Internal medicine - Differential diagnostic procedures

Question 1

INT - 19.1
A potential reason for febrile leucopenia, except:
A) agranulocytosis

B) SLE (systemic lupus erythematosus)

C) typhoid fever

D) epidemic typhus

Answer 1

ANSWER
D) epidemic typhus

EXPLANATION
Leukopenia means lower than physiologic (4.6–10.2 x 109/l) white blood cell count. In case of agranulocytosis myeloid elements of the blood that represent the majority of white blood cells in a healthy peripheral blood are depleted. In SLE, a systemic autoimmune disease is associated with lower than normal white blood cell count. Typhoid fever is an enteral infectious disease that is characterized by fever, splenomegaly and leukopenia, and it is caused by S. typhi, a Gram-negative bacterium. Murine typhus is caused by Rickettsia prowazekii and transmitted via infected body lice. The symptoms of this disease include high fever, strong headache, maculopapulous exanthema and occasional splenomegaly, but it does not cause leukopenia.

Question 2

INT - 19.2
The following febrile conditions are often associated with splenomegaly, except:
A) bacterial endocarditis

B) malignant lymphoma

C) rheumatic fever

D) typhoid fever

Answer 2

ANSWER
C) rheumatic fever

EXPLANATION
In bacterial endocarditis splenomegaly, septicemia and splenic infarction caused by septic emboli are common, and these can be diagnosed by physical examination and ultrasonography. In subacute bacterial endocarditis, which used to be considered as a distinct entity, the Schottmueller triad is a usual abnormality. The heart disease is associated with splenomegaly and hematuria; this latter is caused by renal infarctions due to septic embolization. Splenomegaly can also occur is various forms and stages of malignant lymphomas. In typhoid fever, it is a characteristic sign (see BGY-19.1. question). Rheumatic fever is not associated with splenomegaly.

Question 3

INT - 19.3
The following non-dermatologic conditions may cause generalized itching, except:
A) hypothyroidism

B) hemolysis

C) chronic kidney disease

D) malignant lymphoma

E) polycythaemia vera

F) primary biliary cirrhosis

Answer 3

ANSWER
B) hemolysis

EXPLANATION
Apart from hemolysis, all diseases listed may be associated with generalized itching. Most often, chronic renal disease causes this symptom. In primary biliary cirrhosis itching may be the first symptom to occur.

Question 4

INT - 19.5
The most common reason for hyperuricemia in the hospital setting:
A) chronic kidney disease

B) undertreated hypertension

C) chronic diuretic administration

D) obesity and purine-rich diet

E) type 2 diabetes mellitus

Answer 4

ANSWER
C) chronic diuretic administration

EXPLANATION
The long-term administration of thiazide-type diuretics decrease urate clearance, resulting in hyperuricemia. This is the most common cause of the laboratory abnormality. As regards the other diseases listed, chronic kidney disease causes hyperuricemia via the decreased GFR. Purine-rich diet may cause hyperuricemia even in the absence of renal disease. Uncomplicated hypertension and diabetes mellitus do not cause hyperuricemia.

Question 5

INT - 19.7
In which one of the following disorders would expect xanthelasma to occur the most frequently?
A) diabetes insipidus

B) hemorrhagic acute pancreatitis

C) diabetes mellitus

D) acute glomerulonephritis

E) liver cirrhosis due to portal hypertension

Answer 5

ANSWER
C) diabetes mellitus

EXPLANATION
Yellow, flat structures of some mm diameter appearing on the eyelid are expected to be seen in diabetes mellitus. In portal type liver cirrhosis they are not typical, unlike in primary biliary cirrhosis, in which their appearance may precede the typical symptoms. Their origin is associated with hyperlipidemia. It is a known fact that in familiar hypercholesterolemia xanthomas appear over tendons, the knees and the elbows

Question 6

INT - 19.8
All can cause heartburn (pyrosis), except:
A) duodenal ulcer

B) umbilical hernia

C) hiatus hernia

D) gastric ulcer

E) reflux esophagitis (GERD)

Answer 6

ANSWER
B) umbilical hernia

EXPLANATION
Heartburn or pyrosis is elicited by the abnormal neuromuscular activity of the supra-cardiac part of the esophagus. This may be caused not only by hiatus hernia or reflux esophagitis, but, through a reflex, by gastric or duodenal ulcers as well. Umbilical hernias do not cause heartburn.

Question 7

INT - 19.9
All are risk factors of cardiovascular diseases, except:
A) high level of HDL -cholesterol

B) high level of uric acid

C) high level of LDL-cholesterol

D) high level of total cholesterol

E) high level of triglyceride

Answer 7

ANSWER
A) high level of HDL -cholesterol

EXPLANATION
Elevated (>5.2 mmol/l) total cholesterol, elevated (>3.8 mmol/l) LDL-cholesterol and elevated (>1.7 mmol/l) triglyceride levels are well known risk factors of atherosclerosis. High uric acid level is a so-called secondary risk factor. HDL cholesterol, on the other hand, is antiatherogenic.

Question 8

INT - 19.10
All may cause bloody ascites, except:
A) acute pancreatitis

B) hemochromatosis

C) carcinomatous peritonitis

D) tuberculous peritonitis

Answer 8

ANSWER
B) hemochromatosis

EXPLANATION
Carcinomatous peritonitis usually causes bloody ascites. Hemorrhagic necrotizing pancreatitis or tuberculous peritonitis may also result is the presence of blood in the ascites. Hemochromatosis, a congenital disorder of iron metabolism, causes diabetes and liver cirrhosis. This latter complication can be associated with ascites in its decompensated state, but that ascites is never bloody.

Question 9

INT - 19.11
In case of renal transplantation, hypertension may be the consequence of the following, except:
A) renal artery stenosis

C) corticosteroid treatment

D) renin production from the original kidneys

E) azathioprine treatment

Answer 9

ANSWER
E) azathioprine treatment

EXPLANATION
After renal transplantation, all of the listed may cause hypertension, except for azathioprine used for immunosuppression.

Question 10

INT - 19.12
A middle-aged patient has hypertension and its complications coupled with polyuria and polydipsia. Laboratory investigation reveals Na:152 mmol/l and K: 2.2 mmol/l. The suspected diagnosis is:
A) Addison’s disease

B) Conn syndrome

C) Cushing syndrome

D) phaeochromocytoma

Answer 10

ANSWER
B) Conn syndrome

EXPLANATION
Severe hypokalemia and moderate polyuria accompanying untreated hypertension is typical of primary hyperaldosteronism (Conn’s syndrome). Addison’s disease is the synonym of primary adrenal insufficiency, in which electrolyte abnormalities are the opposite. Hyponatremia and hyperkalaemia usually belong to late signs of Addison’s disease, and the blood pressure is low. There is cortisol overproduction in Cushing’s syndrome with a typical clinical picture (moonface, livid striae, and central obesity). The classic form of phaeochromocytoma is caused by a tumor of the adrenal medulla. The typical clinical picture includes turning pale and becoming tachycardic during blood pressure surges. It is important to note, however, that steady hypertension often occurs in this disease.

Question 11

INT - 19.13
Common cardiopulmonary manifestations of sarcoidosis, except
A) pleural exudate

B) pulmonary fibrosis

C) cor pulmonale

D) hilar lymphadenopathy

Answer 11

ANSWER
A) pleural exudate

EXPLANATION
Boeck-sarcoidosis is a tuberculoid, granulomatous disease of unknown origin. It is characterized by bilateral hilar lymphadenopathy. Lung infiltrates may result in pulmonary fibrosis and chronic cor pulmonale. Pleural fluid is not part of the clinical picture.

Question 12

INT - 19.14
A patient has recurrent pneumonia in the same site. The underlying disorder may be best diagnosed using:
A) bronchoscopy, bronchography

B) hilar tomography

C) chest CT

D) summation X-ray

E) lung scintigraphy (perfusion and ventilation)

Answer 12

ANSWER
A) bronchoscopy, bronchography

EXPLANATION
When pneumonia recurs the same site, the clinician has to screen the patient for an aspirated foreign body, localized bronchiectasis or a tumor narrowing the bronchi. The most accurate diagnostics, therefore, include bronchoscopy and biopsy or bronchography.

Question 13

INT - 19.15
In case of hematochesia - unless caused by a dysentery outbreak – the most important steps of management include
A) determination of bleeding time, aPTI, prothrombin time and thrombocyte count

B) digital rectal examination and urgent rectoscopy or colonoscopy

C) in case of visible hemorrhoids, no further steps are necessary

D) native X-ray and abdominal ultrasound to screen for swallowed foreign bodies (needles, nails etc.)

Answer 13

ANSWER
B) digital rectal examination and urgent rectoscopy or colonoscopy

EXPLANATION
Hematochesia (passing red blood through the rectum with or without feces) necessitates the observation of the anus, and then the digital rectal examination. Rectoscopy should not be omitted, even if bleeding hemorrhoids are present. In this case the examination can be postponed by some days. The observation of upper segments of the colon via colonoscopy is also necessary, as a lesion found by rectoscopy may not be the only lesion of the large bowel. A patient receiving anticoagulant or antithrombotic treatment may start to bleed from a colorectal lesion (primarily from a tumor) earlier than patients without such treatments. Swallowed foreign bodies do not typically cause rectal bleeding.

Question 14

INT - 19.16
The following disorders may cause isolated ascites, except:
A) nephrotic syndrome

B) tuberculous peritonitis

C) carcinomatous peritonitis

D) v. portae thrombosis

Answer 14

ANSWER
A) nephrotic syndrome

EXPLANATION
Isolated ascites means that pathological fluid accumulation occurs only in the abdominal cavity without being part of a generalized edema (such as in nephrotic syndrome). Isolated ascites is expected to occur in conditions marked with B, C and D.

Question 15

INT - 19.18
What does the Bernstein-test serve for?
A) to relieve esophageal spasm

B) to diagnose esophageal diverticula

C) to identify fecal occult blood loss

D) to confirm that retrosternal pain is caused by reflux disease

Answer 15

ANSWER
D) to confirm that retrosternal pain is caused by reflux disease

EXPLANATION
Bernstein –test serves for the evaluation of the esophageal acid sensitivity. During the test, the esophagus is perfused through a nasogastric tube with diluted hydrochloric acid (0.1N) alternating with a neutral solution (0.9% NaCl). Reflux esophagitis is supported if hydrochloric acid elicits the retrosternal pain, whereas physiologic saline eliminates it. As nitroglycerine may decrease not only angina pectoris but esophageal retrosternal pain caused by abnormal neuromuscular activity as well, this rarely used diagnostic procedure’s role is to distinguish between the two conditions.

Question 16

INT - 19.19
The most common cause of upper gastrointestinal bleeding in alcoholics
A) esophageal varicosities

B) hemorrhagic gastritis

C) duodenal ulcer

D) duodenitis

E) Mallory-Weiss syndrome

Answer 16

ANSWER
B) hemorrhagic gastritis

EXPLANATION
All conditions listed may result in upper gastrointestinal bleeding in alcoholics, the most common of them being erosive hemorrhagic gastritis. Esophageal varicosities and variceal rupture carry an imminent risk of massive bleeding in case of liver cirrhosis. Alcohol-related gastritis is often associated with vomiting in the morning, which may result in a longitudinal tear of the esophageal mucous membrane, causing bleeding (Mallory-Weiss syndrome).

Question 17

INT - 19.20
The most common endocrine disorder associated with Zollinger–Ellison syndrome:
A) phaeochromocytoma

B) hyperthyroidism

C) hyperparathyroidism

D) hypoparathyroidism

Answer 17

ANSWER
C) hyperparathyroidism

EXPLANATION
Zollinger-Ellison syndrome is characterized by hypergastrinemia and consequent gastric hyperacidity with recurring peptic ulcer formation. When investigating gastric secretion, the basal acid output (BAO) is high. Increased gastrin production originates from the non-β-cell adenoma of the pancreas. Pancreatic islet cell tumors often appear as a part of the MEN (multiple endocrine neoplasia) I syndrome. Other components of the syndrome include parathyroid and pituitary adenomas. The correct answer is C.

Question 18

INT - 19.21
In which segment of the large bowel do unnoticed carcinomas occur most frequently?
A) cecum

B) hepatic flexure

C) descending colon

D) sigmoid colon

E) rectum

Answer 18

ANSWER
A) cecum

EXPLANATION
Tumors of the left part of the colon (descending and sigmoid colon) usually make the disease symptomatic at a relatively early stage. Typical symptoms include the alternation of diarrhea with constipation, subileus, ileus, or manifest bleeding. Tumors of the ascending colon or the cecum, however, may remain unnoticed for a longer period, and may be suspected from general signs and symptoms such as subfebrility, high erythrocyte sedimentation rate or anemia. In these cases, the demonstration of fecal occult blood loss is of utmost importance in diagnostics, likewise colonoscopy, especially in patients with positive family history of colorectal cancer.

Question 19

INT - 19.22
The most common site of diverticulosis in the colon:
A) rectum

B) sigmoid colon

C) descending colon

D) transverse colon

E) cecum

Answer 19

ANSWER
B) sigmoid colon

EXPLANATION
Diverticula of the large bowel are common findings in the elderly, and they occur most frequently in the sigmoid colon. Sometimes, they are accidental findings during barium enema or colonoscopy. Complications of diverticulosis include diverticulitis, peridiverticulitis, bleeding or perforation.

Question 20

INT - 19.23
How common is the recto-sigmoid involvement in ulcerative colitis?
A) 10–20%

B) 25–30%

C) 50–70%

D) 70–85%

E) 85–100%

Answer 20

ANSWER
E) 85–100%

EXPLANATION
The two inflammatory bowel diseases, Crohn’s disease and ulcerative colitis often represent a differential diagnostic task. Synonyms of Crohn’s disease are terminal ileitis and regional enteritis. Crohn’s disease may occur at any site of the intestinal tract (from the oral cavity to the rectum), with the terminal ileum being the most frequently affected site. In contrast to ulcerative colitis, in Crohn’s disease healthy and diseased bowel segments may alternate, fistula formation is common and bleeding is less frequent. Ulcerative colitis occurs in the large bowel, either in its entire length, or only in the distal part. The rectum is basically invariably involved, making E the correct answer.

Question 21

INT - 19.24
The most common disorder misdiagnosed as regional ileitis:
A) acute pyelonephritis

B) irritable colon

C) diverticulosis

D) appendicitis

E) gastroenteritis

Answer 21

ANSWER
D) appendicitis

EXPLANATION
Regional enteritis (Crohn’s disease) may start with a relatively acute abdominal pain, and tenderness around McBurney point. In such cases, distinguishing it accurately from acute appendicitis is very difficult. If operation is performed, however, the diseased small bowel segment does not have to be removed for many reasons. The typical location of diverticulitis is the left side of the abdomen. Gastroenteritis, diarrhea, pyelonephritis and irritable bowel syndrome are associated with clinical pictures and laboratory findings clearly different from appendicitis or regional ileitis.

Question 22

INT - 19.25
Abnormality responsible for congenital megacolon
A) hypertrophy of the descending colon

B) diverticulosis of the sigmoid colon

C) aganglionosis affecting the distal colon

D) rectal atresia

E) lack of internal rectal sphincter

Answer 22

ANSWER
C) aganglionosis affecting the distal colon

EXPLANATION
The bowel segment affected cannot relax, and histological evaluation reveals the lack of autonomic ganglia belonging to Auerbach and Meissner plexuses. Due to such a congenital anomaly, the segment affected becomes narrow, dilating the more proximal segments of the large bowel. Dilation may reach extreme degree. The clinical picture is characterized by constipation, passing stool may be absent for weeks. Treatment should include the surgical removal of the narrow colon segment.

Question 23

INT - 19.26
Fatal liver disorders can be treated with liver transplantation. Improved survival of the transplanted patients is primarily due to the following
A) better selection of patients

B) early diagnosis of malignant liver diseases

C) better understanding of the pathogenesis of liver failure

D) cyclosporine A

Answer 23

ANSWER
D) cyclosporine A

EXPLANATION
To avoid rejection, cyclosporin A is more favorable than other immunosuppressive agents after transplantation. This is the principal reason why survival is improved. The other factors listed are important as well, but their role is smaller.

Question 24

INT - 19.27
The most common cause of foreign body-related intestinal obstruction is
A) bezoars

B) parasites

C) bowel stones

D) swallowed iron-containing stones

E) gallstones

Answer 24

ANSWER
E) gallstones

EXPLANATION
Gallstones being passed to the small intestine represent foreign bodies. In developed countries, gallstone ileus is the most common cause of small bowel ileus caused by foreign bodies. Parasites are common in tropic areas. Bezoars are balls formed from swallowed hair or long vegetal fibers and they rarely cause ileus in Central Europe.

Question 25

INT - 19.28
Urine is typically isosmotic…
A) in acute tubular necrosis

B) in hepatorenal syndrome

C) in acute glomerulonephritis

D) in volume-depleted condition

E) after iv. urography

Answer 25

ANSWER
A) in acute tubular necrosis

EXPLANATION
In acute tubular necrosis the kidneys are incapable of concentrating or diluting glomerular filtrate, therefore, urine is isostenuric (its gravity is 1010, equivalent with that of the protein- free plasma). Hepatorenal syndrome is acute renal failure associated with severe liver failure, caused by variable pathomechanism. In this syndrome, isoosmolar urine is feasible, but not a general phenomenon. In acute glomerulonephritis as well as in volume-depleted conditions with healthy kidneys, concentrated urine is produced in small amount. After an iv. urography, contrast material makes the urine hyperosmotic.

Question 26

INT - 19.29
A middle-aged female patient complains weakness and increased need of sleep. Physical examination reveals slightly enlarged thyroid gland, sparse axillary hair, and vitiligo of the hands. Laboratory evaluation found markedly elevated TSH and depressed fT3 and fT4 levels, therefore, L-thyroxin supplementation was initiated in increasing doses (50μg and 100 μg/day). Initially she felt better, but after some weeks progressive weakness and anorexia developed. She visited her GP because of vomiting. The GP found no abdominal disorders, and measured her blood pressure which was 95/60 mmHg. She was sent to hospital. The most probable disease is
A) L-thyroxin overdose

B) intermittent porphyria

C) adrenal hypofunction due to autoimmune adrenal damage

D) central adrenal hypofunction caused by a pituitary tumor – the same tumor had caused the hypothyroidism

Answer 26

ANSWER
C) adrenal hypofunction due to autoimmune adrenal damage

EXPLANATION
Initial signs and symptoms revealed hypothyroidism, the adequate treatment of which was initiated. This treatment increased the glucocorticoid need of the body, however, the failing adrenal gland could not meet the requirement. The latent adrenal hypofunction became manifest, moreover, a pre-crisis condition set in. The presence of vitiligo suggests an autoimmune disease resulting in insufficient thyroid and adrenal function. Adrenal hypofunction may be associated with other endocrine disorders such as hypoparathyroidism and diabetes mellitus (Schmidt-syndrome). Intermittent porphyria has different clinical picture and course, therefore, it can be excluded. Elevated TSH levels are against central hypothyroidism.

Question 27

INT - 19.30
A young female patient lost 3.5 kg in 2 months. Her appetite is fine, and she did not change her diet. She has disturbed sleep, and she sweats a lot. Sometimes she has diarrhea. Physical examination reveals increased alertness, moist and warm skin, and fine tremor of the fingers. She has no exophthalmos. RR: 150/80 mmHg, pulse: 106/min, rhythmic. The most probable reason for weight loss is
A) a malignant hematologic disease

B) tuberculosis

C) helminthiasis

D) hyperthyroidism

E) diabetes mellitus

Answer 27

ANSWER
D) hyperthyroidism

EXPLANATION
The description suggests hyperthyroidism. Exophthalmos is present only in certain forms (such as Graves’ disease) of the disorder, and its absence does not contradict the diagnosis. Weight loss despite good appetite and adequate caloric intake may be present in the early stage of diabetes mellitus, but in that disease the concomitant symptoms are different (polyuria, polydipsia). Malignant diseases and tuberculosis are not associated with good appetite. Helminthiasis associated with the listed signs and symptoms is not present in our geographical region.

Question 28

INT - 19.31
The most common reason for Addison’s disease
A) autoimmune adrenal atrophy

B) amyloid deposition in the adrenal cortex

C) tumor metastasis in the adrenal cortex

D) bilateral adrenal apoplexy

E) adrenal tuberculosis

Answer 28

ANSWER
A) autoimmune adrenal atrophy

EXPLANATION
Previously, the most common cause of Addison’s disease was tuberculosis. These days, autoimmune adrenalitis is the most prevalent reason. Amyloid deposition rarely, tumor metastases or malignant infiltration more often cause gradually developing adrenal hypofunction. Bilateral hemorrhage of the glands causes an acute insufficiency instead of Addison’s disease. Waterhouse-Friedrichsen syndrome occurs in meningococcal septicemia in children or in septic adults receiving anticoagulant therapy

Question 29

INT - 19.32
Which of the following drugs does not decrease urine volume in diabetes insipidus, if given in high dose?
A) hydrochlorothiazide

B) chlortalidone

C) furosemide

D) etacrin acid

E) spironolactone

Answer 29

ANSWER
E) spironolactone

EXPLANATION
Thiazide type as well as loop diuretics deplete extracellular volume and increase water reabsorption in the proximal tubules, therefore, they may paradoxically decrease urine output in diabetes insipidus, especially if the lack of ADH is incomplete. The aldosterone-antagonist diuretic spironolactone has no such effect.

Question 30

INT - 19.33
The most probable condition associated with eosinophilia
A) pinworm infection

B) diarrhea caused by Giardia lamblia

C) schistosomiasis

D) measles

E) corticosteroid therapy

Answer 30

ANSWER
C) schistosomiasis

EXPLANATION
Eosinophilia ( > 400/μl) is most often caused by allergic diseases and parasite infections in which the parasites such as Schistosoma (blood fluke) invade the tissues. Other diseases associated with eosinophilia include Hodgkin’s disease and other lymphomas, solid tumors, eosinophilic pneumonia, dermatitis herpetiformis and idiopathic eosinophilia. Measles, a viral infection and glucocorticoid treatment do not cause eosinophilia.

Question 31

INT - 19.34
In case of long-term bedrest, the following complications can occur, except
1) pressure ulcer, muscle atrophy, osteoporosis

2) diabetes mellitus

3) thromboembolism, pneumonia

4) decubital angina, progressive dementia

A) answers 1, 2 and 3 are correct

B) answers 1 and 3 are correct

C) answers 2 and 4 are correct

D) only answer 4 is correct

E) all 4 answers are correct

Answer 31

ANSWER
C) answers 2 and 4 are correct

EXPLANATION
Long-term bed rest increases the risk of pressure ulcers, musculoskeletal disorders, thromboembolic events and hypostatic pneumonia. Adequate patient care is essential in their prevention. Long-term bed rest does not cause diabetes, dementia or angina pectoris. The term decubital angina refers to the appearance of the ischemic chest pain in supine position (usually at night).

Question 32

INT - 19.35
During pregnancy, the diagnosis and differential diagnosis of hyperthyroidism is difficult, because
1) thyroid-scintigraphy cannot be carried out

2) there may be a physiologic rise in heart rate

3) there may be a physiologic rise in total T3- and total T4-levels

4) TSH-levels cannot be interpreted

A) answers 1, 2 and 3 are correct

B) answers 1 and 3 are correct

C) answers 2 and 4 are correct

D) only answer 4 is correct

E) all 4 answers are correct

Answer 32

ANSWER
A) answers 1, 2 and 3 are correct

EXPLANATION
Performing isotope investigations during pregnancy is contraindicated. There is a physiologic rise in heart rate during pregnancy, owing to the rise in cardiac output by 30-50%. High estrogen levels result in the elevation of thyroxine-binding globulin, therefore, total T4 and T3 levels rise in blood. Free T3 and T4 levels are unaltered. TSH level does not change during pregnancy, thus it remains a good marker of thyroid function.

Question 33

INT - 19.36
Potential treatment of hyperthyroidism during pregnancy:
1) mercaptoimidazole, thiamazole in high dose

2) propylthiouracil in relatively low dose

3) radioiodine therapy

4) operation in the 2nd trimester

A) answers 1, 2 and 3 are correct

B) answers 1 and 3 are correct

C) answers 2 and 4 are correct

D) only answer 4 is correct

E) all 4 answers are correct

Answer 33

ANSWER
C) answers 2 and 4 are correct

EXPLANATION
Performing isotope treatment or administering mercaptoimidazole or thiamazole during pregnancy is contraindicated. Rarely, metothyrin causes fetal malformations (aplasia cutis). Thyroid surgery may result in miscarriage during the first trimester and increases the risk of preterm delivery in the third trimester. Operation may be carried out in the second trimester, however, contraindication of drug treatment is the only setting when it is recommended. Drug treatment may include propylthiouracil applied in the lowest effective dose without the combination of exogenous l-thyroxine. Thorough investigation and follow-up of the newborn is necessary, as TSH-receptor stimulating immunoglobulins, thyroid hormones and propylthiouracil all can cross the placenta, which may result in goiter, hypothyroidism or hyperthyroidism.

Question 34

INT - 19.37
This is the first examination of a 26-year-old patient as a male partner of an infertile couple. The couple has been unable to become pregnant for 2 years. The female partner is 22 years old, her menstrual cycle is regular, and their sexual life is normal (2-3 intercourse/week). They have never used any contraception. The male partner shaves twice a week, his pubic hair is slightly sparse (feminine). He is moderately obese, his pelvis is a bit wider than normal, and his breasts have been „somewhat feminine” since his puberty. Physical examination reveals walnut-size symmetrical gynecomastia. His penis is somewhat hypoplastic, the testes are in the scrotum and their volume is 10 (left) and 8 (right) cm3. As initial approach, diagnostic procedure should include the following steps.
1) measurement of hormone levels [testosterone, SHBG (sex hormone binding globulin), estradiol, LH, FSH, prolactin]

2) order karyotype

3) MRI to screen for pituitary microadenoma

4) examination of the semen

5) testicular biopsy

A) answers 1, 2 and 4 are correct

B) answers 1, 4 and 5 are correct

C) answers 1, 3 and 4 are correct

D) only answer 3 is correct

E) all answers are correct

Answer 34

ANSWER
A) answers 1, 2 and 4 are correct

EXPLANATION
The described hypogonadal appearance, gynecomastia and infertility suggest Klinefelter syndrome. After physical examination, the initial further diagnostic steps should include non-invasive laboratory evaluations. Low testosterone levels and free androgen index (FAI = testosterone level (nmol/ml) / SHBG*100) and elevated gonadotropin levels, especially FSH all confirm the hypothesis. In case of gynecomastia, estradiol levels, whereas in case of hypogonadism, prolactin levels should be measured. Klinefelter syndrome is proven by the karyotype 47 XXY. Evaluation of the semen reveals azoospermia. As a second step, sella MRI has to be ordered in case of elevated prolactin levels. Testicular biopsy shows typical abnormalities in Klinefelter syndrome, but it is not needed for the diagnosis.

Question 35

INT-19.38-19.41
Associate the condition that may cause fever of unknown origin or subfebrility with the best treatment option!
A) antibiotics

B) glucocorticoid

C) NSAID (non-steroid anti-inflammatory drug)

D) sedatives

INT - 19.38 - bacterial infection

INT - 19.39 - autoimmune disease

INT - 19.40 - neoplasia

INT - 19.41 - neuro-vegetative subfebrility

Answer 35

ANSWER
INT - 19.38 - bacterial infection- A)

INT - 19.39 - autoimmune disease - B)
INT - 19.40 - neoplasia- C)

INT - 19.41 - neuro-vegetative subfebrility- D)

Question 36

INT-19.42-19.46
Associate the hypertensive conditions with the most probable blood pressure value!
A) 160/90 mmHg

B) 147/80 mmHg

C) 180/115 mmHg

D) 190/40 mmHg

E) 135/95 mmHg

INT - 19.42 - isolated diastolic hypertension

INT - 19.43 - severe aortic insufficiency

INT - 19.44 - grade II hypertension

INT - 19.45 - hyperthyroidism

INT - 19.46 - grade III hypertension

Answer 36

ANSWER
INT - 19.42 - isolated diastolic hypertension - E)

INT - 19.43 - severe aortic insufficiency - D)

INT - 19.44 - grade II hypertension- A)

INT - 19.45 - hyperthyroidism- B)

INT - 19.46 - grade III hypertension- C)

Question 37

INT-19.51-19.54
Associate the disorders characterized by hiccup with their typical features!
A) a disease causing acute abdomen

B) gastroesophageal reflux

C) generalized itching is common

D) viral etiology

INT - 19.51 - encephalitis

INT - 19.52 - esophagitis

INT - 19.53 - peritonitis

INT - 19.54 - uremia

Answer 37

ANSWER
INT - 19.51 - encephalitis - D)

INT - 19.52 - esophagitis - B)

INT - 19.53 - peritonitis - A)

INT - 19.54 - uremia - C)

Question 38

INT-19.55-19.59
Associate the diseases causing acute abdomen with the characteristic brief case descriptions!
A) 15-year-old female, virgin, initial nausea and epigastric tenderness, then right-sided abdominal / lower abdominal pain

B) 22-year-old female, strong, cramping lower abdominal pain, paleness, tachycardia.

C) 40-year-old female, bloated abdomen without bowel sounds, diffuse muscle guarding

D) 50-year-old female with known gallstones, profuse vomiting after dietary excess (large, fatty meal), belt-like pain in the upper abdomen

E) 60-year-old female, sudden, strong pain in the lower abdomen

INT - 19.55 - acute appendicitis

INT - 19.56 - ectopic (extrauterine) gravidity

INT - 19.57 - rupture of a malignant ovarian cyst

INT - 19.58 - acute pancreatitis

INT - 19.59 - peritonitis

Answer 38

ANSWER
INT - 19.55 - acute appendicitis- A)

INT - 19.56 - ectopic (extrauterine) gravidity- B)

INT - 19.57 - rupture of a malignant ovarian cyst- E)

INT - 19.58 - acute pancreatitis- D)

INT - 19.59 - peritonitis- C)

Question 39

INT-19.60-19.63
Associate the disorder characterized by jaundice with the typical short description!
A) right subcostal pain, joint pain, palpable and tender liver, elevated direct and indirect bilirubin levels, high SGOT and SGPT

B) moderate jaundice, splenomegaly, elevated indirect bilirubin, normal SGOT and SGPT, low or absent haptoglobin

C) progressive jaundice, that initiates with or without cramping pain, in the latter case large and painless gallbladder can be palpable, urine is dark, stool is light, itching can occur with time, increased direct bilirubin levels, SGOT and SGPT are initially normal, ultrasound reveals wider bile ducts

D) the liver can be tender, and itching may occur, there is more profound elevation in the direct bilirubin level, SGOT and GSPT are elevated from the beginning, ultrasound reveals normal width of the bile ducts

INT - 19.60 - acute hepatitis

INT - 19.61 - hemolysis

INT - 19.62 - extrahepatic obstruction

INT - 19.63 - intrahepatic cholestasis

Answer 39

ANSWER
INT - 19.60 - acute hepatitis - A)

INT - 19.61 - hemolysis - B)

INT - 19.62 - extrahepatic obstruction - C)

INT - 19.63 - intrahepatic cholestasis - D)

Question 40

INT-19.64-19.68
Associate the disorders characterized by polyuria with their typical signs and symptoms!

A) daily urine volume varies between 2-4 liters, urine specific gravity is high (around 1030), past medical history includes weight loss

B) daily urine volume varies between 5-10 liters, urine specific gravity is 1002-1003, water deprivation does not affect polyuria or urine osmolality

C) Urine volume is variable, it can reach 40 liters / day in extreme cases, and urine specific gravity is low. Water deprivation decreases polyuria and increases urine osmolality.

D) Urine volume is not extremely large, urine osmolality is low (less than 1008). Administration of ADH-derivatives has no effect.

E) Daily urine volume varies between 2-3 liters, and urine osmolality is ~1010. Patients typically have hypertension.

INT - 19.64 - central diabetes insipidus

INT - 19.65 - type 1 diabetes mellitus

INT - 19.66 - chronic kidney disease (polyuric phase)

INT - 19.67 - psychogenic polydipsia

INT - 19.68 - renal diabetes insipidus

Answer 40

ANSWER
INT - 19.64 - central diabetes insipidus - B)

INT - 19.65 - type 1 diabetes mellitus - A)

INT - 19.66 - chronic kidney disease (polyuric phase) E)

INT - 19.67 - psychogenic polydipsia - C)

INT - 19.68 - renal diabetes insipidus - D)

Question 41

INT-19.69-19.74
Associate the diseases with their characteristic laboratory abnormalities.
A) Bence-Jones protein in the urine

B) elevated serum IgM levels

C) eosinophilia

D) hyperuricemia

E) polyclonal rise of γ-globulins in the serum

F) elevated porphyrin levels in the urine

INT - 19.69 - Hodgkin’s disease

INT - 19.70 - gout

INT - 19.71 - multiple myeloma

INT - 19.72 - lead poisoning

INT - 19.73 - portal liver cirrhosis

INT - 19.74 - primary biliary cirrhosis

Answer 41

ANSWER
INT - 19.69 - Hodgkin’s disease - C)

INT - 19.70 - gout - D)

INT - 19.71 - multiple myeloma - A)

INT - 19.72 - lead poisoning - F)

INT - 19.73 - portal liver cirrhosis - E)

INT - 19.74 - primary biliary cirrhosis - B)

Question 42

INT - 19.75
During pregnancy, the dose of glucocorticoid substitution can be reduced in an individual suffering from adrenal hypofunction, because the fetal adrenal hormone production can compensate for the maternal hormonal deficiency.
A) the statement and the explanation are both correct, and there is causative relationship between them

B) the statement and the explanation are both correct, without any causative relationship between them

C) the statement is correct but the explanation is false

D) the statement is false but the explanation in itself is correct

E) the statement and the explanation are both false

Answer 42

ANSWER
E) the statement and the explanation are both false

EXPLANATION
During pregnancy, glucocorticoid supplementation should be increased in patients with adrenal insufficiency, because cortisol-binding globulin (CBG) levels in the blood rise, lowering free, biologically active cortisol levels. At the end of pregnancy, further stimulation of fetal adrenal gland by decreasing exogenous corticosteroid administration is unnecessary. By that time the fetal adrenal gland reaches its physiologic, adult-like size. Fetal adrenal gland produces primarily dehydroepiandrosterone-sulphate in large amount.

Question 43

INT - 19.76
During pregnancy, the dose of L-thyroxin substitution should be elevated in hypothyreotic patients, because the increasing fetal requirement of thyroid hormone has to be fulfilled.
A) the statement and the explanation are both correct, and there is causative relationship between them

B) the statement and the explanation are both correct, without any causative relationship between them

C) the statement is correct but the explanation is false

D) the statement is false but the explanation in itself is correct

E) the statement and the explanation are both false

Answer 43

ANSWER
C) the statement is correct but the explanation is false

EXPLANATION
The statement is true, because estrogen elevates the thyroxin-binding globulin (TBG) levels in the blood during pregnancy, therefore the dose of administered L-thyroxin has to be increased (see BGY-19.35. and 19.36.) The explanation, however, is false, as the fetal thyroid gland starts to produce hormones from the 12th gestational week, with a profound rise in hormone production between weeks 18-20.

Question 44

Which of the patients should be visited first?
Two urgent phone calls are received by a general practitioner, who works alone in a village. A) A 50-year-old housewife stabs her arm with a knife while cooking. Her wound bled moderately, and local wound management was done by her neighbor, a health visitor. There is no major bleeding, but the patient complains about pain and she is worried about tetanus. B) A 72-year old, hypertensive male patient started feeling unwell while he was doing some exhausting jobs in garden. He complains about severe shortness of breath, his face is bluish, he produces gargling sounds and watery, foamy, pinkish sputum when coughing.
A) The wounded, otherwise healthy female

B) The suddenly ill, old male with known long-term hypertension; the other patient is referred to emergency care

Answer 44

ANSWER
B) The suddenly ill, old male with known long-term hypertension; the other patient is referred to emergency care

EXPLANATION
Limited resources often necessitate the determination of the order of emergency patient care. There are rules to be followed for example in warfare or in case of a mass casualty incident. In the two situations described, both patients require emergency care. Obviously, the critically ill man, suffering from pulmonary edema has to be treated first. Spontaneous recovery from a pulmonary edema caused by acute left ventricular failure is not possible (B). The deep wound caused by accidental self-stabbing also requires urgent care. If medical history indicated arterial bleeding, immediate antihemorrhagic treatment was necessary. It is important to note, that primary care was provided by a healthcare professional. Wound revision by a surgeon, cleaning and disinfection are nevertheless essential, disinfection may be performed using 3% H2O2 solution or Betadine. Wound drainage and open treatment are also necessary. Medical history may suggest wound contamination with soil that increases the risk of tetanus as well as gas gangrene. Injuries that are deep or of unknown depth have to be managed by ER surgeons. (Correct answers for question 78 are marked with numbers 2 and 4)

Question 45

INT - 19.78
Select the correct statement(s)!
Two urgent phone calls are received by a general practitioner, who works alone in a village. A) A 50-year-old housewife stabs her arm with a knife while cooking. Her wound bled moderately, and local wound management was done by her neighbor, a health visitor. There is no major bleeding, but the patient complains about pain and she is worried about tetanus. B) A 72-year old, hypertensive male patient started feeling unwell while he was doing some exhausting jobs in garden. He complains about severe shortness of breath, his face is bluish, he produces gargling sounds and watery, foamy, pinkish sputum when coughing.

1) The temporarily bandaged wound requires no further interventions for 1-2 days.

2) The elderly male patient has lung edema that requires immediate medical intervention and represents a life-threatening condition.

3) The illness of the elderly male patient that was caused by strenuous physical activity will be probably ceased spontaneously after some rest.

4) Deep wounds caused by stabbing require adequate wound debridement and active immunization by a toxoid against tetanus, even if they do not cause imminent, life-threatening bleeding.
A) only answer 1 is correct

B) answers 1 and 3 are correct

C) answers 2 and 4 are correct

D) only answer 3 is correct

Answer 45

ANSWER
C) answers 2 and 4 are correct

EXPLANATION
Limited resources often necessitate the determination of the order of emergency patient care. There are rules to be followed for example in warfare or in case of a mass casualty incident. In the two situations described, both patients require emergency care. Obviously, the critically ill man, suffering from pulmonary edema has to be treated first. Spontaneous recovery from a pulmonary edema caused by acute left ventricular failure is not possible (B). The deep wound caused by accidental self-stabbing also requires urgent care. If medical history indicated arterial bleeding, immediate antihemorrhagic treatment was necessary. It is important to note, that primary care was provided by a healthcare professional. Wound revision by a surgeon, cleaning and disinfection are nevertheless essential, disinfection may be performed using 3% H2O2 solution or Betadine. Wound drainage and open treatment are also necessary. Medical history may suggest wound contamination with soil that increases the risk of tetanus as well as gas gangrene. Injuries that are deep or of unknown depth have to be managed by ER surgeons. (Correct answers for question 78 are marked with numbers 2 and 4)

Question 46

INT - 19.79
Which is the most probable diagnosis?
A 30-year-old female complains about fever and painful, red, 2-3cm nodules on the extensor side of her lower extremities 3 months after her delivery. Her GP sends her to a chest X-ray that reveals bilateral, foiled, hilar decrease of transparency. CBC, erythrocyte sedimentation rate and other laboratory parameters are normal.

A) Hodgkin’s disease

B) tuberculosis

C) sarcoidosis

D) leukemia

E) infectious mononucleosis

Answer 46

ANSWER
C) sarcoidosis

EXPLANATION
The age of the patient, the skin abnormality corresponding to erythema nodosum and the bilateral hilar lymphadenopathy all suggest the diagnosis of Boeck sarcoidosis (Question 79. C). The diagnosis may be confirmed by transbronchial biopsy or a by a biopsy taken during mediastinoscopy. When decreased transparency appears in the central lung areas, bronchoscopy has to be performed for differential diagnostic purposes The correct answers for Question 80 are marked with numbers1 and 4 and with letter B). Sarcoidosis is a tuberculoid, granulomatous disease of unknown origin, in which histological evaluation does not identify caseous necrosis and M. tuberculosis cannot be detected in the lesions. Previously, combined glucocorticoid and antituberculotic treatment was applied, as a close etiologic relationship was supposed to exist between tuberculosis and sarcoidosis. These days, however, the administration of corticosteroids alone represents the adequate therapy to which around 90% of patients react well. The correct answer to Question 81 is A (see also BGY-19.13.).

Question 47

INT - 19.80
Which diagnostic procedures to be used to confirm the diagnosis?
A 30-year-old female complains about fever and painful, red, 2-3cm nodules on the extensor side of her lower extremities 3 months after her delivery. Her GP sends her to a chest X-ray that reveals bilateral, foiled, hilar decrease of transparency. CBC, erythrocyte sedimentation rate and other laboratory parameters are normal.

1) bronchoscopy

2) Klassen-biopsy

3) pleural biopsy

4) mediastinoscopy

5) thoracotomy

A) answers 1 and 3 are correct

B) answers 1 and 4 are correct

C) answers 2 and 4 are correct

D) answers 1 and 5 are correct

E) answers 3 and 5 are correct

Answer 47

ANSWER
B) answers 1 and 4 are correct

EXPLANATION
The age of the patient, the skin abnormality corresponding to erythema nodosum and the bilateral hilar lymphadenopathy all suggest the diagnosis of Boeck sarcoidosis (Question 79. C). The diagnosis may be confirmed by transbronchial biopsy or a by a biopsy taken during mediastinoscopy. When decreased transparency appears in the central lung areas, bronchoscopy has to be performed for differential diagnostic purposes The correct answers for Question 80 are marked with numbers1 and 4 and with letter B). Sarcoidosis is a tuberculoid, granulomatous disease of unknown origin, in which histological evaluation does not identify caseous necrosis and M. tuberculosis cannot be detected in the lesions. Previously, combined glucocorticoid and antituberculotic treatment was applied, as a close etiologic relationship was supposed to exist between tuberculosis and sarcoidosis. These days, however, the administration of corticosteroids alone represents the adequate therapy to which around 90% of patients react well. The correct answer to Question 81 is A (see also BGY-19.13.).

Question 48

INT - 19.81
In case of a proven diagnosis, which therapy should be applied?
A 30-year-old female complains about fever and painful, red, 2-3cm nodules on the extensor side of her lower extremities 3 months after her delivery. Her GP sends her to a chest X-ray that reveals bilateral, foiled, hilar decrease of transparency. CBC, erythrocyte sedimentation rate and other laboratory parameters are normal.
A) steroid

B) combined antituberculotic therapy

C) antibiotics + steroid

Answer 48

ANSWER
A) steroid

EXPLANATION
The age of the patient, the skin abnormality corresponding to erythema nodosum and the bilateral hilar lymphadenopathy all suggest the diagnosis of Boeck sarcoidosis (Question 79. C). The diagnosis may be confirmed by transbronchial biopsy or a by a biopsy taken during mediastinoscopy. When decreased transparency appears in the central lung areas, bronchoscopy has to be performed for differential diagnostic purposes The correct answers for Question 80 are marked with numbers1 and 4 and with letter B). Sarcoidosis is a tuberculoid, granulomatous disease of unknown origin, in which histological evaluation does not identify caseous necrosis and M. tuberculosis cannot be detected in the lesions. Previously, combined glucocorticoid and antituberculotic treatment was applied, as a close etiologic relationship was supposed to exist between tuberculosis and sarcoidosis. These days, however, the administration of corticosteroids alone represents the adequate therapy to which around 90% of patients react well. The correct answer to Question 81 is A (see also BGY-19.13.).

Question 49

INT - 19.82
Select the most probable diagnosis!
A 47-year-old female patient complains about joint pain that has been present for 6 months. Her fingers has recently became swollen and red, her fingers, toes, wrists and knees are stiff in the morning after waking up, and the stiffness reduces only after an hour. Physical examination reveals swelling and redness of the proximal interphalangeal joints and some small nodules over the extensor side of the elbow.
A) osteoarthritis

B) rheumatoid arthritis

C) scleroderma

D) psoriatic arthritis

Answer 49

ANSWER
B) rheumatoid arthritis

EXPLANATION
The description including age, morning stiffness of the joints and proximal interphalangeal joint involvement are typical of rheumatoid arthritis (Question 82 B). In this disease erythrocyte sedimentation rate is high and CRP is increased. Rheumatoid factor (RF) positivity, increased level of immunoglobulins in the plasma, joint space narrowing, marginal destruction and subperiarticular osteoporosis on hand X-ray all support the diagnosis. Concomitant, moderate degree anemia is typically normochromic, and not iron-deficiency related (Question 83 B).

Question 50

INT - 19.83
All of the following tests yield abnormal values, except
A 47-year-old female patient complains about joint pain that has been present for 6 months. Her fingers has recently became swollen and red, her fingers, toes, wrists and knees are stiff in the morning after waking up, and the stiffness reduces only after an hour. Physical examination reveals swelling and redness of the proximal interphalangeal joints and some small nodules over the extensor side of the elbow.
A) erythrocyte sedimentation rate

B) bone marrow iron stores

C) RF (rheumatoid factor)

D) immunoglobulin levels

E) X-ray of the hands

F) CRP

Answer 50

ANSWER
B) bone marrow iron stores

EXPLANATION
The description including age, morning stiffness of the joints and proximal interphalangeal joint involvement are typical of rheumatoid arthritis (Question 82 B). In this disease erythrocyte sedimentation rate is high and CRP is increased. Rheumatoid factor (RF) positivity, increased level of immunoglobulins in the plasma, joint space narrowing, marginal destruction and subperiarticular osteoporosis on hand X-ray all support the diagnosis. Concomitant, moderate degree anemia is typically normochromic, and not iron-deficiency related (Question 83 B).

Question 51

INT - 19.86
Which anti-inflammatory drug differs from the others listed below?
A) Apranax (naproxen)

B) Ibuprofen (ibuprofen)

C) Indometacinum (indometacin)

D) Oradexon (dexamethasone)

E) Prolixan (azapropazon)

F) Voltaren (diclofenac)

Answer 51

ANSWER
D) Oradexon (dexamethasone)

EXPLANATION
Drugs listed in alphabetical order are all non-steroid anti-inflammatory drugs (NSAIDs), except for dexamethasone (Oredexon), a synthetic corticosteroid. NSAIDs exert their anti-inflammatory effect through the inhibition of cyclooxygenase enzyme. Dexamethasone is also a potent anti-inflammatory drug, but it is not a NSAID (Question 87. C). Natural and synthetic corticosteroids inhibit the process of inflammation at multiple points, and they have a profound immunosuppressive effect. Their application can be manifold such as intravenous, oral, inhalational or topical (cream, or rectal instillation). Administration of corticosteroids in suppository, however, is uncommon. Side effects of both NSAIDs and corticosteroids include gastrointestinal bleeding from gastric erosions or ulcers, due to the impaired function of the mucous membrane. As prevention, administration of appropriate prophylactic drugs (such as PPIs) is necessary, especially in case of gastric problems or past ulcers / upper gastrointestinal bleeding. A severe or potentially fatal complication of long-term and high-dose glucocorticoid treatment is arterial or venous thrombosis (Question 88 D), which may cause myocardial infarction, cerebrovascular damage or pulmonary embolism. The pathomechanism of thromboembolic events includes elevated platelet count, increased coagulability and vessel wall damage. It must be emphasized, however, that there is no contraindication of corticosteroid administration in situations when corticosteroids are life-saving.

Question 52

INT - 19.88
Which of the following drugs may cause thromboembolic complications if given in large doses?
A) Apranax (naproxen)

B) Ibuprofen (ibuprofen)

C) Indometacinum (indometacin)

D) Oradexon (dexamethasone)

E) Prolixan (azapropazon)

F) Voltaren (diclofenac)

Answer 52

ANSWER
D) Oradexon (dexamethasone)

EXPLANATION
Drugs listed in alphabetical order are all non-steroid anti-inflammatory drugs (NSAIDs), except for dexamethasone (Oredexon), a synthetic corticosteroid. NSAIDs exert their anti-inflammatory effect through the inhibition of cyclooxygenase enzyme. Dexamethason is also a potent anti-inflammatory drug, but it is not a NSAID (Question 87. C). Natural and synthetic corticosteroids inhibit the process of inflammation at multiple points, and they have a profound immunosuppressive effect. Their application can be manifold such as intravenous, oral, inhalational or topical (cream, or rectal instillation). Administration of corticosteroids in suppositories, however is uncommon. Side effects of both NSAIDs and corticosteroids include gastrointestinal bleeding from gastric erosions or ulcers, due to the impaired function of the mucous membrane. As a prevention, administration of appropriate prophylactic drugs (such as PPIs) is necessary, especially in case of gastric problems or past ulcers / upper gastrointestinal bleeding. A severe or potentially fatal complication of long-term and high-dose glucocorticoid treatment is arterial or venous thrombosis (Question 88 D), which may cause myocardial infarction, cerebrovascular damage or pulmonary embolism. The pathomechanism of thromboembolic events includes elevated platelet count, increased coagulability and vessel wall damage. It must be emphasized, however, that there is no contraindication of corticosteroid administration in situations when corticosteroids are life-saving.

Question 53

INT - 19.89
Which of the following drugs differs from the others listed below?
A) Astrix (acetylsalicylic acid)

B) Colfarit (acetylsalicylic acid)

C) Heparin (sodium heparin)

D) Semicillin (ampicillin)

E) Syncumar (acenocoumarol)

F) Ticlid (ticlopidine)

Answer 53

ANSWER
D) Semicillin (ampicillin)

EXPLANATION
Drugs listed in question 89 are all antithrombotic or anticoagulant medications except for ampicillin (D), an antibiotic. (Question 90. C).

Question 54

INT - 19.92
Which of the listed drugs can be used for arterial thrombosis prophylaxis in a patient who has arteriosclerosis and who underwent gastric bleeding?
1) Astrix (acetylsalicylic acid)

2) Colfarit (acetylsalicylic acid)

3) Syncumar (acenocoumarol)

4) Ticlid (ticlopidine)

A) answers 1, 2 and 3 are correct

B) answers 1 and 3 are correct

C) answers 2 and 4 are correct

D) only answer 4 is correct

E) all 4 answers are correct

Answer 54

ANSWER
D) only answer 4 is correct

EXPLANATION
Therapeutic anticoagulation using heparin or acenocoumarol increases the risk of hematoma after intramuscular injections (Question 91., numbers 2 and 4, letter C). No such risk increment is seen with acetylsalicylic acid (Astrix, Colfarit), ticlopidine (Ticlid) or clopidogrel (Plavix). Ampicillin is not an antithrombotic agent, moreover, it can be given in intramuscular injections. To prevent arterial and venous thromboses, platelet aggregation inhibitors (such as acetlysalicilic acid) and prothrombin synthesis inhibitors (such as acenocoumarol) can be given, respectively. A patient who underwent upper gastrointestinal bleeding should avoid taking acetlysalicilic acid due to its unfavorable effects on gastric mucous membrane protection. Such patients may be treated with other antithrombotic agents such as ticlopidine (Ticlid) or clopidogrel (Plavix) (Question 92 D). A potential side effect of ticlopidine is neutropenia.

Question 55

INT - 19.91
In case of the administration of which drug(s) would you avoid intramuscular injections?
1) Astrix (acetylsalicilic acid), Ticlid (ticlopidine), Plavix (clopidogrel)

2) Heparin

3) Semicillin (ampicillin), Colfarit (acetylsalicilic acid), Plavix (clopidogrel)

4) Syncumar (acenocoumarol)

A) answers 1, 2 and 3 are correct

B) answers 1 and 3 are correct

C) answers 2 and 4 are correct

D) only answer 4 is correct

E) all 4 answers are correct

Answer 55

ANSWER
C) answers 2 and 4 are correct

EXPLANATION
Therapeutic anticoagulation using heparin or acenocoumarol increases the risk of hematoma after intramuscular injections (Question 91., numbers 2 and 4, letter C). No such risk increment is seen with acetylsalicylic acid (Astrix, Colfarit), ticlopidine (Ticlid) or clopidogrel (Plavix). Ampicillin is not an antithrombotic agent, moreover, it can be given in intramuscular injections. To prevent arterial and venous thromboses, platelet aggregation inhibitors (such as acetlysalicilic acid) and prothrombin synthesis inhibitors (such as acenocoumarol) can be given, respectively. A patient who underwent upper gastrointestinal bleeding should avoid taking acetlysalicilic acid due to its unfavorable effects on gastric mucous membrane protection. Such patients may be treated with other antithrombotic agents such as ticlopidine (Ticlid) or clopidogrel (Plavix) (Question 92 D). A potential side effect of ticlopidine is neutropenia.