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1. A microslide demonstrates an organ with its wall consisting of three membranes. The inner membrane has tubular glands and undergoes cyclic changes. Name this organ:

Explanation

The uterus or womb is the major female reproductive organ of most mammals, including humans.  One end, the cervix, opens into the vagina; the other is connected on both sides to the fallopian tubes (uterine tubes).  The Uterus has 3 layers: endometrium (further divided into basal layer and functional layer); Myometrium (middle layer) and the Perimetrium (outer layer). The endometrium builds a lining periodically which, if no pregnancy occurs, is shed - Menstrual cycle. Menstrual cycle includes periodic changes in the endometrium (menstrual phase, proliferative phase and secretory phase). The basal layer of the endometrium has endomethrial glands, which have cambial cells responsible for regeneration of epithelium. The basal layer is unaffected during menses. The functional layer is usually shed in a cyclic manner of approximately 28 days.
2. During examination of a patient a doctor should use anatomical division of anterior abdominal wall into regions for more precise diagnostics. How many regions can abdomen be divided into?

Explanation

 

Anterolateral abdominal wall is the muscular aponeurotic formation limited by the abdominal wall from the anterior and lateral sides. There are two horizontal orientation lines and two vertical orientation lines that divides it into 9 regions, namely:

·        Right hypochondriac region

·        Proper epigastric region

·        Left hypochondriac region

·        Right lateral abdominal region

·        Umbilical region

·        Left lateral abdominal region

·        Right inguinal (ilioinguinal) region

·        Hypogastric (suprapubic) region

·        Left inguinal (ilioinguinal) region.

3. A child has a wound located posterior to the mastoid process. Bright red blood flows from the wound. Damaged are the branches of the following artery:

Explanation

The occipital artery (Latin: Arteria occipitalis) is one of the posterior branches of the external carotid artery. It arises opposite the facial artery, near the lower border of the posterior belly of the digastric muscle. Along the digastric muscle, it runs to the interval between the mastoid process of the temporal bone and the transverse process of the atlas. It reaches the groove on the under surface of the mastoid portion of the temporal bone.
4. When investigating human saliva it is necessary to assess its hydrolytic properties. What substance should be used as a substrate in the process?

Explanation

When food enters the mouth, digestion of the food starts by the action of mastication, a form of mechanical digestion, and the wetting contact of saliva. Saliva, a liquid secreted by the salivary glands, contains salivary amylase, an enzyme which starts the digestion of starch in the food. After undergoing mastication and starch digestion, the food will be in the form of a small, round slurry mass called a bolus. It will then travel down the esophagus and into the stomach by the action of peristalsis. Gastric juice in the stomach starts protein digestion.  The best substance to use as a substrate to test the hydrolytic properties of the salivary amylase is starch as that is the main food substance that starts the process of digestion in the mouth.
5. A person with the fourth blood group (genotype IAIB) has in erythrocytes both antigen A controlled by allele IA and antigen B controlled by allele IB. This phenomenon is an example of the following gene interaction:

Explanation

Codominance: there are several conditions where two or more alleles do not show complete dominance or recessiveness due to the failure of any allele to be dominant in the heterozygous condition. In most cases the heterozygote has a prototype, which is intermediate between the homozygous dominant and recessive conditions. Codominance refers to instances in which two alleles are expressed independently in the heterozygote. The human AB blood group provides a classic example of codominant alleles.
6. A patient with diabetes mellitus suffers from persistently nonhealing surgical wound, which is a sign of disrupted tissue trophism. What is the cause of such disorder?

Explanation

7. A patient with signs of intestinal infection (vomiting, diarrhea, abdominal pain) has been presenting with increasing symptoms of intoxication for three days. Papular rash appeared on the uncovered skin areas and spread to the torso. A doctor suspected pseudotuberculosis. What laboratory test allows confirming this diagnosis within the first week from the onset of disease?

Explanation

Genus Yersinia includes the following three bacterial species: Y. pestis, Y. pseudotuberculosis, and Y. enterocolitica.

Yersinia pseudotuberculosis is primarily an animal pathogen, infecting both wild and domestic animals. Humans acquire the infection by way of an oral route after contact with infected animals. The most common manifestation of human infection is the painful swelling of the mesenteric lymph nodes, resulting in an appendicitis-like syndrome, although diarrhea and fever also are usual.

Laboratory findings: 

Using the Bacteriological method - Yersinia Pseudotuberculosis may be found in feces, urine, blood and mucus within a couple of days after infection. To confirm this diagnosis within the first week from the onset of disease, bacteriological method is the best option.

8. A patient with femoral neck fracture, who for a long time had to remain in bed in a forced (supine) position, has developed dark-brown lesions along the backbone; soft tissues are swollen, in the areas of maceration there is a foul-smelling liquid. Name the clinicopathologic type of necrosis:

Explanation

Sustained or repeated pressure on skin over bony prominences can cause ischemia and pressure sores. These are common in patients over 70 years old who are confined to hospital, especially those with a fracture of the neck of femur. The morbidity and mortality of those with deep ulcers is high.

Causes:

*prolonged immobility and recumbency

*vascular disease (atherosclerosis)

*neurological disease causing diminished sensation.

*malnutrition,severe systemic disease and general debility.

Clinical Features: The sore begins as an area of erythema which progresses to a superficial blister or erosion. If pressure continues, deeper damage occurs with the development of a black eschar which  when removed or shed reveals a deep ulcer, often colonized by Pseudomonas aeruginosa. The skin overlying the sacrum, greater trochanter, ischial tuberousity, the heel and the lateral malleolus is especially at risk.

9. A patient is 20 years old, an athlete. He addressed a doctor with complaints of fatigue, fever up to 38oC - 40oC. Objectively: the liver and spleen are enlarged, lymph nodes on palpation are slightly enlarged, dense, painless. Blood test: Нb- 100 g/l; erythrocytes - 2, 9 · 1012/l; leukocytes - 4, 4 · 109/l. Leukogram: 68% of blast cells. Cytochemical investigation of blast cells revealed negative reactions to glycogen, peroxidase, non-specific esterase, lipids. Name this disease:

Explanation

Blast cells > 20% - Acute Leukemia Blast cells < 10% - Chronic Leukemia Blast cells 11 - 19% : Blast Crisis To know the specific type, we need to know if its lymphoblast or myeloblast. If Lymphoblast; it becomes Acute or Chronic lymphoblastic Leukemia (depending on the number of blast cells present) If Myeloblast; it beocmes Acute or Chronic Myeloblastic Leukemia (depending on the number of blast cells present). In this question the type of blast cell was not stated, so it is undifferentiated. 68% of blast cells - Acute Therefore, final answer becomes ACUTE UNDIFFERENTIATED LEUKEMIA
10. Impression smear of mucosa biopsy material has been obtained from a patient with peptic ulcer disease of the stomach. Gram-negative arcuate bent microorganisms were detected, urease activity test was positive. What microorganisms were detected in the patient?

Explanation

 Helicobacter pylori causes gastritis and peptic ulcers. Infection with H. pylori is a risk factor for gastric carcinoma and is linked to mucosal-associated lymphoid tissue (MALT) lymphoma. It is a gram negative, flexibacteria, oxidase positive, microaerophilic, motile and the only species in the Helicobacter genus to have multiple unipolar – sheathed flagella. Microaerophiles need O2 because they cannot ferment or respire anaerobically. However, they are poisoned by high concentrations of O2. They gather in the upper part of the test tube but not the very top. CO2 is essential for initial growth of H. pylori in liquid media (microaerophilic property). They produce urease, so it’s a diagnostic tool and not a necessary consideration for cultivation (culture medium).
11. A patient after disrupted cerebral circulation has developed paralysis. Choose the anticholinesterase drug to be prescribed in this case:

Explanation

Acetylcholine esterase (AChE) is an enzyme that specifically cleaves acetylcholine to acetate and choline and thus, terminates its actions. Inhibitors of AChE indirectly provide a cholinergic action by prolonging the lifetime of acetylcholine produced endogenously at the cholinergic nerve endings. This results in the accumulation of Acetylcholine in the synaptic space by blocking the step No5.

Therefore, these drugs can provoke a response at all cholinoreceptors in the body, including both muscarinic and nicotinic receptors of the autonomic nervous system as well as at neuromuscular junctions and in the brain.

Neostigmine (proserine) is a synthetic compound that is also a carbamic acid ester and it reversibly inhibits acetylcholine esterase (AChE).

12. 30 minutes after drinking mango juice a child suddenly developed a local swelling in the area of the soft palate, which impeded swallowing and, eventually, respiration. Mucosa of the swollen area was hyperemic and painless. Blood test revealed moderate eosinophilia. Body temperature was normal. Anamnesis states that the elder sister of the child has been suffering from bronchial asthma attacks. What kind of edema has developed in the child?

Explanation

Type I hypersensitivity is also known as immediate, atopic, allergic, anaphylactic hypersensitivity. The reaction may involve skin (urticaria and eczema), eyes (conjunctivitis), nasopharynx (rhinorrhea, rhinitis), bronchopulmonary tissues (bronchial asthma) and gastrointestinal tract (gastroenteritis). The reaction may cause a range of symptoms from minor inconvenience to death. The reaction usually takes 15 - 30 minutes from the time of exposure to the antigen, although sometimes it may have a delayed onset (10 - 12 hours). Immediate hypersensitivity is mediated by IgE. The primary cellular component in this hypersensitivity is the mast cell or basophil. The reaction is amplified and/or modified by platelets, neutrophils and eosinophils. A biopsy of the reaction site demonstrates mainly mast cells and eosinophils.
13. Coenzym A participates in numerous important metabolic reactions. It is a derivative of the following vitamin:

Explanation

Vitamin B5 (Pantothenic Acid) is an essential component of coenzyme A (CoA, a cofactor for acyl transfers) and fatty acid synthase. Deficiency of Vit. B5 will result in: dermatitis, enteritis, alopecia, adrenal insufficiency. Vitamin B1 (Thiamine): TPP - Thiamine Pyrophosphate Vitamin B3 (Niacin): NAD+; NADP+ Vitamin D (Calciferol): Vit. D3 active form - Calcitriol Vitamin Q (Ubiquinone): Coenzyme Q
14. A patient diagnosed with acute dysentery has been treated for 3 days in an infectious diseases hospital. On admission there were complaints of high temperature, stomachache and fluid excrements with mucus up to 8-10 times a day. What sample should be taken for analysis?

Explanation

Dysentry refers to bloody diarrhea  with mucus. It can be caused by a variety of micro-organism. It is a sign of large bowel disease. It can also be of infectious origin. Diarrhea could be a sign of infection, laxative abuse, inflammatory bowel disease. Diarrhea- more than 250g of stool per day. Acute diarrhea is defined as less than 3 weeks, chronic diarrhea over 4 weeks.

Important screening tests:

*Fecal smear for leucocytes.

*Stool osmotic gap.

15. A patient with arthritis has been prescribed an anti-inflammatory selective COX-2 inhibitor. Select this drug among those given below:

Explanation

 

The nonsteroidal anti-inflammatory drugs (NSAIDs) are a group of chemically dissimilar agents that differ in their antipyretic, analgesic and anti-inflammatory activities. They act primarily by inhibiting the cyclooxygenase (COX 1 and 2) enzymes that catalyze the first step in prostanoid biosynthesis. This leads to decrease prostaglandin synthesis with both beneficial and unwanted effects. Aspirin is one of the most important NSAID. Its most common side effect is its gastrointestinal (GI) effect. Normally, prostacyclin (PGI2) inhibits gastric acid secretion, whereas PGE2 and PGF2α stimulate synthesis of protective mucus in both the stomach and small intestine.

Celecoxib is a selective cyclooxygenase 2 (COX-2) inhibitor. Approved for treatment of rheumatoid arthritis, osteoarthritis, acute to moderate pain, also approved for patients with peptic ulcers or gastroduodenitis. This is due to the fact that only COX 1 is responsible for the gastrointestinal protective functions.

16. Parkinson’s disease is caused by disruption of dopamine synthesis. What brain structure synthesizes this neurotransmitter?

Explanation

Parkinson disease is associated with a loss of dopaminergic neurons in the substantia nigra. Parkinsonism is a progressive neurological disorder of muscle movement, characterized by tremors, muscular rigidity, bradykinesia (slowness in initiating and carrying out voluntary movements) and postural and gait abnormalities. Most cases involve people over the age of 65.

The disease is correlated with destruction of dopaminergic neurons in the substantial nigra with a consequent reduction of dopamine actions in the corpus striatum, parts of the brain’s basal ganglia system that are involved in motor control.

The substantial nigra, part of the extrapyramidal system is the source of dopaminergic neurons that terminate in the neostriatum.

Treatment: drugs – levodopa, carbidopa, selegiline, rasagiline

So far, levodopa has been the only drug tested on Parkinson.

17. Name the halogen-containing antiseptic with fungicidal properties, which is used to treat dermatomycosis:

Explanation

Antimicrobial agents are drugs for the treatment and prevention of infectious diseases. They are divided into disinfectants, antiseptics and chemotherapeutics. Disinfectants realize their antimicrobial properties in the environment outside the body. Antiseptics act on the surface of the body. Chemotherapeutics produce an antimicrobial effect inside the body.

Antiseptics could be inorganic or organic.

·        Inorganic substances: halogens, oxidizing agents, metallic salts, acids and alkalis

·        Organic substances: aldehydes, alcohols, phenol derivatives, dyes, detergents, nitrofuran derivatives

Halogens: iodine alcohol solution – effects of iodine are based on the interaction between atoms of halogen and proteins resulting in halogenization and oxidation of proteins. It has bactericidal, fungicidal and irritative actions. Indications – processing of small cuts of the skin, dermatomycoses, processing of the surgery skin area and surgeon’s hands.

Other halogens include solution of lugol, iodinol, ioddiccerinum, chlorinated lime, chloramine B, chlorhexidine etc.

18. Due to severe pain syndrome a patient was prescribed a narcotic analgesic. Name this drug:

Explanation

Pain is an unpleasant sensation that can be either acute or chronic and is a consequence of complex neurochemical processes in the peripheral and central nervous system.

Analgesics are drugs reversibly and selectively inhibiting pain in the body without significant changing of consciousness. Opoid (narcotic) analgesics are the drugs that relieve intense pain which mimic the action of endogenous opiopeptides and may cause drug dependence.

Strong agonists of opoid receptors:

·        Natural compounds: morphine hydrochloride, codeine phosphate

·        Synthetic compounds: fentanyl, promedol

Acute poisoning with morphine: signs – state of sleep, unconsciousness, miosis, bradycardia, cheyne-stokes breathe, retention of urination, spasm of the intestine and bowel. Emergency help:

·        Lavage of stomach by 0.5% sol. of potassium permanganate

·        Naloxone, IV (an antagonist of narcotic analgesics)

·        Atropine (for a decrease in the vagal action of morphine)

19. During pathomorphological renal investigation of a patient, who for a long time had been suffering from osteomyelitis and died of progressing renal failure, the following was revealed: deposits of homogeneous eosinophilic masses in glomerular mesangium, arterial and arteriolar walls, and stroma, which colored red when stained with Congo red. What pathological process is this?

Explanation

Amyloidosis is the term used for a group of diseases characterized by extracellular deposition of fibrillar proteinaceous substance called amyloid.

Amyloidosis of the kidneys is the most common and most serious because of ill-effects on renal function. Cut surface of kidney is pale, waxy and translucent. In the glomeruli, the deposits initially appear on the basement membrane of the glomerular capillaries but later extend to produce luminal narrowing and distortion of the glomerular capillary tuft. There is also narrowing of the small arterioles and venules and consequent ischemic effects.

The deposits in the kidneys are found in most cases of secondary amyloidosis. The histologic diagnosis of amyloid is based almost entirely on its staining characteristics: Congo red – all types of amyloid have affinity for Congo red stain.

20. During experiment a dog has developed conditioned digestive reflex in response to a sound stimulus. This conditioned reflex will not be exhibited anymore after the extirpation of the following areas of the cerebral hemispheres:

Explanation

Conditioning, in physiology, is a behavioral process whereby a response becomes more frequent or more predictable in a given environment as a result of reinforcement, with reinforcement typically being a stimulus or reward for a desired response. In this traditional technique, which is based on the work of the Russian physiologist Ivan Pavlov, a dog is placed in a sound-shielded room. On each conditioning trial the sound of a bell is promptly followed by food for the dog. Here the tone of the bell is known as the conditioned (or sometimes conditional) stimulus. The dog’s salivation upon hearing this sound is the conditioned reflex. And the part of the brain cortex responsible for registering sound stimulus is the right and left Temporal lobe. Conditioned reflex always involve the activity of the brain cortex because the response was learnt.
21. An athlete (long-distance runner) during a contest developed a case of acute cardiac insufficiency. This pathology resulted from:

Explanation

22. A man is suffering from diarrhea. In summer he spent his vacation in the south at the sea coast. Bacteria with the following properties were detected in his feces: gram-negative curved mobile monotrichous bacilli that do not produce spores or capsules. Bacilli are undemanding to nutrient medium but require alkaline reaction (рН 8,5- 9,5). Described are the agents of the following enteric infection:

Explanation

Vibrio cholera is the cause of cholera. It is curved, comma-shaped, gram negative rods. It is transmitted by fecal contamination of water and food, primarily from human sources. Clinically, watery diarrhea in large volumes is the hallmark of cholera. There are no red blood cells or white blood cells in the stool. Rice-water stool is the term often applied to the non-bloody effluent. Grows in an alkaline media. Dark-field and phase contrast microscopy have been used for screening fecal specimens for the presence of V. cholera. With these techniques, liquid stools are microscopically examined for the presence of organisms with typical darting (“shooting star”) mobility [analogous to ‘hanging drop’].
23. When ascending to the top of Elbrus, a mountain climber experiences oxygen starvation, dyspnea, palpitations, and numbness of the extremities. What kind of hypoxia has developed in the mountain climber?

Explanation

Hypoxia is a typical pathological process, which arises owing to insufficient oxygen supply of tissues  or insufficient use it by tissues. Four main hypoxia types are distinguished – hypoxic, hemic, circulational and histotoxic. Hypoxic hypoxia: The main cause of this type is the decrease of partial oxygen pressure in inhaled air. This is common most especially in mountain (climbers, contributors) or in the case of respiratory insufficiency. On a sea level the partial oxygen pressure is equalled to 159 mm Hg, at the height of 5500 m - only 80 mm Hg, that is twice as less. Diffusion of oxygen from alveoles into blood occurs with the influence of a partial oxygen pressure difference in alveolar air and blood. The higher this gradient is the faster oxygen diffusion in pulmonary blood capillaries is made. Thus, the gradient of partial oxygen pressure (рО2) is the major physical factor, which advances oxygen from air in blood. Hemic hypoxia: in case of anemia or toxic substances poinsoning.   Circulatory hypoxia: cardiovascular insufficiency. Histotoxic hypoxia: decrease of respiratory enzymes activity.
24. A 2-year-old boy is diagnosed with Down syndrome. What chromosomal changes can cause this disease?

Explanation

 

Chromosomal disorders: trisomy 21 (down’s syndrome); trisomy 18 (edward’s syndrome); trisomy 13 (patau’s syndrome); monosomy X (turner’s syndrome-XO); trisomy X (XXX);

normal female (XX); normal male (XY)

25. A 62-year-old patient has been hospitalized due to massive cerebral hemorrhage. Blood pressure is 70/30 mm Hg, heart rate is 120/min., respiratory rate is 4/min., unconscious, no response to external stimuli. Such condition can be determined as:

Explanation

A coma is a state of prolonged unconsciousness that can be caused by a variety of problems (in this case, massive hemorrhage) — traumatic head injury, stroke, brain tumor, drug or alcohol intoxication, or even an underlying illness, such as diabetes or an infection. Some of the other symptoms are extreme bradycardia, low blood pressure and no response to external stimuli. Acute loss of a large amount of blood can quickly lead to the development of coma.
26. A 3-year-old girl with mental retardation has been diagnosed with sphingomyelin lipidosis (Niemann-Pick disease). In this condition synthesis of the following substance is disrupted:

Explanation

27. What condition may develop 15-30 minutes after re-administration of an antigen as a result of the increased level of antibodies, mainly IgE, that are adsorbed on the surface of target cells, namely tissue basophils (mast cells) and blood basophils?

Explanation

 

Type I Hypersensitivity reaction (HSR); anaphylactic and atopic: free antigen cross-links IgE on presensitized (i.e. exposed to the antigen before) mast cells and basophils, triggering immediate release of vasoactive amines that act at postcapillary venules (i.e. histamine). Reaction develops rapidly after antigen exposure because of preformed antibody from first exposure. IgE is the main immunoglobulin involved in type I HSR. Type I: uses IgE and IgG4

Type I (Immediate, Anaphylaxis, Reagin): IgE (immunoglobulin E)-dependent activation of mast cells/basophils, usually accompanied by eosinophilia e.g. urticaria (hives), hay fever, asthma (wheezing), rhinitis and conjunctivitis (stuffy nose and itchy eyes; usually seasonal)

Type II (cytotoxic): antibody dependent reactions e.g. Goodpasture syndrome, Myasthenia gravis, Graves disease, ABO hemolytic disease of newborn etc.

Type III (immune-complex): deposition of antigen-antibody complexes e.g. systemic lupus erythromatous (SLE), Arthus reaction, serum sickness, poststreptococcal glomerulonephritis etc.

Type IV (cell mediated, delayed): antibody-independent T-cell mediated reactions e.g. positive mantoux reaction (tuberculin test), hashimoto’s thyroiditis or transplant rejection etc.

28. Local anesthetics (novocaine, lidocaine and others) decreases pain sensitivity of tissues by blocking Na+ and K+ ions from permeating membranes of nerve fibers and endings. Such mechanism of drug action is called:

Explanation

29. After a road accident a victim has tachycardia, arterial blood pressure 130/90 mm Hg, tachypnoe, the skin is pale and dry, excitation of central nervous system is observed. What shock stage is the patient most likely in?

Explanation

Pirogov’s stages of shock

* Erectile phase: is characterized by strong motor agitation, sweating, tremor of skeletal muscles, staggering gait, frequent urination, transient increase in blood pressure, heart rate and breath rate increases, body temperature also. Painful impulses reach CNS.

* Torpid phase: decompensation in CNS leads to deep oppression. Patient is motionless, does not answer questions or answers very silently and with long time of delay, reflexes are lowered or absent.

30. A woman complaining of sharp pain in her lower abdomen has been delivered into an admission room. A gynecologist on examination makes a provisional diagnosis of extrauterine pregnancy. What anatomical structure should be punctated to confirm diagnosis?

Explanation

 In the female lesser pelvis, there are two excavations: the rectouterine pouch and vesicouterine pouch. The rectouterine pouch (pouch of douglas) is an intraperitoneal space between the uterus and the rectum. It is a common place for pelvic fluid or blood from hemorrhage to collect after surgery, or rupture of any etiology.

The vesicouterine pouch is between the urinary bladder anteriorly and the uterus posteriorly. It is a shallower recess (pouch).

31. A passenger of a fixed-run taxi has a sudden and expressed attack of tachycardia. A doctor travelling by the same taxi has managed to slow down his heart rate by pressing upon the eyeballs and thus causing the following reflex:

Explanation

Aschner’s reflex (press on eyeball) → ↓heart rate. This is mediated by nerve connections between the ophthalmic branch of trigeminal cranial nerve via the ciliary ganglion and the vagus nerve of parasympathetic nervous system.

Goltz reflex (press or blow to the epigastric region) → ↓heart rate.

32. A patient complains of palpitations after stress. Pulse is 104/min., P-Q=0,12 seconds, there are no changes in QRS complex. What type of arrhythmia does the patient have?

Explanation

Sinus tachycardia is the increase in discharge of impulses from the sinoatrial (SA) node, resulting in increase in heart rate (heart rate increase up to 100beats/min).ECG is normal, except for short R-R interval.

Sinus bradycardia is the reduction in discharge of impulses from SA node resulting in decrease in heart rate. Heart rate is less than 60beats/min. Extrasystole is the premature contraction of the heart before its normal contraction. ECG is altered. Sinus arrhythmia is characterized by irregular generation of impulses and may be due to variations in the tone of the vagus nerve. ECG is altered.

33. The key reaction of fatty acid synthesis is production of malonyl-CoA. What metabolite is the source of malonyl-CoA synthesis?

Explanation

In adult humans, fatty acid synthesis occurs primarily in the liver, lactating mammary glands and adipose tissues. The process incorporates carbons from acetyl CoA into the growing fatty acid chain, using ATP and NADPH. The carboxylation of acetyl CoA to form Malonyl CoA is catalyzed by acetyl CoA carboxylase. The coenzyme is the vitamin - Biotin.
34. A family of healthy students, who have arrived from Africa, gave birth to a child with signs of anemia. The child has died shortly after. Examination has revealed that the child’s erythrocytes are abnormally crescent-shaped. The disease is characterized by autosomal recessive inheritance. Determine the genotype of the child’s parents:

Explanation

For the parents to survive and have a sick anemic child, they must be heterozygous i.e. they only carry a recessive anemic allele.

 A – normal gene (dominant); a – anemic gene (recessive)

            Aa       X          Aa

AA       Aa       Aa       aa

aa – only this child will be anemic

35. A 35-year-old man has been delivered into a surgical ward with a suppurating wound in the neck, anterior to trachea (previsceral space). If a surgical operation is not performed urgently, there is a risk of infection spreading to:

Explanation

36. Characteristic sign of glycogenosis is muscle pain during physical work. Blood examination usually reveals hypoglycemia. This pathology is caused by congenital deficiency of the following enzyme:

Explanation

    Glycogen phosphorylase is the rate-determining enzyme in Glycogenolysis (break down of glycogen). Glycogen phosphorylase cleaves glycogen to glucose 1-phosphate (first step in glycogenolysis). This pathway mobilizes stored glycogen in liver to replenish used glucose. It also breaks down glycogen in muscle to glucose, to produce energy during physical work. If this enzyme is deficient, then used glucose cannot be replaced leading to hypoglycemia.

In lysosomal glycosidase, there is still normal blood sugar levels (no hypoglycemia). α-amylase and ɣ-amylase is involved in digestion of polysaccharides. Glucose 6-phosphate dehydrogenase (G6PD) is the rate-limiting enzyme in pentose phosphate pathway which catalyzes an irreversible oxidation of glucose 6-phosphate to 6-phosphogluconolactone.

37. Histologic specimen of a kidney demonstrates cells closely adjoined to the renal corpuscle in the distal convoluted tubule. Their basement membrane is extremely thin and has no folds. These cells sense the changes in sodium content of urine and influence renin secretion occurring in juxtaglomerular cells. Name these cells:

Explanation

Juxtaglomerular apparatus is formed by 3 different structures:

·        Macula densa: is the end portion of thick ascending segment as it opens into the distal convoluted tubule. It is situated between the afferent and efferent arterioles of the same nephron. It is very close to afferent arteriole. Macula densa is formed by tightly packed cuboidal epithelial cells.

·        Mesangial cells: are situated in the triangular region bound by afferent arteriole, efferent arteriole and macula densa.

·        Juxtaglomerular cells: are specialized smooth muscle cells situated in the wall of afferent arteriole just before it enters the Bowman’s capsule.

38. Bacteriological analysis of tap water has resulted in the following: total bacterial count in 1,0 ml of water is 80, coli index is 3. What would be the conclusion?

Explanation

39. The process of metabolism in the human body produces active forms of oxygen, including superoxide anion radical − 2 . This anion is inactivated by the following enzyme:

Explanation

Superoxide dismutases (SOD) are a group of enzymes that catalyze the dismutation of superoxide radicals (O2−) to molecular oxygen (O2) and hydrogen peroxide (H2O2), providing cellular defense against reactive oxygen species.

40. What kind of muscle contraction occurs in an upper limb during an attempt to lift a load beyond one’s strength?

Explanation

             Muscle contraction is classified into 2 types: Isotonic and Isometric.

·        Isotonic contraction: the tension in the muscle remains the same but the length of the muscle fiber is changing (Iso = same; tonic = tension) e.g. simple flexion of arm, where shortening of muscle fibers occurs but the tension does not change.

·        Isometric contraction: the length of muscle fibers remains the same but the tension is increased e.g. pulling any heavy object when the muscles become stiff and strained with increased tension but the length does not change. Holding (but not moving) – length does not change.

41. A patient suffers from high fever, apnoea, pain in the thorax on the right. Pleurocentesis yielded 700 ml of yellow-green viscous liquid. Make the diagnosis:

Explanation

     Empyema is a purulent inflammation of serous membranes (empyema of pleura, empyema of gall bladder and urinary bladder etc). Purulent or suppurative inflammation is characterized by the production of large amounts of pus or purulent exudates (liquids) consisting of a lot of neutrophils, necrotic cells and edema fluid.
42. A patient suffers from disrupted patency of the airways at the level of small and medium-sized bronchial tubes. What changes of acid-base balance can occur in the patient?

Explanation

43. Upon toxic damage of hepatic cells resulting in disruption of liver function the patient developed edemas. What changes of blood plasma are the main cause of edema development?

Explanation

Low protein levels (low oncotic pressure) in the blood caused by malnutrition, kidney and liver disease can cause edema. The proteins help to hold salt and water inside the blood vessels so fluid does not leak out into the tissues. If a blood protein, especially albumin, gets too low, fluid is retained and edema occurs, especially in the feet, ankles and lower legs.

44. A 6-year-old child with suspected active tuberculous process has undergone diagnostic Mantoux test. What immunobiological preparation was injected?

Explanation

Tuberculin (Mantoux) skin test: this test is done by intradermal injection of tuberculoprotein (tuberculin), purified protein derivative (PPD). Type IV hypersensitivity reaction.

Immunization against tuberculosis is induced by injection of attenuated strains of bovine type of tubercle bacilli, Bacilli Calmette Guerin (BCG).

45. A 15-year-old boy has been diagnosed with acute viral hepatitis. What blood value should be determined to confirm acute affection of hepatic cells?

Explanation

In viral hepatitis, there is generalized liver dysfunction involving uptake and conjugation of unconjugated bilirubin, secretion of conjugated bilirubin into bile ducts, and recycling of urobilinogen. Alanine transaminase (ALT) and Aspartate transaminase (AST) are increased (↑), but ALT is higher than AST and there is a slight ↑ in alkaline phosphatase (ALP) and ɣ-glutamyltransferase (GGT).

ALT is a specific enzyme for liver necrosis; present in the cytosol. ALT>AST: viral hepatitis.

AST is present in the mitochondria. Alcohol damages mitochondria AST>ALT indicates alcoholic hepatitis

46. A 53-year-old man is diagnosed with Paget’s disease. Concentration of oxyproline in daily urine is sharply increased, which primarily means intensified disintegration of:

Explanation

Collagen, most abundant protein in human body; organizes and strengthens extracellular matrix. Collagen contains Gly-X-Y (X and Y are proline or lysine). Glycine(Gly) makes 1/3 of collagen. Oxyproline (hydroxyproline) is a major collagen amino acid which enables it to be regarded as a marker that reflects the catabolism of collagen.

Paget disease of bone (osteitis deformans): localized disorder of bone remodeling caused by increase in both osteoclastic and osteoblastic activity.

47. When taking exams students often have dry mouth. The mechanism that causes this state results from the following reflexes:

Explanation

Reflex activity is the response to a peripheral nervous stimulation that occurs without our consciousness. It can be:

* Inborn or unconditioned: present from birth, does not require previous learning or training.

* Acquired or conditioned: developed after conditioning or training. Acquired after birth.

It is conditioned because the students have had a previous experience with examinations before. The manifestation of dry mouth is a sympathetic effect.

48. A patient has hoarseness of voice. During laryngoscopy a gray-white larynx tumor with papillary surface has been detected. Microscopic investigation has shown the following: growth of connective tissue covered with multilayer, strongly keratinized pavement epithelium, no cellular atypia. What is the most likely diagnosis?

Explanation

Papillomas are benign epithelial neoplasms producing microscopically or macroscopically visible fingerlike or warty projections from epithelial surfaces. Polyp: when a neoplasm – benign or malignant produces a macroscopically visible projection above a mucosal surface and projects, for example, into the gastric or colonic lumen. Fibroma: benign, node of differentiated connective tissue. Angioma and angiofibroma are related to vessels.
49. During autopsy approximately 2,0 liters of pus have been found in the abdominal cavity of the body. Peritoneum is dull and of grayish shade, serous tunic of intestines has grayish-colored coating that is easily removable. Specify the most likely type of peritonitis in the patient:

Explanation

Fibrinopurulent peritonitis: Supurative or purulent inflammation is characterized by the production of large amounts of pus. The cellular inflammatory response in peritoneal cavity is composed primarily of dense collections of neutrophils and fibrinopurulent debris that coat the visceral and abdominal wall. Serous peritonitis – thin fluid (not pus); Hemorrhagic peritonitis  - hemorrhage; Tuberculous peritonitis – the patient must have TB, before there can be an extrapulmonary TB.
50. Autopsy of a body revealed bone marrow hyperplasia of tubular and flat bones (pyoid marrow), splenomegaly (6 kg) and hepatomegaly (5 kg), enlargement of all lymph node groups. What disease are the identified changes typical of?

Explanation

  In chronic leukemia: spleen can weigh (6-8kg); liver (5-6kg). Chronic myelogenous leukemia (CML) is characterized by hepatosplenomegaly and generalized painless lymphadenopathy; pyoid bone marrow.
51. A bacteriological laboratory has been investigating a sample of homemade dried fish that was the cause of severe food poisoning. Microscopy of the culture inoculated in Kitt-Tarozzi medium revealed microorganisms resembling a tennis racket. What diagnosis can be made?

Explanation

The causative agent of botulism is  Clostridium botulinum.

 Morphology. Cl. botulinum is a large pleomorphous rod with rounded ends, 4.4-8.6 mcm in length and 0.3-1.3 mcm in breadth. The organism sometimes occurs in short forms or long threads. Cl. botulinum is slightly motile and produces from 4 to 30 flagella per cell. In the external environment Cl. botulinum produces oval terminal or subterminal spores which give them the appearance of tennis rackets . The organisms are Gram-positive.

Pathogenesis and disease in man. Botulism is contracted by ingesting meat products, canned vegetables, sausages, ham, salted and smoked fish (red fish more frequently), canned fish, chicken and duck flesh, and other products contaminated with Cl. botulinum. The organisms enter the soil in the faeces of animals (horses, cattle, minks, and domes-tic and wild birds) and fish and survive there as spores.

The test specimens are inoculated into Kitt-Tarozzi medium which has previously been held at 100 C for 10-20 minutes.

52. An infant has been diagnosed with microcephaly. Doctors suspect that this brain disorder developed due to the fact that the mother had been taking actinomycin D during her pregnancy. What germinal layers have been affected by this teratogen?

Explanation

53. A patient demonstrates sharp decrease of pulmonary surfactant activity. This condition can result in:

Explanation

54. A patient is diagnosed with diabetic coma. Blood sugar is 18,44 mmol/l. What glucose-regulating drug should be prescribed in the given case?

Explanation

55. Initial inoculation of water in 1% peptone water resulted in growth of a thin film on the medium surface in 6 hours. Such cultural properties are characteristic of causative agent of the following disease:

Explanation

Cholera:      

They are actively motile, monotrichous, nonsporeforming, noncapsulated, and Gram-negative.

Vibrio cholera are facultative (anaerobes). The organisms grow readily on alkaline media at pH 6.0-9.0, and on solid media the colonies are transparent with a light-blue hue, forming domes with smooth edges. On gelatin the organisms produce transparent granular colonies which, when examined under a microscope, resemble broken glass. In 48 hours the medium surrounding the colonies becomes liquefied and the colonies sink into this area. Six-hour-old cultures on alkaline meat broth and peptone water produce a thin pellicle, which consists of cholera vibrios.

56. An infant born prematurely 2 days ago presents with yellow coloring of skin and mucosa. Such a condition in the infant is caused by temporary deficiency of the following enzyme:

Explanation

  In the hepatocyte, the solubility of unconjugated bilirubin is increased (i.e. it is made soluble) by the addition of two molecules of glucuronic acid to produce conjugated bilirubin. This process is reffered to as conjugation. This reaction is catalyzed by Uridine diphosphate (UDP) glucuronyltransferase – UGT. Varying degrees of deficiency of this enzyme result in Crigler-Najjar I & II and Gilbert syndrome; with Crigler-Najjar I being the most severe deficiency.

Deficiency of UGT inhibits conjugation and therefore increase unconjugated bilirubin in serum (Jaundice).

57. It has been determined that one of a pesticide components is sodium arsenate that blocks lipoic acid. Enzyme activity can be impaired by this pesticide. Name this enzyme:

Explanation

Pyruvate dehydrogenase complex: Mitochondrial enzyme complex linking glycolysis and citric acid cycle. The complex contains 3 enzymes that require 5 cofactors: Vit B1, B2, B3, B5, lipoic acid. Pyruvate → Acetyl-CoA.

The complex is similar to the α-ketoglutarate dehydrogenase complex (same cofactors, similar substrate and action), which converts α-ketoglutarate → Succinyl-CoA (CAC or TCA cycle). Arsenic inhibits lipoic acid. Findings: vomiting, rice-water stools, garlic breath.

58. A patient with hypertension has developed headache, tinnitus, vomiting, high BP up to 220/160 mm Hg. On examination: facial asymmetry on the right, volitional mobility is absent, increased tendon reflexes and muscle tone of extremities on the right. What motor disorder of nervous system occurred in this case?

Explanation

Hypertension can result in hemorrhagic stroke on one side of the brain which then results in paralysis of one half of the body. Hemiplegia is paralysis on one vertical half of the body. Paraplegia is paralysis on either upper or lower half of the body. Tetraplegia (Quadriplegia) is paralysis on all four limbs.
59. A 7-year-old child in the state of allergic shock caused by a bee sting has been delivered into an emergency ward. High concentration of histamine was observed in blood. Production of this amine was the result of the following reaction:

Explanation

 

Certain amino acids undergo decarboxylation that means the removal of their α-carboxyl group resulting in liberation of CO2 and formation of biogenic amines. Biogenic amines are physiologically active substances such as hormones, neurotransmitters etc. decarboxylation of amino acids:

·        Tryptophan → Niacin → NAD+/NADP+

         Tryptophan → Serotonin →Melatonin

·        Histidine → Histamine

·        Glutamine → GABA

         Glutamine → Glutathione

60. A 26-year-old woman consulted a doctor about having stool with white flat moving organisms resembling noodles. Laboratory analysis revealed proglottids with the following characteristics: long, narrow, with a longitudinal channel of the uterus with 17-35 lateral branches on each side. What kind of intestinal parasite was found?

Explanation

  Taeniarhynchus saginatus (Taenia saginata) is a tapeworm. An intestinal parasite. It can be differentiated from other tapeworms by the number of uterine branches. Taenia saginata has 13 and more uterine branches, while other species such as Taenia solium have 5-12. Humans are infected by eating raw or undercooked beef containing larvae.
61. A man is 28 years old. Histological investigation of the cervical lymph node revealed a change of its pattern due to proliferation of epithelioid, lymphoid cells and macrophages with horseshoe-shaped nuclei. In the center of some cell clusters there were non-structured light-pink areas with fragments of nuclei. What disease are these changes typical of?

Explanation

  When tubercle bacilli are introduced into the tissue, they are ingested by the alveolar macrophage. Macrophages undergo changes resembling epithelial cells – EPITHELOID cells. Some of the macrophages form MULTINUCLEATED GIANT cells by fusion of adjacent cells (langerhan’s or foreign body type). The giant cells may have 20 or more nuclei. These nuclei may be arranged at the periphery like HORSE-SHOE, RING or clustered at the poles or they may be present centrally (foreign body giant cells). Lymphocytes, plasma cells and fibroblasts surround the epitheloid cells and giant cells (hard tubercle- no central necrosis). Within 10-14 days, the centre of the cellular mass begins to undergo caseation necrosis – soft tubercle. This is the hallmark of tuberculous lesions.
62. Sex chromatin was detected during examination of a man’s buccal epithelium. It is characteristic of the following chromosome disease:

Explanation

Drumstick – barr body. Barr body is an inactive X-chromosome. So a boy (XY) with an inactive X-chromosome must have an additional X-chromosome – XXY (Klinefelter’s syndrome). Causes :

* nondisjunction (maternal and paternal nondisjunction in meiosis I)

* Mosaicism: with the karyotype being 46, XY/47, XXY

Manifestations: gynecomastia, female pattern of pubic hair distribution, no facial hair, high voice.

63. A patient, having suffered a thermal burn, developed painful boils filled with turbid liquid in the skin. What morphological type of inflammation has developed in the patient?

Explanation

Serous inflammation.

•             It is marked by the outpouring of a thin fluid that is derived from either the bloodstream or the secretions of mesothelial cells.

•             The skin blister resulting from a burn or viral infections represents a large accumulation of serous fluid, either within or immediately beneath the epidermis of the skin.

•             Serous exudates contain up to 2% protein and less quantity cells (neutrophils, macrophages, desquamative epithelium).

•             Serous inflammation can also occur on serous membranes (poly-serositis at rheumatic diseases, autointoxications - uremia), in mucus (serous rhinitis), in skin (streptococcus infections, herpes, burn), seldom in internal organs (serous pneumonia).

64. Autopsy of a man with tuberculosis revealed a 3x2 cm large cavity in the superior lobe of the right lung. The cavity was interconnected with a bronchus, its wall was dense and consisted of three layers: the internal layer was pyogenic, the middle layer was made of tuberculous granulation tissue and the external one was made of connective tissue. What is the most likely diagnosis?

Explanation

Secondary tuberculosis usually results from reactivation of dormant, endogenous tubercle bacilli in a sensitized patient who has had previous contact with the tubercle bacillus. Reactivation typically begins in the apical or posterior segments (often 1st and 2nd segments) of one or both upper lobes (“simon’s foci”), where the organisms were seeded during the primary infection. There are 8 forms or stages of the secondary tuberculosis: Acute local tuberculosis; Fibrous local tuberculosis; Infiltrative tuberculosis; Tuberculoma; Caseous pneumonia; Acute cavernous tuberculosis; Fibrous cavernous tuberculosis; Cirrhotic tuberculosis.

Fibrous cavernous tuberculosis is the most frequent form. Macroscopically, the lesions are spherical and cavitary (cavity can contain blood and blood clots); the so-called coin lesions. Microscopically, the outer wall of cavity shows fibrosis or sclerosis. Internal surface may be connected with bronchus. The wall of cavern has 3 membranes:

·        Internal membrane occurs by necrotic tissue

·        Middle membrane occurs by special granular tissue

·        External membrane occurs by connective fibrous tissue

65. A 7-year-old child has acute onset of disease: temperature rise up to 38oC, rhinitis, cough, lacrimation, and large-spot rash on the skin. Pharyngeal mucosa is edematous, hyperemic, with whitish spots in the buccal area. What kind of inflammation caused the changes in the buccal mucosa?

Explanation

Catarrhal inflammation is one of the morphologic patterns in acute inflammation. In this type, a surface inflammation is associated with greatly increased secretion of clear mucus (nasal discharges). Rhinitis is inflammation of mucous lining of the nose.
66. A 50-year-old woman diagnosed with cardiac infarction has been delivered into an intensive care ward. What enzyme will be the most active during the first two days?

Explanation

67. Stool culture test of a 6-month-old bottlefed baby revealed a strain of intestinal rod-shaped bacteria of antigen structure 0-111. What diagnosis can be made?

Explanation

Colienteritis - Antigen structure 0-111

The causative agents of colienteritis in children are O-groups -25; -26; -44; -55; -86; -91; -111; -114; -119; -125; -126; -127; -128; -141; -146 and others (they cause diseases in infants of the first month of life and in older infants). Most widely spread serotype is O-111:K58:H2

68. Parents of a sick 5-year-old girl visited a genetic consultation. Karyotype investigation revealed 46 chromosomes. One chromosome of the 15th pair was abnormally long, having a part of the chromosome belonging to the 21st pair attached to it. What mutation occurred in this girl?

Explanation

  Translocations occur when two chromosome regions join together, when they would not normally. Chromosome translocations in somatic cells may be associated with tumorogenesis. We can have reciprocal and robertsonian translocations. Examples of diseases due to translocations are: Burkitt lymphoma t(8:14); Chronic myelogenous leukemia t(9;22) – Philadelphia chromosome.

Duplications occur when a portion of the chromosome is present on the chromosome in two copies.

Inversion involve an end-to-end reversal of a segment within the same chromosome (turn of 180o).

Deletion is a mutation in which a part of a chromosome or a sequence of DNA is missing. Deletion is the loss of genetic material.

69. A patient consulted a doctor with complaints of dyspnea occurring after physical exertion. Physical examination revealed anemia, paraprotein was detected among gamma globulins. What value should be determined in the patient’s urine to confirm the diagnosis of myeloma?

Explanation

Paraprotein, myeloma protein, M protein or spike protein is an abnormal immunoglobulin (Ig) fragment or immunoglobulin (Ig) light chain that is produced in excess by an abnormal clonal proliferation of plasma cells, typically in multiple myeloma. Monoclonal free light chains in the serum or urine are called bence jones (BJ) proteins.

Bence jones (BJ) protein: free kappa (κ) or lambda (λ) light chains that are excreted in urine associated with plasma cell malignancies (myeloma) and Waldenstrὄm macroglobulinemia. In myeloma, urinalysis for BJ protein is positive in 60-80% of cases.

70. A patient complaining of dizziness, thirst, difficult swallowing, and impaired vision of close objects has addressed a doctor. Objectively: respiratory rate is increased, pupils are dilated, general agitation, talkativeness, though the speech is indistinct. BP is 110/70 mm Hg, heart rate is 110/min. Given symptoms can indicate overdosage of the following drug:

Explanation

71. A dry-cleaner’s worker has been found to have hepatic steatosis. This pathology can be caused by disruption of synthesis of the following substance:

Explanation

Hepatic steatosis can occur when humans are deprived of choline.

Choline + Phosphatidic acid → Phosphatidylcholine (lecithin, PC). In the liver PC can also be synthesized from phosphatidylserine (PS) and phosphatidylethanolamine (PE), when free choline levels are low, because it exports significant amounts of PC in bile and as a component of serum lipoproteins (needed for fat metabolism)

PS → PE →→→ PC. 3 methylation reactions between PE and PC. S-adenosylmethionine is the methyl group donor. If choline, phosphatidylcholine or methionine is deficient, there will be abnormal phospholipid synthesis, oxidative damage caused by mitochondrial dysfunction, lipoprotein secretion (remember, if VLDL cannot be secreted it will be accumulated & cause fatty liver degeneration as seen in hepatic steatosis). PC is also a major lipid component of lung surfactant.

72. A 35-year-old man with peptic ulcer disease has undergone antrectomy. After the surgery secretion of the following gastrointestinal hormone will be disrupted the most:

Explanation

  GRP - gastrin releasing peptide; GIP - gastric inhibitory peptide; ACh - acetylcholine The body of stomach ends in antrum. Junction between body and antrum is marked by an angular notch called Incisura angularis. Antrum is continued as the narrow canal, which is called pyloric canal or pyloric end. Pyloric canal opens into first part of small intestine called duodenum. Gastrin: source - G cells (antrum of stomach, duodenum) Cholecystokinin (CCK): source - I cells (duodenum, jejunum) Secretin: source - S cells (duodenum) Histamine: source - Enterochromaffin-like (ECL) cells [NB: Antrectomy is the resection of the antrum of the stomach.]
73. A 16-year-old adolescent is diagnosed with hereditary UDP (uridine diphosphate) glucuronyltransferase deficiency. Laboratory tests revealed hyperbilirubinemia caused mostly by increased blood content of the following substance:

Explanation

 

In the hepatocyte, the solubility of unconjugated bilirubin is increased (i.e. it is made soluble) by the addition of two molecules of glucuronic acid to produce conjugated bilirubin. This process is referred to as conjugation. This reaction is catalyzed by Uridine diphosphate (UDP) glucuronyltransferase – UGT. Varying degrees of deficiency of this enzyme result in Crigler-Najjar I & II and Gilbert syndrome; with Crigler-Najjar I being the most severe deficiency.

Deficiency of UGT inhibits conjugation and therefore increase unconjugated bilirubin in serum (Jaundice).

74. A 60-year-old patient with a long history of atherosclerosis and a previous myocardial infarction developed an attack of retrosternal pain. 3 days later the patient was hospitalized and then died of progressive cardiovascular insufficiency. During autopsy a white fibrous depressed area about 3 cm in diameter with clear margins was found within the area of posterior wall of the left ventricle and interventricular septum. The dissector considered these changes to be:

Explanation

Focal cardiosclerosis: Focal –white fibrous depressed area 3cm in diameter. Cardiosclerosis - Atherosclerosis.
75. After a traffic accident a 36-year-old patient has developed muscle paralysis of the extremities on the right, lost pain and thermal sensitivity on the left, and partially lost tactile sensitivity on both sides. What part of the brain is the most likely to be damaged?

Explanation

76. A 4-year-old child has been admitted to an orthopaedic department with displaced shin fracture. Bone fragments reposition requires analgesia. What drug should be chosen?

Explanation

All options listed are all opoid analgesics (except panadol); but Promedol remains the best answer because it has a spasmolytic effect (antispasmodic). Therefore, it is very effective for pains associated with spasms of smooth muscles of internal organs and blood vessels. In comparison with morphine hydrochloride, it has less oppressing activity on respiratory centers, less than excites the center of the vagus nerve and the vomiting center. When the pain is associated with spasms of smooth muscle (angina pectoris, liver, kidney, intestinal cramps) you can assign promedol with atropine, metacin, papaverine etc.
77. While examining foot blood supply a doctor checks the pulsation of a large artery running in the separate fibrous channel in front of articulatio talocruralis between the tendons of long extensor muscles of hallux and toes. What artery is it?

Explanation

  Pulses on the feet: dorsalis pedis pulse is found on the midanterior foot. Posterior tibial pulse – posterior to the medial malleolus. The anterior tibial artery passes through an opening in the interosseous membrane medial to the fibula and then becomes dorsalis pedis artery at the ankle/talocrural joint. Pulses on the feet: dorsalis pedis pulse is found on the midanterior foot. Posterior tibial pulse – posterior to the medial malleolus. The anterior tibial artery passes through an opening in the interosseous membrane medial to the fibula and then becomes dorsalis pedis artery at the ankle/talocrural joint.
78. Representatives of a certain human population can be characterized by elongated body, height variability, decreased volume of muscle mass, increased length of limbs, decreased size and volume of rib cage, increased perspiration, decreased indices of base metabolism and fat synthesis. What type of adaptive evolution is it?

Explanation

79. A 59-year-old woman has been hospialized in a surgical ward due to exacerbation of chronic osteomyelitis of the left shin. Blood test: leukocytes - 15, 0 · 109/l. Leukogram: myelocytes - 0%, metamyelocytes - 8%, stab neutrophils - 28%, segmented neutrophils - 32%, lymphocytes - 29%, monocytes - 3%. Such blood count would be called:

Explanation

Neutrophilic leukocytosis: increase in neutrophil count. Depending on the proportion between the mature and premature forms of neutrophils, two types of the nuclear shift may be distinguished: to the left, when there is an elevated content of immature forms of neutrophilic granulocytes (myelocytes, metamyelocytes, bands) in the blood; And to the right, when the mature neutrophils with a large number of segments (5 – 6) prevail against a background of younger cells disappearing. The nuclear shift may be subdivided into: regenerative, hyperregenerative, degenerative and regenerative-degenerative shifts.

Regenerative shift develops against a background of mild general leukocytosis, accompanied with elevated content of bands and metamyelocytes (immature forms). This shift results from the reactive leukopoiesis (granulocytopoiesis) activation and is common in suppurative septic processes.

Neutrophils: Stab (band): 1-6%             (8%)↑

                     Segmented: 47-72%         (59%) normal

                     Myelocyte and Metamyelocyte: 0-1%      Juvenile forms (2%)↑

Since there is an elevated content of immature forms of neutrophils, then it is a regenerative left shift.

80. A 41-year-old man has a history of recurrent attacks of heartbeats (paroxysms), profuse sweating, headaches. Examination revealed hypertension, hyperglycemia, increased basal metabolic rate, and tachycardia. These clinical presentations are typical of the following adrenal pathology:

Explanation

  Adrenal medulla produces catecholamines (epinephrine, norepinephrine and dopamine). Increased secretion of epinephrine & norepinephrine can result in these symptoms listed. Since the patient is 41yrs old, this can be pheochromocytoma - if it is a tumor.
81. During autopsy of a man, who died of acute transmural cardiac infarction, the following has been detected on the pericardium surface: fibrous whitish-brown deposit connecting parietal and visceral pericardial layers. What kind of inflammation occurred in the pericardium?

Explanation

82. A 12-year-old child developed nephritic syndrome (proteinuria, hematuria, cylindruria) 2 weeks after a case of tonsillitis, which is a sign of affected glomerular basement membrane in the kidneys. What mechanism is the most likely to cause the basement membrane damage?

Explanation

  Acute poststreptococcal glomerulonephritis: most frequently seen in children. Occurs approximately 2 weeks after group A streptococcal infection of pharynx or skin. Resolves spontaneously. Type III hypersensitivity reaction (Immune complex). Presents with peripheral and periorbital edema, cola-coloured urine, hypertension. On immunofluorescent microscopy: granular appearance due to IgG, IgM and C3 deposition along glomerular basement membrane and mesangium. On electron microscopy: subepithelial immune complex humps. On light microscopy: glomeruli enlarged and hypercellular.
83. A man arrived into a traumatological department with a trauma of the right shoulder. Examination revealed a displaced humeral shaft fracture on the right in the middle one-third of the humerus; the patient cannot extend the fingers of his right hand. What nerve is damaged?

Explanation

84. Work in a mine is known to cause inhalation of large amounts of coal dust. Inhaled coal dust can be detected in the following pulmonary cells:

Explanation

Alveolar macrophages remove inhaled particulate matter from the air spaces and red blood cells (RBCs) from the septum of alveoli. They are unusual in that they function both in the connective tissue of the septum (alveolar wall) and in the air space of the alveolus (surface of alveolar cells). In air spaces they scavenge the surface to remove inhaled particulate matter (e.g. dust, pollen, pathogens), thus giving them one of their alternate names – Dust cells. They also phagocytose infectious organisms such as Mycobacterium tuberculosis. Other macrophages remain in the septal connective tissue, where, filled with accumulated phagocytized material, they may remain for much of an individual’s life. Thus, at autopsy, the lungs of urban dwellers as well as smokers will usually show many alveolar and septal macrophages filled with carbon particles, anthracotic pigment and birefringent needle-like particles of silica.

Type I alveolar cells (type I pneumocytes): the junctions formed between this cells form an effective barrier between the air space and the components of the septal wall. They are not capable of cell division. They make up 95% of the surface of the alveoli.

Type II alveolar cells: secretory cells; have lamellar bodies; progenitor cells for type I alveolar cells.

Clara cells: non-ciliated; low columnar/cuboidal cell with secretory granules. They secrete components of surfactant, degrade toxins and act as reserve cells.

Endothelial cells line blood vessels.

85. What drug will be the most appropriate for a patient suffering from chronic gastritis with increased secretion?

Explanation

Pirenzepine (selective M1-cholinoblocker) – decrease gastric secretion. Pancreatine (polyenzyme drug) – increase gastric secretion. Aprotinin (contrycal, gordox) – antitrypsin; antiprotease. Chlorphentermine (desopimonum): appetite suppressant, stimulating CNS.
86. A 63-year-old man, who has been suffering from chronic fibrous-cavernous pulmonary tuberculosis for 24 years, has been delivered to a nephrology department with uremia. Intravital diagnostic test for amyloid in the kidneys was positive. What amyloidosis is it in this case?

Explanation

Amyloidosis is the term used for a group of diseases characterized by extracellular deposition of fibrillar proteinaceous substance called amyloid. Systemic amyloidosis contain amyloid associated (AA) protein. It occurs as a complication of chronic infectious or noninfectious inflammatory conditions associated with tissues destruction such as tuberculosis, bronchiectasis, chronic osteomyelitis, chronic pyelonephritis etc. It is typically distributed in solid abdominal organs like liver, spleen, kidneys and adrenals. Morphologically, the kidneys may be normal-sized, enlarged or terminally contracted due to ischemic effect of narrowing of vascular intima. Cut surface is pale waxy and translucent.   Primary: Can occur in plasma cell disorder or associated with multiple myeloma. Secondary: Seen with chronic conditions. (patient has been sick with pulmonary tuberculosis for 24 years)
87. Cells of a healthy liver actively synthesize glycogen and proteins. What organelles are the most developed in them?

Explanation

The network of membrane enclosed spaces that extends throughout the cytoplasm constitutes endoplasmic reticulum (ER). Some of these thread-like structures extend from the nuclear pores to the plasma membrane.

A large portion of the ER is studded with ribosomes to give a granular appearance which is referred to as rough endoplasmic reticulum (rER). Ribosomes are the factories of protein biosynthesis. The smooth ER (agranular ER) does not contain ribosomes. It is involved in the synthesis of lipids (triacylglycerols, phospholipids, sterols) and metabolism of drugs, besides supplying Ca2+ for the cellular functions.

88. Immune-enzyme assay has detected HBs antigen in blood serum. What disease is it characteristic of?

Explanation

Hepatitis B virus (HBV): incubation period 30-180 days; it’s a DNA virus. Transmission: sexual, blood, vertical transmission via pregnancy and breast feeding. Primarily spread by blood, accidental needle sticks. HBV diagnosis is accomplished by testing for a series of serological markers of HBV. Nucleic acid testing for HBV-DNA is increasingly being used to quantify HBV viral load and measure the effectiveness of therapeutic agents. HBs Antigen (HBsAg): Antigen found on surface of Hepatitis B virus. It indicates hepatitis B infection.
89. A patient has been diagnosed with gonorrhea. As fluoroquinolones are the drugs of choce for treatment of gonorrhea the patient should be prescribed:

Explanation

Fluoroquinolones: Ciprofloxacin, Norfloxacin, Levofloxacin, Ofloxacin Clinical Use: Gram-negative rods of urinary and Gastrointestinal tracts (including Pseudomonas), Neisseria. Causative agent of Gonorrhea: Neisseria gonorrhea The only Fluoroquinolone present in the option is Ciprofloxacin.
90. Autopsy of a Middle-Eastern woman, who had been suffering from wasting fever for a long time, revealed enlarged blackened liver and spleen. Bone marrow was hyperplastic and black-colored as well. Cerebral cortex was smoky grey. What disease is it characteristic of?

Explanation

The most pronounced changes related to malaria involve the blood and the blood-forming system, the spleen and the liver. Red blood cells are the principal sites of infection in malaria. All the clinical manifestations are primarily due to the involvement of red blood cells.  The liver is generally enlarged and may be black from malaria pigment. The spleen is often dark or black from malaria pigment, enlarged, soft and friable. It is full of erythrocytes containing mature and immature parasites. 
91. Human red blood cells contain no mitochondria. What is the main pathway for ATP production in these cells?

Explanation

Lactate, formed by the action of lactate dehydrogenase (converting pyruvate to lactate) is the final product of anaerobic glycolysis in eukaryotic cells. In organs or cells that are poorly vascularized and/or lack mitochondria, formation of lactate is the major fate of pyruvate as seen in lens, cornea of the eye, kidney medulla, testes, leukocytes and red blood cells.

Aerobic glycolysis progresses to citric acid cycle from pyruvate. The cycle occurs totally in the mitochondria.

92. Atria of an experimental animal were superdistended with blood, which resulted in decreased reabsorption of Na+ and water in renal tubules. This can be explained by the influence of the following factor on kidneys:

Explanation

 Antidiuretic hormone (vasopressin) is secreted in response to decrease blood volume and increase plasma osmolarity. It binds to receptors on principal cells of collecting ductules causing increase number of aquaporins and increase water reabsorption which leads to decreased diuresis.

Atrial natriuretic peptide is secreted in response to increase atrial pressure. It causes increase glomerular filtration rate (GFR) and increase sodium ion filtration with no compensatory sodium ion reabsorption and water in distal nephron which leads to increase diuresis.

93. A woman gave birth to a stillborn baby with numerous malformations. What protozoan disease could cause intrauterine death?

Explanation

ToRCHeS infections: Toxoplasma gondii; Rubella; Cytomegalovirus; HIV; Herpes simplex virus-2; Syphilis. These are microbes that may pass from mother to fetus. Transmission is transplacental in most cases or via delivery. Toxoplasma gondii causes toxoplasmosis. It is transmitted from cat faeces or ingestion of undercooked meat. Congenital infection of the fetus occurs only when the mother is infected during pregnancy. Congenital infection can result in abortion, stillbirth or neonatal disease with encephalitis, chorioretinitis and hepatosplenomegaly.
94. A 42-year-old patient complains of pain in the epigastral area, vomiting; vomit masses have the color of coffee-grounds; the patient suffers from melena. Anamnesis records gastric ulcer disease. Blood formula: erythrocytes - 2, 8 · 1012/l, leukocytes - 8 · 109/l, Hb- 90 g/l. What complication is it?

Explanation

Principal complications of peptic ulcer are perforation, penetration, hemorrhage, stenosis, malignization (cancer). Gastric hemorrhage is a very important symptom. It can be manifested by vomiting blood (hematemesis) or by black tarry stools (melena). The vomitus looks like coffee grounds. If hemorrhage is profuse (damage to a large vessel) the vomitus contains much scarlet (unaltered) blood. Hematemesis occurs in peptic ulcer, cancer and polyps, in erosive gastritis etc.
95. A patient has been hospitalised with provisional diagnosis of virus B hepatitis. Serological reaction based on complementation of antigen with antibody chemically bound to peroxidase or alkaline phosphatase was used for disease diagnostics. What is the name of the applied serological reaction?

Explanation

Immune-enzyme analysis (enzyme-linked immunosorbent assays): used to detect the presence of either a specific antigen or a specific antibody in a patient’s blood sample. Common enzymes used are peroxidase, alkaline phosphatase or glucose oxidase. Producing an observable colour change or fluorescence. When radioactive isotopes are incorporated – Radioimmunoassay.
96. A patient with insulin-dependent diabetes mellitus has been administered insulin. After a certain period of time the patient developed fatigue, irritability, excessive sweating. What is the main mechanism of such presentations developing?

Explanation

A major set-back with insulin therapy is the development of Hypoglycemia. After an insulin injection, signs such as fatigue, irritability, cold sweats, palpitation, confusion (which can eventually result in coma) clearly indicate the development of hypoglycemia. Carbohydrate starvation of the brain refers to low glucose supply to the brain due to hypoglycemia.
97. Examination of a 52-year-old woman has revealed a decrease in the amount of red blood cells and an increase in free hemoglobin in the blood plasma (hemoglobinemia). Color index is 0,85. What type of anemia is being observed in the patient?

Explanation

Increase in free hemoglobin in blood plasma is characteristic for intravascular hemolysis. It is definitely acquired since patient is 52years old. If it has an Hereditary cause, it will probably have an early onset.
98. Poisoning caused by mercury (II) chloride (corrosive sublimate) occurred in the result of safety rules violation. In 2 days the patient’s diurnal diuresis was 620 ml. The patient developed headache, vomiting, convulsions, dyspnea; moist crackles were observed in the lungs. Name this pathology:

Explanation

Acute tubular necrosis/Necrotic nephrosis/Necronephrosis involves the death of tubular epithelial cells that form the renal tubules of the kidneys. Most common cause of acute renal failure. It can be ischemic or nephrotoxic.

·        Ischemic acute tubular necrosis occurs due to hypoperfusion of the kidneys.

·        Nephrotoxic acute tubular necrosis occurs as a result of direct damage to tubular cells by ingestion, injection or inhalation of a number of toxic agents. Toxic agents causing nephrotoxic acute tubular necrosis includes mercuric chloride, ethylene glycol, carbon tetrachloride etc.

Macroscopically, the kidneys are enlarged and swollen (edematous). On cut section, the cortex is pale, while the medulla is slightly darker than normal. The capsule can be easily removed.

99. For people adapted to high external temperatures profuse sweating is not accompanied by loss of large volumes of sodium chloride. This is caused by the effect the following hormone has on perspiratory glands:

Explanation

Aldosterone produced in adrenal cortex (zona glomerulosa): causes increased sodium (Na+) reabsorption; increased potassium and hydrogen ions (↑K+, H+) excretion. They increase sodium (↑Na+) channel and Na+ /K+-pump insertion in principal cells of collecting duct; enhances K+ and H+ excretion by way of principal cell K+ channels and α-intercalated cell H+ ATPases of collecting duct. Therefore, increase in aldosterone → ↑ K+ in urine (excretion) and ↓ Na+ in urine (↑ reabsorption); And decreased aldosterone → ↓ K+ excretion (↓K+ in urine) and ↓ Na+  reabsorption (i.e. ↑Na+ in urine); same effects on sweats glands too.
100. The processes of heat transfer in a naked person at room temperature have been studied. It was revealed that under these conditions the greatest amount of heat is transferred by:

Explanation

Heat Radiation is a way the surface of the human body emits heat to the environment in the form of infrared rays. The amount of heat the body radiates to the environment is proportional to the surface of radiation area and to the difference between the mean values of skin and environment temperature. The surface radiation area is the total surface area of body parts that contact the air. Elimination of heat by radiation increases with a decrease in ambient temperature and decreases with its increase. It is possible to reduce elimination of heat by radiation via reduction of the surface of radiation area (“winding oneself into a ball”). Heat radiation does not require a medium for transfer of heat. (Key words: naked or lightly clothed).

Convection is a way the body eliminates heat by means of transferring heat via moving particles of air or water. To dissipate heat by means of convection, body surface shall be airflowed at a temperature that is lower than the temperature of the skin. At that, air layer contacting with the skin warms up, decreases its density, rises and is replaced by cooler, denser air. By increasing the speed of the air flow (wind, ventilation) heat emission increases significantly as well (forced convection). Convection requires convection current; current of gases or liquids (Key words: air over exposed area of skin).

Evaporation is a way the body dissipates heat to the environment by its evaporation via sweat or evaporation of moisture from the skin and respiratory tract mucous membranes of (“wet” heat loss). Evaporation closely related to relative humidity.

Conduction is a way the body eliminates heat by means of direct contact with another object. Heat is transferred down the temperature gradient (i.e. from the object of higher temperature to the object of lower temperature). Conduction requires contact with another object (Key words:  in water).

101. Due to destruction of certain structures of the brainstem an animal has lost its orientation reflexes in response to strong light stimuli. What structures were destroyed?

Explanation

  Quadritubercular (Quadrigeminal) bodies/tectal plate is the dorsal portion of the midbrain comprises 4 colliculi – two superior and two inferior. The nuclei of colliculi are responsible for reflexes associated with sudden sound and visual stimuli (auditory and visual orientative reflexes); they also maintain consciousness. The nuclei give rise to the tectospinal tract. Superior or Anterior colliculi – visual orientative reflex; Inferior or Posterior colliculi – auditory orientative reflex.
102. Urine analysis has shown high levels of protein and erythrocytes in urine. This can be caused by the following:

Explanation

When blood passes through glomerular capillaries, the plasma is filtered. All substances of plasma are filtered except the plasma proteins and plasma cells, due to their large molecular size which is larger than the slit pores present in the endothelium of capillaries. Glomerular capillary membrane, basement membrane and visceral layer of bowman capsule form the filtration membrane through which glomerular filtration occurs. So, if protein and erythrocytes are increased or present in urine, it has to do with increase in renal filter permeability.
103. Along with normal hemoglobin types there can be pathological ones in the organism of an adult. Name one of them:

Explanation

  Sickle cell hemoglobin (HbS) point mutation causes a single amino acid replacement in β chain of hemoglobin (substitution of glutamic acid with valine). Pathogenesis of sickle cell anemia: low O2, high altitude or acidosis precipitates sickling – modified shape (deoxygenated HbS polymerizes) → anemia and vaso-occlusive disease. Clinical findings include: dizziness, general weakness, fatigue, “crew-cut” on skull X-ray due to marrow expansion from increased erythropoiesis (this is also seen in thalassemia)  etc. Sickle cells are crescent-shaped RBCs.
104. Development of both immune and allergic reactions is based upon the same mechanisms of immune system response to an antigen. What is the main difference between immune and allergic reactions?

Explanation

Immune reactions are directed against antigens. Allergic reactions (hypersensitivity) destroys tissue while trying to destroy the antigen leading to development of tissue lesion (tissue lesion – tissue injury). But both of them have the same mechanism.
105. Histologic preparation stained with orcein demonstrates from 40 to 60 fenestrated elastic membranes within the middle coat of vessel. Name this vessel:

Explanation

All blood vessels except capillaries have 3 basic tunics or coats: -Tunica Intima (Inner coat) -Tunica Media (middle coat) -Tunica Adventitia (Outer coat)   The following are visible in the Tunica Media of elastic arteries stained with orcein: - Elastic tissue in the form of 40 - 70 fenestrated elastic membranes. - Smooth muscles and collagen fibers in matrix - A layer of elastic fibers external elastic lamina forms the boundary between Tunica media and Tunica adventitia   Presence of elastic fibers in the wall of elastic arteries allows it to expand during contraction (systole) and recoil during relaxation (diastole).
106. Angiocardiography of a 60-year-old man revealed constriction of a vessel located in the left coronary sulcus of the heart. Name this pathological vessel:

Explanation

 

* Ramus circumflexus (circumflex coronary artery) branch of left anterior descending artery runs within – left coronary sulcus.

* Arteria coronaria dextra (right coronary artery) – right coronary sulcus.

* Ramus interventricularis posterior (posterior interventricular branch): runs along the sulcus of the same name; greatest branch of right coronary artery

* Ramus interventricularis anterior (anterior interventricular branch): runs along the sulcus of the same name.

* Vena cordis parva (small cardiac veins): right portion of coronary sinus.

107. A comatose patient was taken to the hospital. He has a history of diabetes mellitus. Objectively: Kussmaul breathing, low blood pressure, acetone odor of breath. After the emergency treatment the patient’s condition improved. What drug had been administered?

Explanation

The described symptoms are for type I diabetes mellitus (especially acetone odor of breath as a result of excess ketone bodies). Type I diabetes mellitus is due to decrease or absent insulin. Insulin facilitates the transport of glucose and amino acids into target organs: In liver – insulin increases the storage of glucose as glycogen. It decreases protein catabolism; In muscles – it stimulates glycogen synthesis and protein synthesis; In Adipose tissue – it facilitates triglyceride storage by activating plasma lipoprotein lipase which increase glucose transport into the cell and by reducing intracellular lipolysis.

Glibenclamide is typically used for type 2 diabetes mellitus.

Adrenaline will further exacerbate the hyperglycemic condition because it stimulates glycogen phosphorylase. Isadrinum is a non-selective β1-β2 adrenergic agonists (β-adrenomimetics); it’ll have the same effect as adrenaline. Furosemide is a loop diuretic and will not correct the comatose state of the patient; It has no effect on glucose metabolism or ketone bodies.

108. A patient complains of pain in the right lateral abdomen. Palpation revealed a dense, immobile, tumor-like formation. The tumor is likely to be found in the following part of the digestive tube:

Explanation

Anterolateral abdominal wall has 9 regions and 4 quadrants (RUQ, LUQ, RLQ, LLQ)

·        Right lateral abdominal region: Ascending colon (colon ascendens), right kidney, right ureter and loops of small intestine.

·        Umbilical region: Transverse colon (colon transversum), head of pancreas, duodenum (except superior part)

·        Left lateral abdominal region: Descending colon (colon descendens), left kidney, left ureter and loops of small intestine.

·        Left inguinal region: Sigmoid colon (colon sidmoideum), left ureter, left external iliac artery of artery and vein.

·        Right Inguinal region: Caecum, vermiform appendix, right ureter

109. A patient hospitalized due to mercury intoxication presents with the following processes in the kidneys: focal necrotic changes of tubules of major renal regions, edema, leukocyte infiltration and hemorrhages in the interstitial tissue, venous congestion. What condition developed in the patient?

Explanation

Acute tubular necrosis/Necrotic nephrosis/Necronephrosis involves the death of tubular epithelial cells that form the renal tubules of the kidneys. Most common cause of acute renal failure. It can be ischemic or nephrotoxic.

·        Ischemic acute tubular necrosis occurs due to hypoperfusion of the kidneys.

·        Nephrotoxic acute tubular necrosis occurs as a result of direct damage to tubular cells by ingestion, injection or inhalation of a number of toxic agents. Toxic agents causing nephrotoxic acute tubular necrosis includes mercuric chloride, ethylene glycol, carbon tetrachloride etc.

Macroscopically, the kidneys are enlarged and swollen (edematous). On cut section, the cortex is pale, while the medulla is slightly darker than normal. The capsule can be easily removed.

110. According to phenotypic diagnosis a female patient has been provisionally diagnosed with X-chromosome polysomia. This diagnosis can be confirmed by cytogenetic method. What karyotype will confirm the diagnosis?

Explanation

Barr body is an inactive X-chromosome. A normal female has one barr body XX, a normal male has no barr body XY.

Trisomy X – XXX (only one X is active in a female; therefore, 2 barr bodies)

Klinefelter – XXY (one barr body)

Turner’s – XO (no barr body)

46 XX is a normal female sex chromosome. All other options are karyotypes for male patients.

111. An uconscious young man in the state of morphine intoxication has been delivered into an admission room. The patient’s respiration is slow and shallow due to suppression of the respiratory center. What kind of respiratory failure occurred in this case?

Explanation

Morphine is the major analgesic drug contained in crude opium. Opoids exert their major effects by interacting with opoid receptors in the CNS and in other anatomic structures, such as the GIT and the urinary bladder. Severe respiratory depression can occur and result in death from acute opoid poisoning. A serious effect of the drug is stoppage of respiratory exchange in patients with emphysema or Cor pulmonale. In this case, there is dysregulation of the respiratory center in the CNS.
112. On histological examination of uterine mucosa the following is detected: sinuous glands, serratiform and corkscrew-shaped elongated growths of stroma with cell proliferation. Make the diagnosis:

Explanation

  Hyperplasia of endometrium is classified into 3 types:

·        Simple hyperplasia (cystic glandular hyperplasia)

·        Adenomatous hyperplasia (complex hyperplasia without atypia)

·        Atypical hyperplasia (complex hyperplasia with atypia)

Simple hyperplasia (cystic glandular hyperplasia) is characterized by the presence of large and cystically dilated varying-sized glands, which are lined by atrophic epithelium.

113. 10 minutes after the beginning of heavy physical work a person demonstrates increase of erythrocyte number in blood from 4, 0 · 1012/l to 4, 5 · 1012/l. What is the cause of this phenomenon?

Explanation

The circulatory system also adapts to training. When you exercise, blood flow is redistributed-less blood goes to all major organs except the heart and brain, and more blood flows to the working muscles and skin. At rest, 20 percent of your blood flows to the muscles, compared to 88 percent at maximum exertion. Spleen is the main organ responsible for storing blood serving as a blood depot in the body. It is known as the blood bank because its blood reserve can be valuable in case of hemorrhagic shocks or when blood redistribution is necessary in the body. Due to the increase in blood flow to the skeletal system during exercise and general increase in the circulating volume of blood it can result in a relative increase in red blood cell (erythrocyte) count.
114. A patient has a traumatic injury of sternocleidomastoid muscle. This has resulted in a decrease of the following value:

Explanation

 

All muscles that elevate the rib cage are muscles of inspiration and those that depress the rib cage are muscles of expiration.

Muscles of inspiration:

·        Sternocleidomastoid: lift upward on the sternum.

·        Anterior serrati: lift many of the ribs.

·        Scalene: lift the first two ribs.

Muscles of expiration: Abdominal recti – pull down the lower ribs and other abdominal muscles also compress the abdominal contents upwards against the diaphragm and internal intercostals.

Normal respiration is accomplished by the movement of the diaphragm only.

115. Autopsy of a 40-year-old woman, who died of cerebral hemorrhage during hypertensic crisis, revealed: upperbody obesity, hypertrichosis, hirsutism, stretchmarks on the skin of thighs and abdomen. Pituitary basophil adenoma is detected in the anterior lobe. What diagnosis is the most likely?

Explanation

 

Cushing Syndrome: Etiology

*INCREASE Cortisol due to a variety of causes (Glucocorticoids).

*Exogenous corticosteroids:  result in DECREASE ACTH (MCC).

*Primary adrenal adenoma, hyperplasia or carcinoma (Cushing’s Syndrome).

*ACTH-secreting pituitary adenoma (Cushing Disease).

Findings: Hypertension, Weight Gain, Moon Facies, Truncal Obesity, Buffalo Hump, Skin Changes (thinning striae), Osteoporosis, Hyperglycemia (Insulin resistance), Amenorrhea, Immunosuppression.

116. A specimen shows an organ covered with the connective tissue capsule with radiating trabeculae. There is also cortex containing lymph nodules, and medullary cords made of lymphoid cells. What organ is under study?

Explanation

Lymph nodes are small encapsulated organs located along the pathway of lymphatic vessels. The supporting elements of the lymph node are:

 *Capsule: composed of dense connective tissue that surrounds the node.

*Trabeculae: composed of dense connective tissue, which extend from the capsule into the substance of the node, forming a gross framework.

*Reticular tissue: composed of reticular cells and reticular fibers that forms a fine supporting meshwork throughout the remainder of the organ.

The parenchyma of the lymph node is divided into a cortex and medulla. The cortex consists of lymphocytes which are organized into nodules. The medulla of the lymph node consists of the medullary cords and medullary sinuses.

Tonsils: form a ring of lymphatic tissue at the entrance of the oropharynx; consisting of aggregations of lymphatic nodules.

Thymus is a lymphoepithelial organ located in the superior mediastinum. It possess a thin connective tissue capsule from which trabeculae extend into the parenchyma of the organ. The trabeculae establish domains in the thymus called thymic lobules. Thymic or hassall’s corpuscles are a distinguishing feature of the thymic medulla.

Spleen is the largest lymphatic organ. Most of the spleen consists of splenic pulp. Splenic pulp is divided into white pulp and red pulp. The spleen is enclosed by a dense connective tissue capsule from which trabeculae extend into the parenchyma of the organ.

Red bone marrow lies entirely within the spaces of bone in the medullary cavity of young long bones and the spaces of spongy bone.
117. After a craniocerebral injury a patient has lost the ability to recognize shapes of objects by touch (stereognosis). What area of cerebral cortex normally contains the relevant center?

Explanation

118. Monoamine oxidase inhibitors are widely used as psychopharmacological drugs. They change the level of nearly all neurotransmitters in synapses, with the following neurotransmitter being the exception:

Explanation

 

Monoamine oxidase (MAO) is a mitochondrial enzyme found in nerve and other tissues, such as the gut and liver. In the neuron, MAO functions as a “safety valve” to oxidatively deaminate and inactivate any excess neurotransmitter molecules (norepinephrine, dopamine and serotonin) that may leak out of synaptic vesicles when the neuron is at rest.

The MAO inhibitors (MAOIs) may irreversibly or reversibly inactivate the enzyme, permitting neurotransmitter molecules to escape degradation and therefore, to both accumulate within the presynaptic neuron and leak into the synaptic space. This is believed to cause activation of norepinephrine and serotonin receptors, and it may be responsible for the indirect antidepressant action of these drugs. Four MAOIs are currently available for treatment of depression: phenelzine, tranylcypromine, isocarboxazid, selegiline.

119. A worker of an agricultural enterprise had been suffering from an acute disease with aggravating intoxication signs, which resulted in his death. On autopsy: the spleen is enlarged, flaccid, dark cherry-red in the section, yields excessive pulp scrape. Soft meninges of fornix and base of the brain are edematous and saturated with blood (”cardinal’s cap”). Microscopically: seroushemorrhagic inflammation of meninges and cerebral tissues. Make the diagnosis:

Explanation

There are two medically important Bacillus species: Bacillus anthracis and Bacillus cereus. Bacillus anthracis causes anthrax. Human disease occurs in 3 main forms: cutaneous, pulmonary (inhalation) and gastrointestinal. Humans are most often infected cutaneously at the time of trauma to the skin, which allows the spores on animal products such as hides, bristles and wool to enter. Spores can also be inhaled or when contaminated meat is ingested. After being inhaled, the organism moves rapidly to the mediastinal lymph nodes and causes hemorrhagic mediastinitis. Pathogenesis is based on the production of two exotoxins  (Anthrax toxin) – edema factor and lethal factor. Hemorrhagic mediastinitis, septic shock hemorrhagic meningitis and death are severe life-threatening complications. In fatal cases, the organism may affect the spleen, liver, intestines, kidneys, adrenal glands and meninges.
120. Autopsy of an 8-month-old boy, who died of severe pneumonia complicated with sepsis, revealed absence of thymus. Lymph nodes have no lymphoid follicles and cortical substance. In the spleen the follicles are decreased in size and have no light centers. What is the cause of such changes?

Explanation

There is a certain correlation between age of an individual and thymus activity. In neonates, it already appears to have a considerable mass of 13.3g on the average. Most intensive growth occurs during first 3 years of life, when the gland doubles in size. Having reached the maximum weight (about 26 – 30g), the thymus retains it until 20 years of life. After 20 years of age, the thymus parenchyma experiences gradual involution and is substituted with fat tissue. After 50 years of age, the fat constitutes 90% of gland mass. Therefore, for a 9-month-old girl, lack of thymus indicates that the thymus did not develop at all, hence, Thymus agenesis.
121. A patient has been delivered into a surgical ward with an incised wound of the anterior surface of the shoulder in its lower one-third. Flexing function was disrupted in the shoulder and elbow joints, which is caused by the damage to the:

Explanation

122. A 40-year-old patient suffers from bronchial asthma and prolonged tachycardia. Choose the optimal drug for rapid relief of bronchial spasm in the given case:

Explanation

123. A patient with urolithiasis has developed severe pain attacks. For pain shock prevention he was administered an antispasmodic narcotic analgesic along with atropine. Name this drug:

Explanation

All options listed are all opoid analgesics; but Promedol remains the best answer because it has a spasmolytic effect (antispasmodic). Therefore, it is very effective for pains associated with spasms of smooth muscles of internal organs and blood vessels. In comparison with morphine hydrochloride, it has less oppressing activity on respiratory centers, less than excites the center of the vagus nerve and the vomiting center. When the pain is associated with spasms of smooth muscle (angina pectoris, liver, kidney, intestinal cramps) you can assign promedol with atropine, metacin, papaverine etc.
124. A patient suffers from acute cardiopulmonary failure with pulmonary edema. What diuretic should be prescribed in the given case?

Explanation

Bumetanide, furosemide, torsemide, ethacrynic acid are diuretics that have their major action on the ascending limb of the loop of henle (loop diuretics). These drugs are useful in emergency situation which calls for a rapid, intense dieresis (forced dieresis). Loop or high-ceiling diuretics inhibit the cotransport of Na+/K+/2Cl- on the luminal membrane in the ascending limb of the loop of henle.
125. A patient with acute myocardial infarction has been administered heparin as a part of complex therapy. Some time after heparin injection the patient developed hematuria. What heparin antagonist should be injected to remove the complication?

Explanation

Heparin is a natural anticoagulant produced in mast cells and basophils. It is an injectable, rapidly acting anticoagulant that is often used acutely to interfere with the formation of thrombi. Heparin is used in the prevention of venous thrombosis and the treatment of a variety of thrombotic diseases such as pulmonary embolism and acute myocardial infarction. Heparin binds to antithrombin III, with the subsequent rapid inactivation of coagulation factors. Antithrombin III inhibits serine proteases, including several of the clotting factors, most importantly, thrombin (factor IIa) and Factor Xa (a-active).

Protamine sulphate antagonizes the anticoagulant effects of heparin. The positively charged protamine interacts with the negatively charged heparin forming a stable complex without anticoagulant activity.

126. At a certain stage of cell cycle chromosomes reach cellular poles, undergo despiralization; nuclear membranes are being formed around them; nucleolus is restored. What stage of mitosis is it?

Explanation

Mitosis is the form of cell division by which a somatic (nonsex) cell duplicates. One of the basic characteristic of mitotic cell division is that one maternal cell divides into two identical ''daughter'' cells, each with its own set of the genetic material. After mitosis, the chromosome number in each daughter nucleus is the same as it was in the original dividing cell – it is the biological significance of mitosis. It includes 4 major phases: Prophase, Metaphase, Anaphase and Telophase (PMAT)  Prophase: chromosomes condense, nucleoli and nuclear envelope disappear.  Metaphase: chromosomes are aligned in a plane on the metaphase plate at equator.  Anaphase: diploid set of daughter chromosomes move toward each opposite poles.  Telophase: reformation of the nuclear envelope around the condensed chromosomes in the daughter cells; reappearance of nucleoli (nucleolus is restored).
127. Cardiac arrest occurred in a patient during a surgery of the small intestine. What regulatory mechanisms resulted in the cardiac arrest in this case?

Explanation

Goltz’ reflex: by pressing/strong blow to the epigastric region produces parasympathetic responses. Aschner’s reflex: press on the eyeball produces similar parasympathetic effects. They are parasympathetic reflexes and because no prior learning is involved – it is an unconditioned reflex.
128. Vestibular receptors of semicircular canals of an animal have been destroyed. What reflexes will disappear as a result?

Explanation

The vestibular apparatus consists of two distinct sensory organs: static and kinetic sensors. The static sensor is formed by utricle and saccule. The Kinetic sensor is formed by three mutually perpendicular semicircular canals. Semicircular canals - anterior, posterior and lateral. There is crista ampullaris with hair cells in every canal. The surface of crista ampullaris is covered in mucopolysaccharidic substance with otoliths. The semicircular canals registers angular acceleration. While the Utricle and saccule registers linear acceleration.
129. A patient working at a pig farm complains of paroxysmal abdominal pain, liquid feces with mucus and blood, headache, weakness, fever. Examination of large intestine revealed ulcers from 1 mm up to several cm in diameter, feces contained oval unicellular organisms with cilia. What disease can be suspected?

Explanation

  Balantidium coli causes balantidiasis. It is the only ciliated protozoan that causes human disease i.e. diarrhea. Domestic animals, especially pigs are the main reservoir for the organism and humans are infected after ingesting the cysts in food or water contaminated with animal or human faeces. Diagnosis is made by finding large ciliated trophozoites or large cysts with a characteristic V-shaped nucleus in the stool. The trophozoites excyst in the small intestine, travel to the colon (large intestine) and by burrowing into the wall cause an ulcer similar to that of Entamoeba histolytica.
130. Blood group of a 30-year-old man has been determined before a surgery. The blood was Rhesus-positive. Agglutination did not occur with standard 0 (I), А (II), and В (III) serums. The blood belongs to the following group:

Explanation

 

Blood group O(I): no antigens, therefore no agglutination.

Blood group A(II): A antigen, agglutinate with blood group B(III) and O(I).

Blood group B(III): B antigen, agglutinate with blood group A(II) and O(I).

Blood group AB(IV): A and B antigen, agglutinate with all blood groups. No antibody.

Blood group name is determined by the antigen present on RBC, but the patient has an opposite antibody. So whenever, the antibody corresponds to the antigen, there is agglutination. Since O does not have any antigen, no agglutination can occur.

131. Histological specimen of a hemopoietic organ shows clusters of node- and bandshaped lymphocytes that along with stroma elements compose cortical and medullar substances. Name this organ:

Explanation

Lymph nodes are small encapsulated organs located along the pathway of lymphatic vessels. The supporting elements of the lymph node are:

 *Capsule: composed of dense connective tissue that surrounds the node.

*Trabeculae: composed of dense connective tissue, which extend from the capsule into the substance of the node, forming a gross framework.

*Reticular tissue: composed of reticular cells and reticular fibers that forms a fine supporting meshwork throughout the remainder of the organ.

The parenchyma of the lymph node is divided into a cortex and medulla. The cortex consists of lymphocytes which are organized into nodules. The medulla of the lymph node consists of the medullary cords and medullary sinuses.

Tonsils: form a ring of lymphatic tissue at the entrance of the oropharynx; consisting of aggregations of lymphatic nodules.

Thymus is a lymphoepithelial organ located in the superior mediastinum. It possess a thin connective tissue capsule from which trabeculae extend into the parenchyma of the organ. The trabeculae establish domains in the thymus called thymic lobules. Thymic or hassall’s corpuscles are a distinguishing feature of the thymic medulla.

Spleen is the largest lymphatic organ. Most of the spleen consists of splenic pulp. Splenic pulp is divided into white pulp and red pulp. The spleen is enclosed by a dense connective tissue capsule from which trabeculae extend into the parenchyma of the organ.

Red bone marrow lies entirely within the spaces of bone in the medullary cavity of young long bones and the spaces of spongy bone.
132. It is known that in catecholamine metabolism a special role belongs to monoamine oxidase (MAO). This enzyme inactivates mediators (noradrenalin, adrenalin, dopamine) by:

Explanation

  Norepinephrine (noradrenaline), epinephrine (adrenaline) and dopamine are catecholamines produced in chromaffin cells of adrenal medulla from tyrosine. The catecholamines are inactivated by oxidative deamination catalyzed by monoamine oxidase (MAO) and by O-methylation carried out by Catechol-O-methyltransferase. The metabolic products of these reactions are excreted in the urine as vanillymandelic acid from epinephrine and norepinephrine; and homovanillic acid from dopamine.
133. Cellular composition of exudate largely depends on the etiological factor of inflammation. What leukocytes are the first to be involved in the focus of inflammation caused by pyogenic bacteria?

Explanation

Neutrophils are the first leukocytes that cross the blood vessel wall to enter inflammatory sites. Under normal conditions, leukocytes are restricted to the center of small blood vessels, where the flow is fastest. In inflammatory sites, where the vessels are dilated, the slower blood flow allows the leukocytes to move out of the center of the blood vessel and interact with the vascular endothelium. Even in the absence of infection, monocytes migrate continuously into the tissues, where they differentiate into macrophages; meanwhile, during an inflammatory response, the induction of adhesion molecules on the endothelial cells, as well as induced changes in the adhesion molecules expressed on leukocytes recruit large numbers of circulating leukocytes, initially Neutrophils and later monocytes, into the site of an infection (inflammatory focus).

First –Neutrophils; second –monocytes and macrophages; third –lymphocytes.

134. A surgeon has detected inflammation of the Meckel’s diverticulum in a patient. During surgical invasion it can be located in the:

Explanation

Ileal diverticulum or Meckel’s diverticulum is a congenital anomaly that occurs in 1-2% of the population. A remnant of the proximal part of the embryonic omphaloenteric duct (yolk stalk), the diverticulum usually appears as a finger-like pouch. It is always at the site of attachment of the omphaloenteric duct on the antimesenteric border (border opposite the mesenteric attachment) of the ileum. The diverticulum is usually located 30-60cm from the ileocecal junction in infants and 50cm in adults. It may be free (74%) or attached to the umbilicus (26%). Although its mucosa is mostly ileal in type, it may also include areas of acid-producing gastric tissue, pancreatic tissue or jejuna or colonic mucosa. An ileal diverticulum may become inflamed and produce pain mimicking that produced by appendicitis.
135. A patient complains of acute pain attacks in the right lumbar region. During examination the nephrolithic obturation of the right ureter in the region between its abdominal and pelvic segments was detected. What anatomical boundary exists between those two segments?

Explanation

 

Linea terminalis = pectineal line (pubis) + Arcuate line + sacral promontory + superior margin of pubic symphysis. Boundary between the abdominal and pelvic cavity.

Linea semilunaris found on the lateral margin of rectus abdominis.

Linea arcuata: the region on the posterior layer, where aponeuroses end and continue into the anterior layer. Part of linea terminalis anteriorly.

136. A patient died of cancerous cachexia with primary localization of cancer in the stomach. Autopsy revealed acutely enlarged liver with uneven surface and numerous protruding nodes; the nodes had clear margins in the section, rounded shape, gray-pink color, varying density, sometimes contained necrotic foci. Histologically: there are atypical cells in the nodes. What pathologic process occurred in the liver?

Explanation

Oftentimes, stomach cancer becomes advanced and metastasizes (spreads) to the liver. Gastric cancer with liver metastasis have multiple metastatic nodules in the liver. More importantly, the presence of atypical cells in the nodes clearly indicates the progression of cancer in the liver.
137. A patient has insufficient blood supply to the kidneys, which caused the development of pressor effect due to the constriction of arterial resistance vessels. This is the result of the vessels being greately affected by the following substance:

Explanation

↓blood supply → activates renin. Renin catalyzes the conversion of angiotensinogen to angiotensin I. Angiotensin converting enzyme (ACE) converts angiotensin I → angiotensin II. Angiotensin II causes:

- vasoconstriction → ↑BP

- vasopressin (ADH) → ↑H2O reabsorption → ↑plasma volume

- aldosterone → ↑Na+ and H2O reabsorption → ↑plasma volume → ↑BP

138. Experimental stimulation of sympathetic nerve branches that innervate heart caused an increase in force of heart contractions because membrane of typical cardiomyocytes permitted an increase in:

Explanation

  When a muscle is excited (stimulated) by the impulses passing through neuromuscular junction, action potential is generated which spreads over sarcolemma (plasma membrane of muscles). When the action potential reaches the cisternae of ‘L’ tubules, Ca2+ stored in the cisternae are released into the sarcoplasm (cytoplasm of muscles). The Ca2+ moves towards the actin filaments to produce the contraction. Therefore, it is Ca2+ entry into the sarcoplasm.
139. Parents of a 5-year-old child report him to have frequent colds that develop into pneumonias, presence of purulent rashes on the skin. Laboratory tests have revealed the following: absence of immunoglobulins of any type; naked cells are absent from the lymph nodes punctate. What kind of immune disorder is it?

Explanation

X-linked (Bruton) agammaglobulinemia: defect in Bruton’s tyrosine kinase (BTK), a tyrosine kinase gene → no B cell maturation. X-linked recessive (↑in boys). Findings: absent B cells in peripheral blood, ↓immunoglobulin of all classes. Absent/scanty lymph nodes and tonsils.
140. A microslide contains the specimen of a gland composed of several secretory saccule-shaped parts that open in the common excretory duct. What gland is it?

Explanation

141. Microelectrode technique allowed to register a potential following ”all-or-none” law and capable of undecremental spreading. Specify this potential:

Explanation

Action potential is a series of electrical changes that occur in the membrane potential when the muscle or nerve is stimulated. It occurs in 2 phases: depolarization and repolarization. Excitable tissues obey the all-or-none law which states that when an excitable tissue is stimulated by a stimulus, it gives maximum response or does not give any response at all. Below the threshold level i.e. if the strength of stimulus is not adequate, the tissue does not give any response. Action potential obeys the all-or-none law because a particular threshold must be reached for an action potential to occur.
142. Examination of a patient revealed hypertrophy and inflammation of lymphoid tissue, edema of mucous membrane between palatine arches (acute tonsillitis). What tonsil is normally situated in this area?

Explanation

  The paired palatine tonsil (tonsilla palatina) lies in the tonsillar sinus, (fossa tonsillaris) between the palatoglossal and palatopharyngeal arches (palatine arches). Palatoglossal arch (the anterior pillar of fauces), is paired running down from the soft palate to the margins of the tongue. Palatopharyngeal arch, also paired runs down from the soft palate to the lateral wall of the pharynx, ending behind the latter. Tonsillar sinus is a depression between the palatine arches, which contains the palatine tonsil.
143. Histological specimen of an ovary demonstrates a spherical structure composed of large glandular cells containing lutein. What hormone is produced by the cells of this structure?

Explanation

Usually ovulation occurs right at the middle of menstrual-ovarial cycle (14th day). After that the remnant of follicle is transformed into Corpus luteum. At mid-cycle (about 14 days) there is a great surge of Luteinizing Hormone (LH) from the pituitary, coinciding with the time of ovulation. The follicular epithelium that remains behind undergoes a marked hyperplasia and differentiates into granulosa lutein cells, which form the bulk of the new corpus luteum. Under the influence of pituitary LH, these cells now produce progesterone.   
144. A patient, who has been subsisting exclusively on polished rice, has developed polyneuritis due to thiamine deficiency. What substance is an indicator of such avitaminosis, when it is excreted with urine?

Explanation

There is a severe thiamine -deficiency syndrome found in areas where polished rice is the major component of the diet. The oxidative decarboxylation of pyruvate and alpha-ketoglutarate, which plays a key role in energy metabolism of most cells is particularly dependent on thiamine (Vit. B1). In thiamine deficiency, the activity of the enzymes necessary to decarboxylate pyruvate is significantly decreased, resulting in decreased production of ATP and, thus, increased pyruvic acid levels which eventually gets into the urine. Thiamine pyrophosphate (TPP) is the biologically active form of Vitamin B1.
145. When blood circulation in the damaged tissue is restored, lactate accumulation stops and glucose consumption decelerates. These metabolic changes are caused by activation of the following process:

Explanation

Lactate, formed by the action of lactate dehydrogenase (converting pyruvate to lactate) is the final product of anaerobic glycolysis in eukaryotic cells. In organs or cells that are poorly vascularized and/or lack mitochondria, formation of lactate is the major fate of pyruvate as seen in lens, cornea of the eye, kidney medulla, testes, leukocytes and red blood cells.

Aerobic glycolysis progresses to citric acid cycle from pyruvate, especially when there is blood supply to make the necessary oxygen available for the process. The cycle occurs totally in the mitochondria.

146. A 67-year-old patient complains of periodic heartache, dyspnea during light physical activities. ECG reveals extraordinary contractions of heart ventricles. Such arrhythmia is called:

Explanation

Extrasystole is the premature contraction (an extra contraction) of the heart before its normal contraction. In other words, it is an extra contraction of the heart before its normal contraction. It is caused by an ectopic focus (discharge of an impulse from any part of the heart other than the Sinoatrial node).

Bradycardia: ↓heart rate; Tachycardia: ↑heart rate; Flutter: rapid heart contractions; Fibrillation: very rapid heart contractions. (In all this, there is no extra heart contraction, we just have faster contractions).

147. In investigation of serum proteins various physical and physicochemical methods can be used. In particular, serum albumins and globulins can be separated by the method of:

Explanation

Electrophoresis uses the principle of electric charge size and shape to separate substances. Proteins carry a positive or a negative electrical charge and they move in fluid when placed in an electrical field. The two major types of protein present in the serum are albumin and globulin proteins. Albumin is the major protein component of serum and represents the largest peak that lies closest to the positive electrode. Globulins comprise a much smaller fraction of the total serum protein but represent the primary focus of interpretation of serum protein electrophoresis. Five (5) globulin categories are expressed – α1, α2, (alpha 1 & 2), β1, β2 (beta 1 & 2) and ɣ (gamma). ɣ is the closest to the positive electrode.
148. Pupil dilation occurs when a person steps from a light room into a dark one. What reflex causes such a reaction?

Explanation

Pupillary response is a physiological response which entails constriction or dilation of the pupil in relation to bright or low light respectively, that is the pupil dilates in a dark room and constrict in bright light. In low light conditions, as in a dark room, a dilated pupil lets more light into the eye. Constriction of the pupil is controlled by the parasympathetic nervous system while pupillary dilation is controlled by the sympathetic nervous system. Therefore, it is unconditioned (physiological, not learnt, present in everyone) and the pupil dilation is a sympathetic process.
149. Cells of a person working in the Chornobyl Exclusion Zone have undergone a mutation in DNA molecule. However, with time the damaged interval of DNA molecule has been restored to its initial structure with a specific enzyme. In this case the following occurred:

Explanation

The DNA is constantly being subjected to environmental insults that cause the alteration or removal of nucleotide bases. In this case, the damaging agents is radiation from the Chornobyl Exclusion Zone. If the damage is not repaired, a permanent mutation may be introduced that can result in deleterious effects, including loss of control over the proliferation of the mutated cell, leading to cancer. Luckily, cells are remarkably efficient at repairing damage done to their DNA. Most of the repair systems involve recognition of the damage (lesion) on the DNA, removal or excision of the damage, replacement or filling the gap left by excision using the sister strand as a template for DNA synthesis and ligation.
150. When studying the signs of pulmonary ventilation, reduction of forced expiratory volume has been detected. What is the likely cause of this phenomenon?

Explanation

Obstructive respiratory disease is the abnormal respiratory condition characterized by difficulty in expiration. E.g asthma, chronic bronchitis, emphysema, cystic fibrosis. Forced expiratory volume (FEV) is the volume of air, which can be expired forcefully in a given unit of time. It is very much decreased in obstructive diseases like asthma and emphysema. Restrictive respiratory disease is the abnormal respiratory condition characterized by difficulty in inspiration. E.g poliomyelitis, myasthenia gravis, paralysis of diaphragm, spiral cord diseases, pleural effusion, fibrosis. (lung fibrosis-pneumofibrosis)
151. A specimen of a parenchymal organ shows poorly delineated hexagonal lobules surrounding a central vein, and the interlobular connective tissue contains embedded triads (an artery, a vein and an excretory duct). What organ is it?

Explanation

  There are 3 ways to describe the structure of the liver in terms of a functional unit: the classic lobule; portal lobule and the liver acinus. The classic lobule is the traditional way to describe the organization of the liver parenchyma. The classic hepatic lobule is a roughly hexagonal (6-sided) mass of tissue. At the center of the lobule is a relatively large venule, the terminal hepatic venule (central vein), into which the sinusoids drain. At the angles of the hexagon are the portal areas (portal canals), loose stromal connective tissue characterized by the presence of the portal triad. The portal triad is composed of the branches of the hepatic artery, portal vein and the bile duct.
152. A patient had a trauma that caused dysfunction of motor centers regulating activity of head muscles. In what parts of cerebral cortex can these centers normally be located?

Explanation

  Primary motor area extends throughout the precentral gyrus and the adjoining lip of central sulcus. Areas 4 and 4S are present here. Muscles of various parts of the body are represented in area 4 in an inverted way from medial to lateral surface. Lower parts of the body are represented in the lateral (upper) surface and upper parts of the body are represented in the lateral (lower) surface. Order of representation from medial (superior, upper) to lateral (inferior, lower) surface: toes, ankle, knee, hip, trunk, shoulder, arm, elbow, wrist, hand, fingers and face. Area 4 is concerned with contraction of discrete muscles.
153. At the post-mortem examination the stomach of a patient with renal failure was found to have a yellow-brown coating on the thickened mucosa. The coating was firmly adhering to its surface and had significant thickness. Microscopy revealed congestion and necrosis of mucosal and submucosal layers, fibrin presence. What is the most likely diagnosis?

Explanation

Fibrinous inflammation is an inflammatory response of mucous surface (oral, respiratory, bowel) to toxins of diphtheria (diphtheric gastritis) or irritant gases. As a result of denudation of epithelium, plasma exudes on the surface where it coagulates and together with necrotized epithelium, forms false membrane that gives this type of inflammation its name. Histologically, fibrin appears as an eosinophilic network of threads or sometimes as an amorphous coagulum.
154. A 60-year-old man suffering from chronic hepatitis frequently observes nasal and gingival hemorrhages, spontaneous hemorrhagic rashes on the skin and mucosa. Such presentations result from:

Explanation

Substances necessary for coagulation or clotting of blood are called clotting factors. Fibrinogen is the factor I of the thirteen clotting factors. Most of the clotting factors are proteins in the form of enzymes synthesized in the liver.

In chronic hepatitis (i.e. relatively prolonged course of inflammation of the liver), the protein-synthetic function of the liver is impaired. Meaning, there is a marked decrease of clotting factors which results in uncontrolled and protracted hemorrhage.

155. Leading symptoms of primary hyperparathyroidism are osteoporosis and renal damage resulting in urolithiasis development. What substances are the basis of uroliths in such cases?

Explanation

Urolithiasis or formation of urinary calculi at any level of the urinary tract is a common condition. There are 4 main types of urinary calculi, namely:

·        Calcium stones: are the most common comprising 75% of all urinary calculi. They may be pure stones of calcium oxalate (50%) or calcium phosphate (5%) or mixture of calcium oxalate.

·        Mixed (struvite) stones: about 15% of urinary calculi are made of magnesium-ammonium-calcium phosphate often called struvite. “Staghorn stone”

·        Uric acid stones: can be seen in gout, Lesch-Nyhan syndrome (hyperuricemia).

·        Cystine stones: seen in cases like cystinuria.

NB: hyperparathyroidism → ↑Ca2+ concentration in blood.

156. An oncology department has admitted a patient with suspected pulmonary tumor. On examination a pathology localized within the lower lobe of the right lung was detected. How many bronchopulmonary segments are there in this lobe?

Explanation

  The inferior lobe of left lung has 5 segments: superior, medial basal, anterior basal, lateral basal, posterior basal segments.
157. Autopsy of a 5-year-old child revealed in the area of the vermis of cerebellum a soft grayish-pink node 2 cm in diameter with blurred margins and areas of haemorrhage. Histologically this tumour consisted of atypical monomorphous small round cells with large polymorphous nuclei. What tumour is it?

Explanation

Medulloblastoma is a tumor made by immature cells, medulloblasts; therefore it is highly malignant. It is localized in the vermis of cerebellum. Macroscopically, it is pinkish-gray. Microscopically, medulloblastoma consists of homogenous small cells with dark round or oval nucleus and poorly seen rim of cytoplasm. The cells are located close to each other. Rosette is typical. Mitoses are numerous. Vessels are not numerous. Metastasis spread through the liquor routs.
158. A 45-year-old woman suffers from arterial hypertension with high blood concentration of angiotensin II. What antihypertensive drug is the most recommended in the given case?

Explanation

 

Lisinopril is an angiotensin converting enzyme inhibitor (ACE Inhibitor). This drug block the ACE that cleaves angiotensin I to form the potent vasoconstrictor angiotensin II. Rennin converts angiotensinogen to angiotensin I.

Propranolol is a β-blocker; Prazosin – α1-adrenoblocker; Nifedipine – Ca2+-channel blocker; Dichlothiazide – thiazide diuretic.

For a high rate of renin, the antihypertensive drugs that are effective are: renin inhibitor (Aliskiren); angiotensin II receptor blocker and angiotensin converting enzyme (ACE) inhibitors because they block the renin –angiotensin system.

159. An alcoholic suffers from alcoholic psychosis with evident psychomotor agitation. What neuroleptic drug should be administered for emergency aid?

Explanation

·        Aminazine – neuroleptic (it is better than reserpine for emergency care. It has also proved to be useful in control of intracted hiccup).

·        Diazepam – tranquilizer

·        Sodium bromide – sedative

·        Reserpine – neuroleptic

·        Halothane – general anesthesia

160. In one of Polessia regions there was an outbreak of helminthiasis manifested by cramps and facial edemas. The developed preventive measures in particular included ban for eating infested pork even after heat processing. What helminthiasis was the case?

Explanation

Trichinosis: causative agent – Trichinella spiralis. Transmission – fecal-oral; undercooked meat (especially pork). Findings: fever, vomiting, nausea, periorbital edema, myalgia. These findings are specific for Trichinosis.
161. A patient demonstrates functional loss of nasal halves of the retinas. What area of visual pathways is affected?

Explanation

162. A 26-year-old woman with bronchitis has been administered a broad spectrum antibiotic as a causal treatment drug. Specify this drug:

Explanation

The tetracyclines (minocycline, doxycycline) are broad spectrum bacteriostatic antibiotics.

Mechanism of action: entry of these drugs into susceptible organisms is mediated both by passive diffusion and by an energy-dependent transport protein mechanism. The drug binds reversibly to the 30S subunit of the bacterial ribosome, thereby blocking access of the amino acyl-tRNA to the mRNA-ribosome complex at the acceptor site.

Taking these drugs concomitantly with diary foods in the diet decreases absorption due to the formation of non-absorbable chelates of the tetracyclines with calcium ions. Non-absorbable chelates are also formed with other divalent and trivalent cations (e.g. those found in magnesium and aluminum antacids and in Iron preparations).

Adverse effects:

·         Discolouration and hypoplasia of the teeth in growing children

·         Phototoxicity: such as sunburn

·         Dysbacteriosis

·         Gastric discomfort

So far, Doxycycline has been the only tetracycline tested in Krok.

163. A 16-year-old young man suffering from seasonal allergic rhinitis has been prescribed a highly active second generation H1 blocker, which can be characterized by absence of marked sedative action. Name this drug:

Explanation

Loratidine : Antihistamine (antiallergic); blocks H1-histamine receptors as well as adrenergic, cholinergic & serotonin-binding recpetors. They do not influence the formation or release of histamine, but rather they competitively block the receptor-mediated response of target tissue.
164. Examination of a 56-year-old woman with a history of type 1 diabetes mellitus revealed a disorder of protein metabolism that is manifested by aminoacidemia in the laboratory blood test values, and clinically by the delayed wound healing and decreased synthesis of antibodies. Which of the following mechanisms causes the development of aminoacidemia?

Explanation

Type I diabetes: lack of insulin. Normally, insulin stimulates storage of lipids, proteins and glycogen. But in the absence of insulin, glucagon and epinephrine stimulates use fuel reserves through hepatic glycogenolysis, hepatic gluconeogenesis, adipose release of free fatty acids (FFA). ↑in glucagon and epinephrine → ↑protein degradation (muscle) → ↑amino acid → aminoacidemia. Protein degradation = proteolysis.
165. A patient with injury sustained to a part of the central nervous system demonstrates disrupted coordination and movement amplitude, muscle tremor during volitional movements, poor muscle tone. What part of the central nervous system was injured?

Explanation

The cerebellum is involved in the coordination of voluntary motor movement, balance and equilibrium and muscle tone. It is located just above the brain stem and toward the back of the brain. Cerebellar injury results in: - Loss of coordination of motor movement (asynergia) - The inability to judge distance and when to stop (dysmetria) - The inability to perform rapid alternating movements (adiadochokinesia) - Movement tremors (intention tremor) - Staggering, wide based walking (ataxic gait) - Tendency toward falling - Weak muscles (hypotonia) - Slurred speech (ataxic dysarthria) - Abnormal eye movements (nystagmus)
166. A 36-year-old patient has been administered a depolarizing muscle relaxant during a surgery. Name this drug:

Explanation

Dithylinum is a neuromuscular blocking drug (myorelaxants). It attaches to the N-cholinoreceptor depolarizing the junction and providing a constant stimulation of the receptor. The continued binding of the depolarizing agent renders the receptor incapable of transmitting further impulses. They are used to relax muscles during surgery.
167. A man has suffered multiple bone fractures of his lower extremities during a traffic accident. During transportation to a hospital his condition was further aggravated: blood pressure decreased, there were signs of pulmonary artery embolism. What kind of embolism is the most likely in the given case?

Explanation

Embolism is occlusion of a vessel by material travelling in the circulation.

* Fat/Adipose embolism: obstruction of arterioles and capillaries by fat globules constitutes fat embolism. It may occur following severe fracture trauma to bones, inflammation of bones and soft tissues, fatty liver

* Thromboembolism: a detached thrombus or part of thrombus which may arise in the arterial or venous circulation.

* Gas embolism: two main forms of gas embolism are air embolism and decompression sickness. Air embolism is usually due to accidental pumping of air into the venous circulation during intravenous (IV) injection or transfusion ( bubble – air escaped).

Tissue embolism: fragments of tissue.

168. UN volunteers have arrived in Nigeria to assist the locals in aftermath of earthquakes. What drug should they prescribe for individual chemoprophylaxis of malaria?

Explanation

  Chingamin (chloroquine) prevents polymerization of the hemoglobin breakdown product (heme) into hemozoin. Intracellular accumulation of heme is toxic to the parasite. It is a weak base and may buffer intracellular pH, thereby inhibiting cellular invasion by parasitic organisms. The drug is solely a blood schizonticide (erythrocytic) and will not eradicate secondary tissue schizonts. It is the drug of choice for acute attacks, prophylaxis and treatment of malaria, has been used in amebic liver disease in combination with metronidazole and in autoimmune disorders including rheumatoid arthritis, systemic lupus erythematous (interstitial disease).
169. After an extended treatment with sulfanamides a patient has developed macrocytic anemia. Production of active forms of the following vitamin is disrupted in such a condition:

Explanation

Sulfonamides: Sulfamethoxazole (SMX), Sulfisoxazole, Sulfadiazine They inhibit dihydropteroate synthase, thus inhibiting folate synthesis. This further leads to the development of macrocytic, megaloblastic anemia as a result of deficiency of Folic acid. Deficiency can also be caused by other drugs such as phenytoin, methotrexate. Such drugs are referred to as Folate antagonists.
170. A woman resting in the countryside has been stung by a bee. Immediately after she developed pain in the stung area. In a few minutes there developed a vesicle, erythema and intense itch; later - urticaria and expiratory dyspnea. What factors resulted in the patient developing expiratory dyspnea?

Explanation

Histamine is localized in ready form in granules of the mast cells and basophils. In the blood of healthy people, histamine almost totally stays in basophils.  Histamine acts on the tissues cells through its receptors – H1 and H2 (commonly found in GIT). Their correlation and spreading on the cells of different cells is different.

Stimulation of H1 promotes the contraction of bronchial smooth muscles (resulting in expiratory dyspnea), endothelial cells and postcapillary part of microcirculation. This leads to increase in permeability of vessels, development of edema and inflammation (vesicle, erythema). In many cases, increase in quantity of histamine in blood is observed in the intensive stage of bronchial asthma, nettle-rash, officinal allergy, urticaria.

171. Autopsy of a 28-year-old patient, who had been suffering from rheumatism and died of heart failure, revealed pancarditis. Histological investigation of myocardium of the left ventricle posterior wall and interventricular septum detected perivascular cellular focal infiltrates composed of macrophages and creating palisade structures surrounding areas of fibrinoid necrosis. Determine the type of myocarditis:

Explanation

The cardiac manifestations of Rheumatism are in the form of focal inflammatory involvement of the interstitial tissue of all the three layers of the heart, the so-called pancarditis. The pathognomonic feature of pancarditis in Rheumatism is the presence of distinctive Aschoff nodules or Aschoff bodies. These cells tend to be arranged in a palisade manner.

Fully developed Aschoff bodies are granulomatous structures consisting of fibrinoid change, lymphocytic infiltration, occasional plasma cells and characteristically abnormal macrophages surrounding necrotic centers.

The Aschoff bodies are commonly found in the interstitium of the heart and may be visible to the naked eye. They are often found in the vicinity of small blood vessel in the myocardium and endocardium (perivascular cellular focal infiltrates) and occasionally in the pericardium and the adventitia of the proximal part of the aorta.

3 stages of development: Fibrinoid degeneration (fibrinoid necrosis); Granulomatous (proliferative or Intermediate ) Stage; Late (healing) stage.

172. A 47-year-old man developed intestinal colic against the background of essential hypertension. In this situation it would be the most efficient to arrest the colic by administering drugs of the following group:

Explanation

Only myotropic antispasmodics (muscle relaxants) can effectively manage both intestinal colic and essential hypertension. Because sympathomimetics and adrenomimetics will exacerbate hypertension the more. Anticholinesterase agents and M-cholinomimetics will ↑acetylcholine effects in neuromuscular junction → ↑arteriolar smooth muscle tone → exacerbate hypertension. But the myotropic antispasmodics can ↓ muscle tone in intestinal smooth muscle (thereby relieving intestinal colic) and also ↓ arteriolar smooth muscle tone (thereby relieving essential hypertension).
173. A therapeutist has an appointment with a 40-year-old patient complaining of recurrent pain attacks in his hallux joints and their swelling. Urine analysis revealed its marked acidity and pink color. What substances can cause such changes in urine?

Explanation

  This is a classic description of gout. The end product of the purine nucleotides catabolism in humans and other primates is uric acid (urate) which is excreted in urine. Allopurinol and febuxostat inhibits Xanthine oxidase (XO). Hypoxanthine and Xanthine which is more soluble is excreted in urine. Purine nucleotides (adenine and guanine).  AMP – Adenosine monophosphate; GMP – Guanosine monophosphate
174. Exophthalmus observed during thyrotoxicosis is caused by accumulation of highly water-binding substances within the retrobulbar tissues. Name these substances:

Explanation

  Glycosaminoglycans (GAG) accumulation in the retrobulbar space of patients with thyroid-associated ophthalmopathy has been documented in a number of studies. The ophthalmopathy occurring in Thyroid disease (especially Graves disease) appears to be caused by antibodies against antigens shared by the thyroid and eye muscle. Thyroid Stimulating Hormone (TSH) receptors have been identified in retro-orbital adipocytes and might represent a target for antibodies. The antibodies that bind to the extraocular muscles and orbital fibroblasts stimulate the synthesis of glycosaminoglycans by orbital fibroblasts and produce cytotoxic effects on muscle cells.
175. A patient presents with dry peeling skin, frequent cases of acute respiratory diseases, xerophthalmia. What vitamin preparation should be prescribed in this case?

Explanation

Xerophthalmia refers to the group of ocular signs and symptoms associated with Vitamin A (retinol) deficiency. It includes conjunctival and corneal xerosis, Bitot's spots, keratomalacia, nyctalopia (night blindness), and retinopathy. Even today, Xerophthalmia is a major problem in developing countries and is a leading cause of preventable blindness. Causes of Xerophthalmia: reduced dietary intake of Vitamin A, defects in Vitamin A metabolism and storage in case of chronic liver disease (alcoholism, upper gastrointestinal surgery, inflammatory bowel disease, pancreatitis).
176. Parenchyma of an organ is composed of pseudounipolar neurons localized under the capsule of connective tissue. Central place belongs to nerve fibers. Name this organ:

Explanation

According to the size and shape of their processes, most neurons can be placed in one of the following categories: multipolar neurons, which have more than two cell processes, one process being the axon and the others dendrites; bipolar neurons, with one dendrite and one axon; and pseudounipolar neurons, which have a single process that is close to the perikaryon and divides into two branches. The process then forms a T shape, with one branch extending to a peripheral ending and the other toward the central nervous system. In pseudounipolar neurons, stimuli that are picked up by the dendrites travel directly to the axon terminal without passing through the perikaryon. Most neurons of the body are multipolar. Bipolar neurons are found in the cochlear and vestibular ganglia as well as in the retina and the olfactory mucosa. Pseudounipolar neurons are found in the spinal ganglia (the sensory ganglia located in the dorsal roots of the spinal nerves). They are also found in most cranial ganglia.
177. A patient consulted a physician about chest pain, cough, fever. Roentgenography of lungs revealed eosinophilic infiltrates that were found to contain larvae. What kind of helminthiasis are these presentations typical of?

Explanation

Ascaris lumbricoides (giant roundworm) is the causative agent of Ascariasis. Transmission: fecal-oral; eggs are visible in faeces under microscope. Some patients may have pulmonary symptoms or neurological disorders during migration of the larvae. A bolus of worms may obstruct the intestine; migrating larvae may cause pneumonitis and eosinophilia.

Ascaridiasis (Ascariasis) caused by Ascaris lumbricoides (giant roundworm). The major damage occurs during larval immigration rather than from the presence of the adult worm in the intestines. The principal sites of tissue reaction are the lungs, where inflammation with an eosinophilic exudates occurs in response to larval antigens. Ascaris pneumonia with fever, cough and eosinophilia can occur with a heavy larval burden.

178. During appendectomy a patient had the a. appendicularis ligated. This vessel branches from the following artery:

Explanation

The ileocolic artery (arteria ileocolica) is a branch of superior mesenteric artery. The ileocolic artery arises from the right aspect of the main trunk. The artery descends rightwards and reaches the ileocecal angle to give off the branches. The arcades give off the branches to the caecum (the anterior and posterior caecal arteries); to the vermiform appendix (the appendicular artery) and to the terminal portion of the ileum (the ileal branches).
179. A patient with signs of osteoporosis and urolithiasis has been admitted to an endocrinology department. Blood test revealed hypercalcemia and hypophosphatemia. These changes are associated with abnormal synthesis of the following hormone:

Explanation

 

Parathyroid hormone: secreted by chief cells of parathyroid gland. Effects include:

↑bone resorption of Ca2+ and PO43- → ↑their plasma levels

↑kidney reabsorption of Ca2+ in distal convoluted tubule → ↑ Ca2+ plasma level

↓reabsorption of PO43- in proximal convoluted tubule → ↓ PO43- plasma levels

↑Calcitriol (vit D3) production by stimulating kidney 1α-hydroxylase in proximal convoluted tubule. It increases Ca2+ and PO43- absorption in the intestine.

In general, parathyroid hormone ↑ Ca2+ plasma level but ↓ PO43- plasma levels. Abnormal synthesis (↑synthesis) of parathyroid hormone can lead to hypercalcemia and hypophosphatemia.

Calcitonin is secreted by parafollicular cells (C cells of the thyroid gland). It ↓bone resorption of Ca2+. It opposes actions of parathyroid hormone. But its not important in normal Ca2+ homeostasis. Calcitriol ↑ circulating Ca2+ ions as a means of enhancing intestinal absorption of calcium (NB: Calcitriol production is dependent on parathyroid hormone). Aldosterone: reabsorption of Na+, excretion of K+. Cortisol – glucocorticoid: ↑ blood pressure and gluconeogenesis; ↓ inflammatory and immune responses; ↓ bone formation (↓osteoblast activity).

180. Prescription of penicillin G sodium salt has caused development of neurotoxic effects (hallucinations, convulsions). Such reaction is the result of antagonism with the following neurotransmitter:

Explanation

Certain amino acids undergo decarboxylation that means the removal of their α-carboxyl group resulting in liberation of CO2 and formation of biogenic amines. Biogenic amines are physiologically active substances such as hormones, neurotransmitters etc. decarboxylation of amino acids:

·        Tryptophan → Niacin → NAD+/NADP+

Tryptophan → Serotonin →Melatonin

·        Histidine → Histamine

·        Glutamine → GABA

Glutamine → Glutathione

181. A 30-year-old woman exhibits signs of virilism (growth of body hair, balding temples, menstrual disorders). This condition can be caused by overproduction of the following hormone:

Explanation

These symptoms indicates an increase in male sex hormones. This can probably be a pathology of the adrenals or ovaries in a female, which leads to increase production of testosterone (the only male sex hormone in the options)
182. During a surgery for femoral hernia a surgeon operates within the boundaries of femoral trigone. What structure makes up its upper margin?

Explanation

 

Boundaries of femoral triangle:

*Superiorly: inguinal ligament

*Medially: medial border of adductor longus muscle

*Laterally: medial border of the Sartorius muscle

*Roof: fascia lata

*Floor: adductor longus muscle, pectineus muscle and the iliopsoas muscle

183. Activation of a number of hemostatic factors occurs through their joining with calcium ions. What structural component allows for adjoining of calcium ions?

Explanation

The GLA (gamma-carboxyglutamic acid-rich) domain contains glutamate residues that have been post-translationally modified by vitamin K-dependent carboxylation to form gamma-carboxyglutamate. The GLA domain is responsible for the high-affinity binding of calcium ions. Vitamin K is responsible for post-translational activation of blood clotting factor (hemostatic factors) II, VII, IX, X, Protein C and Protein S. In the body, osteocalcin, contains γ- carboxyglutamic acid and synthesis of osteocalcin is vitamin K and vitamin D dependent.
184. A patient has arterial hypertension. What long-acting calcium channel blocker should be prescribed?

Explanation

Calcium-channel blockers: verapamil, diltiazem, nifedipine, amlodipine, felodipine, nicardipine.

The dihydropyridines are calcium channel blockers with 2 generations (e.g. nifedipine, amlodipine, felodipine etc). all dihydropyridines have a much greater affinity for vascular calcium channels than for calcium channels in the heart. They are therefore, particularly attractive in treating hypertension.

The intracellular concentration of calcium plays an important role in maintaining the tone of smooth muscle and in the contraction of the myocardium. Calcium channel blockers block the inward movement of calcium by binding to L-type calcium channels in the heart and in smooth muscle of the coronary and peripheral arteriolar vasculature. This causes vascular smooth muscle to relax, dilating mainly arterioles. Calcium-channel blockers do not dilate veins.

185. Material obtained from a patient contains several types of microorganisms (staphylococci and streptococci) causative of the patient’s disease. Name this type of infection:

Explanation

A mixed infection is where a single infection is caused by a variety of bacterial species which are simultaneous causing the same infection; mixed infection (staphylococcus and streptococcus). Superinfection: a new infection occurring in a patient having a preexisting infection; for example, bacterial infection may occur in patients with viral respiratory disease; reinfection or a second infection with a microbial agent (such as a bacterium, fungus, or virus). Coinfection: When a person has two or more infections at the same time. For example, a person infected with HIV may be coinfected with hepatitis C (HCV) or tuberculosis (TB) or both.
186. A laboratory has been investigating virulence of a diphtheria agent. In the process of the experiment the infection was introduced intraperitoneally into test animals. The dosage of bacteria resulting in 95% mortality of test animals was found. What unit of virulence measurement was determined?

Explanation

In characterizing pathogenic microbes a unit of virulence has been established: - DLM (Dosis Letalis Minima): representing the minimum amount of live microbes which in a certain period of time bring about 95-97% death of the corresponding laboratory animals. - DCL (Dosis Certa Letalis): the absolute dose of pathogenic microbe which will kill 100% of the experimental animals has been established. - LD50: the dose which is lethal to one half of the infected animals. It is considered to be the most suitable and may serve as an objective criterion for comparison with other units of virulence.
187. A patient consulted a dentist about restricted mouth opening (trismus). He has a history of a stab wound of the lower extremity. What infection can cause these symptoms?

Explanation

Tetanus is caused by Clostridium tetani that secretes a toxin called tetanospasmin. Findings: spasticity, risus sardonicus (raised eyebrows and open grin) and lockjaw (trismus); toxin prevents release of inhibitory (GABA and glycine) neurotransmitters from Renshaw cells in spinal cord. It can be prevented with tetanus vaccine.
188. Patient’s systolic blood pressure is 90 mm Hg, diastolic - 70 mm Hg. Such blood pressure is caused by decrease of the following factor:

Explanation

The left ventricle is the heart\\\'s main pumping chamber. Normal blood pressure: Systolic: 115 - 120mmHg (pressure at heart contraction) Diastolic: 75 - 80mmHg (pressure at heart relaxation) A systolic blood pressure of 90 mmHg is significantly decreased which can point to a decrease in the contracting power of the left ventricle of the heart which is responsible for pumping blood to the systemic circulation. The right ventricle of the heart is also a pumping chamber but the maximum pressure that can be recorded there is approximately 25 mmHg and it pumps blood to the pulmonary circulation.
189. A 29-year-old man with a knife wound of the neck presents with bleeding. During the initial d-bridement of the wound a surgeon revealed the injury of a vessel situated along the lateral edge of the sternocleidomastoid muscle. Specify this vessel:

Explanation

  External jugular vein is a subcutaneous vein that arises by the union of the anterior (which is the anastomosis with the retromandibular vein) and posterior (formed of the occipital and posterior auricular veins). External jugular vein crosses the sternocleidomastoid muscle laterally and at its midpoint, then opens into the venous angle – the junction point of the subclavian and internal jugular veins.
190. A 6-year-old child suffers from delayed growth, disrupted ossification processes, decalcification of the teeth. What can be the cause?

Explanation

 

Vitamin D is a fat soluble vitamin. Cholecalciferol (Vit. D3) is found in animals. It is regarded as a sunshine vitamin. Calcitriol is the biologically active form of Vit. D. Calcitriol acts at 3 different levels (intestine, kidney and bone) to maintain plasma calcium.

It increases the intestinal absorption of calcium and phosphate.

In the osteoblasts of bone, it stimulates calcium uptake for deposition as calcium phosphate. Thus, calcitriol is essential for bone formation.

Calcitriol is also involved in minimizing the excretion of calcium and phosphate through the kidney, by decreasing their excretion and enhancing reabsorption.

Deficiency of Vit D causes rickets in children and osteomalacia in adults. Rickets in children is characterized by bone deformities due to incomplete bone mineralization, resulting in soft and pliable bones and delay in teeth formation. The weight bearing bones are bent to form bow legs.

191. A patient addressed a hospital with complaints of lost sensitivity of the skin of the little finger. What nerve is the most likely to be damaged?

Explanation

The Ulnar nerve supplies the dorsal and palmar surface of the 5th finger (little finger) and half of the 4th finger. Median nerve: 1 - 3 fingers and half of the 4th finger. Radial Nerve: Loss of sensation over posterior arm/forearm and dorsal hand. Musculocutaneous nerve: Loss of sensation over lateral forearm. Medial cutaneous nerve of the forearm: Supplies the forearm  
192. A 30-year-old patient’s blood test has revealed the following: erythrocyte count is 6 · 1012/l, hemoglobin is 10,55 mmol/l. Vaquez’s disease was diagnosed. Name the leading part of pathogenesis:

Explanation

Hemoblastoses refer to neoplastic clonal diseases, arising from hemopoietic organs. Erythrocytes which originate from the hemopoietic organ can be greatly increased (erythrocytosis) in myeloproliferative disorders. Myeloproliferative disorders includes chronic myeloleukemia, polycythemia vera (erythemia, Vaquez disease, Osler’s disease, osler-vaquez disease) etc. Vaquez disease is a primary form of erythrocytosis.
193. Pancreas is known as a mixed gland. Endocrine functions include production of insulin by beta cells. This hormone affects metabolism of carbohydrates. What is its effect on the activity of glycogen phosphorylase (GP) and glycogen synthase (GS)?

Explanation

  Insulin stimulates glycogen synthase by dephosphorylation. Insulin is an anabolic hormone (build up). So, it stimulates glycogen synthase to favor the synthesis of glycogen (glycogenesis) and inhibits glycogen phosphorylase used in glycogenolysis (glycogen breakdown). Glucagon and Epinephrine stimulates glycogen phosphorylase to break down glycogen to glucose and make energy available for “fight and flight” reactions.
194. This year influenza epidemic is characterized by patients’ body temperature varying from 36, 9oC to 37, 9oC. Such fever is called:

Explanation

Normal 36.5 – 36.8oC

Subfebrile 36.9 – 37.9oC

Febrile 38.0 – 38.9oC

Pyretic 39.0 – 40.9oC

Hyperpyretic ≥41oC

195. Fructosuria is known to be connected with inherited deficiency of fructose 1- phosphate aldolase. What product of fructose metabolism will accumulate in the organism resulting in toxic action?

Explanation

Hereditary deficiency of Aldolase results in Fructose intolerance. Fructose-1-phosphate accumulates. You need to note that whenever an enzyme is deficient, the substance before it will be accumulated in the body. So, in this case, Fructose-1-phosphate Aldolase is deficient which results in the accumulation of Fructose 1-phosphate in the body leading to Fructosuria. Symptoms: hypoglycemia, jaundice, cirrhosis, vomiting Treatment: Decrease intake of both fructose and sucrose (glucose + fructose)
196. A woman complains of visual impairment. Examination revealed obesity in the patient and her fasting plasma glucose level is hyperglycemic. What diabetes complication can cause visual impairment/blindness?

Explanation

Microangiopathy is a chronic complication of diabetes mellitus (fasting hyperglycemia) affecting small blood vessels and manifested as retinopathy (vision impairment), nephropathy, neuropathy. Macroangiopathy affects larger vessels causing symptoms such as gangrene, ulceration, transient ischemic attack.
197. Administration of doxycycline hydrochloride has caused an imbalance of the symbiotic intestinal microflora. Specify the kind of imbalance caused by the antibiotic therapy:

Explanation

Administration of doxycycline hydrochloride (antibiotic) can cross react with the normal microflora in the intestine thereby causing dysbacteriosis (an imbalance in the normal microflora). All broad spectrum antibiotics can be associated with dysbacteriosis.
198. Cholesterol content in blood serum of a 12-year-old boy is 25 mmol/l. Anamnesis states hereditary familial hypercholesterolemia caused by synthesis disruption of receptor-related proteins for:

Explanation

Type IIa (familial hyperlipoproteinemia: ↑LDL and cholesterol. Autosomal dominant; due to absent or defective LDL receptors.

Type I:  ↑chylomicrons, triacylglycerol (TAG), cholesterol. Autosomal recessive; due to lipoprotein lipase deficiency or altered apolipoprotein C-II.

Type IV: ↑very low density lipoprotein (VLDL) and TAG. Autosomal dominant; due to hepatic overproduction of VLDL.

Type IIb: similar to Type IIa, except that VLDL is also increased and VLDL is normal for IIa.

199. During recording of a spirogram a patient calmly exhaled. How do we call the volume of air remaining in the lungs?

Explanation

200. A 40-year-old woman was diagnosed with glomerulonephritis based on her clinical symptoms and the results of urine analysis. Anamnesis states chronic tonsillitis. What microorganisms are the most likely cause for the kidney damage in this case?

Explanation

Acute poststreptococcal glomerulonephritis: most frequently seen in children. Occurs approximately 2 weeks after group A streptococcal infection of pharynx or skin. Resolves spontaneously. Type III hypersensitivity reaction (Immune complex). Presents with peripheral and periorbital edema, cola-coloured urine, hypertension. On immunofluorescent microscopy: granular appearance due to IgG, IgM and C3 deposition along glomerular basement membrane and mesangium. On electron microscopy: subepithelial immune complex humps. On light microscopy: glomeruli enlarged and hypercellular.