Internal Medicine Complex (Krok 2010)

A 45-year-old male patient was admitted to the intensive care unit because of myocardial
infarction. An hour later the ventricular facilitation occurred. Which of the following should be
administered?

A 45-year-old driver was admitted to the hospital with 5 hour substernal pain.
Nitroglycerin is not effective. He is pale, heart sounds are regular but weak. HR 96perminute, BP
of 100/60mmHg.What is the most likely diagnosis?

A 60-year-old female patient was admitted to a hospital for acute transmural infarction.
An hour ago the patient’s condition got worse. She developed progressing dyspnea, dry cough.
Respiratory rate - 30/min, heart rate - 130/min, AP- 90/60 mm Hg. Heart sounds are muffled,
diastolic shock on the pulmonary artery. There are medium moist rales in the lower parts of
lungs on the right and on the left. Body temperature 36,4oC. What drug should be given in the
first place?

A patient has got acute macrofocal myocardial infarction complicated by cardiogenic
shock. The latter is progressing under conditions of weak general peripheric resistance and
decreased cardiac output. What antihypotensive drug should be injected to the patient in the first
place?

A 33-year-old man with a history of rheumatic fever complains of fever up to 38 − 39oC,
abdominal pain, dyspnea, tachycardia. Heart borders are displaced to the left by 2 cm, systolic
and diastolic murmurs above aorta, BP of 160/30mm Hg. Petechial rash occurs after
measurement of blood pressure. Liver is enlarged by 3 cm, spleen is palpable. Urine is brownyellow.
What is the most likely diagnosis?

A 30-year-old patient complains of breathlessness, pain in the right rib arc region, dry
cough and the edema of legs. He is ill for 2months. He had been treated for rheumatic fever
without any effect. On exam: cyanosis, edema of legs, BT of 36,6oC, RR of 28/min, HR of
90/min, BP of110/80 mmHg, crackles above low parts of both lungs, heart borders are displaced
to the left and to the right, weak sounds, systolic murmur above the apex. What is the
preliminary diagnosis?

A 32-year-old patient complains of cardiac irregularities, dizziness, dyspnea at physical
stress. He has never suffered from this before. Objectively: Ps- 74 bpm, rhythmic. AP- 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 interventricular septum was 2 cm. What is the most
likely diagnosis?

A 52-year-old male patient complains about attacks of asphyxia, pain in his right side
during respiration. These manifestations turned up all of a sudden. It is known from his
anamnesis that he had been treated for thrombophlebitis of the right leg for the last month. In the
admission ward the patient suddenly lost consciousness, there was a sudden attack of asphyxia
and pain in his side. Objectively: heart rate - 102/min, respiratory rate - 28/min, AP- 90/70 mm
Hg. Auscultation revealed diastolic shock above the pulmonary artery, gallop rhythm, small
bubbling rales above the lungs under the scapula on the right, pleural friction rub. What
examination method will be the most informative for a diagnosis?

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

A 60-year-old patient complains about asphyxia, palpitation, rapid
fatiguability.Hehas8yearhistoryofessential hypertension. Objectively: the left cardiac border is 2
cm deviated to the left from the medioclavicular line, heart sounds are rhythmic and weak; there
is diastolic shock above aorta. AP- 170/100 mm Hg. Liver - +2 cm; shin pastosity is present.
ECG shows deviation of cardiac axis to the left, left ventricle hypertrophy. Ejection fraction -
63%. What type of cardiac insufficiency is observed?

A 30-year-old patient presented with body temperature rise up to 38,5oC, pain in the
small articulations of hands; face edemata and erythema. In blood: RBCs 2,6 · 1012/l; Hb- 98
г/л; WBCs - 2 · 109/l; ESR - 58 mm/h. In the urine: protein - 3,1 g/l; RBCs - 10-15 in the vision
field. What disease can be suspected in this case?

A 58-year-old patient complains about sensation of numbness, sudden paleness of II-IV
fingers, muscle rigidness, intermittent pulse. The patient presents also with polyarthralgia,
dysphagia, constipations. The patient’s face is masklike, solid edema of hands is present. The
heart is enlarged; auscultation revealed dry rales in lungs. In blood: ESR - 20 mm/h, crude
protein - 85/l, γglobulines - 25%. What is the most likely diagnosis?

A 36-year-old female patient complains of general weakness, edemata of her face and
hands, rapid fatiguability during walking, difficult diglutition, cardiac irregularities. These
symptoms turned up 11 days after a holiday at the seaside. Objectively: face erythema, edema of
shin muscles. Heart sounds are muffled, AP is 100/70 mm Hg. In blood: ASAT activity is 0,95
millimole/h·l, ALAT - 1,3 millimole/h·l, aldolase - 9,2 IU/l, creatine phosphokinase - 2,5
millimole Р/g·l. What method of study would be the most specific?

On the second day after preventive vaccination a 2-year-old boy presented with
abdominal pain without clear localization, body temperature rose up to 38oC. On the third day
the child got red papular haemorrhagic eruption on the extensor surfaces of limbs and around the
joints. Knee joints were edematic and slightly painful. Examination of other organs and systems
revealed no pathological changes. What is the most likely diagnosis?

A 35-year-old patient complains about pain and morning stiffness of hand joints and
temporomandibular joints that lasts over 30 minutes. She has had these symptoms for 2 years.
Objectively: edema of proximal interphalangeal digital joints and limited motions of joints. What
examination should be administered?

A 47-year-old obese man complained of periodic attacks of acute arthritis in the left
tarsophalangeal joint. Labexam revealed increased serum rate of uric acid. What is the
diagnosis?

A 32-year-old male patient has been suffering from pain in the sacrum and coxofemoral
joints, painfulness and stiffness in the lumbar spine for a year. ESR - 56 mm/h. Roentgenography
revealed symptoms of bilateral sacroileitis. The patient is the carrier of HLA B27 antigen. What
is the most likely diagnosis?

A man, aged 25, presents with facial edema, moderate back pains, body temperature of
37,5oC, BP- 180/100 mm Hg, hematuria (up to 100 in v/f), proteinuria (2,0 g/l), hyaline casts -
10 in v/f, specific gravity - 1020. The onset of the disease is probably connected with acute
tonsillitis 2 weeks ago. The most likely diagnosis is:

After supercooling a 38-yearold woman developed muscle pain, body temperature rise
up to 39oC, headache, dysuria, positive Pasternatsky’s symptome. In the urine: leukocyturia,
bacteriuria. In blood: Decreasein Hb rate down to 103 g/l, left shift leukocytosis, ESR
acceleration up to 32 mm/h. Blood urea - 6,0 millimole/l. What is the most likely diagnosis?

A 68-year-old female patient complains about temperature rise up to 38,3oC, haematuria.
ESR- 55mm/h. Antibacterial therapy turned out to be ineffective. What diagnosis might be
suspected?

A 58-year-old female patient complains about periodical headache, dizziness and ear
noise. She has been suffering from diabetes mellitus for 15 years. Objectively: heart sounds are
rhythmic, heart rate is 76/min, there is diastolic shock above aorta, AP is 180/110 mm Hg. In
urine: OD- 1,014. Daily loss of protein with urine is 1,5 g. What drug should be chosen for
treatment of arterial hypertension?

A 30-year-old woman with a long history of chronic pyelonephritis complains about
considerable weakness, sleepiness, decrease in diuresis down to 100 ml per day. AP- 200/120
mmHg.In blood: creatinine - 0,62 millimole/l, hypoproteinemia, albumines - 32 g/l, potassium -
6,8 millimole/l, hypochromic anemia, increased ESR. What is the first step in the patient
treatment tactics?

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

A33-year-old patient has acute blood loss: erythrocytes - 2,2·1012/l, Hb- 55 g/l, blood
group is A(II)Rh+. Accidentally the patient got a transfusion of donor erythrocyte mass of
AB(IV)Rh+ group. An hour later the patient became anxious, got abdominal and lumbar pain.
Ps- 134 bpm, AP- 100/65 mm Hg, body temperature- 38,6oC. After catheterization of urinary
bladder 12 ml/h of dark brown urine were obtained. What complication is it?

A 35-year-old man complains about intense lumbar pain irradiating to the inguinal area,
external genitalia, thigh; frequent urination, chill, nausea, vomiting. Objectively: positive
Pasternatsky’s symptom. 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 67-year-old female patient complains about edemata of face and legs, pain in the
lumbar area that is getting worse at moving; great weakness, sometimes nasal haemorrhages, rise
of body temperature up to 38,4oC. Objectively: painfulness of vertebral column and ribs on
palpation. Laboratorial study revealed daily proteinuria of 4,2 g, ESR- 52 mm/h. What changes
of laboratory indices are to be expected?

In which of the following disorders does the pathophysiology of portal hypertension
involve presinusoidal intrahepatic obstruction?

A 60-year-old woman, mother of 6 children, developed a sudden onset of upper
abdominal pain radiating to the back, accompanied by nausea, vomiting, fever and chills.
Subsequently, she noticed yellow discoloration of her sclera and skin. On physical examination
the patient was found to be febrile with temp. of 38,9oC, along with right upper quadrant
tenderness. The most likely diagnosis is

A 50-year-old patient complains about having pain attacks in the right subcostal area for
about a year. He pain arises mainly after taking fattening food. Over the last week the attacks
occurred daily and became more painful. On the 3rd day of hospitalization the patient presented
with icteritiousness of skin and scleras, light-colored feces and dark urine. In blood: neutrophilic
leukocytosis 13,1 · 109/l, ESR - 28 mm/h. What is the most likelydiagnosis?