2016 BOOKLET WITH EXPLANATIONS (EXCLUDING ALL REPEATS) "Wherever the art of Medicine is loved, there is also a love of Humanity." - Hippocrates. 2 © krokplanner.com 3 © krokplanner.com HOW YOU CAN FIND US OUR CONTACTS…. OUR WEBSITE https://www.krokplanner.com INSTAGRAM https://instagram.com/krokplanner?igshid=MGNiNDI5ZTU= TELEGRAM STUDY CHANNEL https://t.me/+xt79xsZS74xiMjUy 4 © krokplanner.com WHATSAPP (MESSAGING) Message krokplanner.com on WhatsApp. https://wa.me/message/Q36XUJ6VVZ4PJ1 WhatsApp number +380938755942 TELEGRAM (MESSAGING) https://t.me/+380938755942 5 © krokplanner.com 2016 BOOKLET WITH EXPLANATIONS (EXCLUDING ALL REPEATS) PART -1 (FOR SAMPLE USE) "Passion, determination, and hard work can turn dreams into reality. This handbook is dedicated to those who believe that anything is possible with unwavering dedication and belief in themselves." Contents QUESTIONS ................................................................... 6 EXPLANATIONS ........................................................ 15 6 © krokplanner.com QUESTIONS 1. You are a doctor on duty. A patient after a successful resuscitation (drowning) was delivered to an admission room. BP is 90/60 mm Hg, heart rate is 120/min., respiration rate is 26/min. The patient is unconscious, pupils are moderately dilated, general clonic and tonic convulsions are observed. Make the diagnosis: • • • • • Postresuscitation disease Apparent death Coma of unknown origin Unconsciousness Vegetative state 2. A 32-year-old welder complains of weakness and fever. His illness initially presented as tonsillitis one month earlier. On examination: BT- 38.9°C, RR- 24/min., HR 100/min., BP100/70 mm Hg, hemorrhages on the legs, enlargement of the lymph nodes. CBC shows Hb70 g/l, RBC- 2.2 · 1012/l, WBC- 3.0 · 109/l with 32% of blasts, 1% of eosinophiles, 3% of bands, 36% of segments, 20% of lymphocytes, and 8% of monocytes, ESR- 47 mm/hour. What is the cause of anemia? • • • • • Acute leukemia Chronic lympholeukemia Aplastic anema B12-deficient anemia Chronic hemolytic anemia 3. A regional cardiologist is tasked with the development of a plan for medioprophylactic measures aimed at decrease of cardiovascular mortality. What measures should be planned for secondary prevention? • • • • • Prevention of recurrences and complications Referring patients for sanatorium-and-spa treatment Prevention of diseases Referring patients for in-patient treatment Optimization of life style and living conditions 7 © krokplanner.com 4. An 8-year-old boy developed a temperature of 37.5°Ctwo days after his recovery from the case of URTI. He complains of suffocation, heart pain. Objectively: the skin is pale, tachycardia, the I heart sound is weakened, short systolic murmur in the 4th intercostal area near the left edge of the breastbone. What heart disorder such clinical presentation is characteristic of? • • • • • Nonrheumatic myocarditis Primary rheumatic carditis Myocardiodystrophy Fallot’s tetrad Cardiomyopathy 5. A woman complains of muscle weakness and general fatigue, dyspnea, vertigo, brittleness of her hair and nails, an urge to eat chalk. Anamnesis states uterine fibroid. Common blood analysis: erythrocytes – 2.8 Т/l, Hb- 80 g/l, color index – 0.78, anisocytosis, poikilocythemia, serum iron - 10 mcmol/l. What diagnosis is most likely? • • • • • Iron-deficiency anemia B12-deficient anemia Autoimmune hemolytic anemia Aplastic anemia Hypoplastic anemia 6. A 32 year old patient complains of cardiac irregularities, dizziness, dyspnea at physical exertion. He has never suffered from such condition before. Objectively: Ps- 74/min., rhythmic. BP- 130/80 mm Hg. Auscultation revealed systolic murmur above aorta, the first heart sound was normal. ECG showed hypertrophy of the left ventricle, signs of repolarization disturbance in the I, V5 and V6 leads. Echocardiogram revealed that interventricular septum was 2 cm. What is the most probable diagnosis? • • • • • Hypertrophic cardiomyopathy Aortic stenosis Essential hypertension Myocardium infarction Coarctation of aorta 8 © krokplanner.com 7. A 35-year-old patient’s wound with suppurative focus was surgically cleaned. On the 8th day after the surgery the wound cleared from its purulo-necrotic content and granulations appeared. However, against the background of antibacterial therapy the body temperature keeps at 38.5-39.5°C. There are chills, excessive sweating, euphoria, heart rate is 120/min. What complication of local pyoinflammatory process can it be? • • • • • Sepsis Purulent absorption fever Thrombophlebitis Meningitis Pneumonia 8. A 37-year-old woman complains of headaches, nausea, vomiting, spasms. The onset of the disease occurred the day before due to her overexposure to cold. Objectively: fever up to 40°C; somnolence; rigid neck; Kernig’s symptom is positive on the both sides; general hyperesthesia. Blood test: leucocytosis, increased ESR. Cerebrospinal fluid is turbid, yellowtinted. What changes of the cerebrospinal fluid are most likely? • • • • • Neutrophilic pleocytosis Lymphocytic pleocytosis Blood in the cerebrospinal fluid Xanthochromia in the cerebrospinal fluid Albuminocytological dissociation 9. A 48-year-old woman complains of pain in the thoracic spine, sensitivity disorder in the lower body, disrupted motor function of the lower limbs, body temperature rise up to 37.5°C. She has been suffering from this condition for 3 years. Treatment by various specialists was ineffective. X-ray reveals destruction of adjacent surfaces of the VIII and IX vertebral bodies. In the right paravertebral area at the level of lesion there is an additional soft tissue shadow. What diagnosis is most likely? • • • • • Tuberculous spondylitis of the thoracic spine Spinal tumor Multiple sclerosis Metastases into the spine Osteochondrosis 9 © krokplanner.com 10. A 56-year-old patient complains of pain in the epigastrium after eating, eructation, loss of appetite, slight loss of weight, fatigability. The patient smokes; no excessive alcohol consumption. Objectively: pale mucosa, BP110/70 mm Hg. The tongue is ”lacquered”. The abdomen is soft, sensitive in the epigastric area. Blood test: erythrocytes – 3.0 T/l, Hb- 110 g/l, color index – 1.1; macrocytosis; leukocytes – 5.5 g/l, ESR- 13 mm/hour. On fibrogastroduodenoscopy: atrophy of fundic mucosa. What pathogenesis does this disorder have? • • • • • Producing antibodies to parietal cells Н.pylori persistence Alimentary factor Chemical factor Gastropathic effect 11. A 42-year-old woman has been hospitalized with complaints of intense pain attacks in the lumbar and right iliac areas, which irradiate to the vulvar lips, frequent urination, nausea. The pain onset was acute. Objectively: the abdomen is soft, moderately painful in the right subcostal area, costovertebral angle tenderness on the right. Common urine analysis: specific gravity - 1016, traces of protein, leukocytes - 6-8 in the vision field, erythrocytes - 12-16 in the vision field, fresh. What diagnosis can be made? • • • • • Right-sided renal colic Acute right-sided pyelonephritis Acute right-sided adnexitis Acute cholecystitis Acute appendicitis 12. Examination of a group of persons living on the same territory revealed the following common symptoms: dark-yellow pigmentation of the tooth enamel, diffuse osteoporosis of bone apparatus, ossification of ligaments and joints, functional disorders of the central nervous system. This condition may be caused by the excessive concentration of the following microelement in food or drinking water: • • • • • Fluorine Copper Nickel Iodine Cesium 10 © krokplanner.com 13. In a pre-school educational establishment the menu consists of the following dishes: milk porridge from buckwheat, pasta with minced meat, cucumber salad, kissel (thin berry jelly), rye bread. What dish should be excluded from the menu? • • • • • Pasta with minced meat Milk porridge from buckwheat Kissel (thin berry jelly) Rye bread Cucumber salad 14. A patient suffering from infiltrative pulmonary tuberculosis was prescribed streptomycin, rifampicin, isoniazid, pyrazinamide, vitamin C. One month after the beginning of the treatment the patient started complaining of reduced hearing and tinnitus. What drug has such a side effect? • • • • • Streptomycin Isoniazid Rifampicin Pyrazinamide Vitamin C 15. A woman has developed sudden thoracic pain on the right with expectoration of pink sputum and body temperature rise up to 37.7°C on the 4th day after the surgery for cystoma of the right ovary. On lung examination: dullness of the lung sound on the lower right is observed. Isolated moist crackles can be auscultated in the same area. What complication is the most likely? • • • • • Pulmonary infarction Pneumonia Pulmonary abscess Exudative pleurisy Pneumothorax 11 © krokplanner.com 16. A 58-year-old patient was delivered to an admission room with complaints of pain in the thorax on the left. On clinical examination: aside from tachycardia (102/min.) no other changes. On ECG: pathologic wave Q in I, аVL, QS in V1, V2, V3 leads and ’domed’ ST elevation with negative T. What diagnosis is most likely? • • • • • Acute left ventricular anterior myocardial infarction Variant angina pectoris Aortic dissection Acute left ventricular posterior myocardial infarction Exudative pericarditis 17. A 48-year-old woman has thermal burns of both hands. The epidermis of the palms and backs of her hands is exfoliating, and blisters filled with serous liquid are forming. The forearms are intact. What diagnosis is most likely? • • • • • 2-3A degree thermal burn 4 degree thermal burn 1 degree thermal burn 3B degree thermal burn 1-2 degree thermal burn 18. A 30-year-old patient, who has been suffering from headaches, suddenly developed extreme headache after lifting a heavy load, as if he had been hit over the head. Nausea, vomiting, and slight dizziness are observed. In a day he developed pronounced meningeal syndrome and body temperature up to 37.6°C. A doctor suspects subarachnoid hemorrhage. What additional examination is necessary to confirm this diagnosis? • • • • • Lumbar puncture with investigation of the spinal fluid Skull X-ray Computed tomography of the brain Rheoencephalography Angiography of the brain vessels 19. A worker of a blowing shop complains of headache, irritability, sight impairment - he sees everything as if through a ”net”. Objectively: hyperemic sclera, thickened cornea, decreased opacity of pupils, visual acuity is 0.8 in the left eye, 0.7 in the right eye. The worker uses no means of personal protection. What diagnosis is most likely? • • • • • Cataract Conjunctivitis Keratitis Blepharospasm Progressive myopia 12 © krokplanner.com 20. A 45-year-old woman is undergoing treatment for active rheumatism, combined mitral valve failure. During her morning procedures she suddenly sensed pain in the left hand, which was followed by numbness. Pain and numbness continued to aggravate. Objectively: the skin of the left hand is pale and comparatively cold. Pulse in the hand arteries is absent along the whole length. What treatment tactics is most efficient? • • • • • Urgent embolectomy Prescription of fibrinolytics and anticoagulants Prescription of antibiotics and antiinflammatory agents Cardiac catheterization Urgent thrombintimectomy 21. A 40-year-old patient has acute onset of disease caused by overexposure to cold. Temperature has increased up to 39°C. Foul-smelling sputum is expectorated during coughing. Various moist crackles can be auscultated above the 3rd segment on the right. Blood test: leukocytes – 15.0 · 109/l, stab neutrophils - 12%, ESR- 52 mm/hour. On Xray: in the 3rd segment on the right there is a focus of shadow 3 cm in diameter, low density, with fuzzy smooth margins and a clearing in its center. What disease is most likely in the given case? • • • • • Pneumonia complicated by an abscess Infiltrative tuberculosis Peripheral pulmonary cancer Cystic echinococcosis Pulmonary cyst 22. A 48-year-old patient was found to have diffuse enlargement of the thyroid gland, exophthalmia, weight loss of 4 kg in 2 months, sweating. Objectively: HR- 105/min., BP140/70 mm Hg. Defecation act is normal. What kind of therapy is recommended in this case? • • • • • Mercazolil Radioiodine Propranolol Lugol’s solution Thyroxine 13 © krokplanner.com 23. A 48-year-old man complains of constant pain in the upper abdomen, predominantly on the left, which aggravates after eating, diarrhea, loss of weight. The patient has alcohol use disorder. Two years ago he had a case of acute pancreatitis. Blood amylase is 4 g/hour·l. Feces analysis: steatorrhea, creatorrhea. Blood sugar is 6.0 mmol/l. What treatment should be prescribed? • • • • • Panzinorm forte (Pancreatin) Insulin Gastrozepin (Pirenzepine) Contrykal (Aprotinin) No-Spa (Drotaverine) 24. In 10 hours after eating canned mushrooms a 27-year-old patient has developed diplopia, bilateral ptosis, disrupted swallowing, shallow breathing with respiratory rate 40/min., muscle weakness, enteroparesis. What measure should be taken first? • • • • • Intubation of the trachea for artificial respiration Gastrointestinal lavage Introduction of antibotulinic serum Introduction of glucocorticosteroids Intravenous detoxication therapy 25. A 32-year-old patient complains of reddening, burning, and sensation of a foreign body in the right eye. The disease is acute. On examination: visual acuity of the both eyes is 1.0. In the right eye there are hyperemy and swelling of the conjunctiva, superficial injection. There is purulent discharge in the conjunctival sac. The cornea is clear. The color and pattern of the iris are unchanged, the pupil is mobile. What diagnosis is most likely? • • • • • Acute conjunctivitis Acute iridocyclitis Acute attack of glaucoma Foreign body of the cornea Acute dacryocystitis 14 © krokplanner.com 26. Monthly dysentery morbidity in the region given in absolute figures is as follows: January - 6; February - 9; March - 11; April - 10; May 16; June - 23; July - 19; August - 33; September - 58; October - 19; November - 11; December - 5. Annual total is 220 cases. What graphic presentation would provide the best visual for monthly deviations of dysentery morbidity from the average? • • • • • Radar chart Map Cartogram Pie chart Bar chart 27. A full term baby born from the 1st noncomplicated pregnancy with complicated labor was diagnosed with cephalohematoma. On the 2nd day of life the child developed jaundice; on the 3rd day of life there appeared neurological changes: nystagmus, Graefe syndrome. Urine is yellow, feces are golden yellow. The mother’s blood group is А (II) Rh−, the child’s А (II) Rh+. On the 3rd day the results of the child’s blood test are as follows: Hb- 200 g/l, erythrocytes – 6.1·1012/l, blood bilirubin - 58 mcmol/l due to the presence of its unconjugated fraction, Ht- 0.57. In this case the jaundice is caused by: • • • • • Craniocerebral birth injury Physiologic jaundice Hemolytic disease of newborn Atresia of bile passages Fetal hepatitis 28. A 46-year-old patient with temporarily undetermined diagnosis was prescribed pleurocentesis based on the results of the Xray. The puncture yielded 1000 ml of a liquid with the following properties: clear, specific gravity – 1.010, protein content - 1%, Rivalta’s test is negative, erythrocytes - 2-3 in the field of vision. What disorder are these pathologic changes characteristic of? • • • • • Cardiac failure Pleuropneumonia Pleural mesothelioma Pulmonary tuberculosis Pulmonary cancer 15 © krokplanner.com EXPLANATIONS You are a doctor on duty. A patient after a successful resuscitation (drowning) was delivered to an admission room. BP is 90/60 mm Hg, heart rate is 120/min., respiration rate is 26/min. The patient is unconscious, pupils are moderately dilated, general clonic and tonic convulsions are observed. Make the diagnosis: CORRECT ANSWER Postresuscitation disease The patient was successfully resuscitated after drowning, but is now presenting with low blood pressure (90/60 mm Hg), tachycardia (heart rate of 120/min), increased respiratory rate (26/min), unconsciousness, moderately dilated pupils, and clonic and tonic convulsions. These findings are suggestive of postresuscitation disease, which is a syndrome that can occur after successful resuscitation from a cardiac arrest or drowning, and is characterized by neurological and systemic manifestations due to the lack of oxygen during the arrest and subsequent resuscitation efforts. Apparent death: This option can be ruled out as the patient was successfully resuscitated and is showing vital signs, such as a heart rate, blood pressure, and respiratory rate. Coma of unknown origin: the patient's clinical presentation is likely related to the drowning event and subsequent resuscitation, rather than an unknown origin of coma. Unconsciousness: While the patient is indeed unconscious, this option is not a specific diagnosis and does not provide information about the cause of the unconsciousness, which in this case is likely related to the drowning and postresuscitation syndrome. Vegetative state: This option is not appropriate as the patient's clinical presentation is suggestive of postresuscitation disease rather than a vegetative state, which is a long-term condition characterized by impaired consciousness but preserved autonomic functions. 16 © krokplanner.com A 32-year-old welder complains of weakness and fever. His illness initially presented as tonsillitis one month earlier. On examination: BT38.9°C, RR- 24/min., HR 100/min., BP- 100/70 mm Hg, hemorrhages on the legs, enlargement of the lymph nodes. CBC shows Hb- 70 g/l, RBC2.2 · 1012/l, WBC- 3.0 · 109/l with 32% of blasts, 1% of eosinophiles, 3% of bands, 36% of segments, 20% of lymphocytes, and 8% of monocytes, ESR- 47 mm/hour. What is the cause of anemia? CORRECT ANSWER Acute leukemia The patient presents with weakness, fever, hemorrhages on the legs, enlarged lymph nodes, and a complete blood count (CBC) showing a low hemoglobin level (70 g/l) and a low red blood cell count (2.2 · 1012/l). The CBC also reveals 32% of blasts, which are immature white blood cells, along with other abnormal percentages of different types of white blood cells. These findings are suggestive of acute leukemia, a type of cancer that involves the rapid production of abnormal white blood cells in the bone marrow, leading to a decrease in normal red blood cells and subsequent anemia. chronic lymphocytic leukemia (CLL) typically presents in an indolent manner with gradual onset, and the patient in this case has symptoms of weakness, fever, hemorrhages, and enlarged lymph nodes, which are more suggestive of an acute process. aplastic anemia is characterized by a decrease in the number of all types of blood cells (red blood cells, white blood cells, and platelets) due to bone marrow failure, whereas the patient in this case has an increase in immature white blood cells (blasts) and other abnormal percentages of different types of white blood cells on CBC. the patient's symptoms and CBC findings are not suggestive of vitamin B12 deficiency, which typically presents with megaloblastic anemia, neurologic symptoms, and other characteristic findings. 17 © krokplanner.com chronic hemolytic anemia involves the destruction of red blood cells, whereas the patient in this case has a low red blood cell count and a high percentage of blasts on CBC, which are suggestive of an acute leukemia rather than a chronic hemolytic process. Reference:Arber DA, Orazi A, Hasserjian R, et al. The 2016 revision to the World Health Organization classification of myeloid neoplasms and acute leukemia. Blood. 2016 May 19;127(20):2391-405. doi: 10.1182/blood-2016-03643544. 18 © krokplanner.com A regional cardiologist is tasked with the development of a plan for medioprophylactic measures aimed at decrease of cardiovascular mortality. What measures should be planned for secondary prevention? CORRECT ANSWER Prevention of recurrences and complications Secondary prevention aims to prevent further episodes or complications of a disease in individuals who have already experienced an initial event, such as a cardiovascular event (e.g., heart attack or stroke). This may involve implementing strategies to reduce risk factors, providing appropriate medical treatments, lifestyle modifications, and regular monitoring to prevent recurrences and complications. Referring patients for sanatorium-and-spa treatment: This option may not be directly related to secondary prevention of cardiovascular mortality. Sanatorium-and-spa treatment is typically used for rehabilitation or convalescent purposes and may not directly address the prevention of recurrences or complications of cardiovascular disease. Prevention of diseases: it pertains to primary prevention, which aims to prevent the development of diseases in individuals who have not yet experienced an initial event. Secondary prevention, on the other hand, focuses on individuals who have already experienced a disease or event and aims to prevent recurrences or complications. Referring patients for in-patient treatment: This option may be relevant in certain cases where in-patient treatment is necessary for managing acute cardiovascular events or complications. However, it may not be a general measure for secondary prevention of cardiovascular mortality. Optimization of lifestyle and living conditions: While lifestyle modifications are an important part of secondary prevention of cardiovascular disease, the option "Prevention of recurrences and complications" is more specific and comprehensive as it encompasses not only lifestyle modifications but also other medical treatments and interventions to prevent further events or complications in individuals who have already experienced a cardiovascular event. 19 © krokplanner.com 20 © krokplanner.com An 8-year-old boy developed a temperature of 37.5°Ctwo days after his recovery from the case of URTI. He complains of suffocation, heart pain. Objectively: the skin is pale, tachycardia, the I heart sound is weakened, short systolic murmur in the 4th intercostal area near the left edge of the breastbone. What heart disorder such clinical presentation is characteristic of? CORRECT ANSWER Nonrheumatic myocarditis Nonrheumatic myocarditis: Myocarditis is an inflammation of the myocardium (heart muscle) and can be caused by various infectious and non-infectious factors. The given clinical presentation with a history of URTI, tachycardia, weakened heart sounds, and a systolic murmur is suggestive of acute myocarditis. It can be caused by viral or bacterial infections, drug reactions, or autoimmune diseases Primary rheumatic carditis: Rheumatic carditis is a complication of rheumatic fever, which is caused by an immune response to a group A streptococcal infection. It typically presents with fever, chest pain, and symptoms related to cardiac involvement, such as murmurs, weakened heart sounds, and other signs of heart failure. However, the given clinical presentation does not have a clear history of rheumatic fever or group A streptococcal infection, making primary rheumatic carditis less likely. Primary rheumatic carditis, caused by rheumatic fever, is mainly a complication of untreated streptococcal throat infection. Myocardiodystrophy: Myocardiodystrophy refers to a group of heart muscle disorders that are usually of unknown origin and result in abnormal changes in the structure and function of the myocardium. Fallot's tetrad is a congenital heart condition characterized by four specific features: ventricular septal defect, pulmonary stenosis, overriding aorta, and right ventricular hypertrophy. Cardiomyopathy refers to a group of diseases that affect the structure and function of the heart muscle. The given clinical presentation is not specific to any particular type of cardiomyopathy. 21 © krokplanner.com A woman complains of muscle weakness and general fatigue, dyspnea, vertigo, brittleness of her hair and nails, an urge to eat chalk. Anamnesis states uterine fibroid. Common blood analysis: erythrocytes – 2.8 Т/l, Hb80 g/l, color index – 0.78, anisocytosis, poikilocythemia, serum iron - 10 mcmol/l. What diagnosis is most likely? CORRECT ANSWER Iron-deficiency anemia The clinical symptoms of muscle weakness, general fatigue, dyspnea, vertigo, brittleness of hair and nails, and an urge to eat chalk (known as pica) are consistent with iron-deficiency anemia. Uterine fibroids can also cause chronic bleeding, leading to iron deficiency due to blood loss. The blood analysis results of low erythrocyte count, low hemoglobin level, low color index, anisocytosis, poikilocytosis, and low serum iron level further support the diagnosis of iron-deficiency anemia. B12-deficient anemia typically presents with symptoms such as fatigue, weakness, and dyspnea, but vertigo, brittleness of hair and nails, and an urge to eat chalk are not typical features of B12 deficiency. Blood analysis results showing low erythrocyte count, low hemoglobin level, low color index, anisocytosis, poikilocytosis, and low serum iron level are not suggestive of B12-deficient anemia. Autoimmune hemolytic anemia is characterized by destruction of red blood cells by the immune system, resulting in anemia. It typically presents with symptoms such as jaundice, dark urine, and an enlarged spleen, which are not mentioned in the given clinical presentation. Blood analysis results showing low erythrocyte count, low hemoglobin level, low color index, anisocytosis, poikilocytosis, and low serum iron level are not consistent with autoimmune hemolytic anemia. Aplastic anemia is a condition characterized by bone marrow failure, leading to low production of red blood cells, white blood cells, and platelets. It typically presents with symptoms such as fatigue, weakness, and increased susceptibility to infections and bleeding, but dyspnea, vertigo, brittleness of hair and nails, and an urge to eat chalk are not typical features of aplastic anemia. 22 © krokplanner.com Blood analysis results showing low erythrocyte count, low hemoglobin level, low color index, anisocytosis, poikilocytosis, and low serum iron level are not suggestive of aplastic anemia. Hypoplastic anemia is a condition characterized by decreased production of red blood cells in the bone marrow. It typically presents with symptoms such as fatigue, weakness, and pallor, but dyspnea, vertigo, brittleness of hair and nails, and an urge to eat chalk are not typical features of hypoplastic anemia. Blood analysis results showing low erythrocyte count, low hemoglobin level, low color index, anisocytosis, poikilocytosis, and low serum iron level are not consistent with hypoplastic anemia. Reference:Camaschella C. Iron-deficiency anemia. N Engl J Med. 2015 Oct 22;373(17):1648-60. doi: 10.1056/NEJMra1401038. PMID: 26488693. 23 © krokplanner.com A 32 year old patient complains of cardiac irregularities, dizziness, dyspnea at physical exertion. He has never suffered from such condition before. Objectively: Ps- 74/min., rhythmic. BP- 130/80 mm Hg. Auscultation revealed systolic murmur above aorta, the first heart sound was normal. ECG showed hypertrophy of the left ventricle, signs of repolarization disturbance in the I, V5 and V6 leads. Echocardiogram revealed that interventricular septum was 2 cm. What is the most probable diagnosis? CORRECT ANSWER Hypertrophic cardiomyopathy Based on the given clinical presentation of cardiac irregularities, dizziness, dyspnea on exertion, along with the objective findings of systolic murmur above the aorta, left ventricular hypertrophy on ECG, and echocardiogram showing an interventricular septum thickness of 2 cm, the most probable diagnosis is hypertrophic cardiomyopathy. Hypertrophic cardiomyopathy is a condition characterized by thickening of the heart muscle, particularly the left ventricle, which can result in symptoms such as cardiac irregularities, dizziness, and dyspnea on exertion. The ECG findings of repolarization disturbance in the I, V5, and V6 leads are also suggestive of hypertrophic cardiomyopathy. Other options such as aortic stenosis, essential hypertension, myocardial infarction, or coarctation of the aorta may have similar clinical manifestations, but the given clinical findings point towards hypertrophic cardiomyopathy as the most probable diagnosis in this case. Reference:ACCF/AHA guideline for the diagnosis and treatment of hypertrophic cardiomyopathy: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Journal of the American College of Cardiology, 24 © krokplanner.com A 35-year-old patient’s wound with suppurative focus was surgically cleaned. On the 8th day after the surgery the wound cleared from its purulo-necrotic content and granulations appeared. However, against the background of antibacterial therapy the body temperature keeps at 38.5-39.5°C. There are chills, excessive sweating, euphoria, heart rate is 120/min. What complication of local pyoinflammatory process can it be? CORRECT ANSWER Sepsis Based on the given clinical presentation of persistent fever (38.5-39.5°C) despite antibacterial therapy, chills, excessive sweating, and tachycardia (heart rate of 120/min) in the setting of a recent surgical wound with purulent content, the most likely complication is sepsis. Sepsis is a serious and potentially life-threatening condition that occurs when an infection, such as a local pyoinflammatory process, spreads throughout the body and triggers a systemic inflammatory response.The presence of fever, chills, excessive sweating, and tachycardia can be indicative of systemic infection and sepsis. Other options such as purulent absorption fever (also known as pyemia) may present with similar symptoms. The key difference between the two conditions is that sepsis is a systemic response to an infection, whereas purulent absorption fever is a localized response to an infection. In sepsis, the infection has spread to the bloodstream and is affecting the entire body, whereas in purulent absorption fever, the infection is confined to a specific area. In the given scenario, the clinical presentation is more suggestive of sepsis rather than purulent absorption fever, as the patient has persistent fever despite antibacterial therapy and signs of systemic inflammation.Thrombophlebitis, meningitis, and pneumonia are also possible complications of local pyoinflammatory processes, but the given clinical presentation is more suggestive of sepsis. Meningitis typically presents with symptoms such as severe headache, neck stiffness, altered mental status, and other neurological signs. Reference:Singer, M., Deutschman, C. S., Seymour, C. W., Shankar-Hari, M., Annane, D., Bauer, M., ... & Angus, D. C. (2016). The Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis- 25 © krokplanner.com A 37-year-old woman complains of headaches, nausea, vomiting, spasms. The onset of the disease occurred the day before due to her overexposure to cold. Objectively: fever up to 40°C; somnolence; rigid neck; Kernig’s symptom is positive on the both sides; general hyperesthesia. Blood test: leucocytosis, increased ESR. Cerebrospinal fluid is turbid, yellow-tinted. What changes of the cerebrospinal fluid are most likely? CORRECT ANSWER Neutrophilic pleocytosis Neutrophilic pleocytosis: This refers to an increased number of neutrophils (a type of white blood cell) in the cerebrospinal fluid. In the given scenario, the patient presents with symptoms of meningitis, such as fever, headache, nausea, vomiting, and rigidity of the neck. The positive Kernig's sign and hyperesthesia further support the diagnosis of meningitis. Neutrophilic pleocytosis in the cerebrospinal fluid is commonly seen in bacterial meningitis, which can be caused by exposure to cold and other infectious agents. Xanthochromia in the cerebrospinal fluid: This refers to a yellow discoloration of the cerebrospinal fluid, which is typically seen in subarachnoid hemorrhage. In the given scenario, there is no mention of trauma or other factors that would suggest a hemorrhagic event. Lymphocytic pleocytosis: This refers to an increased number of lymphocytes (a type of white blood cell) in the cerebrospinal fluid. It is commonly seen in viral meningitis, which can present with similar symptoms as bacterial meningitis. However, in the given scenario, the presence of fever, leucocytosis, and positive Kernig's sign suggests a more acute and severe form of meningitis, making lymphocytic pleocytosis less likely. Blood in the cerebrospinal fluid: This refers to the presence of red blood cells in the cerebrospinal fluid, which can be seen in cases of traumatic tap or hemorrhagic events. However, there is no mention of trauma or hemorrhage in the given scenario, making blood in the cerebrospinal fluid less likely. 26 © krokplanner.com Albuminocytological dissociation: This refers to an increased level of protein (albumin) in the cerebrospinal fluid without a corresponding increase in the number of cells. It is typically seen in Guillain-Barré syndrome and other peripheral nervous system disorders, but not in meningitis. Therefore, albuminocytological dissociation is less likely in this case. Reference:Kumar, V., Abbas, A. K., & Aster, J. C. (Eds.). (2020). Robbins and Cotran Pathologic Basis of Disease. Elsevier. 27 © krokplanner.com A 48-year-old woman complains of pain in the thoracic spine, sensitivity disorder in the lower body, disrupted motor function of the lower limbs, body temperature rise up to 37.5°C. She has been suffering from this condition for 3 years. Treatment by various specialists was ineffective. Xray reveals destruction of adjacent surfaces of the VIII and IX vertebral bodies. In the right paravertebral area at the level of lesion there is an additional soft tissue shadow. What diagnosis is most likely? CORRECT ANSWER Tuberculous spondylitis of the thoracic spine Tuberculous spondylitis of the thoracic spine: The clinical presentation of pain in the thoracic spine, sensitivity disorders in the lower body, disrupted motor function of the lower limbs, and a history of symptoms persisting for 3 years, along with the X-ray findings of destruction of adjacent surfaces of the VIII and IX vertebral bodies and an additional soft tissue shadow in the right paravertebral area at the level of lesion, are suggestive of tuberculous spondylitis. Tuberculous spondylitis, also known as Pott's disease, is a form of spinal tuberculosis that affects the vertebrae and can cause destruction of the vertebral bodies, leading to pain, deformity, and neurological symptoms. • Spinal tumor: This could be a possibility, but given the history of symptoms persisting for 3 years and the X-ray findings of destruction of adjacent surfaces of the vertebral bodies, tuberculous spondylitis is more likely. • Multiple sclerosis: This is less likely based on the clinical presentation and X-ray findings described. Multiple sclerosis is a chronic autoimmune disease that affects the central nervous system, typically presenting with symptoms such as fatigue, muscle weakness, sensory disturbances, and visual changes, but destruction of vertebral bodies on X-ray would not be characteristic of multiple sclerosis. • Metastases into the spine: While metastases into the spine could be a possibility, the X-ray findings of destruction of adjacent surfaces of the 28 © krokplanner.com VIII and IX vertebral bodies and the additional soft tissue shadow in the right paravertebral area at the level of the lesion are more suggestive of tuberculous spondylitis, as metastatic lesions would typically present with other radiographic features. • Osteochondrosis: Osteochondrosis is a degenerative condition that affects the joints and cartilage, typically seen in younger individuals. It is less likely to cause destruction of adjacent surfaces of vertebral bodies on X-ray, as described in the case scenario. 29 © krokplanner.com A 56-year-old patient complains of pain in the epigastrium after eating, eructation, loss of appetite, slight loss of weight, fatigability. The patient smokes; no excessive alcohol consumption. Objectively: pale mucosa, BP110/70 mm Hg. The tongue is ”lacquered”. The abdomen is soft, sensitive in the epigastric area. Blood test: erythrocytes – 3.0 T/l, Hb- 110 g/l, color index – 1.1; macrocytosis; leukocytes – 5.5 g/l, ESR- 13 mm/hour. On fibrogastroduodenoscopy: atrophy of fundic mucosa. What pathogenesis does this disorder have? CORRECT ANSWER Producing antibodies to parietal cells The clinical presentation of pain in the epigastrium after eating, eructation, loss of appetite, slight weight loss, and fatigue, along with the findings of atrophy of the fundic mucosa on fibrogastroduodenoscopy, suggest a possible autoimmune process targeting the parietal cells of the stomach. Antibodies produced against the parietal cells can interfere with the production of gastric acid, leading to reduced acid secretion, which can result in symptoms such as pain after eating, eructation, and loss of appetite. • H. pylori is a bacterium that can persist in the stomach and cause chronic gastritis, which can lead to atrophy of the gastric mucosa over time. However, in this case scenario, there is no mention of H. pylori infection, and the symptoms and findings are not typical of H. pylori-associated gastritis. • Alimentary factors, such as dietary habits, can contribute to the development of gastritis or other gastric disorders. For example, a diet high in spicy or irritating foods, or frequent consumption of alcohol or caffeine, can irritate the gastric mucosa and potentially lead to the symptoms described. However, in this case scenario, there is no specific mention of such dietary habits contributing to the disorder. • Chemical factors, such as exposure to certain chemicals or toxins, can also cause gastric mucosal damage and lead to symptoms similar to those described. However, in this case scenario, there is no specific mention of exposure to chemicals or toxins as a possible cause of the disorder. • Gastropathy refers to a group of disorders that affect the gastric mucosa, typically characterized by mucosal damage without significant inflammation. Gastropathy can be caused by various factors, such as medications (such as nonsteroidal antiinflammatory drugs), alcohol, or stress. However, in this case scenario, there is no specific mention of any medications, alcohol consumption, or stress as potential causes of the disorder. 30 © krokplanner.com A 42-year-old woman has been hospitalized with complaints of intense pain attacks in the lumbar and right iliac areas, which irradiate to the vulvar lips, frequent urination, nausea. The pain onset was acute. Objectively: the abdomen is soft, moderately painful in the right subcostal area, costovertebral angle tenderness on the right. Common urine analysis: specific gravity - 1016, traces of protein, leukocytes - 6-8 in the vision field, erythrocytes - 12-16 in the vision field, fresh. What diagnosis can be made? CORRECT ANSWER Right-sided renal colic The patient's symptoms of intense pain attacks in the lumbar and right iliac areas, which irradiate to the vulvar lips, along with frequent urination and presence of leukocytes and erythrocytes in urine analysis, are indicative of a possible renal colic. Costovertebral angle tenderness on the right side also suggests involvement of the right kidney. Renal colic typically presents with sudden and severe pain caused by the passage of a kidney stone through the ureter, leading to urinary tract obstruction and subsequent symptoms. • • • • Acute right-sided pyelonephritis: This is a possible differential diagnosis, as it can present with similar symptoms such as flank pain, frequent urination, and leukocytes in urine analysis. However, the presence of intense pain attacks that irradiate to the vulvar lips, along with the absence of fever or systemic signs of infection, makes renal colic more likely. Acute right-sided adnexitis: This is less likely based on the given clinical presentation, as the pain is not localized to the lower abdomen or pelvis, and the presence of leukocytes and erythrocytes in urine analysis suggests a urinary tract origin of the symptoms. Acute cholecystitis: This is less likely based on the absence of typical symptoms such as right upper quadrant abdominal pain, fever, and systemic signs of inflammation. Acute appendicitis: This is less likely based on the absence of typical symptoms such as right lower quadrant abdominal pain, fever, and localized tenderness. 31 © krokplanner.com Examination of a group of persons living on the same territory revealed the following common symptoms: dark-yellow pigmentation of the tooth enamel, diffuse osteoporosis of bone apparatus, ossification of ligaments and joints, functional disorders of the central nervous system. This condition may be caused by the excessive concentration of the following microelement in food or drinking water: CORRECT ANSWER Fluorine The dark-yellow pigmentation of tooth enamel, diffuse osteoporosis of bone apparatus, ossification of ligaments and joints, and functional disorders of the central nervous system are consistent with the symptoms of fluorosis, which is caused by excessive consumption of fluorine. Fluorosis is a condition that occurs due to prolonged exposure to high levels of fluoride in food or drinking water, leading to the deposition of excess fluoride in bones, teeth, and soft tissues. Copper, nickel, iodine, and cesium are unlikely to be the cause of the given symptoms, as excessive consumption of these microelements is not typically associated with the described clinical presentation. Reference:Kumar, V., Abbas, A. K., & Aster, J. C. (Eds.). (2020). Robbins Basic Pathology (10th ed.). Elsevier. 32 © krokplanner.com In a pre-school educational establishment the menu consists of the following dishes: milk porridge from buckwheat, pasta with minced meat, cucumber salad, kissel (thin berry jelly), rye bread. What dish should be excluded from the menu? CORRECT ANSWER Pasta with minced meat In a pre-school educational establishment, the menu should be designed to provide balanced and nutritious meals for growing children. Pasta with minced meat is typically high in carbohydrates and can be lower in nutritional value compared to other options such as milk porridge from buckwheat, cucumber salad, kissel (thin berry jelly), and rye bread. It may also be high in saturated fat depending on the type and amount of meat used. Therefore, to ensure a balanced diet, pasta with minced meat may be considered less nutritious and can be excluded from the menu in favor of other healthier options. Milk porridge from buckwheat, cucumber salad, kissel (thin berry jelly), and rye bread are generally considered healthy and can provide important nutrients for growing children. Reference:National Health and Medical Research Council. (2013). Get up & grow: Healthy eating and physical activity for early childhood - Director/carer booklet. Australian Government Department of Health. 33 © krokplanner.com A patient suffering from infiltrative pulmonary tuberculosis was prescribed streptomycin, rifampicin, isoniazid, pyrazinamide, vitamin C. One month after the beginning of the treatment the patient started complaining of reduced hearing and tinnitus. What drug has such a side effect? CORRECT ANSWER Streptomycin Streptomycin is an antibiotic commonly used in the treatment of tuberculosis. However, it is known to have ototoxic effects, which means it can cause damage to the inner ear and result in reduced hearing and tinnitus. This side effect may occur after the initiation of streptomycin treatment, as in the case described in the question. Isoniazid, rifampicin, pyrazinamide, and vitamin C are not known to have ototoxic effects and are not typically associated with reduced hearing or tinnitus.It's important to note that all medications can have potential side effects, and the occurrence and severity of side effects may vary from person to person. Reference:World Health Organization. (2017). Treatment of tuberculosis: guidelines. World Health Organization. 34 © krokplanner.com A woman has developed sudden thoracic pain on the right with expectoration of pink sputum and body temperature rise up to 37.7°C on the 4th day after the surgery for cystoma of the right ovary. On lung examination: dullness of the lung sound on the lower right is observed. Isolated moist crackles can be auscultated in the same area. What complication is the most likely? CORRECT ANSWER Pulmonary infarction The sudden onset of thoracic pain on the right side, pink sputum, and body temperature rise after surgery for cystoma of the right ovary, along with dullness of lung sounds, isolated moist crackles, and other clinical findings, is suggestive of pulmonary infarction. Pulmonary infarction refers to the blockage of blood flow to a portion of the lung, leading to tissue death and subsequent inflammation. It can occur as a complication after surgery due to various factors, including immobility, increased risk of blood clots, and altered blood flow dynamics. • Pneumonia is an infection of the lung tissue and typically presents with symptoms such as fever, cough, and chest pain. However, in this case, the sudden onset of symptoms, along with findings of dullness of lung sounds and moist crackles, is more suggestive of pulmonary infarction rather than pneumonia. • Pulmonary abscess is a localized collection of pus in the lung tissue, usually caused by bacterial infection. It is less likely in this case, as the clinical presentation and findings are more suggestive of pulmonary infarction. • Exudative pleurisy refers to inflammation of the pleura (the lining of the lungs) with accumulation of fluid. It typically presents with pleuritic chest pain and may have associated fever, but the pink sputum and other findings described in the question are not typical of exudative pleurisy. • Pneumothorax is the presence of air in the pleural cavity, which can cause partial or complete collapse of the lung. It is less likely in this case, as the clinical presentation and findings are more suggestive of pulmonary infarction. 35 © krokplanner.com A 58-year-old patient was delivered to an admission room with complaints of pain in the thorax on the left. On clinical examination: aside from tachycardia (102/min.) no other changes. On ECG: pathologic wave Q in I, аVL, QS in V1, V2, V3 leads and ’domed’ ST elevation with negative T. What diagnosis is most likely? CORRECT ANSWER Acute left ventricular anterior myocardial infarction Based on the given symptoms of chest pain on the left, tachycardia, and ECG findings of pathologic wave Q in I, aVL, QS in V1, V2, V3 leads, along with 'domed' ST elevation with negative T, the most likely diagnosis is acute left ventricular anterior myocardial infarction. These ECG findings are indicative of a myocardial infarction involving the anterior wall of the left ventricle. • • • • Variant angina pectoris: Variant angina pectoris typically presents with transient episodes of chest pain caused by coronary artery vasospasm, and the ECG findings in this condition are usually different Aortic dissection: Aortic dissection is a condition where there is a tear in the inner layer of the aorta, leading to separation of the layers of the aortic wall. It usually presents with severe tearing or ripping chest pain that may radiate to the back or other areas Acute left ventricular posterior myocardial infarction: ST segment depression in leads V1-V3,Deep and symmetric T-wave inversion in leads V1-V3,Absence of Q waves in leads V1-V3 are the main ecg findings. Exudative pericarditis: Exudative pericarditis is inflammation of the pericardium with an exudative effusion. Reference:Braunwald, E. (2019). Acute myocardial infarction: Cardiovascular Medicine. Philadelphia, PA: Elsevier. 36 © krokplanner.com 37 © krokplanner.com A 48-year-old woman has thermal burns of both hands. The epidermis of the palms and backs of her hands is exfoliating, and blisters filled with serous liquid are forming. The forearms are intact. What diagnosis is most likely? CORRECT ANSWER 2-3A degree thermal burn Based on the description given, the most likely diagnosis is a 2-3A degree thermal burn, which is also known as a superficial to partialthickness burn. Patient's symptoms, including exfoliation of the epidermis of the palms and backs of the hands, and formation of blisters filled with serous liquid, the most likely diagnosis is a 2-3A degree thermal burn. This type of burn typically affects the epidermis and dermis, resulting in blisters and skin exfoliation. There are four degrees of burns, ranging from first-degree to fourth-degree, which vary in severity based on the extent and depth of tissue damage. Here's an explanation of each degree of burn: 1. First-degree burn: A first-degree burn affects only the outermost layer of the skin, known as the epidermis. Symptoms of a first-degree burn include redness, pain, and mild swelling. Sunburn is an example of a first-degree burn. 2. Second-degree burn: A second-degree burn affects both the epidermis and the underlying layer of skin, known as the dermis. Symptoms of a second-degree burn include redness, pain, swelling, and blisters filled with clear fluid. • • Superficial second-degree burn (1-2 degree thermal burn): The burn involves the upper layer of the dermis, and the blisters are filled with clear fluid. The skin usually heals within two to three weeks with minimal scarring. Deep second-degree burn: The burn damages deeper layers of the dermis, and the blisters are filled with blood or pus. Healing time is longer, and scarring is more severe. 38 © krokplanner.com 3. Third-degree burn: A third-degree burn affects all layers of the skin, including the underlying tissues. Symptoms of a third-degree burn include charred or white skin, dry and leathery skin, and a lack of sensation in the affected area. Third-degree burns require immediate medical attention, as they can be life-threatening and may require skin grafting. • • Superficial third-degree burn (3A degree thermal burn): The burn involves the upper layers of the skin and appears white and waxy. There may be some blistering, but it is usually minor. Deep third-degree burn (3B degree thermal burn): The burn damages all the layers of the skin and appears black, brown, or white. There is no sensation in the affected area, and the skin is dry and leathery. 4. Fourth-degree burn: A fourth-degree burn is the most severe type of burn, and it affects all layers of the skin, including the underlying tissues, such as muscles, tendons, and bones. Symptoms of a fourth-degree burn include charring of the affected area, a lack of sensation, and the loss of function in the affected area. Fourth-degree burns require immediate medical attention and can be life-threatening. In summary, first-degree burns are the least severe, while fourth-degree burns are the most severe Reference: American Burn Association. Burn Incidence and Treatment in the US: 2016 Fact Sheet. Available at https://ameriburn.org/wp-content/uploads/2017/04/fact-sheet.pdf 39 © krokplanner.com A 30-year-old patient, who has been suffering from headaches, suddenly developed extreme headache after lifting a heavy load, as if he had been hit over the head. Nausea, vomiting, and slight dizziness are observed. In a day he developed pronounced meningeal syndrome and body temperature up to 37.6°C. A doctor suspects subarachnoid hemorrhage. What additional examination is necessary to confirm this diagnosis? CORRECT ANSWER Lumbar puncture with investigation of the spinal fluid In suspected cases of subarachnoid hemorrhage (SAH), a lumbar puncture with investigation of the spinal fluid is a crucial diagnostic test to confirm the diagnosis. This is because SAH refers to bleeding into the subarachnoid space, which is the space between the arachnoid and pia mater layers of the meninges that surround the brain and spinal cord. Blood in the cerebrospinal fluid (CSF) collected from a lumbar puncture can indicate the presence of a subarachnoid hemorrhage, even when other imaging studies such as computed tomography (CT) of the brain may initially be negative. • • • • Skull X-ray is not typically used as a primary diagnostic tool for subarachnoid hemorrhage. It may be used to rule out other conditions such as skull fractures, but it is not sensitive enough to reliably detect the presence of blood in the subarachnoid space. CT of the brain is often used as an initial imaging study in suspected cases of SAH. However, it may not always detect small bleeds or bleeds that have occurred recently. In some cases, CT may be negative even when a subarachnoid hemorrhage is present. This is why lumbar puncture is necessary to confirm or rule out SAH definitively. Rheoencephalography is a technique used to measure changes in electrical impedance in the brain. It is not a standard diagnostic test for subarachnoid hemorrhage Angiography is a specialized imaging study that involves injecting a contrast dye into the blood vessels to visualize the blood flow. It may be used in cases where a ruptured cerebral aneurysm is suspected as the cause of subarachnoid hemorrhage, but it is not typically used as a primary diagnostic tool for SAH. It is usually reserved for cases where further investigation of the blood vessels is needed after other diagnostic tests have been performed. 40 © krokplanner.com A worker of a blowing shop complains of headache, irritability, sight impairment - he sees everything as if through a ”net”. Objectively: hyperemic sclera, thickened cornea, decreased opacity of pupils, visual acuity is 0.8 in the left eye, 0.7 in the right eye. The worker uses no means of personal protection. What diagnosis is most likely? CORRECT ANSWER Cataract Cataract is a condition characterized by clouding of the normally clear lens of the eye, which can cause visual disturbances such as blurred or decreased vision. The symptoms described in the scenario, including hyperemic sclera, thickened cornea, decreased opacity of pupils, and reduced visual acuity, can be indicative of cataract. The history of the worker being exposed to a blowing shop without using any means of personal protection may not directly relate to the symptoms ,However, prolonged exposure to environmental factors without proper eye protection can increase the risk of developing cataract, as UV radiation and other harmful substances can damage the lens of the eye over time. Differential diagnosis: Conjunctivitis, or inflammation of the conjunctiva, typically presents with symptoms such as redness, itching, tearing, and discharge. Keratitis, or inflammation of the cornea, may cause symptoms such as eye pain, redness, blurred vision, and sensitivity to light. Blepharospasm is a condition characterized by abnormal, involuntary eyelid closure or twitching. Progressive myopia refers to nearsightedness that worsens over time. None of these conditions fully match the symptoms and findings described in the scenario. Reference:American Academy of Ophthalmology. (2020). Cataract. Retrieved from https://www.aao.org/eye-health/diseases/what-is-cataract 41 © krokplanner.com A 45-year-old woman is undergoing treatment for active rheumatism, combined mitral valve failure. During her morning procedures she suddenly sensed pain in the left hand, which was followed by numbness. Pain and numbness continued to aggravate. Objectively: the skin of the left hand is pale and comparatively cold. Pulse in the hand arteries is absent along the whole length. What treatment tactics is most efficient? CORRECT ANSWER Urgent embolectomy Based on the description provided, the most likely diagnosis is acute arterial embolism, which is a sudden blockage of blood flow to an artery due to an embolus (a blood clot or other debris) that has traveled from another location in the body. The patient's symptoms of sudden pain and numbness in the left hand, along with pale and cold skin and absence of pulse in the hand arteries, suggest compromised blood flow to the hand, which requires urgent intervention. Treatment for acute arterial embolism typically involves removal of the embolus to restore blood flow to the affected area. Embolectomy, which is the surgical removal of the embolus, is considered the most efficient treatment tactic in this scenario. Other options such as fibrinolytics and anticoagulants, antibiotics and anti-inflammatory agents, cardiac catheterization, or thrombintimectomy may not be as effective in restoring blood flow promptly in cases of acute arterial embolism. Differential diagnosis: Other conditions that could present with similar symptoms, such as pain, numbness, and absence of pulse in the hand arteries, include acute arterial thrombosis, compartment syndrome, or nerve impingement. However, the description provided in the scenario of a patient with active rheumatism and mitral valve failure, along with sudden onset of symptoms in the left hand, is suggestive of acute arterial embolism as the most likely diagnosis. Reference:Cronenwett, J. L., & Johnston, K. W. (2014). Rutherford's Vascular Surgery. Elsevier Saunders. 42 © krokplanner.com A 40-year-old patient has acute onset of disease caused by overexposure to cold. Temperature has increased up to 39°C. Foul-smelling sputum is expectorated during coughing. Various moist crackles can be auscultated above the 3rd segment on the right. Blood test: leukocytes – 15.0 · 109/l, stab neutrophils - 12%, ESR- 52 mm/hour. On Xray: in the 3rd segment on the right there is a focus of shadow 3 cm in diameter, low density, with fuzzy smooth margins and a clearing in its center. What disease is most likely in the given case? CORRECT ANSWER Pneumonia complicated by an abscess The clinical presentation and diagnostic findings described in the scenario are suggestive of pneumonia complicated by an abscess. The patient has acute onset of disease after overexposure to cold, with an increased body temperature (39°C), foul-smelling sputum, and moist crackles auscultated above the 3rd segment on the right side of the chest. The blood test shows leukocytosis (leukocytes - 15.0 · 109/l) with an elevated percentage of stab neutrophils (12%) and an elevated erythrocyte sedimentation rate (ESR) of 52 mm/hour. The X-ray findings reveal a focus of shadow in the 3rd segment on the right with a low density, fuzzy smooth margins, and a clearing in its center, which is suggestive of an abscess. The other options listed, including infiltrative tuberculosis, peripheral pulmonary cancer, cystic echinococcosis, and pulmonary cyst, are less likely based on the clinical presentation and diagnostic findings provided in the scenario. Infiltrative tuberculosis would typically have a different pattern of shadow on X-ray, and peripheral pulmonary cancer would typically present with different symptoms and may not have foulsmelling sputum or crackles on auscultation. Cystic echinococcosis and pulmonary cyst are also less likely based on the clinical findings described. Reference:Medscape. (2019). Lung Abscess Imaging. Retrieved from https://emedicine.medscape.com/article/361833-overview#a4 43 © krokplanner.com A 48-year-old patient was found to have diffuse enlargement of the thyroid gland, exophthalmia, weight loss of 4 kg in 2 months, sweating. Objectively: HR- 105/min., BP140/70 mm Hg. Defecation act is normal. What kind of therapy is recommended in this case? CORRECT ANSWER Mercazolil The clinical presentation described in the scenario is suggestive of hyperthyroidism, specifically Graves' disease, which is an autoimmune disorder causing overactive thyroid gland. The patient presents with diffuse enlargement of the thyroid gland, exophthalmia (bulging eyes), weight loss, sweating, tachycardia (heart rate of 105/min), and normal defecation. Mercazolil (Methimazole or Thiamazole) is an anti-thyroid medication that is commonly used in the treatment of hyperthyroidism. It works by inhibiting the production of thyroid hormones in the thyroid gland, thus helping to normalize the overactive thyroid function. It is typically used as the first-line treatment for hyperthyroidism, including Graves' disease. The other options listed, including Radioiodine, Propranolol, Lugol's solution, and Thyroxine, may also be used in the treatment of hyperthyroidism, but they are not the recommended initial therapy for this condition. Radioiodine is typically used as a second-line treatment option, and Propranolol may be used to manage the symptoms of hyperthyroidism, such as tachycardia, but it does not directly address the underlying thyroid dysfunction. Lugol's solution is a source of iodine that may be used in preparation for thyroid surgery or as a temporary measure to reduce thyroid hormone production, but it is not typically used as the first-line treatment. Thyroxine is a thyroid hormone replacement therapy and is used in cases of hypothyroidism, not hyperthyroidism. Reference:Bahn, R. S., & Burch, H. B. (2016). Graves' disease and toxic nodular goiter. In Werner & Ingbar's The Thyroid: A Fundamental and Clinical Text (10th ed., pp. 361-393). Lippincott Williams & Wilkins. 44 © krokplanner.com A 48-year-old man complains of constant pain in the upper abdomen, predominantly on the left, which aggravates after eating, diarrhea, loss of weight. The patient has alcohol use disorder. Two years ago he had a case of acute pancreatitis. Blood amylase is 4 g/hour·l. Feces analysis: steatorrhea, creatorrhea. Blood sugar is 6.0 mmol/l. What treatment should be prescribed? CORRECT ANSWER Panzinorm forte (Pancreatin) The clinical presentation described in the scenario is suggestive of chronic pancreatitis. The patient complains of constant pain in the upper abdomen, predominantly on the left, which worsens after eating, along with diarrhea, weight loss, and a history of acute pancreatitis. Blood amylase level is normal (4 g/hour·l), feces analysis shows steatorrhea and creatorrhea, and blood sugar level is elevated (6.0 mmol/l). Panzinorm forte (Pancreatin) is a pancreatic enzyme supplement that contains amylase, lipase, and protease, which are enzymes that help digest carbohydrates, fats, and proteins, respectively. It is commonly used in the treatment of pancreatic. Pancreatic enzyme supplements can help improve digestion and absorption of nutrients, relieve abdominal pain, and reduce steatorrhea (excess fat in feces) in patients with chronic pancreatitis. Insulin is used in the treatment of diabetes, but it is not indicated for chronic pancreatitis. Gastrozepin (Pirenzepine) is an anti-acid medication used to reduce stomach acid secretion and is not directly related to pancreatic insufficiency. Contrykal (Aprotinin) is a protease inhibitor used in the treatment of acute pancreatitis, especially in severe cases where there is extensive autodigestion of the pancreas and is not typically used in the treatment of chronic pancreatitis. No-Spa (Drotaverine) is a smooth muscle relaxant used to relieve spasms in various organs, but it is not indicated for the treatment of chronic pancreatitis. Reference:Domínguez-Muñoz, J. E. (2018). Pancreatic enzyme replacement therapy for pancreatic exocrine insufficiency: when is it indicated, what is the goal and how to do it?. Advances in Medical Sciences, 63(1), 4-10. 45 © krokplanner.com In 10 hours after eating canned mushrooms a 27-year-old patient has developed diplopia, bilateral ptosis, disrupted swallowing, shallow breathing with respiratory rate 40/min., muscle weakness, enteroparesis. What measure should be taken first? CORRECT ANSWER Intubation of the trachea for artificial respiration Given the severity of the patient's symptoms, including shallow breathing with a respiratory rate of 40/min, and enteroparesis (paralysis of the intestinal muscles), it is important to prioritize respiratory support to ensure adequate ventilation. Intubation of the trachea for artificial respiration would help maintain the patient's airway and provide mechanical ventilation, which is crucial in cases of severe respiratory distress or failure. Gastrointestinal lavage, introduction of antibotulinic serum, introduction of glucocorticosteroids, and intravenous detoxication therapy may be considered as additional measures in the management of botulism, but the immediate priority in this case would be to ensure proper ventilation through intubation of the trachea. Reference:Centers for Disease Control and Prevention (CDC). (2019). Botulism - Diagnosis and Treatment. Retrieved from https://www.cdc.gov/botulism/healthcare-providers/diagnosistreatment.html 46 © krokplanner.com A 32-year-old patient complains of reddening, burning, and sensation of a foreign body in the right eye. The disease is acute. On examination: visual acuity of the both eyes is 1.0. In the right eye there are hyperemy and swelling of the conjunctiva, superficial injection. There is purulent discharge in the conjunctival sac.The cornea is clear. The color and pattern of the iris are unchanged, the pupil is mobile. What diagnosis is most likely? CORRECT ANSWER Acute conjunctivitis Acute conjunctivitis is an inflammation of the conjunctiva, which is the clear membrane that covers the white part of the eye and the inner surface of the eyelids. It is commonly caused by viral or bacterial infections and presents with symptoms such as reddening, burning, foreign body sensation, and purulent discharge from the conjunctival sac. The cornea is usually clear, and the iris and pupil appear normal. Acute iridocyclitis is an inflammation of the iris and ciliary body inside the eye. It typically presents with severe eye pain, photophobia (sensitivity to light), blurred vision, and a small or irregular pupil. In this case, the pupil is described as mobile, and the iris and pupil appear normal, which is not consistent with acute iridocyclitis. Acute glaucoma is a condition characterized by increased intraocular pressure leading to optic nerve damage. It presents with severe eye pain, redness, blurred vision, and a fixed, dilated pupil. In this case, the pupil is described as mobile, which is not consistent with an acute attack of glaucoma.Foreign bodies on the cornea, such as dust, debris, or particles, can cause similar symptoms of reddening, burning, and foreign body sensation. However, the absence of corneal involvement and clear cornea on examination in this case makes foreign body of the cornea less likely.Acute dacryocystitis is an inflammation of the tear sac located in the inner corner of the eye. It typically presents with redness, swelling, and tenderness over the tear sac, along with tearing and discharge. However, in this case, the symptoms and signs are more consistent with conjunctivitis rather than dacryocystitis. Reference:Yanoff M, Duker JS. Ophthalmology. 4th edition. Mosby; 2013. 47 © krokplanner.com Monthly dysentery morbidity in the region given in absolute figures is as follows: January - 6; February - 9; March - 11; April - 10; May 16; June 23; July - 19; August - 33; September - 58; October - 19; November - 11; December - 5. Annual total is 220 cases. What graphic presentation would provide the best visual for monthly deviations of dysentery morbidity from the average? CORRECT ANSWER Radar chart A radar chart, also known as a spider chart or web chart, is a graphical representation that displays data points on a two-dimensional chart with multiple axes emanating from a central point. Each axis represents a different variable or category, and the data points are plotted along these axes to show the values for each variable. A radar chart can be useful for displaying monthly deviations from the average because it allows for easy comparison of values across multiple variables (in this case, the months) in a circular pattern. The central point represents the average, and the data points plotted along each axis show how each month's value deviates from the average. This can provide a visual representation of the monthly fluctuations in dysentery morbidity in relation to the average. Other options such as a map, cartogram, pie chart, or bar chart may not be as suitable for this specific requirement of displaying monthly deviations from the average, as they may not effectively convey the comparative information in the given data. A radar chart, on the other hand, can provide a clear visual representation of the monthly deviations from the average in a concise and easily understandable manner. 48 © krokplanner.com A full term baby born from the 1st noncomplicated pregnancy with complicated labor was diagnosed with cephalohematoma. On the 2nd day of life the child developed jaundice; on the 3rd day of life there appeared neurological changes: nystagmus, Graefe syndrome. Urine is yellow, feces are golden yellow. The mother’s blood group is А (II) Rh−, the child’s - А (II) Rh+. On the 3rd day the results of the child’s blood test are as follows: Hb- 200 g/l, erythrocytes – 6.1· 1012/l, blood bilirubin - 58 mcmol/l due to the presence of its unconjugated fraction, Ht- 0.57. In this case the jaundice is caused by: CORRECT ANSWER Craniocerebral birth injury Craniocerebral birth injury refers to an injury to the head or brain that occurs during childbirth. In this case, the baby was diagnosed with cephalohematoma, which is a collection of blood between the skull and the periosteum due to birth trauma. The subsequent development of jaundice, nystagmus, and other neurological changes may be indicative of underlying brain injury. Physiologic jaundice is a normal condition that occurs in many newborns and is typically self-limiting. Hemolytic disease of the newborn would have been unlikely in this case as the baby is the first born . Atresia of bile passages and fetal hepatitis are less common causes of jaundice in newborns compared to craniocerebral birth injury. 49 © krokplanner.com A 46-year-old patient with temporarily undetermined diagnosis was prescribed pleurocentesis based on the results of the Xray. The puncture yielded 1000 ml of a liquid with the following properties: clear, specific gravity – 1.010, protein content - 1%, Rivalta’s test is negative, erythrocytes - 2-3 in the field of vision. What disorder are these pathologic changes characteristic of? CORRECT ANSWER Cardiac failure Cardiac failure, also known as congestive heart failure, is a condition in which the heart is unable to pump blood effectively, leading to fluid accumulation in various parts of the body, including the pleural cavity. Pleural effusion is a common manifestation of cardiac failure, and the pleural fluid in cardiac failure is typically clear with a specific gravity close to that of water (around 1.010), as mentioned in the question. The protein content in pleural fluid in cardiac failure is usually low, with a value of around 1%, as stated in the question. Rivalta's test, which is a test for differentiating between exudative and transudative pleural effusions, is usually negative in pleural effusions due to cardiac failure. Pleuropneumonia refers to an infection involving both the pleura (the lining of the lungs) and the underlying lung tissue. In pleuropneumonia, the pleural fluid is usually exudative, meaning it has a higher protein content and may be cloudy or purulent. Additionally, erythrocytes (red blood cells) in the pleural fluid are not commonly seen in pleuropneumonia. Pleural mesothelioma is a type of cancer that affects the lining of the lungs (pleura) and is usually associated with asbestos exposure. The characteristics of pleural fluid in pleural mesothelioma can vary, but it is typically exudative with a higher protein content. Pulmonary tuberculosis is a bacterial infection of the lungs caused by Mycobacterium tuberculosis. Pleural effusion can be a complication of pulmonary tuberculosis, but the characteristics of pleural fluid in tuberculosis may vary depending on the stage of the disease and other 50 © krokplanner.com factors. However, the specific gravity of pleural fluid in pulmonary tuberculosis is not typically mentioned as being close to 1.010. Pulmonary cancer, or lung cancer, is a malignant tumor that originates in the lungs. Pleural effusion can be a complication of advanced lung cancer, but the characteristics of pleural fluid in lung cancer may vary depending on the type and stage of the cancer. Reference:UpToDate. Approach to the adult with pleural effusion. Available at: https://www.uptodate.com/contents/approach-to-the-adult-with-pleural-effusion. Accessed on April 23, 2023. A test tube is filled with distilled water and acetic acid is added. To this mixture one drop of the effusion to be tested is added. If the drop dissipates, the test is negative, indicating a transudate. If the drop precipitates, the test is positive, indicating an exudate.
