Question From ( 51 To 100 )

All Previous Years Krok 2 Papers with Explanations

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Question From ( 51 To 100 )

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

A. Autoimmune thyroiditis

B. Diffuse toxic goiter

C. Thyroid carcinoma

D. Subacute thyroiditis

E. Juvenile basophilism

Answer: Autoimmune thyroidit

Explanation

Autoimmune thyroiditis, also known as Hashimoto’s thyroiditis, is a chronic inflammatory condition of the thyroid gland. It is characterized by diffuse enlargement of the thyroid gland (goiter) and the presence of autoantibodies against thyroid tissue. It is more common in females and often presents during adolescence or early adulthood.

In this case, the girl’s initial presentation of diffuse enlargement of the thyroid gland (grade II) was regarded as a pubertal manifestation and was not treated. However, over time, her symptoms progressed.

The development of irritability, tearfulness, and subsequent apathy could be attributed to the underlying autoimmune thyroiditis affecting the thyroid gland’s function.

The progression of symptoms, including puffy face, soft tissue edema, bradycardia, constipation, skin pallor, and waxen hue, are consistent with the clinical manifestations of hypothyroidism, which can occur in autoimmune thyroiditis as the disease progresses.

52. 4 hours after having meals a patient with signs of malnutrition and steatorrhea experiences stomach pain, especially above navel and to the left of it. Diarrheas take turns with constipation lasting up to 3-5 days. Palpation reveals moderate painfulness in the choledochopancreatic region. The amylase rate in blood is stable. X-ray reveals some calcifications located above navel. What is the most likely diagnosis?

A. Chronic pancreatitis

B. Chronic gastroduodenitis

C. Duodenal ulcer

D. Zollinger-Ellison syndrome

E. Chronic calculous cholecystitis

Answer: Chronic pancreatitis

Explanation

Chronic pancreatitis is a condition characterized by inflammation and irreversible damage to the pancreas over a long period of time. It is commonly associated with alcohol abuse, but other causes such as gallstones, genetic factors, and certain autoimmune conditions can also contribute to its development.

The presented symptoms and findings are consistent with chronic pancreatitis. The patient experiences stomach pain, especially above the navel and to the left of it, which is a typical location for pancreatic pain. The pain occurring 4 hours after meals can be attributed to the release of pancreatic enzymes during digestion, which further irritate the inflamed pancreas.

The presence of steatorrhea (fat in the stool) suggests impaired digestion and absorption of fats due to insufficient pancreatic enzyme production. The alternating episodes of diarrhea and constipation can be indicative of the disrupted digestive function of the pancreas.

Palpation revealing moderate painfulness in the choledochopancreatic region is another characteristic feature of chronic pancreatitis. The presence of calcifications on X-ray above the navel can indicate the presence of calcified pancreatic tissue, which is a common finding in chronic pancreatitis. The stability of amylase levels in the blood is worth noting since amylase levels may be elevated during acute pancreatitis but can return to normal in chronic pancreatitis.

53. A 56-year-old patient with diffuse toxic goiter has ciliary arrhythmia withpulse rate of 110 bpm, arterial hypertension, AP- 165/90 mm Hg. What preparation should be administered along with mercazolil?

A. Propranolol

B. Radioactive iodine

C. Procaine hydrochloride

D. Verapamil

E. Corinfar

Answer: Propranolol

Explanation

Diffuse toxic goiter, also known as Graves’ disease, is a condition characterized by an overactive thyroid gland that produces excessive amounts of thyroid hormones. It commonly presents with symptoms such as ciliary arrhythmia (irregular heart rhythm), hypertension (high blood pressure), and tachycardia (rapid heart rate).

Propranolol is a beta-blocker medication that works by blocking the effects of adrenaline on the beta receptors in the body, including the beta receptors in the heart. By doing so, it helps to reduce the heart rate, blood pressure, and other symptoms associated with hyperthyroidism, including palpitations and tremors.

In this case, the patient has ciliary arrhythmia with a pulse rate of 110 bpm and arterial hypertension. Propranolol can effectively control these symptoms by slowing down the heart rate and reducing blood pressure.

54. On the 3rd day of life a baby presented with haemorrhagic rash, bloody vomit, black stool. Examination revealed anaemia, extended coagulation time, hypoprothrombinemia, normal thrombocyte rate. What is the optimal therapeutic tactics?

A. Vitamin K

B. Sodium ethamsylate

C. Epsilon-aminocapronic acid

D. Fibrinogen

E. Calcium gluconate

Answer: Vitamin K

Explanation

The symptoms described in the scenario, including hemorrhagic rash, bloody vomit, and black stool, along with the laboratory findings of anemia, prolonged coagulation time, hypoprothrombinemia, and normal thrombocyte (platelet) count, suggest a bleeding disorder in the newborn.

Vitamin K is an essential nutrient for the production of clotting factors in the liver. Newborns are born with low levels of vitamin K and have limited ability to synthesize it in their intestines. This puts them at risk of developing vitamin K deficiency bleeding, also known as hemorrhagic disease of the newborn.

Administering vitamin K can effectively treat and prevent this bleeding disorder. Vitamin K can be given orally or through an intramuscular injection. The most common and recommended route is the intramuscular injection of vitamin K, which provides immediate and reliable absorption.

55. A woman consulted a doctor on the 14th day after labour about sudden pain, hyperemy and induration of the left mammary gland, body temperature rise up to 39oC, headache, indisposition. Objectively: fissure of nipple, enlargement of the left mammary gland, pain on palpation. What pathology would you think about in this case?

A. Lactational mastitis

B. Lacteal cyst with suppuration

C. Fibrous adenoma of the left mammary gland

D. Breast cancer

E. Phlegmon of mammary gland

Answer: Lactational mastitis

Explanation

Lactational mastitis is the most likely pathology in this case based on the given symptoms and clinical findings. Mastitis is an inflammation of the breast tissue that can occur during breastfeeding. Let’s break down the symptoms and objective findings to understand why this is the correct answer:

Sudden pain, hyperemia (redness), and induration (hardening) of the left mammary gland: These symptoms suggest an inflammatory process occurring in the breast. Body temperature rise up to 39oC: Fever is a common symptom of mastitis, indicating an infection. Headache and indisposition: These general symptoms are often associated with systemic inflammation and infection. Fissure of the nipple: Nipple fissures can develop during breastfeeding, providing an entry point for bacteria into the breast tissue.

Enlargement of the left mammary gland and pain on palpation: These findings are consistent with inflammation and swelling of the affected breast. Lactational mastitis typically occurs due to bacterial infection, most commonly Staphylococcus aureus, which enters the breast tissue through nipple cracks or ductal openings.

The infection causes an inflammatory response, resulting in pain, redness, swelling, and fever. It’s important to note that lactational mastitis can usually be treated successfully with antibiotic therapy, continued breastfeeding or pumping, and proper breast hygiene. It’s recommended to consult a healthcare professional for an accurate diagnosis and appropriate treatment.

56. On the 5th day of a respiratory disease accompanied by fever a 24-year-old man developed progressing headaches, systemic dizziness, double vision, facial muscles paresis on the right, choking from swallowing. He was diagnosed with acute viral encephalitis. Identify the main tendency of the emergency treatment:

A. Zovirax

B. Glucocorticoids

C. Ceftriaxone

D. Lasix

E. Haemodezum

Answer: Zovirax

Explanation

In this case, the main tendency of emergency treatment for the 24-year-old man with acute viral encephalitis would be to administer antiviral medication such as Zovirax (acyclovir). Let’s understand why this is the correct answer based on the given symptoms:

Respiratory disease accompanied by fever: This suggests a viral infection as the underlying cause of the symptoms. Progressing headaches, systemic dizziness, double vision, facial muscle paresis on the right, choking from swallowing:

These neurological symptoms indicate involvement of the central nervous system (CNS) and suggest the development of encephalitis, which is inflammation of the brain. Acute viral encephalitis is a serious condition that requires prompt treatment.

Antiviral medications, such as acyclovir (brand name Zovirax), are the mainstay of treatment for viral encephalitis caused by the herpes simplex virus (HSV) or varicella-zoster virus (VZV). Acyclovir is effective against these viruses and helps to suppress viral replication and reduce the severity of the infection.

57. A 54-year-old male patient complains of aching pain in the lumbar region, that is getting worse after standing in an upright position, physical exercise, supercooling. The patient also reports of experiencing weakness in the afternoon. Pain in the lumbar region, said about 10 years old. Objectively: pale skin, t o- 37, 2oC, AP- 180/100 mm Hg, minor costovertebral angle tenderness (Pasternatsky symptom). In blood: RBCs – 3, 5 · 1012/l, WBCs – 6, 5 · 109/l, ESR – 22 mm/h. In urine: the relative density – 1010, leukocytes – 12-15 in the field of vision, erythrocytes – 2-3 in the field of vision. Urine bacterial count – 100000 in 1 ml. What is the most likely diagnosis?

A. Chronic pyelonephritis

B. Nephrolithiasis

C. Polycystic renal disease

D. Chronic glomerulonephritis

E. Amyloidosis

Answer: Chronic pyelonephritis

Explanation

Let’s analyze the given symptoms and findings to understand why chronic pyelonephritis is the most probable diagnosis: Aching pain in the lumbar region that worsens after standing upright, physical exercise, and supercooling: This type of pain pattern is consistent with renal (kidney) involvement.

Weakness in the afternoon: Fatigue and weakness are common symptoms of chronic kidney disease. Pain in the lumbar region reported for about 10 years: Chronic pyelonephritis is a persistent inflammation of the renal parenchyma and renal pelvis, which can lead to long-term symptoms.

Pale skin: Pale skin can be associated with anemia, which is common in chronic kidney disease. Blood pressure (BP) – 180/100 mm Hg: Hypertension (high blood pressure) is frequently observed in chronic pyelonephritis due to the renal damage and impaired regulation of blood pressure.

Minor costovertebral angle tenderness (Pasternatsky symptom): Tenderness in the costovertebral angle area can indicate inflammation or infection in the kidneys. Blood parameters: The red blood cell count (RBCs) is slightly decreased (3.5 x 10^12/l), and the white blood cell count (WBCs) is within the normal range (6.5 x 10^9/l). The erythrocyte sedimentation rate (ESR) is slightly elevated (22 mm/h).

These findings can be seen in chronic inflammation, such as chronic pyelonephritis. Urine parameters: The relative density is 1010, leukocytes are 12-15 in the field of vision, erythrocytes are 2-3 in the field of vision, and the urine bacterial count is 100,000 in 1 ml. These findings indicate the presence of infection (leukocytes) and inflammation (erythrocytes), along with a high bacterial count, suggesting a urinary tract infection involving the kidneys.

58. A 49-year-old male patient complains of dyspnea of combined nature, cough, shin edemata, abdomen enlargement due to ascites. He has a 20-year history of chronic bronchitis. For the last 3 years he has been disabled (group II) because of cardiac changes. Objectively: mixed cyanosis, edemata. Ps – 92/min, rhythmic, AP – 120/70 mm Hg, respiration rate – 24/min. There is accentuation of the second sound above the pulmonary artery. Auscultation reveals the box resonance above the lungs. There are also dry rales over the entire surface of lungs. What is the mechanism of heart changes development in this patient?

A. Euler-Liljestrand reflex

B. Kitaev’s reflex

C. Bainbridge reflex

D. Cardiovascular reflex

E. Respiratory reflex

Answer: Euler-Liljestrand reflex

Explanation

The mechanism of heart changes development in this patient is related to the Euler-Liljestrand reflex. Let’s understand why this is the correct answer based on the given symptoms and findings: Dyspnea of combined nature, cough, shin edema, abdomen enlargement due to ascites:

These symptoms suggest the presence of congestive heart failure (CHF), a condition where the heart’s pumping ability is compromised, leading to fluid accumulation in various parts of the body. History of chronic bronchitis: Chronic bronchitis is a chronic respiratory condition characterized by inflammation and narrowing of the airways, which can contribute to the development of pulmonary hypertension (high blood pressure in the pulmonary arteries). Disability due to cardiac changes:

The patient’s disability classification suggests significant cardiac impairment. Mixed cyanosis, edema: Cyanosis (bluish discoloration) and edema (fluid retention) are common signs of congestive heart failure. Accentuation of the second sound above the pulmonary artery: This finding indicates increased pressure in the pulmonary artery, further suggesting the presence of pulmonary hypertension. Box resonance above the lungs and dry rales over the entire surface of lungs: These findings indicate the presence of lung congestion due to fluid accumulation.

59. A 43-year-old female patient complains of unstable defecation with frequent constipations, abdominal swelling, headache, sleep disturbance. Body weight is unchanged. What disease are these clinical presentations typical for?

A. Irritable colon syndrome

B. Chronic enteritis

C. Chronic pancreatitis

D. Chronic atrophic gastritis

E. Colorectal cancer

Answer: Irritable colon syndrome

Explanation

Let’s understand why IBS is the most likely diagnosis based on the given symptoms: Unstable defecation with frequent constipations: IBS is characterized by changes in bowel habits, including constipation, diarrhea, or a combination of both. The term “unstable defecation” suggests an alteration between periods of constipation and diarrhea.

Abdominal swelling: Abdominal bloating and distension are common symptoms in IBS. It is often described as a feeling of fullness or tightness in the abdomen. Headache: Headaches are reported by many individuals with IBS. The exact cause of the association between IBS and headaches is not fully understood, but it is believed to be related to shared underlying mechanisms such as altered pain perception and increased sensitivity.

Sleep disturbance: Sleep disturbances, such as difficulty falling asleep, staying asleep, or having unrefreshing sleep, can occur in individuals with IBS. The relationship between IBS and sleep disturbances is complex and can be influenced by various factors, including stress, anxiety, and altered gut-brain interactions.

Unchanged body weight: Typically, IBS does not cause significant weight loss or weight gain. Irritable bowel syndrome is a functional gastrointestinal disorder that affects the large intestine (colon). It is a chronic condition characterized by a combination of recurrent abdominal pain or discomfort associated with altered bowel habits.

The exact cause of IBS is not known, but it is believed to involve a combination of factors such as abnormal gut motility, heightened sensitivity to visceral sensations, changes in the gut microbiota, and psychosocial factors.

60. A 43-year-old man who often contacts with ethyl gasoline was admitted to a hospital with complaints of general weakness, dizziness, memory impairment, sleepiness at daytime and insomnia at night, sensation of a hair in the mouth, colicky pains in the right subcostal region. What is the most likely diagnosis?

A. Chronic tetraethyl lead intoxication

B. Alcoholic delirium

C. Chronic mercury intoxication

D. Chronic manganese intoxication

E. Chronic lead intoxication

Answer: Chronic tetraethyl lead intoxication

Explanation

Let’s analyze the given symptoms and exposure history to understand why chronic tetraethyl lead intoxication is the most probable diagnosis: Exposure to ethyl gasoline: The patient’s frequent contact with ethyl gasoline is important because tetraethyl lead was historically used as an additive in gasoline. Inhalation or ingestion of lead-containing substances, such as gasoline, can lead to lead intoxication. General weakness, dizziness, memory impairment, sleepiness at daytime, and insomnia at night:

These symptoms are commonly associated with lead toxicity. Lead affects the central nervous system and can lead to neurological symptoms, including weakness, dizziness, cognitive impairment, and sleep disturbances. Sensation of a hair in the mouth: This symptom, known as “lead palsy” or “lead line,” is a classic finding in lead intoxication. It is caused by the deposition of lead sulfide on the gingival margin, leading to a gritty or metallic sensation in the mouth.

Colicky pains in the right subcostal region: Abdominal pain is a common symptom in lead intoxication. Lead can affect the gastrointestinal system and lead to abdominal colic, particularly in the right subcostal region. Based on these findings, chronic tetraethyl lead intoxication is the most likely diagnosis. Tetraethyl lead is a highly toxic compound, and chronic exposure to lead can lead to cumulative toxicity over time.

61. A 35-year-old patient has been in the intensive care unit for acute renal failure due to crush for 4 days. Objectively: the patient is inadequate. Breathing rate – 32/min. Over the last 3 hours individual moist rales can be auscultated in lungs. ECG shows high T waves, right ventricular extrasystoles. CVP – 159 mm Hg. In blood: the residual nitrogen – 62 millimole/l, K+- 7,1 millimole/l, Cl−- 78 millimole/l, Na+- 120 millimole/l, Ht – 0,32, Hb – 100 g/l, blood creatinine – 0,9 millimole/l. The most appropriate method of treatment would be:

A. Hemodialysis

B. Plasma sorption

C. Hemosorption

D. Plasma filtration

E. Ultrafiltration

Answer: Hemodialysis

Explanation

The patient is experiencing acute renal failure, as indicated by the laboratory findings of high blood potassium (K+), low blood sodium (Na+), and elevated blood creatinine. These are all signs of impaired kidney function. Additionally, the patient has been in the intensive care unit for four days, which suggests a severe condition.

The clinical presentation of the patient also supports the need for hemodialysis. The presence of moist rales in the lungs indicates pulmonary edema, which can occur in cases of severe fluid overload, such as in acute renal failure. The elevated central venous pressure (CVP) of 159 mm Hg further suggests fluid overload.

Moreover, the ECG findings of high T waves and right ventricular extrasystoles can be attributed to the imbalances in electrolytes, particularly the high potassium (K+) level. Hyperkalemia can lead to cardiac arrhythmias and potentially life-threatening complications, necessitating urgent treatment.

Hemodialysis is a renal replacement therapy that removes waste products, excess fluids, and electrolytes from the blood. It is effective in managing acute renal failure and correcting the imbalances seen in this patient, such as high potassium (K+) levels and fluid overload.

62. A 47-year-old woman underwent a thyroid gland resection on ccount of nodular euthyroid goiter. What preparations are most likely to prevent the disease recurrence?

A. Thyroid hormones

B. Mercazolil

C. Thyrotropin

D. Antistruminum (potassium iodide)

E. Radioactive iodine

Answer: Thyroid hormones

Explanation

Nodular euthyroid goiter refers to the presence of multiple nodules in the thyroid gland without any associated thyroid hormone abnormalities. In cases where a thyroid gland resection has been performed, the goal is to prevent disease recurrence and maintain thyroid hormone balance.

Thyroid hormones, such as levothyroxine (T4) or liothyronine (T3), are commonly prescribed as replacement therapy following thyroid surgery. These medications provide the necessary thyroid hormones that the body requires for normal metabolic function. By taking thyroid hormone replacement therapy, the patient can maintain normal thyroid hormone levels in the absence of the removed thyroid tissue. Thyroid hormone replacement serves several purposes in preventing disease recurrence:

Suppression of Thyroid-Stimulating Hormone (TSH): By taking exogenous thyroid hormones, the feedback loop between the hypothalamus, pituitary gland, and thyroid gland is disrupted. Elevated levels of thyroid hormones in the blood help suppress the production of TSH from the pituitary gland. Lower levels of TSH reduce the stimulation of any remaining thyroid tissue, potentially preventing the growth of residual nodules and reducing the risk of recurrence.

Maintaining Thyroid Hormone Balance: Thyroid hormone replacement ensures that the patient’s body has an adequate supply of thyroid hormones, which helps regulate various bodily functions. By maintaining normal thyroid hormone levels, the patient is less likely to develop an imbalance that could lead to goiter formation or the growth of new nodules. Options B (Mercazolil), D (Antistruminum or potassium iodide), and E (radioactive iodine) are not typically used for preventing disease recurrence after thyroid gland resection in cases of nodular euthyroid goiter.

63. A 30-year-old man was injured in a fire and got thermic burns of III-A and III-B degree that affected 20% of the total skin. AP – 110/70 mm Hg, heart rate -120/min. What transfusion means should be used for blind infusion before transportation?

A. Saline solutions

B. Polyglycine

C. 10% glucose solution

D. Fresh frozen plasma

E. Albumin

Answer: Saline solutions

Explanation

Thermic burns can result in significant fluid loss due to damaged skin, increased capillary permeability, and the inflammatory response. In this case, the patient’s clinical parameters, such as blood pressure (AP) of 110/70 mm Hg and a heart rate of 120/min, suggest signs of hypovolemia or reduced blood volume.

The primary goal of fluid resuscitation in burn patients is to restore intravascular volume and maintain organ perfusion. Blind infusion refers to the administration of fluids without knowing the patient’s specific blood type or cross-matching for blood products.

Saline solutions, such as normal saline (0.9% sodium chloride), are the most appropriate initial choice for blind infusion in burn patients before transportation to a burn center or specialized facility. Saline solutions are isotonic, meaning they have a similar concentration of salts as the body’s extracellular fluid. They help expand the intravascular volume, restore blood pressure, and improve tissue perfusion.

64. A patient has an over a year-old history of fast progressive rheumatoid arthritis. X-raying confirms presence of marginal erosions. What basic drug would be the most appropriate in this case?

A. Methotrexate

B. Chloroquine

C. Prednisolone

D. Diclofenac sodium

E. Aspirin

Answer: Methotrexate

Explanation

Rheumatoid arthritis (RA) is a chronic autoimmune disease characterized by inflammation and destruction of joints, including the presence of erosions. The treatment of RA aims to reduce inflammation, control symptoms, prevent joint damage, and improve the patient’s quality of life.

Methotrexate (MTX) is considered the cornerstone of treatment for rheumatoid arthritis. It is a disease-modifying antirheumatic drug (DMARD) that exerts immunosuppressive and anti-inflammatory effects. Here are the reasons why methotrexate is the most appropriate choice in this case:

Efficacy: Methotrexate has been extensively studied and demonstrated to be effective in managing rheumatoid arthritis. It helps to reduce joint inflammation, control disease activity, and slow down the progression of joint damage, including the development of erosions.

Disease Modification: Methotrexate is a DMARD that not only provides symptomatic relief but also works to modify the course of the disease. By suppressing the immune system and reducing inflammation, it helps prevent further joint destruction and disability. Long-Term Safety: Methotrexate has a well-established safety profile when used in appropriate doses and with proper monitoring. It is generally well-tolerated and has a lower risk of serious adverse effects compared to some other DMARDs.

65. A 3-year-old child has been delivered to a hospital in soporose state with considerable amyotonia, inhibition of tendon and periosteal reflexes. Miosis and asthenocoria are also present. Corneal reflexes are preserved. Pulse is rapid and weak. AP- 80/50 mm Hg. The parents suspect the child of accidental taking some tablets. Such clinical presentations are typical for intoxication with the following tableted drugs:

A. Tranquilizers

B. Antropine drugs

C. Antihypertensive drugs

D. Barbiturates

E. Beta-2-adrenoceptor agonists

Answer: Tranquilizers

Explanation

Tranquilizers, also known as sedative-hypnotics or central nervous system depressants, are medications that are commonly prescribed for anxiety, sleep disorders, and sometimes as antipsychotics. However, in cases of accidental ingestion or overdose, tranquilizers can lead to significant central nervous system depression and other related symptoms. The clinical manifestations observed in the child are consistent with the effects of tranquilizers:

Soporose state: Tranquilizers can cause profound sedation and drowsiness, leading to a soporose state where the child is difficult to rouse or has a decreased level of consciousness. Amyotonia and inhibited reflexes: Tranquilizers have muscle relaxant properties and can cause a decrease in muscle tone (amyotonia) and inhibition of reflexes, including tendon and periosteal reflexes.

Miosis and asthenocoria: Tranquilizers often cause constriction of the pupils (miosis) due to their effects on the autonomic nervous system. Asthenocoria refers to the weakness or absence of pupillary constriction in response to light. Preserved corneal reflexes:

Despite the overall central nervous system depression, the corneal reflex, which is mediated by cranial nerve V (trigeminal) and cranial nerve VII (facial), remains intact. This preservation distinguishes tranquilizer intoxication from other types of drug intoxications. Rapid and weak pulse, low blood pressure: Tranquilizers can lead to cardiovascular depression, resulting in a rapid and weak pulse, as well as low blood pressure.

66. A 23-year-old patient complains of a dull ache, sensation of heaviness and distention in the epigastrium immediately after meals, foul-smelling eructation; dry mouth, empty stomach nausea, diarrhea. Objectively: the skin is pale, the patient is of thin build. Abdomen is soft on palpation, there is epigastric pain. The liver does not extend beyond the costal arch. In blood: Hb – 110 g/l, RBCs – 3, 4 · 1012/l, WBC count is normal. ESR – 16 mm/h. What is the most informative study that will allow make a diagnosis?

A. Esophageal gastroduodenoscopy

B. X-ray of digestion organs

C. Study of gastric juice

D. pH-metry

E. Duodenal probing

Answer: Esophageal gastroduodenoscopy

Explanation

Esophageal gastroduodenoscopy, also known as upper endoscopy, is a procedure where a flexible tube with a camera is inserted through the mouth and used to examine the esophagus, stomach, and duodenum. It allows for direct visualization of the gastrointestinal tract and provides valuable information for diagnosing various conditions.

In this case, the patient’s symptoms and clinical findings, such as epigastric pain, foul-smelling eructation, and gastrointestinal complaints after meals, suggest a possible disorder of the upper digestive tract. The most likely diagnosis based on the presented symptoms is gastritis or peptic ulcer disease.

Esophageal gastroduodenoscopy can help confirm this diagnosis and provide additional information, including: Evaluation of the gastric mucosa: Esophageal gastroduodenoscopy allows direct visualization of the gastric mucosa to assess for any inflammation, erosions, or ulcers.

This can help diagnose gastritis or peptic ulcers, which can present with symptoms such as epigastric pain and discomfort. Biopsy: During the procedure, biopsies can be taken from the gastric mucosa to evaluate for specific conditions, such as Helicobacter pylori infection, which is commonly associated with gastritis and peptic ulcers.

67. A 49-year-old patient complains of deglutition problems, especially with solid food, hiccups, voice hoarseness, nausea, regurgitation, significant weight loss (15 kg within 2,5 months). Objectively: body weight is reduced. Skin is pale and dry. In lungs: vesicular breathing, heart sounds are loud enough, heart activity is rhythmic. The abdomen is soft, painless on palpation. Liver is not enlarged. What study is required to make a diagnosis?

A. Esophageal duodenoscopy along with biopsy

B. Clinical blood test

C. X-ray of digestive tract organs

D. X-ray in Trendelenburg’s position

E. Study of gastric secretion

Answer: Esophageal duodenoscopy along with

Explanation

Esophageal duodenoscopy, also known as upper endoscopy, is a procedure where a flexible tube with a camera is inserted through the mouth to examine the esophagus, stomach, and duodenum. It allows for direct visualization of the gastrointestinal tract and provides valuable information for diagnosing various conditions.

The patient’s symptoms, including deglutition problems, hiccups, voice hoarseness, nausea, regurgitation, and significant weight loss, are indicative of possible esophageal pathology. The most likely diagnosis based on the presented symptoms is esophageal cancer. Esophageal duodenoscopy with biopsy is the most appropriate study for the following reasons: Evaluation of the esophageal mucosa:

Esophageal duodenoscopy allows direct visualization of the esophageal mucosa, which can help identify any abnormalities, such as tumors or strictures. It can provide information on the extent and location of the lesion. Biopsy: During the procedure, biopsies can be taken from suspicious areas in the esophagus. Biopsy samples can be examined under a microscope to determine the presence of cancer cells or other pathological changes.

The corneal reflex, which is mediated by cranial nerve V (trigeminal) and cranial nerve VII (facial), remains intact. This preservation distinguishes tranquilizer intoxication from other types of drug intoxications.

68. A 60-year-old patient has been admitted to a hospital with complaints of dyspnea, tightness in the right subcostal area, abdomen enlargement. These presentations have been progressing for a year. Heart auscultation reveals presystolic gallop rhythm. Objectively: swelling of the neck veins, ascites, palpable liver and spleen. What disease requires differential diagnostics?

A. Constrictive pericarditis

B. Hepatocirrhosis

C. Lung cancer with invasion to the pleura

D. Chronic pulmonary heart

E. Pulmonary embolism

Answer: Constrictive pericarditis

Explanation

Constrictive pericarditis is a condition characterized by inflammation and fibrosis of the pericardium, the sac-like structure surrounding the heart. It can lead to impaired cardiac filling and subsequent symptoms such as dyspnea, abdominal symptoms, and signs of right-sided heart failure.

The presented symptoms and clinical findings are consistent with constrictive pericarditis for the following reasons: Dyspnea: Constrictive pericarditis can cause impaired cardiac filling, leading to increased pressure in the cardiac chambers. This can result in dyspnea, especially during physical activity or when lying flat.

Right subcostal tightness and abdominal enlargement: Constrictive pericarditis can lead to increased pressure in the hepatic veins and inferior vena cava, causing fluid to accumulate in the abdomen. This can result in right subcostal tightness and abdominal distension.

Presystolic gallop rhythm: A presystolic gallop rhythm, also known as a fourth heart sound (S4), can be heard on cardiac auscultation in patients with constrictive pericarditis. It occurs due to impaired ventricular filling during late diastole. Swelling of the neck veins:

Constrictive pericarditis can lead to elevated central venous pressure, causing jugular venous distention and swelling of the neck veins. Ascites: The increased pressure in the hepatic veins and inferior vena cava can lead to fluid accumulation in the abdomen, resulting in ascites. Palpable liver and spleen: The elevated central venous pressure can also cause hepatomegaly (enlarged liver) and splenomegaly (enlarged spleen).

69. A 40-year-old patient, the forester, complains of severe headache, body temperature rise up to 39, 5oC, trembling limbs. From the patient’s history we know that he had seriously cut his hand during the dissection of a killed fox. Objectively: depressed mood. The patient asks not to turn on the light or open the door. Any noise causes apparent motor excitation. When he saw a carafe of water, he developed convulsive throat spasms. What tactics should an emergency doctor choose?

A. Deliver the patient to the infectious disease hospital

B. Deliver the patient to the resuscitation department

C. Deliver the patient to the neurological department

D. Deliver the patient to the psychiatric hospital

E. Let him stay at home and consult a psychiatris

Answer: Deliver the patient to the infectious disease hospital

Explanation

The presented symptoms and history raise concerns about a possible infectious disease transmission from the fox to the patient. The following factors support this suspicion: Hand injury during the dissection of a killed fox: The patient’s hand injury during the dissection of a potentially infected animal raises the possibility of exposure to infectious agents present in the fox’s body fluids or tissues. Severe headache, high body temperature, and trembling limbs:

These symptoms, along with the history of the hand injury, are indicative of systemic infection and suggest the presence of an infectious disease. Aversion to light, noise, and apparent motor excitation: These symptoms can be consistent with neurological manifestations seen in certain infectious diseases, such as meningitis or encephalitis.

Convulsive throat spasms: This symptom raises concerns about the involvement of the central nervous system and could be associated with certain infectious diseases. Given these considerations, the most appropriate tactic for the emergency doctor is to deliver the patient to the infectious disease hospital.

This specialized facility is equipped to handle and diagnose infectious diseases. The patient’s symptoms, history, and potential exposure to an infectious source necessitate a thorough evaluation and appropriate management in a setting where infectious diseases can be diagnosed and treated effectively.

70. A 5-year-old child developed an acute disease starting from body temperature rise up to 38, 5oC, running nose, cough and conjunctivitis. On the 4th day the child presented with maculo-papular rash on face. Body temparature rose again up to 39, 2oC. Over the next few days the rash spread over the whole body and extremities. Mucous membrane of palate was hyperemic, there was whitish deposition on cheek mucous membrane next to molars. What is your provisional diagnosis?

A. Measles

B. Acute viral respiratory infection

C. Yersinia

D. Enterovirus diseases

E. Rubella

Answer: Measles

Explanation

Acute disease with fever, running nose, cough, and conjunctivitis: These initial symptoms are consistent with the prodromal phase of measles. Measles is a highly contagious viral infection that commonly presents with respiratory symptoms, including runny nose, cough, and conjunctivitis. Maculo-papular rash on the face: On the 4th day, the child developed a maculo-papular rash on the face. This is a classic characteristic of measles.

The rash typically starts on the face and then spreads to the rest of the body and extremities. High body temperature: The recurrence of high body temperature (39.2°C) after the appearance of the rash is another typical feature of measles. This pattern of fever, followed by the onset of rash, is known as “Fever-Rash-Fever.”

Spread of rash and involvement of mucous membranes: The rash spreading over the whole body and extremities, along with the hyperemic mucous membrane of the palate and whitish deposition on the cheek mucous membrane next to molars, are additional signs consistent with measles. The presence of Koplik spots (whitish spots on the mucous membranes) is a specific finding seen in measles and is often found on the buccal mucosa near the molars.

71. A 28-year-old woman has a 12-year history of chronic glomerulonephritis with latent course. Over the past six months she has developed general weakness, loss of appetite, low work performance, nausea. The patient complains of headache, pain in the joints. On examination: anemia, blood urea – 34,5 millimole/l, blood creatinine – 0,766 millimole/l, hyperkalemia. What complication has developed?

A. Chronic renal insufficiency

B. Acute renal insufficiency

C. Nephrotic syndrome

D. Renal amyloidosis

E. Pyelonephritis

Answer: Chronic renal insufficiency

Explanation

History of chronic glomerulonephritis: The patient’s long-standing history of chronic glomerulonephritis indicates an ongoing kidney disease that has been present for 12 years. Chronic glomerulonephritis is characterized by persistent inflammation and damage to the glomeruli, which are the filtering units of the kidneys.

Symptoms of general weakness, loss of appetite, low work performance, nausea: These symptoms are consistent with the systemic manifestations of chronic kidney disease (CKD). As kidney function declines, it can lead to a buildup of waste products in the blood, resulting in symptoms such as fatigue, decreased appetite, and impaired concentration.

Anemia: Anemia is a common complication of chronic renal insufficiency. The kidneys play a crucial role in the production of erythropoietin, a hormone responsible for stimulating red blood cell production. In CKD, reduced kidney function can lead to decreased erythropoietin production and subsequent anemia.

Elevated blood urea and creatinine levels: The elevated blood urea level (34.5 mmol/L) and slightly elevated creatinine level (0.766 mmol/L) suggest impaired kidney function. In chronic renal insufficiency, the kidneys gradually lose their ability to adequately filter waste products from the blood, resulting in elevated levels of urea and creatinine.

Hyperkalemia: Hyperkalemia, which refers to an elevated level of potassium in the blood, can occur as kidney function declines. The kidneys are responsible for maintaining electrolyte balance, including regulating potassium levels. In chronic renal insufficiency, impaired kidney function can lead to the accumulation of potassium in the blood.

72. A child is 1 year old. Ater the recent introduction of complementary feeding the child has presented with loss of appetite, diarrhea with large amounts of feces and occasional vomiting, body temperature is normal. Objectively: body weight is 7 kg, the child is very pale, there are edemata of both legs, abdomen is significantly enlarged. Coprogram shows many fatty acids and soaps. The child has been diagnosed with celiac disease and administered the gluten-free diet. What is to be excluded from the ration?

A. Cereals – wheat and oats

B. Milk and dairy products

C. Fruit

D. Animal protein

E. High digestible carbohydrates

Answer: Cereals – wheat and oats

Explanation

Celiac disease: Celiac disease is an autoimmune disorder triggered by the ingestion of gluten, a protein found in certain grains. It causes damage to the small intestine and impairs nutrient absorption. The only effective treatment for celiac disease is a strict gluten-free diet.

Loss of appetite, diarrhea, and vomiting: These symptoms are common manifestations of celiac disease in children. When a child with celiac disease consumes gluten-containing foods, it can lead to gastrointestinal symptoms such as loss of appetite, diarrhea with large amounts of feces, and occasional vomiting. Edema, pale appearance, and enlarged abdomen:

These clinical findings indicate malnutrition and poor absorption of nutrients, which are characteristic features of celiac disease. The damage to the small intestine hinders the absorption of essential nutrients, leading to weight loss, pale appearance, edema, and an enlarged abdomen.

Coprogram findings: The presence of fatty acids and soaps in the coprogram suggests malabsorption of dietary fats, which is common in celiac disease. When gluten is consumed, it triggers an immune response that damages the lining of the small intestine, leading to impaired fat absorption and fatty stools.

Excluding cereals – wheat and oats: Wheat is one of the main sources of gluten, and oats can also be contaminated with gluten during processing. Both wheat and oats contain gluten proteins that can trigger an immune reaction and worsen the symptoms in individuals with celiac disease. Therefore, these cereals should be eliminated from the diet.

73. Development of chronic venous insufficiency of lower extremities depends on the functional condition of so-called musculovenous pump. This term refers to the following group of muscles:

A. Shin muscles

B. Abdominal wall muscles

C. Buttock region muscles

D. Thigh muscles

E. Foot muscles

Answer: Shin muscles

Explanation

Chronic venous insufficiency (CVI) refers to a condition where the veins in the lower extremities fail to efficiently return blood back to the heart. The musculovenous pump plays a crucial role in maintaining venous return by assisting the upward flow of blood against gravity.

This pump mechanism involves the contraction of specific muscles that help propel blood through the veins. The shin muscles, specifically the calf muscles, are the primary muscles involved in the musculovenous pump. These muscles include the gastrocnemius and soleus muscles, which are located in the posterior aspect of the lower leg. When these muscles contract during activities such as walking or calf raises, they compress the veins and propel blood towards the heart.

The contraction and relaxation of the calf muscles act as a pump, squeezing the deep veins and pushing the blood upwards. This action helps to overcome the effects of gravity and facilitates venous return. The valves within the veins prevent the backflow of blood, ensuring that it moves in one direction towards the heart.

The other options listed (B. Abdominal wall muscles, C. Buttock region muscles, D. Thigh muscles, E. Foot muscles) do contribute to overall muscle tone and blood circulation, but they are not directly involved in the musculovenous pump mechanism responsible for venous return in the lower extremities.

74. After treating a field with pesticides a machine operator presents with great weakness, headache, nausea, vomiting, diarrhea, visual impairment, watery eyes. Objectively: the patient is excited, hypersalivation, hyperhidrosis, muscle fibrillation of tongue and eyelids are oberved. Pupils are narrowed, there is tachycardia, lung auscultation reveals moist small and medium bubbling rales. In blood: changed level of cholinesterase activity. What is the most likely diagnosis?

A. Intoxication with organophosphorous pesticides

B. Intoxication with organochlorine pesticides

C. Intoxication with organomercurial pesticides

D. Intoxication with arsenic-containing pesticides

E. Intoxication with carbamic acid derivatives

Answer: Intoxication with organophosphorous pesticides

Explanation

Organophosphorus pesticides are a class of chemicals commonly used in agriculture to control pests. They work by inhibiting the activity of an enzyme called acetylcholinesterase, which is responsible for breaking down the neurotransmitter acetylcholine in the body. When acetylcholinesterase is inhibited, acetylcholine accumulates, leading to overstimulation of the nervous system. The symptoms described in the scenario are consistent with acute poisoning from organophosphorus pesticides.

Here’s why: Weakness, headache, nausea, vomiting, and diarrhea: These are common symptoms of acute organophosphate poisoning. The inhibition of acetylcholinesterase can affect various systems in the body, including the gastrointestinal tract, leading to gastrointestinal symptoms.

Visual impairment, watery eyes, hypersalivation, hyperhidrosis: These are signs of increased cholinergic activity due to excess acetylcholine. The effects on the visual system and the increased secretions (saliva and sweat) are characteristic of organophosphate poisoning.

Excitement, muscle fibrillation of tongue and eyelids: Excessive acetylcholine activity can cause neurological symptoms, including hyperexcitability and muscle twitching (fibrillation). These manifestations are commonly seen in organophosphate poisoning. Narrowed pupils (miosis) and tachycardia: Organophosphate poisoning can lead to cholinergic stimulation of the autonomic nervous system, resulting in symptoms such as miosis (constriction of the pupils) and increased heart rate (tachycardia).

Lung auscultation findings: Moist small and medium bubbling rales in the lungs can be observed due to excessive secretions in the respiratory tract caused by cholinergic stimulation. Decreased cholinesterase activity in blood: Organophosphorus pesticides inhibit the activity of cholinesterase enzymes, and a decreased level of cholinesterase activity in the blood is a characteristic finding in cases of organophosphate poisoning.

75. A 7-year-old child was brought to a doctor for a check. The child has a 4-year history of bronchial asthma, asthma attacks occur mainly in spring and summer. Allergy tests revealed hypersensitivity to poplar seed tufts, field herbs. What recommendation should be given?

A. Specific hyposensitization

B. Physiotherapy

C. Treatment at a health resort

D. Phytotherapy

E. Needle reflexotherapy

Answer: Specific hyposensitization

Explanation

Specific hyposensitization, also known as allergen immunotherapy or allergy shots, is a treatment approach aimed at desensitizing the immune system to specific allergens. It involves the administration of gradually increasing doses of the allergen to which the person is allergic. The goal of specific hyposensitization is to modify the immune response to the allergen, reducing the severity and frequency of allergic reactions.

In this case, since the child has a known history of bronchial asthma and has identified specific allergens (poplar seed tufts and field herbs) that trigger their asthma attacks, specific hyposensitization would be the most appropriate recommendation. By exposing the child’s immune system to increasing amounts of these allergens over time, specific hyposensitization can help reduce the allergic response and minimize asthma symptoms.

It’s important to note that specific hyposensitization is a specialized treatment that should be administered under the guidance of an allergist or immunologist. The treatment involves careful evaluation and individualized allergy testing to determine the appropriate allergens and dosing regimen for each patient.

76. A farmer hurt his right foot during working in a field and came to the emergency station. He doesn’t remember when he got last vaccination and he has never served in the army. Examination of his right foot revealed a contaminated wound up to 5-6 cm long with uneven edges. The further treatment tactics will be:

A. To make an injection of tetanus anatoxin and antitetanus serum

B. To make an injection of tetanus anatoxin

C. To make an injection of antitetanus serum

D. Surgical d-bridement only

E. To administer an antibiotic

Answer: To make an injection of tetanus anatoxin and antitetanus serum

Explanation

Tetanus is a serious bacterial infection caused by Clostridium tetani, which can enter the body through contaminated wounds. The bacteria produce a toxin that affects the nervous system, leading to muscle stiffness and spasms. In this case, the farmer’s wound is contaminated and of a size that increases the risk of tetanus infection.

Since the patient does not remember his last tetanus vaccination and has never served in the army, it is crucial to administer both tetanus anatoxin and antitetanus serum. Tetanus anatoxin, also known as tetanus toxoid, is a vaccine that stimulates the production of protective antibodies against tetanus.

It helps to prevent the development of the disease in individuals who have not been adequately immunized.Antitetanus serum, also called tetanus immune globulin (TIG), is a concentrated solution of antibodies against tetanus toxin. It provides immediate passive immunity and helps neutralize the toxin if the infection is already present.

77. A 35-year-old patient has been admitted to a hospital for pain in the left sternoclavicular and knee joints, lumbar area. The disease has an acute character and is accompanied by fever up to 38oC. Objectively: the left sternoclavicular and knee joints are swollen and painful. In blood: WBCs – 9, 5 · 109/l, ESR – 40 mm/h, CRP – 1,5 millimole/l, fibrinogen – 4,8 g/l, uric acid – 0,28 millimole/l. Examination of the urethra scrapings reveals chlamydia. What is the most likely diagnosis?

A. Reiter’s syndrome

B. Rheumatic arthritis

C. Gout

D. Bechterew’s disease

E. Rheumatoid arthritis

Answer: Reiter’s syndrome

Explanation

Reiter’s syndrome, also known as reactive arthritis, is a type of inflammatory arthritis that typically occurs as a reaction to an infection in another part of the body, usually the genitourinary or gastrointestinal tract. It is characterized by joint pain, swelling, and inflammation, along with other symptoms such as fever, fatigue, and urinary symptoms.

In this case, the patient’s symptoms of joint pain and swelling, along with the presence of chlamydia in the urethra scrapings, suggest an infectious origin for the arthritis. Reiter’s syndrome is commonly associated with genitourinary infections, particularly with chlamydia.

The laboratory findings of elevated white blood cell count (WBCs), elevated erythrocyte sedimentation rate (ESR), and elevated C-reactive protein (CRP) indicate an inflammatory response in the body. These findings are consistent with the inflammatory nature of Reiter’s syndrome

78. Topographic percussion of lungs in a patient who got a serious job-related barotrauma revealed that the lower lungs borders were located one rib below normal, there was a significant increase in both lungs height and Kronig’s isthmus. What disease should be suspected in the first place?

A. Pulmonary emphysema

B. Exudative pleuritis

C. Chronic bronchitis

D. Bronchial asthma

E. Pneumothorax

Answer: Pulmonary emphysema

Explanation

Pulmonary emphysema is a condition characterized by the destruction of the lung tissue, specifically the alveoli, which are responsible for the exchange of oxygen and carbon dioxide. This destruction leads to the enlargement of the air spaces and loss of lung elasticity.

As a result, the lungs may appear hyperinflated, causing an increase in both lung height and the distance between the lower lung border and the normal anatomical position. The changes observed in the percussion findings, such as the lower lung border being located one rib below normal, are consistent with the characteristic anatomical changes seen in pulmonary emphysema.

This condition is often associated with chronic obstructive pulmonary disease (COPD) and is commonly caused by long-term exposure to irritants, such as cigarette smoke or occupational hazards.

It’s important to note that a comprehensive evaluation, including clinical history, physical examination, and additional diagnostic tests, would be necessary to confirm the diagnosis of pulmonary emphysema. This may include pulmonary function tests, imaging studies (such as chest X-ray or CT scan), and possibly a consultation with a pulmonologist.

79. A 32-year-old patient lives in an area endemic for echinococcosis. In the last 6 months he reports of pain in the right subcostal area, fever. He is suspected to have liver echinococcosis. What study would be the most informative in this case?

A. USI

B. Survey radiography of abdominal cavity

C. Biochemical laboratory examination

D. Angiography

E. Liver scanning

Answer: USI

Explanation

Ultrasound (USI) is a non-invasive imaging technique that utilizes sound waves to create real-time images of the internal structures of the body. It is particularly useful for evaluating liver pathologies, including echinococcosis.

With USI, the presence of characteristic cystic lesions, such as hydatid cysts, in the liver can be visualized and assessed for size, location, and potential complications. USI can also help differentiate between different types of liver lesions and guide further management decisions.

Compared to other diagnostic options listed, such as survey radiography of the abdominal cavity (B), biochemical laboratory examination (C), angiography (D), and liver scanning (E), ultrasound (USI) is considered the most informative and commonly used imaging modality for the detection and characterization of liver echinococcosis. It is widely available, cost-effective, and does not involve radiation exposure.

80. A 30-year-old gravida consulted a gynecologist about bright red bloody discharges from the vagina in the 32 week of gestation. She was hospitalized with a suspicion of placental presentation. Under what conditions is it rational to conduct the internal examination in order to make a diagnosis?

A. In the operating room prepared for the operation

B. In the examination room of antenatal clinic

C. In the admission ward of maternity hospital

D. In the delivery room keeping to all the aseptics regulations

E. The examination is not to be conducted because of risk of profuse haemorrhage

Answer: In the operating room prepared for the operation

Explanation

The most appropriate option is A: In the operating room prepared for the operation. Placental presentation, also known as placenta previa, occurs when the placenta partially or completely covers the opening of the cervix. It is a potentially serious condition that requires careful evaluation and management. Conducting an internal examination in this situation carries a risk of profuse hemorrhage, which can be life-threatening for both the mother and the fetus.

Therefore, it is essential to perform the examination in an environment where immediate access to necessary medical interventions, such as surgical procedures, blood transfusions, and skilled medical personnel, is available.

The operating room, prepared for the operation, ensures that all necessary equipment and resources are readily accessible to manage any potential complications that may arise during the examination. It provides a controlled and sterile environment, which is crucial to minimize the risk of infection and ensure the safety of the patient.

81. After a serious nervous stress a 35- year-old patient has developed on the dorsal surface of hands redness and swelling that were later replaced by small inflammatory nodules, vesicles and following erosion with a significant serous discharge. The process is accompanied by severe itching. What is the most likely diagnosis?

A. True eczema

B. Allergic dermatitis

C. Microbal eczema

D. Simple contact dermatitis

E. Toxicoderma

Answer: True eczema

Explanation

True eczema, also known as atopic dermatitis, is a chronic inflammatory skin condition characterized by redness, swelling, and itching. It often occurs in individuals with a personal or family history of allergic conditions such as asthma or hay fever.

The condition can be triggered or exacerbated by various factors, including stress. In this case, the patient developed redness and swelling on the dorsal surface of the hands following a serious nervous stress.

These symptoms are typical of the acute phase of eczema. Later on, the appearance of small inflammatory nodules, vesicles, and erosion with serous discharge is also characteristic of eczema. The severe itching reported by the patient is another common symptom associated with eczema.

It is important to note that the definitive diagnosis of eczema is typically made based on a combination of clinical evaluation, patient history, and, in some cases, additional tests or investigations. However, the provided description strongly suggests true eczema as the most likely diagnosis in this scenario.

82. A 36-year-old patient complains of skin rash that appeared a week ago and doesn’t cause any subjective problems. Objectively: palm and sole skin is covered with multiple lenticular disseminated papules not raised above the skin level. The papules are reddish, dense on palpation and covered with keratinous squamae. What is the provisional diagnosis?

A. Secondary syphilis

B. Verrucosis

C. Palmoplanar psoriasis

D. Palmoplanar rubrophytosis

E. Palm and sole callosity

Answer: Secondary syphilis

Explanation

Secondary syphilis is a stage of syphilis infection that occurs several weeks to months after the initial infection. It is characterized by a wide range of symptoms, including skin rashes. The rash associated with secondary syphilis is typically non-itchy and can appear on various parts of the body, including the palms and soles.

In this case, the patient presents with lenticular disseminated papules on the palms and soles, which is consistent with the rash seen in secondary syphilis. The papules are described as reddish, dense on palpation, and covered with keratinous squamae (scaly skin). These characteristics align with the typical features of secondary syphilis rash.

It is important to note that a definitive diagnosis of secondary syphilis would require additional confirmatory tests, such as serological tests for syphilis antibodies. However, based on the provided information, secondary syphilis is the most likely provisional diagnosis for the patient’s skin rash. Further evaluation by a healthcare professional and appropriate testing would be necessary to confirm the diagnosis.

83. A 30-year-old patient complains of paroxysmal abdominal pain, frequent liquid stools up to 10 times a day. Throughout the first 3 days he had a fever, since the 2nd day of disease there were scant liquid stools mixed with mucus. On palpation: tenderness of all colon segments. Sigmoid colon was found spastic. What is your provisional diagnosis?

A. Acute dysentery

B. Intestinal amebiasis

C. Salmonellosis

D. Cholera

E. Balantidiasis

Answer: Acute dysentery

Explanation

Acute dysentery is an infection of the intestines, typically caused by bacteria or parasites. It is characterized by paroxysmal abdominal pain and frequent, liquid stools. The presence of scant liquid stools mixed with mucus, along with the tenderness of all colon segments and spastic sigmoid colon on palpation, are consistent with the symptoms of acute dysentery.

The term “dysentery” refers to the inflammation of the intestines, particularly the colon, which leads to symptoms such as abdominal pain and diarrhea. In acute dysentery, the stools are often watery or bloody, and mucus may be present.

While the specific causative agent cannot be determined based on the given information, the symptoms described align with the typical presentation of acute dysentery. Further diagnostic tests, such as stool culture or microscopy, may be required to identify the specific pathogen responsible for the infection.

84. A 38-year-old woman experiences episodic increases in arterial pressure up to 240/120 mm Hg, which is accompanied by nausea, vomiting, tachycardia, increased sweating, hyperglycemia. The attack is usually followed by the excessive urination. Renal sonography reveals an additional formation adjacent to the upper pole of the right kidney and possibly belonging to the adrenal gland. What laboratory test will allow to clarify the diagnosis?

A. Determination of urinary excretion of catecholamines and vanillylmandelic acid

B. Blood test for insulin and C-peptide

C. Estimation of glomerular filtration rate by measuring endogenous creatinine clearance

D. Blood test for thyroxine and thyrotrophic hormone

E. Blood test for renin level

Answer: Determination of urinary excretion of catecholamines and vanillylmandelic acid

Explanation

The symptoms described in the scenario, such as episodic increases in arterial pressure, nausea, vomiting, tachycardia, increased sweating, hyperglycemia, excessive urination, and the presence of an additional formation adjacent to the upper pole of the right kidney, suggest the possibility of a catecholamine-secreting tumor, such as a pheochromocytoma or paraganglioma.

Pheochromocytomas are tumors that arise from chromaffin cells in the adrenal medulla or sympathetic ganglia, and they can secrete excessive amounts of catecholamines, including adrenaline (epinephrine) and noradrenaline (norepinephrine). The increased catecholamine levels can lead to episodes of hypertension, along with other associated symptoms.

To confirm the presence of a catecholamine-secreting tumor, a laboratory test that measures the urinary excretion of catecholamines (epinephrine, norepinephrine) and their metabolites, such as vanillylmandelic acid (VMA), is commonly used. Elevated levels of these substances in the urine can indicate the presence of a pheochromocytoma or paraganglioma.

85. A 32-year-old patient has a 3-year history of asthma attacks, that can be hardly stopped with berotec. Over a few last months he has experienced pain in the joints and sensitivity disorder of legs and feet skin. Ps – 80/min, AP – 210/100 mm Hg. In blood: eosinophilia at the rate of 15%. What disease can be suspected in this case?

A. Periarteritis nodosa

B. Systemic lupus erythematosus

C. Systemic scleroderma

D. Dermatomyositis

E. Wegener’s disease

Answer: Periarteritis nodosa

Explanation

Periarteritis nodosa is a systemic vasculitis that primarily affects medium-sized arteries. It can involve various organs, including the joints, skin, peripheral nerves, and gastrointestinal tract. The patient in the scenario has a history of asthma attacks, joint pain, and sensitivity disorder of the legs and feet skin, which are consistent with the involvement of multiple systems.

The elevated blood pressure (210/100 mm Hg) and eosinophilia (15%) seen in the patient are additional findings that can be associated with periarteritis nodosa. Hypertension is a common manifestation of the disease, and eosinophilia can be present due to the inflammation and immune response associated with the condition.

While other autoimmune diseases, such as systemic lupus erythematosus, systemic scleroderma, dermatomyositis, and Wegener’s disease, can also present with overlapping symptoms, the combination of asthma attacks, joint pain, sensitivity disorder, hypertension, and eosinophilia makes periarteritis nodosa the most likely diagnosis in this case.

86. A 46-year-old patient complains of sudden palpitation, which is accompanied by pulsation in the neck and head, fear, nausea. The palpitation lasts for 15-20 minutes and is over after straining when holding her breath. What kind of cardiac disorder may be suspected?

A. An attack of supraventricular paroxysmal tachycardia

B. An attack of ventricular paroxysmal tachycardia

C. An attack of atrial flutter

D. An attack of ciliary arrhythmia

E. An attack of extrasystolic arrhythmia

Answer: An attack of supraventricular

Explanation

Supraventricular paroxysmal tachycardia (SVT) is a type of abnormal heart rhythm characterized by sudden episodes of rapid heart rate originating from above the ventricles. It typically presents with sudden palpitations, accompanied by pulsation in the neck and head, fear, and sometimes nausea.

The palpitations are usually self-terminated or can be stopped by certain maneuvers, such as straining or holding the breath. The fact that the palpitations in this patient last for 15-20 minutes and can be terminated by straining or holding the breath suggests the possibility of SVT.

These maneuvers, known as Valsalva maneuvers, can help restore normal heart rhythm by stimulating the vagus nerve and interrupting the abnormal electrical circuit responsible for the tachycardia.

87. The patient complains of a painful swelling in the chin region, malaise, headache. Examination reveals an acutely inflamed cone-shaped dense node. The skin over it is tense, red. In the center of the node there is an ulcer with overhanging edges and a necrotic core of a dirtygreen colour. Submandibular lymph nodes on the right are enlarged and painful. What is the most likely diagnosis?

A. Furuncle

B. Tuberculosis

C. Carbuncle

D. Tertiary syphilis (gummatous form)

E. Parasitic sycosis

Answer: Furuncle

Explanation

A furuncle, commonly known as a boil, is a localized infection of a hair follicle and the surrounding tissue. It is typically caused by the bacteria Staphylococcus aureus. The symptoms presented by the patient, including painful swelling in the chin region, malaise, headache, and an acutely inflamed node with a tense, red skin over it, are consistent with the characteristics of a furuncle.

The presence of an ulcer with overhanging edges and a necrotic core of a dirty green color further supports the diagnosis of a furuncle. These features are typically seen in the later stages of the infection, where the necrotic core represents the tissue breakdown.

The enlargement and tenderness of the submandibular lymph nodes on the right side indicate that the infection is spreading to the nearby lymph nodes, which is a common occurrence in furuncles.

While other conditions such as tuberculosis, carbuncle, tertiary syphilis (gummatous form), and parasitic sycosis could present with similar symptoms, the acute nature of the presentation, the presence of a single inflamed node, and the typical characteristics of a furuncle make it the most likely diagnosis.

88. A welder at work got the first-degree burns of the middle third of his right shin. 5 days later the skin around the burn became edematic and itchy. Objectively: on a background of a well-defined erythema there is polymorphic rash in form of papules, vesicles, pustules, erosions with serous discharge. What is the most likely diagnosis?

A. Microbal eczema

B. True eczema

C. Toxicoderma

D. Occupational eczema

E. Streptococcal impetigo

Answer: Microbal eczema

Explanation

Microbial eczema, also known as infected eczema or eczema with secondary infection, occurs when an existing eczematous skin lesion becomes infected by bacteria. In this case, the initial burn on the welder’s shin has become infected, leading to the development of microbial eczema.

The progression of symptoms is indicative of an infection. Five days after the burn, the surrounding skin has become edematous and itchy. The presence of a well-defined erythema along with a polymorphic rash consisting of papules, vesicles, pustules, erosions with serous discharge further suggests an infectious process.

Microbial eczema commonly occurs due to the introduction of bacteria into an existing eczematous area. The compromised skin barrier allows bacteria to invade and multiply, leading to an inflammatory response and the characteristic symptoms observed in this case.

While other conditions such as true eczema, toxicoderma, occupational eczema, and streptococcal impetigo may also present with similar symptoms, the presence of an initial burn injury and the subsequent development of an infected rash indicate microbial eczema as the most likely diagnosis.

89. A 58-year-old patient has a 3-year history diabetes mellitus type II. He has been keeping to a diet and regularly taking glyburide. He has been delivered to a hospital on an emergency basis for acute abdomen. Objectively: the patient is of supernutrition type. The skin is dry. In the lungs vesicular breathing can be auscultated. Heart sounds are regular, 90/min. AP- 130/70 mm Hg. The symptom of “wooden belly”is visible. Blood sugar – 9,8 millimole/l. The patients has indication for laparotomy. What is the most appropriate way of further treatment of diabetes?

A. To administer short insulin

B. To continue taking glyburide

C. To administer Semilong to be taken in the morning and insulin – in the evening

D. To administer 1 tablet of Glurenorm three times a day

E. To administer 1 tablet of Maninil three times a day

Answer: To administer short insulin

Explanation

In the given scenario, the patient’s acute abdomen suggests a potentially serious underlying condition that requires surgical intervention. It is important to stabilize the patient’s blood glucose levels prior to surgery to minimize the risk of complications.

Despite the patient’s adherence to diet and regular intake of glyburide, the blood sugar level of 9.8 millimole/l indicates inadequate control. In the presence of acute illness or surgical stress, the use of oral hypoglycemic agents such as glyburide may not be sufficient to maintain optimal blood glucose control. Insulin therapy is preferred in such situations as it allows for better glycemic management and flexibility in adjusting doses.

90. An 8-year-old girl has been admitted to the cardiology department. Objectively: there is a skin lesion over the extensor surfaces of joints with atrophic cicatrices, depigmentation, symmetrical affection of skeletal muscles (weakness, edema, hypotrophy). What disease are these changes most typical for?

A. Dermatomyositis

B. Systemic scleroderma

C. Nodular periarteritis

D. Systemic lupus erythematosus

E. Reiter’s disease

Answer: Dermatomyositis

Explanation

Dermatomyositis is a rare autoimmune disorder that primarily affects the muscles and skin. It commonly occurs in children and young adults, and the characteristic skin findings often accompany muscle weakness.

The skin manifestations in dermatomyositis can include a variety of changes, such as a heliotrope rash (reddish-purple rash on the upper eyelids), Gottron’s papules (red or violaceous patches over the knuckles and other extensor surfaces), and atrophic or poikilodermatous (skin discoloration) changes.

The atrophic cicatrices, depigmentation, and symmetrical involvement of skeletal muscles described in the case are consistent with the cutaneous features of dermatomyositis. In addition to skin findings, dermatomyositis is characterized by muscle weakness, particularly in the proximal muscles (e.g., shoulders, hips).

This weakness can result in difficulties with activities such as climbing stairs, getting up from a sitting position, or lifting objects. Other common symptoms may include fatigue, joint pain, and systemic involvement.

91. A 43-year-old female patiet complains of eruption on her right leg skin, pain, weakness, body temperature rise up to 38oC. The disease is acute. Objectively: there is an edema on the right leg skin in the region of foot, a well-defined bright red spot in form of flame tips which feels hot. There are isolated vesicles in focus. What is your provisional diagnosis?

A. Erysipelas

B. Microbial eczema

C. Contact dermatitis

D. Toxicoderma

E. Haemorrhagic vasculitis

Answer: Erysipelas

Explanation

Erysipelas is an acute bacterial skin infection that is typically caused by Streptococcus pyogenes bacteria. It commonly affects the lower extremities, such as the legs. The characteristic features of erysipelas include:

Edema and erythema: The affected skin shows swelling (edema) and a well-defined, bright red spot. In this case, the red spot is described as being in the form of flame tips, which suggests a characteristic pattern of erythema. Heat and tenderness: The affected area may feel hot to the touch and be tender.

Systemic symptoms: The patient reports a rise in body temperature up to 38°C, which indicates the presence of an infection. Other systemic symptoms such as weakness can also be associated with erysipelas. Vesicles: In some cases, small vesicles may be present within the affected area.

92. A 45-year-old patient complains of some painless nodular elements tending to peripheral growth and fusion. He has a 2-year history of this disease. Aggravation takes place mainly in spring. In anamnesis: the patient’s father had similar skin lesions. Objectively: pathological elements looke like guttate and nummular nodules, plaques covered with white scales. What is your provisional diagnosis?

A. Psoriasis

B. Lichen ruber planus

C. Neurodermitis

D. Pityriasis rosea

E. Seborrheic eczema

Answer: Psoriasis

Explanation

Psoriasis is a chronic inflammatory skin condition that is characterized by the development of well-defined, raised, red patches of skin covered with silvery-white scales. It commonly presents with skin lesions that tend to grow and merge together, forming larger plaques.

The lesions can occur anywhere on the body, including the scalp, elbows, knees, and lower back. The clinical features that support the diagnosis of psoriasis in this case include: Painless nodular elements: Psoriasis lesions can manifest as nodules that are painless and tend to enlarge and merge over time.

Peripheral growth and fusion: The lesions in psoriasis have a tendency to spread to the periphery and merge together, resulting in larger plaques. Chronic course with seasonal aggravation: Psoriasis is a chronic condition that can persist for years.

It often exhibits exacerbations and remissions, with seasonal flares being common. In this case, the aggravation of symptoms mainly in spring aligns with the characteristic pattern of psoriasis. Family history: The presence of a similar skin condition in the patient’s father suggests a possible genetic predisposition to psoriasis. Psoriasis has a genetic component, and a family history of the disease increases the likelihood of its diagnosis.

93. A 47-year-old patient came to see a doctor on the 7th day of disease. The disease developed very fast: after the chill body temperature rose to 40oC and lasted up to 7 hours, then dropped abruptly, which caused profuse sweat. There were three such attacks occuringonce in two days. Two days ago the patient arrived from Africa. Objectively: pale skin, subicteric sclera, significantly enlarged liver and spleen. What is the cause of fever attacks in this disease?

A. Erythrocytic schizogony

B. Tissue schizogony

C. Exotoxin of a causative agent

D. Endotoxin of a causative agent

E. Gametocytes

Answer: Erythrocytic schizogony

Explanation

Based on the provided information, the patient presents with a history of rapid onset fever, reaching high temperatures of 40°C, lasting for approximately 7 hours, and recurring every two days. The patient recently arrived from Africa, which is a crucial clue for the diagnosis.

These clinical features are highly suggestive of malaria, a parasitic disease transmitted by mosquitoes. Malaria is caused by Plasmodium parasites, and the cyclic pattern of fever described in the patient’s case is characteristic of certain species of Plasmodium, particularly Plasmodium falciparum.

During the erythrocytic schizogony phase of the Plasmodium life cycle, the parasites replicate within red blood cells (erythrocytes). This replication involves a series of asexual divisions known as schizogony, during which the parasite multiplies and releases merozoites into the bloodstream. The release of merozoites triggers the characteristic fever episodes associated with malaria.

94. On the 2 nd day of illness a 27-yearold patient complains of the unbearable headache, repeated vomiting. Objectively: the patient is in a grave condition. He is conscious but adynamic. Lies in a forced position with his head thrown back. There is no skin rash. Occipital muscles are evidently rigid, there are Kernig’s and Brudzinski’s signs. t o- 39, 5oC, Ps120/min., AP- 130/80 mm Hg. What is the reason for the leading syndrome of this disease?

A. Liquor hypertension

B. Liquor hypotension

C. Affection of the cranial nerve nuclei

D. Haemorrhages into the adrenal glands

E. Hyperthermy

Answer: Liquor hypertension

Explanation

The presented clinical findings suggest the presence of meningitis, an inflammation of the meninges (the protective membranes surrounding the brain and spinal cord). Meningitis can be caused by various infectious agents, such as bacteria, viruses, or fungi.

The patient’s symptoms, including severe headache, repeated vomiting, and a grave condition, are indicative of increased intracranial pressure. This increased pressure in the skull is known as liquor hypertension. Additional examination findings support this diagnosis.

The patient’s forced position with the head thrown back (referred to as opisthotonus) and the evident rigidity of the occipital muscles suggest meningeal irritation. Kernig’s sign and Brudzinski’s sign are both clinical tests used to assess meningeal irritation.

Kernig’s sign refers to the resistance and pain experienced when attempting to extend the leg at the knee after flexing the hip, while Brudzinski’s sign is characterized by involuntary flexion of the hips and knees when flexing the neck.

95. On the 1st day of life a full-term girl (2nd labour) weighing 3500g, with Apgar score of 8 points, presented with jaundice. Indirect bilirubin of blood – was 80 micromole/l, 6 hours later – 160 micromole/l. What is the optimal method of treatment?

A. Exchange blood transfusion

B. Phototherapy

C. Infusion therapy

D. Phenobarbital treatment

E. Enterosorbents

Answer: Exchange blood transfusion

Explanation

Jaundice in newborns is a common condition caused by an accumulation of bilirubin, a yellow pigment produced during the breakdown of red blood cells. In most cases, jaundice in newborns is due to physiological jaundice, which is a normal process as the newborn’s liver gradually adapts to metabolizing bilirubin effectively.

However, in some cases, such as when the bilirubin levels rise rapidly or reach high levels, treatment is necessary to prevent complications associated with severe hyperbilirubinemia. In this particular case, the newborn girl has a significant increase in bilirubin levels from 80 micromole/l to 160 micromole/l within 6 hours.

Exchange blood transfusion is the most effective and immediate treatment option for rapidly rising or severe hyperbilirubinemia in newborns. This procedure involves removing a small volume of the baby’s blood and replacing it with compatible donor blood or a blood product such as fresh frozen plasma.

Exchange transfusion helps to rapidly lower the bilirubin levels and reduce the risk of bilirubin-induced neurologic dysfunction (BIND), also known as kernicterus, which can lead to permanent neurological damage.

96. A 42-year-old female patient suffers from micronodular cryptogenic cirrhosis. Over the last week her condition has deteriorated: there appeared convulsions, mental confusion, increased jaundice. What study may explain such aggravation?

A. Determination of serum ammonia

B. Determination of cholesterol ethers

C. Determination of alpha-phetoprotein rate

D. Determination of ALAT and ASAT

E. Determination of alkaline phosphatase rate

Answer: Determination of serum ammonia

Explanation

In patients with liver cirrhosis, the liver’s ability to metabolize and eliminate ammonia from the blood is impaired. Ammonia is a byproduct of protein metabolism, and in healthy individuals, it is efficiently converted into urea in the liver and excreted through the urine.

However, in cirrhotic patients, the liver’s dysfunction leads to an accumulation of ammonia in the bloodstream. Ammonia is toxic to the brain and can cause neurological symptoms when its levels become elevated. The symptoms described in the patient, including convulsions, mental confusion, and increased jaundice, suggest hepatic encephalopathy, which is a condition characterized by brain dysfunction due to liver disease.

To confirm the presence of hepatic encephalopathy and assess the severity, the determination of serum ammonia levels is a crucial diagnostic test. Elevated levels of ammonia in the blood indicate impaired liver function and provide insight into the degree of hepatic encephalopathy.

97. A 30-year-old patient was hospitalized with a diagnosis: intestinal obstruction. During the surgery it was revealed that the obstruction of the small intestine had been caused by a mass of helminths. What helminths are these?

A. Ascarids

B. Guinea worms

C. Filarial worms

D. Cysticerci

E. Pinworms

Answer: Ascarids

Explanation

98. On the 5th day after a surgery for colon injury a patient complains of bursting pain in the postoperative wound, weakness, drowsiness, headache, fever up to 40oC. Objectively: the skin around the wound is swollen, there is gas crepitation. The wound discharges are scarce foulsmelling, of dark-gray colorl. What is the most likely diagnosis?

A. Anaerobic clostridial wound infection

B. Abscess

C. Postoperative wound infection

D. Erysipelas

E. Phlegmon

Answer: Anaerobic clostridial wound infection

Explanation

The most likely diagnosis in this scenario is anaerobic clostridial wound infection, which is also known as gas gangrene or clostridial myonecrosis. Gas gangrene is a serious and potentially life-threatening infection that can occur after surgery, particularly in cases where there has been damage to the colon with exposure of the intestinal contents to the surgical site.

The symptoms of gas gangrene include severe pain, weakness, drowsiness, headache, fever, and the presence of gas crepitation, which means that gas is being produced within the tissues. The skin around the wound is typically swollen, and there may be a foul-smelling discharge that is dark-grey in color.

These symptoms are consistent with the scenario described in the question. Gas gangrene is caused by the anaerobic bacteria Clostridium perfringens, which produces a number of toxins that can damage the tissues and cause gas to accumulate. Treatment typically involves surgical removal of dead tissue, antibiotics, and hyperbaric oxygen therapy.

99. A child was born at a gestational age of 34 weeks in grave condition. The leading symptoms were respiratory distress symptoms, namely sonorous and prolonged expiration, involving additional muscles into respiratory process. The Silverman score at birth was 0 points, in 3 hours it was 3 points with clinical findings. Which diagnostic study will allow to diagnose the form of pneumopathy?

A. X-ray of chest

B. Clinical blood test

C. Determination of blood gas composition

D. Proteinogram

E. Immunoassay

Answer: X-ray of chest

Explanation

In this case, the most appropriate diagnostic study to diagnose the form of pneumopathy would be an X-ray of the chest, which can provide valuable information about the presence and extent of lung disease. The clinical presentation of the newborn in this scenario suggests the presence of respiratory distress syndrome (RDS), which is a common condition in premature infants.

RDS is caused by insufficient production of surfactant, a substance that helps to keep the air sacs in the lungs open, and can result in breathing difficulties, including sonorous and prolonged expiration. The Silverman score is a tool used to assess the severity of respiratory distress in newborns, and a score of 3 points with clinical findings indicates moderate respiratory distress.

However, this score alone is not sufficient to diagnose the form of pneumopathy. A clinical blood test, determination of blood gas composition, proteinogram, or immunoassay may be helpful in evaluating the overall health status of the newborn, but they are unlikely to provide a specific diagnosis of the form of pneumopathy.

100. A children’s surgical unit admitted a 1-month-old boy who had been prenatally diagnosed with the left-sided pyelectasis. Such studies as drip infusion urography, cystography and USI allowed to reveal initial hydronephrosis. There is no information confirming the secondary pyelonephritis. What tactics of this patient management is most advisable?

A. 6-month surveillance

B. Urgent nephrostomy

C. Anderson-Hynes operation

D. There is no need in further surveillance and treatment

E. Antibacterial therapy

Answer: 6-month surveillance

Explanation

In this scenario, the most advisable management tactic for the patient with left-sided pyelectasis and initial hydronephrosis would be 6-month surveillance. Pyelectasis refers to a dilation or enlargement of the renal pelvis, which is the part of the kidney that collects urine before it is transported to the bladder.

This condition can be detected prenatally or after birth, and in some cases, it can be associated with other abnormalities, such as hydronephrosis. Hydronephrosis is a condition in which there is an enlargement or swelling of the kidney due to a buildup of urine. It can be caused by a blockage in the urinary tract, such as a narrowing or obstruction in the ureter, or it can be a result of pyelectasis. In some cases, hydronephrosis can lead to kidney damage or infection, but there is no information in this scenario confirming the presence of secondary pyelonephritis.

Given that there is no evidence of secondary pyelonephritis and the patient is stable, the most advisable management tactic would be 6-month surveillance, which involves monitoring the patient’s condition with regular follow-up appointments and imaging studies, such as ultrasound or MRI.

This approach allows for early detection of any progression of the condition or development of complications, such as infection or kidney damage, while avoiding unnecessary interventions or surgery. Antibacterial therapy may be considered if there is evidence of a urinary tract infection or pyelonephritis, but it is not necessary in the absence of infection.

Urgent nephrostomy or Anderson-Hynes operation are not indicated in this scenario, as they are more invasive interventions that are typically reserved for cases of severe or progressive hydronephrosis with evidence of kidney damage or infection.

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