4120 1397
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 192 questions answered correctly

You have reached of 192 points, ( %)

Your time

Question 1 of 192

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:

Explanation

 

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

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?

Explanation

Pneumothorax is air in the pleural cavity i.e., accumulation of air between the lungs and chest wall. Accumulation of air will prevent chest excursion on the affected side during respiration, that is why we see no chest movement on that side ( here the right side of the chest lags during respiration).Pneumothorax develops when air enters the pleural space as the result of disease or injury. This leads to a loss of negative pressure between the two pleural membranes, which can result in the partial or complete collapse of the lung. Pneumothorax is classified as spontaneous or traumatic. Spontaneous pneumothorax can be further classified as primary (i.e., no underlying lung disease) or secondary (i.e., due to underlying lung disease). Any type of pneumothorax can progress to tension pneumothorax. Symptoms include;  dyspnea, ipsilateral chest pain, diminished breath sounds, and hyper-resonant percussion on the affected side

 

Hemothorax, hydrothorax will give dull sounds during percussion because of the presence of fluid.

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?

Explanation

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

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

Division of the burns on superficial (I, II, IIIA st.) and deep (IIIB-IV st.)

I stage – hyperemia of the skin

II stage – separation of epidermis with formation of bullas/

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

IIIB stage – necrosis of all the derma

 

IV stage – necrosis of the skin and underlying tissues.

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?

Explanation

Notice that on ultrasound examination, pyelocaliectasis was observed. This refers to the dilation of the renal pelvis and calyces. The most common causes of pyelectasis are:

  • Ureteropelvic junction obstruction: A blockage of urine between the kidneys and the ureter

  • Vesicoureteral reflux: An abnormal flow of urine from the bladder to the kidneys. 

 

This Presents with excruciating spasms around the lumbar region ( renal colic). 

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?

Explanation

 

This patient is said to have a nonspecific ulcerative colitis which is an inflammatory bowel disease characterised by the presence  of ulcers and sores in the innermost lining of your large intestine (colon) and rectum. On the other had, corticosteroids possess anti-inflammatory, immunosuppressive and anti-pyretic actions, in patients with inflammatory bowel diseases such as chrohns and ulcerative colitis, these drugs are administered as short term treatment because they quickly reduce inflammation ( within few days to month).

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:

Explanation

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

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

 

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

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?

Explanation

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?

Explanation

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?

Explanation

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?

Explanation

 

A positive Kulenkampff’s symptom refers to an acute pain during palpation of the stomach and an absent tension of muscles of the anterior abdominal wall. This sign helps in the diagnosis of abdominal bleeding. The main symptom of a ruptured spleen is pain located around the left costal arch. A kidney related pathology will present with pain in the lumbar region (since the kidney is a retroperitoneal organ) and also have an effect on urine. Pancreatic pathologies will present with belt-like pain. In peritonitis, the pain is dull and poorly localised.

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?

Explanation

 

This patient is experiencing multiple hemorrhages; notice that the platelets are very low ( Platelet count 150 − 400 · 109/L- norm) and due to the continuous hemorrhage, the rbc, hemoglobin level and wbc levels are low - this signals the increased production of reticulocytes ( which are immature red blood cells). Recall that the spleen acts as a blood filter, removing damaged or abnormal blood cells. In patients with Immune thrombocytopenia, their immune system treats the blood platelets as foreign bodies, thereby signaling their removal by the spleen leading to thrombocytopenia. Therefore, if the spleen is removed, more platelets can be preserved.

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?

Explanation

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?

Explanation

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?

Explanation

 

A carbuncle is a collection of boils ( pus filled inflammation) all connected under the skin. This patient presents to the surgeon with carbuncle and edema of the upper lip and eyelids.  The surgeon should admit this patient, drain the carbuncle, followed by an antibiotic regime with observation of the patient to see if any complication arises.

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:

Explanation

 

Duroziez sign is elicited as an audible systolic murmur heard over the femoral artery when the artery is compressed proximally along with a diastolic murmur when the femoral artery is compressed distally. This patient presents with signs of an occluded left femoral artery, these include; pain while walking, numbness and coldness. Also notice that since this issue began just 3 hours before- it is an acute case. The state of the skin of the left foot and shin; a marbled skin is seen when blood supply is not adequate to that area - in this case due to an occlusion to the left femoral artery.

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?

Explanation

A strangulated hernia is a life threatening condition. This is because this form of hernia cuts off blood supply to the intestines and tissues of the abdomen; it can be complicated by perforation of the intestine, shock, gangrene etc. This condition requires a surgical emergency.
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?

Explanation

 

From anamnesis, there is an abscess ( fluid filled cavity) in the left lung. The development of sudden pain, dyspnea and tachycardia raises a question about the worsening of the patient’s current state. The result from the Ro-gram ( pulmonary function study) shows the presence of air and fluid in the pleural cavity of the left lung thereby indicating that the earlier mentioned abscess has burst open and its content has spread into the pleural space.

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?

Explanation

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?

Explanation

This patient is currently having a spontaneous pneumothorax. Spontaneous pneumothorax refers to the sudden collapse of the lungs in the absence of any apparent cause such as trauma or any underlying lung pathology. Notice that the chest radiography shows the collapse of the left lung indicating a spontaneous pneumothorax. This is an emergency procedure that requires a Thoracostomy to be carried out ( a small surgical incision that allows the drainage of air, fluid etc). 

The type of drainage selected depends on the cause and type of pleural disease.

Passive drainage relies on the increased intrathoracic pressure generated during exhalation. This will force air from the pleural space. This has been shown to be very effective in treating spontaneous pneumothorax and traumatic pneumothorax. There is no active suction on the lungs, the theory being this will allow small ruptures in the pulmonary parenchyma to heal whereas constant suction could dislodge the fibrin and lead to delayed healing of the tear in the pulmonary tissue.

 

Active drainage entails suction consistently placed on the thoracostomy tube and works well in the case of marked pleural effusion and pyothorax.

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?

Explanation

 

Intestinal obstruction refers to the blockage of food from getting into the small intestine and colon. These blockades can be as a result of strictures ( from an inflammatory condition), medications, fibrotic changes etc. Abdominal cramps, bloating, constipation, inability to pass stool are key findings in this condition. For confirmation of diagnosis of intestinal obstruction, an abdominal X-ray is recommended. Although not all obstructions can be viewed via an abdominal x-ray, additional examinations include abdominal ultrasound and CT.

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?

Explanation

Bronchiectasis is the abnormal and persistent dilatation of the smaller bronchi and mainly the segmental or subsegmental bronchi due to destruction of elastic tissues and muscles of the bronchial wall.

Social limitations in addition to treatment failure, despite preventive precautions and aggressive medical treatment, are the main indications for surgery in patients with bronchiectasis. For a patient that has lived with this condition for 12 years, we can safely assume that she must have tried conservative management which definitely did not work as we can still see exacerbations of the symptoms.

Cases with long-term treatment lead a life without comfort and with high risk due to life-threatening complications. It is important to perform surgical treatment when indicated to save patients from these risks and to minimize the surgical risks in delayed cases.

 

The left lower lobe is affected so the surgery will be a resection of the left lower lobe - left lower lobectomy.

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?

Explanation

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

 

We can pick out: muffled heart sounds; low blood pressure (hypotension 60/20mmHg); elevated jugular venous pressure (evidenced by swelling and throbbing of the neck veins). These three signs are known as Beck’s triad. They indicate a Cardiac Tamponade (the impaired pumping ability of the heart due to accumulation of fluid in the pericardium). Note that percussion reveals heart border extension in both directions. The most suitable approach  should be a pericardial puncture (pericardiocentesis) to remove the fluid in the pericardium. A thoracotomy can be carried out to gain access to the pleural cavity.

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?

Explanation

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

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

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

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?

Explanation

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

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

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

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

 

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

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?

Explanation

 The idea here is to Place the tourniquet between the injured vessel and the heart and the tourniquet should be over a bone, not on a joint. For arterial bleeding, the tourniquet should be above the wound which usually falls between the wound and the heart. And venous bleeding is usually below the wound.

Understanding the anatomy will help you to understand this better. Arteries take blood away from the heart, so for arterial bleeding, the blood is flowing from the heart to the wound, so you tie above it to stop the flow.

 

For Venous bleeding, Veins take blood to the heart, so you tie below the wound to stop the flow towards the wound (heart).

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?

Explanation

A filling defect was observed in the imaging technique used, which is a well defined oval mass indicating a tumor. Notice that mucosal walls are intact and wall peristalsis and elasticity are not affected- these rule out the options of achalasia cardia, Esophageal burns and barrett's esophagus ( because in these pathologies, one or more of the above listed is/are affected). The result from the x-ray shows a mass with clear oval borders thereby indicating a tumour.

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

 
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?

Explanation

 

Intravenous or Excretory Urography 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.

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?

Explanation

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

Explanation

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?

Explanation

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

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

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

Explanation

 

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

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:

Explanation

 

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

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?

Explanation

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

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

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

 

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

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?

Explanation

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

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

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

 
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?

Explanation

 

A person who has frostbite should be covered with a warm blanket ( a warm bandage on the affected area). The frostbitten area should be warmed slowly and should not be warmed in front of a fire nor rubbed with snow. A vasodilatory injection such as Reserpine can be administered to improve blood flow to the affected area. Antibiotic therapy can also be given.

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?

Explanation

 

An abscess is a purulent filled cavity found within the body tissue. A wound abscess occurred in this process mainly due to an infection before or during the closure of the wound. This is confirmed by the presence of edema and purulent content from the wound gap 4 days after the closure. The sutures of this wound should be removed and the purulent content should be drained followed by an antibiotic therapy.

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?

Explanation

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

 

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

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?

Explanation

[caption id="attachment_1376" align="aligncenter" width="1924"]Complete Blood Count Complete Blood Count[/caption]

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

 

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

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?

Explanation

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

 

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

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?

Explanation

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

 

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

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?

Explanation

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

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.

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?

Explanation

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

 

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

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?

Explanation

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

 

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

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?

Explanation

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?

Explanation

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

Explanation

Notice that this patient has thrombophlebitis- a condition in which blood clots form and block  an already inflamed vein(s). This condition can be superficial or deep (deep vein thrombosis- as in this case). Pulmonary embolism is one of the various complications of DVT- this occurs when a clot or substance formed elsewhere travels and blocks an artery in the lungs. Sharp pain in the thorax and hemoptysis coupled with weakened respiration are clinical findings in this condition.
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?

Explanation

A positive Homan’s sign ( calf pain at the dorsiflexion of the foot ) indicates a case of Deep Vein Thrombosis (blood clot within a deep vein). Patients with DVT are mostly predisposed by 

Stasis - due to post operation (as in this case), long drive/flight.

Hypercoagulability- can be due to a defect in coagulation cascade proteins eg factor V Leiden; oral contraceptive use.

Endothelial damage. 

One major complication of DVT is pulmonary embolism.

 

Unfractionated heparin or LMWH are used for prophylaxis or acute management.

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:

Explanation

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:

Explanation

 

Note that the color of blood and the rate of its flow helps us detect the type of bleeding. Arterial bleeding is characterized by bright red color with a pulsating stream (flow) while dark red blood is found in venous bleeding with the rate of flow being less. 

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:

Explanation

 

Aure-rozanov sign is commonly seen in cases of retrocecal appendix; it refers to the presence of pain in the right petit triangle when palpated.  The location of pain in the lower abdomen and right lumbar area rules out the option of cholecystitis ( right hypochondrium). The results from deep palpation of the abdomen helps put the provisional diagnosis of acute appendicitis.

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?

Explanation

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:

Explanation

 

From anamnesis, this patient had a trauma to the head which led to the results from palpation “ tense neck muscles and protruding spinous process of C4 vertebra. These findings help us put a provisional diagnosis of an Uncomplicated cervical fracture.

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?

Explanation

A thyroid fine needle aspiration biopsy is a procedure that removes a small sample of tissue from your thyroid gland. Cells are removed through a small, hollow needle. The sample is sent to the lab for analysis. In some cases, hard nodules form inside the gland. Most times, the nodules are not dangerous. But in some cases they can be thyroid cancer. A thyroid fine needle aspiration biopsy can take a sample from the nodule to test for cancer.

 

Thyroid scan (thyroid scintigraphy) is a nuclear medicine examination used to evaluate thyroid tissue. Clinical indications include; functional status of a thyroid nodule, thyrotoxicosis: differential diagnosis and thyroid cancer. Note that an ultrasound procedure has already been carried out therefore, carrying out a thyroid scintigraphy will just be a repetitive test.

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?

Explanation

Note the high level of not only bile but amylase. This indicates pancreatitis. Also note that the production of a large amount of abdominal discharge began 3 days after the duodenal operation ( postoperative), This patient is currently having a postoperative pancreatitis which occurred as a complication of the duodenal procedure carried out three days earlier.
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?

Explanation

 

Of all the listed injuries sustained, the brain concussion should be addressed first. Recall that brain concussion refers to a mild traumatic brain injury that affects your brain function. Effects are usually temporary but can include headaches and problems with concentration, memory, balance and coordination.

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?

Explanation

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?

Explanation

For the temporary stop of hemorrhage; - the imposition of a pressure

bandage;

- the elevated position of the limb;

- digital pressure of the artery

throughout;

- maximum limb flexion in the joint;

- stop bleeding with a tourniquet;

- stop bleeding with a tourniquet;

- stop bleeding from the carotid

 

artery according to the method of Mikulich. This patient is bleeding from the carotid artery ( bright red blood from the neck) therefore, the highlighted procedures should be followed. 

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?

Explanation

 

The key finding here is ‘ the right part of the thorax is distended and takes no part in respiration’ this is an indicator for Tension Pneumothorax ( of the right side). Pneumothorax is the collapse of the lung when air accumulates between the parietal and visceral pleura inside the chest. A tension pneumothorax is a severe condition that results when air is trapped in the pleural space under positive pressure, displacing mediastinal structures, and compromising cardiopulmonary function i.e., (distended neck veins, tracheal deviation, and hemodynamic instability)

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:

Explanation

 

A peritonsillar abscess is a bacterial infection that usually begins as a complication of untreated strep throat or tonsillitis (4 days ago, the patient had a case of tonsillitis). also known as quinsy, it leads to the  accumulation of pus due to an infection behind the tonsil. Key symptoms include; throat pain, difficulty swallowing , drooling , swelling of the face or neck, fever and chills. Notice that this patient presents with signs affecting the TONSILS; in a case of Pharyngitis, the posterior pharyngeal wall will be affected. In a case of infectious mononucleosis, Atypical lymphocytes will be present on analysis.

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?

Explanation

 

Notice that this patient had a trauma to the head from which he developed the signs of bradycardia, anisocoria, hemi-hyperreflexia, hemihyperesthesia and a convulsive disorder; a CT scan (computed tomography)  should be immediately carried out to get a clear image of the internal structures of the head to  find possible damages.

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?

Explanation

The results from the x-ray shows the fracture of the skull coupled with the fact that this patient is in a state of unconsciousness; from the listed options, an immediate surgical intervention should be carried out.
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?

Explanation

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?

Explanation

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?

Explanation

Pneumothorax is air in the pleural cavity ie, accumulation of air between the lungs and chest wall. A spontaneous pneumothorax is a form of pneumothorax without any underlying lung issue (just happens suddenly). N/B Tympanic resonance sound during  chest percussion indicates the presence of air. Accumulation of air will prevent chest excursion on the affected side during respiration, that is why we see no chest movement on that side

 

Hemothorax, hydrothorax will give dull sounds during percussion because of the presence of fluid.

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?

Explanation

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:

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.

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?

Explanation

 

Normal Rbc level in the blood ranges from about Male: 4.3 − 5.9 · 1012/L Female: 3.5 − 5.5 · 1012/L and hemoglobin levelMale: 135-175 g/L Female: 120-160 g/L. A reduction in these values in the blood test indicates Anemia. Red blood cells are produced in the bone marrow of large bones and a bone marrow biopsy is needed for diagnosis.

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?

Explanation

Renal calculus is simply kidney stones. These stones may be composed of calcium, fats, uric acid etc). These stones can cause a blockade in the ureter causing a very severe pain (as seen in  the patient). An x-ray (KUB- kidney, urather,bladder film) can be used for diagnosis. N/B Radiolucent stones cannot be detected by an x-ray; this is why the plain abdominal x-ray did not produce a result in the patient in review. Other diagnostic methods such as ultrasound will be effective.

 

A cyst is a fluid filled cavity. Both cysts and tumors can be seen on x-rays and can be differentiated by the level of contrast on the film.

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?

Explanation

Surgically, lung cancer is divided into 3: Central, Peripheral and atypical. Central cancer includes the tumors of the first to third order bronchi ( main bronchi, secondary/lobar bronchi and tertiary/segmented bronchi). Peripheral cancer includes rounded tumour, pneumonia like tumor and pancoast’s cancer. Atypical forms include miliary carcinomatosis etc.

Basic complaints and signs of a central lung cancer include: Constant cough accompanied by hemoptysis, dyspnea, rales and prolonged or obstructive pneumonia.

On physical examination, asymmetry of the chest and delayed breathing movements on the affected side are observed.

On percussion; dull sound on the side of the lesion.

 

On auscultation, bronchial breathing or moist rales are observed

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?

Explanation

From the question stem, the patient presents with symptoms indicating a gallbladder related issue (cholelithiasis, cholecystitis, cholangitis etc); these symptoms include: pain in the right subcostal area especially after eating food rich in fat, bitter taste in her mouth in the morning, constipations, and flatulence. 

 

An ultrasound allows sonologists to view images of the organs and soft tissues inside your body. This procedure is used in diagnosing conditions related to the gallbladder. It is fast, accessible, not cumbersome and less expensive, which makes it a first choice in this case.

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?

Explanation

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?

Explanation

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

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

 

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

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?

Explanation

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

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

 

Raynaud's disease is a rare disorder of the blood vessels, usually in the fingers and toes. It causes the blood vessels to narrow when you are cold or feeling stressed. When this happens, blood can't get to the surface of the skin and the affected areas turn white and blue.

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?

Explanation

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?

Explanation

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

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

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

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:

Explanation

 

Extension of a tonsil infection can take place in the surrounding tissue and is referred to as  a Peritonsillar abscess or quinsy. This complication of tonsillitis is usually caused by a B-hemolytic streptococcal infection and are characterized by an extremely sore throat and high fever ( as seen in the patient) . Note that, Retropharyngeal abscess is also a complication of tonsillitis but is virtually limited to infants in the first two years of life; the characteristic findings are fever, hyperextension of the neck, dysphagia and noisy respiration.

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?

Explanation

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?

Explanation

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

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

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

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

 
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?

Explanation

 

The Presence of an increased body temperature and pain a days after the wound closure indicates ‘An Infection’ - most likely a bacterial form. To correct this, the sutures/wound dressing should be undone,  drained ( if there be any purulent process), an antiseptic should be used in cleaning the affected area coupled with the administration of an antibiotic therapy to the patient.

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?

Explanation

Aromatic compounds such as benzene and its products (es nitrobenzene, benzidin etc) are major components in factories producing dyes and resins and upon exposure are dangerous  to health. One major negative effect is the conversion of hemoglobin to methemoglobin. In recent times, it has been proved that these compounds act as carcinogens and lead to bladder related tumors.

Chronic Prostatitis is ruled out since the patient wasn’t experiencing pain while passing out urine.

 

In Chronic Cystitis, the patient often observes severe burning sensation in the pelvic region.

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?

Explanation

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

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

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

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

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

 
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:

Explanation

Vetebrogenous lumbar ischialgia  is one of the clinical forms of reflex syndromes at lumbar – sacral level. Characterised by pain located in the lumbar area and irradiates towards the hips, legs ( as seen in the patient). It has three forms namely;

  • Muscle-tonic

  • Neurodystrophic

  • Autonomic-vascular

In Vertebrogenic radicular syndrome of L5-S1, pain is experienced in the external posterior surface of the  hip, crus, foot, the 4th and 5th toes; sensory disorders in the same zones, paresis of toe flexors, absent or low achilles tendon reflex.

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:

Explanation

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:

Explanation

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:

Explanation

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?

Explanation

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?

Explanation

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?

Explanation

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?

Explanation

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?

Explanation

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:

Explanation

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?

Explanation

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:

Explanation

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?

Explanation

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?

Explanation

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?

Explanation

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?

Explanation

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?

Explanation

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?

Explanation

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?

Explanation

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?

Explanation

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:

Explanation

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?

Explanation

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:

Explanation

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?

Explanation

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?

Explanation

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:

Explanation

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?

Explanation

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?

Explanation

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?

Explanation

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?

Explanation

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?

Explanation

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?

Explanation

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?

Explanation

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?

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 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?

Explanation

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?

Explanation

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?

Explanation

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?

Explanation

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?

Explanation

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?

Explanation

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?

Explanation

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?

Explanation

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:

Explanation

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?

Explanation

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?

Explanation

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?

Explanation

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?

Explanation

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?

Explanation

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?

Explanation

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?

Explanation

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?

Explanation

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

Explanation

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?

Explanation

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?

Explanation

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?

Explanation

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?

Explanation

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?

Explanation

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?

Explanation

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:

Explanation

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?

Explanation

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?

Explanation

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?

Explanation

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:

Explanation

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:

Explanation

 

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

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?

Explanation

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:

Explanation

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:

Explanation

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?

Explanation

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?

Explanation

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?

Explanation

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?

Explanation

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?

Explanation

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?

Explanation

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?

Explanation

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?

Explanation

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?

Explanation

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?

Explanation

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

Explanation

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?

Explanation

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?

Explanation

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:

Explanation

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?

Explanation

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:

Explanation

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?

Explanation

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?

Explanation

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?

Explanation

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?

Explanation

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:

Explanation

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?

Explanation

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?

Explanation

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:

Explanation

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:

Explanation

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?

Explanation

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?

Explanation

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?

Explanation

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?

Explanation

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?

Explanation

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?

Explanation

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?

Explanation

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?

Explanation

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

Explanation