Otázky s chybnou odpovědí, č.j. 3902206
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TEST:usmle1en  Varianta:6         Tisknuto:04/06/2019
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  3. ( 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) + Posterior cricoarytenoid (nezaškrtl-a)
 3) - Cricothyroid (zaškrtl-a)
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  9. ( 25.orig.) A 50-year-old man is awakened in the middle of the night with acute pain and tenderness of the right knee.  He has a low-grade fever.  His knee is hot, red, tender, and swollen. Analysis of the fluid from the right knee shows: Leukocytes: 70,000/mm3 with 75%  neutrophils; Crystal analysis: negatively birefringent; Gram's stain: negative. The most likely diagnosis is 
 1) + Gout (nezaškrtl-a)
 4) - Septic arthritis (zaškrtl-a)
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 10. ( 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? 
 4) - Diffuse scarring in subcutaneous fibrous tissue (zaškrtl-a)
 5) + Attachments of suspensory ligaments (retinacula cutis) to the dermis (nezaškrtl-a)
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 13. ( 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? 
 1) + Fat embolization (nezaškrtl-a)
 5) - Contrecoup injury (zaškrtl-a)
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 29. (  6.orig.) A 36-year-old woman has a hysterectomy and bilateral salpingo-oophorectomy because of uncontrolled hemorrhage. She is very concerned because her mother has vertebral compression fractures due to osteoporosis. Which of the following is the most appropriate single treatment to prevent bone loss?
 1) + Estrogen (nezaškrtl-a)
 3) - Calcium, oraly (zaškrtl-a)
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 30. ( 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)
 3) + Suprachiasmatic (nezaškrtl-a)
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 33. (  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?  
 4) + C (nezaškrtl-a)
 5) - D (zaškrtl-a)
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 35. (  7.orig.) A 58-year-old man with chronic congestive heart failure requires ongoing hydrochlorothiazide therapy. His monthly serum chemistry profile shows persistent hypokalemia.  The most appropriate next step is to add which of the following diuretics to the regimen? 
 2) - Metolazone (zaškrtl-a)
 3) + Amiloride (nezaškrtl-a)
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 56. ( 16.orig.) A 38-year-old woman with hypertension and hypokalemia is suspected of having hyperaldosteronism. In addition to serum aldosterone measurement, initial evaluation of this patient should include measurement of which of the following? 
 1) - Plasma cortisol (zaškrtl-a)
 3) + Plasma renin (nezaškrtl-a)
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 58. ( 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? 
 2) + Sheets and cords of epithelial cells in the serosal layer (nezaškrtl-a)
 5) - Formation of new vascular channels and hemorrhage (zaškrtl-a)
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 63. ( 11.orig.) Patients X and Y both have respirations of 12/min and tidal volumes of 500 mL. However, patient X has an arterial PCO2 of 35 mm Hg, while patient Y has an arterial PCO2 of 45 mm Hg. The difference in PCO2 between these patients is best explained by a difference in which of the following? 
 1) + Dead space ventilation (nezaškrtl-a)
 3) - Forced expiratory volume in 1 sec  (FEV1) (zaškrtl-a)
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 80. ( 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 release of histamine (zaškrtl-a)
 4) + Local fixation of complement by preformed circulating antibodies (nezaškrtl-a)
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 82. ( 12.orig.) An 18-year-old female athlete reports easy fatigability and weakness. Findings on physical examination are unremarkable.  Laboratory data are:  SERUM: Na+ 141 mmol/l (136-145), Cl- 85 mmol/l (95-105), K+ 2,1 mmol/l (3,5-5), HCO3- 35 mmol/l (22-28); URINE: Na+ 80 mmol/24h, K+ 170 mmol/24h. The most likely diagnosis is 
 1) - Aldosterone deficiency (zaškrtl-a)
 4) + Surreptitious use of diuretics (nezaškrtl-a)
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 88. ( 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? 
 3) - Muscle creatine phosphate (zaškrtl-a)
 5) + Serum fatty acids (nezaškrtl-a)
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 90. ( 38.orig.) The intracellular domain of the insulin receptor has which of the following enzyme activities? 
 2) - Adenylyl cyclase (zaškrtl-a)
 3) + Tyrosine kinase (nezaškrtl-a)
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 93. ( 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) - Nucleus of the oculomotor nerve (zaškrtl-a)
 3) + Medial longitudinal fasciculus (nezaškrtl-a)
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 95. ( 33.orig.) While smoking crack cocaine, a 16-year-old boy develops substernal chest pain. An ECG is consistent with anterior wall myocardial ischemia. The drug most likely had which of the following effects on the heart? 
 1) - Direct stimulation of -adrenergic receptors (zaškrtl-a)
 5) + Indirect stimulation of -adrenergic receptors (nezaškrtl-a)
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 98. (  5.orig.) A 4-week-old infant has a loud systolic murmur with a systolic thrill; otherwise, the infant appears healthy. There is no cyanosis. The most likely cause of the murmur is
 3) + ventricular septal defect (nezaškrtl-a)
 5) - atrial septal defect (zaškrtl-a)
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101. ( 18.orig.) A 23-year-old woman has a progressive increase in serum human chorionic gonadotropin (hCG) concentrations over an 8-week period. A hydatidiform mole is removed, but the hCG concentration continues to increase. The most likely diagnosis is 
 1) + choriocarcinoma (nezaškrtl-a)
 3) - a second noninvasive mole (zaškrtl-a)
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103. ( 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? 
 2) - Smear  + Gram stain (zaškrtl-a)
 3) + Taking samples of the discharge with a syringe and transferring them directly to the laboratory (nezaškrtl-a)
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105. ( 21.orig.) A 56-year-old woman has adenocarcinoma of the colon that is surgically resected. Which of the following patterns of growth by the neoplasm most strongly suggests a poor prognosis? 
 1) - Extension to the muscularis mucosa (zaškrtl-a)
 2) + Extension to the serosa (nezaškrtl-a)
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111. (  8.orig.) Moderate alcohol consumption may protect against coronary artery disease by which of the following mechanisms? 
 4) - Decreasing serum concentration of LDLs (zaškrtl-a)
 5) + Increasing serum concentration of HDLs (nezaškrtl-a)
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118. ( 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 
 3) - spermatocele (zaškrtl-a)
 4) + varicocele (nezaškrtl-a)
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TEST:usmle2en  Varianta:6         Tisknuto:04/06/2019
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  5. ( 31.orig.) A previously healthy 34-year-old woman is brought to the physician because of fever and headache for 1 week. She has not been exposed to any disease. She takes no medications. Her temperature is 39,3°C (102°F), pulse is 104/min, respirations are 24/min, and blood pressureis 135/88 mm Hg. She is confused and oriented only to person. Examination shows jaundice of the skin and conjunctivae. There are a few scattered petechiae over the trunk and back. There is no lympadenopathy. Physical and neurologic examinations show no other abnormalities. Test of the stool for occult blood is positive. Laboratory studies show:BLOOD: hematocrit 0,32 (0,36-0,46), with fragmented and nucleated erythrocytes; leukocyte count 12,500/mm3 (4,500-11,000); platelet count 20,000/mm3 (150,000-400,000); prothrombin time 10 sec (11-15); partial thromboplastin time 30 sec (40);fibrin split products - negative. SERUM: urea nitrogen (BUN) 6,0 mmol urea/l (1,2-3,0); creatinine 265 mmol/l (53-106); bilirubin total 50 mmol/l (2-17); bilirubin direct 10 mmol/l (0-5); lactate dehydrogenase 1000U/l (45-90). Blood and urine cultures are negative. A CT scan of the head shows no abnormalities. Which of the following is the most likely diagnosis?
 1) - Disseminated intravascular coagulation (zaškrtl-a)
 4) + Thrombotic thrombocytopenic purpura (nezaškrtl-a)
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 17. (  4.orig.) An 18-year-old male high school basketball player comes to the physician for a routine physical examination. He is 193 cm (6 ft 4 in) tall; arm span is 201 cm (79 in). He has long fingers and toes. His pulse is 64/min, and blood pressure is 146/62 mm Hg. There is a grade 2/6, long, high-frequency diastolic murmur at the second right intercostal space. Which of the following is the most likely diagnosis? 
 1) + Aortic regurgitation (nezaškrtl-a)
 5) - Coarctation of the aorta (zaškrtl-a)
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 18. ( 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? 
 2) - Systemic lupus erythematosus (zaškrtl-a)
 4) + Dermatomyositis (nezaškrtl-a)
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 19. ( 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) + Polymyalgia rheumatica (nezaškrtl-a)
 3) - Hyperthyroid myopathy (zaškrtl-a)
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 20. ( 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? 
 1) - Lumbar puncture (zaškrtl-a)
 2) + CT scan of the head (nezaškrtl-a)
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 38. ( 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?
 1) - Continuation of current oxygen with the addition of a respiratory stimulant (zaškrtl-a)
 5) + Endotracheal intubation and mechanical ventilation (nezaškrtl-a)
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 41. (  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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 44. ( 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? 
 3) + Opiate withdrawal (nezaškrtl-a)
 5) - Tricyclic intoxication (zaškrtl-a)
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 50. ( 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? 
 3) - Measurement of serum carcinoembryonic antigen (CEA) concentration (zaškrtl-a)
 4) + Colonoscopy with polypectomy (nezaškrtl-a)
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 57. ( 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?
 1) - Gentamicin (zaškrtl-a)
 5) + Oxacilin (nezaškrtl-a)
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 70. (  2.orig.) A 43-year-old woman who works as a seamstress has a 3-month history of pain, weakness, and numbness of the right hand that is worse at night. Examination shows hypoesthesia and atrophy of the thenar eminence. These findings are most likely caused by compression of which of the following nerves? 
 2) - Ulnar (zaškrtl-a)
 5) + Median (nezaškrtl-a)
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 72. ( 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? 
 2) - Melanoma (zaškrtl-a)
 4) + Basal cell epithelioma (nezaškrtl-a)
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 73. ( 36.orig.) A 20-year-old primigravid woman delivers a full-term 3200-g (7-lb 1-oz) newborn vaginally under epidural anesthesia. A second-degree midline episiotomy was required.  On postpartum day 1, she has perineal pain.  The perineum is slightly edematous with no evidence of purulent drainage or episiotomy breakdown. Which of the following is the most appropriate next step in management? 
 1) + Sitz baths twice daily (nezaškrtl-a)
 5) - Local injection of lidocaine in the perineum (zaškrtl-a)
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 75. ( 28.orig.) A previously healthy 16-year-old boy is brought to the emergency department 1 hour after the sudden onset of abdominal and scrotal pain. There is severe tenderness in the region of the inguinal canal on the right; the right side of the scrotum is empty. Urinalysis shows normal findings. Which of the following is the most effective initial management? 
 1) + Immediate operation (nezaškrtl-a)
 5) - Administration of analgesics and observation (zaškrtl-a)
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 76. ( 38.orig.) A 14-year-old boy is brought to the walk in clinic by his father late on Saturday afternoon because his left ear is swollen and painful. The boy´s ear has been black and blue since he injured it in a wrestling match 3 days ago. Symptoms have increased significantly following a repeat injura 3 hours ago. On physical examination, his left ear is markedly swollen and tender to palpation. Which of the following is the most appropriate next step?
 1) + Refer him to a surgeon for immediate drainage of the lesion (nezaškrtl-a)
 4) - Recommend that he apply cold pycks to the ear for the next 12 hours (zaškrtl-a)
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 84. ( 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? 
 3) - Preseptal (periorbital) cellulitis (zaškrtl-a)
 4) + Orbital cellulitis (nezaškrtl-a)
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100. ( 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? 
 4) + Placement of a Foley catheter (nezaškrtl-a)
 5) - Administration of 20 U of regular insulin (zaškrtl-a)
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117. ( 39.orig.) A 37-year-old woman, gravida 3, para 3, comes to the physician because of labor-like pains and a small amount of vaginal bleeding for 2 days. She has had increasingly heavy, regular menstrual periods over the past 3 years; her last menstrual period was 18 days ago. Her youngest child is 10 years old. The cervix is moderately effaced and 2 cm dilated; there is beefy red tissue in the os. Which of the following is the most likely diagnosis? 
 2) + Pedunculated submucous leiomyoma (nezaškrtl-a)
 3) - Incomplete abortion (zaškrtl-a)
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TEST:usmle3en  Varianta:6         Tisknuto:04/06/2019
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  4. ( 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? 
 1) + Serum calcium of 1,6 mmol/l (nezaškrtl-a)
 3) - Serum amylase of 2,000 U/L (zaškrtl-a)
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  8. ( 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? 
 3) + Karyotype from peripheral leukocytes (nezaškrtl-a)
 5) - Serum gonadotropin concentrations (follicle-stimulating hormone and luteinizing hormone) (zaškrtl-a)
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 16. ( 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) + Alveolar hypoventilation (nezaškrtl-a)
 5) - Pulmonary embolus (zaškrtl-a)
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 22. ( 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? 
 2) - Thoracic ultrasonography (zaškrtl-a)
 4) + CT scan of the chest with contrast (nezaškrtl-a)
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 25. ( 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? 
 4) + Myocardial infarction (nezaškrtl-a)
 5) - Acute pericarditis (zaškrtl-a)
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 36. (  8.orig.) A 56-year-old man is admitted to the hospital from the emergency department because of an acute myocardial infarction. He has no identified risk factors and no history of heart disease. He had no major complications and is discharged after 8 days. At discharge, which of the following diagnostic tests should be scheduled for the 2-week follow-up visit in order to predict most accurately his risk for another infarction? 
 2) - Radionuclide ventriculography (zaškrtl-a)
 5) + Exercise stress test (nezaškrtl-a)
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 39. ( 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? 
 1) + Administer phentolamine, intravenously (nezaškrtl-a)
 3) - Administer meperidine, intramuscularly (zaškrtl-a)
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 43. ( 26.orig.) A 46-year-old man with Marfan syndrome, aortic insufficiency and mitral regurgitation comes to the emergency department because of severe substernal chest pain for the past 3 hours. He describes the pain as tearing in quality and radiating to the neck. One week earlier he experienced similar, but less severe, chest pain and treated himself with aspirin. Which of the following is the most likely underlying cause for his worsening symptoms? 
 3) - Acute myocardial infarction (zaškrtl-a)
 4) + Dissection of the aorta (nezaškrtl-a)
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 46. ( 36.orig.) A 12-month-old boy is brought to the office by his mother for his routine health check-up. She informs you that she has just been diagnosed with hypercholesterolemia. Her fasting serum total cholesterol concentration was 6,8mmol/l (3,9-6,2) and her LDL-cholesterol concentration was 3,41 mmol/l (<4,2). She is unaware of a family history of coronary artery disease because she was raised by her godmother when her parents died in their early 30s in a motor vehicle accident. A special diet has been recommended for her; however, she is very concerned about the risk of hypercholesterolemia for her son. Which of the following is the most appropriate management at this time? 
 2) + Do nothing until the child is 2 years of age (nezaškrtl-a)
 5) - Obtain a random serum total cholesterol concentration for the child today (zaškrtl-a)
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 48. (  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?" 
 4) + Atlanto-axial instability (nezaškrtl-a)
 5) - Anxiety (zaškrtl-a)
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 51. (  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? 
 2) + Sulfasalazine and corticosteroids are not known to be teratogenic (nezaškrtl-a)
 3) - Occurrence of spontaneous abortions does not correlate with disease activity (zaškrtl-a)
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 55. ( 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? 
 1) - Macrocytic erythrocytes (zaškrtl-a)
 3) + Basophilic stippling of erythrocytes (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? 
 2) + Acute papillary necrosis (nezaškrtl-a)
 4) - Renal lithiasis (zaškrtl-a)
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 64. (  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)
 3) - Ensure that she does not have orthostatic hypotension (zaškrtl-a)
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 67. ( 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? 
 1) - Basal cell carcinoma (zaškrtl-a)
 5) + Squamous cell carcinoma (nezaškrtl-a)
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 78. ( 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? 
 2) - Order x-ray films of the lumbar spine (zaškrtl-a)
 3) + Reassure her and treat with a nonsteroidal anti-inflammatory drug (NSAID) (nezaškrtl-a)
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 79. ( 15.orig.) A 19-year-old white woman returns to the office 2 months after having a medroxyprogesterone injection for contraception. She is complaining of nonstop bleeding since her menses 3 weeks ago. She is using eight pads a day. She denies any sexual activity since she received the injection. She realizes that spotting is a side effect; however, she is anxious about the length of time and the amount of the bleeding. She tells you, "I can't stand this, Doctor. I want the bleeding to stop now!" Repeat pregnancy test is negative. Which of the following is the most appropriate treatment option for her bleeding? 
 1) + Conjugated estrogen therapy for 2 weeks (nezaškrtl-a)
 4) - Reassurance and counseling (zaškrtl-a)
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 91. ( 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) + "It sounds like there is more to this story than you are telling me; maybe we should talk about it." (nezaškrtl-a)
 2) - "I wish I could help you, but I never prescribe that medication for a patient unless I have seen the patient myself." (zaškrtl-a)
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109. ( 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? 
 2) + Order determination of erythrocyte sedimentation rate (nezaškrtl-a)
 5) - Order x-ray films of the cervical spine (zaškrtl-a)
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113. ( 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) - Somatization disorder (zaškrtl-a)
 3) + Histrionic personality disorder (nezaškrtl-a)