37 y.o woman -> Ovarectomy.

1
Which of following structures is at risk of damage during ovarian vessel ligation?

Uterine artery
Pudendal nerve
Ureter
Internal pudendal artery
Vaginal artery

64 y.o male diagn with Pulm. Emb. 2

First he got Unfair. Heparin.
Later Rivaroxaban
How do u determine dose of rivaroxaban ?

Initial dose dep on the indication, thereafter the dose should be adjusted according to INR levels
to achieve 2,5-3,5
The dose depend on the indication and renal function, monitoring of INR + APTT is not
necessary
Initial dose dep on the indication, thereafter the dose should be adjusted according to INR levels
to achieve 2-3.
Initial dose dep on the indication, thereafter the dose should be adjusted according to APTT
levels to achieve 1,5-2 times the baseline value

70 yo woman DM2. Diet for 3 months. Physical activity. Glucose lvl’s remained higher than 3
normal. Prescribed Metformin 850(?) mg x 3. Started nausea + diarrhea. Metformin taken on
empty stomach. What do u recommend?

Discontinue metformin due to intolerance and prescribe insulin.

Reduce dose to 500 mg x 3 + continue take it on empty stomach.
Reduce the dose to 500 mg x 1 + gradually increase until lowest effective dose. Take drug with
food.
Reduce the dose to 250 mg x 2, continue to take it on empty stomach.

22 y.o man complaint of intermittent cough and chest tightness for ca 2 years. Patient has 4
frequent bronchiolitis. Auscultation show bilateral wheezes. SpO2 93(83?) % What test
should you do first?

Chest CT
Spirometry

Gas diffusion test

Bronchial challenge test

5
28 y.o male with Chrons dis for 6 y + im.suppr. 7 days after changed treatment start progression
of fever, cough and sputum. A simple chest ray, CT and MRI shows inflam infiltr. What features do
you see on the image ? (Ej säker på svaret)

X-ray - Focal pneumonia in R upper lobe. CT - Focal pneumonia in R lung parenchyma +

mediastinal LN enlargm. MRI - Focal pneumonia in the R lung parenchyma, small focuses in
both parenchyma and hydrothorax in R side.
X-ray - Confluent multiple focuses in the R lower lobe(focal pneumonia), CT/MRI - only
hydrothorax in the R side.
X-ray - focal pneumonia in the R upper + lower lobes. CT - only mediastinal LN enlargm. MRI -
only hydrothorax in the R side.
X-ray or CT and MRI - Right hydrothorax and focal pneumonia in the R upper lobe. (Ngt med all
.. same view)
X-ray - R hydrothorax and focal pneumonia in the R upper + mid lobes. CT and MRI - focuses
on R lung parenchyma, Mediastinal LN enlargm.

27 y.o woman complain of intermittent wheezing in the chest, coughing. Symptoms occur at 6
night. Symptoms started 6 months ago. Live in a old house with mold. Bilateral wheezes on
auscultation. SpO2 95%. Normal spirometry. What’s your next step?

Bronchial challenge with metacholine

Chest CT
Gas diffusion test
Bronchodilator test with salbutamol
No test + recommend change house.

7
56 yo woman consulted her GP with a 3 month history of weakness, increased sweating, thirst,
dry mouth, and urination. Gained 12 kg last year, struggle with overweight. Higher BP but don't
measure it + untreated. History of bronchial asthma. FH of DM. GP made glucose test -> FG 7,2.
Enough data to confirm DM 2?

Not enough, you need to make 2 point GTT.

Not enough, glucose level don't meet diabetes criteria(> 11,1)
Enough, there are typical complaints of diabetes and pathological glucose lvl > 7.
Not enough, you should repeat the FG again(must have FG > 7, two times)

25? y.o man started having dry cough and fever up to 39,5°. Ausc -> fine crackles in the R 8
lung area. SpO2 9X% in room air. CRP: 215, RBC 5,3, NG’s: 8X%. Chestray: R lung infiltr.
Pneumonia diagnosed. Hospitalized in pulmo departm. What’s the empirical treatment?

Mild CAP in hospital is treated with Ampicillin, BenzylPC IV.

No AB’s, just antipyretics and mucolytics.

Severe CAP in hospital is treated wit Carbapenem.
Oral PC group antibiotics.

What determines the meniscus rupture treatment xxxx for athletes? ( tror d e rätt svar ) 9

Leg axis
Conditions of hip joint
Ankle joint conditions
Meniscus rupture time, size, vascular area
Injury mechanism

70 y.o with cough, sputum. Smoking for 50 y. Spirometry -> FEV1/VC 50%, prolonged 10
FVC(forced vital capacity) exhalation time. Bronchodilator test negative. What objective
signs do u expect?

Increased Tactile fremitus, bibasilar fine crackles

Tympanic percussion sound, No vesicular breathing sounds
Coarse crackles, No tactile fremitus
Wheeze, Decreased breathing sounds
Normal auscultation, perc + palp.

35 y.o woman. Thirst, frequent nocturnal urination. Pregnant in 2nd pregnancy. Previous 11
vaginal delivery. Gestational age = 25w. In 1st trimester x week pregnancy FG test was = 5
mmol/l. What diagnosis is suspected + what tests to determine diagnosis.
 Gestational diabetes, take urine test for ketonuria + fasting glucose
Gestational diabetes, take glucose tolerance test
Gestational diabetes, make US for fetal weight and ev macrosomia.
Take fasting glucose
Take urine test for ketonuria, test glycemia 4 times / day for 2-X days.

79 y.o. with dizziness, gradually deteriorating memory, difficulties to remember where 12

things are located, what needs to be done, forgetting appointments, names of people.
History from daughter who does not live together, the mother became forgetful in recent years,
the symptoms deteriorate, confusion in place + time. She has been lost a couple of times
when going to the doctor, she does not cook and need help with home care. Which of
following tests is obligatory to evaluate the patient.?

Head CT
EEG
Transcranial doppler
SPECT

7.yo febrile fever, runny nose, dry cough, photophobia. After 3 days, ↓ fever, next day got rash 13
on face + fever again. At emergency department - nasopharyngitis, conjunctivitis,
maculopapular confluent rash on face, neck and small white spots in oral mucosa(koplik’s
spots). Later the rash progressed to other sites ( extremities. Not vaccinated. What infection
do u suspect?

Varicella
Measles
Scarlet fever
Rubella

Patient Glasgow coma scale is 8. You notice signs of tongue obstruct the aw. Choose basic 14
aw maneuver to improve the aw’s.

Bend head forward

Open the mouth with your fingers via scissor maneuver
Head tilt + chin lift
Turn patient to the side

24y.o woman with knee injury during skiing. Swollen knee joint on exam. What is the most 15
informative examination to determine pathology of knee joint internal structures?
 Bone scintigraphy
2 way radiography
US
MRI
Knee puncture

68 y.o woman comes for a follow up visit. History of COPD + DM , both longstanding + well 16
controlled. The daughter is with her. Daughter notice that mother is get more forgetful, forgets
names of grandchildren, important events, pays same bill twice. Also more fatigue + fallen
several times lately. Live alone, cooks, drives without problems. She said that she is a bit
more tired than usual and don't think that the forgetfulness is unusual. Physical exam
unremarkable. No signs of neurological deficits. Which of following is the most appropriate
referral for this patient?

Admission to assisted living facility

Comprehensive geriatric assessment
Respite program for daughter
Home services

19 yo woman is brought by ambulance after collapsing. Her friends tell that she was drunk with 17
high amount of alcohol, GCS : 8. Which of following sympt’s indicate that there is a risk of
fall of the tongue root into larynx, which makes a n aw obstruction ?

Inspiratory stridor
Use of ass muscles on ventilation
Noisy breathing, snoring
Paradoxical chest and abdominal movements

39 yo male with severe lower back pain, started few days ago, and increased into his left 18
groin + left leg. VAS 7-8. Used Diclofenac without success. Have LBP problems for ca 10
years, but no radiation to groin/leg. No chronic dis’s. No fever, BP 160/85. XX? No abdominal
pain. Neurologic - stiff back muscles, decreased mobility range due to pain. Lamxxx test - R-
leg: x° ? L-leg: 55°.
Which treatment is appropriate ?

Myorelaxants + Vit. B + NSAID’s + Antispasmic drugs

Pregabalin/Gabapentin + NSAIDs + Myorelaxants + Physiotherapy
NSAID injections + Physiotherapy
Rest + Ice patches on painful areas

17 yo girl with thirst, frequent + abundant urination, weightloss, weakness. Ketone smell 19
from mouth. Fast Blood test - glucose : 3,7 mmol/l and significant ↓ insulin, O-peptide, Amylin.
Amylin inhibit glucagon secretion. How does blood glucose change in response to lack of
amylin?
 Increases because alpha cells release a lot of glucagon
Increases because a lot of glucagon is secreted from beta cells
Decreases because a large amount of glucagon is secreted from alpha cells
Increases because of a lot of glucagon is released from delta cells
Decreases because then glucagon is secreted in large amounts from delta cells

24 yo female with headache. Pain stared 2 months ago and recurs every day. VAS 4-5. 20
Sometimes takes NSAIDs, which helps. No history of previous headaches or chronic dis’s. Birth
control pills since 3 years. BP 111/65. HR 81. Normal neurologic status. Which long term
treatment do u recommend for the headache?

Physiotherapy, Proper sleep hygiene, Education in Stress relieving factors.)

Paracetamol
NSAIDs
Triptanes

65 yo man, 2 days swelling of 1st left MCP joint, he had his first episode of acute arthritis few 21
weeks ago, podagra diagnosed. Urate: 480 µmol/l.(n<357)He takes x for hypertension. BMI:27,
BP:135/80. 1st MCP joint is red, swollen, painful. Which drug must NOT be given during
acute gout attack?

Allopurinol
Colchicine
Prednisolone
Naproxen

Leder till nedbrytning av kristaller som orsakar ännu mer flare up

Pathology suspected ? 22
 Pleuritis R side ( Hydrothorax)
Rupture of left lung
Hydropneumothorax R side
R lung pneumonia
Hydrothorax in L side

2,5 month baby became more irritable, exhibiting more frequent X(sweating?) 2 weeks ago. Clin 23
- Hair loss back of head on one side and a few areas of softening on occipital bone. No
changes on the internal organs. Weight 5200g, Born in October after 36 weeks of gestation.
Birth weight 2100 g. The mother had never used complementary vitamins?? Baby was given
prophylactic 400 IU Vit. D every other day. Starting at 3 w after birth. What could be the
underlying cause of the baby developing rickets? (Tror svaret är rätt då 400 IU är
rec prophylactic dos)

Insufficient amount Vit.D with food, low birth weight, insufficient growth of baby weight, impaired
synthesis of vit. D in the skin
Quick increase on baby body weight, insufficient amount of vit.D in food, impaired synthesis of
Vit.D in the skin, Insufficient amount prophylactic Vit.D dose.
Insufficient amount Vit.D with food, Insufficient amount prophylactic Vit.D dose, Increased
sweating, Low birth weight.
Baby is breast fedd, Insufficient amount prophylactic Vit.D dose, excess sweating, Impaired Vit.D
synthesis in skin.

Woman 5th time pregnant, come to emergency department with bloody vaginal discharge and 24
uterus contractions every 5-7 minutes. Gestational age 31 w and 4 days acc to 1st trimester
US. Which test to make diagnosis ? (Vet ej svaret, gissar )
Inspection of cervix by speculum
Vaginal us and CTG to check fetal condition and uterine contractions

CTG to check fetal condition + uterus contraction

Vaginal US

76 yo woman hospitalized 1 year ago due to bleeding peptic ulcer. Today she is seeking for 25
developing pain and swelling. Something about Ibuprofen and Osteoarthritis. Temp 37,7°. Very
unclear text. BUT something like Inflam of hands, right knee, large effusions. Aspiration
shows yellow + cloudy fluid, leucocyte count 500(1500?). Which test is helpful for diagnosis
?

Culture and crystal analysis

Glucose measurement
Antinuclear antibody measurement
Protein measurement

Glucose tolerance test were made for 48 yo pat. Results — FG: 4,7, 2H: 9 mmol/l. What 26
disease is suspected ?
 Impaired glucose tolerance
Impaired fasting glucose
Diabetes insipidus
Diabete mellitus
Glucose tolerance normal

Which graft is most commonly used to anterior cruciate ligament reconstruction? 27

Thigh flexion tendons

Rectus thigh muscle fascia
Supraspinatus tendons
Delts muscle tendons
Achilles tendons

52 yo man with 2 years history of progressive symptomatic rheumatoid arthritis. Hes unable 28
to work due to persistent pain + swelling in proximal interphalangeal, MCP joints an
bilateral wrist. Also hard to climb the stairs due to swelling of knees. Meds: Methotrexate 25
mg weekly, Prednisolone 10 mg daily, Diclofenac, Folic acid. Clin - Tenderness, swelling in
affected joints. Imaging - hand + wrists - PA Osteopenia, Erosion, Narrowed joint space, Knees -
medial + lateral joint space narrowing. Which of following is next step in the management?

Increase prednisolone
Increase methotrexate
Add rituximab
Add etanercept (TNF inhibitor)

6-yo patient in the ER, Irritable + Incontacable?. HR: 160? RR: 15 ? , BP 95/60? Severe 29
retractions and grunting. SpO2 89%. T: 37,6°, Pale, mottled skin, Weak peripheral pulse.
What’s the physiologic state of the kid?

Acute appendicitis
Acute myocarditis
Decompensated shock
Respiratory failure
Respiratory distres

Patienten is in the ER after serious bleeding. He was found lying on the floor near the stair 30
case- Low consciousness level, can't maintain open aw, Contusions, Hematoma in face and
deformed nose. Signs of previous nose bleed. What intervention will you choose to
maintain patients aw if you dont have other equipment?
 High flow oxygen mask
Ventilation with bag valve mask
Nasopharyngeal tube
Oropharyngeal tube

65 y.o man in ER febrile fever, headache, vertigo, nausea, vomiting. Spend a lot time in 31
nature, noticed few ticks on his body but no tick bites. 10 days ago a episode of febrile fever
and myalgia that resolved in 3 days. Obj: Conscious, well oriented. Nuchal rigidity, Tremor in
eyelids + fingers. Rombergs - can’t maintain balance. Blood: WBC: 12 x....., CRP 18.
Glucose: 6. CSF: WBC 84 x(↑), NG: 20%, Lymphocytes: 80%, Proteins: 0,82 (<1) Gluc: 3,2,
Lactate: 1,4(N). Treatm. until confirmed diagnosis ?

Only symptomatic treatment

Aciclovir 10 mg/kg x 3 IV
Ceftriaxone 2g x 2 IV
Ampicillin 2g x 3 IV

Tick borne encephalitis - finns ingen specific antiviral behandling

25 yo woman, 3 months lasting gen weakness, dry mouth, frequent urination, weight loss, 32
abd.ache. Glycemia: 13. Urine : Glucosuria, Ketonuria, Obj: BMI 22,5, Low skin turgor, Dry
tongue, Aceton breath. Preliminary diagnosis ?
Most data for type 2 Dm with ketonuria. Start metformin treatment.
Most data for type 1 DM with diabetic KA. Advisable to asses arterial blood pH, Antibodies
against structures of pancreas, To initiate insulin therapy.
Most data for pancreatic diabets mellitus with ketonuria. Perform abdominal us, start insulin.
Most data for type 1 DM with ketonuria. Advisable to evaluate antibodies against pancreas
structures, and to initiate insulin therapy.
There is not enough data to confirm the diagnosis of diabetes mellitus, it is advisable to perform
glucose tolerance test.

33
48 yo woman to gyn outpatient, prolonged vaginal bleeding. Bleeding despite that last
menstrual period started 20 days ago. Had same bleeding every 3 months age!?. Menstrual
period had become irregular 6 months ago. Vaginal exam: Discharge low amount of dark
blood. US exam: endometrium 8 mm thick.

You made endometrial biopsy. Histological findings, menstrual endometrium. What is the
most appropriate treatment for. This patient ?

Hormonal Intrauterine device

Gestagens implant
Dilation and curettage
Progesterone only pills
Hysterectomy

You hear cabin crew asking for a doctor. Patient unconscious middle aged whit. No company. 34
You hear snoring. How will you select appropriate length of oropharyngeal tube?
Measure distance from nostrils -> lobule
According weight
Measure distance from lip corner to ear lobule

Measure distance from middle of mouth to ear lobule

Patienten suffered a non contact injury of the knee joint (Knee sprain), while exercising 1 year 35
ago. At this point, knee instability, swelling, restricted movement, pain. What knee injury do
u suspect?
 Intra articular fracture
Purulent inflam
Injury of cruciate ligament and mensicus
Damage to superficial ligaments of knee joint.
Cartilage damage

77 yo woman, recurrent falls, come for clarification of her diagn. Complaints: unstable balance, 36
dizzy, anxiety, insomnia. Last time she fell a week ago. Hist: IHD, Chronic HF, AHT, Dementia.
Meds: Spironolactone, Eisonopril, Aspirin, Metoprolol, Clonazepam, Atorvastatin. Obj:
Conscious, Impaired time orientation, waddling gait, walks with a stick. Tests: Up & go 22 sec,
Gait speed 0,8 m/s. MMSE: 18 points.
Which drug increase risk of falling the most?

Clonazepam
Eisonopril
Simvastatin
Metoprolo
Spironolactone

68 yo woman come to family door. Complaints: Cough, Fever 38,3° for 2 days. History: DM2, 37
AHT for many years. Obj: BP: ?, HR 64, Slight red throat, Lung ausc: you hear something in the
right lung. No leg edema.
What test would you do to determine the cause?
(Borde vara rätt svar!?)

CBC, ESR, Test for allergies

CBC, CRP, Chest ray
No test needed, Diagnosis is clear
Immediate pulmonologist consultation
CBC, Chest CT

You are treating a 87 yo woman with confusion, hypoglycemia, and recurrent falls. History: 38
Diagnosed with DM2, IHD, AHT, Hypothyrosis and endarteritis!?
Meds: Metformin 1g x3, Levothyroxine 150 x1, Perindopril 10 mg x 1, Atorvastatin 80 mg x 1,
Paracetamol 1g x 4. Tests: BMI 17,2, BP 106/56?, HBA1c 4-6!?, Crea 124, GFR 45, MMSE:
22!?,
You are supposed to ”clean up” her meds.
Which medicine is essential for this patient + can’t be discontinued?
(Vet ej svaret på denna - gissar bara)
 Levothyroxine
Metformin
Atorvastatin
Perindopril
Paracetamol

25 yo with head trauma, his car hit a tree. All other causes is excluded and he had developed 39
psychotic hallucinations due to the head trauma. Which of following med are most helpful
to treat him?
Diazepam
Lithium
Valproic acid
Sertraline
Risperidone

24 yo female with headache. Pain stared 2 months ago and recurs every day. VAS 4-5. 40
Sometimes takes NSAIDs, which helps. No history of previous headaches or chronic dis’s. Birth
control pills since 3 years. BP 111/65. HR 81. Normal neurologic status. What test is necessary
to determine the cause of the headaches?

Brain CT / Angiography with contrast

CBC, CRP, Cervical spine x-ray

No test needed, diagn is clear
Cervical spine MRI

You are examining a 4 hour old (39 w) Nb in obstetric dep. Baby refuse breast feeding. Sleepy 41
+ grunting started 1 h ago. Obj: Grunting. HR: 180, No arrhythmia/murmurs. RR: ?, CRT: 4s,
Temp 35,7°. Preliminary diagnosis? What lab test you need to perform?

Late onset neonatal sepsis, CBC, Blood smear, CRP, Urinalysis

Congenital HD, Cardiac US
Hypothermia, No lab test needed
Early onset neonatal sepsis, CBC, Blood smear, CRP

42
75 yo woman in ER. Fever up to 38, 7°??, Gen weakness, abdominal pain? Pain in lumbar area
?
Sympt’s started 2 days ago. Taken paracetamol but didn’t get better. Previously healthy. Obj: T:
39??, HR 84, BP 130/72?. Abdomen is soft, tender in the lower areas. Normal breath sounds.
Positive Jordan sign on the right side. No other changes / sympt’s.
RBC 4,5. HB 123, WBC 15, Neutophils > Lymphocytes. CRP 213.

What empiric antimicrobial therapy would u prescribe after taking sample specimen for
diagnosis?
(Antar att det är pyelonephritis!?)

Cefazoline 2g x 3 IV
Cefuroxime 1g x 3 IV
Oxacillin 2g x 4 IV
Ampicillin 2g x 4IV
Meropenem 2g x 3 IV

37 y.o male. Compl’s: Palpitations, Increased sweating, Discomfort while ??, Decreased 43
weight.
Obj - skin is warm + moist, Thyroid is normal size + soft on palpation. Finger tremor is
observed.

Sen går d inte tyda riktigt - HR 98? Normal rytm,, BP135/76?.

Thyroid us -> ser inte vad, troligt abnormalities bilateral

What test would u do to determine diagnosis ?

No additional test ended

CRP, CBC, ESR, Thyroid hormones, Neck CT
TSH, Thyroid hormones
CBC, ESR, TSH, T4, T3

40 yo female. Hist: DM diagn when she was 3 y.o. Insuli dependent. Noticed periorbital edema, 44
Decreased urination rate? and Weakness and X (troligtvis annan neurologisk sign)?

Family doctor detected increased creatinine + Urea? In urine .

What of following complications can explain what developed in this patient. ?

 Microangiopathy
Diabetic coma
Polyneuropathy
Macroangiopathy

Dom har valt fel tror jag ?- då microangiopathy leder till samtliga besvär ->
Retino/Neuro/Nephropathy

15 yo girl to pediatric ER. Parent noticed that she Didn’t get out of bed, was sluggish + called 45
ambulance. Går ej läsa men snappar upp detta typ. Ungen har mentala problem som
förvärrats de sista. Konflikt med mamma, har gamla märken på underarmarna. Träffat
psykiatriker men det har inte hjälpt. Patient mår nu bättre på avdelningen och vill hem.
Vad borde du prescribe as treatment ?
(Gissat svaret)

Referral to family doctor for follow up

Referral to outpatient consultation of child psychiatrist
Urgent consultation of child psychiatrist, Hospitalization in child psychiatric department.
Hospitalization in pediatric department

20 y.o man. Suffer from water nasal discharge, nasal itch and occasional sneezing. Itchy + red 46
eyes. Affected his sleeping, concentration + learning problems. Symptoms occur all year round
for 2 years. Atopic dermatitis in childhood. Exam: very watery eyes. Rhinoscopy: Swollen +
pale. XXX + House dust mites allergens was found and confirmed via skin prick test.
Treatment recommendation?

Pharmacological treatm (Oral AH’s, Intranasal CCS’s, Allergen spec. immuno therapy)
Avoid allergen, Pharmacological treatm. (Oral AH’s, Intranasal CCS’s) Allergen spec. immuno
therapy
Avoid allergen, Pharmacological treatm (XXX AH’s and oral CCS’s) Allergen spec. immuno
therapy
Allergen specific immunotherapy

47
2X yo woman complain of dull pain in bottom of abdomen, more on the Left side. Something is
seen?
Although regular menstruation cycle. Kan inte se
US -> thickened uterine mucosa + xx/something in the left ovary. Positive pregnancy test.
You suspect ectopic pregnancy

What cells of the mucosa of Fallopian tube could have be the cause of such morbid
condition?
Basal cells
T lymphocytes
Smooth myocytes
Secretory cells
Ciliated cells

3 y.o boy in childr ER at night. Dizzy in the evening + Stay up? at night due to unproductive 48
barking cough, difficult to breath. Obj: 36,6°, Hoarse voice, Inspiratory stridor. Lung ausc: No
wheezing or rales. RR: 30, Accessory muscle use, HR ?, SpO2 9x?. Other systems = Ok.

Actions?

Amoxicillin, O2 via mask

Prednisolone IV, Salbutamol inhalation via spacer
Dexamethasone or Prednisolone orally, Adrenaline inhalation

No treatment or testing needed. Monitoring.

O2 via mask, Salbutamol inhalation via spacer.

68y.o female complain of urge and frequent to urinate, nocturia, urinary incontinence. Pees ≥ 8 49
times daytime + 2-3 times night time with small amounts of urine. Something about burning in
urethra + smell + color change. She restricted water intake because she’s afraid that she won’t
reach the toilet in time. XXX.
Hist: Hypertension, Obesity, Constipation. Amlodipine, Xx, Urinary tract infections in past.

Preliminary diagnosis ?

Functional incontinence + Cystitis

Overflow incontinence + Cystitis
Mixed urinary incontinence + Cystitis
Stress urinary incontinence + Cystitis
Irritable bladder + Cystitis

50
43 y.o man complains of fever up to 39,5°, myalgia, fever, fatigue. He got yesterday, at first he
had chills followed by fever headache, nausea + vomiting. The fever held for 9-4 h. Then profuse
sweating. Today, the symptoms repeated agin. For 2 months ago he was in Ghana in Africa.
Says he was vaccinated against yellow fever, Hepatitis A + Typhoid fever. Obj: T 39,5, Dry
tongue, HR 110, BP 120/70. Liver ca 10 cmNO other changes.
What test would u do for diagnosis ?

Thick blood smear for meningococcal infection

Microscopic examination of thin and thick blood smears for malaria
Blood culture for typhoid fever
Serological blood test for yellow fever

39 yo woman complains of bloody discharge after sex and physical activity. First noticed bloody 51
discharge 1 month ago. Last menstrual period 2 week ago. Regular menstrual cycle. 5 vaginal
deliveries. Smoke + use alcohol. Last gynecologist visit 7 years ago + never participated in
cervical screening program. Vaginal exam: Vaginal discharge bloody + bad odor, Cervix size
3x4 cm, 3x3 cm cxxtumor, Rectovaginal exam: Cervix immobile, Bilateral parametrical
infiltration spans to pelvic wall. No changes in uterus and adnexa. Which one of following will
confirm the diagnosis ?

Tumor biopsy + Histol exam

Vaginal US
Colposcopy
Pelvic CT
Pelvic MRI

52
69 year old man complains of shortness of breath during light exercise + cough for about 3
years. Symptoms are progressing. Smokes for 35 years. Bilateral wheeze on auscultation. SpO2
92%.
What is the clinical diagnosis based on clinical data + spirometry?

Severe COPD
Moderate COPD
III° Bronchial obstruction
Moderate uncontrolled allergic asthma
Severe uncontrolled non-allergic asthma

29 year old patient came to the emergency department due to chemical burns. The degree of 53
chemical burn damage mainly depends on?

The surface area of the body that has been exposed to the burn
Type of substance strong acid or strong alkali
Duration of exposure
Patients general condition or comorbidities
62 year old woman noticed leg swelling 6 months ago. She has not visited doctors before. 54
Denies other diseases. Spot urine test: specific gravity 1.030, protein > 3 g/L, leukocytes 8/µL,
no erythrocytes. 24h proteinuria 8g, eGFR 102 ml/min. Serum albumin 25g/L (35-50)and total
cholesterol 9 mmol/L. Nephrotic syndrome was diagnosed. What are the typical causes?

Chronic tubulointerstitial renal diseases

Acute tubulointerstitial renal diseases
Chronic renal disease of any etiology
Glomerular damage in chronic glomerulonephritis, renal amyloidosis, diabetic nephropathy
Acute glomerulonephritis

62 years old man, heavy smoker, without comorbidities was hospitalized in the urology 55
department due to painless urination with blood clots. US showed 4cm mass in bladder, no signs
of hydronephrosis. Cystoscopy was performed and confirmed the presence of the 4cm tumor in
the left bladder wall.
The pathological evaluation of the specimen showed presence of muscle invasive, pT2, G3
urothelial bladder cancer. CT showed no local spread or distal metastases. Bone scan
showed no bone metastases. Which of the following treatment plans are recommended for this
patient with muscle-invasive bladder cancer?

Chemotherapy alone
Radiotherapy alone
Transurethral resection of bladder tumor
Radical cystoprostatectomy

A female patient presents to the emergency department with severe pulsating left-sided 56
fronto-temporal headache radiating to the other side of the head. The headache lasted for
8h and is accompanied by nausea + vomiting, worsened by movement or loud sounds. No
abnormalities deteced on physical examination, no focal neurological deficits are noted. What is
the diagnosis?

Meningitis
Migraine
Subarachnoid hemorrhage
Meniere’s disease

Increased liver enzymes were discovered on a routine blood test of a 52-year old woman. She 57
has a BMI of 24 and hepatomegaly. She does not have a history of jaundice, no medications and
drinks alcohol occasionally. 35 years ago she had a cesarian section and blood transfusion.
Complete blood count, bilirubin and prothrombin are normal. ALT 105 U/l (5-35), AST 90 (5-35).
What is the most likely diagnosis?

Viral hepatitis
Autoimmune hepatitis
Steatohepatitis
Liver cirrhosis
35 years old patient suddenly felt severe pain in the right groin area during physical work in the 58
garden. He had nausea and vomited several times. The pain did not disappear and became
spasmodic. The patient had open hemioplasty for umbilibal hernia five years ago. When the
patient is examined general condition is good, the abdomen is slightly swollen upon palpation,
no signs of peritoneal irritation. The peristalsis is active by auscultation. Bulging is felt in the
groin area. What pathology do you suspect?
Complete small bowel obstruction due to adhesions
Strangulated right groin hernia
Right kidney stone attack
Hydrocele
Acute appendicitis

69 years old patient is admitted to the hospital with intense left sided chest pain. ECG reveals 59
hypokinetic ventricular septal muscle mycardial infarction in the anterior two thirds of the
interventricular septum, and left anterior ventricular wall. ECG also exhibited LBBB. Which
of the following arteries is most likely occluded?

Posterior interventricular artery

Proximal right coronary artery
Circumflex artery
Proximal left anterior interventricular artery
Proximal eft coronary artery

A 52 years old patient presents with 6 month history of rigidity in upper limbs, resting tremor in 60
the right hand (occasionally in the left) and changed handwriting. Recently became more difficult
to get up from sitting position and increasing salivation at night. The patient recalls having had
mood disturbances and nightmares abot a year ago. Blood tests, head CT and ECG showed no
abnormalities. Patients father hade bilateral hand tremor. What is the disease and its main
pathological mechanism?

Wilson’s disease: disorder of copper metabolism

Cerebrovascular accident: internal carotid artery stenosis
Essential tremor: genetic factors
Spinal cord lesion at cervical level: spinal stenosis
Parkinson’s disease: dopamine metabolism disorder

A patient developed sudden weakness of the left extremities, head CT revealed 30ml right 61
putaminal hemorrhage. GCS: 12, BP: 175/112, SpO2: 96%. Which of the following would be
performed first?
Platelet transfusion to activate coagulation and prevent further hematoma expansion
Correct hypertension to prevent further hematoma expansion
There is no need for further active treatment. Monitoring of patients conciousness, vital functions
and prepare CT scan
Transport patient to operation room to remove hematoma as soon as possible
A 40 year old man suddenly complained of significant headache…. 62
CT revealed hemorrhage in brainstem area. What is the most likely cause of the brainstem
hemorrhage?

Cerebral neoplasm with secondary hemorrhage into neoplastic tissue

Portal hypertension
Cerebral infarction with secondary bleeding into infarction area
Rupture of congenital cerebral artery aneurism

Paranasal sinusitis was diagnosed for a 55 year old patient 7 weeks ago. One day ago…. right 63
eye and headache, weakness and double vision. Chemosis and hyperemia of the conjunctiva.
Proptosis of the right eye…
Exophtalmometry data: OD -21mm, OS -16,5mm….
Preliminary diagnosis

Orbital tumor
Orbital cellullitis
Carotid-cavernous sinus fistula
Endocrine ophtalmology

61 years old woman arrived to the ED. Patient has chronic renal disease, heart failure. She 64
takes spirinolactone. Lab tests: potassium 7,1 mmol/L (3,5-5,1), serum creatinine 200, urea 28
(3,9-7,2). ECG: no P-waves, prolonged QRS and peaked T-waves. How will you manage the
hyperkalemia?

Immediatly inject calcium gluconate 10% 10-20 ml intraveniously, initiate conservative

medication treatment of hyperkalemia and arrange acute hemodialysis as soon as possible
Administer 5% glucose solution, 5 IU of short-acting insulin, inhalation of salbutamol, injection of
furosemide 80mg and repeat serum potassium test.
Inject calcium gluconate 10% 10-20mg intravenously and repeat serum potassium test
Administer 5% 500ml glucose solution with 5 IU short-acting insulin intravenously and repeat
serum potassium test
Administer salbutamol inhalation and repeat serum potassium test

65 years old patient, who complains of abdominal pain lasting for 3 days was referred to ED for 65
consultation by a surgeon. The pain began in the lower left part of the abdomen and then spread
to the entire abdomen. Yesterday the temperature increased to 38,5 C°. Objective examination:
hyperstenic body composition, BMI: 35, HR: 90, BP: 150/90, RR: 22. Abdomen is large, bloated,
palpable painful throughout the area, peritoneal irritation in the lower left iliac region. US was not
informative. CT revealed multiple diverticuli in the ileum and descending colon, ileum was
infiltrated , thickened, free fluid in the abdomen up to 1,5 cm thick as well as … in the
mesenterium, fat tissue of ileum and retroperitoneal space. What degree of acute diverticulitis
has the patient according to Hinchey classification?
 IA
IB
II
III
IV

59 years old man arrived to the ED due to shortness of breath. He is lethargic. RR: 28, SpO2: 66
92%. Auscultation revealed bilateral vesicular breath sounds and coarse cracles on the left. BP:
85/38, MAP 55, HR: 118. Skin is mottled, CRFT: 5 sec. Fever 38,9 C°. WBC: 15,9 x 10^9, Neu:
13,9 x 10^9, Hb: 148 g/L, platelets: 120 x 10^9, CRP: 359, Crea: 115 µmol/L, urea: 18 mmol/L.
Chest x-ray showed pneumonia of left lung. What treatment should be initiated?

Crystalloid infusion, O2 therapy, broad-spectrum antibiotics within 1h

Dopamine infusion
O2 therapy, norepinephrine, antimicrobial treatment
Crystalloid infusion, O2 therapy, broad-spectrum antibiotics within 24h

62 years old male with medical history of secondary renal systemic arterial hypertension died. 67
Autopsy revealed thickness of left ventricular wall: 2,5 cm, thickness of interventricular septum:
2,4 cm, thickness of right cardiac wall: 0,5 cm. What are the most likely microscopic
morphological features of left cardiac ventricular wall detected by light and electrical
microscopy?

Atrophy of mitochondria and cardiomyocytes

Hypertrophy and hyperplasia of mitochondria of cardiomyocytes
Atrophy of contractility elements in cardiomyocytes
Hypertrophy and hyperplasia of cardiomyocytes

A 67 years old patient arrived to ED complaining of progressive limb weakness. 10 days ago 68
she had fever and flu-like symptoms. 2 days ago she developed pain in her lower back and
neck followed by numbness in the limbs and …
This morning patient fell down in the bathroom and could not get up due to weakness.
Examination: strenght is diminished in both proximal and distal muscles of the legs and
distal muscles of the arms. Deep tendon reflexes are absent in both arms and legs. Slight
glove-socks type of hypoesthesia is present in the limbs. What is the most likely diagnosis?

Guillan-Barre syndrome
Multiple sclerosis, first attack
Tick-born encephalitis
Myelopathy induced by an epidural abscess of thoracic of thoracic spine

9 years old boy complains of a scaly rash on the scalp which was treated with topical 69
corticosteroids. Clinical examination revealed 3cm diameter, clear bordered pink pale covered
with dandruff ….
Months ago he bought a dog. What is the diagnosis?
 Psoriasis
Scalp folliculitis
Tinea capitis
Seborrheic dermatitis

A 30 years old man complains of epigastric pain, especially during prolonged periods of 70
fasting or at night. The pain briefly revealed after meal or taking anti-acids. He reports no
changes in apetite, weight or voiding habits. He does not take any medications. His epigastric
region is tender upon palpation. Hb 125 g/L (120-150), blood biochem is normal. Fecal occult
blood test is negative. What is the most likely diagnosis?

Duodenal ulcer

Functional dyspepsia
Chronic pancreatitis
Gastric cancer

The patient burned his head and neck with an open flame. You evaluate the burns as IIa-Ib 71
degree. Which action in the emergency department is priority?

Ensure normal ABP

Take care of wounds and bandage to avoid infections.
Ensure and maintain open airways
Protect patient against hypothermia

55 year old woman presents with burning postprandial upper abdominal pain. … own 2 hours 72
of fasting. The symptoms appeared a few weeks ago. There is no loss of apetite or weight
changes. Patient takes metoprolol and 75mg of acetylsalicylic acid daily. She is a non-smoker
and denies alcohol consumption. Physical exam shows tender upon palpation of epigastric
region. Hb 125 g/L (120-150), blood biochem is normal. Fecal occult blood test is negative.
What is the most likely diagnosis?

Gastric cancer
Functional dyspepsia
Chronic pancreatitis
Stomach ulcer

A 58-year-old male with ischaemic heart disease, hypertension and bipolar disorder was taking 73
metoprolol and risperidone. ECG findings: heart rate 66 bpm, PQ interval 180 ms, QT 420 ms.
The patient developed atrial fibrillation;the sinus rhythm was restored by electrical cardioversion.
The patient was additionally prescribed amiodarone and rivaroxaban. Current ECG findings:
Heart rate 66 bpm, PQ interval 188 ms, QTc interval 490 ms. What adverse drug reaction do you
suspect and why did it develop?
 QTc-prolongation due to risperidon interaction with rivaroxaban
QTc-prolongation due to risperidon interaction with amiodarone
QTc-prolongation due to metoprolol interaction with amiodarone
First degree AV-block due to metoprolol interaction with amiodarone

54 years old man presents with jaundice, abdominal distention, bleeding gums and edema of 74
lower extremeties. For a few months he has been suffering from malaise and reduction in
productivity. Reports no past diseases, does not deny drinking alcohol. Smokes regularily.
Physical exam: slight jaundice, a few spider angioma on the chest, distended abdomen, a few
tattoos, hepatosplenomegaly. Blood test: anemia, thrombocytopenia, tot bilirubin 100 µmmol/ml
(3,4-17), indirect bilirubin 65 µmol/ml. INR: 1,5 (0,8-1,2). ALT 150 U/L (5-35), AST 280 U/L (5-
35), GGT 500 U/L (0-49). Abdominal US: enlarged non-hemogenous liver, normal bile ducts,
enlarged spleen, free fluid in the peritoneal cavity. What is the most likely diagnosis?
Viral hepatitis
Alcohol steatohepatitis
Liver cancer
Liver cirrhosis

Doctor gastroenterologist has detected a suspicious most likely pathological lesion on the gastric 75
mucosal surface during endoscopic examination of the stomach. A biopsy of 3 mm was taken
from the lesion area for a histological examination. Conclusion of doctor pathologist -
"adenocarcinoma in situ* means that.
Neoplastic changes are extent only in the stomach epithelial layer without invasion into the
basement membrane
Epithelial neoplasm is detected in early stages
Glandular epithelial neoplasm is excised radically
Squamous neoplasm is only in the stomach epithelial layer without invasion into the basement
membrane

A woman underwent percutaneous coronary intervention of the circumflex artery (S11, S12) 2 76
year ago. Her medical record included arterial hypertension and type 2 diabetes mellitus. After
the procedure she had no chest pain, arterial blood pressure and glycemia are well controlled.
Which is the level of cardiovascular risk in this case?
Low risk
Moderate risk
High risk
Very high risk

The patient was found unconscious on the street, was admitted to the ED. During examination 77
pinpoint sized pupils were found, RR: 4-6, BP: 105/60, HR: 104. What is your preliminary
diagnosis?
 Acute amphetamine poisoning
Hypoglycemic coma
Acute opioid poisoning
Drunkeness

The patient burned his back with hot steam. The skin is red, very painful, no blisters. When you 78
press the skin it fades. What degree of burn is it?
1 degree
2a degree

2b degree
3 degree

A 25 year old man develops glomerulonephritis, and his glomerular filtration rate(GFR)decreases 79
by 53% and remains at that level. For which of the following substances would you expect to find
the greatest increase in plasma concentration?

Na
H
K
Creatinine
Clucose

A 65 year old lady had symptoms of typical angina pectoris lasting for the last 9 months. 80
Scheduled coronary angiography was performed. A significant (95%) stenosis of the right
coronary artery was observed and successful percutaneous coronary intervention (PC) was
done. Which medications should be started to prevent a stent thrombosis?

Aspirin + Clopidogrel
Aspirin + Rivaroxaban
Aspirin + Warfarin
Clopidogrel + Ticagrelor
Clopidogrel + apixaban

A 70 years old female was brought to the emergency department for peritonitis … patients 81
illness is about 3 days. The patient also has arterial hypertension and type 1 diabetes mellitus.
Patient undergoes emergency surgery. What treatment has a significant impact on surgical
outcome? (tror)

Vasopressors and antibiotics

Infusion therapy and vasopressors

Infusion therapy and antibiotics
Infusion therapy and steroids
Vasopressors and steroids
Which of these patients is at most risk for complications? 82

25 years old woman with burns on her face, neck, chest and back. IIa-IIb degree burn

10 years old child with burn on leg, Ia degree burn

36 years old man burns his left arm with hot oil, IIb degree burn.
42 years old man is scalded by boiling water on the front surfaces of both forearms.

A 64 years old man with a long-standing history of arterial hypertension, IHD, atrial fibrillation 83
treated with indirect anticoagulants, suffered ischemic stroke with right-sided hemiparesis two
months ago. Two and a half hours ago she suddenly developed dizziness and left-sided limb
weakness. On examination patient is conscious, well-oriented, HR:120, Pulse: 96, BP: 230/115.
Movements are restricted of left limbs, left toungue deviation, left flattened nasolabial fold. Only
muscle contraction with no movement is observed in the left leg. Diminished tendon reflexes,
hemi-hypesthesia, hemianopia and positive babinski on left side. Preliminary diagnosis?

Acute cerebrovascular accident in the right medial cerebral artery

Hemorrhagic stroke
Acute cerebrovascular accident in the left medial cerebral artery
Ischemic stroke
Acute neuroinfection

A 65 years old man suffered a high volt electrical injury. There is a burn of the entire thickness … 84
and right arm. What is the most common early complication that may occur in this patient?
Cerebral ischemia
Arrythmia
Sepsis
Pneumonia

A 70-year-old man with a history of myocardial infarction 10 years ago, usually has to take a 85
short rest due to dyspnea after climbing stairs to the second floor. Bi-basilar fine crackles in the
lungs are observed during physical examination. Which disease do you suspect?

Acute left ventricular failure

Total heart failure
Chronic left ventricular failure
Chronic right ventricular failure
Pulmonary embolism

86
55-year-old man, heavy smoker, complains of intermittent jaundice associated with itching. This
is associated with weight loss and upper abdominal discomfort. On examination the patient has
scratch marks over his body, is slightly jaundiced and has a gallbladder that is just palpable.
Transabdominal ultrasound examination determined dilated Common bile duct and the Main
pancreatic duct. Mass in the head of the pancreas can be identified. What is the most commonly
used imaging modality to detect and stage the suspected disease?
MRI with MRCP
PET scan
US guided percutaneous biopsy
CT with contrast
ERCP

There are 4 groups of signs and symptoms listed below, for which ot the following lumbar 87
puncture is contraindicated?

Frequent micturition, gait disorder, signs of brain atrophy on head CT

Positive meningeal signs, enlarged all ventricles with periventricular edema
Enlarged pupils, tachycardia, hypotension, midline shift on head CT
Headache, positive Kernig’s, subarachnoid hemorrhage on head CT

A 64 years old man has been admitted to the ICU due to confirmed pulmonary embolism. On 88
examination cyanotic, cold, clammy and mottled. SpO2: 84%, MAP: 55, HR: 124, CRFT: 5 sec.
Patient was given oxygen and heparin infusion and norepinephrine, which stabilized the critical
condition. What further treatment is adequate?

To continue current therapy

To continue current therapy and consiter thrombolytic therapy if situation worsens
To continue current therapy and perform Vena Cava filter due to risk for pulmonary emboli
To consider a primary reperfusion therapy (systemic thrombolysis)
Perform a surgical embolectomy due to the existing obstructive shcok

A 8-year-old girl is brought to the physician due to oliguria and puffiness around the eyes. She 89
complains of a frequent urination and changed urine color - it is almost brown. Two weeks ago
the girl had returned from school with a sore throat. Therefore, she didn't attend classes for
several days and afterwards medical advice was sought. Laboratory blood test: the amount of
urea and creatinine level are slightly increased, reduced C3 and an elevated antistreptolysin O
titer is found. Analysis of urine reveals moderate proteinuria and hematuria. Which disease do
you suspect?
 Acute cystitis
Chronic glomerulonephritis
Acute renal failure
Poststreptococcal glomerulonephritis
Acute pyelonephritis

68 years old patient complains of shortness of breath while walking, climbing stairs, swelling of 90
legs in the evening, weight gain and nocturia. Symmetrical edema is observed in the feet and
ankles during physical examination, edema of the face is absent.

Nephritic syndrome
Nephrotic syndrome
Pretibial myxedema
Hypoproteinemia
Edema due to chronic right ventricular failure

A 62 year old patient has been diagnosed with tachysystolic atrial fibrillation. He has a history of 91
ischemic heart disease and atrial hypertension. His physical examination revealed heart rate
122 beats/min, arterial blood pressure 146/92 mmHg. Left ventricle ejection fraction 50%. Which
medication is suitable for heart rate control in this case?
Propofenon
Metoprolol
Ivabradin
Amlodipin
Perindopril

A sixty years old man noticed flashing lights and floaters in his left eye one week ago. Two days 92
ago… grey curtain moving from below over the field of vision. The vision of his left eye recently
OD=1,0, VA OS- light perception without projection, no color vision. What is the preliminary
diagnosis?

Central retinal vein occlusion

Optic neuritis
Vitreous hemorrhage
Retinal detatchment
Central retinal artery occlusion

A 30-year-old man complains of epigastric pain, especially during prolonged periods of fasting or 93
at night. The pain is briefly relieved after a meal or by taking antacids. He reports no change in
appetite, weight or voiding habits. He does not take any medications. His epigastric region is
tender upon palpation. A duodenal ulcer was diagnosed during esophagogastroduodenoscopy.
What do you need to do before starting treatment?
 Test for clostridium difficile
Test for serum amylase
Test complete blood count
Test for H.pylori)

A 77-years old female referred to an outpatient department because of intermittent jaundice and 94
chills. Sometimes she has aches in the epigastric region. Weight loss (about 10 kg per month).
Blood tests; white blood cells 8,9x10^9/l (4-10 x 10^9/l). Haemoglobin -121g/1(120-140
g/1),platelets- 140x10°/1 (150 - 350 x10°/1), C-reactive protein(CRP) - 5 mg/l) (<5 mg/l),
Aspartat Aminotransferase (AST) - 54 IU/L (10-40 IU/L), Alanine Aminotransferase (ALT) - 78
IU/L (5-40 10/L), Gamma - Glutamyl Transpeptidase (GGT) - 310 IU/I (0-30 IU/L), common
bilirubin - 78 umol/I 3,4 - 17umol/l) (direct bilirubin - 56 umol/l). Abdominal sonography: liver ~ 16
cm large, intrahepatic bile duct ~ 4 mm,Common bile duct (CBD) ~ 1.2 cm, gallbladder ~ 14 cm,
wall thin, the content is transparent. Pancreatic duct is normal size. What disease do you
suspect and what are the investigation tactics?

I suspect cholangiocarcinoma and first line examination is abdominal MRI

I suspect cholangiocarcinoma and first line examination and treatment is ERCP
suspect gallstones and first line examination is abdominal CT
I suspect cholangiocarcinoma and first line examination is abdominal CT
I suspect gallstones in common bile duct and first line examination and treatment is ERCP

A 72 years old woman arrives to hematologist, complains of shortness of breath and no previous 95
significant past medical history. CBC: Hb: 80…. white blood cell count 1,8 x 10^9 (4,5-10). In
bone marrow megaloblastic changes in erythroid and granulocytic lineage, hypersegmentation
of neutrophils. Blood tests: serum folate 8 ng/L (>4,7), serum Vit B12 < 150 µg/L. Which
treatment would you prescribe?

Cyanocobolamine 1000 µg IM, once

Cyanocobolamine 1000 µg /d IM, for one week, then 1000 µg / week, then 1000 µg / month
Cyanocobolamine 1000 µg /d orally, for 1-2 months
Folic acid 2g /d for 3 months

A 53 year man has been complaining of dyspnea during light physical activity and shortness of 96
breath even at rest for the last week. Dry cough, general weakness, swelling of legs are
accompanying dyspnea. Which functional class of heart failure according to NYHA do you
determine in this case?

I functional class
II functional class
III functional class
IV functional class
A 40 years old carpenter complains of about half a year of obstructive nasal breathing, persistent 97
runny nose, watery eyes, recurrent mild forehead and cheek pain. To fascilitate breathing he
uses topical nasal decongestants several times per week. Face is symmetrical, eyes are not
swollen. Nasal endoscopy shows: bilateral nasal polyps without ... to the nasopharynx. What
treatment will you start?

Endoscopic nasal polyp removal surgery

Endonasal steoid spray
Bilateral endonasal biopsy

The 85-year-old man suddenly felt severe abdominal pain around the umbilicus after meal, 98
nausea, but did not vomit.The patient began to defecate in raspberry colored stools. The
patient had open appendectomy for acute appendicitis and a history of myocardial infarction. He
is suffering from chronic atrial fibrillation. When the patient is examined, his general condition is
satisfactory, the abdomen by palpation is soft, painless, there are no signs of muscle
tension,peritoneal irritation, peristalsis is active by auscultation. Cardiac activity is arrhythmic,
heart rate - 86 b/min, ABP 140/90 mm/Hg. Complains of very severe abdominal pain. What
pathology do you suspect?

Complete small bowel obstruction due to adhesions

Acute pyelonephritis
Duodenal ulcer perforation
Acute pancreatitis
Acute mesenteric ischemia

A 82 year old man, complaining of syncope and recurrent collapses, is undergoing an 99

examination by a cardiologist. During auscultation, severe IV* systolic murmur is present at the
left parasternal intercostal auscultation point with irradiation to the neck and apex of the heart.
Heart rate 74 b/min, arterial blood pressure 128/76 mmHg. Which investigation should be for the
first choice to determine the cause of syncope in this case?

Cardiac MRI
Stress ECG
2D transthoracic echocardiography
Holter monitoring
Coronary angiography

48 year old patient with a history of mechanical aortic valve replacement, heart failure and 100
partial epilepsy, was hospitalized for ischemic stroke. At home was taking warfarin 15mg QD
(INR values ranged 1,3 -1,7), spironolactone 25 mg QD) carbamazepine 200 mg TID, and
omeperazole 40 mg QD. What changes are needed to prevent interaction resulting in
decreased anticaggulation activity?

Continue warfarin at the same dose, as INR target values are achieved slower in case of
enhanced metabolism by carbamazepine
Switch carbamazepine to another antiepileptic drug to prevent warfarin metabolism induction:
continue warfarin
Switch warfarin to direct oral anticoagulant
Reduce the dose of omeprazol to prevent interaction with warfarin
28 years old woman has fever of 38 C°, chills, frequent urination, pain in the left flank, nausea 101
and vomiting for several days. Examination: positive jordans sign in the left flank region.
Urinalysis revealed eleveated WBC and moderate hematuria. What additional tests will you
perform to clarify the diagnosis?

Serum creatinine and CRP are enough to clarify diagnosis

Kidney CT, total blood count, serum crea, urine culture
I will do kidney palpation by suspecting possible kidney enlargement
Total blood count, serum crea, CRP
Kidney US, total blood count, serum crea, CRP, urine culture

28 years old female complains of diplopia, weakness, in her right arm and leg, numbness, 102
disturbed gait. Symptoms started a few days ago. She had no fever or tick bite. Experience
some fatigue and concentration difficulties at work last 6 months. Two years ago patient had
sudden sight impairment in left eye that lasted for a week. She did not go to the doctor. No
history of other diseases. Somatic status is fine. Neurological findings: limited lateral movement
of the left eye when looking to the left. Other CN without pathology. Muscle strength in right arm
and leg 4 points. Proximal increase of muscle tone in the right, deep tendon reflex brisk and
increased on the right. Rossolimo's and babinski's sign is positive on the right. Decreased
abdominal reflexes on the right. Finger-nose test done with intensive tremor. Heel-knee test
shows ataxia on left limb. Tilt to the left while in romberg’s position, gait slightly ataxic-paretic.
What diagnosis do you suspect and what investigations are needed to confirm it?

Gullian-Barre syndrome: ENMG, CSF analysis

Acute encephalitis: CSF analysis, specific serum Ab’s
Multple sclerosis: Head and/or spinal MRI, CSF analysis, Evoked potential examination Acute
vertebrobasilar cerbral vascular accident: urgent head CT

65 years old man comes to ER due to speech disorder. After main investigation there is motor
103
aphasia. What features define motor aphasia?

Impaired spontaneous speech, preserved comprehension, impaired repitition

Preserved spontaneous speech, impaired comprehension, impaired repitition
Impaired spontaneous speech, impaired comprehension, preserved repitition
Impaired spontaneous speech, impaired comprehension, impaired repitition

A 69 yrs-old patient has been admitted to Emergency Room (ER) with 20 yrs of arterial
104
hypertension history complaining of severe headache, dizziness, nausea and visual
disturbances. The patient is somnolent, disoriented, on neurological examination no focal
signs. Vital signs: HR 135 bpm, arterial blood pressure 230/125 mmHg, mean arterial pressure
(MAP) 157 mmHg, RR 32/m, SpO2 96%. Cerebral CT is presenting no signs of acute damage.
What is your optimal choice?
 Urgent reduction of ABP until 150/80, patient has to be hospitalized in neurology department
Patient has to be admitted for monitoring and treatment in ICU, immediate IV administration of
rapidly acting antihypertensive drugs may be provided with aim to reduce MAP with 20-25%
Patient is further monitored in the ER with oral antihypertensives, consultation with cardiologist
abot further management.
Patient must be sedated and intubated to maintain safe airway, antihypertensive drugs
administered IV, further treatment in ICU.

25 years old female with diplopia when looking to the right, neurological examination reveals 105
impaired adduction of left eye with mono-occular horizontal right beating nystagmus of the right
eye. Other movements are normal. Where is the lesion located?

Right medial longitudinal fasciculus

Left medial longitudinal fasciculus (x)
Left abducens nerve
Nuclei of abducens and oculomotor nerves in brainstem
Right oculomotor nerve

50 years old patient underwent laparoscopic suture repair of a perforated … a few days later
106
the patient developed high fever, became somnolent and started complaining of a right sharp
pain during inspiration. Muscle rigidity of the right upper abdominal quadrant … where not
painful or rigid. What illness or post-op complication do you suspect, what treatment will ypu
provide?

Subhepatic abscess. Abdominal US and CT. When confirmed, percutaneous abscess drainage
Right sholder inflammation. Prescribe NSAIDs. Order CBC, CRP, blood glucose ….
Evaluate if gallbladder attack. Prescribe analgesics
Inflammatory reaction in abdominal cavity after surgery. Prescribe …..

After experiencing a back injury, the 44 year- old male has been suffering from severe lumbar 107
pain for several years, resulting in regular use of Ketorolac, Diclofenac and ibuprofen. The
patient smoked up to 20 cigarettes per day. Tonight the patient suddenly felt severe pain in his
upper abdomen that quickly spread to other areas of the abdomen. He was immediately
brought to the ED of the hospital. Obj: abdomen tense, hard, painful on the whole area with
palpation of the peritoneum. Bowel movements are sluggish, single peristaltic waves are heard.
Heart rate - 94 rpm, ABP-110/70 mmHg. BR- 23 rpm, rhythmic pulse (ECG - SR). What
diagnosis is most likely and what is the first choice of investigations?

Perforated stomach or duodenal ulcer. Chest and abdominal X-ray.

Hepatitis: urgent exam of liver enzymes
Acute pancreatitis: evaluate serum amylase
Acute gastroduodenitis: perform general blood test, CRP and gastric endoscopy
Acute cholecystitis: urgent abdominal US
68 years old man suddenly developed weakness in left limb, unclear speech accompanied with 108
strange behavior. He was attempting to leave for work and refused to go to the hospital despite
paralysis. When called upon the patient would turn and respond to the other side. These
symtoms are common for?

Acute neuroinfection
Acute psychiatric disorder
Stroke with hemiparesis and hemianopia
Acute cerebral vascular accident presenting with neglect and anosognosia

A 82 years old male diabetic patient was brought by ambulance to ED due to bleeding in the 109
calf. History reveals patient has varicose veins 15-20 years, only treated conservatively
because he refuses surgery. Physical examination: Bandage of the right calf is soaked with
blood. Blood is still oozing through the bandage. ….
What are your actions?

You perform ulcer bandaging and assess condition of the ulcer, the source of bleeding.. When
bleeding is detected from a damaged varicose node, elevate the leg and put pressure on it. In
case of insufficient hemostasis perform ligature of the ruptured varicose node.
Order blood glucose test in case of hyperglycemia you should contact endocrinologist for
consulting insulin dose. Persorm US to assess arteries and veins … After you place a sterile
pressure bandage on the calf ulcer. Further treatment tactics ….
You remove the bandage and put on a new pressure bandage that is moistured with saline
Add additional bandage without removing the first one already applied and numb the ulcer

Cardiologist heard a midsystolic II-III murmur and split S2 heart sound at position of pulmonary 110
artery. Cardiac US revealed left ventricular ejection fraction 55%. Which pathology is likely?

Atrial septum defect

Mitral valve prolapse
dilatative cardiomyopathy
Mitral valve regurgitation
Aortic valve regurgitation

A 30 years old female arrives to ED with pain in the right hip area, nausea and single vomiting. 111
Pain started 24h ago with discomfort in epigastrium. Temp: 37,8 C°, BP: 130/90, CRP: 30,
WBC: 12,8 x 10^9 (4-10), neutrophilic deviation. US: appendix with enlarged diameter and 2mm
wall thickness, 2cm free fluid in the right lateral corner of the abdomen.
What is the choice of treatment?

Diagnostic laparoscopy
Antibiotic therapy
Laparoscopy and appendectomy
Laparatomy and appendectomy
Percutaneous free fluid puncture and antibiotic therapy
An 11 year old boy was examined because of short stature (<3rd percentile), no other 112
complaints. Lab. tests: low Insulin-like growth factor 1 (IGF-1), Somatotropin hormone (STH)
stimulation tests showed growth hormone deficiency, Brain Magnetic resonance imaging (MRI)-
no pathology. Thyroid and adrenal axis no pathology, Mother's height 170 cm,father's - 180 cm.
Physical exam: no dysmorphic signs, puberty P1-2G1-2. What pathology would you suspect for
this patient?

Isolated growth hormone deficiency

Constitutional growth delay
Familial short stature
Multiple hypopituitarism
Pubertal delay

A 38-year-old man had undergone a splenectomy after a car accident. Now in April he came for 113
a visit after finishing his rehabilitation therapy. He complains of mild discomfort at the site of the
surgical incision but otherwise feels fine. Physical examination appears normal. Against which
severe infections will you recommend to get immunised as soon as possible for the patient with
an increased risk after the splenectomy?

Pneumococcal infection, H. influenza B infection, meningococcal infection

Meningococcal infection, tick-born encephalitis, influenza
Influenza, pneumococcal infection, H. influenza B infection
H. influenza B infection, tick-born encephalitis, Pneumococcal infection
Pneumococcal infection, influenza, menigococcal infection

A 3 year old boy is evaluated by a paediatrician for symptoms of malabsorption. The child's 114
mother explains that at about 5 month age, the boy began to have bulky, strong- smelling stools
with painful abdominal bloating and flatulence after consumption of his morning cereal.
Currently, the child is on a normal diet but is exhibiting signs of muscle wasting in his legs and
buttocks and loss of subcutaneous fat. The child's stomach is distended on the physical exam.
Which of the following histologic findings would be present, if this child's intestinal tissue was
biopsied?

Small granulomas in colonic mucosa

Crypt abscesses in colonic mucosa
Flattened intestinal villi
Foamy macrophages with PAS-positive granules
Nests of cells with small round nuclei and chromogranin-positive cytoplasm

You are consulting .. years old woman for contraception. Her menstrual cycle is regular. She is 115
complaining of menstrual bleeding, severe cramps and problem with acne on face. Anamnesis:
nulliparti, no gynecological surgeries or illnesses, non-smoker, takes no medications. No
pathology was found during ultrasound or cervical pap-smear. Which contraception is the most
suitable?

Spermocides
Barrier contraceptives
Combined oral contraceptive pills
Levonogestrel intrauterine device
32 year old women woke up due to lower left abdominal pain. She also felt nauseous, 116
weakness and was sweating but cold. Patient had one vaginal delivery 7 and a half years ago.
After delivery she had never conceived, even though no contraception was used. Last year, the
patient was treated in gynecology inpatient unit due to pelvic inflammatory disease. Menstrual
cycle is regular (MC 5/28). The last menstrual period was 7 weeks ago, due to late
menstruation the woman has planned to visit gynecologist in 4 days. Which of following
condition you suspect?

Tubo-ovarian abscess
Ectopic pregnancy
Ovarian cyst rupture
Adnexal rupture

A 15 years old boy, 176 cm, 100 kg, was sent to the pediatric cardiologist for acute high blood 117
pressure and complained of heacaches. On examination: overweight, HR rythmical, 80 bpm,
BP: 134/85, palpable a.femoralis. Vesicular breathing sounds. Liver and spleen non-palpable.
No leg edema. No pathological changes in instrumental or lab tests. What are your
recommendations?

Diuretics
Beta-blockers, Ca-channel blockers and ACE-inhibitors
You recommend non-medical treatment: lifestyle change, physical activity, weight loss and diet
change for 6 months
No treatment is required as arterial blood pressure is normal

A 28 y old woman experience episodes of swelling of the — fråga 73 i pdf 118

Acute urticara with angioedema

Hereditary angioedema due to C1 inhibitor def
Angioedema caused by local anaesthetics
Chronic urticaria with anhioedema
ACE (angiotensin converting enzyme inh) induced angioedema n

A 29 year old man comes into his family doctor office complains of severe lower back pain 119
which occured just a few days ago and radiates to his left groin area and left leg. He uses
Diclofenac but without success. From anamnesis it is known that he had problems with lower
back pain for the past 10y. …… Inital no radiation to groin area or left leg. He has no history of
chronic conditions. Obj:BP 144/85, HR… bpm. No pain in abdominal area. Neuro: ….. back
mucles, decrease in mobility range due to pain. U…… test: right leg 80°, left leg 55°. Which
treatment would you prescribe as long-term pain relief for this patient?

Myorelaxants
Pregabalin/Gabapentin + Vit B
Antispasmodic drugs
Physiotherapy and morning stretch
NSAIDs
A 43 year old woman was hospitalized in the gynaecology department due to acute abdominal 120
pain and suspected ectopic (tubal) pregnancy. Pregnancy test was done in the emergency
department and it was positive. Patient has had two pregnancies and two vaginal deliveries in
the past. She is not using contraception even though she is unwilling to get pregnant.
Hemodynamics are stable. Ultrasound examination: suspected intraperitoneal hemorrhage
(hemoperitoneum). Rest is normal but haemoglobin is 108 g/l. Red blood cells are reserved if
hemotransfusion will be needed. What are your tactics?

Laparoscopy and salpingectomy

Laparatomy and salpingectomy
Laparoscopic removal of ectopic pregnancy tissue and bleeding coagulation
Laparotomic removal of ectopic pregnancy tissue and bleeding coagulation

A 65 year old man seeks advice regarding dietary modifications to help prevent gout flares. He 121
recently experienced his first episode of podagra. Serum Urate level was 420 umol/l (155-357
umol/1), For hypertension he takes losartan. Obj: Body mass index (BMI) is 27, blood pressure
is 135/80 mmHg, other - unremarkable. In addition to meat restriction, intake of which of the
following may help to decrease this patient's risk of gout flares?

Shellfish
Sugary drinks
Red wine
Low fat dairy youghurt

You are seeing a 15 days old newborn in ED. Baby was born premature week 35. Parents
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complain that the son refuses to breast-feed and started grunting a few hours ago. During
examination you find baby is grunting, HR: 190, RR: 80, CRT: 4 sec, T: 36,1 C°. What is your
diagnosis and what tests are you going to perform?

Late onset neonatal sepsis. CBC, CRP, urinalysis

Congenital heart disease. Heart US
Hypothermia. CBC, CRP
Early onset neonatal sepsis. CBC, CRP

A 36 years old man with diabetes type 1 had an injection of 14 IU of short acting insulin. He
123
was preparing to eat lunch but had a friend calling and spent 25 mins talking on the phone.
Soon after he felt general weakness, dizziness, his speech became slurged. Physical
examination: he is breathing normally, sweaty, muscle tremor is observed, unconscious, does
not respond to questions. What condition do you suspect?

Ketoacidosis
Hypoglycemic coma
Stupor due to hypoglycemia
Hyperglycemic coma
Hypovolemia
A 25 year old woman complains of intermittent cough and wheezing for about 1 year. 124
Furthermore, shortness of breath during exercise appeared in the last 4 months, The
symptoms are more intense in the morning (the patient wakes up due to these symptoms once
per week). During forced expiration wheezes are heard bilaterally. Sp02 - 97 %. Spirometry is
normal, bronchial challenge test with methacholine is positive. The patient was diagnosed with
moderate asthma, What asthma treatment would you prescribe?

Stage II treatment: low-dose inhaled GCCS + short-acting inhaled Beta-2-agonist during

shortness of breath
A combination of long-acting bronchodilators
No specific asthma treatment is required yet
Stage IV treatment: moderate-dose inhaled GCCS + long-acting inhaled Beta-2-agonist + short-
acting inhaled Beta-2-agonist uring shortness of breath

A 30 years old man is brought to the emergency department by companions. He does not know 125
why he is here. He clearly responds but is also agitated and paranoid. He says he feels
”fantastic” but is variable when answering any questions. The patient has moderate elevated
BP + HR. He is most likely intoxicated with which of the following substances?
Cocaine

Alcohol
Barbiturates
Benzodiazepines
Opioids

A 69-year-old female patient came into her family physician's office complaining of cough and 126
fever up 38,4 C for the past 2 days. From anamnesis it is known that she has had type 2
diabetes and arterial hypertension for many years. Objectively - BP 137/72 mmHg, HR 64 bpm.
Slight redness to her posterior pharyngeal wall. During auscultation you hear rales in her lower
right lung. No edema in her legs. Which antibiotic is a first-line treatment for community
acquired pneumonia in Lithuania?

Amoxicillin
Clarithromycin
Amoxiclav
Phenoxymethylpenicillin

Patient was brought to the ED with nausea and vomiting… gave IV infusion. As you do the 127
primary survey you notice stridor while patient is breathing.
SpO2: 95% without supplemental O2. BP 80/40. HR: 125. The patient claims these symotoms
started after eating shrimps. What treatment?

Metoclopramide IV
Epinephrine IM
Prednisolone IV
Epinephrine IV
A 54 year old man is evaluated during a follow-up visit for gout. One year ago, he had been 128
treated with allopurinol and developed a hypersensitivity reaction. Over the past several
months, he has had recurrent attacks of acute, episodic swelling of the 1st
metatarsophalangeal joint, and involvement of ankles and knees. Lab tests showed significant
hyperuricemia, and glomerular filtration rate of 47 ml/min/1,73 m2. History - hypertension
(controlled by diltiazem),chronic kidney disease, nephrolithiasis, non alcoholic fatty liver
disease. Which of the following is the main contraindication to the use of uricosuric drug in this
patient?

Diltiazem
Non-alcoholic fatty liver
Renal insufficiency
History of nephrolithiasis

A 16 year old girl was examined because of amenorrhea and no signs of breast development. 129
From 7 years old, she has been followed up because of short stature Had multiple middle ear
infections. Mother's height - 168 cm, father's 181 cm. Both parents are healthy with normal
puberty in the past. Physical examination: height 146 cm (< 3%.), weight 50 kg (10 %). Thyroid
I°, soft. Tanner stage P1-2 B1-2. Cardiovascular system - no pathology. Dysmorphic signs: low-
set ears, webbing of neck. Lab tests: high Luteinizing hormone (LH) and follicle-stimulating
hormone (FSH), low estradiol, low insulin-like growth factor 1 (IGF-1). Thyroid Stimulating
Hormone (TSH) and Free thyroxine (FT4)- normal, high anti-TPO. Referred for genetic
counselling and karyotype analysis. Which syndrome would you suspect?

Pendred
Klinefelter
Cushing’s
Turner
Prader Willi

A 39 year old traveller is planning to go to Cuba at the beginning of the COVID-19 pandemic.
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He is known to have had viral hepatitis A in the past. He is vaccinated against tick-borne
encephalitis, viral hepatitis B and yellow fever. The last time he was immunised against
tetanus/ diphtheria was at the age of 16. He was also immunised against typhoid fever 15
years ago. On the internet he learnt that viral hepatitis A and B, Dengue and typhoid fever are
endemic in Cuba. Which vaccines will you recommend for this traveller?

Dengue fever and typhoid fever

Viral B hepatitis, dengue fever, tetanus/diphteria
Tetanus/diphteria, typhoid fever
Viral A hepatitis, tetanus/diphteria
Viral hepatitis A and B, typhoid fever