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Question 1 of 200

1. A 34-year-old man complains of pale edema of the face, feet, shins, and lumbar area, elevated blood pressure up to 160/100 mm Hg, and general weakness. He has a clinical history of nonspecific ulcerative colitis. Objectively: pulse - 84/min., rhythmic, blood pressure - 165/100 mm Hg; edemas all over the body; the skin is pale and dry, with low turgor. The kidneys cannot be palpated, on an attempt to palpate them they are painless. Blood test: erythrocytes - 3.0∙1012/L, Hb - 100 g/L, erythrocyte sedimentation rate - 50 mm/hour. Urinalysis: proteins - 3.5 g/L, erythrocytes - 7-10 in the vision field, leukocytes - 5-6 in the vision field. Daily proteinuria - 6 grams. What analysis should be conducted additionally to verify the diagnosis?

Explanation

2. After overexposure to cold a 45-year- old woman developed acute pain in her suprapubic and lumbar areas during urination, sharp pains at the end of urination, false urges to urinate. Urine is turbid with blood streaks. The doctor suspects urinary tract infection. What results of laboratory analysis would be the most indicative of such infection?

Explanation

Urinary tract infections are commonly associated with dysuria, urinary frequency, urinary urgency and lumboabdominal pains.

When you have a UTI, the lining of the bladder and urethra become inflammed and irritated just as your throat does when you have phrayngitis, common cold - upper respiratory tract infections. The irritation can cause pain in your lower abdomen - pelvic area and even lower back, and will usually make you feel like urinating more often (false urges). Burning or pain when urinating is the most common symptom. You may even feel a strong urge or need to urinate but only get a few drops. This is because the bladder is so irritated that it makes you feel like you have to urinate, even when you don't have much urine in your bladder. UTIs can be found by analyzing a urine sample for Urine Microscopy/Culture/Sensitivity (Urine M/C/S). The urine is examined under a microscope for bacteria or white blood cells (leukocyturia), which are signs of infection. Blood can also be found in the urine sample (hematuria); this can be due to an infective or mechanical cause.

 

The other options given are more specific for kidney pathologies - proteinuria, gross hematuria, creatinine and urea. Rarely are they elevated in pathologies relating to Urinary Tract Infections except in cases where UTI’s become complicated and the kidney is affected after a prolonged and untreated UTI.

3. A 40-year-old man with Bekhterev disease (ankylosing spondylitis) complains of elevated body temperature up to 37.8°C, back pain and stiffness, especially observed during the second half of the night. This condition has been lasting for 2 years. Objectively: reduced spinal mobility, painful sacroiliac joint, erythrocyte sedimentation rate - 45 mm/hour. X-ray shows narrowing of the intervertebral disc space and of the sacroiliac joint. What eye pathology is often associated with this type of disease progression?

Explanation

Ankylosing Spondylitis(AS) is a type of arthritis. It causes pain and stiffness, mainly in your spine. But it can also cause eye inflammation called uveitis. Left untreated, uveitis can harm your vision and, in some cases, lead to blindness.

Uveitis - An inflammation of the middle layer of the eye (uvea).

The most common type is an inflammation of the iris called iritis (anterior uveitis). If the ciliary body is also involved, it is called iridocyclitis.

About half of people with ankylosing spondylitis have uveitis at least once. It’s one of the most common complications of that form of arthritis.

Your eye doctor could actually be the first to figure out you have AS. That’s because the same inflammation that makes your back hurt can also cause inflammation in your eyes and other parts of your body.

4. A 27-year-old man complains of pain in his leg joints, purulent discharge from the eyes, and painful burning sensations during urination. Disease onset was acute. He has a history of influenza. The patient smokes and drinks alcohol in excess. In his line of work he is often away on business trips. What is the most likely etiological factor of this disease?

Explanation

Reactive arthritis is an inflammatory arthritis which manifests after several days to weeks after a gastrointestinal or genitourinary infection. It is also described as a classic triad of arthritis, urethritis and conjunctivitis. However, a majority of patients do not present with the classic triad. It was previously called "Reiter syndrome."

Classic triad:

Conjunctivitis: purulent discharge from the eyes

Urethritis: painful burning sensations during urination

Arthritis: pain in leg joints

 

Reactive arthritis is known to be triggered by a bacterial infection, particularly of the genitourinary (Chlamydia trachomatis, Neisseria gonorrhoeae, Mycoplasma hominis, and Ureaplasma urealyticum) or gastrointestinal (GI) tract (Salmonella enteritidis, Shigella flexneri, and dysenteriae, Yersinia enterocolitica, Campylobacter jejuni, Clostridium difficile). 

The classic triad can be remembered using this:

 

Conjunctivitis; Urethritis; Arthritis - Can’t See; can’t pee, can’t bend my knee

 
5. After a long drive with the window open a man developed facial asymmetry; he cannot close his right eye, his right nasolabial fold is smoothed out, movements of expression are absent on the right, there is a disturbance of gustatory sensation in the tongue on the right. No other neurological pathologies were detected. What disease can be provisionally diagnosed in this patient?

Explanation

 

Bell's palsy is a form of facial paralysis resulting from a dysfunction of the cranial nerve VII (the facial nerve). Signs include an impaired facial expression on the affected side, drooping of the eyelid, a change in taste, pain around the ear, and increased sensitivity to sound etc. In trigeminal neuropathy, sensation of the face is disturbed. 

6. During an outdoors school event in hot weather, a 10-year-old girl lost her consciousness. Body temperature - 36.7°C. Objectively her skin is pale and cold to touch, her pupils are dilated. Blood pressure - 90/50 mm Hg. Heart rate - 58/min. What pathology occurred in this case?

Explanation

Syncope is a temporary loss of consciousness usually related to insufficient blood flow to the brain. It's also called fainting or "passing out." It most often occurs when blood pressure is too low (hypotension 90/50mmHg) and the heart doesn't pump enough oxygen to the brain. 

Syncope is a symptom that can be due to several causes, ranging from benign to life-threatening conditions. Many non life-threatening factors, such as overheating, dehydration, heavy sweating (this patient was outdoors in hot weather), exhaustion or the pooling of blood in the legs due to sudden changes in body position, can trigger syncope.

 

Heat stroke is also sometimes referred to as sun stroke. It is severe hyperthermia and defined as a body temperature of 104 F (40 C) or higher. Patient’s body temperature - 36.7C.

7. A 47-year-old man developed the signs of decompensated laryngeal stenosis against the background of acute flegmonous laryngitis. He presents with inspiratory dyspnea at rest, forced position, cyanotic skin covered in cold sweat, tachycardia, deficient pulse, and low blood pressure. What urgent treatment tactics should be chosen?

Explanation

Tracheotomy Tube

Stenosis of the Larynx: narrowing of the larynx resulting in difficulty breathing through it.

Phlegmonous laryngitis: acute inflammatory disease of the larynx characterized by a purulent process that spreads through the submucous, muscular, sometimes perichondrium and cartilages, often caused by bacteria. At the development of acute laryngeal stenosis, urgent tracheostomy is indicated.

A tracheostomy is an opening (made by an incision) through the neck into the trachea (windpipe). A tracheostomy opens the airway and aids breathing. This opening is made below the stenotic process (Tracheostomy - incision made on the trachea which is below the larynx in order to bypass the stenosis). A tracheostomy may be done in an emergency, at the patient’s bedside or in an operating room.

A tracheostomy (trach) tube is a small tube inserted into the tracheostomy to keep the stoma (opening) clear. Tracheostomy tubes are available in several sizes and materials including semi-flexible plastic, rigid plastic or metal. The tubes are disposable or reusable. They may have an inner cannula that is either disposable or reusable.

Urgent Tracheostomy is the best choice in this case so as to clear the airway for the patient to breath properly before other management plans can be initiated.

8. 10 hours after birth a child developed jaundice, hypotonia, hyporeflexia, and moderate hepatosplenomegaly. Feces and urine are of normal color. Umbilical cord blood bilirubin is 51 mcmol/L due to unconjugated bilirubin levels. In venous blood: erythrocytes - 3.5∙1012/L, Hb - 140 g/L, reticulocytes - 1.5%, bilirubin - 111 mcmol/L, conjugated - 11 mcmol/L, ALT - 40 U/L, AST - 30 U/L. Mother’s blood group is A(II) Rh(-), child’s blood group is A(II) Rh(+). What laboratory test can confirm the diagnosis?

Explanation

9. A 51-year-old man complains of vomiting with blood. He has been drinking alcohol excessively. Health disorder has been observed since he was 40, when he first developed jaundice. On examination the skin and visible mucosa are icteric, with a stellate vascular pattern. The patient is malnourished and presents with abdominal distension, umbilical hernia, and ascites. The edge of the liver is tapered and painless, +3 cm, the spleen is +2 cm. Blood test: Hb - 80 g/L, leukocytes - 3∙109/L, platelets - 85∙109/L. What is the cause of portal hypertension in this patient?

Explanation

Cirrhosis is a complication of liver disease that involves loss of liver cells and irreversible scarring of the liver. The scarring is accompanied by loss of functioning liver cells. Cirrhosis is usually a late-stage disease of the liver that is not reversible in severe cases.

Hepatitis B, C, and chronic alcohol abuse are frequent causes (Question stem - patient takes alcohol excessively). Initially patients may experience fatigue, weakness and weight loss. During later stages, patients may develop jaundice (yellowing of the skin), gastrointestinal bleeding, abdominal swelling and confusion.

The most common cause of portal hypertension is cirrhosis of the liver. Portal hypertension is an increase in the blood pressure within a system of veins called the portal venous system. Veins coming from the stomach, intestine, spleen, and pancreas merge into the portal vein, which then branches into smaller vessels and travels through the liver. If the vessels in the liver are blocked due to liver damage, blood cannot flow properly through the liver. As a result, high pressure in the portal system develops.

 

Budd-Chiari syndrome is a condition in which the hepatic veins (veins that drain the liver) are blocked or narrowed by a clot (mass of blood cells). It may lead to portal hypertension, ascites, cirrhosis etc. Budd-Chiari syndrome can be caused by conditions and situations that cause your blood to clot (form a blockage) like sickle cell disease, pregnancy, myeloproliferative disorders. It is not caused by excessive alcohol intake or Hepatitis.

 

Hemochromatosis, Constrictive Pericarditis and Thrombosis of the splenic vein will not directly lead to portal hypertension.

 
10. An 18-year-old patient always obeys others and adapts his needs to the demands of the people on whom he depends. He excessively defers to their wishes and makes them responsible for his wellbeing, cannot defend his interests and needs support from other people. Such psychic profile has been formed in the childhood, remains unchanged, and hinders adaptation. What psychic disorder is observed in this patient?

Explanation

Dependent personality disorder (DPD) is an anxious personality disorder characterized by an inability to be alone. People with DPD develop symptoms of anxiety when they’re not around others. They rely on other people for comfort, reassurance, advice, and support. They are emotionally overdependent on other people and spend great effort trying to please others. People with DPD tend to display needy, passive, and clinging behavior, and have a fear of separation.
11. A 45-year-old man with thrombophlebitis of the deep veins in his legs suddenly after physical exertion developed sharp pain in his thorax on the right, dyspnea, and hemoptysis. Objectively his condition is severe; he presents with acrocyanosis, shortening of pulmonary percussion sound on the right, and weakened respiration. Respiration is 30/min., blood pressure is 110/80 mm Hg. ECG shows sinus tachycardia, heart rate is 120/min., electrical axis of the heart deviates to the right, SI- QIII. What is the most likely diagnosis?

Explanation

Most times, a pulmonary embolism is caused by blood clots that travel from the legs, or rarely, other parts of the body (deep vein thrombosis or DVT). Pulmonary embolism is caused by a blocked artery in the lungs. Pulmonary embolism is the sudden blockage of a major blood vessel (artery) in the lung, usually by a blood clot. In most cases, the clots are small and aren't deadly, but they can damage the lung. But if the clot is large and stops blood flow to the lung, it can be deadly.

This patient suffers from thrombophlebitis of the deep veins which is a risk factor for developing Pulmonary Embolism. Almost all blood clots that cause pulmonary embolism are formed in the deep leg veins. Clots also can form in the deep veins of the arms or pelvis. Sometimes blood clots form in surface veins. But these clots rarely lead to pulmonary embolism.

The most common symptoms of pulmonary embolism are:

 
  • Sudden shortness of breath.

  • Sudden, sharp chest pain that's worse when you cough or take a deep breath.

  • A cough that brings up blood or pink, foamy mucus (hemoptysis).

12. A 15-year-old girl complains of dizziness and sensation of lack of air that she develops in emotionally straining situations. Relief occurs after she takes corvalol. Objectively: hyperhidrosis and marble-like pattern of the skin of her palms and feet. Clinical and instrumental examination revealed no organic changes in the central nervous, cardiovascular, and respiratory systems. What provisional diagnosis can be made?

Explanation

 

In Somatoform Autonomic dysfunction, 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. Notice that this patient experiences these symptoms only during emotional stress, Clinical and instrumental examination revealed no organic alterations in any system therefore indicating a somatoform autonomic dysfunction.

13. A middle school teacher with 4-year-long record of work was issued a medical certificate for pregnancy and childbirth leave. What amount of pay will she receive for the duration of her leave in this case?

Explanation

14. A 53-year-old man complains of general weakness, loss of appetite, and painful vesicles appearing on his skin. The disease onset occurred suddenly, after hyperinsolation one week ago. Examination detects isolated vesicles with wrinkled opercula and occasional painful erosions on the skin of the patient’s torso and limbs. Nikolsky sign is positive. What is the most likely diagnosis?

Explanation

Nikolsky's sign has been a very useful diagnostic tool in cases of skin disorders like pemphigus, toxic epidermal necrolysis, etc., The sign is demonstrated when lateral pressure is applied on the border of an intact blister, which results in the dislodgment of the normal epidermis and extension of the blister. For the Nikolsky sign in patients with active blistering, firm sliding pressure with a finger separates normal-appearing epidermis, producing an erosion. This sign is made possible due to the loss of cell-to-cell adhesion in the epidermis.

Acantholysis is the loss of intercellular connections, such as desmosomes, resulting in loss of cohesion between keratinocytes, seen in diseases such as pemphigus vulgaris. It is absent in bullous pemphigoid, making it useful for differential diagnosis. Hence, Nikolsky’s sign will be negative in non-acantholytic pemphigus.

Nikolsky's sign is pathognomonic for pemphigus, toxic epidermal necrolysis, and staphylococcal scalded skin syndrome (SSSS). This sign basically differentiates intraepidermal blisters from subepidermal blisters.

 

Toxicoderma are usually caused by drugs and this patient has no history of taking any medication that would have resulted in toxicoderma. Dermatitis herpetiformis is an autoimmune blistering disorder associated with a gluten-sensitive enteropathy (patient wasn’t diagnosed of celiac disease). Herpes usually presents as grouped vesicles, meanwhile, on examination of the patient isolated vesicles were detected.

15. A 45-year-old woman came to the maternity clinic with complaints of periodical pains in her mammary glands that start 1 day before menstruation and stop after the menstruation begins. Palpation of the mammary glands detects diffuse nodes predominantly in the upper outer quadrants. What is the most likely diagnosis?

Explanation

A fibrocystic mastopathy is a benign condition of the breast, it is the most common disorder of the female breast. Fibrocystic change is characterised  by hyperplastic overgrowth of components of the mammary unit, i.e lobules, ductules and stroma. In this condition, there are 4  characteristic features namely: Fibrosis (an increase in the amount of collagen rather than true growth of fibrous tissue), Adenosis (an increase in the number of lobules and in the size of existing lobules), Cyst formation (cyst are lined by flattened epithelium derived from lobal ductal unit and are filled with watery fluid) and Fibrocystic changes (most commonly epithelial hyperplasia).

 

A mastitis is simply an inflammation of the mammary gland.

16. A 48-year-old woman developed insomnia, depressive mood, anxiety, fears and suicidal thoughts after the death of her husband that occurred one month ago. During her stay in the hospital she speaks in a low voice, is depressed, anxious, avoids sleeping, refuses to eat. What medications should be prescribed in this case?

Explanation

The question specifies that the described lady is Depressed therefore, antidepressant is the best choice among the listed groups. Antipsychotic drugs/neuroleptics are used in cases of Schizophrenia or bipolar disorders. Nootropics are memory enhancing drugs.

Examples of antidepressants:

 
  • Tricyclic antidepressants: Amitriptyline, Imipramine

  • Monoamine oxidase inhibitors: Selegiline

  • Selective Serotonin reuptake inhibitors: Fluoxetine, Paroxetine, Sertraline

  • Serotonin-Norepinephrine reuptake Inhibitors: Venlafaxine, Duloxetine

17. A 22-day-old infant developed subcutaneous red nodes from 1.0 to 1.5 cm in size on the scalp; later the nodes suppurated. Temperature increased up to 37.70C, intoxication symptoms appeared, regional lymph nodes enlarged. Complete blood count: anemia, leukocytosis, neutrocytosis, increased ESR. What diagnosis can be made?

Explanation

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.

18. The 5-year-old child has been ill for 2 weeks. Cough attacks developed first and were then followed by reprises. During coughing the child’s face turns red and cervical veins bulge. The cough attacks induce vomiting. X- ray shows intensified bronchial pattern. Blood test: leukocytes - 16∙109/L , lymphocytes - 72%, erythrocyte sedimentation rate - 4 mm/hour. What is the most likely diagnosis?

Explanation

Pertussis (whooping cough) is caused by Bordetella pertussis - a gram negative bacteria, aerobic cocobacillus (rod).

It can be prevented by pertussis vaccine.

 

The disease usually starts with cold-like symptoms and maybe a mild cough or fever. Early symptoms can last for 1 to 2 weeks.

After 1 to 2 weeks and as the disease progresses, the traditional symptoms of pertussis may appear and include:

* Paroxysms (fits) of many, rapid coughs followed by a high-pitched “whoop” sound

* Vomiting (throwing up) during or after coughing fits

* Exhaustion (very tired) after coughing fits

 

Child coughs on expiration and “whoops” on inspiration. Pertussis can cause violent and rapid coughing, over and over, until the air is gone from your lungs. When there is no more air in the lungs, you are forced to inhale with a loud “whooping” sound. This extreme coughing can cause you to throw up and be very tired.

 
19. A woman has been provisionally diagnosed with pheochromocytoma. At the stage of intermission her BP is within norm; there is a tendency towards tachycardia. No urine pathologies. The decision has been made to perform a provocative test with histamine. What drug should be kept close at hand for emergency aid in case of positive test result?

Explanation

It is important to note that certain drugs can be used for the diagnosis of Pheochromocytoma (a tumor of the adrenal medulla). The Histamine test was the first test introduced and later on drugs such as  piperoxan, tetraethylammonium bromide, methacholine chloride  and phentolamine hydrochloride (Regitine) were added. Histamine, tetraethylammonium bromide, and methacholine chloride (Mecholyl) stimulate the discharge of the pressor substances from the tumor. Thus, tests with these drugs are useful in cases of paroxysmal hypertension to produce attacks similar to those that occur spontaneously. Phentolamine (Regitine) and piperoxan (Benzodioxane), on the other hand, lower blood pressure by blocking the pressor effect of epinephrine and norepinephrine in the blood if a pheochromocytoma is present.
20. A 46-year-old woman came to the maternity clinic with complaints of moderate blood discharge from the vagina, which developed after the menstruation delay of 1.5 months. On vaginal examination: the cervix is clean; the uterus is not enlarged, mobile, painless; appendages without changes. Make the diagnosis:

Explanation

A dysfunctional uterine bleeding (DUB) is the bleeding, not associated with organic diseases of women’s genitals, interrupted pregnancy or systemic diseases of the organism.

 

The dysfunctional uterine bleeding can appear at any age. Depending on the time of their onset, juvenile bleeding (at childhood and in period of pubescence), bleeding of reproductive period, climacteric bleeding are classified. DUB are the manifestations of initial stages of neuroendocrinological diseases, especially of blood diseases. From the question stem, on examination, the cervix is clean, the uterus is not enlarged and shows no pathologic changes.

21. In the inpatient gynecological unit within a year 6500 women underwent treatment. They spent there a total of 102000 bed-days. What indicator of the gynecological unit work can be calculated based on these data?

Explanation

22. A 52-year-old man for the last 3 years has been suffering from difficult swallowing of solid food, burning retrosternal pain that aggravated during eating, loss of body mass, and occasional vomiting with undigested food. Esophageal X-ray shows S-shaped deformation of the esophagus and its dilation; at the cardiac orifice the esophagus is constricted; esophageal mucosa is smooth, without signs of peristalsis. Make the provisional diagnosis:

Explanation

 

23. A woman is 40 weeks pregnant. The fetus is in the longitudinal lie and cephalic presentation. Pelvic size: 26-29-31-20. Expected weight of the fetus is 4800 gram. The labor contractions has been lasting for 12 hours, within the last 2 hours they were extremely painful, the parturient woman is anxious. The waters broke 4 hours ago. On external examination the contraction ring is located 2 finger widths above the navel, Henkel-Vasten sign is positive. Fetal heart rate is 160/min., muffled. On internal examination the uterine cervix is fully open, the head is engaged and pressed to the entrance into the lesser pelvis. What is the most likely diagnosis?

Explanation

 Positive Vasten’ sign (if disproportion between fetal head and symphisis pubis is prominent  - Vasten’ sign is positive, if disproportion between fetal head and symphisis pubis is absent - Vasten’ sign is negative).

Danger of uterine ruptureWhen the disproportion between the head and the pelvis is so pronounced that engagement and descent do not occur, the lower uterine segment becomes increasingly stretched, and the danger of its rupture becomes imminent. In such cases,. a pathologic contractile ring may develop and can be felt as a transverse or oblique ridge extending across the uterus somewhere between the symphysis and the umbilicus. Whenever this condition is noted, prompt cesarean delivery must be employed to terminate labor and prevent rupture of the uterus.

   
24. At the railroad crossing a passenger train collided with a bus. In this collision 26 bus passenges died, another 18 passengers received mechanical injuries of varying severity. Where will be professional medical aid provided for the victims of this accident? Who will provide this aid?

Explanation

25. A 6-month-old child on breastfeeding is hospitalized in the inpatient department. After the child recovers, the doctor recommends the mother to start introducing solid food to the child’s diet. What products should be introduced to the child’s diet first?

Explanation

26. A surgery unit received a person with an incised stab wound on the upper third of the right thigh. Examination detects an incised stab wound 3.0x0.5x2.0 cm in size on the inner surface of the upper third of the right thigh. Bright-red blood flows from deep within the wound in a pulsing stream. Characterize this type of bleeding:

Explanation

Arterial

With this type of bleeding, the blood is typically bright red in colour, due to the high degree of oxygenation. A wound to a major artery could result in blood ‘pulsing’ in time with the heartbeat, several meters and the blood volume will rapidly reduce.

From the question stem, it is most likely bleeding from the femoral artery. The localization described is the femoral triangle, which is an anatomical region of the upper third of the thigh.

Venous

This blood is flowing from a damaged vein. As a result, it is blackish in colour (due to the lack of oxygen it transports) and flows in a steady manner. Caution is still indicated: while the blood loss may not be arterial, it can still be quite substantial, and can occur with surprising speed without intervention.

 

The key first aid treatment for all of these types of bleeding is direct pressure over the wound.

27. A 38-year-old patient has been brought by an ambulance to the surgical department with complaints of general weakness, indisposition, black stool. On examination the patient is pale, there are dotted hemorrhages on the skin of his torso and extremities. On digital investigation there are black feces on the glove. Blood test: Hb - 108 g/L, thrombocytopenia. Anamnesis states that a similar condition was observed 1 year ago. Make the diagnosis:

Explanation

Immune thrombocytopenic purpura (ITP) is a clinical syndrome in which a decreased number of circulating platelets (thrombocytopenia) present as a bleeding tendency, easy bruising (purpura), or extravasation of blood from capillaries into skin and mucous membranes (petechiae). Recall that the patient presents with dotted hemorrhages on the skin (petechiae) and on analysis, thrombocytopenia. Caused by the binding of an autoantibody (specifically IgG) to platelets leading to platelet destruction.

 

In Hemophilia, patients will present with bleeding from joints (hemathrose[is), easy bruising or a case of bleeding after surgery, dental procedure. Has three forms; Hemophilia A ( Factor VIII deficient), Hemophilia B ( factor IX deficient), C ( factor XI def.).

28. A 23-year-old man complains of severe pain in his left knee joint. Objectively the left knee joint is enlarged, with hyperemic skin, painful on palpation. Complete blood count: erythrocytes - 3.8∙1012/L, Hb - 122 g/L, leukocytes - 7.4∙109/L, platelets - 183∙109/L. Erythrocyte sedimentation rate - 10 mm/hour. Bleeding time (Duke method) - 4 min., Lee-White coagulation time - 24 min. Partial thromboplastin time (activated) - 89 seconds. Rheumatoid factor - negative. What is the most likely diagnosis?

Explanation

Partial Thromboplastin Time (PTT): <28seconds (normal)

PTT in this patient is 89seconds.

Defect in the Intrinsic coagulation pathway results in an Increased Partial Thromboplastin Time (PTT).

Intrinsic pathway coagulation defect:

Hemophilia A: deficiency of Factor VIII

Hemophilia B: deficiency of Factor IX

Hemophilia C: deficiency of Factor XI

Hemophilia is usually an inherited bleeding disorder in which the blood doesn't clot properly. This can lead to spontaneous bleeding as well as bleeding following injuries or surgery. Blood contains many proteins called clotting factors that can help to stop bleeding. People with hemophilia have low levels of any of factor VIII (8); factor IX (9) or factor XI (11).

 

Hemophilia commonly presents as hemarthrosis (bleeding into joints e.g. knee); easy bruising; bleeding after trauma or surgery (e.g. dental procedures).

29. A 42-year-old man, a dispatcher, suffes from peptic ulcer disease of the duodenum. The disease is of moderate severity. He wants to be assigned a disability group. Make the conclusion regarding his working ability:

Explanation

30. A 16-year-old girl has primary amenorrhea, no pubic hair growth, normally developed mammary glands; her genotype is 46 XY; uterus and vagina are absent. What is your diagnosis?

Explanation

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).

31. A 72-year-old man diagnosed with ischemic heart disease presents with diffuse cardiosclerosis, permanent tachysystolic atrial fibrillation, heart failure IIa, FC III. Objective examination of vital signs: blood pressure is 135/80 mm Hg, heart rate is 160/min., pulse is 125/min. Left ventricular ejection fraction is 32%. What drug is indicated in this case and should be presribed to the patient?

Explanation

Basically, in this patient we are looking for a medication that will take care of all the conditions - atrial fibrillation and heart failure.

Digoxin is a cardiac glycoside used to treat atrial fibrillation, mild to moderate heart failure in adults, and heart failure in children. Digoxin belongs to a class of drugs called antiarrhythmics. It works by slowing your heart rate down and improving the way your ventricles are filled with blood. In patients with heart failure, it increases contractility and in Atrial fibrillation, it decreases conduction at AV node and depression of SA node.

Verapamil: Class IV antiarrhythmic drug - calcium channel blocker. It is contraindicated in patients with heart failure.

Ivabradine: mainly used to treat heart failure conditions.

Procainamide: Class I antiarrhythmic drug - sodium channel blocker. It can be used for both atrial and ventricular arrhythmias but not heart failure. 

Isadrine (Isoprenaline): is a non-selective β adrenoceptor agonist, a bronchodilator that works by relaxing muscles in the airways to improve breathing.
32. A 32-year-old woman complains of tumor-like formation on the anterior surface of her neck that appeared 2 years ago. Within the last 3 months the tumor has been rapidly growing. It hinders swallowing and impairs speech; the tumor causes a sensation of pressure. Objectively the skin moisture is normal, pulse is 80/min., rhythmic, blood pressure is 130/80 mm Hg. In the right lobe of the thyroid gland there is a dense lumpy node 3.0x3.5 cm that moves during swallowing. Scanning image shows a ”cold nodule” in the thyroid gland. Make the provisional diagnosis:

Explanation

Your doctor may recommend a thyroid scan to help evaluate thyroid nodules. During this test, an isotope of radioactive iodine is injected into a vein in your arm. You then lie on a table while a special camera produces an image of your thyroid on a computer screen.

Nodules that produce excess thyroid hormone — called hot nodules — show up on the scan because they take up more of the isotope than normal thyroid tissue does. Hot nodules are almost always non-cancerous.

In some cases, nodules that take up less of the isotope — called cold nodules — are cancerous. 

 

Therefore, the best choice here is Thyroid Cancer, as the scanning image shows a “cold nodule.”

33. A 17-year-old girl has made an appointment with the doctor. She plans to begin her sex life. No signs of gynecological pathology were detected. In the family history the patient’s grandmother had cervical cancer. The patient was consulted about the maintenance of her reproductive health. What recommendation will be the most helpful for prevention of invasive cervical cancer?

Explanation

From the family history, there was a case of cervical cancer (patient’s grandmother). Cervical cancer occurs in the cells of the cervix- the lower parts of the uterus that connects to the vagina. This malignancy is mostly caused by an infection by Human papilloma virus (HPV 16 & 18). Since there is a family history, the chances of occurrence is very high therefore, vaccination against HPV is the best possible preventive/prophylactic measure.

 

HPV vaccines eg. Gardasil are recombinant vaccines administered as prophylaxis against Genital warts, cervical cancers; they target HPV strains 6, 11, 16 and 18.

34. In the air of the feed kitchen at the poultry factory, at the area where formula feed is being mixed, the dust concentration reaches 200 mg/m3. Air microflora is represented predominantly by Asperqillus and Mucor fungi. What effect determines pathogenic properties of the dust?

Explanation

35. A 32-year-old woman complains of body weight loss despite her increased appetite, nervousness, and tremor of the extremities. Objectively: the skin is moist; the thyroid gland is diffusely enlarged, painless, soft, and mobile. Blood test: increased level of T3, T4, and thyroid-stimulating hormone (THS). What is the most likely diagnosis?

Explanation

Diffuse toxic goiter or grave’s disease is an autoimmune disease characterised by an increased amount of thyroid hormones ( T3- triiodothyronine and T4- thyroxine). Symptoms include; loss of weight, with increased appetite, increased sweating, cardiac findings (tachycardia, increased risk for atrial fibrillation), tremors of extremities, heat intolerance, diarrhea, anxiety etc.

It is the most common cause of hyperthyroidism and more common in females than males. There is production of IgG antibodies against the TSH receptor (stimulating type of antibody - Type II hypersensitivity reaction)

Hashimoto’s thyroiditis is a destructive autoimmune thyroiditis leading to hypothyroidism.

 

In Diffuse non-toxic goiter, thyroid function is normal and patients are often asymptomatic. It manifests without hyperthyroidism, hypothyroidism, or inflammation.

36. A 78-year-old man with a prostate adenoma underwent a herniotomy for a direct inguinal hernia. After the surgery he presents with absent urination. Enlarged urinary bladder is detectable above the patient’s pubis. What measures should be taken in this case?

Explanation

Prostate Hyperplasia/Adenoma

Urinary bladder catheterization is performed for both therapeutic and diagnostic purposes.

The indications for bladder catheterization are:

Diagnostic:

  • Measurement of urodynamics

  • Sample collection for urinalysis

  • Radiographic studies (cystogram)

Therapeutic

  • Urinary retention

  • Neurogenic bladder dysfunction

  • Acutely ill patients requiring close urinary output measurement

  • Chemotherapy drug delivery

  • Bladder irrigation

Urinary retention can be acute or chronic. The main cause of urinary retention in men is Benign Prostate Hyperplasia or Prostate Cancer/Adenoma. This patient has prostate Adenoma and this has obstructed the outflow of urine. With or without the herniotomy done, the prostate adenoma can cause urinary retention and it is very painful and uncomfortable to the patient. 

 

In this case, the first aid to give such a patient on presentation to the hospital is to catheterize using foley’s catheter and drain urine from the bladder. If the bladder isn’t emptied, urine can build up and lead to pressure in the kidneys. The pressure can lead to kidney failure and infections, which can be dangerous and result in permanent damage to the kidneys.

37. An 11-year-old boy for a month has been presenting with increasing pain in the right femur. In the painful area there is a non- mobile painful tumor with unclear margins. The child complains of general indisposition, weakness, increased body temperature up to 39°C. X-ray shows widened medullary cavity, small foci of cancellous bone destruction, and onion-like lamellar exfoliation of the cortical layer. What is the most likely pathology resulting in such clinical presentation?

Explanation

Ewing's sarcoma typically occurs in children and young adults. Symptoms include pain, swelling and fever.

Ewing sarcoma is cancer that occurs primarily in the bone or soft tissue. While Ewing sarcoma can develop in any bone, it is most often found in the hip bones, ribs, or long bones (e.g., femur (thighbone), tibia (shinbone) or humerus (upper arm bone)). It can involve the muscle and the soft tissues around the tumor as well. Ewing sarcoma cells can also metastasize (spread) to other areas of the body, including the bone marrow, lungs, kidneys, heart, adrenal glands and other soft tissues.

 

Findings on imaging:

 
  • lesion may be purely lytic or have variable amounts of reactive new bone formation

  • periosteal reaction may give “onion skin” or “sunburst” appearance 

  • large destructive lesion in the diaphysis or metaphysis with a permeative moth eaten appearance.

38. A 45-year-old man, a farmer, presents with acute onset of a disease. He complains of headache, high temperature, pain in the gastrocnemius muscles, icteric face, and dark urine. Objectively: body temperature - 38°C, blood pressure - 100/70 mm Hg, conjunctival hemorrhages, hepatosplenomegaly, and oliguria. What is the most likely provisional diagnosis?

Explanation

Leptospirosis is an acute generalized infectious disease, characterized by extensive vasculitis, caused by spirochetes of the genus Leptospira. It presents with flu-like symptoms, myalgias (majorly calf muscles eg gastrocnemius), jaundice (icteric face), Photophobia etc. The icterohemorrhagic form of leptospirosis presents with a severe form of jaundice and azotemia from the liver and kidney dysfunction coupled with anemia. Leptospira is commonly found in water contaminated with animal urine.

N/B Virus hepatitis has a gradual onset, without chills, the temperature rises at the pre-icteric period. Muscle pains, scleritis, conjunctivitis are not characteristic of it.

 

Brucellosis is caused by gram negative bacteria, transmitted via ingestion of contaminated animal products (eg, unpasteurized milk). Typically presents with fever, night sweats, and arthralgia but jaundice is usually absent.

39. During medical examination of high and middle school students, the doctors vere assessing correlation between biological and calendar age of the school students based on the following criteria: height growth rate per year, ossification of the carpal bones, the number of permanent teeth. What additional development criterion should be assessed at this age?

Explanation

Tanner Stage

Most students in high school are 10 - 11 years and above. Development of secondary sexual characteristics begins in puberty, therefore it should be considered when considering the biological age of high and middle school students.

There are two types of physical changes that occur during puberty: a) changes to primary sex characteristics and b) changes to secondary sex characteristics. Primary sex characteristics refer to changes to the sexual organs themselves (uterus, vagina, penis, and testes). Secondary sex characteristics refer to other visible changes that mark adult maturation such as changes in height and body shape.

For males, secondary characteristics include facial and chest hair, increased body hair, pelvic build (lack of rounded hips), upper body muscular build, and the ability to generate muscle mass at a faster rate than the female. For females, secondary sex characteristics include relative lack of body hair, thicker hair on the head (in some cases), rounded hips/figure, a decreased ability to generate muscle mass at a fast rate, decreased upper body strength, breasts, ability to nurse children, a menstrual cycle, and increased body fat composition. 

 

Tanner staging is a very helpful tool in determining the stage of secondary sex characteristic development.

40. A 3-week-old infant developed large, flaccid vesicles with purulent contents on the skin of chest and abdomen. The vesicles rupture quickly. Make the provisional diagnosis:

Explanation

Pemphigus Neonatorum is a disease of the newborn, in which vesicles or blebs, usually flat on the top, appear with or without fever, on a perfectly normal or reddened skin with pin-head size vesicle elevation, which rapidly develops into a large bleb. As the disease progresses, relapses may occur, yet the infant may recover promptly after a single outbreak of but few blebs. In some cases these blebs show a marked tendency to peripheral extension, which finally dry, leaving a thin brown crust. Staphylococcus aureus have been implicated as the causative agent.

The distinction between Pemphigus and syphilis in the newborn may be determined by the localization of the eruption. Syphilis will be localized to the palms of the hands and soles of the feet, as well as by the associating symptoms of syphilis.

Vesiculo Pustulosis is also a disease of the newborn, characterized by multiple pustules, emerging in the openings of ducts of eccrine sweat glands. In pathogenesis the main role is played by maceration of the skin, prematurity, artificial feeding. Localization - skin of butttocks, hips, inguinal folds, head etc.

 

Erythema toxicum occurs more often in term babies of multigravidas. It usually arises in the first 4 days of life and fades within 4 days. Occasionally onset is delayed until 10 days after birth or it recurs in the first 2–6 weeks after birth. It is characterised by red macules and papules, with pustules appearing in a third of cases.

41. A 42-year-old man, a worker at the meat processing factory, developed an itching spot on his lower jaw, which gradually transformed into a slightly painful carbuncle 3 cm in diameter, surrounded by a painless swelling that reaches the clavicle. Temperature is subfebrile, under 37.8°C. The doctor suspects anthrax. What drug should this man be prescribed for treatment?

Explanation

Bacillus anthracis is an aerobic, non-motile, spore forming, large non-hemolytic Gram-positive rod that grows well on blood agar. The clinical manifestations of human anthrax - Cutaneous and Inhalation. 

Cutaneous anthrax, the most common form of naturally occurring disease, begins as a small, painless, pruritic papule that within 2 days enlarges, develops vesicles, and ulcerates to form an eschar. Inhalational anthrax follows inhalation of infectious doses of anthrax spores.

 

Four antibiotics are approved for use for post exposure prophylaxis following exposure to aerosolized spores of B. anthracis: doxycycline, ciprofloxacin, levofloxacin, and parenteral procaine penicillin G. Of all these four antibiotics, only Penicillin is listed as a choice for this question.

42. A child is 1 year old. After solid food was introduced into the diet, within the last several months the child developed loss of appetite, diarrhea with large amount of feces, and occasional vomiting. Body temperature remains normal. Body weight is 7 kg. The child is very pale, has leg edemas and extremely distended abdomen. Feces analysis detects high levels of fatty acids and soaps. Diagnosis of celiac disease was made and gluten-free diet was prescribed. What should be excluded from the diet in this case?

Explanation

Celiac disease is an immune reaction to eating gluten, a protein found in wheat, barley and rye. Sometimes called celiac sprue or gluten-sensitive enteropathy. When people with celiac disease eat gluten (a protein found in wheat, rye and barley), their body mounts an immune response that attacks the small intestine. These attacks lead to damage on the villi, small fingerlike projections that line the small intestine, that promote nutrient absorption. When the villi get damaged, nutrients cannot be absorbed properly into the body.

Celiac disease is hereditary, meaning that it runs in families. People with a first-degree relative with celiac disease (parent, child, sibling) have a 1 in 10 risk of developing celiac disease.

Celiac disease can develop at any age after people start eating foods or medicines that contain gluten.

 

Oats contain avenin, which is a protein similar to gluten. Research has shown that most people with coeliac disease can tolerate gluten free oats with no problems. The issue is that sometimes oats are produced in the same place as wheat, barley and rye, and then become contaminated with these other grains.

43. A patient is being treated in the tuberculosis clinic. Throughout the last 3 weeks he has been suffering from headaches of increasing intensity. Neurological examination detects nuchal rigidity without focal signs. Make the provisional diagnosis:

Explanation

Meningitis is an acute infectious disease with involvement of the arachnoid and pia mater of the brain and spinal cord by pathogenic microorganisms. Etiologically, the various forms include; bacterial, viral. Fungal and tuberculous meningitis. The tuberculous form occurs as a secondary infection (from anamnesis, the patient already suffers from pulmonary tuberculosis).

 

The classic triad of fever, headache, and neck stiffness (nuchal rigidity) is usually present.

44. A 37-year-old man suddenly developed acute headache accompanied by nausea, vomiting, and impaired consciousness. Objectively blood pressure is 190/120 mm Hg, the face is hyperemic. Patient’s consciousness is clouded, his answers to the questions are short, monosyllabic. Movement and sensory disturbances are absent. Meningeal signs are positive. Cerebrospinal fluid contains blood. What provisional diagnosis can be made?

Explanation

The term subarachnoid hemorrhage (SAH) refers to extravasation of blood into the subarachnoid space i.e. the space between the pia and arachnoid membranes.

The subarachnoid space is the space where the cerebrospinal fluid (CSF) circulates, therefore, hemorrhage into this space will result in bloody CSF as mentioned in the question. The CSF is responsible for protecting your brain from injury by serving as a cushion. A hemorrhage in this space can cause a coma, paralysis, and even death. It is often characterized by a severe headache (often referred to as ‘worst headache of my life’).

Severe headaches and bloody CSF are the hallmarks for making Subarachnoid hemorrhage diagnosis especially in patients with Severe Hypertension.

 

The most common cause of primary Subarachnoid Hemorrhage is a berry aneurysm. These aneurysms swell up and weaken the walls of the arteries over time. Brain aneurysms are more common in smokers, and in those with elevated blood pressure. In some cases, trauma to the brain during an injury can cause aneurysms and result in a subarachnoid hemorrhage.

45. A 20-year-old student after failing an exam developed complaints of a sensation of a round foreign body in her throat, difficult swallowing. She fixates on her condition, limits her diet, often cries, seeks attention, exhibits demonstrative attitude. She is highly susceptible to psychotherapeutic suggestion. What psychiatric diagnosis can be made in this case?

Explanation

46. Employees work in conditions of high dust concentration. Certain chemical (silicon dioxide content) and physical properties of dust aerosols contribute to the development of occupational dust- induced diseases. What is the main physical property of dust aerosols?

Explanation

47. A 32-year-old man complains of pain in his legs that intensifies during walking, intermittent claudication, numbness of his toes, extremity coldness, and inability to walk more that 100 meters. When he sleeps, his leg usually hangs down. The patient has been smoking since he was 16. He drinks alcohol in excess. The left leg is colder than the right one; the skin of the extremities is dry. No pulse can be detected on the pedal arteries, while pulsation of the femoral arteries is retained. What is the most likely diagnosis?

Explanation

Obliterating Endarteritis is also known as Buerger’s disease and vasculitis. The condition is thought to occur as a result of tobacco use and more common in males. The disease is characterized by inflammation and thrombosis of small and medium arteries of the legs and feet which recurs and progresses in stages. During the ischemic period, the veins of the lower leg are inflamed, skin has ulceration, and there is gangrene with intermittent claudication. During the nutritional disorder period there is persistent pain and muscle atrophy. During the necrosis period, the pain becomes worse as infection leads to the development of ulcers and gangrene. Pains usually persist; In addition, the patient usually complains of coldness and numbness. Burning sensations is another disturbing symptom.

Treatment usually has to do with smoking cessation.

Raynaud disease is a condition in which some areas of the body feel numb and cool in certain circumstances. In Raynaud's phenomenon, smaller arteries that supply blood to the skin constrict excessively in response to cold, limiting blood supply to the affected area. The fingers, toes, ears and tip of the nose are commonly involved and feel numb and cool in response to cold temperatures or stress.

 

Leriche Syndrome, also commonly referred to as aortoiliac occlusive disease, is a product of atherosclerosis affecting the distal abdominal aorta, iliac arteries, and femoropopliteal vessels.

48. A 10-year-old boy with symptoms of arthritis and myocarditis was brought to a hospital. Based on clinical examination the provisional diagnosis of juvenile rheumatoid arthritis was made. What symptom is the most contributive for the diagnostics of this disease?

Explanation

 

Juvenile Rheumatoid  Arthritis is an autoimmune form of inflammation and is different from osteoarthritis which is due to mechanical wear and tear (continuous use). N/B in JRA, the inflammation is always symmetrical (on both sides of the body) and the patient always presents with the complaint of joint stiffness in the morning that lasts for more than an hour.

49. A 39-year-old man suffers from chronic rheumatic heart disease. He complains of dyspnea during physical exertion, cough with expectoration, and palpitations. Auscultation detects intensified I heart sound and diastolic murmur; the sound of opening mitral valve can be auscultated at the cardiac apex. The II heart sound is accentuated over the pulmonary artery. The patient is cyanotic. X-ray shows dilated pulmonary root and enlargement of the right ventricle and left atrium. What is the most likely diagnosis?

Explanation

Valvular diseases

Mitral stenosis

Aortic stenosis

Aortic regurgitation

Mitral regurgitation

Tricuspid regurgitation

Main causes and risk factors

Almost always caused by rheumatic heart disease

-Calcification of tricuspid aortic valve with age (>50%)

-Calcification of bicuspid aortic valve (30-40%)

-Rheumatic fever (<10%)

Hypertension, diabetes mellitus, hyperlipoproteinemia and uremia may speed up the process.

Acute

-Infective endocarditis

-Trauma

Chronic

-Primary valvular: rheumatic fever, bicuspid aortic valve, Marfan's syndrome, Ehlers–Danlos syndrome, ankylosing spondylitis, systemic lupus erythematosus

-Disease of the aortic root: syphilitic aortitis, osteogenesis imperfecta, aortic dissection, Behçet's disease, reactive arthritis, systemic hypertension

Acute

-Endocarditis, mainly S. aureus

-Papillary muscle rupture or dysfunction, including mitral valve prolapse

Chronic

-Rheumatic fever

-Marfan's syndrome

-Cardiomyopathy

Usually secondary to right ventricular dilation

Other causes: Tricuspid endocarditis, rheumatic fever, Ebstein's anomaly, carcinoid syndrome and myxomatous degeneration

Symptoms

Heart failure symptoms, such as dyspnea on exertion, orthopnea and paroxysmal nocturnal dyspnea

-Palpitations

-Chest pain

-Hemoptysis

-Thromboembolism

-Ascites and edema (if right-sided heart failure develops)

Symptoms increase with exercise and pregnancy

-Heart failure symptoms, such as dyspnea on exertion (most frequent symptom), orthopnea and paroxysmal nocturnal dyspnea

-Angina pectoris

-Syncope, usually exertional

-Heart failure symptoms, such as dyspnea on exertion, orthopnea and paroxysmal nocturnal dyspnea

Palpitations,

-Angina pectoris

-In acute cases: cyanosis and circulatory shock

-Heart failure symptoms, such as dyspnea on exertion, orthopnea and paroxysmal nocturnal dyspnea

-Palpitations

-Pulmonary edema

Symptoms of right-sided heart failure, such as ascites, hepatomegaly, edema and jugular venous distension

Medical signs

-Opening snap followed by a low-pitched diastolic rumble with presystolic accentuation.

The opening snap follows closer to the S2 heart tone with worsening stenosis.

The murmur is heard best with the bell of the stethoscope lying on the left side and its duration increases with worsening disease.

-Loud S1 - may be the most prominent sign

-Advanced disease may present with signs of right-sided heart failure such as parasternal heave, jugular venous distension, hepatomegaly, ascites and/or pulmonary hypertension (presenting with a loud P2.

Signs increase with exercise and pregnancy

Systolic murmur of a harsh crescendo-decrescendo type, heard in 2nd right intercostal space, radiating to the carotid arteries

-Pulsus parvus et tardus, that is, diminished and delayed carotid pulse

-Fourth heart sound

-Decreased A2 sound

-Sustained apex beat

Precordial thrill

-Increased pulse pressure by increased systolic and decreased diastolic blood pressure, but may not be significant if acute

-Diastolic decrescendo murmur best heard at left sternal border

Water hammer pulse

-Austin Flint murmur

-Apex beat displaced down and to the left

-Third heart sound may be present

Holosystolic murmur at the apex, radiating to the back or clavicular area

Commonly atrial fibrillation

Third heart sound

Laterally displaced apex beat, often with heave

Loud, palpable P2, heard best when lying on the left side

-Pulsatile liver

-Prominent V waves and rapid  descents in jugular venous pressure

-Inspiratory third heart sound at left lower sternal border (LLSB)

-Blowing holosystolic murmur at LLSB, intensifying with inspiration, and decreasing with expiration and -Valsalva maneuver

-Parasternal heave along LLSB

-Atrial fibrillation is usually present

50. A 14-year-old girl came to the general practitioner with complaints of weakness, loss of appetite, headache, rapid fatigability. Her last menstruation was profuse and lasted for 14 days after the previous delay of 2 months. Objectively: the skin is pale, heart rate is 90/min., BP is 110/70 mm Hg, Hb is 88 g/L. Rectal examination: the uterus and its appendages are without changes, no discharge from the genital tracts. What complication occurred in the patient?

Explanation

Complete Blood Count

From the question stem, Hb is 88g/L plus the symptoms listed which all points to anemia.

Anemia is decrease of erythrocytes amount and hemoglobin in unit of blood volume which is accompanied by qualitative changes of erythrocytes.

Hemoglobin concentration   – in men is lower than 130 g/l, in women is lower than 120 g/l;

In this girl, Hb concentration less than  120g/L is anemia and we know that she had a history of profuse menstruation (hemorrhage) for 14 days.

So the best answer here is Posthemorrhagic anemia.

Posthemorrhagic anemia is an anemia which develops as a result of hemorrhage which can either be acute or chronic.

 

Dysmenorrhea is a wrong answer considering the fact that the uterus and its appendages are without changes and no discharge from the genital tracts.

51. An 18-year-old young man complains of pain in his knee and elbow joints and body temperature up to 39.5°C. One week and a half earlier he developed sore throat. On examination his body temperature is 38.5°C. Swelling of the knee and elbow joints is observed. Pulse is 106/min.. rhythmic. Blood pressure is 90/60 mm Hg. Cardiac borders are unchanged, heart sounds are weakened, at the cardiac apex there is a soft systolic murmur. What factor would be the most indicative of the likely disease etiology?

Explanation

 

The Patient in question has a rheumatic Fever. RF is gotten from prior infection of the throat (acute tonsillitis, pharyngitis etc) by group A beta hemolytic streptococci. For diagnosis, the Jones criteria (major criteria)is used. They include migratory polyarthritis, carditis, subcutaneous nodules, erythema marginatum (rash with a ring margin) and sydenham chorea; and some minor criteria such as fever. It is classified as a type II hypersensitivity reaction (immune mediated) and occurs due to molecular mimicry. Aschoff bodies (granuloma with giant cells), anitschkow cells, increased antistreptolysin O and anti-DNase B titers are seen in lab findings.

52. A woman undergoing in-patient treatment for viral hepatitis type B developed headache, nausea, recurrent vomiting, memory lapses, flapping tremor of her hands, and rapid pulse. Sweet smell from her mouth is detected. Body temperature is 37.6°C, heart rate is 89/min. What complication developed in the patient?

Explanation

Acute liver failure is a state of hepatic cells dysfunction, caused by unknown earlier liver disease, resulting in general intoxication, coagulation violations, neurological and mental disorders. Its etiology is usually connected with: viral hepatitis (hepatitis B virus, hepatitis A virus), poisonings (mushrooms, dichloroethane, phosphorus, carbon tetrachloride, arsenic), eclampsia, burn disease, anaesthetic gas, antibiotics, sulfanilamides, massive bacterial pneumonia, cirrhosis, hepatic tumours and metastasis.

 

Advanced liver failure manifests in a coma. The patient in question presents with viral hepatitis B (the probable cause of the liver failure) and a list of other symptoms which indicate neurological and intoxication disorder.

53. A 56-year-old woman was diagnosed with stage 2 hypertension of the 2nd degree. She belongs to the group of moderate risk and has bronchial asthma. What group of drugs is CONTRAINDICATED to this patient?

Explanation

Beta Blockers include: Atenolol, Bisoprolol, Carvedilol, Labetalol, Metoprolol, Propranolol etc (they end with ‘lol’).

They are effective as antihypertensives because they decrease cardiac output and also decrease renin secretion (due to Beta 1 receptor blockade on Juxtaglomerular cells in the Kidney).

However, they can also cause Asthma/COPD exacerbations; Erectile dysfunction; bradycardia or AV block. 

Hence, this group of medications are contraindicated in patients with Bronchial Asthma.

 

Bronchial Asthma/COPD are pathological states associated with bronchoconstriction. In physiological states, when Beta 2 receptors in the bronchi are stimulated, they result in bronchodilation. So, when a Beta blocker is administered, it will result in Bronchoconstriction thereby exacerbating bronchial asthma in this patient.

54. A newborn girl has Apgar score of 7-8 points at the 1-5 minutes after birth. During the labor there was a brief difficulty with extraction of the shoulder girdle. After birth the baby presents with disturbed function of the proximal segment and forced position of the right arm. The shoulder is rotated inwards, the elbow is extended, the forearm is pronated, and the whole upper limb resembles an arm of a doll. What is the most likely clinical diagnosis in this case?

Explanation

Duchenne-Erb's palsy is a form of brachial plexus palsy. Erb's palsy leads to a weakness of a newborn baby's arm. It is caused by a stretch injury to the brachial plexus (C5-C6). The brachial plexus is a network of nerves near the neck that give rise to all the nerves of the arm. These nerves provide movement and feeling to the arm, hand, and fingers. Causes: Infants - lateral traction on neck during delivery; Adults - trauma. Muscle deficits: Deltoid, Supraspinatus, Infraspinatus, Biceps brachii.  

Klumpke paralysis (C7-8, T1) results in weakness of the intrinsic muscles of the hand; grasp reflex is absent. 

 

If cervical sympathetic fibers of the first thoracic spinal nerve are involved, Horner syndrome is present.

55. A 13-year-old girl for a month has been complaining of fatigability, dull pain in her right subcostal area, abdominal distension, and constipations. Abdominal palpation reveals positive Kehr, Murphy, and Ortner signs, while Desjardins and Mayo-Robson points are painless. Total bilirubin is 14.7 mcmol/L, predominantly indirect, ALT - 20 U/L, AST - 40 U/L, amylase - 6.3 mmol/L. Echocholecystography shows practically no contraction of the gallbladder. Make the provisional diagnosis:

Explanation

Biliary dyskinesia or hypokinetic gallbladder disease refers to decreased contractility and poor emptying of the gallbladder that leads to presentations which include right upper quadrant or epigastric pain, nausea, vomiting and fatty food intolerance. 

Murphy’s sign: is a delay of breathing during palpation of gall-bladder on inhalation.

Kehr’s Symptom: is strengthening  of pain at pressure on the area of gallbladder, especially on deep inhalation.

Ortner’s Symptom: pain on pressing on the right costal arc with the edge of the palm.

 

Mayo-Robson and Desjardins points are related to Pancreatic pathologies.

56. During examination a 4-month-old child with meningococcemia presents with acrocyanosis, cold extremities, tachypnea, and thready pulse, blood pressure of 30/0 mm Hg, anuria, and sopor. What clinical syndrome is it?

Explanation

Meningococcemia is a bacterial infection of the blood due to a diplococcus, Neisseria meningitidis. Complications include septic shock, failure of multiple organs, lack of circulation to the extremities (with loss of limbs), and death. 

 

Toxic shock syndrome is a rare but serious medical condition caused by a bacterial infection. Toxic shock syndrome (TSS) is a toxin-mediated acute life-threatening illness characterized by multiorgan failure (involving at least 3 or more organ systems), rash, hypotension, and desquamation, typically of the palms and soles, 1-2 weeks after the onset of acute illness.

57. A 25-year-old woman has been suffering from diabetes mellitus since she was 9. She was admitted into the nephrology unit with significant edemas of the face, arms, and legs. Blood pressure - 200/110 mm Hg, Hb - 90 g/L, blood creatinine - 850 mcmol/L, urine proteins - 1.0 g/L, leukocytes - 10-15 in the vision field. Glomerular filtration rate - 10 mL/min. What tactics should the doctor choose?

Explanation

The patient is suffering from Diabetic Nephropathy and requires Hemodialysis. 

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 (Norm is about 90-120 ml/min). Notice that his blood values are also deranged - Creatinine - 850 mcmol/ (Norm: 53 - 106 mcmol/L). Recall that the kidney has three basic functions; filtration, reabsorption and secretion, and a distortion in these values indicates a kidney related issue.

 

There is also elevated blood pressure 200/110mmHg which is likely nephrogenic.

58. During regular medical examination a lyceum student presents with signs of cheilitis that manifests as epithelial maceration in the area of lip seal. The lips are bright-red, with single vertical cracks covered with brown- red scabs. These clinical signs are most likely caused by insufficient content of the following in the diet:

Explanation

Vitamin B2 also called Riboflavin is a component of flavins FAD and FMN, used as cofactors in redox reactions e.g. the succinate dehydrogenase reaction in the Tricyclic Acid Cycle.

Deficiency: Cheilosis (inflammation of lips, scaling and fissures at the corners of the mouth); Corneal vascularization.

Ascorbic Acid: Vitamin C; deficiency - Scurvy: swollen gums, easy bruising, petechiae, hemarthrosis, poor wound healing. 

Retinol: Vitamin A; deficiency - Night blindness (nyctalopia), dry scaly skin (xerosis cutis)

Thiamine: Vitamin B1; deficiency - Wet and Dry BeriBeri; Wernicke-Korsakoff syndrome

 

Calciferol: Vitamin D; deficiency - Rickets in Children; Osteomalacia in Adults.

59. A 34-year-old man on the 3rd day of ceftriaxone treatment for acute otitis (daily dosage - 2 grams) developed diarrhea occurring 5-6 times per day. Feces are without mucus or blood admixtures. Temperature is 36.6°C. Gregersen reaction (occult blood in feces) is negative. Stool culture detected no pathogenic germs. What is the most likely cause of diarrhea in this case?

Explanation

Antibiotics taken affect both good and bad bacteria. A good number of bacteria make up the normal flora of humans; some of which are opportunistic bacteria and some keep these opportunistic bacteria in check. If antibiotics taken affect these good bacteria, the opportunistic ones will cause a negative effect on the body which in most cases presents a diarrheal symptom. An example of these opportunistic bacteria is Clostridium difficile.

 

Dysbiosis refers to the imbalance in the normal flora in the body. Can be associated with disorders such as inflammatory diseases, cancer, bacterial vaginosis etc.

60. A 13-year-old girl has 30% of excessive body mass, she started to gain weight at the age of 3. She has a family history of obesity. Her height and sexual development are normal for her age. The appetite is excessive. She complains of periodical headaches. Blood pressure - 120/80 mm Hg. Subcutaneous fat is evenly distributed, she has no stretch marks. There is juvenile acne on her face. What type of obesity is it?

Explanation

61. Disease onset was acute. A child developed general weakness, pain in the joints, and elevated temperature. Later these signs became accompanied by itching skin rash manifested as erythematous spots 2- 5 mm in size. The rash gradually turned hemorrhagic. Large joints are painful and swollen; pain attacks periodically occur in the paraumbilical area; there are signs of intestinal hemorrhage. What is the most likely diagnosis?

Explanation

Henoch-Schönlein purpura (HSP) is an acute immunoglobulin A (IgA)–mediated disorder characterized by a generalized vasculitis involving the small vessels of the skin, the gastrointestinal (GI) tract, the kidneys, the joints, and, rarely, the lungs and the central nervous system (CNS).

It is a disease involving inflammation of small blood vessels. It most commonly occurs in children. The main symptom is a rash with numerous small bruises, which have a raised appearance, over the legs or buttocks.

 

It is characterized by a triad of palpable purpura (without thrombocytopenia), abdominal pain, and arthritis. In the skin, the disease causes palpable purpura (small, raised areas of bleeding underneath the skin), often with joint pain and abdominal pain. With kidney involvement, there may be a loss of small amounts of blood and protein in the urine (hematuria and proteinuria), but this usually goes unnoticed; in a small proportion of cases, the kidney involvement proceeds to chronic kidney disease. HSP is often preceded by an infection, such as a throat infection.

62. Clinical trials have proved the ”Lipoflavon” drug to be effective for treatment of unstable angina pectoris in the control group and experimental group of patients. Neither patients nor researchers knew who belonged to which group. Name this type of study:

Explanation

A double blind study is a randomized clinical trial in which:

  • You as the patient don’t know if you’re receiving the experimental treatment, a standard treatment or a placebo, and

  • Your doctor doesn’t know.

Only those directing the study know the treatment that each participant receives.

Double blind studies prevent bias when doctors evaluate patients’ outcomes. This improves reliability of clinical trial results.

 

Double-blind trials are seen as the most reliable type of study because they involve neither the participant nor the doctor knowing who has received what treatment. The aim of this is to minimize the placebo effect and minimize bias.

63. A 26-year-old man complains of chills, rhinitis, dry cough, and fever up to 38°C. Examination shows him to be in a moderately severe condition; there are small pale pink non-merging spots on the skin of his back, abdomen, and extremities. Palpation reveals enlarged occipital and axillary lymph nodes. No information about vaccination history could be obtained. What is the likely etiology of this disease?

Explanation

Rubella (caused by rubella virus) is an acute viral infection characterised by a short prodromal period, Exanthema ( rash) during three days and lymphadenopathy. The type of rash found is roseola and small maculo-papula. Note that the rash elements do not merge (non-merging spots) and are usually concentrated on the extensor surface of extremities, back, buttocks and outer surface of thigh. Commonly associated with enlarged occipital lymph nodes.

Epstein-barr virus is  one of the causative agents of Infectious mononucleosis- a disease characterised by prolonged fever, systemic lymphadenopathy,acute tonsillitis, acute adenoiditis, hepatosplenomegaly, along with typical blood changes  such as lymphocytosis, monocytosis, presence of specific cells called atypical mononuclear cells or virocytes. 

 

Mumps infection is a systemic disease characterised by hyperthermic syndrome, symmetrical or unilateral swelling of parotid glands, epididymo-orchitis etc.

64. A 3-year-old child presents with dyspnea that abates in the sitting position, occasional loss of consciousness and seizures, delayed physical development, cyanosis, drumstick fingers. Echocardioscopy detects aortic dextraposition, ventricular septal defect, pulmonary artery stenosis, and right ventricular hypertrophy. What is the most likely diagnosis?

Explanation

 

Tetralogy of fallot is a combination of four congenital heart defects occurring together; they include- pulmonary valve stenosis, ventricular septal defect,  hypertrophy of the right ventricle and an overriding aorta (aortic dextraposition). Symptoms include; a heart murmur, clubbing of the fingers (drumstick fingers), cyanosis, prolonged crying, poor weight gain etc; majority of which are seen in the described patient.

65. A 55-year-old woman complains of pain and popping sounds in her left knee joint, which occur when she climbs the stairs. Occasionally during movements her joint becomes ”stuck”. 5 years ago she suffered a trauma of her left knee. Complete blood count and biochemical blood analysis show normal results. X-ray shows marked osteosclerosis and osteophytes. The joint space is narrowed. Make the provisional diagnosis:

Explanation

Osteoarthritis (OA): mechanical wear and tear - it’s a degenerative joint disease.

Associated with Pain in weight bearing joints commonly experienced after use (i.e. at the end of the day), and the pain improves with rest. The pain associated with OA could also be precipitated by trauma.

Joint findings: joint space narrowing; osteophytes (bone spurs); subchondral sclerosis and cysts.

Involves distal interphalangeal joints on the hands (heberden nodes) and Proximal interphalangeal joints (Bouchard nodes); does not affect Metacarpophalangeal joints.

Rheumatoid Arthritis: autoimmune which erodes articulated cartilage and bone. The inflammatory cells and cytokines then induce pannus (proliferative granulation tissue) formation, deep usurations.

 

Associated with pain, swelling and morning stiffness, lasting >1hr and the pain improves with use.

 
66. A 16-year-old patient has made an appointment with an otolaryngologist. He complains of elevated body temperature and sore throat. Disease onset was 2 days ago, after the patient ate two portions of ice-cream. Pharyngoscopy shows hyperemic mucosa of the palatine tonsils, with purulent exudate in the lacunae. Make the provisional diagnosis:

Explanation

Tonsillitis is a generalized infectious disease with in­flammation of the pharyngeal lymphoid structures, and with swelling of the regional lymphatic glands. The cause of tonsillitis is invasion by streptococci and, less frequently, by staphylocci and pneumococci. 

Tonsillitis may occur in the catarrhal, lacunar and fol­licular forms.

In lacunar tonsillitis  the general symptoms are more pronounced, more se­vere than in catarrhal tonsillitis, with pain on swal­lowing, sometimes radiates to the ear, headache, fever as high as 40 °C. The disease often disappears on the fourth or fifth day. 

A continuous coat made up of yellowish-white membranes or patches often covers the free surface of the tonsils without extending beyond their limits (doesn’t extend beyond the lacunae or crypts). In lacunar tonsillitis the formation of patches in the lacunar openings distinguishes this disease from diphtheria.

Take note of this statement in the question stem:

 

Pharyngoscopy shows hyperemic mucosa of the palatine tonsils, with purulent exudate in the lacunae.

67. A 10-year-old girl exhibits high level of physical development (M + 3σ), her body length increased by 10 cm within a year (which is double the norm for her age group), the number of permanent teeth corresponds with the age norm (20), the development of her secondary sex characteristics is three years ahead of her age (Ma, P, Ax, Menarche). Development rate ahead of her biological age can occur due to:

Explanation

 

Hormones and glands make up the endocrine system. From the question, the 10 year old girl experiences an acceleration in both physical development and sexual characteristics; this indicates that she has a high level of the growth hormone (somatotropin) either due to increased production, increased receptor sensitivity or decreased clearance. Somatotropin is a peptide hormone produced by the anterior pituitary gland.

68. A 30-year-old woman came to the gynecological department. She complains of sharp pain in her lower abdomen and temperature of 38.8°C. She has a history of extramarital sexual activity and 2 artificial abortions. On gynecological examination the uterus is unchanged. The appendages are bilaterally enlarged and painful. Profuse purulent discharge is being produced from the vagina. What examination needs to be conducted to clarify the diagnosis?

Explanation

69. A 27-year-old woman complains of foul-smelling discharge from her genital tracts, pain in her lower abdomen, and elevated temperature. The complaints arose 2 days ago. She has a history of surgical abortion at the term of 8 weeks one week ago. Mirror examination: the uterine cervix is clear, external orifice produces foul-smelling discharge. Vaginal examination: the uterus lies in anteflexion, is mobile, painful, and slightly enlarged. The appendages are without changes. Make the provisional diagnosis:

Explanation

Look closely at the clue given in the question, the patient had abortion a week ago then the symptoms listed above started. This is a clear pointer to a post-abortion complication.

You’re at risk of getting an infection that can cause endometritis after a miscarriage or after childbirth, especially following a long labor or a cesarean delivery. You’re also more likely to get endometritis after a medical procedure that involves entering the uterus through the cervix. This can provide a pathway for bacteria to enter. Medical procedures that can increase your risk of developing endometritis include: hysteroscopy, placement of an intrauterine device, dilation and curettage (uterine scraping).

Endometritis is an inflammatory condition of the lining of the uterus and is usually due to an infection. It’s usually not life-threatening, but it’s important to get it treated as soon as possible. Endometritis typically causes the following symptoms: abdominal swelling, abnormal vaginal bleeding, abnormal vaginal discharge, fever, general feeling of sickness, pain in the pelvis, lower abdominal area, or rectal area.

In this scenario, the patient had a surgical abortion and this procedure most likely introduced the infection into the patient.

 

Appendicitis is often characterized by right iliac fossa tenderness. From the question, the appendages are without changes, so we can rule out salpingoophoritis (inflammation of the fallopian tube and ovaries). This has nothing to do with the respiratory system (acute respiratory disease) or colon (enterocolitis).

70. A 2-year-old child with persisting cough and subfebrile body temperature after a case of URTI developed dyspnea, cyanosis of the nasolabial triangle, percussion dullness and weakened respiration in the lower lobe of the right lung, and a slight mediastinal displacement to the left. What pulmonary pathology is likely to cause this clinical presentation?

Explanation

When you breathe, the thin tissues that line your lungs and chest wall, called the pleura, rub together. Typically, this isn’t a problem because the tissue is satiny and generates no friction. However, when this tissue is inflamed or infected, it becomes irritated and swollen, causing significant pain. This condition is known as pleurisy or pleuritis.

Viral infections are the most common cause of pleurisy which is suspected in this case with a subfebrile temperature in a patient with Upper Respiratory Tract Infection (URTI). Bacteria, heart surgery complications, autoimmune disorders, trauma could also cause pleurisy.

The chief symptom associated with pleurisy is a sharp, stabbing pain when you breathe. This pain often limits respiratory excursions on the affected side thereby limiting gaseous exchange which can manifest as shallow breathing to avoid feeling pain, cyanosis and dyspnea.

 

Pleurisy can be accompanied by a fluid buildup that puts pressure on the lungs and causes them to stop working properly. This fluid accumulation is called a pleural effusion (percussion dullness on the right lower lung lobe). A person with a pleural effusion will eventually experience shortness of breath as the fluid increases.

71. A 58-year-old woman came to the gynecological clinic. She complains of bloody discharge from her genital tracts. Menopause is 8 years. Gynecological examination: the uterus is slightly enlarged, dense to touch, with limited mobility; the uterine appendages cannot be detected; parametrium is free. Fractional curettage of the uterine cavity yields a significant amount of medullary substance in the scrape. What is the most likely diagnosis?

Explanation

Menopause means a complete cessation of menses for 12 uninterrupted months. Therefore, any form of bleeding after menopause should be a cause of concern.

The uterus is where a fetus grows and develops when a woman is pregnant. It has 2 main parts:

  • The upper part of the uterus is called the body or the corpus. (Corpus is the Latin word for body.). This body has 3 layers - Endometrium (innermost layer); Myometrium (middle layer) and the perimetrium (serosa outermost layer).

  • The cervix is the lower end of the uterus that joins it to the vagina.

Endometrial cancer starts when cells in the endometrium (the inner lining of the uterus) start to grow out of control. Carcinoma of the epithelial lining (endometrium) of the uterine corpus is the most common female pelvic malignancy. Endometrial cancer is primarily a disease of postmenopausal women.

Symptoms include vaginal bleeding after menopause and bleeding between periods. Patients complain of abnormal vaginal discharge, and majority of these women experience abnormal bleeding, usually after menopause.

The question clearly states that the medullary substance came from the uterine cavity, so we are not concerned about the cervix (Uterine cervix cancer) or ovary (hormone-producing ovarian tumor).

Adenomyosis is a gynecological condition in which endometrial tissue exists within and grows into the myometrium. However, it disappears after menopause. It most often occurs late in childbearing years.

 

Chorioepithelioma, also called chorioblastoma, choriocarcinoma or chorionic carcinoma, is mainly associated with the reproductive age. It is a fast-growing tumor that develops from trophoblastic cells (cells that help an embryo attach to the uterus and help form the placenta). Almost all chorioepitheliomas form in the uterus after fertilization of an egg by a sperm, but a small number form in a testis or an ovary.

72. A 59-year-old man complains of pain in his left eye and left side of his head, significant vision impairment of the left eye, nausea, and vomiting. Visual acuity of the right eye is 1.0. Visual acuity of the left eye is 0.03, attempts at correction bring no improvement. Right eye intraocular pressure - 21 mm Hg, left eye intraocular pressure - 65 mm Hg. Congestive injection is observed on the sclera of the left eye. The cornea is thick and swollen. The anterior chamber is shallow, moist, and clear. The pupil is dilated and unresponsive to the light, the fundus of the eye is not visible. What is the most likely diagnosis?

Explanation

Glaucoma is a set of ocular disorders often defined by increased intraocular pressures leading to optic neuropathy and vision loss if untreated. Acute attack of glaucoma is caused by a rapid or sudden increase in pressure inside the eye, called intraocular pressure (IOP). Symptoms include - eye pain, severe headache, very blurry or hazy vision, redness in the white part of the affected eye, nausea or vomiting, sudden loss of sight etc.

The commonly accepted range for intraocular pressure is 10-22 mmHg (left eye is 65mmHg). Three factors that affect the intraocular pressure are the rate of production of aqueous humor by the ciliary body, the resistance to aqueous outflow through the trabecular meshwork and Schlemm’s canal, and the episcleral venous pressure. 

 

The normal flow of aqueous humor starts in the ciliary body, goes through the pupil and out through the trabecular meshwork and Schlemm's canal in the angle of the anterior chamber. In acute angle-closure glaucoma, intraocular pressure increases rapidly due to outflow obstruction of the aqueous humor.

73. A 39-year-old man suffers from chronic adrenal insufficiency and receives replacement glucocorticoid therapy (hydrocortisone - 15 mg/day). He is to undergo elective surgery for calculous cholecystitis. What medication adjustment should be made on the day of the surgery to prevent the development of acute adrenal insufficiency?

Explanation

 

Acute adrenal Insufficiency is a sudden failure in adrenal gland hormone production (aldosterone and cortisol). It can be triggered by stress, trauma, infection, Surgery etc. The above patient suffers from a chronic case of adrenal insufficiency and is already on hydrocortisone (a glucocorticoid); to avoid an adrenal gland crisis triggered by the surgical process, the patient should be administered an increased dose of glucocorticoid. An antibiotic regimen should be added to prevent sepsis, while large intravenous fluid should be used in case of dehydration.

74. An 8-year-old girl complains of frequent painful urination in small amounts and urinary incontinence. The signs have been present for 2 days already. She explains her disease by overexposure to cold. Costovertebral angle tenderness is absent. Complete blood count is without pathologies. Urine test: leukocytes - 20-30 in the vision field, erythrocytes - 40-50 in the vision field, unchanged, bacteriuria. What is the most likely diagnosis?

Explanation

Cystitis is the medical term for inflammation of the bladder. Most of the time, the inflammation is caused by a bacterial infection, and it's called a urinary tract infection (UTI). Cystitis signs and symptoms often include: strong, persistent urge to urinate (urinary urgency); burning and painful sensation when urinating; Passing frequent, small amounts of urine (urinary frequency); Blood in the urine (hematuria); Passing cloudy or strong-smelling urine; Pelvic discomfort; feeling of pressure in the lower abdomen; Low-grade fever etc. Cystitis is more common in females due to their relatively short urethra and proximity to the anus.

 

Absent costovertebral angle tenderness rules out pyelonephritis. Proteinuria will also be associated with glomerulonephritis and pyelonephritis which were not mentioned in this patient. Urolithiasis is often associated with lumboabdominal colicky pain that comes in the form of an attack and relieves the patient after some time. The pain is usually along the path of the ureter connecting the kidney to the urinary bladder.

75. A chronic alcoholic was hospitalized into the therapeutic inpatient unit due to pneumonia. On the day 5 of his hospitalization he became disoriented in time and space, developed fear-inducing visual hallucinations and motor agitation. Full body tremor and tremor of the limbs are observed. X- ray and physical examinations detect the signs of his convalescence from pneumonia. What tactics should be chosen regarding this patient?

Explanation

Alcohol Withdrawal

The patient in question has been hospitalized for 5 days now. This information can help us know that he has probably not had alcohol since admission. Therefore, he is probably in a state of Acute Withdrawal syndrome evidenced by the symptoms listed (check image with timeline for onset of some of the symptoms). This is a clear indication that he is addicted and requires help from experts in the field of Narcology.

Narcology is the study of drug abuse and was introduced in the early 1960s and 1970s as a separate medical field in the former Soviet Union countries. It is a medical discipline of psychiatry studies that deals with the prevention, diagnosis, treatment, recovery and social care of substance-dependent people.

 

Narcology uses basic drug and alcohol dependence healthcare infrastructure and approaches in the treatment of addiction. People diagnosed with alcoholism are taken through a treatment process and then refrain from further alcohol abuse. The procedure involves a course of detoxification and regular outpatient observation by a narcologist for five years.

76. During medical examination a cadet in the naval college was detected to have a painless dense ulcer 1.5x0.5 in size in his perianal area at the 2 o’clock position. The ulcer floor resembles ”old fat”. What is the provisional diagnosis?

Explanation

Syphilis is a sexually transmitted disease caused by the spirochete Treponema Pallidum- a spiral shaped microorganism stained by Romanowsky–Giemsa method. It has three stages namely:

  • Primary

  • Secondary

  • Tertiary

 

Primary stage is characterised by the presence of Hard Chancre which are firm, painless genital ulcers. Lymphadenitis and Lymphagitis are also seen in this stage.

77. A 52-year-old woman has been suffering for 2 years from dull, occasionally exacerbating pain in her right subcostal area, occurring after eating high-fat foods, bitter taste in her mouth in the morning, constipations, and flatulence. Objectively she has excess weight, her body temperature is 36.9°C; there is a coating on the root of her tongue; the abdomen is moderately distended and painful in the area of gallbladder projection. What examination would be the most helpful for diagnosis-making?

Explanation

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

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

 

The other options are a bit cumbersome eg, Cholecystography requires use of contrast, and Duodenoscopy is more expensive.

78. In a rural health care area there is an increasing cervical cancer morbidity observed. The decision is made to conduct a medical examination of the women living in this locality. What type of medical examination is it?

Explanation

79. A 45-year-old man diagnosed with acute pulmonary abscess suddenly developed sharp pain in his chest on the right and dyspnea up to 30/min. Examination detects facial cyanosis and shallow rapid respirations. Auscultation reveals acutely weakened respiration throughout the whole right lung; percussion reveals a vesiculotympanitic (bandbox) resonance at the lung apex and dullness in the lower lobe. What complication developed in this patient?

Explanation

Pyopneumothorax occurs most frequently as a complication of a pulmonary abscess. The rupture of such an abscess into the pleural space usually occurs during its acute stage, while active destruction of pulmonary tissue is still going on.

Acute pulmonary abscess is a fluid filled cavity in the lungs, evidenced by air-fluid level in a well circumscribed cavity on chest X-ray. When there is rupture, both air and fluid can leak out resulting in Pyo - PUS; Pneumo - AIR; - Pyopneumothorax. On X-ray: Air is above due to its lesser density and fluid is below.

 

From the question stem, there is dullness in the lower lobe which is usually associated with fluid and high resonance is usually associated with air. Therefore, a pneumothorax occurring alone without ‘Pyo’ will result in hyperresonance in all lung fields.

80. A 30-year-old multigravida has been in labour for 18 hours. 2 hours ago the pushing stage began. Fetal heart rate is clear, rhythmic, 136/min. Vaginal examination reveals complete cervical dilatation, the fetal head in the pelvic outlet plane. Sagittal suture is in line with obstetric conjugate, the occipital fontanel is near the pubis. The patient has been diagnosed with primary uterine inertia. What is the further tactics of labor management?

Explanation

UTERINE INERTIA  (“Failure to progress”, hypotonic uterine dysfunction) describes lack of progressive cervical dilatation and/or descent of the fetus.  It is such a condition in which uterine contractions strength, duration and frequency are inadequate, that’s why cervical effacement, dilation and fetal descending is slower than in normal labor. Since the baby’s head is already in the pelvic outlet plane and can't proceed further due to inadequate contractions, an outlet forceps is used in assisting delivery.

 

Labour stimulation will occur in situations such as post-datism, premature rupture of membranes etc. Cesarean session in cases of severe preeclampsia, eclampsia, breech or fetal distress.

81. A 45-year-old man was brought by an ambulance into the emergency hospital. He complains of sudden pain in the lumbar area, frequent painful urination, and vomiting. Examination detects pain in the lumbar area, costovertebral angle tenderness, pain on palpation of kidneys and along the ureter on the right. Urine test: proteins, fresh erythrocytes, leukocytes. Make the provisional diagnosis:

Explanation

 

Renal colic is the term used to refer to pain experienced in individuals with stones obstructing their urinary tract especially the ureters. This  pain is usually located in the flanks (lumboabdominal region) and radiates to the groin area. From urine analysis, key finding is usually the presence of gross or microscopic hematuria  marked by the increase in erythrocyte level.

82. A 26-year-old woman is suspected to suffer from systemic lupus erythematosus due to systemic lesions of skin, vessels, joints, serous tunics, and heart that developed after photosensitization. The following is detected: LE cells, antibodies to native DNA, isolated anti-centromere antibodies, rheumatoid factor is 1:100, Wassermann reaction is positive, circulating immune complex is 120 units. What immunological indicators are considered to be specific to this disease?

Explanation

 

Systemic Lupus erythematosus (SLE) is an autoimmune disease characterised by appearance of a butterfly rash (malar rash), arthritis, oral ulcers, endocarditis etc. Organ damage is due to type III hypersensitivity ( immune complex) and type II (to a lesser extent). For diagnosis, Antinuclear antibodies are tested for. Subtypes of antinuclear antibodies specific for SLE include: Anti Smith and anti double stranded DNA antibodies (ds-DNA antibodies).

83. A 40-year-old victim of a traffic accident sustained the following injuries: closed diaphyseal femur fracture, brain concussion, multiple rib fractures, hemopneumothorax, degloving shin injuries. What injuries require the most urgent attention?

Explanation

In resuscitating a patient, C-A-B sequence is very important. 

C is to help maintain blood circulation; A - airway and B - Breathing.

Hemopneumothorax can be considered under these 3.

Hemo - active internal hemorrhage into the pleural cavity.

Pneumo - ongoing air leakage into the pleural cavity.

If these are not attended to first, eventually, the lungs will not be able to expand, hence, no gaseous exchange compromising both A- airway and B- breathing. If no action is taken, and the hemorrhage and air leakage into the pleural cavity continues, it will eventually lead to hypovolemia and the accumulated blood will compress the mediastinum which houses the heart thereby preventing the heart from contracting as well and eventually compromises C- circulation.  Once this is attended to, the other injuries can receive proper care as well but hemopneumothorax comes first.

Now, considering this patient, there is no active external bleeding going on. Closed diaphyseal femur fracture just needs immobilization as first aid. It is not open and the question did not state that there is an injury to a major blood vessel. In Degloving shin injuries, if there is an active bleeding, the vessel can be ligated and the wound dressed.

 

The most common and least serious type of traumatic brain injury is called a concussion. A concussion is most often caused by a sudden direct blow or bump to the head.

84. A 36-year-old man complains of marked dyspnea and cardiac pain. He ascribes his disease to the case of influenza that he had 2 weeks ago. Objectively he leans forward when sitting. The face is swollen, cyanotic, cervical veins are distended. Heart borders are extended on the both sides, heart sounds are muffled, heart rate = Ps = 118/min., BP is 90/60 mm Hg. Blood test: ESR is 46 mm/hour. ECG shows low voltage. X-ray shows trapezoidal cardiac silhouette and signs of pulmonary congestion. Choose the treatment tactics:

Explanation

 

We can pick out: Extended heart borders, low blood pressure and an increased pulse . These three signs are known as Beck’s triad. They indicate a Cardiac Tamponade (the impaired pumping ability of the heart due to accumulation of fluid in the pericardium). Note that on the x-ray, a trapezoid cardiac silhouette sign was present- this means that the normal cardiac borders were lost (thus confirming one of the earlier stated signs). The most suitable approach  should be a pericardial puncture (pericardiocentesis) to remove the fluid in the pericardium.

85. Increased general morbidity of the local population is observed in the area near a factory, where atmosphere is being intensively polluted with sulfurous gas. What effect does polluted air have on human body in this case?

Explanation

86. Heart X-ray of a 31-year-old man has revealed the following: with tightly filled opacified esophagus there is a marginal filling defect in its middle third on the posterior wall; the defect is 1.8xl.3 cm in size with clear oval border. Mucosal folds are retained and envelop the defect; wall peristalsis and elasticity are not affected. There are no complaints regarding the condition of the patient’s alimentary canal. Make the provisional diagnosis:

Explanation

Notice that mucosal walls are retained and wall peristalsis and elasticity are not affected- these rule out the options of achalasia cardia, Esophageal burns and barrett's esophagus ( because in these pathologies, one or more of the above listed is/are affected). The result from the x-ray shows a mass with clear oval borders thereby indicating a tumour.

 

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

87. 3 hours after a trauma, a young man developed bradycardia of 46/min., anisocoria D>S, hemi- hyperreflexia S>D, hemihypesthesia on the left, and a convulsive disorder. The character of this process needs to be clarified. What method of examination will be the most accurate for this purpose?

Explanation

A cranial CT scan is a diagnostic tool used to create detailed pictures of features inside your head, such as your skull, brain, paranasal sinuses, ventricles, and eye sockets. CT stands for computed tomography, and this type of scan is also referred to as a CAT scan. The pictures created by a cranial CT scan are far more detailed than regular X-rays.

 

Electroencephalogram (EEG) is the most common test used to diagnose epilepsy, but in this case, the convulsive disorder is not the only abnormality we need to investigate. There are other disorders like bradycardia, anisocoria (greater on the right i.e. Dextra>Sinistra), hyperreflexia (more on the left i.e. Sinistra>Dextra) and hemihypesthesia. Hence, a brain CT scan is the best choice to start with in this case.

88. A 25-year-old woman complains of fatigue, dizziness, hemorrhagic rashes on the skin. She has been presenting with these signs for a month. Blood test: erythrocytes - 1.0∙1012/L, Hb - 37 g/L, color index - 1.1, leukocytes - 1.2∙109/L, platelets - 42∙109/L. What analysis would be the most advisable for diagnosis-making in this case?

Explanation

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

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

89. A 48-year-old woman has been hospitalized due to development of tachysystolic atrial fibrillation. She has lost 5 kg of body weight within 2 months. On palpation there is a node in the left lobe of the thyroid gland. What pathology resulted in the development of this condition?

Explanation

 

A toxic goiter refers to goiters which cause Hyperthyroidism eg. diffuse toxic goiter. A non toxic goiter does not cause hyperthyroidism - it refers to a diffuse or nodular enlargement of the thyroid gland that does not result from an inflammatory or neoplastic process and is not associated with abnormal thyroid function.. Notice that this patient shows symptoms of hyperthyroidism (loss of weight, tachycardia); this rules out the option of a non-toxic goiter. Nodular goiter is palpated as painless tumour with regular contours, smooth surface, not connected with adjacent tissues and displaced during swallowing. In this patient, the node on the left lobe coupled with signs of hyperthyroidism indicates a nodular goiter.

90. Having studied the relationship between the distance from villages to the local outpatient clinics and frequency of visits to the clinics among the rural population of this area, it was determined that the rank correlation coefficient in this case equals -0.9. How can this relationship be characterized?

Explanation

The Spearman's Rank Correlation Coefficient is used to discover the strength of a link between two sets of data. This example looks at the strength of the link between the distance from villages to the local outpatient clinics and frequency of hospital visits.

Correlation is a bivariate analysis that measures the strength of association between two variables and the direction of the relationship.  In terms of the strength of relationship, the value of the correlation coefficient varies between +1 and -1.  A value of ± 1 indicates a perfect degree of association between the two variables.  As the correlation coefficient value goes towards 0, the relationship between the two variables will be weaker.  A correlation coefficient of zero indicates that no relationship exists between the variables. The direction of the relationship is indicated by the sign of the coefficient; a + sign indicates a positive relationship and a – sign indicates a negative relationship.

An inverse correlation, also known as negative correlation, is a contrary relationship between two variables such that when the value of one variable is high then the value of the other variable is probably low.

The value of the correlation coefficient ‘r’ can range from 0.0, indicating no relationship between the two variables, to positive or negative 1.0, indicating a strong linear relationship between the two variables.

 

Value of r

Indications

0.0

No linear relationship between the two variables

+1.0

Strong positive linear relationship; as X increases in value, Y increases in value also; or as X decreases in value, Y decreases also.

-1.0

Strong inverse linear relationship; as X increases in value, Y decreases in value; or as X decreases in value, Y increases in value.

 

Therefore, a value of -0.9 is very close to -1.0 and that will give us a strong inverse relationship.

91. A 63-year-old man complains of unmotivated weakness and pressing and bursting sensation in the left subcostal area. According to him, these signs have been present for a year already. Previously he was healthy. He took part in containment measures during the accident at the Chornobyl Nuclear Power Plant. Objectively: the skin is pale, peripheral lymph nodes are not enlarged, the liver is +3 cm, the spleen is +10 cm. Complete blood count: erythrocytes - 3.1∙1012/L, Hb - 100 g/L, leukocytes - 46∙109/L, blasts - 2%, promyelocytes - 10%, myelocytes - 18%, band neutrophils - 27%, segmented neutrophils - 10%, lymphocytes - 12%, eosinophils - 6%, basocytes - 3%, monocytes - 2%, erythrocyte sedimentation rate - 20 mm/hour. What is the most likely diagnosis?

Explanation

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

Leukemias are malignant neoplasms of the hematopoietic stem cells characterized by diffuse replacement of the bone marrow by neoplastic cells.

From the question stem, using the full blood count, we can denote that there is Leukemia. 

Total leukocytes count: 46 X 10*9 (excessively high)

To distinguish between Acute and Chronic leukemia, the blast count is always very important. Blasts are immature white blood cells.

In chronic Leukemia, the blood and bone marrow contain less than 10% blasts (blast - 2%). In Acute leukemia, blasts are usually more than 20%.

Using the lab values given in the question, we have more immature promyelocytes, myelocytes which will help to distinguish between Chronic Lymphatic Leukemia and Chronic Myeloleukemia.

 

Lymphoblasts will show up on blood film in lymphatic leukemia which is absent in this case.

92. At night a 2-year-old child with upper respiratory tract infection suddenly developed dyspnea with labored inspiration. Objectively the skin is pale, perioral cyanosis and slight acrocyanosis are observed. Breathing is loud, respiration rate is 32/min. Jugular, supra- and infraclavicular fossae retract during breathing. Respiration is coarse on auscultation. Heart sounds are clear and sonorous, heart rate is 120/min. What condition was complicated by the development of the upper respiratory tract infection?

Explanation

 

The patient presents with symptoms of croup also called laryngotracheobronchitis; classic symptoms include barking cough, noisy breathing (stridor), intercostal retraction (hoover’s sign). This can be caused by a virus ( parainfluenza, influenza A or B) or bacteria (corynebacterium diphtheriae, staph. Aureus, strep pneumonia etc). It is most commonly seen in children aged 6 months- 5 years.

93. A 50-year-old patient was brought to a hospital with complaints of blood in urine. Urination is painless and undisturbed. Macrohematuria had been observed for 3 days. Objectively: kidneys cannot be palpated, suprapubic area is without alterations, external genitalia are non-pathologic. On rectal investigation: prostate is not enlarged, painless, has normal structure. Cystoscopy revealed no changes. What is the most likely diagnosis?

Explanation

Renal Cell Carcinoma is most common in men 50-70 years old. It manifests clinically with the classic triad of flank pain, hematuria, and flank mass. There could also be secondary polycythemia; fever and weight loss.

From the question stem: 

Supra public area is without alteration and no abnormal findings on cystoscopy (i.e. no problem with the urinary bladder).

External genitalia and prostate - no abnormal findings.

 

So the best option here associated with hematuria (blood traces in urine) is Renal carcinoma.

94. A 23-year-old woman came to the gynecological clinic. She complains of pain, itching, and burning in her vulva, general weakness, indisposition, elevated body temperature up to 37.2°C, and headache. On examination in the vulva there are multiple vesicles up to 2-3 mm in diameter with clear contents against the background of hyperemia and mucosal edema. Make the provisional diagnosis:

Explanation

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, prepuce, 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.

 

Cytomegalovirus is also known as human herpes virus-5, it is usually seen in immunocompromised patients and infected cells have characteristic ‘ owl's eye’ intranuclear inclusions. 

95. After a pain attack in the right subcostal area, a 58-year-old woman with overnutrition developed icteric skin and sclera, light-colored feces, and dark urine. Her abdomen is distended and painful on palpation in the right subcostal area. Palpation detects liver enlargement by 2-3 cm. Blood test: total bilirubin - 90 mcmol/L, conjugated bilirubin - 60 mcmol/L. What method of examination will be the most informative for diagnosis clarification?

Explanation

From the question stem, it is evident that the patient has obstructive, mechanical or post-hepatic jaundice (icteric skin, light colored feces, dark urine).

Obstructive jaundice is a condition in which there is blockage of the flow of bile out of the liver. Therefore, it is caused by conditions that block the normal flow of bile from the liver into the intestines including: Biliary stricture (narrowing of the bile duct), cancer of the gallbladder or pancreas, Cholangitis (infection or inflammation of the common bile duct), Cholelithiasis (gallstones), Cysts of the bile duct, pancreatitis, parasitic infection, or trauma, including surgical complications.

 

ERCP (short for endoscopic retrograde cholangiopancreatography) is a procedure used to diagnose diseases of the gallbladder, biliary system, pancreas, and liver. During an ERCP, a gastroenterologist (doctor who specializes in treating diseases of the gastrointestinal system), uses a special endoscope (a long, flexible tube with a light and camera at the end) to examine the inside of the digestive system. The doctor identifies the place where the bile duct comes into the intestine and then feeds a tiny catheter (a plastic tube) into the duct and squirts in a contrast agent while X-rays are taken. The contrast agent allows the doctors to see the bile ducts, the gallbladder, and the pancreatic duct on the X-rays. Once the source of the problem is identified, the doctor may then treat it.

96. A 30-year-old woman made an appointment with the family doctor for scheduled vaccination of her 2-year-old child. What type of healthcare provides such medical services?

Explanation

According to levels of specialization, types of medical care include: Emergency, Primary, Secondary, Tertiary, palliative, medical rehabilitation and dentistry.

Primary medical care: involves care given by nurses, midwives, general physicians, family doctors, in polyclinics etc. Primary healthcare is the first contact a person has with the health system when they have a health problem. 

Secondary medical care: When your primary care provider refers you to a specialist, you are then in secondary care. Secondary care simply means you will be taken care of by someone who has more specific expertise eg cardiologist, endocrinologist etc

Tertiary Medical Care: Once a patient is hospitalized and needs a higher level of specialty care within the hospital, he may be referred to tertiary care. Tertiary care requires highly specialized equipment and expertise. For example Cardiosurgery.

 

At this level, you will find procedures such as coronary artery bypass surgery, renal or hemodialysis, and some plastic surgeries or neurosurgeries.

97. A 38-year-old woman after physical overexertion suddenly developed palpitations, dyspnea, and a dull pain in the cardiac area. For 10 years she has been registered for regular check-ups due to rheumatism and mitral valve disease with non-disturbed blood circulation. Oblectively her pulse is 96/min., of unequal strength. Blood pressure is 110/70 mm Hg, heart rate is 120/min. ECG registers small unevenly-sized waves in place of P-waves, R-R intervals are of unequal length. What is the most likely diagnosis

Explanation

Atrial Fibrillation

Mitral Valve Stenosis is commonly caused by recurrent attacks of Rheumatic Fever. Left Atrium becomes dilated and hypertrophied because of increased work imposed on the Left Atrium in filling the Left Ventricle during diastole. Atrial fibrillation (irregularly irregular pulse - Pulse is 96/min of unequal strength) is a complication of Left atrial dilation and hypertrophy.

Atrial fibrillation is often diagnosed with the ECG. There is a chaotic and erratic baseline with no discrete P waves in between irregularly spaced QRS complexes. RR intervals are not equal.

 

In Atrial Flutter, the length of RR intervals are equal.

98. A man was brought into the admission room after an overexposure to cold. He complains of sharp pain in the small of his back and elevated body temperature up to 38°C. He took some aspirin. Blood test: leukocytes - 10.5∙1012/L, eosinophils - 5%, band neutrophils - 8%, segmented neutrophils - 51%, lymphocytes - 32%, monocytes - 4%, erythrocyte sedimentation rate - 28 mm/hour. Urinalysis: protein - 0.6 g/L, leukocytes - cover the whole vision field, large amount of mucus. What is the most likely diagnosis?

Explanation

Acute pyelonephritis is a bacterial infection of the renal parenchyma that can be organ- and/or life-threatening and that often leads to renal scarring. The bacteria in these cases have usually ascended from the lower urinary tract, but may also reach the kidney via the bloodstream.

Mainly, neutrophils (band and segmented neutrophils) infiltrate the renal interstitium with relative sparing of glomeruli and vessels. It presents with fever, flank pain (costovertebral angle tenderness), nausea, vomiting, chills. It is commonly associated with white blood cells (leukocytes) in urine and white blood cell casts. The question says, Leukocytes cover the whole vision field.

Acute interstitial nephritis also called tubulointerstitial nephritis presents with pyuria (classically eosinophils) and azotemia occurring after administration of drugs inducing hypersensitivity. In this patient, the disease condition already started before he took Aspirin, so we can’t conclude that the condition was induced as a result of drug hypersensitivity.

 

Glomerulonephritis often follows upper respiratory tract infections and commonly seen in children 2-4 weeks after a Group A streptococcal infection.

99. After a surgery for a left thigh phlegmon the disease progression was complicated by sepsis. On the 7th day after the surgery there are marked signs of a generalized inflammatory reaction, in blood there are signs of toxic anemia and progressing hypoproteinemia, bilirubin levels are 40 mcmol/L, AST and ALT exceed the norm by 2.5 times. Oliguria persists (700 mL of urine per day). Name the phase of sepsis progression

Explanation

Stress response caused by events such as surgical trauma includes endocrine, metabolic and immunological changes.

 

It is divided into 2 phases, the ebb and flow.

Ebb Phase: survival phase (few hours after injury). Reversible by early and prompt resuscitation.

 

Flow Phase follows (only attenuated): 2 parts

Catabolic Phase: 3 - 10days

Anabolic Phase: Weeks

-Catabolic: increase metabolic rate; lasts 3 - 10days; negative nitrogen balance and weight loss. This phase usually lasts about a week in moderate trauma but usually longer in severe trauma and if sepsis sets in.

 

-Anabolic Phase: protein and fat stores restoration + weight gain (positive nitrogen balance). The recovery phase usually lasts 2 - 4 weeks.

 
100. A 9-month-old infant presents with delayed tooth eruption and fontanel closure, weakness, and excessive sweating. What type of hypovitaminosis is the most likely in this child?

Explanation

The symptom of delayed fontanelle closure and tooth eruption indicates the 9 month old baby has issues in relation to reduced calcium levels (calcium is responsible for formation/modelling of bones and teeth). In relation to vitamins, vitamin D is responsible for the intestinal absorption of elements like calcium, magnesium etc. In humans, vit D₃- cholecalciferol and D₂- ergocalciferol are the most important. Deficiency of vitamin D will lead to Rickets (in children) and osteoporosis(in adults).

 

Vitamin C deficiency will lead to scurvy characterised by bleeding gums, petechial bleeding (small hemorrhages). Vitamin B1 deficiency leads to Beri-Beri; Vit A deficiency results in night blindness.

101. A 24-year-old woman, a kindergarten teacher, has been sick for 2 days already. Disease onset was acute. She presents with elevated body temperature up to 38.0°C, pain attacks in her lower left abdomen, liquid stool in small amounts with blood and mucus admixtures 10 times a day. Pulse - 98/min., blood pressure - 110/70 mm Hg. Her tongue is moist and coated with white deposits. The abdomen is soft, the sigmoid colon is painful and spastic. Make the provisional diagnosis:

Explanation

Bacterial gastroenteritis is caused by a variety of organisms, including Campylobacter, Salmonella, Shigella, Yersinia, Vibrio cholerae, Staphylococcus aureus, diarrheagenic Escherichia coli, Clostridium difficile, Clostridium perfringens, and non cholera Vibrio species. Shigellosis is also known as bacillary dysentery caused by the infection of the shiga toxin. It is characterised by High-fever, tenesmus, Profuse inflammatory, mucoid-bloody diarrhea and basically affects the large intestine. Commonly transmitted via fecal-oral route. This patient experiences pain in the sigmoid colon accompanied by profuse diarrhea (mixed with blood and mucus). 

 

Salmonellosis presents often without blood and commonly transmitted with poultry products (eggs, omelette etc)

102. A 25-year-old woman was brought into the gynecological department with profuse bloody discharge from her genital tracts. She is 12 weeks pregnant, the pregnancy is planned. Within the last 3 days she was experiencing pains in her lower abdomen that eventually started resembling cramps, she developed bleeding. Her skin is pale, pulse - 88/min., blood pressure - 100/60 mm Hg, body temperature - 36.8°C. Vaginal examination: the uterus size corresponds with 11 weeks of pregnancy, the cervical canal allows inserting 1 finger and contains fragments of the fertilized ovum, the discharge is bloody and profuse. What is the most likely diagnosis?

Explanation

Abortion is the removal of pregnancy tissue, products of conception or the fetus and placenta (afterbirth) from the uterus. It is the extraction or the expulsion of the product of conception that weighs less than or equal to 500g. Abortions could either be spontaneous or Induced (legal or therapeutic abortion).

Spontaneous Abortion includes: threatened, inevitable, incomplete, complete, missed, or septic.

There are 3 classical features of Abortion: Bleeding per vagina, Abdominal pain and History of amenorrhea (physiological amenorrhea - the woman is pregnant, so no menses).

 

In this case, she is 12 weeks pregnant and the spontaneous abortion is in progress because the cervix is open (cervical canal allows 1 finger which means 2cm open). In threatened abortion, the cervix is closed.

103. A 23-year-old man complains of facial edemas, headache, dizziness, low urinary output, and urine discoloration (dark red). These complaints arose after a case of acute tonsillitis. On examination there are facial edemas, the skin is pale, temperature is 37.4°C; heart rate is 86/min., blood pressure is 170/110 mm Hg. Heart sounds are muffled, the II heart sound is accentuated over the aorta. What etiological factor is the most likely in this case?

Explanation

 

The Patient in question has a rheumatic Fever. RF is gotten from prior infection of the throat (acute tonsillitis, pharyngitis etc) by group A beta hemolytic streptococci.For diagnosis, the Jones criteria (major criteria) is used. They include migratory polyarthritis, carditis, subcutaneous nodules, erythema marginatum (rash with ring margin) and sydenham chorea; and some minor criteria such as fever. It is classified as a type II hypersensitivity reaction (immune mediated) and occurs due to molecular mimicry. Aschoff bodies (granuloma with giant cells), anitschkow cells, increased antistreptolysin O and anti-DNase B titers are seen in lab findings.

104. A newborn with gestational age of 31 weeks presents with hypotonia and depressed consciousness. Hematocrit is 35%, general cerebrospinal fluid analysis shows increased content of erythrocytes and protein, and low glucose. These data correspond with the clinical presentation of:

Explanation

 

Intracranial hemorrhage can be confirmed by cerebrospinal fluid analysis (CSF Analysis). An increased content of Erythrocytes in CSF findings indicates “ intracranial hemorrhage”. Presence of protein and low glucose in CSF are not specific and can indicate pathologies such as an infarct, meningitis, sepsis etc.  Hypertonia and depressed consciousness are also general signs and can be found in any of the above pathology.

105. A 37-year-old patient complains of pain in the spinal column, reduced mobility. The condition persists for 7 years. ”Sway back” is observed, there is no movement in all spinal regions. X-ray shows ”bamboo spine” vertebral column. What is the most likely diagnosis?

Explanation

Ankylosing spondylitis (AS) is a chronic, multisystem inflammatory disorder primarily involving the sacroiliac (SI) joints and the axial skeleton. Overtime, it results in the fusion of  the small bones in your spine (vertebrae) making the spine less flexible and can result in a hunched-forward posture. The term “swayback” is an inappropriate curve of the upper lumbar spine; And Bamboo spine is a radiographic feature seen in ankylosing spondylitis that occurs as a result of vertebral body fusion.

 

Spondylitis deformans is characterised by degeneration in the intervertebral discs followed by the presence of bony spurs or osteophytes along the edges of the bones of the spine.

106. Human body receives from the atmosphere a number of chemicals. What type of action results in the combined effect that is less than the sum of isolated effects of these chemicals on the body?

Explanation

In Antagonism, two different chemicals oppose the action of each other either directly (competitively) or Indirectly (non-competitive). Hence, when both act together they will produce an effect less than the sum of the individual chemicals.

 

Chemical antagonism occurs when a drug reduces the concentration of an agonist by forming a chemical complex (e.g. chelating agents). Example: protamine sulfate is a positively charged substance that when given intravenously will bind to heparin, a strongly negatively charged anticoagulant drug. As a result, protamine sulfate administration is a type of “antidote” for heparin overdose, because once heparin binds to protamine sulfate, it cannot exert its anticoagulant effects. 

Pharmacokinetic antagonism occurs when one drug accelerates the metabolism or elimination of another (e.g. phenobarbital-induced enzyme induction increases the metabolism of the anticoagulant coumadin).

 

Synergism: the combined action of two drugs is greater than the activity of either alone (in total). For example: monobactams and aminoglycosides

 

Potentiation: drug A is required for the full effect of drug B to occur, but drug A itself does not have much of an effect (unlike synergism). So when drug A is Co-administered with drug B, they will produce a greater effect.

 
107. A 33-year-old man developed multiple rashes on the skin of his torso and extensor surfaces of his upper and lower limbs. The rashes itch and occasionally fuse together and form plaques. The elements of rash are covered with silver-white fine scales that easily flake off when scratched. Grattage test results in three sequential phenomena: stearin spot, terminal film, and punctate hemorrhage. What diagnosis can be suspected?

Explanation

Psoriasis is a common skin disorder characterised by the presence of papules and plaques with silvery scaling especially on the extensor surfaces (knees and elbows). Other characteristics include acanthosis, parakeratosis and pinpoint bleeding (Auspitz sign). The patient presents with a thimble symptom which translates into a pitting or a psoriatic nail.

The “psoriatic triad” - Grattage test: Stearin spot; terminal film; and Punctate hemorrhage

  1. the “stearin spot” phenomena (scraping the top layer of psoriatic plaques enhances the peeling);

  2. the “wet film” phenomena (if you remove all the scales from a psoriatic skin lesion, you can see smooth, pinkish, slightly wet surface);

  3. the “blood dew” phenomena (when removing the wet terminal film the area get covered with tiny droplets of blood, also known as point hemorrhage).

 

The combination of all three attributes eliminates the error in diagnosis.

108. After eating shrimps, a 25-year-old man suddenly developed skin itching, some areas of his skin became hyperemic or erupted into vesicles. Make the diagnosis:

Explanation

Urticaria or Hives are pruritic (itchy) wheals or elevations of the skin. Urticaria commonly develops in areas of mechanical pressure on skin. Most often due to mast cell release of histamine. It’s a Type I IgE-mediated reactions associated with certain exposures like certain foods (e.g. peanuts - in this case shrimps); Insect bites (e.g. fire ant); drugs (e.g. penicillin, morphine, aspirin, laxative); emotional stress; Hepatitis B virus. Urticaria resolves when you discontinue offending agent while urticaria pigmentosa can resolve sponatneously.

Urticaria pigmentosa (UP) or cutaneous mastocytosis commonly affects children and resolves spontaneously. Scratching of the lesions results in erythematous swelling and pruritus called Darier sign. Lesions in Urticaria pigmentosa remain hyperpigmented even when they regress. Other findings in UP include Abdominal pain and diarrhea, headaches with flushing of the skin.
109. A 58-year-old man complains of weakness and tumor-like formations that appeared on the anterior surface of his neck and in the inguinal region. Palpation detects soft painless mobile cervical and inguinal lymph nodes up to 2 cm in diameter. The liver protrudes by 2 cm from the edge of the costal margin, the lower splenic pole is at the umbilical level. In blood: erythrocytes - 3.5∙1012/L, Hb - 88 g/L, leukocytes - 86∙109/L, band neutrophils - 1%, segmented neutrophils - 10%, lymphocytes - 85%, eosinophils - 2%, basocytes - 0%, monocytes - 2%, erythrocyte sedimentation rate - 15 mm/hour, Gumprecht shadows. What is the most likely diagnosis?

Explanation

Complete Blood Count

Leukemia is a cancer of the marrow and blood. The major forms of leukemia are divided into four categories. The terms myelogenous or lymphocytic denote the cell type involved. Myelogenous and lymphocytic leukemia each have an acute or chronic form. Thus, the four major types of leukemia are acute or chronic myelogenous and acute or chronic lymphocytic leukemia. Acute leukemia is a rapidly progressing disease that affects mostly cells that are unformed or immature (Blast cells). These immature cells cannot carry out their normal functions. Chronic leukemia progresses slowly and permits the growth of greater numbers of more developed cells. 

From the question stem, using the full blood count, we can denote that there is Leukemia. 

Total leukocytes count: 86 X 10*9 (excessively high)

 

Also, the question also notes the presence of Gumprecht shadows - Smudge cells (Gumprecht shadows) are Chronic Lymphocytic Leukemic cells ruptured during peripheral blood smear preparation.

110. A 28-year-old man complains of skin rash and itching on the both of his hands. The condition persists for 1.5 years. The exacerbation of his condition he ascribes to the occupational contact with formaldehyde resins. Objectively the lesion foci are symmetrically localized on both hands. Against the background of erythema with blurred margins there are papulae, vesicles, erosions, crusts, and scales. What is the most likely pathology?

Explanation

 

Eczema (dermatitis) is a chronic inflammatory disease of the skin characterized by the presence of red, itchy, vesicles, papules, dry scaly rashes. Occupational eczema (dermatitis) is gotten from contact with certain chemicals in the course of working. The patient in question had occupational contact with formaldehyde. So it is safe to say, it is an occupational eczema.

111. A 73-year-old woman came to the family physician for one of her regular follow-up examinations. Three months ago she was found to have type 2 diabetes mellitus. She was keeping to her diet and exercise plan and taking phytopreparations. On examination her fasting glucose was within the range of 7.8-8.6 mmol/L, HbA1c - 7.9%. Height - 164 cm, weight - 83 kg. What blood sugar- controlling medicine should she be prescribed first in the course of her pharmacological therapy?

Explanation

112. At night a 63-year-old woman suddenly developed an asphyxia attack. She has a 15- year-long history of essential hypertension and had a myocardial infarction 2 years ago. Objectively her position in bed is orthopneic, the skin is pale, the patient is covered with cold sweat, acrocyanosis is observed. Pulse - 104/min. Blood pressure - 210/130 mm Hg, respiration rate - 38/min. Pulmonary percussion sound is clear, with slight dullness in the lower segments; throughout the lungs single dry crackles can be heard that become bubbling and non-resonant in the lower segments. What is the most likely complication in this patient?

Explanation

Poorly controlled hypertension and Myocardial Infarction can eventually lead to a heart failure. And the Left-sided heart failure is the most common type of heart failure.

Left-sided heart failure occurs when the left ventricle doesn’t pump efficiently. This prevents your body from getting enough oxygen-rich blood. The blood backs up into your lungs instead, which causes shortness of breath and a buildup of fluid. 

 

Slight dullness and non-resonant sound in the lower segments of the lungs is an indication that there is a buildup of fluid in the lungs. (air - COPD, Asthma produces resonant sound on percussion; fluid - left heart failure or consolidation - pneumonia will produce a dull sound) Right-sided heart failure will cause a buildup of fluid in the lower extremities and portal circulation.

113. A 10-year-old boy, who was outdoors in windy and cold weather, developed moderate pain and tingling in his fingers and toes. When he returned home, his parents noticed that the tips of his fingers and toes were white and their sensitivity was lost. As the affected areas were warming up, the fingers and toes developed tingling and painful sensations. Skin pallor changed into redness, tingling stopped, mild itching and swelling of the fingers appeared. Determine the frostbite degree in this child:

Explanation

Frostbite is an injury of the skin and underlying tissues that occur due to exposure to cold ( low temperature). There are 4 degrees of frostbite:

I Degree: lasts for about 5-7 days; after warming, paleness changes to hyperemia (redness). Edema of tissues progresses for about 2 days and then it decreases to 6-7 days when shelling (peeling) of epidermis appears. Tactile and pain sensitiveness (sensation) are preserved but sometimes with disorders.  Pain in injured areas could be severe, itching also could be.

II Degree: characterised by the spreading of edema, appearance of bullaes. The bottom of the opened bullaes are covered with fibrin. Cyanotic skin and difficulty of movement of phalanges. Necrosis of keratic and granular layers. N/B growth layer of the skin is not lost and regeneration appears after 2 weeks. Scars are not formed.

III Degree: Necrosis of all skin layers or even fatty tissue appears. Inflammation develops: firstly aseptic and then on 5th- 7th day purulent . Bullas contain blood . Decrease of tactile and temperature sensation. Edema of tissues spreads on the proximal areas. Firstly skin has cyanotic color then dark brown and black crusts are formed.

 

IV Degree: Necrosis of all skin, fat tissue and even bones and joints. Results in amputation of the affected area.

114. A 32-year-old woman complains of episodes of intense fear that occur without visible cause and last for 10-20 minutes; the episodes are characterized by rapid pulse, sweating, labored breathing, and vertigo. Specify the likely diagnosis:

Explanation

The essential features of Panic Disorder are recurrent attacks of severe anxiety (panic attacks) which are not restricted to any particular situation or set of circumstances.

Typical symptoms are palpitations, chest pain, choking sensations, dizziness, and feelings of unreality (depersonalisation or derealization). Individual attacks usually last for minutes only. 

Manic syndrome is characterised by an elevated, expansive or irritable mood, an increased psychomotor, speech and thought activities coupled with an unusual alertness, trying to do many things at one time.

Paranoid personality disorder is a personality disorder characterized by intense mistrust and suspicion of others.
115. A 7-year-old boy has been an inpatient for 1.5 months. He had been brought to the hospital with complaints of edemas all over his body, low urine output, and headache. Clinical urinalysis: proteins - 7.1 g/L, leukocytes - 1-2 in the vision field, erythrocytes - 3-4 in the vision field. During the course of treatment the edemas gradually dissipated, headache abated, diuresis normalized. Daily urine proteins - 3 g/L. Biochemical blood test: total protein - 43.2 g/L, urea - 5.2 mmol/L, cholesterol - 9.2 mmol/L. What glomerulonephritis syndrome is the most likely to be present in the patient?

Explanation

Nephrotic Syndrome - Massive proteinuria (> 3.5g/ day) with hypoalbuminemia, edema (due to decrease in oncotic pressure). Occurs due to podocyte damage, focal segmental glomerulosclerosis, membranous nephropathy, amyloidosis or diabetic glomerulonephropathy.

Nephritic Syndrome- usually due to glomerular inflammation which further damages the glomerular basement membrane, loss of rbc into urine leading to hematuria. Occurs in acute post streptococcal glomerulonephritis, rapidly progressive glomerulonephritis, IgA nephropathy, Alport syndrome, membranoproliferative glomerulonephritis. 

 

Observe that the patient loses about 7.1g of protein per litre of urine daily  (> 3.5g/ day) and also presents with edema which indicates a nephrotic syndrome.

116. A 62-year-old woman was brought into the admission room with complaints of severe burning retrosternal pain and asphyxia. She has a 10-year-long history of essential hypertension. Objectively her condition is moderately severe. She presents with skin pallor, cyanotic lips, and vesicular respiration over her lungs. The H heart sound is accentuated over the aorta. Blood pressure - 210/120 mm Hg, heart rate (pulse) - 76/min. ECG shows elevation of ST segment in the leads I, AVL, and V5-V6. What is the most likely diagnosis?

Explanation

To start with, the blood pressure is dangerously elevated (210/120mmHg) - Hypertensive crisis. From the question stem, ECG shows ST segment elevation (STEMI) - Myocardial Infarction. 

ST-segment elevation Myocardial Infarction (STEMI) is a transmural infarcts which means the full thickness of myocardial wall is involved. Non-ST-segment elevation MI (NSTEMI - ST depression on ECG) is a subendocardial infarct. Subendocardium (inner ⅓) are especially vulnerable to ischemia. 

From the question, ST segment is elevated in leads I, aVL and V5-V6 - this indicates a lateral wall full thickness infarct.

Leads II, III, aVF - Inferior Wall; 

 

V1-V4: Anterior Wall

117. A 35-year-old patient developed an epileptic attack with tonoclonic spasms that lasted for 3 minutes. After the attack the patient fell asleep but in 5 minutes the second attack occurred. The first step of emergency aid would be to:

Explanation

If you are with someone having a tonic-clonic seizure (where the body stiffens, followed by general muscle jerking), try to: 

  • Stay calm and remain with the person.

  • If they have food or fluid in their mouth, roll them onto their side immediately.

  • Keep them safe and protect them from injury.

  • Place something soft under their head and loosen any tight clothing.

  • Reassure the person until they recover.

  • Time the seizure, if you can.

  • Gently roll the person onto their side after the jerking stops.

 

Do not put anything into their mouth or restrain or move the person, unless they are in danger. The major step is to ensure the airway is clear, to keep them breathing until the seizure stops.

118. On the day 4 after the cesarean section a woman developed fever with body temperature up to 39°C and abdominal pain. Pulse - 104/min. She vomited twice. The patient is sluggish, her tongue is dry and has gray coating. The abdomen is distended. Signs of peritoneal irritation are positive in all segments. Peristalsis cannot be auscultated. No passage of gas occurs. Uterine fundus is located at the level of the navel. The uterus is painful on palpation. The discharge is moderate and contains blood and pus. What is the most likely diagnosis?

Explanation

119. On the 15th day after a small trauma of the right foot, the patient developed indisposition, fatigability, irritability, headache, elevated body temperature, and sensation of constriction, tension, and twitching in the muscles of the right shin. What disease can be suspected?

Explanation

Clostridium tetani is a gram positive, obligate anaerobic, spore forming bacillus that resembles a tennis racket or drumstick; it is the causative agent of tetanus (lockjaw). This pathology is characterised by the stiffness of muscles (spactic muscle), spasms that last for a few minutes, fever, trouble swallowing, increased blood pressure etc. This bacteria produces a toxin ( a neurotoxin called tetanospasmin) that has a potent effect in the CNS leading to the above mentioned stiffness.
120. A 57-year-old patient complains of dyspnea at rest. The patient presents with orthopnea, acrocyanosis, bulging cervical veins. On percussion: dull sound over the lower lung segments. On auscultation: no respiratory sounds. Heart rate is 92/min. Right-sided cardiac dilatation is observed. The liver is +7 cm. Shins are swollen. Pleural effusion is suspected. What indicator would confirm the presence of transudate in this case?

Explanation

 

In the case of a pleural effusion, there can be different types of fluids; Transudate and Exudate. 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.

121. A 38-year-old woman works in flax processing, she dries flax. She came to the hospital complaining of difficult breathing, constricting sensation in her chest, and cough attacks. These signs appear on the first day of her working week and gradually diminish on the following days. What respiratory disease is likely in this case?

Explanation

Byssinosis is a disease of the lungs. It is caused by breathing in cotton dust or dusts from other vegetable fibers such as flax, hemp, or sisal while at work. Breathing in (inhaling) the dust produced by raw cotton can cause byssinosis. It is most common in people who work in the textile industry.

 

Those who are sensitive to the dust can have an asthma-like condition after being exposed. Smoking increases risk of developing this disease. Being exposed to the dust many times can lead to long-term (chronic) lung disease.

122. A 30-year-old man came to the family physician. 2 months ago he underwent a surgery for open fracture of the humerus. On examination the patient’s condition is satisfactory; in the area of the postoperative wound there is a fistula that discharges a small amount of pus; the area itself is red; fluctuation is detected. X-ray shows destruction of the humerus with sequestra. What complication did the patient develop during the postoperative period?

Explanation

Osteomyelitis is an infection of the bone tissue. Bone can get infected via several means majority are post operative, post traumatic or hematogenous means. From anamnesis, we can see that the patient had an open fracture of the brachial bone; through this portal, the infection was able to gain access and cause the above written bone disorder (sequestration, purulent discharge from this area). We can conclude that this patient has a post traumatic form of osteomyelitis since the bone infection happened via the open fracture.

 

Hematogenous osteomyelitis usually occurs in children; is a systemic infection that occurs due to bacteremia.

123. A 35-year-old man suffers from insulin-dependent diabetes mellitus and chronic cholecystitis. He takes NPH insulin: 20 units in the morning and 12 units in the evening. After a meal he developed pain in the right subcostal area, nausea, vomiting, sleepiness, and increased polyuria. What prehospital measures will be the most effective for prevention of crisis within the next several hours?

Explanation

The signs and symptoms listed in the question in a known diabetic patient after a meal are indicative of Hyperglycemia. Though, the time the meal was taken is not certain but since the patient is already on an Insulin regimen, it clearly shows that either the dose is not enough or the doctor might have to prescribe another regimen that should be taken 30mins - 1hr before every meal.

 

Remember that this patient is Insulin-dependent, so we just have to adjust the Insulin regimen until we get an optimal dose/schedule that will prevent further hyperglycemic crisis.

124. A 38-year-old woman complains of weakness, sleepiness, pain in the joints, weight gain despite low appetite, and constipations. She presents with dry and thickened skin, puffy and amimic face, narrowed palpebral fissures, thick tongue, and deep hoarse voice. Her heart sounds are weak, pulse is 56/min. Low levels of free T4 are observed. This patient needs to take the following on a regular basis:

Explanation

From the question stem, the patient presented with signs and symptoms of hypothyroidism and low levels of free T4. Hormonal replacement is the best for hypothyroidism. So, the patient should be given L-thyroxin also known as levothyroxine, a synthetic form of Thyroxine, T4. 

 

Mercazolil (thiamazole) is indicated in Hyperthyroidism.

125. A 40-year-old man claims that his wife is cheating on him and presents a ”proof” of her infidelity. He repeatedly initiated scandals with his wife at home and at work, demanding that she confess her infidelity, insulted her, and threatened to kill her. What preventive measures should be taken against socially dangerous actions on his part?

Explanation

126. Having examined a 52-year-old patient, the doctor diagnosed him with obesity (body mass index - 34 kg/m2, waist circumference - 112 cm) and arterial hypertension (170/105 mm Hg). 2-hour postprandial blood sugar is 10.8 mmol/L. What biochemical blood analysis needs to be conducted to diagnose the patient with metabolic syndrome X?

Explanation

Metabolic syndrome X is a group of risk factors which includes high blood pressure, high blood sugar, high triglycerides, low HDL cholesterol, and belly fat - that increases risk of heart disease and diabetes. Diet, exercise, and medications can help improve this condition.

From the question stem, the 52 year old patient has arterial hypertension (170/105mmHg); High blood sugar (10.8mmol/L 2hrs post prandial); Belly fat (112cm Waist circumference, BMI - 34 kg/m obesity). At this point, we are only left with the lipid profile which will tell us the triglyceride level, LDL, and HDL cholesterol levels.
127. A 10-year-old boy was brought into the hospital with complaints of expiratory dyspnea, respirations are 30/min. He explains his state by a change in the weather conditions. For the last 4 years the boy has been registered for regular check-ups due to his diagnosis of third degree persistent bronchial asthma. To provide emergency aid for this child, first he needs to be given:

Explanation

The symptoms of Bronchial Asthma are as a result of bronchoconstriction - expiratory dyspnea, wheezing, shortness of breath etc.

Salbutamol is a short-acting beta 2 agonist (another example is Albuterol) commonly used in clinical practice as an emergency antiasthmatic agent because of its fast acting quality. 

2 receptors are found in the bronchioles of lungs and the arteries of skeletal muscles. This drug dilates (opens up) the bronchi (bronchodilation). 

Short acting beta agonists are the same medications as those in your quick-acting inhaler. Other medications that can be used to treat emergency asthma attacks are Oral corticosteroids, Ipratropium, Oxygen.

Adrenaline is a beta agonist but not a first choice drug in the treatment of Asthma attack. Aminophylline is a bronchodilator used to prevent and treat shortness of breath and difficulty in breathing caused by asthma. This is also not commonly used to treat emergency asthma attacks.

Note: as a doctor in an emergency situation, you are more interested in a medication that can act fast and bring immediate relief to the patient, that is why Salbutamol is still the best choice in this case.

 

Loratadine is an antihistamine commonly used in allergic conditions but not in Asthma. Dexamethasone is a glucocorticoid, it has anti inflammatory, immunosuppressive and antipyretic effects.

 
128. A 43-year-old man complains of a protrusion in the right inguinal region, that enlarges due to strain. He has been presenting with this condition for 6 months. Within this period the protrusion has grown. Objectively in the right inguinal region an elastic protrusion 8x5 cm is visible. On palpation it disappears, leaving an empty space 4x4 cm between the pedicles of the Poupart ligament. ”Cough push” sign is positive over this opening. Make the diagnosis:

Explanation

Hernia occurs when an organ pushes through an opening in the muscle or tissue that holds it in place. For example, the intestines may break through a weakened area in the abdominal wall. 

The most common symptom of a hernia is a bulge or lump in the affected area. For example, in the case of an inguinal hernia, you may notice a lump on either side of your pubic bone where your groin and thigh meet. You may find that the lump disappears when you’re lying down. You’re more likely to feel your hernia through touch when you’re standing up, bending down, or coughing (positive cough push sign). Discomfort or pain in the area around the lump may also be present.

In the question stem, the mass was noticeable between the Poupart’s ligament which is another name for inguinal, or groin ligament. Inguinal hernias are the most common type of hernia. These occur when the intestines push through a weak spot or tear in the lower abdominal wall, often in the inguinal canal. This type is also more common in men.

These hernias are more common in men because the testicles descend through the inguinal canal shortly after birth. The canal is supposed to close almost completely behind them. Sometimes the canal doesn’t close properly, leaving a weakened area.

Inguinal Hernia can be reducible or irreducible. Reducible hernia: is one which can be pushed back into the abdomen by putting manual pressure to it. Irreducible/Incarcerated/Strangulated hernia: is one which cannot be pushed back into the abdomen by applying manual pressure.

Lymphadenitis is associated with inflamed and painful inguinal lymph nodes. Femoral hernia will be noticed in the femoral triangle way below the inguinal canal. Cyst of the spermatic cord is not reducible and it will be located in the testis.

 

The arcuate line of rectus sheath, linea semicircularis, arcuate line, or Douglas' line is a horizontal line that demarcates the lower limit of the posterior layer of the rectus sheath. It is also where the inferior epigastric vessels perforate the rectus abdominis. Hernia can be located here as well. But this is more of a midline and below the umbilicus hernia location and not related to the inguinal canal or inguinal/poupart ligament.

129. A 39-year-old man, a battery attendant, suddenly developed weakness, loss of appetite, nonlocalized colicky abdominal pains, and nausea. Objectively his skin is gray; there is a pink-gray stripe on his gums; the stomach is soft and sharply painful. Blood test detected erythrocytes with basophilic stippling and anemia. The patient has a history of peptic ulcer disease of the stomach. Constipation tends to occur every 3-4 days. What is the most likely provisional diagnosis?

Explanation

Lead-based paint and its dust, usually found in older buildings, are common sources of exposure. Young children are especially at risk. Adults - occupational exposure (welding, batteries, ammunition).

Symptoms include developmental delays, abdominal pain, constipation, headaches, irritability, memory problems, inability to have children, and tingling in the hands and feet.. At very high levels, it can be fatal.

Lead in the body is distributed to the brain, liver, kidney and bones. It is stored in the teeth (pink-gray stripe on the patient’s gum) and bones, where it accumulates over time.

 

Ferrochelatase and Delta-aminolevulinic acid dehydratase are enzymes necessary for the synthesis of heme. In lead poisoning, these enzymes are inhibited leading to anemia and an increased delta aminolevulinic acid content in urine. This presents with microcytic anemia (basophilic stippling in peripheral smear, ringed sideroblast in bone marrow), GI and kidney disease. The above patient presents with signs of asthenic vegetative syndrome coupled with the above stated reasons confirming a case of lead poisoning.

130. A newborn has Apgar score of 9. When should this infant be put to the breast?

Explanation

APGAR SCORE CHAT  

An apgar score is a test used in assessment of the health of a newborn child. In this test, the skin colour, pulse rate, irritability, muscle tone and respiration are checked and scored individually between 0-2. A score of 7 and above means the baby is normal, 4-6 is fairly low, 3 below refers to a critical condition; immediate actions to restore the child’s health should be taken. For a baby with normal response, he/she should be taken immediately to the mother to be breastfed.

131. In the process of hiring, a prospective employee has undergone preventive medical examination and was declared fit to work in this manufacturing environment. What type of preventive medical examination was it?

Explanation

132. A 45-year-old man underwent a cardiac surgery one week ago. His general state has been deteriorating since then: dyspnea at rest, retrosternal pain that irradiates to the neck, marked weakness. Objectively his body temperature is hectic. His cardiac borders are expanded, apical beat is weakened. Auscultation detects pericardial friction rub. What is the most likely diagnosis?

Explanation

A pericardial friction rub, also pericardial rub, is an audible medical sign used in the diagnosis of pericarditis. A pericardial friction rub is highly specific for acute pericarditis. It is generally heard over the left sternal border, louder at inspiration and on bending forward.

The pericardium is a thin, two-layered, fluid-filled sac that covers the outer surface of the heart. It provides lubrication for the heart, shields the heart from infection and malignancy, and contains the heart in the chest wall. It also keeps the heart from over-expanding when blood volume increases, which keeps the heart functioning efficiently.

Acute pericarditis is an inflammation of the pericardium characterized by pericarditic chest pain, pericardial friction rub, and serial electrocardiographic (ECG) changes (eg, new widespread ST-elevation or PR depression; new/worsening pericardial effusion).

 

There are many causes of pericarditis: viral, fungi, bacterial, parasitic, autoimmune. Your risk of pericarditis is higher after a heart attack, heart surgery (postpericardiotomy syndrome), radiation therapy or a percutaneous treatment, such as cardiac catheterization or radiofrequency ablation. Just as the patient in question underwent a cardiac surgery one week ago.

133. A 48-year-old woman complains of disturbed menstrual cycle: her periods last for 7-9 days and are excessively profuse throughout the last half-year. She notes occasional hot flashes in her head, insomnia, irritability, and headaches. Her skin is of normal color. Blood pressure - 150/90 mm Hg, pulse - 90/min., rhythmic. The abdomen is soft and painless. Bimanual examination shows no uterine enlargement, the appendages cannot be detected. The vaginal fornices are free. What is the most likely diagnosis?

Explanation

When a woman reaches her 40s or 50s she begins to experience a natural decline in reproductive hormones, which eventually leads to Menopause. Menopause is signalled by 12 months since last menstruation. However, the period - perimenopausal, i.e. premenopause and immediate post menopause when the female reproductive functions begins to decline is called Climacteric period.

Peri- and postmenopausal women often seek medical help, and climacteric symptoms are their most common reason for doing so. These symptoms are due to changes in ovarian function during the menopause. The transition from full ovarian function in the premenopausal period to a complete lack of ovarian estrogen synthesis in the postmenopausal period is, fundamentally, a normal aspect of human physiology.

Climacteric, is that particular phase in ageing women, which marks the transition from the reproductive phase to non-reproductive state and is often associated with symptomatology, referred to as climacteric syndrome.

Symptoms: vasomotor symptoms (hot flashes, diaphoresis); vaginal dryness; sleep disturbances; mood changes; urinary tract symptoms; sexual problems (loss of libido, dyspareunia, other) etc.

 

NB: just as menarche doesn't start with regular periods, so is menopause. Before a full blown menopause, women will begin to have irregular and abnormal periods then it ceases completely. That’s why the patient in question still saw her period (but it's disturbed menstrual cycle - meaning it's not regular).

134. A 62-year-old patient has been hospitalized with complaints of pain in the thorax on the right during breathing, dyspnea, and dry cough. Ten days ago he slipped and fell hitting his right side. On examintaion: the patient lies on the left side. The right side of the thorax lags during breathing. On the right there are crepitation and pain in the III-IV ribs. Dullness of percussion sound and sharply diminished breath sounds can be observed. On X-ray: signs of exudate, fracture of the III- IV ribs. On pleurocentesis: blood is detected. Choose the further tactics:

Explanation

135. A 19-year-old young man complains of cough with expectoration of purulent sputum in the amount of 100 mL per day, hemoptysis, dyspnea, increased body temperature up to 37.8°C, general weakness, weight loss. The patient’s condition lasts for 4 years. Exacerbations occur 2-3 times a year. The patient presents with malnutrition, pale skin, cyanosis of the lips, drumstick (clubbed) fingers. Tympanic percussion sound in the lungs, weakened respiration, numerous various moist crackles in the lower pulmonary segments on the left can be observed. In blood: erythrocytes - 3.2∙1012/L, leukocytes - 8.4∙109/L, ESR - 56 mm/hour. On X-ray: lung fields are emphysematous, the left pulmonary root is deformed and dilated. What is the most likely diagnosis?

Explanation

Bronchiectasis is a permanent dilation of the bronchi and bronchioles causing repeated episodes of airway infection and inflammation due to destruction of cartilage and elastic tissue by chronic necrotizing infections.

Bronchiectasis is a chronic necrotizing infection of the bronchi and bronchioles leading to or associated with abnormal dilation of these airways.

Clinical findings: cough productive of copious sputum (often cupfuls); hemoptysis that is sometimes massive; digital clubbing; Cor pulmonale. 

Symptoms include  cough and daily mucopurulent sputum production, often lasting for months; blood-streaked sputum (hemoptysis), dyspnea, low grade fever, pleuritic chest pain, wheezing, fever, weakness, fatigue and weight loss. Presence of moist crackles on auscultation indicates an infectious or inflammatory process; digital clubbing is seen in 2-3% of patients as a result of prolonged state of decreased oxygenation. A dilated and deformed left pulmonary root confirms bronchiectasis of the left lung.

 

Lung abscesses are characterized by large cavities filled with suppurative debris.

136. A 72-year-old man with pneumonia complains of marked dyspnea, chest pain, severe cough with expectoration, t° is 39.5-40°C, no urination for a whole day. Objectively the patient is conscious. Respiratory rate is 36/min. Over the right lower pulmonary lobe percussion sound is dull; on auscultation there is bronchial respiration and numerous moist crackles. Blood pressure is 80/60 mm Hg. Heart rate is 120/min. Heart sounds are muffled, there is tachycardia. What tactics should the family doctor choose in the management of this patient?

Explanation

The patient in question presents with pneumonia (an infection of the lungs). He is currently experiencing a bacteremia (systemic spread of bacteria in the blood) characterised by;  increased temperature, increased heart rate, increased breathing rate; a low blood pressure, reduced blood supply to certain organs eg, kidney ( confirmed by the absence of urine for a day). This  patient should be immediately taken to the ICU with major steps taken to prevent a septic shock. The fact that the condition is tending towards shock is the more reason why the patient should be transferred to the Intensive Care Unit, when he is more stable, the pulmonology unit can take over management.
137. 2 hours after eating unknown mushrooms, a 28-year-old man sensed a decrease in his mobility and deterioration of his ability to focus. This condition was then followed by a state of agitation add agression. On examiantion he is disoriented and his speech is illegible. 4 hours later he developed fetor hepaticus and lost his consciousness. What syndrome can be observed in this patient?

Explanation

Amanita phalloides is the most common and fatal cause of mushroom poisoning. This mushroom contains amanitins, which are powerful hepatotoxins that inhibit RNA polymerase II in the liver. Amanita phalloides intoxication has four consecutive phases in the classical course: lag phase, gastrointestinal phase, apparent convalescence, and acute liver failure. Acute Liver Failure is the last phase in which the transaminases rise dramatically and liver and renal function deteriorate. This process results in hyperbilirubinemia, coagulopathy, hypoglycemia, acidosis, hepatic encephalopathy, and hepatorenal syndrome.

 

Fetor hepaticus is associated with severe liver disease, which causes scarring and poor functioning of your liver.

138. A 20-year-old man was hospitalized on the 9th day of the disease. He attributes his disease to eating of insufficiently thermally processed pork. At its onset this condition manifested as periorbital edemas and fever. Objectively his body temperature is 38.5°C. The face is puffy and the eyelids are. markedly swollen. Palpation of gastrocnemius muscles is sharply painful. Blood test shows hypereosinophilia. What is the etiology of this disease?

Explanation

Trichinellosis, also called trichinosis is caused by the roundworm (nematode) - Trichinella spiralis. Transmission: undercooked meat especially pork.

When humans eat undercooked meat containing trichinella larvae, the larvae mature into adult worms in the small intestine over several weeks. The adult worms then produce larvae that travel through various tissues, including muscle.

About a week after infection, the adult female worms produce larvae that go through the intestinal wall, enter your bloodstream, and eventually burrow into muscle or other tissue. This tissue invasion can cause:

  • High fever

  • Muscle pain and tenderness

  • Swelling of the eyelids or face (periorbital edema)

  • Weakness

  • Headache

  • Sensitivity to light

  • Pink eye (conjunctivitis)

Treatment: Bendazoles

Echinococcus: etiology - Echinococcus granulosus; Disease - hydatid cysts (eggshell calcification) in liver; Transmission - ingestion of eggs in food contaminated with dog feces. Sheep are an intermediate host.

Leptospira: etiology - Leptospira interrogans; spirochete with hook-shaped ends found in water contaminated with animal urine. Disease - flu-like symptoms, myalgias, jaundice, photophobia

Ascarididae: etiology - Ascaris lumbricoides (giant roundworm); Disease - may cause obstruction at ileocecal valve, biliary obstruction, intestinal perforation. Transmission - fecal-oral

 

Trichuris: etiology - Trichuris trichiura (whipworm); Disease - often asymptomatic, loose stool, anemia, rectal prolapse in children. Transmission - fecal-oral

139. A 1.5-month-old child on breasfeeding presents from birth with daily vomiting, irregular liquid foamy feces, and meteorism, which are resistant to antibacterial and probiotic therapy; no increase of body mass is observed. The child’s condition improved, when breastmilk was substituted with ”NAN low lactose” formula. What pathology is it?

Explanation

Note that the above symptoms were developed after breastfeeding and the child’s conditions improved after a change of diet . Recall that the main constituent of breast milk is lactose and the child fared well when the level was lowered. This child is said to have a lactose intolerance and is due to the deficiency in the enzyme. Lactase, an enzyme responsible for the breakdown of lactose. 

 

Functional dyspepsia is a chronic disorder of sensation and movement (peristalsis) in the upper digestive tract. Peristalsis is the normal downward pumping and squeezing of the esophagus, stomach, and small intestine, which begins after swallowing. We call this disorder functional because there are no observable or measurable structural abnormalities found to explain persistent symptoms. You might hear other terms used to describe this condition, such as non-ulcer dyspepsia, pseudo-ulcer syndrome, pyloro-duodenal irritability, nervous dyspepsia, or gastritis.

140. A 45-year-old woman complains of intolerable paroxysmal facial pain on the left with attacks that last for 1-2 minutes. Attacks are provoked by chewing. The disease onset was two months ago after the overexposure to cold. Objectively: pain at the exit points of the trigeminal nerve on the left. Touching near the wing of the nose on the left induces a pain attack with tonic spasm of the facial muscles. What is the most likely diagnosis?

Explanation

Trigeminal Neuralgia is a condition which produces repetitive,unilateral, shooting/shot-like pain in the areas innervated by the trigeminal nerve (the face). It is triggered by chewing, talking or touching certain parts of the face. Typically lasts for seconds to minutes but episodes often increase in intensity and frequency over time.

Recall that the trigeminal nerve, Cranial Nerve V is a mixed type of nerve, and has 3 major branches;

 

V1 (ophthalmic); V2( Maxillar); V3(mandibular). This nerve is responsible for mastication, facial sensation, somatosensation from anterior ⅔ of the tongue, and innervates the tensor tympani.

141. It is the 3rd day after the first normal term labor; the infant is rooming-in with the mother and is on breastfeeding. Objectively: the mother’s general condition is satisfactory. Temperature is 36.4°C, heart rate is 80/min., BP is 120/80 mm Hg. Mammary glands are soft and painless; lactation is moderate, unrestricted milk flow. The uterus is dense, the uterine fundus is located 3 finger widths below the navel. Lochia are sanguino-serous, moderate in volume. Assess the dynamics of uterine involution:

Explanation

Involution is the term used to describe the physical reduction in size of the uterus and cervix after parturition. This process begins immediately after expulsion of the placenta with contraction of the uterine smooth muscle. The uterus, which at full term weighs approximately 11 times its prepregnancy weight, involutes to approximately 500 g by 1 week after birth and to 350 g by 2 weeks after birth. At 6 weeks it weighs 50-60 g. 

 

Subinvolution is the failure of the uterus to return to a nonpregnant state. The most common causes of subinvolution are retained placental fragments and infection.

142. A 24-year-old pregnant woman on her 37th week of pregnancy has been brought to the maternity obstetric service with complaints of weak fetal movements. Fetal heartbeats are 95/min. On vaginal examination the uterine cervix is tilted backwards, 2 cm long, external orifice allows inserting a fingertip. Biophysical profile of the fetus equals 4 points. What tactics of pregnancy management should be chosen?

Explanation

A biophysical profile is a prenatal test used to check the well being of a baby. It involves using an ultrasound in evaluating the fetal heart rate, breathing, movement ,muscle tone and amniotic fluid level combined with a non-stress test for checking the fetal heart rate. Points are allocated for every measurement taken. This test is recommended for pregnant women at high risk of complications and a tendency of pregnancy loss. In most cases, a low biophysical profile score might indicate an early or immediate child delivery. 

 

Note that the score of the above profile is 4 (indicating an immediate delivery).

143. 2 hours after a traffic accident a 28-year- old man in a grave condition was brought to a hospital. The patient complains of abdominal pain. He received a blow to the abdomen with the steering wheel. Objective examination revealed the following: the abdomen does not participate in respiration, is tense and acutely painful on palpation; the abdominal muscles are defensively tense, peritoneal irritation signs are positive, hepatic dullness is absent. BP is 90/60 mm Hg, heart rate is 120/min. What further treatment tactics should be chosen?

Explanation

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

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

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

 

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

144. A 13-year-old girl for the last two weeks has been complaining of dyspnea and shin and foot edemas that appear after a physical exertion. In the morning the edemas significantly decrease. Clinical examination revealed enlarged liver and coarse systolic murmur over the heart area. Blood test and urinalysis are without changes. What is the most likely cause of edemas in this child?

Explanation

Congestive heart failure can cause peripheral (lower extremity edema), pulmonary and abdominal edema (ascites). This is because the heart is too weak to pump blood around the body properly, so the blood accumulates in other parts of the body before getting to the heart. Because of this, and due to the increased blood pressure in the veins, fluid seeps out into the surrounding tissue. This may cause swelling in the legs or a build-up of fluid in the abdomen. A rasping systolic murmur also indicates an organic heart pathology.

Edema due to cardiac origin are commonly seen after stressful activities (physical exertion) or in the evening after the day’s work. This is because the heart has been overworked and cannot perform its normal duty of pumping blood around the body effectively. Cardiac edema generally resolves with rest.

Nephrotic syndrome also leads to edema but will be characterised by severe proteinuria and an increased depletion in albumin levels. Also it is characterized by generalized edema commonly seen in the morning when the patient wakes up in contrast to cardiac edema.

Angioneurotic edema is seen in individuals with deficiency in C1 esterase inhibitor deficiency. It is also referred to as quinke’s edema.

 

Edema as a result of hepatocirhosis will be seen in an individual with a chronic alcohol abuse history or one with a liver related pathology and associated with ascites, esophageal varices, caput medusa and rectal varices.

145. A patient has the second and third degree burns of the 15% of the body surface. On the 20th day after the trauma the patient presents with sharp increase of body temperature, general weakness, rapid vesicular respiration; facial features are sharpened, BP is 90/50 mm Hg, heart rate is 112/min. What complication is it?

Explanation

Complications of burns include - Sepsis, hypovolemia, hypothermia or fever, contractures and formation of keloids.

Burn patients lose their primary barrier to infection, the skin, and thus the risk of infection persists as long as that barrier is absent. 

 

Sepsis has recently been defined as “life-threatening organ dysfunction caused by a dysregulated host response to infection”.

 

The diagnoses were based on signs of Sepsis: temperature >38 °C or <36 °C, heart rate >90 beats per minute, respiratory rate >20 breaths per minute. Two or more of these signs were considered to diagnose sepsis. Septic shock was defined as sepsis associated with persistent hypotension.

 
146. In the factory cafeteria there was an outbreak of food poisoning. Clinical presentation indicates staphylococcal etiology of this disease. 15 people are sick. To confirm the diagnosis of food poisoning, samples need to be sent to the laboratory. What samples should be obtained for analysis?

Explanation

Food poisoning most often results from infectious processes via the fecal-oral route. For diagnosis, it is best to take fecal or vomit samples for Microscopy, Culture and Sensitivity (M/C/S) as these microorganisms reside within the Gastrointestinal tract.

 

For diseases like Malaria - Blood culture; Urinary Tract Infection - Urine Samples.

147. A 3-year-old child has been brought to a hospital with complaints of pain in the legs, fever, and loss of appetite. Objectively: pale skin and mucosa, hemorrhagic rash. Lymph nodes are enlarged, painless, dense and elastic, not matted together. Bones, joints, and abdomen are painful. The liver and spleen are enlarged. Hemogram: Hb - 88 g/L, color index - 1.3, platelets - 80∙109/L, leukocytes - 25.8∙109/L, lymphoblasts - 70%, ESR - 52 mm/hour. Make the provisional diagnosis:

Explanation

 

Blast cells are immature WBC. Presence of 70% of Blast cells (Lymphoblasts) in the analysis indicates an acute form of leukemia. Less than 10% of blast cells will indicate a chronic form and greater than 20% - Acute. 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 (pale skin), thrombocytes, presenting with hemorrhagic rash.

148. A 46-year-old woman has diarrhea with abdominal distension, loss of body mass, and large amounts of porridge-like foul-smelling stool without blood streaks or tenesmus. Objective examination detects moderate tenderness in the mesogastrium and left abdominal flank. Feces analysis detects steatorrhea with neutral fat and creatorrhea. What prescription would be the most advisable in this case?

Explanation

The pancreas plays a major role in digestion (its exocrine function). It produces digestive enzymes such as; trypsin and chymotrypsinogen (for protein digestion), Amylase (for carbohydrate digestion), lipase ( for breakdown of fats). 

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.

In pathologies relating to the pancreas such as pancreatitis, this function is affected leading to indigestion and absorption issues. For example, due to a disruption in the release of lipase, fat breakdown is negatively affected leading to malabsorption and its appearance in stool (steatorrhea). Likewise a disruption in chymotrypsin and trypsin secretion will lead to an abnormal excretion of muscle fibres in faeces (creatorrhea).

 

Therefore, the best prescription to remedy the situation is to prescribe a multi-enzyme preparation - Trypsin; Chymotrypsin; Amylase; Lipase.

149. A 7-year-old girl has been twice treated with antibacterial agents for urinary tract infection. US shows no severe renal defects. The child presents with recurrence of leukocyturia and bacteriuria, elevated body temperature up to 38.5°C, and pain in her left lumbar area. What examination should be conducted first to clarify the cause of urinary infection recurrence?

Explanation

A micturating cystourethrogram (MCUG) is a scan that shows how well your child’s bladder works. It is used to diagnose why your child may have urinary tract infections. It is also used to show up any abnormalities with your child’s urinary system.

Various types of scan such as CT, ultrasound and x-rays (most other options listed) can show the size and shape of your child’s bladder, but not how it is emptying. 

A micturating cystourethrogram or voiding cystourethrography is a procedure allowing the urethra to be x-rayed using contrast dye passing from the bladder through the urethra. It is a frequently performed technique for visualizing a person's urethra and urinary bladder while the person urinates. The bladder is first filled with x-ray contrast dye by inserting a urinary catheter into the bladder through the urethra. A contrast medium is a clear liquid that shows up on an X-ray. Babies and young children will naturally pee when the bladder is full. Older children will be given a jug to pee into while lying on the table, when they feel ready. The radiographer will take a few X-ray pictures while your child is peeing, which you will be able to see on the screen. 

For this patient having recurrent Urinary Tract Infections, it could be as a result of vesicoureteral reflux. This method is commonly used in the diagnosis of vesicoureteral reflux.

Recall that the US shows no severe renal defects, so there is no urgent need to repeat retrograde pyelography, excretory urography and radioisotope renography. Intravenous urography (IVU), also referred to as intravenous pyelography (IVP) or excretory urography (EU), is a radiographic study of the renal parenchyma, pelvicalyceal system, ureters and the urinary bladder.

 

Since the question states that there is no renal defect, we are more concerned about the lower urinary tract which makes micturating cystourethrography the best choice.

150. A 30-year-old man was brought to the neurosurgical department with complaints of constant headaches, nausea, vomiting, fever, and weakness of the right-side limbs. Anamnesis states that one month ago the patient had a surgery for left-sided suppurative otitis and mastoiditis. He has been undergoing treatment in an ENT department. Approximately 2 weeks ago the temperature increased, and the patient developed headaches. Objectively: heart rate - 98/min., BP - 140/90 mm Hg, temperature - 38.3°C. Neurologically manifested stiff neck: bilateral Kernig’s symptom, unsteadiness during the Romberg’s maneuver. Computer tomography of the brain revealed a three- dimensional growth with a capsule in the left hemisphere. Make the diagnosis:

Explanation

Recall that most infections of the paranasal sinuses and mastoid process spread to the surrounding structures e.g. 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.

151. A 35-year-old pregnant woman with degree 1 essential hypertension, developed edemas and headache at the 33 week of her pregnancy. Objectively her general condition is satisfactory, blood pressure - 160/100 mm Hg, normal uterine tone. Fetal heart rate is 140/min., rhythmic. She was diagnosed with daily proteinuria - 4 g/L, daily diuresis - 1100 mL. Creatinine - 80 mcmol/L, urea - 7 mmol/L, platelets - 100∙109/L. What complication of pregnancy occurred?

Explanation

Preeclampsia, a pregnancy-specific condition in which hypertension develops after 20 weeks of gestation in a previously normotensive woman. It is characterized by hemoconcentration, hypertension, and proteinuria. The following are the differences between a mild and severe Preeclampsia: 

However, some texts also classify Moderate Pre-eclampsia on the following criteria:

Diastolic Blood Pressure: 100 - 109mmHg

Proteinuria: 0.3 - 5.0 g in 24hrs

Others: Edema (face and/or hands).

MIld Preeclampsia

Severe Preeclampsia

BP reading of 140/90 mm Hg twice, 4-6 hr apart

Proteinuria of 0.3 g/L in a 24 hr specimen or >0.1 g/L in a random day-time specimen on two or more occasions 6 hr apart

Dependent edema, some puffiness of eyes, face, fingers; pulmonary edema absent

Output matching intake, ≥30 ml/hr or <650 ml/24 hr

Rise to >160/110 mm Hg on two separate occasions 4-6 hr apart with pregnant woman on bed rest

Proteinuria of >0.5 g/L in 24 hr

Generalized edema, noticeable puffiness; eyes, face, fingers; pulmonary edema possibly present

<20 ml/hr or <400 ml to 500 ml/24 hr

 
152. A 1-year-old child with a case of URTI suddenly developed noisy respirations with difficult inspiration, intercostal retractions, and barking cough on the 2nd night after the disease onset. What is the most likely diagnosis?

Explanation

 

The patient presents with symptoms of croup also called laryngotracheobronchitis; classic symptoms include barking cough, noisy breathing (stridor), intercostal retraction (hoover’s sign). This can be caused by a virus (parainfluenza, influenza A or B) or bacteria (corynebacterium diphtheriae, staph. Aureus, strep pneumonia etc). It is commonly seen in children aged 6 months- 5years.

153. During regular preventive gynecological examination a 30-year-old woman was detected to have dark blue punctulated ”perforations” on the vaginal portion of the uterine cervix. The doctor suspects endometriosis of the vaginal portion of the uterine cervix. What investigation method would be most informative for diagnosis confirmation?

Explanation

A colposcopy is a simple procedure used to look at the cervix, the lower part of the womb at the top of the vagina (Colposcopy is like a microscope put near the vagina to allow more detailed examination of the cervix). It\'s often done if cervical screening finds abnormal cells in your cervix. Under the guidance of colposcopy, a piece of the lesion will be removed (called a biopsy) and sent to the laboratory for detailed examination.

A hysteroscopy is used in detecting pathologies involving the Uterus. Curettage is a procedure used in removing tissues from the uterine cavity.

154. The burns unit received a patient, who 6 hours ago during a fire received flame burns. On the patient’s body there is gray-brown area of necrosis that covers 3/4 of the body perimeter. Occasionally there are small blisters with hemorrhagic contents and patches of shredded epidermis. What local therapy is necessary in this case?

Explanation

155. A 40-year-old man, a welder, uses manganese electrodes in his line of work (18 years of experience). He complains of difficulties with writing, bad mood, inertness, gait abnormalities, problems with speech, and hand tremors. Objectively the following is observed in the patient: hypomimia, increased muscle tone of plastic type, and quiet monotonous speech, tremor of the tongue, pill-rolling tremor of the fingers, and retropulsion. What syndrome developed in this patient due to manganese poisoning?

Explanation

Manganese (Mn) is an essential trace element necessary for physiological processes that support development, growth and neuronal function. Secondary to elevated exposure or decreased excretion, Mn accumulates in the basal ganglia region of the brain and may cause a parkinsonian-like syndrome, referred to as manganism.

 

Despite its essentiality, excessive and prolonged inhalation of Mn particulates in mining, welding and industries results in its accumulation in selected brain regions that causes central nervous system (CNS) dysfunctions and an extrapyramidal motor disorder, referred to as manganism. Prolonged and chronic occupational exposure to Mn (>1 mg/m3) represents a risk factor Parkinson’s disease

156. A young man has made an appointment with the dermatologist. He complains of a painful facial rash in the beard and mustache area. This condition has been persisting for several weaks already. After shaving, the patient’s condition aggravates. The diagnosis of sycosis is made. What primary morphological elements can be observed in the rash in this case?

Explanation

Sycosis is a chronic inflammatory disease involving the hair follicles, especially the bearded part of the face and marked by papules, pustules, and tubercles perforated by hairs with crusting.

Primary morphological elements include - Macule, Papule, Pustule, Patch, Vesicle etc.

 

Papules are elevated solid skin lesion <1cm. Pustule - vesicle containing pus.

157. A 22-year-old postparturient woman on the 12th day after the normal childbirth informs of elevated body temperature up to 39°C for the last 3 days and pain in her right mammary gland. The right mammary gland is enlarged, hot to touch, tense, hyperemic, and painful. Palpation reveals there a dense infiltration 8x8 cm with a fluctuation in its center. What is the most likely diagnosis?

Explanation

From the question stem, it is evident that she’s on the 12th day post-partum. On examination of the right mammary gland, there are clear signs of inflammation (mastitis) which is infiltrative with a fluctuation (Infiltrative-purulent) 

 

Mastitis is a bacterial infection of the mammary gland. It occurs mostly in pregnant or postpartum women; due to lactation, the nipples present with some erosions and are enlarged making it easier for bacterial invasion. This infection is often characterised by the production of purulent exudates.

158. During analysis of morbidity in the city, it was determined that age structure of population is different in each district. What statistical method allows to exclude this factor, so that it would not skew the morbidity data?

Explanation

159. A boy had a foreign body removed from under his nail plate. 3 days later he developed a sharp throbbing pain at the end of his distal phalanx, which intensifies when the phalanx is pressed, hyperemia of the nail fold, elevated body temperature up to 38.5°C, and nail plate discoloration. Make the diagnosis:

Explanation

Panaritium or Whitlow - an acute purulent inflammation of tissues of the finger or feet. 

Different types include;  A. Surface shape - paronychia, subungual, cutaneous, subcutaneous, B. Deep shape - bone, joint, tendon, pandactylitis.

Subungual whitlow - characterized by an accumulation of pus under the nail plate. With advanced processes seen under one of its edges.

Articular whitlow - occurs more frequently after finger injury to the back surface of the joint. The pain is intense, skin furrows in the joint are smoothed, the skin is red, because of the swelling of the finger becomes fusiform. Trying to bend the finger leads to a sharp increase in pain. In advanced cases, the joint is destroyed. There is an unnatural mobility, crunching sensation in the area of diseased joints.

Bone whitlow -  develops during the transition inflammation of soft tissue or bone by direct injury (injection sewing needle, chips, fish bone). In case the inflammation of the soft tissues surrounding the bone, after a period of apparent improvement complete recovery does not occur. The pain is constant aching in nature, formatted fistula with purulent discharge meager. Finger  gradually thickens, its functions are completely lost.

Tendon whitlow - a purulent process in subcutaneous felons without proper treatment can spread to the flexor tendons of fingers. It comes with significant deterioration. Throbbing, pulling pain spreads throughout the fingers. All fingers along the length present with edema,  red. Interphalangeal creases smoothed. Finger becomes like a sausage and slightly bent. This forced position reduces tendon tension and reduces pain.

Pandactylitis - purulent inflammation of all tissues of the finger, accompanied by headache, high body temperature. Pandactylitis may develop as a result of injury to the finger, but more likely it is untreated simple felons.
160. A woman with atopic bronchial asthma was found to have one allergen to dog hair +++. Carpets were removed from the apartment, the apartment was renovated, and air conditioner was installed. However, recurrent asphyxia attacks still occur every night, despite the patient undergoing pathogenetic therapy. What long-term treatment tactics can help this patient to decrease her sensitivity to the allergen?

Explanation

The patient suffers from atopic bronchial asthma which is an allergic disorder and studies have shown that this group of patients benefit from Hyposensitisation also known as desensitisation or allergen immunotherapy.

During hyposensitisation the aim is to expose a patient with sensitivity to a known allergen, to progressively larger doses of the allergen so that the severity of their hypersensitive response is reduced or even abolished. Allergen immunotherapy (also called allergy vaccine therapy) involves the administration of gradually increasing quantities of specific allergens to patients with IgE-mediated conditions until a dose is reached that is effective in reducing disease severity from natural exposure.

Specific hyposensitization is a causal treatment for patients with IgE-mediated allergies like seasonal or perennial allergic rhino-conjunctivitis, asthma or hymenoptera venom allergy. The principal and most effective route of allergen application is the subcutaneous injection. Specific hyposensitization is the practice of administering gradually increasing quantities of a specifically relevant allergen to allergic patients until reaching a maintenance dose or loss of symptoms. Allergen extracts are obtained by extraction of the active constituents from animal or vegetable substances with a suitable menstruum.

 

For the long term plan, specific hyposensitization is the best choice as it is aimed at reducing her sensitivity to the particular allergen. Prescribing anti-histamine wouldn’t be the first choice here. It will take care of the symptoms but not affect the sensitivity in any way. It would also be wrong to ask the patient to continue with previous medications or treatment when it is clear that the symptoms keep coming back. Speleotherapy is the use of salutary microclimate of salt caves and mines to treat diseases. This won’t suffice for a long term treatment plan aimed at decreasing her sensitivity.

161. A 38-year-old woman developed a medical condition 7 days after her return from Bangladesh. Periodical elevation of temperature was accompanied by chills and excessive sweating. She was diagnosed with tropical malaria. Next day her condition further deteriorated: body temperature - 38°C, inertness, periodical loss of consciousness, generalized seizures, tachycardia, hypotension, and icteric skin. What complication can be suspected in this case?

Explanation

Poorly treated malaria often leads to the development of cerebral malaria. Cerebral malaria is the most severe neurological complication of infection with Plasmodium falciparum malaria. It is a clinical syndrome characterized by coma and asexual forms of the parasite on peripheral blood smears.

The World Health Organization defines cerebral malaria as a clinical syndrome characterized by coma at least 1 hour after termination of a seizure or correction of hypoglycemia, asexual forms of Plasmodium falciparum parasites on peripheral blood smears and no other cause to explain the coma.

 

Patients develop fever, headache, body ache, loss of consciousness, seizures and, progressively delirium, then coma. Anemia, hemoglobinuria, jaundice, shock, renal failure, lactic acidosis, abnormal bleeding, pulmonary edema, and adult respiratory distress syndrome may also develop. Some develop cortical infarcts and cerebral venous or dural sinus thrombosis as part of a disordered coagulation.

162. On laboratory investigation of a pork sample there is 1 dead trichinella detected in 24 sections. This meat should be:

Explanation

 

The meat is infected by Trichinella and should be properly disposed of.

163. A 43-year-old man, a coal-face worker with 15-year-long record of work, complains of cough, thoracic pain, and dyspnea. The cough is mild, usually dry, occurs mostly in the morning. The pain is localized in the interscapular region and aggravates during a deep intake of breath. Dyspnea occurs during physical exertion. Vesicular respiration in the lungs is weakened. Heart sounds are rhythmic, hieart rate is 86/min., blood pressure is 135/80 mm Hg. The abdomen is soft and painless. X- ray shows micronodular pulmonary fibrosis. Make the provisional diagnosis:

Explanation

The patient in question is a coal-face worker for 15 years.

Pneumoconiosis are professional diseases caused by long inhalation of an industrial dust and described by chronic diffuse aseptic inflammation of lungs with development of pneumofibrosis.

Carboconiosis includes anthracosis, grafitosis, carbon black pneumoconiosis. It is pneumoconiosis from coal dust exposure with varying degrees of coalification, which is the main criterion of its fibrogenic properties. 

Berylliosis: exposure to beryllium and its compounds and It is associated with aerospace manufacturing, microwave semiconductor electronics, beryllium mining or manufacturing of fluorescent light bulbs.

Byssinosis is caused by inhaling hemp, flax, and cotton particles and is sometimes referred to as brown lung disease. It’s a form of occupational asthma.

Siderosis: excess iron in the body. Also known as pulmonary siderosis or Welder's disease. Commonly seen with welding, grinding, foundry work, paint manufacture or iron ore mining.

 

Hard-metal pneumoconiosis is caused by the inhalation of fine particles of hard metals, such as cobalt, tungsten, nickel, and titanium. Metal workers and persons who sharpen tools or polish diamonds are at increased risk of the condition.

164. A district doctor has diagnosed one of his patients with dysentery. What accounting document reflects this type of morbidity?

Explanation

Dysentery is an intestinal infection that causes severe diarrhea with blood. In some cases, mucus may be found in the stool. Dysentery is usually spread as a result of poor hygiene. For example, if someone who has dysentery doesn’t wash their hands after using the toilet, anything they touch is at risk.

The infection is also spread through contact with food or water that has been contaminated with fecal matter. Careful hand washing and proper sanitation can help prevent dysentery and keep it from spreading.

Shigellosis and amebic dysentery are very common examples. It spreads rapidly in environments where people who don’t have dysentery come into contact with fecal matter from people who do have dysentery.

This contact may be through: contaminated food; contaminated water and other drinks; poor hand washing by infected people; swimming in contaminated water, such as lakes or pools and physical contact.

Children are most at risk of shigellosis, but anyone can get it at any age. It’s easily spread through person-to-person contact and by contaminated food and drink.

 

So, it should be reported as urgent to prevent further spread and limit the number of people that will be infected so as to locate the source of infection and those infected can be isolated.

165. A patient has gradually lost consciousness. The skin is pale and dry. There is a smell of ammonia from the mouth. Respirations are deep and noisy. Heart sounds are muffled, pericardial friction rub is present. Blood pressure is 180/130 mm Hg. Blood test: Hb - 80 g/L, leukocytes - 12∙109/L, blood glucose - 6.4 mmol/L, urea - 50 mmol/L, creatinine - 1200 mcmol/L, blood osmolarity - 350 mOsmol/L. No urinary excretion. Make the diagnosis:

Explanation

Observe that there is the presence of an ammonia smell and from the biochemical analysis, urea level is - 50 mmol/L ( 3.33 - 8.32 mmol/L normal). Recall that ammonia is converted to urea (via the ornithine cycle) which is later excreted through the urine. Note that this patient has no urinary excretion leading to the accumulation of urea. Urea is a very toxic substance, it possesses the potential of crossing the blood brain barrier, causing a toxic effect on the brain leading to a uremic coma.

 

Hyperglycemic coma will be experienced in very high levels of blood glucose while acute renal failure can be seen when the kidneys aren't able to meet up the excretory requirements of the body.

166. Clinical statistical investigation was performed to determine effectiveness of a new pharmacological preparation for patients with ischemic heart disease. What parametric test (coefficient) can be used to estimate the reliability of the results?

Explanation

 

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. It checks the differences between means of 2 groups for example comparing the effectiveness of the new pharmacological preparation for patients with Ischemic heart disease who took the medication (experimental group) and those that did not (control group).

167. A woman in her early- to mid-thirties has lost her consciousness 3-5 minutes ago. On examination: the skin is pale, no pulse over the carotid arteries, no spontaneous respiration, pupils are dilated; the patient is nonresponsive, presents with atony. The patient’s condition can be determined as:

Explanation

Preagony, terminal pause, Agony, clinical and biological death all refer to terminal states of the body. 

  •  Preagony- central nervous system is depressed (coma is possible);

heart sounds are weak, pulse is thready, systolic blood pressure is

lower than the critical level of 70 mm Hg; external respiration is

weak and not effective, tidal volume and respiratory frequency are

inadequate; functions of parenchymal organs are violated. Preagony

can last for minutes, hours or even days.

 
  • Terminal pause- patient faints, blood pressure and pulse become hard to measure, respiratory arrest appears and reflexes are lost. Lasts for minutes.

  • Agony- Muscular tone, reflexes and external respiration (chaotic, with auxiliary respiratory muscles participation) are restored.

  • Clinical death- absence of pulse, dilated pupil and lack of photoreaction, gray or cyanotic skin colour (skin is pale), unconsciousness, lack of reflexes and muscular atony. No spontaneous respiration.

  • Biological death- Irreversible changes in the body especially the CNS.

168. A 35-year-old woman complains of high body temperature and pain in the upper outer quadrant of her right buttock, which developed after an injection. She has been presenting with this condition for 3 days. At the site of injection the skin is hyperemic; there is a painful infiltrate with an area of softening in its center. The woman is diagnosed with a postinjection abscess of the right buttock. What tactics should the surgeon choose in this case?

Explanation

Intramuscular injections can lead to local infectious complications, such as abscesses, skin necrosis, or intra-articular infections. Abscess formation following intramuscular injections is rare and they are most commonly seen in immunocompromised individuals. 

An abscess is a confined collection of pus surrounded by inflamed tissue. Most abscesses are found on the extremities, buttocks, breast, axilla, groin, and areas prone to friction or minor trauma, but they may be found in any area of the body. Abscesses are formed when the skin is invaded by microorganisms. 

 

Treatment of an abscess is primarily through incision and drainage (I&D). Smaller abscesses (<5 mm) may resolve spontaneously with the application of warm compresses and antibiotic therapy. Larger abscesses will require I&D as a result of an increase in collection of pus, inflammation, and formation of the abscess cavity, which lessens the success of conservative measures.

169. A woman has been working as a polisher for a year and a half. Her workstation is equipped with a grinding machine (grinding wheels). She complains of white discoloration of her fingers and toes that appears when she is nervous. Objectively there are no changes in the coloration of the distal segments of her limbs. Grip strength measured with a dynamometer is 25 kg, algesimetry findings are 0.1; 0.3; 0.5. Cold stimulus is extremely positive on the upper and lower limbs. Internal organs are without pathologies. Make the diagnosis:

Explanation

Vibrating hand tools can cause vibration syndrome, a condition also known as vibration white finger and as Raynaud’s phenomenon of occupational origin. Vibration white finger (VWF), also known as hand-arm vibration syndrome (HAVS) or dead finger, is a secondary form of Raynaud’s syndrome, an industrial injury triggered by continuous use of vibrating hand-held machinery. Vibration syndrome has adverse circulatory and neural effects in the fingers. The signs and symptoms include numbness, pain, and blanching (turning pale and ashen). Of particular concern is evidence of advanced stages of vibration syndrome after exposures as short as one year. Workers tend to underreport the syndrome because symptoms are intermittent and occur most frequently under conditions not present in a doctor’s office (e.g., early in the morning or when the hands are cold or wet).

Early stages of vibration syndrome are characterized by tingling or numbness in the fingers. To be diagnosed as vibration syndrome, these neurologic symptoms must be more persistent and occur without provocation by immediate exposure to vibration. Other symptoms of vibration syndrome include blanching, pain, and flushing. The symptoms usually appear suddenly, and are precipitated by exposure to cold. With continuing exposure to vibration, the signs and symptoms become more severe and the pathology may become irreversible.

 

From the question stem, the patient is a polisher and uses a grinding machine, these predisposes to vibration disease. Hence, Vibration disease is the best choice here and a preferred choice over Raynaud disease.

170. A woman came to the doctor with complaints of increased body temperature up to 37.8°C and moderately sore throat for the last 3 days. Objectively: mandibular lymph nodes are enlarged up to 3 cm. Palatine tonsils are hypertrophied and covered with gray coating that spreads to the uvula and anterior pillars of the fauces. What is the most likely diagnosis?

Explanation

The key finding here are grey-white coatings on the tonsils that spreads to the uvula and anterior pillars of the fauces. Usually, these grey coatings are difficult to remove (or bleeds when removed); these are the main findings of a diphtheria infection ( causative agent -Corynebacterium Diphtheriae which produces an Exotoxin ie.,diphtheria toxin). 

 

The posterior pharynx of patients with Infectious Mononucleosis (EBV infection)  is often uniformly erythematous. Oropharyngeal candidiasis are easily scraped off.

171. A 57-year-old woman complains of weakness, dyspnea, loss of appetite, and liquid feces. She has been suffering from this condition for 2 years. Objectively she presents with pale skin, subicteric sclerae, and bright-red fissured tongue. Lymph nodes are not enlarged. Pulse - 100/min. BP- 105/70 mm Hg. Liver +3 cm, the spleen cannot be palpated. Blood test: erythrocytes - 1.2∙1012/L, Hb - 56 g/L, color index - 1.4, macrocytes, leukocytes - 2,5∙109/L, eosinophils - 1%, juvenile - 1%, metamyelocytes - 1%, band neutrophils - 8%, segmented neutrophils - 47%, lymphocytes - 38%, monocytes - 4%, reticulocytes - 0.1%, platelets - 100∙109/L, ESR - 30 mm/hour, indirect bilirubin - 26 mmol/L. What changes can be expected in the bone marrow puncture material?

Explanation

 

Appearance of  pale skin and low RBC level indicates anemia. On the full blood count film, we observe the presence of macrocytes and an increased colour index; this indicates a megaloblastic anemia. The bone marrow puncture will be characterised by the presence of megaloblasts (immature macrocytes). Megaloblastic anemia occurs mostly in Vitamin B12 and Folic acid deficiency.

172. A 26-year-old woman presents with amenorrhea. 10 months ago she gave birth for a second time. In her early postpartum period she developed a massive hypotonic hemorrhage. No breasfeeding. Lately she has been presenting with loss of weight, loss of hair, and indisposition. Gynecological examination revealed atrophy of the external genitals, the uterus is abnormally small, no uterine appendages can be detected. What is the most likely diagnosis?

Explanation

 

From the question stem, the woman delivered 10 months ago and experienced a significant amount of blood loss; this is the leading cause of Sheehan’s syndrome (Postpartum Pituitary Gland Necrosis). 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 are associated symptoms.

173. A 3-month-old child with signs of rickets presents with positive Chvostek, Trousseau, and Maslov signs. One day ago the parents witnessed a cyanotic attack in their child - the child broke into a cold sweat, the eyes bulged, and respiratory arrest occurred. One minute later the child drew in a loud breath and the child’s condition normalized again. What is the cause of the described signs of the disease?

Explanation

Rickets is a disease of growing organisms, which appears as a result of polyhypovitaminosis with primary insufficiency of vitamin D, that leads to disturbances in metabolism of phosphorus and calcium and processes of ossification with changes of organs and systems function. 

In the vitamin D deficiency state, hypocalcemia develops. 

The following are positive in hypocalcemic states:

Maslov‟s symptom – prick on the heel causes apnoe instead of quickening of breathing.

Chvostek’s sign: twitching of facial muscles in response to tapping over the facial nerve.

Trousseau’s sign: carpopedal spasm induced by pressure applied to the arm by an inflated sphygmomanometer cuff.

 

Test for the Trousseau sign by placing a blood pressure cuff on the patient’s arm and inflating to 20 mm Hg above systolic blood pressure for 3-5 minutes. This increases the irritability of the nerves, and a flexion of the wrist and metacarpophalangeal joints can be observed with extension of the interphalangeal joints and adduction of the thumb (carpal spasm). The Trousseau sign is more specific than the Chvostek sign.

174. A 7-year-old boy has severe pulmonary mucoviscidosis (cystic fibrosis). He complains of dyspnea and blood expectoration. Objectively he presents with lagging physical development, acrocyanosis, hepatomegaly, drumstick fingers, and nail plates resembling a ”clock face” Provisional diagnosis of chronic pulmonary heart disease is made. What examination would be the most informative for diagnosis confirmation?

Explanation

A doppler echocardiography is a diagnostic method for heart related issues. It is a combination of an echocardiogram (which uses sound waves to create an image of the heart) and a doppler technology ( which shows the velocity ie, speed and direction of blood flow in cardiac tissues). An Electrocardiography shows the electrical activity of the heart.

In patients with cystic fibrosis (CF), continuous pulmonary infection and inflammation with thickened secretions cause airways obstruction and hyperinflation. As the disease progresses, these patients develop disabling lung disease and eventually respiratory failure and pulmonary hypertension (PH).

PH is considered to be a consequence of several mechanisms that either raise the pressure downstream of the pulmonary capillaries, induce vasoconstriction, increase blood flow to the lung, or obstruct the pulmonary vessels either by embolism or in situ fibrosis.

The echocardiogram is an integral part of the evaluation of a patient with PH. Common echocardiographic findings in PH includes right atrial and right ventricular (RV) enlargement, reduced RV function, displacement of the intraventricular septum to the left, and tricuspid regurgitation that permits the estimation of the pulmonary artery systolic pressure (PASP).

 

Therefore, Doppler echocardiography will be the best choice to evaluate a patient with a chronic pulmonary heart disease.

175. A parturient woman is 30 years old, stage I of the labor is ongoing. The fetus is in the cephalic presentation. Auscultation of the fetal heart sounds detects bradycardia. Evaluation of cardiotocogram yielded the following data: decrease of basal heart rate down to 90/min., variability - monotonous (2 and less); late decelerations with amplitude of 50/min. Make the diagnosis and choose the obstetrical tactics necessary in this case:

Explanation

Simply put, Fetal distress is an indication that the baby may not be doing well in utero. When a baby is in distress they may require immediate intervention, such as delivery by Cesarean section or certain methods of intrauterine resuscitation. If fetal distress goes unmanaged it can lead to more severe injuries such as hypoxic-ischemic encephalopathy (HIE). 

The normal fetal heart rate should be between 110 and 160 beats per minute during the third trimester of pregnancy and labor.

Heart rate abnormalities that are signs of fetal distress:

 
  • Tachycardia (an abnormally fast heart rate)

  • Bradycardia (an abnormally slow heart rate)

  • Variable decelerations (abrupt decreases in heart rate)

  • Late decelerations (late returns to the baseline heart rate after a contraction).

176. A 35-year-old man complains of rapidly incresing fatigue, palpitations, “visual snow”, and dizziness. He has a history of peptic ulcer of the stomach. Objectively the skin is pale. Vesicular respiration is observed in the lungs. Systolic murmur is detected over the cardiac apex, heart rate is 100/min., BP is 100/70 mm Hg. The epigastrium is slightly tender on palpation. Blood test: erythrocytes - 3.2∙1012/L, Hb - 100 g/L, color index - 0.95. What type of anemia is the most likely present in this case?

Explanation

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

Anemia is decrease of erythrocytes amount and hemoglobin in unit of blood volume which is accompanied by qualitative changes of erythrocytes.

In men is lower than 4×1012, in women is lower than 3,7×1012 in 1L of blood.

Hemoglobin concentration   – in men is lower than 130 g/l, in women is lower than 120 g/l;

Posthemorrhagic anemia is an anemia which develops as a result of hemorrhage. There are two types of anemias of this group according to the character of hemorrhage: 

acute posthemorrhagic and;

chronic posthemorrhagic anemia.

Chronic posthemorrhagic anemia develops after repeated hemorrhages, caused by injury of blood vessels during number  diseases (ulcer of  stomach, hemorrhoids, dysmenorrhea etc.).

Note that that question stem states that he has a history of peptic ulcer of the stomach and one of the complications of peptic ulcer disease is hemorrhage.

Anemias which arise after destruction (hemolysis) of erythrocytes are called hemolytic usually due to mechanical trauma, ionizing radiation, Chemical agents (hemolytic poisons); Biological factors (causative agents of infectious diseases, toxins, enzymes); Immune factors (antibodies).

Iron deficiency anemia arises as a result of: Insufficient iron in organism due to an alimentary anemia in the infants (feeding with cow or goat milk); disorder of iron absorption   (resection of stomach, intestines, gastritises, enteritis); increased use of iron in pregnancy,  lactation or Hemorrhage which is the most widespread reason   of iron deficiency in organism;

However to differentiate posthemorrhagic and iron deficiency anemia:

reduction  of  color index is typical for iron deficiency anemia, whereas it is often normal in posthemorrhagic anemia.

 

The patient has a normal color index (0.85-1.05)

177. Mother of a 5-year-old child noticed on the the head of her child a round ”bald” spot 3 cm in diameter. All the hairs in the focus are broken off at the length of 5-6 mm. The day before the child was petting a stray cat. Make the diagnosis:

Explanation

178. For three years a 31-year-old woman has been complaining of pain and swelling of her radiocarpal and metacarpophalangeal articulations and their reduced mobility in the morning, which persisted up to 1.5 hours. Two weeks ago she developed pain, swelling, and reddening of her knee joints, her body temperature increased up to 37.5°C. The treatment was untimely. Examination of the internal organs revealed no pathologic alterations. Diagnosis of rheumatoid arthritis was made. What changes are most likely to be visible on the arthrogram?

Explanation

The question stem clearly states that the patient has been diagnosed with Rheumatoid Arthritis.

So basically, we need to differentiate Rheumatoid Arthritis (RA) and Osteoarthritis (OA) so that we can arrive at the correct answer specific for Rheumatoid Arthritis.

 

RA: autoimmune which erodes articulated cartilage and bone. The inflammatory cells and cytokines then induce pannus (proliferative granulation tissue) formation, deep usurations.

Associated with pain, swelling and morning stiffness, lasting >1hr and the pain improves with use.

Joint findings: joint space narrowing; erosions; juxtaarticular osteopenia; soft tissue swelling; subchondral cysts

Involves Metacarpophalangeal joints; wrist; proximal interphalangeal joints. Does not affect distal interphalangeal joints on the hands

 

OA: mechanical wear and tear - it’s a degenerative joint disease.

Associated with Pain in weight bearing joints after use (i.e. at the end of the day), and the pain improves with rest.

Joint findings: joint space narrowing; osteophytes (bone spurs); subchondral sclerosis and cysts.

Involves distal interphalangeal joints on the hands (heberden nodes) and Proximal interphalangeal joints (Bouchard nodes); does not affect Metacarpophalangeal joints.

 

So let’s answer the question:

From the question stem - Radiocarpal (wrist joints); metacarpophalangeal joints were affected with morning stiffness lasting >1.5hrs

These are clearly signs and symptoms of Rheumatoid Arthritis...

 

From the options it is clear that the only option talking about RA is joint space narrowing; usuration 

 

The other options are talking about Osteoarthritis.

 
179. A 27-year-old woman, a teacher in the elementary school, complains of frequent stools, up to 3 times per day, with lumpy feces and large amount of mucus, abdominal pain that gradually abates after a defecation, irritability. Her skin is pale and icteric. Pulse is 74/min., rhythmic, can be characterized as satisfactory. Blood pressure is 115/70 mm Hg. The abdomen is soft, moderately tender along the colon on palpation. Fiberoptic colonoscopy detects no changes. What disease can be suspected?

Explanation

Irritable bowel syndrome is an inflammatory bowel disease characterised by recurrent abdominal cramps (pain), change in form (consistency) and frequency of stool, constipation etc. N/B the patient’s  Bowel movements are intermittent: 3 defecations and abates (alternating between constipation and normal states). This condition is common in middle aged women and is associated with underlying conditions such as stress, anxiety, depression or a previous case of intestinal infection.

Crohn’s disease and ulcerative colitis are also inflammatory bowel diseases; Crohn’s disease affects any portion of the GIT while ulcerative colitis affects the colon and presents with a bloody diarrhea.
180. A pregnant woman is 28 years old. Anamnesis: accelerated labor complicated by the II degree cervical rupture. The following two pregnancies resulted in spontaneous abortions at the terms of 12 and 14 weeks. On mirror examination: the uterine cervix is scarred from previous ruptures at 9 and 3 hours, the cervical canal is gaping. On vaginal examination: the cervix is 2 cm long, the external orifice is open 1 cm wide, the internal orifice is half-open; the uterus is enlarged to the 12th week of pregnancy, soft, mobile, painless, the appendages are without changes. What diagnosis can be made?

Explanation

From the question stem, 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 during Labor). These changes in the cervix are typically seen in a condition termed ‘cervical weakness’ or ‘cervical insufficiency’ i.e., cervical dilation and effacement occurring in preterm pregnancy. At 12weeks gestational age, the cervix should be closed and not open. This woman can benefit from Cervical Cerclage.

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.

181. A 48-year-old woman has arrived to the surgical unit with wounds in her thigh. On examination the wound surface has dirty-gray coating with unpleasant sweet smell. Wound content resembles raspberry jelly. Skin tissues around the wound are glossy and turgid. Palpation reveals moderate crepitation in the tissues. What microflora is the most likely to cause such inflammation?

Explanation

Clostridium is a gram positive anaerobic, spore forming bacillus. Its major species include 

C. Botulinum- botulism; 

C. perfringens- enterocolitis, gas gangrene; 

C. Tetani- tetanus; 

C. difficile- pseudomembranous colitis

 

The description of the wound in the above patient (dirty gray coating, unpleasant sweet smell, raspberry jelly content, moderate crepitation of surrounding tissues upon palpation) indicates a Gangrene, crepitation - gas (Gas Gangrene). Gangrene is a serious condition where a loss of blood supply causes body tissue to die. Loss of blood supply is most likely due to  an illness, injury or infection (mostly C. Perfringens).

182. A 65-year-old woman on abdominal palpation presents with a tumor in the umbilical region and above it; the tumor is 13x8 cm in size, moderately painful, non- mobile, pulsing. On auscultation systolic murmur can be observed. What is the most likely diagnosis?

Explanation

An abdominal aortic aneurysm is an enlarged area in the lower part of the major vessel that supplies blood to the body (aorta). The aorta runs from your heart through the center of your chest and abdomen.

The aorta is the largest blood vessel in the body, so a ruptured abdominal aortic aneurysm can cause life-threatening bleeding.

Aneurysms can develop anywhere along the aorta, but most aortic aneurysms occur in the part of your aorta that's in your abdomen. A number of factors can play a role in developing an aortic aneurysm, including: Hardening of the arteries (atherosclerosis), High blood pressure, Blood vessel diseases, Infection in the aorta or Trauma.

Most people with abdominal aortic aneurysms don't have symptoms. But symptoms may occur if the aneurysm gets bigger and puts pressure on surrounding organs.

The most common symptom is general belly pain or discomfort, which may come and go or be constant.

Other symptoms may include: Pain in the abdomen or lower back. It may spread to the groin, buttocks, or legs. The pain may be deep, aching, or throbbing, and it may last for hours or days. It is generally not affected by movement. 

Another very important symptom is a pulsating feeling over the abdomen.

 

The tumor mentioned in the question is not referring to an actual tumor literally. It is used to describe the dilated portion of the abdominal aortic aneurysm.

183. The body of a 24-year-old woman with suspected poisoning has been found on the street. Forensic medical examination was requested by an investigator during examination of the site and the body. According to the Criminal Procedure Code currently in force in Ukraine, forensic medical examination is required when it is necessary to determine the:

Explanation

 

According to the Criminal Procedure Code currently in force in Ukraine, forensic medical examination is required to determine the cause of death.

184. A woman with the pregnancy term of 8 weeks complains of elevated temperature up to 37.6°C, skin rash that can be characterized as macular exanthema, enlargement of posterior cervical and occipital lymph nodes, small amount of bloody discharge from the genital tracts. She was examined by the infectious diseases specialist and diagnosed with rubella. What tactics should the obstetrician-gynecologist choose?

Explanation

Rubella (German measles) is a single stranded RNA virus, which is transmitted by airborne droplets between close contacts. Infection with rubella during pregnancy can have serious consequences for the fetus, and it remains an important diagnosis. 

Classic triad for congenital Rubella: Abnormalities of the eye (Cataracts); Deafness and Congenital heart disease (Patent Ductus Arteriosus).

 Any pregnant woman with a positive rubella screen should be immediately referred to a fetal medicine specialist for counselling and further management. The risk of vertical transmission to the fetus, and likelihood of developing congenital rubella syndrome is determined by the gestational age at the time of infection:

The recommended management varies according to the gestational age at infection:

 
  • <12 weeks – high likelihood of defects, it is reasonable to consider a termination of the pregnancy (NB: the patient is 8 weeks pregnant).

  • 12-20 weeks – prenatal diagnosis of fetal rubella infection required. This is usually performed by RT-PCR on amniotic fluid samples.

    • If transmission to the fetus is confirmed, management options include termination of pregnancy or ultrasound surveillance to identify features of congenital rubella syndrome (although some features of CRS cannot be detected by ultrasound).

  • >20 weeks – No action required.

185. A 59-year-old woman was brought into the rheumatology unit. Extremely severe case of scleroderma is suspected. Objectively she presents with malnourishment, ”mask-like” face, and acro-osteolysis. Blood: erythrocytes - 2.2∙109/L, erythrocyte sedimentation rate - 40 mm/hour. Urine: elevated levels of free oxyproline. Name one of the most likely pathogenetic links in this case:

Explanation

Scleroderma is a group of rare diseases that involve the hardening and tightening of the skin and connective tissues. Scleroderma affects women more often than men. It results from an overproduction and accumulation of collagen in body tissues. Collagen is a fibrous type of protein that makes up your body's connective tissues, including your skin.

Autoantibodies to basement membrane and interstitial collagens may participate in the pathogenesis of scleroderma. Using the enzyme-linked immunosorbent assay (ELISA), antibodies to interstitial (type I) and basement membrane (type IV) collagens can be detected in the sera of patients with scleroderma (systemic sclerosis). 

The primary structure of collagen contains basically 3 amino acids - Glycine, Proline and Lysine. Hence, the elevated levels of oxyproline in this patient’s urine.

 

Additional Info:

 

CREST is an acronym for the clinical features that are seen in a patient with this disease. The "C" stands for calcinosis, where calcium deposits form under the skin on the fingers or other areas of the body. The "R", stands for Raynaud's phenomenon, spasm of blood vessels in the fingers or toes in response to cold or stress. The "E" represents esophageal dysmotility, which can cause difficulty in swallowing. The "S" is for sclerodactyly, tightening of the skin causing the fingers to bend. Finally, the letter "T" is for telangiectasia, dilated vessels on the skin of the fingers, face, or inside of the mouth. Usually only 2 of the 5 symptoms of the CREST syndrome is necessary to be diagnosed with the disease.

 
186. A 57-year-old woman during a regular ultrasound examination presented with a space-occupying heterogeneous lesion in the right kidney. What is the most informative method of renal tumor diagnostics?

Explanation

Ultrasonography (US) and Computed Tomography (CT) have currently a prominent role in the diagnostic evaluation of renal tumors, compared to conventional radiology (excretory urography, retrograde pyelography, radioisotope renography). The use of Spiral Computed Tomography (spiral CT) has definitely improved the efficacy of CT and has its advantages in both diagnosing and staging renal tumors over Ultrasound.

 

CT is currently the technique of choice in the diagnosis and staging of renal masses, since it allows to recognize lesion site, size and densitometric patterns and provides an excellent visualization of surrounding structures (vessels and lymph nodes). Spiral CT further improves the examination quality, reducing the sedation time and requiring lower radiation doses.

187. A 25-year-old man was hospitalized with complaints of pain in his lower abdomen and right lumbar area that appeared one hour ago. Patient’s general state is moderately severe. Body temperature - 38.2°C, heart rate - 102/min. The tongue is dry. The abdomen is painful on deep palpation in the right iliac area and in the Petit triangle. Aure-Rozanov and Gabay signs are positive. Make the provisional diagnosis:

Explanation

Petit Triangle

The borders of Petit’s triangle, also known as the inferior lumbar triangle, is bounded by the latissimus dorsi posteriorly, the external oblique anteriorly, and the iliac crest inferiorly, which is the base of the triangle. The floor of the triangle is the internal oblique muscle. 

Aure-Rozanov and Gabay signs: a medical sign that is typically seen in retrocecal appendix. It is characterized by increased pain on palpation with the finger in the right Petit triangle (can be a positive Shchetkin-Boomberg's sign).

The diagnosis of acute appendicitis is predominantly a clinical one; many patients present with a typical history and examination findings. The cause of acute appendicitis is unknown but is probably multifactorial; luminal obstruction and dietary and familial factors have all been suggested. Appendicectomy is the treatment of choice and is increasingly done as a laparoscopic procedure.

 

Abdominal pain is the primary presenting complaint of patients with acute appendicitis. The diagnostic sequence of colicky central abdominal pain followed by vomiting with migration of the pain to the right iliac fossa. The patient is often flushed, with a dry tongue and an associated fetor oris. The presence of pyrexia (up to 38°C) with tachycardia is common. Abdominal examination reveals localised tenderness and muscular rigidity after localisation of the pain to the right iliac fossa. Rebound tenderness is present. The site of maximal tenderness is often said to be over McBurney's point, which lies two thirds of the way along a line drawn from the umbilicus to the anterior superior iliac spine.

188. A 28-year-old woman complaining of irregular menstruations and infertility came to the gynecological clinic. Menstruations occur since the age of 15, irregular, with delays up to 2 months. On examination she presents with marked hirsutism and excessive body weight. On vaginal examination the uterus is reduced in size and painless. The ovaries on the both sides are dense and enlarged. Ultasound shows microcystic changes in the ovaries, the ovaries are 5x4 cm and 4.5x4 cm in size with dense ovarian capsule. Basal body temperature is monophasic. What is the most likely diagnosis?

Explanation

Polycystic ovarian syndrome is a disorder found in women of reproductive age commonly due to hormonal disorder (high level of androgens). This disorder is characterized by infrequent menstrual cycle, pelvic pain, weight gain etc. The ovaries mostly develop follicles (collection of fluids). Note that the patient is of a reproductive age and experiences infrequent menstruation; the result of ultrasound, confirms the polycystic ovary pathology.
189. The dermatologist has an appointment with a 30-year-old man that complains of severely itching rashes that especially disturb him at night. The rashes developed 2 weeks ago, after he had returned from a travel. Objectively on the lateral surfaces of his fingers, hands, wrists, elbows, lower abdomen, genitals, and thighs there are paired papulovesicles, single pustules, and scratch marks. What disease can be suspected?

Explanation

Scabies is an itchy skin condition caused by a tiny burrowing mite called Sarcoptes scabiei. Intense itching occurs in the area where the mite burrows. The urge to scratch may be especially strong at night. The first time a person is exposed to the scabies mite, it can take upwards of 2 to 6 weeks for symptoms to develop.

Scabies is contagious and can spread quickly through close physical contact in a family, child care group, school class, nursing home or prison. Because scabies is so contagious, doctors often recommend treatment for entire families or contact groups.

The most common site of infestation in adults and older children include: in between the fingers; around fingernails; armpits; waistline; inner parts of the wrists; inner elbow; soles of the feet; the breasts, particularly the areas around the nipples; male genitalia; buttocks; knees; shoulder blades.

 

Infants and young children experience infestation in other areas of the body, including the: scalp; face; neck; palms of the hands; soles of the feet.

190. An 18-year-old girl was brought into the gynecology deparment with complaints of elevated body temperature up to 37.8°C, sharp pain in her lower abdomen, more intense on the right, and difficult defecation. Vaginal examination detected a painful dense elastic formation 5x6 cm in the area of her right ovary. Pregnancy test is negative. What is the most likely diagnosis?

Explanation

Ovarian torsion, which affects females of all ages, is a gynecological emergency. The main risk in ovarian torsion is an ovarian mass. The most common symptom of ovarian torsion is acute onset of pelvic pain, followed by nausea and vomiting.

Ovarian torsion occurs when an ovarian cyst or mass presents and rotates both the infundibulopelvic ligament and the utero-ovarian ligament. The cyst or mass is usually a benign lesion over 5 cm in diameter.

The ovary, and often the fallopian tube (adnexal torsion), become twisted around their vascular pedicle. The cause of this twisting can be multifactorial. The initial twisting causes obstruction of venous return. This leads to vascular congestion, which causes engorgement and edema. The congestion progresses until arterial flow is compromised, leading to ischemia and infarction. Untreated ovarian torsion can result in complete loss of the ovary, as well as ovarian necrosis and infection. 

From the question stem, the pregnancy test is negative, so we can rule out Ectopic pregnancy. A mass of 5x6cm is located around the right ovary, this mass won’t be visible if we have a ruptured cyst. 

 

Ovarian apoplexy (ovarian rupture) – is a sudden rupture (integrity violation) of ovarian tissue, accompanied by bleeding in the abdominal cavity and pain. Similarly, this won’t be the best choice in this case.

191. A 45-year-old man developed constricting retrosternal pain that occurs during walks at the distance of 200 m. Objectively: heart rate is 80/min., BP is 160/90 mm Hg. During cardiopulmonary exercise test at 50 W there is a depression of S-T segment by 3 mm below the isoline in V3-V4. What is the provisional diagnosis?

Explanation

NEW YORK HEART ASSOCIATION NYHA

An angina refers to chest pain due to an ischemic myocardium secondary to coronary artery narrowing or spasms. Canadian Cardiovascular Society grading of angina pectoris is a classification used to grade the severity of Angina.

Class 0: Asymptomatic Angina- Mild myocardial ischemia with no symptoms.

Class I: Angina only with strenuous exertion- Presence of angina during strenuous, rapid, or prolonged ordinary activity (walking or climbing the stairs).

Class II:Angina with moderate exertion- Slight limitation of ordinary activities when they are performed rapidly, after meals, in cold, in wind, under emotional stress, during the first few hours after waking up, but also walking uphill, climbing more than one flight of ordinary stairs at a normal pace and in normal conditions.

Class III: Angina with mild exertion- Having difficulties walking one or two blocks or climbing one flight of stairs at normal pace and conditions e.g walking short distances (20 - 100m)

Class IV: Angina at rest- No exertion needed to trigger angina.

The patient in perspective experiences anginal symptoms after he walks about 200m ( a short distance).

 

The New York Heart Association (NYHA) also classifies the extent of heart failure. It classifies patients in one of the four categories based on their limitations during physical activity.

CLASS I: No symptoms and no limitation in ordinary physical activity

CLASS II: Mild symptoms (mild shortness of breath and/or angina) and slight limitation during ordinary activity.

CLASS III: Marked limitation in activity due to symptoms, even during less than ordinary activity e.g. walking short distances (20 - 100m). Comfortable only at rest.

 

CLASS IV: Severe limitations. Experiences symptoms even while at rest.

 
192. A 72-year-old man complains of lower extremity edema, sensation of heaviness in the right subcostal area, dyspnea at rest. For over 25 years he has been suffering from COPD. Objectively: orthopnea, jugular venous distention, diffuse cyanosis, acrocyanosis. Barrel chest is observed, on percussion there is a vesiculotympanitic (bandbox) resonance, sharply weakened vesicular respiration on both sides, moist crepitant crackles in the lower segments of the lungs. Heart sounds are weakened, the II heart sound is accentuated over the pulmonary artery. The liver is +3 cm. What complicated the clinical course of COPD in this patient?

Explanation

193. To assess the effectiveness of medical technologies and determine the power and direction of their effect on the public health indicators, the research was conducted to study the immunization rate of children and measles incidence rate by district. What method of statistical analysis should be applied in this case?

Explanation

The Spearman's Rank Correlation Coefficient is used to discover the strength of a link between two sets of data. This example looks at the strength of the link between the immunization rate of children and measles incidence rate by district.

Correlation is a bivariate analysis that measures the strength of association between two variables and the direction of the relationship.  In terms of the strength of relationship, the value of the correlation coefficient varies between +1 and -1.  A value of ± 1 indicates a perfect degree of association between the two variables.  As the correlation coefficient value goes towards 0, the relationship between the two variables will be weaker.  A correlation coefficient of zero indicates that no relationship exists between the variables. The direction of the relationship is indicated by the sign of the coefficient; a + sign indicates a positive relationship and a – sign indicates a negative relationship.

An inverse correlation, also known as negative correlation, is a contrary relationship between two variables such that when the value of one variable is high then the value of the other variable is probably low. 

 

In this case, it is expected that as the immunization rate increases, measles incidence should decrease.

194. A 5-year-old child was brought to the ENT department by an ambulance. The child presents with cough and difficult respiration. From the patient’s history it is known that the child was playing with a toy construction set, when suddenly started coughing and developed labored breathing. Examination detects periodical cough, labored expiration, and respiratory lag in the left side of the child’s thorax. Auscultation: diminished respiration on the left. Percussion: tympanitis. X-ray shows a displacement of the mediastinal organs to the right. Make the diagnosis:

Explanation

The question says it all already.

The child was playing with a toy and presented with labored breathing and cough. On examination, there is a respiratory lag on the left. On auscultation, there is diminished respiration on the left and on X-ray, there is a mediastinal shift to the right. This clearly shows the foreign body (toy) was lodged in the left bronchus.

If the foreign body were to be in the trachea, there will be no respiration in both lung fields. It won’t be localized to only one side.

To differentiate if it is a complete or valvular bronchostenosis. Take a close look at the X-ray report - displacement of the mediastinal organs to the right. (Mediastinum is the space and organs located between both lungs i.e. the heart, aorta, thymus, trachea etc).

 

In complete bronchostenosis, air cannot enter or leave the left bronchus so the volume of the left lung will remain the same while in valvular bronchostenosis, air can enter the left lungs but cannot come out. Therefore, in valvular bronchostenosis, there is a gradual increase in the left lung volume which eventually shifts the mediastinum towards the right side.

195. In April during the medical examination of various population groups, 27% of individuals presented with low working ability and rapid fatigability. The following symptoms were observed in the affected individuals: swollen friable gingiva that bleeds when pressed, hyperkeratosis follicularis not accompanied by skin dryness. These symptoms most likely result from the following pathology:

Explanation

Vitamin C is needed for the regulation of collagen synthesis (it stabilizes collagen mRNA, thereby increasing collagen synthesis). In its absence, collagen synthesis is unstable leading to reduced wound healing and strength of tissues; symptoms include frequent gingival and petechial hemorrhages as seen in the patient. Vitamin C deficiency is known as Scurvy

 

In Vit A deficiency, the patient will experience impaired vision especially at night; this is because Vit A is a precursor of rhodopsin- the photo pigment found in rods (responsible for black and white vision). Vit B1 deficiency leads to Beri Beri

196. A 45-year-old woman is registered for regular check-ups due to Werlhof disease (immune thrombocytopenia). Complete blood count: Hb - 100 g/L, erythrocytes - 2.8∙1012/L, platelets - 90.0∙109/L, leukocytes - 8.4∙109/L, erythrocyte sedimentation rate - 13 mm/hour. Examination detects a single small hematoma on the anterior surface of the thigh, developed after the patient accidentally stumbled on a table. What treatment tactics should be chosen in this case?

Explanation

197. A 23-year-old man has accidentally swallowed brake fluid. After that he has been presenting with anuria for 5 days already; his creatinine levels elevated up to 0.569 mmol/L. What treatment tactics should be chosen in this case?

Explanation

Indications for Dialysis:

Plasma Urea >30mmol/L

Creatinine >600mcmol/L

Hyperkalemia>6mmol/L

Metabolic acidosis (HCO3 <10mmol/L)

Uraemic encephalopathy

Fluid overload and pulmonary edema

Uraemic pericarditis

GFR < 15mls/min

Oliguria (less than 200ml in 12 hours)

Anuria (0-50ml in 12 hours) 

Patient had Anuria for 5 days plus elevated creatinine - Dialysis

Types of Dialysis:

  • Hemodialysis: countercurrent flow of blood and dialysate (usually acetate or bicarbonate

  • Hemofiltration: Removal of plasma and its dissolved constituents

  • Peritoneal dialysis: uses peritoneum as a semipermeable membrane

 

The typical reference range for serum creatinine is 60 to 110 micromoles per liter (μmol/L) (0.7 to 1.2 milligrams per deciliter (mg/dL)) for men and 45 to 90 μmol/L (0.5 to 1.0 mg/dL) for women.

 

Reference ranges for Laboratory values are usually given at the end of your question paper. Check the last few pages during exams to confirm the reference range used. We also have the Lab values on this site.

198. A 20-year old man, a calibrator of dosimetry equipment, committed a gross violation of safety regulations, when he put two ampoules with cobalt-60, each with the radioactivity of 7 MCi, in the pockets of his trousers and jacket. He has been keeping the ampoules in his pockets for 8 hours. The tissues at the distance of 0.5cm from the source received the dose of 30Gy (3000R), while the tissues at the distance of 20cm - 2R. Did this man develop radiation sickness?

Explanation

199. Indicators of work of inpatient departments in the city hospitals for the past year were analyzed. After that the meeting was held at the central city hospital and, based on the results of the analysis, a decision was made to decrease the number of beds in the inpatient departments, and instead open daycare units with partial hospitalization in the city polyclinics. What is the main goal of this decision?

Explanation

200. A 65-year-old man complains of dyspnea, severe cough with expectoration of small amounts of blood-streaked sputum, weight loss, body temperature 37.2*C, loss of appetite, and weakness. He has been suffering from this condition for years. The patient’s condition deteriorated one year ago, dyspnea developed 3 weeks ago. The patient is a lifelong smoker. He is a carpenter by occupation. Objectively he is of normal body type but emaciated. Right side of the chest is retracted, excurcions are limited, accessory muscles take part in the respiration, respiratory rate is 22/min. Percussion detects dull sound over the right upper segment. Chest X-ray shows shrunken right upper lobe with homogeneous shadow connected to the root of the lung; the root is deformed; mediastinal organs are displaced to the right. What is the most likely diagnosis?

Explanation

Atelectasis is a partial or complete collapse of the entire lung or a specific area, or lobe, of the lung, leading to impaired exchange of carbon dioxide and oxygen. From the question, the Chest X-ray confirms this: shows a shrunken right upper lobe. Also, the right part of the chest is retracted and percussion sounds are dull (if the lungs were to be filled with air, resonance sounds would be heard).

Further radiographic findings such as, changes in the mediastinum and diaphragm, facilitate diagnosis. As the lung volume decreases with atelectasis, the mediastinum shifts towards the affected field on the radiograph. Furthermore, a unilateral elevated diaphragm increases the suspicion for atelectasis.

 

Pneumothorax will produce resonance sounds on percussion, not dull sounds as seen in this patient. Tuberculosis and Sarcoidosis can present with hilar lymphadenopathy and  a well circumscribed granuloma on chest X-ray (Tuberculosis - caseating granuloma; Sarcoidosis - non caseating granuloma).