Otázky s chybnou odpovědí, č.j. 5562370
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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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  6. ( 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? 
 2) - Tetanus toxoid plus adjuvant (zaškrtl-a)
 4) + Tetanus antitoxin plus toxoid (nezaškrtl-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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 11. ( 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? 
 1) + Hirschsprung disease (nezaškrtl-a)
 2) - Hypertrophic pyloric stenosis (zaškrtl-a)
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 15. ( 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? 
 2) + Offer analgesia prior to mammography (nezaškrtl-a)
 3) - Exaggerate her risk for breast cancer (zaškrtl-a)
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 23. ( 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? 
 4) + Vagally denervated stomach (nezaškrtl-a)
 5) - Increased concentration of secretin (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)
 2) - Vitamin D (zaškrtl-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?  
 1) - E (zaškrtl-a)
 4) + C (nezaškrtl-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? 
 3) + Amiloride (nezaškrtl-a)
 4) - Acetazolamide (zaškrtl-a)
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 40. ( 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? 
 1) - Obturator internus (zaškrtl-a)
 3) + Gluteus maximus (nezaškrtl-a)
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 49. ( 14.orig.) A 38-year-old woman has congestive heart failure, premature ventricular contractions, and repeated episodes of ventricular tachycardia. Her blood pressure is normal and there are no murmurs. Her heart is markedly enlarged. Coronary angiography shows no abnormalities. Which of the following is the most likely diagnosis? 
 3) - Acute rheumatic fever (zaškrtl-a)
 5) + Primary cardiomyopathy (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? 
 2) - Urinary sodium (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? 
 1) - Mucin within and outside epithelial cells (zaškrtl-a)
 2) + Sheets and cords of epithelial cells in the serosal layer (nezaškrtl-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? 
 3) - Accumulation of mononuclear cells at the site of antigen injection (zaškrtl-a)
 4) + Local fixation of complement by preformed circulating antibodies (nezaškrtl-a)
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 81. ( 29.orig.) Lactation does not occur during pregnancy because the action of prolactin is blocked by increased concentrations of which of the following hormones? 
 2) + Estrogen and progesterone (nezaškrtl-a)
 4) - Thyroxine (T4) and dopamine (zaškrtl-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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 87. ( 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? 
 1) + Ingestion (nezaškrtl-a)
 5) - Chemotaxis (zaškrtl-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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 97. ( 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? 
 2) + Regression (nezaškrtl-a)
 3) - Sublimation (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? 
 3) + Taking samples of the discharge with a syringe and transferring them directly to the laboratory (nezaškrtl-a)
 5) - Using a calibrated inoculating loop to enable direct enumeration of the bacteria in the specimen (zaškrtl-a)
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111. (  8.orig.) Moderate alcohol consumption may protect against coronary artery disease by which of the following mechanisms? 
 1) - Increasing thromboxane B2 release from platelets (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 
 1) - indirect inguinal hernia (zaškrtl-a)
 4) + varicocele (nezaškrtl-a)
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TEST:usmle2en  Varianta:6         Tisknuto:04/06/2019
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  7. (  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?
 1) + Folic acid (nezaškrtl-a)
 2) - Vitamin B12 (cobalamin) (zaškrtl-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)
 4) - Rheumatoid arthritis (zaškrtl-a)
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 32. (  5.orig.) A full-term 2-month-old boy appeared well until 3 weeks ago when he became dyspneic and had difficulty feeding.  A loud holosystolic murmur is heard at the left lower sternal border.  An ECG shows left and right ventricular hypertrophy. Which of the following is the most likely diagnosis? 
 2) - Atrial septal defect (zaškrtl-a)
 3) + Ventricular septal defect (nezaškrtl-a)
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 34. ( 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) + Axillary-subclavian venous thrombosis (nezaškrtl-a)
 4) - Superficial thrombophlebitis of the cephalic vein (zaškrtl-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?
 3) - Administration of 24% oxygen by Venturi mask (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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 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?
 2) - Ampicillin (zaškrtl-a)
 5) + Oxacilin (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? 
 3) - Actinic keratosis (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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 85. ( 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? 
 2) - Hyperthyroidism (zaškrtl-a)
 3) + Hot flash (nezaškrtl-a)
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 89. ( 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?
 2) - Factor VII (zaškrtl-a)
 3) + Factor VIII (nezaškrtl-a)
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 94. (  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? 
 4) - Fluid bolus with 2 L of lactated Ringersolution (zaškrtl-a)
 5) + Hemodialysis (nezaškrtl-a)
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 99. ( 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 anaerobes (nezaškrtl-a)
 4) - Pneumonia secondary to gram-positive aerobes (zaškrtl-a)
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107. (  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? 
 4) + Normal grief (nezaškrtl-a)
 5) - Major depressive disorder (zaškrtl-a)
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108. ( 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? 
 3) - Decline to answer, because the administrator is not a medical doctor (zaškrtl-a)
 5) + Decline to answer, because the information is confidential (nezaškrtl-a)
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110. ( 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?
 2) + Systemic lupus erythematosus (nezaškrtl-a)
 5) - Reactive arthritis (zaškrtl-a)
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115. ( 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) - Emergence of bacterial resistance (zaškrtl-a)
 5) + Reinfection from the partner (nezaškrtl-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)
 4) - Carcinoma of the cervix (zaškrtl-a)
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119. ( 29.orig.) An 18-year-old woman comes to the emergency department because of lower abdominal pain for 16 hours. She also reports loss of appetite and mild nausea. She is sexually active and takes an oral contraceptive. Her last menstrual period was 3 weeks ago. Her temperature is 37.9°C (100.2°F). There is guarding and tenderness to palpation of the right lower quadrant of the abdomen; palpation of other areas of the abdomen results in referred pain in the right lower quadrant. Bowel sounds are absent. Pelvic examination shows scant mucous discharge from the cervical os.  Palpation on the right produces pain. There is no cervical motion tenderness, and the adnexa and ovaries appear normal. Which of the following is the most likely diagnosis? 
 4) + Appendicitis (nezaškrtl-a)
 5) - Tubo-ovarian abscess (zaškrtl-a)
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120. ( 33.orig.) A 15-year-old boy is brought to the emergency department 1 hour after an episode of syncope while running in a 400-meter race. He had a similar episode 2 years ago. His mother and maternal first cousin died suddenly at the ages of 32 and 17 years, respectively. Examination shows abrasions of the face, hands, and knees. Cardiac and neurologic examinations show no abnormalities. Which of the following is the most approproate next step in diagnosis?
 4) + ECG (nezaškrtl-a)
 5) - EEG (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)
 5) - Serum bilirubin of 84 mmol/l (2-17)(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? 
 2) - Serum estrogen and testosterone concentrations (zaškrtl-a)
 3) + Karyotype from peripheral leukocytes (nezaškrtl-a)
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 12. ( 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? 
 3) - Severe preeclampsia and should continue bed rest pending further diagnostic studies (zaškrtl-a)
 4) + Severe preeclampsia and requires immediate medical management and delivery (nezaškrtl-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? 
 1) - Primary cardiac irritability and failure (zaškrtl-a)
 2) + Alveolar hypoventilation (nezaškrtl-a)
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 27. ( 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? 
 3) - Methaqualone (zaškrtl-a)
 5) + Cocaine (nezaškrtl-a)
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 28. (  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? 
 1) - "How would you feel if you fell again and had another fracture?" (zaškrtl-a)
 3) + "I would like to talk with you in private now." (nezaškrtl-a)
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 31. (  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? 
 2) - Acalculous cholecystitis (zaškrtl-a)
 3) + Herpes zoster (nezaškrtl-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? 
 4) - Electrocardiogram (zaškrtl-a)
 5) + Exercise stress test (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)
 3) - Have the child return for a fasting lipoprotein analysis (zaškrtl-a)
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 47. ( 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? 
 3) - Decrease the dosage of propranolol and add nitrates and salicylates (zaškrtl-a)
 5) + Admit him immediately for cardiac monitoring and adjustment of therapy (nezaškrtl-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)
 5) - Abortion should be considered because of the teratogenic effects of her colitis therapy (zaškrtl-a)
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 52. ( 19.orig.) A 25-year-old woman who is pregnant with her third child comes to the office for a regular prenatal visit. Medical history shows that she developed deep vein thrombosis of the left calf in the 22nd week of her last pregnancy 2 years ago. She is now 26 weeks pregnant, and she complains of left calf tenderness during the examination. Deep vein thrombosis is confirmed by Doppler ultrasonography. Which of the following is the most appropriate management? 
 1) + Prescribe heparin until delivery (nezaškrtl-a)
 5) - Do venous ligation proximal to the point of obstruction (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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 61. (  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? 
 1) - Thrombosis of the catheterized femoral vein (zaškrtl-a)
 2) + Inadvertent injury of the femoral artery (nezaškrtl-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)
 2) - Provide her with assistance for activities of daily living (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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 74. ( 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? 
 3) + Accurate risk estimation is impossible without further evaluation (nezaškrtl-a)
 4) - They can have amniocentesis during pregnancy to test whether the infant will be hearing-impaired (zaškrtl-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? 
 3) + Reassure her and treat with a nonsteroidal anti-inflammatory drug (NSAID) (nezaškrtl-a)
 4) - Order CT scan of the lumbar spine (zaškrtl-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)
 5) - A second injection of medroxyprogesterone (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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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? 
 3) + Histrionic personality disorder (nezaškrtl-a)
 4) - Borderline personality disorder (zaškrtl-a)
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116. ( 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) - Have his psychiatrist, with whom he has been working for several years, take the lead in presenting medical treatment options (zaškrtl-a)
 5) + Explain the rationale for any diagnostic procedures and treatment regimens in some detail, adopting a professional, but not overly friendly stance (nezaškrtl-a)