Internal Medicine Complex (Krok 2012)

A 56-year-old scientist experiences constricting retrosternal pain several times a day while
walking for 100-150 m. The pain lasts for up to10 minute sand can be relieved by nitroglycerine.
Objectively: the patient is overweight, heart borders exhibit no abnormalities, heart sounds are
rhythmic, Ps-78bpm, AP- 130/80mmHg. ECG contains low amplitude of T wave in V4−5. What
disease might be suspected?

A 45-year-old woman, mother of four children, comes to the emergency room
complaining of a sudden onset of the epigastric and right upper quadrant pain, radiating to the
back, accompanied by vomiting. On examination, tenderness is elicited in the right upper
quadrant, bowel sounds are decreased, and laboratory data shows leukocytosis, normal serum
levels of amylase, lipase, andbilirubin. The most likely diagnosis is:

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. AP- 240/120 mm Hg, HR92/min. Auscultation reveals some fine moisr rales in the
lower parts of the lungs. Liver is not enlarged. ECG shows signs of hypertrophy and left
ventricular overload. What is the most likely diagnosis?

A 67-year-old male complains of dyspnea on exertion, attacks of retrosternal pain,
dizziness. He has no history of rheumatism. Objectively: pale skin, acrocyanosis. There are rales
in the lower parts of lungs. There is systolic thrill in the II intercostal space on the right, coarse
systolic murmur conducted to the vessels of neck. AP- 130/90 mm Hg, heart rate - 90/min,
regular rhythm. The liver extends 5 cm under the edge of costal arch, skin edemata are present.
Specify the assumed valvular defect:

A 55-year-old male had been treated at the surgical department for acute lower extremity
thrombophlebitis. On the 7th day of treatment he suddenly developed pain in the left part of
chest, dyspnea and cough. Body temperature was 36,1oC, respiratory rate - 36/min. The patient
was also found to have diminished breath sounds without wheezing. Ps- 140/min, thready. AP-
70/50 mm Hg. The ECG shows Q1II-S1 syndrome. What is the most likely diagnosis?

A 56-year-old patient was undergoing a surgery for suture repair of perforated ulcer.
During the operation the cardiomonitor registered ventricular fibrillation. The first-priority
measure should be:

A 53-year-old woman complained of cardiac pain and rhythm intermissions. She had
experienced these presentations since childhood. The patient’s father had a history of cardiac
arrhythmias. Objectively: the patient was in grave condition, Ps- 220 bpm, AP- 80/60 mm Hg.
ECG: heart rate - 215/min, widening and deformation of QRS complex accompanied by
atrioventricular dissociation; positive P wave. Some time later heart rate reduced down to
45/min, there was a complete dissociation of P wave and QRST complex. Which of the
following will be the most effective treatment?

A 60-year-old female patient had been admitted to a hospital for acute transmural
infarction. An hour later the patient’s contition got worse. She developed progressing dyspnea,
dry cough. Respiratory rate - 30/min, heart rate - 130/min, AP- 90/60 mm Hg. Heart sounds were
muffled, there was also diastolic shock on the pulmonary artery. The patient presented with
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?

During dynamic investigation of a patient the increase of central venous pressure is
combined with the decrease of arterial pressure. What process is proved by such combination?

A 57-year-old man complains of shortness of breath, swelling on shanks, irregularity in
cardiac work, pain in the left chest half with irradiation to the left scapula. Treatment is
uineffective. On physical exam: heart’s sounds are diminished, soft systolic murmur on the apex.
Ps - 100/min, arrhythmical, BP - 115/75 mm Hg. The liver is +2 cm, painful. Roentgenoscopy:
enlargement of heart shadow to all sides, pulsation is weak. Electrocardiogram (ECG):
leftventricled extrasystolia, decreased voltage. What method of investigation is necessary to do
to determine the diagnosis?

A patient has chronic heart failure of the II stage. He takes furosemide regularly three
times a week. He had developed bronchopneumonia and had been administered combined
pharmacotherapy. On the fifth day of therapy the patient complained of hearing impairment.
What drug coadministered with furosemide might have caused the hearing loss?

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 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 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 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 mm Hg. 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 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 likely diagnosis?

A 35-year-old patient complains of heartburn, sour eructation, burning, compressing
retrosternal pain and pain alongthe esophagusrisingduringforward bending of body. The patient
hasn’t been examined,takesAlmagelon hisown initiative, claims to feel better after its taking.
Make a provisional diagnosis:

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