Differential diagnostic procedures

Question 1

A potential reason for febrile leucopenia, except:
A) agranulocytosis
B) SLE (systemic lupus erythematosus)
C) typhoid fever
D) epidemic typhus

Answer 1

D) epidemic typhus

Question 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

C) rheumatic fever

Question 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

B) hemolysis

Question 4

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

C) chronic diuretic administration

Question 5

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

C) diabetes mellitus

Question 6

All can cause heartburn (pyrosis), except:
A) duodenal ulcer
B) umbilical hernia
C) hiatus hernia
D) gastric ulcer
E) reflux esophagitis (GERD)

Answer 6

B) umbilical hernia

Question 7

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

A) high level of HDL -cholesterol

Question 8

All may cause bloody ascites, except:
A) acute pancreatitis
B) hemochromatosis
C) carcinomatous peritonitis
D) tuberculous peritonitis

Answer 8

B) hemochromatosis

Question 9

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

E) azathioprine treatment

Question 10

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

B) Conn syndrome

Question 11

Common cardiopulmonary manifestations of sarcoidosis, except
A) pleural exudate
B) pulmonary fibrosis
C) cor pulmonale
D) hilar lymphadenopathy

Answer 11

A) pleural exudate

Question 12

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

A) bronchoscopy, bronchography

Question 13

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

B) digital rectal examination and urgent rectoscopy or colonoscopy

Question 14

The following disorders may cause isolated ascites, except:
A) nephrotic syndrome
B) tuberculous peritonitis
C) carcinomatous peritonitis
D) v. portae thrombosis

Answer 14

A) nephrotic syndrome

Question 15

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

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

Question 16

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

B) hemorrhagic gastritis

Question 17

The most common endocrine disorder associated with Zollinger–Ellison syndrome:
A) phaeochromocytoma
B) hyperthyroidism
C) hyperparathyroidism
D) hypoparathyroidism

Answer 17

C) hyperparathyroidism

Question 18

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

A) cecum

Question 19

The most common site of diverticulosis in the colon:
A) rectum
B) sigmoid colon
C) descending colon
D) transverse colon
E) cecum

Answer 19

B) sigmoid colon

Question 20

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

E) 85–100%

Question 21

The most common disorder misdiagnosed as regional ileitis:
A) acute pyelonephritis
B) irritable colon
C) diverticulosis
D) appendicitis
E) gastroenteritis

Answer 21

D) appendicitis

Question 22

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

C) aganglionosis affecting the distal colon

Question 23

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

D) cyclosporine A

Question 24

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

E) gallstones

Question 25

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

A) in acute tubular necrosis

Question 26

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

C) adrenal hypofunction due to autoimmune adrenal damage

Question 27

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

D) hyperthyroidism

Question 28

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

A) autoimmune adrenal atrophy

Question 29

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

E) spironolactone

Question 30

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

C) schistosomiasis

Question 31

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

C) answers 2 and 4 are correct

Question 32

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

A) answers 1, 2 and 3 are correct

Question 33

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

C) answers 2 and 4 are correct

Question 34

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

A) answers 1, 2 and 4 are correct

Question 35

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

38- A
39- B
40- C
41- D

Question 36

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

42- E
43- D
44- A
45- B
46- C

Question 37

Associate the disorders characterized by upper gastrointestinal bleeding with their prevalence!
A) the third most common
B) the second most common
C) the least common
D) the most common

INT - 19.49 - Esophageal and subcardial varix rupture

Answer 37

49- A

Question 38

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 38

51- D
52- B
53- A
54- C

Question 39

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 39

55- A
56- B
57- E
58- D
59- C

Question 40

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 40

60- A
61- B
62- C
63- D

Question 41

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 41

64- B
65- A
66- E
67- C
68- D

Question 42

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 42

69- C
70- D
71- A
72- F
73- E
74- B

Question 43

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 43

E) the statement and the explanation are both false

Question 44

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 44

C) the statement is correct but the explanation is false

Question 45

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 45

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

Question 46

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 46

C) answers 2 and 4 are correct

Question 47

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 47

C) sarcoidosis

Question 48

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 48

B) answers 1 and 4 are correct

Question 49

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 49

A) steroid

Question 50

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 50

B) rheumatoid arthritis

Question 51

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 51

B) bone marrow iron stores

Question 52

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 52

D) Oradexon (dexamethasone)

Question 53

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 53

D) Oradexon (dexamethasone)

Question 54

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 54

D) Semicillin (ampicillin)

Question 55

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

C) answers 2 and 4 are correct

Question 56

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 56

D) only answer 4 is correct