Otázky s chybnou odpovědí, č.j. 7548948
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TEST:usmle1en  Varianta:1         Tisknuto:04/06/2019
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 19. ( 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? 
 2) + Posterior cricoarytenoid (nezaškrtl-a)
 5) - Cricothyroid (zaškrtl-a)
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 20. ( 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 
 2) - Rheumatoid arthritis (zaškrtl-a)
 3) + Gout (nezaškrtl-a)
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 22. ( 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? 
 3) - Absence of chief cells (zaškrtl-a)
 4) + Vagally denervated stomach (nezaškrtl-a)
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 27. ( 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) + Sheets and cords of epithelial cells in the serosal layer (nezaškrtl-a)
 2) - Formation of new vascular channels and hemorrhage (zaškrtl-a)
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 31. ( 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? 
 4) + Tetanus antitoxin plus toxoid (nezaškrtl-a)
 5) - Tetanus antitoxin (zaškrtl-a)
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 33. ( 37.orig.) A 38-year-old man reports with some embarrassment that he is unable to urinate in a public urinal, but at home he experiences no difficulty.  The most likely diagnosis is 
 2) - generalized anxiety disorder (zaškrtl-a)
 5) + social phobia (nezaškrtl-a)
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 34. (  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?
 1) + Hemagglutinin (nezaškrtl-a)
 3) - Nucleocapsid (zaškrtl-a)
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 41. ( 36.orig.) A 4-year-old girl has been unable to eat for 2 days because of a gastrointestinal tract disorder. Which of the following is the major source of fuel being oxidized by her skeletal muscles? 
 3) + Serum fatty acids (nezaškrtl-a)
 5) - Muscle creatine phosphate (zaškrtl-a)
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 55. (  8.orig.) Moderate alcohol consumption may protect against coronary artery disease by which of the following mechanisms? 
 3) - Decreasing serum concentration of LDLs (zaškrtl-a)
 5) + Increasing serum concentration of HDLs (nezaškrtl-a)
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 67. ( 16.orig.) A 38-year-old woman with hypertension and hypokalemia is suspected of having hyperaldosteronism. In addition to serum aldosterone measurement, initial evaluation of this patient should include measurement of which of the following? 
 1) - Plasma cortisol (zaškrtl-a)
 5) + Plasma renin (nezaškrtl-a)
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 71. ( 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 longitudinal fasciculus (nezaškrtl-a)
 3) - Medial forebrain bundle (zaškrtl-a)
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 76. ( 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? 
 3) + Attachments of suspensory ligaments (retinacula cutis) to the dermis (nezaškrtl-a)
 5) - Focal invasion of the dermis by neoplastic cells (zaškrtl-a)
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 80. ( 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? 
 3) - Iliopsoas (zaškrtl-a)
 5) + Gluteus maximus (nezaškrtl-a)
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 84. ( 21.orig.) A 56-year-old woman has adenocarcinoma of the colon that is surgically resected. Which of the following patterns of growth by the neoplasm most strongly suggests a poor prognosis? 
 2) + Extension to the serosa (nezaškrtl-a)
 5) - Surface ulceration (zaškrtl-a)
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 88. ( 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? 
 1) + Offer analgesia prior to mammography (nezaškrtl-a)
 5) - Show her photographs of the results of untreated cancer (zaškrtl-a)
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 90. ( 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? 
 2) + Primary cardiomyopathy (nezaškrtl-a)
 5) - Constrictive pericarditis (zaškrtl-a)
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 93. ( 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? 
 3) - Chemotaxis (zaškrtl-a)
 5) + Ingestion (nezaškrtl-a)
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 94. ( 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) - Denial (zaškrtl-a)
 4) + Regression (nezaškrtl-a)
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 96. ( 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) - Placing a swab in transport medium at room temperature (zaškrtl-a)
 3) + Taking samples of the discharge with a syringe and transferring them directly to the laboratory (nezaškrtl-a)
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105. (  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)
 5) - A (zaškrtl-a)
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109. (  6.orig.) A 36-year-old woman has a hysterectomy and bilateral salpingo-oophorectomy because of uncontrolled hemorrhage. She is very concerned because her mother has vertebral compression fractures due to osteoporosis. Which of the following is the most appropriate single treatment to prevent bone loss?
 1) + Estrogen (nezaškrtl-a)
 3) - Vitamin D (zaškrtl-a)
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111. ( 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 
 3) + choriocarcinoma (nezaškrtl-a)
 5) - a second noninvasive mole (zaškrtl-a)
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117. ( 34.orig.) A healthy 19-year-old man receives a tetanus immunization booster prior to induction in the Marines. Six hours later, he has pain and massive swelling at the site of injection. The following day, the skin breaks down, forming an ulcer at the site. Which of the following events plays a critical role in this reaction? 
 1) + Local fixation of complement by preformed circulating antibodies (nezaškrtl-a)
 3) - Predominance of IgM antibodies (zaškrtl-a)
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TEST:usmle2en  Varianta:1         Tisknuto:04/06/2019
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  4. (  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? 
 3) + Non-small cell lung carcinoma (nezaškrtl-a)
 4) - Tuberculosis (zaškrtl-a)
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 13. (  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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 15. ( 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? 
 4) - Hyperthyroidism (zaškrtl-a)
 5) + Hot flash (nezaškrtl-a)
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 16. ( 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)
 2) - Hepatitis B immune globulin (HBIG) only at birth (zaškrtl-a)
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 17. ( 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? 
 4) + Pedunculated submucous leiomyoma (nezaškrtl-a)
 5) - Incomplete abortion (zaškrtl-a)
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 32. ( 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) - Administration of 24% oxygen by Venturi mask (zaškrtl-a)
 4) + Endotracheal intubation and mechanical ventilation (nezaškrtl-a)
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 46. ( 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) - Torsion of the testicular appendix (zaškrtl-a)
 5) + Torsion of the testicle (nezaškrtl-a)
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 52. ( 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? 
 4) - Administration of analgesics and observation (zaškrtl-a)
 5) + Immediate operation (nezaškrtl-a)
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 53. ( 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 diplococci (zaškrtl-a)
 5) + Gram-positive cocci in chains (nezaškrtl-a)
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 58. ( 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? 
 4) - Answer, because it will expedite handling of insurance issues at the medical center (zaškrtl-a)
 5) + Decline to answer, because the information is confidential (nezaškrtl-a)
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 61. ( 31.orig.) A previously healthy 34-year-old woman is brought to the physician because of fever and headache for 1 week. She has not been exposed to any disease. She takes no medications. Her temperature is 39,3°C (102°F), pulse is 104/min, respirations are 24/min, and blood pressureis 135/88 mm Hg. She is confused and oriented only to person. Examination shows jaundice of the skin and conjunctivae. There are a few scattered petechiae over the trunk and back. There is no lympadenopathy. Physical and neurologic examinations show no other abnormalities. Test of the stool for occult blood is positive. Laboratory studies show:BLOOD: hematocrit 0,32 (0,36-0,46), with fragmented and nucleated erythrocytes; leukocyte count 12,500/mm3 (4,500-11,000); platelet count 20,000/mm3 (150,000-400,000); prothrombin time 10 sec (11-15); partial thromboplastin time 30 sec (40);fibrin split products - negative. SERUM: urea nitrogen (BUN) 6,0 mmol urea/l (1,2-3,0); creatinine 265 mmol/l (53-106); bilirubin total 50 mmol/l (2-17); bilirubin direct 10 mmol/l (0-5); lactate dehydrogenase 1000U/l (45-90). Blood and urine cultures are negative. A CT scan of the head shows no abnormalities. Which of the following is the most likely diagnosis?
 1) + Thrombotic thrombocytopenic purpura (nezaškrtl-a)
 4) - Meningococcal meningitis (zaškrtl-a)
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 77. ( 14.orig.) A 20-year-old woman is brought to the emergency department because of fever, severe myalgias diarrhea, and a diffuse scarlatiniform rash for hours. She recovered from a similar illness 6 months ago. She is menstruating and using a tampon. She appears very ill.  Her temperature is 40°C (104°F), pulse is 130/min, and blood pressure is 75/30 mm Hg Which of the following is the most appropriate pharmacotherapy?
 1) - Chloramphenicol (zaškrtl-a)
 4) + Oxacilin (nezaškrtl-a)
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 89. ( 15.orig.) A 19-year-old college student is brought to the emergency department by his roommate because the patient was difficult to arouse in the morning. He has had a flu-like illness with fever and muscle and joint aches for 12 hours.  His temperature is 39.5°C (103.1°F), pulse is 120/min, and blood pressure is 90/60 mm Hg.  There is a diffuse petechial rash over the trunk and extremities. He has a stiff neck that cannot be passively flexed. Which of the following is the most likely pathogen? 
 3) + Neisseria meningitidis(nezaškrtl-a)
 5) - Echovirus (zaškrtl-a)
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 91. ( 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?
 3) + Pneumonia secondary to anaerobes (nezaškrtl-a)
 4) - Pneumonia secondary to gram-positive aerobes (zaškrtl-a)
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 97. ( 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 X (zaškrtl-a)
 5) + Factor VIII (nezaškrtl-a)
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100. (  8.orig.) A 54-year-old woman comes to the physician 2 months after her husband died of a myocardial infarction. She tires easily and has chest pain when she inhales deeply at rest. She has had frequent crying spells associated with thoughts of her husband and feels uninvolved in daily activities. Which of the following is the most likely diagnosis? 
 2) + Normal grief (nezaškrtl-a)
 3) - Conversion disorder (zaškrtl-a)
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102. ( 25.orig.) A 50-year-old woman comes to the physician because of a 4-week history of aching limbs, difficulty climbing stairs, and difficulty rising from a chair. Examination shows tenderness of the quadriceps muscles. There is purple-red discoloration of the skin over the upper forehead, eyelids, and cheeks and flat-topped, purple nodules over the elbows and knees. Which of the following is the most likely diagnosis? 
 1) - Systemic lupus erythematosus (zaškrtl-a)
 3) + Dermatomyositis (nezaškrtl-a)
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104. (  3.orig.) A 32-year-old woman, gravida 5, para 4, is admitted to the hospital at 32 weeks gestation because of mild, bright red vaginal bleeding for 2 hours.  She has had no pain or contractions. Her last two children were delivered by low cervical cesarean section.  Vital signs are stable, and the fetal heart rate is 140/min and regular. Blood is drawn for complete blood count and typing and crossmatching, and intravenous administration of fluids is begun.  Which of the following is the most appropriate next step in management? 
 3) - Doppler umbilical blood flow study (zaškrtl-a)
 4) + Placental localization by ultrasonography (nezaškrtl-a)
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106. ( 23.orig.) A 67-year-old man comes to the physician because of a nontender lesion on the top of his forehead that has recently bled. He states that the lesion has been there since he was hit on the head with a bottle 18 months ago. Examination shows erythematous areas on other parts of his forehead. The lesion is 1 cm in diameter with a rolled-up, darkened border and a translucent, ulcerated center. Which of the following is the most likely diagnosis? 
 1) + Basal cell epithelioma (nezaškrtl-a)
 4) - Melanoma (zaškrtl-a)
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112. ( 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?
 4) - Thrombosis of preexisting upper extremity varicosities (zaškrtl-a)
 5) + Axillary-subclavian venous thrombosis (nezaškrtl-a)
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119. (  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? 
 1) - Intravenous administration of ACE inhibitors (zaškrtl-a)
 2) + Hemodialysis (nezaškrtl-a)
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TEST:usmle3en  Varianta:1         Tisknuto:04/06/2019
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 14. ( 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? 
 3) + "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)
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 24. (  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)
 4) + Herpes zoster (nezaškrtl-a)
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 26. ( 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 amylase of 2,000 U/L (zaškrtl-a)
 4) + Serum calcium of 1,6 mmol/l (nezaškrtl-a)
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 28. (  7.orig.) You plan to discharge an 81-year-old woman in a few days following a 3-week stay in the hospital for repair of a fractured hip that she sustained while gardening. She now ambulates with difficulty using a walker, but she is determined to become independent again and to return to her own home. Which of the following is most likely to prevent another fall and a possible fracture in this patient? 
 1) + Request a visiting nurse to assess the safety of her living environment (nezaškrtl-a)
 3) - Ensure that she does not have orthostatic hypotension (zaškrtl-a)
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 36. ( 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) - Degranulation of eosinophils (zaškrtl-a)
 4) + Basophilic stippling of erythrocytes (nezaškrtl-a)
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 38. (  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?" 
 2) - Cardiac arrhythmia (zaškrtl-a)
 5) + Atlanto-axial instability (nezaškrtl-a)
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 42. ( 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) + CT scan of the head (nezaškrtl-a)
 2) - Serum test for HIV antibodies (zaškrtl-a)
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 45. ( 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? 
 1) - Heroin (zaškrtl-a)
 5) + Cocaine (nezaškrtl-a)
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 47. ( 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) + Administer phentolamine, intravenously (nezaškrtl-a)
 5) - Prescribe oral oxycodone and nasal corticosteroids (zaškrtl-a)
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 51. ( 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? 
 2) - Situational anxiety disorder (zaškrtl-a)
 5) + Suicidal ideation (nezaškrtl-a)
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 57. ( 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? 
 3) - Acute pericarditis (zaškrtl-a)
 4) + Myocardial infarction (nezaškrtl-a)
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 59. ( 34.orig.) A 45-year-old woman is brought to the health center by her husband because of nausea, confusion, chills, fever, flank pain and cloudy urine. She has a history of insulin-dependent diabetes mellitus, poorly controlled hypertension and recurrent urinary tract infections. Her vital signs are: temperature 40.0°C (104.0°F), pulse 120/min, respirations 24/min, blood pressure 110/70 mm Hg. Funduscopic examination shows diabetic retinopathy, which is unchanged from the previous examination. Neck is supple. Lungs are clear to auscultation and percussion. Examination of the abdomen is normal. Marked pain is present at the right costovertebral angle. Several hemorrhagic bullous lesions are noted on the extremities. If this patient were to develop anuria, which of the following would be the most likely cause? 
 1) - Bladder outlet obstruction (zaškrtl-a)
 5) + Acute papillary necrosis (nezaškrtl-a)
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 60. ( 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?
 4) - Estrone (zaškrtl-a)
 5) + Dihydrotestosterone (nezaškrtl-a)
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 66. ( 32.orig.) A 62-year-old man strikes the steering wheel of his car during a low-speed automobile accident. In the emergency department he is alert and his vital signs are normal. He complains of mild tenderness on sternal compression. Chest x-ray film shows a widened mediastinum. The most appropriate first step is to order which of the following? 
 1) + CT scan of the chest with contrast (nezaškrtl-a)
 2) - Thoracic ultrasonography (zaškrtl-a)
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 69. ( 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) - They can have amniocentesis during pregnancy to test whether the infant will be hearing-impaired (zaškrtl-a)
 3) + Accurate risk estimation is impossible without further evaluation (nezaškrtl-a)
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 72. (  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) + Exercise stress test (nezaškrtl-a)
 2) - 24-Hour ambulatory electrocardiographic monitoring (zaškrtl-a)
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 74. ( 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) - Administer intravenous heparin initially, followed by warfarin until delivery (zaškrtl-a)
 4) + Prescribe heparin until delivery (nezaškrtl-a)
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 78. ( 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)
 2) - Borderline personality disorder (zaškrtl-a)
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 79. ( 22.orig.) A 25-year-old man has been on life support systems for the past 48 hours following blunt head trauma. Which of the following is the most important criterion to declare the patient brain dead and to permit removal of life support systems? 
 2) + Bedside EEG showing no electrical activity (nezaškrtl-a)
 4) - Glasgow coma score of 3 or less (zaškrtl-a)
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 81. (  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) + Inadvertent injury of the femoral artery (nezaškrtl-a)
 4) - Paradoxical embolus from the femoral vein (zaškrtl-a)
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 82. ( 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? 
 2) + Oxycodone (nezaškrtl-a)
 5) - Fluoxetine (zaškrtl-a)
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 85. ( 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? 
 1) + Do nothing until the child is 2 years of age (nezaškrtl-a)
 5) - Refer the child to a lipid specialist (zaškrtl-a)
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 98. ( 15.orig.) A 19-year-old white woman returns to the office 2 months after having a medroxyprogesterone injection for contraception. She is complaining of nonstop bleeding since her menses 3 weeks ago. She is using eight pads a day. She denies any sexual activity since she received the injection. She realizes that spotting is a side effect; however, she is anxious about the length of time and the amount of the bleeding. She tells you, "I can't stand this, Doctor. I want the bleeding to stop now!" Repeat pregnancy test is negative. Which of the following is the most appropriate treatment option for her bleeding? 
 3) - Reassurance and counseling (zaškrtl-a)
 4) + Conjugated estrogen therapy for 2 weeks (nezaškrtl-a)
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101. ( 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? 
 1) + Severe preeclampsia and requires immediate medical management and delivery (nezaškrtl-a)
 2) - Severe preeclampsia and should continue bed rest pending further diagnostic studies (zaškrtl-a)
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107. ( 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)
 5) - Perforated peptic ulcer (zaškrtl-a)
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108. ( 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) + Reassure her and treat with a nonsteroidal anti-inflammatory drug (NSAID) (nezaškrtl-a)
 4) - Order MRI of the lumbar spine (zaškrtl-a)
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110. ( 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? 
 4) - Occult hemorrhage (zaškrtl-a)
 5) + Alveolar hypoventilation (nezaškrtl-a)
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114. ( 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? 
 3) - Go out of your way to be warm and friendly so that he can develop trust in you (zaškrtl-a)
 4) + Explain the rationale for any diagnostic procedures and treatment regimens in some detail, adopting a professional, but not overly friendly stance (nezaškrtl-a)
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118. ( 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? 
 1) + Karyotype from peripheral leukocytes (nezaškrtl-a)
 5) - Serum prolactin concentration (zaškrtl-a)