3 Уровень

22

!* A man, 42 years old, in routine examination the biochemisty test carried out: ALT – 130 IU/ml, AST 84 IU/ml, bilirubin – 14 µmol/l. In anamnesis – 6 months ago he received hematransfusion after accident.

Which examination should be performed on the next stage of diagnostics?

*АМА level

*Albumin and GGT level

*Serum markers of В, С, D hepatitis

*PCR for HCV RNA

*PCR for HBC DNA

23

!*A man, 28 year old, at CBA examination: Er – 4.0 × 10¹²/l, hemoglobin – 160 g/l, Tr – 280 × 10⁹/l, L – 6.6 × 10⁹/l, ESR – 4 mm/h. Biochemistry: bilirubin – 44.6 µmol/l, indirect – 38 µmol/l, ALT – 24 IU/ml, AST 14 IU/ml. Screening: HBsAg – positive, a-HCV – neg.

Which examination should be performed on the next stage of diagnostics?

* PCR HCV RNA

* antibodies for HDV

* AMA

* ANA

* ANCA

24

!* A man, 22 years old, cocaine drug-consumer, complains of aching pain in the right hypochondrium, weakness, decreased appetite, which bother her for 2 weeks. At examination: jaundice on skin and sclera, liver enlarged +0.5 cm, dark urine, feces discolorated. ALT – 230 IU/l, AST 320 IU/l.

Your preliminary diagnosis?

*liver cirrhosis

*chronic cholecystitis

*chronic toxic hepatitis

*chronic autoimmune hepatitis

*acute viral hepatitis A

25

!*A 25-yeatr old woman. 2 years ago – cesarean section carried out. During a month she notes decreased appetite, adding heaviness in the right hypochondrium, weakness, pains in joints. At blood count : Hb 102 g/l, erythrocytes 3.2 × 10¹²/l, CP 0.9, leukocytes 3.4 × 10⁹/l, ESR 17 mm/h. Blood biochemistry: ALT – 2.5 mmol/l, AST – 1.2 mmol/l. Screening: HBsAg – negative, a-HCV – neg. HBeAg – positive.

Which diagnosis is MOST probable in this patient?

*chronic pancreatitis

*chronic autoimmune hepatitis

*chronic toxic hepatitis

*chronic viral hepatitis B

*chronic viral hepatitis D

26

!*A man, 47 years old, gynecologist. In blood: bilirubin – 34.6 µmol/l, indirect – 28 µmol/l, ALT –2.89 mmol/l, AST – 1.34 mmol/l. Screening: HBsAg – neg., a-HCV – pos.; Marker diagnostics: a-HBs – positive, a-HBcore IgM – neg., a-HBVcore IgG – neg., HBe Ag – neg., a-HBe – neg., anti-HCV IgM – negative, anti-HCV IgG – pos., anti-HDV – neg.

What examination must be done on next step?

*PCR on HBV DNA

*PCR on HCV RNA

*AMA

*ANA

*anti HIV

27

!*A woman, 35 years old, nurse. She felt weakness and indisposition after use of disinfectants, containing chlorine, performing a spring-clean in the procedure unit. Objectively: Kurlov's liver dimensions – 11-9-7 cm. Biochemistry: glucose – 5.2 mmol/l, cholesterol – 4.0 mmol/l, ALT – 268 IU/ml, AST – 195 IU/ml, total bilirubin – 42 µmol/l, direct – 38 µmol/l, GGT – 52 IU/l, AP – 156 FIU/l. Screening: HBsAg – neg., anti-HCV IgG – negative. ANA – positive, RF – positive, AMA – neg. HBcor IgM – positive, antibodies HBe - positive

Which diagnosis is MOST probable?

*drug-induced hepatitis

*autoimmune hepatitis

*acute toxic hepatitis

*chronic viral hepatitis В

*chronic viral hepatitis С

28

!* Patient P., 32 years old, suffered form of acute viral hepatitis В. One year later, weakness, nausea, loosened stool, pains in joints have appeared. At the examination: Liver comes out 0.5 cm from the edge of costal margin, it has thick elastic consistency, smooth, edge is rounded. Spleen is not palpable. HBsAg – positive.

Which diagnosis is MOST probable?

*chronic pancreatitis

*liver cirrhosis

*Krohn’ disease

*chronic viral hepatitis В

*chronic viral hepatitis С

29

!*A man, 35 years old, in anamnesis – chronic viral hepatitis C, genotype 1b. There are contraindications to anti-viral therapy with interferons (epilepsy). In the blood test: Er – 4.0 × 10¹²/l, hemoglobin – 160 g/l, Tr – 280 × 10⁹ l, L – 6.6 × 10⁹/l, ESR – 4 mm/h. Biochemistry: bilirubin – 78.6 µmol/l, direct – 52 µmol/l, ALT – 1.89 mmol/l, AST – 1.14 mmol/l, alkaline phosphatase – 200 units, cholesterol – 5.0 µmol/l.

Which of listed preparations can be MOST reasonably prescribed?

*Lamivudine and zidovudin

*Sylimarine and fumarine

*ademethionine and hepadif

*Tenofavir and entacovir

*Sofosbuvir and ribavirine

30

!*Man А., 45 years old, complains of weakness, nausea, decreased appetite, aching pains in the right hypochondrium. He is ill for 2 years. He notes worsened general state after consumption of alcohol and fatty food. Sclera, mucous membranes, coverlets are icteric, discolorated feces, urine has "beer color". Pulse – 72 per min. Abdomen is soft, tender at palpation in the right hypochondrium, liver comes out from the costal margin edge by 4 cm, its edge is rounded. Spleen is not enlarged.

Which of listed preparations can be MOST reasonably prescribed?

*Essencial phospholypids

*Sylimarine and fumarine

*ademethionine and UDCA

*Tenofavir and entacovir

*Sofosbuvir and ribavirine

31

!* Man 46 years old. During the last year complaints on weakness, fatigue, appetite decreased, nasal bleeding, constipation. Liver comes out by 1.0 cm from the costal edge, has thick consistency. Spleen is enlarged by 1.0 cm. In CBA, platelets 120 × 10⁹/l, ESR 20 mm/h. In biochemical blood analysis, ALT 30 U/l, AST 21 U/l, total bilirubin 66 µmol/l, alkaline phosphatase – 240 IU/l, albumin 28 g/l, liver elastography – 24 kPa (stage F4).

Which diagnosis is MOST probable?

*compensative liver cirrhosis

*subcompensative liver cirrhosis

*decompensative liver cirrhosis

*primary biliary cirrhosis

*secondary biliary cirrhosis

32

!* In a decompensated liver cirrhosis patient, at objective examination, spleen enlargement by 1.0 cm was detected, in blood test – leukocytes 4.5 × 10⁹/l, erythrocytes 4.2 × 10¹²/l, platelets 56 × 10⁹/l.

Which is MOST probable cause of modifications, found in hemogram?

*low production of thrombopoietin

*low production of erythropoietin

*hypersplenism

*DIC syndrome

*antiphospholypide syndrome

33

!Male patient, 54 years old, is bothered by weakness, skin itch, which increase in the evening time. Objectively: condition of moderate severity, swarthy coverlets, on upper lids – xanthelasmas. In biochemical blood analysis – ALT 55.5 U/l, AST – 48.4 U/l, APh 1035 U/l, total bilirubin 18 µmol/l, albumin 28 g/l. AMA – positive.

Which is the MOST probable diagnosis?

*chronic cholecystitis

*chronic viral hepatitis С

*chronic viral hepatitis В

*primary biliary cirrhosis

*Wilson's syndrome

34

!*A man, 50 years old, during last 5 months is bothered by weakness, heaviness in the right hypochondrium, gingival hemorrhage. At the examination, HBsAg and anti—HDV were detected. Objectively: moderately severe condition, coverlets are pale with icteric faint, liver is enlarged by 2.0 cm, edge is dull, with thick consistency, lower pole of the spleen comes out by 1.0 cm from the costal margin. On US, v.portae 1.5 cm. Elastography – 18 kPa.

Name the MOST probable diagnosis?

*liver cirrhosis in the outcome of chronic viral hepatitis B with delta virus

*chronic viral hepatitis B at stage of cirrhosis

*chronic viral hepatitis В with delta antigen

*chronic viral hepatitis В with acute delta superinfection

*acute co-infection HBV+HDV

35

!*A woman, 37 years old, complains of weakness, heaviness in the right hypochondrium. Objectively: condition of average severity, moderate jaundice, liver +0.5-1.0 cm, spleen +1.0-1.5 cm. In the biochemical blood analysis – ALT 570 U/l, AST – 200 U/l, APh – 240 U/l, total bilirubin – 44.0 µmol/l, albumin 28 g/l, ELISA – HbsAg, anti-HDV. On EPGDS – grade 1 esophageal varicose veins dilatation.

Name the MOST probable diagnosis?

*liver cirrhosis in the outcome of chronic viral hepatitis B with delta virus

*chronic viral hepatitis B at stage of cirrhosis

*chronic viral hepatitis В with delta antigen

*chronic viral hepatitis В with acute delta superinfection

*acute co-infection HBV+HDV

36

!*In a man, 60 years old, at the performance of indirect elastography, liver elasticity of 45 kPa was determined. In the examination, bilirubin level 87 mmol/l, albumin 24 g/l, prothrombin index 67%, ascites, hepatic encephalopathy signs.

Indicate the MOST probable diagnosis?

*liver cirrhosis class B by Child- Turcotte-Pugh

*liver cirrhosis class C by Child- Turcotte-Pugh

*liver cirrhosis class A by Child- Turcotte-Pugh

*primary biliary cirrhosis

*secondary biliary cirrhosis

37

!* A man, 65 years old, has type II diabetes mellitus, arterial hypertension, has BMI 34.0, doesn't consume any alcoholic drinks. At the examination, his condition is good, liver +0.5-1.0 cm. In the biochemical blood analysis – ALT 120 U/l, AST 80 U/l, APh 240 U/l, total bilirubin 24.0 µmol/l, albumin 36 g/l. Cholesterol – 7,8 mmol/l. ELISA: HBsAg, aHCV negative.

Indicate the MOST probable diagnosis?

*autoimmune hepatitis

*cryptogenic cirrhosis

*non-alcoholic fatty liver disease, steatohepatitis

*primary biliary cirrhosis

*chronic hepatitis of undetermined etiology

38

!*Hemostasis system examination in a liver cirrhosis patient has found: platelets 50 × 10⁹/l, APTT – 110 s, prothrombin time – 42 s; fibrinogen 0.8 g/l, clotting time – 20 min, in a large amount the degradation products of fibrin.

Which syndrome MOST probably has developed in the patient?

*Antiphospholypide syndrome

*Immune thrombocytopenia

*DIC-syndrome, hypocoagulation stage

*DIC-syndrome, hypercoagulation stage

*DIC-syndrome, transition stage

39

!* The patient of 16 years with cirrhosis in the outcome of viral hepatitis B+C, a liver is increased by 5 cm, a spleen – by 6 cm, an ascites, a gullet varicosity 2 degrees, ALT – 22 ME/ml, a bilirubin – 134 µmol/l, an albumin – 27 g/l, PTI – 55%. 3 times had bleeding from varicose veins of a gullet. What medical tactics will most possibly increase survival of the patient to 80% in the next 5 years?

*Transplantation of a liver

* Imposing of the porto-caval shunt

* Purpose of analogs of nucleosides for life

* The regular carrying out courses of hepatoprotectors

* Performing therapy pegylated interferons

40

!*

What will most possibly be revealed at the patient's FEGDS (the man of 35 years) with such picture of a computer tomography of a liver: the liver is deformed, the right lobe - 15 cm, the left lobe – 5 cm, contours irregular, tuberous. A portal vein – 2,0 cm, a splenic vein - 1,3 cm. The area of a spleen - 57 cm2?

*Ulcer of an ampoule of a duodemum

*Tesselated hyperemia of stomach mucous

*Varicosity of a gullet and stomach

*The bleeding erosion of pylorum

*A hyperemia mucous a stomach

41

!*A man, 53 years old, has in anamnesis the liver cirrhosis as a result of viral hepatitis C. In the last week, weakness started to grow, sleep disturbance in form of sleepiness at day and insomnia at night, periods of euphoria are replaced by periods of apathy. At the admission, condition is poor, mental confusion, psychomotor agitation. Liver at the costal edge, urine is dark, breathing – 24 per min, pulse – 100 bpm, BP – 90/60 mmHg.

Which complication of liver cirrhosis MOST PROBABLY developed in this patient?

*Hepatic encephalopathy

*Infectious-toxic shock

*Hypovolemic shock

*Stroke

*Hepato-renal syndrome

42

!*In a woman with liver cirrhosis, abdomen is significantly enlarged, hypostasis. At the examination, condition is poor, moderate jaundice. Clear consciousness. Heart sounds are muffled. BP 100/70 mmHg, pulse 78 per 1 min. Abdomen is tense, no symptoms of peritoneum irritation. Liver comes out by 3.0 cm from the costal arch, spleen is enlarged by 2.0 cm. In biochemical analyses, ALT 55.5 U/l, AST 48.4 U/l, total bilirubin 38 µmol/l, albumin 28 g/l, creatinine 76 µmol/l, urea 6.7 mmol/l.

What preparation most usable in this patient?

*spironolacton

*indapamid

*furosemid

*hypothiaside

*toresemid

43

!* The patient of 47 years fast lost weight for the last month by 10 kg, pale, a palmary erythema, vascular asterisks, expanded venous network on a stomach, a hepatomegalia, a subfebrile fever. At liver CT the following picture (photo).

What the MOST probable diagnosis?

*Cirrhosis, portal hypertension

*Cholecellular carcinoma

*Hepatocellular carcinoma

*Metastasis in a liver parenchyma

*Liver echinococcosis

44

!* The man of 32 years suffers from diarrhea with mucilage and blood, defecations 3-4 times a day, abdominal pains, disappeared after a defecation, fever to 37ºC, knee joint and spin pains. An ESR – 15 mm/h. A hemoglobin – 112 g/l. At a colonoscopy: mucous is hyperemic, edematous, places tuberous, friable, vulnerable, with a great many pointwise and drain needle strictures throughout sigmoid gut.

What medicine is medicine of the first row in treatment of this pathology at such severity of a current?

*Budesonid

*Prednisolon

*Sulfosalazinum

*Infliximab

*Hydrocortisone

45

!*Male 41 years, BI=34, Complaints: eructation sour, feeling of "lump" behind a breast,

sometimes heartburn behind a sternum with an irradiation in a back. These symptoms appears after a late meal and in a prone position.

What investigation need to verify diagnosis?

*Manometry in gullet

*ECG with functional test

*Esophagogastroduodenoscopy

*CT of chest and abdomen

*X-ray of gullet with reongen –contrast

46

!*Patient with the long-lived anamnesis of pains and burnings behind a breast, an eructation sour, amplifying before going to bed in a prone position and after night having a snack

The signs of chronic inflammation, the histologic research revealed a metaplasia of a multilayer plan epithelium in cylindrical were found at EFGDS.

How often should the patient carry out EFGDS in the future?

*1 time in 3 years

*1 time in 2 years

*Every year

*Each 3-6 months

*Each 1-2 months

47

!*A man, 70 years old, visited a doctor for consultation with complaints against epigastric pains, appearing right after the meal, general weakness, weight loss. In anamnesis, stomach ulcer for 5 years. Objectively: pale coverlets, malnutrition. CEA – increased. On EGDS, 3 months earlier: stomach ulcer with the size 4 × 4 (cm) on the greater curvature.

Your further tactics:

*Provide investigation of another oncomarkers

*to repeat EGDS with target biopsy

*to apply eradication therapy

*to send for surgical treatment

*to prescribe X-ray photography with barium

48

!*The man of 49 years shows complaints to the severe pains in epigastriums and left hypochondrium, amplifying in a prone position. Pain developed in 1 hour after a meal. The day before alcohol abusing. Also heartburn, an eructation, a meteorism, an unstable stool disturb. Examination: the subnutrition of the patient, a tremor of hands, a hepatomegalia, morbidity in the Shoffara’ zone. What diet is necessary in the first 1-3 days of exacerbation of this pathology?

*Fractional delivery in the small portions

*To exclude dairy products

*Restriction of proteins

*Restriction of fats

*The complete hunger

49

!*A patient, 32 years old, is complaining of epigastric pains, heartburn, abdominal distension, nausea. On EGDS: corporeal gastric erosions, hyperemia, edema of duodenal mucosa. Respiratory urease test – positive.

Besides eradication therapy with the aim to normalize the motor function of duodenum, it is most reasonable to prescribe:

*bismuth preparations

*solkoseril

*Itoprid

*amoxicilline

*drotaverine

50

!*A patient, 26 years old, with complaints against colicky pains in the right hypochondrium, dyspepsia and skin itch. In blood: leukocytes – 11x10⁶/l , eosinophils – 15%.

Which of listed drug must be used in treatment?

*ornidasol

*sylimarin

*drotaverine

*clarithromycine

*cephtrioxon

51

!* In a woman, 42 years old, with BMI 32, suffering from cholecystitis, pulsing pains above the navel with irradiation into the left hypochondrium have appeared; vomiting; instable stool of ointment-like consistency; abdominal distension. Objectively: coverlets and scleras are subicteric, tenderness in the right hypochondrium and in Shoffar's zone, liver is not enlarged. In blood: leukocytes – 11x10⁶/l., ESR – 25 mm/h, total bilirubin 80 µmol/l, α-amylase - 190 IU/l.

Prescription of which of listed preparation is MOST reasonable?

*contrical

*creon

*drotaverine

*ranitidine

*ursodesoxycholic acid

52

!*Woman R.,32 years old, in the age of 26 had cesarean section. At present, she has no complaints. In the systematic inspection, four-time increase of blood serum transaminases was detected, anti-HCV-antibodies RNA НСV-positive, genotype 1b, viral rate 10⁶ copies/ml.

Prescription of which of listed preparation is MOST reasonable?

* essential phospholipids

*interferon of short action

*direct antiviral agents

*ademethionine

*hepadif

53

!*A woman, 48 years old, with complaints against heaviness in the right hypochondrium, weakness, hyperhydrosis. Objectively: malnutrition, subicteritiousness of sclera. Liver comes out of the edge of costal arch by 0.5 cm. In marker diagnostics: HBsAg – positive, a-HBs – negative, anti- HBe Ag – negative, HBe Ag – positive, a-HBcore – positive, HBV DNA – positive, a-HCV – neg.; anti-HCV IgM – neg., anti-HCV IgG – neg., anti-HDV – neg.

Which treatment is MOST reasonable?

*sofosbuvir

*entecavir

*essential phospholipids

*interferon of short action

*ademethionine

54

!*A female patient, 43 years old, complains of rapid fatigue, loss of appetite, nausea, feeling of heaviness in epigastric area, bitter taste in mouth. Objectively: pulse 76 per 1 min, body temperature 37.2°C. Pale skin, single vascular "spiders" in the upper part of chest. Liver comes out by 2 cm from the costal arch. In blood: bilirubin 36 mmol/l, AST 128 IU, ALT 180 IU. Anti-HBc not detected, HВsAg and HВeAg positive.

Which treatment is MOST reasonable?

*sofosbuvir

*lamivudine

*essential phospholipids

*interferon of short action

*ademethionine

55

!*In a man, 20 years ago, HCV infection was detected. At the moment of examination, there are no signs of hepatogenic intoxication, jaundice. Liver has thick consistence, comes out from the costal arch by 2.0 cm. Lower spleen pole is palpated. On EFGDS, stage 1-2 varicose dilated esophageal veins were detected.

Which preventive measures should be taken to decrease the risk of complication development?

*beta-blockers

*calcium channel antagonists

*nitrates

*omeprasol

*vitamin K

56

!*In a woman, 49 years old, in the life history there is hepatic disease, accompanied by skin itch, at biochemical investigation, alkaline phosphatase activity 980 U/l, total bilirubin 39.5 µmol/l, ALT 48 U/l. Serum markers on viral hepatitis B, C and D – negative.

What examination must be done on next step?

* PCR on HBV DNA

* PCR on HCV RNA

* AMA

*ANA

*anti HIV

57

!* The woman 22 years, pregnancy 24 weeks. In the last 2 weeks notes a skin itch, weakness. Biochemistry: alkaline phosphatase activity 480 U/l, total bilirubin 14.5 µmol/l, ALT 28 U/l.

What medical tactics is most expedient?

* ademetionin

* hepadif

* interferon in the form of candles before childbirth

* ursodesoxycholic acid

* essential phospholipids to 38-39 weeks

58

!* The woman of 25 years came to an infectious diseases hospital with suspicion of viral hepatitis which was excluded by results of marker diagnostics. The inadequate behavior, a tremor is noted. Biochemistry: ALT – 2, 2 mmol/l. On ultrasonography: consolidation of a parenchyma of a liver. In the anamnesis she received oral contraceptives within 6 months. At exam of eyes revealed (photo).

What inspection will most possibly allow to verify the diagnosis?

* Determination of level of anti-LKM-1

* Determination of level of a ceruloplasmin

* Determination of level of an a1-antitrypsin

* Determination of level of serum iron

* Determination of level of anti-mitochondrial antibodies (AMA)

59

!*The woman of 58 years receives a course of treatment (Isoniazidum + Rifampicinum) concerning tuberculosis. In 1 month from beginning of treatment it had complaints to fatigue, weakness, headaches and temperature increase to 37,5ºC, yellowness. Biochemistry: ALT of 664 ME/ml, AST –551 ME/ml, a bilirubin – 178 µmol/ml. HBsAg –positive, anti HBs – negative., antiHBc IgM –negative, antiHBc IgG – – negative HBeAg – – negative, anti HBe – – negative; anti-HCV – – negative. PCR HBV DNA - 500 copies/ml.

What further tactics of maintaining the patient is most expedient?

* To decrease Isoniazidum dose

* To decrease Rifampicinum dose

* The complete stop of tuberculostatics also to begin UDCA

* To leave Isoniazidum and a course of an ademetionin plus UDCA

* To leave Rifampicinum and a course L - an ornithine - L - aspartate

60

!* The patient with rheumatoid polyarthritis, activity 2, a roentgen stage 3-4, as basic therapy receives Methotrexatum of 7,5 mg/week. At testing before treatment: HBsAg – positive, anti HBs – negative, antiHBc IgM – negative, antiHBc IgG –positive, HBeAg – negative, anti HBe – negative; anti-HCV – negative. PCR HBV DNA - 2400 copies/ml. PCR HCV RNA – negative. Biochemistry: ALT – 32 ME/ml, AST – 14 ME/ml. In 3 months of treatment the patient notes weakness, fatigue, feeling weight in right hypochondrium. ALT – 134 ME/ml, AST – 78 ME/ml, a bilirubin – 48 µmol/l. What caused of biochemical changes?

* Acute viral hepatitis B

* Replication of a virus of hepatitis B

* Accession of autoimmune hepatitis

* The medicinal (toxic) hepatitis caused by Methotrexatum

* Reactive hepatitis in a corollary of exacerbation of chronic pancreatitis