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1. A 40-year-old patient complains of colic pains in the lower abdomen and profuse bloody discharges from the genital tracts. Over the last 2 years she has been having menses for 15-16 days, profuse, with clots, painful. In anamnesis there are 2 medical abortions. On bimanual investigation: in the canal of the uterine cervix some fibromatous nodes are palpable, they are 3 cm in diameter, on the thin crus. Discharges are bloody, moderate. Choose the correct treatment tactics:

A. Operation: untwisting of the nodes

B. Hormonal hemostasis

C. Step-by-step vitamin therapy

D. Supravaginal ablation of the uterus without appendages

E. Hysterectomy without appendages


Answer:  Operation: untwisting of the nodes

 Explanation

The patient’s symptoms and findings are consistent with uterine fibroids, also known as leiomyomas. Uterine fibroids are benign tumors that arise from the smooth muscle cells of the uterus and can cause a range of symptoms, including abnormal uterine bleeding, pelvic pain, and pressure symptoms.   In this case, the patient has a history of heavy and prolonged menstrual bleeding, painful periods, and two previous medical abortions.

On examination, fibroid nodules are palpable in the cervix, and the patient is experiencing profuse bloody discharges.   The most appropriate treatment in this case would be an operation to untwist the fibroids. Twisting of the fibroids can cause ischemia and necrosis, which can further exacerbate the patient’s symptoms and lead to infection or other complications. Untwisting the fibroids can relieve the symptoms and improve the patient’s overall condition.  

Hormonal hemostasis (B) is a treatment option for abnormal uterine bleeding, but it is less effective for fibroids than other causes of bleeding. Vitamin therapy (C) is not typically used to treat uterine fibroids. Supravaginal ablation of the uterus without appendages (D) involves removing the upper part of the uterus but leaving the cervix intact.

This procedure is sometimes used to treat fibroids, but it may not be appropriate in this case given the location of the fibroids in the cervix. Hysterectomy without appendages (E) involves removing the entire uterus and is typically reserved for cases of severe symptoms or when other treatments have failed. It may be considered in cases of large or multiple fibroids, but it is not typically the first-line treatment option.


2. 13 months after the first labor a 24-yearold patient complained of amenorrhea. Pregnancy ended in Caesarian section because of premature detachment of normally positioned placenta which resulted in blood loss at the rate of 2000 ml owing to disturbance of blood clotting. Choose the most suitable investigation:

A. Estimation of gonadotropin rate

B. USI of small pelvis organs

C. Progesteron assay

D. Computer tomography of head

E. Estimation of testosteron rate in blood serum


Answer:  Estimation of gonadotropin rate

Explanation

The patient’s history suggests a potential complication of the previous Caesarian section, specifically a placental abruption which can lead to significant bleeding and coagulation disturbances. Given the timing of the amenorrhea, it is possible that the patient has developed hypothalamic-pituitary dysfunction, which can result in decreased gonadotropin production and subsequent amenorrhea.   Estimation of gonadotropin levels would be the most suitable investigation in this case.

Gonadotropins are hormones produced by the pituitary gland that stimulate the ovaries to produce estrogen and progesterone, which are necessary for menstrual cycles. Decreased gonadotropin levels can lead to amenorrhea and other menstrual disturbances.  

USI of small pelvis organs (B) may be useful for evaluating the structure of the reproductive organs, but it is less likely to be helpful in this case, as the cause of amenorrhea is likely related to hormonal dysfunction rather than structural abnormalities.  

Progesterone assay (C) may be useful for evaluating ovulation and luteal phase function, but it is less likely to be helpful in this case, as the patient’s amenorrhea suggests a lack of ovarian activity.   Computer tomography of the head (D) and estimation of testosterone levels (E) are unlikely to be helpful in this case, as there is no indication of neurological or androgen-related symptoms.

3. A 20-year-old patient was delivered to the hospital in summer from the street with haemorrage from the brachial artery. First medical aid involved application of a tourniquet for provisional arrest of bleeding. What is the maximal exposure of the tourniquet?

A. 120 minutes

B. 15 minutes

C. 30 minutes

D. 60 minutes

E. 180 minutes


Answer: 120 minutes

Explanation

The use of a tourniquet is a temporary measure to control bleeding and should not be used for extended periods of time. Prolonged use of a tourniquet can lead to tissue ischemia, nerve damage, and other complications.  

The maximal exposure time for a tourniquet is typically recommended to be no longer than 60 minutes. After 60 minutes, the tourniquet should be released to allow blood flow to return to the affected area and to prevent tissue damage.  

Option A (120 minutes) and Option E (180 minutes) are both longer than the recommended maximal exposure time and would be associated with an increased risk of complications.

Option B (15 minutes) and Option C (30 minutes) may be too short to allow for effective control of bleeding in some cases, but 60 minutes is generally considered the maximum time that a tourniquet should be used. Therefore, the correct answer is D. 60 minutes.


4. Head of a department and a tradeunion group have appealed to the head of a hospital about dismissal of the senior nurse who has 17 year record of service. The facts of charge were confirmed and recognized by the nurse herself. This nurse lives with a daughter (who is divorced and unemployed) and a 9-monthold grandson. Make an administrative decision:

A. To continue the worker in office with a warning of dismissal in case of repeated violation of labor discipline

B. To discharge the worker, i.e. to satisfy demands of the collective

C. To issue the sick list

D. To shift the solution of this problem on other officials or public organizations

E. –


Answer: To continue the worker in office with a warning of dismissal in case of repeated violation of labor discipline

Explanation

The situation described involves a senior nurse with a long record of service who has been found guilty of violating labor discipline. While the facts of the charges have been confirmed and acknowledged by the nurse herself, the circumstances of her personal life (living with a daughter and grandchild) may be taken into consideration when making an administrative decision.  

Dismissing the worker (B) may be too severe a punishment considering the nurse’s long record of service and personal circumstances. Issuing a sick leave (C) would not be appropriate if the nurse is not actually sick. Shifting the problem to other officials or organizations (D) would not be an appropriate resolution either.  

Therefore, the most appropriate decision would be to continue the worker in her current position but issue a warning of dismissal in case of any future violations of labor discipline. This would allow the nurse to continue working and supporting her family while also providing a clear message about the importance of adhering to labor discipline standards.

5. 25 unorganized children in the age 2-3 year will be observed on a pediatric district it in the current year. What scheduled number of initial visitations will make to this group of children?

A. 50

B. 20

C. 40

D. 100

E. 200


Answer: 50

Explanation

For children in the age range of 2-3 years, the recommended frequency of pediatric visits is once every three months. Therefore, for a group of 25 children, the number of initial visitations scheduled would be:   25 children x 1 visit every 3 months = 25 visits every 3 months  

To calculate the number of initial visitations in a year, we can multiply the number of visits every 3 months by the number of 3-month periods in a year (4):   25 visits every 3 months x 4 = 100 visits per year  

However, since we are interested in the number of initial visitations, we need to divide the total number of visits by 2 (since each child would have two visits in a year, the initial visit and the follow-up visit):   100 visits per year / 2 = 50 initial visitations per year   Therefore, the correct answer is A. 50 initial visitations.


6. A patient with high temperature came to a first-aid post in the evening. The fact of temporary disability was established. Indicate the order of examination in this case:

A. The night duty doctor should issue a medical certificate, which will be subsequently used for issuing a sick list from the date of the previous day

B. The sick list for 1 day should be issued

C. The sick list for up to 3 days should be issued

D. The sick list for 3 days should be issued

E. Any document shouldn’t be issued


Answer: The night duty doctor should issue a medical certificate, which will be subsequently used for issuing a sick list from the date of the previous day

Explanation

When a patient presents with a high temperature and is found to have temporary disability, it is important to establish the appropriate documentation to ensure that the patient receives the necessary medical care and time off from work if needed.  

In this case, the night duty doctor should issue a medical certificate that states the patient’s diagnosis and the need for temporary disability. This medical certificate can subsequently be used to issue a sick leave from the date of the previous day, as the patient had already been experiencing symptoms and was unable to work.  

The length of the sick leave (options B, C, and D) would depend on the severity and duration of the patient’s illness, which would need to be assessed by the doctor. However, the first step would be to issue a medical certificate to document the patient’s condition and establish the necessary paperwork for a sick leave.  

Option E (not issuing any document) would not be appropriate, as temporary disability needs to be documented to ensure that the patient receives the necessary medical care and time off from work if needed.


7. An 8-year-old boy fell ill acutely: he presents with fever, weakness, headache, abdominal pain, recurrent vomiting, then diarrhea and tenesmus. Stools occur 12 times daily, are scanty, contain a lot of mucus, pus, streaks of blood. His sigmoid gut is tender and hardened. What is your diagnosis?

A. Dysentery

B. Salmonellosis

C. Cholera

D. Staphylococcal gastroenteritis

E. Escherichiosis


Answer:  Dysentery

Explanation

The symptoms described in the case, such as fever, weakness, headache, abdominal pain, vomiting, and diarrhea with mucus, pus, and streaks of blood, are consistent with the diagnosis of dysentery. Dysentery is an inflammatory condition of the intestines that is typically caused by a bacterial infection, such as Shigella, which is transmitted through contaminated food or water.  

The tender and hardened sigmoid gut is a characteristic finding of dysentery, as the inflammation and infection often affect the lower part of the colon. The high frequency of stools (12 times daily) is another characteristic feature of dysentery, as is the presence of mucus, pus, and blood in the stool.  

Salmonellosis (B) is another bacterial infection that can cause similar symptoms, but it is less likely in this case given the presence of mucus, pus, and blood in the stool, which are not typically seen in Salmonella infections.

Cholera (C) is characterized by profuse watery diarrhea and vomiting, and is unlikely in this case given the presence of mucus, pus, and blood in the stool. Staphylococcal gastroenteritis (D) is typically characterized by vomiting and diarrhea, but not with mucus, pus, or blood.

Escherichiosis (E) is caused by a different bacterium, Escherichia coli, and is typically associated with watery diarrhea and abdominal cramps.   Therefore, the most likely diagnosis in this case is dysentery, which requires appropriate treatment with antibiotics and supportive care to prevent complications.


8. An infant was born with body mass 3 kg and body length 50 cm. Now he is 3 years old. His brother is 7 years old, suffers from rheumatic fever. Mother asked the doctor for a cardiac check up of the 3-year-old son. Where is the left relative heart border located?

A. 1 cm left from the left medioclavicular line

B. 1 cm right from the left medioclavicular line

C. Along the left medioclavicular line

D. 1 cm left from he left parasternal line

E. 1 cm right from the left parasternal line


Answer: 1 cm left from the left medioclavicular line

Explanation

The location of the left relative heart border can vary depending on the age and size of the individual, as well as any underlying cardiac conditions. However, in general, the left relative heart border is located approximately 1 cm left from the left medioclavicular line in a healthy individual.  

In this case, the patient is a 3-year-old child who was born at a normal weight and length, and there is no indication of any underlying cardiac conditions. Therefore, the left relative heart border would be expected to be located approximately 1 cm left from the left medioclavicular line.  

Option B (1 cm right from the left medioclavicular line) and Option C (along the left medioclavicular line) are less likely to be correct, as the left relative heart border is typically located to the left of the medioclavicular line. Option D (1 cm left from the left parasternal line) is also less likely, as the left relative heart border is typically located more laterally than the parasternal line.

Option E (1 cm right from the left parasternal line) is also less likely, as the left relative heart border is typically located to the left of the parasternal line.


9. A 14-year-old boy has rheumatism. Over the last 2 years he has had 3 rheumatic attacks. What course of rheumatism does the patient have?

A. Prolonged

B. Acute

C. Subacute

D. Latent

E. Persistent-reccurent


Answer: Prolonged

Explanation

The description of a 14-year-old boy with rheumatism who has had 3 rheumatic attacks over the last 2 years suggests a course of persistent-recurrent rheumatism. Persistent-recurrent rheumatism is characterized by repeated episodes of rheumatic activity over a prolonged period of time, with periods of remission in between.  

Acute rheumatism (B) is a term that is not commonly used today, but in the past it was used to describe the acute phase of rheumatic fever. Subacute rheumatism (C) is a term that is also not commonly used today, but it may have been used in the past to describe a milder form of rheumatic fever.

Latent rheumatism (D) refers to a period of time when the symptoms of rheumatism are not present but the disease is still present and may become active again in the future.   Therefore, based on the information provided, the most appropriate course of rheumatism for this patient is persistent-recurrent.


10. The patient with aquired heart failure has diastolic pressure of 0 mm Hg. What heart failure does the child have?

A. Aortal insufficiency

B. Mitral stenosis

C. Aortal stenosis

D. Mitral insufficiency

E. Rheumatism


Answer: Aortal insufficiency

Explanation

A diastolic pressure of 0 mm Hg is not possible and would indicate that the patient is not alive. Diastolic pressure is the pressure in the arteries when the heart is relaxed between beats, and a normal diastolic pressure range is typically between 60-80 mm Hg.  

Therefore, this question seems to contain an error and cannot be accurately answered. It is important to ensure that questions and answers are based on accurate and reliable information to avoid confusion and potential harm to patients.


11. An 18-month-old child was taken to a hospital on the 4-th day of the disease. The disease began acutely with temperature 39, weakness, cough, breathlessness. He is pale, cyanotic, has had febrile temperature for over 3 days. There are crepitative fine bubbling rales on auscultation. Percussion sound is shortened in the right infrascapular region. X-ray picture shows non-homogeneous segment infiltration 8- 10 mm on the right, the intensification of lung pattern. Your diagnosis:

A. Segmentary pneumonia

B. Grippe

C. Bronchitis

D. Bronchiolitis

E. Interstitial pneumonia


Answer: Segmentary pneumonia

Explanation

The symptoms and findings described in the case, such as acute onset of high fever, weakness, cough, and breathlessness, along with the presence of crepitative fine bubbling rales on auscultation, shortened percussion sound in the right infrascapular region, and non-homogeneous segment infiltration with intensification of the lung pattern on X-ray, are all consistent with the diagnosis of segmentary pneumonia.  

Segmentary pneumonia is a type of pneumonia that affects a specific segment of the lung. It is typically caused by bacterial infection, and is characterized by the presence of lung consolidation, which can be seen on X-ray as a non-homogeneous infiltration pattern.   Grippe (B), which is another term for influenza, can cause high fever, weakness, cough, and breathlessness, but is not typically associated with lung consolidation.

Bronchitis (C) is an inflammation of the bronchial tubes, and is usually characterized by cough, mucus production, and wheezing, but does not typically cause lung consolidation. Bronchiolitis (D) is a viral infection that affects the small airways in the lungs, and is typically seen in infants and young children. It is characterized by wheezing and difficulty breathing, but does not typically cause lung consolidation.

Interstitial pneumonia (E) is a type of pneumonia that affects the interstitial tissues of the lung, and is typically caused by viral or fungal infection. It is typically characterized by diffuse infiltrates on X-ray, and is less likely in this case given the presence of segment infiltration.   Therefore, based on the information provided, the most likely diagnosis is segmentary pneumonia, which requires appropriate treatment with antibiotics and supportive care to prevent complications.


12. A baby was born at 36 weeks of gestation. Delivery was normal, by natural way. The baby has a large cephalohematoma. The results of blood count are: Hb- 120g/l, Er- 3, 5 · 1012/l, total serum bilirubin – 123 mmol/l, direct bilirubin – 11 mmol/l, indirect – 112 mmol/l. What are causes of hyperbilirubinemia in this case?

A. Erythrocyte hemolysis

B. Intravascular hemolysis

C. Disturbance of the conjugative function of liver

D. Bile condensing

E. Mechanical obstruction of the bile outflow


Answer: Erythrocyte hemolysis

Explanation

The presence of a large cephalohematoma in a newborn is a risk factor for the development of hyperbilirubinemia, as the breakdown of red blood cells from the hematoma can lead to an increase in bilirubin levels. In this case, the blood count results show a normal hemoglobin level (Hb- 120g/l) but a low red blood cell count (Er- 3, 5 · 1012/l), which suggests erythrocyte hemolysis as the cause of hyperbilirubinemia.  

The bilirubin levels in the blood are also indicative of erythrocyte hemolysis, as the total serum bilirubin level is elevated (123 mmol/l), along with both direct (11 mmol/l) and indirect (112 mmol/l) bilirubin levels. The direct bilirubin level is within the normal range, which suggests that the conjugative function of the liver is not significantly affected.  

Options B, D, and E (intravascular hemolysis, bile condensing, and mechanical obstruction of the bile outflow) are less likely causes of hyperbilirubinemia in this case, as there is no evidence to suggest that these conditions are present.   Therefore, based on the information provided, the most likely cause of hyperbilirubinemia in this case is erythrocyte hemolysis, which requires appropriate management to prevent complications such as kernicterus.


13. A 4-month-old girl with blond hair and blue eyes has “mousy”odor of sweat and urine, delayed psychomotoric development. The most typical laboratory data for this disorder is:

A. Positive urine ferric chloride test

B. High level of oxyproline in urine

C. High level of glycosaminoglycanes in urine

D. High concentration of chlorides in sweat

E. Low level of thyroid gland hormones in blood


Answer: Positive urine ferric chloride test

Explanation

The symptoms and physical characteristics described in the case, such as blond hair, blue eyes, “mousy” odor of sweat and urine, and delayed psychomotoric development, are consistent with the diagnosis of phenylketonuria (PKU). PKU is an inherited disorder of amino acid metabolism that leads to the accumulation of phenylalanine in the blood and tissues, which can cause brain damage if not treated early.  

The most typical laboratory data for PKU is a positive urine ferric chloride test. This test detects the presence of excess phenylalanine in the urine, which reacts with ferric chloride to produce a green color.   Option B (high level of oxyproline in urine) and Option C (high level of glycosaminoglycanes in urine) are not associated with PKU.

Option D (high concentration of chlorides in sweat) is associated with cystic fibrosis, which is a separate inherited disorder that affects the function of the sweat glands and other organs. Option E (low level of thyroid gland hormones in blood) is associated with hypothyroidism, which can cause developmental delays, but is not typically associated with the other symptoms and physical characteristics described in the case.  

Therefore, based on the information provided, the most typical laboratory data for this disorder is a positive urine ferric chloride test, which should prompt further diagnostic testing and early treatment to prevent complications.


14. A man, aged 25, presents with facial edema, moderate back pains, body temperature of 37, 5oC, BP- 180/100 mm Hg, hematuria (up to 100 in v/f), proteinuria (2,0 g/l), hyaline casts – 10 in v/f, specific gravity – 1020. The onset of the disease is probably connected with acute tonsillitis 2 weeks ago. The most likely diagnosis is:

A. Acute glomerulonephritis

B. Acute pyelonephritis

C. Cancer of the kidney

D. Urolithiasis

E. Chronic glomerulonephritis


Answer: Acute glomerulonephritis

Explanation

The symptoms and findings described in the case, such as facial edema, moderate back pains, hematuria, proteinuria, hyaline casts, and high blood pressure, are all consistent with the diagnosis of acute glomerulonephritis. This condition typically develops 1-4 weeks after a streptococcal infection, such as acute tonsillitis, and is characterized by inflammation of the glomeruli in the kidneys, which can lead to impaired kidney function and the symptoms described.  

Acute pyelonephritis (B) is another type of kidney infection, but it is typically characterized by fever, chills, and flank pain, and is not usually associated with high blood pressure or significant proteinuria.   Cancer of the kidney (C) is a possibility, but it would be less likely given the patient’s age and the acute onset of symptoms following a recent infection.  

Urolithiasis (D) is the presence of stones in the urinary tract, and can cause symptoms such as flank pain and hematuria, but would not typically be associated with significant proteinuria or high blood pressure.   Chronic glomerulonephritis (E) is a long-term condition that can result from repeated episodes of acute glomerulonephritis, and is characterized by slow and progressive loss of kidney function.

However, the onset of symptoms in this case is acute, suggesting acute glomerulonephritis rather than chronic.   Therefore, based on the information provided, the most likely diagnosis is acute glomerulonephritis, which requires appropriate management to prevent complications and promote recovery of kidney function.


15. A 62-year-old patient has DM-2. Diabetes is being compensated by diet and Maninilum. Pаtient has to undergo an operation for inguinal hernia. What tactics of hypoglycemic therapy should be chosen?

A. Prescribe the short-acting insulin

B. Give Glurenorm in place of Maninilum

C. To continue with the current therapy

D. Prescribe thelong-acting insulin

E. Prescribe guanylguanidine


Answer:  Prescribe the short-acting insulin

Explanation

The patient has DM-2, which is being controlled by diet and Maninilum (a sulfonylurea drug that stimulates insulin secretion from the pancreas). However, undergoing surgery can disrupt blood glucose control, and there is a risk of hypoglycemia during and after the procedure.   To minimize the risk of hypoglycemia, the patient should be switched from oral hypoglycemic agents to short-acting insulin before the surgery.

Short-acting insulin can be more easily adjusted to maintain normal blood glucose levels during the perioperative period, and can be rapidly adjusted or discontinued if necessary.   Option B (giving Glurenorm in place of Maninilum) is not recommended, as Glurenorm is also a sulfonylurea drug and can increase the risk of hypoglycemia during the perioperative period.   Option C (continuing with the current therapy) is not ideal, as the risk of hypoglycemia may be increased due to the stress of surgery, fasting, and anesthesia.  

Option D (prescribing long-acting insulin) may not be appropriate for this situation, as long-acting insulin has a slower onset and longer duration of action, which may make it more difficult to adjust and may increase the risk of hypoglycemia.  

Option E (prescribing guanylguanidine) is not recommended for this situation, as guanylguanidine is not typically used for the treatment of diabetes and may not be effective in controlling blood glucose levels.   Therefore, based on the information provided, the best tactic of hypoglycemic therapy for this patient undergoing surgery for inguinal hernia is to prescribe short-acting insulin to minimize the risk of hypoglycemia during and after the procedure.


16. A neonate is 5 days old. What vaccination dose of BCG vaccine (in мg) is necessary for vaccination of this child?

A. 0,05 мg

B. 0,025 мg

C. 0,075 мg

D. 0,1 мg

E. 0,2 мg


Answer: 0,05 мg

Explanation

BCG vaccine is a vaccine used to prevent tuberculosis (TB) in children and adults. The vaccine is commonly given to newborns in many countries, including Russia.   The standard dose of BCG vaccine for a newborn is 0.05 mg, regardless of the infant’s weight or size.  

Therefore, based on the information provided, the vaccination dose of BCG vaccine necessary for vaccination of this 5-day-old neonate is 0.05 mg.


17. Patient, male, 16 years old was behind other children in development since early childhood and still has moderate mental retardation. He is short, has dismorphic body, his face is round, flattened, his eyes are narrow and slanted, and there are epicantial folds in the corners of his eyes. There is only one transversal flexor line on his palms. What is the probable etiology of this state?

A. Chromosome abnormality

B. Gene abnormality

C. Maternal alcohol abuse during pregnancy

D. Pathological delivery

E. Infection in mother during pregnancy


Answer: Chromosome abnormality

Explanation

The patient’s clinical features, such as developmental delay, moderate mental retardation, short stature, dysmorphic body, and distinctive facial features (round, flattened face; narrow, slanted eyes; and epicantial folds), are consistent with the diagnosis of Down syndrome.  

Down syndrome is a genetic disorder caused by the presence of an extra copy of chromosome 21, also known as trisomy 21. This chromosomal abnormality can occur spontaneously during the formation of the reproductive cells or during early fetal development.  

Options B (gene abnormality), C (maternal alcohol abuse during pregnancy), D (pathological delivery), and E (infection in mother during pregnancy) are less likely to be the cause of the patient’s clinical features, as they are not typically associated with the characteristic dysmorphic features and developmental delay seen in Down syndrome.  

Therefore, based on the information provided, the most probable etiology of this state is a chromosome abnormality, specifically trisomy 21 or Down syndrome.


18. A patient who works as a nightman was diagnosed with of chronic arsenious intoxication. What form of anemia is characteristic for this disease?

A. Haemolytic anemia

B. Aplastic anemia

C. Iron deficiency anemia

D. Hyper sideric anemia

E. Normochromic anemia


Answer: Haemolytic anemia

Explanation

Chronic arsenic intoxication can lead to a variety of symptoms and health problems, including anemia. The type of anemia that is characteristic of chronic arsenic intoxication is haemolytic anemia.   Haemolytic anemia is a type of anemia that occurs when red blood cells are destroyed faster than they can be produced, leading to a decrease in the number of circulating red blood cells.

Arsenic can cause haemolytic anemia by damaging the red blood cells, leading to their premature destruction.   Option B (aplastic anemia) is a type of anemia that occurs when the bone marrow fails to produce enough red blood cells, and is not typically associated with chronic arsenic intoxication.  

Option C (iron deficiency anemia) is a type of anemia that occurs when there is a deficiency of iron in the body, leading to a decrease in the production of red blood cells. Arsenic can interfere with iron metabolism, but iron deficiency anemia is not typically associated with chronic arsenic intoxication.  

Option D (hyper sideric anemia) is a rare type of anemia that is characterized by excessive iron accumulation in the body, and is not typically associated with chronic arsenic intoxication.   Option E (normochromic anemia) is a type of anemia in which the color and size of the red blood cells are normal, but there is a decrease in the number of circulating red blood cells.

Normochromic anemia can be caused by a variety of factors, but is not typically associated with chronic arsenic intoxication.   Therefore, based on the information provided, the form of anemia that is characteristic of chronic arsenious intoxication is haemolytic anemia.


19. A patient, aged 52, works as a street cleaner. He has been suffering from pneumoconiosis for 2 years. What treatment should be recommended?

A. Alkaline inhalations

B. Broncholitics

C. Oil inhalations

D. Sulfonilamides

E. Antibiotics


Answer:  Alkaline inhalations

Explanation

Pneumoconiosis is a group of lung diseases caused by the inhalation of dust or other particulate matter, such as silica, coal dust, or asbestos fibers. It can lead to chronic inflammation, fibrosis, and scarring of the lungs, and can cause symptoms such as cough, shortness of breath, and chest pain.  

Alkaline inhalations can be helpful in treating pneumoconiosis, as they can help to soothe the inflammation in the airways and reduce the risk of further lung damage. Alkaline inhalations involve breathing in a solution of sodium bicarbonate or other alkaline substances, which can help to neutralize the acidic environment in the airways caused by inflammation.  

Option B (bronchodilators) may be helpful in treating the symptoms of pneumoconiosis, particularly if the patient has bronchospasm or other obstructive lung disease, but they do not address the underlying inflammation and scarring of the lungs.  

Option C (oil inhalations) is not a recommended treatment for pneumoconiosis, as there is no evidence that inhaling oils or other substances can improve lung function or reduce inflammation.   Option D (sulfonamides) and Option E (antibiotics) are not typically used to treat pneumoconiosis, as they are not effective against the underlying inflammation and scarring of the lungs.  

Therefore, based on the information provided, the most appropriate treatment recommendation for this patient with pneumoconiosis who works as a street cleaner is alkaline inhalations to help soothe the inflammation in the airways and reduce the risk of further lung damage.


20. A 28-year-old patient was hospitalized with preliminary diagnosis “influenza”. Roseolous-petechial rash appeared on the 5th day of disease on the trunk. The temperature is 41oC. Hyperemia of face, reddening of scleras, tremor of tongue, tachycardia, splenomegaly are present. What is the most likely diagnosis?

A. Epidemic typhus

B. Measles

C. Alcohol delirium

D. Leptospirosis

E. Typhoid fever


Answer: Epidemic typhus

Explanation

The presence of a roseolous-petechial rash on the trunk, along with a high fever (41°C), hyperemia of the face, reddening of the sclera, tremor of the tongue, tachycardia, splenomegaly, and the patient’s age, suggest a diagnosis of epidemic typhus.  

Epidemic typhus is a bacterial infection caused by the bacterium Rickettsia prowazekii, and is transmitted to humans by the body louse. It typically presents with a high fever, headache, myalgia, and a maculopapular rash that spreads from the trunk to the extremities.

Other symptoms may include nausea, vomiting, abdominal pain, and neurological symptoms such as tremor and delirium.   Option B (measles) may present with a rash, fever, and other symptoms similar to those described in the case, but the rash in measles typically starts on the face and spreads downward, and is not typically associated with hyperemia of the face, reddening of the sclera, or splenomegaly.  

Option C (alcohol delirium) is less likely, as the symptoms described are not typically associated with alcohol delirium, and the patient’s occupation and lack of history of alcohol abuse suggest another underlying cause.   Option D (leptospirosis) is a bacterial infection that can cause fever, myalgia, and a rash, but is not typically associated with the characteristic rash described in the case, and is more commonly associated with exposure to contaminated water or soil.  

Option E (typhoid fever) is caused by the bacterium Salmonella typhi, and can cause symptoms such as fever, abdominal pain, and rash, but is typically associated with a slower onset of symptoms and is less likely to cause the characteristic rash described in the case.   Therefore, based on the information provided, the most likely diagnosis for this patient with a high fever, rash, and other symptoms is epidemic typhus.


21. The diagnostics of the AIDS epidemic initially was made in the USA by means of:

A. The epidemiological method

B. The bacteriological method

C. The virological method

D. The viroscopic method

E. The serological method


Answer: The epidemiological method

Explanation

The AIDS epidemic was first identified in the United States in the early 1980s. At that time, there was not yet a specific diagnostic test for AIDS, and the diagnosis was made based on clinical symptoms and epidemiological information.   The epidemiological method involves the study of the distribution and determinants of diseases in populations. In the case of AIDS, epidemiologists were able to identify a pattern of cases that suggested the emergence of a new disease.

They noted that the disease was disproportionately affecting certain populations, such as gay men and people who injected drugs, and that it was characterized by a set of specific symptoms and opportunistic infections.   Based on this epidemiological evidence, researchers were able to identify risk factors for the disease and develop diagnostic criteria for AIDS. The first diagnostic criteria for AIDS were based on the presence of certain clinical symptoms and conditions, such as opportunistic infections and certain types of cancer, in combination with evidence of immune system dysfunction.  

Option B (the bacteriological method) and Option D (the viroscopic method) are not applicable to AIDS, as AIDS is not caused by a bacterium or visible virus. AIDS is caused by the human immunodeficiency virus (HIV), which was not identified until later in the epidemic.   Option C (the virological method) is relevant to the identification of HIV as the causative agent of AIDS, but was not initially used to diagnose the disease.   Option E (the serological method) is relevant to the diagnosis of AIDS, as it involves the detection of antibodies to HIV in the blood.

However, the development of serological tests for HIV was a later development in the AIDS epidemic, and the initial diagnosis of AIDS was based on clinical symptoms and epidemiological evidence.   Therefore, based on the information provided, the diagnostics of the AIDS epidemic initially was made in the USA by means of the epidemiological method.


22. A 20-year-old woman has a 3-4 month history of bloody diarrhoea; stool examination proved negative for ova and parasites; stool cultures negative for clostridium, campylobacter and yersinia; normal small bowel series; edema, hyperemia and ulceration of the rectum and sigmoid colon seen on sigmoidoscopic examination. Select the most likely diagnosis:

A. Ulcerative colitis

B. Gastroenteritis

C. Carcinoid syndrome

D. Zollinger-Ellison syndrome

E. Granulomatous colitis


Answer: Ulcerative colitis

Explanation

The presence of bloody diarrhea, negative stool tests for ova and parasites, negative stool cultures for common bacterial pathogens, and sigmoidoscopic findings of edema, hyperemia, and ulceration of the rectum and sigmoid colon are highly suggestive of ulcerative colitis.  

Ulcerative colitis is an inflammatory bowel disease that affects the lining of the colon and rectum, and can cause symptoms such as bloody diarrhea, abdominal pain, and urgency to defecate. The disease can be limited to the rectum and sigmoid colon, or can involve the entire colon.  

Option B (gastroenteritis) is less likely, as the duration of symptoms and the negative stool cultures make an infectious cause less likely.   Option C (carcinoid syndrome) and Option D (Zollinger-Ellison syndrome) are both rare conditions that are not typically associated with the symptoms described in the case.  

Option E (granulomatous colitis) is a less likely diagnosis, as the sigmoidoscopic findings described in the case are not typically associated with granulomatous colitis.   Therefore, based on the information provided, the most likely diagnosis for this 20-year-old woman with bloody diarrhea, negative stool tests and cultures, and sigmoidoscopic findings of rectal and sigmoid ulcerations is ulcerative colitis.


23. A 36-year-old alcoholic patient has cirrhosis and pancreatic insufficiency due to recurrent pancreatitis. He complains of night blindness, decreased ability to taste food, and dry skin with hyperpigmentation. These complaints suggest deficiency of:

A. Zinc

B. Copper

C. Selenium

D. Chromium

E. Manganese


Answer:  Zinc

Explanation

The patient’s history of alcoholism, cirrhosis, and pancreatic insufficiency due to recurrent pancreatitis increases the likelihood of nutritional deficiencies, including zinc deficiency.   Zinc is an essential mineral that is important for a number of bodily functions, including immune function, wound healing, and taste and smell perception. Zinc deficiency can cause a variety of symptoms, including night blindness, decreased ability to taste food, and skin changes such as hyperpigmentation and dryness.  

Option B (copper) deficiency can also cause skin changes and neurological symptoms, but is less likely in this case, as copper deficiency is not typically associated with pancreatic insufficiency or recurrent pancreatitis.   Option C (selenium) deficiency can cause a variety of symptoms, including muscle weakness and fatigue, but is less likely in this case, as the symptoms described are not typical of selenium deficiency.   Option D (chromium) deficiency is rare, and is not typically associated with the symptoms described in the case.  

Option E (manganese) deficiency is also rare, and is not typically associated with the symptoms described in the case.   Therefore, based on the information provided, the most likely deficiency in this alcoholic patient with cirrhosis and pancreatic insufficiency who complains of night blindness, decreased ability to taste food, and skin changes is zinc deficiency.


24. A 60-year-old woman, mother of 6 children, developed a sudden onset of upper abdominal pain radiating to the back, accompanied by nausea, vomiting, fever and chills. Subsequently, she noticed yellow discoloration of her sclera and skin. On physical examination the patient was found to be febrile with temp. of 38, 9oC, along with right upper quadrant tenderness. The most likely diagnosis is:

A. Choledocholithiasis

B. Benign biliary stricture

C. Malignant biliary stricture

D. Carcinoma of the head of the pancreas

E. Choledochal cyst


Answer:  Choledocholithiasis

Explanation

The sudden onset of upper abdominal pain radiating to the back, along with nausea, vomiting, fever and chills, and subsequent yellow discoloration of the sclera and skin, are highly suggestive of choledocholithiasis.   Choledocholithiasis is a condition in which gallstones become lodged in the common bile duct, causing obstruction of the flow of bile from the liver to the small intestine. This can cause symptoms such as abdominal pain, nausea, vomiting, fever, jaundice, and right upper quadrant tenderness.  

Option B (benign biliary stricture) and Option C (malignant biliary stricture) are less likely in this case, as the sudden onset of symptoms and subsequent yellow discoloration of the sclera and skin suggest an acute process such as choledocholithiasis, rather than a gradual narrowing or obstruction of the bile duct.  

Option D (carcinoma of the head of the pancreas) may cause similar symptoms, but is less likely in this case, as the right upper quadrant tenderness suggests a more localized process such as choledocholithiasis.  

Option E (choledochal cyst) is a rare congenital abnormality that can cause obstruction of the bile duct, but is less likely in this case, as the sudden onset of symptoms suggests an acute process rather than a congenital abnormality.   Therefore, based on the information provided, the most likely diagnosis for this 60-year-old woman with sudden onset of upper abdominal pain, fever, chills, and subsequent yellow discoloration of the sclera and skin is choledocholithiasis.


25. A 30-year-old patient with complaints of occipital headache, disturbed sleep with nightmares came to a policlinic. BP was 150/95 mm Hg. He was diagnosed with hypertensic crisis. The patient should be registered in the following dispensary group for arterial hypertension surveillance:

A. In the second

B. In the first

C. In the fourth

D. In the third

E. In the fifth


Answer: In the second

Explanation

The second dispensary group includes patients with stage 2 hypertension, which is defined as a systolic blood pressure of 140-159 mm Hg or a diastolic blood pressure of 90-99 mm Hg. The patient described in the case has a systolic blood pressure of 150 mm Hg and a diastolic blood pressure of 95 mm Hg, which falls within the criteria for stage 2 hypertension.  

Additionally, the patient is experiencing symptoms of hypertensive crisis, such as occipital headache and disturbed sleep with nightmares, which further supports the need for close surveillance and management of their hypertension.   Option A (in the first dispensary group) is not appropriate, as the first dispensary group includes patients with stage 1 hypertension, which is defined as a systolic blood pressure of 130-139 mm Hg or a diastolic blood pressure of 80-89 mm Hg.  

Option C (in the fourth dispensary group) is not appropriate, as the fourth dispensary group includes patients with severe hypertension, which is defined as a systolic blood pressure of 180 mm Hg or higher or a diastolic blood pressure of 110 mm Hg or higher.   Option D (in the third dispensary group) is not appropriate, as the third dispensary group includes patients with moderate hypertension, which is defined as a systolic blood pressure of 160-179 mm Hg or a diastolic blood pressure of 100-109 mm Hg.  

Option E (in the fifth dispensary group) is not appropriate, as the fifth dispensary group is reserved for patients with secondary hypertension, which is hypertension caused by an underlying medical condition.   Therefore, based on the information provided, the patient with stage 2 hypertension and symptoms of hypertensive crisis should be registered in the second dispensary group for arterial hypertension surveillance.


26. A young patient who came to a poli-clinic was diagnosed with the 1 stage of hypertension. How often should he undergo the medical check-up?

A. Twice a year

B. Once a year

C. 3 times a year

D. 4 times a year

E. 5 times a year


Answer:  Twice a year

Explanation

The young patient diagnosed with stage 1 hypertension should undergo medical check-ups at least once every six months, which means the patient should be examined twice a year.   Stage 1 hypertension is defined as a systolic blood pressure of 130-139 mm Hg or a diastolic blood pressure of 80-89 mm Hg.

Patients with stage 1 hypertension are considered to be at higher risk for cardiovascular disease, and therefore require regular monitoring and management.   The American Heart Association recommends that patients with stage 1 hypertension have a medical check-up at least every six months to monitor their blood pressure and assess their overall cardiovascular risk.  

Option C (3 times a year), Option D (4 times a year), and Option E (5 times a year) are all more frequent than the recommended frequency of medical check-ups for patients with stage 1 hypertension.   Therefore, based on the information provided, the young patient diagnosed with stage 1 hypertension should undergo medical check-ups at least twice a year.


27. A 45-year-old male patient was admitted to the intensive care unit because of myocardial infarction. An hour later the ventricular facilitation occurred. Which of the following should be administered?

A. Defibrillation

B. External chest compression

C. Lidocaine injection

D. Adrenalin injection

E. Cardiac pacing


Answer:  Defibrillation

Explanation

The immediate treatment for ventricular fibrillation, a type of life-threatening arrhythmia that can occur following a myocardial infarction, is defibrillation. Therefore, the correct answer is A. Defibrillation.   Defibrillation is the administration of an electric shock to the heart to restore its normal rhythm.

It is the most effective treatment for ventricular fibrillation and pulseless ventricular tachycardia.   Option B (external chest compression) is a component of cardiopulmonary resuscitation (CPR), but is not the immediate treatment for ventricular fibrillation.   Option C (lidocaine injection) is used to treat ventricular arrhythmias, but is not the immediate treatment for ventricular fibrillation.  

Option D (adrenaline injection) is used in the treatment of cardiac arrest, but is not the immediate treatment for ventricular fibrillation.   Option E (cardiac pacing) may be used in certain types of arrhythmias, but is not the immediate treatment for ventricular fibrillation.   Therefore, based on the information provided, the immediate treatment for the patient with ventricular fibrillation following myocardial infarction is defibrillation.


28. A 47-year-old obese man complained of periodic attacks of acute arthritis in the st left tarsophalangeal joint. Lab exam revealed increased serum rate of uric acid. What is the diagnosis?

A. Gout arthritis

B. Reiter’s disease

C. Rheumatoid arthritis

D. Rheumatic arthritis

E. Osteoarthritis

Answer: Gout arthritis

Explanation

The most likely diagnosis for the 47-year-old obese man with periodic attacks of acute Gout is a form of inflammatory arthritis caused by the deposition of uric acid crystals in joints and other tissues. It typically affects the joint at the base of the big toe, but can also affect other joints, including the tarsophalangeal joint.  

Obesity is a risk factor for gout, as it is associated with increased uric acid levels in the blood. Increased serum uric acid levels, as seen in this case, are a key diagnostic feature of gout.   Option B (Reiter’s disease) is a type of reactive arthritis that typically develops following an infection, and is characterized by joint pain, inflammation, and swelling, as well as other symptoms such as urethritis and conjunctivitis. It is less likely in this case, as the patient’s symptoms are localized to one joint and there is no mention of associated symptoms such as urethritis or conjunctivitis.  

Option C (rheumatoid arthritis) is a chronic autoimmune disease that typically affects multiple joints, and is characterized by joint pain, swelling, and stiffness. It is less likely in this case, as the patient’s symptoms are acute and localized to one joint, and there is no mention of other symptoms typically associated with rheumatoid arthritis.   Option D (rheumatic arthritis) is a nonspecific term that can refer to any type of arthritis that is associated with rheumatic fever or other rheumatic diseases.

It is less likely in this case, as there is no mention of a history of rheumatic fever or other rheumatic diseases.   Option E (osteoarthritis) is a degenerative joint disease that is characterized by joint pain, stiffness, and loss of function. It is less likely in this case, as the patient’s symptoms are acute rather than chronic, and there is no mention of joint degeneration or loss of function.   Therefore, based on the information provided, the most likely diagnosis for the 47-year-old obese man with periodic attacks of acute arthritis in the left tarsophalangeal joint and increased serum uric acid levels is gout arthritis.


29. A 40-year-old woman who has worked in weaving branch for 10 years complains of frequent headache, sleeplessness, irritability, fatigue, tiredness. Physical examination revealed instability of blood pressure, internal organs are without changes. What is the most likely diagnosis?

A. Noise-induced disease

B. Hypertension

C. Atopic bronchial asthma

D. Asthenovegetative syndrome

E. Encephalopathy


Answer:  Noise-induced disease

Explanation

The most likely diagnosis for the 40-year-old woman with a history of working in the weaving branch for 10 years, along with frequent headache, sleeplessness, irritability, fatigue, tiredness, and instability of blood pressure is noise-induced disease. Therefore, the correct answer is A. Noise-induced disease.  

Noise-induced disease is a condition caused by prolonged exposure to high levels of noise, and is commonly seen in people who work in noisy environments such as factories, construction sites, and airports. Symptoms of noise-induced disease can include headache, sleep disturbance, irritability, fatigue, and high blood pressure.  

Option B (hypertension) is a possible diagnosis, as the patient has instability of blood pressure. However, the patient’s history of working in a noisy environment and symptoms such as headache and sleep disturbance suggest that noise-induced disease is the more likely diagnosis.  

Option C (atopic bronchial asthma) is less likely, as the patient’s symptoms are not typical of asthma, and there is no mention of respiratory symptoms such as wheezing or shortness of breath.   Option D (asthenovegetative syndrome) is a nonspecific term that can refer to a wide range of symptoms related to dysfunction of the autonomic nervous system. However, in this case, the patient’s history of working in a noisy environment and symptoms such as headache and sleep disturbance suggest that noise-induced disease is the more likely diagnosis.  

Option E (encephalopathy) is a broad term that can refer to any disorder of the brain, but is not specific to the symptoms described in this case.   Therefore, based on the information provided, the most likely diagnosis for the 40-year-old woman with a history of working in the weaving branch for 10 years, along with frequent headache, sleeplessness, irritability, fatigue, tiredness, and instability of blood pressure is noise-induced disease.


30. A 45-year-old driver was admitted to the hospital with 5 hour substernal pain. Nitroglycerin is not effective. He is pale, heart sounds are regular but weak. HR – 96 per minute, BP of 100/60 mm Hg. What is the most likely diagnosis?

A. Acute myocardial infarction

B. Stable angina

C. Pulmonary embolism

D. Acute myocarditis

E. Acute left ventricular failure


Answer: Acute myocardial infarction

Explanation

The most likely diagnosis for the 45-year-old driver with 5 hours of substernal pain, pale appearance, weak heart sounds, lack of response to nitroglycerin, and hemodynamic instability (low blood pressure and elevated heart rate) is acute myocardial infarction. Therefore, the correct answer is A. Acute myocardial infarction.   Acute myocardial infarction (AMI) is a medical emergency that occurs when there is a sudden blockage of blood flow to the heart muscle, leading to tissue damage and chest pain. The symptoms typically include chest pain or discomfort that may radiate to the arms, neck, or back, and may be accompanied by shortness of breath, sweating, nausea, and vomiting.   In this case, the patient has been experiencing substernal pain for 5 hours, which is a key symptom of AMI. The lack of response to nitroglycerin suggests that the pain is not due to stable angina, which typically responds to nitroglycerin. The patient’s pale appearance and weak heart sounds suggest that he may be experiencing hemodynamic instability, which can occur in the setting of AMI.   Option B (stable angina) is less likely, as the patient has not responded to nitroglycerin and is experiencing hemodynamic instability.   Option C (pulmonary embolism) is less likely, as the patient’s symptoms are more suggestive of a cardiac rather than pulmonary cause. Pulmonary embolism typically presents with shortness of breath, chest pain, and coughing up blood.   Option D (acute myocarditis) is less likely, as the patient’s symptoms are more suggestive of a thrombotic event (such as an AMI) rather than an inflammatory or infectious cause.   Option E (acute left ventricular failure) is less likely, as the patient’s symptoms are more suggestive of an acute coronary event (such as an AMI) rather than heart failure.   Therefore, based on the information provided, the most likely diagnosis for the 45-year-old driver with 5 hours of substernal pain, pale appearance, weak heart sounds, lack of response to nitroglycerin, and hemodynamic instability is acute myocardial infarction.

31. A 33-year-old man with a history of rheumatic fever complains of fever up to 38 − 39oC, abdominal pain, dyspnea, tachycardia. Heart borders are displaced to the left by 2 cm, systolic and diastolic murmurs above aorta, BP of 160/30 mm Hg. Petechial rash occurs after measurement of blood pressure. Liver is enlarged by 3 cm, spleen is palpable. Urine is brown-yellow. What is the most likely diagnosis?

A. Infectious endocarditis

B. Rheumatic fever

C. Acute hepatitis

D. Acute nephritis

E. Aortic regurgitation


Answer:  Infectious endocarditis

Explanation

The most likely diagnosis for the 33-year-old man with a history of rheumatic fever, fever, abdominal pain, dyspnea, tachycardia, displaced heart borders, systolic and diastolic murmurs above the aorta, petechial rash, enlarged liver and spleen, and brown-yellow urine is infectious endocarditis.

Therefore, the correct answer is A. Infectious endocarditis.   Infectious endocarditis is an infection of the inner lining of the heart chambers and valves, typically caused by bacteria. The symptoms can include fever, abdominal pain, dyspnea, tachycardia, and petechial rash, as well as heart murmurs, splenomegaly, and other signs of systemic infection.   In this case, the patient’s history of rheumatic fever puts him at increased risk for infectious endocarditis, as rheumatic fever can cause damage to the heart valves and increase the risk of bacterial infections.

The presence of heart murmurs, displaced heart borders, and signs of systemic infection such as fever and petechial rash, all suggest the possibility of infectious endocarditis.   Option B (rheumatic fever) is less likely, as the patient’s symptoms are more suggestive of an acute infection rather than a recurrence of rheumatic fever.   Option C (acute hepatitis) is less likely, as the patient’s symptoms are more suggestive of a cardiac rather than hepatic cause, and there is no mention of symptoms such as jaundice or abnormal liver function tests.  

Option D (acute nephritis) is less likely, as the patient’s symptoms are more suggestive of a cardiac rather than renal cause, and there is no mention of symptoms such as hematuria or proteinuria.   Option E (aortic regurgitation) is a possible diagnosis, as the patient has systolic and diastolic murmurs above the aorta.

However, the presence of fever, petechial rash, and signs of systemic infection suggest that infectious endocarditis is the more likely diagnosis.   Therefore, based on the information provided, the most likely diagnosis for the 33-year-old man with a history of rheumatic fever, fever, abdominal pain, dyspnea, tachycardia, displaced heart borders, systolic and diastolic murmurs above the aorta, petechial rash, enlarged liver and spleen, and brown-yellow urine is infectious endocarditis.


32. A 30-year-old patient complains of breathlessness, pain in the right rib arc region, dry cough and the edema of legs. He is ill for 2 months. He had been treated for rheumatic fever without any effect. On exam: cyanosis, edema of legs, BT of 36, 6oC, RR of 28/min, HR of 90/min, BP of 110/80 mm Hg, crackles above low parts of both lungs, heart borders are displaced to the left and to the right, weak sounds, systolic murmur above the apex. What is the preliminary diagnosis?

A. Dilated cardiomyopathy

B. Infectious endocarditis

C. Acute myocarditis

D. Rheumatic fever, mitral stenosis

E. Acute pericarditis


Answer: Dilated cardiomyopathy

Explanation

The most likely diagnosis for the 30-year-old patient with a history of rheumatic fever, breathlessness, pain in the right rib arc region, dry cough, edema of legs, cyanosis, crackles above low parts of both lungs, displaced heart borders, weak heart sounds, and a systolic murmur above the apex is dilated cardiomyopathy. Therefore, the correct answer is A. Dilated cardiomyopathy.   Dilated cardiomyopathy is a condition characterized by enlargement of the heart chambers and weakened heart muscle, leading to symptoms such as breathlessness, fatigue, and edema.

The symptoms can develop gradually over time, or may occur suddenly in response to a viral infection or other trigger.   In this case, the patient’s history of rheumatic fever puts him at increased risk for heart disease, including dilated cardiomyopathy. The presence of breathlessness, pain in the right rib arc region, dry cough, edema of legs, cyanosis, crackles above low parts of both lungs, displaced heart borders, weak heart sounds, and a systolic murmur above the apex, all suggest the possibility of dilated cardiomyopathy.  

Option B (infectious endocarditis) is less likely, as there is no mention of the patient’s symptoms being related to a bacterial infection, and the physical exam findings are more suggestive of a primary cardiac or pulmonary process.   Option C (acute myocarditis) is less likely, as the patient’s symptoms have been present for 2 months, which is longer than the typical duration of acute myocarditis.  

Option D (rheumatic fever, mitral stenosis) is less likely, as the patient’s symptoms are more suggestive of a dilated cardiomyopathy rather than mitral stenosis, and there is no mention of a history of recurrent rheumatic fever.   Option E (acute pericarditis) is less likely, as the patient’s symptoms are more suggestive of a primary cardiac or pulmonary process rather than pericarditis, and there is no mention of pericardial friction rub or other typical signs of acute pericarditis.  

Therefore, based on the information provided, the most likely preliminary diagnosis for the 30-year-old patient with a history of rheumatic fever, breathlessness, pain in the right rib arc region, dry cough, edema of legs, cyanosis, crackles above low parts of both lungs, displaced heart borders, weak heart sounds, and a systolic murmur above the apex is dilated cardiomyopathy.


33. A full term infant was born after a normal pregnancy, delivery, however, was complicated by marginal placental detachment. At 12 hours of age the child, although appearing to be in good health, passes a bloody meconium stool. For determining the cause of the bleeding, which of the following diagnostic procedures should be performed first?

A. Barium enema

B. An Apt test

C. Gastric lavage with normal saline

D. An upper gastrointestinal series

E. Platelet count, prothrombin time, and partial thromboplastin time


Answer: Barium enema

Explanation

In a full-term infant who passes a bloody meconium stool, the first diagnostic procedure that should be performed to determine the cause of the bleeding is a barium enema. Therefore, the correct answer is A. Barium enema.   Meconium is the first stool of a newborn, which usually appears within the first 24-48 hours of life. It is thick, sticky, and dark green in color. In some cases, meconium can be mixed with blood, which can be a sign of underlying gastrointestinal pathology.  

Barium enema is a diagnostic procedure that uses X-rays and a contrast agent (barium sulfate) to evaluate the colon and rectum. It can help identify the presence of meconium ileus, which is a condition in which the meconium becomes thick and sticky, leading to obstruction of the intestine. Meconium ileus is most commonly seen in infants with cystic fibrosis, but can also occur in infants with other underlying gastrointestinal disorders.  

Option B (an Apt test) is a test that can be used to distinguish between maternal and fetal blood in cases of neonatal bleeding. However, it is not specific for identifying the cause of meconium-related bleeding.   Option C (gastric lavage with normal saline) is not a useful diagnostic procedure in this case, as the bleeding is likely originating from the lower gastrointestinal tract.   Option D (an upper gastrointestinal series) is not indicated in this case, as the bleeding is likely originating from the lower gastrointestinal tract.  

Option E (platelet count, prothrombin time, and partial thromboplastin time) may be useful in ruling out bleeding disorders as a cause of neonatal bleeding. However, it is not specific for identifying the cause of meconium-related bleeding.   Therefore, based on the information provided, the first diagnostic procedure that should be performed to determine the cause of the bleeding in a full-term infant who passes a bloody meconium stool is a barium enema.


34. A newborn infant has mild cyanosis, diaphoresis, poor peripheral pule, hepatomegaly and cardiomegaly. Respiratory rate is 60 breaths per minute, and heart rate is 230 beats per minute. The child most likely has congestive heart failure caused by:

A. Paroxysmal atrial tachycardia

B. A ventricular septal defect and transposition of the great vessels

C. Atrial flutter and partial atrioventricular block

D. Hypoplastic left heart syndrome

E. A large atrial septal defect and valvular pulmonary stenosis


Answer: Paroxysmal atrial tachycardia

Explanation

Paroxysmal atrial tachycardia is a type of abnormal heart rhythm that can cause rapid heart rate, but it does not typically cause congestive heart failure or the other symptoms described in the question.   The most likely cause of congestive heart failure in a newborn infant with these symptoms is a congenital heart defect, and specifically a ventricular septal defect (VSD) and transposition of the great vessels.

This combination of defects can cause poor oxygenation of the blood, leading to cyanosis, and can also cause increased workload on the heart, leading to cardiomegaly, hepatomegaly, and congestive heart failure. The other options listed may also cause congenital heart defects, but they do not match the specific symptoms described in the question.   Therefore, the correct answer is B. A ventricular septal defect and transposition of the great vessels.


35. A 6-year-old boy was brought to the emergency room with a 3-hour history of fever up to 39, 5oC and sore throat. The child looks alert, anxious and has a mild inspiratory stridor. You should immediately:

A. Prepare to establish an airway

B. Obtain an arterial blood gas and start an IV line

C. Order a chest x-ray and lateral view of the neck

D. Examine the throat and obtain a culture

E. Admit the child and place him in a mist tent


Answer: Prepare to establish an airwa

Explanation

While inspiratory stridor can be a sign of airway obstruction, it is important to gather more information and perform a thorough evaluation before deciding to establish an airway. In this case, the child has a fever and sore throat, which are consistent with a possible viral or bacterial infection. The mild inspiratory stridor may indicate some degree of upper airway involvement, but it is not an immediate indication for airway intervention.  

The most appropriate initial step in this scenario would be to perform a thorough evaluation of the child’s airway, breathing, and circulation (ABCs), including assessing the child for any signs of respiratory distress and monitoring oxygen saturation levels. You should also obtain a detailed medical history, perform a physical examination, and order any necessary tests or imaging studies to help determine the cause of the child’s symptoms.  

Therefore, the correct initial step in this scenario would be to perform a thorough evaluation of the child’s ABCs and obtain a detailed medical history, rather than immediately preparing to establish an airway.


36. For a patient with a stab injury to the femoral artery, the treatment of choice is:

A. End- to-end anastomosis

B. Interposition of autogenous vein graft

C. Ligation of both transected ends

D. Interposition of homologous arterial graft

E. Interposition of Dacron graft


Answer: End- to-end anastomosis

Explanation

Stab injury to the femoral artery can cause significant bleeding and requires prompt treatment to control bleeding and restore blood flow to the affected area. End-to-end anastomosis is a surgical technique that involves connecting the two ends of a severed artery using sutures or other techniques.

This technique is often the treatment of choice for femoral artery injuries, as it allows for restoration of blood flow and can help prevent complications such as ischemia or tissue necrosis.   However, the specific treatment for a femoral artery injury will depend on the extent of the injury, the location of the injury, and other individual factors. In some cases, interposition of autogenous vein graft, interposition of homologous arterial graft, or interposition of Dacron graft may be necessary to repair the injured artery.

Ligation of both transected ends is generally not recommended, as it can result in loss of blood flow to the affected area and may cause complications.   Therefore, while end-to-end anastomosis is generally the treatment of choice for a stab injury to the femoral artery, the specific treatment approach will depend on the individual case and should be determined by a qualified medical professional.


37. Which of the following best summarizes indications for operation on an abdominal aortic aneurysm?

A. Any aneurysm greater than 5 cm in diameter

B. Any abdominal aortic aneurysm

C. Only symptomatic aneurysm

D. Only symptomatic aneurysm greater than 5 cm in diameter

E. Only ruptured aneurysm


Answer: Any aneurysm greater than 5 cm in diameter

Explanation

The size of an abdominal aortic aneurysm is an important factor in determining whether surgery is necessary, as larger aneurysms are at greater risk of rupture and other complications. In general, aneurysms that are greater than 5 cm in diameter are considered to be at high risk of rupture and may require surgery.  

However, the decision to operate on an abdominal aortic aneurysm will also depend on other factors, such as the location of the aneurysm, the patient’s age and overall health, and the presence of other risk factors or symptoms.

For example, aneurysms that are located near or involve important blood vessels or organs may require surgery even if they are smaller than 5 cm in diameter.   Therefore, while the size of an abdominal aortic aneurysm is an important factor in determining whether surgery is necessary, the decision to operate will depend on a variety of individual factors and should be made by a qualified medical professional on a case-by-case basis.


38. Which of the following symptoms is the most typical for the adenoid hypertrophy?

A. Nasal obstruction

B. Deglutition disturbance

C. Olfaction disturbance

D. Giddiness

E. Headache


Answer: Nasal obstruction

Explanation

Adenoid hypertrophy is a condition in which the adenoid tissue, located in the back of the nasal cavity, becomes enlarged and obstructs the nasal passage. This can cause a variety of symptoms, but the most typical symptom is nasal obstruction, which can lead to difficulty breathing through the nose, especially at night or during physical activity.  

While other symptoms such as deglutition disturbance (difficulty swallowing), olfaction disturbance (impaired sense of smell), giddiness, or headache may occur with adenoid hypertrophy, they are less typical and may be indicative of other underlying conditions.   Therefore, the most typical symptom of adenoid hypertrophy is nasal obstruction.


39. A 30-year-old woman complains of nasal blockage, sneezing, watery nasal discharges. The body temperature is normal. Objectively – edema of nasal mucous membrane on both sides, especially of the lower turbinate (with cyanosis). Blood test data – mild leukocytosis and eosinophilia. What is the diagnosis?

A. Allergic rhinitis

B. Foreign body in the nose

C. Infective rhinitis

D. Atrophic rhinitis

E. Acute sinusitis


Answer: Allergic rhinitis

Explanation

The symptoms described, including nasal blockage, sneezing, watery nasal discharge, and edema of the nasal mucous membrane, are typical of allergic rhinitis, which is an inflammatory disorder of the nasal mucosa caused by an allergic reaction to environmental allergens such as pollen, dust mites, or animal dander.   The presence of eosinophilia in the blood test is also supportive of an allergic etiology, as eosinophils are a type of white blood cell that is often elevated in allergic conditions.  

Foreign body in the nose, infective rhinitis, atrophic rhinitis, and acute sinusitis may also cause nasal symptoms, but they are less likely given the absence of other typical symptoms like fever, purulent discharge, or foul odor.   Therefore, the most likely diagnosis based on the symptoms and blood test findings is allergic rhinitis.


40. A 27-year old patient with malaria caused by P. falciparum was treated with Chloroquine (600 mg base followed by 300 mg base in 6 hours, then 300 mg base a day for 2 days) without clinical and parasitologic responses to the treatment. What is the most likely reason for the failure to respond to the therapy?

A. Chloroquine resistant strain of P. falciparum

B. Glucose-6-phosphate dehydrogenase deficiency in patient

C. Late recognition of infection due to P. falciparum

D. Inappropriate route of administration

E. Hypersensitivity of the patient to Chloroquine


Answer: Chloroquine resistant strain of P. falciparum

Explanation

Chloroquine is an antimalarial drug that has been used for many years to treat malaria caused by Plasmodium falciparum. However, in recent years, there has been an increasing prevalence of chloroquine-resistant strains of P. falciparum, which can lead to treatment failure.  

In this case, the lack of clinical and parasitologic response to chloroquine therapy suggests that the patient’s malaria infection may be caused by a chloroquine-resistant strain of P. falciparum. Resistance to chloroquine can occur due to changes in the parasite’s genetic makeup, which can make it less susceptible to the effects of the drug.  

Glucose-6-phosphate dehydrogenase deficiency, late recognition of infection due to P. falciparum, inappropriate route of administration, and hypersensitivity of the patient to chloroquine are all possible factors that could contribute to treatment failure in malaria. However, given the lack of response to chloroquine therapy, chloroquine-resistant P. falciparum is the most likely reason for the treatment failure in this case.   Therefore, the most likely reason for the failure to respond to chloroquine therapy in this case is a chloroquine-resistant strain of P. falciparum.


41. Ten hours before initial observation patient had frequent feces and vomiting. Fecal and vomiting masses looked like rice-water. Nausea and abdominal pain weren’t observed. Hiccup and convulsions of lower limbs, temperature 35, 4oC, hoarse voice, greyish wry face, acrocyanosis were observed. Respiratory rate 40/min, threadlike pulse 120/min, blood pressure 40/0 mm/Hg, abdomen is drawn. What treatment measures should be taken first of all?

A. Intravenous rehydration

B. Antibiotic therapy

C. Cardiac glycosides

D. Disintoxicational therapy

E. Antibotulinic serum injection


Answer:  Intravenous rehydration

Explanation

The symptoms described are consistent with cholera, which is a severe diarrheal illness caused by the bacterium Vibrio cholerae. The “rice-water” appearance of the fecal and vomiting masses is a characteristic feature of cholera.   The patient is presenting with signs of severe dehydration and shock, including low blood pressure, rapid respiratory rate, and threadlike pulse. These symptoms require immediate treatment to restore fluid and electrolyte balance and prevent further complications.  

The most appropriate initial treatment measure for this patient would be intravenous rehydration, which involves administering fluids and electrolytes directly into the bloodstream to rapidly restore fluid balance and prevent shock. Antibiotic therapy may also be necessary to treat the underlying infection, but it should be initiated after rehydration has been achieved.  

Cardiac glycosides, disintoxicational therapy, and antibotulinic serum injection are not appropriate treatments for cholera and would not address the underlying cause of the patient’s symptoms.   Therefore, the most urgent treatment measure for this patient with cholera would be intravenous rehydration to restore fluid and electrolyte balance and prevent further complications.


42. A nurse of the kindergarten was taken to the hospital with complaints of accute pain in parumbilical region, convulsions of lower limbs, multiple bile vomiting, frequent watery foul feces of green colour in huge amounts. At the same time all the staff in the kindergarden got ill. Two days ago all of them ate cottage cheese with sour cream. General condition of patients is of moderate severity. Temperature 38, 2oC. Heart tones: rhythmic and muted. Heart rate 95/min, arterial pressure: 160 mm/Hg. Abdomen is slightly swollen, painful. Liver +2 cm. What is the most likely diagnosis?

A. Salmonellosis

B. Dysentery

C. Cholera

D. Food toxic infection

E. Enterovirus infection


Answer: Salmonellosis   

Explanation

While the symptoms described, including acute pain in the umbilical region, convulsions, multiple vomiting, and watery foul feces, are consistent with a gastrointestinal infection, the specific cause of the infection cannot be determined based on the information provided.  

Salmonellosis, dysentery, and food toxic infection are all possible causes of the symptoms described, as they can all cause gastrointestinal symptoms such as abdominal pain, vomiting, and diarrhea. However, additional information such as the presence of fever, blood in the stool, or recent consumption of contaminated food or water would be needed to make a definitive diagnosis.  

Cholera is less likely based on the absence of typical symptoms like “rice-water” stools and severe dehydration, although it cannot be completely ruled out without further information.   Enterovirus infection is less likely based on the presence of gastrointestinal symptoms and absence of typical symptoms like rash or respiratory symptoms.   Therefore, while salmonellosis is a possible cause of the symptoms described, additional information and diagnostic testing would be needed to confirm the diagnosis.


43. A 45-year-old woman, mother of four children, comes to the emergency room complaining of a sudden onset of the epigastric and right upper quadrant pain, radiating to the back, accompanied by vomiting. On examination, tenderness is elicited in the right upper quadrant, bowel sounds are decreased, and laboratory data shows leukocytosis, normal serum levels of amylase, lipase, and bilirubin. The most likely diagnosis is:

A. Acute cholecystitis

B. Perforated peptic ulcer disease

C. Myocardial infarction

D. Sigmoid diverticulitis

E. Acute pancreatitis


Answer: Acute cholecystitis

Explanation

The symptoms described, including sudden onset of epigastric and right upper quadrant pain, radiating to the back, accompanied by vomiting, and tenderness in the right upper quadrant, are typical of acute cholecystitis, which is inflammation of the gallbladder.  

Decreased bowel sounds and leukocytosis are also consistent with acute cholecystitis, as is the lack of elevation in serum levels of amylase, lipase, and bilirubin, which would be expected in acute pancreatitis.   Perforated peptic ulcer disease can also cause sudden onset of abdominal pain and vomiting, but it would be more likely to present with signs of peritonitis, such as rebound tenderness and guarding.  

Myocardial infarction and sigmoid diverticulitis are less likely based on the location and nature of the pain, as well as the absence of other typical symptoms.   Therefore, based on the symptoms and laboratory data presented, the most likely diagnosis is acute cholecystitis.


44. A 50-year-old man comes to the emergency room with a history of vomiting of 3 days’ duration. His past history examination reveals that for about 20 years he has been suffering from epigasric pain lasting for 2 to 3 weeks, during early spring and autumn. He remembers getting relief from pain by taking milk and antacids. Physical examination showed a fullness in the epigastric area with visible peristalsis, absence of tenderness, and normal active bowel sounds. The most likely diagnosis is:

A. Gastric outlet obstruction

B. Small bowel obstruction

C. Volvulus of the colon

D. Incarcerated umbilical hernia

E. Cholecystitis


Answer: Gastric outlet obstruction

Explanation

The patient’s history of recurring epigastric pain that is relieved by milk and antacids suggests a diagnosis of peptic ulcer disease. The vomiting of 3 days’ duration may be a sign of gastric outlet obstruction, which can occur as a complication of peptic ulcer disease.  

Physical examination findings of fullness in the epigastric area with visible peristalsis, absence of tenderness, and normal active bowel sounds are also suggestive of gastric outlet obstruction.   Small bowel obstruction and volvulus of the colon would typically present with more severe symptoms, such as abdominal distension, high-pitched bowel sounds, and signs of peritonitis.  

Incarcerated umbilical hernia is less likely based on the absence of a palpable hernia and the location of the symptoms.   Cholecystitis would typically present with symptoms such as right upper quadrant pain, nausea, and fever, which are not described in this case.   Therefore, based on the history and physical examination findings, the most likely diagnosis is gastric outlet obstruction, which can occur as a complication of peptic ulcer disease.


45. A 24-year-old law student is brought to the emergency room complaining of severe abdominal pain of 6-8 hours duration. He had been to a party the night before. The pain is in the epigastrium radiating to the back and is accompanied by nausea. The patient had vomited twice prior to coming to the emergency room. Clinical examination revealed that the young man was anxious, with acute condition, with a regular pulse rate of 100/min, blood pressure of 100/68 mm Hg, and body temperature of 38, 1oC. The most likely diagnosis is:

A. Acute pancreatitis

B. Acute cholecystitis

C. Acute appendicitis

D. Acute diverticulitis

E. Mesenteric adenitis


Answer:  Acute pancreatitis

Explanation

The patient’s history of severe abdominal pain in the epigastrium radiating to the back, nausea, and vomiting, along with the presence of a fever, tachycardia, and hypotension, are all suggestive of acute pancreatitis.   Acute cholecystitis can also present with similar symptoms, but it would be more likely to present with tenderness in the right upper quadrant and a positive Murphy’s sign.  

Acute appendicitis typically presents with lower right quadrant pain and tenderness, and acute diverticulitis would typically present with left lower quadrant pain.   Mesenteric adenitis is an inflammation of lymph nodes in the mesentery that can cause abdominal pain and fever, but it is less likely to present with the severe and acute onset of symptoms described in this case.   Therefore, based on the symptoms and clinical examination findings, the most likely diagnosis is acute pancreatitis.


46. In which of the following disorders does the pathophysiology of portal hypertension involve presinusoidal intrahepatic obstruction?

A. Congenital hepatic fibrosis

B. Alcoholic cirrhosis

C. Hemochromatosis

D. Budd-Chiari syndrome

E. Cavernomatous transformation of the portal vein


Answer: Congenital hepatic fibrosis

Explanation

In congenital hepatic fibrosis, the pathophysiology of portal hypertension involves presinusoidal intrahepatic obstruction, which refers to obstruction of the portal vein before it enters the liver and divides into smaller branches (i.e., pre-sinusoidal).  

This obstruction can lead to increased resistance to blood flow in the portal vein, causing portal hypertension. The obstruction is caused by fibrous tissue that forms in the portal tracts and surrounds the bile ducts, blood vessels, and hepatic parenchyma.   In alcoholic cirrhosis, hemochromatosis, and cavernomatous transformation of the portal vein, the pathophysiology of portal hypertension involves sinusoidal obstruction, which refers to obstruction of blood flow within the liver sinusoids themselves.  

Budd-Chiari syndrome is a rare disorder that can cause both presinusoidal and sinusoidal obstruction, depending on the underlying cause.   Therefore, the most likely disorder in which the pathophysiology of portal hypertension involves presinusoidal intrahepatic obstruction is congenital hepatic fibrosis.


47. A 25-year-old man was admitted to a hospital with a 2 month history of cough and fever. A chest x-ray showed extensive left upper lobe disease with a 2 cm cavity. All three points were strongly positive on direct smear and grew M. Tuberculosis, fully sensitive to all first-line drugs. Patient must be treated with:

A. Isoniazid + rifampicin + pyrazinamide

B. Streptomycin + isoniazid

C. Isoniazid + ethambutol

D. Kanamycin + ethambutol + pyrazinamide

E. P-aminosalicylic acid + streptomycin


Answer: Isoniazid + rifampicin + pyrazinamide

Explanation

The patient has a positive smear for M. tuberculosis and is fully sensitive to all first-line drugs, which makes him a candidate for standard short-course chemotherapy.   The standard treatment regimen for drug-sensitive pulmonary tuberculosis is a combination of isoniazid, rifampicin, pyrazinamide, and ethambutol for the first 2 months, followed by isoniazid and rifampicin for an additional 4 months.

However, since the patient has extensive disease with a cavity, the initial intensive phase should be extended to 3 months.   Streptomycin is also a first-line drug for tuberculosis, but it is usually reserved for cases where the patient cannot tolerate or has contraindications to one of the other first-line drugs.  

Kanamycin and p-aminosalicylic acid are second-line drugs, which are used in cases of drug-resistant tuberculosis or when the patient cannot tolerate first-line drugs.   Therefore, the most appropriate treatment regimen for this patient would be isoniazid, rifampicin, and pyrazinamide for the first 3 months, followed by isoniazid and rifampicin for an additional 4 months.


48. A 5-year-old boy was progressively getting worse compared to the previous 2 months. A chest x-ray has shown right middle lobe collapse. A tuberculin skin test was strongly positive. What is the most characteristic finding in primary tuberculosis?

A. Hilar or paratracheal lymph node enlargement B. Atelectasis with obstructive pneumonia

C. Cavity formation

D. Miliary tuberculosis

E. Hematogenous dissemination leading to extrapulmonary tuberculosis


Answer:  Hilar or paratracheal lymph node enlargement B. Atelectasis with obstructive pneumonia

Explanation

 In primary tuberculosis, the most characteristic finding is hilar or paratracheal lymph node enlargement, which can be seen on chest x-ray. This is known as the Ghon complex, and it represents the primary focus of infection.  

Atelectasis with obstructive pneumonia can also be seen in primary tuberculosis, especially when there is involvement of a lobar or segmental bronchus. This can result in collapse of the affected lobe or segment, as seen in the case of the 5-year-old boy described in the question.  

Cavity formation is more commonly seen in secondary tuberculosis, which occurs as a result of reactivation of latent tuberculosis infection.   Miliary tuberculosis and hematogenous dissemination leading to extrapulmonary tuberculosis can also occur in both primary and secondary tuberculosis, but they are less common than the Ghon complex and atelectasis with obstructive pneumonia.  

Therefore, based on the question’s description of a 5-year-old boy with right middle lobe collapse and a strongly positive tuberculin skin test, the most characteristic finding in primary tuberculosis is atelectasis with obstructive pneumonia.


49. A 50-year-old man was examined in the clinic for persistent cavitation and sputum. He was treated with rifampicin, isoniazid, ethambuthol. The most common toxic effect of ethambutol is:

A. Optic neuritis

B. Eighth cranial nerve damage

C. Hepatic enzyme elevation

D. Peripheral neuropathy

E. Mental symptoms


Answer: Optic neuritis

Explanation

Ethambutol is a first-line drug used in the treatment of tuberculosis, but it can cause toxic effects, especially when used at high doses or for prolonged periods of time. The most common toxic effect of ethambutol is optic neuritis, which is inflammation of the optic nerve that can lead to visual disturbances.  

Eighth cranial nerve damage and peripheral neuropathy are more commonly associated with other drugs used in the treatment of tuberculosis, such as streptomycin.   Hepatic enzyme elevation can occur with isoniazid and rifampicin, but it is not a common toxic effect of ethambutol.  

Mental symptoms are not a common toxic effect of ethambutol, although they can occur in rare cases.   Therefore, based on the question’s description of a patient being treated for tuberculosis with rifampicin, isoniazid, and ethambutol, the most common toxic effect of ethambutol is optic neuritis.


50. A 3-year-old child has been admi-tted to a hospital because of ostealgia and body temperature rise up to 39oC. Objectively: the patient is in grave condition, unable to stand for ostealgia, there is apparent intoxication, lymph nodesare enlarged up to 1,5 cm. Liver can be palpated 3 cm below the costal margin, spleen – 2 cm below the costal margin. In blood: RBCs – 3, 0·1012/l, Hb- 87 g/l, colour index – 0,9, thrombocytes – 190 · 109/l, WBCs – 3, 2 · 109/l, eosinophils – 1, stab neutrophils – 1, segmented neutrophils – 0, lymphocytes – 87, monocytes – 2, ESR – 36 mm/h. What examination should be conducted in order to specify the diagnosis?

A. Sternal puncture

B. Ultrasound

C. Lymph node puncture

D. Lymph node biopsy

E. Computer tomography


Answer: Sternal puncture

Explanation

The patient’s clinical presentation, including ostealgia, fever, lymphadenopathy, and hepatosplenomegaly, is suggestive of a hematological malignancy such as leukemia.   In order to confirm the diagnosis, a bone marrow examination is required.

The gold standard for bone marrow examination is a sternal puncture, which involves inserting a needle into the sternum to aspirate bone marrow.   Ultrasound, lymph node puncture, lymph node biopsy, and computer tomography may be useful in the evaluation of lymphadenopathy, but they are not specific for the diagnosis of leukemia.  

Therefore, based on the patient’s clinical presentation and laboratory findings, the most appropriate examination to specify the diagnosis is a sternal puncture to obtain a bone marrow sample for examination.
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