Otázky s chybnou odpovědí, č.j. 7317860
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TEST:usmle1en  Varianta:9         Tisknuto:04/06/2019
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  2. ( 38.orig.) The intracellular domain of the insulin receptor has which of the following enzyme activities? 
 1) - Phosphodiesterase (zaškrtl-a)
 3) + Tyrosine kinase (nezaškrtl-a)
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  8. (  8.orig.) Moderate alcohol consumption may protect against coronary artery disease by which of the following mechanisms? 
 1) - Decreasing serum concentration of LDLs (zaškrtl-a)
 3) + Increasing serum concentration of HDLs (nezaškrtl-a)
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 11. ( 35.orig.) A 45-year-old man has abnormal circadian variation disruption of the sleep-wake cycle, and an impaired nocturnal surge of secretion of melatonin. An MRI of the head is most likely to show a lesion involving which of the following nuclei? 
 4) + Suprachiasmatic (nezaškrtl-a)
 5) - Pretecal (zaškrtl-a)
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 18. ( 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)
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 22. (  4.orig.) In sensitized persons, immediate (type I) hypersensitivity responses are primarily the result of  liberation of vasoactive substances by the action of which of the following? 
 3) + IgE on basophils and mast cells  (nezaškrtl-a)
 4) - Activated T lymphocytes on smooth muscle  cells  (zaškrtl-a)
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 28. ( 23.orig.) An 8-year-old boy needs to be coaxed to go to school and, while there, often complains of severe headaches or stomach pain.  His mother frequently has to take him home because of his symptoms. At night, he tries to sleep with his parents.  When they insist that he sleep in his own room, he says there are monsters in his closet. Which of the following best explains this behavior? 
 2) - Normal concerns of latency-age children (zaškrtl-a)
 4) + Separation anxiety disorder (nezaškrtl-a)
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 29. (  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)
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 31. ( 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)
 5) - Plasma ACTH (zaškrtl-a)
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 33. ( 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? 
 4) + Sheets and cords of epithelial cells in the serosal layer (nezaškrtl-a)
 5) - Formation of new vascular channels and hemorrhage (zaškrtl-a)
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 40. ( 15.orig.) A 53-year-old woman dies 4 days after an automobile collision. She sustained multiple injuries including a femoral fracture. Widespread petechiae are found in the cerebral white matter at autopsy. Which of the following is the most likely cause of these findings? 
 2) - Contrecoup injury (zaškrtl-a)
 3) + Fat embolization (nezaškrtl-a)
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 63. ( 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? 
 3) - Direct stimulation of adenosine receptors (zaškrtl-a)
 5) + Indirect stimulation of -adrenergic receptors (nezaškrtl-a)
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 65. ( 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) - Diffuse scarring in subcutaneous fibrous tissue (zaškrtl-a)
 2) + Attachments of suspensory ligaments (retinacula cutis) to the dermis (nezaškrtl-a)
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 66. ( 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) - 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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 68. (  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) - Vitamin D (zaškrtl-a)
 2) + Estrogen (nezaškrtl-a)
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 75. ( 30.orig.) A neonate develops meningitis. Streptococcus is isolated from the mother's vagina. The organism agglutinates with antiserum directed against type B surface carbohydrate. The virulence of this organism is related to a bacterial constituent that interferes with	 which of the following host phagocyte functions? 
 2) - Intracellular killing (zaškrtl-a)
 3) + Ingestion (nezaškrtl-a)
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 83. ( 36.orig.) A 4-year-old girl has been unable to eat for 2 days because of a gastrointestinal tract disorder. Which of the following is the major source of fuel being oxidized by her skeletal muscles? 
 1) + Serum fatty acids (nezaškrtl-a)
 2) - Muscle triglycerides (zaškrtl-a)
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 89. ( 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) - ectopic pregnancy (zaškrtl-a)
 4) + choriocarcinoma (nezaškrtl-a)
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 91. ( 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) - Human chorionic somatomammotropin and prostaglandin (zaškrtl-a)
 4) + Estrogen and progesterone (nezaškrtl-a)
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 99. (  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) - A (zaškrtl-a)
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100. ( 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)
 2) - Gluteus minimus (zaškrtl-a)
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106. ( 32.orig.) During a prenatal visit, a 25-year-old woman who is 10 weeks' pregnant comments that she feels too nauseated and fatigued to be interested in sex, and her husband wonders if they will ever be sexually active again.  The most appropriate next step is to advise her that sexual interest often returns during which of the following periods? 
 1) + Second trimester (nezaškrtl-a)
 4) - Five month postpartum (zaškrtl-a)
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108. ( 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)
 3) + Medial longitudinal fasciculus (nezaškrtl-a)
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109. ( 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)
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110. ( 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) - Repression (zaškrtl-a)
 5) + Regression (nezaškrtl-a)
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TEST:usmle2en  Varianta:9         Tisknuto:04/06/2019
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 13. ( 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) + HBIG and hepatitis B vaccination at birth (nezaškrtl-a)
 4) - Hepatitis B immune globulin (HBIG) only at birth (zaškrtl-a)
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 15. ( 13.orig.) A 24-year-old jackhammer operator comes to the physician because of a 1-week history of pain and swelling that involves the entire right upper extremity; the pain worsens with exercise. Examination shows enlarged cutaneous veins over the right anterior chest wall. Which of the following is the most likely diagnosis?
 1) + Axillary-subclavian venous thrombosis (nezaškrtl-a)
 5) - Superficial thrombophlebitis of the breast (zaškrtl-a)
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 19. (  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? 
 2) + Hemodialysis (nezaškrtl-a)
 4) - Intravenous administration of ACE inhibitors (zaškrtl-a)
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 46. ( 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?
 1) - Gram-positive diplococci (zaškrtl-a)
 3) + Gram-positive cocci in chains (nezaškrtl-a)
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 51. (  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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 72. ( 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? 
 3) + Pedunculated submucous leiomyoma (nezaškrtl-a)
 5) - Incomplete abortion (zaškrtl-a)
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 77. (  2.orig.) A 43-year-old woman who works as a seamstress has a 3-month history of pain, weakness, and numbness of the right hand that is worse at night. Examination shows hypoesthesia and atrophy of the thenar eminence. These findings are most likely caused by compression of which of the following nerves? 
 2) + Median (nezaškrtl-a)
 3) - Ulnar (zaškrtl-a)
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 78. ( 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? 
 2) - Inadequate treatment with penicillin (zaškrtl-a)
 4) + Reinfection from the partner (nezaškrtl-a)
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 80. ( 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?
 4) - Doxycycline (zaškrtl-a)
 5) + Oxacilin (nezaškrtl-a)
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 87. ( 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) - Renal ultrasonography (zaškrtl-a)
 4) + Placement of a Foley catheter (nezaškrtl-a)
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 88. ( 40.orig.) A 6-year-old man with emphysema is brought to the emergency department 1 hour after becoming lethargic and incoherent. Over the past 3 days, he has had increasing episodes of dyspnea, cough, and sputum production. Oxygen was administered en route to the hospital. On arrival, the patient is confused and lethargic but responsive to painful stimuli. Arterial blood gas analysis while breathing 6l/min of oxygen shows: pH 35 [H+] nmol/l (36-44), pCO2 12,7 kPa (4,4-5,9), pO2 13,3 kPa (10,0-14,0). Which of the following is the most appropriate next step in management?
 1) + Endotracheal intubation and mechanical ventilation (nezaškrtl-a)
 4) - Administration of 24% oxygen by Venturi mask (zaškrtl-a)
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 93. ( 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? 
 2) - Measurement of serum ammonia concentration (zaškrtl-a)
 3) + CT scan of the head (nezaškrtl-a)
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102. ( 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? 
 1) - Hemorrhagic tumor (zaškrtl-a)
 4) + Torsion of the testicle (nezaškrtl-a)
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103. ( 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)
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104. ( 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? 
 2) + Colonoscopy with polypectomy (nezaškrtl-a)
 3) - Reexamination in 1 year (zaškrtl-a)
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107. ( 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?
 2) + ECG (nezaškrtl-a)
 3) - EEG (zaškrtl-a)
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112. (  7.orig.) A 64-year-old woman comes to the physician because of a 5-month history of increasing shortness of breath, sore throat, and a cough productive of a small amount of white phlegm. Over the past week, she has had nausea related to excess coughing.  Over the past year, she has had a 3.2-kg (7-lb) weight loss. She has asthma treated with theophylline and inhaled beta-adrenergic agonists and corticosteroids. She has smoked one pack of cigarettes daily for 44 years and drinks one alcoholic beverage daily. She appears thin. Examination shows a 2-cm, nontender lymph node in the right supraclavicular area. Examination shows no other abnormalities. An x-ray of the chest shows a large right lower lobe density. A CT scan of the chest shows a 7.5 x 7.5 x 6-cm right lower lobe mass with some scattered calcifications. The lesion abuts the posterior chest wall without clear invasion. There are right lower peritracheal, precarinal, right hilar, and subcarinal lymph nodes. There is a 1.5-cm mass in the right adrenal gland. A biopsy specimen of the lung mass is most likely to show which of the following? 
 2) - Metastatic adenocarcinoma of the breast (zaškrtl-a)
 5) + Non-small cell lung carcinoma (nezaškrtl-a)
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115. (  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? 
 1) + Ventricular septal defect (nezaškrtl-a)
 3) - Pulmonary hypertension (zaškrtl-a)
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116. ( 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) - Preseptal (periorbital) cellulitis (zaškrtl-a)
 5) + Orbital cellulitis (nezaškrtl-a)
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117. ( 32.orig.) A 28-year-old woman comes to the emergency department 6 hours after the onset of insomnia, flank discomfort, and constipation that she attributes to a kidney stone. She is a resident of another state and is here visiting relatives. She takes oxycodone (six to eight tablets daily) for chronic low back pain, sumatriptan for migraines, and amitriptyline (25 mg at bedtime) and paroxetine (30 mg daily) for bulimia nervosa. Her pulse is 100/min, and blood pressure is 130/80 mm Hg. Examination shows diaphoresis and dilated pupils. She is alert and cooperative but seems restless. She has not had hallucinations or suicidal ideation. She becomes angry when she is asked for the telephone numbers of her regular physicians. Serum amitriptyline concentration is 150 mg/100 ml. Urinalysis shows 0-2 RBC/hpf. Which of the following is the most likely explanation for her symptoms? 
 3) - Anticholinergic poisoning (zaškrtl-a)
 4) + Opiate withdrawal (nezaškrtl-a)
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119. (  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) - Hypothyroidism (zaškrtl-a)
 2) + Acute stress disorder (nezaškrtl-a)
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TEST:usmle3en  Varianta:9         Tisknuto:04/06/2019
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  1. ( 25.orig.) A 52-year-old woman who has had low back pain for several years is admitted to the hospital because the pain has suddenly worsened. Her current medications include oxycodone, amitriptyline, perphenazine, fluoxetine and trazodone. On physical examination, the patient is 10% below her ideal body weight, pupils are constricted and skin turgor is poor. She seems sluggish and her speech is slow. Results of neurologic examination and x-ray films of the lumbosacral spine are normal. If a medication is responsible for her mental condition, the medication is most likely to be which of the following? 
 1) + Oxycodone (nezaškrtl-a)
 4) - Amitriptyline (zaškrtl-a)
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  9. ( 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 alanine aminotransferase (ALT) of 106 U/L (10-40)(zaškrtl-a)
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 12. ( 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? 
 2) + Conjugated estrogen therapy for 2 weeks (nezaškrtl-a)
 3) - A second injection of medroxyprogesterone (zaškrtl-a)
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 17. ( 34.orig.) A 45-year-old woman is brought to the health center by her husband because of nausea, confusion, chills, fever, flank pain and cloudy urine. She has a history of insulin-dependent diabetes mellitus, poorly controlled hypertension and recurrent urinary tract infections. Her vital signs are: temperature 40.0°C (104.0°F), pulse 120/min, respirations 24/min, blood pressure 110/70 mm Hg. Funduscopic examination shows diabetic retinopathy, which is unchanged from the previous examination. Neck is supple. Lungs are clear to auscultation and percussion. Examination of the abdomen is normal. Marked pain is present at the right costovertebral angle. Several hemorrhagic bullous lesions are noted on the extremities. If this patient were to develop anuria, which of the following would be the most likely cause? 
 2) + Acute papillary necrosis (nezaškrtl-a)
 3) - Renal lithiasis (zaškrtl-a)
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 20. ( 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) - Because they are hearing-impaired, all their children will be hearing-impaired (zaškrtl-a)
 3) + Accurate risk estimation is impossible without further evaluation (nezaškrtl-a)
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 21. ( 28.orig.) A 35-year-old woman is seen in the emergency department because of the sudden onset of severe low back pain 12 hours earlier. The pain began when she bent over to pick up her 2-year-old child. She has been unable to stay in bed because of the need to care for her child. Low doses of ibuprofen have eased the discomfort slightly. Careful physical examination, including a neurologic examination, is normal except for evidence of muscle spasm. She believes she has a herniated disc because 2 years ago her father developed the sudden onset of back pain that required immediate surgery. Which of the following is the most appropriate first step? 
 1) - Order MRI of the lumbar spine (zaškrtl-a)
 5) + Reassure her and treat with a nonsteroidal anti-inflammatory drug (NSAID) (nezaškrtl-a)
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 32. (  3.orig.) An obese 10-year-old boy with diabetes mellitus is admitted to the hospital because of severe ketoacidosis and cardiovascular collapse. Initial management consists of cardiac monitoring and intravenous administration of fluids, electrolytes and insulin. Because of the difficulty in obtaining satisfactory peripheral venous access, the left femoral vein is catheterized percutaneously. Six hours later, his mental status is improved, blood pressure is 120/70 mm Hg and serum glucose concentration is 13,6 mmol/l (3,8-6,1). Physical examination at that time shows a cold left foot with diminished pulses compared with those of the right foot. Which of the following is the most likely explanation for this patient's diminished pulses? 
 2) - Thrombosis of the catheterized femoral vein (zaškrtl-a)
 3) + Inadvertent injury of the femoral artery (nezaškrtl-a)
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 37. ( 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? 
 2) + Explain the rationale for any diagnostic procedures and treatment regimens in some detail, adopting a professional, but not overly friendly stance (nezaškrtl-a)
 3) - Have his psychiatrist, with whom he has been working for several years, take the lead in presenting medical treatment options (zaškrtl-a)
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 42. ( 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? 
 2) + Histrionic personality disorder (nezaškrtl-a)
 4) - Somatization disorder (zaškrtl-a)
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 43. ( 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? 
 3) - Macrocytic erythrocytes (zaškrtl-a)
 4) + Basophilic stippling of erythrocytes (nezaškrtl-a)
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 44. (  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)
 3) - Adrenal insufficiency (zaškrtl-a)
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 48. ( 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? 
 2) + Squamous cell carcinoma (nezaškrtl-a)
 4) - Leukoplakia (zaškrtl-a)
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 55. (  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? 
 1) - Penetrating duodenal ulcer (zaškrtl-a)
 2) + Herpes zoster (nezaškrtl-a)
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 59. (  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? 
 3) - Electrocardiogram (zaškrtl-a)
 4) + Exercise stress test (nezaškrtl-a)
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 62. ( 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) - Acute myocardial infarction (zaškrtl-a)
 3) + Dissection of the aorta (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? 
 2) - Ensure that she does not have orthostatic hypotension (zaškrtl-a)
 3) + Request a visiting nurse to assess the safety of her living environment (nezaškrtl-a)
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 67. ( 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) + Do nothing until the child is 2 years of age (nezaškrtl-a)
 5) - Obtain a random serum total cholesterol concentration for the child today (zaškrtl-a)
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 70. ( 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? 
 1) + Untreated patients are at increased risk for cardiac arrhythmias (nezaškrtl-a)
 2) - She will not be able to become pregnant (zaškrtl-a)
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 74. ( 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? 
 3) - Pulmonary embolus (zaškrtl-a)
 5) + Alveolar hypoventilation (nezaškrtl-a)
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 84. ( 39.orig.) A 76-year-old woman returns to the office because of aching and weakness in her arms to the point where she cannot lift her arm to brush her hair. Physical examination shows no muscle tenderness or other evidence of joint disease in both arms. The aching improves when she takes the prescribed nonsteroidal anti-inflammatory drug (NSAID). She also describes tenderness over the right parietal area of her scalp. Physical examination of the scalp shows no lesions. Which of the following is the most appropriate next step? 
 2) + Order determination of erythrocyte sedimentation rate (nezaškrtl-a)
 4) - Order determination of serum rheumatoid factor (zaškrtl-a)
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 90. (  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? 
 4) + Potassium (nezaškrtl-a)
 5) - Bicarbonate (zaškrtl-a)
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 95. ( 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)
 2) - Testosterone (zaškrtl-a)
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 96. ( 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 cardiac monitoring and adjustment of therapy (nezaškrtl-a)
 3) - Advise resting from work and sedation at night and digitalization (zaškrtl-a)
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 97. ( 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? 
 3) + Prescribe heparin until delivery (nezaškrtl-a)
 4) - Prescribe warfarin until delivery (zaškrtl-a)
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120. (  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) + "I would like to talk with you in private now." (nezaškrtl-a)
 5) - "Are you sure you want to go home with your daughter?" (zaškrtl-a)