Otázky s chybnou odpovědí, č.j. 6307840
------------------------------------------------------------------------------------------
TEST:usmle1en  Varianta:2         Tisknuto:04/06/2019
------------------------------------------------------------------------------------------
  7. (  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?
 4) - Nucleocapsid (zaškrtl-a)
 5) + Hemagglutinin (nezaškrtl-a)
------------------------------------------------------------------------------------------
 10. ( 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? 
 3) - Sublimation (zaškrtl-a)
 4) + Regression (nezaškrtl-a)
------------------------------------------------------------------------------------------
 12. (  3.orig.) A 40-year-old man with a 20-year history of alcohol abuse is brought to the hospital by his friends because he was difficult to rouse. He ate a large meal several hours ago. He is emaciated and lethargic. Examination shows severely restricted horizontal eye movements and ataxia of both upper extremities. The most likely cause of these findings is a deficiency of which of the following nutrients? 
 2) + Vitamin B1 (thiamine) (nezaškrtl-a)
 5) - Vitamin B12 (cobalamin) (zaškrtl-a)
------------------------------------------------------------------------------------------
 25. (  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? 
 1) - Metolazone (zaškrtl-a)
 4) + Amiloride (nezaškrtl-a)
------------------------------------------------------------------------------------------
 27. (  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)
 4) - B (zaškrtl-a)
------------------------------------------------------------------------------------------
 29. ( 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)
 5) - ectopic pregnancy (zaškrtl-a)
------------------------------------------------------------------------------------------
 34. ( 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) + Gluteus maximus (nezaškrtl-a)
 3) - Iliopsoas (zaškrtl-a)
------------------------------------------------------------------------------------------
 55. ( 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? 
 3) + Medial longitudinal fasciculus (nezaškrtl-a)
 5) - Medial rectus muscle (zaškrtl-a)
------------------------------------------------------------------------------------------
 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? 
 3) + Sheets and cords of epithelial cells in the serosal layer (nezaškrtl-a)
 5) - Mucin within and outside epithelial cells (zaškrtl-a)
------------------------------------------------------------------------------------------
 66. ( 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) - Contrecoup injury (zaškrtl-a)
 2) + Fat embolization (nezaškrtl-a)
------------------------------------------------------------------------------------------
 70. (  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?
 2) + Estrogen (nezaškrtl-a)
 3) - Vitamin D (zaškrtl-a)
------------------------------------------------------------------------------------------
 72. ( 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) - Diabetes mellitus with ketoacidosis (zaškrtl-a)
 3) + Surreptitious use of diuretics (nezaškrtl-a)
------------------------------------------------------------------------------------------
 75. ( 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? 
 2) + Dead space ventilation (nezaškrtl-a)
 4) - Lung compliance (zaškrtl-a)
------------------------------------------------------------------------------------------
 84. ( 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)
 3) + Indirect stimulation of -adrenergic receptors (nezaškrtl-a)
------------------------------------------------------------------------------------------
 87. ( 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? 
 1) - Increased concentration of somatostatin (zaškrtl-a)
 3) + Vagally denervated stomach (nezaškrtl-a)
------------------------------------------------------------------------------------------
 93. ( 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) - Rheumatoid arthritis (zaškrtl-a)
 5) + Gout (nezaškrtl-a)
------------------------------------------------------------------------------------------
 95. ( 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? 
 3) - Omohyoid (zaškrtl-a)
 4) + Posterior cricoarytenoid (nezaškrtl-a)
------------------------------------------------------------------------------------------
106. ( 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 renin (nezaškrtl-a)
 4) - Plasma ACTH (zaškrtl-a)
------------------------------------------------------------------------------------------
110. ( 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)
 2) - Aggregation (zaškrtl-a)
------------------------------------------------------------------------------------------
112. ( 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)
 2) - Using a calibrated inoculating loop to enable direct enumeration of the bacteria in the specimen (zaškrtl-a)
------------------------------------------------------------------------------------------
116. ( 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) - Local release of histamine (zaškrtl-a)
 4) + Local fixation of complement by preformed circulating antibodies (nezaškrtl-a)
------------------------------------------------------------------------------------------
117. ( 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 serosa (nezaškrtl-a)
 4) - Extension to the muscularis mucosa (zaškrtl-a)
------------------------------------------------------------------------------------------
TEST:usmle2en  Varianta:2         Tisknuto:04/06/2019
------------------------------------------------------------------------------------------
  8. ( 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?
 1) + Pneumonia secondary to anaerobes (nezaškrtl-a)
 3) - Pneumonia secondary to gram-positive aerobes (zaškrtl-a)
------------------------------------------------------------------------------------------
 16. ( 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? 
 1) + Orbital cellulitis (nezaškrtl-a)
 4) - Preseptal (periorbital) cellulitis (zaškrtl-a)
------------------------------------------------------------------------------------------
 40. ( 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? 
 1) + Polymyalgia rheumatica (nezaškrtl-a)
 5) - Rheumatoid arthritis (zaškrtl-a)
------------------------------------------------------------------------------------------
 41. ( 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?
 2) - Immune thrombocytopenic purpura (zaškrtl-a)
 4) + Thrombotic thrombocytopenic purpura (nezaškrtl-a)
------------------------------------------------------------------------------------------
 42. ( 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) + Basal cell epithelioma (nezaškrtl-a)
------------------------------------------------------------------------------------------
 47. ( 18.orig.) A hospitalized 60-year-old man has had no urine output for 8 hours.  He underwent a total hip replacement 36 hours ago. He has a history of type 1 diabetes mellitus and takes nitrates for stable angina pectoris. During the operation, the estimated blood loss was 1500 mL. Intraoperatively, he had one brief episode of hypotension that resolved spontaneously. His temperature is 37.2°C (99°F), pulse is 80/min, respirations are 16/min, and blood pressure is 130/85 mm Hg. There is suprapubic fullness and a clean incision over the left hip. Examination shows no other abnormalities. His hemoglobin concentration is1,4 mmol/l (2,09-2,71), leukocyte count is 11,000/mm3 (4,500-11,000), and platelet count is 150,000/mm3 (150,000-400,000). A fingerstick blood glucose concentration is 10,3 mmol/l (3,8-6,1). Which of the following is the most appropriate initial step in management? 
 3) - Administration of 20 U of regular insulin (zaškrtl-a)
 4) + Placement of a Foley catheter (nezaškrtl-a)
------------------------------------------------------------------------------------------
 54. ( 35.orig.) A16-year-old girl is brought to the physician because of intermittent pain and swelling of both ankles over the past month. She is currently not in pain. When the pain occurs, it is so severe that she is unable to walk. There is no associated fever or chills. She is sexually active and has had one sexual partner for 12 months. Her temperature is 37°C, pulse is 80/min, and blood pressure is 145/87 mm Hg. Examination shows no abnormalities or tenderncess of the ankle joints. There is a nonpainful ulcer on the oral buccal mucosa. The lungs are clear to auscultation. Cardiac examination shows no abnormalities. Laboratory studies show: BLOOD: leukocyte count 4000/mm3 (4500-11000), segmented neutrophils 65% (54-62), eosinophils 3% (1-3), lymphocytes 25% (25-33), monocytes 7% (3-7), platelet count 60,000/mm3 (150,00-400,000), erythrocyte sedimentation rate 100mm/h; SERUM: antinuclear antibodies 1:320, anti-DNA antibodies - positive, rapid plasma reagin 1:16, rheumatoid factor - negative; URINE: protein +++, RBC casts negative, RBC none, WBC +. X-rays of the ankles show no abnormalities other than tissue swelling. Which of the following is the most likely diagnosis?
 1) - Reactive arthritis (zaškrtl-a)
 2) + Systemic lupus erythematosus (nezaškrtl-a)
------------------------------------------------------------------------------------------
 67. ( 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) - Continuation of current oxygen with the addition of a respiratory stimulant (zaškrtl-a)
 3) + Endotracheal intubation and mechanical ventilation (nezaškrtl-a)
------------------------------------------------------------------------------------------
 79. ( 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) + Oxacilin (nezaškrtl-a)
 4) - Gentamicin (zaškrtl-a)
------------------------------------------------------------------------------------------
 81. ( 21.orig.) An asymptomatic 18-year-old primigravid woman at 18 weeks´ gestation is found to be positive for hepatis B surface antigen (HBsAg) on routine prenatal screening. Her husband was diagnosed with hepatitis B 3 months ago. She states that the intends to breast-feed her infant. Examination shows a firm liver with a span of 12 cm. Serologic testing for hepatis shows: anti-HbsAg - negative; IgM-anti-HbcAg - positive; anti-HAV - negative. Which of the following should be administered to the newborn to prevent transmission of hepatitis?
 1) - Hepatitis B vaccination only at birth (zaškrtl-a)
 3) + HBIG and hepatitis B vaccination at birth (nezaškrtl-a)
------------------------------------------------------------------------------------------
 82. ( 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)
 5) - Deep venous valvular insufficiency of the extremity (zaškrtl-a)
------------------------------------------------------------------------------------------
 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?
 1) - Factor VII (zaškrtl-a)
 2) + Factor VIII (nezaškrtl-a)
------------------------------------------------------------------------------------------
 91. ( 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-negative diplococci (zaškrtl-a)
------------------------------------------------------------------------------------------
101. ( 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) - Sarcoma of the uterus (zaškrtl-a)
 4) + Pedunculated submucous leiomyoma (nezaškrtl-a)
------------------------------------------------------------------------------------------
104. (  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?
 2) - Vitamin B12 (cobalamin) (zaškrtl-a)
 3) + Folic acid (nezaškrtl-a)
------------------------------------------------------------------------------------------
TEST:usmle3en  Varianta:2         Tisknuto:04/06/2019
------------------------------------------------------------------------------------------
  4. ( 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) + Basophilic stippling of erythrocytes (nezaškrtl-a)
 5) - Howell-Jolly bodies (zaškrtl-a)
------------------------------------------------------------------------------------------
  5. ( 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) + Squamous cell carcinoma (nezaškrtl-a)
 5) - Keratoacanthoma (zaškrtl-a)
------------------------------------------------------------------------------------------
 11. ( 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? 
 3) - Serum alanine aminotransferase (ALT) of 106 U/L (10-40)(zaškrtl-a)
 5) + Serum calcium of 1,6 mmol/l (nezaškrtl-a)
------------------------------------------------------------------------------------------
 13. ( 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? 
 4) - Obtain a random serum total cholesterol concentration for the child today (zaškrtl-a)
 5) + Do nothing until the child is 2 years of age (nezaškrtl-a)
------------------------------------------------------------------------------------------
 14. (  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? 
 3) + Inadvertent injury of the femoral artery (nezaškrtl-a)
 4) - Thrombosis of the catheterized femoral vein (zaškrtl-a)
------------------------------------------------------------------------------------------
 26. ( 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 and indomethacin therapy until delivery (zaškrtl-a)
 4) + Prescribe heparin until delivery (nezaškrtl-a)
------------------------------------------------------------------------------------------
 44. ( 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)
 3) - Do a transrectal prostatic biopsy (zaškrtl-a)
------------------------------------------------------------------------------------------
 52. ( 12.orig.) A 50-year-old woman comes to the office for the first time because of recurrent abdominal pain. Review of her extensive medical chart, which she has brought with her, discloses that she has a long history of varying physical complaints. Definitive causes for these complaints have not been found despite extensive diagnostic studies, consultations with many physicians and several surgical explorations. She gives dramatic and exaggerated descriptions of her present and past symptoms, and she makes conflicting statements about her history. She has been hospitalized at least 23 times since age 18 years. Which of the following is the most likely diagnosis? 
 1) + Histrionic personality disorder (nezaškrtl-a)
 4) - Somatization disorder (zaškrtl-a)
------------------------------------------------------------------------------------------
 56. ( 18.orig.) A 68-year-old man with documented alcohol abuse returns to the office because of abdominal pain and bloating. When you meet with him, he appears dejected and his eye contact is poor. Physical examination is normal. Since his last visit, he has moved from the neighborhood where he had lived for 40 years. In addition, he mentions that approximately 6 months ago breast cancer was diagnosed in his wife; she is currently receiving radiation therapy for bony metastases. The most important next step in management of his symptoms is evaluation for which of the following? 
 1) + Suicidal ideation (nezaškrtl-a)
 3) - Pancreatic carcinoma (zaškrtl-a)
------------------------------------------------------------------------------------------
 62. (  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) - Occurrence of spontaneous abortions does not correlate with disease activity (zaškrtl-a)
 4) + Sulfasalazine and corticosteroids are not known to be teratogenic (nezaškrtl-a)
------------------------------------------------------------------------------------------
 63. ( 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) + Reassure her and treat with a nonsteroidal anti-inflammatory drug (NSAID) (nezaškrtl-a)
 5) - Order CT scan of the lumbar spine (zaškrtl-a)
------------------------------------------------------------------------------------------
 65. ( 30.orig.) A 42-year-old Anglo-American man is brought to the emergency department by his same sex partner because of confusion, diplopia and mild right arm weakness. On examination the patient is somewhat agitated and shows confusion for recent events. There is decreased pupillary response on the left with some paresis of lateral gaze on the right. Temperature is 38.3°C (101.0°F). Peripheral leukocyte count is increased. Which of the following is the most appropriate next step in evaluation of his neurologic signs and symptoms? 
 1) - Bilateral carotid arteriography (zaškrtl-a)
 4) + CT scan of the head (nezaškrtl-a)
------------------------------------------------------------------------------------------
 69. ( 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) + Myocardial infarction (nezaškrtl-a)
 5) - Pulmonary embolism (zaškrtl-a)
------------------------------------------------------------------------------------------
 73. ( 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) - Serum estrogen and testosterone concentrations (zaškrtl-a)
 4) + Karyotype from peripheral leukocytes (nezaškrtl-a)
------------------------------------------------------------------------------------------
 85. ( 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 serum rheumatoid factor (zaškrtl-a)
 3) + Order determination of erythrocyte sedimentation rate (nezaškrtl-a)
------------------------------------------------------------------------------------------
 98. ( 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? 
 2) + "It sounds like there is more to this story than you are telling me; maybe we should talk about it." (nezaškrtl-a)
 4) - "I wish I could help you, but I never prescribe that medication for a patient unless I have seen the patient myself." (zaškrtl-a)
------------------------------------------------------------------------------------------
 99. ( 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? 
 1) + Dissection of the aorta (nezaškrtl-a)
 3) - Perforated peptic ulcer (zaškrtl-a)
------------------------------------------------------------------------------------------
103. (  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? 
 1) - 24-Hour ambulatory electrocardiographic monitoring (zaškrtl-a)
 3) + Exercise stress test (nezaškrtl-a)
------------------------------------------------------------------------------------------
105. ( 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)
 5) + CT scan of the chest with contrast (nezaškrtl-a)
------------------------------------------------------------------------------------------
109. ( 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? 
 3) - Order CT scan of the head (zaškrtl-a)
 5) + Administer phentolamine, intravenously (nezaškrtl-a)
------------------------------------------------------------------------------------------
115. (  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? 
 3) - Provide her with assistance for activities of daily living (zaškrtl-a)
 4) + Request a visiting nurse to assess the safety of her living environment (nezaškrtl-a)