Otázky s chybnou odpovědí, č.j. 4134020
------------------------------------------------------------------------------------------
TEST:usmle1en  Varianta:4         Tisknuto:04/06/2019
------------------------------------------------------------------------------------------
  4. ( 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 
 3) - Chondrocalcinosis (pseudogout) (zaškrtl-a)
 5) + Gout (nezaškrtl-a)
------------------------------------------------------------------------------------------
  6. ( 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) - Accumulation of mononuclear cells at the site of antigen injection (zaškrtl-a)
------------------------------------------------------------------------------------------
 11. ( 22.orig.) A 52-year-old woman is admitted to the hospital because of  breast cancer metastatic to the liver. Her prognosis is poor. She begs her husband to stay with her at the hospital because she is afraid to be left alone. Which of the following defense mechanisms best explains her behavior? 
 1) + Regression (nezaškrtl-a)
 4) - Repression (zaškrtl-a)
------------------------------------------------------------------------------------------
 13. ( 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? 
 2) + Extension to the serosa (nezaškrtl-a)
 5) - Surface ulceration (zaškrtl-a)
------------------------------------------------------------------------------------------
 22. ( 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)
 5) + Preeclampsia (nezaškrtl-a)
------------------------------------------------------------------------------------------
 29. ( 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)
 2) - Contrecoup injury (zaškrtl-a)
------------------------------------------------------------------------------------------
 30. ( 38.orig.) The intracellular domain of the insulin receptor has which of the following enzyme activities? 
 2) + Tyrosine kinase (nezaškrtl-a)
 4) - Phospholipase C (zaškrtl-a)
------------------------------------------------------------------------------------------
 33. ( 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 forebrain bundle (zaškrtl-a)
 2) + Medial longitudinal fasciculus (nezaškrtl-a)
------------------------------------------------------------------------------------------
 34. ( 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)
------------------------------------------------------------------------------------------
 42. ( 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? 
 2) - Urinary sodium (zaškrtl-a)
 5) + Plasma renin (nezaškrtl-a)
------------------------------------------------------------------------------------------
 44. (  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)
 4) - Vitamin D (zaškrtl-a)
------------------------------------------------------------------------------------------
 72. (  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?
 2) - Nucleocapsid (zaškrtl-a)
 3) + Hemagglutinin (nezaškrtl-a)
------------------------------------------------------------------------------------------
 78. ( 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? 
 1) - Openings of sebaceous glands (zaškrtl-a)
 4) + Attachments of suspensory ligaments (retinacula cutis) to the dermis (nezaškrtl-a)
------------------------------------------------------------------------------------------
105. ( 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) + Taking samples of the discharge with a syringe and transferring them directly to the laboratory (nezaškrtl-a)
 3) - Smear  + Gram stain (zaškrtl-a)
------------------------------------------------------------------------------------------
109. ( 39.orig.) A neonate develops abdominal distention. X-ray films of the abdomen show markedly dilated loops of small bowel and colon. Which of the following is the most likely diagnosis? 
 3) - Multiple polyps in the colon (zaškrtl-a)
 4) + Hirschsprung disease (nezaškrtl-a)
------------------------------------------------------------------------------------------
112. (  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? 
 4) + Amiloride (nezaškrtl-a)
 5) - Acetazolamide (zaškrtl-a)
------------------------------------------------------------------------------------------
113. ( 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 
 4) - Anxiety reaction with hyperventilation (zaškrtl-a)
 5) + Surreptitious use of diuretics (nezaškrtl-a)
------------------------------------------------------------------------------------------
118. (  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)
 2) - A (zaškrtl-a)
------------------------------------------------------------------------------------------
119. ( 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? 
 2) - Direct inhibition of -adrenergic receptors (zaškrtl-a)
 5) + Indirect stimulation of -adrenergic receptors (nezaškrtl-a)
------------------------------------------------------------------------------------------
TEST:usmle2en  Varianta:4         Tisknuto:04/06/2019
------------------------------------------------------------------------------------------
  2. ( 26.orig.) A 17-year-old boy comes to the physician because of right groin pain for 2 hours; elevation of the scrotum does not relieve the pain. There is no history of trauma.  He is sexually active and has had multiple sexual partners over the past 3 years. He does not use condoms regularly. He had chlamydial urethritis 1 year ago treated with doxycycline. Examination shows an enlarged, swollen, erythematous, and acutely tender right scrotum. The left testis is found in a horizontal position; the cremasteric reflex is absent on the right. Which of the following is the most likely diagnosis? 
 4) - Epididymitis (zaškrtl-a)
 5) + Torsion of the testicle (nezaškrtl-a)
------------------------------------------------------------------------------------------
  7. ( 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) + CT scan of the head (nezaškrtl-a)
 5) - X-rays of the sinuses (zaškrtl-a)
------------------------------------------------------------------------------------------
 10. ( 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? 
 4) - Repeat test of the stool for occult blood after 3 days on a meat-free diet (zaškrtl-a)
 5) + Colonoscopy with polypectomy (nezaškrtl-a)
------------------------------------------------------------------------------------------
 14. ( 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)
 4) + Dermatomyositis (nezaškrtl-a)
------------------------------------------------------------------------------------------
 15. (  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) + Placental localization by ultrasonography (nezaškrtl-a)
 2) - Doppler umbilical blood flow study (zaškrtl-a)
------------------------------------------------------------------------------------------
 17. (  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? 
 2) - Conversion disorder (zaškrtl-a)
 4) + Normal grief (nezaškrtl-a)
------------------------------------------------------------------------------------------
 21. ( 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? 
 2) + Orbital cellulitis (nezaškrtl-a)
 3) - Preseptal (periorbital) cellulitis (zaškrtl-a)
------------------------------------------------------------------------------------------
 23. ( 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? 
 1) + Decline to answer, because the information is confidential (nezaškrtl-a)
 3) - Decline to answer, because the administrator is not a medical doctor (zaškrtl-a)
------------------------------------------------------------------------------------------
 25. ( 20.orig.) A 9-month-old infant is brought to the physician for a well-child visit. She was born at 33 weeks gestation. Her diet consists of whole milk and commercial baby food vegetables, fruits, and meat. Her length is at the 50th percentile for age, and weight is at the 75th percentile. Examination shows no abnormalities except for pallor.  Her hematocrit is 25%. A blood smear shows microcytic, hypochromic erythrocytes. Which of the following is most likely to have prevented this condition? 
 1) + Regular consumption of iron-containing formula (nezaškrtl-a)
 2) - Dietary supplementation with vitamin E (zaškrtl-a)
------------------------------------------------------------------------------------------
 26. (  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) - Coarctation of the aorta (zaškrtl-a)
 4) + Aortic regurgitation (nezaškrtl-a)
------------------------------------------------------------------------------------------
 31. ( 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?
 3) - Disseminated intravascular coagulation (zaškrtl-a)
 4) + Thrombotic thrombocytopenic purpura (nezaškrtl-a)
------------------------------------------------------------------------------------------
 51. ( 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? 
 1) - Carcinoma of the endometrium (zaškrtl-a)
 4) + Pedunculated submucous leiomyoma (nezaškrtl-a)
------------------------------------------------------------------------------------------
 68. ( 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?
 3) - Ampicillin (zaškrtl-a)
 4) + Oxacilin (nezaškrtl-a)
------------------------------------------------------------------------------------------
 69. ( 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? 
 3) - Hyperthyroid myopathy (zaškrtl-a)
 4) + Polymyalgia rheumatica (nezaškrtl-a)
------------------------------------------------------------------------------------------
 74. ( 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? 
 3) + Reinfection from the partner (nezaškrtl-a)
 4) - Inadequate treatment with penicillin (zaškrtl-a)
------------------------------------------------------------------------------------------
 86. (  1.orig.) A 54-year-old woman with a 10-year history of progressive systemic sclerosis (scleroderma) undergoes an emergency laparotomy for a perforated appendix with peritonitis. During the immediate postoperative period, she has a blood pressure of 180/110 mm Hg. Over the next 3 days, her serum creatinine concentration increases, and her urinary output decreases to 250 ml/day. On postoperative day 4, she has mild shortness of breath. Her peripheral oxygen saturation on room air is 89%. Serum studies show a potassium concentration of 6.2 mmol/l (3,5-5,0), a urea nitrogen concentration of 5,8 mmol/l (1,2-3,0), and a creatinine concentration of 344,5 mmol/l (53-106). Which of the following is the most appropriate next step in management? 
 3) - Intravenous administration of ACE inhibitors (zaškrtl-a)
 4) + Hemodialysis (nezaškrtl-a)
------------------------------------------------------------------------------------------
 89. ( 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) - Kaposi sarcoma (zaškrtl-a)
 4) + Basal cell epithelioma (nezaškrtl-a)
------------------------------------------------------------------------------------------
 95. ( 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?
 2) + Endotracheal intubation and mechanical ventilation (nezaškrtl-a)
 3) - Administration of 2l/min of oxygen by nasal prongs (zaškrtl-a)
------------------------------------------------------------------------------------------
 96. (  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)
 3) - Panic disorder (zaškrtl-a)
------------------------------------------------------------------------------------------
 99. ( 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? 
 4) - Release of lymphokines from mast cells (zaškrtl-a)
 5) + Release of histamine from mast cells (nezaškrtl-a)
------------------------------------------------------------------------------------------
101. ( 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? 
 4) + Opiate withdrawal (nezaškrtl-a)
 5) - Renal calculi (zaškrtl-a)
------------------------------------------------------------------------------------------
102. ( 10.orig.) A 45-year-old woman comes to the physician because of a 3-month history of episodes in which she becomes overwhelmingly hot and sweats so much that her clothes become wet. The episodes last approximately 5 minutes and have increased in frequency; they now occur at least once daily, mostly at night.  During an episode, her heart rate increases, and she feels anxious; she has a chilled feeling afterward.  Menses are regular, but the intermenstrual interval has decreased by 5 days over the past 6 months. She takes no medications. She drinks five cups of coffee daily. Her temperature is 37°C (98.6°F), pulse is 74/min, and blood pressure is 110/70 mm Hg. Examination shows no other abnormalities. Which of the following is the most likely explanation for these findings? 
 3) + Hot flash (nezaškrtl-a)
 4) - Hyperthyroidism (zaškrtl-a)
------------------------------------------------------------------------------------------
106. ( 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?
 3) - Disseminated gonococcal disease (zaškrtl-a)
 5) + Systemic lupus erythematosus (nezaškrtl-a)
------------------------------------------------------------------------------------------
110. ( 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?
 3) - Deep venous valvular insufficiency of the extremity (zaškrtl-a)
------------------------------------------------------------------------------------------
114. ( 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 cocci in chains (nezaškrtl-a)
 4) - Gram-positive diplococci (zaškrtl-a)
------------------------------------------------------------------------------------------
116. ( 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?
 1) - Factor VII (zaškrtl-a)
 4) + Factor VIII (nezaškrtl-a)
------------------------------------------------------------------------------------------
TEST:usmle3en  Varianta:4         Tisknuto:04/06/2019
------------------------------------------------------------------------------------------
  8. ( 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)
 2) - Serum amylase of 2,000 U/L (zaškrtl-a)
------------------------------------------------------------------------------------------
  9. ( 40.orig.) A 74-year-old man with urinary frequency and urgency has benign prostatic hyperplasia. He refuses operative intervention but agrees to a trial of finasteride therapy (5-a-reductase infibitor). During the trial, synthesis of which of the following substances is most likely to be inhibited?
 1) + Dihydrotestosterone (nezaškrtl-a)
 3) - Androstenedione (zaškrtl-a)
------------------------------------------------------------------------------------------
 12. ( 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? 
 4) - Order x-ray films of the lumbar spine (zaškrtl-a)
 5) + Reassure her and treat with a nonsteroidal anti-inflammatory drug (NSAID) (nezaškrtl-a)
------------------------------------------------------------------------------------------
 16. ( 14.orig.) A 66-year-old African-American man who has been a patient for several years calls the office to report an episode of apparently bloody urine. He is instructed to come to the office, where urinalysis confirms gross hematuria without proteinuria or casts. The patient denies any pain and is anxious for an explanation. Physical examination is normal. Which of the following is the most appropriate next step? 
 1) + Schedule cystoscopy (nezaškrtl-a)
 2) - Schedule bilateral renal angiography (zaškrtl-a)
------------------------------------------------------------------------------------------
 19. ( 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? 
 4) - Macrocytic erythrocytes (zaškrtl-a)
------------------------------------------------------------------------------------------
 24. (  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? 
 4) + Inadvertent injury of the femoral artery (nezaškrtl-a)
 5) - Intense arteriolar constriction induced by hyperosmolality (zaškrtl-a)
------------------------------------------------------------------------------------------
 39. ( 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? 
 3) - Triphasic oral contraceptive therapy for one cycle (zaškrtl-a)
 5) + Conjugated estrogen therapy for 2 weeks (nezaškrtl-a)
------------------------------------------------------------------------------------------
 54. (  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?" 
 1) + Atlanto-axial instability (nezaškrtl-a)
 5) - Cardiac arrhythmia (zaškrtl-a)
------------------------------------------------------------------------------------------
 55. (  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? 
 1) - Bicarbonate (zaškrtl-a)
 3) + Potassium (nezaškrtl-a)
------------------------------------------------------------------------------------------
 57. (  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) - Abortion should be considered because of the teratogenic effects of her colitis therapy (zaškrtl-a)
 3) + Sulfasalazine and corticosteroids are not known to be teratogenic (nezaškrtl-a)
------------------------------------------------------------------------------------------
 62. ( 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)
 4) + "It sounds like there is more to this story than you are telling me; maybe we should talk about it." (nezaškrtl-a)
------------------------------------------------------------------------------------------
 66. ( 16.orig.) A 28-year-old woman of Scandinavian descent comes to the office because of fatigue, weakness and palpitations. She is divorced and lives with her 4-year-old daughter. Complete evaluation shows that this patient has hyperthyroidism and mild ophthalmopathy caused by Graves disease. Before initiating therapy, the patient wants to know what she can expect in the future. In advising her about the prognosis, which of the following is the most accurate statement? 
 2) - Graves ophthalmopathy will resolve as thyroid hormone secretion is lowered (zaškrtl-a)
 4) + Untreated patients are at increased risk for cardiac arrhythmias (nezaškrtl-a)
------------------------------------------------------------------------------------------
 75. ( 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) - Thoracentesis (zaškrtl-a)
 5) + CT scan of the chest with contrast (nezaškrtl-a)
------------------------------------------------------------------------------------------
 80. ( 24.orig.) A 20-year-old woman who is 35 weeks pregnant with her first child is admitted to the hospital because of persistent hypertension and 1+ protein on urinalysis obtained 36 hours ago. She is confined to bed awaiting further diagnostic studies for preeclampsia. Her blood pressure is now 160/100 mm Hg. She is complaining of headaches, blurred vision and epigastric pain. At this time it is most appropriate to conclude that this patient has which of the following? 
 2) + Severe preeclampsia and requires immediate medical management and delivery (nezaškrtl-a)
 3) - Mild preeclampsia and should continue bed rest pending further diagnostic studies (zaškrtl-a)
------------------------------------------------------------------------------------------
 87. ( 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? 
 1) + Explain the rationale for any diagnostic procedures and treatment regimens in some detail, adopting a professional, but not overly friendly stance (nezaškrtl-a)
 5) - Avoid giving him excessive details about possible, but infrequent, side effects and complications in order to avoid triggering his paranoia (zaškrtl-a)
------------------------------------------------------------------------------------------
 91. (  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)
------------------------------------------------------------------------------------------
 92. (  1.orig.) A 6-week-old infant is brought to the health center by his mother because of projectile vomiting. You have not seen this infant before and the mother says he has not been seen by a physician since birth. Weight at birth was 3550 g (7 lb 13 oz) and physical examination was normal. Examination today is normal except for weight, now 4000 g (8 lb 13 oz), and slight dehydration. Which of the following is the most appropriate management for this infant? 
 4) - Order supine and decubitus x-ray films of the abdomen (zaškrtl-a)
 5) + Order ultrasonography of the pylorus (nezaškrtl-a)
------------------------------------------------------------------------------------------
 93. ( 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) - Only their male children will be hearing-impaired (zaškrtl-a)
 5) + Accurate risk estimation is impossible without further evaluation (nezaškrtl-a)
------------------------------------------------------------------------------------------
 98. ( 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? 
 2) - Serum gonadotropin concentrations (follicle-stimulating hormone and luteinizing hormone) (zaškrtl-a)
 5) + Karyotype from peripheral leukocytes (nezaškrtl-a)
------------------------------------------------------------------------------------------
104. ( 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? 
 4) + Dissection of the aorta (nezaškrtl-a)
 5) - Acute bacterial endocarditis (zaškrtl-a)
------------------------------------------------------------------------------------------
107. ( 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? 
 2) - Hyperventilation syndrome (zaškrtl-a)
 5) + Myocardial infarction (nezaškrtl-a)
------------------------------------------------------------------------------------------
108. ( 20.orig.) A 69-year-old Chinese-American man with diabetes mellitus had a myocardial infarction 2 years ago. He has had exertional angina since then and has been taking propranolol. During the past few days he has had one episode of chest pain at rest, two episodes postprandially and one at night. Electrocardiogram reveals an old myocardial infarction. Which of the following is the most appropriate management? 
 2) - Admit him immediately for coronary artery bypass surgery (zaškrtl-a)
 5) + Admit him immediately for cardiac monitoring and adjustment of therapy (nezaškrtl-a)
------------------------------------------------------------------------------------------
117. ( 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) - Order CT scan of the head (zaškrtl-a)
 3) + Administer phentolamine, intravenously (nezaškrtl-a)
------------------------------------------------------------------------------------------
120. ( 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? 
 3) - Ask her to reduce the child's fat intake and give him skim milk instead of whole milk (zaškrtl-a)
 4) + Do nothing until the child is 2 years of age (nezaškrtl-a)