Internal Medicine Krok 2016

A regional cardiologist is tasked with the development of a plan for medioprophylactic measures aimed at decreaseof cardiovascular mortality. What measures should be planned for secondary prevention?

A 30-year-old woman complains of pain in the heart area (”aching, piercing pain”) that arises primarily in the morning hours in autumn and spring. Pain irradiates into the neck,back,abdomenandis attendedbyrapid heart rate and low vital tonus. This condition occurs independently from physical exertion. In the evening her condition improves. Somatic and neurologic state and ECG have no pathologies. What pathology is likely to result in suchclinical presentation?

In the morning upon waking a 65-yearold patient developed weakness in the rightside limbs, speech disorder, decreased sensitivity of the left side of the body. On examination: conscious, BP- 100/60 mm Hg, motor aphasia, right-sided central hemiparesis and hemihypalgesia. Make the preliminary diagnosis:

A 37-year-old man suffers from attacks of unconsciousness, dyspnea during physical exertion, periodical sensations of heart rate disorder. Father of the patient died suddenly at the age of 45. Objectively: heart rate is 90/min., BP is 140/90 mm Hg. On heart US: ejection fraction - 49%, significant myocardium thickening of the left ventricle and interventricular septum. What drug should be prescribed for the treatment?

A 58-year-old patient was delivered to an admissionroomwithcomplaintsofpaininthe
thorax on the left. On clinical examination: aside from tachycardia (102/min.) no other changes. On ECG: pathologic wave Q in I, аVL, QS in V1, V2, V3 leads and ’domed’ ST elevation with negative T. What diagnosis is most likely?

A 58-year-old patient complains of a headache in the occipital region, nausea, choking, opplotentes. The presentations appeared after a physical exertion. Objectively: the patient is excited. Face is hyperemic. Skin is pale. Heart sounds are regular, the 2nd aortic sound is accentuated. BP- 240/120 mm Hg, HR- 92/min. Auscultation reveals some fine moist crackles in the lower lungs. Liver is not enlarged. ECG shows signs of hypertrophy and left ventricular overload. What is the most likely diagnosis?

A week ago a 65-year-old patient suffered an acute myocardial infarction, his general condition deteriorated: he complains of dyspnea at rest, pronounced weakness. Objectively: edema of the lower extremities, as citesis present. Heart border sare extended, paradoxical pulse is observed 2 cm from the apex beat to the left. What is the most likely diagnosis?

A 19-year-old patient complains of dyspnea during physical exertion. He often has bronchitis and pneumonia. Cardiac murmur has been observed since his childhood. On auscultation: there is splitting of the II heart sound over pulmonary arteria, systolic murmur in the third intercostal space near the left sternum margin. ECG test shows right bundle-branch block. What is the provisional diagnosis?

A 67-year-old man complains of dyspnea on exertion, attacks of retrosternal pain, dizziness. He has no history of rheumatism. Objectively:paleskin,acrocyanosis. Thereare crackles in the lower lungs. There is systolic thrill in the II intercostal space on the right, coarse systolic murmur conducted to the vessels of neck. BP- 130/90mm Hg, heart rate -
90/min., regular rhythm. The liver extends 5 cm from under the edge of costal arch, shin edemas are present. Specify the suspected valvular defect:

A 33-year-old patient has developed dyspnea during physical exertion, palpitations, disruptions of heart rate, swollen legs. In the childhood the patient had a case of acute rheumatic fever that required in-patient treatment. There were no further requests for medical care. Objectively: heart rate is 92/min., rhythmic; BP is 110/70 mm Hg. At the apex the I heart sound is increased, triple rhythm, diastolic murmur.What heart disease is most likely?

An8-year-oldboydevelopedatemperature of 37,5oC two days after his recovery from the case of URTI. He complains of suffocation, heart pain. Objectively: the skin is pale, tachycardia, the I heart sound is weakened, short systolyc murmur in the 4th intercostal area near the left edge of the breastbone. What heart disorder such clincal presentation is characteristicof?

A 32 year old patient complains of cardiac irregularities, dizziness, dyspnea at physical exertion. He has never suffered from such condition before. Objectively: Ps- 74/min., rhythmic. BP- 130/80 mm Hg. Auscultation revealed systolic murmur above aorta, the first heart sound was normal. ECG showed hypertrophy of the left ventricle, signs of repolarization disturbance in the I, V5 and V6 leads. Echocardiogram revealed that interventricularseptum was 2 cm. What is the mostprobablediagnosis?

A woman has developed sudden thoracic pain on the right with expectoration of pink sputum and body temperature rise up to 37,7oC on the 4th day after the surgery for cystoma of the right ovary. On lung examination: dullness of the lung sound on the lower right is observed. Isolated moist crackles can be auscultated in the same area.What complication is the most likely?

A 56-year-old patient with diffuse toxic goiterhasciliaryarrhythmia,heartrateis110120/min., arterial hypertension, BP is 165/90 mm Hg. What drug besides Mercazolil (Thiamazole) should be prescribedin this case?

An 8-year-old girl periodically has sudden short-term heart pains, sensation of chest compression, epigastric pain, dizziness, vomiting. Objectively: the patient is pale, respiratory rate - 40/min., jugular pulse is present. Ps- 185/min., of poor volume. BP- 75/40 mm Hg. ECG taken during an attack shows ectopic P waves, QRS wave is not deformed. Attheendofanattackacompensatorypause is observed. The most likely cause of the attack is:

ECG revealed the following in a 10year-old child: sharp acceleration of the heart rate - 240/min., P wave overlaps with T wave and deforms it, moderate lengthening of PQ interval, QRS complex is without changes. What pathology does this child have?

4 weeks after myocardial infarction a 56year-old patient developed acute heart pain, pronounced dyspnea. Objectively: the patient’s condition is extremely grave, there is marked cyanosis of the face, swelling and throbbing of the neck veins, peripheral pulse is absent, carotid artery pulse is rhythmic, 130/min., BP is 60/20 mm Hg. Auscultation ofthe heart reveals extremely muffled sounds, percussion reveals heart border extension in bothdirections.Whatistheoptimaltreatment tactis for this patient?

A 36 year old female patient complains ofgeneral weakness, edemas of her face and hands, rapid fatigability during walking, difficult diglutition, cardiac irregularities. These symptoms developed 11 days after holiday at the seaside. Objectively: face erythema, edema of shin muscles. Heart sounds are muffled, BP is 100/70 mm Hg. In blood: ASAT activity is 0,95 millimole/h·l, ALAT1,3 micromole/h·l, aldolase - 9,2 IU/l, creatinephosphokinase-2,5micromoleР/g·l.What method of study would be most specific?

A 25-year-old patient is not married and has sexual relations with several partners. During the last 3 months he noticed small amount of mucoserous secretions produced from urethra. Subjectively: periodical itching or burning pain in urethra. Two months ago pain in the knee join developed. Possibility of trauma or exposure to cold is denied by the patient. During the last week eye discomfort is noted-lacrimation and itching. What provisional diagnosis can be suggested?

A 46-year-old woman complains of pain attacks in the right lumbar area, which irradiate to the lower abdomen, and nausea. This kind of pain attacks has never been detected in the patient before. Survey Xray of the abdominal cavity reveals no pathologic shadows. Ultrasonic scan detects a hyperechogenic growth 1,5 cm in diameter, which reflects sound wave, in the enlarged rightrenalpelvis.Whatdiagnosisismostlikely?

A 45-year-old patient with urolithiasis had an attack of renal colic. What is the mechanismof the attack development?

For the last 15yearsa 48-year-oldpatient has been working at the factory producing synthetic resins. Lately he has been complaining of significant general fatigue, headaches, frequent urination (predominantly during the day), red color of urine. What complication of benzene nitrocompounds poisoning can be suspected?

A 35-year-old man complains of intense lumbar pain irradiating to the inguinal area, external genitalia, thigh; frequent urination, chill, nausea, vomiting. Objectively:
positive Pasternatsky’ssymptom(costovertebralangle tenderness). Urine analysis revealed that RBCs and WBCs covered the total field of microscope; the urine exhibited high protein concentration. These clinical presentations were most likely caused by the following pathology:

A 20-year-old patient complains of pain in the left lumbar region, arterial pressure rise up to 160/110 mm Hg. US revealed that the structure and size of the right kidney were within age norms, there were signs of 3 degree hydronephrotic transformation of the left kidney. Doppler examination revealed an additional artery running to the lower pole of the kidney.Excretory urogram shows an arrowing in the region of ureteropelvic junction. Specify the treatment tactics:

A 39-year-oldpatient complains of morning headache, appetite loss, nausea, morning vomiting, periodic nasal haemorrhages. The patient had a case of acute glomerulonephritis at the age of 15. Examination revealedrise ofarterialpressureupto220/130mmHg,skin haemorrhages on his arms and legs, pallor of skinandmucousmembranes.Whatbiochemical parameter is most important for making diagnosis in this case?

A 30-year-old woman suffers from polycystic renal disease. She has been admitted with signs of fatigue, thirst and nocturia. Diuresis is up to 1800 ml per day. BP is 200/100 mm Hg. Blood test: erythrocytes 1,8·109/l, Hb- 68 g/l. Urine analysis: specific gravity-1005,leukocytes-50-60,erythrocytes - 3-5 in the vision field, creatinine - 0,82
mmol/l, potassium - 6,5 mmol/l, glomerular filtration rate - 10 ml/min. What tactics would be leading in the patient’s treatment?

A 48-year-old man complains of constant pain in the upper abdomen, predominantly on the left, which aggravates after eating, diarrhea, loss of weight. The patient has alcohol use disorder. Two years ago he had a case of acute pancreatitis. Blood amylase is 4 g/hour·l. Feces analysis: steatorrhea, creatorrhea. Blood sugar is 6,0 mmol/l. What treatment should be prescribed?

A 45-year-old patient complains of pain in the epigastric region, left subcostal area, abdominal distension, diarrhea, loss of weight.Hehasbeensufferingfromthis condition for 5 years. Objectively: tongue is moist with white coatingneartheroot;deeppalpationof abdomen reveals slight pain in the epigastric regionandМауо-Robson’spoint.Liverispainless andprotrudes1cm fromthecostalarch. Spleen cannot be palpated. What disease can be primarily suspected?

A 48-year-old woman has been suffering from chronic pancreatitis for the last 7 years. Lately she has been noticing an increase in daily feces with foul smell, abdominal distention, gurgling. The patient complains of diarrhea, weakness, fatigability, loss of appetite, loss of weight. What syndrome can be suspectedin this case?