3 Уровень
16
*!A man, 27 years old, complains of constraint after rest, pain in neck, spine, strengthening in the second half of the night, which decrease at physical exercises. He was treated due to spondylosis with short-term effect. He was observed by ophthalmologist because of iridocyclitis. Objectively: there is a flatness of lumbar lordosis, muscle tension in lumbar region. Symptoms: Tomeier's – 29 cm, Shober's + 1.5 cm, chin-sternum symptom – 9 cm. Blood analysis: ESR 36 mm/h. X-ray: bilateral peri-articular hardening and joint space narrowing in both sacroiliac joints.
Which diagnosis is most probable?
*Rheumatoid arthritis
*Reactive arthritis
*Acute rheumatic fever
*Ankylosing spondylitis
*Systemic lupus erythematosus
17
*!A man, 54 years old, called a physician in his home. Complaints against severe pain in the left foot, body temperature increase to 38ºC and headache. Day before he visited friend's birthday, eating grilled meat and red wine in large volume. Pain commenced suddenly, about 5 am, and was localized mostly in the area of I-II metatarsophalangeal articulations of the left foot. Skin over the big toe joint is acutely hyperemic, hot at touch, swelled, palpation is very painful, movements and walking is virtually impossible. Such condition occurred for the first time in his life.
Which diagnosis is most probable?
*Rheumatoid arthritis
*Gouty arthritis
*Reactive arthritis
*Osteoarthritis
*Rheumatic arthritis
18
*!Female patient, 69 years old, complains of evident pains in both knee joints mainly in walking, morning constraint about 30 min, limited volume of movements. She is ill for more than 20 years. BMI - 36. Objectively, genu valgus, expressed disfiguration of knee joints, in palpation, evident crepitation will be determined. Somatically – no pathology.
Choose the most reasonable methods of patient examination:
*Hands radiography
*Knee joints radiography
*Densitometry
*Knee joints MRI
*Knee joints CT
19
*!Female patient, 26 years old, was delivered to the emergency hospital with complaints against progressing dyspnea, fever up to 39,5ºC for a week. During inquiry was determined that she is bothered by pains in small hand joints for more than a year, in last 4 months she noticed appearance of small ulcers in mouth. In chest radiography, pleural effusion was detected, in CBA – ESR – 42 mm/h with normal CRP level.
Which diagnosis is most probable?
*Systemic lupus erythematosus
*Systemic scleroderma
*Sjögren's sicca syndrome
*Discoid lupus erythematosus
*Behçet's disease
20
*!A man, 75 years old, complains of headaches in temporal area with irradiation to eyes, pains in leg muscles with movements limitation due to pain, decreased appetite, in the last 2 months he lost 10 kg. In the beginning of last December, temporal veins swelling, headaches, absence of appetite, weakness, body temperature raise to 38.5ºC occurred. In the laboratory: L – 10.5 *109/l, Hb 90 g/l, Pl 450*109/l, ESR - 68 mm/h, RF 25.8; C-reactive protein 17; anti cyclic citrulline antibodies - negative, ANA – negative, ANCA – positive.
Damage of which vessels is MOST typical in this disease?
*Small- and middle-caliber arteries
*Capillaries and postcapillaries
*Veins and venules
*Aorta and its branches
*Large-caliber arteries
21
*!An adolescent, 16 years old, notices pain and swelling of knee joints, body temperature elevation to 38,8C, scratching in throat. In examination: swollen both knee joints; on the body – annular erythema. Heart tones are muffled, systolic murmur on the apex, HR 105 bpm. BP 100/70 mmHg.
Which laboratory indices are MOST important to make a diagnosis?
*Antinuclear antibodies
*Antibodies to native DNA
*Rheumatoid factor
*Antibodies to extracellular streptococcus ferments
*С-reactive protein
22
*!A
14
years old
girl,
accompanied
by her mother, has applied to doctor with complaints against general
weakness, discomfort and intermittences in heart area, dyspnea at
physical exertion, body temperature elevation to 38.5C.
Two weeks before she had acute tonsillitis,
took
amoxicillin 250 mg 3 times a day for 7 days with positive effect.
Objectively: pale skin,
left
border of relative
heart dullness shifted by 1.5 cm outside. Heart sounds are muffled,
systolic murmur on 1st
point. On CBA: ESR – 40 mm/h, L –
13*109/l
,
fibrinogen
– 7.2
g/l,
ASL-O
– 1:800 units.
On ECG – decreased waves voltage, sinus rhythm, interrupted by
group atrial
extrasystoles,
HR
– 110
per
minute.
Which therapy is most reasonable?
*prednisolone, azytromycine, diclofenac, bisoprolol
*benzylpenillin, digoxin, diclofenac, nitroglycerin
*amoxicilline, strofantin, prednisolone, hypothiazide
*heparin, digoxin, furasemide, trimetazidine
*prednisolone, trimetazidine, diclofenac, amiodarone
23
*!In a patient, 45 years old, with ascites, hepatomegaly, edemas on legs, on ECG was detected: in leads II, III, aVF – high (> 2.5 mm) Р wave; on chest X-ray examination: enlarged shadow of right atrium and right cava, and no signs of congestion in lungs and pulmonary artery trunk dilatation; on EchoCG – dilatation of right atrium, lower cava at normal size of the right ventricle. Heart sonography – fraction of exile 61%.
Which drug it is reasonable to prescribe in the first line?
*furosemide
*captopril
*strofantin
*indapamide
*bisoprolol
24
*!In a man, 72 years old, with acute myocardial infarction with Q, on day 5 systolic murmur appeared in 1 point, acute asthma enhancement.
Which examination method from listed below is most reasonable in this case?
*Echocardiography
*Electrocardiography
*Coronaangiography
*Chest organs radiography
*Pulmonary arteries contrast study
25
*!A 45 years old woman, has admitted to rheumatologist with complaints against pains and swelling in small joints of both hands and radiocarpal, both knees and ankles joints for three months, also she notes the presence of morning stiffness until the lunch. At the examination, radiocarpal and metacarpophalangeal and proximal interphalangeal and knee and ankle joints are swollen, local hyperthermia will be determined. In the blood, ESR – 37 mm/h, rheumatoid factor – 29 IU (norm to 12 IU).
Choose the most reasonable tactics of female patient management:
*Monotherapy with NSAID
*Prednisolone and NSAID
*Anti-TNF-therapy
*Gold preparations
*Prednisolone and metotrexate
26
*!A 45 years old woman, with rheumatoid arthritis, has applied to district physician because of permanent arthralgia, morning stiffness for more than 3 hours, on the background of application metotrexate 12.5 mg 1 time a week. Physician prescribed her NSAID, folic acid and physio treatment. During of obtained treatment, patient's condition worsened.
What most probably was the cause of worsened condition?
*Prescribed physio treatment
*Prescribed treatment with vitamins
*Absence of glucocorticosteroids
*Prescribed NSAID
*Insufficient metotrexate dose
27
*!A 28 years old man, taxi driver, complains of pains and swelling in left ankle and right knee joints, limited movements in these joints, feeling of sand in eyes, colic pains during urination. He became ill gradually, during 2 weeks. At the examination, disfiguration, reddening of involved joints. No skin eruptions. Heart sounds are clear, rhythm is regular. No peripheral edema was detected. In his case history - treatment by urologist. On X-ray exmaination of ileosacral joints – unilateral sacroileitis. ESR 30 mm/h. ELISA for Chlamydia positive.
Prescription of which basic drug is MOST effective in this patient?
*Cyclophosphane
*D-penicillamide
*Sulfasalazone
*Leflunamide
*Metotrexate
28
*!A 39 years old female patient, housewife, complains of pains in knee and hip joints of mechanical nature, morning stiffness for short time, starting pains in knee joints. BMI – 36. Objectively: genu valgus, at the palpation, evident crepitation will be determined. Somatically – no pathology. On knee joints X-ray films, expressed joint spaces narrowing, marginal bone points of intercondylar heights knobs, osteophytosis. To female patient was already prescribed chondroprotective therapy.
What of below-listed can be most reasonable recommended to female patient?
*Physical stress limitation
*Body mass decrease
*Physical exercises with weights
*Exercise bicycle
*Aquatherapy
29
*!31 years female - during pregnancy last year a spontaneous abortion happened at 22nd week. In examination – complaints to body temperature till 38-39ºC without chilling, the expressed weakness, loss in body weight. In examination: polyarthritis, polylymphadenitis, erythematic rashes. Pain and swelling in both shins. Sonography - shin deep vein thrombosis. ESR - 44 mm/h. At the patient the systemic lupus erythematosus is suspected. АНА- high positive, Wassermann reaction – high positive. What medical tactics is MOST EXPEDIENT in this situation?
*Prednisolone 60 mg/days warfarin of 5 mg/days
*Prednisolone of 20 mg/days Azathioprine of 50 mg/days
*Prednisolone of 30 mg/days in combination with plasma exchange sessions
*pulse therapy methylprednisolone of 1000 mg i.v. plasma exchange
*pulse therapy methylprednisolone of 1000 mg i.v. plasma exchange
30
*!A18 years old man. Diagnosis - Takayasu aortoarteriitis. The angiography revealed the expressed stenosis of the left renal artery. Stenting and treatment is carried out by Prednisolone. In 6 months – restenosis of renal artery that demanded performing of angioplasty. Antibodies to a cardiolipin - are twice higher than norm. What medical tactics is MOST EXPEDIENT in this situation?
*Nifedipine
*Warfarin
*Hydrochlorothiazide
*ACE inhibitor
*Atenolol