3 Уровень

29

*!In a man, 46 years old, at the examination was found BP 160/90 mmHg. No complaints. From life history: his father has arterial hypertension. Height 176 cm, weight – 86 kg. Examination data: at 2-fold measurement BP 160/100 mmHg, HR 84 per 1 minute. Apical thrust will be determined in 5 intercostal space 1.0 cm outside of middle-clavicular line. Cholesterol 5.4 mmol/l, blood glucose 5.8 mmol/l. EchoCG: interventricular septum 1.1 cm, Left ventricular wall 1.2 cm. Carotid arteries US – intima media layer thickness – 1.5 mm. On ECG:

Which diagnosis is MOST probable?

*Grade 2 arterial hypertension, low risk

*Grade 2 arterial hypertension, moderate risk

*Grade 2 arterial hypertension, high risk

*Grade 2 arterial hypertension, very high risk

*Symptomatic arterial hypertension

30

*!A man, 52 years old, applied to doctor with complaints against headaches in the morning. At the examination: BP 180/110 mmHg, HR 82 per 1 minute, correct rhythm. Apical thrust will be determined in 5^th intercostal space 0.5 cm outside from the left middle-clavicular line. Examination of eye-ground vessels: artery/vein ratio – 1:3. On ECG:

Which diagnosis is MOST probable?

*Grade 2 arterial hypertension, low risk

*Grade 2 arterial hypertension, moderate risk

*Grade 2 arterial hypertension, high risk

*Grade 2 arterial hypertension, very high risk

*Symptomatic arterial hypertension

31

*!A woman, 63 years old, suffers from arterial hypertension, occasionally takes captopril. After stress, one hour earlier, acute headache appeared, aching pains in heart area, vomiting, dizziness, weakness in right limbs, BP 220/120 mmHg. On ECG:

Which is MOST probable cause of patient's condition worsening?

*progressive angina pectoris

*hypertensive encephalopathy

*acute myocardial infarction

*non-complicated hypertensic crisis

*complicated hypertensic crisis

32

*!Man М., 67 years old, applied with complaints about feeling of shortness of breath, dyspnea at rest, cough with white foam-like sputum. From anamnesis: he notes arterial pressure increase during 15 years, regularly took bisoprolol and indapamide. In the last day he interrupted his medication. Worsened condition the last 2 hours. General condition is poor, he is gasping for breath, facial hyperemia. In lungs: at auscultation – crepitation in both lungs. BR 28 per 1 min. Heart sounds are subdued, correct rhythm, HR 100 per 1 min, BP 210/120 mmHg.

Which complication MOST probably developed in patient?

*dissecting aneurysm

*status asthmaticus

*pulmonary thromboembolism

*pulmonary edema

*myocardial infarction

33

*!Patient K., 58 years old, has admitted to cardiologic department with complaints against severe headaches, vomiting, "net" appearance before his eyes. In last months he has continuous stress at his work. He was not examined. Objectively: Coverlets of increased moisture, face and neck hyperemia is noted. In lungs, vesicular respiration, no rales. BR 19 per min, BP – 195/100 mmHg. Heart borders: left – 1.5 cm outside from the left middle-clavicular line. Heart sounds are sonorous, rhythmic, 2 tone accent on the aorta. HR – 92 bpm.

Which complication has developed MOST probably in this case?

*hypertensive encephalopathy

*hemorrhagic stroke

*hypertensic crisis

*ishemic stroke

*myocardial infarction

34

*!A woman С., 57 years old, applied with complaints against headaches, flittering "flies before her eyes". She has excessive weight from young age (BMI – 40.0). Her parents suffered from arterial hypertension. Her father died in the age of 50 of myocardial infarction, and her mother – in the age of 65 of stroke. From 30 years of age on – periodical BP increases to 150 – 160/90 mmHg. At the examination: cholesterol 7.8 mmol/l, blood sugar 6.0 mmol/l. On ECG: in RV5 > RV4, SV1 deep, EA horizontal.

What treatment tactic?

*monotherapy by bisoprolol

*monotherapy by lisinopril

*monotherapy by valsartan

*perdinopril plus carvedilol

*amlodipine plus captopril

35

*!Young woman, 30 years old, is bothered by headaches at the end of working day, fever, rash, sensor neuropathy. Objectively: Height – 175 cm, weight – 75 kg. Borders of heart: left – on the left MCL, in 5 intercostal space. Heart sounds are rhythmic. 2 tone accent on aorta. BP – 190/120 mmHg on right hand, 170/105 – on left. Systolic murmur over the area of abdominal section of aorta. After using of 50 mg captopril, BP decrease to 90/60 mmHg was noted, urine – 300 ml per day and serum creatinine change – 220 µmol/l, .

Which of below-listed diagnoses is MOST probable?

*Vasorenal hypertension

*Itsenko-Coushing's syndrome

*Conn's syndrome

*Chronic glomerulonephritis

*Itsenko-Coushing's disease

36

*!A woman, 39 years old, has admitted to the clinic for precise definition of a cause of arterial hypertension. She is ill for about 1 year, headaches, weakness, increased body weight have occurred. At the examination: weight – 110 kg, height – 168 cm. BP 170/100 mmHg, heart sounds are subdued, rhythm is correct. Serum glucose – 6.5 mmol/l.

Which is the MOST probable diagnosis?

*Conn's syndrome

*Itsenko-Coushing's disease

*Diabetes mellitus

*Graves' disease

*Thyrotoxicosis

37

*!A man, 48 years old. After stress, 4 hours before, headache increased acutely, dizziness appeared. At the examination: hyperemic face, narrowing of vision fields. In lungs, vesicular perspiration. AP 160/100 mmHg, heart sounds are rhythmic. HR – 90 per minute. Sound 2 accent on aorta.

Application of which drug is MOST reasonable?

*Propranalol

*Nitroglycerin

*Nifedipine

*Furosemide

*Valsartan

38

*!A man, 63 years old, suffers from arterial hypertension with BP – 150-160/90-85 mmHg. He had myocardial infarction 7 months ago. Objectively: left border is 1 cm to the left from left middle-clavicular line. Vesicular respiration in lungs, no rales. RR – 16 per minute. Heart tones are muffled, correct rhythm. HR – 84 per minute. BP – 140/80. Liver at the edge of costal arch. Serum cholesterol – 5.5 mmol/l, serum creatinine – 75 µm/l. Blood glucose – 5.4 mmol/l. ECG:

Application of which preparation is MOST reasonable?

*amlodipine monotherapy

*bisoprolol plus lisinopril

*indapamide plus nifedipine

*hydrochlorothiazide plus valsartan

*diltiazem plus spironolacton

39

*!A man, 53 years old, suffers from arterial hypertension and type 2 diabetes mellitus. He receives metformin and insulinotherapy. Objectively: Vesicular respiration in lungs, no rales. RR – 17 per min. Left border on the left middle-clavicular line. Heart tones are clear, rhythm is correct. HR – 88 per min. BP – 140/90 mmHg. Liver at the edge of costal arch. Serum cholesterol – 5.5 mmol/l, serum creatinine – 65 µmol/l. Blood sugar – 5.8 mmol/l.

Application of which hypotensive is MOST reasonable?

*captopril

*bisoprolol ,

*metoprolol

*hydrochlorothiazide

*losartan

40

*!In a man, 20 years old, 2 weeks after suffered tonsillitis, in the morning suddenly paleness occurred, puffy face, massive edemas of legs, waist, ascites. Urine amount decreased to 150.0 ml. BP 190/100 mmHg. CUA: specific weight – 1010, protein – 4,5 g/l, erythrocytes – 50 to 60 in f/v, cylinders: hyaline, granular. CBA: hemoglobin 110 g/l, erythrocytes 3.6 × 10/l, leukocytes 8.3 × 10/l, ESR – 40 mm/h. BBA: creatinine 600 µmol/l, urea 20 mmol/l, potassium 6.9 mmol/l, sodium 150 mmol/l. On pleural cavity US: hydrothorax, on the left – 200.0 ml, on the right – 350.0 ml.

Application of which combination of preparations is MOST optimal?

*bisoprolol, hypothiazide, prednisolone

*captopril, spironolactone, prednisolone

*nifedipine, furosemide, diclofenak

*lisinopril, indapamide, indometacine

*losartan, furosemide, prednisolone

41

*!A woman, 42 years old, notes frequent crises with maximal BP rise to 200/110 mmHg, muscle weakness, nocturnal pollakiuria. In urine: specific weight 1009. BBA: total cholesterol – 6.5 mmol/l, triglycerides – 1.1 mmol/l, LDL – 4 mmol/l, HDL – 1.8 mmol/l. On ECG:

Which is the MOST probable diagnosis?

*Conn's syndrome

*Itsenko-Coushing's disease

*Diabetes mellitus

*Graves' disease

*Thyrotoxicosis

42

*!A woman, 30 years old, applied to physician with complaints against general weakness, increased appetite, weight loss by 10 kg in 2 months, palpitation, trembling of whole body, irritability. Together with that, BP increases to 160/90 mmHg, refractory to hypotensive therapy. Mood lability is noted, she is fidgety, fine tremor of extended fingers. At palpation, thyroid gland is enlarged to stage 2, soft, painless. Body temperature – 37.2ºC. HR 110 per minute.

Application of which hypotensive is MOST reasonable?

*captopril

*bisoprolol

*amlodipine

*indapamide

*losartan

43

*!A man, 78 years old, suffers from stable angina pectoris for a long time. In the last 3 months he notes palpitation and occurrence of intermittances in heart function, dyspnea at any physical activity. Objectively: hypostasis at ankles. At heart auscultation: rhythm is incorrect, heartbeats rate 110 per min, pulse – 96 per min, irregular. Liver is 2 cm below the costal margin edge. On ECG:

Which diagnosis from listed ones is MOST probable?

*IHD, acute myocardial infarction, ventricular premature beats, CHF I

*IHD, stable angina, atrial fibrillation, CHF II B

*IHD, stable angina, atrial fibrillation, CHF II A

*IHD, progressing angina, atrial premature beats, CHF I

*IHD, progressing angina, AV paroxysmal tachycardia. CHF I

44

*!A man, 59 years old, complains of dyspnoe, more often in horizontal position, under physical stress, dry cough, more often in the night. Anamnesis has burden of IHD. He smokes for 25 years. Heart sounds are subdued, II tone accent on the pulmonary artery, rhythm is correct. BP 140/90 mmHg. Over lungs in lower posterior parts are fine crackles. BR – 22 per min. Liver is 3 cm below the costal margin edge. Hypostasis at ankles. Troponin 0.01 ng/ml.

On ECG:

Which diagnosis from listed ones is MOST probable?

*IHD, progressing angina pectoris, CHF II A

*IHD, postinfarction cardiosclerosis, CHF II A

*IHD, arterial hypertension, CHF II B

*IHD, acute myocardial infarction, acute heart failure

*IHD, acute myocarditis, CHF I

45

*!Man М., 35 years old, after flu, one week later aching pains in cardiac area appeared, palpitation, dyspnea in horizontal position. Objectively: cyanosis of lips. Vesicular respiration in lungs. Left border of heart is shifted 0.5 cm outside from the middle-clavicular line. Sounds are subdued, on the apex and in Botkin's point, systolic murmur is heard. Feet edemas. HR – 102 per 1 min, BP – 105/80 mmHg. In CBA: leukocytes – 5 × 10⁹/l, ESR – 35 mm/h. On ECG:

For which pathology are MOST typical these clinical manifestations?

*cardiomyopathy, CHF II A

*chronic myocarditis, relapse, CHF II A

*cardiomyopathy, CHF I

*acute myocardial infarction, acute heart failure

*acute myocarditis, CHF II A

46

*!Woman 23 years old arrived with complaints to the stabbing pains in heart, dyspnea. Had an adenoviral infection two weeks ago. In blood: leukocytes – 15,2 thousand, an ESR – 48 mm/hour, C-reactive protein, AST – 112 IE/l. On an ECG

.

The main preparation in treatment plan:

*prednisolone

*acetylsalicylic acid

*amoxicilline

*azitromycine

*nimesulide

47

*!Woman 56 years old suffering from Chronic Obstructive Lung Disease complains to the interruptions in heart area, dyspnea, the expressed edemas on extremities. At examination the signs of a heart failure corresponding to chronic heart failure IIB 3 FC are revealed. On an ECG

.

What appointment from the listed preparations is MOST advisable in this situation?

*Verapamilum

*Labetalol

*Amlodipine

*Amiodaron

*Metoprolol

48

*!Man 66 years old is delivered by an ambulance crew in a serious condition with complaints to the common weakness. Objectively: skin paled, wet, gray cyanosis, cold snap of extremities. Cardiac tones are dulled, a cantering rhythm, HR-115 per min. BP of 80/40 mm hg, the expressed oligurea. On an ECG:

What of the listed preparations needs first of all?

*adrenaline

*alteplasa

*dopaminum

*heparin

*atropin

49

*!Man of 48 years old arrived with complaints to fever, dyspnea, headaches. At examination: the linear hemorrhages under nails, the painful foci of consolidation in skin of finger-tips by red violet color; traces of numerous injections in elbow bends; petechias on the transitional fold of a conjunctiva, fine crackles in lungs. Hemoculture - green streptococcus.

What examination must be provided to confirm the diagnosis?

*Electrocardiography

*CT of heart

*MRT of heart

*Echocardiography

*Coronarography

50

*!Man 26 years old with congenital heart disease complains of the fever, a chilling, pouring sweat which appeared in a month after invasive intervention. At examination petechias on the transitional fold of a conjunctiva, the linear hemorrhages under nails are revealed. In blood: Er. 3.8 × 10¹²/l; Hb – 107 g/l, CI – 1.0, platelets 110 × 10⁹/l, leukocytes – 14.5 thousand, b/neutrophils – 15%, s/neutrophils – 45%, ESR – 36 mm/h.

Basic preparation for treatment of this disease are:

*gentamycine

*levofloxacine

*amoxicilline

*prednisolone

*claritromycine

51

*!Woman of 48 years old is on treatment in a hospital with the diagnosis of a viral myocarditis. Suddenly there was a heart consciousness, weakness, cold sweat. At survey: cardiac sounds of the weakened sonority, a rhythm the exact. The HR 160 in a min. BP of 70/40 mm of Hg. On an ECG:

What is the exact tactics of emergency aid:

*Amiodaronum

*Lidocainum

* Verapamilum

* Electric cardiostimulation

* Electric cardioversion

52

*!At the woman of 44 years at an echocardiographic research enlarged left auricle, the expressed hypertrophy of a left ventricle and an interventricular septum are revealed. The valves are intact without any changes. According to doppler echocardiography: pathological currents are not revealed.

The MOST probable diagnosis?

*Nonrheumatic myocarditis

*Acute rheumatic fever, carditis

*Restrictive cardiomyopathy

*Dilatated cardiomyopathy

*Hypertrophic cardiomyopathy

53

*!Man 75 years old complains of the pressing pains behind a breast which developed about an hour ago. On an ECG – STV1-V6 elevation. Troponin – normal.

What examination should be done to the patient FIRST OF ALL?

*MRT of heart

*CT of heart

*echocardiography

*the coronaroangiography

*cholter monitoring of an ECG

54

*!A man, 59 years old, complains of dyspnoe, more often in horizontal position, under physical stress, dry cough, more often in the night. Anamnesis has burden of IHD. He smokes for 25 years. Heart sounds are subdued, II tone accent on the pulmonary artery, rhythm is correct. BP 140/90 mmHg. Over lungs in lower posterior parts are fine crackles. BR – 22 per min. Liver is 3 cm below the costal margin edge. Hypostasis at ankles. Troponin 0.01 ng/ml.

On ECG:

What treatment tactic?

* Nitrates and metabolics

* Inhibitors of ACE and diuretics

* Antagonists of calcium channels and diuretics

* Cardiac glycosides and antagonists of calcium channels

* Nitrates and nonsteroid antiinflammatory drugs

55

*!Woman of 54 years old after the postponed pneumonia was disturbed by the "barking" cough, became complicated swallowing, dyspnea amplified. At examination: increase in borders of heart, cardiac tones muffled, the HR 80 in mines, a BP of 130/65 mm of Hg. In several hours the severe weakness, tachycardia, cold sweat, a cyanosis developed, a BP of 60/40 mm Hg. On an ECG:

What is the medical tactics?

*Application of glucocorticoids

*Use of anticoagulants

*Application of dopamine

*Application of a defibrillator

* Pericardium punction

56

*!Man, 62 years old. From life history: he smokes 1.5 packages of sigarettes daily, drinks 2 cans of beer once a week, his father has arterial hypertension. Height 176 cm, weight – 96 kg. At the examination: pale skin, pulsation of jugular vessels. Cardiac borders are enlarged to the left, cardiac impulse is resistant, shifted to the left and down. At auscultation: soft protodiastolic murmur in the II intercostal space at right, HR 82 per min, BP 185/60 mmHg. Cholesterol 8.8 mmol/l, blood glucose 5.9 mmol/l.

Which is most probable cause of arterial hypertension?

*Essential arterial hypertension

*Drug-induced arterial hypertension

*Primary renal sodium retention

*Aortic regurgitation of atherosclerotic genesis

* "White gown" hypertension

57

*! The man of 45 years is disturbed by the pressing pains in a chest arising when walking on distance of 250 - 300 m, which are stopped by using of Isoketum – spray, sometimes spontaneously after rest. What of the listed diagnoses is MOST PROBABLE?

*Angina pectoralis of FC I

*Angina pectoralis of FC II

*Angina pectoralis of FC III

*Angina pectoralis of FC IV

*Angina pectoralis instable

58

*! Man of 52 years old complains of chest pain at night and early morning. On an ECG a typical horizontal depression of an interval of ST after ergometrin test. At a coronarography - lack of signs of damage of epicardial coronary arteries. What most probable diagnosis?

*Dysmetabolic cardiomyopathy

*Stable angina pectoralis

*Prinzmetal angina

*Unstable angina

*Subendocardial myocardial infarction

59

*!The man of 78 years has arterial hypertension and an ischemic heart disease. In the anamnesis – the postponed heart attacks. Receives treatment. Recently the state worsened.

What the listed criteria demonstrates lack of effectiveness of the appointed treatment?

*Decrease of intensity and frequency of stenocardia attacks

*Decrease in a systolic BP by 10-15% of a datum level

*Decrease in tolerance to an exercise stress

*Increase in the HR on 7-10 beats in a minute

*Disappearance of episodes of an ischemia of a myocardium

60

During a coronarography the patient of 62 years suddenly fainted. On an ECG:

As a result of electric cardioversion the sinoatrial rate was restored, the patient recovered. What violation of a rhythm is revealed?

*Ventricular flutter

*Tachycardia like "pirouette"

*ventricular fibrillation

*ventricular tachycardia

*ventricular premature contraction