1. Head of a department and a trade-union group have appealed to the head of a hospital about dismissal of the senior nurse who has 17-year record of service. The facts of charge were confirmed and recognized by the nurse herself. The nurse lives with a daughter (who is divorced and unemployed) and a 9-month-old grandson. Make an administrative decision:
2. A 50-year-old female patient complains of aching pain in the lower abdomen. She has a history of normal menstrual cycle. At the age of 40, the patient underwent a surgery for gastric ulcer. Examination findings: abdomen is soft, in the hypogastrium there is a well defined nodular tumor of limited mobility. Vaginal examination findings: the cervix is clean, of cylindrical shape. Body of the uterus cannot be palpated separately. On both sides of the uterus palpation reveals tight tumors with an uneven surface. The tumors are immobile and fill the whole pelvic cavity. What is the most likely diagnosis?
3. A 38-year-old male patient complains of marked dyspnea that escalates with physical exertion. The problems, namely acute chest pain on the left and cough, arose unexpectedly 2 hours before at work. The pain abated, but there were progressing dyspnea, dizziness, pallor, cold sweat, cyanosis. Auscultation reveals the absence of vesicular breath sounds, radiograph shows a shadow on the left. What pathology can be suspected?
4. A 2-year-old boy has been admitted to the casualty department for the pain and deformity of his right thigh. Radiograph shows a femoral fracture with longitudinal displacement. What method of treatment is indicated for the patient?
5. What juice should be included in a complex drug and dietary therapy for patients with gastric ulcer or duodenal ulcer and increased gastric juice acidity in order to accelerate the ulcer healing?
6. A 7-year-old child complains of itching, papular erythematous rash, dry skin. Objectively: there is lichenification in the popliteal fossae and antecubital spaces. What immunologic indicator if found in the blood serum will verify the diagnosis (atopic dermatitis)?
7. A 7-year-old patient presents with body temperature rise up to 39oC, dry cough, pain in the lateral abdomen. Objectively: there is cyanosis of the nasolabial triangle, inspiratory dyspnea with accessory muscle recruitment. Percussion reveals pulmonary dullness; among auscultation findings there are diminished breath sounds, crepitant rales. Respiratory rate is of 50/min, HR- 120/min. Evaluate the grade of respiratory failure in the patient:
8. A 43-year-old alcohol abuser had not consumed alcohol for the last two days. In the evening he claimed to see rats and feel like they bite his feet. The patient is disoriented, agitated, all the time attempts to run somewhere. Specify the psychopathological syndrome
9. A 67-year-old male patient complains of rash, severe pain in the subscapular region on the right. Objectively: skin in the right subscapular region is covered with linearly arranged pink red edematous lesions that are somewhat infiltrated, and have clear boundaries. On the lesion surface there are vesicles with transparent exudate. What is the most likely diagnosis?
10. An 8-year-old boy was brought to the admission department by his parents. Parents report that he has had pain in the right knee for the last 9 months, recently mother has noticed some limitation of motion in his right leg, and morning stiffness that doesn’t last till the evening. What is the most likely diagnosis?
11. A 13-year-old girl was admitted to the gynecology department for having a significant bleeding from the genital tract for 10 days. The patient has a history of irregular menstrual cycle since menarche. Menarche occurred at the age of 11. Recto abdominal examination revealed no pathology. What is the provisional diagnosis?
12. A 64-year-old male patient has a 35 year history of chronic pancreatitis. In the last 5 years, he claims to observe the pain abatement, bloating, frequent bowel movements up to 3-4 times a day, grayish, glossy stool with undigested food rests, the progressive loss of body weight. Change of symptoms in the patient is due to over lay of:
13. During the doctor’s round, a 56 year old male patient with decompensated cirrhosis complains of dizziness, palpitations, moving black specks seen before the eyes, general weakness. The patient is pale, Ps- 110/min, AP- 90/50 mm Hg. What complication is most likely to have occurred in the patient?
14. A 57-year-old female patient complains of intense pain in the right hypochondrium irradiating to the right supraclavicular region. Skin and sclerae are icteric. There is tension and tenderness in the right hypochondrium on palpation. Body temperature is 38, 8oC. Blood test results: WBC- 11, 2 · 109/l, total bilirubin - 112 mmol/l (conjugated - 86 mmol/l, unconjugated - 26 mmol/l). What is the most likely diagnosis?
15. A 3-year-old girl has had an increase in body temperature up to 38, 5oC for four days. The child refuses to eat. Over the last two days, nose and mouth breathing has become difficult. Mesopharyngoscopy reveals hyperthermia and enlargement of tonsils, as well as hyperemia and bulging of the posterior wall of the oropharynx, which significantly narrows the oropharyngeal lumen. What complication of quinsy occurred in the patient?
16. Within a year, in a maternity hospital there were 616 livebirths, one stillbirth, one infant died on the 5th day of life. What index can most accurately describe this situation?
17. In one of the surgical departments the quality assurance testing of sterilization of surgical instruments was performed. After an instrument had been treated with 1% phenolphthalein, the solution turned pink. This indicates that the instrument has:
18. A 21-year-old female patient consulted a gynecologist about itching, burning, watery vaginal discharges with a fish like smell. Speculum examination revealed that the cervical and vaginal mucosa was of a normal pink color. Vaginal examination revealed no alterations of the uterus and appendages. Gram stained smears included clue cells. What is the most likely pathology?
19. A 9-year-old patient has measles. On the 6th day after the rash appeared, the boy developed a condition manifested by dyspnea, barking cough, stenotic respiration. Objectively: the rash on the face, neck and torso turned brown. There is a branny desquamation. Respiratory rate is 22/min. What complication should be diagnosed?
20. A 26-year-old secundipara at 40 weeks of gestation arrived at the maternity ward after the beginning of labor activity. 2 hours before, bursting of waters occurred. The fetus was in a longitudinal lie with cephalic presentation. Abdominal circumference was 100 cm, fundal height - 42 cm. Contractions occurred every 4-5 minutes and lasted 25 seconds each. Internal obstetric examination revealed cervical effacement, opening by 4 cm. Fetal bladder was absent. Fetal head was pressed against the pelvic inlet. What complication arose in childbirth?
21. Examination of a 35-year-old patient with rheumatism revealed that the right heart border was 1 cm displaced outwards from the right parasternal line, the upper border was on the level with inferior margin of the 1st rib, the left border was 1 cm in from the left midclavicular line. Auscultation revealed atrial fibrillation, loud apical first sound, diastolic shock above the pulmonary artery. Echocardiocopy revealed abnormal pattern of the mitral valve motion. What heart disease is characterized by these symptoms?
22. A 54-year-old male patient works as an engineer. At the age of 35, he got infected with syphilis and treated it with \\\"traditional remedies\\\". About 5 years ago, he became forgetful, unable to cope with work, told cynical jokes, bought useless things, collected cigarette butts in the street. Objectively: the patient is indifferent, has slow speech, dysarthria, can make only primitive judgments, is unabe to perform simple arithmetic operations or explain simple metaphors. The patient is untidy, takes no interest in anything, passive. Considers himself to be completely healthy. Qualify mental condition of the patient:
23. A 13-year-old boy with hypertrophic cardiomyopathy complains of dyspnea on minimal exertion. EhoCG reveals asymmetric left ventricular hypertrophy, signs of pulmonary hypertension, dilatation of the left atrium. EF is 64%. The revealed alterations are indicative of:
24. Study of natural illumination for a workplace in a secondary school classroom revealed that the angle of sunlight incidence was 25o, window opening angle - 3o, window to floor area ratio - 1:4, daylight ratio - 0,5%, depth ratio - 2. What indicators do not meet hygienic standards?
25. Bakers at bread production work in conditions of high temperature and high heat radiation. What is used to increase the body’s resistance to the unfavorable effects of these harmful work environment factors?
26. A 24-year-old male patient got a puncture injury below the Poupart’s ligament, which was accompanied by intense arterial bleeding. The best method to temporarily stop the bleeding in the patient would be:
27. 5 days before, a 26-year-old female patient developed an acute condition. Objectively: marked headache, vomiting, weakness, poor appetite, temperature up to 39oC. Objectively: the patient is in a moderately grave condition, excited. The face is hyperemic, sclerae are injected. The tongue is coated with brown fur. The trunk and limbs are covered with plentiful roseolous and petechial rash. Hepatosplenomegaly is present. Complement binding reaction with Rickettsia prowazekii is positive with the titer of 1:640. What drug should be administered?
28. A 39-year-old female patient complains of dyspnea when walking, palpitation, edemata in the evening. The patient’s height is 164 cm, weight - 104 kg. Objectively: overnutrition. Heart sounds are weak, and tachycardia is present. The menstrual cycle is not broken. Blood sugar is 5,6 mmol/l, ACTH-response tests revealed no alterations. X-ray of the Turkish saddle revealed no pathology. What disease is it?
29. A 26-year-old male patient complains of a rash on the upper lip skin, which arose on a background of influenza with high-grade fever and is accompanied by pain and burning. The rash has been present for 3 days. Objectively: the skin of the upper lip is edematic and erythematous, grouped vesicles are filled with serous fluid and have a rough surface. What is the most likely diagnosis?
30. A 6-year-old boy complains of paroxysmal pain that occurs after a mental stress, consuming cold drinks or ice cream. After clinical and instrumental examination the boy has been diagnosed with hypertensive biliary dyskinesia. The drugs of the following groups should be administered in the first place:
31. A15-year-old patient consulted a dermatologist about a painful lump in the armpit. Objectively: there is a walnut sized node, lymphadenitis, infiltration of the surrounding tissues. The patient has bee n dignosed with hidradenitis. What is the most likely causative agent of this disease ?
32. A 36 year old female has a 7 year history of pollen allergy. Over the last 2 years in August and September (during ragweed flowering), the patient has had 2-3 asthma attacks that could be treated with one dose of salbutamol. Objectively: body temperature - 36, 5oC, respiratory rate - 18/min, Ps- 78/min, AP- 115/70 mm Hg. There is vesicular breathing above the lungs. Cardiac sounds are sonorous, of regular rhythm. What drug would be most effective to prevent asthma attacks during the critical season for the patient?
33. A study of the structure of death causes in the urban population revealed that cardiovascular diseases accounted for 55,0% of all deaths. What statistic value represents these data?
34. A 25 year old female patient complains of marked weakness, sleepiness, blackouts, di zziness, taste disorder. The patient has a history of menorrhagia. Objectively: the patient has marked weakness, pale skin, cracks in the corners of mouth, peeling nails, systolic apical murmur. Blood test results: RBC 3, 4 · 1012/l, Hb- 70 g/l, color index - 0,75, platelets - 140 · 109/l, WBC- 6, 2 · 109/l. What is the most likely diagnosis?
35. A 51-year-old female is a weaving factory worker with 15 years of service record. During a regular preventive examination she complained of frequent headaches, poor sleep, tingling in the heart, irritability, rapid fatigability, hearing impairment. For years, the noise level has exceeded the maximum allowable concentration by 10-15 dB. A year ago, the patient underwent a course of treatment for essential hypertension. Specify the most likely diagnosis:
36. A 49-year-old male patient who had been scheduled for a surgery for gastric cancer underwent preoperative infusion therapy. Up to 3,0 liters of liquid was introduced into the right cubital vein. The following day, he felt a dragging pain in the right shoulder. Objectively: on the inner surface of the shoulder there is a longitudinal hyperemic zone, edema of skin, a tender cord. What complication occurred in the patient?
37. Some of the population of a city district have uneven teeth color. The individuals have white spots, transverse brown stripes on the incisors. Occurrence of these symptoms is associated with the quality of drinking water from a deep well. Which of the following components of water can be the cause of the disease?
38. A 22-year-old female patient has been delivered by an ambulance team to a surgical clinic with symptoms of acute intestinal obstruction. It is known from the past history that 2 years ago she was operated for acute destructive appendicitis. For two years, she has repeatedly complained of bloating and abdominal pain. Which of the following etiological factors has led to the intestinal obstruction in the patient?
39. Mother of a 10-month-old baby reports significant pallor, poor appetite, enlarged abdomen in the baby. As a neonate, the child underwent treatment in the in-patient hospital for jaundice and anemia. Objectively: the skin is pale and jaundiced, teeth are absent, abdomen is enlarged, spleen is palpable. Blood test results: Hb- 90 g/l, RBC- 3, 0·1012/l, c olor index - 0,9, microspherocytosis, reticulocytosis up to 20%, serum bilirubin - 37 mmol/l, unconjugated bilirubin - 28 mmol/l. What type of anemia has occurred in the patient?
40. A lumbar puncture was performed for a newborn suspected of having an intracranial birth injury. Bloody cerebrospinal fluid was obtained. What hemorrhage occurred in this case?
41. A 36-year-old female patient complains of intense pain in the knee joints and neck. In the morning she experiences pain in the interscapular region and leg joints; pain subsides after warm-up gymnastics. The patient is overnourished, there is a clicking sound in the knees when squatting, the knees are some what disfigured, painful on palpation. Blood test results: ESR- 18 mm/h, WBC- 8, 0·109/l. Radiography reveals subchondral sclerosis in the left knee. What is the basis of this pathology?
42. A 35-year-old female reports heart pain (aching and drilling) occurring mainly in the morning in autumn and spring and irradiating to the neck, back and abdomen; rapid heartbeat; low vitality. Occurrence of this condition is not associated with physical activity. In the evening, the patient’s condition improves. Study of somatic and neurological status, and ECG reveal no pathology. What pathology is most likely to have caused these clinical presentations?
43. An hour before an elective surgery, a 56 year old patient of the surgical department got a dramatic increase in blood pressure, tachycardia, hand tremor. The patient is confused, anxious, depressed, fearful, is pessimistic about the operation outcome, refuses the surgery. What tactics should be chosen by a surgeon?
44. A 33-year-old female complains of escalating spastic pain in the abdomen after the psycho-emotional stress. The patient has intermittent bowel movements, that is 2-3 bowel movements after waking up alternate with constipation lasting for 1-2 days. Objectively: body weight is unchanged, there is moderate pain on palpation of the sigmoid colon. Hb- 130 g/l, WBC- 5, 2 · 109/l, ESR- 9 mm/h. Proctosigmoidoscopy causes pain due to spastic bowel condition, intestinal mucosa is not changed. In the lumen there is a lot of mucus. What is the most likely diagnosis?
45. An infant is 2 days old. He was born full-term with signs of intrauterine infection, and therefore receives antibiotics. Neonates should be given antibiotics at longer intervals and lower doses compared to older children and adults because:
46. After a holiday in the Crimea, a 36-year- old female patient presents with severe pain in the elbow joints, dyspnea and weakness. The body temperature is of 37, 6oC, the skin is pale, there is erythema of cheeks and nose, lower lip ulceration. Visual inspection reveals no changes in the joints, the right elbow movement is limited. There is murmur and pleural friction in the lungs below the right angle of the scapula. Cardiac sounds are muffled, there is tachycardia, gallop rhythm, Ps- 114/min. AP- 100/60. What is the most li kely diagnosis?
Explanation
The key finding here is the erythema on the cheeks and bridge of nose which describes a malar/ butterfly rash classically seen in patients with Systemic lupus erythematosus.
SLE is a chronic inflammatory disease of unknown cause which can affect the skin, joints, kidneys, lungs, nervous system, serous membranes and/or other organs of the body. Distinct immunologic abnormalities, especially the production of a number of antinuclear antibodies, other signs include, arthralgia, myalgia, nephritis, systolic murmurs in about 30% of patients, dry pleurisy in the lungs etc. The dry pleurisy is characterised by an abnormal sound on auscultation called a pleural friction rub.
Rheumatic carditis and arthritis will be observe in a case of rheumatic fever ( prior infection by group A beta hemolytic streptococci infection)
47. A 63-year-old male patient complains of cough with expectoration of mucous blood streaked sputum, asthma, low-grade fever, general weakness. These presentations have been observed for 3 months. The patient has been a smoker since childhood. Objectively: t o- 37, 4oC, respiratory rate is 26/min, Ps- 82/min, rhythmic. AP- 130/85 mm Hg. There is limited breathing movement in the right side of chest cavity, as well as percussive dullness and diminished breath sounds. Radiograph shows a homogeneous opacity of the pulmonary field on the right with the mediastinum displacement to the affected side. What is the most likely diagnosis?
48. A 33-year-old male patient developed a condition that had a stormy clinical course: chills, fever up to 39oC, vomiting, epigastric pain, diarrhea with watery smelly feces. 6 hours before, he ate a raw egg, fried potatoes with stewed meat, drank some juice. What pathogen is likely to have caused this condition?
49. Chief physician of a polyclinic encharged a district doctor with a task to determine the pathological prevalence of disease N in his district. What document allows to estimate the disease prevalence in the population of a medical district?
50. A 76-year-old male consulted a therapist about slow discharge of urine with a small jet. The patient reported no cardiac problems. Examination revealed atrial fibrillation with a heart rate of 72/min and without pulse deficit. There are no signs of heart failure. ECG confirms the presence of atrial fibrillation. From history we know that the arrhythmia was detected three years ago. What tactics for the treatment of atrial fibrillation in the patient should be chosen?
51. A 53-year-old male has been admitted to a hospital for an attack of renal colic which has repeatedly occurred throughout the year. Objectively: in the region of auricles and the right elbow some nodules can be seen that are covered with thin shiny skin. Ps- 88/min, AP- 170/100 mm Hg. There is bilateral costovertebral angle tenderness (positive Pasternatsky’s symptom). The patient has been scheduled for examination. What laboratory value would be most helpful for making a diagnosis?
52. A 58-year-old female patient complains of spontaneous bruises, weakness, bleeding gums, dizziness. Objectively: the mucous membranes and skin are pale with numerous hemorrhages of various time of origin. Lymph nodes are not enlarged. Ps- 100/min, AP- 110/70 mm Hg. There are no changes of internal organs. Blood test results: RBC - 3,0·1012/l, Нb - 92 g/l, colour index - 0,9, anisocytosis, poikilocytosis, WBC - 10·109/l, eosinophils - 2%, stab neutrophils - 12%, segmented neutrophils - 68%, lymphocytes -11%, monocytes - 7%, ESR - 12 mm/h. What laboratory test is to be determined next for making a diagnosis?
53. A 48-year-old male in-patient undergoes treatment for essential hypertension of II - B stage. It is known from history that he works in a design engineering office. His job involves neuro-emotional stress. Which of these foodstuffs do not stimulate the central nervous system and can be recommended for the patient?
54. In an urban settlement situated on the riverbank, an outbreak of hepatitis A was registered. The disease might have water origin. This assumption can be confirmed by growth of the following values of water quality:
55. A 48-year-old male patient complains of pain in the lower extremities, especially when walking, intermittent claudication, numbness in the fingers, cold extremities, inability to walk more than 100 meters. Sleeps with his leg lowered. The patient has been a smoker
Explanation
Obliterating Endarteritis is also known as Buerger’s disease and vasculitis. The condition is thought to occur as a result of tobacco use and more common in males. The disease is characterized by inflammation and thrombosis of small and medium arteries of the legs and feet which recurs and progresses in stages. During the ischemic period, the veins of the lower leg are inflamed, skin has ulceration, and there is gangrene with intermittent claudication. During the nutritional disorder period there is persistent pain and muscle atrophy. During the necrosis period, the pain becomes worse as infection leads to the development of ulcers and gangrene. Pains usually persist; In addition, the patient usually complains of coldness and numbness. Burning sensations is another disturbing symptom.
Treatment usually has to do with smoking cessation.
Raynaud disease is a condition in which some areas of the body feel numb and cool in certain circumstances. In Raynaud's phenomenon, smaller arteries that supply blood to the skin constrict excessively in response to cold, limiting blood supply to the affected area. The fingers, toes, ears and tip of the nose are commonly involved and feel numb and cool in response to cold temperatures or stress.
Leriche Syndrome, also commonly referred to as aortoiliac occlusive disease, is a product of atherosclerosis affecting the distal abdominal aorta, iliac arteries, and femoral popliteal vessels. Its triad include; claudication, erectile dysfunction and decreased distal pulse.
56. A 38-year-old male complains of tonic tension of the masticatory muscles, so that he cannot open his mouth. 12 days before, he was bitten by an unknown dog. Objectively: there is pronounced tension and twitching of the masticatory muscles. What is the most likely diagnosis?
57. A 72-year-old male had had a moderate headache. Two days later, he developed the progressing speech disorders and weakness in the right extremities. The patient has a history of myocardial infarction, arrhythmia. Study of the neurologic status revealed elements of motor aphasia, central paresis of the VII and XII cranial nerves on the right, central hemiparesis on the same side and hyperaesthesia. What is the most likely diagnosis?
58. A 28-year-old female patient has been admitted to the gynecology department for abdominal pain, spotting before and after menstruation for 5 days. The disease is associated with the abortion which she had 2 years ago. Anti-inflammatory treatment had no effect. Bimanual examination findings: the uterus is enlarged, tight, painful, smooth. Hysteroscopy reveals dark red holes in the fundus with dark blood coming out of them. What diagnosis can be made on the grounds of these clinical presentations?
59. 2 weeks after having quinsy, a 26-year-old male patient got facial edemata, moderate pain in the sacrum. Objectively: body temperature is 37, 5oC, AP- 100/80 mm Hg. Urinalysis results: RBC- up to 100 fresh cells in per HPF, protein - 2,2 g/l, hyaline cylinders - up to 10 per HPF, relative density 1002. What is the most likely diagnosis?
60. Examination of a full-term 6 day old infant revealed that different areas of skin had erythemas, flaccid bubbles, eroded surface, cracks, peeling of the epidermis looking like being scalded with boiling water. There was positive Nikolsky’s symptom. General condition of the child was serious. The child was restless, hypersensitive, febrile. What is the most likely diagnosis in this case?
Explanation
Nikolsky’s sign is a skin finding in which the top layers of the skin slips away from the top layers when rubbed. It is usually positive in Pemphigus Vulgaris, Scalded skin syndrome (Ritter’s exfoliative dermatitis, lyell’s disease), impetigo neonatorum and erythema multi form.
Ritter’s Exfoliative dermatitis is widespread erythema and scaling of the skin caused by preexisting skin disorders, drugs, cancer, or unknown causes. Symptoms and signs are pruritus, diffuse erythema, and epidermal sloughing.
pseudofurunculosis, is observed in neonates and infants. The disease begins with the appearance of superficial pustules in the ostium of sweat glands (periporitis). Caused by staphylococcus aureus, which penetrates in the depth of the sweat gland and causes the forming of deep indurated painful nodules. The nodules are very similar to furuncles, but they have not got core in the center (hence the name pseudofurunculosis).
Neonatal pemphigus is characterised by cutaneous, mucosal or mucocutaneous erosions. It results from transplacental passage of IgG maternal autoantibodies. 61. A 39-year-old female patient complains of rapid fatigability, drowsiness, dry skin, hair loss, swelling of the face. A month ago, she underwent a surgery for thyrotoxicosis. The patient has the following gland dysfunction:
62. A 27-year-old patient has a severe headache, nausea and vomiting. Objectively: body temperature is 38, 9oC, there is a haemorrhagic stellate rash on the legs. The patient takes meningeal pose in bed. Meningeal symptoms are strongly positive. Deep reflexes are brisk, uniform. Pathological reflexes are absent. It has been suspected that the patient has epidemic cerebrospinal meningitis. Which of additional tests should be performed in the first place to verify the diagnosis?
63. 3 hours before, a 68-year-old male patient got a searing chest pain radiating to the neck and left forearm, escalating dyspnea. Nitroglycerin failed to relieve pain but somewhat reduced dyspnea. Objectively: there is crimson cyanosis of face. Respiratory rate is 28/min. The patient has vesicular breathing with isolated sibilant rales. Heart sounds are muffled, with a gallop rhythm. Ps- 100/min, AP- 100/65 mm Hg. ECG shows negative T- wave in V 2 − V 6 leads. What drug can reduce the heart’s need for oxygen without aggravating the disease?
64. A 5-year-old girl has had thirst, polyuria, increased appetite for two months. At the same time, there is a 3 kg decrease in body weight. During the last week, these presentations got accompanied by nocturnal enuresis. Examination revealed hyperglycemia at the rate of 14 mmol/l. The child has been diagnosed with type I diabetes. What is the most likely genesis of this disease?
65. An 8-year-old child with a 3-year history of diabetes was hospitalized in hyperglycemic coma. Specify the initial dose of insulin to be administered:
ExplanationInitial intravenous administration of 10 to 14 units of short-acting insulin has to be prescribed for the patient during the first hour. Continuous intravenous infusion of insulin in a dose 0,1 unit/kg/hour in 0,9 % sodium chloride infusion has to be given after that.
66. A 12-year-old girl undergoes regular gastroenterological check-ups for duodenal ulcer, biliary dyskinesia. What is the recommended frequency of anti-relapse treatment?
67. On the 2nd day of disease a 27-year-old patient complains of unbearable headache, repeated vomiting. Objectively: the patient is in a grave condition. He is conscious but adynamic. Lies in a forced position with his head thrown back. There is no skin rash. Nuchal muscles are evidently rigid, there are Kernig’s and Brudzinski’s signs. t o - 39, 5oC, Ps- 120/min, AP- 130/80 mm Hg. The leading syndrome of this disease is caused by:
Explanation
This patient presents with intracranial hypertension. This is a condition in which the pressure of the fluid that surrounds the brain (cerebrospinal fluid or CSF or liquor) is too high. There are two categories of IH: primary intracranial hypertension and secondary intracranial hypertension. Primary intracranial hypertension, now known as idiopathic intracranial hypertension (IIH), occurs without known cause. Secondary intracranial hypertension has an identifiable, causative agent, including drugs (such as tetracycline, lithium, Vitamin A-derived oral acne medications or excessive ingestion of Vitamin A, and oral or intrathecal steroids, growth hormone treatments), sleep apnea and certain systemic diseases such as lupus, leukemia, kidney failure (uremia), meningitis and dural venous sinus thrombosis. The most common symptom is often an unbearably painful or frequent headache, sometimes associated with nausea and vomiting that is not relieved by medication.
68. Two years ago, a 46-year-old patient was diagnosed with stage I silicosis. Currently the patient complains of escalating dyspnea, pain in the infrascapular regions. Radiograph shows a diffuse enhancement and distortion of lung markings, as well as multiple nodular shadows 2-4 mm in diameter. There is interlobar pleural density on the right. Dense shadows are found in the hilar regions. Specify the form of radiographic pulmonary fibrosis in this case:
69. A 63-year-old female complains of general weakness, a feeling of heaviness, compressi on in the epigastrium, postprandial fullness, nausea, belching after meals. These symptoms have been observed for about 15 years. Objectively: body temperature is 36, 4oC, respiratory rate - 20/min, Ps - 88/min, blood pressure - 115/75 mm Hg. Skin and mucous membranes are pale. Blood test results: RBC - 2,0·1012/l, Hb - 100 g/l. Tests revealed parietal cell antibodies. What is the most likely reason for the development of anemia in this patient?
70. During dressing of a poorly granulating wound Pseudomonas aeruginosa infection was revealed. What medication would be optimal for the wound d-bridement?
71. A 39-year-old male patient complains of moderate pain and weakness in the shoulder, back and pelvic girdle muscles, that has been progressing for the last 3 weeks; great difficulty in getting out of bed, going up and down the stairs, shaving. Dermatomyositis has been suspected. Blood test results: Hb- 114 g/l, WBC- 10, 8 · 109/l, eosinophils - 9%, ESR -22 mm/h, C-reactive protein (++). The alteration in the following laboratory value wil be of decisive diagnostic significance:
72. A 60-year-old female patient complains of recurrent pain in the proximal interphalangeal and wrist joints, their periodic swelling and reddening that have been observed for 4 years. X-ray picture represents changes in form of osteoporosis, joint space narrowing and single usuras. What is the most likely diagnosis?
73. A 30-year-old female patient has been delivered to a hospital for sudden dyspnea progessing to asthma, sensation of having a \"lump in the throat\", hand tremor, fear of death. The attack has developed for the first time and is associated with a strong emotion. There is no previous history. Objectvely: respiratory rate - 28/min, Ps- 104/min, rhythmic, AP- 150/85 mm Hg. The patient has rapid superficial vesicular breathing with extended expiration. Percussion findings: heart borders are not changed. Cardiac sounds are loud, rhythmic. What is the most likely diagnosis?
74. A 42-year-old male patient wth essential hypertension presents with headache, palpitations, unexplained fear. Objectively: Ps- 100/min, AP- 200/100 mm Hg, the left border of cardiac dullness is displaced by 1,5 cm to the left, vesicular breathing is present. ECG shows sinus tachycardia, signs of left ventricular hypertrophy. What drug should be administered as an emergency?
75. A 37-year-old male patient has a history of diabetes of moderate severity. On the left side of face the patient has a carbuncle. What severe complication might have occurred in the patient?
76. A 42-year-old female patient complains of a dull pain in her left side, low-grade fever, accelerated painful urination in small portions. These presentations have been observed for three years. For a long time, the patient has had cystitis with frequent exacerbations, there is pulmonary tuberculosis in the past history. Urinalysis results: microscopic hematuria, leukocyturia. What is the most likely provisional diagnosis?
77. A woman at 30 weeks pregnant has had an attack of eclampsia at home. On admission to the maternity ward AP- 150/100 mm Hg. Predicted fetal weight is 1500 g. There is face and shin pastosity. Urine potein is 0, 66o/oo. Parturient canal is not ready for delivery. An intensive complex therapy has been started. What is the correct tactics of this case management?
78. Examination of a dead man who died from hanging revealed that cadaver spots disappeared when pressed upon and restored after 50 seconds, rigor mortis was moderately expressed only in the masticatory muscles and the muscles of neck and fingers. Body temperature was 31oC. Specify the time of death:
79. A 65-year-old male patient complains of dyspnea that is getting worse with exertion, morning cough with expectoration of mucous sputum. For about 15 years, he has been subject to regular medical check-up for chronic bronchitis. The patient takes berodual (16 inhaled doses per day). Objectively: body temperature is 36, 8oC, RR- 24/min, Ps- 110/min, AP- 145/90 mm Hg. Auscultation reveals a lot of dry rales above the lungs. FEV1- 65%. What is the optimal tactics of further management of the patient?
80. A 49-year-old countryman got an itching papule on the dorsum of his right hand. In the centre there is a vesicle with serosanginous exudate. Within the next 2 days the patient developed a painless edema of hand and forearm. On the 4th day the temperature rose to 38, 5oC, in the right axillary region a large painful lymph node was found. One day before the onset of the disease the patient had examined a dead calf. What is the most likely diagnosis?
Explanation
Bacillus anthracis is an aerobic, non-motile, spore forming, large non-hemolytic Gram-positive rod that grows well on blood agar. The clinical manifestations of human anthrax - Cutaneous and Inhalation.
Cutaneous anthrax, the most common form of naturally occurring disease, begins as a small, painless, pruritic papule that within 2 days enlarges, develops vesicles, and ulcerates to form an eschar. Inhalational anthrax follows inhalation of infectious doses of anthrax spores.
When anthrax spores get into the skin, usually through a cut or scrape, a person can develop cutaneous anthrax. Human cases may follow contact with contaminated carcasses (dead calf) or animal products. This can happen when a person handles infected animals or contaminated animal products like wool, hides, or hair. Cutaneous anthrax is most common on the head, neck, forearms, and hands. It affects the skin and tissue around the site of infection.
Bubonic plague is caused by bacteria called Yersinia pestis. It’s usually spread by fleas. These bugs pick up the germs when they bite infected animals like rats, mice, or squirrels.
81. An employee of a petrol station with 15 years of service record having contact with ethylated gasoline presents with memory impairment, bradycardia, sensation of having a hair in the mouth, skin paresthesia. In this case, one can assume intoxication with the following substance:
Explanation
From anamnesis, this patient has been exposed to Ethylated gasoline from the nature of his Job. Tetraethyl Lead is a lead compound found in Ethylated gasoline. On chronic exposure, individuals present with memory loss, neurological problems, insomnia, psychosis, tremors etc.
Patients with organophosphate poisoning usually present with Salivation, Lacrimation, Urination, Defecation, Gastric cramps, Emesis (SLUDGE) symptoms.
82. A 38-year-old female suddenly developed acute inflammatory rash in form of roseolas, papules, vesicles that are scattered on the skin of trunk in irregular and predominantly focal manner. The rash appeared a few hours after visiting a restaurant. The patient complains of itching skin. What is the most likely diagnosis?
Explanation
Toxicodermatosis is a disease of the skin caused by a poison or by an allergen. The causative agents may be such chemical substances as antibiotics, sulfanilamides, and bromine, iodine, arsenic, and mercury compounds, or such food products as berries, cheese, or fish. As described in this scenario, the rash appeared after visiting a restaurant. Toxicoderma can also occur as a metabolic disorder or an occupational disease.
The causative agent enters the body through the respiratory organs or the digestive tract, during injections, or by direct contact with the skin. The primary manifestation of toxicoderma is a rash, which is generally symmetrical; it can take the form of inflamed or hemorrhagic maculae, papule, or vesicles (blisters). In severe cases, widespread areas of the skin are affected (erythroderma) and the patient manifests fever, cardiovascular disorders, or symptoms of anaphylactic shock.
With the removal of the allergen the symptoms of toxicoderma rapidly disappear, although relapses (usually severe) may occur with subsequent repeated exposure to the causative agent. Treatment consists in avoiding contact with the suspected allergen or toxic agent, as well as in the use of desensitizing agents and of expectant treatment.
Atopic dermatitis is a chronic condition that requires symptom management. It’s characterized by an itchy, red rash that usually appears at joints in your body, such as knees or elbows, and even around the neck. This condition occurs in flare-ups or bouts, meaning that it gets worse and improves in irregular cycles.
Many doctors use the terms “atopic dermatitis” and “eczema” interchangeably. They are both generic terms for “inflammation of the skin.” Eczema usually starts in early infancy, but also affects a substantial number of adults. It is commonly associated with elevated levels of immunoglobulin E (IgE) and a series of allergic diseases—including food allergy, asthma, and allergic rhinitis.
Contact Dermatitis occurs when your skin has a reaction to something it’s come in contact with. This can include bleach, soap, poison ivy, certain metals, or other irritants. The rash is typically red and may itch or burn.
83. The institutions which take part in medical examinations can be prevention and treatment facilities, medical board of Ministry of Defense, medical board of Ministry of Home Affairs, medico-social expert commissions, forensic medical boards etc. What institutions are responsible for temporary disability examination?
84. After lifting a load, a 36-year-old male patient has experienced a severe pain in the lumbar region, which spread to the right leg and was getting worse when he moved his foot or coughed. Objectively: the long back muscles on the right are strained. Achilles jerk is reduced on the right. There is a pronounced tenderness of paravertebral points in the lumbar region. The straight leg raise (Lasegue’s sign) is positive on the right. What additional tests should be performed in the first place?
85. A 17-year-old male patient consulted a therapist about malaise, chills, runny nose, aching muscles and joints, nausea and diarrhea. The patient asks to prescribe him a lot of painkillers and sedatives (tramadol orsolpadein that help the best, and diazepam). Pharyngeal mucosa is pale pink, clean. Auscultation reveals vesicular breathing. Tachycardia is present. The pupils are dilated, there is sluggish response to light. There are injection marks on the forearm skin. During examination, the patient’s manner is vulgar, irritable, rude and untruthful. Make a diagnosis:
Explanation
Opioids, sometimes called narcotics, are a type of drug. They include strong prescription pain relievers, such as oxycodone, hydrocodone, fentanyl, and tramadol. The illegal drug heroin is also an opioid. They are commonly used to treat moderate to severe or refractory pain. Examples of opioids include:
-Full agonist: Morphine, Heroin, Meperidine, Methadone, Codeine, Fentanyl
-Partial agonists: Buprenorphine
-Mixed agonist/antagonist: Pentazocine
-Antagonist: Naloxone, Naltrexone
Treat toxicity with Naloxone (competitive opioid receptor antagonist) and prevent relapse with Naltrexone.
The risks of using prescription opioids include dependence and addiction. Dependence means feeling withdrawal symptoms when not taking the drug. Addiction is a chronic brain disease that causes a person to compulsively seek out drugs, even though they cause harm.
Common Signs of Opioid Addiction: The inability to control opioid use; Uncontrollable cravings; Drowsiness; Frequent flu-like symptoms; Isolation from family or friends; Stealing from family, friends or businesses; New financial difficulties.
This patient has injection marks on the forearms and cravings for Tramadol in addition to showing signs of opioid withdrawal - sweating, dilated pupils, rhinorrhea, lacrimation, nausea, stomach cramps, diarrhea (“flu-like” symptoms), piloerection (“cold turkey”). Flu-like symptoms here include - malaise, chills, runny nose, aching muscles and joints.
Even though Solpadein contains both Paracetamol and Caffeine which are Pain killers, the best choice here is Opioid addiction due to the signs of withdrawal manifested by this patient.
86. A 4-year-old boy had untimely vaccination. He complains of painful swallowing, headache, inertness, fever. Objectively: the child is pale, has enlarged anterior cervical lymph nodes, swollen tonsils with cyanotic hyperemia, tonsils are covered with gray white pellicles which cannot be easily removed. When the pellicles are forcibly removed, the tonsils bleed. What is the most likely diagnosis?
87. Public nurseries are designed as a single or several one- or two-storey buildings linked by covered walkways. Planning the structure of preschool instiutions is based upon the following principle:
88. A city somatic hospital with 300 beds has a main building which houses the therapeutic and surgical departments. Several separate buildings house the maternity, pediatric and radiologic departments that are connected to the main building by underground walkways and above-ground covered skybridges. Specify the building system of the hospital:
89. A 43-year-old female patient complains of dyspnea, swelling of legs, abdomen enlargement, pricking heart pain. She has a history of tuberculous bronchadenitis, quinsies. The patient’s condition deteriorated 6 months ago. Objectively: cyanosis, bulging neck veins, vesicular breathing. Heart borders are not displaced. Heart sounds are muffled, Ps- 106/min, liver is +4 cm, ascites is present. Low voltage on the ECG has been revealed. Radiograph shows a thin layer of calcium deposits along the left contour of heart. What treatment should be recommended to the patient?
90. A 26-year-old female patient has an 11 year history of rheumatism. Four years ago she suffered 2 rheumatic attacks. Over the last 6 months there have been paroxysms of atrial fibrillation every 2-3 months. What option of antiarrhythmic therapy or tactics should be proposed?
91. Blood typing resulted in positive isohemagglutination reaction with standard sera of A(II) and B(III) groups and negative reaction with sera of 0(I) and AB(IV) groups. What is this result indicative of?
92. A 9-year-old girl has been admitted to a hospital for an elevated body temperature (39, 8oC), painful dry cough, abdominal pain on the right. Examination reveals dullness on percussion on the right, diminished breath sounds, crepitus. What study is required to make a diagnosis?
93. A newborn has purulent discharges from the umbilical wound, the skin around the navel is swollen. The baby’s skin is pale, with a yellow-gray tint, generalized hemorrhagic rash is present. What is the most likely diagnosis?
Explanation
Sepsis is a medical condition caused by the body’s reaction to an infection. Neonatal sepsis can be caused by organisms such as E. coli, listeria, Group B streptococcus, Herpes simplex virus etc. Conditions that increase the risk of neonatal sepsis include: Preterm birth, early rupture of membrane, chorioamnionitis etc.Key signs include: Fever, vomiting, diarrhea, pale skin with yellow and white tint ( jaundice), irritability, difficulty in breathing and feeding etc.
Hemorrhagic disease of newborn occurs as a result of deficiency in vitamin K or essential blood clotting factors, trauma. It is characterised by excessive bleeding.
Hemolytic disease of newborn occurs due to ABO incompatibility or Rhesus Incompatibility between mother and child ( mother -ve, child +ve).
94. A pregnant 26-year-old woman was admitted to a hospital for abdominal pain and Bleeding from the genital tract. Bimanual examination revealed that uterus was the size of 9 weeks of pregnancy, the cervical canal let a finger through. Fetal tissues could be Palpated in the orifice. There was moderate vaginal bleeding. What is the tactics of choice?
95. On the second day of the disease a 22- Year-old male patient complains of high-grade Fever, headache in the region of forehead and Superciliary arches, and during eye movement; Aching muscles and joints. Objectively: body Temperature is 39oC. Face is hyperemic, Sclerae are injected. The mucous membrane Of the soft palate and posterior pharyngeal wall is bright hyperemic and has petechial Hemorrhages. What changes in the hemogram Are typical for this disease?
96. A 44-year-old male patient complains of severe non-localized abdominal pain, pain in the right shoulder girdle, repeated vomiting, red urine. The onset of the disease is associated with alcohol consumption. The face is hyperemic. AP- 70/40 mm Hg. Abdominal radiography reveals no pathological shadows. Hemodiastase is 54 mg/h/l. Prothrombin is 46%. What is the provisional diagnosis?
97. A 41-year-old male patient was delivered to a hospital unconscious. During the previous 7 days he had been taking large doses of biseptolum for a cold. The night before, he began complaining of dyspnea, especially when lying down, swollen legs, 2-day urinary retention. In the morning he had seizures and lost consciousness. Objctively: noisy breathing at the rate of 30/min, edematous legs and lumbar region, Ps- 50/min. Plasma creatinine is 0,586 mmol/l, plasma potassium - 7,2 mmol/l. What treatment is necessary for this patient ?
98. A 10-year-old child with a history of nonrheumatic carditis has periodic attacks manifested by heart pain, dyspnea, pallor, high blood pressure, a dramatic increase in heart rate up to 180/min. What drug would be most effective to treat this patient?
99. A 45-year-old male patient with acute abscess of the left lung has suddenly developed acute chest pain and dyspnea while coughing, tachycardia has increased. The control Ro-gram shows left lung collapse, the air in the left pleural cavity and a horizontal fluid level. What is the mechanism of this complication?
100. A 24-year-old male patient had been diagnosed with class III diffuse toxic goiter. There is moderate hyperthyroidism. A surgery was suggested, and the patient agreed to it. What preoperative measures should be taken for prevention of thyrotoxic crisis in the postoperative period?
Explanation
The patient in question already has diffuse toxic goiter with clinical manifestation of hyperthyroidism. Thyroid storm, also referred to as thyrotoxic crisis, is an acute, life-threatening, hypermetabolic state induced by excessive release of thyroid hormones in individuals with thyrotoxicosis. During a thyroid storm, an individual’s heart rate, blood pressure, and body temperature can soar to dangerously high levels. Without prompt, aggressive treatment, thyroid storm is often fatal. Thyroid storm may be precipitated by the stress of surgery, anesthesia, or thyroid manipulation and may be prevented by pretreatment with antithyroid drugs.
101. A 26-year-old male patient complains of pain in the right knee, which is getting worse in the morning. Two weeks before, he consulted an urologist about prostatitis. Objectively: conjunctivitis is present. There is also periarticular edema of the knee joint, redness of the overlying skin. Rheumatoid factor was not detected. Until further diagnosis is specified, it would be reason able to start treatment with the following antibiotic:
102. A 66-year-old female patient has been admitted to a hospital for massive gross hematuria with release of shapeless blood clots, frequent painful urination. The patient also reports a moderate weight loss within 3-4 months. Gross hematuria that was not accompanied by pain and dysuria first occurred three months ago for no apparent reason, and after a few days the bleeding subsided independently. What is the most likely diagnosis?
103. A 36-year-old female pesented to a gynecological hospital with a significant bleeding from the genital tract and a 1-month delay of menstruation. Bimanual examination revealed soft barrel-shaped cervix. Uterus was of normal size, somewhat softened. Appendages were unremarkable on both sides. Speculum examination revealed that the cervix was cyanotic, enlarged, with the the external orifice disclosed up to 0,5 cm. Urine hCG test was positive. What is the most likely diagnosis?
104. A 47-year-old female patient has an 8- year history of ulcerative colitis, has been treated with glucocorticoids. She complains of cramping pain in the umbilical region and left iliac region which has significantly increased during the past 2 weeks, diarrhea with mucus and blood 4-6 times a day, elevated body temperature up to 38 − 39oC, headache and pain in the knee joints. Objectively: the patient is in moderate condition, Ps- 108/min, AP- 90/60 mm Hg; heart and lungs are unremarkable; the tongue is moist; abdominal muscle tone is significantly decreased; peristaltic noises are absent. What complication developed in the patient?
Explanation
The term inflammatory bowel disease describes a group of disorders in which the intestines become inflamed. Two major types of inflammatory bowel disease are Ulcerative colitis and Crohn’s disease. Ulcerative colitis is limited to the colon or large intestine. Crohn’s disease, on the other hand, can involve any part of the gastrointestinal tract from the mouth to the anus.
The patient in question suffers from Ulcerative colitis. Common complications include; Toxic megacolon (toxic dilatation of the colon), or fulminant colitis. If Ulcerative colitis attack is severe, the colon might burst, or infection could spread through your body. Your intestines stop moving waste, and your belly swells. However, if a toxic megacolon is not urgently attended to, it could further lead to perforation.
Fistulas, abscess, and strictures are commonly associated with Crohn’s disease.
105. A 10-year-old child has been admitted to a hospital with a closed craniocerebral injury with a suspected cerebral edema. The patient is in grave condition, unconscious. The dyspnea, tachycardia, hypertension are present. Muscle tone is increased, there is nystagmus, pupillary and oculomotor reactions are impaired. The mandatory component of intensive care is dehydration. What diuretic is adequate in this case?
106. For 3 days, a 28-year-old emale patient had had the body temperature increase up to 38oC, weakness, poor appetite, nausea, a single vomiting. On the 4th day the temperature was normal, the condition improved, but the jaundice developed. Objectively: moderate ictericity of skin, +3 cm enlarged liver of elastic consistency. Ortner’s, Kehr’s and Voznesensky’s symptoms are negative. What test will verify the diagnosis?
107. An 11-year-old girl has been immunized according to her age and in compliance with the calendar dates. What vaccinations should the children receive at this age?
Explanation
It is recommended that diphtheria, tetanus, and acellular pertussis vaccination be administered across the lifespan. Children younger than 7 years of age receive DTaP or DT, while older children and adults receive Td.
D- Diphtheria; T- Tetanus; P- Pertussis (Whooping cough); aP- acellular pertussis vaccine.
-
Give infants and children 5 doses of DTaP. Give one dose at each of these ages: 2 months, 4 months, 6 months, 15 through 18 months, and 4 through 6 years.
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Give adolescents a single dose of Tdap, preferably at 11 to 12 years of age.
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Give pregnant women a single dose of Tdap during every pregnancy, preferably during the early part of gestational weeks 27 through 36.
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Give adults who have never received Tdap a single dose of Tdap. This can be given at any time, regardless of when they last got Td. This should be followed by either a Td booster every 10 years.
108. A 40-year-old male patient has had heaviness in the epigastric region for the last 6 months. He has not undergone any examinations. The night before, he abused vodka. In the morning there was vomiting, and 30 minutes after physical activity the patient experienced dizziness and profuse hematemesis. What pathology should be suspected in the first place?
109. A 55-year-old patient complains of severe itching, burning and pain in the eyes, skin redness in the outer corners of the palpebral fissure. Objectively: skin around the outer corners of the palpebral fissure is macerated, eczematous, there are single moist cracks. Palpebral conjunctiva is hyperemic, quaggy. There are minor discharges in form of stringing mucus. What is the most likely diagnosis?
Explanation
The conjunctiva is a thin, translucent, relatively elastic tissue layer with both bulbar and palpebral portions. The bulbar portion of the conjunctiva lines the outer aspect of the globe, while the palpebral portion covers the inside of the eyelids.
Conjunctivitis refers to any inflammatory condition of the membrane that lines the eyelids and covers the exposed surface of the sclera. It is the most common cause of “red eye.”
Chronic conjunctivitis is most commonly caused by Staphylococcus species, although other bacteria are occasionally involved. This type of conjunctivitis often develops in association with blepharitis - bacterial colonization of the eyelid margins (palpebral conjunctiva is hyperemic and quaggy). The symptoms of chronic conjunctivitis include itching, burning, a foreign-body sensation and morning eyelash crusting, flaky debris, erythema and warmth along the lid margins, as well as eyelash loss and bulbar conjunctival injection (red eye).
Acute bacterial conjunctivitis typically presents with burning, irritation, tearing and, usually, a mucopurulent or purulent discharge and usually self-limited.
110. A 3-month-old infant has occipital alopecia, restless sleep, excessive sweating. What disease can you think of?
111. A 50-year-old male in a grave condition has been admitted to the intensive care unit. It is known from life history that the patient works in agriculture, and 3 hours ago was engaged into insecticide treatment of crops for control of colorado potato beetle. Condition on admission: acrocyanosis, bronchorrhea, tachypnea, AP- 100/60 mm Hg, Ps- 44/min. What method of efferent therapy would be most appropriate at this stage?
Explanation
Hemosorbtion: Removal of toxins or metabolites from the circulation by the passing of blood, within a suitable extracorporeal circuit, over semipermeable microcapsules containing adsorbents (e.g., activated charcoal) or enzymes, or other adsorbents (e.g., various resins, albumin-conjugated agarose).
Hemodialysis: A medical procedure to remove fluid and waste products from the blood and to correct electrolyte imbalances. This is accomplished using a machine and a dialyzer, also referred to as an \"artificial kidney.\"
Hemodialysis is used to treat both acute (temporary) and chronic (permanent) kidney failure.
Plasmapheresis (PP) is the removal of whole blood from the patient, its separation by machine into component parts, and then the return of certain of those components to the patient. Indications include Gulliane barre syndrome, good pasture syndrome, chronic demyelinating disorders , Thrombotic thrombocytopenic purpura etc.
112. An 80-year-old patient complains of constantly urinating small amounts, a feeling of pressure in the lower abdomen. Objectively: there is a suprapubic spherical bulging with percussion dullness over it. What syndrome occurred in the patient?
113. Carpathian region is characterized by permanently high (over 80%) air humidity. In the cold season the population of this region feels very cold at moderately low temperatures. This is due to an increase in the heat transfe by:
114. An 18-year-old girl complains of breast pain and engorgement, headaches, irritability, swelling of the lower extremities. These symptoms have been observed since menarche and occur 3-4 days before the regular menstruation. Gynecological examination revealed no pathology. Make a diagnosis:
115. A 56-year-old male patient has been delivered to the emergency department with frostbite on both feet. What aid should be rendered to the victim?
116. A 21-year-old male patient got a deep cut wound in his right thigh. In the emergency room a surgeon on duty performed primary debridement of the wound and primary wound closure with a suture. After 4 days, there appeared pain, redness, edema, purulent discharge from the wound gap, body temperature rose up to 39oC. What kind of wound complication can you think of and what actions should be taken?
117. A general practitioner visited a 2-year-old child and diagnosed him with measles. The child attends a nursery, has a 5-year-old sister. What document must be filled in for the effective antiepidemic measures in the given health locality?
118. An employee has been diseased for 4 months, further treatment is necessary, the patient is incapacitated. Who is authorized to provide further disability examination of this patient?
119. It has been suspected that a newborn has congenital diaphragmatic hernia (asphyctic incarceration). What study will allow to confirm the diagnosis?
120. A 25-year-old female presented to a women’s welfare clinic and reported the inability to get pregnant within 3 years of regular sexual activity. Examination revealed. increased body weight, male pattern of pubic hair growth, excessive pilosis of thighs, dense enlarged ovaries, monophasic basal temperature. What is the most likely diagnosis?
Explanation
Polycystic ovarian syndrome is a disorder found in women of reproductive age commonly due to hormonal disorder (high level of androgens). This disorder is characterised by infrequent menstrual cycle, pelvic pain, weight gain male pattern pubic hair growth, excessive hair on the thighs etc. The ovaries mostly develop follicles (collection of fluids). Realise that the patient is of a reproductive age and experiences infrequent menstruation;
Premenstrual syndrome is a wide variety of signs and symptoms that affects a woman’s emotion, physical health, and behavior during certain days of the menstrual cycle, generally just before her menses. Symptoms start five to 11 days before menstruation and typically go away once menstruation begins. Signs include abdominal pain and bloating, vomiting ,meteorism, change in sleep patterns, emotional instability etc. 121. A factory’s sectorial doctor selects a group of persons who often fall ill for thorough monitoring. At the same time he takes into consideration the number of etiologically related cases with temporary disability in each of the employees over the last year. An employee falls into this group if the number of sickness cases is:
122. A 23-year-old female consulted a gynecologist on the 20th day postpartum period about pain in the left breast, purulent discharge from the nipple. Objectively: Ps-120/min, t-39C. The left breast is painful, larger than the right one, hyperemic. In the upper quadrant there is an infiltrate sized 10x15 cm with a softening inside. Blood test results: ESR- 50 mm/h, WBC- 15, 0 · 109/l. What is the tactics of choice?
123. A family lives in the town situated within the zone of radiation pollution. A 6-year-old child had been ill with ARVI for 19 days. The child was undergoing outpatient treatment and was nursed by his mother, a cafe worker. Specify the order of disability examination:
124. A 49-year-old female patient with schizophrenia is all the time listening to something, insists that \\\"there is a phone in her head\\\"as she hears the voice of her brother who tells her to go home. The patient is anxious, suspicious, looks around all the time. Specify the psychopathological syndrome:
125. During the first home visit to a full-term boy after his discharge from the maternity hospital a pediatrician revealed a symmetrical swelling of mammae without skin changes over them, swelling of the scrotum. The body temperature was of 36, 5oC. The baby was calm, sucked the mother’s breast actively. What condition should you think of?
126. A 30-year-old male patient complains of inertness, low-grade fever, bleeding gums, frequent quinsies, aching bones. Objectively: the patient has pale skin and mucous membranes, sternalgia, +2 cm liver, +5 cm painless spleen. Blood test results: RBC- 2, 7 · 1012/l, Нb- 80 g/l, WBC- 3 · 109/l, eosinophils - 4%, basophils - 5%, blasts - 4 segmented neutrophils - 17%, lymphocytes -29%, myelocytes - 25%, promyelocytes - 12%, monocytes - 2%, platelets - 80 · 109/l, ESR -57 mm/h. What test should be performed to verify the diagnosis?
127. A 46-year-old male patient complains of periodic epigastric pain that occurs at night. Objectively: HR- 70/min, AP- 125/75 mm Hg, tenderness in the epigastric region is present. EGD confirms duodenal ulcer of 0,6 cm in diameter. Test for H. Pylori is positive. Which of the given antisecretory drugs will be a compulsory element of the treatment regimen?
Explanation
Infection with H pylori is associated with the development of peptic ulcer disease, gastric cancer, and mucosa-associated lymphoid tissue lymphoma. Treatment Regimens for Eradication of H. pylori are omeprazole, amoxicillin, and clarithromycin (OAC) for 10 days; bismuth subsalicylate, metronidazole, and tetracycline (BMT) for 14 days; and lansoprazole, amoxicillin, and clarithromycin (LAC), which has been approved for either 10 days or 14 days of treatment.
Proton Pump Inhibitors (PPI) are the first line antisecretory agents used in treating H. Pylori associated Peptic Ulcer Disease. Examples of PPI’s include: Omeprazole; Lansoprazole; Esomeprazole; Pantoprazole. They irreversibly inhibit H+/K+ ATPase in stomach parietal cells.
Famotidine, Cimetidine are examples of H2-Histamine receptor blockers. This class of antisecretory agents are older than Proton Pump Inhibitors and no longer first line antisecretory agents due to their adverse effect profile such as multiple drug interactions, antiandrogenic effects etc.
128. A 47-year-old male patient has been lately complaining of compressing chest pain that occurs when he walks a distane of 700-800 m. Once a week, he drinks 2 liters of beer. Rise in arterial pressure has been observed for the last 7 years. Objectively: Ps- 74/min, AP- 120/80 mm Hg. The bicycle ergometry performed at workload of 75 watts shows 2 mm ST-segment depression in V 4 − V 6 leads. What is the most likely diagnosis?
Explanation
An angina refers to chest pain due to an ischemic myocardium secondary to coronary artery narrowing or spasms. Canadian Cardiovascular Society grading of angina pectoris is a classification used to grade the severity of Angina.
Class 0: Asymptomatic Angina- Mild myocardial ischemia with no symptoms.
Class I: Angina only with strenuous exertion- Presence of angina during strenuous, rapid, or prolonged ordinary activity (walking or climbing the stairs).
Class II:Angina with moderate exertion- Slight limitation of ordinary activities when they are performed rapidly, after meals, in cold, in wind, under emotional stress, during the first few hours after waking up, but also walking uphill, climbing more than one flight of ordinary stairs at a normal pace and in normal conditions.
Class III: Angina with mild exertion- Having difficulties walking one or two blocks or climbing one flight of stairs at normal pace and conditions e.g walking short distances (20 - 100m)
Class IV: Angina at rest- No exertion needed to trigger angina.
The patient in perspective experiences anginal symptoms after he walks about 700 - 800m (a short distance and normal activity).
The New York Heart Association (NYHA) also classifies the extent of heart failure. It classifies patients in one of the four categories based on their limitations during physical activity.
CLASS I: No symptoms and no limitation in ordinary physical activity
CLASS II: Mild symptoms (mild shortness of breath and/or angina) and slight limitation during ordinary activity.
CLASS III: Marked limitation in activity due to symptoms, even during less than ordinary activity e.g. walking short distances (20 - 100m). Comfortable only at rest.
CLASS IV: Severe limitations. Experiences symptoms even while at rest.
129. A puerperant is 28 years old. It’s the 3rd day post-partum after a second, normal, term delivery. The body temperature is of 36, 8oC, Ps 72/min, AP- 120/80 mm Hg. Mammary glands are moderately engorged, the nipples are clean. Abdomen is soft, painless. The fundus is 3 fingers’ breadth below the navel. Moderate bloody lochia are present. What diagnosis can be made?
Explanation
The postpartum physiological changes are those expected changes that occur to the woman's body after childbirth, in the postpartum period. These changes mark the beginning of the return of pre-pregnancy physiology and of breastfeeding.
Involution, a part of postpartum physiology, is the term given to the process of reproductive organs returning to their prepregnant state. Immediately following the delivery, the uterus, and the placental site contracts rapidly to prevent further blood loss.
After birth, the fundus of the uterus contracts downward into the pelvis one centimeter each day. After two weeks the uterus will have contracted and returned into the pelvis. Hence, the 3 finger’s breadth below the navel on the 3rd day postpartum.
The lochia is the vaginal discharge that originates from the uterus, cervix, and vagina. The lochia is initially red and consists of blood and fragments of decidua, endometrial tissues, and mucus and lasts 1 to 4 days. The lochia then changes color to yellowish or pale brown, lasting 5 to 9 days, and is composed mainly of blood, mucus, and leukocytes. Finally, the lochia is white and contains mostly mucus, lasting up to 10 to 14 days.
The lactogenesis or milk secretion starts the third or fourth day postpartum making the mammary glands engorged.
Subinvolution of the uterus is seen after childbirth, when the uterus does not return to its normal size. But a fundus 3 finger’s breadth below the navel on the 3rd day postpartum clearly indicates a physiologic process taking place.
130. A 29-year-old unconscious patient has been delivered to a hospital. Objectively: skin and mucous membranes are pale, cyanotic, breath sounds are dramatically diminished on the right and cannot be auscultated in thelower parts, at the level of the 6 rib along the interior axillary line there is a wound hole with moderate bleeding and passage of air during inspiration. Radiography reveals a bullet in the pleural cavity. What is the medical tactics of choice?
Explanation
Many patients with penetrating thoracic injuries do not survive to the Emergency Department (ED), and those that do survive to the ED often require immediate interventions such as tube thoracostomy, intubation, and thoracotomy. Thus, the emergency clinician must be able to rapidly diagnose and treat injuries that are immediately life-threatening as in this case that presented with a Gunshot injury.
The above patient presents with a major trauma to the right side of the chest which is confirmed by a hemothorax and pneumothorax (Hemopneumothorax). Thoracotomy is a surgical procedure carried out inorder to have access to thoracic organs such as the lungs, heart or esophagus. This procedure is the first step in gaining access to the thoracic cavity and thus is indicated in cases of a lobectomy, major trauma of the chest, pneumonectomy. In the case of this patient, an urgent thoracotomy should be carried out in order to take out the bullet and prevent eventual collapse of the lungs.
Thoracentesis or Pleural puncture is a procedure in which a needle is inserted into the pleural space between the lungs and the chest wall. This procedure is done to remove excess fluid, known as a pleural effusion, from the pleural space to help you breathe easier. In this case, it’s not just fluid, there are blood clots. So, an incision (thoracotomy) should be made and arrest the bleeding, then drain. This patient needs this to be done as soon as possible, that’s why the best answer choice is the Emergency Thoracotomy.
It’s not enough to use hemostatic therapy, the clots must be removed and blood drained. Thoracoscopy is an imaging technique and the X-ray has given enough information at this point.
131. A patient had four generalized convulsive seizures within a day. Between the seizures the patient did not come to waking consciousness (was in a coma or stupor). Specify his state:
Explanation
Status epilepticus (SE) is a common, life-threatening neurologic disorder that is essentially an acute, prolonged epileptic crisis. Status epilepticus is defined as a continuous seizure lasting more than 30 min, or two or more seizures without full recovery of consciousness between any of them. Based on recent understanding of pathophysiology, it is now considered that any seizure that lasts more than 5 min probably needs to be treated as SE.
It can also be defined as a seizure that persists for a sufficient length of time or is repeated frequently enough that recovery between attacks does not occur. Therefore, the key phrase here is “recovery between attacks does not occur.” The question puts it this way - ‘between the seizures the patient did not come to waking consciousness.’
Prolonged Status epilepticus can lead to cardiac dysrhythmia, metabolic derangements, autonomic dysfunction, neurogenic pulmonary edema, hyperthermia, rhabdomyolysis, and pulmonary aspiration. Permanent neurologic damage can occur with prolonged SE. 132. A 12-year-old boy presents with nausea, frequent repeated vomiting that first occurred after eating canned vegetables. Objectively: the patient has dry mucous membranes, muscular hypotonia, anisocoria, mydriasis, dysphagia and dysarthria. What is the most likely diagnosis?
133. A full-term neonate weighing 4500 g was born asphyxiated with Apgar score of 4-6 points. During the delivery shoulder dystocia occurred. Neurologic assessment revealed non focal neurologic symptoms, total flaccid paresis of the upper extremities since the arm was atonic and pronated. Grasping, Babkin’s and Moro’s reflexes were absent. What segments of spinal cord had been affected?
134. A newborn (mother’s I pregnancy) weighing 3500 g has been found to have jaundice, lethargy, reduced reflexes. Objectively: second grade jaundice of skin with saffron tint, liver - +2 cm, spleen - +1 cm. Urine and feces are yellow. Blood count: Hb- 100 g/l, RBC-3, 2 · 1012/l, WBC- 18, 7 · 109/l, mother’s blood type - 0(I) Rh(+), baby’s blood type - A(II) Rh(-), bilirubin - 170 mmol/l, indirect fraction. ALT, AST rates are normal. What is the most likely disease in the child?
135. As a result of a road accident a 45-year-old male patient got multiple injuries, namely closed fractures of the right humerus and the left antebrachial bones with a displacement of bone fragments, a closed blunt abdominal injury. The patient was delivered to the emergency department 30 minutes after the injury. Objectively: the skin is pale. AP-90/20 mm Hg, there is pain and deformation at the fracture sites. Abdomen is tense, palpation causes severe pain, there is rebound tenderness (positive Blumberg’s sign). What is the treatment tactics of choice?
136. A 34-year-old male visited Tajikistan. After return, he complains of fever up to 40oC which occurs every second day and is accompanied by chills, sweating. Hepatosplenomegaly is present. Blood test results: RBC- 3 · 1012/l, Нb- 80 g/l, WBC- 4 ·109/l, eosinophils - 1%, stab neutrophils - 5%, segmented neutrophils - 60%, lymphocytes 24%, monocytes - 10%, ESR - 25 mm/h. What is the provisional diagnosis?
137. A 23-year-old male patient consulted a doctor about pain occurring in the lower third of the thigh with weight bearing activities and unloaded. The patient denies any injuries to the region. Objectively: the skin is of normal color, deep palpation reveals pastosity and tenderness, movements of the knee joint are limited. Radiograph of the distal femoral metaepiphyseal region shows a zone of degradation and spicules. In blood: immature cells are present, there are no signs of inflammation. What is the most likely diagnosis?
138. It is planned to organize a rural outpatient clinic. The patients will be able to visit the doctors of the following specialities:
Explanation
139. A 12-year-old girls has minor functional and morphological abnormalities: 1,0 D myopia, reduced body resistance. The patient has no history of chronic diseases. Over the last year, there were 4 cases of respiratory diseases. The girl belongs to the following health group:
140. 4 weeks after a myocardial infarction, a 56-year-old male patient developed acute heart pain, pronounced dyspnea. Objectively: the patient’s condition is extremely grave, there is marked cyanosis of face, swelling and throbbing of neck veins, peripheral pulse is absent, the carotid artery pulse is rhythmic, 130 bpm, AP- 60/20 mm Hg. Auscultation of heart reveals extremely muffled sounds, percussion reveals heart border extension in both directions. What is the optimal treatment tactis for this patient?
141. A puerperant is 32 years old, it’s her first childbirth, term precipitate labor, the III period is unremarkable, the uterus is contracted, tight. Examination of the birth canal revealed a rupture in the left posterior vaginal wall that was closed with catgut. Two hours later, the patient complained of a feeling of pressure on the anus, pain in the perineum, minor vaginal discharges, edema of the vulva. These clinical presentations are indicative most likely of:
142. .A hospital nutrition unit received a batch of beef. Sanitation physician examined the meat and revealed the presence of 5 bladder worms per 40 cm2 of meat. Give the hygienic assessment of meat:
143. A 47-year-old female patient complains of having pain on swallowing and difficult passing of solid food for two months. The patient has taken to the liquid and semi liquid food. During the last week the liquid food has barely passed through. General condition is satisfactory, the patient is undernourished, the appetite is preserved, there is a fear of eating. What is the provisional diagnosis?
144. A 31-year-old female patient complains of infertility, amenorrhea for 2 years after the artificial abortion that was complicated by endometritis. Objectively: examination of the external genitalia revals no pathology, there is female pattern of hair distribution. According to the functional tests, the patient has biphasic ovulatory cycle. What form of infertility is the case?
145. A 49-year-old male patient consulted a doctor about difficult swallowing, voice hoarseness, weight loss. These symptoms have been gradually progressing for the last 3 months. Objectively: the patient is exhausted, supraclavicular lymph nodes are enlarged. Esophagoscopy revealed no esophageal pathology. Which of the following studies is most appropriate in this case?
146. A 36-year-old male patient complains of having headache, obstructed nasal breathing, purulent nasal discharge for 2 weeks. A month before, he had his right maxillary premolar filled. Radiolography revealed an intense opacity of the right maxillary sinus. Diagnostic puncture revealed a large amount of thick malodorous crumbly pus. What is the most likely diagnosis?
147. A 5-year-old boy has a history of repeated pneumonia, frequent acute respiratory viral diseases. Objectively: exertional dyspnea, minor fatigabilty. There is a systolic murmur having its epicenter in the IV intercostal space on the left. Left relative dullness is found along the midclavicular line. According to the findings of instrumental methods of examination (electrocardiography, echocardiography), the patient has been diagnosed with ventricular septal defect, subcompensation stage. What is the main method of treatment?
148. A patient with autoimmune thyroiditis accompanied by multinodular goiter underwent the right lobe ectomy and subtotal resection of the left lobe. What drug should be administered to prevent postoperative hypothyroidism?
149. A 49-year-old female patient has type 1 diabetes of moderate severity. The disease is complicated by retinopathy and polyneuropathy. Besides that, repeated analyses of the daily urinary excretion of albumin revealed microalbuminuria (200-300 mg/day). Glomerular filtration rate is 105 ml/min. Blood pressure is within normal range. Normalization of the following indicator should be the first-priority task in the secondary prevention of diabetic nephropathy:
150. 10 days after birth, a newborn developed a sudden fever up to 38, 1oC. Objectively: the skin in the region of navel, abdomen and chest is erythematous; there are multiple pea-sized blisters with no infiltration at the base; single bright red moist erosions with epidermal fragments on the periphery. What is your provisional diagnosis?
Explanation
Epidemic pemphigus of newborn or Pemphigus Neonatorum is a disease of the newborn, in which vesicles or blebs, usually flat on the top, appear with or without fever, on a perfectly normal or reddened skin with pin-head size vesicle elevation, which rapidly develops into a large bleb. As the disease progresses, relapses may occur, yet the infant may recover promptly after a single outbreak of but few blebs. In some cases these blebs show a marked tendency to peripheral extension, which finally dry, leaving a thin brown crust. Staphylococcus aureus have been implicated as the causative agent.
The distinction between Pemphigus and syphilis in the newborn may be determined by the localization of the eruption. Syphilis will be localized to the palms of the hands and soles of the feet, as well as by the associating symptoms of syphilis.
Impetigo commonly presents with honey crusted vesicles and papules. Atopic dermatitis is an allergic reaction and patient most often have other allergic conditions or family history of asthma, allergic rhinitis, eczema etc.
151. An emergency physician arrived to provide medical care for a hangman taken out of the loop by his relatives. The doctor revealed no pulse in the carotid arteries, lack of consciousness, spontaneous breathing and corneal reflexes; cadaver spots on the back and posterior parts of extremities. A person can be declared dead if the following sign is present:
Explanation
Forensic pathologists are essentially required to estimate the time since death (TSD) to assist in death investigation. The early post-mortem phase is most frequently estimated using the classical triad of post-mortem changes – rigor mortis, algor mortis and livor mortis.
Algor Mortis: Humans are warm-blooded organisms, which means that we maintain a constant internal temperature, regardless of the outside environment. The brain is our thermostat and the circulatory system is the main heat dissipator. However, within seconds of death, the brain cells begin to die and the heart stops pumping blood. Without the brain and and the blood distributing heat, the corpse eventually starts to match the outside temperature.
Rigor mortis is the post-mortem stiffening of muscles, caused by the depletion of adenosine triphosphate (ATP) from the muscles.
Livor Mortis: This is the final stage of death. When the heart stops beating, the blood is now at the mercy of gravity. It tends to collect at certain parts of the body. Depending on the position of the body, these parts would vary. For instance, if the person was flat on their back when they died, the blood would collect in the parts that are touching the ground (just as in this patient - cadaver spots were on the back and posterior parts of the extremities). If the person was hanging, it would collect in their fingertips, toes, and earlobes. Lividity starts with the skin where the blood has settled developing a bright red color. After a few hours, the color changes from red to bluish-purple. The bluish coloring of the skin is called livor mortis or cadaver spots.
152. A 69-year-old male patient has been hospitalized with hypothermia. Objectively: the patient is pale, has shallow breathing. AP-100/60 mm Hg, Ps- 60/min. Palpation of the abdomen and chest reveals no pathological signs. The body temperature is of 34, 8oC. The patient’s breath smells of alcohol. Give treatment recommendations:
Explanation
Hypothermia is a severe condition in which the body temperature drops to an abnormally low level. It occurs when the body is unable to produce enough heat to counter the heat that it is losing. Under healthy conditions, the body maintains a relatively stable temperature of around 98.6˚F or 37˚C.
The following techniques can help treat hypothermia:
Passive external rewarming: This uses the individual’s heat-generating ability. It involves removing their cold, wet clothing, ideally replacing it with adequately insulated, dry clothing, and moving them to a warm environment.
Active external rewarming: This involves applying warming devices, such as hot-water bottles or warmed forced air, externally to truncal areas of the body. For example, the individual could hold a hot-water bottle under each arm.
Active core rewarming: This uses warmed, intravenous fluids to irrigate body cavities, including the thorax, peritoneum, stomach, and bladder. Other options include getting the individual to inhale warm, humidified air, or applying extracorporeal rewarming by using a heart-lung machine.
Do not give a person alcohol if they have signs of hypothermia, and avoid giving any drinks to an unconscious person.
Considering the critical condition of this patient, active core warming by using warmed intravenous fluids which gets into the system immediately and will bring the most desired result at the shortest time possible is by far the best treatment recommendation.
153. A 26-year-old male patient consulted a doctor abut sore throat, fever up to 38, 2oC. A week before, the patient had quinsy, didn’t follow medical recommendations. On examination, the patient had forced position of his head, trismus of chewing muscles. Left peritonsillar region is markedly hyperemic, swollen. What is the provisional diagnosis?
154. A 21-year-old female patient has been hospitalized on an emergency basis because of severe dyspnea, pain in the left side of chest. Body temperature is 38, 8oC. The condition developed three days ago. Respiratory rate is 42/min, auscultation reveals shallow breathing. There is percussive dullness on the right starting from the middle of the blade, breath sounds cannot be heard. The left border of heart is 3 cm displaced outwards. Embryocardia is present, HR is 110/min. The right hypochondrium is painful on palpation. What urgent therapeutic measures should be taken in this situation?
155. A 77-year-old male patient complains of inability to urinate, bursting pain above the pubis. The patient developed acute condition 12 hours before. Objectively: full urinary bladder is palpable above the pubis. Rectal prostate is enlarged, dense and elastic, well-defined, with no nodes. Interlobular sulcus is distinct. Ultrasonography results: prostate volume is 120 cm3, it projects into the bladder cavity, has homogeneous parenchyma. Prostate-specific antigen rate is of 5 ng/ml. What is the most likely disease that caused acute urinary retention?
156. At the first minute of life a full-term infant born with umbilical cord entangled around his neck has total cyanosis, apnea, HR- 80/min, hypotonia and areflexia. There are no signs of meconium aspiration. After the airway suctioning the newborn did not start breathing. What is the next action of the doctor?
157. Examination of an 11-year-old boy revealed frequent nosebleeds, fatigue when walking, underdevelopment of the lower half of the body, increased blood pressure in the upper extremities and decreased pressure in the lower ones, extension of the left heart border, blowing systolic murmur in the interscapular region. ECG shows the horizontal axis of heart. Radiography reveals left cardiomegaly, costal usuration. What is the most likely diagnosis?
158. During the preventive examination a 17-year-old young man reports no health problems. Objectively: the patient is undernourished, asthenic; blood pressure is 110/70 mm Hg, Ps- 80/min. Heart borders are within normal range. Auscultation reveals three apical heart sounds, murmurs are absent. ECG shows no pathological changes, PCG registers the S3 occurring 0,15 seconds after the S2. How can you interpret these changes?
159. After having the flu, a 39-year-old male patient with a history of Addison’s disease developed a condition manifested by weakness, depression, nausea, vomiting, diarrhea, hypoglycemia. AP- 75/50 mm Hg. Blood test results: low corticosterone and cortisol, 13-oxycorticosteroids, 17-oxycorticosteroids levels. What condition developed in the patient?
Explanation
An Addisonian crisis most often occurs in a patient with known adrenal insufficiency (this patient has a history of Addison’s disease), either primary or secondary. Primary adrenal insufficiency (Addison Disease) is characterized by low cortisol and high ACTH from the destruction of the adrenal glands. Chronic, stable primary adrenal insufficiency is called Addison's disease, which is a chronic condition controlled with long-term glucocorticoid therapy.
Addisonian crisis, also known as adrenal crisis or acute adrenal insufficiency is an endocrinologic emergency commonly seen in patients with known adrenal insufficiency. It is characterized as an acute change in physiologic status, quickly progression from nonspecific symptoms of fatigue, weakness, nausea, vomiting, abdominal pain, back pain, diarrhea, dizziness, hypotension, syncope, eventually to obtundation, metabolic encephalopathy, and shock.
Most cases are patients with known adrenal insufficiency who experience an acute stress event (patient had flu), who do not adjust their usual dose of glucocorticoid therapy and their body's cortisol stores are quickly depleted leading to an Addisonian crisis as these patients cannot produce their own cortisol. Roughly half of the patients have undiagnosed Addison's disease and present to the emergency room in acute crisis and shock after an acute stress event.
160. A female patient complains of being unable to get pregnant for 5 years. A complete clinical examination brought the following results: hormonal function is not impaired, urogenital infection hasn’t been found, on hysterosalpingography both tubes were filled with the contrast medium up to the isthmic segment, abdominal contrast was not visualized. The patient’s husband is healthy. What tactics will be most effective?
161. A 19-year-old primiparous woman with a body weight of 54,5 kg gave birth at 38 weeks gestation to a full-term live girl after a normal vaginal delivery. The girl’s weight was 2180,0 g, body length - 48 cm. It is known from history that the woman has been a smoker for 8 years, and kept smoking during pregnancy. Pregnancy was complicated by moderate vomiting of pregnancy from 9 to 12 weeks pregnant, edemata of pregnancy from 32 to 38 weeks. What is the most likely cause of low birth weight?
162. In a cold weather, the emergency room admitted a patient pulled out of the open water. There was no respiratory contact with the water. The patient is excited, pale, complains of pain, numbness of hands and feet, cold shiver. Respiratory rate is 22/min, AP- 120/90 mm Hg, Ps- 110/min, rectal temperature is 34, 5oC. What kind of warming is indicated for this patient?
Explanation
Hypothermia is a severe condition in which the body temperature drops to an abnormally low level. It occurs when the body is unable to produce enough heat to counter the heat that it is losing. Under healthy conditions, the body maintains a relatively stable temperature of around 98.6˚F or 37˚C.
The following techniques can help treat hypothermia:
Passive external rewarming: This uses the individual’s heat-generating ability. It involves removing their cold, wet clothing, ideally replacing it with adequately insulated, dry clothing, and moving them to a warm environment.
Active external rewarming: This involves applying warming devices, such as hot-water bottles or warmed forced air, externally to truncal areas of the body. For example, the individual could hold a hot-water bottle under each arm.
Active core rewarming: This uses warmed, intravenous fluids to irrigate body cavities, including the thorax, peritoneum, stomach, and bladder. Other options include getting the individual to inhale warm, humidified air, or applying extracorporeal rewarming by using a heart-lung machine.
Do not give a person alcohol if they have signs of hypothermia, and avoid giving any drinks to an unconscious person.
From the vitals given, this patient is fairly stable except for the tachycardia (110bpm) and low body temperature, therefore passive warming will suffice. The patient was pulled out of the open water in a cold weather so removing the wet clothing, and replacing it with adequately insulated, dry clothing, and moving them to a warm environment will keep the patient warm.
163. A week before, a 65-year-old male patient suffered an acute myocardial infarction. His general condition has deteriorated: he complains of dyspnea at rest, pronounced weakness. Objectively: edema of the lower extremities, ascites is present. Heart borders are extended, paradoxical pulse is 2 cm displaced from the apex beat to the left. What is the most likely diagnosis?
164. A 41-year-old patient consulted a dermatologist about discoloration, thickening, brittleness of toenails. These symptoms have been present for about five years. Objectively: nail plates in all toes are thickened, of dirty yellow color, lustreless, crumble over the edge. Microscopy of the nail plate material treated with alkali revealed mycelial filaments. Material inoculation onto Sabouraud medium resulted in growth of the Trichophyton rubrum colony. What is the most likely diagnosis?
Explanation
Dermatophyte infections, also known as tinea, are the most common fungal infections of the skin, hair, and nails.The term "Dermatophyte" refers to fungal species that infect keratinized tissue, and includes members of the Trichophyton, Microsporum, and Epidermophyton genera.
Trichophyton rubrum is a dermatophytic fungus. It colonizes the upper layers of dead skin, and is the most common cause of athlete's foot, fungal infection of nail, jock itch, and ringworm worldwide. T. rubrum colony shows Partial yellow-green fluorescence under wood-lamp.
T. rubrum is now the most common cause of invasive fungal nail disease (called onychomycosis or tinea unguium). Nail invasion by T. rubrum tends to be restricted to the underside of the nail plate and is characterized by the formation of white plaques on the lunula that can spread to the entire nail. The nail often thickens and becomes brittle, turns brown or black.
The question clearly states that inoculation onto Sabouraud medium resulted in growth of T. rubrum colony which makes Rubromycosis the correct answer and rules out Epidermophytosis and Psoriasis (patient must have psoriasis first before a diagnosis of Psoriasis of the nails can be made).
165. Examination of an electric welder with 15 years of service record revealed dry rales in the lower lung fields. Radiograph shows diffuse nodules sized 3-4 mm in the middle and lower lung fields. What disease can be suspected?
166. A 12-year-old boy periodically has short episodes (10-15 seconds) of a brief loss of awareness with a dazed look and eyes stare in an upright position, blank expression of face, absence of motions and subsequent amnesia. Specify the described state:
167. Evaluation results of sanitary and hygiene conditions in a 4-bed ward were as follows: ward area - 30 m2, height - 3,2 m, temperature- 20oC, humidity - 55%, air velocity - 0,1 m/s, window-to-floor area ratio - 1:5, daylight ratio- 0,6%, concentration of carbon dioxide in the air - 0,1%. Which of the given indicators does not meet hygienic requirements?
168. A 25-year-old patient works as a tractor driver. Four days ago, he got pain in the left axillary region, general weakness, fever up to 38oC. He hadn’t sought medical help until a painful solid lump appeared in this region. Objectively: in the left axilla there is a very painful cone-shaped mass sized 3x2,5 cm, with a destruction in the center of the pointed vertex. The surrounding skin is hyperemic, there are purulent discharges. What is the most likely diagnosis?
169. A 19-year-old male patient complains of intense pain in the left knee joint. Objectively: the left knee joint is enlarged, the overlying skin is hyperemic, the joint is painful on palpation. Blood test results: RBC- 3, 8·1012/l, Hb- 122 g/l, lymphocytes - 7, 4 · 109/l, platelets - 183 · 109/l. ESR- 10 mm/h. Duke bleeding time is 4 minutes, Lee-White clotting time - 24 minutes. A-PTT is 89 sec. Rheumatoid factor is negative. What is the most likely diagnosis?
170. A 29-year-old female patient complains of dyspnea and palpitations on exertion. According to her mother, as a child she had heart murmur, did not undergo any examinations. Objectively: the patient has pale skin, Ps- 94/min, rhythmic. AP- 120/60 mm Hg. In the II intercostal space on the left auscultation reveals a continuous rasping systolodiastolic murmur, diastolic shock above the pulmonary artery. Blood and urine are unremarkable. What is the most likely diagnosis?
171. A 6-year-old boy had had a quinsy. 9 days later, there appeared edemata of the face, extremities and trunk, general health condition deteriorated. Urine became turbid. Objectively: expressive edemata, ascites. AP-100/55 mm Hg, diuresis - 0,2 l of urine per day. Results of the biochemical blood analysis: total protein - 50 g/l, cholesterol - 11,28 mmol/l, urea - 7,15 mmol/l, creatinine - 0,08 mmol/l. Urinalysis results: leukocytes - 3-5 per HPF, red blood cells are absent. What is the provisional diagnosis?
172. A 13-year-old boy has had abdominal pain, bloating, nausea, liquid fatty gray stool with putrid smell for the last 3 years. Palpation reveals epigastric tenderness, as well as tenderness in the Desjardins’ pancreatic point, Chauffard’s triangle; there is positive Mayo Robson’s sign. Failure of exocrine pancreatic function has been suspected. What is the most informative method for evaluating the state of exocrine pancreatic function?
Explanation
Apart from the endocrine function of the pancreas ( production of hormones such as insulin, glucagon, somatostatin etc), the Pancreas also possess exocrine function ie, it produces enzymes that aid in in food digestion eg amylase for the digestion of carbohydrate, lipase for the breakdown of fats and trypsin and chymotrypsin for proteins, elastase. Notice that this patient has an issue with digestion revealed by the presence of bloating, liquid, gray and smelly stool.
Pancreatic fecal elastase-1 (FE-1) has become the first-line test of pancreatic function. FE-1 is well documented in quantitative studies to be stable during intestinal transit and studies demonstrate significant correlation between fecal elastase and levels of other pancreatic enzymes such as duodenal lipase, amylase, trypsin, and bicarbonate concentration. Fecal elastase is concentrated in human feces compared with pancreatic juice and is a simple, non-invasive and inexpensive test.
173. Explosion of a tank with benzene at a chemical plant has killed and wounded a large number of people. There are over 50 victims with burns, mechanical injuries and intoxication. Specify the main elements of medical care and evacuation of population in this situation:
Explanation
In this case, A Triage system is to be followed. Triage is a procedure followed in a medical emergency. It involves the sorting of and allocation of treatment to patients and especially battle and disaster victims according to a system of priorities designed to maximize the number of survivors
These individuals should be allocated into categories such as: Minor, Deceased, Immediate and delayed. Those in the immediate category require instant medical assistance. Lastly, all 50 victims should be evacuated from the site of explosion. 174. A 36-year-old injured has been taken to the emergency station with open tibial fractures. Examination reveals bleeding: pulsating blood spurts out of the wound. What medical manipulations are required at this stage of medical care?
175. The outpatient department of a city hospital works also as a 60-bed day hospital for somatic patients. The department operates in a single-shift mode. What specialist selects patients for admission to the day hospital?
176. A 67-year-old female patient with hypertensive crisis has asthma, cough with expectoration of frothy pink sputum, moist rales in the lungs. The patient stays in sitting position, respiratory rate is 40/min, AP-214/136 mm Hg, heart rate - 102/min. What is the most rational tactics of this patient management?
177. A 23-year-old primigravida at 39 weeks gestation has been admitted to the maternity ward with irregular contractions. The intensity of uterine contractions is not changing, the intervals between them stay long. Bimanual examination reveals that the cervix is centered, soft, up to 1,5 cm long. There is no cervical dilatation. What diagnosis should be made?
Explanation
The Preliminary stage of labor is characterized by:
The first stage of labor is considered to last from the onset of regular uterine contractions to full dilation of the cervix. The first stage is much longer than the second and third combined. The first stage of labor has been divided into three phases: a latent phase, an active phase, and a transition phase. During the latent phase there is more progress in effacement ( stretching and thinning) of the cervix and little increase in descent. During the active phase and the transition phase there is more rapid dilation of the cervix and increased rate of descent of the presenting part.
The second stage of labor lasts from the time the cervix is fully dilated to the birth of the fetus. The second stage takes an average of 20 minutes for a multiparous woman and 50 minutes for a nulliparous woman.
The third stage of labor lasts from the birth of the fetus until the placenta is delivered. The placenta normally separates with the third or fourth strong uterine contraction after the infant has been born.The duration of the third stage may be as short as 3 to 5 minutes, although up to 1 hour is considered within normal limits
The fourth stage of labor arbitrarily lasts approximately 2 hours after delivery of the placenta. It is the period of immediate recovery, when homeostasis is reestablished. It serves as an important period of observation for complications, such as abnormal bleeding.
Notice that this patient presents with irregular contraction and no cervical dilation.
178. A 49-year-old male patient complains of retrosternal pain, heartburn, weight loss of 8 kg over the last year, constipation, weakness. The patient has been a smoker for 20 years, and has a 10-year history of gastroesophageal reflux disease. The patient is asthenic, has dry skin. EGD revealed an ulcer in the lower third of the esophagus and esophageal stricture accompanied by edema, hyperemia and multiple erosions of the mucosa. What study is required for more accurate diagnosis?
179. A 63-year-old male patient with persistent atria fibrillation complains of moderate dyspnea. Objectively: peripheral edemata are absent, vesicular breathing is present, heart rate - 72/min, AP- 140/90 mm Hg. What combination of drugs will be most effective for the secondary prevention of heart failure?
180. A 57-year-old male patient had an attack of retrosternal pain that lasted more than 1,5 hours. Objectively: the patient is inert, adynamic, has pale skin, cold extremities, poor volume pulse, heart rate - 120/min, AP- 70/40 mm Hg. ECG shows ST elevation in II, III, aVF leads. What condition are these changes typical for?
181. During an exam, a 22-year-old female student fainted. She grew up in a family with many children, has a history of frequent acute respiratory infections. Objectively: the patient has pale skin and mucous membranes, splitend hair, brittle nails. Blood test results: RBC-2, 7 · 1012/l, Hb- 75 g/l, color index - 0,7, WBC-3, 2·109/l, platelets - 210·109/l, ESR- 30 mm/h. Blood serum iron is 6 mmol/l. What is the most likely diagnosis?
182. During the ultrasound study of carotid and vertebral arteries a 74-year-old patient developed a condition manifested by dizziness, weakness, nausea, transient loss of consciousness. Objectively: pale skin, AP-80/60 mm Hg, Ps- 96/min of poor volume. ECG shows sinus tachycardia, left ventricular hypertrophy. Focal neurological symptoms were not found. What is the provisional diagnosis
183. On the 10th day postpartum a puerperant woman complains of pain and heaviness in the left breast. Body temperature is 38, 8oC, Ps- 94 bpm. The left breast is edematic, the supero-external quadrant of skin is hyperemic. Fluctuation symptom is absent. The nipples discharge drops of milk when pressed. What is a doctor’s further tactics?
184. During the breast self-exam a 37-year-old female patient revealed a lump in the lower inner quadrant of her left breast. Palpation confirms presence of a mobile well-defined neoplasm up to 2 cm large. Peripheral lymph nodes are not changed. What is the way of further management?
185. An 8-year-old child was hospitalized for fever up to 39, 8oC, inertness, moderate headache, vomiting. Examination revealed meningeal symptoms. Lumbar puncture was performed. The obtained fluid had raised opening pressure, it was transparent, with the cell count of 450 cells per 1 mcL (mainly lymphocytes - 90%), glucose level of 2,6mmol/l. What causative agent might have caused the disease in the child?
186. A 25-year-old female has a self detected tumor in the upper outer quadrant of her right breast. On palpation there is a painless, firm, mobile lump up to 2 cm in diameter, peripheral lymph nodes are not changed. In the upper outer quadrant of the right breast ultrasound revealed a massive neoplasm with increased echogenicity sized 21x18 mm. What is the most likely diagnosis?
187. A 49-year-old female patient complains of itching, burning in the external genitals, frequent urination. The symptoms have been present for the last 7 months. The patient has irregular menstruation, once every 3-4 months. Over the last two years she has had hot flashes, sweating, sleep disturbance. Examination revealed no pathological changes of the internal reproductive organs. Complete blood count and urinalysis showed no pathological changes. Vaginal smear contained 20-25 leukocytes per HPF, mixed flora. What is the most likely diagnosis?
188. A 45-year-old male patient complains of acute pain in his right side irradiating to the right thigh and crotch. The patient claims also to have frequent urination with urine which resembles a meat slops. The patient has no previous history of this condition. There is costovertebral angle tenderness on the right (positive Pasternatsky’s symptom). What is the most likely diagnosis?
189. After a holiday in the Crimea, a 49-year-old male patient with a history of lung tuberculosis felt increased weakness, periodic dizziness, easing bowel movements with abdominal pain, the need for additional salting his meals. The patient has noted that his condition improves after some sweet tea and validol taken sublingually. Objectively: there is an intense darkening of skin, AP- 70/50 mm Hg, glycemia is 3,0 mmol/l. What is the possible cause of health deterioration:
Explanation
Note that Tuberculosis is the most common cause of Addisson’s disease ( primary adrenal insufficiency). Adrenal insufficiency is the decreased production of adrenocortical hormones (glucocorticoids, mineralocorticoids, and adrenal androgens) and can be primary, secondary, or tertiary. Primary adrenal insufficiency (Addison disease) is caused by a disorder of the adrenal glands. Patients with long-standing adrenal insufficiency can present with postural hypotension, nausea, vomiting, weight loss, anorexia, lethargy, depression, and/or chronic hyponatremia. Patients can also present with loss of libido as a result of hypoandrogenism. Patients with primary adrenal insufficiency also tend to develop hyperpigmentation of the skin, mild hyperkalemia, and metabolic acidosis. The glycemic level of 3.0 mmol/l rules out the option of diabetes mellitus.
190. A 42-year-old male patient has been delivered to a hospital in a grave condition with dyspnea, cough with expectoration of purulent sputum, fever up to 39, 5oC. The first symptoms appeared 3 weeks ago. Two weeks ago, a local therapist diagnosed him with acute right-sided pneumonia. Over the last 3 days, the patient’s condition deteriorated: there was a progress of dyspnea, weakness, lack of appetite. Chest radiography confirms a rounded shadow in the lower lobe of the right lung with a horizontal fluid level, the right sinus is not clearly visualized. What is the most likely diagnosis?
191. An 11-year-old boy complains of general weakness, fever up to 38, 2oC, pain and swelling of the knee joints, feeling of irregular heartbeat. 3 weeks ago, the child had quinsy. Knee joints are swollen, the overlying skin and skin of the knee region is reddened, local temperature is increased, movements are limited. Heart sounds are muffled, extrasystole is present, auscultation reveals apical systolicmL murmur that is not conducted to the left inguinal region. ESR is 38 mm/h. CRP is 2+, anti streptolysin O titre - 400. What is the most likely diagnosis?
192. A 28-year-old male patient complains of sour regurgitation, cough and heartburn that occurs every day after having meals, when bending forward or lying down. These problems have been observed for 4 years. Objective status and laboratory values are normal. FEGDS revealed endoesophagitis. What is the leading factor in the development of this disease?
193. On admission a 35-year-old female reports acute abdominal pain, fever up to 38, 8oC, mucopurulent discharges. The patient is nulliparous, has a history of 2 artificial abortions. The patient is unmarried, has sexual contacts. Gynecological examination reveals no uterus changes. Appendages are enlarged, vilaterally painful. There is profuse purulent vaginal discharge. What study is required to confirm the diagnosis?
194. A 20-year-old female consulted a gynecologist about not having menstrual period for 7 months. History abstracts: early childhood infections and frequent tonsillitis, menarche since 13 years, regular monthly menstrual cycle of 28 days, painless menstruation lasts 5-6 days. 7 months ago the patient had an emotional stress. Gynecological examination revealed no alterations in the uterus. What is the most likely diagnosis?
195. A 48-year-old female has been admitted to the gynecology department for pain in the lower right abdomen and low back pain, constipations. Bimanual examination findings: the uterus is immobile, the size of a 10-week pregnancy, has uneven surface. Aspirate from the uterine cavity contains atypical cells. What diagnosis can be made?
196. A 27-year-old male patient consulted a doctor about pain in the lower third of the thigh with weight bearing activities and unloaded. Two years ago, the patient underwent treatment in the casualty depatment for the open fracture of the lower third of femur. The fracture healed slowly, the healing process was accompanied by prulent inflammation. Objectively: edema of the lower third of the thigh, elevated local temperature. Radiograph shows signs of destruction and sequestration. What is the most likely diagnosis?
Explanation
From anamnesis, we observe that this patient had an open fracture (trauma) of the lower third of the femur 2 years ago. The healing process was slow and accompanied by purulent inflammation. Osteomyelitis is a serious bone inflammation that can result from a previous trauma, puncture wound, surgery, bone fracture, abscessed tooth, or infection of soft tissue, the ear or sinus. Chronic osteomyelitis usually occurs after an acute episode of osteomyelitis when the infection has not been totally cured. Purulent discharge, bone pain, redness, swelling and elevation of temperature in the affected area are key findings.
Hematogenous Osteomyelitis usually occurs in Children and takes place on the background of a spreading infection via the blood.
Multiple myeloma is a cancer of the plasma cells and is characterised by the presence of bence jones proteins.
197. A 30-year-old male patient had been admitted to the TB hospital because of the following changes detected by fluorography: an ill-defined shadow of low intensity up to 1 cm in diameter in the S1 of the right lung. CT scan showed a destruction area in the center of the shadow. Sputum analysis revealed MTB. The patient was diagnosed with focal tuberculosis. What phases of tuberculosis are the identified changes typical for?
198. A 43-year-old female complains of significant weakness, sore throat, occurrence of multiple unexplained bruises on her skin. These symptoms have been present for a week, the disease is associated with quinsy which she had some time before. Objectively: body temperature - 38, 9oC, respiratory rate -24/min, Ps- 110/min, AP- 100/65 mm Hg. The patient has pale skin, petechial rash on the extremities, enlarged lymph nodes. Blood test results: Hb- 80 g/l, RBC- 2, 2 · 1012/l; WBC-3, 5 · 109/l; blasts - 52%; eosinophils - 2%; stab neutrophils - 3%; segmented neutrophils 19%; lymphocytes - 13%; monocytes - 1%; platelets - 35 · 109/l. ESR - 47 mm/h. What test is required to specify the diagnosis?
199. A 47-year-old male patient complains of compressive chest pain that occurs both at rest and during light physical activity; irregular heartbeat. These problems arose 3 months ago. The patient’s brother died suddenly at the age of 30. Objectively: Ps- 84/min, arrhythmic, AP- 130/80 mm Hg. ECG confirms signs of left ventricular hypertrophy, abnormal Q-waves in V 4 − V 6 leads. EchoCG reveals that interventricular septum is 1,7 cm, left ventricular wall thickness is 1,2 cm. What is the most likely diagnosis?
200. Within the structure of the region’s population the share of persons aged 0 to 14 years is 25%, the share of persons aged 50 years and older is 30%. What concept most accurately describes this demographic situation?
