V INTERNATIONAL

MEDICAL TOURNAMENT
(English-speaking league)

THE CASES OF THE CORRESPONDENCE STAGE

To participate in the Correspondence stage of the Tournament you must send solutions of
two tasks out of three which were proposed (at your choice). If a team solves all three tasks, the
total score will include the highest scores only from two tasks.

Registration requirements:
I. Solutions of the tasks must be represented by two documents:
1. A presentation of a short solution in Power Point format(.ppt/pptx/pdf). The
presentation can include no more than 10 slides;
2. An expended solution with justifications, comments and a list of references in
Microsoft Office format(.doc/docx/pdf). It can include no more than 6 pages A4, 1.0
interval, Times New Roman, 12 size, centered text alignment.
II. You should write the documents name follow the next example:
"a number of a task" _ " a team's name».
III. The text of the tasks and the presentation mustn't include the name of the team or special
University's symbols to ensure the anonymity of checking.

Send your Correspondence stage solutions to eng.medtourn@gmail.com before February 11,

2018 (23:59 in Moscow time, UTC+03:00).
 Case №1

An 18-year-old female patient presented with complaints of growing weakness and spasms in the
upper limbs in the last few months.
An examination revealed a decrease in total blood calcium level to 1.8 mmol/L and an increase
in total blood phosphorus level to 1.99 mmol/L. The levels of potassium, sodium, chlorine, and
magnesium were within the reference ranges. The patient was referred to an endocrinologist for
consultation.
Medical history. In patient’s words, there were no previous chronic diseases, surgical
interventions, and any medications. There is no significant family history. The patient has had
regular and painless menses since the age of 13. In patient’s words, she has not had chronic
intoxication and allergic reactions.
Objective data. BMI is 21.5 kg/m^2. The patient is hemodynamically stable; blood pressure is
113/71 mm Hg; the heart rate is 61 beats per minute. A positive bilateral Trousseau’s syndrome is
present. Otherwise, a physical examination revealed no cardiovascular, pulmonary, or
musculoskeletal system pathology.
The patient underwent additional examination.
Complete blood count: no significant abnormalities.
Blood chemistry panel: alanine aminotransferase — 17 U/L, aspartate aminotransferase — 19 U/L,
creatinine — 67 μmol/L.
ECG: sinus rhythm; the heart rate is 64 bpm; no pathological changes.
The parathyroid hormone level is 154 pg/mL (10−65); the result was checked twice.
25(OH)D — 45 ng/mL.

Questions:
1. Whether additional examination is reasonable for clarifying the diagnosis? If yes, please
describe suggested diagnostic tests and expected results.
2. Formulate the clinical diagnosis.
3. Whether the described case requires urgent medical intervention? If yes, what type of
intervention? Describe in detail the management approach for this patient.
 Case №2

A 41-year-old male consulted an infectious disease specialist in April 2017 with complaints of
weakness in the upper and lower limbs, accumulation of saliva in the morning, and periodical
spasms in the lower limbs.
History of the present disease: according to the patient, he has been sick since April 4, 2016; he
developed pain in the cervical and thoracic spine, pain in the left shoulder, a decreased strength in
the left upper limb muscles, then weakness in the left lower limb muscles, and later weakness in
the right upper limb and right lower limb muscles.
There was no evidence of fever and severe headache.
The patient consulted a doctor in August 2016 and was hospitalized to the Neurological
Department of the Republican Hospital with the diagnosis of motor neuron disease (ALS, sporadic
case, cervicothoracic form, stage 2) and mixed tetraparesis. There were consequences of traumatic
brain injury in the form of cystic-glial changes in the frontal lobes and mixed hydrocephalus.
The patient underwent treatment with «Cytoflavin»1 (10.0 ml intravenously in saline), «Cortexin»2
(10.0 ml intramuscularly), and «Mefoxin» 3 (2.0 ml intramuscularly). The treatment slightly
decreased lower limb weakness.
In October 2016, the patient was hospitalized to the Neurological Department of the Regional
Clinical Hospital with the following diagnosis: chronic tick-borne encephalitis with a primary-
progredient course; ALS syndrome; mixed tetraparesis, grade 1; limb dysfunction, grade 1−2.
An immunoenzymatic assay for tick-borne encephalitis revealed early antibodies to the tick-borne
encephalitis virus, IgM, and late IgG 1/800.
The patient underwent treatment with anti-tick gamma globulin and «Neovir» 4 as well as
metabolic therapy.
Gradual worsening and a decrease in the motor activity occurred during the last year. Currently,
the patient takes multivitamins and glycine (constantly).
In July 2017, the patient consulted a neurologist; a preliminary diagnosis was made: tick-borne
encephalitis (the meningoencephalitis form, a primary-progredient course). The patient was
referred to an infectious disease specialist for consultation.
Performed examinations: no data.
Medical history
Family history: there is no history of CNS diseases. Social history: he lives in a single-family
home; living conditions are satisfactory. The patient adheres to personal hygiene. Alcohol and
smoking: he smokes and moderately consumes alcohol. Previous diseases: in patient’ words, he
had no viral hepatitis A and pulmonary tuberculosis.
Acute respiratory viral infections: once a year. There was no previous surgery and injuries. There
was no blood transfusion. No allergic history.
Epidemiological history: multiple tick bites and tick attacks in the past (before the year of disease
onset) without subsequent clinical symptoms.
The patient has not been vaccinated against tick-borne encephalitis.

1
INN: Inosine + Nicotinamide + Riboflavin + Acid Succinic
2
INN: Polypeptides de cerebri cortex pecorum
3
INN: Cefoxitin
4
INN: Oxodihydroacridinylacetate sodium
In patient’s words, there was no tick bite 7−30 days before the disease onset.
General examination
The general medical condition is satisfactory. Height is 164 cm. Weight is 52 kg. The body mass
index is 19.3. The body is normally built. The constitution is normosthenic. Consciousness is clear.
The patient’s position is active. The skin and observable mucous membranes are clean and normal
in color. The lymph nodes are not enlarged. The nasopharynx and pharynx are not hyperemic.
Neurological status (described by a neurologist):
There are no meningeal signs. The eye slits on the right and left are equal; the pupils on the right
and left are equal. Facial musculature: the nasolabial fold is smoothed on the right. The tongue is
deflected to the right. Muscle strength in the right upper limb is grade 3, and that in the left upper
limb is grade 2; the muscle tone is high and pyramidal. Muscle strength in the lower limbs is grade
3 on the right and grade 2 on the left. Tendon reflexes are low, equal on the right and left. The gait
is unstable. The patient is unstable in the Romberg position.

Respiratory system: breathing is vesicular, without rales, sounds over all lung fields.
Cardiovascular system: heart sounds are clear and regular. Digestive system: the abdomen is soft,
painless in all parts, without symptoms of peritoneal irritation.
The liver and spleen are not enlarged. Stool is once a day, formed. Urinary system: diuresis is
adequate.

Questions:
1. Identify the leading syndromes. What additional examinations are required to clarify the
patient’s diagnosis? What results do you expect to obtain?
2. Formulate and substantiate the preliminary clinical diagnosis.
3. Specify in detail measures and procedures necessary for the patient treatment.
 Case №3

A female, born in 1976.

Complaints: on examination, the patient has no active complaints. Weight gain is 15 kg for
2 years. Bleeding gums. The patient consulted a gynecologist for planning pregnancy (2017).
History of the disease:
She has had menses since the age of 12, regular, after 28−30 days, for 5−6 days, abundant.
Obstetric history:
Pregnancy 1 (1994): delivery, cesarean section at 40 weeks of gestation due to obstetric indications
(weak labor activity); 12 years of treatment for infertility.
The patient underwent laparoscopy (2006): sactosalpinx, coagulation of external endometriosis
foci.
Pregnancy 2 (2007): cesarean section at 40 weeks.
Pregnancy 3 (2009): termination at 27−28 weeks of gestation due to medical indications (multiple
congenital fetal malformations: agenesis of the corpus callosum).
Pregnancy 4 (2011): cesarean section at 37−38 weeks of gestation.
Pregnancy 5 (2013): twins missed at 7−8 weeks of gestation. Histological examination was not
performed.
Pregnancy 6 (2014): birth in time (cesarean section) at 37−38 weeks of gestation.
Pregnancy 7 (2015): missed abortion at 6 weeks of gestation. A histological examination of the
material revealed dystrophic changes in the chorionic villi.
Pregnancy 8 (2016): missed abortion at 6−7 weeks of gestation. Anemia in early pregnancy (a
hemoglobin level of 104 g/L; a mean cell volume of 86.4 fL), the patient received oral iron
medications («Sorbifer Durules»5).
In 2007, the patient was diagnosed with viral hepatitis C; no antiviral therapy was performed; the
patient was not followed-up by an infectious disease specialist.
Medical history: in patient’s words, she had no HIV and tuberculosis. There was no allergic
history. She has chronic pyelonephritis, with the last exacerbation occurring 5 years ago.
Hereditary history: her mother had recurrent thrombophlebitis since the age of 20 years, there
were several cases of deep vein thrombosis of the leg.
She has periodically (irregularly) used hormonal contraception («Logest», «Lindynette 20»6); she
has discontinued the treatment because of pain in the lower limb muscles.
In patient’s words, she has had no chronic intoxication (smoking, alcohol, drug addiction).
Objective data: the patient’s condition is satisfactory. Height is 160 cm, weight is 80 kg, the body
mass index is 31.25 kg/m2; the body temperature is 36.5 °C. The color and moisture of the skin
are normal; a pinch sign is positive. There are varicose veins in her legs and groin area. The
pharynx is normal. The tongue is slightly covered with a whitish mucus. Breathing is vesicular.
There are no rales. Heart sounds are clear and regular. Blood pressure is 122/74 mm Hg; the heart
rate is 68 bpm. The abdomen is soft and painless. The liver and spleen are not palpable. No edema.
Stool and diuresis are normal.

5
INN: Ferric sulfate + Ascorbic acid
6
INN: Ethinylestradiol+Gestodene
Examination results:
Complete blood count: RBC — 3.86*109/L; hemoglobin — 107 g/L; mean cell volume — 82.1 fL;
hematocrit — 38.5%; RBC distribution width — 17.4%; mean corpuscular hemoglobin
content - 28%; mean corpuscular hemoglobin concentration — 30.2 pg;
platelets - 226 thousand/μL; WBC — 4.4*10 /L; erythrocyte sedimentation rate — 9 mm/h; white
9

cell count is normal.

Blood group — O(I), Rh — negative.
Clinical urinalysis: color — yellow; specific gravity — 1,030 g/L; protein — 0; RBC — 0;
WBC — 1−2 per field of view; glucose — 0. Blennuria ++.
Blood chemistry panel: total protein — 73.7 g/L; glucose — 5.4 mmol/L; total
bilirubin — 8.7 μmol/L; alanine aminotransferase — 62.4 U/mL; aspartate
aminotransferase — 57.3 U/mL; total cholesterol — 5.6 mol/L; high density
lipoproteins — 0.97 mmol/L; low density lipoproteins — 4.89 mmol/L; atherogenicity
coefficient — 5.04; urea — 4.0 mmol/L; creatinine — 92 μmol/L; C-reactive protein — 3.2 mg/L;
iron — 5.6 μmol/L; total calcium — 2.3 mmol/L; homocysteine — 13.4 μmol/L.
The results of serological tests for hepatitis B and HIV and ELISA for syphilis are negative. The
anti-HCV test is positive. ELISA: cytomegalovirus IgM — negative; IgG — 1/210;
avidity — 94%.
Hemostasiogram: activated partial thromboplastin time — 24.6 s; prothrombin time — 12.2 s;
thromboplastin time — 16.1 s; international normalized ratio — 1.04; fibrinogen — 2.01;
D-dimers — 430 ng/mL.
Mutations of hemostasis genes: FV-Leiden G1691A — heterozygote (G>A);
PAI-1 4G/4G — homozygote; FII G20210A — normozygote; ITGA1 (GPIIIb) — heterozygote;
MTHFR (C677T) — heterozygote (C>T).

Questions:
1. What additional examinations are required to clarify the patient’s diagnosis? What
findings do you expect to obtain?
2. Formulate and substantiate the clinical diagnosis.
3. Formulate and substantiate a detailed plan of medical and diagnostic measures during
the preconception preparation stage and pregnancy management.