Otázky s chybnou odpovědí, č.j. 2914406
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TEST:usmle1en  Varianta:1         Tisknuto:04/06/2019
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  1. ( 29.orig.) Lactation does not occur during pregnancy because the action of prolactin is blocked by increased concentrations of which of the following hormones? 
 3) + Estrogen and progesterone (nezaškrtl-a)
 5) - Thyroxine (T4) and dopamine (zaškrtl-a)
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  7. ( 31.orig.) An asymptomatic 26-year-old man has a scrotal mass.  When he is standing, the left scrotal sac is enlarged with a tubular, worm-like, freely movable, nontender mass. The mass is not palpable when he is supine.  The most likely diagnosis is 
 2) - indirect inguinal hernia (zaškrtl-a)
 4) + varicocele (nezaškrtl-a)
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 19. ( 40.orig.) A patient with an aneurysm of the aortic arch develops hoarseness. Paralysis of which of the following muscles on the left side is most likely? 
 1) - Anterior belly of the digastric (zaškrtl-a)
 2) + Posterior cricoarytenoid (nezaškrtl-a)
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 22. ( 26.orig.) After fasting, a patient has no gastric acid secretion when chewing and no receptive relaxation of the proximal stomach when swallowing. Which of the following best explains these findings? 
 2) - Increased concentration of somatostatin (zaškrtl-a)
 4) + Vagally denervated stomach (nezaškrtl-a)
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 27. ( 28.orig.) A 60-year-old man undergoes excision of an obstruction in the large intestine. Which of the following microscopic features in the obstructing lesion most strongly suggests malignant growth? 
 1) + Sheets and cords of epithelial cells in the serosal layer (nezaškrtl-a)
 2) - Formation of new vascular channels and hemorrhage (zaškrtl-a)
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 31. ( 17.orig.) A 17-year-old girl sustains a contaminated deep puncture wound while helping repair a barn. Her immunization record indicates that her last tetanus immunization was 12 years ago. In addition to wound care, which of the following is the most appropriate management? 
 4) + Tetanus antitoxin plus toxoid (nezaškrtl-a)
 5) - Tetanus antitoxin (zaškrtl-a)
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 34. (  1.orig.) Following infection with measles virus, a 6-year-old boy produces antibodies to all eight viral proteins. The following year he is again exposed to measles virus. Antibodies to which viral protein are most likely to be protective?
 1) + Hemagglutinin (nezaškrtl-a)
 2) - Polymerase (zaškrtl-a)
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 37. ( 24.orig.) A 24-year-old woman in the 28th week of her first pregnancy has had nagging headaches, a "puffy-looking" face, and swollen legs for the past week. Blood pressure is 180/95 mm Hg; it was normal earlier in the pregnancy. Urinalysis shows only proteinuria (0.6 g/dL - normally is up to 0.15). Which of the following is the most likely diagnosis? 
 2) - Eclampsia (zaškrtl-a)
 3) + Preeclampsia (nezaškrtl-a)
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 41. ( 36.orig.) A 4-year-old girl has been unable to eat for 2 days because of a gastrointestinal tract disorder. Which of the following is the major source of fuel being oxidized by her skeletal muscles? 
 2) - Muscle glycogen (zaškrtl-a)
 3) + Serum fatty acids (nezaškrtl-a)
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 55. (  8.orig.) Moderate alcohol consumption may protect against coronary artery disease by which of the following mechanisms? 
 4) - Decreasing serum concentration of triglycerides (zaškrtl-a)
 5) + Increasing serum concentration of HDLs (nezaškrtl-a)
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 63. ( 35.orig.) A 45-year-old man has abnormal circadian variation disruption of the sleep-wake cycle, and an impaired nocturnal surge of secretion of melatonin. An MRI of the head is most likely to show a lesion involving which of the following nuclei? 
 1) - Supraoptic (zaškrtl-a)
 4) + Suprachiasmatic (nezaškrtl-a)
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 64. (  3.orig.) A 40-year-old man with a 20-year history of alcohol abuse is brought to the hospital by his friends because he was difficult to rouse. He ate a large meal several hours ago. He is emaciated and lethargic. Examination shows severely restricted horizontal eye movements and ataxia of both upper extremities. The most likely cause of these findings is a deficiency of which of the following nutrients? 
 1) - Vitamin B12 (cobalamin) (zaškrtl-a)
 2) + Vitamin B1 (thiamine) (nezaškrtl-a)
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 71. ( 19.orig.) A 32-year-old man is unable to adduct his right eye during conjugate gaze but is able to adduct it during visual convergence. A lesion of which of the following structures on the right side is most likely to produce this finding? 
 1) + Medial longitudinal fasciculus (nezaškrtl-a)
 4) - Nucleus of the oculomotor nerve (zaškrtl-a)
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 76. ( 20.orig.) Breast carcinomas often cause the skin of the breast to become puffy and pitted, resembling orange peel. The pits most likely correspond with which of the following? 
 3) + Attachments of suspensory ligaments (retinacula cutis) to the dermis (nezaškrtl-a)
 4) - Openings of sebaceous glands (zaškrtl-a)
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 80. ( 27.orig.) A patient with an injury to the gluteal region has difficulty rising from a seated position and straightening his trunk but no difficulty walking on level ground or flexing his leg. Which of the following muscles is affected? 
 4) - Hamstrings (zaškrtl-a)
 5) + Gluteus maximus (nezaškrtl-a)
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 87. ( 15.orig.) A 53-year-old woman dies 4 days after an automobile collision. She sustained multiple injuries including a femoral fracture. Widespread petechiae are found in the cerebral white matter at autopsy. Which of the following is the most likely cause of these findings? 
 2) - Contrecoup injury (zaškrtl-a)
 4) + Fat embolization (nezaškrtl-a)
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 88. ( 13.orig.) A 30-year-old woman whose mother and grandmother have died from carcinoma of the breast refuses to have mammography. She says she knows she is at risk but says, "I hate having my breasts squashed-it's uncomfortable." Her physician would like her to have annual mammograms.  Which of the following is most likely to influence her to agree to have mammograms? 
 1) + Offer analgesia prior to mammography (nezaškrtl-a)
 5) - Show her photographs of the results of untreated cancer (zaškrtl-a)
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 93. ( 30.orig.) A neonate develops meningitis. Streptococcus is isolated from the mother's vagina. The organism agglutinates with antiserum directed against type B surface carbohydrate. The virulence of this organism is related to a bacterial constituent that interferes with	 which of the following host phagocyte functions? 
 2) - Aggregation (zaškrtl-a)
 5) + Ingestion (nezaškrtl-a)
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 96. ( 10.orig.) A 16-year-old girl is incoherent and has a fever, severe lower abdominal pain, and a foul-smelling cervicovaginal discharge. A self-induced abortion is suspected. Which of the following methods should be used to collect a sample of the cervical discharge for bacterial culture? 
 1) - Placing a swab in transport medium at room temperature (zaškrtl-a)
 3) + Taking samples of the discharge with a syringe and transferring them directly to the laboratory (nezaškrtl-a)
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 99. (  2.orig.) Which of the following best explains why neonates with sickle cell disease do not have symptoms at birth? 
 3) + The concentration of hemoglobin S is too low (nezaškrtl-a)
 4) - Maternal erythrocytes protect neonatal erythrocytes from sickling (zaškrtl-a)
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105. (  9.orig.) A 48-year-old woman has loss of pain and temperature sensation in the left upper and lower limbs. Which of the following labeled areas in the medulla is the most likely site of the causal lesion?  
 1) + C (nezaškrtl-a)
 3) - B (zaškrtl-a)
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113. ( 32.orig.) During a prenatal visit, a 25-year-old woman who is 10 weeks' pregnant comments that she feels too nauseated and fatigued to be interested in sex, and her husband wonders if they will ever be sexually active again.  The most appropriate next step is to advise her that sexual interest often returns during which of the following periods? 
 2) - Five month postpartum (zaškrtl-a)
 5) + Second trimester (nezaškrtl-a)
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117. ( 34.orig.) A healthy 19-year-old man receives a tetanus immunization booster prior to induction in the Marines. Six hours later, he has pain and massive swelling at the site of injection. The following day, the skin breaks down, forming an ulcer at the site. Which of the following events plays a critical role in this reaction? 
 1) + Local fixation of complement by preformed circulating antibodies (nezaškrtl-a)
 3) - Predominance of IgM antibodies (zaškrtl-a)
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TEST:usmle2en  Varianta:1         Tisknuto:04/06/2019
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  2. ( 37.orig.) A 7-year-old boy is brought to the physician 3 days after sustaining a small laceration of the left eyebrow. His temperature is 38.8°C (101.8°F). Examination shows erythema and edema of the left eyelid and periorbital region with moderate proptosis and decreased ocular movement; eye movement is painful. The disc margins are sharp, and there are no retinal abnormalities. Which of the following is the most likely diagnosis? 
 4) + Orbital cellulitis (nezaškrtl-a)
 5) - Preseptal (periorbital) cellulitis (zaškrtl-a)
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  4. (  7.orig.) A 64-year-old woman comes to the physician because of a 5-month history of increasing shortness of breath, sore throat, and a cough productive of a small amount of white phlegm. Over the past week, she has had nausea related to excess coughing.  Over the past year, she has had a 3.2-kg (7-lb) weight loss. She has asthma treated with theophylline and inhaled beta-adrenergic agonists and corticosteroids. She has smoked one pack of cigarettes daily for 44 years and drinks one alcoholic beverage daily. She appears thin. Examination shows a 2-cm, nontender lymph node in the right supraclavicular area. Examination shows no other abnormalities. An x-ray of the chest shows a large right lower lobe density. A CT scan of the chest shows a 7.5 x 7.5 x 6-cm right lower lobe mass with some scattered calcifications. The lesion abuts the posterior chest wall without clear invasion. There are right lower peritracheal, precarinal, right hilar, and subcarinal lymph nodes. There is a 1.5-cm mass in the right adrenal gland. A biopsy specimen of the lung mass is most likely to show which of the following? 
 2) - Metastatic adenocarcinoma of the breast (zaškrtl-a)
 3) + Non-small cell lung carcinoma (nezaškrtl-a)
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  9. ( 32.orig.) A 28-year-old woman comes to the emergency department 6 hours after the onset of insomnia, flank discomfort, and constipation that she attributes to a kidney stone. She is a resident of another state and is here visiting relatives. She takes oxycodone (six to eight tablets daily) for chronic low back pain, sumatriptan for migraines, and amitriptyline (25 mg at bedtime) and paroxetine (30 mg daily) for bulimia nervosa. Her pulse is 100/min, and blood pressure is 130/80 mm Hg. Examination shows diaphoresis and dilated pupils. She is alert and cooperative but seems restless. She has not had hallucinations or suicidal ideation. She becomes angry when she is asked for the telephone numbers of her regular physicians. Serum amitriptyline concentration is 150 mg/100 ml. Urinalysis shows 0-2 RBC/hpf. Which of the following is the most likely explanation for her symptoms? 
 1) - Tricyclic intoxication (zaškrtl-a)
 4) + Opiate withdrawal (nezaškrtl-a)
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 13. (  9.orig.) A 45-year-old woman has a 2-week history of increased anxiety, abdominal discomfort, irritability, and difficulty concentrating; she was robbed at knifepoint in a parking lot 3 weeks ago. She takes levothyroxine for hypothyroidism and uses an over-the-counter inhaler as needed for exercise-induced asthma. Her pulse is 100/min, and blood pressure is 140/80 mm Hg. Examination shows dry skin and hair. She is cooperative but appears anxious, glancing around quickly when a loud noise is heard outside the office. Leukocyte count is 12,000/mm3, and serum thyroid-stimulating hormone concentration is 5.0 µU/ml. An ECG shows sinus tachycardia. Which of the following is the most likely diagnosis? 
 1) + Acute stress disorder (nezaškrtl-a)
 5) - Generalized anxiety disorder (zaškrtl-a)
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 18. ( 35.orig.) A16-year-old girl is brought to the physician because of intermittent pain and swelling of both ankles over the past month. She is currently not in pain. When the pain occurs, it is so severe that she is unable to walk. There is no associated fever or chills. She is sexually active and has had one sexual partner for 12 months. Her temperature is 37°C, pulse is 80/min, and blood pressure is 145/87 mm Hg. Examination shows no abnormalities or tenderncess of the ankle joints. There is a nonpainful ulcer on the oral buccal mucosa. The lungs are clear to auscultation. Cardiac examination shows no abnormalities. Laboratory studies show: BLOOD: leukocyte count 4000/mm3 (4500-11000), segmented neutrophils 65% (54-62), eosinophils 3% (1-3), lymphocytes 25% (25-33), monocytes 7% (3-7), platelet count 60,000/mm3 (150,00-400,000), erythrocyte sedimentation rate 100mm/h; SERUM: antinuclear antibodies 1:320, anti-DNA antibodies - positive, rapid plasma reagin 1:16, rheumatoid factor - negative; URINE: protein +++, RBC casts negative, RBC none, WBC +. X-rays of the ankles show no abnormalities other than tissue swelling. Which of the following is the most likely diagnosis?
 1) - Disseminated gonococcal disease (zaškrtl-a)
 4) + Systemic lupus erythematosus (nezaškrtl-a)
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 32. ( 40.orig.) A 6-year-old man with emphysema is brought to the emergency department 1 hour after becoming lethargic and incoherent. Over the past 3 days, he has had increasing episodes of dyspnea, cough, and sputum production. Oxygen was administered en route to the hospital. On arrival, the patient is confused and lethargic but responsive to painful stimuli. Arterial blood gas analysis while breathing 6l/min of oxygen shows: pH 35 [H+] nmol/l (36-44), pCO2 12,7 kPa (4,4-5,9), pO2 13,3 kPa (10,0-14,0). Which of the following is the most appropriate next step in management?
 4) + Endotracheal intubation and mechanical ventilation (nezaškrtl-a)
 5) - Continuation of current oxygen with the addition of a respiratory stimulant (zaškrtl-a)
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 40. (  6.orig.) A 28-year-old woman, gravida 3, para 2, comes to the physician for her first prenatal visit at 36 weeks´ gestation. She has been taking over-the-counter ferrous sulfate. Although her intake of protein and calories has been adequate, she rarely eats fruits or fresh vegetables. This patient is at increased risk for a deficiency of which of the following?
 4) + Folic acid (nezaškrtl-a)
 5) - Vitamin B12 (cobalamin) (zaškrtl-a)
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 43. ( 27.orig.) Over the past week, a 55-year-old woman has had extreme dizziness on lying down and getting up. She says it feels the room is spinning. Examination shows no abnormalities except for fatigable nystagmus toward the left when the patient is lying on her left side. Which of the following is the most likely diagnosis? 
 2) + Benign positional vertigo (nezaškrtl-a)
 3) - Meniere disease (zaškrtl-a)
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 53. ( 34.orig.) A 58-year-old man comes to the physician because of extreme fatique and malaise for 3 weeks. He has felt well except for a toothache 5 weeks ago treated with a root canal procedure. He has a history of a cardiac murmur first noted at the age of 19 years. His temperature is 37,8°C, pulse is 110/min, and blood pressure is 120/80 mm Hg. The lungs are clear to auscultation. Cardiac examination shows a grade 2/6, systolic ejection murmur heard best at the right second intercostal space as well as an S4 and an ejection click. Laboratory studies show: hemoglobi 1,4 mmol/l (2,09-1,71I), leukocyte count 10,000/mm3; segmented neutrophils 90%, bands 10%; erythrocyte sedimentation rate 90mm/h; urine, blood positive. Blood culture are obtained. Gram stain of the blood culture is most likely to show which of the following?
 2) - Gram-positive diplococci (zaškrtl-a)
 5) + Gram-positive cocci in chains (nezaškrtl-a)
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 56. ( 17.orig.) A 70-year-old man comes to the physician because of severe myalgias and malaise over the past 2 months.  He has had a 2.7-kg (6-lb) weight loss during this period.  Examination shows no abnormalities. His hematocrit is 30%, leukocyte count is 11,300/mm3, and erythrocyte sedimentation rate is 112 mm/h.  Serum creatine kinase activity is within normal limits. Which of the following is the most likely diagnosis? 
 2) - Myasthenia gravis (zaškrtl-a)
 4) + Polymyalgia rheumatica (nezaškrtl-a)
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 58. ( 19.orig.) A nurse is hospitalized for an appendectomy at the medical center where she is employed. One week after discharge, the assistant hospital administrator asks the surgeon who performed the procedure about the final diagnosis.  Which of the following is the most appropriate response on the part of the surgeon? 
 4) - Answer, because it will expedite handling of insurance issues at the medical center (zaškrtl-a)
 5) + Decline to answer, because the information is confidential (nezaškrtl-a)
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 62. ( 12.orig.) A 46-year-old man comes to the physician because of intermittent lower abdominal pain over the past 3 months. There is no family history of cancer. Examination shows no other abnormalities. His hematocrit is 38%. Test of the stool for occult blood is positive. Colon contrast studies show a 1.5-cm polyp in the descending colon. An upper gastrointestinal series shows no abnormalities. Which of the following is the most appropriate next step in management? 
 1) + Colonoscopy with polypectomy (nezaškrtl-a)
 2) - Measurement of serum carcinoembryonic antigen (CEA) concentration (zaškrtl-a)
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 73. ( 18.orig.) A hospitalized 60-year-old man has had no urine output for 8 hours.  He underwent a total hip replacement 36 hours ago. He has a history of type 1 diabetes mellitus and takes nitrates for stable angina pectoris. During the operation, the estimated blood loss was 1500 mL. Intraoperatively, he had one brief episode of hypotension that resolved spontaneously. His temperature is 37.2°C (99°F), pulse is 80/min, respirations are 16/min, and blood pressure is 130/85 mm Hg. There is suprapubic fullness and a clean incision over the left hip. Examination shows no other abnormalities. His hemoglobin concentration is1,4 mmol/l (2,09-2,71), leukocyte count is 11,000/mm3 (4,500-11,000), and platelet count is 150,000/mm3 (150,000-400,000). A fingerstick blood glucose concentration is 10,3 mmol/l (3,8-6,1). Which of the following is the most appropriate initial step in management? 
 3) - Transfusion of packed red blood cells (zaškrtl-a)
 4) + Placement of a Foley catheter (nezaškrtl-a)
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 77. ( 14.orig.) A 20-year-old woman is brought to the emergency department because of fever, severe myalgias diarrhea, and a diffuse scarlatiniform rash for hours. She recovered from a similar illness 6 months ago. She is menstruating and using a tampon. She appears very ill.  Her temperature is 40°C (104°F), pulse is 130/min, and blood pressure is 75/30 mm Hg Which of the following is the most appropriate pharmacotherapy?
 2) - Ampicillin (zaškrtl-a)
 4) + Oxacilin (nezaškrtl-a)
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 83. ( 16.orig.) A 32-year-old homosexual man comes to the physician because of a purulent urethral discharge for 2 days. A culture grows Neisseria gonorrhoeae sensitive to penicillin. One week after cessation of penicillin therapy, the patient has a recurrence of the urethral discharge. A culture again shows N. gonorrhoeae sensitive to penicillin.  Both the patient and his sexual partner are HIV negative. Examination of the patients sexual partner shows an anal fissure; urethral culture does not grow N. gonorrhoeae. Which of the following is the most likely cause of the recurrence of urethral infection? 
 1) - Inadequate treatment with penicillin (zaškrtl-a)
 5) + Reinfection from the partner (nezaškrtl-a)
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 86. ( 11.orig.) A 10-year-old boy with chronic sinusitis is brought to the emergency department following a 3-minute generalized tonic-clonic seizure. He has a 3-day history of increasingly severe headaches and a 2-day history of vomiting and temperatures to 38.7°C (101.7°F). His temperature is 39.5°C (103.1°F), pulse is 80/min, respirations are 16/min, and blood pressure is 135/90 mm Hg. He is slightly lethargic but answers questions appropriately. Examination shows papilledema. No other abnormalities are noted. Which of the following is the most appropriate initial step in management? 
 4) + CT scan of the head (nezaškrtl-a)
 5) - EEG (zaškrtl-a)
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 89. ( 15.orig.) A 19-year-old college student is brought to the emergency department by his roommate because the patient was difficult to arouse in the morning. He has had a flu-like illness with fever and muscle and joint aches for 12 hours.  His temperature is 39.5°C (103.1°F), pulse is 120/min, and blood pressure is 90/60 mm Hg.  There is a diffuse petechial rash over the trunk and extremities. He has a stiff neck that cannot be passively flexed. Which of the following is the most likely pathogen? 
 3) + Neisseria meningitidis(nezaškrtl-a)
 4) - Haemophilus influenzae(zaškrtl-a)
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 91. ( 30.orig.) A 22-year-old man with a seizure disorder has had increasing cough and shortness of breath for 3 days and fever for 1 day. He has foul-smelling sputum. He had a generalized tonic-clonic seizure 1 week ago. His temperature is 39,4°C (103°F). Crackles are heard on auscultation of the chest. An x-ray of the chest shows a right upper-lobe infiltrate of the lung. Which of the following is the most likely cause?
 2) - Pneumonia secondary to gram-negative aerobes (zaškrtl-a)
 3) + Pneumonia secondary to anaerobes (nezaškrtl-a)
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 97. ( 22.orig.) A 6-month-old boy bruises easily and has bleeding gums on several occasions for 2 months. A maternal uncle has a bleeding disorder. Examination shows several small bruises on the legs. Partial thromboplastin time is prolonged, and prothrombin time is normal. Which of the following is the most likely coagulation factor deficiency?
 3) - Factor VII (zaškrtl-a)
 5) + Factor VIII (nezaškrtl-a)
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100. (  8.orig.) A 54-year-old woman comes to the physician 2 months after her husband died of a myocardial infarction. She tires easily and has chest pain when she inhales deeply at rest. She has had frequent crying spells associated with thoughts of her husband and feels uninvolved in daily activities. Which of the following is the most likely diagnosis? 
 1) - Pathologic grief (zaškrtl-a)
 2) + Normal grief (nezaškrtl-a)
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102. ( 25.orig.) A 50-year-old woman comes to the physician because of a 4-week history of aching limbs, difficulty climbing stairs, and difficulty rising from a chair. Examination shows tenderness of the quadriceps muscles. There is purple-red discoloration of the skin over the upper forehead, eyelids, and cheeks and flat-topped, purple nodules over the elbows and knees. Which of the following is the most likely diagnosis? 
 1) - Systemic lupus erythematosus (zaškrtl-a)
 3) + Dermatomyositis (nezaškrtl-a)
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104. (  3.orig.) A 32-year-old woman, gravida 5, para 4, is admitted to the hospital at 32 weeks gestation because of mild, bright red vaginal bleeding for 2 hours.  She has had no pain or contractions. Her last two children were delivered by low cervical cesarean section.  Vital signs are stable, and the fetal heart rate is 140/min and regular. Blood is drawn for complete blood count and typing and crossmatching, and intravenous administration of fluids is begun.  Which of the following is the most appropriate next step in management? 
 1) - Immediate cesarean delivery (zaškrtl-a)
 4) + Placental localization by ultrasonography (nezaškrtl-a)
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106. ( 23.orig.) A 67-year-old man comes to the physician because of a nontender lesion on the top of his forehead that has recently bled. He states that the lesion has been there since he was hit on the head with a bottle 18 months ago. Examination shows erythematous areas on other parts of his forehead. The lesion is 1 cm in diameter with a rolled-up, darkened border and a translucent, ulcerated center. Which of the following is the most likely diagnosis? 
 1) + Basal cell epithelioma (nezaškrtl-a)
 2) - Seborrheic keratosis (zaškrtl-a)
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112. ( 13.orig.) A 24-year-old jackhammer operator comes to the physician because of a 1-week history of pain and swelling that involves the entire right upper extremity; the pain worsens with exercise. Examination shows enlarged cutaneous veins over the right anterior chest wall. Which of the following is the most likely diagnosis?
 1) - Deep venous valvular insufficiency of the extremity (zaškrtl-a)
 5) + Axillary-subclavian venous thrombosis (nezaškrtl-a)
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120. ( 24.orig.) A 13-year-old boy has nasal discharge and itching of the eyes each year in the early summer. Fifteen minutes after skin testing with a mixture of grass pollens, he develops erythema and a 15-mm wheal at the site.  The skin test response is most likely a result of which of the following mechanisms? 
 1) + Release of histamine from mast cells (nezaškrtl-a)
 4) - Release of lymphokines from mast cells (zaškrtl-a)
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TEST:usmle3en  Varianta:1         Tisknuto:04/06/2019
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 14. ( 37.orig.) A male colleague asks you to write a prescription for a narcotic analgesic for one of his female patients. You have noticed that this patient frequently has been coming by the office to see your colleague, and that several of the visits have been marked "No Charge." When you ask your colleague why he cannot write the prescription himself, he seems defensive and says, "Because I don't want anybody to get the wrong idea." Which of the following is the most appropriate response to your colleague? 
 1) - "Maybe I should see your patient in the office myself, and then decide if she needs the medication." (zaškrtl-a)
 3) + "It sounds like there is more to this story than you are telling me; maybe we should talk about it." (nezaškrtl-a)
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 21. (  4.orig.) An obese 10-year-old boy with diabetes mellitus is admitted to the hospital because of severe ketoacidosis and cardiovascular collapse. Initial management consists of cardiac monitoring and intravenous administration of fluids, electrolytes and insulin. Because of the difficulty in obtaining satisfactory peripheral venous access, the left femoral vein is catheterized percutaneously. Six hours later, his mental status is improved, blood pressure is 120/70 mm Hg and serum glucose concentration is 13,6 mmol/l (3,8-6,1). A deficit of which of the following electrolytes in this patient is most likely to cause death? 
 2) + Potassium (nezaškrtl-a)
 3) - Chloride (zaškrtl-a)
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 23. (  5.orig.) A 22-year-old woman who has a 5-year history of ulcerative colitis is admitted to the hospital because of increasing abdominal pain, diarrhea and hematochezia. Her disease is limited to the descending colon. Current therapy includes sulfasalazine and corticosteroid enemas. While she is receiving parenteral corticosteroid therapy, she is discovered to be 8 weeks pregnant. Which of the following statements should be emphasized in discussing this pregnancy with her? 
 1) + Sulfasalazine and corticosteroids are not known to be teratogenic (nezaškrtl-a)
 3) - Abortion should be considered because of the teratogenic effects of her colitis therapy (zaškrtl-a)
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 24. (  2.orig.) A 75-year-old woman comes to the clinic because she has band-like burning pain in the right upper quadrant extending from the epigastrium around to the midline of the back. On physical examination, there is no abdominal tenderness. Findings on ultrasonography of the gallbladder are normal; serum amylase concentration is normal. Which of the following is the most likely diagnosis? 
 4) + Herpes zoster (nezaškrtl-a)
 5) - Chronic relapsing pancreatitis (zaškrtl-a)
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 26. ( 21.orig.) A 60-year-old man is admitted to the hospital because of acute pancreatitis. Laboratory studies show: SERUM: Amylase 1,000 U/L (25-125), Calcium 2,1 mmol/l (2,1-2,8), Urea nitrogen 0,85 mmol urea/l (1,2-3); BLOOD: Hematocrit 42% (41-53), WBC 14,000/mm3 (4500-11000).Results of serum liver chemistry profile are normal. After 48 hours of fluid therapy and observation, a poor prognosis would be indicated by which of the following laboratory studies? 
 2) - Serum glucose of 10,9 mmol/l (3,8-6,1)(zaškrtl-a)
 4) + Serum calcium of 1,6 mmol/l (nezaškrtl-a)
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 28. (  7.orig.) You plan to discharge an 81-year-old woman in a few days following a 3-week stay in the hospital for repair of a fractured hip that she sustained while gardening. She now ambulates with difficulty using a walker, but she is determined to become independent again and to return to her own home. Which of the following is most likely to prevent another fall and a possible fracture in this patient? 
 1) + Request a visiting nurse to assess the safety of her living environment (nezaškrtl-a)
 2) - Provide her with assistance for activities of daily living (zaškrtl-a)
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 29. ( 13.orig.) At a routine physical examination, the Pap smear of a 27-year-old woman shows evidence of marked inflammation suggestive of moderate dysplasia (HGSIL). Her last Pap smear 2 years ago was normal. Pelvic examination today is normal. She has never been pregnant and her menstrual periods are regular. She has been in a stable relationship with the same man for 3 years and she uses a diaphragm with spermicidal jelly for contraception. Which of the following is the most appropriate next step? 
 2) + Do colposcopic examination of the cervix after application of 5% acetic acid solution (nezaškrtl-a)
 4) - Advise the patient that her partner should use condoms for contraception and repeat the Pap smear in 3 months (zaškrtl-a)
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 36. ( 10.orig.) A 3-year-old boy is brought to the office by his father because of a 3-month history of decreased activity, poor appetite, sporadic vomiting, clumsiness and speech regression. Since his birth his family has lived in an old area of the city where there is demolition of old buildings. Examination of a peripheral blood smear is likely to show which of the following? 
 2) - Howell-Jolly bodies (zaškrtl-a)
 4) + Basophilic stippling of erythrocytes (nezaškrtl-a)
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 38. (  9.orig.) A 44-year-old Irish-American woman has had arthritis for 10 years, for which she has seen many physicians. She has used many medications and devices, including copper bracelets from Mexico given to her by friends. She seeks your help because for the past several months she has had increasing pain and stiffness in her hands. Her hands now show moderate ulnar deviation of the fingers and she says her wrists and knees also hurt. She has had increasing fatigue for about 1 month, along with a weight loss of 1.8 to 2.2 kg (4 to 5 lb). Review of her medical records, which she has brought with her, convinces you that the initial diagnosis of rheumatoid arthritis is correct. She says, "I had several drop attacks during the past 3 months." She characterizes these attacks as episodes of weakness and loss of feeling in her legs for several minutes. During one of these episodes, she became incontinent. She currently takes aspirin about four times a day and an occasional dose of ibuprofen. On physical examination she has facial plethora and swollen and painful metacarpophalangeal and knee joints, bilaterally. The rest of the examination is normal. Which of the following is the most likely cause of her "drop attacks?" 
 2) - Cardiac arrhythmia (zaškrtl-a)
 5) + Atlanto-axial instability (nezaškrtl-a)
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 42. ( 30.orig.) A 42-year-old Anglo-American man is brought to the emergency department by his same sex partner because of confusion, diplopia and mild right arm weakness. On examination the patient is somewhat agitated and shows confusion for recent events. There is decreased pupillary response on the left with some paresis of lateral gaze on the right. Temperature is 38.3°C (101.0°F). Peripheral leukocyte count is increased. Which of the following is the most appropriate next step in evaluation of his neurologic signs and symptoms? 
 1) + CT scan of the head (nezaškrtl-a)
 5) - Lumbar puncture (zaškrtl-a)
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 45. ( 27.orig.) A 26-year-old man is brought to the emergency department by his family because he says that he is being followed by gangsters and that they are going to kill him. Temperature is 37.8°C (100.0°F), pulse is 110/min and blood pressure is 160/95 mm Hg. His pupils are dilated. The remainder of the physical examination is normal. The family states that he has a history of drug abuse. Which of the following drugs most likely caused this reaction? 
 1) - Heroin (zaškrtl-a)
 5) + Cocaine (nezaškrtl-a)
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 47. ( 29.orig.) A 38-year-old nurse comes to the emergency department after leaving work early because of a "horrible headache." She has had a "cold" with sinus congestion for the past week, and yesterday she began taking an over-the-counter combination of diphenhydramine and pseudoephedrine. She tells you she has a history of "migraines," multiple allergies, premenstrual syndrome and depression, for which she takes phenelzine (a monoamine oxidase inhibitor). Vital signs are: temperature 37.2°C (99.0°F), pulse 90/min, respirations 16/min and blood pressure 210/118 mm Hg. Which of the following is the most appropriate action? 
 2) - Order CT scan of the head (zaškrtl-a)
 3) + Administer phentolamine, intravenously (nezaškrtl-a)
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 57. ( 31.orig.) A 38-year-old Hispanic bank executive comes to the emergency department because of the sudden onset of shortness of breath, light-headedness, diaphoresis, and weakness. He is afebrile. On auscultation of the lungs, bilateral basilar rales are heard. Electrocardiogram is shown. Which of the following is the most likely diagnosis? 
 3) - Acute pericarditis (zaškrtl-a)
 4) + Myocardial infarction (nezaškrtl-a)
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 59. ( 34.orig.) A 45-year-old woman is brought to the health center by her husband because of nausea, confusion, chills, fever, flank pain and cloudy urine. She has a history of insulin-dependent diabetes mellitus, poorly controlled hypertension and recurrent urinary tract infections. Her vital signs are: temperature 40.0°C (104.0°F), pulse 120/min, respirations 24/min, blood pressure 110/70 mm Hg. Funduscopic examination shows diabetic retinopathy, which is unchanged from the previous examination. Neck is supple. Lungs are clear to auscultation and percussion. Examination of the abdomen is normal. Marked pain is present at the right costovertebral angle. Several hemorrhagic bullous lesions are noted on the extremities. If this patient were to develop anuria, which of the following would be the most likely cause? 
 1) - Bladder outlet obstruction (zaškrtl-a)
 5) + Acute papillary necrosis (nezaškrtl-a)
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 66. ( 32.orig.) A 62-year-old man strikes the steering wheel of his car during a low-speed automobile accident. In the emergency department he is alert and his vital signs are normal. He complains of mild tenderness on sternal compression. Chest x-ray film shows a widened mediastinum. The most appropriate first step is to order which of the following? 
 1) + CT scan of the chest with contrast (nezaškrtl-a)
 5) - Thoracentesis (zaškrtl-a)
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 68. ( 17.orig.) A 58-year-old man comes to the office because of a lesion on the lip, which is shown. The patient says he has had the lesion for about 9 months. He has not seen a physician for 5 years and he is in the office today only because, he says, "My wife made me come." On physical examination the lower lip is fixed to the anterior aspect of the mandible. Which of the following is the most likely diagnosis? 
 3) + Squamous cell carcinoma (nezaškrtl-a)
 5) - Keratoacanthoma (zaškrtl-a)
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 69. ( 38.orig.) A husband and wife, ages 29 years and 34 years, respectively, come to the office for advice regarding their risk for having hearingimpaired children. They are both hearing-impaired and require hearing aids. Their hearing loss is sensorineural and is not associated with any other health problems. The wife tells you, "We have both learned to live with this disability, but we want to take it into account before we decide to have children." Their pedigree is shown with the patients identified as II2 and II3. Which of the following is the most appropriate advice to the couple? 
 2) - They can have amniocentesis during pregnancy to test whether the infant will be hearing-impaired (zaškrtl-a)
 3) + Accurate risk estimation is impossible without further evaluation (nezaškrtl-a)
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 78. ( 12.orig.) A 50-year-old woman comes to the office for the first time because of recurrent abdominal pain. Review of her extensive medical chart, which she has brought with her, discloses that she has a long history of varying physical complaints. Definitive causes for these complaints have not been found despite extensive diagnostic studies, consultations with many physicians and several surgical explorations. She gives dramatic and exaggerated descriptions of her present and past symptoms, and she makes conflicting statements about her history. She has been hospitalized at least 23 times since age 18 years. Which of the following is the most likely diagnosis? 
 1) + Histrionic personality disorder (nezaškrtl-a)
 2) - Borderline personality disorder (zaškrtl-a)
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 81. (  3.orig.) An obese 10-year-old boy with diabetes mellitus is admitted to the hospital because of severe ketoacidosis and cardiovascular collapse. Initial management consists of cardiac monitoring and intravenous administration of fluids, electrolytes and insulin. Because of the difficulty in obtaining satisfactory peripheral venous access, the left femoral vein is catheterized percutaneously. Six hours later, his mental status is improved, blood pressure is 120/70 mm Hg and serum glucose concentration is 13,6 mmol/l (3,8-6,1). Physical examination at that time shows a cold left foot with diminished pulses compared with those of the right foot. Which of the following is the most likely explanation for this patient's diminished pulses? 
 2) + Inadvertent injury of the femoral artery (nezaškrtl-a)
 5) - Intense arteriolar constriction induced by hyperosmolality (zaškrtl-a)
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 82. ( 25.orig.) A 52-year-old woman who has had low back pain for several years is admitted to the hospital because the pain has suddenly worsened. Her current medications include oxycodone, amitriptyline, perphenazine, fluoxetine and trazodone. On physical examination, the patient is 10% below her ideal body weight, pupils are constricted and skin turgor is poor. She seems sluggish and her speech is slow. Results of neurologic examination and x-ray films of the lumbosacral spine are normal. If a medication is responsible for her mental condition, the medication is most likely to be which of the following? 
 2) + Oxycodone (nezaškrtl-a)
 3) - Amitriptyline (zaškrtl-a)
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 92. ( 39.orig.) A 76-year-old woman returns to the office because of aching and weakness in her arms to the point where she cannot lift her arm to brush her hair. Physical examination shows no muscle tenderness or other evidence of joint disease in both arms. The aching improves when she takes the prescribed nonsteroidal anti-inflammatory drug (NSAID). She also describes tenderness over the right parietal area of her scalp. Physical examination of the scalp shows no lesions. Which of the following is the most appropriate next step? 
 1) - Order determination of serum rheumatoid factor (zaškrtl-a)
 3) + Order determination of erythrocyte sedimentation rate (nezaškrtl-a)
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108. ( 28.orig.) A 35-year-old woman is seen in the emergency department because of the sudden onset of severe low back pain 12 hours earlier. The pain began when she bent over to pick up her 2-year-old child. She has been unable to stay in bed because of the need to care for her child. Low doses of ibuprofen have eased the discomfort slightly. Careful physical examination, including a neurologic examination, is normal except for evidence of muscle spasm. She believes she has a herniated disc because 2 years ago her father developed the sudden onset of back pain that required immediate surgery. Which of the following is the most appropriate first step? 
 1) + Reassure her and treat with a nonsteroidal anti-inflammatory drug (NSAID) (nezaškrtl-a)
 2) - Order CT scan of the lumbar spine (zaškrtl-a)
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110. ( 23.orig.) A 50-year-old woman is in the recovery room following an uneventful cholecystectomy. Two hours after the procedure she begins to have ventricular extra-systoles and her systolic blood pressure falls from 110 mm Hg to 90 mm Hg. Arterial blood gas values while breathing room air are: PO2 7,7 kPa (10,0-14,0),  PCO2 6,9 kPa (4,4-5,9), pH [H+]36,8 nmol/l (36-44). These signs are most likely the result of which of the following? 
 2) - Primary hypoxemia resulting from anesthetic gases (zaškrtl-a)
 5) + Alveolar hypoventilation (nezaškrtl-a)
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114. ( 35.orig.) A 47-year-old Italian-American man comes to the office for the first time for routine medical care. He has been referred to you by his psychiatrist who has informed you that the patient has paranoid personality disorder. The patient has no other medical problems at this time. He is unmarried, lives alone and has no close friends, but he occasionally attends family gatherings. He functions well working alone in a technical position in an engineering firm. Which of the following is the best way to structure the physician-patient relationship with this patient? 
 3) - Go out of your way to be warm and friendly so that he can develop trust in you (zaškrtl-a)
 4) + Explain the rationale for any diagnostic procedures and treatment regimens in some detail, adopting a professional, but not overly friendly stance (nezaškrtl-a)
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116. (  6.orig.) You plan to discharge an 81-year-old woman in a few days following a 3-week stay in the hospital for repair of a fractured hip that she sustained while gardening. She now ambulates with difficulty using a walker, but she is determined to become independent again and to return to her own home. Her daughter, who is in the room with the patient, says, "I want to take Mother home with me because I'm concerned that she could fall and break her hip again. Mom says she doesn't really want to leave her own home, but she will do what is best." The daughter turns to her mother and says firmly, "Isn't that right, Mom?" The mother says, "Yes, I guess so," averting eye contact with both her daughter and you by looking down toward the floor. Which of the following is the most appropriate response to the mother? 
 3) - "Is this really your decision or is it your daughter's?" (zaškrtl-a)
 5) + "I would like to talk with you in private now." (nezaškrtl-a)
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118. ( 11.orig.) A 32-year-old man and his 29-year-old wife are being evaluated for infertility. The woman's gynecologist reports that the woman had a normal anatomic and physiologic evaluation and suggests the need for assessment of potential male factors. On examination, the man is 188 cm (6 ft 3 in) tall with fair skin and little facial hair. His testicles are small and firm, and he has mild gynecomastia. No sperm are seen on analysis of his semen. Which of the following tests is most likely to establish the underlying cause of the infertility? 
 1) + Karyotype from peripheral leukocytes (nezaškrtl-a)
 3) - Serum gonadotropin concentrations (follicle-stimulating hormone and luteinizing hormone) (zaškrtl-a)