Internal Medicine Complex(2005,2006,2007)

A patient with unstable angina pectoris was given the following
complex treatment: anticoagulants, nitrates, /alpha-adrenoblockers. However
on the third day of treatment the pain still romains. Which investigation shoud be
carried out to establish diagnosis?

A 64 y.o. patient has developed of
squeering substernal pain which had
appeared 2 hours ago and irradiated
to the left shoulder, marked weakness.
On examination: pale skin, cold sweat.
Pulse- 108 bpm, AP- 70/50 mm Hg, heart
sound are deaf, vesicular breathing, soft
abdomen, painless, varicouse vein on the
left shin, ECG: synus rhythm, heart rate is
100 bmp, ST-segment is sharply elevated
in II, III aVF leads. What is the most likely disorder?

A patient had macrofocal myocardial
infarction. He is overweight for 36%, AP
is 150/90 mm Hg, blood sugar- 5,9 mmol/L,
general cholesterol- 4,9 mmol/L, uric acid-
0,211 mmol/L. Which risk factor should be
urgently eradicated during the secondary
prevention?

A 60 y.o. patient experiences acute air
insufficiency following of the venoectomy
due to subcutaneous vein thrombophlebitis 3 days ago. Skin became cianotic, with grey shade.
Marked psychomotor excitement, tachypnea, substernal pain. What
postoperative complication has occured?

A 40 y.o. patient of rheumatic heart
disease complains of anorexia, weakness
and loss of weigth, breathless and swelling
of feet. On examination: t 0- 390C, pulse is
100/min. As ucultation: diastolic murmur
in the mitral area. Petechical lesion a
round clavicle; spleen was palpable, tooth
extraction one month ago.

A 43 y.o. woman complains of shooting heart pain, dyspnea, irregularities in
the heart activity, progressive fatigue during 3 weeks. She had acute respiratory
disease a month ago. On examination:
AP- 120/80 mm Hg, heart rate 98 bpm,
heart boarders +1,5 cm left side, sounds
are muffled, soft systolic murmur at apex
and Botkin’s area; sporadic extrasystoles.
Liver isn’t palpated, there are no edema.
Blood test: WBC- 6, 7 ∗109/L, sedimentation rate- 21 mm/hour. What is the most
probable diagnosis?

A 67 y.o. patient complains of palpitation, dizziness, noise in ears, feeling of
shortage of air. Objectively: pale, damp
skin. Vesicular respiration, respiratory
rate- 22 per min, pulse- 200 bpm, AP-
100/70 mm Hg. On ECG: heart rate-
200 bmp, ventricular complexes are widened, deformed, location of segments
ST and of wave T is discordant. The wave
Р is not changed, superimposes QRST,
natural conformity between Р and QRS is
not present. What kind of arrhythmia is
present?

A 35 y.o. male patient suffers
from chronic glomerulohephritis and
has been on hemodialysis for the last
3 years. He has developed irregularities in the heart activity, hypotension,
progressive weakness, dyspnea. On ECG:
bradycardia, 1st degree atrioventicular
block, high sharpened T-waves. Before
he had severely disturbed the drinking
and diet regimen. What is the most likely
cause of these changes?

A 37 y.o. woman is suffering from
squeezing substernal pain on physical
exertion. On examination: AP- 130/80
mm Hg, heart rate=pulse rate 72 bpm,
heart boarders are dilated to the left side,
aortic systolic murmur. ECG- signs of the
left venticle hypertrophy. What method
of examination is the most informative in
this case?

A 18 y.o. male patient complains of
pain in knee and ankle joints, temperature
elevation to 39, 50C. He had a respiratory
disease 1,5 week ago. On examination:
temperature- 38, 50C, swollen knee and
ankle joints, pulse- 106 bpm, rhythmic,
AP- 90/60 mm Hg, heart borders without changes, sounds are weakened, soft
systolic apical murmur. What indicator is
connected with possible etiology of the
process?

A 17 y.o. patient complains of acute
pain in the knee joint and t 0 – 3 80C. He
was ill with angina 3 weeks ago. Objectively: deformation and swelling of the
knee joints with skin hyperemia. Small
movement causes an acute pain in the joints. Which diagnose is the most correct?

A 30 y.o. female with rheumatoid
arthritis of five years duration complains of pain in the frist three fingers of her right
hand over past 6 weeks. The pain seems
especially severe at night often awakening
her from sleep.The most likelly cause is?

A patient, aged 40, has been ill during approximately 8 years, complains of
pain in the lumbar part of the spine
on physical excertion, in cervical and
thoracal part (especially when coughing), pain in the hip and knee joints on
the right. On examination: the body is fixed
in the forward inclination with head
down, gluteal muscles atrophy. Spine
roentgenography: ribs osteoporosis, longitudinal ligament ossi fication. What is the
most likely diagnosis?

3 weeks ago the patient was ill with tonsillitis. Clinical examination reveals
edema, arterial hypertension, hematuria,
proteinuria (1,8 g/per day), granular and
erythrocital casts. What is the preliminary
diagnosis?

A male patient presents with swollen
ankles, face, eyelids, elevated AP- 160/100
mm Hg, pulse- 54 bpm, daily loss of
albumine with urine- 4g. What therapy
is pathogenetic in this case?

A 24 y.o. patient complains of nausea,
vomiting, headache, shortness of breath.
He had an acute nephritis being 10
y.o. Proteinuria was found out in urine. Objectively: a skin is grey-pale, the
edema is not present. Accent of II tone
above aorta. BP 140/100-180/100 mm Hg.
Blood level of residual N2- 6,6 mmol/L,
creatinine- 406 mmol/L. Day’s diuresis-
2300 ml, nocturia. Speci fic density of urine is 1009, albumin- 0,9 g/L, WBC- 0-2 in
f/vis. RBC.- single in f/vis., hyaline casts
single in specimen. Your diagnosis?

47 y.o. patient complains of intensive skin itching, jaundice, bone pain. The
skin is hyperpigmentated. There is multiple xanthelasma palpebrae. The liver is
+6 cm enlarged, hard with acute edge.
The blood analysis revealed total bilirubin 160 mkmol/L, direct – 110 mkmol/L,
AST (asparate aminotransferase)- 2,1
mmol/L per hour, ALT – 1,8 mmol/L,
alkaline phosphotase- 4,6 mmol/L per
hour, cholesterol – 9,2 mmol/L, antimitochondrial antibodies M2 in a high titer.
What is the probable diagnosis?

A 51 y.o. woman complains of dull pain
in the right subcostal area and epigastric
area, nausea, appetite decline during 6
months. There is a history of gastric peptic
ulcer. On examination: weight loss, pulse
is 70 bpm, AP is 120/70 mm Hg. Diffuse
tenderness and resistance of muscles on
palpation.There is a hard lymphatic node
1x1cm in size over the left clavicle. What
method of investigation will be the most
useful?

A 56 y.o. man, who has taken
alcoholic drinks regularly for 20 years,
complains of intensive girdle pain in the
abdomen. Profuse nonformed stool 2-
3- times a day has appeared for the last
2 years, loss of weight for 8 kg for 2
years. On examination: abdomen is soft,
painless. Blood amylase - 12g/L. Feces
examination-neutral fat 15 g per day,
starch grains. What is the most reasonable
treatment at this stage?

A 61 y.o. man complained of sneezing and substernal pain on exertion. In the last 2 weeks such pain
appeared at rest, with increased frequency, and couldn’t be suppressed by 1 tablet of nitroglycerin.
What is the most likely diagnosis?

A 52 y.o. male patient suffers from squeezing pain attacks in substernal area which irradiates to the
left hand and occurs occasionally and on physical exercises. He has had it for 1 year. On examination:
heart borders are enlargement to the left side, sounds are muffled, Ps- 76 bpm, rhythmic, AP- 155/80
mm Hg, ECG: the left type, the rest signs are normal. What additional examination is necessary to
confirm the diagnosis?

A 58 y.o. man complained of severe inspiratory dyspnea and expectoration of frothy and bloodtinged
sputum. He has been suffering from essential hypertension and ischemic heart disease. On
examination: acrocyanosis, "bubbling"breathing, Ps- 30/min, BP- 230/130 mm Hg, bilateral rales. Choose
medicines for treatment.

A patient has got a sudden attack of severe substernal pain at night. On examination: confusion,
pallor of the skin, acrocyanosis, cold sweat, BP- 80/50 mm Hg, Ps- 120/min, irregular and weak pulse.
What condition are these symptoms typical for?

The doctors in maternity hospital made a newborn boy the following diagnosis: congenital heart
disease (interventricular septal defect). At the age of 2 months the boy has got a dyspnea. Objectively:
BR- up to 60/min, Krok 1 Medicine 2006 19 tachycardia up to 170/min, liver is 3 cm below the costal
margin. What medicines must be immediately prescribed?

A 40 y.o. patient with rheumatic heart disease complains of anorexia, weakness and loss of weigth,
breathlessness and swelling of feet. The patient had tooth extraction one month ago. On examination: t
0- 390C, Ps- 100/min. Auscultation: diastolic murmur in the mitral area. Petechial lesion are round of
clavicle; spleen was palpable.

A 40 y.o. woman is ill with rheumatic disease with composite mitral disease with prevalence of the
stenosis of left venous foramen.Complains of palpitation, fatigability, progressing dyspnea, attacks of
dyspnea and hemoptysis. Now she cannot be engaged even in the easy activities. What tactics is the
most expedient?

On the 3rd day after the acute anterior myocardial infarction a 55 y.o. patient complains of dull ache
behind his breast bone, that can be reduced by bending forward, and of dyspnea. Objectively: AP-
140/180 mm Hg, heart sounds are dull. ECG results: atrial fibrillation with frequence of ventricular
contractions at the rate of 110/min, pathological Q wave and S-T segment raising in the right chest
leads. The patient refused from thrombolisis. What is the most probable diagnosis?

A 35 y.o. male patient suffers from chronic glomerulonephritis and has been treated with
hemodialysis for the last 3 years. He has got irregularities in the heart activity, hypotension, progressive
weakness, dyspnea. On ECG: bradycardia, 1st degree atrioventricular block, high sharpened T-waves.
Some time before he had seriously broken the water consumption and dietary pattern. What is the most
likely cause of these changes?

A 70 y.o. patient complains of weakness, dizziness, short periods of lossof consciousness, pain in
the region of heart. Objectively: HR- 40/min, sounds are rhytmic, the 1st sound is dull, occasionally very
intensive. AP- 180/90 mm Hg. What is the most probable reason of hemodynamic disorders?

A 60 y.o. woman has had increased BP up to 210/110 mm Hg for the last 7 years. On examination:
heart apex is displaced to the left. There are signs of left ventricular hypertrophy on ECG. What is the
most probable diagnosis?

A 17 y.o. patient complains of acute pain in the knee joint and t 0- 380C. He was ill with angina 3
weeks ago. Objectively: deformation and swelling of the knee joints with skin hyperemia. Small
movement causes an acute pain in the joints. Which diagnose is the most correct?

A 10 y.o. boy was ill with angina 2 weeks ago, has complaints of joint pain and stiffness of his left
knee and right elbow. There was fever (38, 50) and ankle disfunction, enlargement of cardiac dullness by
2 cm, tachycardia, weakness of the 1st sound, gallop rhythm, weak systolic murmur near apex. What
diagnosis corresponds with such symptoms?

A patient has complained of great
weakness for 6 years. He fell seriously
ill, the illness is accompanied by body
temperature rise, indisposition, pain in
joints and along the legs muscles. Objectively:
violet-bluish erythema around eyes
and over knee joints. HR- 120/min, heart
sounds are weak. Blood count: leukocytes
- 12 ∗109/L, ESR- 40 mm/h. What is themost probable diagnosis?

A 41 y.o. woman complains of
weakness, fatigue, fever up to 380C, rash
on the face skin, pain in the wrists and
the elbows. On physical examination:
erythematous rash on the cheeks with
"butterfly"look, the wrists and elbow joints
are involved symmetrically, swollen,
sensitive, friction rub over the lungs,
the heart sounds are weak, regular, HR-
88/min, BP- 160/95 mm Hg. CBC shows
anemia, leucopenia, lymphopenia; on urine
analysis: proteinuria, leukocyturia,
casts. What is the main mechanism of disease
development?

A 31 y.o. patient has been suffering from systemic scleroderma for 14 years. She has been treated
in hospital many times. She complains of occasional dull pain in the heart region, palpitation, dyspnea,
headache, eye-lid edemata, weight loss and deformation of extremities joints. What organ affection
worsens the disease prognosis?

A 60 y.o. patient complains of pain in
interphalangeal joints of hand that gets
worse during working. Objectively: distal
and proximal joints of the II-IV fingers
aredefigured, with Heberden’s and
Bouchard’s nodes, painful, stiff. X-ray picture
of joints: joint spaces are constricted,
there are marginal osteophytes,
subchondral sclerosis. What is the most
probable diagnosis?

A man, aged 30, complains of intense
pain, reddening of skin, edema in the
ankle-joint area, fever up to 390_. There
was acute onset of the illness. In the past
there were similar attacks lasting 5-6 days
without residual changes in the joint. The
skin over the joint is hyperemic without
definite borders and without infiltrative
bank on the periphery. What is the most
likely diagnosis?

A 54 y.o. patient has been suffering from osteomyelitis of femoral bone for over 20 years. In the
last month there appeared and gradually progressed edemata of lower extremities. Urine analysis:
proteinuria - 6,6 g/L. Blood analysis: disproteinemia in form of hypoalbuminemia, increase of α2- and γ-
globulins, ESR- 50 mm/h. What is the most probable diagnosis?

3 weeks ago a patient was ill with tonsillitis. Clinical examination reveals edema, arterial
hypertension, hematuria, proteinuria (1,8 g/per day), granular and erythrocital casts. What is the
preliminary diagnosis?

A 29 y.o. woman is critically ill. The illness is presented by high fever, chills, sweating, aching pain in
lumbar area, discomfort during urination and frequent voiding. Pasternatsky’s sign is positive in both
sides. On lab examination: WBC- 20 ∗ 109/L; on urine analysis: protein - 0,6g/L, leukocyturia, bacteriuria.
Your preliminary diagnosis.

A 32 y.o. woman has been suffering for 5 months from pain in lumbar region, low grade fever,
frequent urination. Urine analysis: moderate proteinuria, leukocytes occupy the whole field of sight,
bacteriuria. Blood analysis: leukocytosis, increased ESR. What is the most probable diagnosis?

A 50 y.o. woman who suffers from chronic pyelonephritis was prescribed a combination of
antibiotics for the period of exacerbation - gentamicin (80 mg 3 times a day) and biseptol (960 mg twice
a day). What consequences may be caused by such a combination of antibiotics?

A 28 y.o. woman consulted a
doctor about edematic face, moderate
legsedemata; occasionally her urine
hascolour of "meat slops". When she
was a teenager she often fell ill with
angina. Objectively: skin is pallor,
body temperature is 36, 80_, Ps- 68/min,
rhythmic. AP- 170/110 mm Hg. What urine
changes are the most probable?

A 7 y.o. boy has been treated in a hospital for a month. At the time of admission he had evident
edemata, proteinuria - 7,1 g/L, protein content in the daily urine- 4,2 g. Biochemical blood analysis
reveals permanent hypoproteinemia (43,2 g/L), hypercholesterolemia (9,2 mmol/L). What variant of
glomerulonephritis is the most probable?

An 8 y.o. boy was ill with B hepatitis one year ago. In the last 2 months he has complaints of undue
fatiguability, sleep disorder, appetite loss, nausea, especially in the mornings. Skin isn’t icterious, liver
and spleen are 1 cm below the costal margins, painless. Alanine aminotransferase activity is 2,2
mcmol/L. How can this condition be estimated?

A 16 y.o. teenager complains of weakness, dizziness, sense of heaviness in the left hypochondrium.
Objectively: skin and visible mucous membranes are icteric. Steeple skull. Liver +2 cm, the lower pole of
spleen is at the level of navel. Blood test: RBC- 2, 7 ∗ 1012/L, Hb- 88 g/L, WBC- 5, 6 ∗ 109/L, ESR- 15
mm/h. What is the most probable reason of bilirubin level change?

47 y.o. patient complains of intensive
skin itching, jaundice, bone pain. The skin
ishyperpigmentated. There are multiple
xanthelasmapalpebrae. The liver is +6
cm enlarged, solid with acute edge. The
blood analysis revealed total bilirubin -
160 mkmol/L, direct - 110 mkmol/L, AST-
2,1mmol/L, ALT- 1,8 mmol/L, alkaline
phosphotase - 4,6 mmol/L, cholesterol-
9,2mmol/L, antimitochondrial antibodies
M2 in a high titer. What is the probable
diagnosis?

A 60 y.o. woman complains of unbearable pains in the right hypochondrium. In the medical
hystory: acute pancreatitis. Body temperature is 38, 20. Objectively: sclera icteritiousness. No symptoms
of peritonium irritation arepresent. There are positive Ortner’s and Hubergrits-Skulski’s symptoms.
Urine diastase is 320 g/h. What diagnosis is the most probable?

A52 y.o. patient with previously functional
Class II angina complains of 5 days
of intensified and prolonged retrosternal
pains, decreased exercise tolerance. Angina
is less responsive to Nitroglycerinum.
Which of the following diagnosis is most
likely?

A 58 y.o. patient developed acute
myocardium infarction 4 hours ago, now
he is in the acute care department.
ECG registers short paroxysms of ventricular
tachycardia. The most appropriatemeasure will be to introduct:

A 40 y.o. patient with rheumatic heart
disease complains of anorexia, weakness
and loss of weight, breathlessness and
swelling of feet. The patient had tooth
extraction one month ago. On examination:
t0- 390C, Ps- 100/min.Auscultation: diastolic
murmur in the mitral area. Petechial
lesion around the clavicle; spleen was
palpable.

A42 y.o. woman complains of dyspnea,
edema of the legs, and tachycardia during small physical exertion. Heart borders are
displaced to the left and S1 is accentuated,
there is diastolic murmur on apex. The liver
is enlarged by 5 cm. What is the cause
of heart failure?

A 39 y.o. patient complains of having
dyspnea during physical activity, crus
edemata, palpitation, heart intermissions.
Objectively: HR is 150 bpm, atrial fibrillation.
Heart is both ways enlarged.Heart
sounds are muted. Liver is 6 cm below the
costal margin. Echocardiogram reveals dilatation
of heart chambers (end diastolic
volume of left ventricle is 6,8 cm) is 29%
EF, valve apparatus is unchanged. What is
the most probable diagnosis?

After a long periode of subfebrility
a patient registered increase of dyspnea,
pain in the right hypochondrium, leg
edemata. Objectively: neck veins are
edematic. Ps is 120 bpm, sometimes it disappears
during inspiration. Heart sounds
are very weakened. ECG showed lowvoltage
waves of ventricular complex. A
month ago there was raise of ST V1 − V4
segment. Cardiac silhouette is enlarged,
roundish. What is the most probable diagnosis?

A 35 y.o. patient who suffers
from chronic glomerulonephritis and has
been hemodialysis-dependent for the
last three years developed intermissions
of heart activity, hypotension, increasing
weakness, dyspnea. ECG showed
bradycardia, atrioventricular block type
I, high pointed waves T. The day before
the flagrant violation of diet took place.
What is the most probable cause of these
changes?

A 70 y.o. patient complains of
weakness, dizziness, short periods of
unconsciousness, pain in the cardiac area.
Objectively: HR- 40 bpm, heart sounds
are rhythmic, the S1 is dull, periodically
amplified. AP is 180/90 mm Hg. What is
the most probable cause of hemodynamic
disturbances?

A 74 y.o. patient has been suffering
from hypertension for 20 years. He
complains of frequent headache, dizziness,
he takes enalapril. Objectively:
accent of the SII above aorta, Ps- 84 bpm,
rhythmic, AP- 180/120 mm Hg. What
group of hypotensive medications could
be additionally prescribed under consideration
of the patient’s age?

A 58 y.o. man complaines of severe
inspiratory dyspnea and expectoration
of frothy and blood-tinged sputum.
He has been suffering from essential
hypertension and ischemic heart disease.
On examination: acrocyanosis, "bubbling"
breathing, Ps- 30/min, BP- 230/130mm
Hg, bilateral rales. Choose medicines for
treatment.

A 41 y.o. woman complains of
weakness, fatigue, fever up to 380C, rash
on the face skin, pain in the wrists and
the elbows. On physical examination:
erythematous rash on the cheeks with
"butterfly"look, the wrists and elbow joints
are involved symmetrically, swollen,
sensitive, friction rub over the lungs,
the heart sounds are weak, regular, HR-
88/min, BP- 160/95 mm Hg. Hematology
shows anemia, leucopenia, lymphopenia;
on urinalysis: proteinuria, leukocyturia,
casts. What is the main mechanism of disease
development?

A 32 y.o. patient has been suffering
from systematic scleroderma for 14 years.
She was repeatedly exposed to treatment
in the in-patient department. Complains
of periodical dull cardiac pain, dyspnea,
headache, eyelid edemata, weight loss,
pain and deformation of extremities joints.
What organ’s lesion deteriorates the
prognosis for the disease?

A 21 y.o. man complains of having
morning pains in his back for the last three
months. The pain can be relieved during
the day and after physical exercises. Physical
examination revealed reduced mobility
in the lumbar part of his spine, increase
of muscle tonus in the lumbar area and
sluch during moving. X-ray pattern of spine
revealed bilateral sclerotic changes in
the sacrolumbal part. What test will be
the most necessary for confirming a diagnosis?

A 30 y.o. man complains of intense
pain, reddening of skin, edema in the
ankle-joint area, fever up to 390_. There
was acute onset of the illness. In the past
there were similar attacks lasting 5-6 days
without residual changes in the joint. The
skin over the joint is hyperemic without
definite borders and without infiltrative
bank on the periphery. What is the most
likely diagnosis?

A 54 y.o. woman has been ill with
osteomyelitis of femoral bone for over
20 years. During the last month there
appeared and have been steadily increasing
edemata of lower extremities. Urine
analysis revealed: proteinuria - 6,6 g/l.
Blood analysis: disproteinemia in form
of hypoalbuminemia, raise of α2- and γ-
globulines, ESR- 50 mm/h. What is the
most probable diagnosis?

3 weeks ago a patient was ill with
tonsillitis. Clinical examination reveals
edema, arterial hypertension, hematuria,
proteinuria (1,8 g/per day), granular and
erythrocital casts. What is the preliminary
diagnosis?

A 58 y.o. patient complains
of weakness, leg edemata, dyspnea,
anorexia. He has been suffering from
chronic bronchitis for many years. During
the last 5 years he has been noting intensified
discharge of sputum that is often
purulent. Objectively: RR- 80/min, AP-
120/80 mm Hg. Disseminated edemata,
skin is dry and pale, low turgor. In urine:
intense proteinuria, cylindruria. Specify
the most probable pathological process in
kidneys:

166.Apatient with hepatic cirrhosis drank
some spirits that resulted in headache,
vomiting, aversion to food, insomnia,
jaundice, fetor hepaticus, abdominal
swelling.What complication of hepatic cirrhosis
is meant?

A patient suffers from chronic
recurrent pancreatitis with evident disturbance
of exocrinous function. After
intake of rich spicy food and spirits his stool becomes fatty. Reduced production
of what factor is the most probable cause
of steatorrhea?