Otázky s chybnou odpovědí, č.j. 8899572
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TEST:usmle1en  Varianta:2         Tisknuto:04/06/2019
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 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? 
 1) - Repression (zaškrtl-a)
 4) + Regression (nezaškrtl-a)
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 22. (  2.orig.) Which of the following best explains why neonates with sickle cell disease do not have symptoms at birth? 
 1) - Maternal erythrocytes protect neonatal erythrocytes from sickling (zaškrtl-a)
 4) + The concentration of hemoglobin S is too low (nezaškrtl-a)
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 24. ( 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? 
 3) - Lateral preoptic (zaškrtl-a)
 4) + Suprachiasmatic (nezaškrtl-a)
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 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)
 5) - D (zaškrtl-a)
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 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)
 5) - Obturator internus (zaškrtl-a)
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 39. ( 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? 
 4) - Third trimester (zaškrtl-a)
 5) + Second trimester (nezaškrtl-a)
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 45. ( 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? 
 1) + Tetanus antitoxin plus toxoid (nezaškrtl-a)
 2) - Tetanus toxoid (zaškrtl-a)
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 58. ( 28.orig.) A 60-year-old man undergoes excision of an obstruction in the large intestine. Which of the following microscopic features in the obstructing lesion most strongly suggests malignant growth? 
 3) + Sheets and cords of epithelial cells in the serosal layer (nezaškrtl-a)
 4) - Focal areas of necrosis and acute inflammation (zaškrtl-a)
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 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)
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 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 
 3) + Surreptitious use of diuretics (nezaškrtl-a)
 5) - Aldosterone deficiency (zaškrtl-a)
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 74. (  5.orig.) A 4-week-old infant has a loud systolic murmur with a systolic thrill; otherwise, the infant appears healthy. There is no cyanosis. The most likely cause of the murmur is
 1) - coarctation of the aorta (zaškrtl-a)
 5) + ventricular septal defect (nezaškrtl-a)
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 78. (  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? 
 2) + IgE on basophils and mast cells  (nezaškrtl-a)
 3) - IgE on neutrophils and eosinophils (zaškrtl-a)
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 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? 
 3) + Indirect stimulation of -adrenergic receptors (nezaškrtl-a)
 5) - Indirect inhibition of -adrenergic receptors (zaškrtl-a)
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 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 
 3) - Septic arthritis (zaškrtl-a)
 5) + Gout (nezaškrtl-a)
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 97. ( 29.orig.) Lactation does not occur during pregnancy because the action of prolactin is blocked by increased concentrations of which of the following hormones? 
 1) - Growth hormone and oxytocin (zaškrtl-a)
 5) + Estrogen and progesterone (nezaškrtl-a)
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102. ( 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? 
 1) - Normal concerns of latency-age children (zaškrtl-a)
 4) + Separation anxiety disorder (nezaškrtl-a)
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107. ( 14.orig.) A 38-year-old woman has congestive heart failure, premature ventricular contractions, and repeated episodes of ventricular tachycardia. Her blood pressure is normal and there are no murmurs. Her heart is markedly enlarged. Coronary angiography shows no abnormalities. Which of the following is the most likely diagnosis? 
 3) + Primary cardiomyopathy (nezaškrtl-a)
 5) - Constrictive pericarditis (zaškrtl-a)
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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)
 5) - Smear  + Gram stain (zaškrtl-a)
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113. ( 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) + social phobia (nezaškrtl-a)
 3) - prostatism (zaškrtl-a)
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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)
 2) - Polypoid growth (zaškrtl-a)
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TEST:usmle2en  Varianta:2         Tisknuto:04/06/2019
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  3. ( 29.orig.) An 18-year-old woman comes to the emergency department because of lower abdominal pain for 16 hours. She also reports loss of appetite and mild nausea. She is sexually active and takes an oral contraceptive. Her last menstrual period was 3 weeks ago. Her temperature is 37.9°C (100.2°F). There is guarding and tenderness to palpation of the right lower quadrant of the abdomen; palpation of other areas of the abdomen results in referred pain in the right lower quadrant. Bowel sounds are absent. Pelvic examination shows scant mucous discharge from the cervical os.  Palpation on the right produces pain. There is no cervical motion tenderness, and the adnexa and ovaries appear normal. Which of the following is the most likely diagnosis? 
 2) - Ectopic pregnancy (zaškrtl-a)
 3) + Appendicitis (nezaškrtl-a)
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  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)
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  9. ( 24.orig.) A 13-year-old boy has nasal discharge and itching of the eyes each year in the early summer. Fifteen minutes after skin testing with a mixture of grass pollens, he develops erythema and a 15-mm wheal at the site.  The skin test response is most likely a result of which of the following mechanisms? 
 1) - Influx of phagocytic cells in response to injection of foreign proteins (zaškrtl-a)
 5) + Release of histamine from mast cells (nezaškrtl-a)
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 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)
 5) - Cavernous sinus thrombosis (zaškrtl-a)
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 21. (  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? 
 3) - Hypothyroidism (zaškrtl-a)
 4) + Acute stress disorder (nezaškrtl-a)
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 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?
 1) - Meningococcal meningitis (zaškrtl-a)
 4) + Thrombotic thrombocytopenic purpura (nezaškrtl-a)
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 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? 
 1) - Actinic keratosis (zaškrtl-a)
 3) + Basal cell epithelioma (nezaškrtl-a)
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 43. ( 10.orig.) A 45-year-old woman comes to the physician because of a 3-month history of episodes in which she becomes overwhelmingly hot and sweats so much that her clothes become wet. The episodes last approximately 5 minutes and have increased in frequency; they now occur at least once daily, mostly at night.  During an episode, her heart rate increases, and she feels anxious; she has a chilled feeling afterward.  Menses are regular, but the intermenstrual interval has decreased by 5 days over the past 6 months. She takes no medications. She drinks five cups of coffee daily. Her temperature is 37°C (98.6°F), pulse is 74/min, and blood pressure is 110/70 mm Hg. Examination shows no other abnormalities. Which of the following is the most likely explanation for these findings? 
 2) + Hot flash (nezaškrtl-a)
 3) - Hyperthyroidism (zaškrtl-a)
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 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? 
 1) - Renal ultrasonography (zaškrtl-a)
 4) + Placement of a Foley catheter (nezaškrtl-a)
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 49. ( 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? 
 3) + Torsion of the testicle (nezaškrtl-a)
 4) - Epididymitis (zaškrtl-a)
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 50. (  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? 
 3) + Normal grief (nezaškrtl-a)
 5) - Pathologic grief (zaškrtl-a)
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 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?
 2) + Systemic lupus erythematosus (nezaškrtl-a)
 3) - Secondary syphilis (zaškrtl-a)
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 57. ( 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?
 1) - Tilt test (zaškrtl-a)
 3) + ECG (nezaškrtl-a)
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 60. (  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) - Placental localization by double set-up examination (zaškrtl-a)
 4) + Placental localization by ultrasonography (nezaškrtl-a)
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 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?
 3) + Endotracheal intubation and mechanical ventilation (nezaškrtl-a)
 5) - Discontinuation of the oxygen (zaškrtl-a)
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 68. ( 28.orig.) A previously healthy 16-year-old boy is brought to the emergency department 1 hour after the sudden onset of abdominal and scrotal pain. There is severe tenderness in the region of the inguinal canal on the right; the right side of the scrotum is empty. Urinalysis shows normal findings. Which of the following is the most effective initial management? 
 1) - Cystoscopy (zaškrtl-a)
 2) + Immediate operation (nezaškrtl-a)
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 77. ( 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? 
 1) - Anticholinergic poisoning (zaškrtl-a)
 4) + Opiate withdrawal (nezaškrtl-a)
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 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)
 5) - Chloramphenicol (zaškrtl-a)
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 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)
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 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)
 4) - Superficial thrombophlebitis of the cephalic vein (zaškrtl-a)
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 83. (  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) - Mesothelioma (zaškrtl-a)
 3) + Non-small cell lung carcinoma (nezaškrtl-a)
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 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)
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 92. (  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? 
 1) + Median (nezaškrtl-a)
 3) - Radial (zaškrtl-a)
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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? 
 3) - Incomplete abortion (zaškrtl-a)
 4) + Pedunculated submucous leiomyoma (nezaškrtl-a)
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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)
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118. ( 36.orig.) A 20-year-old primigravid woman delivers a full-term 3200-g (7-lb 1-oz) newborn vaginally under epidural anesthesia. A second-degree midline episiotomy was required.  On postpartum day 1, she has perineal pain.  The perineum is slightly edematous with no evidence of purulent drainage or episiotomy breakdown. Which of the following is the most appropriate next step in management? 
 3) - Local injection of lidocaine in the perineum (zaškrtl-a)
 5) + Sitz baths twice daily (nezaškrtl-a)
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119. ( 27.orig.) Over the past week, a 55-year-old woman has had extreme dizziness on lying down and getting up. She says it feels the room is spinning. Examination shows no abnormalities except for fatigable nystagmus toward the left when the patient is lying on her left side. Which of the following is the most likely diagnosis? 
 1) + Benign positional vertigo (nezaškrtl-a)
 2) - Meniere disease (zaškrtl-a)
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TEST:usmle3en  Varianta:2         Tisknuto:04/06/2019
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  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? 
 3) - Macrocytic erythrocytes (zaškrtl-a)
 4) + Basophilic stippling of erythrocytes (nezaškrtl-a)
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  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)
 4) - Basal cell carcinoma (zaškrtl-a)
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 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)
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 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? 
 2) - Refer the child to a lipid specialist (zaškrtl-a)
 5) + Do nothing until the child is 2 years of age (nezaškrtl-a)
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 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? 
 1) - Intense arteriolar constriction induced by hyperosmolality (zaškrtl-a)
 3) + Inadvertent injury of the femoral artery (nezaškrtl-a)
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 20. ( 13.orig.) At a routine physical examination, the Pap smear of a 27-year-old woman shows evidence of marked inflammation suggestive of moderate dysplasia (HGSIL). Her last Pap smear 2 years ago was normal. Pelvic examination today is normal. She has never been pregnant and her menstrual periods are regular. She has been in a stable relationship with the same man for 3 years and she uses a diaphragm with spermicidal jelly for contraception. Which of the following is the most appropriate next step? 
 1) - Advise the patient that her partner should use condoms for contraception and repeat the Pap smear in 3 months (zaškrtl-a)
 3) + Do colposcopic examination of the cervix after application of 5% acetic acid solution (nezaškrtl-a)
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 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)
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 35. ( 33.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. Without prompt and aggressive treatment, this patient is most likely to develop which of the following? 
 2) + Septic shock (nezaškrtl-a)
 5) - Diabetic ketoacidosis (zaškrtl-a)
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 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)
 4) - Schedule bilateral renal angiography (zaškrtl-a)
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 46. ( 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? 
 4) - Bladder outlet obstruction (zaškrtl-a)
 5) + Acute papillary necrosis (nezaškrtl-a)
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 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)
 5) - Conversion disorder (zaškrtl-a)
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 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)
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 59. ( 15.orig.) A 19-year-old white woman returns to the office 2 months after having a medroxyprogesterone injection for contraception. She is complaining of nonstop bleeding since her menses 3 weeks ago. She is using eight pads a day. She denies any sexual activity since she received the injection. She realizes that spotting is a side effect; however, she is anxious about the length of time and the amount of the bleeding. She tells you, "I can't stand this, Doctor. I want the bleeding to stop now!" Repeat pregnancy test is negative. Which of the following is the most appropriate treatment option for her bleeding? 
 1) - Dilatation and curettage (zaškrtl-a)
 4) + Conjugated estrogen therapy for 2 weeks (nezaškrtl-a)
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 61. ( 35.orig.) A 47-year-old Italian-American man comes to the office for the first time for routine medical care. He has been referred to you by his psychiatrist who has informed you that the patient has paranoid personality disorder. The patient has no other medical problems at this time. He is unmarried, lives alone and has no close friends, but he occasionally attends family gatherings. He functions well working alone in a technical position in an engineering firm. Which of the following is the best way to structure the physician-patient relationship with this patient? 
 1) - Have his psychiatrist, with whom he has been working for several years, take the lead in presenting medical treatment options (zaškrtl-a)
 2) + 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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 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? 
 3) - Abortion should be considered because of the adverse effect of pregnancy on ulcerative colitis (zaškrtl-a)
 4) + Sulfasalazine and corticosteroids are not known to be teratogenic (nezaškrtl-a)
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 64. (  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) - Cardiac arrhythmia (zaškrtl-a)
 5) + Atlanto-axial instability (nezaškrtl-a)
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 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? 
 3) - Electroencephalography (zaškrtl-a)
 4) + CT scan of the head (nezaškrtl-a)
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 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)
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 86. ( 24.orig.) A 20-year-old woman who is 35 weeks pregnant with her first child is admitted to the hospital because of persistent hypertension and 1+ protein on urinalysis obtained 36 hours ago. She is confined to bed awaiting further diagnostic studies for preeclampsia. Her blood pressure is now 160/100 mm Hg. She is complaining of headaches, blurred vision and epigastric pain. At this time it is most appropriate to conclude that this patient has which of the following? 
 2) + Severe preeclampsia and requires immediate medical management and delivery (nezaškrtl-a)
 3) - Mild preeclampsia and should continue bed rest pending further diagnostic studies (zaškrtl-a)
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 90. ( 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)
 2) + Cocaine (nezaškrtl-a)
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 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)
 3) - "Maybe I should see your patient in the office myself, and then decide if she needs the medication." (zaškrtl-a)
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 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)
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100. ( 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) + Accurate risk estimation is impossible without further evaluation (nezaškrtl-a)
 5) - They can have amniocentesis during pregnancy to test whether the infant will be hearing-impaired (zaškrtl-a)
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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? 
 3) - Thoracentesis (zaškrtl-a)
 5) + CT scan of the chest with contrast (nezaškrtl-a)
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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)
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114. ( 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)
 5) - Failure to respond to electroconvulsive stimuli (zaškrtl-a)
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120. (  2.orig.) A 75-year-old woman comes to the clinic because she has band-like burning pain in the right upper quadrant extending from the epigastrium around to the midline of the back. On physical examination, there is no abdominal tenderness. Findings on ultrasonography of the gallbladder are normal; serum amylase concentration is normal. Which of the following is the most likely diagnosis? 
 2) - Acalculous cholecystitis (zaškrtl-a)
 4) + Herpes zoster (nezaškrtl-a)