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+{"274_73": [["This is a grade IIa ulcer (Forrest classification), with a high risk of recurrence\n", "Therefore, endoscopic treatment and hospitalization with intravenous treatment with PPIs (in our setting it is usually omeprazole) for at least 72 hours is clearly indicated\n", "Support"], ["A 52-year-old man with no concomitant diseases comes to the emergency department for melena of 24 hours evolution without hemodynamic repercussions\n", "Surgery is indicated in massive bleeding or bleeding refractory to medical treatment\n", "Attack"]]}
+{"233_104": [["The most frequent cause of microcytic iron deficiency anemia in young women is chronic gynecologic leaks\n", "Gynecological examination\n", "Support"]]}
+[{"315_136": []}]
+{"235_107": [["Antisuppressants seem to be the most suitable\n", "Immunosuppressive therapy with cyclosporine and antithymocyte immunoglobulin\n", "Support"], ["Severe aplastic anemia and not a candidate for allogeneic transplant because of his age\n", "Chemotherapy and if response autologous transplantation of hematopoietic progenitors\n", "Attack"]]}
+[{"429_114": []}]
+[{"540_4": []}]
+{"266_138": [["it could also be correct 2 (echocardiogram) in the case of suspicion of associated cardiopathy, less frequent but also possible\n", "The correct answer could be respiratory polygraphy, especially in the case of an obese patient, which we do not know\n", "Attack"], ["The correct answer could be respiratory polygraphy, especially in the case of an obese patient, which we do not know\n", "Respiratory polygraphy\n", "Support"], ["it could also be correct 2 (echocardiogram) in the case of suspicion of associated cardiopathy, less frequent but also possible\n", "Echocardiogram\n", "Support"]]}
+{"13_150": [["I believe that the correct answer is 4\n", "A cholangioresonance will be performed to delimit the cyst and a laparotomy will be indicated for resection of the cyst and anastomosis of the biliary tract\n", "Support"], ["its treatment is surgical and consists of resection of the cyst and hepaticojejunosotomy\n", "A cholangioresonance will be performed to delimit the cyst and a laparotomy will be indicated for resection of the cyst and anastomosis of the biliary tract\n", "Support"], ["its treatment is surgical and consists of resection of the cyst and hepaticojejunosotomy\n", "I believe that the correct answer is 4\n", "Support"], ["Cholangioresonance is necessary to choose the appropriate technique for the four existing classes of common bile duct cyst (Todani classification)\n", "A cholangioresonance will be performed to delimit the cyst and a laparotomy will be indicated for resection of the cyst and anastomosis of the biliary tract\n", "Support"]]}
+{"299_104": [["I have my doubts between 1 and 2\n", "Mycobacterial cellulitis\n", "Attack"], ["I have my doubts between 1 and 2\n", "Erysipelas\n", "Attack"], ["On the other hand, the case may refer to a severe sepsis with poor initial manifestation at first sight, with incipient rhabdomyolysis and muscle pain\n", "in this case it may be a necrotizing fasciitis, where the most frequently implicated germ is S. pyogenes\n", "Support"], ["in this case it may be a necrotizing fasciitis, where the most frequently implicated germ is S. pyogenes\n", "Streptococcal necrotizing fasciitis\n", "Support"]]}
+{"16_131": [["A 62-year-old man with a history of significant alcohol abuse, carrier of hepatitis C virus, treated with Ibuprofen for tendinitis of the right shoulder, goes to his dermatologist because after spending two weeks on vacation at the beach he notices the appearance of tense blisters on the dorsum of his hands\n", "Porphyria cutanea tarda\n", "Support"], ["On examination, in addition to localization and slight malar hypertrichosis\n", "Porphyria cutanea tarda\n", "Support"], ["60% of patients with PCT are male, many of them drink alcohol in excess, women who develop it are usually treated with drugs containing estrogens\n", "Porphyria cutanea tarda\n", "Support"], ["HCV and HIV infections have been implicated in the precipitation of acquired PCT\n", "Porphyria cutanea tarda\n", "Support"], ["Patients with PCT present with blistering of photoexposed skin, most frequently on the dorsum of the hands and scalp\n", "Porphyria cutanea tarda\n", "Support"], ["In addition to fragility, they may develop hypertrichosis, hyperpigmentation, cicatricial alopecia and sclerodermal induration\n", "Porphyria cutanea tarda\n", "Support"], ["60% of patients with PCT are male, many of them drink alcohol in excess, women who develop it are usually treated with drugs containing estrogens\n", "Porphyria Cutanea Tarda\n", "Support"], ["Most are males with signs of iron overload, this overload reduces the activity of the enzyme uroporphyrinogen decarboxylase, which leads to the elevation of uroporphyrins\n", "Porphyria Cutanea Tarda\n", "Support"], ["HCV and HIV infections have been implicated in the precipitation of acquired PCT\n", "Porphyria Cutanea Tarda\n", "Support"], ["There is a hereditary form with AD pattern\n", "Porphyria Cutanea Tarda\n", "Support"], ["Patients with PCT present with blistering of photoexposed skin, most frequently on the dorsum of the hands and scalp\n", "Porphyria Cutanea Tarda\n", "Support"], ["In addition to fragility, they may develop hypertrichosis, hyperpigmentation, cicatricial alopecia and sclerodermal induration\n", "Porphyria Cutanea Tarda\n", "Support"], ["A 62-year-old man with a history of significant alcohol abuse, carrier of hepatitis C virus, treated with Ibuprofen for tendinitis of the right shoulder, goes to his dermatologist because after spending two weeks on vacation at the beach he notices the appearance of tense blisters on the dorsum of his hands\n", "60% of patients with PCT are male, many of them drink alcohol in excess, women who develop it are usually treated with drugs containing estrogens\n", "Support"], ["A 62-year-old man with a history of significant alcohol abuse, carrier of hepatitis C virus, treated with Ibuprofen for tendinitis of the right shoulder, goes to his dermatologist because after spending two weeks on vacation at the beach he notices the appearance of tense blisters on the dorsum of his hands\n", "Patients with PCT present with blistering of photoexposed skin, most frequently on the dorsum of the hands and scalp\n", "Support"], ["On examination, in addition to localization and slight malar hypertrichosis\n", "In addition to fragility, they may develop hypertrichosis, hyperpigmentation, cicatricial alopecia and sclerodermal induration\n", "Support"], ["A 62-year-old man with a history of significant alcohol abuse, carrier of hepatitis C virus, treated with Ibuprofen for tendinitis of the right shoulder, goes to his dermatologist because after spending two weeks on vacation at the beach he notices the appearance of tense blisters on the dorsum of his hands\n", "HCV and HIV infections have been implicated in the precipitation of acquired PCT\n", "Support"]]}
+{"121_114": [["The correct answer is the fifth one\n", "Trypanosoma cruzi\n", "Support"], ["The cause of Chagas disease is Trypanosoma cruzi.\n", "Trypanosoma cruzi\n", "Support"]]}
+{"241_229": [["Examination is normal, except for the presence of bilateral papilledema\n", "Now the guiding symptom is bilateral papilledema which is indicative of intracranial hypertension\n", "Support"], ["Although he does not comment that a space-occupying lesion has been ruled out, given the normal neurological examination and the other symptoms\n", "it is deduced that it is idiopathic intracranial hypertension or pseudotumor cerebri\n", "Support"], ["Other data suggestive of this entity include: women of reproductive age, obesity, and diplopia (due to involvement of the VI cranial nerve)\n", "it is deduced that it is idiopathic intracranial hypertension or pseudotumor cerebri\n", "Support"], ["A 29-year-old obese woman, with no past history of interest, consults for a month of intense, bilateral, pulsating headache, accompanied by horizontal diplopia and episodes of monocular amaurosis lasting seconds\n", "It is characteristic that the headache and visual blurriness suddenly worsen in the mornings when getting up or changing posture, producing transitory blindness (Neurology, Zarranz)\n", "Support"], ["The lumbar puncture invariably shows an increase in cerebrospinal fluid pressure, so the correct answer is 4\n", "Lumbar puncture\n", "Support"], ["it is deduced that it is idiopathic intracranial hypertension or pseudotumor cerebri\n", "The lumbar puncture invariably shows an increase in cerebrospinal fluid pressure, so the correct answer is 4\n", "Support"], ["It is characteristic that the headache and visual blurriness suddenly worsen in the mornings when getting up or changing posture, producing transitory blindness (Neurology, Zarranz)\n", "The lumbar puncture invariably shows an increase in cerebrospinal fluid pressure, so the correct answer is 4\n", "Support"]]}
+{"576_103": [["A 30-year-old male who consults for unilateral periocular headaches that rapidly progress to become very intense\n", "It is more frequent in males\n", "Support"], ["The pain attacks last 30-60 minutes, occur 2-3 times a day, and are accompanied by tearing in the painful eye and unilateral rhinorrhea\n", "the pain is characteristically unilateral periocular of great intensity, of variable duration, usually minutes, and it associates trigeminoautonomic signs such as rhinorrhea and unilateral conjunctival injection\n", "Support"], ["A 30-year-old male who consults for unilateral periocular headaches that rapidly progress to become very intense\n", "the pain is characteristically unilateral periocular of great intensity, of variable duration, usually minutes, and it associates trigeminoautonomic signs such as rhinorrhea and unilateral conjunctival injection\n", "Support"], ["The preventive treatment par excellence is verapamil associated with a descending corticosteroid regimen, as described in answer 2\n", "Oral prednisone with withdrawal in one month, associated with oral verapamil at a dose of 80-180 mg every 8 hours\n", "Support"], ["It is more frequent in males\n", "They describe a characteristic case of cluster headache\n", "Support"], ["the pain is characteristically unilateral periocular of great intensity, of variable duration, usually minutes, and it associates trigeminoautonomic signs such as rhinorrhea and unilateral conjunctival injection\n", "They describe a characteristic case of cluster headache\n", "Support"]]}
+{"504_87": [["We are presented with a case of PANDAS syndrome, a rare complication of an infection caused by group A beta-hemolytic streptococcus\n", "Beta-hemolytic streptococcus, group A\n", "Support"], ["sudden-onset obsessive-compulsive disorder (OCD) in a 9-year-old boy who also has tics and chorea as neurologic manifestations\n", "We are presented with a case of PANDAS syndrome, a rare complication of an infection caused by group A beta-hemolytic streptococcus\n", "Support"]]}
+{"367_119": [["A normal spirometry and a negative bronchodilator test does not exclude asthma\n", "a methacholine test would confirm the diagnosis, at least of bronchial hyperresponsiveness\n", "Support"], ["the patient's clinical picture is highly suggestive of asthma\n", "a methacholine test would confirm the diagnosis, at least of bronchial hyperresponsiveness\n", "Support"], ["a methacholine test would confirm the diagnosis, at least of bronchial hyperresponsiveness\n", "Methacholine test\n", "Support"]]}
+[{"444_104": []}]
+{"171_226": [["Complementary tests detect the existence of obstructive hypertrophic cardiomyopathy\n", "Our myocardium is thicker than it should be, predominantly in the septum, and it is so thick that it obstructs the LV outflow, producing a \"functional\" stenosis with a pressure gradient\n", "Support"], ["Our objective will be, first of all, to \"relax\" the myocardium: for this purpose, a beta-blocker is recommended, whereas digoxin, as a good positive inotrope, increases the gradient and is contraindicated\n", "Digoxin is useful to reduce the subaortic gradient\n", "Attack"], ["Sport is not highly recommended, given the increased risk of sudden death associated with this pathology\n", "Abandonment of competitive sport should be recommended\n", "Support"], ["Regarding number 5, it is true: it is convenient to perform a careful exploration and an ECG in the relatives of patients with hypertrophy\n", "Given the hereditary nature of the pathology, a screening study should be performed in the rest of the direct relatives\n", "Support"], ["And if we have a fat septum, which protrudes into the LV cavity, it is not advisable to perform volume depletion, since we would also be increasing the gradient\n", "Diuretics should be avoided or used with great care\n", "Support"]]}
+{"555_51": [["In addition, this antiemetic agent provides relief through antagonism of central and peripheral dopamine receptors\n", "Metoclopramide\n", "Support"], ["Physiologically, it accelerates intestinal transit by increasing the tone and amplitude of gastric contractions, increases lower esophageal sphincter pressure and improves antropyloroduodenal coordination\n", "Metoclopramide\n", "Support"], ["It acts as a prokinetic by its antagonistic effect on dopamine 2 (D2) receptors promoting gastric emptying and, in addition, binds to the 5-hydroxytryptamine 4 receptor (serotonin 5-HT4) to stimulate cholinergic nerve pathways in the stomach\n", "Metoclopramide\n", "Support"], ["It was approved as a treatment for gastroparesis by the US Food and Drug Administration (FDA) in 1979 and remains the first-line drug\n", "Metoclopramide\n", "Support"]]}
+{"320_142": [["There is no treatment for this disease, only treatment for flare-ups (colchicine, NSAIDs or corticosteroids)\n", "Once the acute flare-up has passed, treatment with allopurinol should be started to reduce the incidence of new arthritis flare-ups in the future\n", "Attack"], ["Allopurinol has not shown any efficacy in this microcrystal arthropathy, but it has shown efficacy in gout\n", "Once the acute flare-up has passed, treatment with allopurinol should be started to reduce the incidence of new arthritis flare-ups in the future\n", "Attack"]]}
+{"617_119": [["We are presented with the case of a 13 year old patient, with menarche 3 months ago, a T4-L1 thoracolumbar curve of 35\u00ba and a Risser 0\n", "As a general rule we could say that below 50\u00ba the treatment is usually conservative, with two options: observation or use of a brace to slow down the evolution\n", "Support"], ["As a general rule we could say that below 50\u00ba the treatment is usually conservative, with two options: observation or use of a brace to slow down the evolution\n", "In this case, taking into account the remaining growth (menarche 3 months ago and Risser 0) the most indicated would be to use a brace\n", "Support"], ["menarche 3 months ago and Risser 0\n", "In this case, taking into account the remaining growth (menarche 3 months ago and Risser 0) the most indicated would be to use a brace\n", "Support"], ["In this case, taking into account the remaining growth (menarche 3 months ago and Risser 0) the most indicated would be to use a brace\n", "Answer 2 correct\n", "Support"], ["Answer 2 correct\n", "Prescribe a brace type orthosis\n", "Support"]]}
+{"146_231": [["The correct answer is 5\n", "Measles\n", "Support"], ["The clue is in the whitish lesions of the jugal mucosa corresponding to Koplik's spots, which are pathognomonic of measles, although as an observation I would say that they usually appear in the prodromal phase of the disease and are often no longer seen when the exanthema appears\n", "Measles\n", "Support"], ["On oropharyngeal examination there are whitish spots in the jugal mucosa\n", "Measles\n", "Support"], ["In this case you are describing measles complicated by pneumonia\n", "Measles\n", "Support"]]}
+{"467_92": [["A woman presenting with difficulty walking after gynecologic surgery\n", "The femoral nerve (although rare) may be damaged in a cesarean section, hysterectomy or lower abdominal operation\n", "Support"], ["On examination she has weakness in hip flexion and knee extension, and dysesthesias in the anterior aspect of the thigh\n", "This nerve injury produces hypoesthesia and weakness along its distribution\n", "Support"], ["The femoral nerve (although rare) may be damaged in a cesarean section, hysterectomy or lower abdominal operation\n", "Femoral nerve neuropathy\n", "Support"], ["This nerve injury produces hypoesthesia and weakness along its distribution\n", "Femoral nerve neuropathy\n", "Support"], ["On examination she has weakness in hip flexion and knee extension, and dysesthesias in the anterior aspect of the thigh\n", "Femoroneuropathy is manifested by paralysis (25% of cases) of the quadriceps muscles, abolition of patellar reflexes and hypoesthesia of the anterior and inner thigh\n", "Support"], ["Femoroneuropathy is manifested by paralysis (25% of cases) of the quadriceps muscles, abolition of patellar reflexes and hypoesthesia of the anterior and inner thigh\n", "Femoral nerve neuropathy\n", "Support"], ["The femoral nerve (although rare) may be damaged in a cesarean section, hysterectomy or lower abdominal operation\n", "Therefore, answer 1 is correct\n", "Support"], ["This nerve injury produces hypoesthesia and weakness along its distribution\n", "Therefore, answer 1 is correct\n", "Support"], ["Femoroneuropathy is manifested by paralysis (25% of cases) of the quadriceps muscles, abolition of patellar reflexes and hypoesthesia of the anterior and inner thigh\n", "Therefore, answer 1 is correct\n", "Support"], ["Therefore, answer 1 is correct\n", "Femoral nerve neuropathy\n", "Support"], ["She has mild thigh pain and leg failure on support\n", "it would not explain the motor problem of gait\n", "Support"], ["it would not explain the motor problem of gait\n", "The femoral cutaneous or lateral femoral cutaneous nerve (L2,L3) is only sensitive and is responsible for the sensitivity of the skin of the lateral and anterior aspect of the thigh up to the knee\n", "Support"], ["it would not explain the motor problem of gait\n", "2 is false\n", "Support"], ["The femoral cutaneous or lateral femoral cutaneous nerve (L2,L3) is only sensitive and is responsible for the sensitivity of the skin of the lateral and anterior aspect of the thigh up to the knee\n", "2 is false\n", "Support"], ["2 is false\n", "Meralgia paresthetica of the femoral cutaneous nerve\n", "Attack"], ["On examination she has weakness in hip flexion and knee extension, and dysesthesias in the anterior aspect of the thigh\n", "The femoral cutaneous or lateral femoral cutaneous nerve (L2,L3) is only sensitive and is responsible for the sensitivity of the skin of the lateral and anterior aspect of the thigh up to the knee\n", "Attack"], ["At the motor level, it invests the obturator externus, pectineus, short approximator, the approximators (adductors) and gracilis\n", "The obturator nerve (L2-L4) is a mixed nerve\n", "Support"], ["At the sensory level the capsule of the coxofemoral joint, medial aspect of the thigh above the knee\n", "The obturator nerve (L2-L4) is a mixed nerve\n", "Support"], ["Therefore neither affects the sensitivity of the anterior aspect of the thigh nor the extension of the knee so that 3 is false\n", "Obturator nerve neuropathy\n", "Attack"], ["At the motor level, it invests the obturator externus, pectineus, short approximator, the approximators (adductors) and gracilis\n", "Therefore neither affects the sensitivity of the anterior aspect of the thigh nor the extension of the knee so that 3 is false\n", "Support"], ["At the sensory level the capsule of the coxofemoral joint, medial aspect of the thigh above the knee\n", "Therefore neither affects the sensitivity of the anterior aspect of the thigh nor the extension of the knee so that 3 is false\n", "Support"], ["A lesion of the sciatic nerve at motor level affects to the flexion of the knee not to its extension and at distal level to this one (they do not count anything of distal clinic) and at sensitive level also it is distal in the external face of the leg and in the foot reason why 4 also is false\n", "Neuropathy of the sciatic nerve\n", "Attack"], ["On examination she has weakness in hip flexion and knee extension, and dysesthesias in the anterior aspect of the thigh\n", "A lesion of the sciatic nerve at motor level affects to the flexion of the knee not to its extension and at distal level to this one (they do not count anything of distal clinic) and at sensitive level also it is distal in the external face of the leg and in the foot reason why 4 also is false\n", "Support"]]}
+[{"423_89": []}]
+{"449_151": [["Neurologic examination shows vertical gaze palsy and MRI shows a contrast-enhancing lesion in the pineal region obstructing the aqueduct of Sylvius\n", "Germinal tumors are the most frequent in children in the pineal region\n", "Support"], ["Germinal tumors are the most frequent in children in the pineal region\n", "Germ cell tumor\n", "Support"], ["A 13-year-old boy presents with subacute headache and diplopia\n", "Glioblastomas usually occur in adults at the lobar level\n", "Attack"], ["Neurologic examination shows vertical gaze palsy and MRI shows a contrast-enhancing lesion in the pineal region obstructing the aqueduct of Sylvius\n", "Glioblastomas usually occur in adults at the lobar level\n", "Attack"], ["Glioblastomas usually occur in adults at the lobar level\n", "Glioblastoma\n", "Attack"], ["Neurologic examination shows vertical gaze palsy and MRI shows a contrast-enhancing lesion in the pineal region obstructing the aqueduct of Sylvius\n", "medulloblastomas are the most frequent malignant tumors at the posterior fossa level in children (vermis and roof of the IV ventricle) but rare at the pineal level\n", "Attack"], ["medulloblastomas are the most frequent malignant tumors at the posterior fossa level in children (vermis and roof of the IV ventricle) but rare at the pineal level\n", "Medulloblastoma\n", "Attack"], ["A 13-year-old boy presents with subacute headache and diplopia\n", "meningiomas are rare in children and also in the pineal region\n", "Attack"], ["Neurologic examination shows vertical gaze palsy and MRI shows a contrast-enhancing lesion in the pineal region obstructing the aqueduct of Sylvius\n", "meningiomas are rare in children and also in the pineal region\n", "Attack"], ["meningiomas are rare in children and also in the pineal region\n", "Meningioma\n", "Attack"]]}
+{"433_118": [["The dog is domestic, known and can be monitored\n", "we would have to wait for the observation period to pass and prophylaxis is not recommended\n", "Support"], ["we would have to wait for the observation period to pass and prophylaxis is not recommended\n", "At this point we will only have to worry about the possible bacteremia that may be occurring in a patient with the possibility of high risk due to asplenia\n", "Support"], ["The treatment of choice in dog bite is amoxicillin/clavulanic acid but it is not available\n", "we can use another treatment such as clindamycin plus cephalosporin or clindamycin + moxifloxacin but it is not contemplated among the alternatives\n", "Support"], ["At this point we will only have to worry about the possible bacteremia that may be occurring in a patient with the possibility of high risk due to asplenia\n", "The treatment of choice in dog bite is amoxicillin/clavulanic acid but it is not available\n", "Support"], ["the correct answer is 3, because of the second part of the question\n", "In a first attempt we answered 4\n", "Attack"], ["it is a high risk patient with incipient signs of sepsis\n", "the correct answer is 3, because of the second part of the question\n", "Support"], ["it is a high risk patient with incipient signs of sepsis\n", "he should be sent to the hospital\n", "Support"], ["he should be sent to the hospital\n", "Give 400 mg of oral moxifloxacin and send to hospital\n", "Support"], ["if it was in Ceuta or Melilla the protocol may vary\n", "It could be challenged since they do not say in which community the bite occurred\n", "Support"]]}
+{"337_31": [["The answer is 3, mature cystic teratoma\n", "Mature cystic teratoma\n", "Support"], ["20-year-old woman with ovarian tumor of 15 cm, solid-cystic, detected by ultrasound after presenting with unspecific abdominal symptoms\n", "This is due to the characteristics of the tumor: mature teratomas are constituted by adult tissues, coming from the three embryonic leaves, with a clear predominance of ectodermal elements (epidermis, pilosebaceous structures and neural tissue)\n", "Support"], ["In the histopathological study of the corresponding specimen, teeth, hairs, areas of intestinal epithelium, areas of squamous epithelium (15%) and bronchial epithelium, as well as neuroectodermal and embryonic elements are found in several of the histological preparations\n", "This is due to the characteristics of the tumor: mature teratomas are constituted by adult tissues, coming from the three embryonic leaves, with a clear predominance of ectodermal elements (epidermis, pilosebaceous structures and neural tissue)\n", "Support"], ["This is due to the characteristics of the tumor: mature teratomas are constituted by adult tissues, coming from the three embryonic leaves, with a clear predominance of ectodermal elements (epidermis, pilosebaceous structures and neural tissue)\n", "The answer is 3, mature cystic teratoma\n", "Support"]]}
+{"296_17": [["tachypnea, tugging, low saturation, cyanosis, diaphoresis, tachycardia, deviated trachea and absence of vesicular murmur\n", "Physical examination suggests a pneumothorax\n", "Support"], ["the rupture of a bulla although it is related to the appearance of abrupt symptoms does not go hand in hand with the other symptoms\n", "Subpleural emphysematous bulla rupture\n", "Attack"], ["you have to look for something that explains everything or almost everything\n", "the rupture of a bulla although it is related to the appearance of abrupt symptoms does not go hand in hand with the other symptoms\n", "Support"], ["pneumonia although it is true that it can be related to many of the symptoms does not correlate with the image\n", "Community-acquired necrotizing bacterial pneumonia\n", "Attack"], ["the clearest option goes for pneumonia due to P. jirovecii pneumonia\n", "Pulmonary TB could be manifested with all of the above and cause a pneumothorax\n", "Attack"], ["Pulmonary TB could be manifested with all of the above and cause a pneumothorax\n", "Pulmonary tuberculosis\n", "Support"], ["the clearest option goes for pneumonia due to P. jirovecii pneumonia\n", "Pulmonary tuberculosis\n", "Attack"], ["the clearest option goes for pneumonia due to P. jirovecii pneumonia\n", "Pneumocystis jiroveci pneumonia\n", "Support"], ["a patient with a respiratory picture with more than 7 days of evolution that is complicated abruptly,\n", "the clearest option goes for pneumonia due to P. jirovecii pneumonia\n", "Support"], ["a patient with a high suspicion of HIV\n", "the clearest option goes for pneumonia due to P. jirovecii pneumonia\n", "Support"], ["In patients with Pneumocystis, 10%, pneumatoceles appear which can sometimes open into the pleural space producing a spontaneous pneumothorax\n", "the clearest option goes for pneumonia due to P. jirovecii pneumonia\n", "Support"], ["s a reminder, the most frequent germs in pulmonary involvement in patients with HIV/AIDS infection are P. jiroveci (alone or associated with tuberculosis or other mycobacteria), S. pneumoniae, H. influenzae, S. aureus, cytomegalovirus, Legionella, staphylococci and gram-negative bacilli (Pseudomonas)\n", "the clearest option goes for pneumonia due to P. jirovecii pneumonia\n", "Support"]]}
+{"76_87": [["the clinical picture is not one of heart failure\n", "Option 2 is immediately ruled out\n", "Support"], ["Option 2 is immediately ruled out\n", "Cardiac failure\n", "Attack"], ["it does not fit with the clinical picture\n", "Option 3 is also discarded\n", "Support"], ["in addition HSD would give neurological symptoms with locality\n", "Option 3 is also discarded\n", "Support"], ["obstructive renal failure does not give polyuria, dysuria or the rest of the clinical picture\n", "Option 4 is discarded\n", "Support"], ["Option 3 is also discarded\n", "Subdural hematoma\n", "Attack"], ["Option 4 is discarded\n", "Obstructive renal failure\n", "Attack"], ["Option 5 is less likely\n", "Diabetic ketoacidosis with coma\n", "Attack"], ["diabetic ketoacidosis is more typical of type 1 DM\n", "Option 5 is less likely\n", "Support"], ["the correct option is 1\n", "Hyperglycemic hyperosmolar non-ketotic hyperglycemic coma\n", "Support"]]}
+{"159_111": [["Abdominal X-ray is the first imaging study to be performed because it is fast, simple and practically innocuous (except in children and pregnant women)\n", "Simple abdominal X-ray\n", "Support"], ["However, it has a lower yield than the others\n", "Simple abdominal X-ray\n", "Attack"], ["It is a mandatory test in any suspicion of colic pain\n", "Simple abdominal X-ray\n", "Support"], ["90% of the stones are radiopaque and therefore visible, but the sensitivity of this test, used in isolation, decreases to 45-59%\n", "Simple abdominal X-ray\n", "Attack"], ["A 45-year-old male patient with a history of uric lithiasis with repeated expulsive nephritic colic for 25 years, comes to the ED referring palpitations and intense right lumbar pain since 2 hours before\n", "Although the urological history speaks of uric lithiasis (radiotransparent), with an acid pH that reaffirms the diagnosis of uric origin, we can never rule out calcium oxalate lithiasis that can appear synchronously\n", "Support"], ["Urinalysis showed a pH of 5.5 and leukocyturia without proteinuria\n", "Although the urological history speaks of uric lithiasis (radiotransparent), with an acid pH that reaffirms the diagnosis of uric origin, we can never rule out calcium oxalate lithiasis that can appear synchronously\n", "Support"], ["IVUS seems to me to be one of the best performing options\n", "IVU\n", "Support"], ["It will give us diagnostic clarity of obstruction, its magnitude and its renal repercussions\n", "IVUS seems to me to be one of the best performing options\n", "Support"], ["It has long been considered the examination of choice for the study of patients with renal lithiasis.\n", "IVUS seems to me to be one of the best performing options\n", "Support"], ["It is a test with high sensitivity and specificity (87-90% and 94-100%, respectively), relatively innocuous, and available in all hospitals\n", "IVUS seems to me to be one of the best performing options\n", "Support"], ["It informs us of the number, size, shape and location of the stone, as well as the functional status of the affected kidney\n", "IVUS seems to me to be one of the best performing options\n", "Support"], ["Contrast-enhanced CT seems to me to be the most efficient option\n", "CT with contrast\n", "Support"], ["It serves to discover lithiasis that other tests cannot find and gives us a global image of the rest of the structures\n", "Contrast-enhanced CT seems to me to be the most efficient option\n", "Support"], ["Great performance but also more expensive, more time, more radiation\n", "Contrast-enhanced CT seems to me to be the most efficient option\n", "Attack"], ["It has been confirmed as a high sensitivity and specificity scan, surpassing previous tests (94-100% and 92-100%, respectively, for the detection of ureteral calculi) and with its numerous advantages it has become the reference test and is expected to replace IVUS and ultrasound worldwide\n", "Contrast-enhanced CT seems to me to be the most efficient option\n", "Support"], ["It has been confirmed as a high sensitivity and specificity scan, surpassing previous tests (94-100% and 92-100%, respectively, for the detection of ureteral calculi) and with its numerous advantages it has become the reference test and is expected to replace IVUS and ultrasound worldwide\n", "IVU\n", "Attack"], ["It performs a helical scan with 5 mm slices allowing the detection of stones up to 2 mm\n", "Contrast-enhanced CT seems to me to be the most efficient option\n", "Support"], ["With the administration of contrast, it allows the evaluation of renal function\n", "Contrast-enhanced CT seems to me to be the most efficient option\n", "Support"], ["Ultrasound is a fast, cheap and innocuous test, but very radiologist-dependent\n", "Abdominal echography\n", "Attack"], ["It gives great renal information on obstructive repercussions, but less quality in terms of finding a lithiasis.\n", "Abdominal echography\n", "Attack"], ["Ultrasonography only detects calculi larger than 4 mm, located in the pyelo-ureteral junction or the uretero-vesical junction, while the lumbar and pelvic ureter is not very accessible due to the interposition of the intestinal loops\n", "Abdominal echography\n", "Attack"], ["Therefore, ultrasound performed in isolation is not very sensitive (20-45%) for the detection of calculi, but associated with simple abdominal radiography increases its sensitivity and specificity\n", "Simple abdominal X-ray\n", "Support"], ["Therefore, ultrasound performed in isolation is not very sensitive (20-45%) for the detection of calculi, but associated with simple abdominal radiography increases its sensitivity and specificity\n", "Abdominal echography\n", "Support"], ["Doppler echocardiography has no use in urological diagnosis\n", "Doppler echocardiography\n", "Attack"], ["My answer would be CT with ev contrast and excretory phase (answer (c)), in terms of performance, sensitivity and specificity\n", "CT with contrast\n", "Support"], ["Without forgetting that abdominal X-ray should always be done in the suspicion of colic\n", "Simple abdominal X-ray\n", "Support"]]}
+{"52_144": [["The relative mildness of the symptoms, which do not seriously interfere with daily activities, excludes in principle the diagnosis of major depression\n", "Major depression\n", "Attack"], ["There is no evidence of hypomanic phases to justify a bipolar II disorder\n", "Bipolar II disorder\n", "Attack"], ["Dysthymia requires a duration of at least two years\n", "Dysthymia\n", "Attack"], ["what used to be cyclothymics are now called bipolar, contributing to one of the multiple psychiatric epidemics of our time\n", "Cyclothymia is a very rare diagnosis nowadays\n", "Support"], ["But there are no data on such oscillations\n", "which consists of oscillations between the depressive pole and the manifest, mild\n", "Support"], ["Cyclothymia is a very rare diagnosis nowadays\n", "Cyclothymia\n", "Attack"], ["The correct answer is, in all probability, 3\n", "Adjustment disorder\n", "Support"], ["The adaptive disorder appears within 3 months after the stressful event and does not last more than 6 months if the stressful event or its consequences have ceased (which is not the case because the brother of the imaginary patient is still dead)\n", "The correct answer is, in all probability, 3\n", "Support"], ["He reports presenting with anxious symptoms and depressive mood for the last 10 months\n", "The adaptive disorder appears within 3 months after the stressful event and does not last more than 6 months if the stressful event or its consequences have ceased (which is not the case because the brother of the imaginary patient is still dead)\n", "Support"]]}
+{"297_50": [["Of the microorganisms discussed, Microsporum gypseum does not usually manifest dissemination of infection of a lymphangitic aspect\n", "Dermatophytosis by Microsporum gypseum\n", "Attack"], ["in general keratinophilic fungi (dermatophytes) do not have any ability to invade deep tissues\n", "Dermatophytosis by Microsporum gypseum\n", "Attack"], ["we ruled out this option\n", "Dermatophytosis by Microsporum gypseum\n", "Attack"], ["in general keratinophilic fungi (dermatophytes) do not have any ability to invade deep tissues\n", "we ruled out this option\n", "Support"], ["Of the microorganisms discussed, Microsporum gypseum does not usually manifest dissemination of infection of a lymphangitic aspect\n", "we ruled out this option\n", "Support"], ["Staphylococcus aureus infection can affect superficial and deep tissue layers, they can spread following a lymphangitic path, but it is not usual such a long evolution, it is usually acute (days) and usually accompanied by systemic symptoms\n", "we discard this option\n", "Support"], ["we discard this option\n", "Cutaneous infection by Staphylococcus aureus\n", "Attack"], ["Staphylococcus aureus infection can affect superficial and deep tissue layers, they can spread following a lymphangitic path, but it is not usual such a long evolution, it is usually acute (days) and usually accompanied by systemic symptoms\n", "Cutaneous infection by Staphylococcus aureus\n", "Attack"], ["Our patient has no history of exposure to fish or water (they don't say)\n", "considering that usually the diagnosis is based on a high index of suspicion and specifically asking for this history, our case is far from this possibility\n", "Support"], ["considering that usually the diagnosis is based on a high index of suspicion and specifically asking for this history, our case is far from this possibility\n", "Cutaneous infection by Mycobacterium marinum\n", "Attack"], ["Infection in humans occurs by direct contact with fish or contaminated water in the presence of a loss of continuity in the skin of the host.\n", "considering that usually the diagnosis is based on a high index of suspicion and specifically asking for this history, our case is far from this possibility\n", "Support"], ["The patient carries out an activity in contact with soil and plants (which are not provided free of charge)\n", "The Sporothrix schenckii complex is the causative agent of Sporotrichosis, this dimorphic fungus is located in the soil, the complex is formed by 5 species, S. schenckii sensu strictu, S. brasiliensis and S. globosa, capable of causing human and animal disease; the other two are S. mexicana and S. albicana not associated with any disease\n", "Support"], ["Patients are usually infected by exposure to soil by means of a sharp object (thorns, stems, animal claws, etc.) and have a slow evolution, affect deep tissues and their dissemination typically follows a pathway as described in the question\n", "Sporotrichosis\n", "Support"]]}
+{"74_63": [["The separate findings are: normal pH but with alkalosis tendency, acute respiratory failure, hypocapnia and normal bicarbonate\n", "The most appropriate answer seems to me to be 1\n", "Support"], ["the patient does not present a metabolic alkalosis (bicarbonate would be higher), much less an acidosis (bicarbonate would be low)\n", "The most appropriate answer seems to me to be 1\n", "Support"], ["The alkalosis is not mixed either, but is mainly respiratory\n", "The most appropriate answer seems to me to be 1\n", "Support"], ["The patient is probably hyperventilating because of her respiratory failure\n", "The most appropriate answer seems to me to be 1\n", "Support"], ["the kidney which always compensates later is starting to retain HCO3 to compensate and maintain pH\n", "The most appropriate answer seems to me to be 1\n", "Support"], ["The most appropriate answer seems to me to be 1\n", "Hypoxemic respiratory failure with compensated respiratory alkalosis\n", "Support"], ["the patient does not present a metabolic alkalosis (bicarbonate would be higher), much less an acidosis (bicarbonate would be low)\n", "Acute metabolic alkalosis with hypoxemic and hypocapnic respiratory failure\n", "Attack"], ["the patient does not present a metabolic alkalosis (bicarbonate would be higher), much less an acidosis (bicarbonate would be low)\n", "Chronic hypoxemic respiratory failure with compensated metabolic acidosis\n", "Attack"], ["The alkalosis is not mixed either, but is mainly respiratory\n", "Hypoxemic respiratory failure with compensated mixed alkalosis\n", "Attack"], ["I believe the correct answer is 1\n", "Hypoxemic respiratory failure with compensated respiratory alkalosis\n", "Support"]]}
+[{"288_227": []}]
+{"460_174": [["Everything points to adhesive capsulitis, as you say\n", "Adhesive capsulitis\n", "Support"], ["The age, the sex, the clinic... the DM....\n", "Everything points to adhesive capsulitis, as you say\n", "Support"], ["A 60-year-old, insulin-dependent diabetic woman presents with right-sided, nocturnal-predominant omalgia of several weeks' duration\n", "The age, the sex, the clinic... the DM....\n", "Support"]]}
+{"333_90": [["Thyroglobulin is synthesized in the follicular cells and then secreted into the circulation\n", "therefore, after total thyroidectomy it should disappear\n", "Support"], ["therefore, after total thyroidectomy it should disappear\n", "if this does not occur we must think about the existence of remnants of metastatic tissue\n", "Support"], ["if this does not occur we must think about the existence of remnants of metastatic tissue\n", "Delay initiation of TSH replacement-suppressive treatment with levothyroxine and refer the patient to the Nuclear Medicine service for administration of an ablative dose of 100 mCi of I131\n", "Support"]]}
+{"185_66": [["In this case there are important data such as the history of intestinal resection, hypocalcemia and hypophosphoremoia; this should lead us to think in a vitamin D deficit due to malabsorption and therefore, in an osteomalacia\n", "Osteomalacia\n", "Support"], ["The rest of the data: previous fracture, pain and the X-ray support the diagnosis\n", "Osteomalacia\n", "Support"], ["He had suffered a Colles' fracture three months earlier.\n", "The rest of the data: previous fracture, pain and the X-ray support the diagnosis\n", "Support"], ["A 74-year-old patient with bowel resection following mesenteric thrombosis comes to consult for fatigue and bone pain\n", "The rest of the data: previous fracture, pain and the X-ray support the diagnosis\n", "Support"], ["Radiographs of the femur show radiolucent bands perpendicular to the cortex on the inner side of the upper femur\n", "The rest of the data: previous fracture, pain and the X-ray support the diagnosis\n", "Support"]]}
+{"107_206": [["The first step is to detect the mutation and once detected, if the mother is a carrier, to proceed with PGD.\n", "t is indicated after detection of the causative mutation in the index case and eventually in his mother\n", "Support"]]}
+{"114_96": [["A woman with pancytopenia\n", "Acute promyelocytic leukemia\n", "Support"], ["A bone marrow showing massive infiltration by immature elements that are proliferating non-stop...with Auer's canes\n", "Acute promyelocytic leukemia\n", "Support"], ["Acute promyelocytic leukemia\n", "Acute promyelocytic leukemia\n", "Support"], ["Those rods are the fusion of primary granules of developing myelocytes\n", "A bone marrow showing massive infiltration by immature elements that are proliferating non-stop...with Auer's canes\n", "Support"]]}
+{"61_92": [["From the symptoms reported, tingling in the anterior thigh, scrotum and dysesthesia in the feet\n", "there seems to be a vertebral involvement at L2-3 and sacral roots\n", "Support"], ["there seems to be a vertebral involvement at L2-3 and sacral roots\n", "the correct thing to do would be to perform a radiological examination without mobilizing the patient\n", "Support"], ["the correct thing to do would be to perform a radiological examination without mobilizing the patient\n", "But it is necessary to mobilize him to explore him, obviously, en bloc\n", "Attack"], ["the patient mobilizes both arms adequately, without paresthesia\n", "The cervical spine seems to be undamaged\n", "Support"], ["But it is necessary to mobilize him to explore him, obviously, en bloc\n", "Palpate the abdomen and rotate it en bloc to palpate the thoracolumbar spine\n", "Support"], ["The cervical spine seems to be undamaged\n", "We will sit him on the stretcher to be able to explore the cervical spine\n", "Attack"], ["the patient mobilizes both arms adequately, without paresthesia\n", "We will sit him on the stretcher to be able to explore the cervical spine\n", "Support"]]}
+{"231_180": [["Bile duct atresia is the main indication for infant liver transplantation\n", "Bile duct atresia\n", "Support"], ["The increase in direct bilirubin immediately rules out the rest of the options\n", "Breastfeeding jaundice\n", "Attack"], ["The increase in direct bilirubin immediately rules out the rest of the options\n", "Late onset 0-A isoimmunization\n", "Attack"], ["The increase in direct bilirubin immediately rules out the rest of the options\n", "Gilbert's disease\n", "Attack"], ["The increase in direct bilirubin immediately rules out the rest of the options\n", "Hereditary spherocytosis\n", "Attack"], ["the increase in total bilirubin would be at the expense of indirect bilirubin\n", "The increase in direct bilirubin immediately rules out the rest of the options\n", "Support"]]}
+{"87_54": [["Elderly patient with clinical dyspnea and syncope, and systolic murmur radiating to carotids and tip, all typical of this disease\n", "They are describing the \"portrait\" of a degenerative aortic stenosis\n", "Support"], ["They are describing the \"portrait\" of a degenerative aortic stenosis\n", "Degenerative aortic stenosis\n", "Support"]]}
+[{"102_87": []}]
+{"512_153": [["The treatment of choice for Clostridioides difficile infection is vancomycin orally 125mg/6h for 10 days\n", "Change metronidazole for oral vancomycin (125 mg, four times a day for 10 days)\n", "Support"], ["Metronidazole has been relegated to situations where vancomycin is not available\n", "Change metronidazole for oral vancomycin (125 mg, four times a day for 10 days)\n", "Support"], ["He was diagnosed with Clostridium difficile colitis, amoxicillin/clavulanic acid was discontinued and metronidazole was prescribed\n", "The treatment of choice for Clostridioides difficile infection is vancomycin orally 125mg/6h for 10 days\n", "Support"]]}
+[{"218_123": []}]
+{"493_107": [["If they wanted us to answer that it is a TTP (answer 1) they would probably associate anemia and in the smear they would surely tell us about schistocytes\n", "Thrombotic thrombocytopenic purpura\n", "Attack"], ["Not to say that the patient's symptoms would probably be much more than epistaxis\n", "If they wanted us to answer that it is a TTP (answer 1) they would probably associate anemia and in the smear they would surely tell us about schistocytes\n", "Support"]]}
+{"566_149": [["She currently has a creatinine of 3.2 mg/dL with estimated glomerular filtration rate (CKD-EPI) 14 ml/min\n", "A glomerular filtration rate of less than 15 ml/min is classified as stage 5 (G5)\n", "Support"], ["A glomerular filtration rate of less than 15 ml/min is classified as stage 5 (G5)\n", "the renal disease is end-stage\n", "Support"], ["the renal disease is end-stage\n", "He has stage 5 chronic kidney disease and renal replacement therapy should be considered\n", "Support"], ["A glomerular filtration rate of less than 15 ml/min is classified as stage 5 (G5)\n", "the initiation of replacement therapy should be considered\n", "Support"], ["the initiation of replacement therapy should be considered\n", "He has stage 5 chronic kidney disease and renal replacement therapy should be considered\n", "Support"], ["option 2 true\n", "He has stage 5 chronic kidney disease and renal replacement therapy should be considered\n", "Support"], ["the renal disease is end-stage\n", "option 2 true\n", "Support"], ["the renal disease is end-stage\n", "option 1 false\n", "Support"], ["the initiation of replacement therapy should be considered\n", "option 2 true\n", "Support"], ["the initiation of replacement therapy should be considered\n", "option 1 false\n", "Support"], ["option 1 false\n", "He presents stage 3 chronic kidney disease and should initiate phosphorus chelators\n", "Attack"], ["the renal disease is end-stage\n", "He presents stage 3 chronic kidney disease and should initiate phosphorus chelators\n", "Attack"], ["In this situation, good glycemic control is not expected to reverse renal damage, although it may help to delay progression\n", "false choice 3\n", "Support"], ["In this situation, good glycemic control is not expected to reverse renal damage, although it may help to delay progression\n", "Good glycemic control can reverse renal failure\n", "Attack"], ["false choice 3\n", "Good glycemic control can reverse renal failure\n", "Attack"], ["These patients usually present stage A3 albuminuria (above 300 mg/24 h), and may reach the nephrotic range\n", "false choice 4\n", "Support"], ["These patients usually present stage A3 albuminuria (above 300 mg/24 h), and may reach the nephrotic range\n", "It is unlikely to present proteinuria higher than 500 mg/24 h\n", "Attack"], ["false choice 4\n", "It is unlikely to present proteinuria higher than 500 mg/24 h\n", "Attack"]]}
+{"254_89": [["Laboratory tests show normal ALT, AST, GGT and FA, with total bilirubin of 3.2 mg/dl and direct bilirubin of 0.4 mg/dl\n", "An increase in indirect bilirubin less than 5 (intermittently, under stress) in a young healthy boy should make us think of Gilbert's syndrome\n", "Support"], ["A 17-year-old boy, athletic and with no history of interest, comes to the doctor for occasional conjunctival jaundice\n", "An increase in indirect bilirubin less than 5 (intermittently, under stress) in a young healthy boy should make us think of Gilbert's syndrome\n", "Support"], ["In Rotor syndrome, Dubin-Johnson syndrome and choledocholithiasis there is an increase in direct bilirubin\n", "Rotor syndrome\n", "Attack"], ["An increase in indirect bilirubin less than 5 (intermittently, under stress) in a young healthy boy should make us think of Gilbert's syndrome\n", "Gilbert's syndrome\n", "Support"], ["In Rotor syndrome, Dubin-Johnson syndrome and choledocholithiasis there is an increase in direct bilirubin\n", "Choledocholithiasis\n", "Attack"], ["In Rotor syndrome, Dubin-Johnson syndrome and choledocholithiasis there is an increase in direct bilirubin\n", "Dubin-Johnson syndrome\n", "Attack"], ["Laboratory tests show normal ALT, AST, GGT and FA, with total bilirubin of 3.2 mg/dl and direct bilirubin of 0.4 mg/dl\n", "In the case of acute hepatitis there should be an elevation of transaminases\n", "Attack"], ["In the case of acute hepatitis there should be an elevation of transaminases\n", "Acute hepatitis\n", "Attack"]]}
+{"597_180": [["For this, the best option would be to request reticulocytes, however, as it is not among the options, we should request a Coombs' test\n", "the correct answer is 2\n", "Support"], ["the correct answer is 2\n", "Coombs test\n", "Support"], ["Although they want to confuse us with a MCV 108\n", "so that we think of a megaloblastic anemia\n", "Support"], ["Although they want to confuse us with a MCV 108\n", "the MCV is not excessively high, the onset of anemia in our patient has been rapid and would not fit with SLE or the form of presentation\n", "Support"], ["so that we think of a megaloblastic anemia\n", "the MCV is not excessively high, the onset of anemia in our patient has been rapid and would not fit with SLE or the form of presentation\n", "Attack"], ["26-year-old woman diagnosed with systemic lupus erythematosus, on treatment with hydroxychloroquine, who consults for a feeling of generalized weakness that has progressively set in over the last 15 days\n", "In this question, we are presented with a patient with systemic lupus erythematosus presenting with autoimmune hemolytic anemia\n", "Support"], ["The physical examination reveals cutaneous pallor and the CBC shows Hb 7.4 g/dL, Hct 31%, MCV 108\n", "In this question, we are presented with a patient with systemic lupus erythematosus presenting with autoimmune hemolytic anemia\n", "Support"], ["In this question, we are presented with a patient with systemic lupus erythematosus presenting with autoimmune hemolytic anemia\n", "For this, the best option would be to request reticulocytes, however, as it is not among the options, we should request a Coombs' test\n", "Support"], ["Antinuclear antibodies are used for diagnosis, but not for monitoring SLE\n", "Antinuclear antibodies\n", "Attack"]]}
+{"571_170": [["A 75-year-old woman on sertraline treatment who comes to the emergency department with confusional symptoms\n", "We are presented with a patient with moderate euvolemic hyponatremia, suggesting a syndrome of inadequate antidiuresis (SIAD) secondary to sertraline, although it would be necessary to have urinary osmolality to confirm this\n", "Support"], ["The blood test shows Na 126 mEq/l and K 4 mEq/l, natriuria is 45 mEq/l and diuretic intake has been ruled out\n", "We are presented with a patient with moderate euvolemic hyponatremia, suggesting a syndrome of inadequate antidiuresis (SIAD) secondary to sertraline, although it would be necessary to have urinary osmolality to confirm this\n", "Support"], ["Primary adrenal insufficiency produces hypovolemic hyponatremia\n", "It is Addison's disease and corticosteroids should be administered immediately\n", "Attack"], ["incorrect option 1\n", "It is Addison's disease and corticosteroids should be administered immediately\n", "Attack"], ["We are presented with a patient with moderate euvolemic hyponatremia, suggesting a syndrome of inadequate antidiuresis (SIAD) secondary to sertraline, although it would be necessary to have urinary osmolality to confirm this\n", "Primary adrenal insufficiency produces hypovolemic hyponatremia\n", "Attack"], ["Primary adrenal insufficiency produces hypovolemic hyponatremia\n", "incorrect option 1\n", "Support"], ["Diabetes insipidus is the opposite of this pathology, usually presenting with hypernatremia\n", "Request brain MRI, since it is probably diabetes insipidus\n", "Attack"], ["Diabetes insipidus is the opposite of this pathology, usually presenting with hypernatremia\n", "option 4 incorrect\n", "Support"], ["option 4 incorrect\n", "Request brain MRI, since it is probably diabetes insipidus\n", "Support"], ["We are presented with a patient with moderate euvolemic hyponatremia, suggesting a syndrome of inadequate antidiuresis (SIAD) secondary to sertraline, although it would be necessary to have urinary osmolality to confirm this\n", "Diabetes insipidus is the opposite of this pathology, usually presenting with hypernatremia\n", "Attack"], ["With natremia above 125 mmol/l it is not indicated to treat with HSS unless the patient has severe neurological symptoms, which does not seem to be the case\n", "Administer hypertonic saline to restore natremia as soon as possible\n", "Attack"], ["they describe a confusional picture\n", "that would be a moderate hyponatremic encephalopathy\n", "Support"], ["that would be a moderate hyponatremic encephalopathy\n", "With natremia above 125 mmol/l it is not indicated to treat with HSS unless the patient has severe neurological symptoms, which does not seem to be the case\n", "Support"], ["it is not indicated to restore natremia as soon as possible (due to the risk of osmotic demyelination syndrome)\n", "With natremia above 125 mmol/l it is not indicated to treat with HSS unless the patient has severe neurological symptoms, which does not seem to be the case\n", "Support"], ["With natremia above 125 mmol/l it is not indicated to treat with HSS unless the patient has severe neurological symptoms, which does not seem to be the case\n", "Therefore, the correct answer would be 3\n", "Support"], ["Therefore, the correct answer would be 3\n", "Indicate water restriction and if natremia does not rise, switch to slow infusion of saline\n", "Support"], ["since in this case the use of furosemide, tolvaptan or urea should be considered, not saline\n", "What I do not like about this answer is that the second part (\"if natraemia does not rise, switch to slow infusion of saline\") is incorrect\n", "Support"], ["and it does not indicate tonicity either, since isotonic is not the same as hypertonic\n", "What I do not like about this answer is that the second part (\"if natraemia does not rise, switch to slow infusion of saline\") is incorrect\n", "Support"]]}
+{"466_91": [["An 11-year-old, 6-month-old, premenarchal girl with known idiopathic scoliosis\n", "In the juvenile and adolescent forms, treatment depends on the degree of deformity\n", "Support"], ["The current x-ray shows a Cobb angle of 28\u00ba, with an iliac crest maturation (Risser's sign) of 2\n", "- 10 - 20\u00b0: serial observation\n", "Attack"], ["The current x-ray shows a Cobb angle of 28\u00ba, with an iliac crest maturation (Risser's sign) of 2\n", "- 20-50\u00b0: thermoplastic corsets (Boston, Cheneau or Milwaukee, according to where the apex of the main curve is located)\n", "Support"], ["The current x-ray shows a Cobb angle of 28\u00ba, with an iliac crest maturation (Risser's sign) of 2\n", "40-50\u00b0: with Risser less than 3, surgical arthrodesis would be indicated; with Risser greater than or equal to 3, the remaining growth potential of the curve is low and observation may be considered in case it tends to progress in adulthood\n", "Attack"], ["- 20-50\u00b0: thermoplastic corsets (Boston, Cheneau or Milwaukee, according to where the apex of the main curve is located)\n", "Corrective orthopedic brace\n", "Support"]]}
+{"175_53": [["The apnea-hypopnea index obtained in the polysomnography was 18\n", "With an Apneas-Hypopnea Index of less than 30, and in the absence of striking symptoms of OSAHS and in the absence of risk professions such as professional drivers, etc., the correct thing to do is to control weight and the rest of the hygienic-dietary measures, with periodic follow-up\n", "Support"], ["With an Apneas-Hypopnea Index of less than 30, and in the absence of striking symptoms of OSAHS and in the absence of risk professions such as professional drivers, etc., the correct thing to do is to control weight and the rest of the hygienic-dietary measures, with periodic follow-up\n", "Hygienic-dietary measures and evolution control\n", "Support"]]}
+{"91_35": [["The answer is surgical sphincteroplasty 3\n", "Surgical sphincteroplasty\n", "Support"], ["1 is not effective\n", "Medical treatment with hygienic and dietary norms\n", "Attack"], ["2 is not effective for an organic lesion with normal electromyography\n", "Sphincter biofeedback\n", "Attack"], ["4 is not necessary\n", "Surgical repair of the pelvic floor\n", "Attack"], ["since the lesion is only of the external sphincter\n", "4 is not necessary\n", "Support"], ["5 is not indicated in a lesion that can be repaired with surgery with good results\n", "Artificial anal sphincter\n", "Attack"]]}
+{"65_218": [["The changes described in the question statement correspond to an early precirrhotic situation\n", "It is important to reduce weight and adequately control diabetes to avoid the possible development of cirrhosis\n", "Support"], ["A 56-year-old man, diabetic and moderately overweight, presents a discrete hepatomegaly\n", "It is important to reduce weight and adequately control diabetes to avoid the possible development of cirrhosis\n", "Support"], ["Diabetes mellitus causes similar hepatic alterations: fat accumulation in hepatocytes, centroacinar fibrosis, inflammatory infiltrate by polymorphonuclear neutrophils and hyaline degeneration of perinuclear mallory\n", "we can rule out the second question (they are intracellular fat accumulations, not glycogen) and the fourth (if diabetes also produces this situation, there is no reason to mistrust the patient)\n", "Support"], ["we can rule out the second question (they are intracellular fat accumulations, not glycogen) and the fourth (if diabetes also produces this situation, there is no reason to mistrust the patient)\n", "Diagnosis is hepatic glycogenosis associated with diabetes\n", "Attack"], ["we can rule out the second question (they are intracellular fat accumulations, not glycogen) and the fourth (if diabetes also produces this situation, there is no reason to mistrust the patient)\n", "The injury is clearly caused by alcohol despite the patient's refusal\n", "Attack"], ["it is not necessary to repeat a liver biopsy that would not expand information, discarding the first question\n", "Biopsy should be repeated to see if the changes are diffuse\n", "Attack"], ["Based on the primum non nocere and not having special relevance for the treatment if it is a focal or generalized disease\n", "it is not necessary to repeat a liver biopsy that would not expand information, discarding the first question\n", "Support"], ["Fortunately for the hypothetical patient, in the initial phase these changes are reversible when the noxa disappears\n", "we are left with answer number 5\n", "Support"], ["we are left with answer number 5\n", "It is important to reduce weight and adequately control diabetes to avoid the possible development of cirrhosis\n", "Support"], ["Diabetes mellitus causes similar hepatic alterations: fat accumulation in hepatocytes, centroacinar fibrosis, inflammatory infiltrate by polymorphonuclear neutrophils and hyaline degeneration of perinuclear mallory\n", "Although alcohol is the most frequent toxicant that causes this condition, it is not the exclusive cause\n", "Support"], ["A liver biopsy shows accumulations of clear cytoplasmic vacuoles in 50% of the hepatocytes\n", "Diabetes mellitus causes similar hepatic alterations: fat accumulation in hepatocytes, centroacinar fibrosis, inflammatory infiltrate by polymorphonuclear neutrophils and hyaline degeneration of perinuclear mallory\n", "Support"], ["Multiple inflammatory foci with neutrophils, Mallory's hyaline degeneration and fibrosis around the terminal hepatic venules\n", "Diabetes mellitus causes similar hepatic alterations: fat accumulation in hepatocytes, centroacinar fibrosis, inflammatory infiltrate by polymorphonuclear neutrophils and hyaline degeneration of perinuclear mallory\n", "Support"]]}
+{"50_160": [["radical thyroidectomy is usually recommended before the age of 5 years\n", "The correct answer is 4\n", "Support"], ["The correct answer is 4\n", "Genetic study of the RET c634 proto-oncogene mutation, and if positive, prophylactic radical thyroidectomy will be performed at this age\n", "Support"], ["Proto-oncogene carriers usually have early thyroid tumors\n", "radical thyroidectomy is usually recommended before the age of 5 years\n", "Support"]]}
+{"326_173": [["In the case of suspected compartment syndrome, the urgent invasive measure to perform would be to measure the intracompartmental pressure and, depending on the result, proceed with treatment\n", "Intracompartmental pressure monitoring\n", "Support"]]}
+{"354_166": [["Chronic hypertension is defined as hypertension that is present before pregnancy or that is diagnosed before the 20th week of gestation\n", "Chronic hypertension\n", "Support"], ["A pregnant woman, 10 weeks pregnant, comes to the emergency room with a blood pressure of 160/105 mmHg\n", "Chronic hypertension is defined as hypertension that is present before pregnancy or that is diagnosed before the 20th week of gestation\n", "Support"], ["In this case, the patient is 10 weeks pregnant\n", "Chronic hypertension is defined as hypertension that is present before pregnancy or that is diagnosed before the 20th week of gestation\n", "Support"], ["In this case, the patient is 10 weeks pregnant\n", "the correct answer is 3\n", "Support"], ["the correct answer is 3\n", "Chronic hypertension\n", "Support"]]}
+{"531_58": [["In this case what you describe is an oral tumor growing locally and infiltrating the mandibular canal, I believe\n", "Diagnosis of carcinoma with infiltration of the mandibular canal\n", "Support"]]}
+{"93_31": [["2 and 4 are discarded alone\n", "Biopsy skin areas away from the injured areas and prescribe entry opioid analgesics\n", "Attack"], ["2 and 4 are discarded alone\n", "Suspect bilateral lower extremity ischemia of drug origin\n", "Attack"], ["They are explaining erythema nodosum\n", "2 and 4 are discarded alone\n", "Support"], ["so we also rule out (1)\n", "Recommend relative rest and warm cloths on both legs and add antidepressant treatment\n", "Attack"], ["They are explaining erythema nodosum\n", "we would recommend relative rest\n", "Support"], ["antidepressants do not make any sense\n", "we would recommend relative rest\n", "Attack"], ["antidepressants do not make any sense\n", "so we also rule out (1)\n", "Support"], ["if the picture is also accompanied by a flare-up of inflammatory bowel disease, the last option (5) seems the most correct\n", "Adjustment of bowel disease treatment.\n", "Support"], ["in a 17-year-old boy it would be extremely rare\n", "Although erythema nodosum can be secondary to a malignant process, it is more frequent that it is due to Crohn's disease itself\n", "Attack"], ["Although erythema nodosum can be secondary to a malignant process, it is more frequent that it is due to Crohn's disease itself\n", "if the picture is also accompanied by a flare-up of inflammatory bowel disease, the last option (5) seems the most correct\n", "Support"]]}
+{"390_188": [["Assessing capacity is not about taking away the patient's autonomy, but making sure that the patient understands and is aware of the consequences of his decisions\n", "Formal evaluation of the capacity to make decisions concerning their health\n", "Support"], ["This is not done by a psychiatrist, but by the attending physician\n", "Formal evaluation of the capacity to make decisions concerning their health\n", "Support"], ["In fact, it is a protective measure for the most fragile patients to ensure the best care\n", "Formal evaluation of the capacity to make decisions concerning their health\n", "Support"]]}
+{"577_105": [["It is a genetic disease of autosomal dominant inheritance by mutation of the NOTCH3 gene\n", "Genetic study for NOTCH3\n", "Support"], ["He has a history of migraines and some episode of self-limited neurological focality for which he has never consulted\n", "They describe a characteristic case of CADASIL (Cerebral Autosomal Dominant Arteriopathy with Sub-cortical Infarcts and Leukoencephalopathy)\n", "Support"], ["A 45-year-old male brought to the consultation by his relatives for a one-year history of memory loss, which has progressed to the point of needing help with some activities of daily living\n", "They describe a characteristic case of CADASIL (Cerebral Autosomal Dominant Arteriopathy with Sub-cortical Infarcts and Leukoencephalopathy)\n", "Support"], ["He has a history of migraines and some episode of self-limited neurological focality for which he has never consulted\n", "Migraines, cerebrovascular disease and cognitive impairment at early ages stand out, as shown in the clinical case of the question\n", "Support"], ["The neuropsychological examination is compatible with an initial dementia and the brain MRI shows a severe leukoencephalopathy\n", "They describe a characteristic case of CADASIL (Cerebral Autosomal Dominant Arteriopathy with Sub-cortical Infarcts and Leukoencephalopathy)\n", "Support"], ["The neuropsychological examination is compatible with an initial dementia and the brain MRI shows a severe leukoencephalopathy\n", "Migraines, cerebrovascular disease and cognitive impairment at early ages stand out, as shown in the clinical case of the question\n", "Support"], ["A 45-year-old male brought to the consultation by his relatives for a one-year history of memory loss, which has progressed to the point of needing help with some activities of daily living\n", "Migraines, cerebrovascular disease and cognitive impairment at early ages stand out, as shown in the clinical case of the question\n", "Support"], ["This mutation causes vascular involvement of small vessel that generates severe leukoencephalopathy early, which generates various symptoms\n", "It is a genetic disease of autosomal dominant inheritance by mutation of the NOTCH3 gene\n", "Support"], ["Migraines, cerebrovascular disease and cognitive impairment at early ages stand out, as shown in the clinical case of the question\n", "It is a genetic disease of autosomal dominant inheritance by mutation of the NOTCH3 gene\n", "Support"]]}
+{"615_118": [["The Thessaly test is a meniscal exploration maneuver\n", "Answer 1 correct\n", "Support"], ["Answer 1 correct\n", "Meniscal injury\n", "Support"], ["During the examination, the Thessaly test is performed (pain with internal and external rotation movements with the knee flexed), which is positive\n", "The Thessaly test is a meniscal exploration maneuver\n", "Support"], ["The statement focuses exclusively on this part of the examination and also explains that it is indeed positive\n", "which leads to the suspicion of a meniscal lesion\n", "Support"], ["which leads to the suspicion of a meniscal lesion\n", "Meniscal injury\n", "Attack"], ["At no time do they describe any exploration maneuvers of the anterior cruciate ligament, nor do they mention any trauma that may have injured it\n", "Answer 2 incorrect\n", "Support"], ["Answer 2 incorrect\n", "Injury due to rupture of the anterior cruciate ligament\n", "Attack"], ["At no time do they describe any exploration maneuvers of the posterior cruciate ligament, nor do they mention any trauma that could have injured it\n", "Answer 3 incorrect\n", "Support"], ["Answer 3 incorrect\n", "Injury due to rupture of the posterior cruciate ligament\n", "Attack"], ["Although it could occur, it is not to be expected in a 41 year old person with an acutely established clinical condition\n", "Wrong answer 4\n", "Support"], ["Wrong answer 4\n", "Injury due to degenerative arthropathy\n", "Attack"]]}
+{"456_200": [["In the past, beta-blockers were the first choice, but nowadays they have been displaced by the group that lowers intraocular pressure the most: prostaglandins\n", "Beta-blockers\n", "Attack"], ["In the past, beta-blockers were the first choice, but nowadays they have been displaced by the group that lowers intraocular pressure the most: prostaglandins\n", "Prostaglandin derivatives\n", "Support"], ["Their efficacy and more convenient dosage (once a day) generally make them the group of choice\n", "In the past, beta-blockers were the first choice, but nowadays they have been displaced by the group that lowers intraocular pressure the most: prostaglandins\n", "Support"], ["Beta-blockers would remain as a second choice in cases in which the side effects of prostaglandins (change in eye color, increase in eyelash size) make us initially leave them aside\n", "In the past, beta-blockers were the first choice, but nowadays they have been displaced by the group that lowers intraocular pressure the most: prostaglandins\n", "Support"], ["A 67-year-old man, diabetic and asthmatic, with primary open-angle glaucoma in both eyes\n", "Since the patient is asthmatic, we should rule out beta-blockers (wrong answer 2)\n", "Support"], ["Since the patient is asthmatic, we should rule out beta-blockers (wrong answer 2)\n", "Beta-blockers\n", "Attack"], ["Also, since we need a significant drop in intraocular pressure because the numbers are high (34 and 31), we can also rule out carbonic anhydrase inhibitors and alpha-2 agonists (options 1 and 3 incorrect)\n", "Carbonic anhydrase inhibitors\n", "Attack"], ["Also, since we need a significant drop in intraocular pressure because the numbers are high (34 and 31), we can also rule out carbonic anhydrase inhibitors and alpha-2 agonists (options 1 and 3 incorrect)\n", "Alpha-2 agonists\n", "Attack"], ["And opt for the group that can lower intraocular pressure the most\n", "Answer 4 correct.\n", "Support"], ["Answer 4 correct.\n", "Prostaglandin derivatives\n", "Support"]]}
+{"484_175": [["Technically the patient is in a grade II hemorrhage according to the ATLS classification\n", "in principle this means a loss of between 750 and 1500mL of blood and the indicated action is resuscitation with crystalloids\n", "Support"], ["An 18-year-old man arrives at the hospital emergency department transported by a basic life support unit\n", "however, in the guidelines for the care of severe polytraumatized patients, the early use of blood products is increasingly recommended, especially in borderline cases like this one, and in young patients, who may not be able to translate the severity of the blood loss until it becomes much more significant\n", "Support"], ["On arrival he has a heart rate of 115 bpm, a blood pressure of 110/75 mmHg, a palpable radial pulse, a capillary refill of 2.5 seconds and a respiratory rate of 25 rpm\n", "Technically the patient is in a grade II hemorrhage according to the ATLS classification\n", "Support"], ["in principle this means a loss of between 750 and 1500mL of blood and the indicated action is resuscitation with crystalloids\n", "The patient has lost 15 to 30% of blood volume and requires volume replacement\n", "Support"], ["I would therefore hesitate between options 1 and 2\n", "The patient has lost 15 to 30% of blood volume and requires volume replacement\n", "Support"], ["I would therefore hesitate between options 1 and 2\n", "She has lost more than 30% of volemia and needs volume and blood replacement\n", "Support"]]}