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2024 January Krok 2 Paper
Question: 1. Objectively, a 22-year-old patient has numerous non-inflammatory yellowish-brown and pale pink spots on the skin of the chest, neck, shoulders, and sides of the torso. When the spots are scratched, the sign of “shavings” is observed. The disease onset was 2 years ago, the rashes were first noticed after a summer vacation by the sea. What is the most likely diagnosis in this case?
A. Pityriasis rosea Gibert
B. Erythrasma
C. Streptodermia
D. Tinea versicolor (Pityriasis versicolor)
E. Syphilitic roseola
Answer: Tinea versicolor (Pityriasis versicolor)
Explanation
The clinical presentation described, including non-inflammatory yellowish-brown and pale pink spots on the skin of the chest, neck, shoulders, and the sides of the torso, along with the observation of “shavings” when the spots are scratched, is indicative of Tinea versicolor (Pityriasis Versicolor).
Tinea versicolor is a superficial fungal infection caused by Malassezia species, commonly M. globosa or M. furfur. The fungus interferes with normal skin pigmentation, leading to the development of hypo- or hyperpigmented macules, which are often observed on the trunk. The condition is exacerbated by sweating, and the spots become more noticeable after sun exposure.
The other options can be ruled out based on the clinical features:
A. Pityriasis rosea Gibert: Presents with a herald patch followed by the appearance of smaller scaly lesions, typically on the trunk.
B. Erythrasma: Manifests as well-demarcated brown patches with fine scaling, usually in intertriginous areas.
C. Streptodermia: Generally refers to skin infections caused by Streptococcus bacteria, presenting as erythematous, sometimes vesicular lesions.
E. Syphilitic roseola: A manifestation of secondary syphilis, characterized by a coppery or brown maculopapular rash affecting the trunk and extremities.
In summary, the clinical presentation of non-inflammatory yellowish-brown and pale pink spots on the trunk, along with the observation of “shavings,” aligns with the characteristic features of Tinea versicolor.
Question: 2. A 12-year-old girl became acutely ill with a fever of 38.5°C and a rash appearing on her skin. Objectively, her condition is of moderate severity, she has hepatosplenomegaly, fine punctate rash, and maculopapular rash on the flexor surfaces of her limbs, lateral surfaces of the trunk, and lower abdomen. Demarcated bluish-pink coloring is observed on her hands and feet. What is the most likely diagnosis in this case?
A. Measles
B. Scarlet fever
C. Chickenpox
D. Pseudotuberculosis
E. Infectious mononucleosis
Answer: Scarlet fever
Explanation
The clinical presentation described, including an acute onset of fever, hepatosplenomegaly, fine punctate rash, maculopapular rash on the flexor surfaces of the limbs, lateral surfaces of the trunk, and lower abdomen, along with demarcated bluish-pink coloring on the hands and feet, is characteristic of scarlet fever.
Scarlet fever is a streptococcal infection caused by Group A Streptococcus (Streptococcus pyogenes) and is often associated with a preceding streptococcal pharyngitis. The characteristic rash of scarlet fever typically appears on the second day of illness and begins as a fine punctate rash that then becomes more confluent, giving a “sandpaper-like” texture. The rash is most prominent in flexural areas, such as the flexor surfaces of the limbs.
Let’s briefly review the other options and rule them out:
A. Measles: Presents with a prodromal fever, cough, and coryza, followed by the appearance of a maculopapular rash that starts on the face and spreads downward.
C. Chickenpox: Characterized by an itchy vesicular rash that starts on the face, scalp, and trunk and then spreads to other parts of the body.
D. Pseudotuberculosis: Not a common cause of an acute febrile illness with the described rash. Pseudotuberculosis is often associated with Yersinia infections.
E. Infectious mononucleosis: Typically presents with symptoms such as fever, sore throat, and lymphadenopathy. The rash seen in infectious mononucleosis is usually maculopapular but is not as characteristic as the rash seen in scarlet fever.
In summary, the clinical features of an acute febrile illness with hepatosplenomegaly, a fine punctate rash, and a maculopapular rash on flexor surfaces, along with demarcated bluish-pink coloring on hands and feet, align with the diagnosis of scarlet fever.
Question: 3. A 25-year-old woman was hospitalized in the maternity hospital at 34 weeks of her pregnancy with complaints of bright-colored bloody discharge with clots that appeared after a defecation. Objectively, the fetal head is palpable near the uterine fundus. Fetal heart rate 140/min. No labor activity. Vaginal examination shows that the cervix is 3 cm long, its opening allows inserting a fingertip, a soft formation can be palpated through the vaginal fornix. The discharge is hemorrhagic and bright-colored. What is the most likely diagnosis in this case?
A. Premature birth
B. Low-lying placenta
C. Placenta praevia
D. Uterine rupture
E. Placental abruption
Answer: Placenta praevia
Explanation
Placenta praevia is a condition where the placenta implants in the lower uterine segment, partially or completely covering the internal cervical os. This can lead to painless vaginal bleeding, particularly in the third trimester. The bleeding may be sudden and bright-colored, often occurring after activities like defecation or intercourse.
In the scenario described, the 25-year-old woman at 34 weeks of pregnancy presents with bright-colored bloody discharge with clots after defecation. The findings of a soft formation palpable through the vaginal fornix and a cervix that allows inserting a fingertip are indicative of placenta praevia. The fetal head palpable near the uterine fundus suggests that the presenting part is not engaged in the pelvis.
Let’s briefly review the other options and rule them out:
A. Premature birth: The clinical presentation is more suggestive of vaginal bleeding due to placenta-related issues rather than signs of premature birth.
B. Low-lying placenta: While a low-lying placenta can be associated with bleeding, the specific findings described, such as a soft formation through the vaginal fornix, are more characteristic of placenta praevia.
D. Uterine rupture: Uterine rupture is usually associated with severe abdominal pain and signs of fetal distress. The absence of labor activity and the presence of a palpable fetal head make uterine rupture less likely.
E. Placental abruption: Placental abruption typically presents with painful bleeding, and the clinical presentation in this case is more consistent with painless bleeding, characteristic of placenta praevia.
In summary, the clinical features of painless bright-colored bleeding, a soft formation palpable through the vaginal fornix, and a cervix allowing fingertip insertion, along with the absence of labor activity, are indicative of placenta praevia.
Question: 4. A 65-year-old patient with a history of arterial hypertension complains of dizziness and palpitations that occurred throughout the last hour. Objectively, the following is observed: blood pressure 80/40 mm Hg, heart rate 150/min., pulse 106/min. ECG revealed missing P wave and varying RR intervals, ventricular contraction rate is 136-148/min. What aid must be provided to the patient first?
A. Urgent electrical cardioversion
B. Prescription of 3-blockers intravenously
C. Pacemaker implantation
D. Prescription of amiodarone intravenously
E. Prescription of calcium channel blockers intravenously
Answer: Urgent electrical cardioversion
Explanation
The patient’s presentation with dizziness, palpitations, a heart rate of 150/min, blood pressure of 80/40 mm Hg, and an ECG revealing missing P wave and varying RR intervals is indicative of a tachyarrhythmia. Specifically, the absence of P waves and irregular RR intervals suggest atrial fibrillation with a rapid ventricular response.
In the context of severe symptoms and hemodynamic instability, urgent electrical cardioversion is the initial intervention of choice. This procedure aims to restore the normal rhythm by delivering a synchronized electrical shock to the heart. It is especially indicated when the patient is symptomatic and experiences hemodynamic compromise, as in this case with low blood pressure and symptoms of inadequate perfusion.
Let’s briefly review the other options and rule them out:
B. Prescription of β-blockers intravenously: While β-blockers can be used in the management of atrial fibrillation, they are not the first-line treatment in a patient with severe symptoms and hemodynamic instability.
C. Pacemaker implantation: Pacemaker implantation is not the initial intervention for atrial fibrillation with a rapid ventricular response. It may be considered in certain cases, but urgent electrical cardioversion is more appropriate in this acute setting.
D. Prescription of amiodarone intravenously: Amiodarone may be used for rhythm control in stable patients, but in the context of acute symptoms and hemodynamic compromise, urgent electrical cardioversion is more suitable.
E. Prescription of calcium channel blockers intravenously: Calcium channel blockers can be used for rate control in atrial fibrillation, but in a patient with severe symptoms and low blood pressure, urgent electrical cardioversion is the priority to restore sinus rhythm quickly.
In summary, given the acute presentation, hemodynamic instability, and the nature of the rhythm disturbance, urgent electrical cardioversion is the most appropriate initial aid for this patient.
Question: 5. A 3-year-old child has episodes accompanied by cyanosis, sudden anxiety, and squatting. Objectively, the child has “drum-stick deformation of the finger phalanges and nails that resemble a clock face. The cardiac dullness boundaries are shifted to the left and right. A systolic tremor can be detected in the second intercostal space near the left edge of the sternum. A coarse systolic murmur can be heard with p.max in the second intercostal space. The second heart sound is weakened over the base of the heart. X-ray shows that the heart is in the form of a “wooden shoe”, the pulmonary pattern is poorly visible. What is the most likely diagnosis in this case?
A. Dilated cardiomyopathy
B. Atrial septal defect
C. Ventricular septal defect
D. Primary bacterial endocarditis
E. Tetralogy of Fallot
Answer: Tetralogy of Fallot
Explanation
The clinical features described, including episodes of cyanosis, sudden anxiety, squatting, “drumstick deformation” of the finger phalanges, and nails resembling a clock face, are indicative of Tetralogy of Fallot (TOF). TOF is a congenital heart defect characterized by four components:
Pulmonary stenosis: This leads to the systolic tremor and a coarse systolic murmur, with the point of maximum intensity (p.max) typically in the second intercostal space near the left edge of the sternum.
Right ventricular hypertrophy: This is responsible for the “drumstick deformation” of the finger phalanges and nails resembling a clock face.
Overriding aorta: The aorta is positioned over both ventricles, allowing oxygen-poor blood from the right ventricle to mix with oxygen-rich blood from the left ventricle.
Ventricular septal defect (VSD): The VSD contributes to the leftward and rightward shift of the cardiac dullness boundaries and the weakened second heart sound over the base of the heart.
The squatting behavior in the child is a compensatory mechanism to increase systemic vascular resistance, which helps in reducing right-to-left shunting of deoxygenated blood and alleviating cyanosis.
Let’s briefly review the other options and rule them out:
A. Dilated cardiomyopathy: Dilated cardiomyopathy is not characterized by the specific findings mentioned in the case, such as pulmonary stenosis, overriding aorta, and ventricular septal defect.
B. Atrial septal defect: Atrial septal defect does not typically present with the “drumstick deformation” of the finger phalanges and nails resembling a clock face.
C. Ventricular septal defect: While VSD is a component of Tetralogy of Fallot, the full spectrum of findings in this case, including pulmonary stenosis, overriding aorta, and specific physical features, points more towards
Tetralogy of Fallot than isolated VSD.
D. Primary bacterial endocarditis: The clinical presentation and physical examination findings are not consistent with bacterial endocarditis.
In summary, the combination of symptoms, physical examination findings, and characteristic X-ray features align with the diagnosis of Tetralogy of Fallot.
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