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All Previous Years Krok 2 Papers with Explanations

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51. A 27-year-old patient complains of pain in the symmetrical joints of the hands, fever, and morning stiffness. The disease onset was acute. Laboratory testing detected rheumatoid factor, high titer of C-reactive protein, and high titer of antibodies to citrullinated vimentin. X-ray revealed isolated erosions of interphalangeal joints. What initial basic treatment must be prescribed in this case?

A. Xanthine oxidase inhibitors

B. NSAIDS

C. ACE inhibitors

D.Methotrexate

E. Celecoxib

Answer: Methotrexate

Explanation

Clinical Presentation:
Pain in symmetrical joints of the hands, fever, and morning stiffness are characteristic symptoms of rheumatoid arthritis (RA).Laboratory Findings:

Presence of rheumatoid factor, high titer of C-reactive protein (CRP), and antibodies to citrullinated vimentin are common serological markers associated with RA.Radiographic Findings:
X-ray evidence of isolated erosions of interphalangeal joints is consistent with joint damage seen in rheumatoid arthritis.Treatment:

Methotrexate (Option D): It is a disease-modifying antirheumatic drug (DMARD) commonly used as the initial treatment for rheumatoid arthritis. It helps to control symptoms, slow the progression of joint damage, and improve long-term outcomes.Differential Diagnosis for Other Options:

Option A (Xanthine Oxidase Inhibitors): Used in the treatment of gout, not the first-line treatment for rheumatoid arthritis.Option B (NSAIDs): Provide symptomatic relief but are not considered disease-modifying in rheumatoid arthritis.Option C (ACE Inhibitors): Used in conditions like hypertension and heart failure, not the primary treatment for rheumatoid arthritis.

Option E (Celecoxib): A selective COX-2 inhibitor, primarily used for pain relief but not a disease-modifying agent for RA.Therefore, based on the disease presentation and current understanding of RA management, the most appropriate initial treatment is methotrexate (Option D).

52. A patient complains of pain, photophobia, lacrimation, and impaired vision in the right eye. The visual acuity of the right eye is 0.5, which cannot be corrected, the visual acuity of the left eye is 1.0. Objectively, the palpebral fissure is narrowed in the right eye, peri- corneal injection of the eyeball is observed. Precipitates were detected on the posterior corneal surface. The pupil is narrowed, the response to light is slowed. Floating opacities are observed in the anterior part of the vitreous body. The fundus is normal. What is the most likely diagnosis in this case?

A. Acute glaucoma attack

B. Posterior uveitis

C. Bacterial conjunctivitis

D. Acute iridocyclitis

E. Acute keratitis

Answer: Posterior uveitis

Explanation

The patient’s complaint of pain, photophobia, lacrimation, and impaired vision in the right eye suggests an inflammatory process affecting the eye.The visual acuity of the right eye is significantly reduced and cannot be corrected, indicating a severe impairment of vision.

The narrowed palpebral fissure, peri-corneal injection of the eyeball, and the presence of precipitates on the posterior corneal surface are consistent with uveitis, which is inflammation of the uveal tract comprising the iris, ciliary body, and choroid.The narrowed pupil with a slowed response to light is a sign of iris involvement.

Floating opacities in the anterior part of the vitreous body suggest inflammation within the posterior segment of the eye.The normal fundus indicates that the inflammation has not extended to the posterior part of the eye beyond the uvea.

In contrast, acute glaucoma attack (Option A) typically presents with a sudden increase in intraocular pressure, causing severe eye pain, headache, and visual disturbances. Bacterial conjunctivitis (Option C) is more likely to present with redness and discharge from the conjunctiva, and acute iridocyclitis (Option D) would typically involve inflammation of the iris and ciliary body.
Therefore, based on the clinical presentation, the most fitting diagnosis is B. Posterior uveitis.

53. After repeated disinfection of the surgical instruments with a weak solution of a liquid disinfectant, a nurse gradually developed skin inflammation on the palmar surfaces of her hands. Objectively, her palms are edematous. Diffuse erythema without clear boundaries is observed on the palms, with isolated papular rash elements present against its background. The results of allergic skin testing are negative. What is the most likely diagnosis in this case?

A. Toxicoderma (drug corruption)

B. Eczema

C. Erysipelas

D. Chemical burn

E. Contact dermatitis

Answer: Toxicoderma (drug corruption)

Explanation

Clinical Presentation:
Skin inflammation on the palmar surfaces of the hands following repeated disinfection with a weak solution of a liquid disinfectant suggests a skin reaction due to exposure to the disinfectant.Characteristics:
Edematous Palms: Edema observed on the palms is a sign of an inflammatory reaction.Diffuse Erythema: Widespread redness without clear boundaries indicates inflammation.Isolated Papular Rash Elements: Presence of
papular rash elements suggests a skin reaction.Diagnosis:

Toxicoderma (Drug Eruption): This term is used to describe various types of skin rashes or eruptions resulting from exposure to drugs or chemicals.Differential Diagnosis for Other Options:

B. Eczema: Eczema typically presents with red, inflamed, and itchy skin, often with a chronic course. It may have identifiable triggers, but the presentation in this case is more suggestive of a reaction to the disinfectant.C. Erysipelas: Erysipelas is a bacterial skin infection presenting with a well-demarcated, raised edge, which is not described in the scenario.

D. Chemical Burn: While a chemical burn could cause skin inflammation, the gradual development and the presence of papular rash elements are more indicative of a reaction rather than a burn.E. Contact Dermatitis: Contact dermatitis is a broad term for skin inflammation resulting from direct skin contact with an irritant or allergen. In this case, the repeated disinfection with a weak solution of a liquid disinfectant suggests a chemical exposure rather than an allergic reaction.

Therefore, based on the presentation and exposure history, toxicoderma (drug eruption) is the most likely diagnosis.

54. A 3-day-old full-term baby has the following blood test results: indirect bilirubin levels 345 mcmol/L, hourly increase 6.8 mcmol/L. The child’s condition is severe. Objectively, the child presents with decreased reflexes, muscle hypotonia, and limb tremor. The blood of the child and the mother is Rh-incompatible. What would be the most effective method of treatment in this case?

A. Administration of phenobarbital

B. Hemosorption

C. Phototherapy

D. Corticosteroid therapy

E. Exchange blood transfusion

Answer: Exchange blood transfusion

Explanation

Clinical Presentation:
Severe jaundice in a 3-day-old full-term baby, along with signs of neurotoxicity such as decreased reflexes, muscle hypotonia, and limb tremor.Laboratory Findings:
Elevated levels of indirect bilirubin (hyperbilirubinemia) indicate a buildup of unconjugated bilirubin.Rh Incompatibility:

The blood of the child and the mother being Rh-incompatible suggests the possibility of Rh hemolytic disease of the newborn (HDN), where maternal antibodies attack the baby’s red blood cells.Treatment Options:
A. Administration of Phenobarbital:Phenobarbital may help enhance the conjugation of bilirubin in the liver but is not the primary treatment for severe hyperbilirubinemia.

B. Hemosorption:Hemosorption involves removing toxins from the blood but is not the standard treatment for Rh incompatibility or hyperbilirubinemia.

C. Phototherapy:Phototherapy is effective for milder cases of jaundice but may not be sufficient for severe cases, especially in Rh hemolytic disease.

D. Corticosteroid Therapy:Corticosteroids are not the primary treatment for Rh incompatibility or severe hyperbilirubinemia.

E. Exchange Blood Transfusion:Exchange transfusion is the most effective and rapid method for reducing bilirubin levels in severe cases of hyperbilirubinemia, especially when associated with Rh incompatibility.

Conclusion:
Given the severity of the condition, neurotoxic symptoms, and the likelihood of Rh hemolytic disease, exchange blood transfusion is the most appropriate and effective method to rapidly decrease bilirubin levels and prevent complications such as kernicterus.Therefore, the correct answer is E. Exchange Blood Transfusion.

55. An 18-year-old patient complains of cramping abdominal pain, and loose stools up to 6 times a day with mucus and fresh blood. He has been ill for a year and lost 10 kg. Objectively, the abdomen is soft and painful along the large intestine, especially on the left. The sigmoid colon is spastic. Blood test results are as follows: erythrocytes 3.2-1012/L, hemoglobin – 92 g/L, leukocytes -10.6 109/L, ESR 34 mm/hour. Irrigoscopy shows that the large intestine is narrowed, there are no haustra, the contours are unclear, the “lead pipe”sign is observed. What is the most likely diagnosis in this case?

A. Crohn’s disease

B. Chronic enterocolitis

C. Shigellosis

D. Intestinal tuberculosis

E. Nonspecific ulcerative colitis

Answer: Nonspecific ulcerative colitis

Explanation

Clinical Presentation:
Symptoms: Cramping abdominal pain, loose stools with mucus and fresh blood (bloody diarrhea), significant weight loss over a year.Duration: Persistent symptoms for a year.Objective Findings:
Abdomen: Soft and painful along the large intestine, especially on the left.Colon: Sigmoid colon spastic.Blood Tests:Anemia: Low hemoglobin (92 g/L) and low erythrocyte count (3.2 × 10^12/L).Leukocytosis: Elevated leukocyte count (10.6 × 10^9/L).Elevated ESR (34 mm/hour).Imaging Findings:

Irrigoscopy (Barium Enema):Narrowed large intestine.Absence of haustra.Unclear contours.”Lead pipe” sign indicates loss of normal mucosal folds and a feature seen in ulcerative colitis.Diagnosis:
E. Nonspecific Ulcerative Colitis:Chronic inflammatory bowel disease (IBD) characterized by inflammation and ulceration of the colonic mucosa.

Symptoms include bloody diarrhea, abdominal pain, weight loss, and systemic manifestations.The spastic sigmoid colon and characteristic findings on irrigoscopy support the diagnosis.Differential Diagnosis:
A. Crohn’s Disease:Crohn’s disease can involve any part of the gastrointestinal tract, often with skip lesions, and may cause transmural inflammation. However, the specific findings here (lead pipe sign) are more indicative of ulcerative colitis.

B. Chronic Enterocolitis:A nonspecific term and not a distinct diagnosis; the presentation and findings are more consistent with ulcerative colitis.C. Shigellosis:Shigellosis typically presents acutely with fever and dysentery. A chronic, persistent presentation is less characteristic.D. Intestinal Tuberculosis:While tuberculosis can affect the intestine, the lead pipe sign and chronic nature of symptoms are more suggestive of ulcerative colitis.Therefore, the most likely diagnosis is E. Nonspecific Ulcerative Colitis.

56. A 38-year-old patient complains of pain in the lower back and left knee and ankle joints. Blood test results were as follows: leukocytes 11.109/L, ESR-38 mm/hour, CRP ++, ASL-O titer – 125 units, uric acid 375 mcmol/L, rheumatoid factor ve. Chlamydia were detected in the urethral negative- swab. X-ray shows that the articular surfaces on the left are uneven, and indistinct, the joint space is narrowed. What is the most likely diagnosis in this case?

A. Reactive polyarthritis

B. Gouty arthritis

C. Spinal osteochondrosis

D. Ankylosing spondylitis

E. Rheumatoid polyarthritis

Answer: Reactive polyarthritis

Explanation

Clinical Presentation:
Joint Pain:Lower back, left knee, and ankle joints.Laboratory Findings:Leukocytosis (11.1 × 10^9/L).Elevated ESR (38 mm/hour).CRP (C-reactive protein) is significantly increased (++) indicating inflammation.Positive rheumatoid factor (RF).Elevated ASL-O (Anti-Streptolysin O) titer (125 units).Hyperuricemia (uric acid: 375 mcmol/L).Diagnostic Workup:

Chlamydia Testing:Detected in the urethral swab.Imaging (X-ray):Uneven and indistinct articular surfaces on the left.Narrowed joint space.Diagnosis:
A. Reactive Polyarthritis:Etiology:Often triggered by an infection, in this case, Chlamydia.Clinical Features:Asymmetric arthritis, commonly involving large joints.Systemic symptoms, including fever.Laboratory Findings:Elevated acute-phase reactants (ESR, CRP).Positive rheumatoid factor in some cases.Radiographic Findings:Asymmetric joint involvement with signs of inflammation.Differential Diagnosis:

B. Gouty Arthritis:Presents with acute attacks of monoarthritis (not typically involving the lower back).Characterized by the presence of monosodium urate crystals.C. Spinal Osteochondrosis:Primarily affects the spine; unlikely to cause involvement of knee and ankle joints.D. Ankylosing Spondylitis:Chronic inflammatory arthritis affecting the spine and sacroiliac joints; less likely with asymmetric joint involvement.E. Rheumatoid Polyarthritis:Symmetrical polyarthritis with involvement of small joints; not typically associated with reactive arthritis.Therefore, the most likely diagnosis in this case is A. Reactive Polyarthritis, triggered by Chlamydia infection.

57. A 50-year-old patient complains of Headache, itchy skin, and pain in the toes and muscles, especially during walking. Objectively, the skin of the face has a red-cyanotic tint. Lymph nodes are not palpable. Pulse 180/100 mm 76/min. Blood pressure Hg. The lungs have no abnormalities. The borders of the heart are displaced to the left by 2 cm. The liver is +2 cm. The spleen is near the edge of the costal arch, dense and painless. Complete blood count: erythrocytes -6.3-1012/L, hemoglobin – 201 g/L, color index 0.8, leukocytes 10.5-109/L, eosinophils 4%, band neutrophils – 7%, segmented neutrophils – 62%, lymphocytes 22%, monocytes 5%, platelets- 500 10°/L, ESR 1 mm/hour, hematocrit – 55%. What is the most likely diagnosis in this case?

A. Obliterating endarteritis

B. Polycythemia vera

C. Cushing disease

D. Secondary erythrocytosis

E. Essential hypertension

Answer: Polycythemia vera

Explanation

Polycythemia vera is a myeloproliferative disorder characterized by an abnormal increase in the number of red blood cells in the blood. Let’s analyze the given clinical findings:

Headache, Itchy skin, and Pain in toes and muscles: These symptoms can be attributed to increased blood viscosity and reduced blood flow due to the excessive production of red blood cells.
Red-cyanotic tint of the skin: This is consistent with the increased concentration of red blood cells leading to cyanosis.

Hypertension (Blood pressure 180/100 mm Hg): Elevated blood pressure can be a consequence of increased blood volume and viscosity in PV.
Enlarged liver and spleen: Hepatosplenomegaly is a common feature in PV due to increased blood cell production.

Elevated Hemoglobin (201 g/L), Hematocrit (55%), and Platelets (500,000/mm³): These findings are indicative of polycythemia, which is the hallmark of PV.
Normal ESR (1 mm/hour): PV is associated with a low ESR, as it is primarily a disorder of the red blood cells.

Given the combination of symptoms, physical findings, and laboratory results, the most fitting diagnosis is Polycythemia vera (B). The other options are less likely based on the provided information.

58 A 63-year-old woman for the last 5 weeks presents with progressing painless jaundice, skin itching, weight loss of 10 kg, and acholia. A positive Courvoisier sign was detected during palpation. What is the most likely diagnosis in this case?

A. Pancreatic cancer

B. Liver cancer

C. Malaria

D. Viral hepatitis

E. Gallbladder cancer

Answer: Pancreatic cancer

Explanation

The patient’s clinical presentation is suggestive of obstructive jaundice, which is often associated with pancreatic cancer. Let’s break down the key features:

Painless Jaundice: Progressive painless jaundice is a classic symptom of pancreatic cancer, often indicating obstruction of the common bile duct.
Skin Itching (Pruritus): Jaundice can lead to the accumulation of bile salts in the skin, causing itching.

Weight Loss (10 kg): Unintentional weight loss is a common feature in advanced pancreatic cancer.

Acholia: Lack of bile flow can result in pale stools (acholia), as bile is necessary for the normal color of stools.

Positive Courvoisier Sign: This refers to the palpable gallbladder in the setting of painless jaundice. It is typically seen in pancreatic cancer, as opposed to gallstones causing obstruction, where the gallbladder is usually not palpable.

Given these findings, the most likely diagnosis is Pancreatic cancer (A). The other options are less likely based on the specific clinical features described.

59. A 30-year-old woman complains of sudden reddening of her right eye. photophobia, a feeling of sand in the eye. and lacrimation that appeared 3 days ago, as well as rhinitis and a fever of 38°C. Objectively, she has marked edema of the eyelids, hyperemia of the conjunctiva of transitional folds, and fine punctate hemorrhages in the conjunctiva of the upper eyelid. A small amount of mucopurulent secretion is observed. What is the most likely diagnosis in this case?

A. Bacterial conjunctivitis of the right eye

B. Adenoviral conjunctivitis of the right eye

C. Herpetic conjunctivitis of the right eye

D. Allergic conjunctivitis of the right eye

E. Tuberculous conjunctivitis of the right eye

Answer: Bacterial conjunctivitis of the right eye

Explanation

Adenoviral conjunctivitis is a common viral infection affecting the conjunctiva. Let’s analyze the given clinical findings:

Sudden Onset of Symptoms: The sudden onset of symptoms, including reddening of the right eye, photophobia, a feeling of sand in the eye, and lacrimation, is characteristic of viral conjunctivitis.

Systemic Symptoms: The presence of rhinitis and a fever of 38°C suggests a viral infection rather than a localized process.
Eyelid Edema, Conjunctival Hyperemia, and Punctate Hemorrhages: These are common findings in viral conjunctivitis, particularly caused by adenovirus.

Mucopurulent Secretion: Adenoviral conjunctivitis can produce a mucopurulent discharge.

Bacterial conjunctivitis (A) is less likely in this case, as viral conjunctivitis, particularly adenoviral, commonly presents with the described features. Other options, including herpetic conjunctivitis (C), allergic conjunctivitis (D), and tuberculous conjunctivitis (E), are less consistent with the acute onset and specific clinical findings described.

60. A 30-year-old patient has been hospitalized. The patient’s history states that the disease onset was acute and started with frequent watery stools, later followed by thirst and profuse vomiting without nausea. Objectively, the body temperature is 35.4°C. The patient’s condition is severe, the skin is cold. Tissue turgor and skin elasticity are significantly reduced. The facial features are drawn. The voice is hoarse. Acrocyanosis and anuria are observed. Pulse 130/min., weak. Blood pressure – 60/30 mm Hg. The tongue is dry. The abdomen is sunken and painless, palpation detects noticeable rumbling in the intestines. What is the most likely diagnosis in this case?

A. Cholera

B. Foodborne toxic infection

C. Salmonellosis

D. Rotavirus gastroenteritis

E. Shigellosis

Answer: Cholera

Explanation

Cholera is an acute diarrheal infection caused by the bacterium Vibrio cholerae. The key features in this case are indicative of cholera:

Acute Onset with Frequent Watery Stools: Cholera typically presents with a sudden onset of profuse watery diarrhea.

Thirst and Profuse Vomiting without Nausea: Dehydration in cholera leads to extreme thirst and vomiting without the sensation of nausea.

Hypothermia (Body temperature 35.4°C): Severe dehydration can lead to a decrease in body temperature.
Cold Skin, Reduced Tissue Turgor, and Skin Elasticity: These are signs of severe dehydration.

Facial Features Drawn, Hoarse Voice, Acrocyanosis, and Anuria: These are further signs of severe dehydration and circulatory collapse.

Tachycardia, Weak Pulse, and Hypotension: Due to the loss of fluids, there is a decrease in blood volume leading to tachycardia, weak pulse, and low blood pressure.
Dry Tongue and Sunken Abdomen: Indicators of dehydration.

Noticeable Rumbling in the Intestines: Hyperactive bowel sounds (borborygmi) are characteristic of cholera.
Given the combination of symptoms, severe dehydration, and the acute onset of watery diarrhea, the most likely diagnosis is Cholera (A). The other options are less consistent with the specific features described.

61. A 65-year-old patient complains of shortness of breath, cough with foaming pink sputum, lack of air, and fear of death. Objectively, orthopnea, pale skin, acrocyanosis, and cold sticky sweat are observed in the patient. Auscultation detects coarse breathing with wet fine and medium vesicular crackles in the inferior posterior segments on both sides. Respiratory rate 40/min. The heart sounds are sharply muffled. At the top of the heart, a gallop rhythm is observed. What is the most likely diagnosis in this case?

A. Pulmonary edema

B. Focal pneumonia

C. Bronchial asthma

D. Infarction pneumonia

E. Pulmonary thromboembolism

Answer: Pulmonary edema

Explanation

The patient’s symptoms and clinical findings are indicative of acute pulmonary edema, a condition characterized by the accumulation of fluid in the lungs. Let’s analyze the key features:

Shortness of Breath, Cough with Foaming Pink Sputum: These are classical symptoms of pulmonary edema, reflecting the presence of fluid in the airways.
Orthopnea: Difficulty breathing when lying down is a characteristic feature of pulmonary edema.

Pale Skin, Acrocyanosis, Cold Sticky Sweat: These signs suggest poor tissue perfusion, which can occur in severe pulmonary edema.

Coarse Breathing with Wet Fine and Medium Vesicular Crackles: Auscultation findings are consistent with fluid in the alveoli and bronchioles.
Respiratory Rate 40/min: Increased respiratory rate is a compensatory mechanism in response to decreased oxygenation.

Muffled Heart Sounds and Gallop Rhythm: These cardiac findings are associated with the strain on the heart in pumping against increased resistance due to pulmonary congestion.
The overall clinical picture points towards acute decompensated heart failure leading to pulmonary edema. The other options are less likely based on the specific combination of symptoms and findings described.

62. A military medical committee detected arterial hypertension in a 17-year-old boy- his blood pressure on the arms is 190/110 mm Hg. He has no complaints. A disproportionate body structure is observed – a well-developed shoulder girdle and underdeveloped legs. What study would be most informative in this case and should be used to establish the diagnosis?

A. Measuring catecholamines in urine

B. Ultrasound of the kidneys and adrenal glands

C. Dopplerography of vessels

D. Renoscintigraphy

E. Measuring the blood pressure in the legs

Answer: Measuring the blood pressure in the legs

Explanation

The clinical presentation of disproportionate body structure with a well-developed shoulder girdle and underdeveloped legs, along with hypertension in a young individual, raises suspicion of coarctation of the aorta.
Coarctation of the aorta is a congenital heart defect characterized by a narrowing of the aorta.

The upper extremities receive blood at a higher pressure than the lower extremities due to this narrowing. Therefore, measuring blood pressure in the arms and legs can help identify the pressure gradient, which is typical in coarctation of the aorta.

Options A, B, C, and D are less likely to be informative in this specific case of suspected coarctation of the aorta. The key diagnostic step in confirming this condition involves comparing blood pressure measurements in the arms and legs, making option E the most appropriate choice.

63. A 25-year-old woman complains of profuse, foul-smelling, foamy discharge from her vagina and burning and itching in the area of her genitals. She has been ill for a week and has no regular sexual partner. Vaginal examination detects foamy discharge and hyperemic vaginal mucosa that bleeds when touched. What is the most likely diagnosis in this case?

A.Trichomonas colpitis

B.Gonorrheal cervicitis

C. Chlamydial cervicitis

D. Bacterial vaginosis

E. Vaginal candida mycosis

Answer: Bacterial vaginosis

Explanation

Bacterial vaginosis is a common vaginal infection characterized by an overgrowth of certain bacteria in the vagina, leading to a shift in the normal balance of bacteria. Symptoms may include a thin, grayish-white discharge with a characteristic fishy odor, especially after sexual intercourse. Itching and burning sensations can also occur.

While the initial information mentioned foamy discharge, which is more typical of trichomoniasis, it’s important to note that bacterial vaginosis can present with a variety of discharge characteristics, and the clinical picture can vary among individuals.

64. An 11-year-old girl complains of pain in the joints, a fever of 38°C, and weakness. She fell ill 5 days ago. Objectively, she has a maculopapular rash on the bridge of her nose and on her face, the joints are not changed, the heart sounds are weakened. Blood pressure-100/80 mm Hg. Complete blood count: erythrocyte 2.6 102/L leukocytes-3.7-109/L, platelets-12-10/L, ESR 45 mm/hour, CRP (+++). General urinalysis: protein- 0.063 g/L, erythrocytes -15-20 in sight, leukocytes-10-14 in sight. What is the most likely diagnosis in this case?

A. Systemic lupus erythematosus

B. Hemorrhagic vasculitis

C. Acute rheumatic fever

D. Polyarteritis nodosa

E. Dermatomyositis

Answer: Systemic lupus erythematosus

Explanation

Maculopapular Rash on the Face: The characteristic rash, often referred to as the “butterfly rash,” is common in systemic lupus erythematosus.

Joint Pain, Fever, and Weakness: These symptoms are consistent with the systemic nature of lupus, which can affect various organs and tissues.

Weakened Heart Sounds: Cardiac involvement is possible in lupus, and weakened heart sounds may indicate myocarditis.

Low Platelet Count (Thrombocytopenia): Thrombocytopenia is a common finding in lupus, and the platelet count is significantly decreased in this case.

Elevated ESR and CRP: These inflammatory markers are often elevated in lupus, reflecting the inflammatory nature of the disease.

Proteinuria, Hematuria, and Leukocytes in Urinalysis: Renal involvement is common in lupus, and these findings suggest glomerulonephritis.

The combination of the characteristic rash, joint pain, cardiac involvement, low platelet count, and renal abnormalities strongly supports the diagnosis of systemic lupus erythematosus (A). The other options are less likely based on the specific constellation of symptoms and laboratory findings described.

65. A 47-year-old patient complains of pain in the lumbar region. The patient was provisionally diagnosed with radiculitis and a course of physiotherapy was carried out. However, the patient’s condition did not improve. X-ray of the spine and pelvis revealed osteoporosis and significant bone defects. Complete blood count revealed normochromic anemia and total protein of 107 g/L. General urinalysis revealed proteinuria of 4.0 g/L. What study is necessary to establish the final diagnosis in this case?

A. Abdominal ultrasound

B. Comprehensive blood testing

C. Sternal puncture

D. Cytochemistry of blood cells

E. Radioisotope study of the kidneys

Answer: Sternal puncture

Explanation

Pain in Lumbar Region: The patient’s complaint of lumbar pain is a symptom that can have various causes.

Osteoporosis and Significant Bone Defects: These findings on X-ray suggest a bone disorder affecting the spine and pelvis.

Normochromic Anemia: Anemia is a common consequence of various medical conditions, and normochromic anemia indicates a chronic process.

Total Protein of 107 g/L: Elevated total protein could be a result of increased production by abnormal plasma cells seen in conditions like multiple myeloma.

Proteinuria of 4.0 g/L: Significant proteinuria may indicate renal involvement.

Given these findings, the presence of bone defects, normochromic anemia, elevated total protein, and proteinuria, a disorder like multiple myeloma is a consideration. Sternal puncture (C) is necessary for obtaining a bone marrow sample and performing cytological, immunological, and cytogenetic studies to confirm the diagnosis of multiple myeloma.

66. A 20-year-old woman complains that for the last three years she has been observing a cold feeling in her fingers. First they turn bluish-white and numb and then 5-10 minutes later the skin becomes red and the fingers warm up, which is accompanied by sharp pain. What is the most likely diagnosis in this case?

A. Arteriosclerosis obliterans

B. Thromboangiitis obliterans (Buerger disease)

C. Raynaud syndrome

D. Polyneuritis

E. Obliterating endarteritis

Answer: Raynaud syndrome

Explanation

Cold Feeling in Fingers: Raynaud syndrome is characterized by episodic vasospasm of small arteries, leading to reduced blood flow to certain areas, particularly the fingers and toes.

Bluish-White and Numb Fingers: This represents the initial phase of vasoconstriction and reduced blood supply.

Skin Becomes Red and Fingers Warm Up 5-10 Minutes Later: This corresponds to the reactive hyperemia phase following the vasospasm, where there is a sudden increase in blood flow.

Sharp Pain: Pain often accompanies the reperfusion phase as blood flow is restored.

Raynaud syndrome is a disorder of the blood vessels supplying the skin, usually in the fingers and toes. The episodes can be triggered by cold temperatures or emotional stress.

The other options (A, B, D, E) are less likely based on the specific sequence of symptoms and the characteristic features of Raynaud syndrome described in this case.

67 Six hours after fibrocsophagogastroscopy, a 32-year-old woman developed a fever of 39°C, retrosternal pain, dry mouth, and increasing dyspnea. Examination detected positive Romanov-Gerke sign and subcutaneous emphysema in the left supraclavicular space. What is the most likely diagnosis in this case?

A. Acute abscess of the lung

B. Pleural empyema

C. Pneumonia

D. Pyopneumothorax

E. Acute mediastinitis

Answer: Acute mediastinitis

Explanation

Fever, Retrosternal Pain, Dry Mouth, Increasing Dyspnea: These symptoms suggest an inflammatory process in the mediastinum.

Positive Romanov-Gerke Sign: This sign indicates crepitus felt on palpation of the neck or chest wall, suggesting the presence of subcutaneous emphysema.

Subcutaneous Emphysema in the Left Supraclavicular Space: Subcutaneous emphysema can result from the spread of infection into the soft tissues.

Acute mediastinitis is a severe infection of the mediastinal connective tissue, often arising from esophageal perforation, which can occur during procedures like fibrocsophagogastroscopy.

The other options (A, B, C, D) are less likely based on the specific symptoms, signs, and context provided in the question. Acute mediastinitis is a serious condition requiring prompt diagnosis and intervention.

68. A certain statistical method can be used to study the relation between the duration of smoking and the frequency of malignant lung neoplasms being detected. What method of statistical analysis should be used in this study?

A. Comprehensive health assessment

B. Dynamic analysis

C. Normalization of strongly intensive quantities

D. Correlation analysis

E. Direct standardization

Answer: Correlation analysis

Explanation

Correlation Analysis: This statistical method is used to evaluate the strength and direction of the linear relationship between two quantitative variables. In this case, it can assess if there is a correlation between the duration of smoking and the frequency of malignant lung neoplasms.The other options are less suitable for studying the relationship between variables in this context:

Comprehensive health assessment (A): This is a broad term that includes various aspects of health evaluation and may not specifically address the relationship between smoking duration and lung neoplasms.

Dynamic analysis (B): While dynamic analysis may involve studying changes over time, correlation analysis is more appropriate when examining the association between two continuous variables.
Normalization of strongly intensive quantities (C): This term is not directly related to the statistical analysis of relationships between variables.

Direct standardization (E): This is a method used for adjusting rates in different populations, not for assessing the correlation between two continuous variables.
Therefore, Correlation analysis (D) is the most suitable method for studying the relationship between the duration of smoking and the frequency of malignant lung neoplasms in this study.

69 A 19-year-old young woman complains of absence of menstruation, lethargy, and weight loss. One year ago she had a pathological childbirth with significant blood loss and no lactation after the childbirth. Vaginal examination shows that the vagina is narrow, the uterus is reduced in size, and the ovaries are not palpable. Laboratory testing detected hypoestrogenemia. What is the most likely diagnosis In this case?

A. Astheno-vegetative syndrome

B. Genital tuberculosis

C. Sheehan syndrome

D. Hypothyroidism

E. Stein-Leventhal syndrome

Answer: Sheehan syndrome

Explanation

Absence of Menstruation, Lethargy, Weight Loss: These symptoms may suggest a hormonal imbalance, particularly involving the reproductive system.

Pathological Childbirth with Significant Blood Loss: Sheehan syndrome is a condition characterized by pituitary necrosis following severe postpartum hemorrhage.

No Lactation after Childbirth: Failure of lactation is a common feature in Sheehan syndrome due to damage to the pituitary gland.

Vaginal Examination Findings: Narrow vagina, reduced uterine size, and non-palpable ovaries are consistent with the atrophic changes associated with hormonal deficiency.
Hypoestrogenemia: Low estrogen levels are expected in Sheehan syndrome due to the pituitary dysfunction affecting gonadotropin release.

The other options (A, B, D, E) are less likely based on the specific clinical features described in the question. Sheehan syndrome is a form of hypopituitarism resulting from ischemic necrosis of the pituitary gland following severe postpartum hemorrhage, leading to deficiencies in multiple hormones, including those regulating reproductive functions.

70. Chemical analysis of the water has detected increased concentration of nitrogen-

containing salts, iron and sulfates. What parameter of water quality is most informative in such cases and indicates fresh contamination of water with organic substances of

Animal origin?

A. NO2

B. SO4

C. NH3

D. NO3

E. Fe

Answer: NH3

Explanation

Increased Concentration of Nitrogen-Containing Salts: Ammonia (NH3) is a nitrogen-containing compound, and its increased concentration in water can indicate contamination with organic substances, particularly of animal origin.

Increased Concentration of Sulfates (SO4): While sulfates are present in many compounds, they are not specific indicators of fresh contamination with organic substances.

Increased Concentration of Iron (Fe): Elevated iron levels may suggest contamination, but it is not specifically indicative of fresh organic contamination.
NO2 (Nitrites) and NO3 (Nitrates): These are nitrogen compounds, but they are more associated with different stages of nitrogen oxidation in water and may not specifically indicate fresh organic contamination.

In summary, the presence of increased ammonia (NH3) concentration is more likely to indicate fresh contamination of water with organic substances of animal origin.

71. Examination detected 24-hour proteinuria of 2.2 g in a 30-year-old woman. Biopsy revealed changes in the glomerular capillary walls in the shape of wire loops. What

morphological form of kidney damage is indicated by the biopsy results?

A. Mesangial glomerulonephritis

B. IgA nephropathy

C. Nephrosclerosis

D. Dilluse lupus glomerulonephritis

E. Membranous glomerulonephritis

Answer: Dilluse lupus glomerulonephritis

Explanation

24-Hour Proteinuria of 2.2 g: Significant proteinuria is often associated with glomerular pathology.

Changes in Glomerular Capillary Walls in the Shape of Wire Loops: Wire loop lesions are a characteristic histological finding in Lupus Nephritis, specifically in the diffuse proliferative form.

Lupus Nephritis is a common manifestation of systemic lupus erythematosus (SLE) involving the kidneys. The wire loop lesions indicate immune complex deposition and inflammation in the glomeruli.

The other options (A, B, C, E) are associated with different forms of glomerulonephritis or kidney damage, but the description of wire loops is particularly indicative of the diffuse proliferative form of lupus glomerulonephritis.

72. A 30-year-old woman complains of abdominal discomfort on the left, pain in the joints, fever, and periodic hemorrhage Objectively, hepatorenal syndrome observed. Complete blood count revealed the following: leukocytes-200-10/L numerous granulocytes at various degrees of maturity myoblast < 5 % in the bone marrow. The Rh-chromosome is positive. What is the most likely diagnosis in this case?

A. Myelofibrosis

B. Leukemoid reaction

C. Acute leukemia

D. Malignant tumor

E. Chronic myeloid leukemia

Answer: Chronic myeloid leukemia

Explanation

Abdominal Discomfort on the Left, Pain in Joints, Fever, and Periodic Hemorrhage: These symptoms are consistent with systemic manifestations often seen in chronic myeloid leukemia.
Hepatorenal Syndrome: This can occur in the advanced stages of CML due to infiltration of the organs by leukemic cells.

Complete Blood Count Findings: The presence of leukocytosis with numerous granulocytes at various degrees of maturity and myeloblasts in the bone marrow is typical of CML.
Rh-Chromosome Positive: The characteristic chromosomal abnormality in CML is the Philadelphia chromosome, which results from a reciprocal translocation between chromosomes 9 and 22 [t(9;22)].

CML is a myeloproliferative disorder characterized by the abnormal proliferation of granulocytes in the bone marrow. The Philadelphia chromosome is a hallmark of CML, and it leads to the formation of the BCR-ABL fusion gene, a constitutively active tyrosine kinase that drives the excessive proliferation of myeloid cells.

The other options (A, B, C, D) are less likely based on the specific combination of symptoms, laboratory findings, and the presence of the Philadelphia chromosome.

73. A 65-year-old man was diagnosed with hypertension and ischemic heart disease

and prescribed pharmacotherapy. Two weeks later, he consulted a doctor about edemas on his lower legs. Examination detected no signs of diseases with the course that includes edematous syndrome. A side effect of the medication is suspected. What drug has such a side effect?

A. Acetylsalicylic acid

B. Amlodipine

E. Ramipril

D. Bisoprolol

E. Atorvastatin

Answer: Amlodipine

Explanation

Edemas on Lower Legs: Peripheral edema is a known side effect associated with calcium channel blockers, including amlodipine.
Hypertension and Ischemic Heart Disease: Amlodipine is commonly prescribed to manage hypertension and ischemic heart disease.

While other antihypertensive medications may have side effects, amlodipine is particularly known for causing peripheral edema. It’s important to note that individual responses to medications can vary, and side effects may not occur in everyone.

The other options (A, C, D, E) are less likely to cause edematous syndrome, and their main indications and side effect profiles differ from those of amlodipine.

74. A 65-year-old woman with diabetes mellitus was undergoing treatment with

metformin. Because of high blood pressure, she was taking diuretics. Gradually, the

effectiveness of the diuretic decreased and nausea and vomiting appeared. Objectively,

the patient does not respond to stimuli, her skin is dry, the smell of acetone is absent.

Blood pressure – 180/100 mm Hg. The heart sounds are muffled, pulse – 98/min. Her

respiration is vesicular. The liver is +4 cm. Blood testing revealed the following: glucose

– 48 mmol/L, Na – 156 mmol/L, K – 5,2 mmol/L, urea – 15 mmol/L. What complication has developed in the patient?

A. Lactic Acidotic coma

B. Hyperosmolar coma

C. Hypoglycemic coma

D. Dyscirculatory coma

E. Kétoacidotic coma

Answer: Hyperosmolar coma

Explanation

High Blood Pressure: The elevated blood pressure can be associated with various complications in diabetes, including hyperosmolar coma.

Nausea, Vomiting, Dry Skin, Lack of Response to Stimuli: These symptoms are indicative of severe dehydration and neurological impairment, which can occur in hyperosmolar coma.
Blood Glucose Level: The elevated glucose level (48 mmol/L) is consistent with hyperglycemia, a characteristic feature of hyperosmolar coma.

High Sodium Level (Na): The elevated sodium level (156 mmol/L) is indicative of hyperosmolarity.
Ketone Smell Absent: The absence of the smell of acetone suggests that the patient is not in ketoacidosis.

Hyperosmolar coma is a severe complication of uncontrolled diabetes characterized by profound dehydration, hyperglycemia, and hyperosmolarity without significant ketoacidosis.
The other options (A, C, D, E) are less likely based on the specific combination of symptoms, laboratory findings, and the absence of ketone smell.

75. A 13-year-old girl complains of pain in the area of her heart, palpitations, feeling hot, dizziness, weakness. These complaints appeared 2 months ago, the girl lost 4 kg of weight, Her performance at school became worse and she developed a sleep problem. Objectively, she is tearful and irritable, presenting with a finger is trembling. Increased moisture of her skin, and reduced tissue turgor. Heart rate — 104/min. Palpation detects dense and painless thyroid gland that is enlarged to a third-degree goiter. What is the most likely diagnosis in this case?

A. Non-rheumatic carditis

B. Rheumatic chorea

C. Vegetative-vascular dysfunction

D. Diffuse toxic goiter

E. Endemic goiter

Answer: Diffuse toxic goiter

Explanation

Symptoms: The combination of palpitations, feeling hot, weight loss, irritability, and trembling fingers suggests hyperthyroidism.

Enlarged and Dense Thyroid Gland: The presence of a painless and enlarged thyroid gland is indicative of goiter, and in this context, it is specifically described as a third-degree goiter.

Increased Heart Rate (104/min): Tachycardia is a common cardiovascular manifestation of hyperthyroidism.
Tearful, Irritable, Trembling Fingers: These behavioral and neurological symptoms are consistent with hyperthyroidism.

Considering the overall clinical picture, including symptoms, signs, and an enlarged thyroid gland, the most likely diagnosis is diffuse toxic goiter, which is often associated with Graves’ disease.
The other options (A, B, C, E) are less likely based on the specific combination of symptoms and the presence of an enlarged, painless thyroid gland.

76. A district center is being supplied with water from an interlayer water-bearing stratum with high levels of calcium and magnesium salts. What is the optimal method of water treatment that should be applied before pumping the water into the distribution network?

A. Softening

B. Desalination

C. Decontamination

D. Ozonation

E. Sedimentation

Answer: Softening

Explanation

High Levels of Calcium and Magnesium Salts: The presence of calcium and magnesium salts in water leads to hardness, which can result in the formation of scale in pipes and appliances.
Softening: Softening is a water treatment process that aims to reduce the hardness of water by removing or exchanging calcium and magnesium ions. This is typically achieved through methods such as ion exchange or the addition of chemicals that precipitate these ions.

Softening helps prevent the negative effects of hardness, such as scale formation, which can clog pipes and reduce the efficiency of water heaters and other appliances.
The other options (B, C, D, E) are less relevant for addressing the specific issue of hardness due to calcium and magnesium salts in the water. Desalination (B) is more relevant for removing salts but is not specifically designed for calcium and magnesium salts. Decontamination (C), Ozonation (D), and Sedimentation (E) address different aspects of water treatment and are not directly focused on water hardness.

77. After being stung by a bee, an 18-year-old patient feels hot and presents with dyspnea and edema of her lip, face, and neck. The patient’s breathing is difficult and noisy, the patient has a cough. The skin is pale and cold to the touch. Blood pressure 75/50 mm Hg. Pulse 98/min., there. Tachycardia is observed, the heart sounds are muffled and rhythmic. What is the most likely diagnosis in this case?

A. Urticaria

B. Status asthmaticus

C. Anaphylactic shock

D. Hypotonic crisis

E. Quincke’s edema

Answer: Anaphylactic shock

Explanation

Bee Sting: The history of being stung by a bee indicates a potential allergic reaction.

Symptoms: The combination of dyspnea, edema of lip, face, and neck, difficulty breathing, noisy breathing, cough, pale and cold skin, low blood pressure, tachycardia, muffled and rhythmic heart sounds are indicative of a severe allergic reaction, progressing to anaphylactic shock.

Hypotension: The low blood pressure (75/50 mm Hg) is a characteristic feature of anaphylactic shock.
Anaphylactic shock is a severe, life-threatening allergic reaction that can occur rapidly after exposure to an allergen, in this case, a bee sting. The symptoms involve multiple systems, including the respiratory and cardiovascular systems.

The other options (A, B, D, E) are less likely based on the specific combination of symptoms and the history of a bee sting. Anaphylactic shock is a medical emergency that requires immediate intervention, typically with epinephrine, to reverse the severe allergic reaction.

78. A 32-year-old woman complains of general weakness, headache, excess body weight, pain in her bones, and irregular menstrual cycle. Objectively, her skin is dry and cyanotic. Purple-cyanotic stretch marks are observed in the area of her abdomen, shoulders, and thighs. Fat deposition is mainly observed on the face, neck, and trunk. Blood pressure 165/100 mm Hg. Blood testing revealed glucose of 72 mmol/L and elevated ACTH levels X-ray of the bones revealed signs of osteoporosis What is the most likely diagnosis in this case?

A. Cushing syndrome

B. Cushing disease

C. Alimentary obesity

D. Pathological climacteric syndrome

E. Essential hypertension

Answer: Cushing disease

Explanation

General Weakness, Headache, Excess Body Weight, Bone Pain, Irregular Menstrual Cycle: These symptoms are suggestive of an endocrine disorder, particularly one affecting the adrenal glands.
Dry and Cyanotic Skin, Purple-Cyanotic Stretch Marks (Striae): These are characteristic features of Cushing syndrome, indicating skin changes associated with excess cortisol.

Fat Deposition on Face, Neck, and Trunk: The distribution of fat, especially on the face (moon face) and trunk (central obesity), is a classic feature of Cushing syndrome.
Elevated Blood Pressure: Hypertension is common in Cushing syndrome due to the effects of excess cortisol.

Blood Glucose Level of 72 mmol/L: Elevated blood glucose levels can be seen in Cushing syndrome due to the diabetogenic effects of cortisol.

Elevated ACTH Levels: This suggests that the excess cortisol production is likely due to an overstimulation of the adrenal glands by adrenocorticotropic hormone (ACTH), pointing towards Cushing syndrome rather than Cushing disease.

Cushing syndrome refers to the clinical features resulting from chronic exposure to excess glucocorticoids. Cushing disease specifically refers to Cushing syndrome caused by a pituitary adenoma secreting excessive ACTH.
The other options (B, C, D, E) are less likely based on the specific combination of symptoms, signs, and laboratory findings described in the question.

79. A 24-year-old patient complains of sharp pain and a rash in the form of small vesicles on the left side of the trunk. The patient associates this condition with overexposure to cold. Objectively, small vesicles cluster together on the skin of the trunk on the left, along the nerve. Inflammatory erythema is observed on the periphery of the vesicles What is the most likely diagnosis in this case?

A. Eczema

B. Dermatitis herpetiformis (Duhring’s disease)

C. Shingles

D. Herpes simplex

E. Dermatitis

Answer: Shingles

Explanation

Sharp Pain and Rash: Shingles is characterized by sharp, burning pain and a rash of small vesicles.
Location on the Left Side of the Trunk along a Nerve: Shingles typically follows the distribution of a dermatome, reflecting the affected nerve.

Clustering of Vesicles along the Nerve: The vesicles in shingles tend to cluster along the path of the affected nerve.

Inflammatory Erythema on the Periphery of Vesicles: The presence of inflammatory erythema around the vesicles is a characteristic feature of shingles.

Association with Overexposure to Cold: While shingles is not directly caused by cold exposure, stress or illness can trigger a reactivation of the varicella-zoster virus, leading to shingles.
Shingles is caused by the reactivation of the varicella-zoster virus, which also causes chickenpox. After a person has had chickenpox, the virus can remain dormant in the nerve cells and later reactivate, causing shingles.

The other options (A, B, D, E) are less likely based on the specific combination of symptoms, location, and clustering of vesicles along a nerve. Shingles is a painful condition, and prompt medical attention is recommended for appropriate management.

80. On the second day after a thyroidectomy, the patient presents with seizures, numbness and sensation of “crawling ants in her hands and feet, and positive Chvostek and Trousseau signs. What complication has developed in the patient?

A. Laryngeal nerve injury

B. Residual manifestations of thyrotoxicosis

C. Hypoparathyroidism

D. Thyrotoxic crisis (thyroid storm)

E. Hypothyroidism

Answer: Hypoparathyroidism

Explanation

Seizures, Numbness, “Crawling Ants” Sensation: These symptoms are characteristic of hypocalcemia, which can occur due to hypoparathyroidism after a thyroidectomy. The parathyroid glands, which regulate calcium levels, can be inadvertently damaged or removed during thyroid surgery.

Positive Chvostek and Trousseau Signs: These signs are clinical manifestations of hypocalcemia. Chvostek sign is the twitching of facial muscles in response to tapping over the facial nerve, and Trousseau sign is carpal spasm induced by inflating a blood pressure cuff above systolic pressure.

Timing after Thyroidectomy: The onset of symptoms on the second day after thyroidectomy is consistent with the time frame in which hypoparathyroidism-related symptoms might become apparent.
Hypoparathyroidism can result in low calcium levels, leading to neuromuscular irritability and the symptoms described.

The other options (A, B, D, E) are less likely based on the specific combination of symptoms and the timing after thyroidectomy. Laryngeal nerve injury (A) might present with voice changes; residual manifestations of thyrotoxicosis (B) are less likely after thyroidectomy; thyrotoxic crisis (D) is characterized by hyperthyroidism symptoms; and hypothyroidism (E) would not typically present with seizures and positive Chvostek and Trousseau signs.

81. A 32-year-old woman complains of aching pain in her lower abdomen and intensified and painful menstruation. She has a history of 2 abortions and no childbirth. Objectively. The skin is pale, the abdomen is soft and painless, a tumor-like mass is palpable above the pubis. Bimanual examination shows that the body of the uterus is enlarged to 14 weeks of pregnancy, dense, mobile, and with an uneven surface. The appendages are not palpable. What is the most likely diagnosis in this case?

A. Kidney tumor

B. Ovarian cystoma

C. Pregnancy

D. Nodular uterine leiomyoma

E. Endometriosis

Answer: Nodular uterine leiomyoma

Explanation

Aching Pain in Lower Abdomen, Intensified and Painful Menstruation: These symptoms are common presentations of uterine leiomyomas, also known as fibroids.
History of Abortions and No Childbirth: While the history is not specific, uterine leiomyomas are known to be associated with reproductive factors, and nulliparity may be a risk factor.

Pale Skin: This is a non-specific finding, but it may suggest anemia, which can be associated with uterine bleeding from fibroids.
Abdominal Examination: Palpation of a tumor-like mass above the pubis is consistent with the presence of a uterine fibroid.

Bimanual Examination: Enlargement of the uterus to 14 weeks of pregnancy, with a dense, mobile, and uneven surface, further supports the diagnosis of uterine leiomyoma.
Uterine leiomyomas are common benign tumors of the uterus, and they often present with symptoms such as pelvic pain, heavy menstrual bleeding, and reproductive issues.

The other options (A, B, C, E) are less likely based on the specific combination of symptoms, examination findings, and clinical context. Kidney tumor (A), ovarian cystoma (B), and pregnancy (C) would have different characteristic features and examination findings, and endometriosis (E) typically presents with different symptoms and findings.

82. A 62-year-old woman undergoes treatment for bilateral gonarthrosis and has been regularly taking diclofenac sodium for 2 years. During the last six months she notes clevations of her blood pressure to 160/100 mm Hg. X-ray of the knee joints shows decreased height of the intra-articular space, marginal growths on the articular surfaces, and epiphyseal osteoporosis. General urinalysis shows the following specific gravity- 1010, erythrocytes – 5-6 in sight, leukocytes -10-12 in sight, casts (cylinders) – 0-1 in sight, glucose not detected, protein-0.22 g/L. Fasting plasma glucose-6.3 mmol/L What is the most likely cause of the changes observed in the general urinalysis?

A. Tubulointerstitial nephritis

B. Diabetic nephropathy

C. Hypertensive nephropathy

D. Urolithiasis

E. Chronic glomerulonephritis

Answer: Tubulointerstitial nephritis

Explanation

History of Diclofenac Sodium Use: Prolonged use of nonsteroidal anti-inflammatory drugs (NSAIDs) like diclofenac sodium is associated with the development of tubulointerstitial nephritis. NSAIDs can cause renal side effects, including interstitial nephritis.

Elevations of Blood Pressure: The patient has experienced elevated blood pressure (160/100 mm Hg), which can be associated with renal involvement.
X-ray Findings in Knee Joints: The X-ray findings are consistent with gonarthrosis and may be unrelated to the changes in the general urinalysis.

Urinalysis Findings: The specific gravity is normal, but there are elevated levels of erythrocytes and leukocytes. The presence of casts (cylinders) suggests renal involvement.
Normal Glucose and Fasting Plasma Glucose: Exclusion of diabetes as a cause of the renal changes.

Tubulointerstitial nephritis is characterized by inflammation and damage to the renal tubules and interstitium. Drug-induced tubulointerstitial nephritis is a well-known adverse effect of NSAIDs, and it can lead to renal dysfunction.

The other options (B, C, D, E) are less likely based on the specific combination of history, medication use, and urinalysis findings. Diabetic nephropathy (B) and hypertensive nephropathy (C) would typically present with different patterns of urinalysis findings. Urolithiasis (D) might cause changes in urinalysis, but the medication history and other findings make it less likely. Chronic glomerulonephritis (E) would have different characteristic features on urinalysis.

83 A 20-year-old patient came to a doctor with complaints of à rash that appeared on the skin. Objectively, on the skin of the trunk, arms, and the back of the neck, there is a macular rash with light brown spots 1-3 cm in size that in some places merge together. The results of the Balzer test are positive. What is the most likely diagnosis in this case?

A. Secondary syphilis

B. Pityriasis rosea

C. Parapsoriasis

D. Microbial eczema

E. Tinea versicolor (Pityriasis versicolor)

Answer: Tinea versicolor (Pityriasis versicolor)

Explanation

Macular Rash with Light Brown Spots: Tinea versicolor is a superficial fungal infection caused by the yeast Malassezia furfur. It often presents with multiple, well-defined, light brown to hypopigmented macules on the trunk, arms, and neck.

Positive Balzer Test: The Balzer test involves scraping off the scales from the affected area and observing them under the microscope. The presence of hyphae and spores confirms the diagnosis of tinea versicolor.
Appearance of Rash: The rash may vary in color, and the spots can merge together, creating larger areas of involvement.

Tinea versicolor is a common superficial fungal infection that often occurs in young adults. The yeast responsible for this infection is a part of the normal skin flora but can overgrow under certain conditions, leading to the characteristic skin changes.

The other options (A, B, C, D) are less likely based on the specific characteristics of the rash and the positive Balzer test. Secondary syphilis (A) would typically present with a different pattern of rash. Pityriasis rosea (B) may have a herald patch and a different distribution. Parapsoriasis (C) and microbial eczema (D) are less likely based on the described rash and test results.

84.A 20-year-old patient came to a doctor with complaints of general weakness, increased body temperature, swelling and pain in the joints, and a rash on the lower legs. Chest X-ray revealed enlarged internal thoracic lymph nodes. What is the most likely diagnosis in this case?

A. Lymphogranulomatosis

B. Sarcoidosis

C. Pulmonary tuberculosis

D. Lung cancer

E. Mediastinitis

Answer: Sarcoidosis

Explanation

General Weakness, Increased Body Temperature, Swelling, and Pain in Joints: These are nonspecific symptoms that can be associated with various conditions. However, in the context of other findings, they may raise suspicion for certain diseases.

Rash on Lower Legs: Cutaneous involvement is not uncommon in sarcoidosis. Skin lesions in sarcoidosis can present in various forms, including erythema nodosum, which is characterized by painful red nodules typically seen on the shins.

Enlarged Internal Thoracic Lymph Nodes on Chest X-ray: Enlarged lymph nodes are a characteristic finding in sarcoidosis, particularly in the mediastinal region.
Sarcoidosis is a multisystem inflammatory disease of unknown cause, often affecting the lungs, skin, and lymph nodes. The characteristic noncaseating granulomas are a key pathological feature.

The other options (A, C, D, E) are less likely based on the combination of symptoms, chest X-ray findings, and clinical context. Lymphogranulomatosis (A) is another term for Hodgkin’s lymphoma, but it typically presents differently. Pulmonary tuberculosis (C) might cause lymph node enlargement but is less likely to explain the skin involvement.

Lung cancer (D) may cause lymphadenopathy but usually presents with specific pulmonary findings. Mediastinitis (E) is an inflammation of the mediastinum and would not typically present with the characteristic findings described in sarcoidosis

85. A 14-year-old girl complains of a maculopapular rash along her body, a fever of 38.5°C, and a sore throat. Objectively, she has enlarged cervical and submandibular lymph nodes and hyperemic oropharyngeal mucosa, her tongue and tonsils are coated with white plaque. Palpation revealed hepato- and splenomegaly. What is the most likely diagnosis in this case?

A. Infectious mononucleosis

B. Enterovirus infection

C. Scarlet fever

D. Viral hepatitis A

E. Chronic myeloid leukemia

Answer: Infectious mononucleosis

Explanation

Maculopapular Rash, Fever, and Sore Throat: These symptoms are common features of infectious mononucleosis.

Enlarged Cervical and Submandibular Lymph Nodes: Lymphadenopathy is a characteristic finding in infectious mononucleosis.

Hyperemic Oropharyngeal Mucosa with Coated Tongue and Tonsils: The white plaque on the tongue and tonsils can be indicative of exudative pharyngitis, a common feature of infectious mononucleosis.
Hepatomegaly and Splenomegaly: Enlargement of the liver (hepatomegaly) and spleen (splenomegaly) is often seen in infectious mononucleosis.

Infectious mononucleosis is commonly caused by the Epstein-Barr virus (EBV) and occasionally by the cytomegalovirus (CMV). The disease primarily affects adolescents and young adults.

The other options (B, C, D, E) are less likely based on the specific combination of symptoms and clinical context. Enterovirus infection (B) may cause different manifestations. Scarlet fever (C) is associated with Streptococcus pyogenes and presents with a characteristic rash. Viral hepatitis A (D) may cause hepatic symptoms but is less likely to explain the entire clinical picture. Chronic myeloid leukemia (E) is a malignancy and would typically have a different presentation.

86. Throughout the last month a 2-month-old baby had paroxysms of irritability, restlessness, and crying that started for no apparent reason. Such episodes occur during the feeding or immediately after. Noticeable relief often occurs after defecation. The duration of the episodes is approximately three hours a day. Between the episodes, the child is calm, has a good appetite, and the increase in body weight is physiological. What is the most likely diagnosis in this case?

A. Baby colic

B. Functional dyspepsia

C. Lactase deficiency

D. Functional constipation

E. Infant dyschezia

Answer: Baby colic

Explanation

Paroxysms of Irritability, Restlessness, and Crying: These are characteristic features of baby colic. Colicky episodes are often characterized by inconsolable crying without an apparent reason.
Episodes During or After Feeding: Colic often occurs after feeding, causing distress to both the baby and the parents.

Relief After Defecation: Relief after defecation is a common feature of baby colic. Colic is often a self-limiting condition that resolves as the baby’s digestive system matures.
Calm Between Episodes, Good Appetite, Physiological Weight Gain: Babies with colic typically have periods of calmness between episodes, exhibit a good appetite, and experience normal weight gain, reassuring that the condition is not affecting overall growth.

Baby colic is a common condition in infants, and while the exact cause is not well understood, it is thought to be related to gastrointestinal immaturity and sensitivity.
The other options (B, C, D, E) are less likely based on the specific combination of symptoms and the age of the infant. Functional dyspepsia (B), lactase deficiency (C), functional constipation (D), and infant dyschezia (E) present with different patterns of symptoms and would not fully explain the described clinical scenario.

87. A 32-year-old patient has been hospitalized into the surgical department with clinical signs of hemorrhagic shock two hours after receiving a closed abdominal injury During the surgery, a rupture of the spleen was diagnosed, the patient has up to 15 liters of liquid blood in the abdominal cavity. No damage to the hollow organs was detected. What type of transfusion must be provided in this case?

A. Exchange blood transfusion

B. Direct blood transfusion

C. Indirect blood transfusion

D. Transfusion is not indicated

E. Reinfusion

Answer: Direct blood transfusion

Explanation

Rupture of the Spleen: The patient has a diagnosed rupture of the spleen, resulting in significant hemorrhage with up to 15 liters of blood in the abdominal cavity.
Clinical Signs of Hemorrhagic Shock: The patient presents with clinical signs of hemorrhagic shock, indicating a rapid loss of blood.

Closed Abdominal Injury: The injury is described as closed, suggesting that there is no breach in the skin, and the hemorrhage is internal.
No Damage to Hollow Organs Detected: The absence of damage to hollow organs is mentioned, emphasizing the focus on the spleen.

Direct blood transfusion (B) involves the transfusion of blood directly from a donor to the recipient. This can be particularly important in cases of acute, massive blood loss, such as in this scenario with a ruptured spleen and significant hemorrhage.

The other options (A, C, D, E) are not appropriate in the context of acute hemorrhagic shock and the need for immediate blood replacement. Exchange blood transfusion (A) is a specific procedure used for conditions such as sickle cell disease. Indirect blood transfusion (C) is not a recognized term in transfusion medicine. Transfusion is not indicated (D) would be incorrect in the presence of hemorrhagic shock. Reinfusion (E) typically refers to the collection and reinfusion of a patient’s own blood and may not be suitable for acute massive hemorrhage.

88. A 30-year-old woman has a history of three spontaneous miscarriages and one premature childbirth. Examination revealed es and lupus anticoagulant. What is the most positive reaction to anticardiolipin antibodi likely diagnosis in this case?

A. Hemorrhagic syndrome

B. Antiphospholipid syndrome

C. Stein-Leventhal syndrome

D. Sheehan syndrome

E. Testicular feminization syndrome

Answer: Antiphospholipid syndrome

Explanation

History of Three Spontaneous Miscarriages and One Premature Childbirth: Recurrent pregnancy loss is a common feature of antiphospholipid syndrome. The syndrome is associated with thrombosis, including thrombosis of placental vessels, leading to complications such as recurrent miscarriages.

Positive Anticardiolipin Antibodies and Lupus Anticoagulant: Antiphospholipid syndrome is characterized by the presence of specific autoantibodies, including anticardiolipin antibodies and lupus anticoagulant. These antibodies can contribute to thrombosis and adverse pregnancy outcomes.

Association with Autoimmune Disorders: Antiphospholipid syndrome is often associated with autoimmune disorders, and the presence of these antibodies contributes to a hypercoagulable state.
Other Options: The other options (A, C, D, E) are less likely based on the clinical context. Hemorrhagic syndrome (A) is unlikely given the history of thrombotic events. Stein-Leventhal syndrome (C) is associated with polycystic ovary syndrome, which may have different manifestations. Sheehan syndrome (D) is related to pituitary infarction after childbirth. Testicular feminization syndrome (E) is a genetic condition related to androgen insensitivity in individuals with a female phenotype despite having XY chromosomes.

Antiphospholipid syndrome is an autoimmune disorder characterized by the presence of antiphospholipid antibodies, which can lead to thrombosis and adverse pregnancy outcomes. The clinical features often involve recurrent miscarriages, thrombosis, and the presence of specific autoantibodies.

89. A 44-year-old woman complains of generally feeling unwell, chills, a fever of 39°C, and constant burning pain, skin redness, and edema in the area of her left lower leg. The onset of the disease she associates with a scratch on the skin of her left lower leg that she received two days ago. Objectively, in the middle third of the left lower leg, there is a bright area of skin hyperemia with clear borders raised above the unchanged skin. Moderate edema of soft tissues is observed, the soft tissues are painful during palpation. In the center of the hyperemic skin, there is a scab 2×0.2 cm in size that covers a small superficial wound. What complication of microtrauma of the left lower leg is observed in the patient?

A. Acute purulent osteomyelitis

B. Gas gangrene

C. Acute deep vein thrombophlebitis

D. Erysipelas

E. Phlegmon

Answer: Erysipelas

Explanation

Bright Skin Hyperemia with Clear Borders Raised Above the Unchanged Skin: Erysipelas is characterized by a well-demarcated, raised, and erythematous skin lesion with clear borders.
Moderate Edema of Soft Tissues: Edema is commonly associated with erysipelas, and the affected area is typically warm and tender.

Scab in the Center of Hyperemic Skin Covering a Small Superficial Wound: The patient’s description of a scratch on the skin and the presence of a scab align with the entry point for infection in erysipelas.
Systemic Symptoms (Chills, Fever, Feeling Unwell): Erysipelas is often associated with systemic symptoms, including fever and malaise.

Erysipelas (D) is a bacterial skin infection usually caused by beta-hemolytic streptococci, commonly Streptococcus pyogenes. It typically involves the superficial layers of the skin and can arise from minor skin injuries or breaks.

The other options (A, B, C, E) are less likely based on the clinical context. Acute purulent osteomyelitis (A) involves deeper structures and is not typically associated with the described skin changes. Gas gangrene (B) is characterized by tissue necrosis and gas production, which is not evident in this case. Acute deep vein thrombophlebitis (C) would typically present with swelling and tenderness along the course of a deep vein. Phlegmon (E) is a diffuse, spreading inflammation of soft tissues, but erysipelas is more likely given the specific skin findings described.

90. A 45-year-old patient complains of abdominal pain and discomfort that occur in emotionally straining situations. Objectively, no changes were detected in the gastrointestinal tract. The complaints first arose over 10 years ago against the background of severe alcohol poisoning. The patient has been repeatedly visiting gastroenterologists, who were unable to detect any significant changes. The prescribed therapy was ineffective. What is the most likely diagnosis in this case?

A. Chronic alcoholism

B. Functional dyspepsia

C. Organic brain disorder

D. Somatoform autonomic dysfunction

Answer: Somatoform autonomic dysfunction

Explanation

Abdominal Pain and Discomfort in Emotionally Straining Situations: The patient’s symptoms are triggered by emotionally straining situations, suggesting a possible psychosomatic component.
No Objective Changes Detected in the Gastrointestinal Tract: The lack of objective changes in the gastrointestinal tract, despite persistent symptoms and multiple visits to gastroenterologists, raises the possibility of a functional or psychosomatic disorder.

History of Severe Alcohol Poisoning 10 Years Ago: While chronic alcoholism (A) may have long-term consequences, it is less likely to manifest primarily as abdominal pain triggered by emotional stress without objective gastrointestinal findings.

Ineffectiveness of Prescribed Therapy: The lack of improvement with prescribed therapy further supports the consideration of a functional or psychosomatic etiology.
Somatoform Autonomic Dysfunction (D) involves physical symptoms that suggest a medical condition but are not fully explained by a general medical condition, substance use, or another mental disorder. Emotional stress can exacerbate these symptoms.

The other options (A, B, C) are less likely based on the specific combination of symptoms and the lack of objective findings in the gastrointestinal tract. Chronic alcoholism (A) may have various manifestations, but the primary symptom in this case is triggered by emotional stress. Functional dyspepsia (B) typically involves persistent or recurrent pain or discomfort centered in the upper abdomen without identifiable organic causes. Organic brain disorder (C) would be less likely in the absence of neurological signs or symptoms.

91. A 34-year-old woman after rapidly changing her position from horizontal to vertical suddenly paled, fell down, her skin became moist, her limbs are cold, her pupils are dilated. Her pulse is rapid and thready. 50/25 mm Hg. What emergency condition has developed in the patient?

A.Shock

B. Coma

C. Ventricular fibrillation

D. Collapse

E. Morgagni-Adams-Stokes syndrome

Answer: Collapse

Explanation

Rapidly Changing Position from Horizontal to Vertical: The scenario describes a sudden change in position, likely leading to a temporary drop in blood pressure.
Clinical Features:

Paling: The sudden pallor may be indicative of decreased blood flow to the skin.Falling Down: The change in position may have led to a transient loss of consciousness and collapse.Moist Skin, Cold Limbs: These signs suggest sympathetic nervous system activation, leading to peripheral vasoconstriction.Dilated Pupils: Pupillary dilation can be a response to decreased blood flow and decreased stimulation of the parasympathetic nervous system.Hemodynamic Changes:

Rapid and Thready Pulse: The pulse characteristics suggest a compensatory increase in heart rate.Low Blood Pressure (50/25 mm Hg): The blood pressure drop is consistent with decreased cardiac output or systemic vascular resistance.Likely Cause: The described symptoms are typical of orthostatic hypotension, where a sudden change in position results in inadequate compensatory mechanisms to maintain blood pressure, leading to collapse.

Collapse (D) is a sudden, complete loss of strength and consciousness, often resulting in falling. It can be caused by various factors, including orthostatic changes, vasovagal syncope, or other conditions affecting cardiovascular function.

The other options (A, B, C, E) are less appropriate based on the provided clinical features. Shock (A) would typically involve more profound and sustained hypotension. Coma (B) is a state of profound unconsciousness. Ventricular fibrillation (C) is a life-threatening arrhythmia characterized by chaotic, rapid ventricular contractions. Morgagni-Adams-Stokes syndrome (E) typically involves syncopal episodes associated with heart block and bradycardia, which is not evident in this case.

92. A 5-year-old child had an acute onset of the disease with a fever of 39.5°C, marked chills, weakness, lethargy, skin pallor, and headache. Eight hours later a hemorrhagic rash developed on the skin of the buttocks and legs. The child is sluggish, the body temperature has dropped, blood pressure 80/40 mm Hg, respiratory rate-28-30/min., diuresis is decreased. What is the most likely diagnosis in this case?

A. Thrombocytopenic purpura

B. Reye syndrome

C. Meningococcemia

D. Hemorrhagic vasculitis (Henoch-Schonlein purpura)

E. Measles

Answer: Meningococcemia

Explanation

Acute Onset of Disease with High Fever: The sudden onset of a high fever, marked chills, weakness, lethargy, and headache suggests a severe infectious process.
Hemorrhagic Rash on Buttocks and Legs: The development of a hemorrhagic rash is a concerning sign and may indicate disseminated intravascular coagulation (DIC) associated with certain infections.

Sluggishness, Decreased Diuresis, and Drop in Body Temperature: These signs are indicative of systemic involvement and potential circulatory compromise.
Blood Pressure (80/40 mm Hg) and Increased Respiratory Rate: The low blood pressure and increased respiratory rate suggest a state of shock.

Meningococcemia (Neisseria meningitidis): This bacterium is known to cause severe systemic infections, and the clinical presentation, including fever, rash, and circulatory collapse, is consistent with meningococcemia.
Meningococcemia (C) is a life-threatening condition caused by the bacterium Neisseria meningitidis, which can lead to sepsis and shock. The clinical features often include a rapid onset of high fever, petechial or purpuric rash, and signs of circulatory collapse.

The other options (A, B, D, E) are less likely based on the specific combination of symptoms and clinical course described. Thrombocytopenic purpura (A) may present with bleeding, but the rapid onset of high fever is not characteristic. Reye syndrome (B) is associated with aspirin use and is not typically associated with petechial or purpuric rash. Hemorrhagic vasculitis (Henoch-Schonlein purpura) (D) may present with a purpuric rash, but the systemic involvement described is more suggestive of meningococcemia. Measles (E) can cause fever and rash but does not typically lead to such rapid and severe circulatory compromise.

93. A 34-year-old woman with previously normal menstrual function developed irregular cycles that are anovulatory according to functional diagnostic tests. Her breasts are painful to palpation and secrete milk (galactorrhea). What study must be conducted to establish the patient’s diagnosis?

A. Measuring the gonadotropin levels

B. CT scan of the brain

C. Progesterone test

D. Ultrasound of the lesser pelvis

E. Measuring the prolactin level

Answer: Measuring the prolactin level

Explanation

Irregular Menstrual Cycles and Anovulation: These symptoms suggest a disturbance in the normal menstrual cycle, and anovulation indicates a lack of ovulatory cycles.
Breast Pain and Galactorrhea: The presence of breast pain and milk secretion (galactorrhea) suggests elevated levels of prolactin, a hormone responsible for lactation.

Prolactinoma: Elevated prolactin levels can be caused by a prolactin-secreting pituitary adenoma, known as a prolactinoma. This condition can lead to disruptions in menstrual cycles and fertility.
Diagnostic Test: Measuring the prolactin level is a crucial diagnostic step in evaluating the cause of irregular menstrual cycles and galactorrhea. Elevated prolactin levels can confirm the presence of hyperprolactinemia.

CT scan of the brain (B) may be considered if there are additional indications of pituitary adenoma or other structural abnormalities in the brain.
The other options (A, C, D) may also be relevant in certain contexts but, given the specific symptoms described (irregular cycles, anovulation, breast pain, and galactorrhea), measuring the prolactin level (E) is the most appropriate initial step to assess for hyperprolactinemia and its potential causes.

94. A 27-year-old woman came to a doctor with complaints of enlarged lymph nodes on the right side of her neck and in the axillary region, night sweats, and a fever over 38° C. Morphological study of the biopsy material obtained from a lymph node detected Reed- Sternberg cells. What is the most likely diagnosis in this case?

A. Lymph node tuberculosis

B. Malignant lymphoma

C. Tumor metastases in the lymphatic nodes

D. Lymphogranulomatosis

E. Chronic lymphocytic leukemia

Answer: Lymphogranulomatosis

Explanation

Enlarged Lymph Nodes, Night Sweats, and Fever: These symptoms are characteristic of lymphomas, a group of cancers that affect the lymphatic system.
Reed-Sternberg Cells: The presence of Reed-Sternberg cells, as detected in the biopsy of the lymph node, is a characteristic feature of Hodgkin lymphoma.

Hodgkin Lymphoma (Lymphogranulomatosis): This type of lymphoma is characterized by the presence of Reed-Sternberg cells and is divided into classical Hodgkin lymphoma and nodular lymphocyte-predominant Hodgkin lymphoma.

Metastases vs. Primary Lymphoma: Malignant lymphomas can present with enlarged lymph nodes, but the presence of Reed-Sternberg cells specifically points towards Hodgkin lymphoma.
Lymphogranulomatosis (D) is an older term for Hodgkin lymphoma, and this term is often used interchangeably.

The other options (A, B, C, E) are less likely based on the presence of Reed-Sternberg cells, which are characteristic of Hodgkin lymphoma. Lymph node tuberculosis (A) and tumor metastases (C) would not typically show Reed-Sternberg cells. Malignant lymphoma (B) is a broad term that encompasses both Hodgkin and non-Hodgkin lymphomas. Chronic lymphocytic leukemia (E) is a different type of hematologic malignancy characterized by the proliferation of small lymphocytes.

95. A patient has been diagnosed with right-sided pneumothorax and prescribed urgent drainage of the pleural cavity. What site should be used for the pleural tap in this case?

A. The projection of the pleural sinus

B. The second intercostal space, on the midclavicular line

C. The site of the largest percussion dullness

D. The sixth intercostal space, on the posterior axillary line

E. The seventh intercostal space, on the scapular line

Answer: The second intercostal space, on the midclavicular line

Explanation

Second Intercostal Space: The pleural tap is typically performed in the second intercostal space to avoid injury to neurovascular structures that run along the upper ribs.
Midclavicular Line: This is the anterior midline of the chest, passing through the midpoint of the clavicle. Choosing this line helps to avoid damage to major vessels and nerves.

Avoidance of Largest Percussion Dullness: While percussion dullness may indicate the presence of fluid, in the case of pneumothorax, there is an accumulation of air rather than fluid. Therefore, the site of largest percussion dullness is not the optimal location for pleural tap in pneumothorax.

Correctly selecting the second intercostal space on the midclavicular line allows for safer and more effective drainage in the context of pneumothorax

96. A 27-year-old woman complains of pain and morning stiffness in the small joints of her hands. Her condition is weather-dependent. Objectively, she presents with swelling and deformation of her proximal interphalangeal joints and her second and third metacarpophalangeal joints X-ray of the hands detects bone erosions (usurations) and signs of osteoporosis. What is the most likely diagnosis in this case?

A. Rheumatoid arthritis

B. Rheumatic polyarthritis

C. Psoriatic arthritis

D. Systemic scleroderma

E. Systemic lupus erythematosus

Answer: Rheumatoid arthritis

Explanation

Morning Stiffness and Pain in Small Joints: Rheumatoid arthritis commonly presents with morning stiffness and pain, often affecting the small joints.
Weather-Dependent Symptoms: Symptoms being weather-dependent is a characteristic feature of rheumatoid arthritis.

Swelling and Deformation: Rheumatoid arthritis can lead to joint swelling and deformities, especially in the proximal interphalangeal (PIP) joints and metacarpophalangeal (MCP) joints.
Bone Erosions (Usurations) and Osteoporosis: Radiographic findings of bone erosions and osteoporosis are typical in rheumatoid arthritis due to the chronic inflammatory process affecting the joints.

Rheumatoid arthritis is an autoimmune condition that primarily affects the joints, leading to inflammation, joint damage, and deformities.

97. A children’s preschool institution is located near a highway, where carbon monoxide levels in the air are 3-4 times higher than the maximum permissible concentration. What substance, detected in the children’s blood, will confirm the harmful effect of polluted air?

A. Carboxyhemoglobin

B. Carbhemoglobin

C. Hemoglobin

D. Methemoglobin

E. Reduced hemoglobin

Answer: Carboxyhemoglobin

Explanation

Carboxyhemoglobin (COHb): It is a complex formed by the binding of carbon monoxide (CO) to hemoglobin in the blood. This binding reduces the ability of hemoglobin to carry oxygen, leading to tissue hypoxia.
Carbon Monoxide (CO) Exposure: In environments with elevated levels of carbon monoxide, individuals may inhale this toxic gas. Sources include vehicle exhaust, industrial emissions, and improper use of fuel-burning appliances.

Carbon Monoxide Poisoning: Increased levels of carboxyhemoglobin indicate exposure to carbon monoxide, which can lead to carbon monoxide poisoning. Symptoms may include headache, dizziness, nausea, and, in severe cases, can be life-threatening.

Monitoring carboxyhemoglobin levels in the blood helps assess the extent of carbon monoxide exposure and its potential health consequences.

98 A 4-day-old boy developed signs of hemorrhagic disease of the newborn in the form of melena. What drug should the doctor have prescribed in the first hours of life to prevent this disease?

A. Aminocaproic acid

B. Vitamin

C. Vitamin K

D. Calcium gluconate

E. Ethamsylate

Answer: Vitamin K

Explanation

Hemorrhagic Disease of the Newborn (HDN): HDN is a bleeding disorder that occurs in the first few days to weeks of life in newborns. It is characterized by a deficiency of vitamin K-dependent clotting factors.
Vitamin K Deficiency: Newborns are particularly prone to vitamin K deficiency because they have limited stores of vitamin K and the vitamin K cycle in their intestines is not yet established.

Prevention: To prevent hemorrhagic disease of the newborn, it is a common practice to administer vitamin K to newborns shortly after birth. This can be given orally or by injection.
Vitamin K’s Role: Vitamin K is essential for the synthesis of clotting factors in the liver. By providing vitamin K, the risk of bleeding disorders is significantly reduced.

Therefore, in the scenario described, prescribing Vitamin K in the first hours of life is crucial to prevent hemorrhagic disease in the newborn.

99. A 44-year-old woman complains of general weakness, drowsiness, palpitations, dry skin, and reduced working ability Objectively she has normal-colored skin, pulse 72/min., blood pressure 125/80 mm Hg, the thyroid gland is diffusely enlarged to the II degree, dense, mobile, and painful. Ultrasound reveals decreased echogenicity, non-homogeneity of the echo structure, and thickening of the gland capsule. Blood test shows that T4 levels are decreased, TSH levels are increased, and the levels of antibodies to thyroid peroxidase and anti-microsomal antibodies are significantly increased. What is the most likely diagnosis in this case?

A. Diffuse toxic goiter, II degree

B. Diffuse thyroid goiter, Il degree

C. Subacute thyroiditis

D. Autoimmune thyroiditis

E. Thyroid cancer

Answer: Autoimmune thyroiditis

Explanation

Clinical Presentation:
General weakness, drowsiness, palpitations, and reduced working ability are indicative of thyroid dysfunction.The diffusely enlarged thyroid gland, particularly with pain and tenderness, raises suspicion of thyroiditis.Laboratory Findings:

Decreased T4 levels and increased TSH levels suggest hypothyroidism.Elevated levels of antibodies to thyroid peroxidase (anti-TPO antibodies) and anti-microsomal antibodies are characteristic of autoimmune thyroiditis (Hashimoto’s thyroiditis).Autoimmune Thyroiditis (Hashimoto’s Thyroiditis):

It is an autoimmune disorder where the immune system mistakenly attacks the thyroid gland.This attack leads to inflammation, destruction of thyroid cells, and eventual hypothyroidism.The thyroid gland may initially release an excess of thyroid hormones (thyrotoxic phase), leading to symptoms of hyperthyroidism. Subsequently, the gland becomes underactive, resulting in hypothyroidism.Ultrasound Findings:

Decreased echogenicity, non-homogeneity of the echo structure, and thickening of the gland capsule are characteristic ultrasound findings in autoimmune thyroiditis.Thyroid Cancer:

Thyroid cancer typically presents with a thyroid nodule and is less likely in a case with diffuse enlargement, tenderness, and autoimmune markers.Therefore, considering the clinical presentation, laboratory results, and ultrasound findings, the most likely diagnosis is autoimmune thyroiditis (Hashimoto’s thyroiditis).

100. An 8-month-old child’s examination revealed a loud systolic murmur over the entire cardiac region with an epicenter in the III-IV intercostal spaces to the left of the sternum and a systolic tremor, the second tone over the pulmonary artery is of 110/70 increased volume. Blood pressure mm Hg. There are no complaints. X-ray shows that the size and shape of the cardí ac shadow are without changes. What is the most likely diagnosis in this case?

A. Ventricular septal defect

B. Pulmonary artery stenosis

C. Patent ductus arteriosus

D. Atrial septal defect

E. Coarctation of the aorta

Answer: Ventricular septal defect

Explanation

Clinical Findings:
A loud systolic murmur over the entire cardiac region, with an epicenter in the III-IV intercostal spaces to the left of the sternum, suggests a ventricular septal defect (VSD).A systolic tremor and an increased volume of the second heart tone over the pulmonary artery are consistent with the hemodynamic changes associated with VSD.Ventricular Septal Defect (VSD):

VSD is a congenital heart defect characterized by an abnormal opening in the ventricular septum, allowing blood to flow from the left ventricle to the right ventricle.The murmur is often described as a harsh, holosystolic murmur, and the location mentioned in the III-IV intercostal spaces to the left of the sternum is typical for VSD.Other Options:

Pulmonary artery stenosis and patent ductus arteriosus are associated with different murmur characteristics and locations.Atrial septal defect typically presents with a fixed split-second heart sound and a different murmur location.Coarctation of the aorta usually presents with hypertension in the upper extremities and weak or delayed femoral pulses.Considering the loud systolic murmur with its location, along with the other clinical findings, VSD is the most likely diagnosis in this case.

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