1. A 47-year-old patient complains of itching skin in the interdigital folds and on the lower abdomen. The itching has been observed for the last three days and is most intense in the evening. Objectively, small papulopustular rash elements and excoriations are visible in the interdigital folds and on the lower abdomen. What is the most likely diagnosis in this case?
A. Scabies
B. Lichen ruber planus
C. Psoriasis
D. Atopic dermatitis
E. Urticaria
Correct Answer: A. Scabies
Explanation:
Scabies is an infestation caused by the Sarcoptes scabiei mite. It typically presents with:
- Intense itching, especially worse at night
- Papulopustular rash and excoriations
- Affected areas like interdigital spaces, lower abdomen, wrists, and genital area
- Short onset period (a few days to weeks)
The itching is due to a hypersensitivity reaction to the mite, its eggs, and feces. The characteristic distribution and nocturnal pruritus are highly suggestive.
Why Other Options Are Incorrect:
- B. Lichen ruber planus:
Features flat-topped, violaceous papules typically on the wrists and ankles, not papulopustular or in interdigital folds. It’s also more chronic in nature. - C. Psoriasis:
Shows well-demarcated plaques with silvery scales on extensor surfaces like elbows and knees. Not typically pustular or intensely pruritic at night. - D. Atopic dermatitis:
Often chronic, affecting flexural areas in adults, and usually associated with personal or family history of atopy. It doesn’t typically present acutely in this pattern. - E. Urticaria:
Presents with transient, itchy wheals that come and go within 24 hours. No papulopustules or localized distribution like in this case.
2. On the third day after an anterior Q-wave myocardial infarction, a 68-year-old patient suddenly developed palpitations followed by loss of consciousness. On examination: the patient is in a severe condition, has moist skin, acrocyanosis, cold limbs, blood pressure is 70/40 mm Hg. ECG shows no P waves, a heart rate of 190/min, and wide, aberrant ventricular complexes. What emergency aid should be provided in this case?
A. Electrical cardioversion
B. Intravenous infusion of amiodarone
C. Novocainamide (procainamide) intravenously
D. Dexamethasone intravenously
E. Atropine intravenously
Correct Answer: A. Electrical cardioversion
Explanation:
The clinical scenario describes hemodynamically unstable ventricular tachycardia (VT) — a life-threatening arrhythmia often occurring after myocardial infarction. Signs include loss of consciousness, hypotension (BP 70/40 mm Hg), absence of P waves, rapid wide-complex rhythm (HR 190/min). In such cases, immediate synchronized electrical cardioversion is the treatment of choice to restore sinus rhythm and prevent cardiac arrest.
Why Other Options Are Incorrect:
- B. Intravenous infusion of amiodarone:
Amiodarone is useful in stable ventricular tachycardia, but in hemodynamically unstable patients, immediate cardioversion is preferred. Amiodarone acts more slowly and is not first-line in unstable VT. - C. Novocainamide (procainamide) intravenously:
Like amiodarone, procainamide may be used in stable VT. It can lower blood pressure further and worsen hemodynamic compromise, making it inappropriate in unstable VT. - D. Dexamethasone intravenously:
This is a corticosteroid with no role in the acute management of life-threatening arrhythmias. It is not indicated in this emergency situation. - E. Atropine intravenously:
Atropine is used for bradyarrhythmias, especially in cases like sinus bradycardia or AV block. It has no effect in ventricular tachycardia, and would not help this patient.
3. A 32-year-old patient complains of pain in the left leg for the past year, with intermittent claudication after walking 50–100 meters and periodic nocturnal pain. On examination, the left leg is pale, cold, and arterial pulsation is absent in the left lower leg. What is the most likely diagnosis?
A. Aortic embolism
B. Aortic thrombosis
C. Obliterating endarteritis
D. Leriche syndrome
E. Raynaud syndrome
Correct Answer: C. Obliterating endarteritis
Explanation:
Obliterating endarteritis (also called thromboangiitis obliterans or Buerger’s disease) is a chronic, progressive, inflammatory occlusive disease that primarily affects small and medium-sized arteries in the lower limbs of young male smokers. The typical presentation includes:
- Intermittent claudication (pain after walking a short distance)
- Rest/night pain due to poor distal perfusion
- Coldness and pallor of the affected limb
- Absent pulses distally
This patient’s gradual, one-sided progression and age profile are classic for obliterating endarteritis.
Why Other Options Are Incorrect:
- A. Aortic embolism:
An embolism causes a sudden onset of ischemia (acute limb ischemia), not a chronic presentation. This patient has a long-standing, progressive issue, which rules out embolism. - B. Aortic thrombosis:
While thrombosis can cause ischemia, it usually presents acutely and involves bilateral limb involvement when at the aortic bifurcation. Chronic unilateral symptoms suggest another diagnosis. - D. Leriche syndrome:
This is a chronic aortoiliac occlusive disease, but it typically presents with:- Bilateral claudication
- Impotence
- Decreased femoral pulses
This patient has unilateral symptoms, making Leriche syndrome less likely.
- E. Raynaud syndrome:
Raynaud’s typically affects the fingers and toes, presenting with triphasic color change (white-blue-red) due to cold or stress. It does not cause claudication, absent pulses, or leg pain.
4. A pregnant woman is being registered for check-ups with an obstetrician-gynecologist. It is her first pregnancy, and the gestational age is 12 weeks. She has an Rh-negative blood type. To prevent Rh isoimmunization, anti-Rh (anti-D) immunoglobulin should be prescribed. At what term of pregnancy should it be administered?
A. 32–36 weeks
B. 16–20 weeks
C. 20–24 weeks
D. 28–32 weeks
E. 24–28 weeks
Correct Answer: D. 28–32 weeks
Explanation:
Rh isoimmunization occurs when an Rh-negative mother is exposed to Rh-positive fetal red blood cells and develops antibodies against them. To prevent this, anti-D immunoglobulin is administered to prevent maternal sensitization.
The routine prophylactic dose of anti-D immunoglobulin is given at 28–32 weeks of gestation in Rh-negative, unsensitized women. This covers the most likely period when small amounts of fetal blood can enter the maternal circulation (fetomaternal hemorrhage) in late pregnancy.
Additionally, a dose is also administered within 72 hours postpartum if the newborn is Rh-positive, or after any sensitizing events (like amniocentesis, trauma, or miscarriage).
Why Other Options Are Incorrect:
- A. 32–36 weeks:
This is too late for routine prophylaxis. Sensitization may already have occurred by this point. The standard window is 28–32 weeks. - B. 16–20 weeks:
This is too early for routine prophylaxis, as significant fetomaternal hemorrhage is rare at this stage. - C. 20–24 weeks:
Again, this is earlier than the recommended period for routine prophylaxis. - E. 24–28 weeks:
Slightly early. While not dangerous, 28–32 weeks is the standard recommended window for anti-D immunoglobulin administration.
5. 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. Chlamydial cervicitis
B. Bacterial vaginosis
C. Gonorrheal cervicitis
D. Trichomonas colpitis
E. Vaginal candidomycosis
Correct Answer: D. Trichomonas colpitis
Explanation:
Trichomonas colpitis, caused by Trichomonas vaginalis, presents with profuse, frothy, foul-smelling vaginal discharge, vaginal irritation, pruritus, and hyperemic vaginal mucosa that may bleed on contact. It is often sexually transmitted, though non-sexual transmission is also possible.
Why Other Options Are Incorrect:
- A. Chlamydial cervicitis: Typically causes mucopurulent discharge from the cervix, often with minimal symptoms and not foamy or foul-smelling.
- B. Bacterial vaginosis: Discharge is thin and gray-white, with a fishy odor, but no pruritus or mucosal bleeding.
- C. Gonorrheal cervicitis: Presents with purulent cervical discharge but lacks the frothy quality and often has more systemic signs.
- E. Vaginal candidomycosis: Presents with thick, white “cottage cheese” discharge and intense itching, not foamy or foul-smelling.
6. .When bathing their 8-month-old child, the parents noticed that the child’s abdomen was enlarged and asymmetrical. Abdominal ultrasound detects a tumor 12×9×10 cm in size in the left lobe of the liver. Blood test detects decreased levels of total protein and albumin and slightly increased levels of liver enzymes. Chest CT scan reveals multiple metastases in the lungs. Measuring the levels of fetal α-fetoprotein marker reveals its significant increase. What is the most likely diagnosis in this case?
A. Embryonal sarcoma
B. Hepatocarcinoma
C. Liver metastasis
D. Immature teratoma
E. Hepatoblastoma
Correct Answer: E. Hepatoblastoma
Explanation:
Hepatoblastoma is the most common primary malignant liver tumor in children, typically occurring in children under 3 years of age. The child in this case is 8 months old, which falls squarely in the peak age range. Key clinical features that support this diagnosis:
- Abdominal mass: Often the first sign noticed by parents.
- Elevated α-fetoprotein (AFP): Hepatoblastoma is strongly associated with markedly elevated AFP levels, which serves as both a diagnostic and prognostic marker.
- Metastases to lungs: Common in hepatoblastoma and seen here on the chest CT.
- Ultrasound and imaging: The large liver mass in the left lobe and its size (12×9×10 cm) are consistent with hepatoblastoma.
- Liver function tests: Mild elevation in liver enzymes and decreased protein/albumin can occur due to hepatic dysfunction from the tumor burden.
All these findings collectively point to hepatoblastoma.
3. Why Other Options Are Incorrect:
- A. Embryonal sarcoma:
This is a rare liver tumor in children but more commonly occurs in older children (6–10 years). It is not typically associated with elevated AFP levels. The age and AFP elevation make this less likely. - B. Hepatocarcinoma:
Hepatocellular carcinoma (HCC) is more common in older children and adults, often associated with chronic liver diseases (like hepatitis B/C or cirrhosis). It can also elevate AFP, but the age of this patient (8 months) makes it very unlikely. - C. Liver metastasis:
Secondary liver tumors in infants are very rare unless there is a known primary elsewhere. Also, liver metastases usually don’t cause elevated AFP unless the primary is an AFP-secreting tumor, which is not indicated here. - D. Immature teratoma:
Teratomas are germ cell tumors and can occur in infants, but primary liver teratomas are extremely rare. They may secrete AFP if they contain yolk sac elements, but the presentation and imaging are more consistent with hepatoblastoma.
7. The parents of a 4-year-old boy complain that their child has rash and fever of 37.7°C. Objectively, the child’s condition is satisfactory. There are minor catarrhal phenomena in the nasopharynx. Medium-sized maculopapular rash is observed all over the body, mainly on the back and on the extensor surfaces of the limbs. Posterior cervical and occipital lymph nodes are enlarged and moderately painful during palpation. What is the most likely diagnosis in this case?
A. Rubella
B. Measles
C. Chickenpox
D. Infectious mononucleosis
E. Scarlet fever
Correct Answer: A. Rubella
Explanation:
Rubella, also known as German measles, typically presents with a low-grade fever (around 37.7°C), a maculopapular rash that starts on the face and spreads downward, and enlarged, tender posterior cervical and occipital lymph nodes, which are characteristic features. The rash usually involves the back and extensor surfaces of limbs. The child’s overall good condition and mild nasopharyngeal symptoms also support rubella.
Why Other Options Are Incorrect:
- B. Measles: Usually causes high fever, cough, coryza, conjunctivitis, and Koplik spots before the rash. The rash is more widespread and the illness is generally more severe.
- C. Chickenpox: Rash is vesicular, appears in crops, and is very itchy. Maculopapular rash is not typical.
- D. Infectious mononucleosis: Presents with generalized lymphadenopathy, sore throat, and fatigue rather than a characteristic rash and fever.
- E. Scarlet fever: Rash is sandpaper-like, often with sore throat and “strawberry tongue,” and involves different lymph nodes rather than posterior cervical and occipital.
8. A 72-year-old patient came to a doctor with complaints of hand tremors, stiffness, slowness of walking and speech, and difficulties in performing routine household chores. Physical examination detects general bradykinesia, hypomimia, amprosthotonus, ‘shuffling’ gait, hand tremors at rest, DSS, plastic type of increased muscle tone, the “cogwheel rigidity” phenomenon, and marked postural instability. What medicines must be prescribed for this patient?
A. Anticholinesterase drugs
B. Medicines that improve microcirculation
C. Medicines containing levodopa
D. Antidepressants
E. Anticholinergic agents
Correct Answer: C. Medicines containing levodopa
Explanation:
The clinical presentation clearly describes Parkinson’s disease (PD), characterized by:
- Resting hand tremors
- Bradykinesia (slowness of movement)
- Rigidity (plastic type muscle tone, cogwheel rigidity)
- Postural instability
- Shuffling gait (festinating gait)
- Hypomimia (reduced facial expression)
Levodopa is the gold standard treatment for Parkinson’s disease because it is converted into dopamine in the brain, replenishing the depleted dopamine that causes PD symptoms. Levodopa helps improve bradykinesia, rigidity, and tremors significantly.
3. Why Other Options Are Incorrect:
- A. Anticholinesterase drugs:
These are primarily used in Alzheimer’s disease and other dementias to improve cognitive function, not in Parkinson’s. - B. Medicines that improve microcirculation:
These may be used for vascular dementia or peripheral vascular diseases but have no proven benefit in Parkinson’s disease. - D. Antidepressants:
While depression can be a comorbidity in PD, antidepressants do not treat the core motor symptoms. - E. Anticholinergic agents:
These can be used as adjunct therapy to reduce tremors in younger Parkinson’s patients but are generally not first-line and not ideal in older patients (like this 72-year-old) because of side effects like cognitive impairment and dry mouth.
9. A 20-year-old patient complains of redness of the eyes, lacrimation, moderate purulent discharge from the conjunctival cavity, and foreign body sensation in the eyes. Examination reveals hyperemia of the eyelid conjunctiva and conjunctival injection on the eyeballs, the cornea is transparent, the pupil is 3 mm in size, rapidly responding to light, the lens and the vitreous body are transparent, the fundus of the eye is normal. What is the most likely diagnosis in this case?
A. Acute bacterial conjunctivitis
B. Acute iridocyclitis
C. Adenoviral keratoconjunctivitis
D. Allergic conjunctivitis
E. Gonoblennorrhea
Correct Answer: A. Acute bacterial conjunctivitis
Explanation:
The clinical presentation fits acute bacterial conjunctivitis, characterized by:
- Redness of eyes (conjunctival hyperemia)
- Lacrimation and moderate purulent discharge (typical for bacterial infection)
- Foreign body sensation
- Cornea is clear and transparent (no keratitis)
- Pupil normal size and reactive to light (no iritis/iritocyclitis)
- Normal fundus (no posterior segment involvement)
These signs indicate inflammation localized to the conjunctiva due to bacterial infection, typically causing purulent (pus-like) discharge.
3. Why Other Options Are Incorrect:
- B. Acute iridocyclitis:
This is inflammation of the iris and ciliary body. It presents with pain, photophobia, a small irregular pupil, decreased vision, and cells in the anterior chamber, none of which are described here. - C. Adenoviral keratoconjunctivitis:
This viral infection causes redness and watery discharge, but usually also affects the cornea (keratitis), causing blurry vision and sometimes pseudomembranes on the conjunctiva. Purulent discharge is uncommon. - D. Allergic conjunctivitis:
Usually causes itching, watery discharge, and redness but no purulent discharge or significant hyperemia of the eyelid conjunctiva. - E. Gonoblennorrhea (Gonococcal conjunctivitis):
A severe, hyperacute bacterial conjunctivitis usually seen in neonates or adults with genital gonorrhea. It causes profuse purulent discharge, severe chemosis, and rapidly progressing keratitis, which is more severe than described here.
10. A 28-year-old woman at 38 weeks of her pregnancy was hospitalized with active labor. Thirty minutes after the onset of labor, a boy was born with the weight of 3500 g and an Apgar score of 8–9. Objectively, the uterus is dense, its apex is at the level of the navel, and no bleeding. What drug should be used to prevent bleeding at the third stage of labor in this case?
A. Estradiol
B. Etamsylate
C. Dexamethasone
D. Progesterone
E. Oxytocin
Correct Answer: E. Oxytocin
Explanation:
Oxytocin is the drug of choice for preventing postpartum hemorrhage during the third stage of labor. It stimulates uterine contractions, promoting uterine muscle tone, which helps compress the uterine blood vessels and prevents excessive bleeding after the placenta is delivered.
In this case, the woman is in active labor, the baby has been delivered with a good Apgar score, and the uterus is described as dense (firm). Administering oxytocin helps maintain uterine tone to reduce the risk of postpartum hemorrhage.
3. Why Other Options Are Incorrect:
- A. Estradiol:
Estradiol is a form of estrogen, not used for managing labor or preventing postpartum bleeding. - B. Etamsylate:
Etamsylate is a hemostatic agent that can reduce capillary bleeding but is not standard or effective for preventing postpartum hemorrhage. - C. Dexamethasone:
A corticosteroid used mainly to promote fetal lung maturation in preterm labor, not for preventing bleeding. - D. Progesterone:
Important in maintaining pregnancy but has no role in preventing postpartum hemorrhage or inducing uterine contractions.
11. A 15-year-old patient complains of facial edema and dark red urine. He has a history of acute tonsillitis that occurred 10 days ago. Auscultation detects vesicular breathing and rhythmic and clear heart sounds. Blood pressure — 150/110 mm Hg. Urinalysis: protein — 1.8 g/L, erythrocytes — 50–60 in sight. Blood test: leukocytes — 14·10⁹/L, ESR — 28 mm/hour. What is the most likely diagnosis in this case?
A. Acute glomerulonephritis
B. Acute cystitis
C. Alport syndrome
D. Acute pyelonephritis
E. Chronic glomerulonephritis
Correct Answer: A. Acute glomerulonephritis
Explanation:
The patient presents with facial edema, gross hematuria (dark red urine), proteinuria, hypertension, and a recent history of acute tonsillitis (streptococcal pharyngitis) — all of which are classic signs of post-streptococcal acute glomerulonephritis (PSAGN).
Key features supporting this diagnosis:
- Latent period of ~1–2 weeks after streptococcal infection
- Facial (periorbital) edema is a hallmark early symptom
- Dark red urine (hematuria) due to glomerular bleeding
- Proteinuria and hematuria on urinalysis
- Hypertension due to fluid retention and renal involvement
- Elevated WBCs and ESR, reflecting recent or ongoing inflammation
This is a classic nephritic syndrome presentation following a streptococcal throat infection.
3. Why Other Options Are Incorrect:
- B. Acute cystitis:
Typically presents with dysuria, urinary frequency, urgency, and suprapubic pain, but not with hypertension, edema, or gross hematuria. - C. Alport syndrome:
A hereditary nephritis (X-linked dominant) causing progressive hematuria, hearing loss, and ocular abnormalities, but it usually has a chronic course, not acute onset after tonsillitis. - D. Acute pyelonephritis:
Presents with fever, flank pain, chills, dysuria, and signs of systemic infection. Hematuria may occur but is usually microscopic and not the primary complaint. - E. Chronic glomerulonephritis:
Progresses slowly over months to years, not acutely. Typically presents with gradual onset of edema, hypertension, and renal insufficiency, not suddenly following a recent infection.
12. A 7-year-old boy complains of fever of 38°C, moderate headache, and redness and itching of the skin on his neck. Three days ago, during a walk in the forest he was bitten by a tick. Objectively, in the area of the tick bite there is a red zone up to 5 cm in diameter, with a bright red border separating it from the unaffected skin. What is the most likely diagnosis in this case?
A. Allergic contact dermatitis
B. Lyme disease
C. Erythema infectiosum
D. Urticaria
E. Benign lymphoreticulosis
Correct Answer: B. Lyme disease
Explanation:
The clinical picture strongly suggests early localized Lyme disease, which is caused by the spirochete Borrelia burgdorferi and transmitted by Ixodes ticks.
Key features that support the diagnosis:
- History of tick bite 3 days ago in a forest (typical exposure setting)
- Development of a red lesion with central clearing and a distinct border (this describes erythema migrans, the hallmark early skin lesion of Lyme disease)
- Mild systemic symptoms: low-grade fever and headache are common early symptoms
- Size of lesion (up to 5 cm) and expanding nature are consistent with erythema migrans
Erythema migrans is often described as a bull’s-eye lesion, although it may not always show classic central clearing in early stages.
3. Why Other Options Are Incorrect:
- A. Allergic contact dermatitis:
Typically presents with itching, erythema, vesicles, and sometimes crusting at the site of contact. It is not usually associated with systemic symptoms like fever or the characteristic expanding red border seen in Lyme disease. - C. Erythema infectiosum:
Caused by Parvovirus B19, typically affects children with “slapped cheek” facial rash and a lace-like rash on the body. No tick bite history, and lesion pattern is not consistent. - D. Urticaria:
Presents as itchy, raised wheals (hives) that are transient and not typically associated with a distinct central tick bite or systemic symptoms. - E. Benign lymphoreticulosis (Cat scratch disease):
Caused by Bartonella henselae, transmitted by a cat scratch or bite, not a tick. Presents with regional lymphadenopathy, and not the described skin lesion.
13. On the fifth day of life, a baby developed vomiting with bile and delayed bowel movements. Examination reveals that the abdomen is slightly distended in the epigastric region and sunken in its lower segments. An obstruction associated with intestinal malrotation is suspected. What method of examination can help confirm the diagnosis of intestinal malrotation?
Options:
A. Irriography
B. Ultrasound
C. Survey abdominal X-ray
D. Gastric probe
E. X-ray monitoring of the passage of contrast through the bowel
Correct Answer: E. X-ray monitoring of the passage of contrast through the bowel
Explanation:
In neonates with suspected intestinal malrotation (especially with bilious vomiting and signs of obstruction), the best diagnostic test is:
Upper gastrointestinal (GI) contrast study — often described as “X-ray monitoring of the passage of contrast through the bowel”.
This test can reveal:
- Abnormal position of the duodenojejunal junction (a key sign of malrotation)
- “Corkscrew” or “beak-like” appearance if volvulus is present
- Evidence of duodenal obstruction
It’s the gold standard for diagnosing malrotation and midgut volvulus.
3. Why Other Options Are Incorrect:
- A. Irriography (contrast enema):
Used for evaluating the colon (e.g., Hirschsprung disease), not ideal for diagnosing malrotation which affects the upper GI tract. - B. Ultrasound:
Can be helpful in some cases (e.g., midgut volvulus may show “whirlpool sign”), but less definitive than a contrast X-ray study for diagnosing malrotation. - C. Survey abdominal X-ray:
Non-specific; may show signs of obstruction (e.g., air-fluid levels), but cannot confirm malrotation. - D. Gastric probe (nasogastric tube):
Can decompress the stomach and detect bilious aspirate, but it’s not diagnostic — it’s part of supportive management.
Question 14
A 35-year-old patient complains of pain in the area of his perineum and frequent painful urination with blood. Objectively, body temperature is 38.3°C. External genitalia and perineal skin show no changes. Costovertebral angle tenderness is negative on both sides. What is the most likely diagnosis in this case?
Options:
A. Urolithiasis
B. Acute pyelonephritis
C. Acute urethritis
D. Tubulointerstitial nephritis
E. Acute prostatitis
Correct Answer: E. Acute prostatitis
Explanation:
The patient presents with classic symptoms of acute prostatitis, which include:
- Pain in the perineum (a hallmark symptom)
- Dysuria (frequent, painful urination)
- Hematuria (blood in urine)
- Fever (38.3°C) — systemic sign of infection
- No external genital or skin changes
- No costovertebral angle tenderness (rules out kidney involvement)
Acute prostatitis is typically caused by ascending bacterial infection, often E. coli, affecting the prostate gland. The perineal pain and urinary symptoms are most characteristic.
3. Why Other Options Are Incorrect:
- A. Urolithiasis (urinary stones):
While it may cause hematuria and pain, the pain is usually colicky and located in the flank or groin, not the perineum. Fever is not typical unless complicated by infection. - B. Acute pyelonephritis:
Causes fever, flank pain, and costovertebral angle tenderness, with systemic signs of infection. This patient has no flank pain or CVA tenderness. - C. Acute urethritis:
Can cause dysuria and sometimes hematuria, but perineal pain and systemic symptoms (fever) are not prominent features. - D. Tubulointerstitial nephritis:
Often drug-induced, it may present with systemic signs, hematuria, and renal dysfunction, but perineal pain and dysuria are not typical.
Question 15
A 10-month-old boy is poorly gaining weight. His mother complains about his constant persistent cough with thick and viscous sputum. The boy had pneumonia three times. His sweat chloride levels are more than 80 mEq/L. What is the most likely diagnosis in this case?
Options:
A. Mucoviscidosis (cystic fibrosis)
B. Chronic bronchitis
C. A foreign body in the bronchi
D. Bronchial asthma
E. Congenital lung abnormality
Correct Answer: A. Mucoviscidosis (cystic fibrosis)
Explanation:
This child presents with classic signs of cystic fibrosis (CF), also known as mucoviscidosis:
- Failure to thrive / poor weight gain despite adequate feeding
- Chronic productive cough with thick, viscous sputum
- Recurrent respiratory infections (e.g., 3 episodes of pneumonia by 10 months of age)
- Sweat chloride > 80 mEq/L — this is diagnostic for CF
(The diagnostic threshold is typically >60 mEq/L on two separate tests)
Cystic fibrosis is a genetic disorder (autosomal recessive) affecting chloride channels (CFTR mutation), leading to thick secretions in the lungs, pancreas, and other organs.
3. Why Other Options Are Incorrect:
- B. Chronic bronchitis:
This diagnosis is extremely rare in infants and usually refers to adult smokers. It would not explain the sweat chloride elevation or failure to thrive. - C. A foreign body in the bronchi:
Could cause sudden onset respiratory symptoms, but would not explain persistent symptoms, failure to thrive, or abnormal sweat chloride. - D. Bronchial asthma:
Typically involves wheezing, episodic symptoms, and no thick purulent sputum in infants. Does not cause failure to thrive or elevated sweat chloride. - E. Congenital lung abnormality:
Could cause recurrent infections but would not explain elevated sweat chloride or systemic findings like poor weight gain and thick sputum across multiple systems.
16.Question 16
Examination of a newborn girl detects a hemorrhage on the child’s head. The hemorrhage is limited to one dome bone, does not pulsate, and is painless. What condition did the child develop?
Options:
A. Physiological birth-related edema
B. Neonatal pemphigus
C. Hydrocephalus
D. Cephalhematoma
E. Intracranial birth injury
Correct Answer: D. Cephalhematoma
Explanation:
A cephalhematoma is a subperiosteal hemorrhage that occurs in newborns due to birth trauma. It presents as:
- A swelling confined to one cranial bone (usually parietal)
- Does not cross suture lines, because it is beneath the periosteum
- Painless, non-pulsatile, and typically appears a few hours after birth
- Soft and may feel fluctuant
- May persist for days to weeks before resorbing spontaneously
The key feature in this question is that the hemorrhage is confined to one dome bone and painless, strongly suggesting a cephalhematoma.
3. Why Other Options Are Incorrect:
- A. Physiological birth-related edema (caput succedaneum):
This crosses suture lines, is soft and diffuse, and may be present at birth. It is not confined to a single bone like cephalhematoma. - B. Neonatal pemphigus:
A skin condition with vesicular or pustular lesions, not a hemorrhagic swelling of the skull. - C. Hydrocephalus:
Involves increased head circumference and bulging fontanelles, not a localized hemorrhage. - E. Intracranial birth injury:
May cause neurological signs, irritability, or seizures, and is not palpable as an external swelling confined to one bone.
Question 17
A 74-year-old patient complains of abdominal pain and retention of gas and defecation. Schwartz test reveals several horizontal air-fluid levels with dome-shaped lucencies above them.What is the most likely diagnosis in this case?
Options:
A. Acute pancreatitis
B. Intestinal obstruction
C. Perforated duodenal or gastric ulcer
D. Ulcerative colitis
E. Acute cholecystitis
Correct Answer: B. Intestinal obstruction
Explanation:
The patient presents with classic symptoms and radiographic signs of intestinal obstruction:
- Abdominal pain
- Absence of gas or stool passage (obstipation — a hallmark of obstruction)
- Schwartz test (abdominal X-ray finding):
Shows multiple horizontal air-fluid levels in dilated bowel loops, with dome-shaped lucencies — this is characteristic of mechanical bowel obstruction.
These signs suggest that gas and fluid are accumulating above a blockage, causing distension and fluid levels visible on upright or decubitus abdominal X-rays.
3. Why Other Options Are Incorrect:
- A. Acute pancreatitis:
Usually presents with epigastric pain radiating to the back, elevated amylase/lipase, and ileus (not mechanical obstruction). It does not show classic air-fluid levels. - C. Perforated duodenal or gastric ulcer:
Typically presents with sudden, severe abdominal pain and free air under the diaphragm, not air-fluid levels. The Schwartz test would more likely show pneumoperitoneum, not obstruction. - D. Ulcerative colitis:
Presents with bloody diarrhea, crampy abdominal pain, and may show colonic wall thickening on imaging, not typical air-fluid levels. - E. Acute cholecystitis:
Causes right upper quadrant pain, fever, and possibly gallbladder distention, but not air-fluid levels in bowel or absent stool/gas passage.
Question 18
A 56-year-old patient complains of shortness of breath, weakness, inability to remain in a horizontal position, palpitations, and tightness in the chest. According to the patient’s medical history, his condition became worse at night and he had an acute myocardial infarction one year ago.
On examination:
- Condition: Severe, forced sitting position
- Cyanotic face
- Cough: White foamy sputum
- Blood pressure: 150/90 mm Hg
- Auscultation: Numerous fine wet vesicular crackles in the lower lung segments
- Respiratory rate: 28/min
- Heart sounds: Dull but rhythmic, HR: 100/min
What is the most likely diagnosis?
Options:
A. COPD
B. Pulmonary edema
C. Chronic bronchitis
D. Pulmonary emphysema
E. Community-acquired pneumonia
Correct Answer: B. Pulmonary edema
Explanation:
This patient presents with classic signs of acute pulmonary edema, likely of cardiogenic origin due to his history of myocardial infarction (MI):
- Shortness of breath and orthopnea (difficulty breathing when lying flat)
- Palpitations
- Cough with white, frothy sputum — hallmark of pulmonary edema
- Cyanosis (hypoxia)
- Fine wet crackles on auscultation — indicates fluid in the alveoli
Post-MI, the patient likely developed left-sided heart failure, causing elevated pulmonary capillary pressure and fluid transudation into alveolar spaces.
3. Why Other Options Are Incorrect:
- A. COPD:
COPD includes chronic bronchitis and emphysema. It presents with chronic productive cough, wheezing, and progressive dyspnea, but frothy sputum and fine crackles are not typical. - C. Chronic bronchitis:
Involves chronic cough with sputum, especially in smokers. It does not usually cause orthopnea or frothy sputum, and crackles are not fine or wet. - D. Pulmonary emphysema:
Characterized by progressive dyspnea and barrel chest, but not frothy sputum, cyanosis early on, or fine crackles. Breath sounds are typically diminished. - E. Community-acquired pneumonia:
Usually causes fever, productive cough with purulent sputum, localized crackles, and consolidation, not frothy sputum or orthopnea.
19Question 19
Question:19
On the second day after overexposure to cold, a 19-year-old patient developed a fever of 38.4°C, turbid urine, and pain in the area of his kidneys that was radiating into the groin.
Blood test: leukocytes — 9.8·10⁹/L
Urinalysis: protein — traces, erythrocytes — 2–3 in sight, leukocytes — all over the vision field.
What is the most likely diagnosis in this case?
Options:
A. Renal tuberculosis
B. Acute glomerulonephritis
C. Kidney tumor
D. Acute cystitis
E. Acute pyelonephritis.
Correct Answer: E. Acute pyelonephritis
Explanation:
This patient has classic features of acute pyelonephritis, which is a bacterial infection of the renal pelvis and parenchyma:
- Fever
- Pain in the kidney region (flank pain), radiating to the groin
- Turbid urine
- Urinalysis: numerous leukocytes in every field → pyuria, a hallmark of pyelonephritis
- History of cold exposure — a common predisposing factor, especially in females
These symptoms reflect an upper urinary tract infection with systemic and local signs.
3. Why Other Options Are Incorrect:
- A. Renal tuberculosis:
Typically chronic, with symptoms like sterile pyuria, hematuria, and possible weight loss. It doesn’t usually present acutely with fever and flank pain. - B. Acute glomerulonephritis:
Usually follows a streptococcal infection, presents with hematuria, proteinuria, edema, and hypertension — not turbid urine with abundant leukocytes. - C. Kidney tumor:
Usually painless until late stages; may present with hematuria, but not with fever, flank pain, and pyuria acutely. - D. Acute cystitis:
Causes dysuria, frequency, and suprapubic pain, but not flank pain or systemic symptoms like fever and radiating kidney pain — those indicate pyelonephritis.
20. Question 20
Question:20
A 45-year-old woman complains of intense pain in the left hypochondrium that radiates into her back. The symptoms appeared after eating fatty fried food. Objective examination reveals that the abdomen is soft and painful in the Chauffard zone. What drug should be prescribed in this case as a component of the complex treatment to reduce the pain syndrome, based on the pathogenetics of the patient’s health condition?
Options:
A. Pancreatin
B. Aprotinin
C. Drotaverine
D. Loperamide
E. Diosmin
Correct Answer: A. Pancreatin
Explanation:
The patient presents Explanation:
The patient presents with epigastric pain radiating to the back, especially after eating fatty food, and tenderness in the Chauffard zone (an anatomical area associated with the pancreas). These features strongly point to chronic pancreatitis or pancreatic enzyme insufficiency.
Pancreatin is a combination of pancreatic enzymes (amylase, lipase, and protease) that aids in the digestion of fats, proteins, and carbohydrates. In chronic pancreatitis, the pancreas fails to produce enough digestive enzymes, leading to malabsorption and pain, particularly after fatty meals. Pancreatin helps compensate for the enzyme deficiency, improves digestion, and reduces the stimulation and workload of the pancreas, thereby alleviating pain and inflammation.
Its use is pathogenetically justified as it addresses the underlying enzyme deficiency causing postprandial pain.
Why Other Options Are Incorrect:
E. Diosmin:
Diosmin is a venotonic agent used primarily for venous insufficiency and hemorrhoids. It has no relevance to pancreatic pain or digestion.with classic symptoms of acute pancreatitis:
B. Aprotinin:
Aprotinin is a protease inhibitor previously used to reduce inflammation in acute pancreatitis, but its clinical use has declined due to safety concerns. It is not routinely used in chronic pancreatitis and does not address enzyme deficiency or pain control.
C. Drotaverine:
Drotaverine is a spasmolytic drug used for smooth muscle spasms (e.g., biliary colic). While it might offer symptomatic relief, it does not address the underlying cause in chronic pancreatitis, which is enzyme deficiency. Therefore, it’s not pathogenetically directed.
D. Loperamide:
Loperamide is an antidiarrheal used for symptomatic treatment of diarrhea. It has no role in managing pancreatic pain or enzyme deficiency, making it inappropriate in this context.
- Intense pain in the left hypochondrium radiating to the back
- Triggered by fatty food (e.g., fried food)
- Tenderness in Chauffard zone (pancreatic area in the epigastrium/left upper quadrant)
- Soft abdomen but localized tenderness → typical in early or mild pancreatitis
Drotaverine is a smooth muscle relaxant (antispasmodic) used to relieve spasms of the sphincter of Oddi and pancreatic duct, helping reduce intraductal pressure and alleviate pancreatic pain.
Thus, it provides pain relief based on the pathogenesis — by improving pancreatic juice outflow and relieving ductal spasm.
3. Why Other Options Are Incorrect:
- A. Pancreatin:
A digestive enzyme replacement used in chronic pancreatitis, not in acute episodes where pancreatic stimulation should be minimized. - B. Aprotinin:
A protease inhibitor formerly used in pancreatitis, but not first-line for acute pain relief and largely outdated. - D. Loperamide:
Used for diarrhea; has no role in treating pancreatic pain and could worsen bowel motility problems. - E. Diosmin:
A venotonic agent used in venous insufficiency and hemorrhoids, unrelated to pancreatic pathology.
21. Question:
A 30-year-old patient complains of weakness, difficulty swallowing, impaired speech, and visual impairment (blurry and double vision). Five days ago he was eating homemade canned meat. What type of thermal treatment of food products is most effective for prevention of this disease?
Options:
A. Pasteurization
B. Boiling for at least 120 minutes
C. Boiling for 50–60 minutes
D. Autoclaving
E. Freezing
Correct Answer: D. Autoclaving
Explanation:
The clinical picture is highly suggestive of botulism, a serious neuroparalytic illness caused by Clostridium botulinum toxin. It commonly occurs from ingestion of improperly canned foods, particularly homemade ones. The spores of C. botulinum are highly heat-resistant and can survive boiling, but they are effectively destroyed by autoclaving, which uses moist heat at 121°C under pressure for at least 15–20 minutes. Autoclaving ensures the destruction of spores and is the most reliable method to sterilize canned foods and prevent botulism.
Why Other Options Are Incorrect:
- A. Pasteurization: This heats food to around 60–85°C, which is insufficient to kill Clostridium botulinum spores.
- B. Boiling for at least 120 minutes: While prolonged boiling may reduce the number of spores, it is not reliable and impractical for food sterilization. It cannot be guaranteed to inactivate all spores.
- C. Boiling for 50–60 minutes: Also inadequate, as C. botulinum spores are highly heat-resistant and can survive this level of heating.
- E. Freezing: Freezing does not kill C. botulinum spores; it merely halts bacterial growth temporarily. Spores can survive and become active once conditions are favorable again.
22. Question:
After rapidly changing her position from horizontal to vertical, a woman suddenly paled and fell down. Her skin became moist, her limbs are cold, her pupils are dilated. Her pulse is rapid and thready, blood pressure — 50/25 mm Hg. What emergency condition has developed in the patient?
Options:
A. Coma
B. Shock
C. Collapse
D. Ventricular fibrillation
E. Morgagni-Adams-Stokes syndrome
Correct Answer: C. Collapse
Explanation:
This case describes a sudden drop in blood pressure following a postural change, leading to symptoms such as pallor, moist skin, cold extremities, rapid thready pulse, and loss of consciousness. These findings are characteristic of collapse, which is an acute vascular insufficiency caused by a sudden decrease in venous return and cerebral perfusion, often due to orthostatic hypotension. It is typically transient and reversible if the patient is returned to a horizontal position and circulation is restored.
Why Other Options Are Incorrect:
- A. Coma: Coma is a deep, prolonged unconscious state caused by severe brain dysfunction. The onset is usually not this sudden, and it is not directly triggered by postural changes.
- B. Shock: Shock is a more prolonged, systemic circulatory failure with multiple potential causes (e.g., hemorrhage, sepsis). While the patient is hypotensive, the sudden nature and trigger suggest collapse rather than full-blown shock.
- D. Ventricular fibrillation: This is a cardiac arrhythmia leading to immediate cardiac arrest. The patient would be pulseless and unconscious, and the scenario would be more dire with no detectable blood pressure or cardiac output.
- E. Morgagni-Adams-Stokes syndrome: This is a transient syncopal attack caused by complete heart block or severe bradyarrhythmia. There’s no mention of cardiac arrhythmia or ECG findings, and the trigger (postural change) is more indicative of orthostatic collapse.
Question 23:
A 24-year-old woman complains of intermittent double vision, observed over the last two months. She says that recently she has been waking up feeling fine, but by the evening she would develop double vision and drooping of one eyelid. Sometimes she has difficulty chewing and swallowing food. Objectively, partial ptosis is observed, mainly in the left eye. What is the most likely diagnosis in this case?
Options:
A. Multiple sclerosis
B. Myasthenia gravis
C. Mononeuropathy
D. Amyotrophic lateral sclerosis
E. Botulism
Correct Answer: B. Myasthenia gravis
Explanation:
Myasthenia gravis is an autoimmune disorder caused by antibodies against the acetylcholine receptors at the neuromuscular junction. It leads to muscle weakness that worsens with activity and improves with rest — known as fatigability. Classic early symptoms include ptosis (drooping eyelid), diplopia (double vision), and difficulty with chewing or swallowing, especially later in the day. The fluctuating nature and involvement of ocular and bulbar muscles strongly point to myasthenia gravis in this case.
Why Other Options Are Incorrect:
E. Botulism: While botulism can cause ptosis and dysphagia, it usually presents acutely (e.g., within hours to days) after exposure, often with gastrointestinal symptoms. It does not cause chronic, fluctuating symptoms over weeks or months.
A. Multiple sclerosis: MS can cause diplopia, but it usually presents with neurologic deficits such as optic neuritis, paresthesia, or ataxia, and symptoms typically don’t fluctuate daily as described here.
C. Mononeuropathy: This affects a single nerve (e.g., cranial nerve III palsy) and does not explain the progressive fatigue, bilateral ocular involvement, or bulbar symptoms like dysphagia and dysarthria.
D. Amyotrophic lateral sclerosis (ALS): ALS causes progressive muscle weakness, but it usually presents later in life and does not exhibit the daily fluctuation or fatigability typical of myasthenia gravis. Ocular muscles are typically spared until late in the disease.
24. Question:
A 22-year-old woman complains of intense pain in her throat on the left, difficulty swallowing and opening her mouth, elevated body temperature, and generally feeling unwell. She was provisionally diagnosed with acute pharyngitis. Examination detects trismus of the masticatory muscles. The left tonsil is displaced towards the midline. The anterior palatal arch is infiltrated and protruding. The regional lymph nodes on the left are enlarged and painful to palpation. What is the most likely diagnosis in this case?
Options:
A. Peritonsillar abscess
B. Infectious mononucleosis
C. Scarlet fever
D. Lacunar tonsillitis
E. Tonsillar tumor
Correct Answer: . Peritonsillar abscess
Explanation:
A peritonsillar abscess (quinsy) is a complication of acute tonsillitis, characterized by pus accumulation between the tonsil and the pharyngeal muscles. Key clinical features include:
- Severe unilateral throat pain
- Trismus (inability to open the mouth fully due to inflammation of masticatory muscles)
- Displacement of the tonsil medially
- Bulging of the soft palate or anterior pillar
- Muffled voice (“hot potato voice”)
- Fever and swollen, tender cervical lymph nodes
These findings perfectly match the case description, especially the unilateral bulging, trismus, and displacement of the tonsil, all hallmarks of peritonsillar abscess.
Why Other Options Are Incorrect:
- B. Infectious mononucleosis: Caused by Epstein-Barr virus, it typically presents with bilateral tonsillar enlargement, generalized lymphadenopathy, splenomegaly, and fatigue, but not trismus or unilateral peritonsillar swelling.
- C. Scarlet fever: Caused by Group A Streptococcus, it presents with diffuse erythematous rash, strawberry tongue, fever, and pharyngitis, but lacks trismus and tonsillar displacement.
- D. Lacunar tonsillitis: A form of acute tonsillitis, it involves pus in the tonsillar crypts, but is bilateral and does not cause trismus or peritonsillar swelling.
- E. Tonsillar tumor: Tumors develop gradually, often without fever or acute inflammation. They do not typically present with acute pain, trismus, or systemic signs of infection.
25. Question:
A 6-year-old boy had acute onset of the disease with the following symptoms: headache, sore throat during swallowing, and fever of 39°C. Objectively, fine, punctate red rash is visible on the hyperemic skin of the body, with rash elements more numerous in the skin folds. The nasolabial triangle is pale, while the pharynx is brightly hyperemic. The left tonsil has purulent coating in the lacunae. The tongue has gray coating. What is the most likely diagnosis in this case?
Options:
A. Measles
B. Diphtheria
C. Scarlet fever
D. Infectious mononucleosis
E. Adenovirus infection
Correct Answer: C. Scarlet fever
Explanation:
Scarlet fever is a disease caused by Group A β-hemolytic Streptococcus (Streptococcus pyogenes). It typically presents with:
- Sudden onset of high fever, sore throat, and headache
- “Scarlatiniform” rash: fine, punctate, sandpaper-like rash that often appears on the trunk and is accentuated in skin folds (Pastia’s lines)
- “Circumoral pallor”: the area around the mouth (nasolabial triangle) appears pale compared to the flushed cheeks
- Bright red pharynx and tonsils with purulent exudate in the lacunae
- Strawberry tongue: initially coated with a white or grayish layer that later sheds to reveal a red, swollen tongue
These classical signs, especially the rash pattern, pale nasolabial triangle, and pharyngeal findings, strongly point to scarlet fever.
Why Other Options Are Incorrect:
- A. Measles: Characterized by Koplik spots, cough, coryza, conjunctivitis, and a maculopapular rash starting behind the ears and spreading downward—not a punctate rash or associated with purulent tonsillitis.
- B. Diphtheria: Causes gray pseudomembranes over the tonsils and pharynx, not a fine red rash. Also, the pseudomembranes are adherent and bleed on removal, which is not mentioned here.
- D. Infectious mononucleosis: Caused by Epstein-Barr virus, it often shows bilateral tonsillar enlargement, fatigue, lymphadenopathy, and atypical lymphocytosis, but not a characteristic rash or circumoral pallor.
- E. Adenovirus infection: Can cause pharyngitis and fever, sometimes exudative, but rash and the specific signs like circumoral pallor and accentuated rash in folds are not typical.
26. Question:
A 64-year-old man fell to the floor, landing on his left side. Objectively, shortening of the left limb and external rotation of the hip are observed. The patient is unable to perform the straight leg raise test. During palpation and tapping on the heel, the patient feels pain in the hip joint. What is the most likely diagnosis in this case?
Options:
A. Femoral neck fracture
B. Greater trochanteric fracture
C. Contusion of the hip joint
D. Hip dislocation
E. Fracture of the upper third of the femur
Correct Answer: A. Femoral neck fracture
Explanation:
This presentation is classic for a femoral neck fracture, especially in an elderly patient following a fall. Key features include:
- Shortened and externally rotated limb: due to the pull of the muscles around the hip
- Inability to perform the straight leg raise test: indicating loss of hip function
- Pain on palpation and axial loading (heel tap test): confirms localization of the fracture to the hip
- Common in older adults due to osteoporosis and increased fall risk
Femoral neck fractures often present subtly, but the combination of external rotation, limb shortening, and localized pain is highly suggestive.
Why Other Options Are Incorrect:
- B. Greater trochanteric fracture: May cause localized pain and swelling over the trochanter but does not usually result in limb shortening or external rotation. Function may be better preserved.
- C. Contusion of the hip joint: Would cause pain and tenderness but not limb deformity or functional impairment as severe as seen here.
- D. Hip dislocation: Typically results in internal rotation and adduction, not external rotation. Dislocations usually occur due to high-energy trauma and cause different limb positioning.
- E. Fracture of the upper third of the femur: May cause pain and deformity but is lower than the neck; physical findings like limb shortening may occur, but pain is more distal, not specifically in the hip joint.
27. Question:
A 40-year-old patient was hospitalized on the sixth day after the onset of the disease with complaints of fever of 39.9°C, general weakness, and headache. Objectively, the following is observed: psychomotor agitation, euphoria, numerous lice on the patient’s clothes, hyperemic and edematous face, injected scleral vessels, petechiae on the transitional fold of the conjunctiva, and roseolar petechial rash on the skin. The tongue trembles and deviates to the left when stuck out. The liver and spleen are enlarged. What is the most likely diagnosis in this case?
Options:
A. Influenza
B. Typhoid fever
C. Scarlet fever
D. Epidemic typhus
E. Lyme disease
Correct Answer: D. Epidemic typhus
Explanation:
Epidemic typhus, caused by Rickettsia prowazekii and transmitted by the body louse (Pediculus humanus corporis), is characterized by:
- High fever, headache, and mental changes like psychomotor agitation or euphoria
- Rash that begins on the trunk and spreads peripherally, usually petechial or maculopapular
- Injected conjunctiva, facial flushing and edema
- Presence of lice on clothing is a hallmark epidemiologic clue
- Neurologic signs (e.g., tongue tremor, deviation) and hepatosplenomegaly can also be seen
This combination of febrile illness, lice infestation, neurologic signs, and rash strongly points to epidemic typhus.
Why Other Options Are Incorrect:
- A. Influenza: Can cause high fever and headache, but does not involve rash, lice, or petechiae. Also lacks splenomegaly and neurologic findings.
- B. Typhoid fever: Can cause fever, headache, and splenomegaly, but the rash is typically rose spots, not petechial, and lice and conjunctival petechiae are not part of the presentation.
- C. Scarlet fever: Presents with a fine sandpaper rash, pharyngitis, and “strawberry tongue”, and is more common in children. Lice and neurologic symptoms are not seen.
- E. Lyme disease: Caused by Borrelia burgdorferi, transmitted by ticks, and the typical rash is erythema migrans, not petechial. It does not cause epidemic symptoms, lice, or psychomotor agitation.
28. Question:
A 68-year-old woman has been hospitalized with complaints of headache in the occipital region, marked dyspnea at rest that intensifies when lying down, and dry cough. Objectively, the woman is in an orthopneic position, acrocyanosis is observed. On her lungs: weakened vesicular breathing can be heard with medium and fine vesicular wet crackles in the lower segments. The heart sounds are weakened, gallop rhythm is observed. Pulse — 102/min, blood pressure — 210/110 mm Hg. The liver protrudes 2 cm from under the edge of the costal arch and is tender during palpation. There are edemas on the lower legs. What drugs should be used to provide emergency aid for this patient?
Options:
A. Ceftriaxone, ambroxol intravenously
B. Nitrolyceryn, furosemide intravenously
C. Levofloxacin intravenously, ambroxol orally
D. Magnesium sulfate intravenously, furosemide intramuscularly
E. Labetalol intravenously, furosemide intramuscularly
Correct Answer: B. Nitrolyceryn, furosemide intravenously
Explanation:
This patient is showing signs of acute decompensated heart failure (ADHF) likely due to hypertensive crisis (BP: 210/110 mm Hg). Her symptoms — orthopnea, pulmonary crackles, gallop rhythm, peripheral edema, and liver congestion — are classic findings of left and right heart failure.
- Nitroglycerin is used to reduce preload and afterload via venodilation and arteriodilation, rapidly lowering pulmonary congestion and blood pressure.
- Furosemide, a potent loop diuretic, is used intravenously in acute settings to relieve volume overload, reduce pulmonary edema, and improve oxygenation.
This combination provides fast symptom relief and hemodynamic stabilization, making it the appropriate emergency management.
Why Other Options Are Incorrect:
- A. Ceftriaxone, ambroxol intravenously
These are used for respiratory infections, not acute heart failure. There’s no evidence of infection (no fever, productive cough, leukocytosis). - C. Levofloxacin intravenously, ambroxol orally
Again, this regimen targets pneumonia or bronchitis, not applicable here given the clear signs of cardiac failure. - D. Magnesium sulfate intravenously, furosemide intramuscularly
Magnesium sulfate is used for conditions like eclampsia or torsades de pointes, not heart failure. IM administration of furosemide is slower and less reliable in emergency settings compared to IV. - E. Labetalol intravenously, furosemide intramuscularly
While labetalol can lower blood pressure, in acute decompensated heart failure, beta-blockers are contraindicated as they may reduce cardiac output further. Also, IM furosemide is not ideal.
29. Question:
A 26-year-old woman consulted a dermatologist with complaints of a red rash on the face in the form of butterfly-shaped erythema covering the cheeks and the bridge of the nose. The patient also complains of weakness, joint pain, and morning stiffness lasting for about an hour. What is the most likely diagnosis?
Options:
A. Systemic lupus erythematosus
B. Rosacea
C. Seborrheic dermatitis
D. Acne vulgaris
E. Contact dermatitis
Correct Answer: A. Systemic lupus erythematosus
Explanation:
The combination of butterfly-shaped (malar) erythema, joint pain, morning stiffness, and systemic symptoms like weakness strongly suggests Systemic Lupus Erythematosus (SLE), a chronic autoimmune disease that can affect the skin, joints, kidneys, and other organs.
- The malar rash is a hallmark feature of SLE, typically sparing the nasolabial folds.
- Arthralgia and morning stiffness lasting more than 30 minutes point toward an inflammatory autoimmune process.
- SLE is most common in women of reproductive age, consistent with this case.
Why Other Options Are Incorrect:
- B. Rosacea
Causes facial redness, often with telangiectasia and acne-like pustules, but it does not cause joint pain or systemic symptoms like weakness or morning stiffness. - C. Seborrheic dermatitis
Involves flaky, greasy scales and erythema in sebaceous areas (e.g., scalp, eyebrows, nasolabial folds), but not associated with systemic symptoms or joint involvement. - D. Acne vulgaris
Characterized by comedones, papules, and pustules, usually without systemic symptoms or a malar distribution of the rash. - E. Contact dermatitis
Caused by an allergic or irritant reaction, typically limited to the area of contact and associated with itching, not systemic features like joint pain and fatigue.
30. Question:
A soldier under fire received a bullet wound to the lower third of the right shoulder. Objectively, bright red blood flows from the wound in a pulsating stream. The soldier is in a supine position, with the wounded limb slightly raised. What method of stopping external bleeding would be optimal in this case?
Options:
A. Maximum limb flexion
B. Tamponade of the wound
C. Coagulation of the wound
D. Combat Application Tourniquet
E. Contact hemostatic agents
Correct Answer: D. Combat Application Tourniquet
Explanation:
The soldier is experiencing arterial bleeding, as indicated by bright red blood flowing in a pulsatile stream. This is a life-threatening situation that requires immediate hemorrhage control, especially in a combat setting.
- A Combat Application Tourniquet (CAT) is the gold standard for rapidly controlling severe extremity bleeding in the field.
- It should be applied proximal to the injury, ideally 5–7 cm above the wound and not over a joint, to effectively stop arterial flow.
- It is fast, reliable, and designed for self-application or by medics under fire, making it optimal in battlefield conditions.
Why Other Options Are Incorrect:
- A. Maximum limb flexion
This technique is outdated and not reliable for controlling major arterial bleeding, especially in the upper arm where tourniquet placement is much more effective. - B. Tamponade of the wound
Wound packing or tamponade can be useful in junctional or non-tourniquetable areas (like the groin or neck), but in the upper arm, a tourniquet is more effective and quicker. - C. Coagulation of the wound
Not practical in the acute field setting. Requires specialized equipment and is not a first-line measure for massive bleeding control. - E. Contact hemostatic agents
These can assist with hemostasis when used in combination with packing, but are not sufficient alone for arterial bleeding in extremities when a tourniquet is an option.
Question 31:
A 36-year-old woman gave premature birth at 35 weeks of gestation. She has a history of metabolic syndrome and varicose veins. The baby’s condition at birth was satisfactory, the adaptation period was without complications, the baby was breastfed. On the fourth day of life, the baby started showing signs of hemorrhagic syndrome: a single episode of coffee ground vomiting and melena. Hemodynamics is stable. Blood test results: hemoglobin — 195 g/L, platelets — 210·10⁹/L, prolonged clotting time, prothrombin time — 18 seconds. What should be prescribed for the baby in this case?
Options:
A. Vitamin K
B. Tranexamic acid
C. Prednisolone
D. Etamsylate
E. Fresh frozen plasma
Correct Answer: A. Vitamin K
Explanation:
The neonate presents with signs of hemorrhagic disease of the newborn (HDN) — specifically the late-onset form, which typically occurs between 2 to 7 days of life in infants who did not receive prophylactic vitamin K at birth, especially exclusively breastfed and premature infants.
Key features supporting this:
- Melena and coffee-ground vomiting (GI bleeding).
- Prolonged prothrombin time and clotting time.
- Normal platelet count rules out thrombocytopenia.
- Vitamin K deficiency leads to decreased synthesis of clotting factors II, VII, IX, and X, which are vitamin K–dependent.
Administering Vitamin K (usually 1 mg intramuscularly or intravenously) quickly corrects the deficiency and helps restore normal coagulation.
Why Other Options Are Incorrect:
- B. Tranexamic acid
This is an antifibrinolytic used for mucosal or surgical bleeding but does not address the underlying vitamin K deficiency, which is the root cause in this neonate. - C. Prednisolone
A corticosteroid used in immune-mediated conditions (e.g., autoimmune thrombocytopenia), but not appropriate here, as there is no evidence of immune involvement or inflammation. - D. Etamsylate
A hemostatic agent that helps capillary integrity but is not effective for bleeding caused by coagulation factor deficiency. - E. Fresh frozen plasma
While this provides clotting factors, it is generally reserved for severe or life-threatening bleeding. In a hemodynamically stable infant with mild bleeding, Vitamin K alone is first-line and sufficient.
Question 32:
A 32-year-old woman complains of pain in her lower abdomen and fever of 38.5°C. According to her menstrual history, the disease onset occurred on the second day after diagnostic curettage of the uterine cavity. Objectively, signs of intoxication are present, the abdomen is painful in its lower part. Objectively, there are no signs of peritoneal irritation. Vaginal examination shows that the cervix is formed, its external os is closed. Bimanual examination shows that the body of the uterus is enlarged, soft, and painful during discharge. The appendages are painless. The most likely diagnosis in this case?
Options:
A. Acute cystitis
B. Acute salpingo-oophoritis
C. Acute parametritis
D. Pelviperitonitis
E. Acute endometritis
Correct Answer: E. Acute endometritis
Explanation:
The patient presents with fever, lower abdominal pain, and systemic signs of intoxication shortly after diagnostic curettage, a common risk factor for endometrial infection. The physical exam findings — enlarged, soft, and tender uterus, with no pain in the adnexal region and absence of peritoneal signs — are classic for acute endometritis, an infection of the endometrial lining.
Key supporting features:
- Recent instrumentation of the uterus (a major risk factor).
- Fever and pain in the lower abdomen.
- Uterine tenderness on bimanual exam.
- Absence of adnexal or peritoneal involvement.
Why Other Options Are Incorrect:
- A. Acute cystitis
Typically presents with dysuria, frequency, and urgency, not with uterine tenderness or fever of this magnitude. Does not follow curettage. - B. Acute salpingo-oophoritis
Involves tenderness of the adnexal regions (tubes and ovaries), which are painless in this case. Also, it usually occurs as a sexually transmitted infection, not post-procedure. - C. Acute parametritis
Involves infection of the parametrial tissues and typically presents with lateral pelvic pain, more diffuse inflammation, and potentially more serious systemic signs. The uterine body would not be the primary site of tenderness. - D. Pelviperitonitis
Would show signs of peritoneal irritation (rebound tenderness, guarding, rigidity), which are absent in this patient.
33. Question:
Question 33:
A hygienist, investigating a case of food poisoning, established that all the affected persons had characteristic impaired vision (“fog in the eyes”), eye accommodation disorders, diplopia, and strabismus. Later, they developed swallowing disorders, difficulty speaking, and progressive weakness with an acutely accelerated pulse, though the body temperature was typically not elevated. What pathogen causes such symptoms in cases of food poisoning?
Options:
A. Clostridium botulinum
B. Streptococcus faecalis
C. Clostridium perfringens
D. Proteus mirabilis et vulgaris
E. Escherichia coliy
Correct Answer: A. Clostridium botulinum
Explanation:
The described symptoms — blurred vision, diplopia, strabismus, dysphagia, dysarthria, and progressive descending paralysis — are classic for botulism, a rare but serious paralytic illness caused by a neurotoxin produced by Clostridium botulinum.
- Botulinum toxin blocks acetylcholine release at neuromuscular junctions, leading to flaccid paralysis.
- Autonomic symptoms like dry mouth, tachycardia, and absent fever are typical.
- It often results from improperly preserved foods, such as home-canned vegetables or cured meats.
- The progression from cranial nerve palsies to respiratory failure is characteristic.
Why Other Options Are Incorrect:
- B. Streptococcus faecalis (Enterococcus faecalis)
Part of normal gut flora, may cause urinary tract or intra-abdominal infections, but not associated with neurotoxic food poisoning or paralysis. - C. Clostridium perfringens
Causes gastroenteritis with abdominal cramps and diarrhea, usually without neurotoxic effects or cranial nerve involvement. - D. Proteus mirabilis et vulgaris
Common cause of urinary tract infections and wound infections, but not associated with foodborne paralysis. - E. Escherichia coli
Some strains (e.g., EHEC) cause bloody diarrhea and hemolytic uremic syndrome, but they do not cause neurotoxic effects or visual disturbances.
Question 34:
A 57-year-old patient was hospitalized with the diagnosis of community-acquired pneumonia, affecting the lower lobe of the right lung, clinical group III. After three days of hospitalization, the patient complained of shortness of breath, fever of 39.7°C, and one episode of discharging approximately 250 mL of purulent sputum with streaks of blood. Objectively, the affected side of the chest lags behind during breathing. Percussion detects dullness of the pulmonary sound. Auscultation detects amphoric breathing and fine vesicular wet crackles. What is the most likely diagnosis in this case?
Options:
A. Pleural empyema
B. Pulmonary hemorrhage
C. Lung abscess
D. Pulmonary gangrene
E. Mediastinitis
Correct Answer: C. Lung abscess
Explanation:
The patient’s history of pneumonia, followed by the sudden expectoration of a large amount (250 mL) of purulent, blood-streaked sputum, is highly suggestive of a lung abscess that has ruptured into a bronchus. Additional supporting findings include:
- High fever (39.7°C) — indicating ongoing infection.
- Amphoric breathing — a classic auscultatory sign of a cavity in the lung, especially post-rupture of an abscess.
- Dullness on percussion and fine crackles are consistent with parenchymal destruction and cavity formation.
- The chest lag on the affected side suggests reduced lung compliance due to the lesion.
Lung abscess is a localized collection of pus within the lung parenchyma caused by microbial infection and tissue necrosis, often secondary to unresolved pneumonia.
Why Other Options Are Incorrect:
- A. Pleural empyema
Involves pus in the pleural space. It presents with fever and chest pain, but does not cause expectoration of a large volume of purulent sputum. Amphoric breathing is not a feature. - B. Pulmonary hemorrhage
Would involve hemoptysis, but not purulent sputum. It does not present with amphoric breathing or large volumes of sputum production. - D. Pulmonary gangrene
A more severe and diffuse necrotizing infection of the lung than an abscess, often producing foul-smelling sputum and systemic toxicity. The scenario is more consistent with localized abscess formation. - E. Mediastinitis
A rare, severe condition typically following esophageal rupture or post-surgical infection. Presents with retrosternal pain, mediastinal crepitus, and systemic toxicity, not purulent sputum or amphoric breath sounds.
Question 35:
A 23-year-old patient developed pain in her left ear 4 days ago. She was administering alcohol-based eardrops, but the pain was intensifying. Objectively, the patient’s general condition is satisfactory, body temperature — 37.3°C. Otoscopy reveals a hyperemic eardrum with a protrusion. What is the most likely diagnosis in this case?
Options:
A. Acute limited otitis externa
B. Acute mastoiditis
C. Acute diffuse otitis externa
D. Acute purulent otitis media
E. Acute parotitis
Correct Answer: D. Acute purulent otitis media
Explanation:
The patient presents with classic signs of acute purulent otitis media (middle ear infection):
- Ear pain (otalgia) lasting several days.
- Hyperemic (red), bulging tympanic membrane seen on otoscopy — a hallmark of middle ear inflammation with pus accumulation.
- Mild fever (37.3°C) and worsening of symptoms despite self-treatment suggest a progressing middle ear infection.
- Use of alcohol-based eardrops likely irritated the area further and was inappropriate for a middle ear pathology, which is not accessible via topical treatments.
Why Other Options Are Incorrect:
- A. Acute limited otitis externa
Refers to a localized infection (often a furuncle) of the external auditory canal, not involving the tympanic membrane. Would not present with a bulging eardrum. - B. Acute mastoiditis
A complication of otitis media with postauricular swelling, tenderness, and more severe systemic symptoms. This patient does not show mastoid area involvement. - C. Acute diffuse otitis externa
Involves the external auditory canal and is associated with itching, pain on ear traction, and no changes in the tympanic membrane. The bulging eardrum here rules this out. - E. Acute parotitis
Affects the parotid gland, presenting with painful swelling near the jaw/cheek, not within the ear. The ear canal and tympanic membrane would be normal.
Question 36:
An 8-year-old girl has been hospitalized with acute respiratory distress syndrome. Her medical history informs that she had fever and pain in her muscles and joints over the last 2 months. Objectively, the child’s condition is severe, muscle hypotension and periorbital erythema are observed, the proximal muscle group is dense and tender during palpation, her breathing is weakened, cardio- and hepatosplenomegaly are detected. Blood test: ESR — 60 mm/hour, leukocytes — 10·10⁹/L, seromucoid — 0.980 U. What is the most likely diagnosis in this case?
Options:
A. Systemic lupus erythematosus
B. Acute rheumatic fever
C. Periarteritis nodosa
D. Juvenile rheumatoid arthritis (Still’s disease)
E. Dermatomyositis
Correct Answer: E. Dermatomyositis
Explanation:
The clinical picture suggests juvenile dermatomyositis, an autoimmune inflammatory myopathy characterized by:
- Proximal muscle weakness and tenderness (muscle hypotension, tender proximal muscle groups).
- Characteristic skin findings, such as periorbital erythema (heliotrope rash).
- Systemic features including fever, joint pain, and organomegaly (cardio- and hepatosplenomegaly).
- Elevated ESR and seromucoid indicate active inflammation.
- The chronicity of symptoms (over 2 months) with progressive muscle involvement supports this diagnosis.
- Respiratory distress can occur due to involvement of respiratory muscles or secondary complications.
Why Other Options Are Incorrect:
- A. Systemic lupus erythematosus
Can have multisystem involvement but typically shows other signs such as malar rash, renal or CNS involvement, and specific serological markers. Muscle weakness with characteristic rash is less prominent. - B. Acute rheumatic fever
Presents mainly with migratory polyarthritis, carditis, chorea, and erythema marginatum; muscle hypotension and skin erythema around the eyes are not typical. - C. Periarteritis nodosa (Polyarteritis nodosa)
A necrotizing vasculitis with systemic symptoms but usually presents with vascular and organ ischemic signs rather than prominent muscle weakness and rash. - D. Juvenile rheumatoid arthritis (Still’s disease)
Presents with high fever, rash, and arthritis, but muscle hypotension and periorbital erythema are not characteristic. The rash is typically salmon-pink and transient.
Question 37:
A 42-year-old patient complains of cough with yellow sputum, dyspnea attacks during physical exertion, and fatigability. The patient has been a smoker over the last 10 years. Objectively, body temperature — 36.7°C, respiratory rate — 20/min. Auscultation detects numerous dry scattered crackles in the lungs. Spirometry: FEV1 = 74%, FVC = 93%. Chest X-ray revealed basal pneumofibrosis. What is the most likely diagnosis in this case?
Options:
A. Bronchial asthma
B. Chronic obstructive pulmonary disease
C. Acute bronchitis
D. Tuberculosis
E. Pneumonia
Correct Answer: B. Chronic obstructive pulmonary diseas
Explanation:
- The patient is a long-term smoker with chronic cough, sputum production, and exertional dyspnea — classic symptoms of COPD.
- Spirometry shows reduced FEV1 (74%), indicating airflow limitation.
- Basal pneumofibrosis on X-ray suggests chronic lung changes consistent with COPD or related complications.
- Crackles can be present due to airway inflammation and fibrosis.
Why other options are incorrect:
- A. Bronchial asthma: Usually involves reversible airflow obstruction and wheezing, not basal pneumofibrosis.
- C. Acute bronchitis: Usually self-limiting, with no chronic symptoms or radiological fibrosis.
- D. Tuberculosis: Would typically have systemic symptoms and specific X-ray findings (cavities, infiltrates), not just fibrosis.
- E. Pneumonia: Usually acute with fever and infiltrates, not chronic basal fibrosis.
3Question 38:
A 65-year-old patient complains of fever of 38.6°C, headache, trouble sleeping, and low appetite. The patient has a 10-year-long history of type 2 diabetes mellitus. Objectively, there is a purple-cyanotic, sharply painful dense infiltrate 8×6.5 cm in size on the back of the patient’s neck. In its center, there is an opening that produces thick yellow-green pus. What is the most likely diagnosis in this case?
Options:
A. Abscess
B. Erysipelas
C. Carbuncle
D. Phlegmon
E. Furunculosis
Correct Answer: C. Carbuncle
Explanation:
- A carbuncle is a cluster of furuncles (boils) forming a large, inflamed, necrotic skin lesion with multiple pus-draining openings.
- The patient’s diabetes is a risk factor for complicated skin infections.
- Purple-cyanotic color, size, and multiple pus openings are characteristic.
Why other options are incorrect:
- A. Abscess: Usually a single pus collection, not multiple interconnected boils.
- B. Erysipelas: A superficial skin infection with sharp margins, no pus formation.
- D. Phlegmon: Diffuse soft tissue infection without a well-defined pus collection.
- E. Furunculosis: Multiple boils but less likely to form large necrotic lesions with multiple openings like a carbuncle.
Question 39:
A 28-year-old pregnant woman has been hospitalized with vaginal bleeding that occurred in her sleep. Objectively, the following is observed: blood pressure — 100/60 mm Hg, heart rate — 76/min, no pain, the uterine tone is normal, fetal heart rate — 150/min. Bleeding from the birth canal has amounted to approximately 500 mL of bright red blood. What is the most likely diagnosis in this case?
Options:
A. Placental abruption
B. Acute hemorrhoidal crisis
C. Placenta previa
D. Uterine rupture
E. Umbilical cord vascular rupture
Correct Answer: C. Placenta previa
Explanation:
- Placenta previa presents with painless bright red vaginal bleeding during the second or third trimester.
- The uterus is soft and non-tender, fetal heart rate is normal.
- This contrasts with placental abruption where bleeding is painful and uterine tone is increased.
Why other options are incorrect:
- A. Placental abruption: Usually painful bleeding with uterine tenderness and fetal distress.
- B. Acute hemorrhoidal crisis: Would not cause significant vaginal bleeding.
- D. Uterine rupture: Usually occurs during labor with severe pain and fetal distress.
- E. Umbilical cord vascular rupture: Rare and presents with fetal distress, not maternal painless bleeding.
Question 40:
A 14-year-old girl complains of fever, weight loss, general weakness, red butterfly-shaped rashes on her face, palmar telangiectasias, and pain and morning stiffness in the joints of her hands. Examination reveals anemia, leukopenia, thrombocytopenia, increased levels of acute phase inflammation markers, presence of anti-nuclear factor, and LE cells. What is the most likely diagnosis in this case?
Options:
A. Systemic lupus erythematosus
B. Acute rheumatic fever
C. Dermatomyositis
D. Juvenile rheumatoid arthritis
E. Scleroderma
Correct Answer: A. Systemic lupus erythematosus
Explanation:
- The butterfly-shaped malar rash, systemic symptoms, joint involvement, cytopenias, positive ANA, and LE cells are all hallmark features of SLE.
- Palmar telangiectasias can also be present in connective tissue diseases.
Why other options are incorrect:
- B. Acute rheumatic fever: Involves migratory arthritis, chorea, and carditis but no malar rash or ANA positivity.
- C. Dermatomyositis: Has characteristic heliotrope rash and muscle weakness, not butterfly rash.
- D. Juvenile rheumatoid arthritis: Presents mainly with arthritis without malar rash or LE cells.
- E. Scleroderma: Skin thickening and fibrosis rather than butterfly rash and hematologic abnormalities.
Question 41:
A 34-year-old woman at 34 weeks of pregnancy complains of right hypochondrium pain, nausea, vomiting, headache. On exam: leg edema, hemorrhages at injection sites, BP 160/100 mm Hg. Palpation reveals pain in the right hypochondrium. Labs: elevated ALT, AST, thrombocytopenia, hemoglobin 85 g/L, Baxter test positive for hemolysis. What is the most likely diagnosis?
Options:
A. HELLP syndrome
B. Severe preeclampsia
C. Acute hepatitis
D. Eclampsia
E. Acute cholecystitis
Correct Answer: A. HELLP syndrome (Hemolysis, Elevated Liver enzymes, Low Platelets)
Explanation:
HELLP syndrome is a severe complication of pregnancy typically occurring in the third trimester and is characterized by:
- Hemolysis (positive hemolysis tests, decreased hemoglobin)
- Elevated Liver enzymes (elevated ALT, AST)
- Low Platelets (thrombocytopenia)
This patient presents with all three hallmark findings:
- Hemolysis (Baxter test positive, low hemoglobin)
- Elevated liver enzymes (ALT, AST)
- Low platelets
Additionally, the hypertension and edema support a hypertensive disorder of pregnancy. Right upper quadrant (right hypochondrium) pain is due to liver involvement.
Why Other Options Are Incorrect:
- B. Severe preeclampsia: Although this condition shares features like hypertension, edema, and headache, it does not include the triad of hemolysis, elevated liver enzymes, and thrombocytopenia that define HELLP syndrome.
- C. Acute hepatitis: This may cause elevated liver enzymes and right upper quadrant pain but does not explain the hypertension, thrombocytopenia, or hemolysis, especially in a pregnant woman.
- D. Eclampsia: Eclampsia is diagnosed after the occurrence of seizures in a woman with preeclampsia. This patient has no seizures.
- E. Acute cholecystitis: While right hypochondrium pain and nausea are consistent, this diagnosis does not explain hypertension, thrombocytopenia, hemolysis, or elevated liver enzymes to this degree.
.Question 42:
During coke production, the concentration of dust in the air of the working area has been for many years 4–8 times higher than the maximum permissible concentration. What disease is most likely to develop among the workers as a result?
Options:
A. Byssinosis
B. Anthracosis
C. Siderosis
D. Silicosis
E. Asbestosis
Correct Answer: B. Anthracosis
Explanation:
- Anthracosis is a form of pneumoconiosis caused by chronic inhalation of coal dust, particularly carbon particles. It is commonly seen in workers in coke plants, coal mines, or other industries involving coal processing.
- Characterized by accumulation of black carbon pigment in the lungs and lymph nodes, often leading to fibrosis and respiratory symptoms.
- Coke production exposes workers to high levels of coal dust, which is the direct cause of anthracosis.
Why Other Options Are Incorrect:
- A. Byssinosis:
Caused by inhalation of cotton, flax, or hemp dust (textile workers), not coal dust. - C. Siderosis:
Caused by inhalation of iron oxide dust (welders, iron/steel workers). Not associated with coal or coke industries. - D. Silicosis:
Caused by inhalation of silica dust (mining, sandblasting, stone cutting). While a pneumoconiosis, it is not typical in coke production unless silica is involved. - E. Asbestosis:
Caused by inhalation of asbestos fibers, typically in construction, insulation, or shipyard work—not in coke production.
Question 43:
A 17-year-old patient objectively presents with no facial hair growth, gynecomastia, fat deposition on the hips, and a high-pitched voice. The patient is tall due to elongated lower limbs with a relatively short torso. Mental retardation is observed. Sex chromatin was detected in the buccal epithelium. What is the most likely diagnosis in this case?
Options:
A. Down syndrome
B. Patau syndrome
C. Turner syndrome
D. Klinefelter syndrome
E. Edwards syndrome
Correct Answer: D. Klinefelter syndrome
Explanation:
Klinefelter syndrome (47,XXY) is a chromosomal disorder affecting males and is characterized by:
- Tall stature with long limbs and a relatively short torso
- Gynecomastia
- Feminized fat distribution (e.g., hips)
- High-pitched voice
- Lack of facial and body hair
- Mental retardation or learning disabilities in some cases
- Presence of sex chromatin (Barr body) in buccal cells (which is normally absent in males)
These features are classic for Klinefelter syndrome and match the presentation in this patient.
Question 44:
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?
Options:
A. Polyneuritis
B. Endarteritis obliterans
C. Arteriosclerosis obliterans
D. Thromboangiitis obliterans (Buerger disease)
E. Raynaud syndrome
Correct Answer: E. Raynaud syndrome
Explanation:
Raynaud syndrome is a vasospastic disorder that affects the small arteries and arterioles, most commonly in the fingers and toes. It typically presents with a triphasic color change in response to cold or emotional stress:
- White (ischemia) – due to vasoconstriction
- Blue (cyanosis) – due to prolonged lack of oxygen
- Red (reperfusion) – due to return of blood flow
The patient describes a classic history: cold sensation, color changes, numbness, and subsequent painful rewarming. It commonly affects young women and can be primary (idiopathic) or secondary to autoimmune diseases.
Why Other Options Are Incorrect:
- A. Polyneuritis: Involves multiple peripheral nerves. Causes sensory and motor dysfunction but not typically associated with cold-induced color changes or vascular symptoms.
- B. Endarteritis obliterans: Involves inflammation and obstruction of arteries, commonly seen in syphilitic aortitis, and doesn’t typically present with episodic color changes or pain in fingers.
- C. Arteriosclerosis obliterans: A form of peripheral artery disease affecting larger arteries (typically of the legs in older individuals), leading to claudication, not episodic vasospasm in fingers.
- D. Thromboangiitis obliterans (Buerger disease): Affects young male smokers with inflammation and thrombosis of small and medium arteries and veins. Presents with ulcers, claudication, and rest pain, not the classic triphasic color change described here.
Question 45:
A woman has been hospitalized into a gynecological inpatient department with complaints of pain in her lower abdomen and dizziness. Her last menstruation was 6 weeks ago. Objectively, her skin is pale, blood pressure — 80/60 mm Hg, pulse — 94/min. The sign of peritoneal irritation in the lower segments is positive. Bimanual examination shows that the uterus is slightly enlarged, the appendages are enlarged on the right and painful. Promontory’s sign is positive. What is the most likely diagnosis in this case?
Options:
A. Acute adnexitis
B. Interrupted ectopic pregnancy
C. Ovarian apoplexy
D. Ruptured cyst of the right ovary
E. Redicle torsion of a cyst of the right ovary
Correct Answer: B. Interrupted ectopic pregnancy
Explanation:
This patient presents with signs of internal bleeding, hemodynamic instability (low BP, pallor, dizziness), positive peritoneal signs, amenorrhea (6 weeks), and painful right adnexa with uterine enlargement. These findings are classic for a ruptured (interrupted) ectopic pregnancy, most commonly occurring in the fallopian tube. A positive Promontory’s sign (pain in the rectouterine pouch) also supports peritoneal irritation due to hemoperitoneum.
An ectopic pregnancy that ruptures can cause life-threatening intra-abdominal bleeding and needs immediate surgical intervention.
Why Other Options Are Incorrect:
- A. Acute adnexitis: Presents with pelvic pain, fever, and adnexal tenderness, but not with amenorrhea, signs of internal bleeding, or hemodynamic shock.
- C. Ovarian apoplexy: Can mimic ectopic pregnancy, but usually occurs mid-cycle and lacks positive pregnancy history or uterine enlargement. It also tends to be less associated with massive bleeding than ectopic rupture.
- D. Ruptured cyst of the right ovary: Can cause acute pain and mimic rupture, but uterine enlargement and history of missed period suggest pregnancy, favoring ectopic rupture.
- E. Redicle torsion of a cyst of the right ovary: Causes acute pain and adnexal mass, but not uterine enlargement, positive pregnancy test, or signs of internal hemorrhage like this case.
Question 46:
A 56-year-old patient with acute Q-wave myocardial infarction is being treated in a cardiac unit. The patient’s condition worsens with oliguria (urine output = 450 mL/day), cold extremities, pulmonary crackles, arrhythmic and muffled heart sounds, hypotension (85/40 mmHg), and elevated creatinine and urea levels.What type of acute kidney injury (AKI) has occurred in the patient?
Options:
A. Renal
B. Postrenal
C. Prerenal
D. Combined
E. Arenal
Correct Answer: C. Prerenal
Explanation:
This patient’s acute kidney injury is prerenal in origin due to hypoperfusion of the kidneys caused by cardiogenic shock following a myocardial infarction. Key features supporting prerenal AKI include:
- Low blood pressure (85/40 mmHg) indicating inadequate renal perfusion
- Cold extremities and wet crackles, suggesting left ventricular failure and low cardiac output
- Oliguria (450 mL/day) and elevated creatinine and urea levels
Prerenal AKI is the most common and often reversible if perfusion is restored quickly.
Why Other Options Are Incorrect:
- A. Renal (Intrinsic AKI): Involves direct damage to the kidney parenchyma (e.g., acute tubular necrosis), typically after prolonged ischemia, toxins, or infections. The presentation here is acute and secondary to hemodynamic instability, not intrinsic renal disease.
- B. Postrenal: Caused by obstruction to urine outflow (e.g., stones, prostate enlargement), which would present with bladder distention, hydronephrosis, and not with cardiogenic shock signs.
- D. Combined: Involves both prerenal and renal causes. While possible in prolonged or severe cases, there is no evidence of intrinsic kidney damage yet, so the diagnosis is still prerenal.
- E. Arena: This is a non-medical term and likely a typographical error or distractor.
Question 47:
A 60-year-old woman reports limited mobility in the distal interphalangeal joints (DIP) of both hands for 12 years, along with periodic back pain. Examination reveals nodular thickening and deformity of the DIP joints, with normal lab test results (blood and urine). What is the most likely diagnosis?
Options:
A. Reactive arthritis
B. Gout
C. Rheumatoid arthritis
D. Ankylosing spondyloarthritis
E. Osteoarthritis
Correct Answer: E. Osteoarthritis
Explanation:
Osteoarthritis (OA) is the most common form of arthritis, especially in older adults. It typically affects the distal interphalangeal (DIP) joints, presenting with nodular thickening (Heberden’s nodes) and deformities over a long period, consistent with this patient’s history. OA is characterized by degenerative cartilage loss, leading to joint pain, stiffness, and decreased mobility.
- The normal blood and urine tests suggest absence of systemic inflammation or metabolic disease.
- The nodular thickening of DIP joints and long history fits classical OA.
- The periodic back pain can be due to degenerative changes in the spine, which often coexist with OA.
Why Other Options Are Incorrect:
- A. Reactive arthritis: Usually affects younger individuals and is characterized by acute asymmetric oligoarthritis, often following an infection. It rarely involves DIP joints symmetrically and does not cause nodular deformities like OA.
- B. Gout: Typically presents with acute, severe monoarticular arthritis, often in the first metatarsophalangeal joint. Chronic tophaceous gout can cause nodules, but DIP involvement is uncommon and lab tests often show hyperuricemia.
- C. Rheumatoid arthritis (RA): Usually involves the proximal interphalangeal (PIP) and metacarpophalangeal (MCP) joints symmetrically, with significant inflammation and systemic symptoms. DIP joints are usually spared in RA.
- D. Ankylosing spondyloarthritis: Primarily affects the axial skeleton (spine and sacroiliac joints) causing inflammatory back pain and stiffness, rather than DIP joint involvement with nodules.
Question 48:
A 34-year-old man with schizophrenia is hospitalized due to an exacerbation. He stays in one position, shows waxy flexibility, hypomimia, no response to environment, and has signs like puckering of lips and “psychological pillow.” He’s been in this state for one week and is being fed parenterally.What type of stupor is it?
Options:
A. Reactive
B. Depressive
C. Organic
D. Neurotic
E. Catatonic
Correct Answer: E. Catatonic
Explanation:
- Catatonic stupor is a type of psychomotor disturbance associated primarily with schizophrenia.
- Hallmark features include:
- Mutism, immobility, waxy flexibility, psychological pillow, negativism, posturing.
- Puckering of lips is a form of stereotypy.
- This patient presents classic signs of catatonia, which can persist for days to weeks.
Why Other Options Are Incorrect:
- A. Reactive:
Occurs after a severe psychological trauma, often short-term, and lacks catatonic features like waxy flexibility. - B. Depressive:
Occurs in major depressive disorder; patients are immobile, but without catatonic signs like waxy flexibility or stereotypies. - C. Organic:
Caused by brain injury or metabolic disorders, often with confusion, disorientation, or seizures, which are absent here. - D. Neurotic:
Found in conversion or dissociative disorders, usually brief and inconsistent, and without classical catatonic signs.
Question:49
A 54-year-old man has been hospitalized with complaints of general weakness, fever of 38.6°C, shortness of breath during significant physical exertion, and frequent nosebleeds. He works in the production of plastics, where he comes into contact with aromatic compounds. Objectively, his skin is pale and dry.
Complete blood count:
- Erythrocytes – 2.1·10¹²/L
- Hemoglobin – 90 g/L
- Leukocytes – 2.2·10⁹/L
- Eosinophils – 1%, band neutrophils – 1%, segmented neutrophils – 75%, lymphocytes – 20%, myelocytes – 3%
- Platelets – 30·10⁹/L
- ESR — 32 mm/hour
What substance has caused chronic intoxication in this man?
Options:
A. Lead
B. Nitrobenzene
C. Tetraethyllead
D. Aniline
E. Benzene
Correct Answer: E. Benzene
Explanation:
Benzene is a well-known cause of bone marrow suppression (pancytopenia), particularly in workers exposed to it over long periods in industrial settings such as plastic manufacturing. The patient shows signs of anemia, leukopenia, and thrombocytopenia, which are hallmark features of aplastic anemia or hypoplastic bone marrow, both linked to chronic benzene exposure. Recurrent infections, bleeding tendencies (epistaxis), and general fatigue are clinical manifestations of this hematologic toxicity.
Why Other Options Are Incorrect:
- A. Lead: Causes anemia (especially with basophilic stippling), abdominal colic, and neurological symptoms (e.g., wrist drop), but not usually pancytopenia. It’s more common in battery workers or people exposed to paints, not plastic factory workers.
- B. Nitrobenzene: Causes methemoglobinemia, which leads to cyanosis, chocolate-colored blood, and hypoxia symptoms. It doesn’t cause pancytopenia or affect the bone marrow in this way.
- C. Tetraethyllead: An organolead compound associated with neurotoxicity and encephalopathy. It doesn’t typically cause significant bone marrow suppression like benzene.
- D. Aniline: Also causes methemoglobinemia and is associated with cyanosis due to oxidized hemoglobin, but not bone marrow suppression or pancytopenia.
Question: 50
A 38-year-old woman complains of heaviness and fullness in her legs, edema of the lower legs and feet in the evening, and pain that disappears in the morning. According to the patient’s medical history, these complaints first appeared during her second pregnancy. Examination of the patient when standing reveals dilated saphenous veins in the lower legs and lower thirds of the thighs. In some places the veins have soft nodular protrusions. In a horizontal position, the veins subside. What is the most likely diagnosis in this case?
Options:
A. Endarteritis obliterans
B. Raynaud’s disease
C. Arteriosclerosis obliterans in the legs
D. Varicose veins in the legs
E. Acute thrombosis of the saphenous veins in the legs
Correct Answer: D. Varicose veins in the legs
Explanation:
The symptoms described — heaviness, fullness, evening edema, dilated and nodular superficial veins that subside when lying down — are classic for varicose veins, especially involving the saphenous system. Pregnancy is a known risk factor due to increased venous pressure and hormonal effects on vein walls. Varicose veins are caused by venous valve insufficiency, leading to venous stasis and vein dilation.
Why Other Options Are Incorrect:
- A. Endarteritis obliterans: This is a chronic occlusive disease of small and medium arteries, typically associated with Buerger’s disease, which presents with claudication and ischemic changes, not superficial vein dilation.
- B. Raynaud’s disease: This affects the fingers and toes and presents with episodic color changes (white, blue, red) in response to cold or stress. It does not involve leg veins or cause evening edema.
- C. Arteriosclerosis obliterans in the legs: This leads to intermittent claudication, cold limbs, and reduced/absent peripheral pulses due to arterial insufficiency, not varicosities or superficial vein dilation.
- E. Acute thrombosis of the saphenous veins in the legs: Would present with acute pain, redness, warmth, and a palpable cord-like structure (thrombosed vein), not with soft compressible veins that subside when lying down.