1. A 38-year-old man works within the range of ionizing radiation. At a routine medical examination he presents no problems. In blood: RBCs - 4, 5 · 1012/l, Hb- 80 g/l, WBCs - 2, 8 · 109/l, thrombocytes - 30 · 109/l. Decide if this person can work with sources of ionizing radiation:
2. A maternity patient breastfeeding for 1,5 weeks has attended a doctor. She considers the onset of her disease to be when proportional breast engorgement occurred. Mammary glands are painful. Body temperature is 36, 6oC. Expression of breast milk is hindered. The most likely diagnosis is:
3. A 12-year-old girl complains of general weakness, rise of body temperature up to 38, 2oC, pain and swelling of knee joints, feeling of cardiac rhythm disruption. The child had tonsillitis 3 weeks ago. The knee joints are swollen, local raise of temperature is observed, mobility is reduced. Heart sounds are weakened, extrasystole is present; at the cardiac apex systolic noise can be auscultated, which is not conducted to the left axillary region. ESR is 38 mm/h. CRP 2+. AntistreptolysinO titers are 400. The most likely disease is:
Explanation
Acute rheumatic fever typically occurs 2-3 weeks after Group A streptococcal pharyngitis. Diagnosis depends on a set of clinical signs that result from this infection ( Jones criteria)- these include chorea, carditis, subcutaneous nodules, erythema marginatum, and migratory polyarthritis. For biochemical analysis, certain key markers are used in diagnosis; these include C reactive protein ( an inflammatory marker), antistreptolysin O titer ( a marker that indicates a group A streptococcal infection ), ESR ( a marker from general blood analysis). Using these criterias, we can observe that this patient has arthritis, carditis and results from the biochemical analysis all appear positive for an acute rheumatic fever.
Reactive arthritis is also known as reiter’s syndrome and refers to the inflammation of joints as a result of a urogenital, intestinal or respiratory infection.
4. A 60-year-old man has a diet consisting of unvaried food staples: mostly cereals, potato, pasta; few vegetables and little fats (especially animal fats). During medical examination he complains of deterioration of his twilight vision. This condition can be caused by lack of:
5. A 45-year-old patient was hospitalised in surgical in-patient unit with intermuscular phlegmon of the right thigh on the 6th day from the onset of disease. Abscess formed under the fascia lata was diagnosed, lanced and widely drained, necrotic tissues were removed. Antibiotic therapy with cephalosporines and the III generation fluoroquinolones was prescribed, as well as immune corrective and detoxification infusion therapy (2,5 liters per day), diuresis stimulation, UV irradiation of blood and plasmapheresis. What is the main component of sepsis prevention?
6. An Rh-negative woman with 32-weeklong term of pregnancy has been examined. It was observed that Rh-antibodies titer had increased four times within the last 2 weeks and was 1:64. First two pregnancies ended in antenatal death of fetus caused by hemolytic disease. What tactics of pregnancy management should be chosen?
7. A 2-year-old child has been suffering since birth from recurring inflammatory diseases of lungs, purulent pansinusites, hearing deterioration, multiple cylindrical bronchiectases. Dextrocardia is observed. On biopsy ultrastructural change of ciliated epithelium. What is the basis of the given syndrome?
Explanation
This patient presents with Kartengener’s Syndrome. This is a rare, autosomal recessive genetic ciliary disorder comprising the triad of situs inversus, chronic sinusitis, and bronchiectasis. The basic problem lies in the defective movement of cilia, leading to recurrent chest infections, ear/nose/throat symptoms, and infertility.
If there are defects in the cilia lining the airways, the body is unable to expel foreign material and clear mucus. This can lead to pulmonary complications, including frequent infections of the lungs, ears, throat and sinuses.
Deficiency of surfactant is the primary cause of Respiratory distress syndrome which is usually seen in premature babies.
8. A newborn infant (the first labor, lasted for 26 hours) is 1-day-old, postmature; body weight is 3850 g; body length is 52 cm. Delivery was performed by applying obstetrical forceps in sincipital presentation, Apgar score is 1/3. The face is bluish-pale. The head is thrown back; severe birth trauma is present; the infant is excitable, shrill \"cerebral scream\" is present; the eyes are half-open; facial expression is attentive; hyperesthesia, hypersthenia and readiness for convulsions are present. Liquor has high content of erythrocytes, lymphocytic cytosis occurs. The most likely diagnosis is:
9. A 74-year-old patient visited a urologist with complaints of pain above the pubis and inability to urinate for 8 hours. At home he had taken antispasmodics and had a warm bath but no improvement occurred. Objectively: abdomen is soft and painful above the pubis; dullness of percussion sound is observed above the pubis. Murphy’s (Pasternatski’s) punch sign is negative on the both sides. What condition does the patient have?
10. A 37-year-old patient has been undergoing treatment of diskogenic lumbosacral radiculitis for a month. There is skin numbness observed at the lateral surface of the right lower extremity, Achilles jerk is absent. MRI of lumbar spine revealed intervertebral disk L5-S1 prolapse up to 8 mm. Choose the further tactics for patient treatment:
11. A 40-year-old patient complains of constant moderate pain in the lumbar spine and significantly reduced mobility. The patient has been suffering from this condition for the last 7 years since pain appeared first in the sacrum area. X-ray: ankylosis of sacroiliac articulation, significant narrowing of intervertebral joint fissures of lumbar vertebrae and calcification of spinal ligaments. What pathology is most likely to cause such X-ray image?
12. A 7-year-old child became ill again 2 weeks after he had tonsillitis. There are the following complaints: temperature rise up to 38oC, hemorrhagic rash on the extremities, enlargement of the ankle joints. Blood test: hemoglobin is 120 g/l, platelets are 170 · 109/l, ESR is 30 mm/h. Urine test: proteinuria up to 0,7 g/l, cylinders - 5-6 in the field of vision, erythrocytes - 8-10 in the field of vision. What mechanism of hemorrhagic syndrome is present in the given case?
13. A 48-year-old patient was delivered to a hospital in-patient unit with uterine bleeding that occurred after the 2-week-long delay of menstruation. Anamnesis states single birth. Examination of the uterine cervix with mirrors revealed no pathologies. On bimanual examination: uterus is of normal size, painless, mobile; uterine appendages have no changes. Discharge is bloody and copious. What primary hemostatic measure should be taken in the given case?
14. A 30-year-old woman complains of irregular copious painful menstruations, pain irradiates to the rectum. Anamnesis states 10- year-long infertility. On bimanual examination: uterus is of normal size; uterine appendages on the both sides are corded, with rectricted mobility, painful; there are dense nodular painful growths detected in the posterior fornix. A doctor suspects endometriosis. What method allows to verify this diagnosis?
15. A 14-year-old girl complains of tooth caries; the tooth should be filled. Anamnesis states that artificial mitral valve was installed 2 years ago due to mitral insifficiency. What antibacterial drug should be prescribed to prevent infective endocarditis?
ExplanationInfective endocarditis (IE) is an infectious inflammation of the endocardium that affects the heart valves. The condition is a result of bacteremia, which is most commonly caused by dental procedures, surgery, distant primary infections, and nonsterile injections. IE clinically presents with either an acute or subacute course. Clinical features include constitutional symptoms (fatigue, fever/chills, malaise) in combination with signs of pathological cardiac changes (e.g., new or changed heart murmur, heart failure signs) and possibly manifestations of subsequent damage to other organs (e.g., glomerulonephritis, septic embolic stroke). Diagnosis is made based on the Duke criteria, whose main features include positive blood cultures and evidence of endocardial involvement in echocardiography. To prevent Infective endocarditis, the patient should be given Amoxicillin PO one hour before the procedure.
16. A 30-year-old woman complains of infertility during her 10-year-long married life. Menstruations occur since she was 14 and are irregular, with delays up to a month and longer. Body mass is excessive. Hirsutism is observed. On bimanual examination: uterine body is decreased in size; ovaries are increased in size, dense, painless, and mobile. The most likely diagnosis is:
17. A 22-year-old woman on a reduced diet, vegetarian, attended a hospital with complaints of distorted smell and taste perception and lesions in the angles of her mouth. Objectively: sclera is distinctly blue. Diagnosis: irondeficiency anemia. What clinical syndrome is expressed primarily?
18. A 15-year-old patient complains of excessive body weight, headache, irritability, rapid fatigability. Significant increase of body weight occurred at the age of 14. Objectively: weight is 90 kg; height is 160 sm, proportional body built. Fatty tissue is distributed evenly. There are thin pink striae (stretch marks) on the thighs, abdomen and mammary glands. BP - 145/90 mm Hg. Provisional diagnosis is:
19. A 6-year-old girl attended a general practitioner with her mother. The child complains of burning pain and itching in her external genitalia. The girl was taking antibiotics the day before due to her suffering from acute bronchitis. On examination: external genitalia are swollen, hyperemic, there is white deposit accumulated in the folds. The most likely diagnosis is:
20. A 44-year-old man complains of dyspnea with sensation of lack of air on inhale, palpitations occurring during slight physical exertion, and shin edemas that appear in evening and resolve in morning. His condition has been lasting for 5 months already, deterioration is gradual. What method of instrumental diagnostics allows to verify decrease of systolic function in this patient?
21. When playing in a kindergarten a 3- year-old child sudenly developed dyspnea, paroxysmal compulsive dry cough. The face is cyanotic, the eyes are tearful. Vomiting occurred several times. Breathing is weakened over the whole right side of the chest. The provisional diagnosis is:
22. A patient with otopyosis is in sharply deteriorating condition: he developed headache, vomiting, febrile temperature, general hyperesthesia. Meningeal symptoms and stagnant optic disks are observed. There is no focal symptoms. Liquor is turbid, blood pressure is high, albuminocytological dissociation occurs with neutrophils. What disease can be suspected?
23. A 25-year-old patient is not married and has sexual relations with several partners. During the last 3 months he noticed small amount of mucoserous secretions produced from urethra. Subjectively: periodical itching or burning pain in urethra. Two months ago pain in knee join developed. Possibility of trauma or exposure to cold is denied by the patient. During the last week eye discomfort is noted - lacrimation and itching. What provisional diagnosis can be suggested?
24. A 19-year-old patient complains of severe pain in axillary crease. Condition onset was a week ago after her swimming in cold river and epilation. The next day painful \"boil\"appeared that was becoming larger every day and became a plum-sized tumor. Upon examination nodular conical growths joined together are detected, the skin covering them is bluishred in colour. Some nodules have fistulous openings producing thick purulent mass. Body temperature is 38, 5Oc, general malaise. The most likely diagnosis is:
25. A patient complains of weight gain, chill, edemas, xeroderma, somnolence, difficulties with focusing. Objectively: height is 165 cm; weight is 90 kg; body proportions are of female type, t o- 35, 8oC, heart rate - 58/min, BP - 105/60 mm Hg. Heart sounds are weakened, bradycardia is observed. Other internal organs have no changes. Thyroid gland cannot be palpated. Milk secretion from mammary glands is observed. Hormone investigation revealed increased levels of thyroid-stimulating hormone (TSH) and prolactin, and decreased level of thyroxine (T4). Which one is the cause for obesity?
Explanation
Hypothyroidism is an endocrine disorder in which the thyroid gland does not produce enough thyroid hormones. It is classified under congenital and acquired. The acquired form is further divided into Primary, secondary and tertiary forms.
Primary Hypothyroidism: Occurs due to thyroid gland disturbances. This can be as a result of environmental factors, autoimmune causes e.g. Hashimoto, radiation etc. Characterised by low levels of T3 triiodothyronine and T4 thyroxine.
Secondary hypothyroidism: occur due to pituitary gland disorders. In this form, thyroid stimulating hormone (TSH) is low.
Tertiary Hypothyroidism: Occurs due to hypothalamic related disorders. Characterised by a low level of thyroid releasing hormone.
Symptoms include intolerance to cold, hair loss, fatigue, brittle nails, weight gain, bradycardia etc. sometimes referred to as Myxedema.
The secretion of T3 and T4 by the thyroid is controlled by an endocrine feedback system involving the pituitary gland and the hypothalamus (structures in the brain). Lowered levels of these thyroid hormones result in increased levels of pituitary and hypothalamic hormones ( TSH, TRH, Prolactin)
26. A 54-year-old patient complains of weakness, jaundice, itching skin. Disease onset was 1,5 months ago: fever up to 39oC appeared at first, with progressive jaundice developed 2 weeks later. On hospitalisation jaundice was severely progressed. Liver cannot be palpated. Gallbladder is enlarged and painless. Blood bilirubin is 190 micromole/l (accounting for direct bilirubin). Stool is acholic. What is the most likely jaundice genesis in this patient?
27. A 22-year-old patient complains of 8-months-long delay of menstruation. Anamnesis: menarche since the age of 12,5. Since the age of 18 menstruations are irregular. No pregnancies. Mammary glands have normal development; when the nipples are pressed, milk drops are discharged. On gynecological examination: moderate uterus hypoplasia. On hormonal examination: prolactin level exceeds the norm two times. On computed tomogram of the sellar region: a space-occupying lesion 4 mm in diameter is detected. The most likely diagnosis is:
28. A 2-year-old child in a satisfactory condition periodically presents with moderate proteinuria, microhematuria. US results: the left kidney is undetectable, the right one is enlarged, there are signs of double pyelocaliceal system. What investigation is required to specify the diagnosis?
29. For the last 3 years a 12-year-old boy has been suffering from stomachache, abdominal distension, nausea, periodical liquid fatty stool, grey in color, with rotten smell. On palpation: pain in the epigastrium, Desjardins’ pancreatic point and Chauffard’s triangle; positive MayoRobson’s sign. Insufficiency of pancreas exocrine function is suspected. What method is the most informative for pancreas exocrine function assessment?
30. A 34-year-old patient was delivered to a first-aid center with open fracture of the lower leg bones. Upon examination bleeding is stated: blood flows in pulsating bursts. What actions should be taken at this stage of medical aid?
31. A 26-year-old patient with affective bipolar disorder has developed a condition manifested by mood improvement, behavioural and sexual hyperactivity, verbosity, active body language, reduced need for sleep. Which of the following drugs are most effective in this case?
Explanation
Neuroleptics, also known as antipsychotic medications, are used to treat and manage symptoms of many psychiatric disorders. They fall into two classes: first-generation or "typical" antipsychotics and second-generation or "atypical" antipsychotics." They are Dopamine D2 receptor antagonists. Antipsychotics are drugs that have a specific sedative effect, and which improve the attitude and calm the behavior of psychotic patients.
Typical antipsychotics: Haloperidol, Chlorpromazine
Atypical antipsychotics: Risperidone, Clozapine, Aripiprazole
This patient is currently having a manic episode and it's best to use a Neuroleptic (antipsychotic) with sedative effect to calm the patient down.
A manic episode requires 3 or more of the following:
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Decreased need for sleep
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Distractibility
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Impulsivity/Indiscretion: seeks pleasure without regard to consequences including sexual pleasure
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Talkativeness or pressured speech
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Grandiosity: inflated self esteem
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Flight of ideas: racing thoughts
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Increased goal oriented activity/psychomotor agitation
Antidepressants are used for Major Depressive Disorders; Tranquilizers are used for General Anxiety Disorder or Panic attacks. Mood stabilizers like Lithium, Valproic acid, Lamotrigine, Carbamazepine are commonly used in Bipolar disorders. Nootropics are used to enhance mental function not mania.
32. An emergency doctor has diagnosed a 32- year-old woman with generalized convulsive status epilepticus. The deterioration in the patient’s condition is caused by a sudden gap in the epilepsy treatment. Specify the doctor’s further tactics:
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.
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. 33. A 19-year-old patient complains of dyspnea during physical exertion. He often has bronchitis and pneumonia. Cardiac murmur has been observed since his childhood. On auscultation: there is splitting of II heart sound over pulmonary arteria, systolic murmur in the third intercostal space near the left sternum margin. ECG test shows right bundle-branch block. What is the provisional diagnosis?
34. A 30-year-old patient was in a car accident. He is unconscious, pale, has thready pulse. In the middle third of the right thigh there is an extensive laceration with ongoing profuse external arterial bleeding. What urgent actions must be taken to save the life of the patient?
35. A 75-year-old male patient complains of slight pain in the right iliac region. The abdominal pain arose 6 days ago and was accompanied by nausea. Surgical examination revealed moist tongue, heart rate - 76 bpm. BP - 130/80 mm Hg. Abdomen is soft, slightly painful in the right iliac region on deep palpation, the symptoms of the peritoneum irritation are doubtful. In blood: RBCs - 4, 0 · 1012/l, Hb135 g/l, WBCs - 9, 5 · 109/l, stab neutrophiles - 5%, segmentonuclear - 52%, lymphocytes - 38%, monocytes - 5%, ESR - 20 mm/h. Specify the doctor’s further tactics:
36. On the 10th day postpartum a puerperant woman complains of pain and heaviness in the left mammary gland. Body temperature is 38, 8oC, Ps- 94 bpm. The left mammary gland 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?
37. 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 2,6 mmol/l. What causative agent might have caused the disease in the child?
38. A 25-year-old patient during selfexamination detected a tumor in the upper external quadrant of the right mammary gland. On palpation: painless, dense, mobile growth 2 cm in diameter is detected in the mammary gland; no changes in the peripheral lymph nodes are observed. On mammary glands US: in the upper external quadrant of the right mammary gland there is a space-occupying lesion of increased echogenicity 21х18 mm in size. The most likely diagnosis is:
39. A 20-year-old woman complains of feeling of air shortage, lingering dull pain in the heart area, irritability. Objectively: general condition is satisfactory, heart rate lability, BP is 130/60 mm Hg. ECG reveals disruption of repolarization proceses. The patient is diagnosed with somatoform autonomic dysfunction of cardial type. Specify the conditions of the patient treatment:
40. A 70-year-old patient consulted a doctor about arrhythmic cardiac activity, dyspnea. Objectively: BP - 150/90 mm Hg, extrasystole arrhythmia (10-12 beats per minute), left ventricular systolic dysfunction (ejection fraction at the rate of 42%). Which of antiarrhythmic drugs should be administered as initial therapy in this case?
41. 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\\\"in color. 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?
42. A 45-year-old patient (14-year-long work record as a house painter) upon the contact with synthetic paint develops skin reddening, edema, severe itching and oozing lesions on her face. Symptoms disappear after the contact with this chemical substance stops but even the smell of paint alone is enough to make them reappear each time. Each recurrence is characterised by increased severity of symptoms. What provisional diagnosis can be made?
43. In cold season a patient was delivered to a hospital. He was rescued from drowning in a body of water. There was no contact of his airways with water. The patient is anxious, pale, complains of pain and numbness of limbs, has cold shivering. Breathing rate is 22/min, BP is 120/90 mm Hg, heart rate is 110/min, rectal temperature is 34, 5oC. What kind of warming should be prescribed to the 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.
44. Survey radiograph of a 52-year-old worker of an agglomeration plant (28 years of experience, the concentration of metal dust is 22-37 mg/m3) shows mildly pronounced interstitial fibrosis with diffused contrast well-defined small nodular shadows. The patient has no complaints. Pulmonary function is not compromised. What is the provisional diagnosis?
45. 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?
46. A 60-year-old patient complains of nearly permanent sensation of heaviness and fullness in the epigastrium, that increases after eating, foul-smelling eructation, occasional vomiting with food consumed 1-2 days ago, weight loss. 12 years ago he was first found to have an ulcer of pyloric channel. The patient has taken ranitidine for periodic hunger pain. The patient’s condition has been deteriorating over the last 3 months. Objectively: splashing sound in the epigastrium is present. What kind of complication is it?
Explanation
Recall that the complications of ulcers include Bleeding (hemorrhage), penetration, perforation, outlet obstruction (stenosis) and malignization.
Hemorrhage: Hemorrhage is the most common complication of peptic ulcer disease. Symptoms include hematemesis (vomiting of fresh blood or \"coffee ground\" material); passage of bloody or black tarry stools (hematochezia and melena, respectively); and weakness, orthostasis, syncope, thirst, and sweating caused by blood loss.
Penetration: A peptic ulcer may penetrate the wall of the stomach or duodenum and enter the adjacent confined space (lesser sac) or organ (eg, pancreas, liver). Pain may be intense, persistent, referred to sites other than the abdomen (usually the back when caused by penetration of a posterior duodenal ulcer into the pancreas), and modified by body position.
perforation: perforation usually presents as an acute abdomen. Ulcers that perforate the peritoneal cavity are usually located in the anterior wall of the duodenum or, less commonly, in the stomach. The patient experiences sudden, intense, steady epigastric pain that spreads rapidly throughout the abdomen, often becoming prominent in the right lower quadrant and at times referred to one or both shoulders.
Gastric outlet obstruction/ Stenosis: This may be caused by scarring, spasm, or inflammation associated with an ulcer. Symptoms include recurrent large volume vomiting, foul smell and often consist of food eaten days ago. Persistent bloating or fullness after eating and loss of appetite also suggest gastric outlet obstruction. Prolonged vomiting may cause weight loss, dehydration, and alkalosis.
Malignization/ Stomach cancer: H. pylori is associated with intestinal-type adenocarcinoma of the gastric body and antrum but not cancer of the gastric cardia. Gastric lymphomas and mucosa-associated lymphoid tissue (MALT) lymphomas have also been linked to this infection.
47. A 5-year-old child has body temperature risen up to febrile numbers, suffers from inertness, weakness. Examination revealed hemorrhage on the skin of limbs and torso. Enlargement of cervical and axillary lymph nodes can be detected. The liver is 4 cm below the costal arch; the spleen is 6 cm below the costal arch. Blood test: erythrocytes - 2, 3 · 1012/l, Hb- 60 g/l, platelets - 40 · 109/l, leukocytes - 32, 8 · 109/l, eosinophiles - 1%, band neutrophiles - 1%, segmented neutrophiles - 12%, lymphocytes - 46%, monocytes - 1%, blasts - 40%, Duke’s bleeding time test result is 9 min. What examination is necessary to make the diagnosis?
48. A child from primipregnancy was born in a term labor and has body weight of 4000 g and body length of 57 cm. When born, he was nonresponsive to examination. Diagniosis is diffuse. Heart rate is 80/min. What resuscitation measures should be prescribed?
49. A 20-year-old patient was delivered to a surgical unit complaining of an incised wound on his right forearm that has been bleeding for 1,5 days. Suffers from general weakness, vertigo, cold sweat, opplotentes. Skin and visible mucous membranes are pale. Heart rate is 110/min, BP is 100/70 mm Hg. Blood test: Hb is 100 g/l, erythrocytes 2, 5 · 1012/l. What is the cause for the paient’s general condition?
50. A 20-year-old parturient woman has the I labor stage. The pregnancy is full-term. Labors occur every 3 minutes and last for 55 seconds. Fetus presentation is polar, the head is pressed to the small pelvis entrance. Heart rate of the fetus is 150/min, distinct and rhythmic. Vagina examination: uterus cervix is smoothed out; mouth of the womb is 2 cm open; fetal bladder is intact; the head is presented over the I plane of small pelvis; moderate mucous-bloody discharge is observed. What phase of the I labor stage is it?
51. A 23-year-old woman after stress has developed thirst, polydipsia, polyuria, weight loss, increasing fatigue. Later she developed nausea and somnolence, lost consciousness and was hospitalised. Glycemia is 27 mmol/l, acetone in urine is sharply positive. Treatment for ketoacidotic coma was initiated. When would it be advisable to start preventive treatment of hypoglycemia by introduction of 5% glucose solution?
52. A 53-year-old woman complains of weight loss up to 10 kg within the last 2 years, liquid foul-smelling stool two times a day that poorly washes off the toilet, periodic bouts of nausea, girdle pain in the upper abdomen. Objectively: pain in Gubergrits zone (on the right from navel) and Mayo-Robson’s point. Biochemical blood analysis: glucose - 3,2 mmol/l, bilirubin - 16,5 micromole/l, crude protein - 56,4 g/l. Urine diastase - 426 g/h/l. D-xylose test (oral administration of 25 g of d-xylose) after 5 hours reveals 3 g of xylose in urine. The most likely diagnosis is:
53. A 23-year-old patient after intake of brake fluid has developed anuria that has been lasting for 5 days already. Creatinine level increased up to 0,769 mmol/l. What treatment tactics should be chosen in the given case?
54. A 15-year-old teenager has undergone medical examination in military recruitment center. The following was revealed: interval systolic murmur at the cardiac apex, accent of the II heart sound over the pulmonary artery, tachycardia. What additional examination method will be the most informative for determining diagnosis?
55. A 64-year-old patient has been hospitalised with complaints of progressive jaundice that developed over 3 weeks ago without pain syndrome, general weakness, loss of appetite. Objectively: temperature is 36, 8oC, heart rate is 78/min, abdomen is soft and painless, peritoneum irritation symptoms are not detected, palpation reveals sharply enlarged tense gallbladder. What disease can be characterised with these symptoms?
56. During a surgical operation necessitated by the patient’s suffering from autoimmune thyroiditis with concomitant multinodular goiter the right lobe was removed and subtotal resection of the left lobe was performed. What should be prescribed to the patient for postoperative hypothyroidism prevention
57. A 54-year-old patient has been suffering from diabetes mellitus for 5 years, with diet being his only treatment. Within the last half a year he lost 7 kg of body weight, complains of thirst, vertigo when raising from bed, decrease of erectile function, frequent stool, especially at night. Objectively: malnutrition, dry skin. BP in lying position is 160/90 mm Hg; BP in standing position is 170/85 mm Hg. No edemas. Fasting plasma glucose level is 12 mmol/l. Glycated hemoglobin accounts for 11%. Albumin excreted with urine is 20 mg per day. The most likely diagnosis is:
58. A young woman suffering from seborrhea oleosa has numerous light-brown and white spots on the skin of her torso and shoulders. The spots have clear margins, branny desquamation, no itching. What provisional diagnosis can be made?
59. 10 days after birth an infant developed a sudden fever up to 38, 1oC. Objectively: the skin 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?
60. In a traffic accident two persons died. An appointed forensic medical expert was called on duty to another accident location; therefore, according to the crininal law in force in Ukraine, an investigator called in the following specialist for examination of the location and bodies:
61. A 35-year-old female patient has gained 20 kg weight within a year with the normal diet. She complains of chill, sleepiness, dyspnea. The patient’s mother and sister are corpulent. Objectively: height - 160 cm, weight - 92 kg, BMI - 35,9. Obesity is uniform, there are no striae. The face is amimic. The skin is dry. The tongue is thickened. Heart sounds are muffled. Heart rate - 56/min, BP - 140/100 mm Hg. The patient has constipations, amenorrhea for 5 months. TSH - 28 mkME/l (normal rate - 0,32- 5). Craniogram shows no pathology. What is the etiology of obesity?
Explanation
Your thyroid produces thyroid hormone, which controls many activities in your body, including how fast you burn calories and how fast your heart beats. Diseases of the thyroid cause it to make either too much or too little of the hormone. Depending on how much or how little hormone your thyroid makes, you may often feel restless or tired, or you may lose or gain weight. Women are more likely than men to have thyroid diseases, especially right after pregnancy and after menopause.
Hypothyroidism is when your thyroid does not make enough thyroid hormones. It is also called underactive thyroid. This slows down many of your body's functions, like your metabolism. Signs and symptoms include the following: Feeling cold when other people do not; Constipation; weight gain, even though you are not eating more food; Feeling sad or depressed; Feeling very tired; Pale, dry skin; Dry, thinning hair; Slow heart rate (bradycardia); puffy face; hoarse voice; abnormal menstrual bleeding etc.
Note that the craniogram shows no pathology so we can rule out Hypothalamic-pituitary. Hypo-ovarian can present with amenorrhea, vaginal dryness, monophasic cycles etc but not with bradycardia or weight gain. Absence of abdominal striaes or skin hyperpigmentation and sometimes diabetes - rules out the option of cushing’s disease (hypercorticoidism).
The increased TSH levels seen in this patient implies an activation of the feedback mechanism signalling the body to produce more thyroid hormones; T3 and T4.
62. A 45-year-old patient has been suffering from essential hypertension for 10 years. After hot bath he suddenly developed sharp headache and recurrent vomiting. Objectively: pronounced meningeal symptoms; BP is 180/110 mm Hg. He was hospitalised in a neurology unit. What additional tests should be primarily prescribed?
63. A 77-years-old patient complains of inability to urinate and bursting pain above his pubis. Acute onset of his condition occurred 12 hours ago. Objectively: overfilled urinary bladder can be palpated above the pubis. On rectal examination: prostate is enlarged, denseelastic, with clear margins and no nodules. Interlobar sulcus is pronounced. US examination: prostate volume is 120 cm3, it protrudes into urinary bladder cavity, parenchyma is homogeneous. Prostate specific antigen is 5 ng/ml. What disease is the most likely to cause acute urinary retention?
64. A patient with uterine fibromyoma sized up to 8-9 weeks of pregnancy consulted a gynaecologist about acute pain in the lower abdomen. Examination revealed pronounced positive symptoms of peritoneal irritation, high leukocytosis. Vaginal examination revealed that the uterus was enlarged up to 9 weeks of pregnancy due to the fibromatous nodes, one of which was mobile and extremely painful. Appendages were not palpable. Discharges were mucous, coming in moderate amounts. What is the treatment tactics?
Explanation
From the vaginal examination, we observe the presence of a very large fibroid mass that causes the enlargement of the uterus and is responsible for the severe pain the woman is experiencing and the mucous discharge. Coupled with the positive symptom of peritoneal irritation, this patient is in need of an urgent surgical procedure.
Uterine fibroids are noncancerous growths that grow in the wall of the uterus. When fibroids cause heavy bleeding or painful symptoms, and other treatments are ineffective, a doctor may recommend surgery. People with asymptomatic fibroids do not require surgery or other treatments. However, other people experience severe abdominal pain, pressure, bloating, pain during sex, frequent urination, and heavy or painful periods. These individuals may require surgery.
Myomectomy is a surgical procedure that removes fibroids. Depending on the location of these growths, a surgeon may also have to remove other tissue in the process. The traditional technique is quite invasive as it uses a relatively large cut (Laparotomy). This incision may go from the bellybutton to the bikini line or run horizontally along the bikini line. Some surgeons also perform laparoscopic surgeries, which use smaller incisions but require more skill. However, in this case, a fibroid as big as 9 weeks gestation will require a big incision and laparoscopic surgery will not be able to get the fibroid out.
65. A 4-month-old child was admitted to a surgical department 8 hours after the first attack of anxiety. The attacks happen every 10 minutes and last for 2-3 minutes, vomiting occurred once. Objectively: the child’s condition is grave. Abdomen is soft, palpation reveals a tumour-like formation in the right iliac area. After rectal examination the doctor’s finger was stained with blood. What is the most probable diagnosis?
66. A 68-year-old patient complains of pain, slight swelling and creaking in the distal joints of her fingers and knee joints. She has been suffering from this condition for 4 years. Objectively: thickening of knee and interphalangeal joints, restricted mobility of these joints. Blood test: leukocytes - 5, 4 · 109/l, ESR - 12 mm/h, fibrinogen - 3,5 g/l; Rheumatoid factor - 1:32; anti-streptolysin O - 160 units; seromucoid - 0,20 units.; CRP+. What mechanism of development is likely for this condition?
67. A 30-year-old male patient consulted a family doctor 2 months after he had been operated for an open fracture of brachial bone. Objectively: the patient’s condition is satisfactory; in the area of the operative wound there is a fistula with some purulent discharge, redness, fluctuation. X-ray image shows brachial bone destruction with sequestra. What complication arose in the postoperative period?
68. A 40-year-old female patient complains of having a bulge on the anterior surface of neck for 5 years. Objectively: Heart rate - 72 bpm, arterial pressure - 110/70 mm Hg, in the right lobe of thyroid gland palpation reveals a mobile 4x2 cm node, the left lobe is not palpable, the basal metabolic rate is 6%. What is the most likely diagnosis?
69. Estimation of community health level involved analysis of a report on diseases registered among the population of catchment area (reporting form 12). What index is calculated basing on this report?
70. A tractor driver with the record of service of 24 years has undergone palestesiometry test (Vibration Sensitivity Measurement). Test revealed increased vibration sensitivity threshold at the frequencies of 63-125-259 Hz to 25 dB. Dynamometry is 20 kg on the right and 16 kg on the left. Cold stimulus test is positive, time of hand temeperature restoration is 52 minutes. Blanching at pressure symptom is positive and equals 21. Hypesthesia of upper and lower limbs is observed and can be classified as \\\"gloves\\\"and \\\"socks\\\"polyneuritic pattern. Make the provisional diagnosis.
Explanation
According to the character of influence to the organism there is local, general and combined vibration. During the local vibration the transmission of mechanical oscillations to the body is realized through the arms. Most often this etiologic factor we can see among the face-workers, chasers, drillers. The sources of the general vibration are the vibro platform, the table vibrator, the forming and concrete-laying machines. The combined vibration is a combination of local and general.
According to the intensity’s degree of pathologic process symbolically mark out 4 stages of disease:
I – initial;
II – moderately expressed (dystrophic disorders);
III – expressed (irreversible organic changes);
IV – generalized
71. A patient’s X-ray image (anteroposterior projection) shows deformation of lung pattern, pneumofibrosis, reticular (honeycomb) lung pattern of lower pulmonary segments, cylindric and fusiform lumps. The most likely diagnosis is:
72. A 41-year-old patient with Addison’s disease had influenza. After that he developed adynamia, depression, nausea, vomiting, diarrhea and hypoglycemia. BP is 75/50 mm Hg. Blood test: decreased content of corticosterone, hydrocortisone, 13-oxycorticosteroids, 17-oxycorticosteroids. What condition has 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.
73. After a contact with chemicals a plant worker has suddenly developed stridor, voice hoarseness, barking cough, progressing dyspnea. Objective examination reveals acrocyanosis. What is your provisional diagnosis?
74. A 58-year-old patient complains of general weakness, weight loss up to 10 kg within the last 1,5 months, progressive pain in the small of the back, raise of blood pressure to 220/160 mm Hg, subfebrile body temperature. Objectively: tuberous slightly movable lump can be palpated in the right subcostal area; veins of spermatic cord and scrotum are dilated. Blood test: Hb - 86 g/l, ESR - 44 mm/h. Urine test: specific gravity - 1020, proteine - 0,99 g/l, erythrocytes - all field of vision, leukocytes - 4-6 in the field of vision. The provisional diagnosis is:
75. A 58-year-old patient complains of headache in the occipital region, nausea, choking, opplotentes. The presentations appeared after a physical exertion. Objectively: the patient is excited. Face is hyperemic. Skin is pale. Heart sounds are regular, the 2nd aortic sound is accentuated. BP - 240/120 mm Hg, heart rate - 92/min. Auscultation reveals some fine moist rales (crackles) in the lower parts of the lungs. Liver is not enlarged. ECG shows signs of hypertrophy and left ventricular overload. What is the most likely diagnosis?
76. A 37-year-old patient complains of pain in the lumbar spine, which increases during walking, limited mobility, edema of the right side of abdomen. Focal tuberculosis is recorded in the anamnesis. X-ray shows destruction of adjacent surfaces of the bodies of the 1- 2 lumbar vertebrae, vertebral bodies height is decreased, intervertebral fissure cannot be detected. Abdominal US reveals a growth 15x20 cm in size in the retroperitoneal space and echo signs of liquid. What diagnosis can be suspected?
77. A 26-year-old woman has attended maternity center complaining of her inability to become pregnant despite 3 years of regular sex life. Examination revealed the following: increased body weight; male-type pubic hair; excessive pilosis of thighs; ovaries are dense and enlarged; basal body temperature is monophasic. The most likely diagnosis is:
78. A workshop resident doctor makes a list of workers, who are often ill, for special supervision. He takes into account the number of etiologically connected cases resulting in temporary disability that occurred in the span of a year for each worker. How many such cases should a worker have to be included in this group?
79. A 28-year-old woman complains of increased intermenstrual periods up to 2 months, hirsutism. Gynaecological examination revealed that the ovaries were enlarged, painless, compact, uterus had no pecularities. Pelvic ultrasound revealed that the ovaries were 4-5 cm in diameter and had multiple enlarged follicles on periphery. X-ray of skull base showed that sellar region was dilated. What is the most probable diagnosis?
80. A woman consulted a therapeutist about fatigability, significant weight loss, weakness, loss of appetite. She has been having amenorrhea for 8 months. A year ago she born a full-term child. Haemorrhage during labour made up 2 l. She got blood and blood substitute transfusions. What is the most probable diagnosis?
81. The correlation between service record and eosinophiles concentration in blood was studied in workers at dyeing shops of textile factories. What index will be the most informative for the analysis of this data?
82. A 39-year-old woman suffering from schizophrenia constantly strains to hear something insisting that \\\"there is a phone connection in her brain and she hears her brother’s voice demanding that she come back home\\\". The patient is anxious, suspicious, constantly looking around. Specify the psychopathologic syndrome.
83. A 3-month-old girl has rhinitis, dyspnea, dry cough. She has been sick for 2 days. Objectively: pale skin, acrocyanosis, hypopnoe; breathing rate is 80/min; over the whole pulmonary surface there is vesiculotympanitic (bandbox) resonance observed with numerous bubbling rales (crackles). The most likely diagnosis is:
84. A 30-year-old patient was hospitalised in an intensive care unit with a diagnosis of multiple bee stings. Skin is pale and covered with cold sweat. Pulse can be palpated only at the carotid arteries and is 110/min; breating rate is 24/min, rhytmical, weakened. What drug must be administered immediately?
85. A 24-year-old patient complains of gaining body mass and increased appetite. Objectively: built of hypersthenic type, body mass index is 33,2 kg/m2, waist circumference is 100 cm. Waist to hips circumference ratio is 0,95. What is the provisional diagnosis?
Explanation
based on the body mass index, there are three classes of obesity;
Class 1 (low-risk) obesity, if BMI is 30.0 to 34.9.
Class 2 (moderate-risk) obesity, if BMI is 35.0 to 39.9.
Class 3 (high-risk) obesity, if BMI is equal to or greater than 40.0.
Alimentary obesity occurs as a result of an increased intake of food (overnutrition).
86. A parturient woman is 27 year old, it was her second labour, delivery was at full-term, normal course. On the 3rd day of postpartum period body temperature is 36, 8oC, heart rate - 72/min, BP - 120/80 mm Hg. Mammary glands are moderately swollen, nipples are clean. Abdomen is soft and painless. Fundus of uterus is 3 fingers below the umbilicus. Lochia are bloody, moderate. What is the most probable diagnosis?
87. A 40-year-old patient suffers from influenza. On the 5th day of illness there are pain behind sternum, cough with sputum, inertness. Temperature is 39, 5oC. Face is pale. Mucosa of conjunctivas and pharynx is hyperemic. Heart rate is 120/min, breathing rate is 38/min. In the lower lung segments shortening of percussion sound and moist rales (crackles) can be detected. What additional investigation should be performed first of all to specify the diagnosis?
88. A 45-year-old patient complains of body temperature rise up to 40oC, general weakness, headache, painfulness and spastic muscle contractions around the wound in the shin. He received this wound 5 days ago when working in his garden. He requested no medical care back then. What wound infection can be suspected?
89. A 60-year-old woman started feeling weakness, vertigo, rapid fatigability during the last year. Recently there have been dyspnea and paresthesia observed. Objectively: skin and mucous membranes are pale and icteric. Lingual papillae are smoothed out. Liver and spleen are situated at the edge of costal arch. Blood test: Hb- 70 g/l, erythrocytes - 1, 7·1012/l, blood color index - 1,2, macrocytes. What drug can be prescribed on pathogenetic grounds?
90. A 34-year-old patient complains of profuse sweating at night, skin itching, weight loss (9 kg within the last 3 months). Examination revealed malnutrition, skin pallor. Palpation of neck and inguinal areas revealed dense elastic lymph nodes of about 1 cm in diameter, nonmobile, non-adhering to skin. What is the most probable diagnosis?
91. A 57-year-old woman complains of having a sensation of esophageal compresion, palpitation, breathing difficulties when eating solid food, occasional vomiting with a full mouth, \\\"wet pillow\\\"sign at night for the last 6 months. Objectively: body tempearture - 39oC, height - 168 cm, weight - 72 kg, heart rate - 76/min, BP120/80 mm Hg. X-ray revealed considerable dilation of esophagus and its constriction in the cardial part. What pathology is most likely to have caused dysphagia in this patient?
92. A 25-year-old man complains of pain in the lower third of his left thigh, which occurs both with and without physical exertion. Possibility of trauma is denied by the patient. Objectively: skin colour is normal; pastosity and pain can be detected with deep palpation; knee joint mobility is reduced. X-ray of distal femoral metaphysis shows an area of destruction and spicule. Blood test: immature cells, no signs of inflammation. The most likely diagnosis is:
93. A 37-year-old woman complains of sharp pains in her external genitalia, edema of the vulvar lips, pain when walking. Objectively: body temperature is 38, 7oC, heart rate is 98/min. Inside the right vulvar lip there is a dense, painful, tumor-like growth 5,0х4,5 cm in size; skin and mucosa of the external genitalia are hyperemic, copious foul-smelling discharge is observed. The most likely diagnosis is
94. In a rural health care area there is a case of child dying during the first month of his life. To analyse this situation, among other measures, an expert assessment of medical records is performed. What medical document should be considered first?
95. Examination of placenta revealed a defect. An obstetrician performed manual investigation of uterine cavity, uterine massage. Prophylaxis of endometritis in the postpartum period should involve the following actions:
96. A 15-year-old boy has developed pain in the area of his left knee joint. Objectively: thigh soft tissues in the painful area are infiltrated, joint function is reduced. X-ray: there is a focus of destruction in the left distal femoral metaphysis, with periosteum detachment and formation of Codman triangle in the bone cortical layer at the margin of the defect. Chest X-ray reveals numerous microfocal metastases. What pathology is the most likely to cause such presentation?
97. A 74-year-old man complains of pain in the left foot and dark color of the 1st toe. He has been sick for 6 days. Objectively: heart rate is 84/min. Body temperature is 37, 8oC. The left foot resembles \\\"chicken claw\\\"due to soft tissues decreasing in volume, skin is dark red. The 1st toe is black, small amount of dark substance is being discharged from under the nail. Pulse over the peripheral arteries of extremity is absent. The most likely diagnosis is:
98. Head circumference of a 1-month-old boy with signs of excitement is 37 cm, prefontanel is 2x2 cm large. After feeding the child regurgitates small portions of milk; stool is normal in its volume and composition. Muscle tone is within norm. What is the most likely diagnosis?
99. A 49-year-old patient complains of difficulties when swallowing food, hoarse voice, weight loss. The patient has been suffering from these symptoms for the last 3 months. The symptoms are gradually progressing. Objectively: the patient is emaciated, supraclavicular lymph nodes are enlarged. Esophagoscopy revealed no pathologies of esophagus. What investigation would be the most advisable in the given case?
100. 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. X-ray 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?
101. A 52-year-old patient complains of pain in the right part of her chest, dyspnea, cough with a lot of albuminoid sputum emitting foul smell of \\\"meat slops\\\". Objectively: the patient’s condition is grave, cyanosis is observed, breathing rate is 31/min, percussion sound above the right lung is shortened, auscultation revealed various moist rales (crackles). What is the most probable diagnosis?
102. A 15-year-old patient suffers from headache, nasal haemorrhages, sense of lower extremity coldness. Objectively: muscles of shoulder girdle are developed, lower extremities are hypotrophied. Pulsation on the pedal and femoral arteries is sharply dampened. BP is 150/90 mm Hg, 90/60 in the legs. Systolic murmur can be auscultated above carotid arteries. What is the most probable diagnosis?
103. A patient with frostbite of both feet was delivered to an admission ward. What actions should be taken?
104. A patient in a clinical death condition is being resuscitated through mouth-to-mouth artificial pulmonary ventilation and external cardiac massage. A doctor noticed that air does not flow into the patient’s airways and his head and torso are positioned at the same level. Why is artificial respiration not effective in the given case?
105. Hygienic assessment of a sample taken from the batch of grain revealed 2% of grains infected with microscopic Fusarium fungi. On the grounds of laboratory analyses this batch of grain should be:
106. Residents of an industrial community situated near a plant suffer from increased morbidity rate caused by nervous and endocrine system conditions and kidney diseases. Blood test: decrease of sulfhydric groups content in blood. The pathologies developed can be caused by environment being polluted by the following:
107. Various population groups mortality has been studied for a long time; territorial distribution of population and resulting changes in mortality trends are considered. What statstical method can be applied?
108. A 45-year-old patient with urolithiasis had an attack of renal colic. What is the mechanism of the attack development?
109. A 28-year-old woman has bursting pain in the lower abdomen during menstruation; chocolate-like discharges from vagina are observed. It is known from the anamnesis that the patient suffers from chronic adnexitis. Bimanual examination revealed a tumour-like formation of heterogenous consistency 7х7 cm large to the left from the uterus. The formation is restrictedly movable, painful when moved. What is the most probable diagnosis?
110. A 6-year-old child complains of frequent liquid stool and vomiting. On the 2nd day of desease the child presented with inertness, temperature rise up to 38, 2oC, heart rate - 150 bpm, scaphoid abdomen, palpatory painful sigmoid colon, defecation 10 times a day with liquid, scarce stool with mucus and streaks of green. What is a provisional diagnosis?
111. A 65-year-old patient complains of pain in the lumbar spine, moderate disuria. He has been suffering from this condition for about half a year. Prostate volume is 45 cm3 (there are hypoechogenic nodes in both lobes, capsule invasion). Prostate-specific antigen is 60 ng/ml. Prostate biopsy revealed an adenocarcinoma. Which of the supplementary examination methods will allow to determine the stage of neoplastic process in this patient?
112. A 12-year-old child has been hit on the stomach. The patient is in moderately grave condition, has a forced position in bed. The skin is pale, heart rate - 122/min. Stress on the left costal arch causes a slight pain. Weinert and Kulenkampff symptoms are positive. Macroscopically the urine is unchanged. What is the most likely diagnosis?
113. Establishments participating in medical examinations include: medical and preventive treatment facility, hygiene and preventive treatment facility, sociomedical expert committees, Ministry of Defence medical committees, Ministry of Domestic Affairs medical committees, forensic medicine agency, etc. Specify what service deals with sociomedical assessment of temporary disability
114. An unconscious 35-year-old patient has been delivered by an ambulance to the intensive care unit. Objectively: the patient is in semicoma. Moderate mydriasis is present. The reaction of pupils to light is reduced. The patient is non-responsive to verbal instructions. BP is150/100 mm Hg, tachycardia is present. Blood contains methanol. What antidote should be administered?
115. 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?
116. A patient is active, lively, fussy. He resists the examination. His speech is fast and loud, his statements are spontaneous and inconsequent. Specify the psychopathological state of this patient:
117. A 4-year-old boy was vaccinated in violation of his vaccination schedule. There are complaints of pain in the throat during swallowing, headache, inertness, fever. Objectively: the child is pale; anterior cervical lymph nodes are enlarged; tonsils are swollen, with cyanotic hyperemy, and covered with greywhite coating that cannot be removed; if it is forcibly removed, tonsils bleed. The most likely diagnosis is
118. A 26-year-old male patient complains of piercing pain during breathing, cough, dyspnea. Objectively: t o- 37, 3oC, respiration rate is 19/min, heart rate is 92/min; BP is 120/80 mm Hg. Vesicular respiration is observed. In the inferolateral parts of chest auscultation in both inspiration and expiration phase revealed noise that was getting stronger at phonendoscope pressing and could be still heard after cough. ECG showed no pathological changes. What is the most likely diagnosis?
119. A child is 3-week-old. Since his birth periodical vomiting is observed occuring several minutes after feeding. Vomit mass does not exceed previous feeding volume. Body mass is appropriate to the child’s age. What is the most likely cause for the symptoms described?
120. A 30-year-old parturient woman was delivered to a maternity hospital with full-term pregnancy. She complains of severe lancinating pain in the uterus that started 1 hour ago, nausea, vomiting, cold sweat. Anamnesis states cesarean section 2 years ago. Uterine contractions stopped. Skin and mucous membranes are pale. Heart rate is 100/min, BP is 90/60 mm Hg. Uterus has no clear margins, is sharply painful. No heartbeat can be auscultated in the fetus. Moderate bloody discharge from the uterus can be observed. Uterus cervix is 4 cm open. Presenting part is not visible. The most likely diagnosis is:
121. 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?
122. A 47-year-old female patient complains of cough with purulent sputum, pain in the lower left chest, periodical body temperature rise. She has been suffering from this condition for about 10 years. Objectively: \"drumstick\"distal phalanges. What examination would be the most informative for making a diagnosis?
123. A patient is 60-year-old, retired, worked as deputy director of a research institute. Behavioural changes appeared 2 years ago after the death of her husband: she stopped looking after herself and leaving the house; then she stopped to clean the apartment and cook. Mental status: temporal disorientation. The patient does not understand many of the questions, is confused; does not know how to cook soup or fasten a button. Her speech is characterized by stumbling and logoclonia. She does not recognize doctors, fellow patients. She cries a lot but can not explain the reason for tears. What is the mechanism of this pathology?
124. An 8-year-old girl periodically has sudden short-term heart pain, sensation of chest compression, epigastric pain, dizziness, vomiting. Objectively: the patient is pale, respiratory rate - 40/min, jugular pulse is present. Heart rate - 185 bpm, of poor volume. BP - 75/40 mm Hg. ECG taken during an attack shows ectopic P waves, QRS wave is not deformed. At the end of an attack a compensatory pause is observed. The most likely cause of the attack is:
125. During examination a patient is unconscious, his skin is dry and hot, face hyperemia is present. The patient has Kussmaul’s respiration, there is also smell of acetone in the air. Symptoms of peritoneum irritation are positive. Blood sugar is 33 millimole/l. What emergency actions should be taken
126. A patient complains of evaginations in the region of anus that appear during defecation and need resetting. Examination with anoscope revealed 1x1 cm large evaginations of mucosa above the pectineal line. What is the most probable diagnosis?
127. During the newborn infant’s examination redness of the skin was detected, which occurred immediately after birth and became the most pronounced on the second day of the infant’s life. What provisional diagnosis can be made?
128. A baby was born by a young smoker. The labour was complicated by uterine inertia, difficult delivery of the baby’s head and shoulders. The baby’s Apgar score was 4. Which of the following is a risk factor for a spinal cord injury?
129. In order to study impact of microclimate on the human organism it is necessary to make systematic observation of air temperature during the period of 3 days. Choose a device that will allow to make the most precise temperature records
130. Against the background of angina a patient has developed pain in tubular bones. Examination revealed generalized enlargement of lymph nodes, hepatolienal syndrome, sternalgia. In blood: RBCs - 3, 6 · 1012/l, Hb87 g/l, thrombocytes - 45 · 109/l, WBCs - 13 · 109/l, blasts - 87%, stab neutrophiles - 1%, segmented neutrophiles - 7%, lymphocytes - 5%, ESR - 55 mm/h. What is the most likely diagnosis?
131. For a long time to eradicate weeds on agricultural lands herbicides retaining in environment have been used. Point out the most probable way of herbicides reaching human organism from soil:
132. A 47-year-old patient came to see a doctor on the 7th day of disease. The disease is acute: after the chill body temperature rose to 40oC and lasted up to 7 hours, then dropped abruptly, which caused profuse sweat. There were three such attacks occurring once every other day. Two days ago the patient arrived from Africa. Objectively: pale skin, subicteric sclera, significantly enlarged liver and spleen. What is the cause of fever attacks in this disease
133. A 49-year-old patient 2 years ago was diagnosed with stage 1 silicosis. He complains of increased dyspnea and pain in the infrascapular regions. X-ray shows diffuse intensification and distortion of lung pattern with numerous nodular shadows 2-4 mm in diameter. Hardening of right interlobar pleura is detected. Lung roots are hardened and expanded. What X-ray type of pneumosclerosis does the patient have?
134. A 24-year-old patient complains of general weakness, dizziness, body temperature rise up to 37, 5oC, sore throat, neck edema, enlargement of submaxillary lymph nodes. Objectively: mucous membrane of oropharynx is edematic and cyanotic, tonsils are enlarged and covered with films that spread beyond the tonsils and cannot be easily removed. What is the leading mechanism of this illness development?
135. A patient suffering from acute posttraumatic pain received an injection of morphine that brought him a significant relief. Which of the following mechanisms of action provided for antishock effect of morphine in this patient?
136. A 9-month-old child presents with fever, cough, dyspnea. The symptoms appeared 5 days ago after a contact with a person having URTI. Objectively: the child is in grave condition. Temperature of 38oC, cyanosis of nasolabial triangle is present. Respiration rate - 54/min, nasal flaring while breathing. There was percussion dullness on the right below the scapula angle, and tympanic sound over the rest of lungs. Auscultation revealed bilateral fine moist rales (crackles) predominating on the right. What is the most likely diagnosis?
137. A 50-year-old patient complains about having pain attacks in the right subcostal area for about a year. The pain arises mainly after taking fatty food. Over the last week the attacks occurred daily and became more painful. On the 3rd day of hospitalization the patient presented with icteritiousness of skin and scleras, light-coloured feces and dark urine. In blood: neutrophilic leukocytosis - 13, 1 · 109/l, ESR - 28 mm/h. What is the most likely diagnosis?
138. A 40-year-old woman with a history of combined mitral valve disease with predominant stenosis complains of dyspnea, asthma attacks at night, heart problems. At present, she is unable to do even easy housework. What is the optimal tactics of the patient treatment?
139. A 30-year-old woman with a long history of chronic pyelonephritis complains of considerable weakness, sleepiness, decrease in diuresis down to 100 ml per day. BP is 200/120 mm Hg. In blood: creatinine - 0,62 millimole/l, hypoproteinemia, albumines - 32 g/l, potassium - 6,8 millimole/l, hypochromic anemia, increased ESR. What is the first step in the patient treatment tactics?
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.
140. A 43-year-old patient had right-sided deep vein thrombosis of iliofemoral segment 3 years ago. Now he is suffering from the sense of heaviness, edema of the lower right extremity. Objectively: moderate edema of shin, brown induration of skin in the lower third of shin, varix dilatation of superficial shin veins are present. What is the most probable diagnosis?
141. A 59-year-old female patient attended a maternity welfare clinic with complains of bloody discharge from the genital tracts. Postmenopause is 12 years. Vaginal examination revealed that external genital organs had signs of age involution, uterus cervix was not erosive, small amount of bloody discharge came from the cervical canal. Uterus is of normal size, uterine appendages are unpalpable. Fornices were deep and painless. What method should be applied for the diagnosis specification?
142. A 41-year-old patient, a hunter, complains of heaviness in the right subcostal area. No other complaints recorded. Anamnesis states causeless urticaria and skin itching that occurred 1 year ago. Objectively: liver margin is rounded, painless, and can be palpated 3 cm below the costal arch. No other pathology was detected during physical examination of the patient. Body temperature is normal. X-ray reveals a hemispherical protrusion in the right cupula of the diaphragm. What disease can be suspected in the given case?
143. A 14-year-old girl has been presenting with irritability and tearfulness for about a year. A year ago she was also found to have diffuse enlargement of the thyroid gland (II grade). This condition was regarded as a pubertal manifestation, the girl did not undergo any treatment. The girl’s irritability gradually gave place to a complete apathy. The girl got puffy face, soft tissues pastosity, bradycardia, constipations. Skin pallor and gland density progressed, the skin got a waxen hue. What disease may be assumed?
144. A 26-year-old woman, who delivered a child 7 months ago, has been suffering from nausea, morning vomiting, sleepiness for the last 2 weeks. She breastfeeds the child, menstruation is absent. She has not applied any contraceptives. What method should be applied in order to specify her diagnosis
145. Over a current year among workers of an institution 10% have not been ill a single time, 30% have been ill once, 15% - twice, 5% - 4 times, the rest - 5 and more times. What is the percentage of workers belonging to the I health
146. A 34-year-old patient after vacation in Crimea has developed severe pain in her elbow joints, dyspnea and weakness. Body temperature is 37, 6oC, skin pallor and erythema on the cheeks and bridge of nose are observed, lip mucosa is ulcerated. The joints are not visibly deformed, movement of the right elbow joint is restricted. Pleura friction sound is detected in the lungs on the right side below the angle of scapula. Heart sounds are dull, tachycardia, gallop rhythm, heart rate - 114/min, BP - 100/60 mm Hg. The most likely diagnosis is:
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)
147. Several hours before, a 28-year-old patient suddenly developed acute headache and repeated vomiting, then lost consciousness.Objectively: focal neurological symptoms were not found. Pronounced meningeal symptoms were revealed. BP - 120/80 mm Hg. According to clinical and liquorological findings the patient was diagnosed with subarachnoid haemorrhage. After administration of dehydrants the patient’s condition somewhat improved. What is the main component of further emergency care?
148. A 42-year-old man has undergone gastric analysis. Free hydrochloric acid is absent at all phases. On endoscopy: pallor, gastric mucosa loss, gastric folds are smoothed out. On microscopy: glands atrophy with intestinal metaplasia. What disease can be characterized by such presentation?
Explanation
The following types of chronic gastritis include;
Type A is caused by your immune system destroying stomach cells. And it can increase your risk of vitamin deficiencies, anemia, and cancer.
Type B, the most common type, is caused by Helicobacter pylori bacteria, and can cause stomach ulcers, intestinal ulcers, and cancer.
Type C is caused by chemical irritants like nonsteroidal anti-inflammatory drugs (NSAIDs), alcohol, or bile. And it can also cause stomach lining erosion and bleeding.
Observe that on examination, free HCL is absent and results from endoscopy and microscopy indicate the gastric cells have been destroyed - this occurs in Type A gastritis.
In menetrier's disease, we see an overgrowth of gastric cells ( foveola) found in the gastric lining which leads to the presence of large gastric folds.
149. A 24-year-old woman, teacher by profession, complains of dizziness and heart pain irradiating to the left nipple. Pain is not associated with physical activity and cannot be relieved by nitroglycerin, it abates after taking Valocordin and lasts for an hour or more. The patient has a nearly 2-year history of this disease. Objectively: Heart rate - 76 bpm. BP - 110/70 mm Hg. Heart borders are normal, heart sounds are clear. The ECG shows respiratory arrhythmia. X-ray of the cervicothoracic spine shows no pathology. Lungs, abdomen are unremarkable. What changes in blood formula can be expected?
150. Chief physician of a polyclinic tasked a district doctor with determining the pathological prevalence of disease N in his district. What document allows to estimate the disease prevalence in the population of a medical district?
151. A 32-year-old woman complains of dizziness, headache, palpitation, tremor. For the last several months she has been under outpatient monitoring for increased arterial pressure. Recently such attacks have become more frequent and severe. Objectively: skin is covered with clammy sweat, tremor of the extremities is present. Heart rate - 110/min, BP - 220/140 mm Hg. Heart sounds are weakened. In blood: WBCs - 9, 8 · 109/l, ESR - 22 mm/h. Blood glucose - 9,8 millimole/l. What disease is the most likely cause of this crisis?
Explanation
The woman not only shows signs of hypertension but also presents with changes relating to body metabolic activities ( tremors, tachycardia, dizziness, palpitations, sweating - these are signs relating to stress ( caused by the release of stress hormones ie, catecholamines). Pheochromocytoma is a tumor of the adrenal gland, it is characterised by the increased production of catecholamines ( adrenaline, noradrenaline) coupled with stress symptoms.
Essential hypertension is also called primary hypertension- a form of hypertension with no underlying disease as its cause.
Preeclampsia is a pregnancy-associated hypertension coupled with other signs.
Primary hyperaldosteronism or Conn’s disease is also associated with the above stated signs , its other signs may include kidney related problems, excessive urination, low potassium content, flank pain etc.
152. A 45-year-old patient complains of pain in the epigastric region, left subcostal area, abdominal distension, diarrhea, loss of weight. He has been suffering from this condition for 5 years. Objectively: tongue is moist with white coating near the root; deep palpation of abdomen reveals slight pain in the epigastric region and Мауо-Robson’s point. Liver is painless and protrudes 1 cm from the costal arch. Spleen cannot be palpated. What disease can be primarily suspected?
153. A 58-year-old woman 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. Heart rate - 100/min, BP- 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, eosinophiles - 2%, stab neutrophiles - 12%, segmented neutrophiles - 68%, lymphocytes - 11%, monocytes - 7%, ESR - 12 mm/h. What laboratory test should be determined additionally to make a diagnosis?
154. After examination a 46-year-old patient was diagnosed with left breast cancer T2N2M0, clinical group II-a. What will be the treatment plan for this patient?
155. In river-side urban community there was an outbreak of hepatitis type A possibly spread by water. What indexes of river water quality can confirm this theory?
156. A 25-year-old patient was delivered to an infectious diseases unit on the 3rd day of illness with complaints of headache, pain in lumbar spine and gastrocnemius muscles, high fever, chill. Objectively: condition of moderate severity. Scleras are icteric. Pharynx is hyperemic. Tongue is dry with dry brown coating. Abdomen is distended. Liver is enlarged by 2 cm. Spleen is not enlarged. Palpation of muscles, especially gastrocnemius muscles, is painful. Urine is dark in colour. Stool is normal in colour. The most likely diagnosis is:
157. A 52-year-old woman complains of face distortion. It appeared 2 days ago after exposure to cold. Objectively: body temperature is 38, 2oC. Face asymmetry is present. Frontal folds are flattened. Left eye is wider than the right one and cannot close. Left nasolabial fold is flattened, mouth corner is lowered. Examination revealed no other pathology. Blood count: leukocytes - 10 · 109/l, ESR - 20 mm/h. What is the most probable diagnosis?
158. A 28-year-old female patient with a six-year history of Raynaud’s syndrome has recently developed pain in the small joints of hands, difficult movement of food down the esophagus. What disease can be suspected in this case?
ExplanationSystemic sclerosis (SSc) is a chronic multisystem disorder of unknown etiology characterized clinically by thickening of the skin caused by accumulation of connective tissue and by involvement of visceral organs, including the gastrointestinal tract, lungs, heart, and kidneys. Antibodies virtually specific for scleroderma include nucleolar autoantibodies, antibodies to ScL-70, a nonhistone nuclear protein, and anticentromere antibodies. The acronym CREST syndrome is used in describing this disease - (calcinosis of the digits, Raynaud's phenomenon, esophageal dysmotility, sclerodactyly, and telangiectasias). Periarteritis Nodosa is a blood vessel disease characterized by inflammation of small and medium-sized arteries (vasculitis), preventing them from bringing oxygen and food to organs.
159. An 8-year-old boy, who has been suffering from diabetes mellitus for 3 years, was delivered to a hospital in a condition of hyperglycemic coma. Primary dose of insulin should be prescribed basing on the following calculation:
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.
160. A 43-year-old female patient complains of rash on the skin of her right leg, pain, weakness, body temperature rise up to 38oC. The disease is acute. Objectively: there is an edema on the skin of her right leg in the foot area, a welldefined bright red spot in the irregular shape of flame tips, which is hot to touch. There are isolated vesicles in the focus. What is your provisional diagnosis?
161. A 9-year-old boy has been suffering from bronchoectasis since he was 3. Exacerbations occur quite often, 3-4 times a year. Conservative therapy results in short periods of remission. The disease is progressing, the child has physical retardation. The child’s skin is pale, acrocyanotic, he has \\\"watch glass\\\"nail deformation. Bronchography revealed saccular bronchiectases of the lower lobe of his right lung. What is the further treatment tactics?
162. A 29-year-old female patient complains of dyspnea, heaviness and chest pain on the right, body temperature rise up to 37, 2oC. The disease is associated with a chest trauma received 4 days ago. Objectively: skin is pale and moist. Heart rate is 90 bpm, regular. Palpation reveals a dull sound on the right, auscultation reveals significantly weakened vesicular breathing. In blood: RBCs - 2, 8 · 1012/l, colour index - 0,9, Hb- 100 g/l, WBCs - 8, 0·109/l, ESR - 17 mm/h. What results of diagnostic puncture of the pleural cavity can be expected?
163. A 54-year-old man had been drowning at sea, when he was found and evacuated to the shore. Objectively: unconscious, pale face, no breathing can be auscultated, thready pulse. Resuscitation measures allowed to save the man. What complication can develop in him in the nearest future?
164. A 7-year-old child complains of cramping pain occuring after mental exertion, cold drinks and eating ice-cream. Instrumental examination allowed to diagnose biliary dyskinesia of hypertensive type. What group of drugs should be prescribed for treatment?
165. Caries morbidity rate is 89% among residents of a community. It is determined that fluorine content in water is 0,1 mg/l. What preventive measures should be taken?
166. A 46-year-old patient once took part in elimination of breakdown at an atomic power plant. Currently he is being treated at an inpatient hospital unit. He was diagnosed with progressing somatoform autonomic dysfunction. This disease relates to the following group of ionizing radiation effects:
167. A patient complains of fatigue, lack of appetite, pain and burning sensation in the tongue, numbness of the distal limbs, diarrhea. Objectively: pale skin with lemon-yellow tint, face puffiness, brown pigmentation in the form of a \\\"butterfly\\\", bright red areas on the tongue. The liver is 3 cm below the costal margin, soft. Blood count: RBCs - 1, 5 · 1012/l, colour index - 1,2, WBCs - 3, 8·109/l, thrombocytes - 180·109/l, eosinophiles - 0%, stab neutrophiles - 1%, segmented neutrophiles - 58%, lymphocytes - 38% monocytes - 3%, RBC macrocytosis. ESR - 28 mm/h. What diagnosis are these presentations typical for?
168. A 25-year-old female patient complains of marked weakness, sleepiness, blackouts, dizziness, taste disorder. The patient has a history of menorrhagia. Objectively: the patient has marked weakness, pale skin, cracks in the corners of her mouth, peeling nails, systolic apical murmur. Blood test results: RBC - 3, 4 · 1012/l, Hb- 70 g/l, colour index - 0,75, platelets - 140 · 109/l, WBC- 6, 2 · 109/l. What is the most likely diagnosis?
169. A 39-year-old patient complains of morning headache, appetite loss, nausea, morning vomiting, periodic nasal haemorrhages. The patient had acute glomerulonephritis at the age of 15. Examination revealed rise of arterial pressure up to 220/130 mm Hg, skin haemorrhages on his arms and legs, pallor of skin and mucous membranes. What biochemical parameter is the most important for making diagnosis in this case?
170. A child was taken to a hospital with focal changes in the skin folds. The child was anxious during examination, examination revealed dry skin with solitary papulous elements and ill-defined lichenification zones. Skin eruption was accompanied by strong itch. The child usually feels better in summer, his condition is getting worse in winter. The child has been on bottle feeding since he was 2 months old. He has a history of exudative diathesis. His grandmother on his mother’s side has bronchial asthma. What is the most likely diagnosis?
Explanation
Atopic dermatitis is a systemic chronic allergic disease that occurs in people with an inherited predisposition to atopy and characterized by typical morphological changes of the skin with itching, lesions of the central and autonomic nervous system, endocrine and immune systems with hyper Ig E. Essential criteria for diagnosis: itch, rash elements`, typical morphology and localization ( flexor surface of extremities in adults (lichenification), extensor surfaces and face in children (eczema)), chronic recurrent course, atopic diseases in personal and family anamnesis (bronchial asthma, allergic rhinitis).
Contact dermatitis: a localized reaction that includes redness, itching, and burning where the skin has come into contact with an irritant such as an acid, a cleaning agent, or other chemical.
Allergic contact eczema (dermatitis): a red, itchy, weepy reaction where the skin has come into contact with a substance that the immune system recognizes as foreign. 171. An electro-gas welding operator working at a machine workshop performs welding and cutting of metal, which is accompanied by intense UV-radiation. His welding station is equipped with effective mechanical ventilation. What occupational disease is most likely to develop in the electro-gas welding operator?
172. 2 weeks after recovering from tonsillitis an 8-year-old boy developed edemas of face and lower limbs. Objectively: the patient is in grave condition, BP - 120/80 mm Hg. Urine is of dark brown colour. Oliguria is present. On urine analysis: specific gravity - 1,015, protein - 1,2 g/l, RBCs are leached and cover the whole vision field, granular casts - 1-2 in the vision field, salts are represented by urates (large quantity). What is the most likely diagnosis?
173. A 48-year-old patient has the following symptoms: diffuse enlargement of thyroid gland, exophthalmus, weight loss up to 4 kg within 2 months, excessive sweating. Objectively: heart rate 105/min, BP - 180/70 mm Hg. Stool is normal. What therapy is advisable in the given case?
174. A patient is on sick leave for 4 months continuously from the date of injury. The treatment is going to last for another 1-2 months. Who is authorised to extend the duration of medical certificate for this patient?
175. A 30-year-old woman complains of pain in the heart area (\\\"aching, piercing pain\\\") that arises primarily in the morning hours in autumn and spring. Pain irradiates into the neck, back, abdomen and is attended by rapid heart rate and low vital tonus. This condition occurs independently from physical exertion. In the evening her condition improves. Somatic and neurologic state and ECG have no pathologies. What pathology is likely to result in such clinical presentation?
176. What juice is recommended to be included in a complex drug and diet therapy for patients suffering from gastric or duodenal ulcer and high acidity of gastric juice to speed up ulcer healing?
177. A 40-year-old woman has been hospitalized for attacks of asphyxia, cough with phlegm. She has a 4-year history of the disease. The first attack of asphyxia occurred during her stay in the countryside. Further attacks occurred while cleaning the room. After 3 days of inpatient treatment the patient’s condition has significantly improved. What is the most likely etiological factor?
178. A 13-year-old girl complains of periodic prickly pain in the heart region. Percussion revealed no changes of cardiac borders. Auscultation revealed arrhythmic enhanced heart sounds, extrasystole at the 20-25 cardiac impulse. ECG showed the sinus rhythm, impaired repolarization, single supraventricular extrasystoles at rest. What is the most likely diagnosis?
179. A 24-year-old patient visited a doctor complaining of enlargement of his submaxillary lymph nodes. Objectively: submaxillary, axillary and inguinal lymph nodes are enlarged. Chest X-ray shows: enlarged lymph nodes of mediastinum. Blood test: erythrocytes - 3, 4 · 1012/l, Hb- 100 g/l, blood colour index - 0,88, platelets - 190 · 109/l, leucocytes - 7, 5 · 109/l, eosinophiles - 8%, band neutrophiles - 2%, segmented neutrophiles - 67%, lymphocytes - 23%, ESR - 22 mm/h. What test must be prescribed to verify the cause of lymphadenopathy?
180. A 60-year-old woman has been suffering from arterial hypertension for 15 years. After recurrent stroke she started complaining about unmotivated bad mood, problems with attention concentration; she forgets to close the entrance door, cannot recall events of the past day. Computer tomography shows areas of postinfarction changes in the cortical postfrontal areas. What is the most probable diagnosis?
181. Clinic of a research instutute for occupational diseases examined a worker who works at a concentration plant and diagnosed him with chronic dust bronchitis. The case is investigated by a commission including the representatives of: the plant, medical unit, territorial sanitation center, department of Social Insurance Fund, trade union. According to the \"regulation on investigation of. . . \", the commission should be headed by the representative of the following authority:
182. 4 days after a patient received a gunshot wound of the middle third of the thigh soft tissues his condition suddenly began deteriorating. There are complaints of bursting pain in the wound; pain increases during the last 12 hours. Edema of skin and hypodermic tissue quickly grows. Body temperature is 38, 2oC, heart rate is 102/min. The wound edges gape, are dull in color; the muscles, viable as of day before, now protrude into the wound, look boiled, are dull in colour, have dirty-grey coating and fall apart when being held with forceps. What infection has developed in the wound?
183. Bacterial analysis of air in a living space in winter period by means of Krotov’s apparatus revealed that total number of microorganisms in 1m3 of air was 7200. What is the allowed number of microorganisms for the air to be characterized as \\\"pure\\\"?
Explanation
-
Air cleanness estimation according to indexes of bacteriological research in different year periods.
|
Air estimation
|
Microorganisms Contents in 1m3 of air.
|
|
|
Generally
|
Streptococcus hemolyticus
|
Generally
|
Streptococcus hemolyticus
|
|
|
Summer period
|
Winter period
|
|
Clean
|
less 1500
|
less 16
|
less 4500
|
less 36
|
|
Moderately muddy
|
1500 - 2500
|
16-35
|
4500-7000
|
36-125
|
|
Muddy
|
more 2500
|
more 35
|
more 7000
|
more 125
|
184. Maximum permissible concentration of carbon dioxide in the air is considered to be a sanitary index of air purity in a classroom. What concentration of carbon dioxide in the air is accepted as a permissible maximum?
185. When examining the parameters of desk natural lighting in a school class it was determined that: light angle is 25o, window angle is 3o, window-to-floor area ratio is 1:4, daylight factor is 0,5%, and window-head-to-roomdepth ratio is 2. What parameter does not correspond to hygienic norms?
Explanation
-
The natural lighting norms for different premises
|
The type of premises
|
The daylight factor (DF)
|
The lighting coefficient (LC)
|
The angle of incidence (a)
|
The aperture angle (g)
|
The depth coefficient of premises
|
|
not less than
|
not less than
|
not less than
|
not less than
|
|
1.Classrooms
|
1.25-1.5%
|
1:4 – 1:5
|
27°
|
5°
|
2
|
|
2.Residential
|
1.0%
|
1:5 – 1:6
|
27°
|
5°
|
2
|
|
3. Wards
|
0.5%
|
1: – 1:8
|
27°
|
5°
|
2
|
|
4. Surgeries
|
2.0%
|
1:2 – 1:3
|
27°
|
5°
|
2
|
186. A 29-year-old patient works as a motor mechanic. Anamnesis shows frequent exposure to cold, exacerbation of chronic bronchitis attended by cough with relativly small amount of mucopurulent sputum, subfebrility,sometimes joined by hemoptysis and pain in the right side of chest. Breathing is vesicular. X-ray shows darkening and sharp decrease in size of the lower lobe distinctly visible on the X-ray image as a streak 2-3 cm wide situated at the angle from lung root to the frontal costodiaphragmatic recess. The most likely diagnosis is:
187. A 52-year-old patient, who has been suffering from angina pectoris for 2 weeks, has more and more frequent pain attacks in the area behind his sternum and his need for nitroglycerine increased. Objectively: the condition is of moderate severity. Skin is pale. Heart sounds are weakened, rhythmic. Heart rate is 84 per minute. ECG shows no signs of focal myocardial damage. What is the most likely diagnosis?
188. An 8-year-old boy during preventive examination was determined to have changes in his spine curvature in frontal plane: the right shoulder is lowered and flat, scapulae angles are of different height due to the right scapula being shifted down. Waist triangles are pronounced on the both sides; longitudinal muscles of the back form muscle cushion on the left. What type of posture is detected in the child?
189. A patient with cardiac infarction is on sick leave with his medical certificate being continuously extended for 4 months according to a standard procedure. The disease is progressing. The issue is put forward to refer the patient to the industrial injury assessment board. Who among the medical staff of medical and preventive treatment facility is authorized to do this
190. A baby was born at 36 weeks of gestation. Delivery was normal, by natural way. The baby has a large cephalohematoma. The results of blood count are: Hb- 120g/l, Er- 3, 5 · 1012/l, total serum bilirubin - 123 mmol/l, direct bilirubin - 11 mmol/l, indirect - 112 mmol/l. What are the causes of hyperbilirubinemia in this case?
191. A patient has been hospitalised. The onset of the disease was gradual: nausea, vomiting, dark urine, аcholic stool, yellowness of the skin and scleras. The liver is enlarged by 3 cm. Jaundice developed on the 14th day of the disease. The liver diminished in size. What complication of viral hepatitis caused deterioration of the patient’s condition?
192. An 18-year-old patient was admitted to a hospital with complaints of headache, weakness, high fever, sore throat. Objectively: enlargement of all groups of lymph nodes was revealed. The liver is enlarged by 3 cm, spleen - by 1 cm. In blood: leukocytosis, atypical lymphocytes - 15%. What is the most probable diagnosis?
193. A 60-year-old woman, mother of 6 children, developed a sudden onset of upper abdominal pain radiating to the back, accompanied by nausea, vomiting, fever and chills. Subsequently, she noticed yellow discoloration of her sclera and skin. On physical examination the patient was found to be febrile with temperature of 38, 9oC, along with right upper quadrant tenderness. The most likely diagnosis is:
194. 13 months after the first labor a 24- year-old patient complained of amenorrhea. Pregnancy ended in Caesarian section because of premature detachment of normally positioned placenta which resulted in blood loss at the rate of 2000 ml due to disturbance of blood clotting. Choose the most suitable investigation:
195. A 24-year-old primipara was hospitalised with complaints of discharge of the amniotic waters. The uterus is tonic on palpation. The position of the fetus is longitudinal, it is pressed with the head to pelvic outlet. Palpitation of the fetus is rhythmical, 140 bpm, auscultated on the left below the navel. Internal examination: cervix of the uterus is 2,5 cm long, dense, the external opening is closed, light amniotic waters are discharged. Point out the correct component of the diagnosis:
196. A patient was delivered to a surgical department after a road accident with a closed trauma of chest and right-sided rib fracture. The patient was diagnosed with right-sided pneumothorax; it is indicated to perform drainage of pleural cavity. Pleural puncture should be made:
197. A primagravida with pregnancy of 37-38 weeks complains of headache, nausea, pain in epigastrium. Objectively: the skin is acyanotic. Face is hydropic, there is short fibrillar twitching of blepharons, muscles of the face and the inferior extremities. The stare is fixed. BP - 200/110 mm Hg; sphygmus is of 92 bpm, intense. Respiration rate is 32/min. Heart activity is rhythmical. Appreciable edemas of the inferior extremities are present. Urine is cloudy. What medication should be administered?
198. A patient with high temperature came to a first-aid post in the evening. The fact of temporary disability was established. Indicate the measure to be taken in this case:
199. A 10-year-old boy complains of pain in his left eye and strong photophobia after he has injured his left eye with a pencil at school. Left eye examination revealed: blepharospasm, ciliary and conjunctival congestion, cornea is transparent, other parts of eyeball have no changes. Visus 0,9. Right eye is healthy, Visus 1,0. What additional method would you choose first of all?
200. An infant was born with body mass 3 kg and body length 50 cm. Now he is 3 years old. His brother is 7 years old, suffers from rheumatic fever. Mother asked a doctor for a cardiac check up of the 3-year-old son. Where is the left relative heart border located?
Explanation
Border’s of hearts relative dullness:
|
|
age of child
|
|
Border
|
until 2 years
|
2-7 years
|
7-12 years
|
older 12 years
|
|
Right
|
right parasternal line
|
right parasternal line or something inward from right parasternal line
|
Between the right parasternal line and the right sternal line
|
the right sternal line
|
|
Upper
|
the II rib
|
the II intercostal space
|
the III rib
|
the III intercostal space
|
|
Left
|
2 cm outward from left midclavicular line
|
1 cm outward from left midclavicular line
|
0,5 cm outward from left midclavicular line
|
0,5 cm medialy from left midclavicular line
|
|
Transversal size
|
6-9 cm
|
8-12 cm
|
9-14 cm
|
9-14 cm
|
