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You are a doctor on duty. A patient after a successful resuscitation (drowning) was delivered to an admission room. BP is 90/60 mm Hg, heart rate is 120/min., respiration rate is 26/min. The patient is unconscious, pupils are moderately dilated, general clonic and tonic convulsions are observed. Make the diagnosis:
Notice that this patient has just been resuscitated; postresuscitation disease is a specific pathophysiologic state of vital organ systems immediately after an episode of ischemic anoxia ( insufficient supply of oxygen to the brain due to a drop in cerebral blood flow or arterial pressure).
A 32-year-old welder complains of weakness and fever. His illness initially presented as tonsillitis one month earlier. On examination: BT- 38, 9o C , RR- 24/min., HR-100/min., BP- 100/70 mm Hg, hemorrhages on the legs, enlargement of the lymph nodes. CBC shows Hb- 70 g/l, RBC- 2, 2 · 1012 /l, WBC- 3, 0 · 109 /l with 32% of blasts, 1% of eosinophiles, 3% of bands, 36% of segments, 20% of lymphocytes, and 8% of monocytes, ESR- 47 mm/hour. What is the cause of anemia?
Blast cells are immature WBC. Presence of 32% of Blast cells in the analysis indicates an acute form of leukemia. Less than 10% of blast cells will indicate a chronic form. This patient also has an anemia (post hemorrhagic form) indicated by the low level of RBC. N/B, when there is leukemia, most of the immature cells will be recruited to produce the cancer cells which will cause a reduction in most of the other cell types especially RBC’s.
Megaloblastic anemia is seen in vitamin B12 deficiency while chronic hemolytic anemia will show reticulocytes ( immature RBCs) on blood film unlike leukemia that show immature wbc.
Primary prevention of a disease is aimed at preventing the onset (start of a disease) ie, the disease is yet to occur so we aim at preventing it from happening via optimization of lifestyle and living conditions etc.
Secondary prevention is aimed at preventing the progress of a disease ( early diagnosis and treatment) ie, the patient already has the disease, so we are more concerned on stopping it from progressing and preventing its complications.
Т/l, Hb- 80 g/l, color index - 0,78, anisocytosis, poikilocythemia, serum iron - 10 mcmol/l.What diagnosis is most likely?
Anemia is a condition characterised by too few RBCs . In iron deficiency anemia, we observe the presence of low hemoglobin levels coupled with a low color index; recall that iron is responsible for the characteristic red color in Rbc and a deficiency in Iron content in blood will lead to a decreased color index. In this patient, together with the RBC level, the color index and hemoglobin levels are also low ( norm Color index 0.85- 1.05, Hemoglobin, blood Male: 135-175 g/L Female: 120-160 g/L); Anisocytosis ( red blood cells of varying sizes on your blood smear.) and poikilocytosis are also key findings in iron deficiency anemia ( red blood cells of varying shapes on your blood smear).
B12 deficiency will lead to the presence of megaloblasts in blood smear with the patient experiencing some neurological disturbances.
In aplastic anemia, there will be a deficiency in all types of blood cells. This is because, in this condition, the body stops producing sufficient blood cells.
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/hour. What test must be prescribed to verify the
A lymph node biopsy removes lymph node tissue to be looked at under a microscope for signs of infection or a disease, such as cancer. Lymph nodes in healthy people are usually hard to feel. But lymph nodes in the neck, armpit, or groin can get bigger and become tender. Swollen lymph nodes usually mean an infection. Open ( excisional) and needle biopsies are major methods of obtaining lymph nodes for diagnosis. open biopsy is a surgical procedure in which the entire lymph node is removed and taken for analysis; in needle biopsy a needle aspirate of the affected lymph node is taken.
Nonrheumatic carditis refers to inflammation and may be caused by many infections, toxic (cocaine, ethanol, heavy metals) or idiopathic processes (giant cell myocarditis, diabetes mellitus, sarcoidosis, systemic lupus erythematosus, thyrotoxicosis), affecting the myocardium with or without associated systemic manifestations of disease process or involvement of the endocardium or pericardium;
The most common manifestation is heart failure, although arrhythmias and sudden death may be the 1st detectable signs. Its manifestations are age dependent:
in early infancy- viral myocarditis often occurs as a acute, fulminant disease;
in toddlers, young children - it occurs as an acute myopericarditis;
in older children, adolescents – it is often asymptomatic.
Primary rheumatic carditis; one of the succeeding signs of Rheumatic fever ( caused by a group A beta hemolytic streptococci infection).
The key findings here are the results from the ECG and the echocardiogram. Notice that the left ventricle has undergone a hypertrophy and the interventricular septum is increased in size ( norm 0.6-1.1cm). Hypertrophic cardiomyopathy is a condition in which the heart becomes enlarged without any underlying disease/pathology; this reduces the heart’s pumping ability leading to cardiac irregularities, dizziness, dyspnea etc.
Aortic stenosis is the narrowing of the walls of the aorta thereby restricting blood flow through the aorta. Chest pain, lightheadedness, difficulty walking are key symptoms
Observe that the patient has a history of stroke which from the CT scan result created postinfarction changes in the cerebral cortex. This patient also presents with problems of reasoning,memory, decision and thought which are signs seen in patients with dementia (a chronic organic mental disorder characterised by impairment in intellectual function,memory and personality). We can conclude that the dementia is as a result of disturbed brain blood supply (vascular dementia).
A positive kernig sign indicates a form of meningitis or subarachnoid hemorrhage; for more information CSF findings are taken; the analysis shows no sign of hemorrhage, but appears turbid and yellow tinted which are signs of a bacterial meningitis. Examination of the CSF in patients with acute bacterial meningitis reveals the characteristic neutrophilic pleocytosis ( a neutrophil count in the CNS greater than 50%). Lymphocytic pleocytosis is found in viral encephalitis.
Realise that this patient is experiencing cervical changes that are more advanced in respect ( corresponding) to the duration of pregnancy. The word ‘gaping’ indicates that the walls of the cervix is weak and from vaginal examination, we observe the dilation and effacement of the cervix. Note that these changes are not due ( In a normal pregnancy, dilation and effacement occurs in response to uterine contractions). These changes in the cervix are typically seen in a condition termed ‘cervical weakness’ or ‘cervical insufficiency’ ie., cervical dilation and effacement occurring in preterm pregnancy.
A cervical pregnancy usually terminates during the first trimester and occurs when implantation takes place in the cervix.
Incipient abortion is a form of spontaenous abortion. It refers to the non induced fetal death before 20 weeks of gestation.
A 56-year-old patient complains of pain in the epigastrium after eating, eructation, loss of appetite, slight loss of weight, fatigability. The patient smokes; no excessive alcohol consumption. Objectively: pale mucosa, BP-110/70 mm Hg. The tongue is ”lacquered”. The abdomen is soft, sensitive in the epigastric area. Blood test: erythrocytes - 3,0 T/l, Hb- 110 g/l, color index - 1,1; macrocytosis; leukocytes - 5,5 g/l, ESR- 13 mm/hour. On fibrogastroduodenoscopy: atrophy of fundic mucosa. What pathogenesis does this disorder have?
The key finding her is the atrophic changes in the FUNDUS of the stomach from the fibrogastroduedenoscopy. Atrophic gastritis in a form of chronic gastritis in which the gastric glandular cells are replaced with intestinal and fibrous tissues. Note that the type A form of atrophic gastritis is caused by the autoimmune destruction of these cells and occurs in the FUNDUS; while the type B form is caused by Helicobacter pylori persistence- this form affects the ANTRUM of the stomach. This patient presents with atrophy of the fundic mucosa thereby indicating antibodies against parietal cells are the causative agent.
A 26-year-old secundipara at 40 weeks of gestation arrived at a maternity ward after the beginning of labor activity. The bursting of waters occurred 2 hours prior. The fetus was in a longitudinal lie with cephalic presentation. Abdominal circumference was 100 cm, fundal height - 42 cm. Contractions occurred every 4-5 minutes and lasted 25 seconds each. Internal obstetric examination revealed cervical effacement, opening by 4cm. Fetal bladder was absent. Fetal head was pressed against the pelvic inlet. What complication arose in the childbirth?
Recall that labor physiologically is divided into 3 stages;
In the first stage the cervix opens to full dilation to allow the head to pass through The second stage is from full dilation to delivery of the fetus. The third stage lasts from delivery of the fetus to delivery of the placenta. Labor often lasts between 12 and 14 hours – or longer – for first-time mothers, but is usually shorter in subsequent births.
The 1st stage—is the longest stage of labor, and is divided into three separate phases:
The early ( latent) phase- averaging 8 1 ⁄2 h in nulliparas and 5 h in multiparas; duration is considered abnormal if it lasts > 20 h in nulliparas or > 12 h in multiparas.
Active labor (the active phase)- here, the cervix dilates to 7cm. On average, the active phase lasts 5 to 7 h in nulliparas and 2 to 4 h in multiparas. The cervix should dilate 1.2 cm/h in nulliparas and 1.5 cm/h in multiparas.
Transition. The cervix dilates from 7 centimeters to 10 centimeters. This is usually the shortest stage of labor, but is often the most unpleasant.
If a woman's “water ―breaking” occurs in the first stage before/ until the active phase, it is called early amniorrhea.
In Primary uterine inertia, uterine contractions fail to be initiated while in the secondary form, uterine inertia ceases in between labor ( before completion)
Air cleanness estimation according to indexes of bacteriological research in different year periods.
Microorganisms Contents in 1m3 of air.
1500 - 2500
A 29-year-old female patient complains of dyspnea, heaviness and chest pain on the right, body temperature rise up to 37, 2o C . The disease is associated with a chest trauma received 4 days ago. Objectively: skin is pale and moist. Ps- 90/min., regular. Palpation reveals a dull sound on the right, auscultation reveals significantly weakened vesicular breathing. In blood: RBCs- 2, 8 · 1012 /l, colour index - 0,9, Hb- 100 g/l, WBCs- 8, 0 · 109 /l, ESR- 17 mm/hour. What results of diagnostic puncture of the pleural cavity can be expected?
From anamnesis, the patient is said to have experienced a chest trauma which is the reason behind the presented symptoms. Observe that the RBC level is low ( norm Female - 3.5-5.5 x 10^12/l), this reduced amount is most likely as a result of bleeding from the chest trauma ( post hemorrhagic anemia). This implies that when the pleural puncture is taken, signs of hemorrhage are going to be found on the punctate ( a hemorrhagic punctate).
A transudate is due to high capillary pressure and has protein levels below 25g/l or 2.5g/dl while an exudate is mostly present in inflammatory processes and its protein content is above 25g/l or 2.5g/dl.
Dental caries is a bacterial disease that begins with demineralization of the outermost dental enamel and progresses, if not halted, can lead to loss of tooth substance and infection of the dental pulp. Fluoride acts in several ways to prevent caries. The principal action is thought to be that fluoride in dental plaque inhibits the initial demineralization of enamel, and then promotes remineralization of early lesions. Fluorine is gotten from drinking water and food materials. Adequate amount of fluorine in water should be from 0.7-1.5mg/l
Examination of a group of persons living on the same territory revealed the following common symptoms: dark-yellow pigmentation of the tooth enamel, diffuse osteoporosis of bone apparatus, ossification of ligaments and joints, functional disorders of the central nervous system. This condition may be caused by the excessive concentration of the following microelement in food or drinking water:
An infant has been born at the 41st week of gestation. The pregnancy was complicated with severe gestosis of the second semester. The weight of the baby is 2400 g, the height is 50 cm. Objectively: the skin is flabby, the layer of subcutaneous fat is thin, hypomyotonia, neonatal reflexes are weak. The internal organs are without pathologic changes. This newborn can be estimated as a:
Norms; gestation period- 280 days or 40 weeks up to 42 weeks
birth weight- 3-3.5kg ( 3000-3500g)
Body length- 45-55cm
The baby in question underwent a full term gestation period (41 weeks) but is underweight ( 2400g). This underweight is due to complications that occurred during gestation as stated “The pregnancy was complicated with severe gestosis in the second semester”. We can therefore conclude that the baby who had a full term gestation had some intrauterine growth restrictions.
A premature infant is one which is born before 37 weeks of gestation.
A post mature infant is one born after 42 weeks of gestation.
Tuberculosis is a disease caused by an acid fast bacteria, Mycobacterium tuberculosis. Streptomycin, Rifampicin, Isoniazid, pyrazinamide and ethambutol are very active drugs chosen for its treatment. The following are lists of side effects associated with these drugs:
Streptomycin- vestibular and auditory ( ototoxicity) dysfunction, non oliguric renal failure
Rifampicin- red/ orange discoloration of body fluids e.g. tears, urine; flu-like symptoms, hepatitis, diarrhea, thrombocytopenia.
Isoniazid- hepatitis, peripheral neuropathies
Pyrazinamide- asymptomatic hyperuricemia, joint pain, rash
Ethambutol- retrobulbar optic neuritis
A woman has developed sudden thoracic pain on the right with expectoration of pink sputum and body temperature rise up to 37, 7o C on the 4th day after the surgery for cystoma of the right ovary. On lung examination: dullness of the lung sound on the lower right is observed. Isolated moist crackles can be auscultated in the same area. What complication is the most likely?
Anatomical relations of leads in a standard 12 lead electrocardiogram
II, III, and aVF: inferior surface of the heart
V1 to V4: anterior surface
I, aVL, V5, and V6: lateral surface
V1 and aVR: right atrium and cavity of left ventricle
Posterior MI will present with ST segment depression (not elevation) in the septal and anterior precordial leads (V1-V4) and ST elevation in the posterior leads of a posterior ECG (leads V7-V9).
rule of “nines” – area of different areas of the body is proportional: anterior surface of the trunk – 18 %, posterior – 18 %, lower limb – 18 %, external genitals – 1 %);
rule of “palm”. It is used if burns are limited and located on different areas of the body. According to the rule of palm takes 1 % of the skin surface.
Division of the burns on superficial (I, II, IIIA st.) and deep (IIIB-IV st.)
I stage – hyperemia of the skin
II stage – separation of epidermis with formation of bullas
III A stage – necrosis of superficial layers of the skin with saving of bulbs hair, sweat glands and sebaceous glands.
IIIB stage – necrosis of all the derma
Creatinine clearance test is one of the tests done to check the Renal function. It involves the measurement of the amount of plasma cleared of creatinine per unit time.The above patient presents with an acute glomerulonephritis and for biochemical analysis, the blood creatinine level is most informative. Another important test is the checking of the glomerular filtration rate.
A worker of a blowing shop complains of headache, irritability, sight impairment - he sees everything as if through a ”net”. Objectively: hyperemic sclera, thickened cornea, decreased opacity of pupils, visual acuity is 0,8 in the left eye, 0,7 in the right eye. The worker uses no means of personal protection. What diagnosis is most likely?
Cataract is the opacification ( clouding ) of the lens which leads to a decrease in vision ( visual acuity). The visual acuity in adults is 60/60 or 6/6 which equals 1. Note that the patient in view has reduced visual acuity in both eyes and has a net like vision ( cloudy); these signs indicate presence of cataract.
In conjunctivitis, we see red eyes ( inflammation of the transparent membrane- conjunctiva), it doesn't affect visual acuity.
Keratitis is an inflammation of the Cornea. Symptoms include; eye redness, photophobia, eye pain coupled with a reduced visual acuity.
From the description of the current state of the patient’s left hand ( pale, numb, pulseless, cold), we can say there is a case of restricted blood flow to the particular region. From anamnesis, this patient has a case of rheumatism which increases the chances of formation of a thrombi or emboli ( deep venous thrombosis, pulmonary embolism etc). The obstruction of blood flow is most likely due to a substance that has traveled and lodged in this area ( an emboli). Because of the severity of the current state of the limb, an urgent embolectomy ( a surgical removal of an embolus) should be carried out. In a less severe case in which pulse can still be felt and the limb is slightly active, fibrinolytics and anticoagulants will be the procedure of choice.
The main risk amongst welders is the inflammation of the cornea and conjunctiva, commonly known as 'arc eye' or 'flash'. This is caused by the irritation of the eyes by the ultraviolet rays produced. Other possible hazards include skin inflammation, cancer.
A 48-year-old patient was found to have diffuse enlargement of the thyroid gland, exophthalmia, weight loss of 4 kg in 2 months, sweating. Objectively: HR- 105/min., BP - 140/70 mm Hg. Defecation act is normal. What kind of therapy is recommended in this case?
The key finding here are grey white coatings on the tonsils that cannot be removed ( or bleeds when removed); these are the main findings of a diphtheria infection ( causative agent -Corynebacterium Diphtheriae which produces an Exotoxin ie.,diphtheria toxin).
N/B The posterior pharynx of patients with Infectious Mononucleosis (EBV infection) is often uniformly erythematous.
This patient has a case of acute Pancreatitis. Recall that the pancreas has both endocrine and exocrine functions; for the exocrine part, it produces enzymes that aid in digestion such as amylase, lipase, trypsin. Absence of these enzymes will lead to symptoms such as steatorrhea (fats in feces), creatorrhea (undigested muscles in feces) etc. Panzinorm Forte is a combination of digestive enzymes. These enzymes are normally produced by the pancreas and are important for digesting fats, proteins, and sugars.
Panzinorm Forte is used to replace digestive enzymes when the body does not have enough of its own. Certain medical conditions can cause this lack of enzymes, such as cystic fibrosis, pancreatitis, pancreatic cancer, or pancreas surgery.
Panzinorm Forte may also be used to treat a condition called steatorrhea (loose, fatty stools).
Pirenzepine is an M1 selective antagonist used in treatment of peptic ulcer ( it reduces gastric acid secretion and muscle spasm). Contrykal is a protease inhibitor and is used in reducing blood loss in surgical procedures. Drotaverine is an antispasmodic drug used for cervical dilation in childbirth
This patient is experiencing a mushroom poisoning; amongst the listed symptoms, notice the presence of shallow breathing with respiratory rate 40/min ( norm 12-20/min) to avoid a complete respiratory failure, tracheal intubation with mechanical ventilation should be performed on the patient. Intubation is done when one cannot maintain their airway on their own due to anesthesia or illness. Notice the question says what should be done first- a gastric lavage and detoxification therapy can follow next but maintenance of respiration should be the first priority.
The key finding here is that visual acuity in both eyes is 1,0 which implies that vision is not affected. From the listed options, conjunctivitis ( red/pink eye) does not affect visual acuity.
Conjunctivitis refers to the inflammation of the transparent membrane that lines the eyelid and the sclera; this inflammation is due to an infection ( bacterial, viral, chlamydial etc). Symptoms include; burning and itchy sensation, sticky mucus discharge, conjunctival injection ( redness of the eye) etc.
Iridocyclitis is the inflammation of the uveal tract ( the iris, ciliary body and choroid), glaucoma involves the increase in intraocular pressure that gradually leads to the loss of vision. Dacryocystitis involves an infected lacrimal sac and an obstruction in the lacrimal duct.
The right of prolongating a medical certificate (in this case a sick list) of invalidity alongside with the medical treatment by the doctor is granted by:
• Chief medical officer (assistant of the chief medical officer on expertise of ability for work);
• Manager of department;
• Medical-consulting commission also known as medical expertise committee
The medical-consulting commission (MCC) is formed in case the doctors staff is above 15 doctors.
Monthly dysentery morbidity in the region given in absolute figures is as follows: January - 6; February - 9; March - 11; April - 10; May - 16; June - 23; July - 19; August - 33; September - 58; October - 19; November - 11; December - 5. Annual total is 220 cases. What graphic presentation would provide the best visual for
monthly deviations of dysentery morbidity from the average?
Radar charts are also known as spider, polar, web charts or star plots); they are used as a way to visualize multivariate data. They are used to plot one or more groups of values over multiple common variables. They do this by giving an axis for each variable, and these axes are arranged radially around a central point and spaced equally.
A cartogram uses a map to differentiate how a variable is distributed
Somatoform disorders - multiple, recurrent and frequent somatic complaints requiring medical attention without association with any physical disorder. The above patient’s heart ache is not related to any physical activity and occurs at a particular period of the year,
Hypochondriacal Disorder is characterized by a persistent preoccupation and a fear of developing or having one or more serious and progressive physical disorders. Physician physical examination does not reveal any disorder, but the fear and convictions persist despite the reassurance.
On the 4th day after recovering from a cold a patient was hospitalized with complaints of solitary spittings of mucoid sputum. On the 2nd day there was a single discharge of about 250 ml of purulent blood-streaked sputum. Objectively: the patient’s condition is moderately severe. Respiratory rate - 28-30/min., Ps- 96/min., BP- 110/70 mm Hg. Respiration above the left lung is vesicular, weak above the right lung. There are various moist crackles above the lower lobe and amphoric breath near the angle of scapula. What is the most likely diagnosis?
Rivalta’s test is a procedure used in differentiating the type of effusion i.e., transudate or exudate. It involves the mixture of a drop of the effusion with acetic acid and distilled water;If the drop dissipates ( disappears), the test is negative, indicating a transudate. If the drop precipitates, the test is positive, indicating an exudate. A transudate is a filtrate, it is typically a clear fluid with a low protein and cell content. Causes include increased capillary hydrostatic pressure (e.g., pleural effusion in congestive heart failure) and/or decreased capillary oncotic pressure (e.g., edema due to lack of albumin).
An exudate is a A protein-rich fluid that occurs as a result of increased vascular permeability from inflammation. Analysis of the fluid reveals a cellular (cloudy) fluid with high protein and low glucose concentration. Can accumulate in cavities (e.g., pleural space, pericardial space).
In a maternity hospital a newborn had been presenting with cough attacks after eating. The child was discharged from the hospital on the 18th day due to a case of pneumonia. During the further 1,5 months the child had 2 cases of pneumonia. Periodically there are cough attacks after eating, especially if the child lies on the left side. Objectively: the II degree hypotrophy, isolated moist crackles, dyspnea. Stool and diuresis are not disrupted. What diagnosis is most likely?
Transesophageal fistula (TEF) is an abnormal connection between the esophagus and the trachea ie, the tube that leads to the stomach and that which leads to the lungs. It is characterised by continuous effusion of saliva from the mouth, choking and vomiting with first feeding. Due to this abnormal connection, contents going to the stomach can easily get into the respiratory tract
Mucoviscidosis ( cystic fibrosis of the pancreas) is a genetic disorder that occurs due to the mutation in CFTR gene. It is characterised by the production of thick and sticky mucus that can clog the lungs and obstruct the pancreas.
The key finding here is from the sputum ‘thick, viscous and difficult to expectorate’. This is characteristic of the disease cystic fibrosis ( pulmonary mucoviscidosis) which refers to a form of genetic disorder that affects the CFTR gene. It basically affects the cells that produce mucus, sweat and digestive juices ( the reason for the thick and viscous sputum); people with this pathology also encounter persistent lung infections. Note that drumstick fingers ( also known as clubbing of the nails) are seen in individuals with cardiovascular diseases and lung pathologies. These lung diseases include; lung cancer, lung infections, interstitial lung disease and cystic fibrosis.
In recurring bronchitis (chronic bronchitis), the individual experiences productive cough for about three months recurring in the space of two consecutive years. Bronchial Asthma is an allergic disease, a chronic obstructive pulmonary disease ( COPD) characterised by the swelling and narrowing of the airway and also the increased production of mucus.
Acute hematogenous osteomyelitis is an infection of the bone usually caused by a bacteria and common in children less than 5 years; typically affects the metaphysis of long tubular bones. Children present with fever, localized pain, swelling, and rarely erythema around a long bone, limited range of motion, and limping or refusal to bear weight or use an extremity (pseudoparalysis).
Brodie's abscess is a sub-acute form of osteomyelitis, presenting as a collection of pus in bone. Classically, this may present after progression to a draining abscess extending from the tibia out through the skin.
A 56-year-old patient with diffuse toxic goiter has ciliary arrhythmia, heart rate is 110-120/min., arterial hypertension, BP is 165/90mm Hg. What drug besides Mercazolil (Thiamazole) should be prescribed in this case?
Propranolol is a drug indicated for the treatment of high blood pressure, a number of types of irregular heart rate, thyrotoxicosis, capillary hemangiomas, performance anxiety, and essential tremors. It is classified as a beta blocker (non- selective); weak indirect α1-adrenoceptor agonist in addition to potent β-adrenoceptor antagonist.
Novocaine is mainly a sodium channel blocker and is used as an anesthesia; Corinfar ( nifedipine) and verapamil are both calcium channel blockers and can be used in this case ( hypertension coupled with hyperthyroidism) only when beta blockers are contraindicated.
Pheochromocytoma is a tumor that affects the chromaffin cells of the adrenal medulla. It leads to the increased production of catecholamines ( epinephrine and norepinephrine) which have vasoconstrictive effects leading to hypertension. Amongst the listed drugs, Phentolamine which is a non-selective alpha adrenergic receptor blocker is used in the management of hypertensive emergencies majorly due to pheochromocytoma. This drug has a vasodilating effect.
Pipolphen ( promethazine) is an antihistamine and is used in the treatment of allergic reactions, motion sickness, anaphylaxis etc. Mesaton is a decongestant and a vasopressor.
Notice that this patient shows signs related to metabolic changes in the body; these signs include weakness, weight loss, frequent urination amongst others. In order to rule out certain disorders such as diabetes, cushing syndrome, pheochromocytoma etc it is necessary to check the fasting glucose level.
Pyloric stenosis is a condition that occurs in babies within the first 6 months. In this case, the pyloric muscle in the stomach becomes enlarged thereby preventing the movement of food from the stomach into the small intestine. Note that in Pyloric stenosis, ‘. The vomit volume exceeds the volume of the previous feeding’ while in pylorospasm, volume does not exceed previous food content. Pyloric stenosis is typically managed with surgery; surgical pyloromyotomy known as Ramstedt's procedure, can also be done laparoscopically. Metoclopramide is an antiemetic drug and can be used to control vomiting.
This patient is experiencing a subarachnoid hemorrhage ( bleeding into the subarachnoid space). From the list of drug groups, anticoagulants ( against coagulation), antiaggregants (against aggregation) and fibrinolytics ( breakdown fibrin) will worsen the current situation if administered. A coagulant will help in the management of the hemorrhagic situation.
A 67-year-old man complains of dyspnea on exertion, attacks of retrosternal pain, dizziness. He has no history of rheumatism. Objectively: pale skin, acrocyanosis. There are crackles in the lower lungs. There is systolic thrill in the II intercostal space on the right, coarse systolic murmur conducted to the vessels of neck. BP- 130/90 mm Hg, heart rate - 90/min., regular rhythm. The liver extends 5 cm from under the edge of costal arch, shin edemas are present. Specify the suspected valvular defect:
Aortic Stenosis: ( most common valvular disease). Causes: Idiopathic, Rheumatic heart disease.
Characteristic Murmur: Heard at aortic area (2nd intercostal space, right sternal border) Ejection-systolic, high pitched murmur with ‘ Crescendo-decrescendo’ character. Radiates to the carotids, often presents with slow rising pulse and narrow pulse pressure. Patients may complain of exertional syncope.
N/B Aortic stenosis causes Left ventricular hypertrophy.
Mitral Regurgitation: Causes: Age related, Ischemic Heart disease, infective endocarditis, Rheumatic diseases,connective tissue disorders eg. Marfan’s syndrome, Ehler Danlos’ syndrome.
Characteristic Murmur: Heard at Mitral area ( 5th intercostal space, midclavicular line), A Pansystolic, high pitched, ‘whistling’ murmur’ which radiates to the left axilla. A 3rd heart sound might be heard.
N/B Mitral Regurgitation causes left atrial dilatation.
Note: Pansystolic murmurs can also be heard in Tricuspid regurgitation (5th intercostal space, left sternal border) and Ventricular Septal defect in children (at the left lower sternal border).
A 24-year-old female teacher 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 an hour or more. The patient has a nearly 2-year history of this disease. Objectively: Ps- 76/min., BP- 110/70 mm Hg. Heart borders are normal, heart sounds are clear. The ECG shows respiratory arrhythmia. Radiograph of the cervicothoracic spine reveals no pathology. Lungs, abdomen are unremarkable. What changes in blood formula can be expected?
Ulcerative colitis involves the continuous inflammation of the mucosa and submucosa of the colon that always involves the rectum. Characterised by the presence of crypt abscess and ulcers, bleeding; patients always present with bloody diarrhea ‘ liquid blood-streaked stools’.
sprue (Tropical and celiac) is a syndrome characterized by acute or chronic diarrhea, weight loss, and malabsorption of nutrients. The celiac form is due to the body’s immune reaction towards a gluten containing diet while the tropical form mostly leads to a decrease in the absorption of vitamins B9 and B12.
Bacillary dysentery is associated with the infection from Enterobacteriaceae; it is most times known as the severe form of shigellosis.
Chief physician of a polyclinic charged a district doctor with a task to determine the pathological prevalence of disease N in his district. What document allows to estimate the disease prevalence in the population of a medical district?
A 32-year-old woman complains of dizziness, headache, palpitation, tremor. For the last several months she has been under outpatient observation for increased arterial pressure. Since recently such attacks have become more frequent and severe. Objectively: the skin is covered with clammy sweat, tremor of the extremities is present. HR- 110/min., BP- 220/140 mm Hg. Heart sounds are muffled. Blood test results: WBCs- 9, 8 · 109 /l, ESR- 22 mm/hour. Blood glucose - 9,8 millimole/l. What disease is the most likely cause of this crisis?
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.
It is stated that the patient has had this condition for 5 years; this rules out the possibility of an Acute form of the disease. The presence of an epigastric pain also confirms the answer isn't a Chronic enteritis. Pain and tenderness in the Mayo robson’s point indicates a pancreatic disorder. N/B Mayo-Robson's point – a point on the border of inner 2/3 with the external 1/3 of the line that represents the bisection of the left upper abdominal quadrant. This is where the tail of the pancreas is located.
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/hour. What index should be determined additionally by a laboratory to make a diagnosis?
Since the patient complains about spontaneous bruises, bleeding gums, numerous hemorrhages of various time of origin, the blood platelet level should be checked. Platelets/ thrombocytes help in blood clot formation.
This patient is experiencing a swallowing disorder; from anamnesis and physical examination. We suspect that the problem lies along the GIT especially within the esophagus.To get a better view of this pathology, an Esophagoduodenoscopy should be carried out. This method involves the use of an endoscope, which is inserted via the mouth down to the duodenum for better visualization of the GIT.
A 9-month-old child presents with fever, cough, dyspnea. The symptoms appeared 5 days ago after a contact with a person suffering from URTI. Objectively: the child is in grave condition. Temperature of 38o C , cyanosis of nasolabial triangle is present. Respiration rate - 54/min., nasal flaring during 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 crackles predominating on the right. What is the most likely diagnosis?
Pneumatic hammer disease is also known as white fingers, traumatic vasospastic syndrome, vasospastic disease of the hands or hypothenar hammer syndrome, It occurs in individuals whose occupation requires the use of huge percussion machines such as hammers, drilling equipment and also in sport related activities such as weightlifting, volleyball. This disorder is as a result disturbed blood flow to the affected hand.
Raynaud phenomenon possess similar physical changes but usually occurs due to temperature changes or emotional distortions.
A 27-year-old woman complains of bleeding gums, nasal hemorrhages, multiple hematomas on the skin of her limbs and on the front of her torso, extreme general fatigue. Blood test: Hb- 64 g/l, erythrocytes - 2, 5 · 1012 /l, reticulocytes - 16%, platelets - 30 · 109 /l, ESR- 22 mm/hour. What approach would be most efficient for treatment of this pathology?
Note that the patient has no history of allergy, no infection or strenuous activity were mentioned; these rule out options B,C and D respectively. Aspirin induced asthma presents with three Keys; An Asthmatic reaction, intake of aspirin or a NSAIDs and presence of nasal polyps (all of which are present in the above case). The disorder is thought to be caused by an anomaly in the arachidonic acid metabolizing cascade. When medications such as NSAIDs or aspirin block the COX-1 enzyme, production of thromboxane and some anti-inflammatory prostaglandins is decreased, and in patients with aspirin-induced asthma, this results in the overproduction of pro-inflammatory leukotrienes ( especially cysteinyl leukotrienes), which can cause severe exacerbations of asthma and allergy-like symptoms.
Acute tonsillitis is an inflammation of the tonsils that frequently occurs in combination with an inflammation of the pharynx (tonsillopharyngitis). It is particularly common in children and young adults and is primarily caused by viruses and group A streptococci (GAS). Acute tonsillitis is characterized by the sudden onset of fever, sore throat, and painful swallowing. Tender, swollen cervical lymph nodes and tonsillar exudates may occur. Recall that white blood cells are classified into granulocytes ( eosinophils, basophils, neutrophils) and agranulocytes ( lymphocytes and monocytes); from analysis ‘ neutrophilic granulocytes ( granulocytes) are practically absent’ while lymphocytes and monocytes ( agranulocyte) are present. From this perspective, we can say this individual has Agranulocitar tonsillitis ( because agranulocytes are mainly represented).
St. Vincent\'s tonsillitis is an ulcero-membranous pharyngitis and tonsillitis caused by Fusospirochetal infection of the pharynx and palatine tonsils. It is characterised by; Superficial ulceration and necrosis of the tonsils and pharynx that often results in formation of a pseudomembrane, Foul smelling breath, Odynophagia ( dysphagia), Submandibular ,lymphadenopathy,Exudate, Patients typically have poor oral hygiene.
A child is 10 years old. The weight is 46 kg. Since birth the child has been gaining excessive weight. The parents are full-bodied. The child has undergone the following tests: carbohydrate tolerance, level of 17-ketosteroids, blood electrolytes, US of adrenal glands, cranium X-ray. The tests revealed no pathologies.The diagnosis of exogenic constitutive obesity has been made. What direction of therapy should be prioritized?
Exogenic ( external cause) obesity is a form of obesity caused by the consumption of food more than one's capacity. Notice that all examinations done on the child were found to have no pathologies ( carbohydrate tolerance, level of 17-ketosteroids, blood electrolytes etc ) this rules out the possibility of an underlying cause of the obesity such as conn’s disease, type 2 diabetes etc. to correct this disorder, diet changes should be made, patient should also undergo regular exercise to lose the weight already gained.
Initial 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.
From anamnesis, we can tell this patient has had prior exposure to contents of mercury, this can be confirmed by the presented symptoms which indicate poisoning by mercury. For the management of mercury poisoning, Unithiol should be administered; it is a chelating agent that is used as a remedy for poisonings by heavy metals. Other chelating agent include dimercaprol, d-penicillamine etc
Atropine sulphate is used as a remedy for organophosphate poisoning, calcium tetacine is used in lead poisoning, amyl nitrite is used for cyanide poisoning.
For first aid after a dog bite, If the skin wasn’t broken, wash the area with warm water and soap. You can also apply an antibacterial lotion to the area as a precaution.
If the skin is broken, wash the area with warm soap and water and gently press on the wound to promote a small amount of bleeding. This will help flush out germs.
If the bite is already bleeding, apply a clean cloth to the wound and gently press down to stop the flow. Follow up with an application of antibacterial lotion and cover with a sterile bandage.
Ascaris lumbricoides is one of the major causes of intestinal obstruction. Ascaris is a round intestinal worm infection transmitted by accidental ingestion of eggs present in human feces that contaminate food, soil, and water in areas of poor hygiene. This obstruction mostly occurs in the ileocaecal valve due to the accumulation of these helminths. Symptoms include abdominal colic, constipation etc
N/B Nikolsky sign is a skin finding in which the top layers of the skin slip away from the lower layers when rubbed. From anamnesis, the mother suffers from chronic pyelonephritis and a case of upper urinary tract infection. This is most likely the source of the newborn’s infection. Impetigo neonatorum is a dermatologically related bacterial infection. It is mostly caused by a staphylococcal aureus or in lesser cases a streptococcus pyogenes The bullous form is mostly seen in children under 2 years while the non bullous form is observed in older persons. Skin elements in the bullous form are characterised by the presence of fluid or pus-filled blisters surrounded by erythemic skin.
pseudofurunculosis, is observed in neonates and infants. The disease begins with the appearance of superficial pustules in the ostium of sweat glands (periporitis). Caused by staphylococcus aureus, which penetrates in the depth of the sweat gland and causes the forming of deep indurated painful nodules. The nodules are very similar to furuncles, but they have not got core in the center (hence the name pseudofurunculosis).
Vesiculopustulosis is a widespread purulent disease, which appears in the first years of life. In the ostium of the sweat glands numerous pustules appear, filled with white yellow matter, the size of a pin head to a small pea, they do not merge with each other and are surrounded by bright edematous circles.
Tonsillitis is considered chronic if it persists for more than 2 weeks- this rules out the option of Acute lacunar tonsillitis ( which is the inflammation of the mucous lining surrounding the tonsillar crypts). The question goes on to describe an inflamed tonsil. In pharyngitis, the patient will present with difficulty in swallowing.
The following indicators were calculated to analyse population health and treatment quality in a cardiological hospital: primary cardiovascular morbidity - 62%; total cardiovascular morbidity - 483,55%; cardiovascular mortality - 10,9%; proportion of cardiovascular mortality within total mortality - 67,0%; primary disablement caused by cardiovascular diseases - 16,2 per 10.000 population. What indicator is an extensive value?
The extensive statistical indicator is used to determine a structure of a disease ( in this case, how many percent ( the proportion) of the total diseased fall under cardiovascular cases) ie., it shows, what part from the general number of all diseases is made with this or that disease which enters into total.
The intensive parameter characterizes frequency or distribution. It shows how frequently the given phenomenon occurs in the given environment.
Artesian well is a type of well from which water flows under natural pressure without pumping. It is dug or drilled wherever a gently dipping, permeable rock layer (such as sandstone) receives water along its outcrop at a level higher than the level of the surface of the ground at the well site. From the above listed options, the artesian well is the best source of clean water.
The T-test is a statistical, hypothetical test used to compare the mean (average) of two related variables. For example comparing the mean of the experimental group to that of the controlled group. It lets you know how significant the differences are.
The Z-test also compares the means of two populations although it relies on the Variance ( the square root of the mean deviation).
A 16-year-old girl has primary amenorrhea, no pubic hair growth, normally developed mammary glands; her genotype is 46 ХY; uterus and vagina are absent. What is your diagnosis?
Testicular feminization syndrome is commonly called complete androgen insensitivity syndrome. This is a genetic condition in which a male (XY) fetus is unresponsive to male hormones ( androgens). This occurs mostly due to defects in androgen receptor resulting in a normal appearing female ( 46, XY DSD) ( DSD- differences in sex development). The individual will present with female external genitalia with scant axillary and pubic hair, rudimentary vagina, uterus and fallopian tubes are absent due to the persistence of the anti-mullerian hormone from the testes.
Mayer-Rokitansky-Kuster-Hauser syndrome is also known as Mullerian Agenesis; it presents with primary amenorrhea due to lack of uterine development in females with fully developed secondary sexual characteristics ( functional ovaries).
A 27-year-old sexually active woman complains of numerous vesicles on the right sex lip, itch and burning. Eruptions regularly appear before menstruation and disappear 8-10 days later. What is the most likely diagnosis?
Herpes simplex viruses are enveloped double stranded linear viruses. HSV-1 is also known as oral herpes ( gingivostomatitis, keratoconjunctivitis etc) while HSV-2 is known as genital or neonatal herpes. The clinical presentation of genital herpes include pain, itching, dysuria, vaginal and urethral discharge, tender lymphadenopathy, appearance of herpes vesicles on the external genitalia, labia majora, labia minora, vaginal vestibule - for women and glans penis, the prepuce, the shaft of the penis, and sometimes on the scrotum, thighs, and buttocks- for men.
Primary syphilis usually presents with a localized painless hard chancre on the genitals.
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?
An aneurysm refers to the bulging out of blood vessels; usually occurs in the aorta or vessels located at the base of the heart septum. In most cases, aneurysm occurs secondary to a myocardial infarction. When the heart muscle (cardiac muscle) partially dies during a heart attack, a layer of muscle may survive, and, being severely weakened, start to become an aneurysm. Blood may flow into the surrounding dead muscle and inflate the weakened flap of muscle into a bubble.
Pylorospasm is a condition in which the Pyloric sphincter fails to relax properly due to continuous contractions (spasms). The key finding here is that vomiting occurs a few minutes after eating and the volume does not exceed previous food content; this helps differentiate it from Pyloric stenosis which occurs due to the narrowing of the pyloric part of the stomach leading to improper digestion. Pyloric stenosis is characterized by splashing sound in the epigastrium, Projectile vomiting followed by an eagerness to take food. In esophageal achalasia, the patient will firstly experience Dysphagia ( difficulty in swallowing) followed by vomiting; this occurs due to failure in the relaxation of the lower esophageal sphincter and peristalsis.
Patent ductus arteriosus is a congenital heart anomaly in which the ductus arteriosus fails to close at birth. PDA is normal in utero and normally closes only after birth. Due to the failure of the ductus arteriosus ( a connection between the aorta and pulmonary artery), oxygenated blood flows from the aorta into the pulmonary artery then back to the lungs for more oxygenation. Key signs include: dyspnea, tachycardia, cyanosis of the lower extremities etc. On objective examination, we observe increased systolic pressure, left subclavicular thrill, a continuous rasping systo diastolic murmur in the 2nd intercostal space on the left; this murmur can also be termed like “a machine gun” or “rolling thunder”. Echocardiogram and normal chest x-ray are used in the diagnosis. One major finding on chest x-ray is the cardiac Silhouette (loss of normal borders between thoracic structures).
Gonadotropin ( luteinizing hormone and follicle stimulating hormone) are hormones that act on the gonads and stimulate the production of sperm ( in males) and ovaries ( in females). LH stimulates the Leydig cells of the testes and the theca cells of the ovaries to produce testosterone (and indirectly estradiol), whereas FSH stimulates the spermatogenic tissue of the testes and the granulosa cells of ovarian follicles, as well as stimulating production of estrogen by the ovaries. Follicle stimulating hormone stimulates the growth of the ovarian follicles thereby enhancing ovulation and menstruation. This patient has problems relating to menstruation and childbirth; a reduction in FSH is most likely the reason behind these changes.
Estrogen is the primary female sex hormone produced in the ovaries and a little from the placenta. It is responsible for puberty changes in females. Progesterone is also a sex hormone, produced from the corpus luteum in the ovaries, just like estrogen, it is involved in changes during pregnancy, menstruation, embryogenesis etc. Note that from examination, there were no pathologic changes of uterus and uterine appendages; this statement rules out the option of estrogen and progesterone ( if these hormones were responsible, there will be a change in uterine appendages eg in the ovaries).
In the presence of kidney stones (urolithiasis), urine builds up ( accumulates) in the urinary tract leading to the dilation, stretching and spasm of these tracts. These corresponding changes lead to the development of painful sensation that radiates towards the groin.
Also called Stein- Leventhal syndrome, Ovarian sclerocytosis is the process of ovarian regeneration, accompanied by the formation of small cystic formations up to 1 cm in size. It usually occurs in patients with polycystic ovarian syndrome. Key findings include; infertility, male pattern hair distribution, weight loss, hormonal disbalance, bilateral enlargement of the ovaries, violation of menstrual cycle etc.
Adrenogenital syndrome ( congenkital adrenal hyperplasia) is a condition characterized by the enlargement of the adrenal gland coupled with the excess production of androgens (sex hormones).
Premenstrual syndrome usually occurs just before a woman’s menses and is characterised by emotional, physical and behavioural changes.
Mining involves the extraction of materials/ minerals from the earth; just like the question states, it involves processes such as drilling, blasting, excavation, sorting etc. Miners are usually exposed to lots of hazards such as earth collapse, dust inhalation, noise, vibrations etc. Of all the above listed hazards, exposure to dust is the most important/frequent hazard to a miners health; depending on the type of dust, this can lead to restrictive lung diseases such as pneumoconiosis, silicosis etc.
In the left mammary gland, we observe the presence of purulent discharge, and presence of a mass. From the above description, this woman should be taken to the surgical department for the drainage of the purulent content and removal of the infiltrate/ mass. A conservative treatment will not be possible at this stage because of the present size of the infiltrate.
Note that acute bronchiolitis and Acute bronchitis are very similar and basically present with almost the same symptoms. One key difference is the age range of people affected ; Bronchitis is found in individuals of all age ranges although mostly seen in older children and adults while bronchiolitis is only found in younger children especially below 2 years. From analysis, we hear vesicular tympanic sound and bubbling rales / crackles - these can be found in both diseases; but the key difference here is the age of the child (3 months).
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.
From the presented symptoms; we can clearly see that this patient has problems with activities regarding muscular action eg.difficulty swallowing, cardiac irregularities etc. From biochemical analysis, we observe an increased aldolase and Creatinine levels. Note that aldolase levels are usually increased in individuals with liver or muscular damage and creatinine levels are also increased in individuals with muscular pathologies; creatinine normal range- 0.5-1.5 mEq/dl. These signs signal the doctor that the problem lies within the muscle; and a muscle biopsy should be carried out for better diagnosis.
Aromatic compounds such as benzene and its products (es nitrobenzene, benzidin etc) are major components in factories producing dyes and resins and upon exposure are dangerous to health. One major negative effect is the conversion of hemoglobin to methemoglobin. In recent times, it has been proved that these compounds act as carcinogens and lead to bladder related tumors.
Chronic Prostatitis is ruled out since the patient wasn’t experiencing pain while passing out urine.
In Chronic Cystitis, the patient often observes severe burning sensation in the pelvic region.
Notice that from the blood analysis, Macrocytes are present- these refer to irregular large Rbcs. The erythrocyte level is also very low ( norm- Female: 3.5 − 5.5 · 1012/L) - this indicates an anemia . The major causes of macrocytic anemia include Vitamin b12 deficiency, Vitamin b9 deficiency or medications such as antiretroviral drugs. Symptoms include loss of appetite, brittle nails , pale skin, fatigue etc.
Ascorbic acid or vitamin C deficiency will lead to scurvy, petechial bleeding or bruises are common in this case.
Ischemic strokes occur when blood flow to the brain is blocked by a blood clot.
There are two major types of ischemic stroke:
Thrombotic strokes are caused when a blood clot forms in an artery leading to the brain.
Embolic strokes begin with a clot forming elsewhere in the body — such as the heart or neck — that breaks loose and travels to the brain.
Patients may experience a combination of symptoms that include numbness or weakness on one side of the body or face, trouble speaking and difficulty with vision or balance.
A hemorrhagic stroke happens when a weak blood vessel bursts and bleeds into the brain.
People who experience this type of stroke, in addition to other stroke symptoms, will likely experience a sudden onset headache or head pain — a warning sign that might not occur during ischemic stroke.
Patients may experience one of the following types:
Intracerebral hemorrhage, a weak blood vessel breaking inside the brain
A subarachnoid hemorrhage, a weak blood vessel breaking on the surface of the brain
Anamnestic assessment is a specific type of clinical assessment whereby the examiner attempts to identify violence risk factors through a detailed examination of the individual's history of violent and threatening behavior. This is a technique in patients clinical assessment.
Hemodialysis is a procedure used for removal of waste materials from the blood through filtration. It is carried out on people with renal failure ( in this patient, the GFR is 10ml/min ( about 90-120 ml/min). Notice that his blood values are not normal; K- 6.5mmol/L ( norm- 3.5-5.5), ,Creatinine - 0.8mmol/l glucose level is also high. Recall that the kidney has three basic functions; filtration, reabsorption and secretion, and a distortion in these values indicates a kidney related issue.
It is stated that there is a 3rd degree hydronephrotic change in the left kidney; Hydronephrosis is swelling of one or both kidneys (dilation of the renal pelvis and calyces). Kidney swelling happens when urine can't drain from a kidney and builds up in the kidney as a result. There are three degrees of Hydronephrosis:
1st degree (mild)- moderate renal pelvis dilation with few calyces
2nd degree (moderate)- full renal pelvis dilation involving all calyces
3rd degree (severe)- includes the above signs coupled with thinning of the parenchyma. In severe hydronephrosis, surgery is recommended.
Neuroleptics are antipsychotic drugs indicated for cases such as schizophrenia, bipolar disorders. They are used in managing psychosis and related symptoms such as delusions, hallucinations, paranoia or disordered thought. Tranquilizers are used in anxiety disorders, fear, tension etc. Nootropics are drugs used in boosting memory and creativity.
The above description is typical for Tinea (pityriasis) versicolor which is caused by malassezia spp. A yeast like fungus. It is characterised by areas of hypopigmentation ‘white spots’. Hyperpigmentation can also occur due to inflammatory response - ‘areas of brown spots .’ It differs from dermatophytes because it is less pruritic (itchy).
Pityriasis rosea is a viral rash that resembles small oval red patches and are very itchy.
Schizophrenia is a mental disorder characterised by disturbances in thought and verbal behaviour,perception, motor behaviour and relationship to the external world. The different clinical types include; Paranoid, disorganised/ hebephrenic, Catatonic, residual or latent, undifferentiated schizophrenia. The described patient is said to have a paranoid schizophrenia; it is characterised by having delusions ( an unrealistic belief) of persecution, reference, control. These delusions are usually well connected and also have no disturbance of speech and motor behaviour.
A catatonic episode is characterised by a marked disturbance of motor behaviour.
Organic delirium is characterised by clouding of consciousness and disorientation.
Delirium tremens also known as Alcohol withdrawal delirium is the most severe form of alcohol withdrawal symptoms. It is characterised by an altered mental status and hyperactivity of the autonomic nervous system. Remember from the question stem, this started a day after one of his drinking bouts.
Delirium tremens occurs in chronic alcohol abusers who abruptly discontinue alcohol use, often as early as 24 - 48 hours. Alcohol acts as a central nervous system depressant. It enhances the effect of inhibitory neurotransmitters while down-regulating excitatory neurotransmitters. Abrupt cessation of alcohol causes a decrease in the inhibitory actions of GABA neurotransmitter resulting in overactivity of the central nervous system.
The overactivity seen with alcohol withdrawal manifests as altered mental status, hallucinations (“may be killed”), anxiety, seizures, tremors, psychomotor agitation, insomnia etc.
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.
This is a case of retained product of conception which probably is an outcome of a missed abortion. Retained product of conception is a very common gynecological condition that you will definitely experience in your everyday Gynecological practice. She had acute respiratory viral infection (ARVI) which must have caused the abortion/miscarriage and presented with bloody discharge along with blood clots with no evidence of a live fetus, just the gestational sac was visible. In such conditions, a curettage or Manual Vacuum Aspiration (MVA) is done to get out the retained product of conception and the bleeding will stop.
Indication for curettage includes Abnormal uterine bleeding: irregular bleeding, menorrhagia, suspected malignant or premalignant condition,Retained material in the endometrial cavity, Evaluation of intracavitary findings from imaging procedures (abnormal endometrial appearance due to suspected polyps or fibroids),
Evaluation and removal of retained fluid from the endometrial cavity (hematometra, pyometra) in conjunction with evaluating the endometrial cavity and relieving cervical stenosis etc.
From 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.
Ileocaecal invagination is also termed ileocaecal intussusception which makes up more than 70% of cases of intussusception in children. Note that the tumour-like formation is in the right iliac area ( the ileocaecal angle - the point at which the ileum and caecum meet). Intussusception is a medical condition in which one section of the intestine gets enclosed or enveloped by another part. Symptoms include, vomiting, abdominal pain, and rectal bleeding (red jelly-like stools).
Wilms tumor is also called nephroblastoma and is a rare tumor that occurs in children, also presents with abdominal pain, anorexia, vomiting, malaise but does not show any signs of rectal bleeding.
Derealization and depersonalization are both types of dissociative disorders. In these cases, the person feels detached or separated from His or her own mental process. In derealization form, the individual feels detached from the environment 9 surrounding) while in depersonalization , the individual feels detached from his/her own life ( the feeling of an outsider). These conditions can be triggered by severe stress. Notice that this patient observes psychological changes in the environment eg buildings, trees etc; this indicates a derealization syndrome. Oneiric syndrome is usually associated with dreams.
The statement ‘isolated small phlyctenas and superficial erosions covered in honey-yellow scabs’ clearly describes an impetigo which is the most common manifestation of streptoderma. Impetigo is characterized by a sudden onset. On the reddened background of the skin appears a bubble, the size of a pea, filled with muddy yellowish contents. This bubble very quickly grows in size, up to 1-2 cm, then it opens, exposing the erosive surface with scraps of the epidermis around the periphery. Almost instantly occurs drying of this element with the formation of honey-yellow crusts. This is accompanied by severe itching.
The contact with chemicals led to the edematic reaction in the worker’s larynx. Recall that the larynx is the voicebox; this is why the edematic reaction presents with symptoms such as stridor, voice hoarseness, barking cough etc.
A person is said to be in a state of hypertensive crisis if the blood pressure exceeds 180mmhg for systolic and 110mmhg for diastolic pressure. The above patient presents with signs of ventricular hypertrophy and overload which complicates his current state of a hypertensive emergency. Other complications of hypertensive crisis include pulmonary edema, a stroke, aneurysm, heart failure etc.
Eczema (dermatitis ) is a chronic inflammatory disease of the skin characterized by the presence of red, itchy, dry scaly rashes. Occupational or professional eczema (dermatitis) is gotten from contact with certain chemicals in the course of working (in this case due to contact with the chemicals in paint ). Allergic dermatitis is a form of contact dermatitis that results from immune reactions towards certain irritants.
For resuscitation of the baby, the CAB approach should be used ( circulation, airway and breathing). From the question, we see that the baby’s circulation is present although reduced ( HR- 80 bpm; should be higher for babies); to assist the baby in breathing, An ALV ( assisted lung ventilation should be used). An intubation is only done if there is a restriction or obstruction in the upper airways or in cases.
An echocardiography is a procedure used in checking the live images of the heart. Information from this procedure shows: Changes in your heart size, Pumping strength, Damage to the heart muscle, Valve problems, Heart defects.
An electrocardiography is a procedure that records electrical signals of the heart. It provides information about the heart rate, rhythm, Inadequate blood and oxygen supply to the heart, Heart attack and some structural abnormalities.
A phonocardiography is the recording of the sounds from the heart.
Cancer of the head of the pancreas appears near the common bile duct. From an early stage, they tend to compress this duct leading to an obstruction in bile flow( causing an obstructive jaundice). Note that Cholecystitis usually presents with tenderness (peritoneal irritation) in the right upper quadrant and signs of systemic infection (pyrexia, raised leukocyte count, raised C-reactive protein). The above patient presents with none of these symptoms thereby ruling out the options of cholecystitis.
Reactive arthritis is an autoimmune condition that develops in response to an infection in another part of the body. Coming into contact with bacteria and developing an infection can trigger reactive arthritis. It has symptoms similar to various other conditions collectively known as "arthritis,". It is caused by another infection and is thus "reactive". The symptoms of reactive arthritis very often include a combination of three seemingly unlinked symptoms—an inflammatory arthritis of large joints, inflammation of the eyes (conjunctivitis and uveitis), and urethritis. A useful mnemonic is "the patient can't see, can't pee and can't bend the knee" or "the patient can't see, can't pee and can't climb a tree". Also known as Reiter’s syndrome.
Average duration of in-patient treatment refers to the Average length of stay; calculated by dividing the sum of inpatient days by the number of patients admissions with the same diagnosis-related group classification.
Hospital Bed Turnover Rate is the number of times there is change of occupant for a bed during a given time period
It is given by the formula:
Hospital Bed turnover rate = Number of discharges (including deaths) in a given time period / Number of beds in the hospital during that time period.
Bed occupancy rate is calculated by the no. of beds occupied (bed days) divided by the total no. of beds available for a year, all multiplied by 100%.
Prehepatic/ hemolytic - occurs due to increased breakdown of RBC eg, hemolytic disease of newborn. There is an increased level of unconjugated bilirubin. Stool and urine colour are normal.
Hepatic/ parenchymatous - Occurs in diseases affecting the liver parenchyma eg, cirrhosis, hepatitis etc. There is an increase in both unconjugated and conjugated bilirubin. Urine appears dark and faeces pale.
Post hepatic/ obstructive/ mechanical jaundice - pathology lies after conjugation of bilirubin and is caused by obstruction of biliary path. Conjugated bilirubin is accumulated, Urine is dark and faeces pale or acholic. Seen in disease such as cholelithiasis.
Notice that the result of the CT shows a bulky mass in the sella; anatomically, the pituitary gland is located in the sella turcica of the sphenoid bone and a bulky formation of such diameter in this location indicates the presence of a tumour. Furthermore, Prolactin levels are twice the normal; this hormone is produced from lactotrophs present in the anterior pituitary gland. The increased production is mostly as a result of the tumour.
Lactational amenorrhea is observed in breastfeeding mothers; the period after child birth in which the lactating mother doesn't menstruate.
From ultrasound, we observe the reduction in size of the right kidney; this may be due to a reduction in blood flow or a chronic infection ( as earlier stated, she previously had a case of pyelonephritis). Due to the constriction of the renal artery, the kidney releases Renin (from juxtaglomerular cells). This renin converts angiotensinogen (produced in the liver) to angiotensin I; Angiotensin I is then converted to angiotensin II by angiotensin converting enzyme, ACE ( an enzyme produced in the vascular endothelial cells of the lungs). Angiotensin II then stimulates the secretion of aldosterone from the adrenal cortex. In this system, angiotensin II is a potent vasoconstrictor that assists in the Increase of blood pressure.
Atrial Septal Defect: A mid-systolic, Crescendo-decrescendo murmur, loudest at the upper left sternal border with a ‘fixed split second heart sound’.
N/B S2 split is normal during inspiration but a fixed split means both during inspiration and expiration.
Patent Ductus Arteriosus: Normal S1 with a continuous Crescendo-decrescendo ‘Machinery’ murmur ( machine gun like) or A systolodiastolic murmur in the II intercostal space on the left. This murmur may continue during the second heart sound, making the 2nd second heart sound difficult to hear.
N/B small sized PDA presents with no abnormal sound.
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.
Enterovirus infections (ECНO and Coxsackie’s infections) a group of an acute diseases caused by ECНO and Coxsackie’s enteroviruses, that are characterized by the variety of clinical displays from the mild fever and simple carrying of virus to protracted meningoencephalitis, myocarditis, myalgia and other. Notice that the cell count in the CSF is 90% lymphocytes which indicates a viral cause; for bacterial origin, the cell count will be mainly neutrophils. Enterovirus is the only viral cause amongst the listed agents.
Mastitis is inflammation of the breast tissue and can be broken down into lactational and non-lactational mastitis. Lactational mastitis is the most common form of mastitis. Lactational mastitis, also known as puerperal mastitis, is typically due to prolonged engorgement of milk ducts, with infectious components from the entry of bacteria through skin breaks. Patients can develop a focal area of erythema, pain, and swelling, and can have associated systemic symptoms, including fever. This occurs most commonly in the first six weeks of breastfeeding but can occur at any time during lactation, with most cases falling off after 3 months. Lactational mastitis is most commonly caused by bacteria that colonize the skin, with Staphylococcus aureus being the most common. Risk factors for lactational mastitis include prior history of mastitis, nipple cracks and fissures, inadequate milk drainage, maternal stress, lack of sleep, tight-fitting bras, and use of antifungal nipple creams.
From the question stem, we can differentiate the different types of mastitis listed. On palpation, an INFILTRATE was found with an area of softening and fluctuation (PURULENT). We can boldly conclude it is purulent because lactational/puerperal mastitis is commonly caused by bacteria which will produce a purulent inflammation.
Malabsorption syndrome is observed when the small intestine is unable to absorb certain nutrients and fluid into the bloodstream. Causes include trauma, surgery, infection, deficiency diseases, underlying diseases such as pancreatitis, cystic fibrosis etc. This patient has a history of chronic pancreatitis; recall that the pancreas produces enzymes that help in digestion ie., trypsin, chymotrypsin, lipase, amylase. In the absence of these enzymes, certain food materials will not be broken down properly thus, absorption will be disturbed.
Irritable colon or irritable bowel syndrome is accompanied by symptoms such as cramping abdominal pain, diarrhea, constipation, bloating and gas etc
Note that The patient above presents with no kidney related issue thereby ruling out the option of Enalapril ( an ACE inhibitor), furosemide (loop diuretic) and hydrochlorothiazide (thiazide diuretic) - these drugs will be the first to be considered in a case of hypertension coupled with a kidney related issue. Bisoprolol ( beta blocker) is the best possible choice, It is a beta 1 selective blocker and acts by competitively blocking adrenaline’s stimulation of beta 1 adrenergic receptors causing a reduction of heart rate and increase in contractility.
Also take note of the ejection fraction ( 55-70 % is the normal)- this patient’s ejection fraction is low which indicates a reduction in the heart’s pumping ability ( contractility); as earlier stated, beta 1 blockers increases heart contractility.
From physical examination, there is a dense tumor ‘without clear margins’ in the right mammary gland - this description is typical for breast cancer. Signs of breast cancer include; presence of lumps in the breast, change in size and shape of the breast, skin depression in the affected area, swollen lymph nodes etc.
A breast lipoma is a non-cancerous tumor (benign) tumor composed of adipose ( fatty) tissues with a thin fibrous capsule around it. These types of tumors have clear margins.
A lacteal cyst is also called galactocele; usually seen shortly after lactation and is characterised the presence of a milk filled cavity
Note that this patient has a somatoform autonomic dysfunction- which is more a mental disorder than physical. The symptoms are presented by the patient as if they were due to a physical disorder of a system or organ that is largely or completely under autonomic innervation and control, i.e. the cardiovascular, gastrointestinal, respiratory, and urogenital systems. Physically, nothing is wrong with the patient. This patient should get an outpatient treatment.
Recall that in outpatient care, the individual does not need to be admitted into the hospital whereas inpatient care requires admission.
Observe that the levels of WBC, hemoglobin and platelets are very low. This can be traced to the effect of radiation from around his workplace. Working in this environment should be prohibited for this individual because of the health effects.
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.
Premenstrual syndrome is a wide variety of signs and symptoms that affects a woman’s emotion, physical health, and behavior during certain days of the menstrual cycle, generally just before her menses. Symptoms start five to 11 days before menstruation and typically go away once menstruation begins. Signs include abdominal pain and bloating, vomiting ,meteorism, change in sleep patterns, emotional instability etc.
Sheehan’s syndrome is one of the major causes of hypopituitarism in females; it is due to pituitary infarction as a result of postpartum hemorrhage. fatigability, significant weight loss, weakness, and loss of appetite all include associated symptoms.
Recall that most infections of the paranasal sinuses and mastoid process spread to the surrounding structures eg brain if not treated on time and properly. From Anamnesis, this patient had a surgical procedure carried out for the issue of suppurative otitis media and mastoiditis. The positive kernig’s sign and the result from the romberg’s maneuver indicates a neurological dysfunction most likely from the spread of the initially stated pathology ( otitis and mastoiditis). A brain abscess refers to a pus filled cavity in the brain; the result from the CT confirms this diagnosis.
In echinococcus, a cerebral hydatid cyst is usually found with a history of contact with infected dogs.
Rh Antibody Titre test is done to determine the type and quantity of antibodies in the blood. Rh antibodies are likely to rise during pregnancy. Depending on the level of other antibodies these antibodies could cause hemolytic problems in the baby and need to be monitored. It is usually repeated several times during pregnancy (at 32, 36, & 38 weeks). A low titer (less than 1:16) may not pose any problem for the baby. any test from 1:64 or higher, is indicative of incompatibility. Notice that the patient has previously had 2 fetal deaths from this incompatibility, to save the current situation, an early delivery should be induced.
Acute Urinary Retention is a Sudden inability to urinate. The patient experiences increasingly agonizing suprapubic pain associated with severe urgency and may dribble (release) only small amounts of urine. Urinary retention is characterised by poor urinary stream with intermittent flow, straining, a sense of incomplete voiding, and hesitancy (a delay between trying to urinate and the flow actually beginning). As the bladder remains full, it may lead to incontinence, nocturia (need to urinate at night), and high frequency. Notice that this patient has only had this for 8 hours (a short period); in the chronic form, it might last for days and also be recurrent.
paradoxal Ischuria is a form urinary incontinence that occurs when the bladder is so full that it continually leaks urine; often attributable to a blocked urethra (e.g., due to prostate enlargement) or weak bladder muscles or nerve damage.
From the description above, the patient is said to have an Immune complex Vasculitis. This is a form of vasculitis, which is characterized by the deposition of immunoglobulin and/or complement on the vessel wall. It affects mainly small vessels and the kidneys; we can confirm this by the presence of hemorrhagic rash and signs of a kidney related disorder ( proteinuria, erythrocytes and cylinders in blood).
Observe that the platelet levels is normal ( norm. 150-400 · 109/l); this rules out the option of a platelet dysfunction.
From anamnesis, The patient had a respiratory infection 3 days prior and now presents with a skin lesion most likely caused by an infection. An etiological treatment is one which is directed at the causative agent ( in this case the microorganism). Augmentin is an antibacterial combination ( amoxiclav) which consists of Amoxicillin and clavulanic acid ( beta lactamase inhibitor). Diclofenac sodium will be used for symptomatic treatment since its effects are on pain and inflammatory reduction.
Kwashiorkor is a disease marked by severe protein malnutrition and bilateral extremity swelling. It usually affects infants and children. It should be differentiated from marasmus which is energy or calorie deficiency. For the correction of kwashiorkor, foods rich in protein should be taken eg, fish, meat, cereals, milk etc.
Atropine is an Anticholinergic drug, it is a competitive antagonist of the muscarinic acetylcholine receptor types M1, M2, M3, M4 and M5. About its effect on the heart, atropine is used in treatment of bradycardia, second-degree heart block Mobitz type 1 (Wenckebach block), and also third-degree heart block with a high purkinje or AV-nodal escape rhythm. It is usually not effective in second-degree heart block Mobitz type 2, and in third-degree heart block with a low Purkinje or ventricular escape rhythm.
A breast abscess is a localised collection of pus in the breast tissue. It is usually caused by a bacterial infection. It is characterised by the presence of a lump on palpation (painful infiltrate can be palpated), swollen and painful nipple. In mastopathy, we observe changes such as swellings, nodules, cysts etc, it is hormone dependent. In cancer, there will be increased proliferation of atypical tissues.
Note: Ejection-systolic murmurs can also be heard in Pulmonary valve stenosis (2nd intercostal space, left sternal border) and Hypertrophic Obstructive Cardiomyopathy in children (4th intercostal space on the left sternal border).
Android type obesity can be differentiated from the gynoid form by the location of fat storage. In the android form, fat is stored in the abdominal region while in the gynoid form, fats are stored around the thighs and hip area. This patient has the android form because his fats distribution is around the abdominal region.
Recall that the hypothalamus controls our rate of eating and drinking; a secondary hypothalamic obesity will be seen in a patient with a hypothalamic tumour or lesion. In neuroendocrine obesity, hormones that control fats breakdown and metabolism especially those produced from the pituitary gland are disturbed.