Krok 2 – 2016 (General Medicine)

You are a doctor on duty. A patient after a successful resuscitation (drowning) was deli-vered 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:

A 32-year-old welder complains of weakness and fever. His illness initially presented as tonsillitis one month earlier. On examination: BT- 38.9^oC , RR- 24/min., HR-100/min., BP- 100/70 mm Hg, hemorrhages on the legs, enlargement of the lymph nodes. CBC shows Hb- 70 g/l, RBC- 2.2×10¹²/l,  WBC- 3.0×10⁹/l with 32% of blasts, 1% of eosinophiles, 3% of bands, 36% of segments, 20% of lymphocytes, and 8% of monocytes, ESR- 47 mm/hour. What is the cause of anemia?

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?

An 8-year-old boy developed a temperature of 37.5^oC two 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?

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?

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?

A 24-year-old patient visited a doctor complaining of enlargement of his submaxillary lymph nodes. Objectively: submaxillary, axillary and inguinal lymph nodes are enlarged. Chest X-ray shows: enlarged lymph nodes of mediastinum. Blood test: erythrocytes – 3.4×10¹²/l, Hb- 100 g/l, blood colour index – 0.88, platelets – 190×10⁹/l, leucocytes – 7.5×10⁹ /l, eosinophiles – 8%, band neutrophiles – 2%, segmented neutrophiles – 67%, lymphocytes – 23%, ESR- 22 mm/hour. What test must be prescribed to verify the cause of lymphadenopathy?

A 35-year-old patient’s wound with suppurative focus was surgically cleaned. On the 8^th 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^oC . There are chills, excessive sweating, euphoria, heart rate is 120/min. What complication of local pyoinflammatory process can it be?

A 60-year-old woman has been suffering from arterial hypertension for 15 years. After recurrent stroke she started complaining of unmotivated bad mood, problems with attention concentration; she forgets to close the entrance door, cannot recall events of the past day. Computer tomography shows areas of postinfarction changes in the cortical postfrontal areas. What is the most probable diagnosis?

Clinic of a research instutute for occupati-onal diseases examined a worker who works at a concentration plant and diagnosed him with chronic dust bronchitis. The case is investigated by a commission including the representatives of: the plant, clinic, local SES, department of Social Insurance Fund, trade union. According to the ”regulation on investigation of. . . ”, the commission should be headed by the representative of the following authority:

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. Objecti-vely: fever up to 40^oC ; 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?

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^oC . 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?

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 12^th week of pregnancy, soft, mobile, painless, the appendages are without changes. What diagnosis would you make?

A 56-year-old patient complains of pain in the epigastrium after eating, eructation, loss of appetite, slight loss of weight, fatigability. The patient smokes; no excessive alcohol consumption. Objectively: pale mucosa, BP-110/70 mm Hg. The tongue is ”lacquered”. The abdomen is soft, sensitive in the epigastric area. Blood test: erythrocytes – 3.0 T/l, Hb- 110 g/l, color index – 1.1; macrocytosis; leukocytes – 5.5 g/l, ESR- 13 mm/hour. On fibrogastroduodenoscopy: atrophy of fundic mucosa. What pathogenesis does this disorder have?

A 26-year-old secundipara at 40 weeks of gestation arrived at a maternity ward after the beginning of labor activity. The bursting of waters occurred 2 hours prior. The fetus was in a longitudinal lie with cephalic presentation. Abdominal circumference was 100 cm, fundal height – 42 cm. Contractions occurred every 4-5 minutes and lasted 25 seconds each. Internal obstetric examination revealed cervical effacement, opening by 4 cm. Fetal bladder was absent. Fetal head was pressed against the pelvic inlet. What complication arose in the childbirth?

Bacterial analysis of air in a living space in winter period by means of Krotov’s apparatus revealed that total number of microorganisms in 1 m³ of air was 7200. What is the allowed number of microorganisms for the air to be characterized as ”pure”?

A 24-year-old patient received a puncture injury below the Poupart’s ligament accompanied by intense arterial bleeding. The best method to temporarily stop the bleeding in the patient would be:

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?

A 29-year-old patient works as a motor mechanic. Anamnesis shows frequent exposure to cold, exacerbation of chronic bronchitis attended by cough with relatively small amount of mucopurulent sputum, subfebrility, sometimes joined by hemoptysis and pain in the right side of chest. Breathing is vesicular. X-ray shows shadows and sharp decrease in size of the lower lobe distinctly visible on the X-ray image as a streak 2-3 cm wide situated at the angle from lung root to the frontal costodiaphragmatic recess. The most likely diagnosis is:

A 29-year-old patient works as a motor mechanic. Anamnesis shows frequent exposure to cold, exacerbation of chronic bronchitis attended by cough with relatively small amount of mucopurulent sputum, subfebrility, sometimes joined by hemoptysis and pain in the right side of chest. Breathing is vesicular. X-ray shows shadows and sharp decrease in size of the lower lobe distinctly visible on the X-ray image as a streak 2-3 cm wide situated at the angle from lung root to the frontal costodiaphragmatic recess. The most likely diagnosis is:

A 29-year-old female patient complains of dyspnea, heaviness and chest pain on the right, body temperature rise up to 37.2^oC . The disease is associated with a chest trauma received 4 days ago. Objectively: skin is pale and moist. Ps- 90/min., regular. Palpation reveals a dull sound on the right, auscultation reveals significantly weakened vesicular breathing. In blood: RBCs- 2.8×10¹²/l, colour index – 0.9, Hb- 100 g/l, WBCs- 8.0×10⁹/l, ESR- 17 mm/hour. What results of diagnostic puncture of the pleural cavity can be expected?

Caries morbidity rate is 89% among residents of a community. It is determined that fluorine content in water is 0.1 mg/l. What preventive measures should be taken?

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:

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?

An infant has been born at the 41st week of gestation. The pregnancy was complicated with severe gestosis of the second semester. The weight of the baby is 2400 g, the height is 50 cm. Objectively: the skin is flabby, the layer of subcutaneous fat is thin, hypomyotonia, neonatal reflexes are weak. The internal organs are without pathologic changes. This newborn can be estimated as a:

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?

A woman has developed sudden thoracic pain on the right with expectoration of pink sputum and body temperature rise up to 37.7^oC on the 4^th 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?

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?

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?

A 39-year-old patient complains of morning headache, appetite loss, nausea, morning vomiting, periodic nasal haemorrhages. The patient had a case of acute glomerulonephritis at the age of 15. Examination revealed rise of arterial pressure up to 220/130 mm Hg, skin haemorrhages on his arms and legs, pallor of skin and mucous membranes. What biochemical parameter is most important for making diagnosis in this case?

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^o C . A doctor suspects subarachnoid hemorrhage. What additional examination is necessary to confirm this diagnosis?

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?

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?

A 10-year-old boy had a case of viral hepatitis type B four years ago. Currently the assumption was made about the formation of hepatic cirrhosis in the patient. What additional investigation can clarify the diagnosis?

A 40-year-old patient has acute onset of disease caused by overexposure to cold. Temperature has increased up to 39^oC . Foul-smelling sputum is expectorated during coughing. Various moist crackles can be auscultated above the 3^rd segment on the right. Blood test: leukocytes – 15.0×10⁹/l, stab neutrophils – 12%, ESR- 52 mm/hour. On X-ray: 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?

An electro-gas welding operator working at a machine workshop performs welding and cutting of metal, which is accompanied by intense UV-radiation. His welding station is equipped with efficient mechanical ventilation. What occupational disease is most likely to develop in an electro-gas welding operator?

A 48-year-old patient was found to have diffuse enlargement of the thyroid gland, exophthalmia, weight loss of 4 kg in 2 months, sweating. Objectively: HR- 105/min., BP-140/70 mm Hg. Defecation act is normal. What kind of therapy is recommended in this case?

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

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?

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?

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 uncanged, the pupil is mobile. What diagnosis is most likely?

A patient is on the sick leave for 4 months continuously from the date of injury. The treatment is going to last for another 1-2 months. Who has the right to extend the duration of medical certificate for this patient?

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?

A 30-year-old woman complains of pain in the heart area (”aching, piercing pain”) that arises primarily in the morning hours in autumn and spring. Pain irradiates into the neck, back, abdomen and is attended by rapid heart rate and low vital tonus. This condition occurs independently from physical exertion. In the evening her condition improves. Somatic and neurologic state and ECG have no pathologies. What pathology is likely to result in such clinical presentation?

A full term baby born from the 1st non-complicated pregnancy with complicated  labor was diagnosed with cephalohematoma. On the 2nd day of life the child developed jaundice; on the 3^rd 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:

On the 4th day after recovering from a cold a patient was hospitalized with complaints of solitary spittings of mucoid sputum. On the 2^nd day there was a single discharge of about 250 ml of purulent blood-streaked sputum. Objectively: the patient’s condition is moderately severe. Respiratory rate – 28-30/min., Ps- 96/min., BP- 110/70 mm Hg. Respiration above the left lung is vesicular, weak above the right lung. There are various moist crackles above the lower lobe and amphoric breath near the angle of scapula. What is the most likely diagnosis?

A 46-year-old patient with temporari-ly undetermined diagnosis was prescribed pleurocentesis based on the results of the X-ray. 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?

A 14-year-old girl has been presenting with irritability and tearfulness for about a year. A year ago she was also found to have diffuse enlargement of the thyroid gland (II grade). This condition was regarded as a pubertal manifestation, the girl did not undergo any treatment. The girl’s irritability gradually gave place to a complete apathy. The girl developed puffy face, soft tissues pastosity, bradycardia, constipations. Skin pallor and gland density progressed, the skin developed a waxen hue. What disease can be suspected?

In a maternity hospital a newborn had been presenting with cough attacks after eating. The child was discharged from the hospital on the 18th day due to a case of pneumonia. During the further 1.5 months the child had 2 cases of pneumonia. Periodically there are cough attacks after eating, especially if the child lies on the left side. Objectively: the II degree hypotrophy, isolated moist crackles, dyspnea. Stool and diuresis are not disrupted. What diagnosis is most likely?

A 26-year-old woman, who gave birth 7 months ago, has been suffering from nausea, morning sickness, somnolence for the last 2 weeks. The patient breasfeeds; no menstruation. She has been using no means of contraception. What method would be most efficient in clarification of the diagnosis?

A 2-year-old girl has a medical history of recurrent obstructive pneumonia. In the lungs various moist and dry crackles can be auscultated, breath sounds are diminished. Sputum is thick, viscous and difficult to expectorate. Drumstick fingers and physical developmental retardation are observed. What preliminary diagnosis can be made?

After a case of purulent otitis a 1-year-old boy has developed pains in the upper third of the left thigh, body temperature up to 39^oC . Objectively: swelling of the thigh in its upper third and smoothed out inguinal fold. The limb is in semiflexed position. Active and passive movements are impossible due to severe pain. What diagnosis is most likely?

A 56-year-old patient with diffuse toxic goiter has ciliary arrhythmia, heart rate is 110-120/min., arterial hypertension, BP is 165/90 mm Hg. What drug besides Mercazolil (Thiamazole) should be prescribed in this case?

A patient has been provisionally diagnosed with pheochromocytoma at the stage of intermission. 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?

A 54-year-old patient complains of weakness, weight loss despite the unchanged appetite, frequent urination, skin itch for six months. Some time ago the patient underwent treatment for furunculosis. She has not been examined recently. Objectively: malnutrition, dry skin with scratch marks. Small lymph nodes can be palpated in the axillary regions. Changes in the internal organs are absent. What test must be performed in the first place?

A child is 1 month 10 days old. ”Gushing” vomiting has been observed since the age of 3 weeks. The vomit volume exceeds the volume of the previous feeding. Objectively: the child is inert. Skin elasticity and tissue turgor are decreased. Hour-glass deformity sign is positive. The preliminary diagnosis is pyloric stenosis. What treatment tactics should be chosen?

A 46-year-old woman complains of pain attacks in the right lumbar area, which irradiate to the lower abdomen, and nausea. This kind of pain attacks has never been detected in the patient before. Survey X-ray of the abdominal cavity reveals no pathologic shadows. Ultrasonic scan detects  a hyperechogenic growth 1.5 cm in diameter, which reflects sound wave, in the enlarged right renal pelvis. What diagnosis is most likely?

Several hours before, a 28-year-old patient suddenly developed acute headache and repeated vomiting, then lost consciousness. Objectively: focal neurological symptoms were not found. Pronounced meningeal symptoms were revealed. BP- 120/80 mm Hg. According to clinical and liquorological findings the patient was diagnosed with subarachnoid haemorrhage. After administration of dehydrants the patient’s condition somewhat improved. What is the main component of further emergency care?

A 24-year-old man has developed increasing headaches, vertigo, diplopia, paresis of the facial muscles on the right, choking during swallowing. The signs appeared on the 5th day of respiratory disorder. He was diagnosed with acute viral encephalitis. Determine the main direction of emergency therapy:

A 23-year-old woman, who works as a milk and dairy inspector, after the miscarriage suffers from high fever up to 38.6^oC , recurring chills, excessive sweating. Objectively: polyadenitis, pain in the lumbosacral spine, swollen left knee joint, enlarged liver and spleen. What diagnosis is most likely?

A 16-year-old adolescent has been hospitalized with complaints of unceasing nasal hemorrhage and unbearable pain in his right elbow joint. Objectively: the large joint is enlarged and defigurated, the skin over the joint is hyperemic. Arthropathy signs can be observed in the other joints. Ps- 90/min. Blood test: erythrocytes – 3.9×10¹²/l, Нb- 130 g/l, color index – 1.0, leukocytes – 5.6×10⁹/l, platelets – 220×10⁹/l, ESR- 6 mm/hour. Lee-White coagulation time: start- 24^_, end-27^_10^__. What drug would be most efficient in the treatment of this patient?

A 67-year-old man complains of dyspnea on exertion, attacks of retrosternal pain, dizziness. He has no history of rheumatism. Objectively: pale skin, acrocyanosis. There are crackles in the lower lungs. There is systolic thrill in the II intercostal space on the right, coarse systolic murmur conducted to the vessels of neck. BP- 130/90 mm Hg, heart rate – 90/min., regular rhythm. The liver extends 5 cm from under the edge of costal arch, shin edemas are present. Specify the suspected valvular defect:

A 24-year-old female teacher complains of dizziness and heart pain irradiating to the left nipple. Pain is not associated with physical activity and cannot be relieved by nitroglycerin, it abates after taking Valocordin and lasts an hour or more. The patient has a nearly 2-year history of this disease. Objectively: Ps- 76/min., BP-110/70 mm Hg. Heart borders are normal, heart sounds are clear. The ECG shows respiratory arrhythmia. Radiograph of the cervicothoracic spine reveals no pathology. Lungs, abdomen are unremarkable. What changes in blood formula can be expected?

A 51-year-old female patient complains of frequent defecation and liquid blood-streaked stools with mucus admixtures, diffuse pain in the inferolateral abdomen, 6 kg weight loss within the previous month. Objectively: body temperature – 37.4^oC , malnutrition, skin is pale and dry. Abdomen is soft, sigmoid is painful and spasmodic, makes a rumbling sound. Liver is dense, painful, extends 3 cm below the costal margin. What is the most likely diagnosis?

Chief physician of a polyclinic charged a  district doctor with a task to determine the pathological prevalence of disease N in his district. What document allows to estimate the disease prevalence in the population of a medical district?

A 32-year-old woman complains of dizziness, headache, palpitation, tremor. For the last several months she has been under outpatient observation for increased arterial pressure. Since recently such attacks have become more frequent and severe. Objectively: the skin is covered with clammy sweat, tremor of the extremities is present. HR-110/min., BP- 220/140 mm Hg. Heart sounds are muffled. Blood test results: WBCs- 9.8×10⁹/l, ESR- 22 mm/hour. Blood glucose – 9.8 millimole/l. What disease is the most likely cause of this crisis?

A 45-year-old patient complains of pain in the epigastric region, left subcostal area, abdominal distension, diarrhea, loss of weight. He has been suffering from this condition for 5 years. Objectively: tongue is moist with white coating near the root; deep palpation of abdomen reveals slight pain in the epigastric region and Мауо-Robson’s point. Liver is painless and protrudes 1 cm from the costal arch. Spleen cannot be palpated. What disease can be primarily suspected?

A 58-year-old woman complains of spontaneous bruises, weakness, bleeding gums, dizziness. Objectively: the mucous membranes and skin are pale with numerous hemorrhages of various time of origin. Lymph nodes are not enlarged. Heart rate – 100/min., BP- 110/70 mm Hg. There are no changes of internal organs. Blood test results: RBC- 3.0×10¹²/l, Нb- 92 g/l, colour index – 0.9, anisocytosis, poikilocytosis, WBC – 10×10⁹/l, eosinophiles – 2%, stab neutrophiles – 12%, segmented neutrophiles – 68%, lymphocytes – 11%, monocytes – 7%, ESR- 12 mm/hour. What index should be determined additionally by a laboratory to make a diagnosis?

A 49-year-old patient complains of swallowing disorder that intensifies during eating solid food, hiccups, hoarse voice, nausea, regurgitation, significant weight loss (15 kg within 2.5 months). Objectively: body weight is reduced; the skin is pale and dry; vesicular respiration; heart sounds are sufficiently sonorous; heart rate is rhythmic. The abdomen is soft, no pain on palpation. The liver is not enlarged. What investigation is most necessary for making the diagnosis in this case?

A 9-month-old child presents with fever, cough, dyspnea. The symptoms appeared 5 days ago after a contact with a person suffering from URTI. Objectively: the child is in grave condition. Temperature of 38^oC , cyanosis of nasolabial triangle is present. Respiration rate – 54/min., nasal flaring during breathing. There was percussion dullness on the right below the scapula angle, and tympanic sound over the rest of lungs. Auscultation revealed bilateral fine moist crackles predominating on the right. What is the most likely diagnosis?

A 50-year-old man, who works as a polisher at a combine-building factory, addressed the factory’s sectorial doctor with complaints of general fatigue, sensations of numbness and pain in his fingers. Objectively: the skin of his fingers is pale. Reaction to pain, tactile and thermal stimuli was revealed to be slightly disrupted. No disruptions can be observed within the other organs and systems. What disorder is most likely?

A 27-year-old woman complains of bleeding gums, nasal hemorrhages, multiple hematomas on the skin of her limbs and on the front of her torso, extreme general fatigue. Blood test: Hb- 64 g/l, erythrocytes -2.5×10¹²/l, reticulocytes – 16%, platelets -30×10⁹/l, ESR- 22 mm/hour. What approach would be most efficient for treatment of this pathology?

A 23-year-old patient had taken 1 g of aspirin to treat acute respiratory infection. After that he developed an asthmatic fit with labored expiration that was arrested by introduction of aminophylline. The patient’s medical history is not burdened with allergies. The patient has undergone two surgeries for nasal polyposis in the past. What diagnosis is most likely?

A 58-year-old woman undergoing chemotherapy for her oncologic disorder has developed sore throat. Examination revealed necrotic areas on the mucosa of the pharynx and tonsils. Many of her teeth are afflicted with caries. In blood: neutrophilic granulocytes are practically absent against the background of leukopenia. Leukocytes are represented mainly by lymphocytes and monocytes. What disease can be suspected in the given case?

A patient complains of constant dull pain in the perineum and suprapubic area, weak flow of urine, frequent difficult painful urination, nocturia. The patient has been suffering from this condition for several months, during which urination was becoming increasingly difficult, and pain in the perineum has developed. On rectal examination: the prostate is enlarged (mainly its right lobe), dense, asymmetrical, central fissure is smoothed out, the right lobe is of stony density, painless, tuberous. What disease is it?

A child is 10 years old. The weight is 46 kg. Since birth the child has been gaining excessive weight. The parents are full-bodied. The child has undergone the following tests: carbohydrate tolerance, level of 17-ketosteroids, blood electrolytes, US of  adrenal glands, cranium X-ray. The tests revealed no pathologies.The diagnosis of exogenic constitutive obesity has been made. What direction of therapy should be prioritized?

An 8-year-old child with a 3-year history of diabetes was hospitalized in hyperglycemic coma. Specify the initial dose of insulin to be administered:

A worker, who was involved in fire fighting inside the building that stored 2 kg of mercury, has been delivered to a hospital with complaints of emotional expansiveness, palpitations, excessive sweating, body tremor, heart pain. Within one day his condition aggravated. Objectively: the skin is pale and moist. The patient is depressed. Permanent red dermographism, erethism, unstable BP are observed. What drug is the serum in this case?

During meat testing Trichinella was detected in diaphragm crura in one of the two muscular tissue samples. What tactics should a doctor choose regarding this meat?

A 40-year-old patient was bitten by a stray dog an hour ago. On the left shin there is a bite mark – the wound is 4x2x0.5 cm in size. What surgical aid would be most efficient in this case?

A 30-year-old patient has been hospitalized with diagnosis of intestinal obstruction. The surgery revealed the obstruction of the small intestine to be caused by a helminth ball. What kind of helminth is it?

Mother of a newborn suffers from chronic pyelonephritis; she had a case of URTI before the delivery. The delivery is at term, for a long period waters were not breaking. On the 2nd day of life the child developed an erythematic rash, later the rash developed into blisters approximately 1 cm in diameter filled with serous purulent substance. Nikolsky’s symptom is positive. After the blisters had been lanced, erosions developed in their place. The child is inert. The child’s body temperature is subfebrile. What diagnosis is most likely?

Three weeks after a case of acute tonsillitis the patient is still weak, inert, subfebrile, his retromaxillary lymph nodes are enlarged. Tonsils are flabby, stick together with arches, there are purulent plugs in lacunae. What is the most probable diagnosis?

The following indicators were calculated to analyse population health and treatment quality in a cardiological hospital: primary cardiovascular morbidity – 62%; total cardiovascular morbidity – 483.55%; cardiovascular mortality – 10.9%; proportion of cardiovascular mortality within total mortality – 67.0%; primary disablement caused by cardiovascular diseases – 16.2 per 10.000 population. What indicator is an extensive value?

A 6-year-old child complains of frequent liquid stool and vomiting. On the 2^nd day of disease the child presented with inertness, temperature rise up to 38.2^oC , Ps- 150/min., scaphoid abdomen, palpatory painful sigmoid colon, defecation 10 times a day with liquid, scarce stool with mucus and streaks of green. What is the provisional diagnosis?

The institutions that take part in medical examinations include prevention and treatment facilities, medical board of Ministry of Defense, medical board of Ministry of Home Affairs, medico-social expert commissions, forensic medical boards etc. What institutions are responsible for temporary disability examination?

After a lengthy march an army regiment has set camp for 3 days near a settlement. Sanitary-hygienic investigation detected several water sources. Choose the source that would satisfy the demands for potable water the most under the given field conditions:

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

A 30-year-old parturient woman was delivered to a maternity hospital with full-term pregnancy. She complains of severe lancinating pain in the uterus that started 1 hour ago, nausea, vomiting, cold sweat. Anamnesis states cesarean section 2 years ago. Uterine contractions stopped. Skin and mucous membranes are pale. Heart rate is 100/min., BP is 90/60 mm Hg. Uterus has no clear margins, is sharply painful. No heartbeat can be auscultated in the fetus. Moderate bloody discharge from the uterus can be observed. Uterus cervix is 4 cm open. Presenting part is not visible. The most likely diagnosis is:

A parturient woman is 23 years old. Internal obstetric examination shows the uterine cervix to be completely open. Fetal bladder is absent. Cephalic presentation is observed in the plane of the small pelvic outlet. Sagittal suture is at the longitudinal section of the small pelvic outlet, small fontanel is situated closer to the uterus. What cephalic position will the newborn have during birth in this case?

During the dynamic observation of a parturient woman in the second stage of labor it was registered that the fetal heart rate decreased to 90-100/min. and did not normalize after contractions. Vaginal examination revealed the complete cervical dilatation, the fetal head filling the entire posterior surface of the pubic symphysis and sacral hollow; the sagittal suture was in the anteroposterior diameter of the pelvic outlet, the posterior fontanelle was in front under the pubic arch. What plan for further labour management should be recommended?

An 8-year-old girl periodically has sudden short-term heart pains, sensation of chest compression, epigastric pain, dizziness, vomiting. Objectively: the patient is pale, respiratory rate – 40/min., jugular pulse is present. Ps- 185/min., of poor volume. BP- 75/40 mm Hg. ECG taken during an attack shows ectopic P waves, QRS wave is not deformed. At the end of an attack a compensatory pause is observed. The most likely cause of the attack is:

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

A planner designs a heating system for a pre-school educational establishment. The highest air temperature should be in the following room:

A 27-year-old sexually active woman complains of numerous vesicles on the right sex lip, itch and burning. Eruptions regularly appear before menstruation and disappear 8-10 days later. What is the most likely diagnosis?

A 35-year-old woman addressed a gynecological in-patient department with complaints of regular pains in her lower abdomen, which increase during menstruation, and dark-brown sticky discharge from the genital tracts. On bimanual examination: the uterine body is slightly enlarged, the appendages are not palpated. Mirror examination of the uterine cervix reveals bluish spots. What diagnosis is most likely?

A 10-year-old patient has a history of mild bronchial asthma. During a regular check-up the patient should be recommended:

A baby was born by a young smoker. The labour was complicated by uterine inertia, difficult delivery of the baby’s head and shoulders. The baby’s Apgar score was 4. Which of the following is a risk factor for a spinal cord injury?

An emergency situation at a chemical plant caused acute occupational intoxication. A doctor who revealed the case of ”acute occupational disease (intoxication)” must notify the following authority:

A 27-year-old woman has been treated in a surgical department for pleural empyema for 6 months. Multiple paracenteses of the pleural cavity were performed along with anti-bacterial treatment. The patient’s condition is slowly aggravating; attempts to fully stretch the lung were unsuccessful. Choose the tactics:

A prematurely born girl is now 8 months old. She has dyspnea, tachycardia, hepatosplenomegaly, physical developmental lag, limb cyanosis. There is parasternal cardiac hump, auscultation revealed systolodiastolic murmur in the II intercostal space on the left. BP is 90/0 mm Hg. What disease can be suspected?

Three days ago a boy underwent removal of a foreign body from under a nail plate. 2 days later he developed acute pulsating pain at the end of the nail bone which aggravated at pressing. Nail fold became hyperemic, body temperature rose up to 37.5^oC , there was a change in nail plate colour. What is the most likely diagnosis?

A 25-year-old woman complains of menstruation retention lasting for 3 years. The patient explains it by a difficult childbirth complicated with profuse hemorrhage, weight loss, brittleness and loss of hair, loss of appetite, depression. Objective examination reveals no pathologic changes of uterus and uterine appendages. What pathogenesis is characteristic of this disorder?

A patient in a clinical death condition is being resuscitated through mouth-to-mouth artificial pulmonary ventilation and external cardiac massage. A doctor noticed that air does not flow into the patient’s airways and his head and torso are positioned at the same level. Why is artificial respiration not effective in the given case?

A 45-year-old patient with urolithiasis had an attack of renal colic. What is the mechanism of the attack development?

A 26-year-old woman has attended maternity center complaining of her inability to become pregnant despite 3 years of regular sex life. Examination revealed the following: increased body weight; male-type pubic hair; excessive pilosis of thighs; ovaries are dense and enlarged; basal body temperature is monophasic. The most likely diagnosis is:

The process of open-cut mining requires drilling and blasting operations, rock and ore excavation, transportation of ore to fragmentation and sorting factories and transportation of barren rock to slag-heaps, road building and maintenance, repair works. What factor of production is most important for miner’s health?

A woman addressed a gynecologist on the 20^th day of puerperal period with complaints of pain in the left mammary gland,  purulent discharge from the nipple. Objectively: Ps- 120/min., body temperature is 39^oC . The left mammary gland is painful, larger than the right one, the skin there is hyperemic; in the upper quadrant there is an infiltrate 10×15 cm in size with soft center. Blood test: ESR-50 mm/hour, leukocytes – 15.0×10⁹/l. What would be the treatment tactics?

The correlation between the service record and eosinophil concentration in blood was studied in workers at dyeing shops of textile factories. What index will be most informative for the analysis of this data?

A 3-month-old girl has rhinitis, dyspnea, dry cough. She has been sick for 2 days. Objectively: pale skin, acrocyanosis, hypopnoe; breathing rate is 80/min.; over the whole pulmonary surface there is vesiculotympanitic (bandbox) resonance observed with numerous bubbling crackles. The most likely diagnosis is:

A 24-year-old patient complains of gaining body mass and increased appetite. Objectively: built of hypersthenic type, body mass index is 33.2 kg/m², waist circumference is 100 cm. Waist to hips circumference ratio is 0.95. What is the provisional diagnosis?

A 36 year old female patient complains of general weakness, edemas of her face and hands, rapid fatigability during walking, difficult diglutition, cardiac irregularities. These symptoms developed 11 days after holiday  at the seaside. Objectively: face erythema, edema of shin muscles. Heart sounds are muffled, BP is 100/70 mm Hg. In blood: ASAT activity is 0.95 millimole/h·l, ALAT-1.3 micromole/h·l, aldolase – 9.2 IU/l, creatine phosphokinase – 2.5 micromole Р/g·l. What method of study would be most specific?

A 14-year-old girl has fainted during a meeting. The day before she complained of a headache. The skin is pale, the limbs are cold, shallow breathing, heart sounds are muffled; heart rate is 51/min.; BP is 90/50 mm Hg. The abdomen is soft. Meningeal symptoms are negative. Make the provisional diagnosis:

For the last 15 years a 48-year-old patient has been working at the factory producing synthetic resins. Lately he has been complaining of significant general fatigue, headaches, frequent urination (predominantly during the day), red color of urine. What complication of benzene nitro compounds poisoning can be suspected?

A 60-year-old woman developed weakness, vertigo, rapid fatigability during the last year. Recently there have been dyspnea and paresthesia observed. Objectively: skin and mucous membranes are pale and icteric. Lingual papillae are smoothed out. Liver and spleen are situated at the edge of costal arch. Blood test: Hb- 70 g/l, erythrocytes -1.7X10¹² /l, blood color index – 1.2, macrocytes. What drug can be prescribed on pathogenetic grounds?

In the morning upon waking a 65-year-old patient developed weakness in the right-side limbs, speech disorder, decreased sensitivity of the left side of the body. On examination: conscious, BP- 100/60 mm Hg, motor aphasia, right-sided central hemiparesis and hemihypalgesia. Make the preliminary diagnosis:

The objective of a statistical study was to find out the extent of seeking medical care by the population. For this purpose 300 residents of the area were interviewed. Information was collected by means of a special questionnaire. What method of collecting information was used by researchers?

A 57-year-old woman complains of having a sensation of esophageal compression, palpitation, difficult breathing during eating solid food, occasional vomiting with a full mouth, ”wet pillow” sign at night for the last 6 months. Objectively: body temperature – 39^oC , height – 168 cm, weight – 72 kg, Ps-76/min., BP- 120/80 mm Hg. X-ray revealed a considerable dilation of the esophagus and its constriction in the cardial part. What pathology is most likely to have caused dysphagia in this patient?

A 25-year-old man complains of pain in the lower third of his left thigh, which occurs both with and without physical exertion. Possibility of trauma is denied by the patient. Objectively: skin colour is normal; pastosity and pain can be detected with deep palpation; knee joint mobility is reduced. X-ray of distal femoral metaphysis shows an area of destruction and spicule. Blood test: immature cells, no signs of inflammation. The most likely diagnosis is:

A 30-year-old woman suffers from polycystic renal disease. She has been admitted with signs of fatigue, thirst and nocturia. Diuresis is up to 1800 ml per day. BP is 200/100 mm Hg. Blood test: erythrocytes – 1.8×10⁹/l, Hb- 68 g/l. Urine analysis: specific gravity – 1005, leukocytes – 50-60, erythrocytes – 3-5 in the vision field, creatinine – 0.82 mmol/l, potassium – 6.5 mmol/l, glomerular filtration rate – 10 ml/min. What tactics would be leading in the patient’s treatment?

In a rural health care area there is a case of child dying during the first month of life. To analyse this situation, among other measures, an expert assessment of medical records is performed. What medical document should be considered first?

A region attended by a central regional hospital demonstrates increased hemorrhagic stroke morbidity. Essential hypertension morbidity, however, remains at the same level and is below the average level registered within the larger area. What managerial decision should be made in this case?

A 42-year-old man was delivered to a surgical in-patient department with complaints of icteric skin, pain in the right subcostal area. Biochemical blood analysis: total bilirubin – 140 mcmol/l, direct bilirubin – 112 mcmol/l. On US: choledoch duct – 1.4 cm, a concrement is detected in the distal area. Gallbladder is 40 cm, no concrements. What treatment tactics should be chosen?

4 weeks after myocardial infarction a 56-year-old patient developed acute heart pain, pronounced dyspnea. Objectively: the patient’s condition is extremely grave, there is marked cyanosis of the face, swelling and throbbing of the neck veins, peripheral pulse is absent, carotid artery pulse is rhythmic, 130/min., BP is 60/20 mm Hg. Auscultation of  the heart reveals extremely muffled sounds, percussion reveals heart border extension in both directions. What is the optimal treatment tactis for this patient?

A 45-year-old man was delivered to a hospital with complaints of vomiting with streaks of blood, loss of weight. On esophagofiberscopy a cauliflower-shaped mucosal growth was detected in the abdominal esophagus. The mucosa there bleeds on contact. What preliminary diagnosis can be made?

A 35-year-old man complains of intense lumbar pain irradiating to the inguinal area, external genitalia, thigh; frequent urination, chill, nausea, vomiting. Objectively: positive Pasternatsky’s symptom (costovertebral angle tenderness). Urine analysis revealed that RBCs and WBCs covered the total field of microscope; the urine exhibited high protein concentration. These clinical presentations were most likely caused by the following pathology:

A 20-year-old patient complains of pain in the left lumbar region, arterial pressure rise up to 160/110 mm Hg. US revealed that the structure and size of the right kidney were within age norms, there were signs of 3 degree hydronephrotic transformation of the left kidney. Doppler examination revealed an additional artery running to the lower pole of the kidney. Excretory urogram shows a narrowing in the region of ureteropelvic junction. Specify the treatment tactics:

As a result of load lifting a 68-year-old woman developed acute pain in the lumbar region, in a buttock, posterolateral surface of her right thigh, external surface of the right shin and dorsal surface of foot. Objectively: weakness of the anterior tibial muscle, long extensor muscle of the right toes, short extensor muscle of the right toes. Low Achilles reflex on the right. Positive Lasegue’s sign. What examination method would be most effective for specification of the diagnosis of L₅ root discogenic compression?

A 23-year-old female patient has been suffering from mental disorder since the age of 18, the course of disorder has no remission periods. At hospital the patient mostly presents with non-purposeful foolish excitation: she makes stereotypic grimaces, exposes herself, publically masturbating, loudly laughs, repeating stereotypical obscene shouts. The patient should be prescribed:

During preventive ultrasound scan of abdomen performed during regular check-up in a school the following was revealed in an 11-year-old student of the 5th grade: the left kidney is 3 cm below the normal position, its shape, size and structure are within the norm, the contralateral kidney cannot be observed at its proper place. The preliminary diagnosis is as follows: congenital anomaly of renal development, dystopic left kidney, right kidney is absent or pelvic dystopic. What X-ray method would be required for making the final diagnosis and determining the functional capacity of both kidneys?

A young woman suffering from seborrhea oleosa has numerous light-brown and white spots on the skin of her torso and shoulders. The spots have clear margins, branny desquamation, no itching. What provisional diagnosis can be made?

In a traffic accident two persons died. An appointed forensic medical expert was  called on duty to another accident location; therefore, according to the criminal law in force in Ukraine, an investigator called in the following specialist for examination of the location and bodies:

A patient is 28 years old. He has been suffering from mental disorder since he was 22. His current condition has changed acutely: for 3 days the patient has been refusing to leave his home. He claims that there is a ”telepathy” occurring between him and other people, through which he receives ”thoughts of strangers” and transmits his own thoughts for everyone to hear. He thinks his thoughts and actions are manipulated through this ”telepathy”. Make the preliminary diagnosis:

A 40-year-old patient is registered in a narcological dispensary. Somatically: skin is dramatically hyperemic, sclera are injected, hyperhidrosis is present. BP- 140/100 mm Hg, heart rate – 100/min. Mental state: autopsychic orientation is intact, allopsychic orientation is distorted. The patient presents with motor anxiety. There is an expression of fear on his face. He refuses to talk about his problems and asks to release him immediately, because he ”may be killed”. This state developed in a day after one of his regular drinking bouts. What is your provisional diagnosis?

A 35-year-old female patient has gained 20 kg weight within a year with the normal diet. She complains of chill, sleepi-ness, dyspnea. The patient’s mother and sister are corpulent. Objectively: height – 160 cm, weight – 92 kg, BMI- 35.9. Obesity is uniform, there are no striae. The face is amimic. The skin is dry. The tongue is thickened. Heart sounds are muffled. Heart rate – 56/min., BP- 140/100 mm Hg. The patient has constipations, amenorrhea for 5 months. TSH- 28 mkME/l (normal rate – 0.32-5). Craniogram shows no pathology. What is the etiology of obesity in this case?

A 10 week pregnant woman was admitted to a hospital for recurrent pain in the lower abdomen, bloody discharges from the genital tracts. The problems developed after a case of URTI. The woman was registered for antenatal care. Speculum examination revealed cyanosis of vaginal mucosa, clean cervix, open cervical canal discharging blood and blood clots; the lower pole of the gestational sac was visible. What tactics should be chosen?

A patient with fibromyoma of uterus sized up to 8-9 weeks of pregnancy consulted a gynaecologist about acute pain in the lower abdomen. Examination revealed pronounced positive symptoms of peritoneal irritation, high leukocytosis. Vaginal examination revealed that the uterus was enlarged corresponding to 9 weeks of pregnancy due to the fibromatous nodes, one of which was mobile and extremely painful. Appendages were not palpable. There were moderate mucous discharges. What is the optimal treatment tactics?

A 4-month-old child was admitted to a surgical department 8 hours after the first attack of anxiety. The attacks happen every 10 minutes and last for 2-3 minutes, vomiting occurred once. Objectively: the child’s condition is grave. Abdomen is soft, palpation reveals a tumor-like formation in the right iliac area. After rectal examination the doctor’s finger was stained with blood. What is the most probable diagnosis?

A woman has focal encephalitis in the anamnesis. Her spatial orientation is not disrupted. She has a sensation, as if ”everything seems surreal: buildings are small, round or distorted; trees are upside down; people are very tall with thin limbs”. Determine the psychopathologic syndrome:

A 56-year-old woman complains of itching skin of her torso, constant nausea, constipation, sensation of heaviness and pain in the right subcostal area, extreme general fatigue. The patient suffers from biliary cirrhosis. The skin is pale icteric. The abdomen is soft, the liver protrudes 2.0 cm from under the margin of the right costal arch, sensitive on palpation. Biochemical investigation: total bilirubin – 142.0 mcmol/l, conjugated bilirubin 139.0 mcmol/l, alanine aminotransferase – 0.98 mmol/hour·l, aspartate aminotransferase 0.82 mmol/hour, alkaline phosphatase – 8.7 mmol/hour·l. What drug should be prescribed in the first place?

A 40-year-old female patient complains of having a bulge on the anterior surface of neck for 5 years. Objectively: Ps- 72/min., arterial pressure – 110/70 mm Hg, in the right lobe of thyroid gland palpation reveals a mobile node 4×2 cm in size, the left lobe is not palpable, the basal metabolic rate is 6%. What is the most likely diagnosis?

Estimation of community health level involved analysis of a report on diseases registered among the population of district under charge (reporting form 12). What index is calculated based on this report?

A 32-year-old woman addressed a dermatologist with complaints of slightly itching rashes in the mouth angles. She has been suffering from this condition for 3 days. Objectively: there are isolated small phlyctenas and superficial erosions covered in honey-yellow scabs against the background of slight hyperemia. Make the diagnosis:

After a contact with chemicals a plant worker has suddenly developed stridor, voice hoarseness, barking cough, progressing dyspnea. Objective examination reveals acrocyanosis. What is your provisional diagnosis?

An 18-year-old woman complains of pains in her lower abdomen, purulent discharge from the vagina, temperature rise up to 37.8^oC . Anamnesis states that she had random sexual contact the day before the signs appeared. She was diagnosed with acute bilateral adnexitis. On additional examination: leukocytes in the all field of vision, bacteria, diplococci with intracellular and extracellular position. What agent is most likely in the given case?

A 45-year-old man has been suffering from duodenal ulcer disease for 5 years. He complains of weakness, dizziness, dryness of the skin. Objectively: the skin and visible mucosa are pale, chapped lips; heart rate is 100/min., BP- 100/70 mm Hg, systolic murmur at all points on heart auscultation. All other internal organs are unchanged. Fecal occult blood test is positive. Blood test: erythrocytes – 3.1×10¹²/l, Hb- 88 g/l, color index – 0.7, leukocytes – 4.6×10⁹/l, platelets -350×10⁹ /l, ESR- 21 mm/hour, anisocytosis, poikilocythemia, serum iron – 9.5 mcmol/l. What treatment tactics would you choose?

A 58-year-old patient complains of a headache in the occipital region, nausea, choking, opplotentes. The presentations appeared after a physical exertion. Objectively: the patient is excited. Face is hyperemic. Skin is pale. Heart sounds are regular, the 2nd aortic sound is accentuated. BP- 240/120 mm Hg, HR- 92/min. Auscultation reveals some fine moist crackles in the lower lungs. Liver is not enlarged. ECG shows signs of hypertrophy and left ventricular overload. What is the most likely diagnosis?

A 45-year-old patient (14-year-long work record as a house painter) upon the contact with synthetic paint develops skin reddening, edema, severe itching and oozing lesions on her face. Symptoms disappear after the contact with this chemical substance stops but even the smell of paint alone is enough to make them reappear each time. Each recurrence is characterised by increased severity of symptoms. What provisional diagnosis can be made?

A 32-year-old woman addressed a maternity clinic with complaints of infertility that has been lasting for 7 years. Her menstrual cycle occurs in two phases. Hysterosalpingography reveals obstruction of the uterine tubes in the ampullar areas, an adhesive process in the small pelvis can be observed. What treatment is most advisable in this case?

Survey radiograph of a 52-year-old worker of an agglomeration plant (28 years of experience, the concentration of metal dust is 22-37 mg/m³) shows mildly pronounced interstitial fibrosis with diffused contrast well-defined small nodular shadows. The patient has no complaints. Pulmonary function is not compromised. What is the provisional diagnosis?

A week ago a 65-year-old patient suffered an acute myocardial infarction, his general condition deteriorated: he complai-ns of dyspnea at rest, pronounced weakness. Objectively: edema of the lower extremities, ascites is present. Heart borders are extended, paradoxical pulse is observed 2 cm from the apex beat to the left. What is the most likely diagnosis?

A 60-year-old patient complains of nearly permanent sensation of heaviness and fullness in the epigastrium, which increases after eating, foul-smelling eructation, occasional vomiting with food consumed 1-2 days ago, weight loss. 12 years ago he was first found to have an ulcer of pyloric channel. The patient has taken ranitidine for periodic hunger pains. The patient’s condition has been deteriorating over the last 3 months. Objectively: splashing sound in the epigastrium is present. What kind of complication is it?

153. A 5-year-old child has body temperature increased up to febrile numbers, suffers from inertness, weakness. Examination revealed hemorrhage on the skin of limbs and torso. Enlargement of cervical and axillary lymph nodes can be detected. The liver is 4 cm below the costal arch; the spleen is 6 cm below the costal arch. Blood test: erythrocytes – 2.3×10¹²/l, Hb- 60 g/l, platelets – 40×10⁹ leukocytes – 32.8×10⁹ eosinophiles – 1%, band neutrophiles – 1%, segmented neutrophiles – 12%, lymphocytes – 46%, monocytes – 1%, blasts – 40%, Duke’s bleeding time is 9 min. What examination is necessary to make the diagnosis?

A child from primipregnancy was born in a term labor and has body weight of 4000 g and body length of 57 cm. When born, he was nonresponsive to examination. Diagnosis is diffuse. Heart rate is 80/min. What resuscitation measures should be taken?

A 15-year-old teenager has undergone medical examination in military recruitment center. The following was revealed: interval systolic murmur at the cardiac apex, accent of the II heart sound over the pulmonary artery, tachycardia. What additional examination method will be most informative for determining a diagnosis?

A 64-year-old patient has been hospitalised with complaints of progressive jaundice that developed over 3 weeks ago without pain syndrome, along with general weakness, loss of appetite. Objectively: temperature is 36.8^oC , heart rate is 78/min., abdomen is soft and painless, peritoneum irritation symptoms are not detected, palpation reveals sharply enlarged tense gallbladder. What disease can be characterised with these symptoms?

A 6-year-old girl attended a general practitioner with her mother. The child complains of burning pain and itching in her external genitalia. The girl was taking antibiotics the day before due to her suffering from acute bronchitis. On examination: external genitalia are swollen, hyperemic, there is white deposit accumulated in the folds. The most likely diagnosis is:

A patient with otopyosis is in sharply deteriorating condition: he developed headache, vomiting, febrile temperature, general hyperesthesia. Meningeal symptoms and stagnant optic disks are observed. There are no focal symptoms. Liquor is turbid, blood pressure is high, albuminocytological dissociation occurs with neutrophils. What disease can be suspected?

A 25-year-old patient is not married and has sexual relations with several partners. During the last 3 months he noticed small amount of mucoserous secretions produced from urethra. Subjectively: periodical itching or burning pain in urethra. Two months ago pain in the knee join developed. Possibility of trauma or exposure to cold is denied by the patient. During the last week eye discomfort is noted – lacrimation and itching. What provisional diagnosis can be suggested?

A 19-year-old patient complains of severe pain in axillary crease. Condition onset was a week ago after her swimming in a cold river and epilation. The next day painful ”boil” appeared that was becoming larger every day and became a plum-sized tumor. Upon examination nodular conical growths joined together are detected, the skin covering them is bluish-red in color. Some nodules have fistulous openings producing thick purulent mass. Body temperature is 38.5^oC , general malaise. The most likely diagnosis is:

Annual report of an in-patient ward presents data about the number of patient days and the number of patients, who have undergone treatment within a year. What work indicator of the in-patient ward can be calculated based on these data?

ECG revealed the following in a 10-year-old child: sharp acceleration of the heart rate – 240/min., P wave overlaps with T wave and deforms it, moderate lengthening of PQ interval, QRS complex is without changes. What pathology does this child have?

A 54-year-old patient complains of weakness, jaundice, itching skin. Disease onset was 1.5 months ago: fever up to 39^oC appeared at first, with progressive jaundice developed 2 weeks later. On hospitalisation jaundice was severely progressed. Liver cannot be palpated. Gallbladder is enlarged and painless. Blood bilirubin is 190 micromole/l (accounting for direct bilirubin). Stool is alcoholic. What is the most likely jaundice genesis in this patient?

A 22-year-old patient complains of 8-month delay of menstruation. Anamnesis: menarche since the age of 12.5. Since the age of 18 menstruations are irregular. No pregnancies. Mammary glands have normal development; when the nipples are pressed, milk drops are discharged. On gynecological examination: moderate uterus hypoplasia. On hormonal examination: prolactin level exceeds the norm two times. On computed tomogram of the sellar region: a space-occupying lesion 4 mm in diameter is detected. The most likely diagnosis is:

A 2-year-old child in a satisfactory condition periodically presents with moderate proteinuria, microhematuria. US results: the left kidney is undetectable, the right one is enlarged, there are signs of double pyelocaliceal system. What study is required to specify the diagnosis?

A 13-year-old girl complains of fatigability, frequent headaches, cardialgia. Eight years ago she had a case of pyelonephritis. Urine analyses periodically revealed leukocyturia. The child has undergone no further treatment. On examination: increased BP up to 150/100 mm Hg. Ultrasound investigation revealed significant reduction of the right kidney. What process is leading in arterial hypertension pathogenesis in this case?

A 26-year-old patient with affective bi-polar disorder has developed a condition manifested by mood improvement, behavioural and sexual hyperactivity, verbosity, active body language, reduced need for sleep. Which of the following drugs are most efficient in this case?

A 32-year-old man complains of pain in the chest on the left, dyspnea, temperature rise up to 38.0^oC , slight cough. The disease onset was 2 weeks ago after overexposure to cold. He had suffered from bronchoadenitis in his childhood. The affected side lags during breathing; percussion reveals dull sound with oblique margin in the lower left lung, where breathing is absent. The right heart border is displaced outwards. Mantoux test with 2 TU resulted in a papule 16 mm in size. What diagnosis is most likely?

An emergency doctor has diagnosed a 32-year-old woman with generalized convulsive status epilepticus. The deterioration in the patient’s condition is caused by a sudden gap in the epilepsy treatment. Specify the doctor’s further tactics:

A 19-year-old patient complains of dyspnea during physical exertion. He often has bronchitis and pneumonia. Cardiac murmur has been observed since his childhood. On auscultation: there is splitting of the II heart sound over pulmonary arteria, systolic murmur in the third intercostal space near the left sternum margin. ECG test shows right bundle-branch block. What is the provisional diagnosis?

A 75-year-old male patient complains of slight pain in the right iliac region. The abdominal pain arose 6 days ago and was accompanied by nausea. Surgical examination revealed moist tongue, Ps- 76/min., BP- 130/80 mm Hg. Abdomen was soft, slightly painful in the right iliac region on deep palpation, the symptoms of the peritoneum irritation were doubtful. In blood: RBCs- 4.0×10¹² /l, Hb- 135  g/l, WBCs- 9.5×10⁹/l, stab neutrophils – 5%, segmentonuclear – 52%, lymphocytes – 38%, monocytes – 5%, ESR- 20 mm/hour. Specify the doctor’s further tactics:

An 8-year-old boy has a 2-year history of blotchy itchy rash appearing after eating citrus fruit. The first eruption occurred at the age of 6 months after the introduction of juices to the baby’s diet. Father has a history of bronchial asthma, mother – that of allergic rhinitis. What is the most likely diagnosis?

A 25-year-old patient has been admitted to the hospital with the following problems: weakness, sweating, itching, weight loss, enlarged submandibular, cervical, axillary, inguinal lymph nodes. Objectively: hepatomegaly. Lymph node biopsy revealed giant Berezovsky-Reed-Sternberg cells, polymorphocellular granuloma composed of lymphocytes, reticular cells, neutrophils, eosinophils, fibrous tissue, plasma cells. What is the most likely diagnosis?

An 8-year-old child was hospitalized for fever up to 39.8^oC , inertness, moderate headache, vomiting. Examination revealed meningeal symptoms. Lumbar puncture was performed. The obtained fluid had raised opening pressure, it was transparent, with the cell count of 450 cells per 1 mcl (mainly lymphocytes – 90%), glucose level of 2.6 mmol/l. What causative agent might have caused the disease in the child?

A 25-year-old patient during self-examination detected a tumor in the upper external quadrant of the right mammary gland. On palpation: painless, dense, mobile growth 2 cm in diameter is detected in the mammary gland; no changes in the peripheral  lymph nodes are observed. On mammary glands US: in the upper external quadrant of the right mammary gland there is a space-occupying lesion of increased echogenicity 21х18 mm in size. The most likely diagnosis is:

2 weeks after labour a parturient woman developed breast pain being observed for 3 days. Examination revealed body temperature at the rate of 39^oC , chills, weakness, hyperaemia, enlargement, pain and deformity of the mammary gland. On palpation the infiltrate was found to have an area of softening and fluctuation. What is the most likely diagnosis?

A 48-year-old woman has been suffering from chronic pancreatitis for the last 7 years. Lately she has been noticing an increase in daily feces with foul smell, abdominal distention, gurgling. The patient complains of diarrhea, weakness, fatigability, loss of appetite, loss of weight. What syndrome can be suspected in this case?

A 37-year-old man suffers from attacks of unconsciousness, dyspnea during physical exertion, periodical sensations of heart rate disorder. Father of the patient died suddenly at the age of 45. Objectively: heart rate is 90/min., BP is 140/90 mm Hg. On heart US: ejection fraction – 49%, significant myocardium thickening of the left ventricle and interventricular septum. What drug should be prescribed for the treatment?

During a regular check-up of a 50-year-old woman a tumor was detected in her right mammary gland. The tumor is 5 cm in diameter, dense, without clear margins. The skin over the tumor resembles lemon rind, the nipple is inverted. The lymph node can be palpated in the axillary region. What diagnosis is most likely?

A 20-year-old woman complains of sensation of air shortage, lingering dull pain in the heart area, irritability. Objectively: general condition is satisfactory, heart rate lability, BP is 130/60 mm Hg. ECG reveals disruption of repolarization processes. The patient is diagnosed with somatoform autonomic dysfunction of cardial type. Specify the conditions of the patient treatment:

A 38-year-old man’s workplace is within the area of effect of ionizing radiation. During regular medical check-up he expresses no complaints. Blood test: erythrocytes – 4.5×10¹²/l, Нb- 80 g/l, leukocytes – 2.8×10⁹/l, platelets – 30×10⁹/l. Can this person continue to work with sources of ionizing radiation?

A maternity patient breastfeeding for 1.5 weeks has attended a doctor. She considers the onset of her disease to be when proportional breast engorgement occurred. Mammary glands are painful. Body temperature is 36.6^oC . Expression of breast milk is hindered. The most likely diagnosis is:

An 11-year-old boy complains of general weakness, fever up to 38.2^oC , pain and swelling of the knee joints, sensation of irregular heartbeat. 3 weeks ago, the child had a case of tonsillitis. Knee joints are swollen, the overlying skin and skin of the knee region is reddened, local temperature is increased, movements are limited. Heart sounds are  muffled, extrasystole is present, auscultation reveals apical systolic murmur that is not conducted to the left inguinal region. ESR is 38 mm/hour. CRP is 2+, antistreptolysin O titre – 400. What is the most likely diagnosis?

An 18-year-old woman complains of mammary glands swelling, headaches, tearfulness, abdominal distension occurring the day before menstruation. The symptoms disappear with the beginning of menstruation. Menstruations are regular, last for 5-6 days wi-th interval of 28 days in between. Gynecological examination revealed no changes of internal genitals. What is your diagnosis?

A 24-year-old patient had been delivered to a thoracic department with a chest injury, a fracture of the IV, V, VI ribs on the right. Plan radiography shows the fluid level in the pleural cavity reaching the III rib on the right. Puncture blood contained clots. What is the optimal treatment tactics?

A 30-year-old man was delivered to a neurosurgical department with complaints of constant headaches, nausea, vomiting, fever, 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^oC . Neurologically pronounced 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:

Examination of a Rh-negative pregnant  woman at 32 weeks of gestation revealed a four-time rise of Rh-antibody titer within 2 weeks, the titer was 1:64. In the first two pregnancies the patient had experienced antenatal fetal death due to hemolytic disease. What is the optimal tactics of pregnancy management?

A 74-year-old patient visited a urologist with complaints of pain above the pubis and inability to urinate for 8 hours. At home he had taken antispasmodics and had a warm bath but no improvement occurred. Objectively: the abdomen is soft and painful above the pubis; dullness of percussion sound is observed above the pubis. Murphy’s (Pasternatski’s) punch sign is negative on the both sides. What condition does the patient have?

A 7-year-old child became ill again 2 weeks after a case of tonsillitis. There are the following complaints: temperature rise up to 38^oC , hemorrhagic rash on the extremities, enlargement of the ankle joints. Blood test: hemoglobin is 120 g/l, platelets are 170×10⁹/l, ESR is 30 mm/hour. Urine test: proteinuria up to 0.7 g/l, cylinders – 5-6 in the field of vision, erythrocytes – 8-10 in the field of vision. What mechanism of hemorrhagic syndrome is present in the given case?

A 33-year-old patient has developed dyspnea during physical exertion, palpitations, disruptions of heart rate, swollen legs. In the childhood the patient had a case of acute rheumatic fever that required in-patient treatment. There were no further requests for medical care. Objectively: heart rate is 92/min., rhythmic; BP is 110/70 mm Hg. At the apex the I heart sound is increased, triple rhythm, diastolic murmur. What heart disease is most likely?

A 64-year-old woman has been suffering from diabetes mellitus for the last 14 years. Approximately 3 days ago the skin on the distal phalanx of the I toe on the left foot became cold and bluish-black in color. Mild pain is observed in the affected area. Pulse on the pedal arteries cannot be detected, pulse on the popliteal artery is retained. Glycemia is 12.4 mmol/l. US scan: stenosis of the shin arteries, collateral compensated blood flow. Ankle-brachial pressure index is 0.7. Foot X-ray: destruction of the distal phalanx of the I toe. Determine the grade of diabetic foot according to Wagner:

A 4-month-old boy has been undergoi-ng in-patient treatment for pneumocystic pneumonia for 4 weeks. The diagnosis has been made based on clinical signs, typical X-ray presentation, presence of severe hypoxemia, positive dynamics caused by intravenous introduction of Biseptol (Co-trimoxazole). Anamnesis states that enzyme-linked immuno sorbent assay (ELISA) detected antibodies to HIV in the umbilical blood. Polymerase chain reaction (PCR) was performed on the child at the ages of 1 month and 3 months, and proviral DNA was detected in the child’s blood. Viral load and number of CD4+-lymphocytes was not measured. Make the diagnosis:

A 35-year-old patient undergoing treatment for heart disorder in cardiological department has developed complaints of acute sudden pain in the epigastrium, temperature rise up to 38.3^oC . Blumberg’s and Razdolsky’s (abduction of femur) signs are positive. What necessitates surgical aid in the given case?

A 5-year-old girl was hospitalized with  complaints of pain and swelling in the right knee joint, temperature rise up to 38.4^oC and a rash diagnosed as erythema annulare centrifugum. The signs developed 3 days after the recovery from a case of acute respiratory disease. Name the etiotropic drug to be prescribed:

During medical examination of a group of children under 4 years carried out by a pediatric team in one of the African countries a set of similar pathological signs was detected in some of the children. The signs are as follows: growth inhibition, mental changes, muscle atrophy, swellings, changes in hair and skin pigmentation. These children were diagnosed with kwashiorkor. What food products should be added to the diet to treat this disorder?

An 8-year-old girl was diagnosed with signs of Morgagni-Adams-Stokes disease that developed against the background of the III degree atrioventricular heart block. What drug should be introduced intravenously for emergency aid?

A 62-year-old man addresed a urologist with complaints of frequent urination at night (5-6 times per night), sensation of incomplete voiding of the urinary bladder, pain in the lower abdomen, slow urination. Anamnesis: the II degree essential hypertension (peak BP is 160/100 mm Hg). Current case: the II degree enlargement of the prostate gland, PSA is 2.2 ng/ml. Select the drug suitable for long-term therapy of the patient’s combined pathology:

On the 9^th day after childbirth the obstetric patient developed high fever up to 38^oC . She complains of pain in the right mammary gland. The examination revealed the following: a sharply painful infiltrate can be palpated in the right mammary gland, the skin over the infiltrate is red, subareolar area and nipple are swollen and painful. What is your diagnosis?

A 16-year-old girl addressed a doctor with complaints of fatigability and dizziness. On heart auscultation: systolic murmur in the II intercostal area along the breastbone edge on the left. ECG revealed signs of the right ventricular hypertrophy. X-ray revealed dilatation of the the pulmonary artery trunk, enlargement of the right heart. What heart disorder is it?

A 32-year-old patient complains of excessive appetite, excess weight, dyspnea during physical exertion. There are fat deposits in the area of abdomen and shoulder girdle. The skin is pale-pink, adult male pattern of hair distribution is observed on the torso, no stretch marks. Heart rate is 90/min., BP is 120/80 mm Hg, body build index equals 35. Blood sugar is 4.9 mmol/l, cholesterol is 6.2 mmol/l. On ophthalmoscopy: fundus of the eye without changes. What provisional diagnosis can be made?