relations/test_relations.jsonl

{"190_94": [["Although other hemorrhagic diseases can have a prolonged thromboplastin time, due to the intensity of the lesion and the child's sex and family history, the most likely diagnosis is hemophilia\n", "Hemophilia A\n", "Support"], ["The ultrasound examination is compatible with hemarthrosis and in the analytical analysis only an APTT lengthening of 52'' (normal 25-35'') stands out\n", "Although other hemorrhagic diseases can have a prolonged thromboplastin time, due to the intensity of the lesion and the child's sex and family history, the most likely diagnosis is hemophilia\n", "Support"], ["In the directed anamnesis, the mother refers that an uncle of hers had similar problems\n", "Although other hemorrhagic diseases can have a prolonged thromboplastin time, due to the intensity of the lesion and the child's sex and family history, the most likely diagnosis is hemophilia\n", "Support"]]}
{"150_201": [["Knowing that we have taken measures of sleep hygiene, we have explored what provokes him not to sleep, and he does not sleep nine hours and still wants to sleep more,...then the less harmful answer is the 2\n", "Lormetacepam\n", "Support"], ["Because it is the one with the shortest half-life and he does not want the lady to fall down the next day\n", "Knowing that we have taken measures of sleep hygiene, we have explored what provokes him not to sleep, and he does not sleep nine hours and still wants to sleep more,...then the less harmful answer is the 2\n", "Support"]]}
{"454_153": [["The answer is 2, an EMG, which would be the diagnostic test to confirm the diagnostic suspicion of ALS\n", "Electromyographic study\n", "Support"], ["the imaging tests both CT, but especially MRI would help us to rule out, but would not confirm the diagnosis\n", "Cerebral CT\n", "Attack"], ["the imaging tests both CT, but especially MRI would help us to rule out, but would not confirm the diagnosis\n", "Cerebral MRI\n", "Attack"]]}
{"541_5": []}
{"602_112": [["The pain appears when the lower limb is lifted with the knee extended, but is relieved when the knee is flexed\n", "In this case, when speaking of \"reappearance of the symptoms when we lift the lower limb with the knee extended\" we are describing the Las\u00e8gue Maneuver\n", "Support"], ["This maneuver is positive in cases of lumbosciatic pain, since it causes a stretching of the sciatic nerve\n", "therefore the correct answer is number 3\n", "Support"], ["therefore the correct answer is number 3\n", "Radiated low back pain / lumbosciatica\n", "Support"], ["In this case, when speaking of \"reappearance of the symptoms when we lift the lower limb with the knee extended\" we are describing the Las\u00e8gue Maneuver\n", "This maneuver is positive in cases of lumbosciatic pain, since it causes a stretching of the sciatic nerve\n", "Support"], ["The rest of the pathologies do not have a positive Las\u00e8gue maneuver\n", "so these options would not be correct\n", "Support"], ["so these options would not be correct\n", "Gouty arthritis of left hip\n", "Attack"], ["so these options would not be correct\n", "Left coxofemoral arthrosis\n", "Attack"], ["so these options would not be correct\n", "Claudication due to canal stenosis\n", "Attack"]]}
{"127_77": [["A 32-year-old diabetic patient on insulin therapy with good control of his blood glucose levels comes to your office with tingling in both hands, with a sensation of corking and thermal insensitivity of progressive onset over the course of 2 weeks\n", "He presents a diabetic patient on insulin treatment with good control (although diabetic neuropathies do not only develop in patients with poor control) with a sensory picture limited to the upper limbs and of short onset time, without motor symptoms or at any other level\n", "Support"], ["She does not report visual disturbances, strength deficit, motor clumsiness or other symptoms\n", "He presents a diabetic patient on insulin treatment with good control (although diabetic neuropathies do not only develop in patients with poor control) with a sensory picture limited to the upper limbs and of short onset time, without motor symptoms or at any other level\n", "Support"], ["On examination she found anesthesia to pain and temperature in both hands and distal forearms; positional and vibratory sensitivity were preserved\n", "In the examination there is a clear dissociation with thermoalgesic anesthesia and preservation of arthrokinetic and vibratory\n", "Support"], ["Muscle reflexes are normal and symmetrical\n", "Reflexes are normal, neither abolished nor exalted\n", "Support"], ["The rest of the neurological examination is strictly normal\n", "In addition, the rest of the examination is strictly normal.\n", "Support"], ["There is no dysmetria, dysdiadochokinesia or intention tremor\n", "In addition, the rest of the examination is strictly normal.\n", "Support"], ["With all this I believe that the correct answer is 5, that is a syringomyelic lesion, whose initial characteristic is the sensitive dissociation with anesthesia for the thermoalgesic and conservation of the posterior cord\n", "Central cervical spinal cord injury\n", "Support"], ["MS and other spinal cord lesions would be accompanied by other exploratory signs such as exaltation of reflexes\n", "Multiple sclerosis type demyelinating disease\n", "Attack"], ["MS and other spinal cord lesions would be accompanied by other exploratory signs such as exaltation of reflexes\n", "Compressive cervical spinal cord injury\n", "Attack"], ["Muscle reflexes are normal and symmetrical\n", "Compressive cervical spinal cord injury\n", "Attack"], ["Muscle reflexes are normal and symmetrical\n", "Multiple sclerosis type demyelinating disease\n", "Attack"], ["for carpal tunnel the exploration exceeds the territory distal to the carpus\n", "Bilateral carpal tunnel syndrome\n", "Attack"], ["and as for answer 1, although there are forms of peripheral polyneuropathy \"pseudosyringomyelic\" they are usually of lumbar onset\n", "Peripheral sensitvo symmetric distal peripheral neuropathy of diabetic cause\n", "Attack"], ["The short evolution time (2 weeks), the respect of the lower limbs and the preservation of muscle reflexes make me rule out this response despite the distribution being \"glove-like\"\n", "Peripheral sensitvo symmetric distal peripheral neuropathy of diabetic cause\n", "Attack"], ["Muscle reflexes are normal and symmetrical\n", "Peripheral sensitvo symmetric distal peripheral neuropathy of diabetic cause\n", "Attack"]]}
{"316_138": [["It is SLE with joint, skin and serositis involvement.\n", "Treatment is EC at moderate-high doses\n", "Support"], ["Treatment is EC at moderate-high doses\n", "Glucocorticoids at high doses\n", "Support"], ["Mycophenolate is never a treatment in acute phase but in maintenance, nor has it proved useful in joint involvement\n", "Glucocorticoids and mycophenolate\n", "Attack"]]}
{"153_74": [["A 75-year-old woman consults for violaceous lesions on the hands and neck together with progressive muscle weakness of 3 months of evolution\n", "Given this clinical picture, one possibility is dermatomyositis\n", "Support"], ["Given this clinical picture, one possibility is dermatomyositis\n", "Of the proposed tests, the determination of serum aldolase may be useful\n", "Support"], ["Of the proposed tests, the determination of serum aldolase may be useful\n", "Determination of serum aldolase\n", "Support"], ["The biopsy should be muscular and not subcutaneous\n", "Biopsy of subcutaneous cellular tissue\n", "Attack"], ["Anti-smooth muscle antibodies are not characteristic of this disease\n", "Given this clinical picture, one possibility is dermatomyositis\n", "Attack"], ["Given this clinical picture, one possibility is dermatomyositis\n", "Determination of anti-smooth muscle antibodies\n", "Attack"], ["Of the proposed tests, the determination of serum aldolase may be useful\n", "Its elevation is characteristic of this disease\n", "Support"], ["Its elevation is characteristic of this disease\n", "Given this clinical picture, one possibility is dermatomyositis\n", "Support"]]}
{"369_122": []}
{"413_68": [["Rupture of the interventricular septum\n", "Rupture in the interventricular septum\n", "Support"], ["Mechanical complications are typical in infarctions in elderly women\n", "Rupture of the interventricular septum\n", "Support"], ["An 87-year-old woman with a history of hypertension was admitted 48 hours ago to the coronary unit for acute myocardial infarction with ST-segment elevation of anterior location\n", "Mechanical complications are typical in infarctions in elderly women\n", "Support"], ["Examination revealed a systolic murmur with fremitus, radiating to the right sternal border, which was not present on admission\n", "Likewise, a murmur that was not present indicates abnormal blood flow\n", "Support"], ["Examination revealed a systolic murmur with fremitus, radiating to the right sternal border, which was not present on admission\n", "the most frequent complications are mitral insufficiency, which would present with a musical or piante murmur, and VSD, which presents with a murmur radiating to the right border (think of the direction of blood flow)\n", "Support"], ["Likewise, a murmur that was not present indicates abnormal blood flow\n", "Rupture of the interventricular septum\n", "Support"], ["the most frequent complications are mitral insufficiency, which would present with a musical or piante murmur, and VSD, which presents with a murmur radiating to the right border (think of the direction of blood flow)\n", "Rupture of the interventricular septum\n", "Support"]]}
{"314_178": [["We have before us a patient with neuropathic pain, which due to the origin of the tumor, is most likely due to involvement of the celiac plexus\n", "It is important to have a radiological diagnosis in view of a possible local treatment, such as neurolytic treatment or plexus blockade\n", "Support"], ["He is taking WHO step 3 analgesia, which is clearly insufficient,\n", "he will need adjuvants\n", "Support"], ["However, we should not leave the patient without a treatment that can alleviate but rather solve the current situation\n", "he will need adjuvants\n", "Support"], ["although opioids for neuropathic pain are not very effective, we will not reduce the dose but will associate the adjuvants\n", "he will need adjuvants\n", "Support"], ["he will need adjuvants\n", "We would manage the patient with gabapentin and corticosteroids\n", "Support"], ["We would manage the patient with gabapentin and corticosteroids\n", "Administer amitriptyline or gabapentin, dexamethasone and increase the dose of morphine\n", "Support"], ["true answer 4\n", "Administer amitriptyline or gabapentin, dexamethasone and increase the dose of morphine\n", "Support"], ["we would not decrease the dose of morphine\n", "Decrease the dose of morphine as it is ineffective in this type of pain\n", "Attack"], ["false answer 3\n", "Decrease the dose of morphine as it is ineffective in this type of pain\n", "Attack"], ["We would manage the patient with gabapentin and corticosteroids\n", "true answer 4\n", "Support"], ["we would not decrease the dose of morphine\n", "false answer 3\n", "Support"], ["in the meantime we would ask for a CT scan (or abdominal MRI) to subsequently assess the plexus block\n", "answers 1 and 2 for future management\n", "Support"]]}
{"263_37": [["It is a claude bernard horner syndrome and probably the correct one is 1\n", "Sympathetic fibers, at some level that would span from the hypothalamus to the interinedio-lateral Clark's column of the dorsal medulla\n", "Support"]]}
{"344_158": [["Patients will be monitored weekly with hCG dosing until it becomes undetectable, for three consecutive times\n", "Subsequent controls are not necessary if the evacuation of the trophoblastic tissue was complete\n", "Attack"], ["After that the monitoring will be monthly for six months and then every two months for another six months before a new pregnancy\n", "Subsequent controls are not necessary if the evacuation of the trophoblastic tissue was complete\n", "Attack"], ["She should not become pregnant until she has undergone regular check-ups and one year has passed with negative beta-HCG levels\n", "She should not become pregnant until periodic check-ups and after one year with negative BHCG levels\n", "Support"]]}
{"43_151": [["The correct answer is 4\n", "Repeat urine sediment in 15 days\n", "Support"], ["Microhematuria without associated symptoms may be a finding without pathologic significance and must be confirmed in a subsequent new sediment (although I do not know if at 15 days or later)\n", "The correct answer is 4\n", "Support"]]}
{"616_119": [["Risser 0\n", "Immature skeleton\n", "Support"], ["Cobb angle between 25\u00ba - 45\u00ba\n", "Orthosis\n", "Support"], ["Orthosis\n", "Prescribe a corset-type orthosis\n", "Support"]]}
{"489_105": [["The patient is already diagnosed with chronic lymphocytic leukemia B (B-CLLL), presents lymphocytosis that is maintained for more than 3 months and by flow cytometry presents a phenotype compatible with it\n", "Therefore, we must first know the risk factors that will indicate with what priority treatment will need to be initiated, their intensity and prognosis\n", "Support"], ["Therefore, we must first know the risk factors that will indicate with what priority treatment will need to be initiated, their intensity and prognosis\n", "the presence of TP53 mutations or 17p deletions depends on this\n", "Support"], ["The bone marrow aspirate or biopsy is only indicated if there are other accompanying cytopenias that are not justified by the B-CLL itself\n", "Bone aspirate/biopsy to confirm diagnosis\n", "Attack"], ["PET-CT is only indicated if Ritcher's syndrome is suspected and we do not have enough data to suspect it\n", "PET/CT to establish the therapeutic attitude\n", "Attack"], ["there are no B symptoms, nor is there any mention of LDH elevation\n", "PET-CT is only indicated if Ritcher's syndrome is suspected and we do not have enough data to suspect it\n", "Support"], ["Therefore, we must first know the risk factors that will indicate with what priority treatment will need to be initiated, their intensity and prognosis\n", "New clinical and analytical control in 6 months\n", "Support"]]}
{"534_119": [["Raynaud's, esophageal involvement, skin induration\n", "This is a clear clinical case of systemic sclerosis (Raynaud's, esophageal involvement, skin induration) presenting with renal crisis\n", "Support"], ["Apart from anti-proteinase 3 antibodies, which are not related to scleroderma (incorrect answer 3), the most likely ones would be antiRNA polymerase III antibodies, which appear in younger patients with renal crises\n", "Anti-proteinase 3 antibodies\n", "Attack"], ["This is a clear clinical case of systemic sclerosis (Raynaud's, esophageal involvement, skin induration) presenting with renal crisis\n", "Apart from anti-proteinase 3 antibodies, which are not related to scleroderma (incorrect answer 3), the most likely ones would be antiRNA polymerase III antibodies, which appear in younger patients with renal crises\n", "Support"], ["Apart from anti-proteinase 3 antibodies, which are not related to scleroderma (incorrect answer 3), the most likely ones would be antiRNA polymerase III antibodies, which appear in younger patients with renal crises\n", "Anti-RNA polymerase III antibodies\n", "Support"]]}
{"273_71": [["both are possible, but the insistence on the patient's atopic burden indicates the likelihood of the latter\n", "Infectious esophagitis\n", "Support"], ["18-year-old young man with a history of asthma, allergy to pollens, mites and cat hair, comes to the emergency room referring sensation of food detention at retrosternal level with practical inability to swallow his own saliva\n", "both are possible, but the insistence on the patient's atopic burden indicates the likelihood of the latter\n", "Support"]]}
{"56_76": [["Turner syndrome: low estradiol and elevated gonadotrophins\n", "Answer 2 is false\n", "Support"], ["Answer 2 is false\n", "As she is a girl of pubertal age, it is most likely that her decreased growth and sexual retardation are due to Turner syndrome\n", "Attack"], ["Gonadotrophins (FSH and LH) and estradiol are low\n", "As she is a girl of pubertal age, it is most likely that her decreased growth and sexual retardation are due to Turner syndrome\n", "Attack"], ["Gonadotrophins (FSH and LH) and estradiol are low\n", "Answer 2 is false\n", "Support"], ["brain tumors affecting the hypothalamus-pituitary gland do not give low gonadotrophins\n", "5 false\n", "Support"], ["5 false\n", "She could have a craniopharyngioma, but it would be rare if she had not shown symptoms before. Also, it would not justify low gonadotrophins and estradiol\n", "Attack"], ["it seems obvious that refractive defects do not give hemianopsia\n", "3 and 4 false\n", "Support"], ["3 and 4 false\n", "She must not have a hypothalamic tumor because of the absence of polyuria and polydipsia. She probably has constitutional delay and her visual problem is refractive\n", "Attack"], ["3 and 4 false\n", "A growth hormone deficiency may explain the developmental delay and low estradiol. To evaluate if she needs glasses, due to her headaches and visual disturbances\n", "Attack"]]}
{"409_191": [["The correct answer is 1\n", "Tolerance\n", "Support"], ["The statement perfectly defines a tolerance phenomenon in which the patient has become \"used to\" the dose and needs more in order to have the same analgesic effect\n", "The correct answer is 1\n", "Support"]]}
{"179_98": [["A 33-year-old woman consults for repeated epistaxis, petechiae and ecchymosis\n", "The initial presumptive diagnosis is chronic immune thrombocytopenic purpura (ITP)\n", "Support"], ["Laboratory tests show thrombocytopenia with a platelet count of 4000 platelets/microliter.\n", "The initial presumptive diagnosis is chronic immune thrombocytopenic purpura (ITP)\n", "Support"], ["In the presence of isolated thrombocytopenia we must not lose sight of the physical examination; thus, the presence of lymphadenopathy forces us to rule out the presence of lymphoma, for example\n", "1 is correct\n", "Support"], ["1 is correct\n", "The presence of lymphadenopathy or splenomegaly in the physical examination suggests a different diagnosis of ITP\n", "Support"], ["When performing a bone marrow biopsy-aspirate it is seen that the number of megakaryocytes is normal or even increased, the failure is not in the marrow but in the peripheral blood, where platelets are destroyed\n", "The false answer is 2.\n", "Support"], ["The false answer is 2.\n", "Bone marrow analysis shows a decreased number of megakaryocytes without other alterations\n", "Attack"]]}
{"353_161": [["A 27-year-old woman referred to the gynecology office for evaluation referring dyspareunia for about 8 months, along with dyschezia and occasional rectorrhagia coinciding with menstruation for 3-4 months\n", "It is a typical case of deep endometriosis, with implants in different parts of the pelvis\n", "Support"], ["She also reports dysmenorrhea for years, which she controls well with ibuprofen\n", "It is a typical case of deep endometriosis, with implants in different parts of the pelvis\n", "Support"], ["She has been trying to get pregnant for 16 months without success\n", "It is a typical case of deep endometriosis, with implants in different parts of the pelvis\n", "Support"], ["In the gynecological examination she only has pain when pressing on the posterior vaginal fornix\n", "It is a typical case of deep endometriosis, with implants in different parts of the pelvis\n", "Support"], ["The definitive diagnosis will be given by the pathological anatomy, so for this we have to do Laparoscopy and send to PA\n", "Diagnostic laparoscopy\n", "Support"]]}
{"438_119": [["She starts with a high fever with chills, headache, myalgia and non-productive cough that she interprets as a flu-like process\n", "It presents with a pseudo-flu-like symptomatology (headache, arthralgias, myalgias, fever...) and other symptoms depending on the route of entry\n", "Support"], ["It presents with a pseudo-flu-like symptomatology (headache, arthralgias, myalgias, fever...) and other symptoms depending on the route of entry\n", "As a possible disease I would consider Brucellosis, typical of cattle (milk, abortion, genital secretions...)\n", "Support"], ["A 38-year-old woman of veterinary profession, in charge of monitoring wild animals and assisting in the delivery of domestic livestock\n", "In our case, when attending animal births, the entry is through the respiratory route\n", "Support"], ["In our case, when attending animal births, the entry is through the respiratory route\n", "the pulmonary infiltrates and chest pain are due to the bacteria\n", "Support"], ["The treatment varies according to the affectation and mortality is very low, almost null.\n", "Mortality in acute forms is almost nonexistent\n", "Support"], ["In our case, when attending animal births, the entry is through the respiratory route\n", "This entity is transmitted by ticks\n", "Attack"]]}
{"579_108": [["According to the described examination the Glasgow is 4 (O1V1M2)\n", "On arrival she is in a Glasgow scale coma of 7\n", "Attack"], ["Cerebral perfusion pressure is mean arterial pressure minus intracranial pressure\n", "Cerebral perfusion pressure is mean arterial pressure plus intracranial pressure\n", "Attack"], ["In the physical examination he does not open his eyes, does not emit sounds before being intubated and presents extension of extremities to nociceptive stimulus\n", "According to the described examination the Glasgow is 4 (O1V1M2)\n", "Support"], ["Cerebral edema in which cellular edema is produced by the introduction of extracellular fluid into the intracellular compartment is cytotoxic\n", "Vasogenic cerebral edema is due to cellular edema, membrane rupture and cell death\n", "Attack"], ["Hypercapnia and acidosis produce vasodilatation causing increased cerebral blood flow\n", "Cerebral vascular flow increases with hypercapnia and acidosis\n", "Support"]]}
{"212_88": [["the question is focused on initial management\n", "the most appropriate answer seems to be 2\n", "Support"], ["Answers 1, 2 and 5 are appropriate treatments for dumping syndrome or postgastrectomy\n", "the question is focused on initial management\n", "Attack"], ["the most appropriate answer seems to be 2\n", "Follow specific dietary measures\n", "Support"], ["Answers 1, 2 and 5 are appropriate treatments for dumping syndrome or postgastrectomy\n", "Apply treatment with a somatostatin inhibitor (octreotide)\n", "Support"], ["Answers 1, 2 and 5 are appropriate treatments for dumping syndrome or postgastrectomy\n", "Follow specific dietary measures\n", "Support"], ["Answers 1, 2 and 5 are appropriate treatments for dumping syndrome or postgastrectomy\n", "Indicate surgical treatment to perform an antiperistaltic Roux-en-Y gastrojejunostomy\n", "Support"]]}
{"507_89": [["Lithemia is 4.1 mEq/L (toxicity > 1.6 mEq/L)\n", "Be careful with lithium\n", "Support"], ["A very effective drug if everyone is forewarned\n", "Hemodialysis\n", "Support"]]}
{"552_89": [["fever of several days of evolution, exanthema, conjunctival injection, red lips, raspberry tongue, edema of acral parts and adenopathy\n", "There is no doubt, they are not meeting the diagnostic criteria of Kawasaki disease\n", "Support"], ["There is no doubt, they are not meeting the diagnostic criteria of Kawasaki disease\n", "Kawasaki disease\n", "Support"]]}
{"598_181": [["A 67-year-old man presents with 3 months of asthenia and febrile fever, with nasal obstruction and mucus emission with some clots in the last month\n", "In this patient, he presents with a granulomatosis with polyangiitis formerly known as Wegener's granulomatosis\n", "Support"], ["Physical examination reveals proptosis of the right eyeball and inspection of the nostrils reveals an erythematous mucosa with serohematic crusts\n", "In this patient, he presents with a granulomatosis with polyangiitis formerly known as Wegener's granulomatosis\n", "Support"], ["Physical examination reveals proptosis of the right eyeball and inspection of the nostrils reveals an erythematous mucosa with serohematic crusts\n", "In the clinical case we are told about the otorhinolaryngologic involvement that is present in 92% of patients\n", "Support"], ["A 67-year-old man presents with 3 months of asthenia and febrile fever, with nasal obstruction and mucus emission with some clots in the last month\n", "In the clinical case we are told about the otorhinolaryngologic involvement that is present in 92% of patients\n", "Support"], ["A 67-year-old man presents with 3 months of asthenia and febrile fever, with nasal obstruction and mucus emission with some clots in the last month\n", "At the pulmonary level, we were told that mucus with a clot was present in 85% of the patients\n", "Support"], ["Blood tests (hemogram, renal and hepatic function) are normal, except for an ESR of 65 mm/h; urinalysis shows microhematuria and proteinuria of 520 mg/24h\n", "Also at the end of the case, they comment us the urinalysis with a glomerulonephritis that is present in 77% of the patients\n", "Support"], ["In this patient, he presents with a granulomatosis with polyangiitis formerly known as Wegener's granulomatosis\n", "Granulomatosis with polyangiitis\n", "Support"], ["In the clinical case we are told about the otorhinolaryngologic involvement that is present in 92% of patients\n", "In this patient, he presents with a granulomatosis with polyangiitis formerly known as Wegener's granulomatosis\n", "Support"], ["At the pulmonary level, we were told that mucus with a clot was present in 85% of the patients\n", "In this patient, he presents with a granulomatosis with polyangiitis formerly known as Wegener's granulomatosis\n", "Support"], ["Also at the end of the case, they comment us the urinalysis with a glomerulonephritis that is present in 77% of the patients\n", "In this patient, he presents with a granulomatosis with polyangiitis formerly known as Wegener's granulomatosis\n", "Support"]]}
{"133_168": [["Of the five options, four could be compatible with the referred symptoms\n", "Senile macular degeneration\n", "Support"], ["We could initially rule out central serous chorioretinopathy because by definition it occurs in young people (up to 55 years of age, more or less)\n", "Central serous chorioretinopathy\n", "Attack"], ["The key to differentiate between the other four is that he had soft drusen in the fundus\n", "That while not a \"diagnosis\" (the question could have been better worded) is a finding related to age-related macular degeneration, or age-related macular degeneration\n", "Support"], ["That while not a \"diagnosis\" (the question could have been better worded) is a finding related to age-related macular degeneration, or age-related macular degeneration\n", "Senile macular degeneration\n", "Support"], ["She reports presenting, since 2 weeks ago, metamorphopsia and significant visual loss in her right eye that prevents her from reading\n", "Macular epiretinal membrane\n", "Attack"], ["An epiretinal membrane usually has a slower course\n", "Macular epiretinal membrane\n", "Attack"], ["In a macular hole, visual loss is more relevant (metamorphopsia may also be reported, but it is less likely in the acute stage)\n", "Macular hole\n", "Attack"], ["She reports presenting, since 2 weeks ago, metamorphopsia and significant visual loss in her right eye that prevents her from reading\n", "Macular hole\n", "Attack"], ["In thrombosis of the central retinal vein, visual loss is more important and does not usually explain metamorphopsia (but may have it, due to macular edema)\n", "Thrombosis of the central retinal vein\n", "Attack"], ["She reports presenting, since 2 weeks ago, metamorphopsia and significant visual loss in her right eye that prevents her from reading\n", "Thrombosis of the central retinal vein\n", "Attack"], ["But the wet or exudative form produces acute or rapidly progressive severe visual loss (usually due to subretinal hemorrhage accompanied by metamorphopsia (image distortion due to retinal lifting)\n", "Senile macular degeneration\n", "Support"]]}
{"186_67": [["We all agree that the patient seems to have Cushing's syndrome (we rule out 1)\n", "Postmenopausal osteoporosis, type 2 diabetes mellitus and essential hypertension, with decreased strength due to diabetic polyneuropathy\n", "Attack"], ["We all agree that the patient seems to have Cushing's syndrome (we rule out 1)\n", "Suggest Cushing's\n", "Support"], ["We all agree that the patient seems to have Cushing's syndrome (we rule out 1)\n", "It looks like Cushing's\n", "Support"], ["We all agree that the patient seems to have Cushing's syndrome (we rule out 1)\n", "Probably has Cushing's\n", "Support"], ["For the diagnosis we have to measure urinary free cortisol, do a dexamethasone suppression test or measure nocturnal salivary cortisol\n", "Determine urinary free cortisol and basal ACTH, which serves to orient its etiology and select the most appropriate imaging technique\n", "Support"], ["the ACTH measurement indicates the origin: suppressed in hypercortisolism of adrenal origin or prolonged use of corticoids and elevated or normal if the origin is pituitary or by ectopic ACTH secretion\n", "Therefore, 4 and 5 are false\n", "Support"], ["Therefore, 4 and 5 are false\n", "If basal ACTH is high, it may be due to corticosteroid use or an adrenal tumor, and an MRI should be performed\n", "Attack"], ["Therefore, 4 and 5 are false\n", "If the basal ACTH is low, he probably has a pituitary micro-adenoma, and a cranial CT scan should be performed\n", "Attack"], ["If ACTH is low, a CT scan of the abdomen should be performed to locate the origin\n", "If the basal ACTH is low, he probably has a pituitary micro-adenoma, and a cranial CT scan should be performed\n", "Support"], ["If ACTH is normal or high, a pituitary MRI should be performed (pituitary adenomas responsible for Cushing's syndrome are very small and CT of the pituitary is less sensitive than MRI)\n", "If basal ACTH is high, it may be due to corticosteroid use or an adrenal tumor, and an MRI should be performed\n", "Support"], ["It is very important to perform the order well to arrive at a proper diagnosis: 1st: confirm hypercortisolism or s\n", "Determine urinary free cortisol and basal ACTH, which serves to orient its etiology and select the most appropriate imaging technique\n", "Support"], ["Cushing's syndrome, 2nd: measure ACTH to orient etiology\n", "Determine urinary free cortisol and basal ACTH, which serves to orient its etiology and select the most appropriate imaging technique\n", "Support"], ["3rd: imaging test according to ACTH levels\n", "Determine urinary free cortisol and basal ACTH, which serves to orient its etiology and select the most appropriate imaging technique\n", "Support"], ["Therefore, answer 2 is false (abdominal CT is not a test to rule out s. Cushing's); an imaging test should only be done once a clear diagnosis of hypercortisolism has been made\n", "It is necessary to rule out Cushing's disease by dexamethasone suppression test and perform a cranial CT scan\n", "Attack"], ["Therefore, the true one is 3\n", "Determine urinary free cortisol and basal ACTH, which serves to orient its etiology and select the most appropriate imaging technique\n", "Support"]]}
{"7_208": [["the treatment of colon cancer is surgical (with neoadjuvant in rectal cancer)\n", "By rule 1 would be easy to eliminate\n", "Support"], ["By rule 1 would be easy to eliminate\n", "Chemotherapy is the treatment of choice\n", "Attack"], ["If biopsies confirm adenocarcinoma, there is no need to repeat them\n", "Since the biopsy is superficial, it should be repeated before proceeding with treatment\n", "Attack"], ["it is necessary to have the complete specimen\n", "If biopsies confirm adenocarcinoma, there is no need to repeat them\n", "Support"], ["Most colon cancer develops on adenomas\n", "we could eliminate this one\n", "Support"], ["we could eliminate this one\n", "It is unlikely that this tumor has developed over a previous adenoma\n", "Attack"], ["Among the other 2, it is important to know that 5 is correct\n", "Microsatellite instability and DNA error repair genes should be studied\n", "Support"], ["they almost always present microsatellite instability even without fulfilling the Amsterdam criteria and have a better prognosis than other poorly differentiated colon cancer\n", "Among the other 2, it is important to know that 5 is correct\n", "Support"]]}
{"152_72": [["In the presence of acute gouty arthritis (the presence of intracellular crystals with negative birefringence confirms this) in a hyperuricemic patient previously treated with allopurinol, an NSAID should be added until the crisis subsides\n", "Add an NSAID until the crisis remits\n", "Support"], ["Arthrocentesis is performed and polarized light microscopy shows intracellular crystals with negative birefringence\n", "In the presence of acute gouty arthritis (the presence of intracellular crystals with negative birefringence confirms this) in a hyperuricemic patient previously treated with allopurinol, an NSAID should be added until the crisis subsides\n", "Support"], ["No changes should be made in the hypouricemic treatment during this period because the uric acid metabolic chain is altered and the situation may worsen\n", "Add an NSAID until the crisis remits\n", "Support"]]}
{"243_112": [["According to the patient, 3 weeks ago she had a sexual relationship that could be a risk for contracting the HIV virus\n", "we know that mononucleosis can be an expression of the first phase of HIV infection, especially when we have a history of a risk contact\n", "Support"], ["we know that mononucleosis can be an expression of the first phase of HIV infection, especially when we have a history of a risk contact\n", "At first glance, we could directly rule out answer 2\n", "Support"], ["At first glance, we could directly rule out answer 2\n", "The clinical process that the patient suffers from is not consistent with acute HIV infection\n", "Attack"], ["ELISA is a very sensitive but not very specific technique and confirmation with a Western-blot test is ALWAYS necessary\n", "Answers 3 and 4 are also easily ruled out\n", "Support"], ["Answers 3 and 4 are also easily ruled out\n", "If the patient's ELISA test was positive, nothing further would be necessary for the diagnosis of HIV infection\n", "Attack"], ["Answers 3 and 4 are also easily ruled out\n", "The ELISA technique has a high sensitivity for the diagnosis of HIV infection, but its specificity is even higher\n", "Attack"], ["it is a very categorical answer (\"rule out\") that does not quite fit the reality\n", "In this case, the false answer is 1\n", "Support"], ["In this case, the false answer is 1\n", "A negative HIV-1/HIV-2 serology performed by ELISA technique rules out the possibility that the patient has been infected with the HIV virus\n", "Attack"], ["As we have said, ELISA is a very sensitive technique, so a negative result could leave us quite calm\n", "In this case, the false answer is 1\n", "Attack"], ["however, we all know that there is no medical test that rules out anything with total certainty (unless its sensitivity is 100%, which is not the case)\n", "In this case, the false answer is 1\n", "Support"], ["In addition, it is only 3 weeks since the contact\n", "our patient is probably in the \"window period\" during which serological techniques may be unprofitable\n", "Support"], ["on the other hand, we could say that in this case we have a high clinical suspicion (the picture is suggestive, and the antecedents are there)\n", "In this case, the false answer is 1\n", "Attack"], ["our patient is probably in the \"window period\" during which serological techniques may be unprofitable\n", "In this case, the false answer is 1\n", "Attack"], ["in the window period a viral load may be indicated for diagnosis (positive if there are more than 10,000 copies)\n", "In conclusion, the answer that best fits us would be 5\n", "Support"], ["In conclusion, the answer that best fits us would be 5\n", "If the ELISA test to diagnose HIV in the patient was negative, we could determine by PCR technique the viral load in blood\n", "Support"], ["although this test is not done routinely\n", "In conclusion, the answer that best fits us would be 5\n", "Attack"]]}
{"458_126": [["Conservative treatment with botulinum toxin offers good results\n", "Intradermal botulinum toxin injection\n", "Support"], ["A 47-year-old man, with a history of a right parotid pleomorphic adenoma, treated with surgery (extrafacial parotidectomy) 6 months ago, who comes to our office for presenting pain with sweating and reddening of the skin in the preauricular region during mastication\n", "It is the clinical expression of a vegetative neuropathy caused by mechanical or irritative lesion of the vegetative fibers of the auriculotemporal nerve in its infratemporal pathway\n", "Support"], ["A 47-year-old man, with a history of a right parotid pleomorphic adenoma, treated with surgery (extrafacial parotidectomy) 6 months ago, who comes to our office for presenting pain with sweating and reddening of the skin in the preauricular region during mastication\n", "In our environment the most frequent cause is surgery of the split gland with a percentage of occurrence between 10 and 80%\n", "Support"], ["It is the clinical expression of a vegetative neuropathy caused by mechanical or irritative lesion of the vegetative fibers of the auriculotemporal nerve in its infratemporal pathway\n", "You are asking about auriculotemporal syndrome or Frey's syndrome\n", "Support"], ["In our environment the most frequent cause is surgery of the split gland with a percentage of occurrence between 10 and 80%\n", "You are asking about auriculotemporal syndrome or Frey's syndrome\n", "Support"]]}
{"123_223": [["The correct answer is the first one\n", "Escherichia coli\n", "Support"], ["The most frequent cause of urinary tract infections is Escherichia coli and in the case of pregnant women as well\n", "Escherichia coli\n", "Support"], ["She refers repeated urinary tract infections (UTI)\n", "Escherichia coli\n", "Support"]]}
{"522_165": [["Regarding weight, metformin to a lesser extent, SGLT-2 inhibitors and, above all, GLP-1 agonists have been associated with a significant decrease in weight in patients with DM-2\n", "answers 1,3 and 4 incorrect\n", "Support"], ["answers 1,3 and 4 incorrect\n", "Metformin (biguanide)\n", "Attack"], ["answers 1,3 and 4 incorrect\n", "Canagliflozin (sodium-glucose cotransporter 2 inhibitor- iSGLT2)\n", "Attack"], ["answers 1,3 and 4 incorrect\n", "Liraglutide (GLP-1 receptor agonist)\n", "Attack"], ["On the other hand, pioglitazone, as reflected in its data sheet, can produce dose-dependent weight gain, mainly due to fat accumulation and added, in some cases, to water retention\n", "Pioglitazone (thiazolidinedione)\n", "Support"]]}
{"209_185": [["This is a typical case of cervical incompetence (and this patient has conization as a risk factor)\n", "This pathology consists of dilatation of the cervix in the absence of contractions, requiring cerclage to prevent miscarriage or immature delivery\n", "Support"], ["This pathology consists of dilatation of the cervix in the absence of contractions, requiring cerclage to prevent miscarriage or immature delivery\n", "I would recommend a cervical cerclage at 14 weeks gestation\n", "Support"], ["The cerclage is ideally performed electively, programmed, and not when the patient arrives at the ER \"in extemis\" (which are also done, but with a lower success rate... the ideal is to do them cold)\n", "I would recommend a cervical cerclage at 14 weeks gestation\n", "Support"]]}
{"282_55": []}
{"464_155": [["The patient presented pulmonary thromboembolism which, in addition to being bilateral, produced severe hemodynamic involvement, shock and required mechanical ventilation\n", "We are not told that he has any contraindication to fibrinolysis, so this would be the most appropriate option due to its rapid administration and action\n", "Support"], ["We are not told that he has any contraindication to fibrinolysis, so this would be the most appropriate option due to its rapid administration and action\n", "Systemic fibrinolysis with rt-PA (alteplase) 100 mg intravenous\n", "Support"], ["Angio-CT shows multiple repletion defects occupying both main pulmonary arteries\n", "The patient presented pulmonary thromboembolism which, in addition to being bilateral, produced severe hemodynamic involvement, shock and required mechanical ventilation\n", "Support"], ["Sodium heparin is reserved for cases in which the patient is stable\n", "Intravenous perfused sodium heparin\n", "Attack"], ["On arrival at the hospital he has hypotension (systolic BP 80 mmHg, diastolic 40 mmHg) and poor perfusion\n", "Sodium heparin is reserved for cases in which the patient is stable\n", "Attack"], ["He is intubated and connected to mechanical ventilation and noradrenaline is started\n", "Sodium heparin is reserved for cases in which the patient is stable\n", "Attack"], ["Echocardiogram shows signs of pulmonary hypertension\n", "Sodium heparin is reserved for cases in which the patient is stable\n", "Attack"], ["We are not told that he has any contraindication to fibrinolysis, so this would be the most appropriate option due to its rapid administration and action\n", "Thromboendarterectomy could be performed urgently in selected centers (not available in all) in patients in whom systemic fibrinolysis is contraindicated, or in centers where the experience with this technique is proven and it can be performed quickly\n", "Attack"], ["Thromboendarterectomy could be performed urgently in selected centers (not available in all) in patients in whom systemic fibrinolysis is contraindicated, or in centers where the experience with this technique is proven and it can be performed quickly\n", "Thromboendartectomy\n", "Attack"], ["The inferior vena cava filter is a treatment indicated in the acute phase in stable patients, when anticoagulation is contraindicated; or a posteriori, as prophylaxis, in this group of patients\n", "Inferior vena cava filter\n", "Attack"], ["On arrival at the hospital he has hypotension (systolic BP 80 mmHg, diastolic 40 mmHg) and poor perfusion\n", "The inferior vena cava filter is a treatment indicated in the acute phase in stable patients, when anticoagulation is contraindicated; or a posteriori, as prophylaxis, in this group of patients\n", "Attack"], ["He is intubated and connected to mechanical ventilation and noradrenaline is started\n", "The inferior vena cava filter is a treatment indicated in the acute phase in stable patients, when anticoagulation is contraindicated; or a posteriori, as prophylaxis, in this group of patients\n", "Attack"], ["Echocardiogram shows signs of pulmonary hypertension\n", "The inferior vena cava filter is a treatment indicated in the acute phase in stable patients, when anticoagulation is contraindicated; or a posteriori, as prophylaxis, in this group of patients\n", "Attack"], ["as in the case presented in the question\n", "In the subgroup of high-risk patients (defined by hypotension or cardiogenic shock criteria), the use of systemic fibrinolysis is much clearer\n", "Support"], ["In the subgroup of high-risk patients (defined by hypotension or cardiogenic shock criteria), the use of systemic fibrinolysis is much clearer\n", "Systemic fibrinolysis with rt-PA (alteplase) 100 mg intravenous\n", "Support"]]}
{"502_77": [["The patient probably presents with bronchiolitis\n", "At this stage, no additional tests should be performed unless there is a clinical worsening\n", "Support"], ["At this stage, no additional tests should be performed unless there is a clinical worsening\n", "Do not request complementary tests\n", "Support"], ["He shows moderate respiratory distress with intercostal and subcostal retraction\n", "The patient probably presents with bronchiolitis\n", "Support"], ["Examination: axillary temperature 37.2\u00b0C, respiratory rate 40 rpm, heart rate 160 bpm, blood pressure 90/45 mmHg, SatO2 95% on room air\n", "The patient probably presents with bronchiolitis\n", "Support"], ["Pulmonary auscultation: scattered expiratory rhonchi, elongated expiration and slight decrease in air entry in both lung fields\n", "The patient probably presents with bronchiolitis\n", "Support"]]}
{"71_50": [["jugular venous pressure is elevated with a deep descending sinus X\n", "Low BP with high jugular pressure should always raise the suspicion of cardiac tamponade\n", "Support"], ["the blood pressure cyphrads are low\n", "Low BP with high jugular pressure should always raise the suspicion of cardiac tamponade\n", "Support"], ["Low BP with high jugular pressure should always raise the suspicion of cardiac tamponade\n", "Pericardial effusion with cardiac tamponade\n", "Support"], ["A patient with a history of fever and chest pain comes to the hospital with dyspnea and tachypnea\n", "Fever and chest pain with dyspnea and tachypnea should raise suspicion of pericardial effusion with hemodynamic compromise\n", "Support"], ["Fever and chest pain with dyspnea and tachypnea should raise suspicion of pericardial effusion with hemodynamic compromise\n", "Pericardial effusion with cardiac tamponade\n", "Support"], ["he has a pulsus paradoxus\n", "Paradoxical pulse is a typical finding of cardiac tamponade\n", "Support"], ["Paradoxical pulse is a typical finding of cardiac tamponade\n", "Pericardial effusion with cardiac tamponade\n", "Support"], ["the correct answer is 5\n", "Pericardial effusion with cardiac tamponade\n", "Support"]]}
{"486_45": [["we are told that the patient does not have an intellectual disability\n", "she could have several genetic pathologies\n", "Attack"], ["an adolescent with pubertal delay and short stature should be a Turner until proven otherwise\n", "Therefore, if that is our first diagnostic suspicion, the HABITUAL test (as the statement says) for diagnosis should be a conventional karyotype (formula: 45, X0)\n", "Support"], ["Therefore, if that is our first diagnostic suspicion, the HABITUAL test (as the statement says) for diagnosis should be a conventional karyotype (formula: 45, X0)\n", "Karyotype\n", "Support"], ["However, both array and NGS are usually reserved for patients with non-obvious clinical pictures, intellectual disability, or suspicion of a genetic syndrome that requires these specific tests (for example, an array to diagnose a 22q11 deletion syndrome or an NGS panel to diagnose a Noonan syndrome)\n", "A Turner can also be diagnosed with a FISH (there would only be one signal for the X instead of the two that females usually have) or with an array\n", "Attack"], ["However, both array and NGS are usually reserved for patients with non-obvious clinical pictures, intellectual disability, or suspicion of a genetic syndrome that requires these specific tests (for example, an array to diagnose a 22q11 deletion syndrome or an NGS panel to diagnose a Noonan syndrome)\n", "Massive sequencing (NGS)\n", "Attack"], ["However, both array and NGS are usually reserved for patients with non-obvious clinical pictures, intellectual disability, or suspicion of a genetic syndrome that requires these specific tests (for example, an array to diagnose a 22q11 deletion syndrome or an NGS panel to diagnose a Noonan syndrome)\n", "FISH\n", "Attack"], ["However, both array and NGS are usually reserved for patients with non-obvious clinical pictures, intellectual disability, or suspicion of a genetic syndrome that requires these specific tests (for example, an array to diagnose a 22q11 deletion syndrome or an NGS panel to diagnose a Noonan syndrome)\n", "DNA and/or RNA microarrays\n", "Attack"]]}
{"216_121": [["The rest of the data (seminules in the biopsy, linear IgG deposition) supports the diagnosis\n", "The diagnostic suspicion for the data given (especially the anti-GBM antibodies and the presence of renopulmonary syndrome) is that of Goodpasture's syndrome\n", "Support"], ["the deposits are of IgG\n", "option 1 speaks to us of an IgA nephropathy (it is not the case\n", "Support"], ["option 1 speaks to us of an IgA nephropathy (it is not the case\n", "It is an IgA nephropathy with acute renal failure\n", "Attack"], ["option 3 is also discarded\n", "It is a membranous glomerulonephritis\n", "Attack"], ["it is not a primary GMN, like the membranous one, but a secondary glomerulopathy\n", "option 3 is also discarded\n", "Support"], ["option 4 is also false\n", "Mycophenolate mofetil is the initial treatment of choice\n", "Attack"], ["the initial treatment is with corticosteroids and cyclophosphamide associated to plasmapheresis\n", "option 4 is also false\n", "Support"], ["the damage is not due to circulating immunocomplexes, but to antibodies deposited in the glomerular basement membrane\n", "option 5 is also false\n", "Support"], ["option 5 is also false\n", "Glomerular involvement is caused by the presence of circulating immunocomplexes\n", "Attack"], ["Blood tests show creatinine 7 mg/dL, urea 250 mg/dL and high titer positive anti-GBM (anti-glomerular basement membrane antibodies)\n", "the damage is not due to circulating immunocomplexes, but to antibodies deposited in the glomerular basement membrane\n", "Support"], ["as it has been previously said, the treatment would be performed combining corticosteroids, cyclophosphamide and plasmapheresis\n", "This leaves option 2 as true\n", "Support"], ["This leaves option 2 as true\n", "Plasmapheresis would be indicated\n", "Support"]]}
{"384_151": [["they do not provide any analytical data and the ultrasound data are ambiguous\n", "It seems that they want to present us with precocious puberty (or premature telarche)\n", "Attack"], ["they do not provide any data on ovarian size\n", "we should assume that by a small uterus they are referring to a prepubertal uterus\n", "Attack"], ["Strictly speaking, without analytical hormonal data, it seems that we could mark option 1, being necessary to follow the girl closely\n", "Follow-up every 3-4 months, as this is a temporary condition that often resolves on its own\n", "Support"], ["If we take all the above data for granted, we could rule out option 4, which would be the treatment of a central precocious puberty\n", "Administration of GnRh analogues\n", "Attack"], ["We are presented with the case of a three-year-old girl with advanced mammary development, in principle without any associated cause\n", "according to the complementary examinations that we are given, it does not seem to be precocious puberty, except for the clinical (Tanner IV)\n", "Support"], ["in principle she does not take drugs that can increase the level of estrogen in the blood, she does not seem to use body creams or eat a lot of chicken meat\n", "according to the complementary examinations that we are given, it does not seem to be precocious puberty, except for the clinical (Tanner IV)\n", "Support"], ["according to the complementary examinations that we are given, it does not seem to be precocious puberty, except for the clinical (Tanner IV)\n", "Strictly speaking, without analytical hormonal data, it seems that we could mark option 1, being necessary to follow the girl closely\n", "Support"], ["Regarding the option of mammography, breast ultrasound is used in pediatrics, and in this case it would be indicated if we were told that there is breast asymmetry\n", "we discard option 3\n", "Support"], ["we discard option 3\n", "Mammography\n", "Attack"], ["We are presented with the case of a three-year-old girl with advanced mammary development, in principle without any associated cause\n", "Regarding the option of mammography, breast ultrasound is used in pediatrics, and in this case it would be indicated if we were told that there is breast asymmetry\n", "Attack"], ["Regarding breast biopsy, it would only be indicated if there are warning signs\n", "Breast biopsy\n", "Attack"]]}
{"238_145": [["A 40-year-old woman consults for approximately 20 episodes per day of intense left periocular pain lasting 15 minutes, accompanied by intense tearing and rhinorrhea\n", "Both the characteristics of the case and the answers suggest that it is a trigemino-autonomic headache (intense, periocular pain with lacrimation and rhinorrhea)\n", "Support"], ["A 40-year-old woman consults for approximately 20 episodes per day of intense left periocular pain lasting 15 minutes, accompanied by intense tearing and rhinorrhea\n", "Paroxysmal hemicrania predominates in women, with episodes of pain similar to cluster headache, but with a shorter duration (2-30 min), and a higher frequency (5-30 episodes per day)\n", "Support"], ["A 40-year-old woman consults for approximately 20 episodes per day of intense left periocular pain lasting 15 minutes, accompanied by intense tearing and rhinorrhea\n", "Cluster headache predominates in males whose duration can vary between 15-180 minutes, between once every 2 days, up to 8 times a day\n", "Attack"], ["A 40-year-old woman consults for approximately 20 episodes per day of intense left periocular pain lasting 15 minutes, accompanied by intense tearing and rhinorrhea\n", "As for SUNCT, the crises are much shorter, lasting seconds (5-240 seconds) and are usually refractory to treatment\n", "Attack"], ["Therefore the diagnosis would be of a paroxysmal hemicrania and its treatment of choice is indomethacin (which also the answer is a diagnostic criterion)\n", "Indomethacin\n", "Support"], ["Therefore correct answer 1 (Indomethacin)\n", "Indomethacin\n", "Support"]]}
{"47_157": [["If I am not mistaken, you are describing a Celso's kerion for which the treatment of choice is oral griseofulvin\n", "The correct answer is 3\n", "Support"], ["The correct answer is 3\n", "Griseofulvin orally\n", "Support"]]}
{"381_139": [["We are presented with a case of monocular amaurosis with a vascular profile, also in an older woman with a history of weight loss\n", "what seems to be symptoms of mandibular claudication and polymyalgia rheumatica\n", "Support"], ["what seems to be symptoms of mandibular claudication and polymyalgia rheumatica\n", "the first cause to think about is giant cell arteritis as the cause of NOIA\n", "Support"], ["the first cause to think about is giant cell arteritis as the cause of NOIA\n", "the correct option would be 2\n", "Support"], ["the correct option would be 2\n", "C Reactive Protein\n", "Support"], ["Option 4 would be considered if we were told of an AINO but with non-arteritic characteristics (without all the accompanying symptomatology)\n", "Carotid ultrasound\n", "Attack"]]}
{"32_64": [["The picture described is very suggestive of pseudocrisis with asynchronous limb movements, pelvic movements, crying and poor response to antiepileptic drugs\n", "Correct answer 1\n", "Support"], ["The picture described is very suggestive of pseudocrisis with asynchronous limb movements, pelvic movements, crying and poor response to antiepileptic drugs\n", "Video-EEG monitoring for diagnosis of pseudocrisis (psychogenic seizures)\n", "Support"]]}
{"106_135": [["All these data, in addition to the analytical data, are describing an immunodeficiency that by the family-maternal history, seems to be X-linked, as several males have died of a similar clinical condition (the father of the patient contributed the Y chromosome, the mother the X)\n", "X-linked severe combined immunodeficiency\n", "Support"], ["2-year-old child\n", "All these data, in addition to the analytical data, are describing an immunodeficiency that by the family-maternal history, seems to be X-linked, as several males have died of a similar clinical condition (the father of the patient contributed the Y chromosome, the mother the X)\n", "Support"], ["ENT infections\n", "All these data, in addition to the analytical data, are describing an immunodeficiency that by the family-maternal history, seems to be X-linked, as several males have died of a similar clinical condition (the father of the patient contributed the Y chromosome, the mother the X)\n", "Support"], ["Pulmonary infections\n", "All these data, in addition to the analytical data, are describing an immunodeficiency that by the family-maternal history, seems to be X-linked, as several males have died of a similar clinical condition (the father of the patient contributed the Y chromosome, the mother the X)\n", "Support"], ["Hospital admissions\n", "All these data, in addition to the analytical data, are describing an immunodeficiency that by the family-maternal history, seems to be X-linked, as several males have died of a similar clinical condition (the father of the patient contributed the Y chromosome, the mother the X)\n", "Support"], ["PTI\n", "All these data, in addition to the analytical data, are describing an immunodeficiency that by the family-maternal history, seems to be X-linked, as several males have died of a similar clinical condition (the father of the patient contributed the Y chromosome, the mother the X)\n", "Support"], ["Family history of infections with deaths due to infections in males (maternal family)\n", "All these data, in addition to the analytical data, are describing an immunodeficiency that by the family-maternal history, seems to be X-linked, as several males have died of a similar clinical condition (the father of the patient contributed the Y chromosome, the mother the X)\n", "Support"], ["Atopic Dermatitis\n", "All these data, in addition to the analytical data, are describing an immunodeficiency that by the family-maternal history, seems to be X-linked, as several males have died of a similar clinical condition (the father of the patient contributed the Y chromosome, the mother the X)\n", "Support"], ["Among the X-linked immunodeficiencies is Wiskott-Aldrich syndrome, an entity described with an initial triad of symptoms consisting of bleeding (typical BUT absent in the case: heavy bleeding after circumcision, bloody diarrhea), recurrent infections and eczema\n", "Wiskott-Aldrich syndrome.\n", "Attack"], ["2-year-old boy\n", "X-linked severe combined immunodeficiency\n", "Support"], ["His personal history includes 3 episodes of acute otitis media, 1 meningococcal meningitis and 2 pneumonias (one middle lobe and one left upper lobe)\n", "X-linked severe combined immunodeficiency\n", "Support"], ["She has been admitted on 3 occasions for thrombopenic purpura (on three occasions antiplatelet antibodies were negative and bone marrow showed normal megakaryocytes).\n", "X-linked severe combined immunodeficiency\n", "Support"], ["Several males of the maternal family had died in childhood due to infectious processes.\n", "X-linked severe combined immunodeficiency\n", "Support"], ["Physical examination showed lesions typical of atopic dermatitis\n", "X-linked severe combined immunodeficiency\n", "Support"], ["The immunological study showed a slight decrease in T-lymphocyte subpopulations; elevated IgA and IgE; decreased IgM and IgG at the lower limit of normal\n", "X-linked severe combined immunodeficiency\n", "Support"], ["The immunological study showed a slight decrease in T-lymphocyte subpopulations; elevated IgA and IgE; decreased IgM and IgG at the lower limit of normal\n", "All these data, in addition to the analytical data, are describing an immunodeficiency that by the family-maternal history, seems to be X-linked, as several males have died of a similar clinical condition (the father of the patient contributed the Y chromosome, the mother the X)\n", "Support"], ["The Hyper-IgE option lacks very characteristic clinical data such as bone alterations and skin lesions, which are not atopic dermatitis, since they follow a different pattern (papulopustular rash on the face and scalp)\n", "Hyper IgE syndrome\n", "Attack"], ["The option of transient hypogammaglobulinemia of infancy and the common severe and variable combined immunodeficiency fails, among other features, the determination of immunoglobulins G and M, which are at the lower limit, but within normality\n", "Transient hypogammaglobulinemia of childhood\n", "Attack"], ["The option of transient hypogammaglobulinemia of infancy and the common severe and variable combined immunodeficiency fails, among other features, the determination of immunoglobulins G and M, which are at the lower limit, but within normality\n", "Common variable immunodeficiency\n", "Attack"], ["The option of transient hypogammaglobulinemia of infancy and the common severe and variable combined immunodeficiency fails, among other features, the determination of immunoglobulins G and M, which are at the lower limit, but within normality\n", "X-linked severe combined immunodeficiency\n", "Attack"]]}
{"62_119": [["The confusional picture is determined by the dementia that the patient already suffers\n", "no matter how much we delay surgery\n", "Support"], ["The confusional picture is determined by the dementia that the patient already suffers\n", "we are not going to achieve anything\n", "Support"], ["The confusional picture is determined by the dementia that the patient already suffers\n", "Delay surgery until the confusional picture has disappeared\n", "Attack"], ["no matter how much we delay surgery\n", "Delay surgery until the confusional picture has disappeared\n", "Attack"], ["we are not going to achieve anything\n", "Delay surgery until the confusional picture has disappeared\n", "Attack"], ["it depends on the type of fracture, which is not specified in the statement: a pertrochanteric fracture would require closed osteosynthesis and a subcapital fracture would require a prosthesis\n", "The last answer is not correct\n", "Support"], ["The elevation of blood pressure is due, in principle, to pain\n", "labetalol could help us\n", "Support"], ["the stressful situation that leads an already hypertensive patient to increase her blood pressure\n", "labetalol could help us\n", "Support"], ["The last answer is not correct\n", "Perform closed osteosynthesis, avoiding in any case the implantation of prosthesis\n", "Attack"], ["no matter how much we delay surgery\n", "Delay surgery and perform an echocardiogram\n", "Attack"], ["we are not going to achieve anything\n", "Delay surgery and perform an echocardiogram\n", "Attack"], ["no matter how much we delay surgery\n", "Delay surgery until good blood pressure control\n", "Attack"], ["we are not going to achieve anything\n", "Delay surgery until good blood pressure control\n", "Attack"], ["labetalol could help us\n", "Start a beta-blocker and initiate surgery\n", "Support"]]}
{"592_76": [["BI-RADS 3 is defined by answer 3\n", "This is a probably benign finding, since there is less than a 2% chance of cancer. He explains that it requires follow-up every 6-12 months until 24 months or a biopsy\n", "Support"], ["BI-RADS Breast Imaging Reporting and Data System\n", "BI-RADS 3 is defined by answer 3\n", "Support"]]}
{"26_117": [["The halo sign is characteristic of pulmonary aspergillosis, especially in an immuodepressed patient.\n", "Aspergillus fumigatus\n", "Support"], ["But it is not pathognomonic\n", "Aspergillus fumigatus\n", "Attack"], ["it has also been associated with TB, some neoplasms and Wegener's granulomatosis\n", "Aspergillus fumigatus\n", "Attack"], ["An immunodeficient patient who presents a pneumonia with meniscus halo sign or crescentic contour on chest X-ray/CT\n", "Aspergillus fumigatus\n", "Support"]]}
{"435_121": [["The first option seems to be the correct one, due to the low probability of P. jirovecii infection in a patient with more than 500 CD4 lymphocytes and undetectable viral load\n", "Cefiriaxone 2 g and azithromycin 500 mg every 24 hours\n", "Support"], ["It is most likely to be a pneumococcal infection that we cover with Ceftriaxone and with azithromycin we cover the so-called \"atypical\" ones\n", "Cefiriaxone 2 g and azithromycin 500 mg every 24 hours\n", "Support"], ["Meropenem is an antibiotic with too broad a spectrum, which would be an option in in-hospital pneumonia caused by P. aeruginosa, a bacterial agent that can also cause pneumonia in HIV patients, but this is not common\n", "Meropenem I g/8 h and vancomycin I g/l2 h\n", "Attack"]]}
{"474_142": [["The first thing is to treat the infection and for this we must remove all the osteosynthesis material, debride and give antibiotherapy\n", "Removal of the nail, debridement, placement of external fixator and antibiotherapy adjusted to culture results\n", "Support"], ["Fixation in this case is better external to avoid all the material around the affected area\n", "Removal of the nail, debridement, placement of external fixator and antibiotherapy adjusted to culture results\n", "Support"], ["Fixation in this case is better external to avoid all the material around the affected area\n", "4 is correct and 1 and 2 is not\n", "Support"], ["4 is correct and 1 and 2 is not\n", "Removal of the nail, debridement, placement of external fixator and antibiotherapy adjusted to culture results\n", "Support"], ["4 is correct and 1 and 2 is not\n", "Triple antibiotherapy (gram-positive, gram-negative and anaerobic) and cleaning of the surgical wound, removing the distal locks to promote bone consolidation\n", "Attack"], ["4 is correct and 1 and 2 is not\n", "Expectant attitude and antibiotic treatment with quinolones\n", "Support"], ["The 3 would be considered after expiration of the infectious picture\n", "Expectant attitude and antibiotic treatment with quinolones\n", "Attack"], ["The infection is understood by the clinical manifestations (suppuration, nonunion) and the history of diabetes and open fracture\n", "We are dealing with an infection associated with an implant (intramedullary nail) and pseudoarthrosis of the tibia fracture (absence of union after 11 months)\n", "Support"], ["An emergency operation was performed by cleaning (Friederich) and placement of an endomedullary steel-plated nail\n", "We are dealing with an infection associated with an implant (intramedullary nail) and pseudoarthrosis of the tibia fracture (absence of union after 11 months)\n", "Support"], ["At 11 months he presents with atrophic pseudarthrosis of the tibia with suppuration in the wound area\n", "We are dealing with an infection associated with an implant (intramedullary nail) and pseudoarthrosis of the tibia fracture (absence of union after 11 months)\n", "Support"], ["Isolated antibiotherapy (option 2) is indicated only in patients with severe comorbidity in whom surgical treatment would be more aggressive than continuing the disease\n", "Expectant attitude and antibiotic treatment with quinolones\n", "Attack"], ["Nail dynamization associated with broad-spectrum antibiotherapy (option 1) is not indicated either\n", "Triple antibiotherapy (gram-positive, gram-negative and anaerobic) and cleaning of the surgical wound, removing the distal locks to promote bone consolidation\n", "Attack"], ["it has not demonstrated benefit in established pseudarthrosis\n", "Nail dynamization associated with broad-spectrum antibiotherapy (option 1) is not indicated either\n", "Support"], ["we have the same issue as option 1, we do not eliminate biofilm\n", "Nail dynamization associated with broad-spectrum antibiotherapy (option 1) is not indicated either\n", "Support"], ["Option 3, discussed, would be considered only if there was no associated infection\n", "Autologous graft and growth factors (BMP 2 and 7) to stimulate the bone consolidation process, which is slowing\n", "Attack"], ["We are dealing with an infection associated with an implant (intramedullary nail) and pseudoarthrosis of the tibia fracture (absence of union after 11 months)\n", "Option 3, discussed, would be considered only if there was no associated infection\n", "Support"]]}
{"17_137": [["A 14-year-old female patient in good general condition presents since 4 days ago a very pruritic generalized cutaneous eruption formed by erythematous-edematous plaques between 2 and 15 cm in diameter without desquamation with a tendency to acquire an annular morphology that individually disappear in less than 24 hours\n", "Urticaria\n", "Support"], ["The mucous membranes are respected\n", "Urticaria\n", "Support"], ["The general condition is usually preserved\n", "Acute urticaria: characterized by erythematous-edematous, evanescent, pruritic, evanescent lesions, lasting less than 24 hours, without desquamation\n", "Support"], ["In children the annular pattern is more frequent\n", "Acute urticaria: characterized by erythematous-edematous, evanescent, pruritic, evanescent lesions, lasting less than 24 hours, without desquamation\n", "Support"], ["A 14-year-old female patient in good general condition presents since 4 days ago a very pruritic generalized cutaneous eruption formed by erythematous-edematous plaques between 2 and 15 cm in diameter without desquamation with a tendency to acquire an annular morphology that individually disappear in less than 24 hours\n", "Rubella\n", "Attack"], ["A 14-year-old female patient in good general condition presents since 4 days ago a very pruritic generalized cutaneous eruption formed by erythematous-edematous plaques between 2 and 15 cm in diameter without desquamation with a tendency to acquire an annular morphology that individually disappear in less than 24 hours\n", "Toxicoderma\n", "Attack"], ["In both rubella and toxicoderma, the general condition is not preserved\n", "Rubella\n", "Attack"], ["In both rubella and toxicoderma, the general condition is not preserved\n", "Toxicoderma\n", "Attack"], ["In staphylococcal shock, the general condition is affected and the lesions are blistering\n", "Staphylococcal toxic shock\n", "Attack"], ["A 14-year-old female patient in good general condition presents since 4 days ago a very pruritic generalized cutaneous eruption formed by erythematous-edematous plaques between 2 and 15 cm in diameter without desquamation with a tendency to acquire an annular morphology that individually disappear in less than 24 hours\n", "Staphylococcal toxic shock\n", "Attack"], ["Scabies lesions are preferably interdigital, in the form of papulocoses that can follow linear trajectories\n", "Scabies\n", "Attack"], ["A 14-year-old female patient in good general condition presents since 4 days ago a very pruritic generalized cutaneous eruption formed by erythematous-edematous plaques between 2 and 15 cm in diameter without desquamation with a tendency to acquire an annular morphology that individually disappear in less than 24 hours\n", "Scabies\n", "Attack"]]}
{"425_92": [["our patient has a normal blood glucose of 96mg/dl\n", "Initially we rule out diabetes mellitus\n", "Support"], ["high plasma osm with low urinary osm\n", "The analytical data suggest diabetes insipidus\n", "Support"], ["The analytical data suggest diabetes insipidus\n", "Now we must differentiate between central diabetes insipidus (lack of ADH) or nephrogenic diabetes insipidus (ADH does not exert its action at the renal level)\n", "Support"], ["Now we must differentiate between central diabetes insipidus (lack of ADH) or nephrogenic diabetes insipidus (ADH does not exert its action at the renal level)\n", "This is achieved by the vasopressin test (intravenous administration of ADH and remeasurement of urinary osmolarity)\n", "Support"], ["This is achieved by the vasopressin test (intravenous administration of ADH and remeasurement of urinary osmolarity)\n", "Administration of desmopressin with serial monitoring of urine osmolality\n", "Support"], ["This is achieved by the vasopressin test (intravenous administration of ADH and remeasurement of urinary osmolarity)\n", "Therefore, the correct answer is option 3\n", "Support"], ["Therefore, the correct answer is option 3\n", "Administration of desmopressin with serial monitoring of urine osmolality\n", "Support"], ["In the first 24 hours of admission a diuresis of 8.2 liters is found and a blood test shows a glycemia of 96 mg/dL, natremia of 148 mEq/L and plasma osmolality of 309 mOsm/kg with urinary osmolality of 89 mOsmlkg\n", "high plasma osm with low urinary osm\n", "Support"]]}
{"8_232": [["The diagnosis would be practically made with the AMA (1)\n", "Anti-mitochondrial antibodies\n", "Support"], ["with 5 we could rule out viral hepatitis\n", "Serology for B and C viruses\n", "Attack"]]}
{"621_60": [["Assuming therefore that we are asked which is one of the most frequent complications of the floor of the orbit, two complications should always be highlighted that may indicate surgical treatment, even urgent: diplopia, due to dislocation of the inferior rectus muscle to the underlying maxillary sinus (and even its entrapment); and enophthalmos, which may cause other associated complications in the medium and long term, such as superior palpebral pseudo-ptosis due to loss of orbital volume\n", "option 4 correct\n", "Support"], ["option 4 correct\n", "Enophthalmos\n", "Support"], ["although relatively close to the orbital cavity, it is not part of the orbito-malar complex\n", "Temporomandibular ankylosis is not considered\n", "Support"], ["Temporomandibular ankylosis is not considered\n", "option 1 discarded\n", "Support"], ["option 1 discarded\n", "Temporomandibular ankylosis\n", "Attack"], ["Temporomandibular ankylosis is not considered\n", "Temporomandibular ankylosis\n", "Attack"], ["A cranial CT scan was performed showing a fracture of the middle third of the face involving the orbito-malar region\n", "Involvement of the maxilla can lead to dental malocclusion, but usually occurs in fractures located lower than the orbital cavity\n", "Attack"], ["Involvement of the maxilla can lead to dental malocclusion, but usually occurs in fractures located lower than the orbital cavity\n", "option 2 discarded\n", "Support"], ["option 2 discarded\n", "Dental malocclusion\n", "Attack"], ["option 3 discarded\n", "Naso-ethmoidal pseudoarthrosis\n", "Attack"], ["A cranial CT scan was performed showing a fracture of the middle third of the face involving the orbito-malar region\n", "Naso-ethmoidal fractures are included in midface fractures, but the bones of the nose are located more anteriorly to the medial orbital rim, and therefore outside the orbit\n", "Attack"]]}
{"470_138": [["In this situation, the first thing to do is to resolve the pain crisis and to propose an appropriate conservative treatment for this osteoarthritis\n", "Explanation of the diagnosis, relative rest, paracetamol 1g/8h plus metamizol 500 mg/ 8 h rescue naproxen\n", "Support"], ["1 correct\n", "Explanation of the diagnosis, relative rest, paracetamol 1g/8h plus metamizol 500 mg/ 8 h rescue naproxen\n", "Support"], ["We are being described an acute pain crisis in a patient with gonarthrosis\n", "In this situation, the first thing to do is to resolve the pain crisis and to propose an appropriate conservative treatment for this osteoarthritis\n", "Support"], ["In this situation, the first thing to do is to resolve the pain crisis and to propose an appropriate conservative treatment for this osteoarthritis\n", "1 correct\n", "Support"], ["A knee arthroplasty is not considered at the outset\n", "2 is false\n", "Support"], ["2 is false\n", "Preferential referral to Traumatology outpatients for evaluation of total cemented prosthesis\n", "Attack"], ["A knee arthroplasty is not considered at the outset\n", "Preferential referral to Traumatology outpatients for evaluation of total cemented prosthesis\n", "Attack"], ["They are not telling us an infectious clinic to suspect an arthritis that would justify a debridement and washing\n", "3 is false\n", "Support"], ["3 is false\n", "Preferential referral to Traumatology outpatient clinic for arthroscopic debridement\n", "Attack"], ["In a patient with gonarthrosis there will always be meniscopathy, it is part of the degenerative changes\n", "Preferred MRI request for evaluation of meniscopathy, Baker's cyst and/or tendinitis\n", "Attack"], ["They are not telling us an infectious clinic to suspect an arthritis that would justify a debridement and washing\n", "Preferential referral to Traumatology outpatient clinic for arthroscopic debridement\n", "Attack"], ["Baker's cyst would only interest us in a severe pain crisis in the differential diagnosis with a deep thrombosis and it is evaluated with an echo-Doppler\n", "Preferred MRI request for evaluation of meniscopathy, Baker's cyst and/or tendinitis\n", "Attack"], ["in the picture of gonarthrosis it has no value to detect a Baker's cyst\n", "Preferred MRI request for evaluation of meniscopathy, Baker's cyst and/or tendinitis\n", "Attack"], ["Tendinitis is diagnosed by examination, not with MRI\n", "Preferred MRI request for evaluation of meniscopathy, Baker's cyst and/or tendinitis\n", "Attack"], ["In a patient with gonarthrosis there will always be meniscopathy, it is part of the degenerative changes\n", "Therefore, 4 is false\n", "Support"], ["Baker's cyst would only interest us in a severe pain crisis in the differential diagnosis with a deep thrombosis and it is evaluated with an echo-Doppler\n", "Therefore, 4 is false\n", "Support"], ["in the picture of gonarthrosis it has no value to detect a Baker's cyst\n", "Therefore, 4 is false\n", "Support"], ["Tendinitis is diagnosed by examination, not with MRI\n", "Therefore, 4 is false\n", "Support"]]}
{"298_103": [["The history of contact with fresh water in an endemic area points to leptospirosis\n", "Leptospirosis\n", "Support"], ["in the clinical picture we also find jaundice and conjunctival injection which also points to leptospirosis and is not so characteristically related to the other three pathogens\n", "Leptospirosis\n", "Support"], ["25-year-old man with no past history of interest presents to the emergency department with fever, headache, myalgia, nausea, vomiting, abdominal pain, jaundice and conjunctival injection, 2 weeks after traveling to Thailand to participate in a freshwater regatta\n", "The history of contact with fresh water in an endemic area points to leptospirosis\n", "Support"], ["25-year-old man with no past history of interest presents to the emergency department with fever, headache, myalgia, nausea, vomiting, abdominal pain, jaundice and conjunctival injection, 2 weeks after traveling to Thailand to participate in a freshwater regatta\n", "in the clinical picture we also find jaundice and conjunctival injection which also points to leptospirosis and is not so characteristically related to the other three pathogens\n", "Support"], ["in the clinical picture we also find jaundice and conjunctival injection which also points to leptospirosis and is not so characteristically related to the other three pathogens\n", "Malaria\n", "Attack"], ["in the clinical picture we also find jaundice and conjunctival injection which also points to leptospirosis and is not so characteristically related to the other three pathogens\n", "Schistosomiasis\n", "Attack"], ["in the clinical picture we also find jaundice and conjunctival injection which also points to leptospirosis and is not so characteristically related to the other three pathogens\n", "Rabies\n", "Attack"]]}
{"365_100": [["On arrival, the patient had a fever of 38.2\u00baC, multiple skin abscesses on the hands, back and buttocks (some with fistulous tracts) and right central facial paralysis, apical infiltrates with small associated pleural effusion on chest X-ray and leukocytosis with neutrophilia\n", "Aspergillus also does not affect the skin\n", "Attack"], ["On arrival, the patient had a fever of 38.2\u00baC, multiple skin abscesses on the hands, back and buttocks (some with fistulous tracts) and right central facial paralysis, apical infiltrates with small associated pleural effusion on chest X-ray and leukocytosis with neutrophilia\n", "Tuberculosis can affect lung and brain but not cutaneous abscesses\n", "Attack"], ["Tuberculosis can affect lung and brain but not cutaneous abscesses\n", "Disseminated tuberculosis\n", "Attack"], ["A 64-year-old patient, farmer, former smoker (5 years), COPD and afflicted with rheumatoid arthritis on corticosteroid therapy\n", "Nocardia can typically affect immunosuppressed patients, especially those with impaired cell-mediated immunity such as that produced by steroids, and can present with pulmonary involvement, brain abscesses and skin abscesses\n", "Support"], ["On arrival, the patient had a fever of 38.2\u00baC, multiple skin abscesses on the hands, back and buttocks (some with fistulous tracts) and right central facial paralysis, apical infiltrates with small associated pleural effusion on chest X-ray and leukocytosis with neutrophilia\n", "Nocardia can typically affect immunosuppressed patients, especially those with impaired cell-mediated immunity such as that produced by steroids, and can present with pulmonary involvement, brain abscesses and skin abscesses\n", "Support"], ["Nocardia can typically affect immunosuppressed patients, especially those with impaired cell-mediated immunity such as that produced by steroids, and can present with pulmonary involvement, brain abscesses and skin abscesses\n", "Nocardiosis\n", "Support"], ["Aspergillus also does not affect the skin\n", "Aspergillosis\n", "Attack"]]}
{"392_223": [["if we look at the patient's ability to maintain sleep, there is a clear fact that \"rules out\" the hypo/manic shift\n", "In this question, one might suspect the possibility of an affective shift after the introduction of the antidepressant drug, according to the patient\n", "Attack"], ["In this question, one might suspect the possibility of an affective shift after the introduction of the antidepressant drug, according to the patient\n", "Drug-induced hypomania\n", "Attack"], ["if we look at the patient's ability to maintain sleep, there is a clear fact that \"rules out\" the hypo/manic shift\n", "Drug-induced hypomania\n", "Attack"], ["Two weeks is not enough time for the drug to have taken full effect on mood\n", "if we look at the patient's ability to maintain sleep, there is a clear fact that \"rules out\" the hypo/manic shift\n", "Support"], ["an initial activation may appear, which patients sometimes do not cope with very well (something that does not seem to be the case)\n", "Normal response to escitalopram\n", "Support"], ["In this patient it is indicated to maintain the treatment and reevaluate in no more than one month\n", "Normal response to escitalopram\n", "Support"]]}
{"285_59": []}
{"301_232": [["In healthy adults there may be palpable inguinal nodes up to 2 centimeters that can be considered normal\n", "By the clinical characteristics it seems to be normal lymph nodes and complementary explorations should not be done\n", "Support"], ["A complementary study of these normal lymph nodes is not warranted\n", "By the clinical characteristics it seems to be normal lymph nodes and complementary explorations should not be done\n", "Support"]]}
{"23_113": [["A 71-year-old woman with a history of rheumatoid arthritis on sulfasalazine, prednisone and etanercept\n", "in an immunocompromised patient and also with data of ocular involvement, admission for intravenous treatment would be indicated due to the high risk of possible complications\n", "Support"], ["in an immunocompromised patient and also with data of ocular involvement, admission for intravenous treatment would be indicated due to the high risk of possible complications\n", "Hospital admission and treatment with acyclovir or famciclovir iv\n", "Support"]]}
{"564_126": [["When the diagnosis is biochemically confirmed, the next test to be performed is a CT scan to determine the subtype and rule out the presence of an adrenal carcinoma\n", "option 3 correct\n", "Support"], ["option 3 correct\n", "CT scan is part of the diagnostic study in case of biochemical confirmation\n", "Support"], ["When the diagnosis is biochemically confirmed, the next test to be performed is a CT scan to determine the subtype and rule out the presence of an adrenal carcinoma\n", "CT scan is part of the diagnostic study in case of biochemical confirmation\n", "Support"], ["Therefore, it is necessary to wait for the imaging test to confirm the etiology\n", "option 1 incorrect\n", "Support"], ["Therefore, it is necessary to wait for the imaging test to confirm the etiology\n", "The origin of hypertension in this case is excessive secretion of aldosterone caused by autonomic hyperfunction of the adrenal medulla\n", "Attack"], ["option 1 incorrect\n", "The origin of hypertension in this case is excessive secretion of aldosterone caused by autonomic hyperfunction of the adrenal medulla\n", "Attack"], ["The most frequent cause is aldosterone-producing adenoma\n", "option 2 incorrect\n", "Support"], ["The most frequent cause is aldosterone-producing adenoma\n", "In most cases the anatomical substrate is a bilateral hyperplasia of the adrenal cortex\n", "Attack"], ["option 2 incorrect\n", "In most cases the anatomical substrate is a bilateral hyperplasia of the adrenal cortex\n", "Attack"], ["Spironolactone is the medical treatment of choice\n", "option 4 incorrect\n", "Support"], ["Spironolactone is the medical treatment of choice\n", "Spironolactone is contraindicated in the management of this pathology\n", "Attack"], ["option 4 incorrect\n", "Spironolactone is contraindicated in the management of this pathology\n", "Attack"], ["When the diagnosis is biochemically confirmed, the next test to be performed is a CT scan to determine the subtype and rule out the presence of an adrenal carcinoma\n", "Therefore, it is necessary to wait for the imaging test to confirm the etiology\n", "Support"]]}
{"292_213": [["Of course, the patient may also have HIV infection or even secondary syphilis (in addition to Reiter's)\n", "He is describing a textbook Reiter's syndrome\n", "Support"], ["palmo-plantar keratoderma, arthritis and ocular manifestations, together with probably a chlamydial urethritis, perhaps asymptomatic (they do not explain urethral exudate)\n", "He is describing a textbook Reiter's syndrome\n", "Support"], ["He is describing a textbook Reiter's syndrome\n", "Reiter's syndrome\n", "Support"]]}
{"477_128": [["35-year-old man admitted for severe chest trauma with multiple rib fractures\n", "Pulmonary contusion is the most serious lesion and the one with the worst prognosis in thoracic trauma\n", "Support"], ["After responding favorably to treatment with analgesics and oxygen, he begins to present severe hypoxemia\n", "It is also the injury that causes hypoxemia the earliest\n", "Support"], ["Contrary to what we may think, an unstable thorax due to multiple rib fractures (costal volet) would cause progressive hypoventilation with atelectasis of the pulmonary parenchyma, which would progress on the one hand to hypercapnia and respiratory acidosis, and on the other, to later hypoxemia due to infection associated with atelectasis\n", "Chest wall instability due to multiple fractures\n", "Attack"], ["After responding favorably to treatment with analgesics and oxygen, he begins to present severe hypoxemia\n", "Contrary to what we may think, an unstable thorax due to multiple rib fractures (costal volet) would cause progressive hypoventilation with atelectasis of the pulmonary parenchyma, which would progress on the one hand to hypercapnia and respiratory acidosis, and on the other, to later hypoxemia due to infection associated with atelectasis\n", "Attack"], ["Respiratory infection due to aspiration would also occur later, and does not appear in all cases of severe chest trauma, only if there has been a decrease in the level of consciousness (associated TBI, uncontrolled intubation with bronchoaspiration...)\n", "Aspiration respiratory infection\n", "Attack"], ["35-year-old man admitted for severe chest trauma with multiple rib fractures\n", "Respiratory infection due to aspiration would also occur later, and does not appear in all cases of severe chest trauma, only if there has been a decrease in the level of consciousness (associated TBI, uncontrolled intubation with bronchoaspiration...)\n", "Attack"], ["Post-traumatic hypovolemia (in this case, as there are multiple rib fractures, it could be due to hemothorax) would occur earlier and would be associated in the first place with hemodynamic instability\n", "Post-traumatic hypovolemia\n", "Attack"], ["Pulmonary contusion is the most serious lesion and the one with the worst prognosis in thoracic trauma\n", "Alteration of gas exchange due to pulmonary contusion\n", "Support"], ["It is also the injury that causes hypoxemia the earliest\n", "Alteration of gas exchange due to pulmonary contusion\n", "Support"]]}
{"572_195": [["When assessing her renal function, she presents a G3a/A1 stage\n", "Stage G3a corresponds to a filtration rate between 45-59 ml/min\n", "Support"], ["When assessing her renal function, she presents a G3a/A1 stage\n", "Stage A1 corresponds to albuminuria less than 30 mg/ml\n", "Support"], ["Stage G3a corresponds to a filtration rate between 45-59 ml/min\n", "Therefore the correct option is 1\n", "Support"], ["Stage A1 corresponds to albuminuria less than 30 mg/ml\n", "Therefore the correct option is 1\n", "Support"], ["Therefore the correct option is 1\n", "Glomerular filtration rate 45-59 ml/min/1.73 m\u00b2 and albuminuria <30 mg/ml\n", "Support"]]}
{"180_232": [["Transfusing this patient and stuffing him with antibiotics is giving him bread for today and hunger for tomorrow\n", "Periodic transfusions and antibiotics\n", "Attack"], ["Androgens and platelet transfusions don't fix the problem either\n", "Androgens and platelet transfusions\n", "Attack"], ["An autologous transplant is not reasonable, since the bone marrow of a patient with bone marrow aplasia is less than 25%, so little can be obtained\n", "Autologous bone marrow transplantation to avoid rejection\n", "Attack"], ["Therefore, we are inclined towards allogeneic bone marrow transplantation if he has an HLA-identical sibling, since this is the treatment of choice according to the protocol of the Spanish Society of Hematology and Hemotherapy for patients under 40 years of age with severe bone marrow aplasia\n", "Correct answer, 3\n", "Support"], ["Correct answer, 3\n", "Allogeneic bone marrow transplantation if HLA identical sibling\n", "Support"]]}
{"270_135": [["The question is tricky: it speaks of a burn of 10% of the body surface\n", "the treatment of choice for second degree burns less than 20% of the BSA should be topical and monitored\n", "Support"], ["However, there is a warning sign: there is no arterial pulse and the burn is circumferential to the limb\n", "This is an emergency that, if allowed to evolve, will compromise the viability of the affected limb and end in amputation\n", "Support"], ["This is an emergency that, if allowed to evolve, will compromise the viability of the affected limb and end in amputation\n", "an emergency escharotomy must be performed in order to relieve the pressure of the third space on the arterial vascular trunk\n", "Support"], ["an emergency escharotomy must be performed in order to relieve the pressure of the third space on the arterial vascular trunk\n", "Escharotomy or emergency decompression incisions\n", "Support"]]}
{"368_121": []}
{"167_85": [["However, emergency reasoning: systolic murmur, something that in systole had to be closed and is not, or had to open, and does not: options 1, 3 and 5\n", "Mitral insufficiency\n", "Support"], ["However, emergency reasoning: systolic murmur, something that in systole had to be closed and is not, or had to open, and does not: options 1, 3 and 5\n", "Tricuspid insufficiency.\n", "Support"], ["However, emergency reasoning: systolic murmur, something that in systole had to be closed and is not, or had to open, and does not: options 1, 3 and 5\n", "Aortic stenosis\n", "Support"], ["on cardiac auscultation a holosystolic murmur is auscultated in the area of the xiphoid appendage that is accentuated with deep inspiration\n", "However, emergency reasoning: systolic murmur, something that in systole had to be closed and is not, or had to open, and does not: options 1, 3 and 5\n", "Support"], ["If in a patient with chronic heart failure we detect prominent v waves in the jugular venous pulse\n", "And if we see repercussion in the jugular pulse, it must be in the right cavities\n", "Support"], ["If in a patient with chronic heart failure we detect prominent v waves in the jugular venous pulse\n", "Apart from the fact that the v wave appears during systole, while the atria are filling: if the RV flow rises to the RA, what will happen is that the v wave will be very large?\n", "Support"], ["And if we see repercussion in the jugular pulse, it must be in the right cavities\n", "Aortic stenosis\n", "Attack"], ["And if we see repercussion in the jugular pulse, it must be in the right cavities\n", "Mitral insufficiency\n", "Attack"], ["And if we see repercussion in the jugular pulse, it must be in the right cavities\n", "Tricuspid insufficiency.\n", "Support"]]}
{"154_75": [["In my opinion, as in these six months she has shown a clear clinical and biological improvement (decrease in acute phase reactants), I would maintain the therapeutic approach taken and wait for a new evaluation\n", "Maintain the therapeutic attitude taken since we have only been on it for 6 months and it would be necessary to wait a minimum of 9 months to evaluate therapeutic response\n", "Support"], ["However, I consider that this question could have another valid answer, 3\n", "If there is no medical contraindication, consider adding an anti-TNF alpha to the treatment\n", "Support"], ["If what you are looking for is a remission of the disease as soon as possible, you could choose to consider associating an anti-TNF alpha\n", "However, I consider that this question could have another valid answer, 3\n", "Support"]]}
{"176_57": [["She presented good clinical evolution except for persistent febrile fever and leukocytosis on the sixth day of treatment\n", "As long as fever persists in an evolving pneumonia, there is a risk of empyematization, especially if a small effusion has already occurred at the beginning of the picture\n", "Support"], ["Admitted for middle lobe pneumonia with a small associated metaneumonic pleural effusion and on treatment with levofloxacin 500 mg/24h\n", "As long as fever persists in an evolving pneumonia, there is a risk of empyematization, especially if a small effusion has already occurred at the beginning of the picture\n", "Support"], ["In principle, antibiotic treatment is correct and before considering changes in treatment, the possibility of empyematization should be evaluated\n", "Perform thoracentesis to rule out empyema\n", "Support"]]}
{"130_82": [["A patient of adolescent age with myoclonus (\"violent jumps\") at breakfast time will almost always lead us to juvenile myoclonic epilepsy (answer 5 correct), a very well characterized entity\n", "Juvenile myoclonic epilepsy\n", "Support"], ["An 18-year-old female patient\n", "Juvenile myoclonic epilepsy\n", "Support"], ["violent jumping of the upper limbs at breakfast\n", "Juvenile myoclonic epilepsy\n", "Support"], ["Among other features is the previous history of seizures or absences, the worsening with nighttime departures, and the EEG with generalized polyp spike discharges at a higher frequency than that of absences\n", "Juvenile myoclonic epilepsy\n", "Support"], ["history of absences between 6 and 9 years of age\n", "Juvenile myoclonic epilepsy\n", "Support"], ["generalized tonic-clonic seizures of recent onset\n", "Juvenile myoclonic epilepsy\n", "Support"], ["The clinical manifestations worsen with nighttime weekend outings\n", "Juvenile myoclonic epilepsy\n", "Support"], ["An EEG shows acute polyp spike discharges at 6 cycles/second\n", "Juvenile myoclonic epilepsy\n", "Support"], ["Lennox Gastaut develops at an early age with other symptomatology\n", "Lennox-Gastaut syndrome\n", "Attack"], ["An 18-year-old female patient\n", "Lennox-Gastaut syndrome\n", "Attack"], ["4 is the same as absences\n", "Small atypical disease\n", "Attack"], ["history of absences between 6 and 9 years of age\n", "Small atypical disease\n", "Support"], ["3 usually presents with complex partial seizures and either way, the EEG is clearly distinct from a temporal focus\n", "Symptomatic epilepsy due to mesial temporal sclerosis\n", "Attack"], ["An EEG shows acute polyp spike discharges at 6 cycles/second\n", "Symptomatic epilepsy due to mesial temporal sclerosis\n", "Attack"]]}
{"276_75": [["hepatitis B virus infection in a 5-year-old patient from Nigeria, with normal physical examination and the following serology for hepatitis B: HBsAg + / ANTI-HBs - / HbeAg - / ANTI-HBe + / ANTI-HBc IgM - / ANTI-HBc IgG + / DNA HBV +\n", "Having antibodies against the core implies natural contact, and that it is IgG, which is not acute\n", "Support"], ["Having antibodies against the core implies natural contact, and that it is IgG, which is not acute\n", "Acute infection\n", "Attack"], ["hepatitis B virus infection in a 5-year-old patient from Nigeria, with normal physical examination and the following serology for hepatitis B: HBsAg + / ANTI-HBs - / HbeAg - / ANTI-HBe + / ANTI-HBc IgM - / ANTI-HBc IgG + / DNA HBV +\n", "The absence of e antigen rules out active replication\n", "Support"], ["hepatitis B virus infection in a 5-year-old patient from Nigeria, with normal physical examination and the following serology for hepatitis B: HBsAg + / ANTI-HBs - / HbeAg - / ANTI-HBe + / ANTI-HBc IgM - / ANTI-HBc IgG + / DNA HBV +\n", "And the persistence of surface antigen (HBsAg) and virus DNA indicates that it is still present\n", "Support"], ["Having antibodies against the core implies natural contact, and that it is IgG, which is not acute\n", "Together, these indicate an asymptomatic carrier\n", "Support"], ["The absence of e antigen rules out active replication\n", "Together, these indicate an asymptomatic carrier\n", "Support"], ["And the persistence of surface antigen (HBsAg) and virus DNA indicates that it is still present\n", "Together, these indicate an asymptomatic carrier\n", "Support"], ["Together, these indicate an asymptomatic carrier\n", "Asymptomatic carrier\n", "Support"]]}
{"183_64": [["All responses are causes of malnutrition except 3\n", "Prolonged vomiting and diarrhea\n", "Support"], ["All responses are causes of malnutrition except 3\n", "Elderly\n", "Support"], ["All responses are causes of malnutrition except 3\n", "Anorexia nervosa\n", "Support"], ["All responses are causes of malnutrition except 3\n", "Previous caloric malnutrition\n", "Support"], ["All responses are causes of malnutrition except 3\n", "Non-morbid obesity\n", "Attack"], ["A patient on enteral nutritional support presents 72 hours after starting enteral nutrition with a CBC showing hypophosphoremia and hypokalemia, with clinical signs of heart failure\n", "Refeeding syndrome occurs in patients with previous malnutrition exposed to either oral, enteral or parenteral nutritional therapy\n", "Support"], ["The patient is diagnosed with refeeding syndrome\n", "Refeeding syndrome occurs in patients with previous malnutrition exposed to either oral, enteral or parenteral nutritional therapy\n", "Support"]]}
{"115_98": [["In the biochemistry LDH 2408\n", "Autoimmune hemolytic anemia associated with respiratory infection and corticosteroids\n", "Support"], ["The irregular antibody study is positive for panagglutinin, making crossmatching difficult\n", "Autoimmune hemolytic anemia associated with respiratory infection and corticosteroids\n", "Support"], ["bilirubin 6.8 mg/dl, (unconjugated bilirubin 6.1 mg/dl)\n", "Autoimmune hemolytic anemia associated with respiratory infection and corticosteroids\n", "Support"], ["The choluria, LDH, presence of panagglutinin and the peripheral blood smear \"smells\" like hemolytic anemia\n", "Autoimmune hemolytic anemia associated with respiratory infection and corticosteroids\n", "Support"], ["bilirubin 6.8 mg/dl, (unconjugated bilirubin 6.1 mg/dl)\n", "Medullary aplasia and immunotherapy with thymoglobulin and cyclosporine\n", "Attack"], ["In the biochemistry LDH 2408\n", "Medullary aplasia and immunotherapy with thymoglobulin and cyclosporine\n", "Attack"], ["The irregular antibody study is positive for panagglutinin, making crossmatching difficult\n", "Medullary aplasia and immunotherapy with thymoglobulin and cyclosporine\n", "Attack"], ["Answer 1 cannot be because a marrow aplasia does not explain the choluria, the elevation of LDH, nor in the study of irregular antibodies is positive in the form of panagglutinin\n", "Medullary aplasia and immunotherapy with thymoglobulin and cyclosporine\n", "Attack"], ["On admission, the CBC showed 16900 leukocytes/mm3 (85% S, 11% L, 4% M), hemoglobin 6.3 g/dL; MCV 109 fl, 360000 platelets/mm3\n", "In addition, pancytopenia is not observed, which is what would incline us more towards this pathology.\n", "Support"], ["On admission, the CBC showed 16900 leukocytes/mm3 (85% S, 11% L, 4% M), hemoglobin 6.3 g/dL; MCV 109 fl, 360000 platelets/mm3\n", "Medullary aplasia and immunotherapy with thymoglobulin and cyclosporine\n", "Attack"], ["In addition, pancytopenia is not observed, which is what would incline us more towards this pathology.\n", "Medullary aplasia and immunotherapy with thymoglobulin and cyclosporine\n", "Attack"], ["The irregular antibody study is positive for panagglutinin, making crossmatching difficult\n", "Hereditary spherocytosis and splenectomy\n", "Attack"], ["Answer 2 is not possible either, since a spherocytosis does not justify the presence of panagglutinin\n", "Hereditary spherocytosis and splenectomy\n", "Attack"], ["Answer 3 is the one I consider correct: an autoimmune hemolytic anemia would justify the data given: elevated LDH and bilirubinemia due to red cell destruction, polychromatophilia, spherocytosis and anisocytosis because the marrow is working hard to try to compensate for the anemia, which is regenerative.\n", "Autoimmune hemolytic anemia associated with respiratory infection and corticosteroids\n", "Support"], ["The morphological study of blood showed macrocytic anisocytosis with frequent spherocytic forms and polychromatophilia without blasts.\n", "Autoimmune hemolytic anemia associated with respiratory infection and corticosteroids\n", "Support"], ["The study of irregular antibodies and the presence of panagglutinin also supports this response, since the binding of an antibody to the hematocyte promotes its lysis and destruction\n", "Autoimmune hemolytic anemia associated with respiratory infection and corticosteroids\n", "Support"], ["The girl presents cough and fever, consistent with a respiratory infection\n", "Autoimmune hemolytic anemia associated with respiratory infection and corticosteroids\n", "Support"], ["A 32-year-old woman with cerebral palsy from childbirth comes to the emergency department for a few days of dark urine associated with an episode of high fever and dry cough\n", "Autoimmune hemolytic anemia associated with respiratory infection and corticosteroids\n", "Support"], ["And the initial treatment is corticosteroids\n", "Autoimmune hemolytic anemia associated with respiratory infection and corticosteroids\n", "Support"], ["Answer 5 is not true because no blasts are seen in the blood nor does it explain the presence of panagglutinin.\n", "Acute leukemia and chemotherapy.\n", "Attack"], ["The irregular antibody study is positive for panagglutinin, making crossmatching difficult\n", "Acute leukemia and chemotherapy.\n", "Attack"], ["Answer 4 gives rise to considerable doubt; it is not possible because a pernicious anemia does not justify the presence of panagglutinin although it would justify the elevation of LDH and bilirubin; moreover, it is an intramedullary, arregenerative hemolysis, there is no reticulocytosis or release into the blood of immature forms in an attempt to compensate and fix the situation\n", "Pernicious anemia and periodic injections of vitamin B12\n", "Attack"], ["The irregular antibody study is positive for panagglutinin, making crossmatching difficult\n", "Pernicious anemia and periodic injections of vitamin B12\n", "Attack"], ["In the biochemistry LDH 2408\n", "Pernicious anemia and periodic injections of vitamin B12\n", "Support"], ["bilirubin 6.8 mg/dl, (unconjugated bilirubin 6.1 mg/dl)\n", "Pernicious anemia and periodic injections of vitamin B12\n", "Support"]]}
{"75_65": [["So the diagnosis is respiratory distress\n", "Respiratory distress\n", "Support"], ["the correct answer is option 5\n", "Respiratory distress\n", "Support"], ["The question tells the story of a patient with acute pancreatitis who is developing acute respiratory failure\n", "So the diagnosis is respiratory distress\n", "Support"], ["The statement lists the criteria for ARDS (acute respiratory distress syndrome): PaO2/fiO2 < 200 + bilateral pulmonary infiltrates + PCP<18\n", "So the diagnosis is respiratory distress\n", "Support"]]}
{"191_125": [["Other drugs are a good choice in urinary tract infections caused by large negative bacilli (most likely: E. coli)\n", "Amoxicillin-clavulanic acid\n", "Support"], ["Other drugs are a good choice in urinary tract infections caused by large negative bacilli (most likely: E. coli)\n", "Cefuroxime-axetil\n", "Support"], ["Other drugs are a good choice in urinary tract infections caused by large negative bacilli (most likely: E. coli)\n", "Cotrimoxazole\n", "Support"], ["Other drugs are a good choice in urinary tract infections caused by large negative bacilli (most likely: E. coli)\n", "Cefixime\n", "Support"], ["Many E Coli are resistant to amoxicillin\n", "Amoxicillin\n", "Attack"]]}
{"323_150": [["This is cryptorchidism\n", "It has to be treated before the age of 2 years\n", "Support"], ["It has to be treated before the age of 2 years\n", "The treatment of first choice is orchidopexy\n", "Support"], ["hormonal treatment is currently in disuse\n", "The treatment of first choice is orchidopexy\n", "Support"], ["The treatment of first choice is orchidopexy\n", "The indication for orchidopexy should not be deferred\n", "Support"]]}
{"311_217": [["None of the other three options give that clinical picture\n", "Acute posterior vitreous detachment\n", "Attack"], ["None of the other three options give that clinical picture\n", "Central retinal artery obstruction\n", "Attack"], ["None of the other three options give that clinical picture\n", "Non-arteritic anterior ischemic optic neuropathy\n", "Attack"], ["DPV is usually asymptomatic\n", "Acute posterior vitreous detachment\n", "Attack"], ["An 84-year-old woman presents with loss of vision in the left eye of 4 days of evolution accompanied by metamorphopsia\n", "DPV is usually asymptomatic\n", "Attack"], ["The macula shows abundant hard exudates, two small deep hemorrhages and a localized neurosensory retinal detachment\n", "DPV is usually asymptomatic\n", "Attack"], ["An 84-year-old woman presents with loss of vision in the left eye of 4 days of evolution accompanied by metamorphopsia\n", "CRVO produces abrupt and total or near total loss of vision with the typical \"cherry red spot\" in the fundus\n", "Attack"], ["CRVO produces abrupt and total or near total loss of vision with the typical \"cherry red spot\" in the fundus\n", "Central retinal artery obstruction\n", "Attack"], ["both an arteritic and non-arteritic NOIA would produce papillary edema usually with peripapillary but not macular hemorrhages\n", "Non-arteritic anterior ischemic optic neuropathy\n", "Attack"], ["The macula shows abundant hard exudates, two small deep hemorrhages and a localized neurosensory retinal detachment\n", "both an arteritic and non-arteritic NOIA would produce papillary edema usually with peripapillary but not macular hemorrhages\n", "Attack"], ["In the contralateral eye there are abundant soft drusen\n", "none of these 3 options have any association with drusen in the contralateral eye\n", "Attack"], ["none of these 3 options have any association with drusen in the contralateral eye\n", "Non-arteritic anterior ischemic optic neuropathy\n", "Attack"], ["none of these 3 options have any association with drusen in the contralateral eye\n", "Central retinal artery obstruction\n", "Attack"], ["none of these 3 options have any association with drusen in the contralateral eye\n", "Acute posterior vitreous detachment\n", "Attack"], ["In the contralateral eye there are abundant soft drusen\n", "AMD in its exudative form presents with both this clinical presentation (loss of vision and metamorphopsia) and the characteristic fundus described in the question, in addition to the fact that drusen are usually observed in the contralateral eye\n", "Support"], ["An 84-year-old woman presents with loss of vision in the left eye of 4 days of evolution accompanied by metamorphopsia\n", "AMD in its exudative form presents with both this clinical presentation (loss of vision and metamorphopsia) and the characteristic fundus described in the question, in addition to the fact that drusen are usually observed in the contralateral eye\n", "Support"], ["AMD in its exudative form presents with both this clinical presentation (loss of vision and metamorphopsia) and the characteristic fundus described in the question, in addition to the fact that drusen are usually observed in the contralateral eye\n", "Exudative age-related macular degeneration (AMD)\n", "Support"]]}
{"137_164": [["Diplopia on vertical gaze is highly suggestive that the bony walls of the orbit are affected\n", "Lefort type I fracture does not affect the orbital contents\n", "Attack"], ["Diplopia on vertical gaze is highly suggestive that the bony walls of the orbit are affected\n", "We are with great probability in front of a Lefort I type fracture of the middle third of the face\n", "Attack"], ["Diplopia on vertical gaze is highly suggestive that the bony walls of the orbit are affected\n", "Knowing this information, the only correct answer is 2\n", "Support"], ["Lefort type I fracture does not affect the orbital contents\n", "Knowing this information, the only correct answer is 2\n", "Support"], ["Knowing this information, the only correct answer is 2\n", "This is probably a unilateral orbitomalar fracture\n", "Support"], ["Whoever posted the question wanted to make sure that the only valid answer was number 2; that is why they added the tag line \"but just in case we check it with a CT scan\n", "This is probably a unilateral orbitomalar fracture\n", "Support"]]}
{"309_215": [["A 47-year-old man with myopia magna, who underwent cataract surgery 2 years ago, comes to the emergency room reporting a profound and painless loss of vision in his right eye\n", "endophthalmitis typically presents with a lot of pain\n", "Attack"], ["endophthalmitis typically presents with a lot of pain\n", "Option 1 is strongly discarded\n", "Support"], ["Option 1 is strongly discarded\n", "Post-surgical endophthalmitis\n", "Attack"], ["A 47-year-old man with myopia magna, who underwent cataract surgery 2 years ago, comes to the emergency room reporting a profound and painless loss of vision in his right eye\n", "it usually occurs in older patients\n", "Attack"], ["it usually occurs in older patients\n", "Option 3 of wet form of age-related macular degeneration is also ruled out\n", "Support"], ["although what a patient with myopia magna may present with is myopic macular degeneration (with a similar clinical picture to AMD, but this is a different pathology)\n", "Option 3 of wet form of age-related macular degeneration is also ruled out\n", "Support"], ["A posterior vitreous detachment (PVD) is usually not very symptomatic, producing myodesopsias but no loss of vision or pain\n", "Posterior vitreous detachment\n", "Attack"], ["A 47-year-old man with myopia magna, who underwent cataract surgery 2 years ago, comes to the emergency room reporting a profound and painless loss of vision in his right eye\n", "A posterior vitreous detachment (PVD) is usually not very symptomatic, producing myodesopsias but no loss of vision or pain\n", "Attack"], ["however, some PVDs are of the hemorrhagic type, by traction of the vessels, producing a vitreous hemorrhage that would cause loss of vision\n", "A posterior vitreous detachment (PVD) is usually not very symptomatic, producing myodesopsias but no loss of vision or pain\n", "Attack"], ["In any case, due to the history of myopia magna and previous intraocular surgery, the first diagnosis to rule out would be retinal detachment, since these are two risk factors for this pathology\n", "Retinal detachment\n", "Support"], ["Technically, both option 2 and 4 (an acute hemorrhagic DPV) could cause these symptoms, but the most correct option is option 2\n", "Retinal detachment\n", "Support"], ["A 47-year-old man with myopia magna, who underwent cataract surgery 2 years ago, comes to the emergency room reporting a profound and painless loss of vision in his right eye\n", "In any case, due to the history of myopia magna and previous intraocular surgery, the first diagnosis to rule out would be retinal detachment, since these are two risk factors for this pathology\n", "Support"]]}
{"279_32": [["Histopathology revealed a thickened area below the superficial lining epithelium, which was more evident by Masson's trichrome technique and involved epithelial atrophy and denudation\n", "In this case, the presence of thickening of the subepithelial collagen layer, more evident with Masson's trichrome (special stain that allows differentiation of the collagen fibers), is pathognomonic of collagenous colitis\n", "Support"], ["In this case, the presence of thickening of the subepithelial collagen layer, more evident with Masson's trichrome (special stain that allows differentiation of the collagen fibers), is pathognomonic of collagenous colitis\n", "Collagenous colitis\n", "Support"], ["Histopathology revealed a thickened area below the superficial lining epithelium, which was more evident by Masson's trichrome technique and involved epithelial atrophy and denudation\n", "Atrophy together with epithelial denudation are characteristic of this disease, which does not usually cause macroscopic alterations of the mucosa\n", "Support"], ["Atrophy together with epithelial denudation are characteristic of this disease, which does not usually cause macroscopic alterations of the mucosa\n", "In this case, the presence of thickening of the subepithelial collagen layer, more evident with Masson's trichrome (special stain that allows differentiation of the collagen fibers), is pathognomonic of collagenous colitis\n", "Support"], ["An increased density of intraepithelial lymphocytes and the absence of mention of architectural alterations of the crypts (characteristic of ulcerative colitis and Crohn's disease) support this diagnosis\n", "In this case, the presence of thickening of the subepithelial collagen layer, more evident with Masson's trichrome (special stain that allows differentiation of the collagen fibers), is pathognomonic of collagenous colitis\n", "Support"]]}
{"437_118": [["Since a splenectomized patient is considered a \"special\" patient, he should receive antibiotic treatment as soon as possible, even if the wound does not appear infected\n", "Give 400 mg of oral moxifloxacin and send to the hospital\n", "Support"]]}
{"112_154": [["The correct answer is 3.\n", "Hysteroscopy and endometrial biopsy\n", "Support"], ["The study that gives us more information about endometrial pathology is hysteroscopy, which allows us to perform a directed endometrial biopsy\n", "Hysteroscopy and endometrial biopsy\n", "Support"], ["Endometrial cytology is performed blindly and has a large number of false negatives\n", "Endometrial cytology\n", "Attack"], ["MRI will help us to stage endometrial cancer\n", "Magnetic resonance imaging of the pelvis\n", "Support"]]}
{"374_101": [["The picture described is typical of a viral meningoencephalitis, more specifically VHZ, with significant tropism by the temporal lobe, causing febrile fever and in many cases aphasia\n", "the correct option would be 2\n", "Support"], ["the cerebrospinal fluid normally shows a moderate lymphocytic pleocytosis, with normal glycorrhachia\n", "the correct option would be 2\n", "Support"], ["the correct option would be 2\n", "Most likely this patient's CSF shows a lymphocyte-predominant pleocytosis with normal glycorrhachia\n", "Support"], ["The rest are not correct\n", "Bacterial meningitis is the first diagnostic impression and treatment with 3rd generation cephalosporin should be initiated as soon as possible\n", "Attack"], ["The rest are not correct\n", "We would suspect limbic encephalitis\n", "Attack"], ["The rest are not correct\n", "This is an early stage brain abscess\n", "Attack"], ["The first one because it is not a bacterial meningitis that would present with more fever\n", "Bacterial meningitis is the first diagnostic impression and treatment with 3rd generation cephalosporin should be initiated as soon as possible\n", "Attack"], ["A 52-year-old man comes to the Emergency Department with headache and fever (37.8\u00b0C) of 2 days' evolution\n", "The first one because it is not a bacterial meningitis that would present with more fever\n", "Support"], ["the third one because limbic encephalitis usually presents afebrile with behavioral changes\n", "We would suspect limbic encephalitis\n", "Attack"], ["the last one because the image they describe is not an abscess, well delimited\n", "This is an early stage brain abscess\n", "Attack"]]}
{"116_101": [["Reading the answers, the first thing that is clear to us is that acenocoumarol should NOT be given to a pregnant woman because of the risk of teratogenicity\n", "Treatment with antivitamin K drugs (acenocoumarol) during pregnancy\n", "Attack"], ["Reading the answers, the first thing that is clear to us is that acenocoumarol should NOT be given to a pregnant woman because of the risk of teratogenicity\n", "We discard answer 5.\n", "Support"], ["We discard answer 5.\n", "Treatment with antivitamin K drugs (acenocoumarol) during pregnancy\n", "Attack"], ["Answer 1 discarded\n", "Since pregnancy is a prothrombotic state, there would be a high risk of venous thromboembolism, so pregnancy should be discouraged\n", "Attack"], ["Advise a woman not to become pregnant when there are treatments that ensure a very low risk of thrombosis and/or fetal involvement?\n", "Answer 1 discarded\n", "Support"], ["Advise a woman not to become pregnant when there are treatments that ensure a very low risk of thrombosis and/or fetal involvement?\n", "Since pregnancy is a prothrombotic state, there would be a high risk of venous thromboembolism, so pregnancy should be discouraged\n", "Attack"], ["It is true that factor V Leiden in heterozygosis is classified as low risk, who has not presented a previous thrombotic episode nor is there a combination with another thrombophilia;\n", "Factor V Leiden in heterozygosis is a low-risk thrombophilia and there is no need for any treatment in pregnancy and puerperium\n", "Support"], ["if we look at the CHEST guide, VIII edition and review what was said at the last congress of the Spanish Society of Gynecology and Obstetrics, we see that aspirin is used in case of phospholipid syndrome and that in the case of this woman, without previous thrombosis, without previous abortions (at least two are needed) and also being heterozygous, treatment is not necessary\n", "Low-dose aspirin should be advised during pregnancy and puerperium\n", "Attack"], ["if we look at the CHEST guide, VIII edition and review what was said at the last congress of the Spanish Society of Gynecology and Obstetrics, we see that aspirin is used in case of phospholipid syndrome and that in the case of this woman, without previous thrombosis, without previous abortions (at least two are needed) and also being heterozygous, treatment is not necessary\n", "Factor V Leiden in heterozygosis is a low-risk thrombophilia and there is no need for any treatment in pregnancy and puerperium\n", "Support"], ["A 25-year-old woman who wishes to become pregnant and wants to know what treatment she should take during the eventual pregnancy, as she is a heterozygous factor V Leiden carrier\n", "Factor V Leiden in heterozygosis is a low-risk thrombophilia and there is no need for any treatment in pregnancy and puerperium\n", "Support"], ["She has never had any thrombotic phenomena\n", "Factor V Leiden in heterozygosis is a low-risk thrombophilia and there is no need for any treatment in pregnancy and puerperium\n", "Support"], ["if we look at the CHEST guide, VIII edition and review what was said at the last congress of the Spanish Society of Gynecology and Obstetrics, we see that aspirin is used in case of phospholipid syndrome and that in the case of this woman, without previous thrombosis, without previous abortions (at least two are needed) and also being heterozygous, treatment is not necessary\n", "Correct answer, 3\n", "Support"], ["Correct answer, 3\n", "Factor V Leiden in heterozygosis is a low-risk thrombophilia and there is no need for any treatment in pregnancy and puerperium\n", "Support"]]}
{"473_141": [["We are being shown a picture of lumbar canal stenosis\n", "Lumbar canal stenosis\n", "Support"], ["We are being shown a picture of lumbar canal stenosis\n", "Answer 4 correct\n", "Support"], ["Answer 4 correct\n", "Lumbar canal stenosis\n", "Support"], ["The patient shows the characteristic clinical picture: lumbar pain that is relieved by flexing the trunk forward, radicular pain with lower limb involvement and neurogenic claudication\n", "We are being shown a picture of lumbar canal stenosis\n", "Support"], ["Low back pain in a patient over 60 years of age accompanied by leg weakness when walking, which has to be interrupted at a certain distance, called neurogenic claudication\n", "the typical picture of stenosis\n", "Support"], ["Low back pain in a patient over 60 years of age accompanied by leg weakness when walking, which has to be interrupted at a certain distance, called neurogenic claudication\n", "We are being shown a picture of lumbar canal stenosis\n", "Support"], ["The patient is relieved by flexing the spine forward because it widens the lumbar canal and worsens with extension..\n", "Lumbar canal stenosis\n", "Support"]]}
{"34_66": [["A 51-year-old woman comes to the emergency department with a sudden decrease in visual acuity, severe headache, nausea and vomiting\n", "Pituitary apoplexy is a syndrome characterized by the sudden onset of headache accompanied by ocular motility disturbances and a variable degree of pituitary insufficiency\n", "Support"], ["The cause is usually a rapidly growing pituitary mass secondary to a vascular event (infarction or hemorrhage)\n", "Lumbar puncture to rule out bacterial meningitis after starting empirical antibiotherapy. Once the patient was stabilized, study of the selar mass\n", "Support"], ["A 51-year-old woman comes to the emergency department with a sudden decrease in visual acuity, severe headache, nausea and vomiting\n", "General symptoms may range from vomiting or nausea to meningeal irritation\n", "Support"], ["A 51-year-old woman comes to the emergency department with a sudden decrease in visual acuity, severe headache, nausea and vomiting\n", "Compression on the chiasm and optic nerve can cause various campimetric deficits (usually greater bitemporal hemianopsia in the superior quadrants) and decreased visual acuity, even blindness\n", "Support"]]}
{"343_158": [["The answer is 2\n", "You should not become pregnant until periodic controls and have spent one year with negative BHCG levels\n", "Support"], ["According to the SEGO (Spanish Society of Gynecology and Obstetrics) in its 2005 protocol \"Gestational trophoblastic disease\", the risk of malignization, i.e. of developing a gestational trophoblastic neoplasm, ranges from 5 to 20% depending on whether it is a partial mole or a complete mole, respectively\n", "It is necessary to perform periodic controls since 40% of the cases will develop a gestational trophoblastic neoplasia\n", "Attack"], ["The risk of a new molar gestation, although increased compared to the normal population, is not 50%\n", "The risk of a new molar gestation in a future pregnancy is 50%\n", "Attack"], ["According to this protocol: \"Patients will be monitored weekly with hcg dosage until it becomes undetectable, for three consecutive times\n", "Therefore, subsequent controls are strictly necessary\n", "Support"], ["After that the monitoring will be monthly, for six months and then every two months for another six months\n", "Therefore, subsequent controls are strictly necessary\n", "Support"], ["Based on the available data, a follow-up of three to six months is recommended for partial mole and 12 months for complete mole\n", "Therefore, subsequent controls are strictly necessary\n", "Support"], ["Therefore, subsequent controls are strictly necessary\n", "Subsequent controls are not necessary if the evacuation of the trophoblastic tissue was complete\n", "Support"]]}
{"210_187": []}
{"187_68": [["It refers to a thyroid nodule, and the indicated test is a FNA (fine needle puncture)\n", "A fine needle puncture\n", "Support"], ["Ultrasound facilitates FNA but is not mandatory, a 2 cm thyroid nodule can be punctured without echo\n", "A cervical CT scan\n", "Attack"]]}
{"406_33": [["Currently the molecular classification of breast cancer is based on the study of hormone receptors, HER2 and the tumor cell proliferation index (Ki67)\n", "Study of hormone receptors and HER2\n", "Support"]]}
{"526_54": [["NNT: 1/0.03= 33.3\n", "33,3\n", "Support"]]}
{"6_45": []}
{"573_92": [["Therefore, we discard 2 and 4\n", "Behavioral symptoms, motor symptoms, decline of functional independence\n", "Attack"], ["Therefore, we discard 2 and 4\n", "Behavioral symptoms, mood changes, motor symptoms\n", "Attack"], ["Between 1 and 3, I choose 3 for the same reason and because of the emphasis on the decline of functional independence that occurs in these patients\n", "Mood changes, cognitive deficit, decline of functional independence\n", "Support"], ["There are behavioral variants, but in the MIR they usually want you to think of other types of dementias in the face of behavioral symptoms\n", "In fact, the appearance of these symptoms in early stages should alert us and open the range of diagnostic possibilities\n", "Support"], ["In fact, the appearance of these symptoms in early stages should alert us and open the range of diagnostic possibilities\n", "Therefore, we discard 2 and 4\n", "Support"]]}
{"164_123": [["The correct answer is: 2\n", "Hyperkalemia\n", "Support"], ["Hyperkalemia\n", "The correct answer is: 2\n", "Support"], ["short QT\n", "The QT space is shortened\n", "Support"], ["In the ECG, there are sharp and elevated T waves\n", "Hyperkalemia produces repolarization disturbances that result in the installation of a large, symmetrical, narrow-based T, visible in the precordial leads\n", "Support"], ["In the ECG, there are sharp and elevated T waves\n", "Above 6.5 mmol/L, electrocardiographic changes are constant, and are dominated by conduction disturbances (making ventricular extrasystoles possible)\n", "Support"], ["ventricular extrasystoles\n", "Above 6.5 mmol/L, electrocardiographic changes are constant, and are dominated by conduction disturbances (making ventricular extrasystoles possible)\n", "Support"], ["short QT\n", "Above 6.5 mmol/L, electrocardiographic changes are constant, and are dominated by conduction disturbances (making ventricular extrasystoles possible)\n", "Support"], ["These anomalies appear with a kalemia of around 5.5 to 6 mmol/l\n", "Hyperkalemia produces repolarization disturbances that result in the installation of a large, symmetrical, narrow-based T, visible in the precordial leads\n", "Support"]]}
{"208_183": [["pH between 7.20-7.25 Prepathological value\n", "Pre-pathological value repeat microtome 15-20 minutes\n", "Support"], ["Repeat microtome in 15-20 min\n", "Moderate acidosis. Repeat microtome in 1-2 hours\n", "Support"]]}
{"232_103": [["Idiopathic thrombocytopenic purpura, but with very low platelets, so replenishment is necessary\n", "Platelet transfusion\n", "Support"], ["The proposed steroid dose is too low\n", "Idiopathic thrombocytopenic purpura, but with very low platelets, so replenishment is necessary\n", "Support"]]}
{"64_210": [["The trick to this question is that there are 8 cervical roots for 7 vertebrae, therefore the C1 root exits ABOVE the atlas, and so on up to C8 which exits BETWEEN C7 and T1\n", "The correct answer is 4\n", "Support"], ["The thoracic roots come out respectively below the vertebra with their same numbering (nerve T1 under T1, T2 under T2, etc.)\n", "The correct answer is 4\n", "Support"], ["Therefore, between C4 and C5 the 5th cervical nerve exits, and between T4 and T5 the 4th thoracic nerve exits\n", "The correct answer is 4\n", "Support"], ["The correct answer is 4\n", "Fifth cervical and fourth thoracic nerve\n", "Support"]]}
{"280_32": [["Everything we are told in this case is typical of COLLAGENOUS COLITIS\n", "Collagenous colitis\n", "Support"]]}
{"545_122": []}
{"257_95": [["Calcium/creatinine urine ratio\n", "Urine calcium/creatinine ratio\n", "Support"], ["In a 30-year-old female patient a calcium level of 11 mg/dl (normal less than 10.5 mg/dl) is found during a routine company examination\n", "This is familial hypocalciuric hypercalcemia or benign familial hypercalcemia\n", "Support"], ["The history is unremarkable except for the fact that the mother and paternal grandfather were diagnosed with hyperparathyroidism and underwent surgery, although they remained hypercalcemic\n", "This is familial hypocalciuric hypercalcemia or benign familial hypercalcemia\n", "Support"], ["This is familial hypocalciuric hypercalcemia or benign familial hypercalcemia\n", "Calcium/creatinine urine ratio\n", "Support"]]}
{"548_126": []}
{"318_140": [["The surgical criteria depends on the patient's symptoms and failure of medical treatment\n", "Treatment with paracetamol, explaining that the evolution is very variable and the surgical indication depends on the functionality and pain control\n", "Support"], ["No medication slows down or modifies the course of the disease\n", "Treatment with paracetamol, explaining that the evolution is very variable and the surgical indication depends on the functionality and pain control\n", "Support"], ["Treatment is medical and sequential, starting with the first analgesic step of the WHO\n", "Treatment with paracetamol, explaining that the evolution is very variable and the surgical indication depends on the functionality and pain control\n", "Support"], ["An MRI is not necessary, it does not contribute anything\n", "Because of the radiological features described, I need a hip MRI before making a therapeutic decision\n", "Attack"]]}
{"147_157": [["She does not present weight phobia or body image distortion\n", "Anorexia nervosa\n", "Attack"], ["As soon as we hear about weight we go to anorexia nervosa, but anorexia nervosa has three features: significant self-induced weight loss, body image distortion and amenorrhea\n", "So we remove 1\n", "Support"], ["So we remove 1\n", "Anorexia nervosa\n", "Attack"], ["3 does not make sense in the MIR because of the clinic -in reality the history is different and in psychiatry everything is evolution\n", "Borderline personality disorder\n", "Attack"], ["4 has to meet temporal criteria that are not met here\n", "Dysthymia\n", "Attack"], ["There is no anxiety clinic and she also meets the criteria for depression\n", "Anxiety disorder\n", "Attack"], ["There is no anxiety clinic and she also meets the criteria for depression\n", "Major depressive disorder\n", "Support"], ["The poor girl has been diagnosed with depression\n", "Major depressive disorder\n", "Support"], ["The poor girl has been diagnosed with depression\n", "The answer is 5\n", "Support"], ["The answer is 5\n", "Major depressive disorder\n", "Support"], ["A 19-year-old female university student comes to the clinic accompanied by her parents, reporting feeling progressively more asthenic in the last two months, with loss of appetite and weight and with greater difficulty in concentrating on her studies\n", "Major depressive disorder\n", "Support"], ["The anamnesis also highlights that she has lost interest in going out with friends, has ideas of death without self-harming ideation and pessimistic cognitions of the future\n", "Major depressive disorder\n", "Support"]]}
{"530_167": [["We describe the case of a patient with a hyperkalemic emergency\n", "The first step is the administration of iv calcium gluconate to counteract the cardiac toxicity of hyperkalemia (option 3 correct), giving us more time to initiate hypokalemic treatments (initially saline glucose with insulin, salbutamol, furosemide, and assessing dialysis if there is no good response)\n", "Support"], ["potassium >6.5 mmol/l with ECG alterations\n", "The first step is the administration of iv calcium gluconate to counteract the cardiac toxicity of hyperkalemia (option 3 correct), giving us more time to initiate hypokalemic treatments (initially saline glucose with insulin, salbutamol, furosemide, and assessing dialysis if there is no good response)\n", "Support"], ["The first step is the administration of iv calcium gluconate to counteract the cardiac toxicity of hyperkalemia (option 3 correct), giving us more time to initiate hypokalemic treatments (initially saline glucose with insulin, salbutamol, furosemide, and assessing dialysis if there is no good response)\n", "Administration of intravenous calcium gluconate\n", "Support"]]}
{"494_157": [["but what they ask us is what to do to treat the anemia\n", "options 2 and 4 are options to identify the autoimmune disease\n", "Attack"], ["options 2 and 4 are options to identify the autoimmune disease\n", "Antinuclear antibodies\n", "Attack"], ["options 2 and 4 are options to identify the autoimmune disease\n", "Anti-DNA antibodies\n", "Attack"], ["so we should suspect that the anemia is secondary to the autoimmune disease\n", "therefore request a direct Coombs test\n", "Support"], ["since if it is positive the patient, except in extreme cases, will not be transfused and the primary cause should be treated\n", "therefore request a direct Coombs test\n", "Support"], ["therefore request a direct Coombs test\n", "Direct Coombs' test\n", "Support"], ["It also speaks of rapid onset, which in the case of vitamin B12 is more progressive\n", "Vitamin B12\n", "Attack"], ["They comment on the case of a young woman with symptoms of systemic disease of probable autoimmune origin (lupus) who presents with macrocytic anemia\n", "options 2 and 4 are options to identify the autoimmune disease\n", "Support"], ["They comment on the case of a young woman with symptoms of systemic disease of probable autoimmune origin (lupus) who presents with macrocytic anemia\n", "so we should suspect that the anemia is secondary to the autoimmune disease\n", "Support"]]}
{"117_112": [["In addition, with this pH (and knowing that the effusion is already loculated), the endothoracic tube is more than indicated\n", "Intravenous antibiotic therapy and placement of a chest tube or catheter to drain all pleural fluid\n", "Support"], ["During thoracentesis, a yellowish fluid is drawn and analysis shows: leukocytes 15,000/uL, 92% neutrophils, glucose 30 mg/dL, pH 7, lactate dehydrogenase 3500 U/L, adenosine deaminase 45 U/L and absence of germs on GRAM stain\n", "Intravenous antibiotic therapy and placement of a chest tube or catheter to drain all pleural fluid\n", "Support"], ["Chest X-ray shows a loculated right pleural effusion occupying two thirds of the hemithorax\n", "Intravenous antibiotic therapy and placement of a chest tube or catheter to drain all pleural fluid\n", "Support"], ["During thoracentesis, a yellowish fluid is drawn and analysis shows: leukocytes 15,000/uL, 92% neutrophils, glucose 30 mg/dL, pH 7, lactate dehydrogenase 3500 U/L, adenosine deaminase 45 U/L and absence of germs on GRAM stain\n", "Intravenous antibiotic therapy and placement of a chest tube or catheter to drain all pleural fluid\n", "Support"], ["since the clinical picture points to a parapneumonic pleural effusion, the macroscopic characteristics of the fluid seem so and the analysis of it shows us that the effusion is also complicated, almost on the verge of being an empyema (very high LDH, cellularity with predominance of PMN, glucose consumption)\n", "Intravenous antibiotic therapy and placement of a chest tube or catheter to drain all pleural fluid\n", "Support"]]}
{"27_203": [["In this case, given the antibiotic treatment given and the severity of the diarrhea\n", "it seems that we are dealing with a Clostridium infection\n", "Support"], ["in fact, as much as patients with CAP may have associated diarrhea, it is unlikely that a bacterium is sensitive to an antibiotic at the beginning of the picture and stops being so after 3 days\n", "Option 2 is not very credible\n", "Support"], ["in fact, as much as patients with CAP may have associated diarrhea, it is unlikely that a bacterium is sensitive to an antibiotic at the beginning of the picture and stops being so after 3 days\n", "The bacterium itself causing pneumonia that has become resistant to the antibiotic\n", "Attack"], ["In this case, given the antibiotic treatment given and the severity of the diarrhea\n", "Clostridium difficile\n", "Support"], ["After 4 days of stay in the ward, his evolution is complicated by the appearance of a severe diarrhea\n", "Clostridium difficile\n", "Support"]]}
{"471_139": [["He presents with fork dorsum deformity of the wrist and functional impotence, with normal distal neurovascular status\n", "With the deformity and pain in the distal radius, we expect a fracture at this level\n", "Support"], ["With the deformity and pain in the distal radius, we expect a fracture at this level\n", "we mark 3\n", "Support"], ["we mark 3\n", "Epiphysiolysis of the distal radius\n", "Support"], ["With the deformity and pain in the distal radius, we expect a fracture at this level\n", "Epiphysiolysis of the distal radius\n", "Support"], ["However, I see it as unquestionable, given that it could also have a concomitant fracture in the ulnar green stalk\n", "Fracture in green stem of ulna\n", "Support"], ["although the main lesion is that of the radius\n", "Fracture in green stem of ulna\n", "Attack"], ["although the main lesion is that of the radius\n", "However, I see it as unquestionable, given that it could also have a concomitant fracture in the ulnar green stalk\n", "Attack"], ["although the main lesion is that of the radius\n", "With the deformity and pain in the distal radius, we expect a fracture at this level\n", "Support"], ["although the main lesion is that of the radius\n", "Epiphysiolysis of the distal radius\n", "Support"]]}
{"327_81": [["Answer 2 incorrect\n", "Hyperthyroidism due to Graves' disease\n", "Attack"], ["Graves' disease is characterized by hyperthyroidism and one or more of the following features: goiter, exophthalmos and pretibial myxedema\n", "Answer 2 incorrect\n", "Support"], ["Answer 4 incorrect\n", "Subacute thyroiditis\n", "Attack"], ["The most obvious symptom of subacute thyroiditis is neck pain\n", "Answer 4 incorrect\n", "Support"], ["Sometimes, the pain may extend to the jaw or ears\n", "Answer 4 incorrect\n", "Support"], ["In the physical examination she has tachycardia, hyperreflexia and absence of goiter\n", "Graves' disease is characterized by hyperthyroidism and one or more of the following features: goiter, exophthalmos and pretibial myxedema\n", "Attack"], ["Painful enlargement of the thyroid gland can last for weeks or months\n", "Answer 4 incorrect\n", "Support"], ["And you usually have low serum thyroid stimulating hormone (TSH)\n", "Answer 4 incorrect\n", "Support"], ["In the blood test TSH values are < 0.01 microU/mL, T4 is elevated and thyroglobulin levels are low\n", "High serum free T4 level\n", "Support"], ["In the blood test TSH values are < 0.01 microU/mL, T4 is elevated and thyroglobulin levels are low\n", "High serum thyroglobulin level\n", "Attack"], ["High serum thyroglobulin level\n", "Answer 4 incorrect\n", "Support"], ["High serum free T4 level\n", "Answer 4 incorrect\n", "Attack"], ["Incorrect answer 4: Very rare tumor\n", "Ovarian teratoma (ovarian stromal tumor)\n", "Attack"]]}
{"450_154": [["They describe a typical hemisection or Brown-Sequard picture\n", "It is a hemimedullary syndrome\n", "Support"], ["A man presents on neurological examination with a thermoalgesic sensory deficit in the left leg associated with a loss of vibratory and positional sensitivity in the right leg\n", "Ipsilateral posterior motor and chordal involvement with contralateral pain and temperature involvement\n", "Support"], ["At the same time he presents with clumsiness and loss of distal strength in the right leg and a right plantar cutaneous reflex in extension\n", "Ipsilateral posterior motor and chordal involvement with contralateral pain and temperature involvement\n", "Support"], ["Ipsilateral posterior motor and chordal involvement with contralateral pain and temperature involvement\n", "It is a hemimedullary syndrome\n", "Support"]]}
{"265_137": [["Dopler ultrasound is the most accurate test and allows subsequent non-invasive monitoring of the evolution of the disease\n", "Venous Doppler ultrasound\n", "Support"]]}
{"189_71": [["A 10-year-old boy with brief episodes of distractions (< 1 minute) in which he does not respond to calls and blinks\n", "The seizures described and the EEG correspond to typical absence seizures and the initial treatment of choice is valproic acid\n", "Support"], ["An EEG shows spike-wave discharges at 3 cycles per second\n", "The seizures described and the EEG correspond to typical absence seizures and the initial treatment of choice is valproic acid\n", "Support"], ["The seizures described and the EEG correspond to typical absence seizures and the initial treatment of choice is valproic acid\n", "Valproate\n", "Support"]]}
{"508_148": [["Given its benign nature, surgery is not recommended, and is reserved only for symptomatic patients or those in whom the nature of the lesion is in doubt after a complete study with CT, MRI and echoendoscopy with biopsy\n", "Follow-up of the lesion by MRI\n", "Support"]]}
{"151_70": [["The clinical and biological picture of this patient raises suspicion of hemolytic anemia in the context of systemic lupus erythematosus\n", "If we have to choose only one diagnostic test, and this should be the first, we are interested in confirming the presence of an autoimmune hemolytic anemia with the direct Coombs' test in order to initiate treatment\n", "Support"], ["If we have to choose only one diagnostic test, and this should be the first, we are interested in confirming the presence of an autoimmune hemolytic anemia with the direct Coombs' test in order to initiate treatment\n", "Direct Coombs test\n", "Support"], ["A 25-year-old female patient with a history of skin rash after sun exposure and occasional polyarthritis in the joints of the hands, controlled with non-steroidal anti-inflammatory drugs, presents with general malaise, progressive feeling of generalized weakness and pallor for the last 15 days\n", "The clinical and biological picture of this patient raises suspicion of hemolytic anemia in the context of systemic lupus erythematosus\n", "Support"], ["Laboratory tests showed hemoglobin 7 g/dL, MCV 108 mm/h, 150,000 platelets/mm3, 3000 leukocytes/mm3, elevated LDH, undetectable haptoglobin\n", "The clinical and biological picture of this patient raises suspicion of hemolytic anemia in the context of systemic lupus erythematosus\n", "Support"]]}
{"404_139": [["This is a woman with abrupt, painless and severe loss (she only sees the movement of the hands) of vision in one eye\n", "We have to rely on systemic symptoms to diagnose the problem\n", "Support"], ["She does not give us much information from the ocular examination, only that there is an afferent pupillary defect\n", "We have to rely on systemic symptoms to diagnose the problem\n", "Support"], ["This is an elderly woman with typical symptoms of polymyalgia rheumatica\n", "It is giant cell arteritis or temporal arteritis\n", "Support"], ["the pain in the temporomandibular region is very suggestive\n", "It is giant cell arteritis or temporal arteritis\n", "Support"], ["A 70-year-old woman with a history of anorexia, weight loss, discomfort in the musculature and proximal joints plus pain in the temporomandibular region who comes to the emergency department for unilateral loss of vision (hand movement), sudden and painless onset (afferent pupillary defect)\n", "The afferent pupillary defect is very characteristic of these severe ischemic optic neuropathies\n", "Support"], ["It is giant cell arteritis or temporal arteritis\n", "Suspecting giant cell arteritis, there are three analytical markers that are characteristically high: CRP, ESR and platelet count\n", "Support"], ["The most common ocular manifestation is anterior ischemic optic neuropathy\n", "It is giant cell arteritis or temporal arteritis\n", "Support"], ["The afferent pupillary defect is very characteristic of these severe ischemic optic neuropathies\n", "The most common ocular manifestation is anterior ischemic optic neuropathy\n", "Support"], ["In the fundus we would certainly see a papillary edema of that eye, with a gypsum white coloration\n", "The most common ocular manifestation is anterior ischemic optic neuropathy\n", "Support"], ["Suspecting giant cell arteritis, there are three analytical markers that are characteristically high: CRP, ESR and platelet count\n", "C-reactive protein\n", "Support"], ["Suspecting giant cell arteritis, there are three analytical markers that are characteristically high: CRP, ESR and platelet count\n", "We will first request one of these parameters and treat it often without waiting for biopsy confirmation\n", "Support"], ["We will first request one of these parameters and treat it often without waiting for biopsy confirmation\n", "Therefore, option 2 is the correct one\n", "Support"], ["Suspecting giant cell arteritis, there are three analytical markers that are characteristically high: CRP, ESR and platelet count\n", "Therefore, option 2 is the correct one\n", "Support"], ["Therefore, option 2 is the correct one\n", "C-reactive protein\n", "Support"]]}
{"215_106": [["they do not give us the quantification of urine protein (they only tell us that urinalysis reveals the presence of kappa light chains, not the amount)\n", "Option 2, nephrotic syndrome, apart from being broad and nonspecific, would not be assessable\n", "Support"], ["Option 2, nephrotic syndrome, apart from being broad and nonspecific, would not be assessable\n", "Nephrotic syndrome\n", "Attack"], ["A urinalysis reveals the presence of kappa light chains\n", "in amyloidosis, the light chains that are usually deposited are of the lambda type\n", "Attack"], ["in amyloidosis, the light chains that are usually deposited are of the lambda type\n", "Option 3 would be unlikely\n", "Support"], ["Option 3 would be unlikely\n", "Amyloidosis\n", "Attack"], ["in IgA myeloma we would expect a monoclonal peak of this Ig, which in this case does not appear\n", "Option 4 also seems unlikely,\n", "Support"], ["Option 4 also seems unlikely,\n", "IgA myeloma with Bence-Jones proteinuria\n", "Attack"], ["this entity fulfills the characteristics described\n", "I would opt for 1\n", "Support"], ["absence of monoclonal peak in most cases, acute renal failure and presence of kappa chains in urine\n", "this entity fulfills the characteristics described\n", "Support"], ["this entity fulfills the characteristics described\n", "I would opt for 1\n", "Support"], ["being light chain myeloma a somewhat broader entity\n", "I would opt for 1\n", "Support"], ["I would opt for 1\n", "Kappa light chain deposition disease\n", "Support"], ["option 5 could also be considered valid\n", "Light chain myeloma\n", "Support"]]}
{"264_135": [["The acidosis with elevated PCO2, hypoxemia and normal bicarbonate suggests an acute respiratory acidosis of rapid onset probably due to drug intoxication\n", "Pure respiratory acidosis\n", "Support"]]}
{"594_80": [["A 2-month-old infant with an upper respiratory tract cold of 3 days of evolution, who begins with moderate respiratory distress and pulmonary auscultation with expiratory wheezing\n", "We are presented with a case of RSV-positive bronchiolitis\n", "Support"], ["Respiratory syncytial virus is isolated in the nasopharyngeal exudate\n", "We are presented with a case of RSV-positive bronchiolitis\n", "Support"], ["We are presented with a case of RSV-positive bronchiolitis\n", "According to current recommendations, it would be indicated to initiate supplemental oxygen therapy\n", "Support"], ["According to current recommendations, it would be indicated to initiate supplemental oxygen therapy\n", "Supplemental oxygen\n", "Support"]]}
{"236_108": [["Not only thrombocytopenia but also headache, schistocytes, high LDH and high bilirubin\n", "Thrombotic thrombocytopenic purpura\n", "Support"]]}