lungs and obstruct the pancreas.

156. A 2-year-old girl has a medical history of recurrent obstructive pneumonia. In the lungs various moist and dry crackles can be auscultated, breath sounds are diminished. Sputum is thick, viscous and difficult to expectorate. Drumstick fingers and physical developmental retardation are observed. What preliminary diagnosis can be made?

Explanation

The key finding here is from the sputum ‘thick, viscous and difficult to expectorate’. This is characteristic of the disease cystic fibrosis ( pulmonary mucoviscidosis)  which refers to a form of genetic disorder that affects the CFTR gene. It basically affects  the cells that produce mucus, sweat and digestive juices ( the reason for the thick and viscous sputum); people with this pathology also encounter persistent lung infections. Note that drumstick fingers ( also known as clubbing of the nails)  are seen in individuals with cardiovascular diseases and lung pathologies. These lung diseases include;  lung cancer, lung infections, interstitial lung disease and cystic fibrosis. In recurring bronchitis (chronic bronchitis), the individual experiences productive cough for about three months recurring in the space of two consecutive years. Bronchial Asthma is an allergic disease, a chronic obstructive pulmonary disease ( COPD) characterised by the swelling and narrowing of the airway and also the increased production of mucus.

157. A child is 10 years old. The weight is 46 kg. Since birth the child has been gaining excessive weight. The parents are full bodied. The child has undergone the following tests: carbohydrate tolerance, level of 17 ketosteroids, blood electrolytes, US of adrenal glands, cranium X-ray. The tests revealed no pathologies.The diagnosis of exogenic constitutive obesity has been made. What direction of therapy should be prioritized?

Explanation

Exogenic ( external cause) obesity is a form of obesity caused by the consumption of food more than one's capacity. Notice that all examinations done on the child were found to have no pathologies ( carbohydrate tolerance, level of 17-ketosteroids, blood electrolytes etc ) this rules out the possibility of an underlying cause of the obesity such as conn’s disease, type 2 diabetes etc. to correct this disorder, diet changes should be made, patient should also undergo regular exercise to lose the weight already gained.

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

Explanation

Bacterial gastroenteritis is caused by a variety of organisms, including Campylobacter, Salmonella, Shigella, Yersinia, Vibrio cholerae, Staphylococcus aureus, diarrheagenic Escherichia coli, Clostridium difficile, Clostridium perfringens, and non cholera Vibrio species. Shigellosis is also known as bacillary dysentery caused by the infection of the shiga toxin. It is characterised by High-fever, tenesmus,Profuse inflammatory, mucoid-bloody diarrhea and basically affects the large intestine. This patient experiences pain in the sigmoid colon accompanied by profuse diarrhea ( mixed with mucus)

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

The intensive parameter characterizes frequency or distribution. It shows how frequently the given phenomenon occurs in the given environment.
159. A 10-year-old patient has a history of mild bronchial asthma. During a regular check-up the patient should be recommended:

Explanation

Bronchial asthma is a medical condition classified under type 1 hypersensitivity ( IgE mediated); it is a chronic inflammatory pulmonary disease that is characterized by periodic cough, wheezing, tachypnea, dyspnea, hypoxemia, increased production of mucus which blocks the airways. Triggers include stress, allergens, viral upper respiratory infections …… add morphology, talk about charcot layd. Cells , cush. Spirals etc 

 
160. A prematurely born girl is now 8 months old. She has dyspnea, tachycardia, hepatosplenomegaly, physical developmental lag, limb cyanosis. There is parasternal cardiac hump, auscultation revealed systolodiastolic murmur in the II intercostal space on the left. BP is 90/0 mm Hg. What disease can be suspected?

Explanation

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

Explanation

Note that acute bronchiolitis and Acute bronchitis are very similar and basically present with almost the same symptoms. One key difference is the age range of people affected ; Bronchitis is found in individuals of all age ranges although mostly seen in older children and adults  while bronchiolitis is only found in younger children especially below 2 years. From analysis, we hear vesicular tympanic sound and bubbling rales / crackles - these can  be found in both diseases; but the key difference here is the age of the child (3 months).
162. A 4-month-old child was admitted to a surgical department 8 hours after the first attack of anxiety. The attacks happen every 10 minutes and last for 2-3 minutes, vomiting occurred once. Objectively: the child’s condition is grave. Abdomen is soft, palpation reveals a tumor-like formation in the right iliac area. After rectal examination the doctor’s finger was stained with blood. What is the most probable diagnosis?

Explanation

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

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

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

Explanation

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