1. A 24-year-old patient got a puncture injury below the Poupart’s ligament accompanied by intense arterial bleeding. The best method to temporarily stop the bleeding in the patient would be:
2. A 64-year-old patient complains of severe pain in the right side of chest, dyspnea, dry cough which appeared suddenly on exertion. Objectively: the right side of the chest lags behind in the act of breathing. Percussion reveals tympanic sound. Auscultation reveals pronouncedly diminished breath sounds on the right. Ps-100/min, weak, arrhythmic. AP- 100/50mm Hg. Cardiac sounds are decreased. What disease can be suspected in this patient?
3. A patient got flame burns of both hands. On the dorsal and palmar surface of hands the blisters are filled with serous fluid. The wrist joint region is hyperemic. The forearms were not injured. What is the provisional diagnosis?
4. A patient complains about sudden onsets of paroxysmal pain in the right lumbar region. 2 hours after the onset the patient had hematuria. Plain radiograph of the lumbar region shows no pathological shadows. USI reveals pyelocaliectasis on the right, the left kidney is normal. What is the most likely diagnosis?
5. A 45-year-old female patient complains of frequent liquid stools with a lot of mucus, pus and blood; pain across the abdomen, loss of 7 kg within 6 months. She has a 1-year history of non-specific ulcerative colitis. What group of drugs should be preferred for this patient?
6. A patient underwent stomach resection. During the operation, the left upper limb of the patient was abducted and fixed to the operating table for anesthetic management. Postoperatively, the patient developed dysfunction of the upper extremity in form of \\\"drop hand.\\\"This symptom results from the damage of the following nerve:
7. A 28-year-old patient has been hospitalized for the pain in the epigastric region. He has a 10-year history of duodenal ulcer (DU). Recently, the pain character has changed: it became permanent, persistent, irradiating to the back. There are general weakness, dizziness, fatigue. The patient has put off weight. Objectively: HR- 68/min, AP- 120/80 mm Hg. What is most likely cause of deterioration?
Explanation
Recall that the complications of ulcers include Bleeding (hemorrhage), penetration, perforation, outlet obstruction and malignization.
Hemorrhage: Hemorrhage is the most common complication of peptic ulcer disease. Symptoms include hematemesis (vomiting of fresh blood or "coffee ground" material); passage of bloody or black tarry stools (hematochezia and melena, respectively); and weakness, orthostasis, syncope, thirst, and sweating caused by blood loss.
Penetration: A peptic ulcer may penetrate the wall of the stomach or duodenum and enter the adjacent confined space (lesser sac) or organ (eg, pancreas, liver). Pain may be intense, persistent, referred to sites other than the abdomen (usually the back when caused by penetration of a posterior duodenal ulcer into the pancreas), and modified by body position.
perforation: perforation usually presents as an acute abdomen. Ulcers that perforate the peritoneal cavity are usually located in the anterior wall of the duodenum or, less commonly, in the stomach. The patient experiences sudden, intense, steady epigastric pain that spreads rapidly throughout the abdomen, often becoming prominent in the right lower quadrant and at times referred to one or both shoulders.
Gastric outlet obstruction: This may be caused by scarring, spasm, or inflammation associated with an ulcer. Symptoms include recurrent large volume vomiting, occurring more frequently at the end of the day and often as late as 6 h after the last meal. Persistent bloating or fullness after eating and loss of appetite also suggest gastric outlet obstruction. Prolonged vomiting may cause weight loss, dehydration, and alkalosis.
Malignization/ Stomach cancer: H. pylori is associated with intestinal-type adenocarcinoma of the gastric body and antrum but not cancer of the gastric cardia. Gastric lymphomas and mucosa-associated lymphoid tissue (MALT) lymphomas have also been linked to this infection.
8. A child undergoes in-patient treatment for acute staphylococcal destruction of the right lung. Unexpectedly he develped acute chest pain on the right, dyspnea, cyanosis. The right side of chest lags behind in the respiratory act. Percussion reveals dullness in the lower parts on the right, bandbox resonance i the upper parts. Borders of the relative cardiac dullness are shifted to the left. What complication has most likely developed?
9. A 28-year-old patient consulted a
surgeon about pain, edema and hyperemia of the left side of his face, weakness, fever up to 39oC. These manifestations has been present for three days. Objectively: there is an inflammatory infiltrate of the left nasolabial fold 4x4 cm large with a necrotic core in the center, the pronounced edema of the left side of face, moderate nuchal rigidity. What treatment is needed?
10. 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, defecation 10 times a day with liquid, scarce stool with mucus and streaks of green. What is a provisional diagnosis?
11. A 12-year-old child has been hit on the stomach. The patient is in moderately grave condition, has a forced position in bed. The skin is pale, Ps- 122/min. The stress on the left costal arch causes a slight pain. There are positive Weinert, kulenkampff symptoms. Macroscopically the urine is unchanged. What is the most likely diagnosis?
12. A 27-year-old patient complains of nasal haemorrhages, multiple bruises on the anterior surface of the trunk and extremities, sudden weakness. In blood: Hb- 74 g/l, reticulocytes - 16%, RBCs -2, 5 · 1012/l, platelets - 30 · 109/l, ESR- 25mm/h. What is the most effective measure for the treatment of thrombocytopenia?
13. After lifting a load a patient felt undurable pain in the loin. He was diagnosed with acute lumbosacral radiculitis. Which of the following is contraindicated for this patient?
14. While lifting a heavy load a 39-year-old patient suddenly felt a severe headache, pain in the interscapular region, and started vomiting. Objectively: the pulse is rhythmic, 60/min, AP- 180/100 mm Hg. The patient is agitated. He presents with photophobia, hyperacusis. There are positive Kernig’s and Brudzinski’s signs on both sides. In blood: WBCs - 10 · 109/l.CSF is bloody, cytosis is 240/3. What is the most likely diagnosis?
15. A patient presented to a hospital with a carbuncle of the upper lip. The body temperature is 39oC. There is a pronounced edema of the upper lip and eyelids. What is the surgeon’s tactics of choice?
16. A 62-year-old male patient complains of intense pain in the left leg that suddenly arose three hours before, leg numbness and coldness. During the year there has been pain in the leg while walking, hypersensitivity to cooling. Objectively: the left foot and shin have marbled skin, subcutaneous veins are collapsed. The foot is cold, active movements of the foot and toes are preserved. Pulse is present only on the femoral artery. There is rough systolic murmur above the artery. Make a provisional diagnosis:
17. A 70-year-old patient with a strangulated inguinal hernia called a therapist in. The strangulation took place 10 hours ago. There are signs of intestinal obstruction. The skin over the herniation is hyperemic. What is the tactics of choice?
18. A 45-year-old patient with acute abscess of the left lung has suddenly developed acute chest pain and dyspnea while coughing, tachycardia has increased. The control Rogram shows collapsed left lung, the air in the left pleural cavity and a horizontal fluid level. What is the mechanism of this complication?
19. Examination of a 38-year-old patient who had been hit with a blunt object on the left side of chest revealed a fracture of the X rib with fragments displacement, parietal pneumothorax. The patient complains of pain in the left subcostal area. Objectively: the patient is pale, AP- 80/40 mm Hg, Ps- 138/min, of poor volume. USI reveals fluid in the left abdomen. Splenic rupture is present. What treatment tactics should be chosen?
20. A 38-year-old patient has suddenly developed pain in the left side of his chest, suffocation. Objectively: moderately grave condition, Ps- 100/min, AP- 90/60mm Hg, breath sounds on the left cannot be auscultated. Chest radiography shows the collapse of the left lung up to 1/2. What kind of treatment should be administered?
21. A 57-year-old patient taken to the surgical department by ambulance has been provisionally diagnosed with acute intestinal obstruction. Acute pancreatitis is suspected. What is the most informative method of study to verify the diagnosis?
22. A 28-year-old female patient has been admitted to a hospital. She states to be ill for 12 years. On examination she has been diagnosed with bronchiectasis with affection of the left lower lobe of lung. What is the optimal treatment tactics for this patient?
23. 4 weeks after myocardial infarction a 56-year-old patient developed acute heart pain, pronounced dyspnea. Objectively: the patient’s condition is extremely grave, there is marked cyanosis of face, swelling and throbbing of neck veins, peripheral pulse is absent, the carotid artery pulse is rhythmic, 130 bpm, AP is 60/20 mm Hg. Auscultation of heart reveals extremely muffled sounds, percussion reveals heart border extension in both directions. What is the optimal treatment tactis for this patient?
24. On the first day after a surgery for diffuse toxic goiter a patient developed difficulty breathing, cold sweats, weakness. Objectively: pale skin, body temperature- 38, 5oC, RR - 25/min, Ps- 110/min, AP-90/60 mm Hg. What early postoperative complication occurred in the patient?
Explanation
A patient that underwent surgery for diffuse toxic goiter presented with a high metabolic rate (elevated body temperature, tachycardia, tachypnea) 24hrs post-operation. This patient currently has a thyrotoxic crisis.
One of the rarer complications from thyroid surgery is precipitation of a thyroid storm, which can occur intraoperatively or postoperatively. It is thought to occur secondary to thyroid gland manipulation in the operating room in patients with hyperthyroidism.
Thyroid (or thyrotoxic) storm is an acute, life-threatening syndrome due to an exacerbation of thyrotoxicosis. Classic features of thyroid storm include fever, marked tachycardia, heart failure, tremor, nausea and vomiting, diarrhea, dehydration, restlessness, extreme agitation, delirium or coma.
Hypothyroid crisis will present with bradycardia, low body temperature, low respiratory rate, constipation etc. Postoperative tetany is a possible postoperative complication in thyroid surgery as the parathyroid gland which resides behind the thyroid could be accidentally resected. Postoperative tetany indicates low calcium levels of which it will most likely be associated with bradycardia instead of the 110bpm (tachycardia) seen in this patient.
25. A 26-year-old patient consulted a doctor abut sore throat, fever up to 38, 2oC. A week ago, the patient had angina, didn’t follow medical recommendations. On examination, the patient had forced position of his head, trismus of chewing muscles. Left peritonsillar region is markedly hyperemic, swollen. What is the provisional diagnosis?
26. A 77-year-old patient complains of inability to urinate, bursting pain above the pubis. The patient developed acute condition 12 hours ago. Objectively: full urinary bladder is palpable above the pubis. Rectal prostate is enlarged, dense and elastic, well-defined, with no nodes. Interlobular sulcus is distinct. Ultrasonography results: prostate volume is 120 cm3, it projects into the bladder cavity, has homogeneous parenchyma. Prostate-specific antigen rate is of 5 ng/ml. What is the most likely disease that caused acute urinary retention?
Explanation
Benign Prostate Hyperplasia (BPH) is a non carcinogenic pathology that occurs in men usually above 40 years of age. It presents with symptoms similar to Prostate cancer. These include painful urination (dysuria), acute urinary retention, urinary frequency, hesitancy, dribbling, and frequent nighttime urination (nocturia). To differentiate between these two pathologies, an objective examination is carried out - a digital rectal examination or prostate biopsy. In this case, on digital rectal examination, the prostate is dense, enlarged, elastic and well defined with no nodes - these findings support the initial diagnosis of BPH because on digital rectal examination, prostatic carcinoma will not be well defined and will present with nodes. To further prove this diagnosis, the Prostate specific antigen is measured (normal <4). A marginal increase is going to support the diagnosis of BPH while PSA of 10 and above will indicate prostate cancer.
27. A patient with fibromyoma of uterus sized up to 8-9 weeks of pregnancy consulted a gynaecologist about acute pain in the lower abdomen. Examination revealed pronounced positive symptoms of peritoneal irritation, high leukocytosis. Vaginal examination revealed that the uterus was enlarged corresponding to 9 weeks of pregnancy due to the fibromatous nodes, one of which was mobile and extremely painful. Appendages were not palpable. There were moderate mucous discharges. What is the optimal treatment tactics?
Explanation
From the vaginal examination, we observe the presence of a very large fibroid mass that causes the enlargement of the uterus and is responsible for the severe pain the woman is experiencing and the mucous discharge. Coupled with the positive symptom of peritoneal irritation, this patient is in need of an urgent surgical procedure.
Uterine fibroids are noncancerous growths that grow in the wall of the uterus. When fibroids cause heavy bleeding or painful symptoms, and other treatments are ineffective, a doctor may recommend surgery. People with asymptomatic fibroids do not require surgery or other treatments. However, other people experience severe abdominal pain, pressure, bloating, pain during sex, frequent urination, and heavy or painful periods. These individuals may require surgery.
Myomectomy is a surgical procedure that removes fibroids. Depending on the location of these growths, a surgeon may also have to remove other tissue in the process. The traditional technique is quite invasive as it uses a relatively large cut (Laparotomy). This incision may go from the bellybutton to the bikini line or run horizontally along the bikini line. Some surgeons also perform laparoscopic surgeries, which use smaller incisions but require more skill. However, in this case, a fibroid as big as 9 weeks gestation will require a big incision and laparoscopic surgery will not be able to get the fibroid out.
28. A 64-year-old patient has been referred to planned hospitalization for general weakness, poor appetite, progressive jaundice which appeared over 3 weeks ago and wasn’t accompanied by pain syndrome. Objectively: body temperature is at the rate of 36, 8oC, Ps-78/min, abdomen is soft and painless, the symptoms of peritoneal irritation are present, palpation reveals a dramatically enlarged, tense gallbladder. What disease are these symptoms typical for?
29. A 30-year-old patient got in a car accident. He is unconscious, pale, has thready pulse. In the middle third of the right thigh there is an extensive laceration with ongoing profuse external arterial bleeding. What urgent actions must be taken to save the life of the patient?
30. A 75-year-old male patient complains of slight pain in the right iliac region. The abdominal pain arose 6 days ago and was accompanied by nausea. Surgical examination revealed moist tongue, Ps- 76 bpm. AP- 130/80 mm Hg. Abdomen was soft, slightly painful in the right iliac region on deep palpation, the symptoms of the peritoneum irritation were doubtful. In blood: RBCs - 4, 0 · 1012/l, Hb- 135 g/l, WBCs - 9, 5 · 109/l, stab neutrophils - 5%, segmentonuclear - 52%, lymphocytes -38%, monocytes - 5%, ESR - 20 mm/h. Specify the doctor’s further tactics:
Explanation
Definitive treatment for Acute Appendicitis is Surgical. Conservative management with medications to relieve pain or stop inflammatory processes will only produce temporary relief.
ESR is elevated which is a sign of an inflammatory process. Right iliac fossa tenderness and right iliac fossa pain (Rebound tenderness, blumberg sign) are pointers to Acute Appendicitis.
Diagnosis of Appendicitis is made clinically, Ultrasound or abdominal X-ray will not give a definite diagnosis. When we say a diagnosis is clinical, it means the diagnosis is based on signs and symptoms elicited clinically. In this case, positive signs of appendicitis will give a better diagnosis than report of X-ray or Ultrasound.
Appendiceal signs: Pain elicited in any of these signs indicates a positive test
Abdominal guarding
Rebound tenderness: To elicit the sign, gentle pressure is placed on the right iliac fossa of the abdomen and then the hand is lifted suddenly. A sudden increase in abdominal pain occurs when the examiner's hand is lifted.
Rovsing's sign is elicited by pushing on the abdomen in the left lower quadrant as in most people the appendix is in the right lower quadrant. While this maneuver stretches the entire peritoneal lining, it only causes pain in any location where the peritoneum is irritating the muscle. In the case of appendicitis, the pain is felt in the right lower quadrant despite pressure being placed elsewhere.
Obturator sign: First the patient lies on his back with the right hip flexed at 90 degrees. The examiner then holds the patient's right ankle in his right hand. With his left hand, the examiner rotates the hip by pulling the right knee to and away from the patient's body.
31. During self-examination a 22-year-old patient revealed a mammary tumour. Palpation revealed a firm, painless, mobile formation up to 2 cm, peripheral lymph nodes were not changed. USI results: in the superior external quadrant of the right mammary gland there was a big formation of increased echogenicity, sized 18x17 mm. The patient was provisionally diagnosed with fibroadenoma. What is a doctor’s further tactics?
Explanation
Fibroadenomas are typically present as firm, mobile, painless, and frequently multiple breast nodules. These tumors are common, benign breast tumors that usually affect women in second and third decades of life. Fibroadenomas are usually small and can be managed conservatively; however, a good percentage of these lesions will grow rapidly.
During pregnancy, fibroadenomas increase in size and may show lactational histologic changes. High concentrations of estrogen, progesterone, and prolactin promote the ductal growth and formation of tubuloalveolar structures. This may be a reason for the significant enlargement in this period.
Hence, it is recommended that it be removed prior to pregnancy.
32. LA patient is 31 years old. Double contrast barium swallow revealed a filling defect on the posterior wall in the middle segment of esophagus. The defect looked like a well-defined oval 1,8x1,3 cm large. Mucosal folds adjacent to the defect were intact, peristalsis and elasticity of the walls remained unchanged. Digestive tract problems were absent. What is the provisional diagnosis?
33. A 56-year-old female patient complains of recurrent attacks of intensive pain irradiating along the ureters. Urine test results: protein - 0,37 g/l, RBCs-20-25 in the field of vision, WBCs - 12-14 in the field of vision. What method of instrumental diagnostics is the most informative for the diagnosis?
34. A 24-year-old patient had been delivered to the thoracic department with a chest injury, a fracture of the IV, V,VI ribs on the right. Plan radiography shows the fluid level in the pleural cavity reaching the III rib on the right. Puncture blood contained clots. What is the optimal treatment tactics?
Explanation
Many patients with penetrating thoracic injuries do not survive to the Emergency Department (ED), and those that do survive to the ED often require immediate interventions such as tube thoracostomy, intubation, and thoracotomy.
Thus, the emergency clinician must be able to rapidly diagnose and treat injuries that are immediately life-threatening as in this case that presented with a Gunshot injury.
The above patient presents with a major trauma to the right side of the chest which is confirmed by a hemothorax (Hemothorax).
Thoracotomy is a surgical procedure carried out inorder to have access to thoracic organs such as the lungs, heart or esophagus. This procedure is the first step in gaining access to the thoracic cavity and thus is indicated in cases of a lobectomy, major trauma of the chest, pneumonectomy. In the case of this patient, an emergency thoracotomy should be carried out in order to drain the blood and prevent compression and eventual collapse of the lungs.
Thoracentesis or Pleural puncture is a procedure in which a needle is inserted into the pleural space between the lungs and the chest wall. This procedure is done to remove excess fluid, known as a pleural effusion, from the pleural space to help you breathe easier. In this case, it’s not just fluid, there are blood clots. So, an incision (thoracotomy) should be made and arrest the bleeding, then drain. This patient needs this to be done as soon as possible, that’s why the best answer choice is the Emergency Thoracotomy.
It’s not enough to use hemostatic therapy, the clots must be removed and blood drained. Thoracoscopy is an imaging technique and the X-ray has given enough information at this point.
35. A 38-year-old male patient complains of marked dyspnea that escalates with physical exertion. The problems, namely acute chest pain on the left and cough, arose unexpectedly 2 hours before at work. The pain abated, but there were progressing dyspnea, dizziness, pallor, cold sweat, cyanosis. Auscultation reveals the absence of vesicular breath sounds, radiograph shows a shadow on the left. What pathology can be suspected?
36. A 2-year-old boy has been admitted to the casualty department for the pain and deformity of his right thigh. Radiograph shows a femoral fracture with longitudinal displacement. What method of treatment is indicated for the patient?
37. A 22-year-old female patient has been delivered by an ambulance team to a surgical clinic with symptoms of acute intestinal obstruction. It is known from the past history that 2 years ago she was operated for acute destructive appendicitis. For two years, she has repeatedly complained of bloating and abdominal pain. Which of the following etiological factors has led to the intestinal obstruction in the patient?
38. An hour before an elective surgery, a 56-year-old patient of the surgical department got a dramatic increase in blood pressure, tachycardia, hand tremor. The patient is confused, anxious, depressed, fearful, is pessimistic about the operation outcome, refuses the surgery. What tactics should be chosen by a surgeon?
39. A 39-year-old female patient complains of rapid fatigability, drowsiness, dry skin, hair loss, swelling of the face. A month ago, she underwent a surgery for thyrotoxicosis. The patient has the following gland dysfunction:
40. A 43-year-old female patient complains of dyspnea, swelling of legs, abdomen enlargement, pricking heart pain. She has a history of tuberculous bronchadenitis, quinsies. The patient’s condition deteriorated 6 months ago. Objectively: cyanosis, bulging neck veins, vesicular breathing. Heart borders are not displaced. Heart sounds are muffled, Ps- 106/min, liver is +4 cm, ascites is present. Low voltage on the ECG has been revealed. Radiograph shows a thin layer of calcium deposits along the left contour of heart. What treatment should be recommended to the patient?
41. A 45-year-old male patient with acute abscess of the left lung has suddenly developed acute chest pain and dyspnea while coughing, tachycardia has increased. The control Ro-gram shows left lung collapse, the air in the left pleural cavity and a horizontal fluid level. What is the mechanism of this complication?
42. A 56-year-old male patient has been delivered to the emergency department with frostbite on both feet. What aid should be rendered to the victim?
43. A 21-year-old male patient got a deep cut wound in his right thigh. In the emergency room a surgeon on duty performed primary debridement of the wound and primary wound closure with a suture. After 4 days, there appeared pain, redness, edema, purulent discharge from the wound gap, body temperature rose up to 39oC. What kind of wound complication can you think of and what actions should be taken?
44. A 23-year-old female consulted a gynecologist on the 20th day postpartum period about pain in the left breast, purulent discharge from the nipple. Objectively: Ps-120/min, t- 39C. The left breast is painful, larger than the right one, hyperemic. In the upper quadrant there is an infiltrate sized 10x15 cm with a softening inside. Blood test results: ESR- 50 mm/h, WBC- 15, 0 · 109/l. What is the tactics of choice?
45. A 30-year-old male patient complains of inertness, low-grade fever, bleeding gums, frequent quinsies, aching bones. Objectively: the patient has pale skin and mucous membranes, sternalgia, +2 cm liver, +5 cm painless spleen. Blood test results: RBC-2, 7 · 1012/l, Нb- 80 g/l, WBC- 3 · 109/l, eosinophils - 4%, basophils - 5%, blasts -4segmented neutrophils - 17%, lymphocytes -29%, myelocytes - 25%, promyelocytes - 12%, monocytes - 2%, platelets - 80 · 109/l, ESR -57 mm/h. What test should be performed to verify the diagnosis?
46. A 29-year-old unconscious patient has been delivered to a hospital. Objectively: skin and mucous membranes are pale, cyanotic, breath sounds are dramatically diminished on the right and cannot be auscultated in the lower parts, at the level of the 6 rib along the anterior axillary line there is a wound hole with moderate bleeding and passage of air during inspiration. Radiography reveals a bullet in the pleural cavity. What is the medical tactics of choice?
47. As a result of a road accident a 45-year-old male patient got multiple injuries, namely closed fractures of the right humerus and the left antebrachial bones with a displacement of bone fragments, a closed blunt abdominal injury. The patient was delivered to the emergency department 30 minutes after the injury. Objectively: the skin is pale. AP-90/20 mm Hg, there is pain and deformation at the fracture sites. Abdomen is tense, palpation causes severe pain, there is rebound tenderness (positive Blumberg’s sign). What is the treatment tactics of choice?
48. 4 weeks after a myocardial infarction, a 56-year-old male patient developed acute heart pain, pronounced dyspnea. Objectively: the patient’s condition is extremely grave, there is marked cyanosis of face, swelling and throbbing of neck veins, peripheral pulse is absent, the carotid artery pulse is rhythmic, 130 bpm, AP- 60/20 mm Hg. Auscultation of heart reveals extremely muffled sounds, percussion reveals heart border extension in both directions. What is the optimal treatment tactics for this patient?
49. 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?
50. A patient with autoimmune thyroiditis accompanied by multinodular goiter underwent the right lobe ectomy and subtotal resection of the left lobe. What drug should be administered to prevent postoperative hypothyroidism?
51. A 21-year-old female patient has been hospitalized on an emergency basis because of severe dyspnea, pain in the left side of chest. Body temperature is 38, 8oC. The condition developed three days ago. Respiratory rate is 42/min, auscultation reveals shallow breathing. There is percussive dullness on the right starting from the middle of the blade, breath sounds cannot be heard. The left border of heart is 3 cm displaced outwards. Embryocardia is present, HR is 110/min. The right hypochondrium is painful on palpation. What urgent therapeutic measures should be taken in this situation?
52. A 36-year-old injured has been taken to the emergency station with open tibial fractures. Examination reveals bleeding: pulsating blood spurts out of the wound. What medical manipulations are required at this stage of medical care?
53. A 49-year-old male patient complains of retrosternal pain, heartburn, weight loss of 8kg over the last year, constipation, weakness. The patient has been a smoker for 20 years, and has a 10-year history of gastroesophageal reflux disease. The patient is asthenic, has dry skin. EGD revealed an ulcer in the lower third of the esophagus and esophageal stricture accompanied by edema, hyperemia and multiple erosions of the mucosa. What study is required for more accurate diagnosis?
54. A 27-year-old male patient consulted a doctor about pain in the lower third of the thigh with weight bearing activities and unloaded. Two years ago, the patient underwent treatment in the casualty department for the open fracture of the lower third of femur. The fracture healed slowly, the healing process was accompanied by prudent inflammation. Objectively: edema of the lower third of the thigh, elevated local temperature. Radiograph shows signs of destruction and sequestration. What is the most likely diagnosis?
Explanation
From anamnesis, we observe that this patient had an open fracture (trauma) of the lower third of the femur 2 years ago. The healing process was slow and accompanied by purulent inflammation. Osteomyelitis is a serious bone inflammation that can result from a previous trauma, puncture wound, surgery, bone fracture, abscessed tooth, or infection of soft tissue, the ear or sinus. Chronic osteomyelitis usually occurs after an acute episode of osteomyelitis when the infection has not been totally cured. Purulent discharge, bone pain, redness, swelling and elevation of temperature in the affected area are key findings.
Hematogenous Osteomyelitis usually occurs in Children and takes place on the background of a spreading infection via the blood.
Multiple myeloma is a cancer of the plasma cells and is characterised by the presence of bence jones proteins.
55. A 45-year-old man with thrombophlebitis of the deep veins in his legs suddenly after physical exertion developed sharp pain in his thorax on the right, dyspnea, and hemoptysis. Objectively his condition is severe; he presents with acrocyanosis, shortening of pulmonary percussion sound on the right, and weakened respiration. Respiration is 30/min., blood pressure is 110/80 mm Hg. ECG shows sinus tachycardia, his heart rate is 120/min., the electrical axis of the heart deviates to the right, SI-QIII. What is the most likely diagnosis?
56. A 65-year-old man underwent a left hemicolectomy due to a malignant tumor in the descending colon. On the 4th day after the surgery he developed pain and edema in his left shin. The Homans sign is positive on the left. What postoperative complication developed in this patient?
57. A newborn has a round red formation in the suprapubic region. Examination shows that urine is being discharged in pulses from the two orifices located in the lower part of this formation. Name this developmental anomaly:
58. A surgery unit received a person with an incised stab wound on the upper third of the right thigh. Examination detects an incised stab wound 3.0x0.5x2.0 cm in size on the inner surface of the upper third of the right thigh. Bright-red blood flows from deep within the woixnd in a pulsing stream. Characterize this type of bleeding:
59. A 25-year-old man was hospitalized with complaints of pain in his lower abdomen and right lumbar area that appeared one hour ago. The patienfs general state is moderately severe. Body temperature - 38.2°C, heart rate - 102/min. The tongue is dry The abdomen is painful on deep palpation in the right iliac area and in the Petit triangle. Aure-Rozanov and Gabay signs are positive. Make the provisional diagnosis:
60. A 35-year-old woman had acute onset of the disease that started with fever up to 39.0°(7 and cough. 3 days later her dyspnea at rest increased up to 35/min. Downward from her right shoulder-blade angle, percussion detects a dull sound. No vocal fremitus, respiratory sounds cannot be auscultated. What is the treatment tactics?
61. A 19-year-old young man was diving and hit his head on the bottom of the pool. He complains of pain in the neck, his head movements are limited and painful. During examination his head is bowed forward and to the right and the patient supports it with his hands. Palpation detects tense neck muscles and protruding spinous process of the IV cervical vertebra (C4). When pressure is applied to this process and to the head (axial load), the pain intensifies. Make the provisional diagnosis:
62. On ultrasound of the thyroid gland, a 47-year-old woman presents with a hypoechoic node 1.6 cm in diameter with blurred margins and intranodular hypervascularization. The doctor suspects thyroid carcinoma. What method should be used to verify the diagnosis?
63. A patient underwent suture plication of the perforated duodenal ulcer On the 3rd day after the operation he started producing a large amount of discharge from, the abdominal drain tube. The discharge contains bile and has high amylase levds. What complication occurred in the patient?
64. A 40-year-old victim of a traffic accident sustained the following injuries: closed diaphyseal femur fracture, brain concussion, multiple rib fractures, hemopneumothorax, degloving shin injuries. What injuries require the most urgent attention?
65. The body of a citizen was found at the place of his dwelling. On his face, neck, and hands there were detected irregular-shaped wounds, varying from 2x3 cm to 4x5 cm in size. The skin and underlying tissues are absent in the wounds. The margins of the wounds are uneven, with major and minor scalloping along the edges and no signs of bleeding. What is the initiating mechanism of these wounds?
66. You witnessed a car accident. When examining the place of the accident you noticed a man of about 30 years, who was hit by the car. He is unconscious. On his neck on the left there is a profuse hemorrhage with bright-red blood. How to stop this hemorrhage?
67. A 7-year-old boy after a fall from a height presents with rapid and shallow breathing and cyanotic face. The right half of his thorax is distended and takes no part in the respiration. Percussion detects tympanitis in the affected area, while auscultation detects no breathing there. What pathology is the most likely cause of this clinical presentation? What instrumental examination would be the most informative in this case?
68. A woman complains of a severe pain in her throat on the left，difficult swallowing and mouth opening, elevated body temperature, and general malaise. The onset of the disease was 4 days ago after a case of tonsillitis. Examination detects a trismus of the masticatory muscles, the left tonsil is displaced toward the midline, the anterior palatal arch is infiltrated and protrudiiig. The regional lymph nodes on the right are enlarged and painful on palpation. Make the diagnosis:
69. 3 hours after a trauma, a young man developed bradycardia of 46/min., anisocoria D>S, hemi-hyperreflexia S>D, hemihypesthesia on the left, and a convulsive disorder The character of this process needs to be clarified. What method of examination will be the most accurate for this purpose?
70. A 9-year-old boy fell off a tree and hit the back of his head. A brief loss of consciousness was observed. The child’s condition is satisfactory he has a headache and vertigo. Skull X-ray scans show a depressed fracture of the occipital bone in the area of the external occipital protuberance. What treatment tactics is indicated for this patient?
71. A 47-year-old man developed the signs of decompensated laryngeal stenosis against the background of acute flegmonous laryngitis. He presents with inspiratory dyspnea at rest, forced position, cyanotic skin covered in cold sweat, tachycardia, deficient pulse, and low blood pressure. What urgent treatment tactics should be chosen?
72. A 78-year-old man with a prostate adenoma underwent a herniotomy for a direct inguinal hernia. After the surgery he presents with absent urination. Enlarged urinary bladder is detectable above the patient’s pubis. What measures should be taken in this case?
73. During physical exertion a man suddenly developed acute chest pain on the right and dyspnea. Objectively he assumes forced half- sitting position in the bed, presents with diffuse cyanosis, resting tachypnea of 38/min., the ri- ght side of the thorax is enlarged and does not participate in the respiratory process; percussi- on on the right reveals tympanic resonance and absence of respiration.What is the most likely diagnosis in this case?
74. A 24-year-old patient visited a doctor complaining of enlargement of his submaxi- llary lymph nodes. Objectively: submaxillary, axillary and inguinal lymph nodes are enlarged. Chest X-ray shows: enlarged lymph nodes of mediastinum. Blood test: erythrocytes - 3.4 · 1012/L, Hb- 100 g/L, blood colour index - 0.88, platelets - 190 · 109/L, leucocytes - 7.5 · 109/L, eosinophiles - 8%, band neutrophi- les - 2%, segmented neutrophiles - 67%, lymphocytes - 23%, ESR - 22 mm/hour. What test must be prescribed to verify the cause of lymphadenopathy?
75. 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, ti- ngling stopped, slight itching and swelling of the fingers appeared. Determine the frostbite degree in this child:
76. A 25-year-old woman complains of fati- gue, dizziness, hemorrhagic rashes on the skin. She has been presenting with these signs for a month. Blood test: erythrocytes - 1.0 · 1012/L, Hb- 37 g/L, colour index - 1.1, leukocytes - 1.2 · 109 /L, platelets - 42 · 109 /L. What analysis would be the most advisable for diagnosis- making in this case?
77. A 46-year-old woman complains of severe pain attacks in the right lumbar area, which irradiate to the lower abdomen, and nausea. This kind of pain attacks has never been detected in the patient before. Plain abdomi- nal X-ray reveals no pathologic shadows. Ultrasound detects a hyperechogenic mass 1.5 cm in diameter, which reflects sound wave, in the enlarged right renal pelvis. What diagnosis is the most likely?
78. A 64-year-old man complains of cough wi- th expectoration consisting of blood-streaked mucus, dyspnea, low grade fever and general fatigue. He has been presenting with these symptoms for 3 months. He has been smoki- ng since early adolescence. Objectively to is 37.4o C , respirations are 26/min., pulse is 82/min., rhythmic, blood pressure is 130/85 mm Hg. The right side of the thorax lags behi- nd in the respiratory process, dull percussion sound and acute decrease of breathing activity are observed there. X-ray shows homogeneous shadow of the lung field on the right with medi- astinum displacement towards the affected side. What is the most likely diagnosis?
79. A 52-year-old woman has been suffering for 2 years from dull, occasionally exacerbating pain in her right subcostal area, occurring after eating high-fat foods, bitter taste in her mouth in the morning, constipations, and flatulence. Objectively she has excess weight, her body temperature is 36.9o C ; there is a coating on the root of her tongue; the abdomen is moderately distended and painful in the area of gallbladder projection. What examination would be the most helpful for diagnosis-making?
80. A 10-year-old girl complains of stomachache that appears and intensifies after she eats rough or spicy food, sour eructation, heartburn, frequent constipations, headaches, irritability. She has been presenting with these signs for 12 months. Her meals are irregular and consist of dry food. Objectively her diet is suffi- cient in calories. The tongue is moist with white coating near the root. The abdomen is soft and painful in the epigastrium. What method would be optimal for diagnosis-making in this case?
Explanation
The patient in question presents with symptoms related to the gastrointestinal system; heartburn, frequent constipations, headaches, irritability, stomach ache. Diseases such as Gastritis, GERD, Ulcers should all be speculated. To confirm one's diagnosis, an Esophagogastroduodenoscopy should be performed. This is a procedure during which a small flexible endoscope is introduced through the mouth (or, with smaller-caliber endoscopes, through the nose) and advanced through the pharynx, esophagus, stomach, and duodenum.
81. A 50-year-old patient was delivered to a hospital with complaints of blood traces in urine. Urination is painless and undisturbed. Macrohematuria had been observed for 3 days. Objectively: kidneys cannot be palpated, suprapubic area is without alterations, external genitalia are non-pathologic. On rectal investi- gation: prostate is not enlarged, painless, has normal structure. Cystoscopy revealed no alterations. What is the most likely diagnosis?
82. A patient with trauma of the lower third of the forearm volar surface caused by a glass shard came to a first-aid center. Objectively: flexion of the IV and V fingers is impaired, sensitivity of the inner dorsal and palmar surfaces of the hand and IV finger is decreased. What nerve is damaged?
83. A 58-year-old patient complains of pain in the lower left extremity, which aggravates during walking, and sensation of cold and numbness in the both feet. The patient has been suffering from this condition for 6 years. Objectively: the skin is pale and dry, with hyperkeratosis. On the left shin hair is scarce. Pulse cannot be detected over the pedal and popliteal arteries and is weakened over the femoral artery. On the right limb pulsation of the popliteal artery is retained. What is the most likely diagnosis?
84. A 47-year-old woman came to the admissi- on room with complaints of general weakness, dizziness, vomiting with blood clots. Conditi- on onset was 3 hours ago. The patient has no preceding illnesses. Blood pressure is 90/60 mm Hg, pulse is 106/min., of poor volume. The abdomen is soft, with mild tenderness in the epigastrium. Blood test: erythrocytes - 2.1·1012/L, Нb- 70 g/L, hematocrit - 28%. What tactics should the doctor on duty choose?
85. A 52-year-old patient complains of pain in the right part of her chest, dyspnea, cough with large amounts of foamy sputum emitting foul smell and resembling ”meat slops”. Objectively: the patient’s condition is grave, cyanosis is observed, breathing rate is 31/min., percussion sound above the right lung is shortened, auscultation revealed various moist rales (crackles). What is the most likely diagnosis?
86. A man complains of sore throat on the left, pain in his left ear, to up to 39o C , and nasal sound of his voice. Disease onset was 5 days ago. Marked trismus and increased salivation are observed. The head tilts to the left shoulder. Left side of the soft palate presents with swelling, hyperemia, and infiltration. Retromandibular lymph nodes on the left are acutely painful on palpation. Otoscopy results are normal. Make the diagnosis:
87. A patient has the second and third degree burns of the 15% of the body surface. On the 20th day after the trauma the patient presents with sharp increase of body temperature, general weakness, rapid vesicular respiration; facial features are sharpened, BP is 90/50 mm Hg, heart rate is 112/min. What complication is it?
88. In 2 hours after a traffic accident a 28-year- old man in grave condition was delivered to a hospital. The patient complains of abdominal pain. He received a blow to the abdomen with the steering wheel. Objective examination revealed the following: the abdomen does not participate in respiration, is tense and acutely painful on palpation; abdominal guarding is present, peritoneal irritation signs are positive, hepatic dullness is absent. BP is 90/60 mm Hg, heart rate is 120/min. What further treatment tactics should be chosen?
89. A 46-year-old woman has been hospitalized with open fracture of the left thigh in its middle third. She underwent the surgery - fixation with extraosseous osteosynthesis plates. On the 4th day after the surgery she developed pain in the wound, body temperature rose over 39*C . What measures should be taken in this case?
90. For the last 15 years a 48-year-old patient has been working at the factory producing synthetic resins. Lately he has been complaining of significant general fatigue, headaches, frequent urination (predominantly during the day), red color of urine. What complication of benzene nitrocompounds poisoning can be suspected?
91. After excessive consumption of fatty food a 60-year-old woman suddenly developed pain in her right subcostal area, nausea, bile vomiting, sharp bitter taste in her mouth. In 2 days she developed jaundice, her urine darkened. Objectively: sclera and skin are icteric, the abdomen is distended, the liver is enlarged by 3 cm, soft and painful on palpation, Ortner’s, Murphy’s, Kehr’s, Zakharyin’s, Mayo-Robson’s signs are positive. What diagnostic technique should be used in the first place to confirm the diagnosis?
92. A 43-year-old woman complains of pain in the lumbar area, which irradiates to her left leg and aggravates on movement, and sensation of numbness in this leg. Objectively palpation of her shin and thigh is painful, there are painful stretch symptoms of on the left and gastrocnemius cramps. There is no sensory loss or weakening of reflex responses. Make the diagnosis:
93. A 43-year-old woman complains of persi- stent stomachache with recurrent pain attacks, nausea, repeated vomiting with stagnant bowel content, abdominal distension, and flatulence. She has been presenting with these signs for 7 hours. Pulse is 116/min. The tongue is dry and brown. The abdomen is symmetrically distemded, soft, painful. Percussion reveals tympanitis. On auscultation there are bowel sounds with metallic overtone, splashing, and dripping. Make the diagnosis:
94. A 38-year-old patient has been delivered by an ambulance to a surgical department with complaints of general weakness, indisposition, black stool. On examination the patient is pale, there are dotted hemorrhages on the skin of his torso and extremities. On digital investigation there are black feces on the glove. Blood test: Hb- 108 g/L, thrombocytopenia. Anamnesis states that similar condition was observed 1 year ago. Make the diagnosis:
95. A 35-year-old patient developed an epi- leptic attack with tonoclonic spasms that lasted for 3 minutes. After the attack the patient fell asleep but in 5 minutes the second attack occurred. The first step of emergency aid would be to:
96. A 3-year-old child presents with sharp deterioration of his general condition. He has a history of purulent otitis. His temperature is now 38.5o C . The left leg is pressed to the torso, active movements are absent, the lower thi- rd 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?
97. A 19-year-old student was urgently hospi- talized due to marked dyspnea and chest pain on the left. Her body temperature is 38.8oC. She has been presenting with these signs for 3 days. Respiratory rate is 42/min., shallow. Percussion sound is dull to the left from the center of the scapula, no respiration can be auscultated. The left heart border is displaced outwards by 3 cm. Embryocardia and heart rate of 110/min are observed. Palpation of the right subcostal area is painful. What urgent measures should be taken in this case?
98. A burn victim with flame burns of the IIIA-B and IV degrees on his face, neck, and anterior surface of the thorax was brought into the admission room. The hairs in his nostri- ls are burnt, his labial and glossal mucosa are gray-white. The voice is hoarse; respirations are frequent and shallow; the patient has trumpet- like cough that produces soot-streaked sputum. The signs of respiratory failure were progressi- ng, while the patient was being transported into the intensive care unit. What emergency care must be provided to this patient?
99. A 27-year-old man was hospitalized in severe condition 50 minutes after receiving a penetrating wound to the left side of the chest. Objectively the patient is in a stupor, his skin is pale and acrocyanotic. Pulse is 120/min., of poor volume, weak. Blood pressure is 80/40 mm Hg. Heart sounds are muffled, cardiac borders are markedly expanded. In the III intercostal area along the parasternal line on the left there is a stab-incised wound. Plain chest X-ray shows enlarged heart shadow with smoothed out wai- st of the heart, there is hemothorax on the left to the 5th rib. What contributes the most to the severity of the patient’s condition?
100. A 59-year-old patient suffering from hypertension was delivered to the hospital with complaints of acute headache, nausea, recurrent vomiting. On examination she presents with acute meningeal symptom complex. BP is 185/105 mm Hg. What additi- onal examination would you recommend to the patient in the first place?
101. A 36-year-old man complains of marked dyspnea and cardiac pain. He ascribes his di- sease to the case of influenza that he had 2 weeks ago. Objectively he leans forward when sitting. The face is swollen, cyanotic, cervical veins are swollen. Heart borders are extended on the both sides, heart sounds are muffled, heart rate = Ps = 118/min., BP is 90/60 mm Hg. Blood test: ESR is 16 mm/hour. ECG shows low voltage. X-ray shows trapezoidal cardiac silhouette and signs of pulmonary congestion. Choose the treatment tactics:
102. A 23-year-old man came to the surgeon with complaints of pain, redness of the skin, and swelling in the area of his proximal interphalangeal joint of the III finger on the right hand. Six days ago he pricked his finger with a wire. Objectively the III finger on the right hand is swollen, hyperemic, prominent in the projection of interphalangeal joint, sharply painful on touch and during movements. Finger mobility is reduced. Fluctuation sign is present. What diagnosis corresponds to the given clini- cal presentation?
103. A 25-year-old woman during self- examination detected a tumor in the upper external quadrant of her right mammary gland. On palpation: painless, dense, mobile growth 2 cm in diameter is detected in the mammary gland; no changes in the peripheral lymph nodes are observed. On US of the mammary glands: in the upper external quadrant of the ri- ght mammary gland there is a space-occupying lesion of increased echogenicity 21х18 mm in size. The most likely diagnosis is:
104. A 45-year-old woman underwent one year ago mastectomy followed by chemo- and radi- ation therapy. She now complains of dyspnea at rest and temperature up to 37.2o C . Her general condition is severe, acrocyanosis is observed. The right side of her chest practically does not participate in respiration. Percussion reveals a dull sound below the 3rd rib; auscultation detects acute weakening of the respiratory sounds. Pleural puncture on the right has yi- elded a large amount of hemorrhagic exudate. What complication has developed in the pati- ent?
105. A 60-year-old man complains of discomfort when swallowing solid food, which he has been observing for a month. He changed his diet to semiliquid food products. At first the di- scomfort had abated but later it renewed despi- te the change in the diet. The patient developed gaseous eructation and hoarse voice. What examination should be performed to clarify the diagnosis?
106. A 60-year-old man complains of discomfort when swallowing solid food, which he has been observing for a month. He changed his diet to semiliquid food products. At first the di- scomfort had abated but later it renewed despi- te the change in the diet. The patient developed gaseous eructation and hoarse voice. What examination should be performed to clarify the diagnosis?
107. A 74-year-old patient visited a urologist with complaints of pain above the pubis and inability to urinate for 8 hours. At home he had taken antispasmodics and had a warm bath but no improvement occurred. Objectively: abdomen is soft and painful above the pubis; dullness of percussion sound is observed above the pubis. Murphy’s (Pasternatski’s) punch sign is negative on the both sides. What condition does the patient have?
108. A 10-year-old boy is delivered into a polytrauma unit after he received a blunt trauma of the thorax, having fallen from the bi- cycle. 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 peri- cardial cavity, in the amount of up to 100 ml. In an hour after the hospitalization the patient started to develop increasing signs of heart failure: jugular venous distention, decreased blood pressure down to 90/70 mm Hg, tachycardia up to 120/min. On auscultation muffled heart sounds. What would be the pri- mary tactics of a physician?
109. A 35-year-old man complains of persisti- ng enlargement of his peripheral lymph nodes that cause him no discomfort. The case history states that the first lymph nodes to enlarge were cervical, supraclavicular, and axillary; new groups of lymph nodes emerged. Objecti- vely the lymph nodes are soft and elastic on palpation, enlarged, painless, not fixed to the surrounding tissue. What examination method would be the most informative for early di- agnostics of this disease?
110. A 32-year-old woman complains of body weight loss despite her increased appetite, nervousness, and tremor of the extremities. Objectively: the skin is moist; the thyroid gland is diffusely enlarged, painless, soft, and mobi- le. Blood test: increased level of T3, T4, and decreased thyroid-stimulating hormone (TSH). What is the most likely diagnosis?
111. A 38-year-old man underwent surgical treatment of a wound with a suppuration focus. On the 8th day after the procedure the wound cleared of purulo-necrotic discharge and granulations appeared. However, against the background of antibacterial therapy, the patient’s body temperature persists as high as 38.5-39.5oC; chills, excessive sweating, and euphoria are observed in the patient; heart rate is 120/min. What complication of the local suppurative inflammatory process can be suspected?
112. A man complains of high fever, pain in the area of his right mastoid bone, and purulent discharge from the right ear. One week ago he had a case of URTI. Objectively the ri- ght auricle protrudes, the skin behind the ear is hyperemic and pastose; on palpation of the mastoid bone the pain intensifies; the auditory meatus is filled with thick pus, posterosuperior meatal wall sags; the tympanic membrane is red and perforated. Make the diagnosis:
113. A 28-year-old man after car accident recei- ved a wound to the right side of his chest infli- cted by a sharp metal object. A foamy liquid flows out from the wound, there are tympani- tis and acutely weakened respirations in the right. Blood pressure is 70/30 mm Hg, pulse is 120/min., Hb is 28 g/L. X-ray shows collapsed right lung, horizontal fluid level is at the 3rd rib. What treatment tactics should be chosen?
114. When her car collided with a tree, a 37- year-old woman felt sharp pain in her left hip joint. She was unable to get out of the car. Her position is forced, the hip is pressed to the abdomen, fixed, and rotated inwards; the li- mb is flexed in the knee, any attempt to change the position results in sharp pain. Make the di- agnosis:
115. On the 9th day after childbirth the obstetric patient developed high fever up to 38o C . She complains of pain in the right mammary gland. The examination revealed the following: a sharply painful infiltrate can be palpated in the right mammary gland, the skin over the infiltrate is red, subareolar area and nipple are swollen and painful. What is your diagnosis?
116. During reanimation procedures an attempt to intubate trachea was made. Nei- ther glottis nor epiglottis can be visualized via laryngoscopy. What tactics should be chosen in this case?
117. A 22-year-old man at 18:00 developed persisting dull pain in the epigastrium. Three hours later nausea appeared, he vomited once. By the morning the pain shifted to the right iliac area. Body temperature rose to 38.6o C , developed tachycardia of 110/min. On examination there are muscle rigidity and Bloomberg’s sign (rebound tenderness) in the right iliac area of the anterior abdominal wall. Plain x-ray of the abdomen shows no fluid levels, free air under the diapragm on the ri- ght. Make the diagnosis:
118. On ultrasound of the thyroid gland, a 47- year-old woman presents with a hypoechoic node 1.6 cm in diameter with blurred margi- ns and intranodular hypervascularization. The doctor suspects thyroid carcinoma. What method should be used to verify the diagnosis?
119. 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 fatigabili- ty. On examination there is no pulse over the leg arteries. ECG shows left ventricular hypertrophy. MRI-scan shows aortic narrowi- ng to 5 mm in the typical place. Coarctation of aorta is diagnosed. What kind of treatment should be prescribed in this case?
120. 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 ri- ght 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?
121. A 44-year-old woman has undergone subtotal thyroid resection due to diffuse toxic goiter. On the second day after the surgery the patient’s condition deteriorated; she developed palpitations, dyspnea, sweating, and diarrhea, and became fearful The patient is anxious, her skin is moist and hot to the touch. Her temperature is 39.2o C . Heart sounds are muffled, tachycardia is observed, pulse is 160/min., blood pressure is 85/40 mm Hg. The stomach is soft and painless. What should be measured to clarify the patient’s condition?
122. A 20-year-old student was brought to the first-aid center. He has a closed fracture of the left forearm and a contused lacerated wound on his left shin. After the patient recei- ved initial wound management, he presented the documents confirming that he has recei- ved all the necessary preventive vaccination as scheduled. What should the doctor do to prevent tetanus in this patient?
123. 5 weeks after hypothermia a 22-year- old patient developed fever, weakness, muscle pain, inability to move independently. Objectively: tenderness, induration of shoulder and shin muscles, restricted active movements, erythema on the anterior surface of the chest. There is a periorbital edema with heliotropic erythema. Gottron’s sign is present. What investigation is required for the diagnosis verification?
124. A 44-year-old patient complains of diffi- cult urination, sensation of incomplete uri- nary bladder emptying. Sonographic exami- nation of the urinary bladder near the urethra entrance revealed an oval well- defined hyperechogenic formation 2x3 cm large that was changing its position during the examination. What conclusion can be made?
125. A parturient woman complains of pain in her mammary gland. In the painful area there is an infiltration 3x4 cm in size with softened center. Body temperature is 38,5oC. What is the most likely diagnosis?
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 di- sease 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?
127. A patient received flame burns of both hands. On the dorsal and palmar surface of the hands there are blisters filled with serous fluid. The wrist joint region is hyperemic. The forearms were not injured. What is the provi- sional diagnosis?
128. A 40-year-old patient has acute onset of disease caused by overexposure to cold. Temperature has increased up to 39o C . Foul-smelling sputum is expectorated duri- ng coughig. Various moist crackles can be auscultated above the 3rd segment on the ri- ght. Blood test: leukocytes - 15, 0 · 109 /l, stab neutrophils - 12%, ESR- 52 mm/hour. On X- ray: in the 3rd segment on the right there is a focus of shadow 3 cm in diameter, low density, with fuzzy smooth margins and a clearing in its center. What disease is most likely in the given case?
129. On the 4th day after recovery from a cold a patient was hospitalized with complai- nts of solitary spittings of mucoid sputum. On the 2nd day there was a single discharge of about 250 ml of purulent blood-streaked sputum. Objectively: the patient’s conditi- on is moderately severe. Respiratory rate - 28-30/min., Ps- 96/min., BP- 110/70 mm Hg. Respiration over the left lung is vesicular, over the right lung - weakened. There are various moist crackles over the lower lobe and amphoric breath sounds near the angle of scapula. What is the most likely diagnosis?
130. A 65-year-old woman on abdominal palpation presents with a tumor in the umbi- lical region and above it; the tumor is 13x8 cm in size, moderately painful, non-mobile, pulsi- ng. On auscultation systolic murmur can be observed. What is the most likely diagnosis?
131. A 74-year-old patient was delivered into admission room with clinical presentations of acute deep vein thrombosis of the shin. What symptom is the most typical of this pathology?
132. A man complains of constant dull pain in the perineum and suprapubic area, weak flow of urine, frequent difficult painful urination, nocturia. The patient has been suffering from this condition for several months, during which urination was becomi- ng increasingly difficult, and pain in the peri- neum has developed. On rectal examinati- on: the prostate is enlarged (mainly its right lobe), dense, asymmetrical, central fissure is smoothed out, the right lobe is of stony densi- ty, painless, tuberous. What disease is it?
133. A 17-year-old young man complains of general weakness, trismus, twitching of the muscles in his left shin. 7 days ago he pierced his foot with a nail. Objectively: at the sole of the foot there is a wound, 0,3х0,2 mm in size, with small amount of serous-purulent discharge, the skin around the wound is hyperemic. What is the most likely diagnosis?
134. A 20-year-old woman on the 10th day after her discharge from the maternity ward developed fever up to 39oC and pain in her left mammary gland. On examination the mammary gland is enlarged, in its upper outer quadrant there is a hyperemic area. In this area a dense spot with blurred margins can be palpated. The patient presents with lactostasis and no fluctuation. Lymph nodes in the ri- ght axillary crease are enlarged and painful. Specify the correct diagnosis:
135. Two days ago a woman fell from the hei- ght of 1,5 m. She complains of severe thoracic pain on the left and dyspnea. Chest X-ray reveals hydropneumothorax on the left with fluid level at the 7th rib and the lung collapsed by 1/3. The 6th-7th ribs are fractured along the scapular line. Serohemorrhagic fluid was obtained during thoracic puncture. What treatment tactics should be chosen?
136. A patient complains of suppuration from the ear and impaired hearing of the left ear, which have been observed for the past 6 years. The patient had periodical headaches, general indisposition, fever. Objectively: otoscopy of the external auditory meatus revealed mucopurulent odorless substance. The eardrum is of normal color, with central perforation. What is the most likely di- agnosis?
137. Posture of an 11-year-old boy was determi- ned during preventive examination. The chi- ld 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?
138. A 65-year-old patient has been suffering from liver cirrhosis associated with hepati- tis C virus for 7 years. During the last 3 weeks the patient developed severe edema of the lower extremities, the abdomen is si- gnificantly distended with fluid. Ultrasound: signs of liver cirrhosis, portal hypertensi- on, lymph nodes are in the area of hepatic portal. Concentration of α-fetoprotein in blood serum is 285 ng/ml. What complicati- on could have developed in this case?
139. A 43-year-old man has undergone a surgery for osteomyelitis of the left thigh. On the 6th day the patient’s condition was complicated with sepsis. Despite complex therapy of sepsis on the 9th day the patient persistently presents with temperature up to 40oC, heart rate is 110/min., respiration rate is 23/min., BP is 100/60 mm Hg. Blood test: leukocytes - 16 · 109 /l, band neutrophils - 16%. What phase of clinical course is it?
140. A 57-year-old woman complains of a sensation of esophageal compression, palpi- tations, difficult breathing when eating solid food, occasional vomiting with a full mouth, ”wet pillow” sign at night for the last 6 months. Objectively: body tempearture - 39oC, height - 168 cm, weight - 72 kg, Ps- 76/min, BP- 120/80 mm Hg. X-ray study revealed considerable dilation of esophagus and its constriction in the cardial part. What pathology is the most likely to have caused dysphagia in this patient?
141. A 37-year-old woman complains of acute pain in the genital area, swelling of the labia, pain when walking. Objectively: body temperature is 38,7oC, Ps- 98/min. In the interior of the right labia there is a dense, painful tumor-like formation 5,0x4,5 cm in si- ze, the skin and mucous membrane of genitals are hyperemic, there is profuse foul-smelling discharge. What is the most likely diagnosis?
142. A 42-year-old man was delivered to a surgical in-patient department with complai- nts of icteric skin, pain in the right subcostal area. Biochemical blood analysis: total bili- rubin - 140 mcmol/l, direct bilirubin - 112 mcmol/l. On US: choledoch duct - 1,4 cm, a concrement is detected in the distal area. Gallbladder is 40 cm, no concrements. What treatment tactics should be chosen?
143. An infant cries during urination, the foreskin swells and urine is excreted in drops. What approach to treatment should be chosen?
144. A 49-year-old patient consulted a doctor about difficult swallowing, voice hoarseness, weight loss. These symptoms have been gradually progressing for the last 3 months. Objectively: the patient is exhausted, there are enlarged supraclavicular lymph nodes. Esophagoscopy revealed no esophageal pathology. Which of the following investigati- ons is the most appropriate in this case?
145. Anamnesis of a 30-year-old patient includes closed thoracic injury. Lately the patient has been suffering from increasing dyspnea, sensation of heaviness in the right subcostal area, and heart rate disturbances. Objectively: acrocyanosis, bulging cervical veins, ascites, edema of the lower extremiti- es. Heart auscultation reveals muffled heart sounds, additional III heart sound is detected. Provisional diagnosis of constrictive peri- carditis was made. What diagnostic technique would NOT confirm the diagnosis?
146. A 64-year-old patient has been hospitali- zed with complaints of progressive jaundice that developed over 3 weeks without pain syndrome and is accompanied by general weakness and loss of appetite. Objectively: temperature is 36,8oC, heart rate is 78/min, abdomen is soft and painless, peritoneum irri- tation symptoms are not detected, palpati- on reveals sharply enlarged tense gallbladder. What disease can be characterised by these symptoms?
147. A 37-year-old patient complains of pain in the spinal column, reduced mobility. The condition persists for 7 years. ”Sway back” is observed, there is no movement in all spi- nal regions. On X-ray: ”bamboo spine” is detected. What is the most likely diagnosis?
148. A 19-year-old woman complains of severe pain in the axillary crease. Conditi- on onset occurred a week ago after her swi- mming in a cold river and epilation. The next day a painful ”boil” appeared. The ”boil” was increasing in size every day and became a plum-sized tumor. Upon examination there are nodular conical growths joined together detected, the skin covering them is bluish-red in color. Some nodules have fistulous openi- ngs producing thick purulent mass. Body temperature is 38, 5o C , general malaise. What is the most likely diagnosis?
149. A 68-year-old man complains of inabili- ty to urinate for a day. On attempt of urinary bladder catheterization there was detected a rough stricture in the membranous portion of the urethra. What first aid tactics should be applied in this case?
150. Heart X-ray of a 31-year-old man has revealed the following: with tightly filled opacified esophagus there is a marginal filli- ng defect in its middle third on the posterior wall; the defect is 1,8x1,3 cm in size with clear oval border. Mucosal folds are retained and envelop the defect; wall peristalsis and elasti- city are not affected. There are no complai- nts regarding the condition of the patient’s alimentary canal. Make the provisional di- agnosis:
151. A patient with signs of general overexposure to cold presenting with local frostbites of fingers has been delivered into an admission room. Objectively: conscious, inert, speech is slow, the skin of the face is cold, body temperature is 34oC, heart rate is 68/min. What would be the actions of a doctor on call?
152. A 24-year-old patient had been delivered to a thoracic department with a chest injury, fracture of the IV, V, VI ribs on the right. Plan radiography showed the fluid level in the pleural cavity to be reaching the III rib on the right. Puncture contained blood clots. What is the optimal treatment tactics?
153. A 36-year-old woman complains of pain in her lumbar area, which irradiates to her lower right limb and increases during movements, and sensation of numbness in her limb. Objectively: palpation of the shin and thigh muscles is painful, positive stretch symptom on the right. MRI scan: herniati- on of intervertebral disk L5-S1 4 mm in size. What is the most likely diagnosis?
154. A woman complains of frequent, li- quid stool (up to 9-10 times per day) with mucus and blood admixtures, dull pain in the hypogastrium, weight loss of 4 kg within the last year. Objectively: malnutrition, dry skin, low turgor, aphthous stomatitis. The stomach is soft, the sigmoid colon is spastic and painful on palpation. Occult blood test is positive. Fi- brocolonoscopy: edema, hyperemia, mucosal granulation, pseudopolyps, small ulcers with irregular edges. Make the diagnosis:
155. A 24-year-old patient received a puncture injury below the Poupart’s ligament accompanied by intense arterial bleeding. The best method to temporarily stop the bleeding in the patient would be:
156. A 42-year-old woman has been hospitali- zed with complaints of intense pain attacks in the lumbar and right iliac areas, which irradiate to the vulvar lips, frequent urination, nausea. The pain onset was acute. Objecti- vely: the abdomen is soft, moderately pai- nful in the right subcostal area, costovertebral angle tenderness on the right. Common uri- ne analysis: specific gravity - 1016, traces of protein, leukocytes - 6-8 in the vision field, erythrocytes - 12-16 in the vision field, fresh. What diagnosis can be made?
157. A 29-year-old patient works as a motor mechanic. Anamnesis shows frequent exposure to cold, exacerbation of chronic bronchitis attended by cough with relati- vly small amount of mucopurulent sputum, subfebrility, sometimes joined by hemoptysis and pain in the right side of chest. Breathing is vesicular. X-ray shows shadows and sharp decrease in size of the lower lobe distinctly vi- sible on the X-ray image as a streak 2-3 cm wi- de situated at the angle from lung root to the frontal costodiaphragmatic recess. The most likely diagnosis is:
158. A 62-year-old patient has been hospitali- zed with complaints of pain in the thorax on the right during breathing, dyspnea, dry cough. Ten days ago he slipped and fell hitti- ng his right side. On examintaion: the pati- ent lies on the left side. The right side of the thorax lags during breathing. On the right there are crepitation and pain in the III-IV ri- bs. Dullness of percussion sound and sharply diminished breath sounds can be observed. On X-ray: signs of exudate, fracture of the III- IV ribs. On pleurocentesis: blood is detected. Choose the further tactics:
159. A 29-year-old female patient complains of dyspnea, heaviness and chest pain on the ri- ght, body temperature rise up to 37, 2o C . The disease is associated with a chest trauma recei- ved 4 days ago. Objectively: skin is pale and moist. Ps- 90/min., regular. Palpation reveals a dull sound on the right, auscultation reveals significantly weakened vesicular breathing. In blood: RBCs- 2, 8 · 1012 /l, colour index - 0,9, Hb- 100 g/l, WBCs- 8,0 · 109/l, ESR- 17 mm/hour. What results of diagnostic puncture of the pleural cavity can be expected?
160. A woman has developed sudden thoracic pain on the right with expectoration of pi- nk sputum and body temperature rise up to 37,7oC on the 4th day after the surgery for cystoma of the right ovary. On lung examinati- on: dullness of the lung sound on the lower right is observed. Isolated moist crackles can be auscultated in the same area. What compli- cation is the most likely?
161. A 48-year-old woman has thermal burns of both hands. The epidermis of the palms and backs of her hands is exfoliating, and bli- sters filled with serous liquid are forming. The forearms are intact. What diagnosis is most likely?
162. A 45-year-old woman is undergoing treatment for active rheumatism, combined mitral valve failure. During her morning procedures she suddenly sensed pain in the left hand, which was followed by numbness. Pain and numbness continued to aggravate. Objectively: the skin of the left hand is pale and comparatively cold. Pulse in the hand arteries is absent along the whole length. What treatment tactics is most efficient?
163. In 10 hours after eating canned mushrooms a 27-year-old patient has developed diplopia, bilateral ptosis, di- srupted swallowing, shallow breathing with respiratory rate 40/min., muscle weakness, enteroparesis. What measure should be taken first?
164. A child is 1 month 10 days old. ”Gushing” vomiting has been observed since the age of 3 weeks. The vomit volume exceeds the volume of the previous feeding. Objectively: the chi- ld is inert. Skin elasticity and tissue turgor are decreased. Hour-glass deformity sign is positive. The preliminary diagnosis is pyloric stenosis. What treatment tactics should be chosen?
165. A 46-year-old woman complains of pain attacks in the right lumbar area, which irradi- ate to the lower abdomen, and nausea. This kind of pain attacks has never been detected in the patient before. Survey X- ray of the abdominal cavity reveals no pathologic shadows. Ultrasonic scan detects a hyperechogenic growth 1,5 cm in diameter, which reflects sound wave, in the enlarged ri- ght renal pelvis. What diagnosis is most likely?
166. A 51-year-old female patient complains of frequent defecation and liquid blood-streaked stools with mucus admixtures, diffuse pain in the inferolateral abdomen, 6 kg weight loss within the previous month. Objectively: body temperature - 37,4oC, malnutrition, skin is pale and dry. Abdomen is soft, sigmoid is pai- nful and spasmodic, makes a rumbling sound. Liver is dense, painful, extends 3 cm below the costal margin. What is the most likely di- agnosis?
167. A patient complains of constant dull pain in the perineum and suprapubic area, weak flow of urine, frequent difficult pai- nful urination, nocturia. The patient has been suffering from this condition for several months, during which urination was becomi- ng increasingly difficult, and pain in the peri- neum has developed. On rectal examinati- on: the prostate is enlarged (mainly its right lobe), dense, asymmetrical, central fissure is smoothed out, the right lobe is of stony densi- ty, painless, tuberous. What disease is it?
168. Three days ago a boy underwent removal of a foreign body from under a nail plate. 2 days later he deeloped acute pulsating pain at the end of the nail bone which aggravated at pressing. Nail fold became hyperemic, body temperature rose up to 37, 5o C , there was a change in nail plate colour. What is the most likely diagnosis?
169. A 45-year-old patient with urolithiasis had an attack of renal colic. What is the mechanism of the attack development?
170. A woman addressed a gynecologist on the 20th day of puerperal period with complaints of pain in the left mammary gland, puruent discharge from the nipple. Objecti- vely: Ps- 120/min., body temperature is 39o C . The left mammary gland is painful, larger than the right one, the skin there is hyperemic; in the upper quadrant there is an infiltrate 10x15 cm in size with soft center. Blood test: ESR- 50 mm/hour, leukocytes - 15, 0 · 109 /l. What would be the treatment tactics?
171. For the last 15 years a 48-year-old patient has been working at the factory producing synthetic resins. Lately he has been complai- ning of significant general fatigue, headaches, frequent urination (predominantly during the day), red color of urine. What complication of benzene nitrocompounds poisoning can be suspected?
172. A 25-year-old man complains of pain in the lower third of his left thigh, which occurs both with and without physical exerti- on. Possibility of trauma is denied by the patient. Objectively: skin colour is normal; pastosity and pain can be detected with deep palpation; knee joint mobility is reduced. X- ray of distal femoral metaphysis shows an area of destruction and spicule. Blood test: immature cells, no signs of inflammation. The most likely diagnosis is:
173. A 45-year-old man was delivered to a hospital with complaints of vomiting wi- th streaks of blood, loss of weight. On esophagofiberscopy a cauliflower-shaped mucosal growth was detected in the abdomi- nal esophagus. The mucosa there bleeds on contact. What preliminary diagnosis can be made?
174. A 35-year-old man complains of intense lumbar pain irradiating to the inguinal area, external genitalia, thigh; frequent urination, chill, nausea, vomiting. Objectively: positive Pasternatsky’s symptom (costovertebral angle tenderness). Urine analysis revealed that RBCs and WBCs covered the total field of microscope; the urine exhibited high protein concentration. These clinical presentations were most likely caused by the following pathology:
175. As a result of load lifting a 68-year-old woman developed acute pain in the lumbar region, in a buttock, posterolateral surface of her right thigh, external surface of the ri- ght shin and dorsal surface of foot. Objecti- vely: weakness of the anterior tibial muscle, long extensor muscle of the right toes, short extensor muscle of the right toes. Low Achi- lles reflex on the right. Positive Lasegue’s si- gn. What examination method would be most effective for specification of the diagnosis of L5 root discogenic compression?
176. During preventive ultrasound scan of abdomen performed during regular check- up in a school the following was revealed in an 11-year-old student of the 5th grade: the left kidney is 3 cm below the normal posi- tion, its shape, size and structure are within the norm, the contralateral kidney cannot be observed at its proper place. The preliminary diagnosis is as follows: congenital anomaly of renal development, dystopic left kidney, right kidney is absent or pelvic dystopic. What X- ray method would be required for making the final diagnosis and determining the functional capacity of both kidneys?
177. 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, vomi- ting occurred once. Objectively: the child’s condition is grave. Abdomen is soft, palpation reveals a tumor-like formation in the right ili- ac area. After rectal examination the doctor’s finger was stained with blood. What is the most probable diagnosis?
178. A 2-year-old child in a satisfactory condi- tion periodically presents with moderate proteinuria, microhematuria. US results: the left kidney is undetectable, the right one is enlarged, there are signs of double pyelocali- ceal system. What study is required to specify the diagnosis?
179. A 75-year-old male patient complains of slight pain in the right iliac region. The abdominal pain arose 6 days ago and was accompanied by nausea. Surgical examination revealed moist tongue, Ps- 76/min., BP- 130/80 mm Hg. Abdomen was soft, slightly painful in the right iliac region on deep palpation, the symptoms of the peritoneum irritation were doubtful. In blood: RBCs- 4, 0 · 1012 /l, Hb- 135g/l, WBCs- 9, 5 · 109 /l, stab neutrophils - 5%, segmentonuclear - 52%, lymphocytes - 38%, monocytes - 5%, ESR- 20 mm/hour. Specify the doctor’s further tactics:
180. A 35-year-old patient undergoing treatment for heart disorder in cardiologi- cal department has developed complaints of acute sudden pain in the epigastrium, temperature rise up to 38,3oC. Blumberg’s and Razdolsky’s (abduction of femur) signs are positive. What necessitates surgical aid in the given case?
181. A 16-year-old girl addressed a doctor wi- th complaints of fatigability and dizziness. On heart auscultation: systolic murmur in the II intercostal area along the breastbone edge on the left. ECG revealed signs of the right ventricular hypertrophy. X-ray revealed di- latation of the the pulmonary artery trunk, enlargement of the right heart. What heart di- sorder is it?
182. A patient was delivered to a surgical department after a road accident with a closed trauma of chest and right-sided rib fracture. The patient was diagnosed with right-sided pneumothorax; it is indicated to perform drai- nage of pleural cavity. Pleural puncture should be made:
183. A 60-year-old woman, mother of 6 children, developed a sudden onset of upper abdomi- nal pain radiating to the back, accompani- ed by nausea, vomiting, fever and chills. Subsequently, she noticed yellow discolorati- on of her sclera and skin. On physical exami- nation the patient was found to be febrile with temperature of 38,9oC, along with right upper quadrant tenderness. The most likely diagnosis is:
184. After examination a 46-year-old patient was diagnosed with left breast cancer T2N2M0, cli- nical group II-a. What will be the treatment plan for this patient?
185. A 50-year-old patient complains about havi- ng pain attacks in the right subcostal area for about a year. The pain arises mainly after taking fatty food. Over the last week the attacks occurred daily and became more pai- nful. On the 3rd day of hospitalization the pati- ent presented with icteritiousness of skin and scleras, light-coloured feces and dark urine. In blood: neutrophilic leukocytosis - 13,1 · 109/l, ESR - 28 mm/h. What is the most likely di- agnosis?
186. A 40-year-old woman with a history of combined mitral valve disease with predomi- nant stenosis complains of dyspnea, asthma attacks at night, heart problems. At present, she is unable to do even easy housework. What is the optimal tactics of the patient treatment?
187. A 43-year-old patient had right-sided deep vein thrombosis of iliofemoral segment 3 years ago. Now he is suffering from the sense of heaviness, edema of the lower right extremi- ty. Objectively: moderate edema of shin, brown induration of skin in the lower third of shin, varix dilatation of superficial shin veins are present. What is the most probable diagnosis?
188. A 65-year-old patient complains of pain in the lumbar spine, moderate disuria. He has been suffering from this condition for about
half a year. Prostate volume is 45 cm3 (there are hypoechogenic nodes in both lobes, capsule invasion). Prostate-specific antigen is 60 ng/ml. Prostate biopsy revealed an adenocarcinoma. Which of the supplementary examination methods will allow to determine the stage of neoplastic process in this patient?
189. A 12-year-old cild has been hit on the stomach. The patient is in moderately grave condition, has a forced position in bed. The skin is pale, heart rate - 122/min. Stress on the left costal arch causes a slight pain. Wei- nert and Kulenkampff symptoms are positive. Macroscopically the urine is unchanged. What is the most likely diagnosis?
190. After lifting a load, a 36-year-old male pati- ent has experienced a severe pain in the lumbar region, which spread to the right leg and was getting worse when he moved his foot or coughed. Objectively: the long back muscles on the right are strained. Achilles jerk is reduced on the right. There is a pronounced tenderness of paravertebral points in the lumbar region. The straight leg raise (Lasegue’s sign) is posi- tive on the right. What additional tests should be performed in the first place?
191. A 15-year-old patient suffers from headache, nasal haemorrhages, sense of lower extremity coldness. Objectively: muscles of shoulder girdle are developed, lower extremi- ties are hypotrophied. Pulsation on the pedal and femoral arteries is sharply dampened. BP is 150/90 mm Hg, 90/60 in the legs. Systolic murmur can be auscultated above carotid arteries. What is the most probable diagnosis?
192. A patient with frostbite of both feet was delivered to an admission ward. What actions should be taken?
