Otázky s chybnou odpovědí, č.j. 3841640
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TEST:usmle1en  Varianta:8         Tisknuto:04/06/2019
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  5. ( 38.orig.) The intracellular domain of the insulin receptor has which of the following enzyme activities? 
 2) + Tyrosine kinase (nezaškrtl-a)
 3) - Phospholipase C (zaškrtl-a)
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 10. ( 20.orig.) Breast carcinomas often cause the skin of the breast to become puffy and pitted, resembling orange peel. The pits most likely correspond with which of the following? 
 2) + Attachments of suspensory ligaments (retinacula cutis) to the dermis (nezaškrtl-a)
 4) - Focal invasion of the dermis by neoplastic cells (zaškrtl-a)
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 12. (  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) + ventricular septal defect (nezaškrtl-a)
 4) - coarctation of the aorta (zaškrtl-a)
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 20. ( 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? 
 2) - Medial rectus muscle (zaškrtl-a)
 5) + Medial longitudinal fasciculus (nezaškrtl-a)
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 27. ( 10.orig.) A 16-year-old girl is incoherent and has a fever, severe lower abdominal pain, and a foul-smelling cervicovaginal discharge. A self-induced abortion is suspected. Which of the following methods should be used to collect a sample of the cervical discharge for bacterial culture? 
 3) + Taking samples of the discharge with a syringe and transferring them directly to the laboratory (nezaškrtl-a)
 4) - Smear  + Gram stain (zaškrtl-a)
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 38. (  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?  
 3) - A (zaškrtl-a)
 4) + C (nezaškrtl-a)
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 51. ( 40.orig.) A patient with an aneurysm of the aortic arch develops hoarseness. Paralysis of which of the following muscles on the left side is most likely? 
 1) - Cricothyroid (zaškrtl-a)
 4) + Posterior cricoarytenoid (nezaškrtl-a)
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 56. ( 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? 
 3) + Second trimester (nezaškrtl-a)
 4) - Five month postpartum (zaškrtl-a)
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 63. ( 15.orig.) A 53-year-old woman dies 4 days after an automobile collision. She sustained multiple injuries including a femoral fracture. Widespread petechiae are found in the cerebral white matter at autopsy. Which of the following is the most likely cause of these findings? 
 3) + Fat embolization (nezaškrtl-a)
 4) - Subdural hematoma (zaškrtl-a)
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 70. ( 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? 
 2) + Indirect stimulation of -adrenergic receptors (nezaškrtl-a)
 4) - Direct stimulation of -adrenergic receptors (zaškrtl-a)
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 72. ( 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? 
 2) + Sheets and cords of epithelial cells in the serosal layer (nezaškrtl-a)
 5) - Focal areas of necrosis and acute inflammation (zaškrtl-a)
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 74. ( 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 ACTH (zaškrtl-a)
 2) + Plasma renin (nezaškrtl-a)
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 79. ( 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? 
 2) - Accumulation of mononuclear cells at the site of antigen injection (zaškrtl-a)
 4) + Local fixation of complement by preformed circulating antibodies (nezaškrtl-a)
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 81. (  8.orig.) Moderate alcohol consumption may protect against coronary artery disease by which of the following mechanisms? 
 1) - Increasing thromboxane B2 release from platelets (zaškrtl-a)
 4) + Increasing serum concentration of HDLs (nezaškrtl-a)
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 85. ( 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? 
 4) - Polypoid growth (zaškrtl-a)
 5) + Extension to the serosa (nezaškrtl-a)
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 95. ( 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) + Gout (nezaškrtl-a)
 4) - Rheumatoid arthritis (zaškrtl-a)
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 98. ( 36.orig.) A 4-year-old girl has been unable to eat for 2 days because of a gastrointestinal tract disorder. Which of the following is the major source of fuel being oxidized by her skeletal muscles? 
 1) + Serum fatty acids (nezaškrtl-a)
 2) - Muscle triglycerides (zaškrtl-a)
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TEST:usmle2en  Varianta:8         Tisknuto:04/06/2019
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  6. ( 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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 14. ( 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? 
 3) - Ovarian cyst (zaškrtl-a)
 4) + Appendicitis (nezaškrtl-a)
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 15. ( 30.orig.) A 22-year-old man with a seizure disorder has had increasing cough and shortness of breath for 3 days and fever for 1 day. He has foul-smelling sputum. He had a generalized tonic-clonic seizure 1 week ago. His temperature is 39,4°C (103°F). Crackles are heard on auscultation of the chest. An x-ray of the chest shows a right upper-lobe infiltrate of the lung. Which of the following is the most likely cause?
 2) + Pneumonia secondary to anaerobes (nezaškrtl-a)
 3) - Pneumonia secondary to gram-positive aerobes (zaškrtl-a)
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 23. ( 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? 
 2) + Benign positional vertigo (nezaškrtl-a)
 5) - Meniere disease (zaškrtl-a)
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 44. ( 12.orig.) A 46-year-old man comes to the physician because of intermittent lower abdominal pain over the past 3 months. There is no family history of cancer. Examination shows no other abnormalities. His hematocrit is 38%. Test of the stool for occult blood is positive. Colon contrast studies show a 1.5-cm polyp in the descending colon. An upper gastrointestinal series shows no abnormalities. Which of the following is the most appropriate next step in management? 
 2) - Reexamination in 1 year (zaškrtl-a)
 4) + Colonoscopy with polypectomy (nezaškrtl-a)
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 59. ( 38.orig.) A 14-year-old boy is brought to the walk in clinic by his father late on Saturday afternoon because his left ear is swollen and painful. The boy´s ear has been black and blue since he injured it in a wrestling match 3 days ago. Symptoms have increased significantly following a repeat injura 3 hours ago. On physical examination, his left ear is markedly swollen and tender to palpation. Which of the following is the most appropriate next step?
 1) - Recommend that he apply cold pycks to the ear for the next 12 hours (zaškrtl-a)
 3) + Refer him to a surgeon for immediate drainage of the lesion (nezaškrtl-a)
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 61. ( 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 only if serologic testing at birth for HbsAg and anti-HbcAg is negative (zaškrtl-a)
 2) + HBIG and hepatitis B vaccination at birth (nezaškrtl-a)
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 76. (  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) - Ulnar (zaškrtl-a)
 5) + Median (nezaškrtl-a)
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 86. ( 39.orig.) A 37-year-old woman, gravida 3, para 3, comes to the physician because of labor-like pains and a small amount of vaginal bleeding for 2 days. She has had increasingly heavy, regular menstrual periods over the past 3 years; her last menstrual period was 18 days ago. Her youngest child is 10 years old. The cervix is moderately effaced and 2 cm dilated; there is beefy red tissue in the os. Which of the following is the most likely diagnosis? 
 3) + Pedunculated submucous leiomyoma (nezaškrtl-a)
 4) - Incomplete abortion (zaškrtl-a)
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 87. ( 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)
 5) - Immune thrombocytopenic purpura (zaškrtl-a)
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 96. ( 34.orig.) A 58-year-old man comes to the physician because of extreme fatique and malaise for 3 weeks. He has felt well except for a toothache 5 weeks ago treated with a root canal procedure. He has a history of a cardiac murmur first noted at the age of 19 years. His temperature is 37,8°C, pulse is 110/min, and blood pressure is 120/80 mm Hg. The lungs are clear to auscultation. Cardiac examination shows a grade 2/6, systolic ejection murmur heard best at the right second intercostal space as well as an S4 and an ejection click. Laboratory studies show: hemoglobi 1,4 mmol/l (2,09-1,71I), leukocyte count 10,000/mm3; segmented neutrophils 90%, bands 10%; erythrocyte sedimentation rate 90mm/h; urine, blood positive. Blood culture are obtained. Gram stain of the blood culture is most likely to show which of the following?
 1) + Gram-positive cocci in chains (nezaškrtl-a)
 2) - Gram-positive cocci in clusters (zaškrtl-a)
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 99. ( 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 testicle (nezaškrtl-a)
 4) - Epididymitis (zaškrtl-a)
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108. (  4.orig.) An 18-year-old male high school basketball player comes to the physician for a routine physical examination. He is 193 cm (6 ft 4 in) tall; arm span is 201 cm (79 in). He has long fingers and toes. His pulse is 64/min, and blood pressure is 146/62 mm Hg. There is a grade 2/6, long, high-frequency diastolic murmur at the second right intercostal space. Which of the following is the most likely diagnosis? 
 1) - Atrial septal defect (zaškrtl-a)
 2) + Aortic regurgitation (nezaškrtl-a)
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110. (  5.orig.) A full-term 2-month-old boy appeared well until 3 weeks ago when he became dyspneic and had difficulty feeding.  A loud holosystolic murmur is heard at the left lower sternal border.  An ECG shows left and right ventricular hypertrophy. Which of the following is the most likely diagnosis? 
 2) + Ventricular septal defect (nezaškrtl-a)
 3) - Allergy to formula (zaškrtl-a)
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112. (  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)
 5) - Pathologic grief (zaškrtl-a)
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113. ( 17.orig.) A 70-year-old man comes to the physician because of severe myalgias and malaise over the past 2 months.  He has had a 2.7-kg (6-lb) weight loss during this period.  Examination shows no abnormalities. His hematocrit is 30%, leukocyte count is 11,300/mm3, and erythrocyte sedimentation rate is 112 mm/h.  Serum creatine kinase activity is within normal limits. Which of the following is the most likely diagnosis? 
 2) + Polymyalgia rheumatica (nezaškrtl-a)
 5) - Rheumatoid arthritis (zaškrtl-a)
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TEST:usmle3en  Varianta:8         Tisknuto:04/06/2019
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  4. (  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) - Cerebral ischemia (zaškrtl-a)
 4) + Atlanto-axial instability (nezaškrtl-a)
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 17. ( 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? 
 2) + Basophilic stippling of erythrocytes (nezaškrtl-a)
 3) - Degranulation of eosinophils (zaškrtl-a)
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 19. ( 37.orig.) A male colleague asks you to write a prescription for a narcotic analgesic for one of his female patients. You have noticed that this patient frequently has been coming by the office to see your colleague, and that several of the visits have been marked "No Charge." When you ask your colleague why he cannot write the prescription himself, he seems defensive and says, "Because I don't want anybody to get the wrong idea." Which of the following is the most appropriate response to your colleague? 
 1) + "It sounds like there is more to this story than you are telling me; maybe we should talk about it." (nezaškrtl-a)
 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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 21. ( 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? 
 1) - Order determination of serum rheumatoid factor (zaškrtl-a)
 2) + Order determination of erythrocyte sedimentation rate (nezaškrtl-a)
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 26. ( 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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 28. ( 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) + Do colposcopic examination of the cervix after application of 5% acetic acid solution (nezaškrtl-a)
 2) - Do conization of the cervix (zaškrtl-a)
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 31. ( 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? 
 3) - Basal cell carcinoma (zaškrtl-a)
 4) + Squamous cell carcinoma (nezaškrtl-a)
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 40. ( 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? 
 2) + Prescribe heparin until delivery (nezaškrtl-a)
 4) - Administer intravenous heparin initially, followed by warfarin until delivery (zaškrtl-a)
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 42. ( 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? 
 2) - Occult hemorrhage (zaškrtl-a)
 4) + Alveolar hypoventilation (nezaškrtl-a)
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 52. ( 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) - Have the child return for a fasting lipoprotein analysis (zaškrtl-a)
 5) + Do nothing until the child is 2 years of age (nezaškrtl-a)
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 66. ( 24.orig.) A 20-year-old woman who is 35 weeks pregnant with her first child is admitted to the hospital because of persistent hypertension and 1+ protein on urinalysis obtained 36 hours ago. She is confined to bed awaiting further diagnostic studies for preeclampsia. Her blood pressure is now 160/100 mm Hg. She is complaining of headaches, blurred vision and epigastric pain. At this time it is most appropriate to conclude that this patient has which of the following? 
 3) + Severe preeclampsia and requires immediate medical management and delivery (nezaškrtl-a)
 5) - Mild preeclampsia and should continue bed rest pending further diagnostic studies (zaškrtl-a)
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 68. ( 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? 
 4) + Oxycodone (nezaškrtl-a)
 5) - Amitriptyline (zaškrtl-a)
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 71. ( 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)
 5) - Situational anxiety disorder (zaškrtl-a)
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 90. ( 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? 
 1) + Administer phentolamine, intravenously (nezaškrtl-a)
 2) - Order CT scan of the head (zaškrtl-a)
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 91. ( 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? 
 2) + CT scan of the head (nezaškrtl-a)
 3) - Lumbar puncture (zaškrtl-a)
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 94. ( 38.orig.) A husband and wife, ages 29 years and 34 years, respectively, come to the office for advice regarding their risk for having hearingimpaired children. They are both hearing-impaired and require hearing aids. Their hearing loss is sensorineural and is not associated with any other health problems. The wife tells you, "We have both learned to live with this disability, but we want to take it into account before we decide to have children." Their pedigree is shown with the patients identified as II2 and II3. Which of the following is the most appropriate advice to the couple? 
 2) - Because they are hearing-impaired, all their children will be hearing-impaired (zaškrtl-a)
 5) + Accurate risk estimation is impossible without further evaluation (nezaškrtl-a)
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103. ( 32.orig.) A 62-year-old man strikes the steering wheel of his car during a low-speed automobile accident. In the emergency department he is alert and his vital signs are normal. He complains of mild tenderness on sternal compression. Chest x-ray film shows a widened mediastinum. The most appropriate first step is to order which of the following? 
 2) + CT scan of the chest with contrast (nezaškrtl-a)
 4) - Thoracic ultrasonography (zaškrtl-a)
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105. (  7.orig.) You plan to discharge an 81-year-old woman in a few days following a 3-week stay in the hospital for repair of a fractured hip that she sustained while gardening. She now ambulates with difficulty using a walker, but she is determined to become independent again and to return to her own home. Which of the following is most likely to prevent another fall and a possible fracture in this patient? 
 3) + Request a visiting nurse to assess the safety of her living environment (nezaškrtl-a)
 5) - Advise her to walk only when accompanied by an adult (zaškrtl-a)
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107. ( 28.orig.) A 35-year-old woman is seen in the emergency department because of the sudden onset of severe low back pain 12 hours earlier. The pain began when she bent over to pick up her 2-year-old child. She has been unable to stay in bed because of the need to care for her child. Low doses of ibuprofen have eased the discomfort slightly. Careful physical examination, including a neurologic examination, is normal except for evidence of muscle spasm. She believes she has a herniated disc because 2 years ago her father developed the sudden onset of back pain that required immediate surgery. Which of the following is the most appropriate first step? 
 3) - Order x-ray films of the lumbar spine (zaškrtl-a)
 5) + Reassure her and treat with a nonsteroidal anti-inflammatory drug (NSAID) (nezaškrtl-a)
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109. ( 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)
 3) - Serum gonadotropin concentrations (follicle-stimulating hormone and luteinizing hormone) (zaškrtl-a)
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119. (  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) + Inadvertent injury of the femoral artery (nezaškrtl-a)
 5) - Paradoxical embolus from the femoral vein (zaškrtl-a)