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[['QUESTION', 'TYPE:', 'PRIMARY', 'CARE'], ['CLINICAL', 'CASE:'], ['A', '75', 'a', 'man', 'is', 'admitted', 'to', 'the', 'hospital', 'because', 'he', 'refuses', 'to', 'eat', 'and', 'has', 'lost', '30%', 'of', 'his', 'weight.'], ['He', 'has', 'a', 'history', 'of', 'multiple', 'sclerosis', 'which', 'has', 'worsened', 'in', 'recent', 'months.'], ['His', 'only', 'family', 'member', 'who', 'was', 'his', 'sister', 'died', '3', 'months', 'ago', 'and', 'since', 'then', 'he', 'has', 'deteriorated.'], ['He', 'has', 'become', 'incontinent,', 'has', 'stopped', 'eating', 'and', 'participating', 'in', 'social', 'events.'], ['He', 'is', 'suffering', 'from', 'psychotic', 'depression.'], ['He', 'is', 'physically', 'able', 'to', 'eat.'], ['Psychotropic', 'medication', 'is', 'started', 'and', 'discontinued', 'due', 'to', 'adverse', 'events.'], ['If', 'his', 'nutritional', 'status', 'improves', 'it', 'is', 'possible', 'to', 'resume', 'his', 'medications.'], ['He', 'refuses', 'intravenous', 'fluids', 'and', 'then', 'accepts', 'them', 'but', 'the', 'IV', 'is', 'started', 'a', 'few', 'hours', 'later.'], ['An', 'alternative', 'is', 'to', 'perform', 'a', 'percutaneous', 'endoscopic', 'gastrostomy', '(PEG)', 'and', 'discharge', 'him', 'to', 'his', 'residence.'], ['Which', 'of', 'the', 'following', 'is', 'the', 'most', 'appropriate', 'course', 'of', 'action', 'for', 'this', 'patient?'], ['1-', 'Ask', 'the', 'hospital', 'ethics', 'committee', 'to', 'help', 'determine', 'the', 'decision', 'that', 'is', 'in', 'the', 'best', 'interest', 'of', 'the', 'patient.'], ['2-', 'Assess', 'whether', 'the', 'residence', 'will', 'take', 'the', 'patient', 'if', 'PEG', 'is', 'not', 'performed.'], ['3-', 'Seek', 'a', 'court', 'order', 'to', 'perform', 'PEG.'], ['4-', 'Enrolling', 'the', 'patient', 'in', 'terminal', 'palliative', 'care.'], ['5-', 'nan'], ['CORRECT', 'ANSWER:', '1'], ['The', 'correct', 'answer', 'is', '1', 'since', 'the', 'patient', 'is', 'in', 'a', 'situation', 'of', 'psychotic', 'depression', 'and', 'is', 'not', 'able', 'to', 'decide', 'for', 'his', 'life', 'and', 'it', 'does', 'not', 'seem', 'that', 'the', 'patient', 'has', 'filled', 'in', 'the', 'last', 'will', 'and', 'testament,', 'the', 'most', 'convenient', 'thing', 'to', 'do', 'is', 'to', 'present', 'the', 'case', 'to', 'the', 'ethics', 'committee', 'of', 'the', 'center', 'to', 'make', 'a', 'decision', 'on', 'the', 'matter', 'in', 'accordance', 'with', 'the', 'law.']]

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361_94

[['QUESTION', 'TYPE:', 'HEMATOLOGY'], ['CLINICAL', 'CASE:'], ['A', '51-year-old', 'man', 'is', 'admitted', 'from', 'the', 'emergency', 'department', 'for', 'macrocytic', 'anemia', '(Hb', '6.3', 'g/dL,', 'MCV', '120', 'fL).'], ['Studies', 'ruled', 'out', 'a', 'deficiency', 'origin.'], ['Reticulocytes', 'were', '24000/microL.'], ['The', 'bone', 'marrow', 'study', 'is', 'compatible', 'with', 'myelodysplastic', 'syndrome', '(MDS).'], ['Cytogenetics', 'shows', 'a', '5q', 'deletion.'], ['Which', 'is', 'the', 'correct', 'statement', 'regarding', 'this', 'patient?'], ['1-', 'This', 'deletion', '(5q-)', 'is', 'an', 'alteration', 'of', 'good', 'prognosis', 'and', 'has', 'a', 'specific', 'treatment', '(lenalidomide).'], ['2-', 'It', 'would', 'be', 'advisable', 'in', 'this', 'patient', 'to', 'perform', 'HLA', 'typing', 'in', 'order', 'to', 'organize', 'an', 'allogeneic', 'transplant.'], ['3-', 'This', 'is', 'a', 'patient', 'with', 'a', 'high', 'International', 'Prognostic', 'Index', '(IPSS).'], ['4-', 'Treatment', 'in', 'this', 'case', 'would', 'be', 'transfusion', 'only.'], ['5-', 'nan'], ['CORRECT', 'ANSWER:', '1'], ['This', 'is', 'a', 'young', 'patient', 'with', 'no', 'comorbidities', 'and', 'is', 'therefore', 'a', 'candidate', 'for', 'treatment', 'with', 'curative', 'intent,', 'so', 'option', '4', 'is', 'ruled', 'out.'], ['Option', '3', 'is', 'also', 'incorrect', 'since', 'we', 'cannot', 'know', 'the', "patient's", 'IPSS', 'since', 'we', 'do', 'not', 'know', 'the', 'number', 'of', 'blasts', 'and', 'the', 'number', 'of', 'leukocytes', 'and', 'platelets', 'to', 'calculate', 'the', 'risk.'], ['Option', '2', 'is', 'also', 'incorrect', 'since', 'the', 'indication', 'for', 'a', 'bone', 'marrow', 'transplant', 'in', 'MDS', 'is', 'those', 'patients', 'with', 'high', 'or', 'intermediate-2', 'IPSS,', 'and', 'in', 'this', 'case', 'we', 'do', 'not', 'know', 'the', 'risk,', 'the', 'only', 'thing', 'we', 'know', 'about', 'the', 'risk', 'is', 'the', 'cytogenetics', 'which', 'is', 'of', 'good', 'prognosis', 'that', 'would', 'give', 'us', '0', 'points.'], ['Therefore', 'the', 'correct', 'one', 'is', '1', 'since', 'it', 'is', 'true', 'that', 'it', 'has', 'a', 'favorable', 'cytogenetics', '(5q-)', 'and', 'has', 'a', 'specific', 'treatment', 'lenalidomide,', 'also', 'used', 'in', 'other', 'pathologies', 'such', 'as', 'multiple', 'myeloma.']]

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172_50

[['QUESTION', 'TYPE:', 'PNEUMOLOGY'], ['CLINICAL', 'CASE:'], ['A', 'patient', 'with', 'severe', 'COPD', 'comes', 'to', 'the', 'ED', 'with', 'an', 'acute', 'onset', 'and', 'presents', 'an', 'arterial', 'blood', 'gas', 'drawn', 'with', 'Fi02', 'of', '31%', 'at', 'sea', 'level', 'with', 'a', 'Pa02', 'of', '86', 'mm', 'Hg,', 'PaC02', '65', 'mm', 'Hg,', 'pH', '7.13', 'and', 'Bicarbonate', '27', 'mmol/liter.'], ['Which', 'of', 'the', 'following', 'statements', 'is', 'FALSE?'], ['1-', 'The', 'patient', 'is', 'hyperventilating.'], ['2-', 'The', 'alveolar', 'arterial', 'oxygen', 'gradient', 'is', 'elevated.'], ['3-', 'The', 'patient', 'is', 'in', 'respiratory', 'acidosis.'], ['4-', 'Bicarbonate', 'level', 'is', 'normal.'], ['5-', 'Initiation', 'of', 'mechanical', 'ventilation', 'should', 'be', 'considered.'], ['CORRECT', 'ANSWER:', '1'], ['Blood', 'gas', 'analysis', 'shows', 'an', 'acute', 'respiratory', 'acidosis,', 'due', 'to', 'an', 'increase', 'in', 'PCO2', 'of', 'short', 'evolution', 'time', 'because', 'the', 'kidney', 'has', 'not', 'yet', 'had', 'time', 'to', 'retain', 'bicarbonates', '(bicarbonate', 'level', 'at', 'the', 'high', 'limit', 'of', 'normality).'], ['The', 'patient', 'is', 'not', 'hyperventilating', 'but', 'hypoventilating', 'because', 'PCO2', 'is', 'elevated.'], ['The', 'alveolar', 'arterial', 'oxygen', 'gradient', 'is', 'altered', 'since', 'the', 'patient', 'has', 'a', 'normal', 'PaO2,', 'but', 'because', 'he', 'has', 'a', 'high', 'FiO2.'], ['If', 'he', 'were', 'without', 'oxygen,', 'he', 'would', 'be', 'hypoxemic.'], ['Respiratory', 'acidosis', 'below', '7.20', 'is', 'a', 'reason', 'to', 'consider', 'noninvasive', 'mechanical', 'ventilation', 'acutely', 'and', 'in', 'principle', 'temporarily', 'in', 'a', 'patient', 'with', 'severe', 'COPD.']]

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83_48

[['QUESTION', 'TYPE:', 'CARDIOLOGY', 'AND', 'VASCULAR', 'SURGERY'], ['CLINICAL', 'CASE:'], ['What', 'therapeutic', 'intervention', 'would', 'you', 'consider', 'in', 'a', '67-year-old', 'patient', 'with', 'idiopathic', 'dilated', 'cardiomyopathy,', 'left', 'bundle', 'branch', 'block,', 'left', 'ventricular', 'ejection', 'fraction', 'of', '26%,', 'mitral', 'insufficiency', 'grade', 'II-III/IV,', 'undergoing', 'treatment', 'with', 'furosemide,', 'spironolactone,', 'enalapril', 'and', 'bisoprolol', 'and', 'who', 'remains', 'in', 'NYHA', 'functional', 'class', 'III?'], ['1-', 'Surgical', 'coronary', 'revascularization.'], ['2-', 'Mitral', 'valve', 'replacement.'], ['3-', 'Implantation', 'of', 'an', 'aortic', 'balloon', 'pump.'], ['4-', 'Implantation', 'of', 'a', 'ventricular', 'assist', 'device.'], ['5-', 'Implantation', 'of', 'a', 'cardiac', 'resynchronization', 'system.'], ['CORRECT', 'ANSWER:', '5'], ['We', 'are', 'talking', 'about', 'a', 'patient', 'with', 'heart', 'failure', 'with', 'severe', 'LV', 'dysfunction', '(EF', '<', '35%),', 'LBBB', '(wide', 'QRS),', 'who', 'is', 'following', 'optimal', 'medical', 'treatment', 'and', 'who', 'remains', 'in', 'advanced', 'functional', 'class', 'despite', 'this.'], ['Coronary', 'revascularization', 'does', 'not', 'appear', 'to', 'be', 'of', 'much', 'benefit', 'in', 'this', 'patient', 'at', 'this', 'time.'], ['Nor', 'does', 'mitral', 'valve', 'replacement,', 'firstly', 'because', 'mitral', 'regurgitation', 'is', 'most', 'likely', 'the', 'result', 'of', 'mitral', 'annular', 'dilatation,', 'and', 'secondly', 'because', 'we', 'would', 'need', 'an', 'echocardiographic', 'assessment', 'of', 'the', 'mitral', 'valve', 'to', 'determine', 'whether', 'there', 'is', 'any', 'alteration.'], ['Intra-aortic', 'balloon', 'counterpulsation', 'implantation', 'would', 'not', 'be', 'indicated', 'in', 'this', 'patient', '(it', 'is', 'used', 'in', 'situations', 'of', 'cardiogenic', 'shock,', 'in', 'post-AMI', 'mechanical', 'complications,', 'as', 'a', 'bridge', 'to', 'cardiac', 'Tx...).'], ['The', 'ventricular', 'assist', 'device', 'would', 'also', 'not', 'be', 'indicated', 'in', 'this', 'patient.'], ['What', 'would', 'really', 'benefit', 'him', 'of', 'all', 'the', 'answers', 'is', 'number', '5,', 'the', 'resynchronization', 'device.'], ['By', 'achieving', 'simultaneous', 'stimulation', 'of', 'both', 'ventricles,', 'a', 'mechanical', 'synergy', 'is', 'achieved', 'that', 'improves', 'cardiac', 'function.'], ['The', 'indications', 'for', 'the', 'application', 'of', 'CRT', '(cardiac', 'resynchronization', 'therapy)', 'are', 'precisely', 'those', 'mentioned', 'at', 'the', 'beginning:', 'severe', 'ventricular', 'dysfunction,', 'asynchrony', 'demonstrated', 'by', 'the', 'presence', 'of', 'wide', 'QRS', 'in', 'the', 'ECG', '(usually', 'due', 'to', 'LBBB)', 'and', 'advanced', 'functional', 'class', '(III-IV)', 'despite', 'optimal', 'medical', 'treatment.']]

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141_135

[['QUESTION', 'TYPE:', 'PEDIATRICS'], ['CLINICAL', 'CASE:'], ['A', '2-year-old', 'boy,', 'his', 'personal', 'history', 'includes:', '3', 'episodes', 'of', 'acute', 'otitis', 'media,', '1', 'meningococcal', 'meningitis', 'and', '2', 'pneumonias', '(one', 'middle', 'lobe', 'and', 'one', 'left', 'upper', 'lobe).'], ['She', 'has', 'been', 'admitted', 'on', '3', 'occasions', 'for', 'thrombopenic', 'purpura', '(on', 'three', 'occasions', 'antiplatelet', 'antibodies', 'were', 'negative', 'and', 'bone', 'marrow', 'showed', 'normal', 'megakaryocytes).'], ['Several', 'males', 'of', 'the', 'maternal', 'family', 'had', 'died', 'in', 'childhood', 'due', 'to', 'infectious', 'processes.'], ['The', 'examination', 'showed', 'typical', 'lesions', 'of', 'atopic', 'dermatitis.'], ['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.'], ['What', 'is', 'the', 'most', 'likely', 'diagnosis?'], ['1-', 'Wiskott-Aldrich', 'syndrome.'], ['2-', 'Hyper', 'IgE', 'syndrome.'], ['3-', 'Transient', 'hypogammaglobulinemia', 'of', 'infancy.'], ['4-', 'Severe', 'X-associated', 'combined', 'immunodeficiency.'], ['5-', 'Common', 'variable', 'immunodeficiency.'], ['CORRECT', 'ANSWER:', '1'], ['The', 'correct', 'answer', 'is', '1.'], ['Wiskott-Aldrich', 'syndrome', 'associates', 'immunodeficiency,', 'thrombopenia', 'and', 'atopic', 'dermatitis', 'with', 'the', 'immunological', 'study', 'described', 'in', 'the', 'statement.']]

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317_139

[['QUESTION', 'TYPE:', 'RHEUMATOLOGY'], ['CLINICAL', 'CASE:'], ['A', '70-year-old', 'woman', 'with', 'a', 'history', 'of', 'anorexia,', 'weight', 'loss,', 'muscle', 'and', 'proximal', 'joint', 'discomfort', 'and', 'pain', 'in', 'the', 'temporomandibular', 'region', 'comes', 'to', 'the', 'emergency', 'department', 'for', 'unilateral', 'vision', 'loss', '(hand', 'movement),', 'sudden', 'and', 'painless', 'onset', '(afferent', 'pupillary', 'defect).'], ['What', 'test', 'would', 'you', 'order', 'first', 'for', 'diagnostic', 'purposes?'], ['1-', 'Lumbar', 'puncture.'], ['2-', 'C', 'Reactive', 'Protein.'], ['3-', 'Magnetic', 'resonance', 'angiography.'], ['4-', 'Carotid', 'ultrasound.'], ['5-', 'nan'], ['CORRECT', 'ANSWER:', '2'], ['It', 'is', 'possibly', 'a', 'temporal', 'arteritis,', 'the', 'clinical', 'picture', 'and', 'a', 'CBC', 'with', 'increased', 'reactants', 'are', 'enough', 'to', 'confirm', 'the', 'suspicion.'], ['Then', 'an', 'ocular', 'evaluation', 'should', 'be', 'done', 'to', 'rule', 'out', 'AIN,', 'urgent', 'treatment', 'should', 'be', 'instituted', '(if', 'there', 'is', 'AIN,', '3', 'boluses', 'of', 'methylprednisolone', '1', 'g,', 'if', 'there', 'is', 'not,', 'prednisone', 'mg/kg)', 'and', 'biopsy', 'should', 'be', 'evaluated.']]

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550_129

110_152

[['QUESTION', 'TYPE:', 'GYNECOLOGY', 'AND', 'OBSTETRICS'], ['CLINICAL', 'CASE:'], ['Patient', '76', 'years', 'old,', 'parity', '3-0-3-1,', 'with', 'menopause', 'at', 'age', '52.'], ['She', 'reports', 'that', 'for', 'at', 'least', '4-5', 'years', 'she', 'has', 'had', 'vulvar', 'pruritus', 'of', 'variable', 'intensity', 'which', 'has', 'been', 'treated', 'sometimes', 'with', 'self-medication', 'and', 'other', 'times', 'on', 'the', 'advice', 'of', 'her', 'general', 'practitioner', 'with', 'topical', 'preparations', '(creams', 'and', 'washes).'], ['The', 'pruritus', 'has', 'evolved', 'intermittently,', 'but', 'for', 'the', 'last', '3-4', 'months', 'she', 'has', 'also', 'noticed', 'a', 'small', 'lump', 'on', 'the', 'left', 'labium', 'majus', 'of', 'the', 'vulva,', 'which', 'has', 'been', 'leaking', 'serohaematically', 'on', 'rubbing', 'for', 'a', 'few', 'days;', 'she', 'therefore', 'consulted', 'a', 'gynecologist.'], ['On', 'questioning,', 'she', 'reports', 'occasional', 'dysuria', 'and', 'her', 'general', 'condition', 'is', 'good.'], ['What', 'is', 'the', 'most', 'likely', 'diagnosis', 'in', 'this', 'patient?'], ['1-', 'Genital', 'herpes.'], ['2-', "Paget's", 'disease', 'of', 'the', 'vulva.'], ['3-', 'Urethral', 'caruncle.'], ['4-', 'Chronic', 'granuloma', 'of', 'the', 'vulva.'], ['5-', 'Vulvar', 'squamous', 'cell', 'carcinoma.'], ['CORRECT', 'ANSWER:', '5'], ['The', 'correct', 'answer', 'is', '5.'], ['Vulvar', 'carcinoma', 'is', 'characterized', 'by', 'chronic', 'vulvar', 'itching', 'resistant', 'to', 'multiple', 'treatments,', 'appearance', 'of', 'lumpiness', 'or', 'ulceration,', 'dysuria', 'and', 'urinary', 'urgency,', 'and', 'late', 'pain', 'and', 'bleeding.']]

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419_77

[['QUESTION', 'TYPE:', 'GENERAL', 'SURGERY'], ['CLINICAL', 'CASE:'], ['An', '80-year-old', 'woman', 'comes', 'to', 'the', 'emergency', 'department', 'with', 'abdominal', 'pain', 'starting', 'in', 'the', 'epigastrium', 'and', 'radiating', 'later', 'to', 'the', 'left', 'iliac', 'fossa.'], ['An', 'abdominal', 'CT', 'scan', 'is', 'performed,', 'showing', 'inflammation', 'of', 'the', 'sigmoid', 'walls', 'and', 'a', '2', 'cm', 'mesenteric', 'abscess.'], ['The', 'treatment', 'of', 'choice', 'is:'], ['1-', 'Admission', 'to', 'the', 'ward', 'with', 'absolute', 'diet', 'and', 'broad-spectrum', 'antibiotic', 'treatment.'], ['2-', 'Discharge', 'colostomy.'], ['3-', 'Drainage', 'by', 'laparoscopic', 'surgery.'], ['4-', 'Urgent', 'surgery', 'with', 'sigmoidectomy', 'and', 'colorectal', 'anastomosis.'], ['5-', 'nan'], ['CORRECT', 'ANSWER:', '1'], ['In', 'this', 'question', 'we', 'are', 'presented', 'with', 'a', 'clinical', 'picture', 'whose', 'manifestations', 'are', 'compatible', 'with', 'acute', 'diverticulitis,', 'already', 'asked', 'on', 'numerous', 'occasions', 'previously.'], ['A', 'case', 'of', 'acute', 'diverticulitis', 'complicated', 'with', 'small', 'mesenteric', 'abscess', '(<', '2-3', 'cm)', 'is', 'presented.'], ['Abscesses', 'should', 'be', 'drained', 'by', 'CT-guided', 'percutaneous', 'puncture,', 'since', 'the', 'intra-abdominal', 'approach', 'can', 'spread', 'the', 'contents', 'into', 'the', 'abdominal', 'cavity.'], ['However,', 'in', 'small', 'abscesses', 'with', 'Hinchey', 'grade', 'I', 'divertciulitis,', 'in', 'patients', 'without', 'great', 'deterioration', 'of', 'the', 'general', 'condition', 'as', 'in', 'the', 'proposed', 'case,', 'they', 'can', 'be', 'managed', 'by', 'conservative', 'treatment', 'with', 'intravenous', 'antiobiotic', 'therapy', 'and', 'absolute', 'diet,', 'therefore', 'the', 'correct', 'option', 'is', '1.'], ['The', 'urgent', 'surgical', 'approach', 'should', 'be', 'reserved', 'for', 'cases', 'that', 'present', 'peritonitis', '(grade', 'III,', 'IV)', 'by', 'resection', 'of', 'the', 'affected', 'segment', 'and', 'primary', 'anastomosis', 'in', 'stable', 'patients', 'or', 'carry', 'out', 'the', 'Hartamn', 'intervention', 'that', 'includes', 'resection', 'with', 'terminal', 'colostomy', 'and', 'closure', 'of', 'the', 'distal', 'rectal', 'stump', 'performing', 'anastomosis', 'in', 'a', 'second', 'surgical', 'time.']]

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37_227

[['QUESTION', 'TYPE:', 'OPHTHALMOLOGY'], ['CLINICAL', 'CASE:'], ['A', '78-year-old', 'woman', 'consults', 'for', 'acute', 'vision', 'loss', 'of', 'the', 'left', 'eye.'], ['In', 'the', 'last', '3', 'weeks', 'she', 'has', 'presented', 'with', 'fever,', 'pain', 'in', 'the', 'shoulders,', 'neck', 'and', 'hips,', 'and', 'moderate', 'headache.'], ['Funduscopy', 'shows', 'a', 'pale', 'and', 'edematous', 'optic', 'disc.'], ['Mobilization', 'of', 'the', 'shoulders', 'and', 'hips', 'produces', 'pain.'], ['There', 'are', 'no', 'alterations', 'on', 'palpation', 'of', 'the', 'temporal', 'arteries.'], ['Laboratory', 'data:', 'hemoglobin', '9.7', 'g/dL', 'ferritin', '450', 'ng/mL', 'erythrocyte', 'sedimentation', 'rate', '115', 'mm/h.'], ['What', 'is', 'the', 'most', 'appropriate', 'immediate', 'action', 'in', 'this', 'patient?'], ['1-', 'Request', 'a', 'Doppler', 'ultrasound', 'of', 'temporal', 'arteries.'], ['2-', 'Start', 'treatment', 'with', 'prednisone', '60mg', 'per', 'day', 'and', 'aspirin', '100', 'mg', 'per', 'day.'], ['3-', 'Start', 'treatment', 'with', 'prednisone', '10', 'mg', 'per', 'day.'], ['4-', 'Request', 'a', 'temporal', 'artery', 'biopsy.'], ['5-', 'Request', 'a', 'brain', 'magnetic', 'resonance', 'imaging.'], ['CORRECT', 'ANSWER:', '2'], ['The', 'clinical', 'presentation', 'is', 'strongly', 'suggestive', 'of', 'giant', 'cell', 'arteritis', '(GCA),', 'with', 'febrile', 'fever,', 'shoulder', 'girdle', 'and', 'pelvic', 'pain,', 'and', 'headache.'], ['Age', 'and', 'sex', 'also', 'point', 'to', 'this', 'possibility.'], ['Abrupt', 'unilateral', 'visual', 'loss', 'with', 'pale', 'papillary', 'edema', 'is', 'highly', 'indicative', 'of', 'arteritic', 'ischemic', 'optic', 'neuropathy', 'due', 'to', 'GCA.'], ['The', 'ESR', 'is', 'elevated,', 'which', 'further', 'clarifies', 'the', 'diagnosis.'], ['We', 'have', 'to', 'quickly', 'start', 'corticosteroid', 'treatment.'], ['We', 'can', 'already', 'rule', 'out', '1', 'and', '5', 'because', 'they', 'do', 'not', 'contribute', 'anything.'], ['4', 'could', 'make', 'us', 'doubt,', 'and', 'it', 'is', 'true', 'that', 'we', 'will', 'have', 'to', 'ask', 'for', 'a', 'temporal', 'artery', 'biopsy,', 'but', 'that', 'is', 'not', 'immediate:', 'the', 'statement', 'makes', 'it', 'very', 'clear', 'that', 'we', 'have', 'to', 'act', 'immediately.'], ['The', 'current', 'trend', 'is', 'to', 'use', 'megadoses', 'of', 'intravenous', 'corticosteroids,', 'and', 'although', 'aspirin', 'has', 'traditionally', 'been', 'proposed', 'to', 'reduce', 'ischemic', 'events,', 'the', 'evidence', 'currently', 'indicates', 'that', 'antiplatelet', 'agents', 'do', 'not', 'contribute', 'much.'], ['An', 'oral', 'corticosteroid', 'dose', 'of', 'around', '1mg/kg', 'would', 'also', 'be', 'acceptable.'], ['Therefore,', 'if', 'we', 'rule', 'out', '3', 'because', 'the', 'dose', 'is', 'too', 'low,', 'we', 'would', 'have', 'to', 'stay', 'with', '2.'], ['With', 'reservations,', 'since', 'aspirin', 'has', 'a', 'rather', 'dubious', 'role,', 'and', 'the', 'corticosteroid', 'dose', 'remains', 'ambiguous', '(we', 'do', 'not', 'know', 'how', 'much', 'the', 'patient', 'weighs).'], ['Of', 'all', 'the', 'ophthalmology', 'questions,', 'this', 'is', 'perhaps', 'the', 'one', 'most', 'likely', 'to', 'be', 'contested.']]

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532_67

272_69

[['QUESTION', 'TYPE:', 'DIGESTIVE', 'SYSTEM'], ['CLINICAL', 'CASE:'], ['A', '60-year-old', 'man', 'with', 'extensive', 'ulcerative', 'colitis', 'of', '15', 'years', 'of', 'evolution', 'and', 'in', 'clinical', 'remission', 'for', 'the', 'last', '3', 'years,', 'comes', 'to', 'our', 'office', 'to', 'be', 'informed', 'about', 'the', 'risk', 'of', 'colorectal', 'cancer', 'and', 'about', 'the', 'possibility', 'of', 'participating', 'in', 'prevention', 'programs.'], ['It', 'is', 'correct', 'to', 'inform', 'him', 'that:'], ['1-', 'Ulcerative', 'colitis', 'is', 'only', 'associated', 'with', 'an', 'increased', 'risk', 'of', 'colorectal', 'cancer', 'in', 'smokers.'], ['2-', 'In', 'her', 'case,', 'given', 'that', 'she', 'is', 'in', 'long-term', 'remission,', 'the', 'screening', 'advised', 'to', 'the', 'general', 'population', 'is', 'considered', 'appropriate.'], ['3-', 'In', 'cases', 'such', 'as', 'yours,', 'it', 'is', 'considered', 'appropriate', 'to', 'undergo', 'periodic', 'colonoscopies', 'with', 'multiple', 'biopsies', 'staggered', 'along', 'the', 'entire', 'colon.'], ['4-', 'In', 'cases', 'such', 'as', 'yours,', 'screening', 'with', 'periodic', 'fecal', 'occult', 'blood', 'tests', 'is', 'considered', 'appropriate,', 'but', 'with', 'a', 'higher', 'frequency', 'than', 'that', 'used', 'in', 'screening', 'the', 'general', 'population.'], ['5-', 'nan'], ['CORRECT', 'ANSWER:', '3'], ['Patients', 'with', 'inflammatory', 'bowel', 'disease', '(IBD)', 'have', 'an', 'increased', 'risk', 'of', 'colorectal', 'cancer,', 'whether', 'or', 'not', 'they', 'are', 'smokers.'], ['It', 'is', 'recommended', 'to', 'start', 'screening', '8-10', 'years', 'after', 'diagnosis', 'of', 'IBD', '(or', 'earlier', 'if', 'primary', 'sclerosing', 'cholangitis', 'or', 'other', 'events', 'occur', 'during', 'this', 'interval).'], ['The', 'recommended', 'techniques', 'are', 'colonoscopy', 'with', 'random', 'biopsies', '(answer', '3)', 'and', 'pancolonic', 'chromoendoscopy', 'with', 'staining,', 'which', 'is', 'currently', 'the', 'gold', 'standard', 'because', 'it', 'detects', 'dysplasia', 'better,', 'although', 'it', 'requires', 'more', 'technical', 'experience.']]

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428_61

[['QUESTION', 'TYPE:', 'INFECTIOUS', 'DISEASES', 'AND', 'MICROBIOLOGY'], ['CLINICAL', 'CASE:'], ['A', '62-year-old', 'man', 'comes', 'to', 'the', 'hospital', 'emergency', 'department', 'with', 'a', 'fever', 'of', '38.3″C', 'and', 'chills.'], ['He', 'is', 'tachycardic', 'and', 'tachypneic.'], ['Blood', 'tests:', 'leukocytosis', 'with', 'left', 'shift.'], ['Blood', 'pressure', 'is', '90/60', 'mmHg.'], ['No', 'murmurs', 'are', 'heard', 'on', 'cardiac', 'auscultation', 'and', 'chest', 'X-ray', 'rules', 'out', 'pneumonia.'], ['As', 'history', 'of', 'interest', 'she', 'refers', 'repeated', 'urinary', 'tract', 'infections.'], ['A', 'week', 'ago', 'the', 'primary', 'care', 'physician', 'prescribed', 'cefuroxime,', 'a', 'drug', 'he', 'is', 'currently', 'taking.'], ['Two', 'blood', 'cultures', 'were', 'taken', 'and', 'urine', 'was', 'sent', 'for', 'sediment', 'examination', 'and', 'microbiological', 'culture.'], ['The', 'sediment', 'was', 'pathological,', 'with', 'intense', 'pyuria,', 'but', 'negative', 'nitrites.'], ['After', '24', 'hours,', 'the', 'microbiology', 'laboratory', 'reported', 'that', 'both', 'the', 'urine', 'and', 'the', 'blood', 'cultures', 'were', 'positive,', 'and', 'the', 'results', 'showed', 'gram-positive', 'cocci', 'grouped', 'in', 'chains,', 'pending', 'identification', 'and', 'antibiogram.'], ['Pending', 'the', 'definitive', 'result,', 'what', 'would', 'you', 'recommend?'], ['1-', 'Continue', 'with', 'cefuroxime', 'while', 'awaiting', 'the', 'definitive', 'result,', 'since', 'the', 'patient', 'has', 'undergone', 'multiple', 'treatments', 'and', 'we', 'should', 'not', 'make', 'a', 'mistake', 'in', 'his', 'current', 'treatment.'], ['2-', 'Change', 'to', 'ertapenem,', 'considering', 'the', 'possibility', 'of', 'multiresistant', 'microorganisms.'], ['3-', 'Switch', 'to', 'a', 'broad-spectrum', 'antimicrobial', 'treatment', 'that', 'covers', 'Enterococcus', 'spp.'], ['4-', 'Switch', 'to', 'broad-spectrum', 'antimicrobial', 'therapy', 'containing', 'imipenem,', 'considering', 'the', 'possibility', 'of', 'Staphylococcus', 'aureus,', 'since', 'our', 'hospital', 'has', 'a', 'high', 'incidence', 'of', 'methicillin-resistant', 'S.', 'aureus', '(MRSA).'], ['5-', 'nan'], ['CORRECT', 'ANSWER:', '3'], ['With', 'the', 'urine', 'nitrite', 'test', 'we', 'detect', 'the', 'presence', 'of', 'nitrites', 'in', 'the', 'urine.'], ['These', 'appear', 'due', 'to', 'the', 'presence', 'in', 'the', 'urine', 'of', 'a', 'high', 'concentration', 'of', 'bacteria', 'possessing', 'the', 'enzyme', 'nitrate', 'reductase,', 'which', 'is', 'capable', 'of', 'reducing', 'the', 'nitrates', 'present', 'in', 'the', 'urine', 'to', 'nitrites.'], ['This', 'enzyme', 'is', 'active', 'in', 'most', 'of', 'the', 'bacteria', 'that', 'most', 'frequently', 'cause', 'urinary', 'tract', 'infection,', 'such', 'as', 'many', 'Gram-negative', 'bacilli.'], ['Other', 'microorganisms,', 'relatively', 'frequent', 'causes', 'of', 'urinary', 'tract', 'infection,', 'do', 'not', 'possess', 'this', 'enzyme', 'and', 'do', 'not', 'reduce', 'nitrates,', 'such', 'as', 'enterococci,', 'staphylococci', 'and', 'yeasts.'], ['As', 'the', 'Gram', 'stain', 'indicates', 'that', 'the', 'bacteria', 'are', 'grouped', 'in', 'chains,', 'as', 'this', 'is', 'typical', 'of', 'enterococcus,', 'we', 'suggest', 'the', 'need', 'to', 'cover', 'this', 'group', 'of', 'bacteria', 'with', 'antibiotic', 'treatment.'], ['Staphylococci', 'are', 'typically', 'seen', 'on', 'Gram', 'stain', 'as', 'Gram-positive', 'cocci', 'forming', 'clusters', 'and', 'yeasts,', 'although', 'with', 'the', 'same', 'staining,', 'have', 'a', 'different', 'typical', 'morphology', 'than', 'Gram-positive', 'cocci.']]

[['O', 'O', 'O', 'O', 'O', 'O'], ['O', 'O'], ['B-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise'], ['B-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise'], ['B-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise'], ['B-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise'], ['B-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise'], ['B-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise'], ['B-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise'], ['B-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise'], ['B-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise'], ['B-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise'], ['O', 'O', 'O', 'O', 'O', 'O', 'O', 'O'], ['O', 'B-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim'], ['O', 'B-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim'], ['O', 'B-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim'], ['O', 'B-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim'], ['O', 'O'], ['O', 'O', 'O'], ['B-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise'], ['B-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim'], ['B-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim'], ['B-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim'], ['B-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim'], ['B-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'B-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim']]

393_224

[['QUESTION', 'TYPE:', 'PSYCHIATRY'], ['CLINICAL', 'CASE:'], ['A', 'patient', 'presents', 'with', 'a', 'long', 'history', 'of', 'multiple', 'physical', 'symptoms:', 'memory', 'loss,', 'headache,', 'dizziness,', 'vomiting,', 'genital', 'pain,', 'limb', 'pain,', 'abdominal', 'distention,', 'and', 'menstrual', 'irregularities.'], ['The', 'various', 'medical', 'examinations', 'have', 'ruled', 'out', 'any', 'medical', 'illness.'], ['Which', 'of', 'the', 'following', 'is', 'most', 'likely', 'to', 'be', 'the', 'case?'], ['1-', 'Conversive', 'disorder.'], ['2-', 'Hypochondriac', 'disorder.'], ['3-', 'Somatization', 'disorder.'], ['4-', 'Dissociative', 'disorder.'], ['5-', 'nan'], ['CORRECT', 'ANSWER:', '3'], ['According', 'to', 'ICD-10', 'the', 'criteria', 'for', 'diagnosing', 'Somatization', 'Disorder', '(F45.0)', 'are:', 'A.'], ['History', 'of', 'multiple', 'physical', 'symptoms,', 'which', 'begins', 'before', 'age', '30,', 'persists', 'for', 'several', 'years,', 'and', 'compels', 'seeking', 'medical', 'attention', 'or', 'causes', 'significant', 'impairment', 'socially,', 'occupationally,', 'or', 'in', 'other', 'important', 'areas', 'of', 'the', "individual's", 'activity.'], ['B.'], ['All', 'of', 'the', 'following', 'criteria', 'must', 'be', 'met,', 'and', 'each', 'symptom', 'can', 'occur', 'at', 'any', 'time', 'during', 'the', 'disturbance:', '1.'], ['Four', 'painful', 'symptoms:', 'history', 'of', 'pain', 'related', 'to', 'at', 'least', 'four', 'areas', 'of', 'the', 'body', 'or', 'four', 'functions', '(e.g.,', 'head,', 'abdomen,', 'back,', 'joints,', 'extremities,', 'chest,', 'rectum;', 'during', 'menstruation,', 'sexual', 'intercourse,', 'or', 'urination).'], ['Two', 'gastrointestinal', 'symptoms:', 'history', 'of', 'at', 'least', 'two', 'gastrointestinal', 'symptoms', 'other', 'than', 'pain', '(e.g.,', 'nausea,', 'bloating,', 'vomiting', '[not', 'during', 'pregnancy],', 'diarrhea,', 'or', 'intolerance', 'to', 'different', 'foods).'], ['3.'], ['A', 'sexual', 'symptom:', 'history', 'of', 'at', 'least', 'one', 'sexual', 'or', 'reproductive', 'symptom', 'other', 'than', 'pain', '(e.g.,', 'sexual', 'indifference,', 'erectile', 'or', 'ejaculatory', 'dysfunction,', 'irregular', 'menses,', 'excessive', 'menstrual', 'leakage,', 'vomiting', 'during', 'pregnancy).'], ['4.'], ['A', 'pseudoneurological', 'symptom:', 'History', 'of', 'at', 'least', 'one', 'symptom', 'or', 'deficit', 'suggestive', 'of', 'a', 'neurological', 'disorder', 'not', 'limited', 'to', 'pain', '(conversion', 'symptoms', 'of', 'the', 'type', 'of', 'impaired', 'psychomotor', 'coordination', 'or', 'balance,', 'localized', 'muscle', 'paralysis', 'or', 'weakness,', 'difficulty', 'swallowing,', 'lump-in-throat', 'sensation,', 'aphonia,', 'urinary', 'retention,', 'hallucinations,', 'loss', 'of', 'tactile', 'and', 'painful', 'sensation,', 'diplopia,', 'blindness,', 'deafness,', 'seizures;', 'dissociative', 'symptoms', 'such', 'as', 'amnesia;', 'or', 'loss', 'of', 'consciousness', 'other', 'than', 'fainting).'], ['C.'], ['Either', 'of', 'the', 'following', 'two', 'characteristics:', '1.'], ['Upon', 'adequate', 'examination,', 'none', 'of', 'the', 'symptoms', 'in', 'Criterion', 'B', 'can', 'be', 'explained', 'by', 'the', 'presence', 'of', 'a', 'known', 'medical', 'illness', 'or', 'by', 'the', 'direct', 'effects', 'of', 'a', 'substance', '(e.g.,', 'drugs', 'or', 'medication).'], ['2.'], ['If', 'a', 'medical', 'illness', 'is', 'present,', 'the', 'physical', 'symptoms', 'or', 'social', 'or', 'occupational', 'impairment', 'are', 'excessive', 'compared', 'to', 'what', 'would', 'be', 'expected', 'from', 'the', 'history,', 'physical', 'examination,', 'or', 'laboratory', 'findings.'], ['D.'], ['The', 'symptoms', 'are', 'not', 'intentionally', 'produced', 'and', 'are', 'not', 'simulated', '(unlike', 'in', 'factitious', 'disorder', 'and', 'simulation).'], ['Everything', 'fits', 'with', 'what', 'is', 'described', 'in', 'the', 'statement.'], ['Conversive', 'or', 'dissociative', 'disorder', 'is', 'ruled', 'out', 'because', 'these', 'are', 'usually', 'related', 'to', 'psychological', 'factors,', 'associated', 'with', 'the', 'symptom', 'or', 'deficit', '(not', 'deliberate).'], ['The', 'onset', 'or', 'exacerbation', 'of', 'the', 'condition', 'is', 'preceded', 'by', 'conflicts', 'or', 'other', 'triggers,', 'which', 'is', 'not', 'mentioned', 'in', 'the', 'statement.'], ['Neither', 'would', 'it', 'be', 'a', 'hypochondriacal', 'disorder', 'because', 'this', 'implies', 'a', 'preoccupation', 'and', 'fear', 'of', 'having,', 'or', 'the', 'conviction', 'of', 'having,', 'a', 'serious', 'illness', 'based', 'on', 'the', 'personal', 'interpretation', 'of', 'somatic', 'symptoms.'], ['But', 'it', 'does', 'not', 'involve', 'physical', 'signs', 'or', 'symptoms.']]

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124_46

[['QUESTION', 'TYPE:', 'NEPHROLOGY'], ['CLINICAL', 'CASE:'], ['A', '58-year-old', 'woman', 'comes', 'for', 'a', 'follow-up', 'visit', 'for', 'diabetes', 'mellitus', 'and', 'hypertension.'], ['She', 'feels', 'well', 'but', 'states', 'that', 'she', 'has', 'stopped', 'taking', 'verapamil', 'because', 'of', 'constipation.'], ['She', 'presents', 'with', 'intolerance', 'to', 'ACE', 'inhibitors', 'due', 'to', 'coughing.'], ['On', 'examination,', 'blood', 'pressure', 'is', '156/92', 'mm', 'Hg.'], ['CBC', 'includes', 'a', 'creatinine', 'of', '1.6', 'mg/dL,', '24-hour', 'urine', 'protein', 'excretion', 'of', '1.5', 'g/day,', 'and', 'a', 'creatinine', 'clearance', 'of', '45', 'ml/min.'], ['On', 'this', 'basis,', 'what', 'is', 'the', 'most', 'effective', 'treatment', 'to', 'slow', 'the', 'progression', 'of', 'the', "patient's", 'type', '2', 'diabetic', 'nephropathy?'], ['1-', 'Angiotensin', 'converting', 'enzyme', 'inhibitor.'], ['2-', 'Angiotensin', 'receptor', 'blocker.'], ['3-', 'Calcium', 'antagonist.'], ['4-', 'Alpha-blocker.'], ['5-', 'Beta-blocker.'], ['CORRECT', 'ANSWER:', '2'], ['This', 'question', 'is', 'typical', 'and', 'quite', 'easy.'], ['The', 'antihypertensive', 'drugs', 'that', 'have', 'been', 'shown', 'to', 'slow', 'the', 'progression', 'of', 'diabetic', 'nephropathy', 'are', 'the', 'ACE', 'inhibitors', 'and', 'ARAIIs.'], ['Specifically,', 'angiotensin', 'II', 'receptor', 'blockers', 'have', 'demonstrated', 'their', 'efficacy', 'in', 'this', 'field', 'for', 'type', '2', 'DM,', 'which', 'together', 'with', 'the', 'side', 'effects', 'that', 'IECAS', 'produce', 'in', 'the', 'patient', 'makes', 'an', 'ARAII', 'the', 'drug', 'of', 'choice.'], ['This', 'does', 'not', 'seem', 'to', 'me', 'to', 'be', 'an', 'open', 'question', '(without', 'going', 'into', 'pharmacoeconomic', 'issues,', 'of', 'course...).']]

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405_31

[['QUESTION', 'TYPE:', 'ONCOLOGY', '(ECTOPIC)'], ['CLINICAL', 'CASE:'], ['A', '20-year-old', 'woman', 'with', 'a', '15-cm', 'solid-cystic', 'ovarian', 'tumor', 'detected', 'by', 'ultrasound', 'after', 'presenting', 'with', 'nonspecific', 'abdominal', 'symptoms.'], ['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.'], ['In', 'reference', 'to', 'this', 'case,', 'point', 'out', 'the', 'correct', 'diagnosis:'], ['1-', 'Teratocarcinoma.'], ['2-', 'Immature', 'teratoma.'], ['3-', 'Mature', 'cystic', 'teratoma.'], ['4-', 'Dysgerminoma.'], ['5-', 'nan'], ['CORRECT', 'ANSWER:', '2'], ['Teratoma', 'is', 'the', 'most', 'frequent', 'germinal', 'tumor.'], ['It', 'presents', 'differentiation', 'in', 'elements', 'of', 'the', 'three', 'embryonic', 'layers:', 'endoderm,', 'mesoderm', 'and', 'ectoderm.'], ['Macroscopically', 'they', 'can', 'be', 'cystic', 'or', 'solid,', 'and', 'histologically', 'the', 'tissues', 'composing', 'the', 'tumor', 'can', 'be', 'mature', '(well', 'differentiated,', 'like', 'adult', 'tissues)', 'or', 'immature', '(like', 'embryonic', 'tissues).Mature', 'cystic', 'teratoma', 'is', 'the', 'most', 'frequent:', 'they', 'represent', 'on', 'average', '10%', 'of', 'ovarian', 'tumors', '(5-25%', 'depending', 'on', 'the', 'casuistry).'], ['They', 'occur', 'at', 'any', 'age.'], ['They', 'predominate', 'in', 'ectodermal', 'tissues,', 'such', 'as', 'skin,', 'lining', 'a', 'cavity', 'of', 'keratinous', 'content.'], ['In', 'the', 'cavity', 'a', 'spur', 'is', 'recognized', 'from', 'which', 'hair', 'or', 'tooth', 'structures', 'often', 'arise.'], ['Frequent', 'tissues', 'include:', 'nervous', 'tissue,', 'usually', 'glial', 'and', 'ependymal', 'epithelium,', 'respiratory', 'and', 'digestive', 'epithelia', 'and', 'various', 'mesodermal', 'structures.'], ['They', 'are', 'bilateral', 'in', 'about', '10%', 'of', 'cases.'], ['The', 'mature', 'cystic', 'teratoma', 'is', 'benign,', 'but', 'in', '2%', 'of', 'them', 'a', 'malignant', 'tumor', 'may', 'develop', 'from', 'one', 'of', 'the', 'tissue', 'components', '(spinocellular', 'carcinoma,', 'carcinoid,', 'adenocarcinoma,', 'thyroid', 'tissue', 'carcinoma,', 'sarcoma).'], ['In', 'this', 'case', 'at', 'first', 'we', 'thought', 'that', 'the', 'option', 'was', 'mature', 'cystic', 'teratoma', 'but', 'thanks', 'to', 'Ramón,', 'when', 'we', 'read', 'it', 'more', 'carefully,', 'we', 'found', 'that', 'it', 'had', 'neuroectodermal', 'and', 'embryonal', 'elements', 'in', 'several', 'of', 'the', 'histological', 'preparations,', 'so', 'we', 'consider', 'that', 'the', 'correct', 'answer', 'is', '2.']]

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497_127

[['QUESTION', 'TYPE:', 'MEDICAL', 'ONCOLOGY'], ['CLINICAL', 'CASE:'], ['A', '60-year-old', 'man,', 'smoker', 'of', '40', 'packs/year,', 'who', 'consults', 'for', 'pain', 'in', 'the', 'ulnar', 'border', 'of', 'the', 'left', 'arm', 'and', 'left', 'palpebral', 'ptosis', 'since', 'one', 'month', 'ago.'], ['Chest', 'X-ray', 'shows', 'a', 'mass', 'in', 'the', 'left', 'upper', 'lobe', 'and', 'CT', 'scan', 'confirms', 'the', 'lesion', 'with', 'invasion', 'of', 'the', 'second', 'rib.'], ['In', 'relation', 'to', 'the', 'suspected', 'diagnosis,', 'the', 'most', 'appropriate', 'treatment', 'is:'], ['1-', 'Neoadjuvant', 'chemotherapy', 'with', 'combined', 'chemoradiotherapy,', 'followed', 'by', 'surgery.'], ['2-', 'Neoadjuvant', 'chemotherapy', 'without', 'surgery,', 'followed', 'by', 'radiotherapy.'], ['3-', 'Surgery', 'followed', 'by', 'combined', 'chemoradiotherapy.'], ['4-', 'Radiotherapy', 'without', 'chemotherapy,', 'followed', 'by', 'surgery.'], ['5-', 'nan'], ['CORRECT', 'ANSWER:', '1'], ['Typical', "smoker's", 'pancoast,', 'probably', 'an', 'epidermoid,', 'with', "Horner's", 'sdr.'], ['Best', 'would', 'be', 'chemoradio', 'followed', 'by', 'surgical', 'salvage.'], ['In', 'the', 'old', 'days', 'it', 'was', 'just', 'RT', 'and', 'surgery.'], ['Maybe', 'not', 'far', 'off', 'enter', 'immunotherapy', 'in', 'first', 'line.'], ['There', 'are', 'more', 'and', 'more', 'new', 'things.']]

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307_207

[['QUESTION', 'TYPE:', 'OPHTHALMOLOGY'], ['CLINICAL', 'CASE:'], ['A', '34-year-old', 'patient', 'playing', 'tennis', 'is', 'hit', 'by', 'a', 'ball', 'at', 'the', 'level', 'of', 'the', 'left', 'orbit.'], ['On', 'examination', 'he', 'presents', 'significant', 'palpebral', 'hematoma,', 'hyposphagmia,', 'diplopia', 'to', 'superior', 'vision', 'with', 'limitation', 'of', 'the', 'upper', 'version', 'of', 'the', 'eyeball.'], ['What', 'would', 'you', 'suspect?'], ['1-', 'Fracture', 'of', 'the', 'inferior', 'wall', 'of', 'the', 'floor', 'of', 'the', 'orbit', 'with', 'trapping', 'of', 'the', 'inferior', 'rectus', 'muscle.'], ['2-', 'Zygomatic', 'arch', 'fracture.'], ['3-', 'Fracture', 'of', 'the', 'superior', 'wall', 'of', 'the', 'orbit', 'with', 'entrapment', 'of', 'the', 'superior', 'rectus', 'muscle.'], ['4-', 'Dentoalveolar', 'fracture.'], ['5-', 'nan'], ['CORRECT', 'ANSWER:', '1'], ['This', 'question', 'has', 'a', 'small', 'typo', '(one', 'would', 'say', '"tennis"),', 'but', 'personally', 'I', 'am', 'a', 'little', 'more', 'bothered', 'by', 'the', 'error', 'in', 'the', 'description', 'of', 'the', 'scan.'], ['Specifically', 'when', 'they', 'say', '"diplopia', 'to', 'superior', 'vision', 'with', 'limitation', 'of', 'the', 'superior', 'version', 'of', 'the', 'eyeball".'], ['Versions', 'are', 'bilateral', 'conjugated', 'movements', 'of', 'both', 'eyes.'], ['That', 'is,', 'a', 'version', 'is', 'composed', 'of', 'the', 'sum', 'of', 'two', 'ductions,', 'since', 'duction', 'is', 'the', 'movement', 'of', 'only', 'one', 'eye.'], ['When', 'you', 'explore', 'the', 'versions,', 'specifically', 'the', 'superior', 'version', 'or', 'supraversion,', 'both', 'eyes', 'rotate', 'upward.'], ['At', 'that', 'time,', 'you', 'may', 'encounter', 'a', 'limitation', 'of', 'the', 'movement', 'of', 'one', 'eye.'], ['In', 'this', 'case,', 'when', 'you', 'scan', 'the', 'supraversion,', 'you', 'suspect', 'or', 'you', 'detect', 'a', 'limitation', 'in', 'the', 'movement', 'of', 'the', 'left', 'eye.'], ['And', 'we', 'would', 'call', 'this', 'a', 'limitation', 'to', 'the', 'supraversion', 'of', 'that', 'eye.'], ['It', "doesn't", 'make', 'sense', 'to', 'talk', 'about', 'limitation', 'to', 'the', 'version', 'of', 'the', 'eyeball,', 'because', 'the', 'version', 'is', 'always', 'of', 'both', 'eyeballs.'], ['Okay,', 'it', 'is', 'understood,', 'but', 'it', 'is', 'an', 'important', 'misconception', 'that', 'should', 'not', 'be', 'made', 'by', 'the', 'person', 'writing', 'the', 'question', '(who', 'is', 'supposed', 'to', 'be', 'an', 'expert', 'on', 'the', 'subject),', 'but', 'well,', 'as', 'I', 'do', 'not', 'think', 'it', 'is', 'a', 'reason', 'to', 'challenge', 'the', 'question,', "let's", 'go', 'on.'], ['It', 'is', 'about', 'a', 'patient', 'who', 'has', 'received', 'a', 'blow.'], ['All', 'four', 'answers', 'are', 'fractures,', 'so', 'we', 'have', 'a', 'pretty', 'definite', 'picture.'], ['The', 'palpebral', 'hematoma', 'and', 'hyposphagma', '(subconjunctival', 'hemorrhage)', 'does', 'not', 'give', 'us', 'the', 'key', 'data.'], ['What', 'is', 'important', 'is', 'that', 'the', 'eye', 'that', 'has', 'received', 'the', 'blow', 'does', 'not', 'go', 'up,', 'and', 'therefore', 'there', 'is', 'double', 'vision', 'in', 'the', 'superior', 'gaze.'], ['It', 'might', 'be', 'tempting', 'to', 'answer', '3,', 'thinking', 'that', 'because', 'the', 'superior', 'rectus', 'is', 'trapped,', 'it', 'does', 'not', 'work', 'and', 'therefore', 'the', 'eye', 'cannot', 'go', 'up.'], ['However,', 'muscles', 'trapped', 'in', 'a', 'fracture', 'do', 'not', 'automatically', 'lose', 'their', 'muscular', 'action.'], ['What', 'happens', 'is', 'that', 'they', 'become', 'trapped,', 'they', 'are', '"hooked",', 'and', 'cannot', 'stretch.'], ['The', 'problem', 'is', 'that', 'the', 'inferior', 'wall', 'has', 'been', 'broken,', 'the', 'inferior', 'rectus', 'has', 'been', 'trapped,', 'and', 'when', 'the', 'eye', 'must', 'look', 'up,', 'this', 'inferior', 'rectus', 'cannot', 'stretch', 'as', 'it', 'should.'], ['It', 'is', 'not', 'paralysis,', 'but', 'a', 'restrictive', 'problem.'], ['This', 'question', 'could', 'also', 'be', 'answered', 'by', 'discarding.'], ['Options', '2', 'and', '4', 'can', 'be', 'ignored', 'because', 'they', 'are', 'too', 'far', 'away', 'from', 'the', 'extraocular', 'muscles', 'to', 'produce', 'diplopia.'], ['And', 'as', 'for', 'the', 'walls', 'of', 'the', 'orbit,', 'the', 'ones', 'that', 'break', 'most', 'frequently', 'are', 'the', 'inferior', 'and', 'medial', 'wall.'], ['The', 'superior', 'wall', 'ruptures', 'very', 'rarely.']]

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589_63

350_160

[['QUESTION', 'TYPE:', 'GYNECOLOGY', 'AND', 'OBSTETRICS'], ['CLINICAL', 'CASE:'], ['A', '45-year-old', 'woman,', 'mother', 'of', '3', 'children,', 'attends', 'an', 'early', 'diagnosis', 'consultation.'], ['Cervicovaginal', 'cytology', 'is', 'compatible', 'with', 'a', 'high-grade', 'squamous', 'intraepithelial', 'lesion.'], ['Which', 'of', 'the', 'following', 'options', 'would', 'you', 'choose?'], ['1-', 'Repeat', 'cytology', 'in', '1', 'month.'], ['2-', 'Colposcopy', 'with', 'possible', 'biopsy.'], ['3-', 'Hysterectomy', 'with', 'bilateral', 'salpinguectomy', 'and', 'ovarian', 'conservation.'], ['4-', 'Fractionated', 'uterine', 'curettage.'], ['5-', 'nan'], ['CORRECT', 'ANSWER:', '2'], ['Colposcopy', 'with', 'possible', 'biopsy.'], ['H-SIL', '(High-grade', 'squamous', 'intraepithelial', 'lesion)*:', 'includes', 'changes', 'suggestive', 'of', 'CIN2', 'and', 'CIN3/CIS.'], ['The', 'cytologic', 'diagnosis', 'must', 'be', 'confirmed', 'by', 'biopsy,', 'for', 'which', 'it', 'is', 'necessary', 'to', 'perform', 'a', 'directed', 'biopsy', 'by', 'colposcopy.']]

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25_116

[['QUESTION', 'TYPE:', 'INFECTIOUS'], ['CLINICAL', 'CASE:'], ['A', '40-year-old', 'woman', 'is', 'admitted', 'to', 'the', 'Emergency', 'Department', 'with', 'a', 'fever', 'of', '38ºC', 'and', 'right', 'lumbar', 'pain.'], ['The', 'CBC', 'shows', '25000', 'leukocytes/mm3', 'with', 'left', 'deviation', 'and', 'an', 'abdominal', 'ultrasound', 'shows', 'a', 'coralliform', 'lithiasis.'], ['What', 'microorganism', 'do', 'we', 'expect', 'to', 'find?'], ['1-', 'Escherichia', 'coli.'], ['2-', 'Enterococcus', 'faecalis.'], ['3-', 'Salmonella', 'typhi.'], ['4-', 'Candida', 'albicans.'], ['5-', 'Proteus', 'mirabilis.'], ['CORRECT', 'ANSWER:', '5'], ['Epidemiology', 'question', 'shared', 'with', 'URO.'], ['Coraliform', 'lithiasis', 'are', 'associated', 'with', 'urea-folding', 'germs:', 'Proteus', 'in', 'the', 'first', 'place,', 'Pseudomonas,', 'Klebsiella', 'and', 'some', 'staphylococci.']]

[['O', 'O', 'O'], ['O', 'O'], ['B-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise'], ['B-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'O', 'B-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise'], ['O', 'O', 'O', 'O', 'O', 'O', 'O'], ['O', 'B-Claim', 'I-Claim'], ['O', 'B-Claim', 'I-Claim'], ['O', 'B-Claim', 'I-Claim'], ['O', 'B-Claim', 'I-Claim'], ['O', 'B-Claim', 'I-Claim'], ['O', 'O', 'O'], ['O', 'O', 'O', 'O', 'O'], ['B-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim']]

103_89

22_112

[['QUESTION', 'TYPE:', 'INFECTIOUS'], ['CLINICAL', 'CASE:'], ['A', 'patient', 'comes', 'to', 'the', 'Emergency', 'Department', 'with', 'fever', 'without', 'focus', 'of', '24', 'h', 'of', 'evolution,', 'hypothyroidism', 'and', 'impression', 'of', 'severity.'], ['She', 'underwent', 'a', 'splenectomy', '2', 'years', 'ago', 'for', 'staging', 'of', "Hosgkin's", 'disease.'], ['Which', 'microorganism', 'is', 'most', 'frequently', 'implicated?'], ['1-', 'Streptococcus', 'pneumoniae.'], ['2-', 'Pseudomonas', 'aeruginosa.'], ['3-', 'Salmonella', 'no', 'typhi.'], ['4-', 'Pneumocystis', 'jirovecii.'], ['5-', 'Streptococcus', 'viridans.'], ['CORRECT', 'ANSWER:', '1'], ['Another', 'one', 'on', 'epidemiology.'], ['In', 'splenectomized', 'patients,', 'the', 'risk', 'of', 'acquiring', 'serious', 'infections', 'by', 'encapsulated', 'germs', 'is', 'increased,', 'again', 'Pneumococcus', 'being', 'the', 'most', 'frequent.']]

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488_105

[['QUESTION', 'TYPE:', 'HEMATOLOGY'], ['CLINICAL', 'CASE:'], ['A', '67-year-old', 'patient', 'who', 'in', 'the', 'last', '6', 'months,', 'in', 'two', 'routine', 'analyses,', 'presents', 'progressive', 'lymphocytosis.'], ['In', 'the', 'last', 'one,', 'hemoglobin', '15.4', 'g/dL;', 'leukocytes', '18.5', 'x103/μL', 'with', '82%', 'of', 'mature', 'lymphocytes', 'that', 'by', 'flow', 'cytometry', 'express', 'CD5/CD19/CD23', 'antigens', 'and', 'platelets', '240', 'x103/μL.'], ['What', 'attitude', 'do', 'you', 'think', 'is', 'correct?'], ['1-', 'Study', 'of', 'TP53', 'mutations', 'to', 'establish', 'prognosis.'], ['2-', 'Bone', 'aspirate/biopsy', 'to', 'confirm', 'the', 'diagnosis.'], ['3-', 'PET/CT', 'to', 'establish', 'the', 'therapeutic', 'attitude.'], ['4-', 'New', 'clinical', 'and', 'analytical', 'control', 'in', '6', 'months.'], ['5-', 'nan'], ['CORRECT', 'ANSWER:', '4'], ['A', 'question', 'that', 'I', 'think', 'can', 'be', 'complicated', 'for', 'a', 'MIR', 'examiner.'], ['We', 'are', 'told', 'of', 'a', 'leukocytosis', 'at', 'the', 'expense', 'of', 'lymphocytes', 'with', 'a', 'B-CLL', 'phenotype.'], ['It', 'seems', 'that', 'there', 'are', 'no', 'other', 'alarming', 'data.'], ['No', 'clinical', 'data', 'are', 'given', '(so', 'we', 'assume', 'that', 'the', 'patient', 'is', 'asymptomatic).'], ['No', 'cytopenias...'], ['Conclusion:', 'FOLLOW', 'UP.'], ['The', 'main', 'hesitation', 'with', 'the', 'answer', 'should', 'be', 'with', 'option', '1.'], ['Why', 'do', 'I', 'consider', 'it', 'incorrect?'], ['Because', 'the', 'TP53', 'mutation,', 'although', 'it', 'establishes', 'prognosis,', 'is', 'not', 'indicated', 'at', 'diagnosis,', 'but', 'when', 'treatment', 'is', 'going', 'to', 'be', 'initiated', '(first', 'line', 'and', 'prior', 'to', 'successive', 'lines', 'in', 'case', 'they', 'are', 'needed).'], ['It', 'would', 'be', 'possible', 'to', 'go', 'too', 'far', 'in', 'this', 'question', 'in', 'which', 'the', 'percentage', 'given', 'does', 'not', 'refer', 'directly', 'to', 'clonal', 'lymphocytes,', 'so', 'that', 'it', 'could', 'even', 'be', 'a', 'monoclonal', 'B', 'lymphocytosis.'], ['But', 'this', 'is', 'going', 'too', 'far.']]

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111_153

[['QUESTION', 'TYPE:', 'GYNECOLOGY', 'AND', 'OBSTETRICS'], ['CLINICAL', 'CASE:'], ['A', '59-year-old', 'woman', 'consults', 'a', 'gynecologist', 'for', 'a', 'spontaneous,', 'spontaneous,', 'uniorificial', 'discharge', 'from', 'the', 'right', 'nipple', '(unilateral)', 'without', 'palpable', 'nodularity.'], ['What', 'is', 'the', 'most', 'likely', 'diagnosis?'], ['1-', 'Given', 'the', 'hematic', 'nature', 'of', 'the', 'discharge,', 'the', 'most', 'likely', 'diagnosis', 'is', 'infiltrating', 'ductal', 'carcinoma.'], ['2-', 'Intraductal', 'papilloma.'], ['3-', "Paget's", 'disease', 'of', 'the', 'nipple.'], ['4-', 'Tumor', 'hyperprolactinemia.'], ['5-', 'Mammography', 'will', 'indicate', 'the', 'diagnosis.'], ['CORRECT', 'ANSWER:', '2'], ['The', 'correct', 'answer', 'is', '2.'], ['In', 'the', 'presence', 'of', 'unilateral', 'and', 'uniorificial', 'hematic', 'telorrhea,', 'the', 'most', 'frequent', 'cause', 'is', 'intraductal', 'papilloma', '(50%),', 'followed', 'by', 'ductal', 'ectasia', 'and', 'carcinoma.'], ['When', 'associated', 'with', 'palpable', 'mass,', '60%', 'correspond', 'to', 'carcinoma.'], ["Paget's", 'disease', 'is', 'of', 'the', 'eczematous', 'type.'], ['In', 'hyperprolactinemia,', 'telorrhea', 'is', 'bilateral', 'and', 'pluriorificial.'], ['Mammography', 'often', 'does', 'not', 'show', 'papillomas,', 'being', 'more', 'useful', 'ultrasound', 'and', 'galactography.']]

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119_119

[['QUESTION', 'TYPE:', 'INFECTOLOGY'], ['CLINICAL', 'CASE:'], ['A', '17-year-old', 'woman', 'comes', 'to', 'the', 'emergency', 'department', 'with', 'a', 'high', 'fever,', 'pharyngeal', 'pain', 'and', 'cervical', 'lymphadenopathy.'], ['She', 'had', 'previously', 'been', 'diagnosed', 'with', 'acute', 'pharyngitis', 'and', 'was', 'treated', 'with', 'amoxicillin,', 'and', 'later', 'presented', 'with', 'a', 'generalized', 'macular', 'skin', 'rash.'], ['Laboratory', 'tests', 'showed', 'slight', 'leukocytosis', 'with', 'lymphocytosis', 'and', 'presence', 'of', 'activated', 'lymphocytes,', 'slight', 'thrombopenia', 'and', 'slightly', 'increased', 'transaminases.'], ['What', 'would', 'be', 'the', 'most', 'likely', 'diagnosis', 'of', 'this', 'clinical', 'picture?'], ['1-', 'It', 'is', 'a', 'typical', 'picture', 'of', 'infectious', 'mononucleosis.'], ['2-', 'Varicella', 'zoster', 'virus', 'infection.'], ['3-', 'Acute', 'toxoplasmosis.'], ['4-', 'Lyme', 'disease.'], ['5-', 'Infection', 'by', 'herpes', 'virus', '8.'], ['CORRECT', 'ANSWER:', '1'], ['Of', 'course', 'it', 'is', 'a', 'typical', 'picture', '(EBV,', 'CMV,', 'VH6,', 'Toxoplasma),', 'of', 'which', 'you', 'will', 'not', 'see', 'so', 'clearly', 'at', 'the', 'emergency', 'room', 'door', 'when', 'you', 'are', 'on', 'call.'], ['Be', 'careful', 'with', 'the', 'bad', 'blood', 'in', 'answer', '3,', 'because', 'an', 'acute', 'toxoplasmosis', 'can', 'behave', 'like', 'this', 'and', 'also', 'give', 'a', 'macular', 'exanthema,', 'although', 'the', 'one', 'of', 'this', 'girl', 'is', 'related', 'to', 'the', 'intake', 'of', 'amoxicillin.'], ['By', 'the', 'way,', 'I', 'add', 'a', 'note,', 'if', 'instead', 'of', 'a', 'girl', 'of', '17', 'years', 'so', 'clear', 'it', 'were', 'a', 'young', 'man/girl', 'with', 'risky', 'sexual', 'relations,', 'do', 'not', 'forget', 'the', 'HIV', 'primoinfection', 'as', 'a', 'cause', 'of', 'mononucleosis', 'syndrome.']]

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562_183

[['QUESTION', 'TYPE:', 'HEMATOLOGY'], ['CLINICAL', 'CASE:'], ['A', '45-year-old', 'woman', 'with', 'no', 'history', 'of', 'interest', 'consults', 'for', 'dyspneic', 'sensation', 'of', 'about', '4', 'days', 'of', 'evolution.'], ['Examination', 'shows', 'rhythmic', 'tachycardia,', 'without', 'murmurs,', 'and', 'pulmonary', 'auscultation', 'is', 'normal.'], ['Arterial', 'blood', 'gases', 'showed', 'a', 'pO2', 'of', '70', 'mmHg', 'and', 'a', 'pCO2', 'of', '32', 'mmHg.'], ['Hemogram,', 'renal', 'and', 'hepatic', 'function', 'are', 'normal.'], ['Prothrombin', 'time', '90%,', 'activated', 'partial', 'thromboplastin', 'time', '(APTT)', 'ratio', 'of', '2', 'to', 'control', '(N', '<1.2).'], ['Which', 'of', 'the', 'following', 'diagnoses', 'is', 'the', 'most', 'likely:'], ['1-', 'Antiphospholipid', 'syndrome.'], ['2-', 'Factor', 'V', 'of', 'Leiden.'], ['3-', 'Hemophilia.'], ['4-', 'Acute', 'pericarditis.'], ['5-', 'nan'], ['CORRECT', 'ANSWER:', '1'], ['In', 'this', 'question', 'what', 'they', 'assume', 'is', 'that', 'this', 'is', 'a', '45-year-old', 'woman', 'who', 'is', 'diagnosed', 'with', 'pulmonary', 'thromboembolism', '(PTE).'], ['With', 'this', 'diagnosis,', 'options', '3', 'and', '4', 'are', 'directly', 'excluded', '(also,', 'she', 'is', 'female,', 'so', 'we', 'would', 'not', 'have', 'to', 'think', 'about', 'hemophilia)', 'As', 'an', 'analytical', 'data,', 'it', 'says', 'that', 'there', 'is', 'a', 'lengthening', 'of', 'the', 'aPTT.'], ['So,', 'they', 'want', 'you', 'to', 'know,', 'she', 'has', 'positive', 'lupus', 'ac', 'and', 'link', 'it', 'directly', 'to', 'antiphospholipid', 'syndrome', '(APS).'], ['A', "Leiden's", 'does', 'not', 'alter', 'coagulation,', 'so', 'it', 'is', 'ruled', 'out', 'as', 'well.'], ['Anyway,', 'although', 'it', 'is', 'not', 'within', 'the', 'possible', 'answers,', 'lupus', 'positivity', 'can', 'be', 'related', 'to', 'a', 'myriad', 'of', 'clinical', 'situations,', 'syndromes', 'and', 'pathologies.'], ['Assuming', 'that', 'a', 'PTE', '+', 'lupus', 'is', 'a', 'PFS', 'seems', 'to', 'me', 'to', 'be', 'a', 'bit', 'of', 'a', 'stretch,', 'but', 'it', 'is', 'the', 'most', 'likely', 'with', 'the', 'data', 'provided.']]

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514_97

[['QUESTION', 'TYPE:', 'CRITICAL', 'AND', 'EMERGENCY', 'CARE'], ['CLINICAL', 'CASE:'], ['After', 'a', 'traffic', 'accident', 'you', 'attend', 'to', 'an', 'injured', 'person.'], ['The', 'patient', 'opens', 'his', 'eyes', 'at', 'your', 'call,', 'but', 'only', 'utters', 'words', 'that', 'are', 'inappropriate.'], ['On', 'motor', 'examination,', 'the', 'pain', 'is', 'localized', 'in', 'the', 'right', 'extremities,', 'but', 'spreads', 'on', 'stimulation', 'of', 'the', 'left', 'extremities.'], ['How', 'would', 'you', 'describe', 'his', 'condition', 'according', 'to', 'the', 'Glasgow', 'Coma', 'Scale?'], ['1-', 'E3V2M4.'], ['2-', 'E3V3M5.'], ['3-', 'E2V3M4.'], ['4-', 'E2V4M5.'], ['5-', 'nan'], ['CORRECT', 'ANSWER:', '2'], ['The', 'first', 'thing', 'we', 'should', 'know', 'when', 'applying', 'the', 'Glasgow', 'Coma', 'Scale', 'to', 'a', 'patient', 'is', 'that', 'we', 'should', 'always', 'keep', 'the', 'best', 'value', 'in', 'each', 'sphere', '(ocular', 'response,', 'motor', 'response', 'and', 'verbal', 'response).'], ['In', 'this', 'case,', 'we', 'have', 'a', 'patient', 'who', 'has', 'an', 'ocular', 'opening', 'to', 'the', 'call', '(ocular', 'response', '3', 'out', 'of', '4),', 'emits', 'inappropriate', 'words', '(verbal', 'response', '3', 'out', 'of', '5)', 'and', 'localizes', 'pain', 'with', 'right', 'extremities', '(motor', 'response', '5', 'out', 'of', '6).'], ['The', 'Glasgow', 'Coma', 'Scale', 'score', 'would', 'be', '11', '(out', 'of', '15).'], ['The', 'best', 'value', 'of', 'the', 'examination', 'is', 'taken', 'because', 'in', 'many', 'cases', '(assessment', 'of', 'a', 'polytraumatized', 'patient,', 'ischemic', 'stroke', 'or', 'spontaneous', 'acute', 'cerebral', 'bleeding),', 'the', 'motor', 'examination', 'may', 'be', 'artifacted', 'by', 'other', 'elements.'], ['For', 'example:', 'in', 'a', 'polytraumatized', 'patient', '(such', 'as', 'the', 'one', 'in', 'question),', 'the', 'response', 'presented', 'with', 'left', 'extremities', 'may', 'be', 'due', 'to', 'localized', 'trauma', 'in', 'that', 'area,', 'and', 'not', 'strictly', 'speaking', 'to', 'an', 'underlying', 'traumatic', 'brain', 'injury.'], ['Likewise,', 'sometimes', 'the', 'verbal', 'response', 'may', 'be', 'underestimated', 'in', 'the', 'polytraumatized', 'patient', 'due', 'to', 'airway', 'obstruction', '(e.g.,', 'due', 'to', 'the', 'tongue', 'retreating', 'into', 'the', 'oropharynx).'], ['By', 'always', 'assessing', 'the', 'best', 'response,', 'we', 'will', 'have', 'a', 'truer', 'picture', 'of', 'the', "patient's", 'condition.']]

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101_86

[['QUESTION', 'TYPE:', 'ENDOCRINOLOGY'], ['CLINICAL', 'CASE:'], ['A', '55-year-old', 'woman', 'consults', 'for', 'fatigue', 'and', 'polyuria', 'of', 'two', "years'", 'evolution.'], ['Laboratory', 'tests', 'reveal', 'hypercalcemia,', 'increased', 'PTH', 'and', 'increased', 'bone', 'turnover', 'markers.'], ['The', 'radiographic', 'study', 'shows', 'subperiosteal', 'resorption', 'and', 'osteoporosis.'], ['Sestamibi', 'scintigraphy', 'revealed', 'a', 'parathyroid', 'adenoma.'], ['Parathyroidectomy', 'was', 'performed', 'with', 'minimally', 'invasive', 'surgery.'], ['Postoperatively,', 'the', 'patient', 'developed', 'severe', 'hypocalcemia', 'and', 'tetany,', 'with', 'PTH', 'below', '5', 'ng/l.'], ['The', 'patient', 'responds', 'well', 'to', 'initial', 'treatment', 'with', 'intravenous', 'calcium', 'and', 'later', 'with', 'oral', 'calcium', 'and', 'vitamin', 'D.'], ['What', 'is', 'the', 'most', 'likely', 'diagnosis?'], ['1-', 'Permanent', 'surgical', 'hypoparathyroidism.'], ['2-', 'Transfusion', 'of', 'citrated', 'blood.'], ['3-', 'Vitamin', 'D', 'insufficiency.'], ['4-', 'Hungry', 'bone', 'syndrome.'], ['5-', 'Osteomalacia.'], ['CORRECT', 'ANSWER:', '4'], ['Question', 'of', 'very', 'high', 'difficulty,', 'I', 'would', 'not', 'worry', 'about', 'having', 'failed', 'it.'], ['It', 'is', 'easy', 'to', 'get', 'confused', 'with', 'the', 'hypoparathyroidism', 'answer.'], ['Permanent', 'post-surgical', 'hypoparathyroidism', 'after', 'parathyroidectomy', 'of', 'an', 'adenoma', 'with', 'minimally', 'invasive', 'surgery', 'is', 'rare.'], ['I', 'write', 'a', 'brief', 'summary', 'of', 'the', 'hungry', 'bone', 'syndrome', 'that', 'I', 'have', 'found', 'in', 'a', 'clinical', 'case', 'in', 'the', 'Annals', 'of', 'Internal', 'Medicine', '[1]:', '"The', 'pathophysiology', 'of', 'the', 'hungry', 'bone', 'syndrome', '(HBS)', 'is', 'related', 'to', 'an', 'imbalance', 'between', 'bone', 'formation', 'and', 'bone', 'resorption,', 'which', 'is', 'associated', 'with', 'hypocalcemia,', 'hypophosphatemia', 'and', 'hypomagnesemia', '(1).'], ['This', 'syndrome', 'can', 'be', 'observed', 'after', 'surgery', 'in', 'patients', 'with', 'primary', 'hyperparathyroidism', '(HPT),', 'as', 'well', 'as', 'in', 'tertiary', 'HPT', 'of', 'chronic', 'renal', 'failure,', 'and', 'to', 'a', 'lesser', 'extent', 'after', 'treatment', 'of', 'processes', 'with', 'excess', 'of', 'circulating', 'thyroid', 'hormones', '(2).'], ['In', 'PTH,', 'there', 'is', 'an', 'excess', 'of', 'parathyroid', 'hormone', '(PTH)', 'which', 'stimulates', 'osteoclastic', 'activity', 'causing', 'demineralization', 'of', 'the', 'bone', 'matrix', 'and', 'releasing', 'calcium', 'into', 'the', 'bloodstream.'], ['After', 'parathyroidectomy,', 'serum', 'PTH', 'levels', 'drop', 'dramatically,', 'thus,', 'PTH-induced', 'bone', 'resorption', 'ceases,', 'while', 'osteoblastic', 'activity', 'continues', 'resulting', 'in', 'increased', 'bone', 'uptake', 'of', 'calcium,', 'phosphate', 'and', 'magnesium,', 'thus', 'SHH', 'appears', '(3)."']]

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230_179

[['QUESTION', 'TYPE:', 'PEDIATRICS'], ['CLINICAL', 'CASE:'], ['A', '4-year-old', 'boy', 'comes', 'to', 'the', 'health', 'center', 'who,', '5', 'minutes', 'before,', 'starts', 'with', 'angioedema', 'in', 'the', 'face,', 'conjunctivitis,', 'nasal', 'congestion', 'and', 'hoarseness,', 'coinciding', 'with', 'the', 'ingestion', 'of', 'a', 'spoonful', 'of', 'yogurt', 'given', 'to', 'him', 'by', 'mistake', 'at', 'school.'], ['Among', 'the', 'antecedents,', 'he', 'was', 'diagnosed', 'with', "cow's", 'milk', 'protein', 'allergy.'], ['Examination', 'revealed', 'mild', 'hypotension,', 'heart', 'rate', '110', 'bpm,', 'O2', 'Sat', '93%,', 'pale', 'and', 'slightly', 'sweaty,', 'with', 'scattered', 'wheezing.'], ['What', 'is', 'the', 'first', 'treatment', 'of', 'choice?'], ['1-', 'Provoke', 'vomiting.'], ['2-', 'Adrenaline', '1/1000', 'subcutaneous.'], ['3-', 'Intramuscular', 'adrenaline', '1/1000.'], ['4-', 'Intramuscular', 'methylprednisolone.'], ['5-', 'Nebulized', 'salbutamol.'], ['CORRECT', 'ANSWER:', '3'], ['We', 'are', 'facing', 'a', 'case', 'of', 'Anaphylaxis', 'so', 'the', 'first', 'measure', 'is', 'to', 'administer', 'Adrenaline', '1/1000', 'intramuscular', '(0.01mg/kg).'], ['Subsequently,', 'systemic', 'corticosteroids', 'such', 'as', 'methylprednisolone', 'will', 'be', 'given,', 'which', 'will', 'take', 'a', 'few', 'hours', 'to', 'take', 'effect.'], ['So', 'adrenaline', 'first,', 'as', 'it', 'is', 'faster', 'acting,', 'then', 'the', 'rest', '(Question', 'very', 'similar', 'to', 'one', 'last', 'year,', 'instead', 'of', 'yogurt,', 'it', 'was', 'omelet).']]

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479_164

[['QUESTION', 'TYPE:', 'CRITICAL', 'CARE'], ['CLINICAL', 'CASE:'], ['A', '72-year-old', 'man', 'presenting', 'since', '48', 'hours', 'with', 'fever', 'of', '38.7°C,', 'cough,', 'purulent', 'expectoration', 'and', 'dyspnea.'], ['Constants:', 'BP', '85/60', 'mmHg,', 'heart', 'rate', '100', 'bpm,', 'respiratory', 'rate', '35', 'rpm,', 'SatO2', '80%.'], ['Of', 'note', 'was', 'the', 'presence', 'of', 'confusion', 'and', 'crackles', 'in', 'the', 'left', 'lower', 'lung', 'field.'], ['Chest', 'X-ray', 'confirms', 'the', 'existence', 'of', 'pneumonia', 'of', 'the', 'lingula', 'and', 'left', 'lower', 'lobe.'], ['What', 'would', 'be', 'the', 'appropriate', 'place', 'of', 'care?'], ['1-', 'Outpatient', 'treatment', 'at', 'home.'], ['2-', 'Admission', 'to', 'an', 'emergency', 'observation', 'unit.'], ['3-', 'Hospital', 'admission', 'to', 'the', 'ward.'], ['4-', 'Admission', 'to', 'the', 'Intensive', 'Care', 'Unit.'], ['5-', 'nan'], ['CORRECT', 'ANSWER:', '4'], ['Applying', 'the', 'CURB-65', 'severity', 'scale', '(one', 'of', 'the', 'most', 'commonly', 'used', 'in', 'the', 'ED', 'for', 'stratifying', 'the', 'severity', 'of', 'pneumonia,', 'although', 'in', 'this', 'case', 'simply', 'applying', 'common', 'sense,', 'the', 'patient', 'should', 'be', 'admitted', 'to', 'the', 'ICU),', 'we', 'would', 'have', 'a', 'score', 'of', 'at', 'least', '4', 'points', '(we', 'would', 'be', 'missing', 'the', 'serum', 'urea', 'data),', 'which', 'gives', 'us', 'severity', 'criteria.'], ['Since', 'there', 'are', 'no', 'criteria', 'that', 'contraindicate', 'admission', 'to', 'the', 'ICU,', 'admission', 'to', 'the', 'unit', 'would', 'be', 'indicated.']]

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515_101

[['QUESTION', 'TYPE:', 'CRITICAL', 'AND', 'EMERGENCY', 'CARE'], ['CLINICAL', 'CASE:'], ['15-year-old', 'male,', 'admitted', 'after', 'being', 'run', 'over', 'on', 'the', 'public', 'road,', 'resulting', 'in', 'being', 'ejected.'], ['He', 'was', 'admitted', 'conscious', 'and', 'oriented,', 'with', 'intense', 'pain', 'in', 'the', 'left', 'hemithorax', 'and', 'dyspnea.'], ['Physical', 'examination', 'showed', 'blood', 'pressure', '90/60', 'mmHg,', 'heart', 'rate', '130', 'bpm,', 'basal', 'oxygen', 'saturation', '90%,', 'respiratory', 'rate', '35', 'rpm.'], ['There', 'is', 'complete', 'hypophonesis', 'in', 'the', 'left', 'hemithorax', 'and', 'dullness', 'to', 'percussion.'], ['Chest', 'X-ray', 'shows', 'multiple', 'left', 'costal', 'fractures', 'and', 'massive', 'ipsilateral', 'pleural', 'effusion.'], ['Placement', 'of', 'a', 'pleural', 'drain', 'is', 'indicated,', 'with', '1700', 'cc', 'of', 'hematic', 'fluid', 'coming', 'out.'], ['What', 'is', 'the', 'decision', 'to', 'be', 'made:'], ['1-', 'Institute', 'noninvasive', 'mechanical', 'ventilation', 'and', 'request', 'blood', 'transfusion.'], ['2-', 'Analgesia,', 'oxygen', 'therapy,', 'request', 'blood', 'transfusion', 'and', 'indicate', 'urgent', 'surgery.'], ['3-', 'Orotracheal', 'intubation,', 'request', 'blood', 'transfusion', 'and', 'observation', 'for,', 'in', 'case', 'of', 'worsening,', 'indicate', 'surgical', 'intervention.'], ['4-', 'Orotracheal', 'intubation', 'and', 'urgent', 'CT', 'scan', 'for', 'accurate', 'assessment', 'of', 'lesions.'], ['5-', 'nan'], ['CORRECT', 'ANSWER:', '2'], ['There', 'are', 'two', 'answers', 'that', 'we', 'can', 'immediately', 'rule', 'out', 'if', 'we', 'stick', 'to', 'the', 'initial', 'management', 'of', 'severe', 'chest', 'trauma:', '1', '(noninvasive', 'ventilation', 'is', 'not', 'indicated', 'because', 'it', 'does', 'not', 'secure', 'the', 'airway)', 'and', '3', '(observation', 'in', 'these', 'cases,', 'waiting', 'for', 'worsening,', 'only', 'leads', 'to', 'increased', 'morbidity', 'and', 'mortality).'], ['Between', 'options', '2', 'and', '4', 'there', 'could', 'be', 'controversy', 'between', 'the', 'literature', 'and', 'the', 'usual', 'clinical', 'practice,', 'in', 'which', 'we', 'usually', 'have', 'to', 'face', 'in', 'a', 'delicate', 'balance', 'the', 'clinical', 'stability', 'of', 'the', 'patient', '(and', 'what', 'we', 'can', '"make', 'up"', 'this', 'stability', 'with', 'our', 'life', 'support', 'therapies)', 'and', 'the', 'actions', 'that', 'result', 'in', 'better', 'patient', 'care', 'for', 'the', 'definitive', 'treatment', 'of', 'the', 'lesions.'], ['We', 'are', 'dealing', 'with', 'a', 'severe', 'polytraumatized', 'patient.'], ['With', 'the', 'data', 'provided', 'by', 'the', 'question,', 'a', 'patient', 'who', 'seems', 'to', 'be', 'in', 'shock', '(tachycardia,', 'hypoxemia,', 'tachypnea...', 'although', 'we', 'do', 'not', 'receive', 'data,', 'for', 'example,', 'on', 'lactacidemia),', 'and', 'in', 'whom', 'we', 'have', 'to', 'our', 'knowledge', 'a', 'left', 'thoracic', 'trauma,', 'which', 'not', 'only', 'implies', 'bone', 'injury,', 'but', 'may', 'mask', 'other', 'injuries', 'of', 'high', 'severity', 'and', 'which', 'are', 'not', 'diagnosed', 'with', 'a', 'chest', 'X-ray:', 'myocardial', 'contusion,', 'pericardial', 'effusion,', 'splenic', 'injury,', 'diaphragmatic', 'injury...'], ['We', 'place', 'a', 'left', 'pleural', 'drain', 'on', 'the', 'patient', 'and', 'obtain', 'a', 'debit', 'of', '1700cc', 'of', 'hematic', 'fluid.'], ['If', 'we', 'follow', 'the', 'ATLS', '(ATLS-Advanced', 'Trauma', 'Life', 'Support', '10th', 'edition)', 'guidelines', 'for', 'the', 'care', 'of', 'severely', 'polytraumatized', 'patients,', 'they', 'tell', 'us', 'that', 'an', 'immediate', 'bleeding', 'of', 'more', 'than', '1500cc', 'of', 'blood', 'is', 'an', 'indication', 'for', 'urgent', 'thoracotomy,', 'and', 'that', 'even', 'in', 'patients', 'with', 'a', 'bleeding', 'of', 'less', 'than', '1500cc,', 'if', 'the', 'debit', 'persists', 'at', 'a', 'rate', 'of', '200mL/h', 'for', '2', 'to', '4h,', 'this', 'indication', 'would', 'also', 'exist.'], ['Therefore,', 'the', 'person', 'who', 'asked', 'the', 'MIR', 'question', 'wants', 'us', 'to', 'answer', 'option', '2.'], ['However,', 'in', 'real', 'life,', 'the', 'course', 'of', 'action', 'will', 'depend', 'on', 'the', 'stability', 'of', 'the', 'patient', 'when', 'we', 'have', 'applied', 'the', 'treatments', 'indicated', 'in', 'option', '2:', 'adequate', 'analgesia,', 'oxygen', 'therapy', 'and', 'initiation', 'of', 'blood', 'transfusion.'], ['If', 'by', 'optimizing', 'the', 'patient', 'we', 'manage', 'to', 'stabilize', 'him', 'and', 'assess', 'that', 'it', 'is', 'safe', 'to', 'transfer', 'him,', 'the', 'performance', 'of', 'a', 'body', 'CT', 'scan', 'will', 'define', 'in', 'much', 'greater', 'detail', 'the', 'lesions', 'he', 'has,', 'and', 'will', 'help', 'to', 'ensure', 'that', 'the', 'surgery', 'he', 'will', 'probably', 'end', 'up', 'undergoing', 'will', 'be', 'a', 'definitive', 'surgery', 'and', 'not', 'just', 'damage', 'control', 'surgery.'], ['In', 'this', 'case,', 'the', 'doubt', 'would', 'arise', 'with', 'option', '4,', 'although,', 'as', 'I', 'say,', 'everything', 'will', 'depend', 'on', 'the', 'clinical', 'stability', 'of', 'the', 'patient', 'and', 'the', 'time', 'we', 'have', 'before', 'achieving', 'definitive', 'control', 'of', 'the', 'hemorrhagic', 'focus', '(which', 'is,', 'after', 'all,', 'what', 'we', 'are', 'after', 'in', 'this', 'situation).']]

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'I-Premise'], ['B-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise'], ['O', 'O', 'O', 'O', 'O', 'O', 'O'], ['O', 'B-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim'], ['O', 'B-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim'], ['O', 'B-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim'], ['O', 'B-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim'], ['O', 'O'], ['O', 'O', 'O'], ['B-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim'], ['O', 'O', 'O', 'O', 'O', 'O', 'O', 'O', 'O', 'O', 'O', 'O', 'O', 'O', 'O', 'O', 'O', 'O', 'O', 'O', 'O', 'O', 'O', 'O', 'O', 'O', 'O', 'O', 'O', 'O', 'O', 'O', 'O', 'O', 'O', 'O', 'O', 'O', 'O', 'O', 'O', 'O', 'O', 'O', 'O', 'O', 'O', 'O', 'O', 'O', 'O', 'O', 'O', 'O', 'O', 'O', 'O', 'O', 'O', 'O', 'O', 'O', 'O'], ['B-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise'], ['B-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim'], ['B-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise'], ['B-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'O', 'O', 'B-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim'], ['B-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim'], ['B-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim'], ['B-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim'], ['B-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'B-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim']]

234_105

[['QUESTION', 'TYPE:', 'HEMATOLOGY'], ['CLINICAL', 'CASE:'], ['A', '72-year-old', 'man', 'comes', 'to', 'the', 'Emergency', 'Department', 'with', 'a', 'pathological', 'fracture', 'of', 'the', 'left', 'femur.'], ['After', 'surgery,', 'a', 'diagnostic', 'study', 'is', 'performed', 'to', 'determine', 'the', 'underlying', 'pathology', 'with', 'the', 'following', 'findings:', 'hemoglobin', '9.5', 'g/dl,', 'total', 'proteins', '11', 'g/dl,', '(VN:', '6-8', 'g/dl),', 'serum', 'albumin', '2', 'g/dl,', '(VN', '3.5-5.0', 'g/dl),', 'beta', '2', 'microglobulin', '6', 'mg/l', '(VN', '1.1-2.4', 'mg/l),', 'serum', 'creatinine', '1.8', 'mg/dl', '(VN:', '0.1-1.4', 'mg/dl).'], ['Indicate', 'which', 'diagnostic', 'tests', 'would', 'be', 'necessary', 'to', 'confirm', 'the', 'most', 'likely', 'diagnosis:'], ['1-', 'Radiological', 'bone', 'series', 'and', 'bone', 'marrow', 'aspirate.'], ['2-', 'Serum', 'and', 'urine', 'electrophoresis', 'and', 'renal', 'function', 'tests.'], ['3-', 'Bone', 'marrow', 'aspirate', 'and', 'serum', 'calcium', 'concentration.'], ['4-', 'Bone', 'marrow', 'aspirate', 'and', 'serum', 'and', 'urine', 'electrophoresis.'], ['5-', 'Biopsy', 'of', 'the', 'pathological', 'fracture', 'and', 'radiological', 'bone', 'series.'], ['CORRECT', 'ANSWER:', '4'], ['She', 'is', 'going', 'to', 'have', 'myeloma.'], ['For', 'diagnosis,', 'a', 'sample', '(bone', 'marrow)', 'and', 'electrophoresis', 'to', 'determine', 'the', 'type', 'of', 'monoclonal', 'peak.'], ['Then,', 'for', 'extension,', 'prognostic', 'value', 'and', 'to', 'decide', 'treatments,', 'the', 'rest,', 'but', 'once', 'diagnosed.']]

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174_52

[['QUESTION', 'TYPE:', 'PNEUMOLOGY'], ['CLINICAL', 'CASE:'], ['A', '67-year-old', 'man', 'consults', 'for', 'moderate', 'exertional', 'dyspnea', 'of', 'progressive', 'onset', 'in', 'recent', 'years.'], ['He', 'has', 'daily', 'whitish', 'expectoration', 'and', 'sometimes', 'breath', 'sounds,', 'especially', 'in', 'winter', 'with', 'respiratory', 'infections.'], ['He', 'has', 'been', 'a', 'smoker', 'of', 'about', '20', 'cigarettes', 'a', 'day', 'for', 'the', 'last', '45', 'years.'], ['On', 'examination', 'he', 'is', 'eupneic,', 'normocolored,', 'with', 'an', 'oxygen', 'saturation', 'of', '94%,', 'and', 'has', 'generalized', 'decreased', 'vesicular', 'murmur', 'on', 'chest', 'auscultation', 'as', 'the', 'only', 'findings', 'of', 'interest.'], ['Chest', 'X-ray', 'shows', 'an', 'elongated', 'cardiac', 'silhouette,', 'with', 'signs', 'of', 'hyperinflation', 'or', 'pulmonary', 'air', 'trapping,', 'without', 'other', 'alterations.'], ['Spirometry', 'was', 'performed', 'with', 'the', 'following', 'result:', 'FVC', '84%,', 'FEV1', '58%,', 'FEV1/FVC', '61%,', 'unchanged', 'after', 'bronchodilator.'], ['Among', 'those', 'indicated,', 'indicate', 'the', 'most', 'appropriate', 'treatment', 'for', 'this', 'patient:'], ['1-', 'Daily', 'inhaled', 'corticosteroid.'], ['2-', 'Home', 'oxygen', 'therapy', 'with', 'portable', 'oxygen', 'source', 'for', 'ambulation.'], ['3-', 'Oral', 'leukotriene', 'antagonist.'], ['4-', 'Oral', 'corticosteroid', 'for', 'three', 'months.'], ['5-', 'Inhaled', 'tiotropium.'], ['CORRECT', 'ANSWER:', '5'], ['In', 'a', 'patient', 'with', 'a', 'low', 'symptomatic', 'COPD', 'that', 'could', 'probably', 'be', 'classified', 'as', 'GOLD', '2,', 'the', 'starting', 'treatment', 'can', 'be', 'either', 'with', 'inhaled', 'tiotropium', 'or', 'with', 'a', 'long-acting', 'beta', 'two.'], ['Therefore', 'there', 'is', 'no', 'doubt', 'in', 'the', 'correct', 'answer.']]

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143_141

[['QUESTION', 'TYPE:', 'PEDIATRICS'], ['CLINICAL', 'CASE:'], ['Given', 'a', '7-month-old', 'child', 'with', 'fever', 'and', 'irritability,', 'bulging', 'fontanel', 'and', 'a', 'cerebrospinal', 'fluid', 'study', 'with', '110', 'cells/mm3', '(75%', 'lymphocytes),', 'protein', '120', 'mg/dl', 'and', 'glucose', '28', 'mg/dl', '(serum', 'glycemia', '89', 'mg/dl),', 'what', 'is', 'the', 'most', 'reasonable', 'diagnostic', 'suspicion?'], ['1-', 'Viral', 'meningitis.'], ['2-', 'Bacterial', 'meningitis.'], ['3-', 'Tuberculous', 'meningitis.'], ['4-', 'Mononucleosis', 'syndrome.'], ['5-', 'Guillain-Barre', 'syndrome.'], ['CORRECT', 'ANSWER:', '3'], ['The', 'correct', 'answer', 'is', '3.'], ['It', 'defines', 'a', 'typical', 'cerebrospinal', 'fluid', 'of', 'tuberculosis.'], ['In', 'clinical', 'practice', 'things', 'might', 'not', 'be', 'so', 'simple......']]

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9_36

[['QUESTION', 'TYPE:', 'SURGERY'], ['CLINICAL', 'CASE:'], ['An', '87-year-old', 'patient', 'with', 'a', 'history', 'of', 'chronic', 'bronchitis', 'and', 'heart', 'failure,', 'has', 'been', 'diagnosed', 'with', 'acute', 'calculous', 'cholecystitis', '.'], ['After', 'four', 'days', 'of', 'treatment', 'with', 'absolute', 'diet,', 'serum', 'therapy', 'and', 'piperacillin/tazobactam,', 'the', 'patient', 'continues', 'with', 'fever,', 'persistent', 'abdominal', 'pain', 'and', 'leukocytosis.'], ['The', 'most', 'appropriate', 'attitude', 'at', 'this', 'time', 'would', 'be:'], ['1-', 'Surgical', 'treatment', '(urgent', 'cholecystectomy).'], ['2-', 'Biliary', 'drainage', 'by', 'percutaneous', 'cholecystostomy.'], ['3-', 'Substitute', 'metronidazole', '+', 'cefotaxime', 'for', 'piperacillin/tazobactam.'], ['4-', 'Replace', 'piperacillin/tazobactam', 'with', 'amikacin+clindamycin.'], ['5-', 'Add', 'gentamicin.'], ['CORRECT', 'ANSWER:', '2'], ['I', 'think', 'the', 'correct', 'answer', 'is', '2', 'although', 'the', 'treatment', 'for', 'acute', 'cholecystitis', 'is', 'cholecystectomy,', 'for', 'this', 'it', 'is', 'necessary', 'that', 'the', 'patient', 'is', 'a', 'surgical', 'candidate,', 'in', 'this', 'case', 'it', 'is', 'an', 'elderly', 'patient,', 'with', 'previous', 'diseases', 'that', 'increase', 'the', 'surgical', 'risk', 'and', 'would', 'be', 'an', 'ASA', 'IV', 'for', 'an', 'urgent', 'intervention.'], ['In', 'these', 'cases', 'cholecystostomy', 'can', 'cure', 'cholecystitis;', 'and', 'after', 'recovery,', 'assess', 'scheduled', 'surgery', 'according', 'to', 'the', "patient's", 'situation.']]

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601_112

[['QUESTION', 'TYPE:', 'TRAUMATOLOGY'], ['CLINICAL', 'CASE:'], ['A', '61-year-old', 'woman,', 'administrative,', 'with', 'a', 'history', 'of', 'overweight,', 'hypertension,', 'dyslipidemia', 'and', 'metabolic', 'syndrome,', 'who', 'consults', 'for', 'pain', 'in', 'both', 'buttocks,', 'left', 'trochanteric', 'region,', 'lateral', 'aspect', 'of', 'the', 'left', 'thigh', 'up', 'to', 'the', 'knee', 'and', 'left', 'leg', 'up', 'to', 'the', 'middle', 'third.'], ['The', 'pain', 'appears', 'when', 'the', 'lower', 'limb', 'is', 'lifted', 'with', 'the', 'knee', 'extended,', 'but', 'is', 'relieved', 'when', 'the', 'knee', 'is', 'flexed.'], ['What', 'is', 'the', 'first', 'clinical', 'suspicion?'], ['1-', 'Gouty', 'arthritis', 'of', 'the', 'left', 'hip.'], ['2-', 'Left', 'coxofemoral', 'arthrosis.'], ['3-', 'Radiated', 'low', 'back', 'pain', '/', 'lumbosciatica.'], ['4-', 'Claudication', 'due', 'to', 'canal', 'stenosis.'], ['5-', 'nan'], ['CORRECT', 'ANSWER:', '3'], ['Positive', "Lasegue's", 'sign,', 'reappearance', 'of', 'the', 'symptoms', 'when', 'performing', 'the', 'extension', 'maneuver', 'of', 'the', 'affected', 'limb,', 'compatible', 'with', 'involvement', 'of', 'nerve', 'roots', 'at', 'the', 'lumbosacral', 'spine', 'level.']]

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202_44

[['QUESTION', 'TYPE:', 'GENERAL', 'SURGERY'], ['CLINICAL', 'CASE:'], ['Patient', 'with', 'acute', 'pancreatitis.'], ['Computerized', 'Axial', 'Tomography', '(CAT)', 'performed', '72', 'hours', 'after', 'admission', 'showed', 'necrosis', 'of', '50%', 'of', 'the', 'pancreas.'], ['At', 'the', '3rd', 'week', 'of', 'admission', 'the', 'patient', 'began', 'with', 'high', 'fever', 'and', 'leukocytosis.'], ['Urgent', 'chest', 'X-ray', 'and', 'urinary', 'sediment', 'are', 'requested,', 'both', 'being', 'normal.'], ['Indicate', 'the', 'next', 'step', 'to', 'follow:'], ['1-', 'Fine', 'needle', 'aspiration', 'of', 'pancreatic', 'necrosis', 'guided', 'by', 'ultrasound', 'or', 'CT.'], ['2-', 'Bronchoalveolar', 'aspirate,', 'urine', 'culture', 'and', 'blood', 'cultures.'], ['3-', 'Abdominal', 'MRI.'], ['4-', 'Urgent', 'cholecystectomy.'], ['5-', 'Echoendoscopy', 'with', 'puncture', 'of', 'the', 'necrosis.'], ['CORRECT', 'ANSWER:', '1'], ['Although', 'the', 'latest', 'recommendations', 'on', 'the', 'management', 'of', 'severe', 'acute', 'pancreatitis', 'advise', 'against', 'FNA', 'because', 'of', 'the', 'risk', 'of', 'infection', 'of', 'sterile', 'necrosis.'], ['Current', 'management', 'is', 'governed', 'by', 'stepwise', 'treatment.'], ['In', 'the', 'situation', 'described', 'in', 'the', 'question', 'the', 'current', 'treatment', 'is', 'to', 'start', 'antibiotics', 'and', 'assess', 'response.']]

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259_97

[['QUESTION', 'TYPE:', 'ENDOCRINOLOGY'], ['CLINICAL', 'CASE:'], ['A', '54-year-old', 'man', 'who', 'goes', 'for', 'a', 'check-up', 'at', 'his', 'company.'], ['A', 'body', 'mass', 'index', 'of', '32.8', 'kg/m2', 'and', 'fasting', 'blood', 'glucose', 'of', '138', 'mg/l', 'were', 'detected.'], ['One', 'month', 'later,', 'glycemia', '13', 'mg/dl.'], ['Which', 'therapeutic', 'recommendation', 'would', 'you', 'make', 'first?'], ['1-', 'Administer', 'metformin.'], ['2-', 'Prescribe', 'a', 'sulfonylurea.'], ['3-', 'Behavioral', 'changes.', 'Diet', 'and', 'physical', 'exercise.'], ['4-', 'Insulin', 'before', 'each', 'meal.'], ['5-', 'Take', 'acarbose', 'at', 'night,', 'before', 'going', 'to', 'bed.'], ['CORRECT', 'ANSWER:', '3'], ['Behavioral', 'changes:', 'diet', 'and', 'physical', 'exercise.'], ['This', 'is', 'the', 'first', 'thing', 'we', 'do', 'when', 'diagnosed', 'with', 'type', '2', 'diabetes.'], ['This', 'is', 'a', 'good', 'question', 'to', 'remember', 'that', 'before', 'any', 'drug,', 'we', 'must', 'insist', 'on', 'changing', 'habits.'], ['Then', 'we', 'would', 'prescribe', 'Metformin.']]

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204_220

[['QUESTION', 'TYPE:', 'GENETICS', 'AND', 'IMMUNOLOGY'], ['CLINICAL', 'CASE:'], ['A', '43-year-old', 'man', 'consults', 'for', 'diarrheal', 'syndrome,', 'and', 'refers', 'among', 'his', 'history', '3', 'pneumonias', 'in', 'adulthood.'], ['Which', 'of', 'the', 'following', 'immunological', 'studies', 'should', 'we', 'request:'], ['1-', 'Serum', 'immunoglobulin', 'count', 'and', 'antibody', 'production', 'capacity', 'test.'], ['2-', 'Phagocytosis', 'test', 'and', 'oxidative', 'metabolism', 'of', 'neutrophils.'], ['3-', 'Apoptosis', 'test', '(programmed', 'cell', 'death)', 'in', 'the', "patient's", 'circulating', 'lymphocytes.'], ['4-', 'Study', 'of', 'the', 'repertoire', 'and', 'clonality', 'of', 'T', 'lymphocytes', '(alpha/beta).'], ['5-', 'In', 'this', 'patient', 'it', 'would', 'not', 'be', 'appropriate', 'to', 'request', 'any', 'immunological', 'study.'], ['CORRECT', 'ANSWER:', '1'], ['More', 'than', '2', 'lobar', 'pneumonias', 'make', 'it', 'necessary', 'to', 'rule', 'out', 'an', 'immunologic', 'deficit.']]

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4_40

[['QUESTION', 'TYPE:', 'DIGESTIVE'], ['CLINICAL', 'CASE:'], ['A', 'man', 'presents', 'abruptly', 'with', 'asthenia', 'and', 'jaundice', 'with', 'transaminases', 'above', '2000', 'IU/L.'], ['Serological', 'markers', 'show', 'the', 'following', 'pattern:', 'anti-HAV', 'IgM', 'negative,', 'HBsAg', 'negative', 'anti-HBc', 'IgM', 'positive,', 'anti-HCV', 'negative.'], ['What', 'is', 'the', 'diagnosis?'], ['1-', 'Chronic', 'hepatitis', 'B.'], ['2-', 'Non-viral', 'acute', 'hepatitis.'], ['3-', 'Acute', 'hepatitis', 'B.'], ['4-', 'D', '(delta)', 'virus', 'superinfection.'], ['5-', 'Acute', 'hepatitis', 'A', 'and', 'B.'], ['CORRECT', 'ANSWER:', '3'], ['An', 'interesting', 'one', 'that', 'in', 'general', 'needs', 'to', 'be', 'studied.'], ['By', 'the', 'form', 'of', 'presentation,', 'it', 'is', 'clearly', 'an', 'acute', 'hepatitis,', 'so', 'option', '1', 'is', 'ruled', 'out.'], ['The', 'negative', 'IgM', 'of', 'HAV', 'rules', 'out', '5', 'and', 'the', 'negative', 'HBs', 'Ag', 'rules', 'out', '4', '(to', 'have', 'delta', 'virus', 'you', 'need', 'surface', 'antigen', 'B).'], ['When', 'having', 'IgM', 'anti', 'HBc', 'we', 'speak', 'of', 'an', 'acute', 'hepatitis', 'B', '(3),', 'since', 'there', 'is', 'a', 'window', 'period', 'of', 'negativization', 'of', 'the', 'antigen.']]

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372_127

[['QUESTION', 'TYPE:', 'PNEUMOLOGY', 'AND', 'THORACIC', 'SURGERY'], ['CLINICAL', 'CASE:'], ['55-year-old', 'man', 'who', 'consults', 'for', 'dysphonia.'], ['In', 'the', 'anamnesis', 'he', 'refers', 'to', 'a', 'month', 'of', 'asthenia', 'and', 'unquantified', 'weight', 'loss.'], ['Chest', 'X-ray', 'shows', 'increased', 'density', 'in', 'the', 'left', 'upper', 'lobe', 'and', 'occupation', 'of', 'the', 'aortopulmonary', 'window.'], ['Bronchoscopy', 'shows', 'paralysis', 'of', 'the', 'left', 'vocal', 'cord,', 'without', 'endoscopic', 'image', 'suggestive', 'of', 'neoplasia.'], ['What', 'is', 'the', 'most', 'likely', 'diagnosis?'], ['1-', 'Pulmonary', 'neoplasia.'], ['2-', 'Sarcoidosis.'], ['3-', 'Silicosis.'], ['4-', 'Tuberculosis.'], ['5-', 'nan'], ['CORRECT', 'ANSWER:', '1'], ['The', 'most', 'frequent', 'cause', 'of', 'recurrent', 'nerve', 'palsy', 'is', 'bronchopulmonary', 'carcinoma.'], ['The', 'fact', 'that', 'it', 'is', 'not', 'accessible', 'to', 'endoscopic', 'vision', 'does', 'not', 'mean', 'that', 'it', 'is', 'not', 'there.']]

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377_131

[['QUESTION', 'TYPE:', 'NEUROLOGY'], ['CLINICAL', 'CASE:'], ['A', '65-year-old', 'female', 'patient', 'debuted', 'two', 'years', 'earlier', 'with', 'an', 'apraxia', 'of', 'speech', 'and', 'has', 'developed', 'rigid-akinetic', 'parkinsonism', 'predominantly', 'in', 'the', 'right', 'hemibody', 'with', 'superimposed', 'myoclonias', 'and', 'alien', 'hand', 'or', 'foreign', 'limb', 'phenomenon.What', 'diagnosis', 'do', 'you', 'consider', 'most', 'likely?'], ['1-', "Parkinson's", 'disease.'], ['2-', 'Corticobasal', 'degeneration.'], ['3-', "Alzheimer's", 'disease.'], ['4-', "Huntington's", 'disease.'], ['5-', 'nan'], ['CORRECT', 'ANSWER:', '2'], ['As', 'it', 'is', 'described', 'as', 'an', 'apraxic', 'phenomenon', 'followed', 'by', 'an', 'asymmetric', 'rigid-akinetic', 'parkinsonism', 'and', 'with', 'superimposed', 'myoclonias,', 'it', 'is', 'typical', 'of', 'corticobasal', 'degeneration.'], ["Parkinson's", 'disease', 'cannot', 'be', 'because', 'they', 'do', 'not', 'present', 'apraxia', 'as', 'initial', 'feature,', "Alzheimer's", 'disease', 'does', 'not', 'present', 'an', 'asymmetric', 'parkinsonism', 'and', 'the', 'typical', "Huntinton's", 'disease', 'is', 'not', 'of', 'so', 'old', 'people', 'and', 'when', 'it', 'debuts', 'with', 'advanced', 'age', 'it', 'behaves', 'like', 'a', 'chorea.']]

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145_143

[['QUESTION', 'TYPE:', 'PEDIATRICS'], ['CLINICAL', 'CASE:'], ['A', '1', 'month', 'old', 'infant,', 'exclusively', 'breastfed,', 'consults', 'because', 'he', 'has', 'a', 'bowel', 'movement', 'every', '5', 'or', '6', 'days', 'with', 'straining', 'but', 'with', 'a', 'soft', 'consistency,', 'what', 'would', 'our', 'attitude', 'be?'], ['1-', 'Start', 'laxative', 'treatment.'], ['2-', 'Supplement', 'breastfeeding', 'with', 'anti-constipation', 'formula.'], ['3-', 'Start', 'daily', 'rectal', 'stimulation.'], ['4-', 'It', 'is', 'considered', 'normal', 'intestinal', 'rhythm.'], ['5-', 'Refer', 'to', 'Pediatric', 'Digestive', 'to', 'rule', 'out', 'aganglionic', 'megacolon.'], ['CORRECT', 'ANSWER:', '4'], ['The', 'correct', 'answer', 'is', '4.'], ['The', 'normal', 'range', 'of', 'stool', 'output', 'in', 'young', 'infants', 'is', 'very', 'wide.'], ['To', 'suspect', 'aganglionic', 'megacolon', 'there', 'is', 'usually', 'a', 'delay', 'in', 'the', 'evacuation', 'of', 'meconium', 'and', 'often', 'other', 'associated', 'symptoms', 'such', 'as', 'abdominal', 'distension,', 'difficulty', 'in', 'gaining', 'weight,', 'etc.']]

[['O', 'O', 'O'], ['O', 'O'], ['B-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'O', 'O', 'O', 'O', 'O'], ['O', 'B-Claim', 'I-Claim', 'I-Claim'], ['O', 'B-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim'], ['O', 'B-Claim', 'I-Claim', 'I-Claim', 'I-Claim'], ['O', 'B-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim'], ['O', 'B-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim'], ['O', 'O', 'O'], ['B-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim'], ['B-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim'], ['B-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim']]

567_150

[['QUESTION', 'TYPE:', 'NEPHROLOGY'], ['CLINICAL', 'CASE:'], ['A', '47-year-old', 'woman', 'consults', 'for', 'voiding', 'syndrome.'], ['She', 'is', 'diagnosed', 'with', 'uncomplicated', 'urinary', 'tract', 'infection', 'and', 'treated', 'with', 'ciprofloxacin', 'for', '5', 'days.'], ['A', 'week', 'later,', 'she', 'consulted', 'again', 'for', 'general', 'malaise,', 'arthralgias', 'and', 'the', 'appearance', 'of', 'a', 'skin', 'rash.'], ['In', 'the', 'analytical', 'analysis,', 'the', 'glomerular', 'filtration', 'rate', 'was', '45', 'ml/min', '(CKD-EPI),', 'whereas', '6', 'months', 'ago', 'it', 'was', '100', 'ml/min.'], ['In', 'the', 'sediment', 'leukocytes', 'are', 'identified,', 'being', 'negative', 'for', 'nitrites.'], ['Of', 'the', 'following,', 'which', 'is', 'the', 'most', 'probable', 'cause', 'of', 'his', 'renal', 'failure?'], ['1-', 'Postinfectious', 'glomerulonephritis.'], ['2-', 'Ciprofloxacin', 'nephrotoxicity.'], ['3-', 'Acute', 'pyelonephritis.'], ['4-', 'Acute', 'interstitial', 'nephritis.'], ['5-', 'nan'], ['CORRECT', 'ANSWER:', '4'], ['General', 'malaise,', 'arthralgias,', 'skin', 'rash,', 'acute', 'renal', 'failure', 'and', 'active', 'sediment', 'with', 'sterile', 'leukocyturia', 'following', 'the', 'intake', 'of', 'a', 'drug', 'is', 'highly', 'suggestive', 'of', 'AIN', '(option', '4', 'correct).'], ['Among', 'drugs,', 'antibiotics', 'are', 'the', 'most', 'frequent', 'cause,', 'and', 'ciprofloxacin', 'is', 'one', 'of', 'the', 'most', 'common.'], ['Direct', 'nephrotoxicity', 'is', 'very', 'rare', 'and', 'is', 'characterized', 'by', 'crystallization', 'in', 'the', 'renal', 'tubules', '(incorrect', 'option', '2).'], ['Postinfectious', 'glomerulonephritis', 'is', 'more', 'typical', 'of', 'children', 'and', 'adults', 'older', 'than', '60', 'years,', 'and', 'usually', 'manifests', 'with', 'hematuria', 'after', 'streptococcal', 'infections', '(option', '1', 'incorrect).'], ['Acute', 'pyelonephritis', 'would', 'have', 'been', 'presented', 'with', 'high', 'fever', 'and', 'renal', 'fossa', 'pain', '(option', '3', 'incorrect).']]

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177_93

[['QUESTION', 'TYPE:', 'HEMATOLOGY'], ['CLINICAL', 'CASE:'], ['A', '30-year-old', 'woman,', 'asymptomatic,', 'is', 'found', 'to', 'be', 'anemic', 'on', 'routine', 'examination.'], ['Physical', 'examination', 'reveals', 'conjunctival', 'jaundice', 'and', 'splenomegaly.'], ['The', 'patient', 'refers', 'to', 'a', 'family', 'history', 'of', 'biliary', 'lithiasis', 'at', 'an', 'early', 'age.'], ['All', 'this', 'suggests', 'the', 'most', 'probable', 'diagnosis', 'of:'], ['1-', 'Glucose', '6-phosphate', 'dehydrogenase', 'deficiency.'], ['2-', 'Thalassemia', 'minor.'], ['3-', 'Vitamin', 'Bl2', 'and/or', 'folic', 'acid', 'deficiency.'], ['4-', 'Familial', 'pyruvate', 'kinase', 'deficiency.'], ['5-', 'Hereditary', 'spherocytosis.'], ['CORRECT', 'ANSWER:', '5'], ['You', 'have', 'probably', 'looked', 'at', 'answer', '5,', 'hereditary', 'spherocytosis,', 'associated', 'with', 'biliary', 'lithiasis', 'at', 'an', 'early', 'age.'], ['Exactly,', 'that', 'is', 'the', 'correct', 'one.'], ['In', 'the', 'statement', 'they', 'have', 'not', 'stopped', 'giving', 'clues:', 'conjunctival', 'jaundice,', 'splenomegaly', 'and', 'family', 'history', 'of', 'biliary', 'lithiasis', 'at', 'an', 'early', 'age.'], ['He', 'has', 'reached', '30', 'years', 'of', 'age', 'without', 'suffering', 'a', 'hemolytic', 'crisis,', 'without', 'suffering', 'any', 'symptoms.'], ['There', 'was', 'no', 'mention', 'of', 'microcytosis', 'or', 'macrocytosis', 'to', 'suggest', 'thalassemia', 'minor', 'or', 'B12', 'and/or', 'folic', 'acid', 'deficiency.'], ['Nor', 'of', 'hemolytic', 'crisis', 'associated', 'with', 'the', 'consumption', 'of', 'drugs,', 'infections', 'or', 'ingestion', 'of', 'beans', 'or', 'peas.'], ['They', 'have', 'not', 'given', 'any', 'clues', 'to', 'stop', 'to', 'think', 'about', 'other', 'possibilities.']]

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125_105

[['QUESTION', 'TYPE:', 'NEPHROLOGY'], ['CLINICAL', 'CASE:'], ['19-year-old', 'woman,', 'weight', '60', 'kg,', 'with', 'acute', 'dehydration', 'due', 'to', 'long', 'exposure', 'to', 'the', 'sun.'], ['Blood', 'pressure', 'lying', 'down', '100/60', 'mmHg.'], ['Standing', '70/50', 'mmHg', 'with', 'dizziness.'], ['Serum', 'sodium', 'levels', '155', 'mmol/L.'], ['What', 'is', 'the', 'most', 'correct', 'treatment,', 'in', 'the', 'first', '24', 'hours,', 'taking', 'into', 'account', 'the', 'data', 'available', 'to', 'us?'], ['1-', 'Hypertonic', 'saline', '(3%),', '500', 'ml', '+', '500', 'ml', 'of', '5%', 'glucose.'], ['2-', 'Hyposaline', 'saline', '(0.45%),', '3000', 'ml.'], ['3-', 'Serum', 'glucose', '5%', '1000', 'ml.'], ['4-', 'Oral', 'hydration', 'with', '1', 'liter', 'of', 'water.'], ['5-', 'Isotonic', 'saline', '(0.9%),', '2000', 'ml.'], ['CORRECT', 'ANSWER:', '2'], ['This', 'question', 'is', 'not', 'an', 'easy', 'one.'], ['The', 'available', 'literature', 'is', 'somewhat', 'controversial', '(some', 'guidelines', 'advise', 'using', 'glucose', 'saline,', 'others', 'absolutely', 'forbid', 'it...)', 'so', 'I', 'have', 'decided', 'to', 'rely', 'on', 'the', 'treatment', 'recommended', 'by', 'Harrison,', 'which', 'is', 'the', 'manual', 'that', 'MIR', 'examiners', 'usually', 'rely', 'on.'], ['This', 'girl', 'presents', 'with', 'hypernatremia', 'due', 'to', 'extrarenal', 'free', 'water', 'losses.'], ['The', 'goal', 'is', 'to', 'replace', 'the', 'lost', 'water', 'and', 'reduce', 'the', 'natremia', 'at', 'a', 'rate', 'of', 'no', 'more', 'than', '12', 'mmol/day.'], ['To', 'calculate', 'fluid', 'therapy,', 'the', 'water', 'deficit', 'must', 'first', 'be', 'calculated.'], ['Water', 'def.', 'Water', '=', '(Natremia-140/140)xTotal', 'body', 'water.', 'TBW', '=', 'Weight', 'in', 'kg', 'x', '0.4', 'in', 'females/0.5', 'in', 'males.'], ['In', 'this', 'case,', 'the', 'water', 'deficit', 'is:', '([[tel:155-140/140|155-140/140]])x60x0.4', '=', '2.57', 'liters.'], ['There', 'are', 'only', 'two', 'answers', 'that', 'come', 'close', 'to', 'this', 'figure,', 'but', '2', 'seems', 'more', 'correct,', 'as', 'it', 'is', 'the', 'only', 'one', 'that', 'completely', 'covers', 'the', 'water', 'deficit', 'and', 'uses', 'a', 'hyposodium', 'solution.']]

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510_151

[['QUESTION', 'TYPE:', 'DIGESTIVE'], ['CLINICAL', 'CASE:'], ['A', '43-year-old', 'male', 'with', 'no', 'past', 'history', 'of', 'interest', 'consults', 'for', 'a', 'ten-day', 'history', 'of', 'jaundice', 'of', 'the', 'skin', 'and', 'mucous', 'membranes,', 'choluria', 'and', 'acholia.'], ['He', 'does', 'not', 'report', 'abdominal', 'pain,', 'weight', 'loss', 'or', 'other', 'symptoms,', 'except', 'generalized', 'pruritus.'], ['She', 'denies', 'alcohol', 'consumption.'], ['She', 'does', 'not', 'take', 'any', 'medication', 'except', 'occasional', 'ibuprofen', 'for', 'muscle', 'pain', 'after', 'sports', 'activities.'], ['The', 'CBC', 'shows', 'increased', 'bilirubin', 'at', 'the', 'expense', 'of', 'direct', 'bilirubin.'], ['An', 'urgent', 'ultrasound', 'shows', 'a', 'normal', 'liver,', 'vesicular', 'cholesterosis', 'and', 'absence', 'of', 'bile', 'duct', 'dilatation,', 'with', 'no', 'other', 'alterations', 'of', 'interest.'], ['What', 'is', 'the', 'most', 'likely', 'diagnosis?'], ['1-', 'Acute', 'cholangitis', 'due', 'to', 'biliary', 'mud.'], ['2-', 'Toxic', 'hepatitis', 'due', 'to', 'ibuprofen.'], ['3-', 'Cholangiocarcinoma.'], ['4-', "Gilbert's", 'syndrome.'], ['5-', 'nan'], ['CORRECT', 'ANSWER:', '2'], ['We', 'believe', 'that', 'this', 'question', 'is', 'open', 'to', 'challenge.'], ['Ibuprofen', 'hepatitis', 'is', 'a', 'rare', 'adverse', 'effect', 'with', 'a', 'prevalence', 'of', 'about', '3.7/100,000', 'users', 'and', '1.1/100,000', 'prescriptions.'], ['It', 'appears', 'that', 'it', 'may', 'be', 'related', 'to', 'dose', 'and', 'duration', 'of', 'treatment,', 'but', 'there', 'is', 'little', 'evidence', 'on', 'this.'], ['Among', 'the', 'NSAIDs', 'with', 'the', 'highest', 'risk', 'are', 'diclofenac', 'and', 'sulindac.'], ['In', 'terms', 'of', 'frequency,', 'the', 'prevalence', 'of', 'cholangiocarcinoma', 'is', '2/100,000', 'patients,', 'a', 'very', 'comparable', 'frequency.'], ['The', 'absence', 'of', 'bile', 'duct', 'dilatation', 'in', 'cholangiocarcinomas', 'can', 'be', 'seen', 'in', 'cases', 'of', 'intrahepatic', 'cholangiocarcinomas', 'or', 'in', 'those', 'with', 'mixed', 'histology', 'with', 'hepatocarcinoma.'], ['It', 'is', 'true', 'that', 'the', 'acute', 'course', 'and', 'the', 'absence', 'of', 'constitutional', 'syndrome', 'may', 'make', 'us', 'think', 'against', 'this', 'option', 'and', 'tip', 'the', 'balance', 'towards', 'ibuprofen', 'hepatitis.'], ['Regarding', 'the', 'other', 'options:', 'acute', 'cholangitis', 'is', 'characterized', 'by', 'the', 'triad', 'of', 'jaundice,', 'abdominal', 'pain', 'and', 'fever;', "Gilbert's", 'syndrome', 'is', 'an', 'increase', 'in', 'bilirubin', 'at', 'the', 'expense', 'of', 'indirectness.']]

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268_140

[['QUESTION', 'TYPE:', 'PULMONOLOGY'], ['CLINICAL', 'CASE:'], ['A', '50-year-old', 'patient', 'presenting', 'with', 'a', 'pleural', 'effusion', 'with', 'the', 'following', 'features:', 'straw-like', 'appearance,', 'pH', '7.3,', 'pleural', 'protein/serum', 'ratio', '0.8,', 'pleural', 'LDH/serum', 'ratio', '0.9,', 'Gram', 'and', "Ziehl's", 'negative,', 'total', 'lipids,', 'cholesterol', 'and', 'triglycerides', 'normal,', 'mesothelial', 'cells', '<5%,', 'intense', 'lymphocytosis', 'without', 'atypia,', 'ADA', '64', 'U/L.'], ['What', 'diagnosis', 'would', 'you', 'suggest?'], ['1-', 'Pleural', 'empyema.'], ['2-', 'Pleural', 'effusion', 'due', 'to', 'heart', 'failure', '(transudate).'], ['3-', 'Pleural', 'mesothelioma.'], ['4-', 'Tuberculous', 'pleural', 'effusion.'], ['5-', 'Effusion', 'secondary', 'to', 'pulmonary', 'infarction.'], ['CORRECT', 'ANSWER:', '4'], ['It', 'is', 'a', 'lymphocytic', 'exudate', 'whose', 'main', 'diagnoses', 'are', 'tumor', 'and', 'tuberculous', 'pleuritis.'], ['They', 'do', 'not', 'give', 'the', 'value', 'of', 'glucose', 'which', 'should', 'be', 'lowered,', 'but', 'if', 'the', 'cytology', 'shows', 'absence', 'of', 'malignant', 'cells', 'so', 'we', 'are', 'left', 'with', 'tuberculous', 'pleuritis.'], ['Other', 'possible', 'diagnoses', 'such', 'as', 'lymphoma', 'are', 'not', 'mentioned', 'in', 'the', 'answers.']]

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465_116

[['QUESTION', 'TYPE:', 'BIOSTATISTICS'], ['CLINICAL', 'CASE:'], ['In', 'a', 'subject', 'over', '65', 'years', 'of', 'age', 'a', 'tuberculin', 'test', 'has', 'shown', 'an', 'induration', 'of', '3', 'mm.'], ['The', 'induration', 'on', 'a', 'second', 'test,', 'performed', '10', 'days', 'later,', 'is', '13', 'mm.'], ['Point', 'out', 'the', 'correct', 'answer:'], ['1-', 'The', 'first', 'reaction', 'is', 'a', 'false', 'positive.'], ['2-', 'The', 'second', 'reaction', 'is', 'a', 'true', 'positive.'], ['3-', 'The', 'first', 'reaction', 'is', 'a', 'true', 'negative.'], ['4-', 'The', 'second', 'reaction', 'is', 'a', 'false', 'positive.'], ['5-', 'nan'], ['CORRECT', 'ANSWER:', '3'], ["Let's", 'see,', 'if', 'that', 'subject', 'was', 'not', 'in', 'any', 'risk', 'group,', 'the', 'positive', 'is', 'in', 'the', '15mm,', 'therefore', 'both', 'tests', 'are', 'negative,', 'and', 'as', 'only', 'one', 'answer', 'refers', 'to', 'negative,', "that's", 'it.'], ['But', 'both', 'could', 'be', 'false', 'negatives.']]

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340_33

[['QUESTION', 'TYPE:', 'GYNECOLOGY', 'AND', 'OBSTETRICS'], ['CLINICAL', 'CASE:'], ['A', '67-year-old', 'woman', 'diagnosed', 'with', 'infiltrating', 'ductal', 'carcinoma', 'of', 'the', 'breast', 'with', 'no', 'family', 'history', 'of', 'neoplasia.'], ['What', 'additional', 'studies', 'should', 'be', 'performed', 'on', 'the', 'tumor', 'because', 'of', 'its', 'clinical', 'and', 'therapeutic', 'implications?'], ['1-', 'Complete', 'phenotypic', 'study', 'by', 'flow', 'cytometry.'], ['2-', 'Study', 'of', 'hormone', 'receptors', 'and', 'HER2.'], ['3-', 'Study', 'of', 'hormone', 'receptors,', 'e-cadherin', 'and', 'study', 'of', 'first', 'degree', 'relatives.'], ['4-', 'Study', 'of', 'BRCA', '1-2', 'and', 'study', 'of', 'first-degree', 'relatives.'], ['5-', 'nan'], ['CORRECT', 'ANSWER:', '2'], ['The', 'answer', 'is', '2,', 'study', 'of', 'hormone', 'receptors', 'and', 'HER2.'], ['This', 'is', 'because', 'no', 'study', 'of', 'first-degree', 'relatives', 'is', 'appropriate,', 'as', 'it', 'does', 'not', 'appear', 'to', 'be', 'hereditary', 'breast', 'cancer', 'since', 'there', 'is', 'no', 'family', 'history', 'of', 'neoplasia.'], ['On', 'the', 'other', 'hand,', 'there', 'is', 'no', 'indication', 'for', 'BRCA', '1-2', 'study.']]

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561_180

[['QUESTION', 'TYPE:', 'HEMATOLOGY'], ['CLINICAL', 'CASE:'], ['A', '26-year-old', 'woman', 'diagnosed', 'with', 'systemic', 'lupus', 'erythematosus,', 'on', 'treatment', 'with', 'hydroxychloroquine,', 'consults', 'for', 'a', 'feeling', 'of', 'generalized', 'weakness', 'that', 'has', 'progressively', 'developed', 'in', 'the', 'last', '15', 'days.'], ['The', 'physical', 'examination', 'reveals', 'cutaneous', 'pallor', 'and', 'the', 'CBC', 'shows', 'Hb', '7.4', 'g/dL,', 'Hct', '31%,', 'MCV', '108.'], ['Which', 'of', 'the', 'following', 'tests', 'will', 'be', 'most', 'useful', 'in', 'deciding', 'the', 'course', 'of', 'action?'], ['1-', 'Haptoglobin.'], ['2-', 'Coombs', 'test.'], ['3-', 'Vitamin', 'B12.'], ['4-', 'Antinuclear', 'antibodies.'], ['5-', 'nan'], ['CORRECT', 'ANSWER:', '2'], ['It', 'tells', 'us', 'about', 'a', 'patient', 'with', 'a', 'diagnosis', 'of', 'lupus', 'and', 'macrocytic', 'anemia.'], ['In', 'the', 'end,', 'all', 'the', 'data', 'are', 'usually', 'given', 'for', 'a', 'reason.'], ['The', 'onset', 'of', 'the', 'picture', 'seems', 'relatively', 'rapid', 'and', 'it', 'is', 'also', 'associated', 'with', 'an', 'autoimmune', 'disease,', 'so', 'it', 'seems', 'that', 'they', 'want', 'you', 'to', 'associate', 'it', 'with', 'an', 'autoimmune', 'hemolytic', 'anemia.'], ['The', 'low', 'haptoglobin', 'would', 'tell', 'us', 'it', 'is', '"hemolytic",', 'the', 'coombs', 'test', 'would', 'tell', 'us', 'it', 'is', '"autoimmune".'], ['Vitamin', 'B12,', 'probably', 'the', 'MCV', 'would', 'be', 'higher', 'than', '108', 'and', 'the', 'onset', 'of', 'the', 'clinical', 'picture', 'would', 'be', 'slower.'], ['The', 'ANA', 'would', 'not', 'give', 'us', 'anything', 'in', 'relation', 'to', 'the', 'anemia,', 'since', 'it', 'already', 'has', 'a', 'diagnosis.'], ['Therefore,', 'correct', 'answer', '2.'], ['As', 'a', 'note,', 'autoimmune', 'hemolytic', 'anemias', 'are', 'usually', 'slightly', 'macrocytic', 'due', 'to', 'reticulocytosis.'], ['Remember', 'to', 'ask', 'for', 'reticulocytes.']]

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451_175

[['QUESTION', 'TYPE:', 'NEUROSURGERY'], ['CLINICAL', 'CASE:'], ['A', '36-year-old', 'man', 'with', 'no', 'PA', 'of', 'interest', 'comes', 'to', 'the', 'emergency', 'department', 'with', 'sudden', 'onset', 'of', 'severe', 'pain', 'in', 'the', 'posterior', 'aspect', 'of', 'the', 'right', 'lower', 'limb', 'extending', 'to', 'the', 'foot.'], ['On', 'examination', 'he', 'presented:', 'Positive', 'right', 'Lasège', 'at', '10º,', 'decreased', 'strength', 'in', 'plantar', 'flexion', 'of', 'the', 'right', 'foot,', 'hypoesthesia', 'in', 'the', 'external', 'border', 'of', 'the', 'right', 'foot', 'and', 'absence', 'of', 'right', 'Achilles', 'reflex.'], ['The', 'simple', 'X-ray', 'of', 'the', 'lumbar', 'spine', 'does', 'not', 'show', 'significant', 'alterations.'], ['Which', 'of', 'the', 'following', 'is', 'the', 'most', 'probable', 'diagnosis?'], ['1-', 'Herniated', 'disc', 'L1/L2.'], ['2-', 'Horsetail', 'syndrome.'], ['3-', 'L4/L5', 'disc', 'herniation.'], ['4-', 'Herniated', 'disc', 'L5/S1.'], ['5-', 'nan'], ['CORRECT', 'ANSWER:', '4'], ['Acute', 'sciatica', 'probably', 'due', 'to', 'disc', 'extrusion.'], ['Both', 'the', 'sensory', 'distribution,', 'the', 'paresis', 'for', 'plantar', 'flexion', '(tiptoe)', 'and', 'the', 'absence', 'of', 'the', 'Achilles', 'reflex', 'are', 'typical', 'of', 'S1', 'root', 'involvement,', 'which', 'is', 'typically', 'affected', 'with', 'L5/S1', 'disc', 'herniation', '(posterolateral).'], ['An', 'L1/L2', '(posterolateral)', 'herniation', 'would', 'affect', 'the', 'L2', 'root,', 'an', 'L4/L5', 'herniation', 'would', 'affect', 'the', 'L5', 'and', 'cauda', 'equina', 'would', 'involve', 'more', 'symptomatology', 'than', 'simple', 'S1', 'involvement.']]

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399_141

[['QUESTION', 'TYPE:', 'TRAUMATOLOGY', 'AND', 'ORTHOPEDICS'], ['CLINICAL', 'CASE:'], ['20-year-old', 'male,', 'who', 'consults', 'for', 'lumbosacral', 'pain', 'of', 'inflammatory', 'rhythm', 'of', '4', 'months', 'of', 'evolution.'], ['Also', 'bilateral', 'thalalgia', 'and', 'morning', 'stiffness', 'for', '1', 'hour.'], ['In', 'the', 'last', '2', 'months,', 'onset', 'of', 'diarrhea', 'with', 'loss', 'of', '4', 'kg', 'of', 'weight.'], ['What', 'is', 'the', 'most', 'correct', 'diagnostic', 'approach?'], ['1-', 'Given', 'the', "patient's", 'age,', 'he', 'most', 'likely', 'suffers', 'from', 'non-specific', 'low', 'back', 'pain', 'and', 'tendonitis', 'of', 'the', 'feet.', 'If', 'the', 'diarrhea', 'persists,', 'a', 'digestive', 'study', 'would', 'be', 'performed.'], ['2-', 'Perform', 'a', 'digestive', 'study', 'to', 'rule', 'out', 'tumor', 'pathology.', 'Low', 'back', 'pain', 'may', 'be', 'due', 'to', 'visceral', 'pathology.'], ['3-', 'The', 'clinical', 'picture', 'is', 'very', 'suggestive', 'of', 'spondyloarthritis.', 'Inflammatory', 'bowel', 'disease', 'should', 'be', 'ruled', 'out.'], ['4-', 'I', 'would', 'request', 'a', 'lumbar', 'MRI', 'to', 'rule', 'out', 'disc', 'herniation', 'and', 'if', 'diarrhea', 'persists,', 'a', 'digestive', 'study.'], ['5-', 'nan'], ['CORRECT', 'ANSWER:', '3'], ['The', 'patient', 'presents', 'the', 'clinical', 'features', 'of', 'spondylarthropathy,', 'which', 'is', 'often', 'associated', 'with', 'inflammatory', 'bowel', 'disease,', 'as', 'this', 'case', 'suggests.']]

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12_92

[['QUESTION', 'TYPE:', 'SURGERY'], ['CLINICAL', 'CASE:'], ['A', '30-year-old', 'man', 'suffers', 'a', 'fall', 'from', 'a', 'standing', 'height', 'of', '2', 'meters.'], ['On', 'arrival', 'at', 'the', 'emergency', 'room', 'on', 'a', 'stretcher,', 'he', 'is', 'conscious', 'and', 'oriented,', 'with', 'bladder', 'catheterization', 'and', 'clear', 'urine.'], ['He', 'shows', 'swelling', 'of', 'the', 'left', 'heel', 'and', 'mild', 'tingling', 'in', 'the', 'anterior', 'aspect', 'of', 'the', 'left', 'thigh', 'and', 'scrotum', 'as', 'well', 'as', 'dysesthesia', 'in', 'both', 'feet.'], ['The', 'patient', 'says', 'goodbye', 'to', 'the', 'stretcher-bearer', 'with', 'a', 'handshake', 'and', 'a', 'simultaneous', 'pat', 'on', 'the', 'shoulder.'], ['Rotation', 'of', 'the', 'lower', 'limbs', 'on', 'the', 'stretcher', 'grasped', 'by', 'the', 'ankles', 'is', 'painless', 'and', 'compression', 'of', 'the', 'pelvis', 'is', 'asymptomatic.'], ['Next:'], ['1-', 'The', 'patient', 'will', 'be', 'seated', 'on', 'the', 'stretcher', 'so', 'that', 'the', 'cervical', 'spine', 'can', 'be', 'explored.'], ['2-', 'Refer', 'to', 'radiology', 'for', 'study', 'of', 'the', 'lower', 'extremities', '(feet,', 'femurs,', 'pelvis).'], ['3-', 'We', 'will', 'palpate', 'the', 'abdomen', 'and', 'roll', 'en', 'bloc', 'to', 'palpate', 'the', 'thoracolumbar', 'spine.'], ['4-', 'We', 'will', 'place', 'a', 'cervical', 'collar', 'and', 'refer', 'to', 'radiology', 'for', 'imaging', 'of', 'the', 'lower', 'extremities', 'and', 'cervical', 'spine.'], ['5-', 'We', 'will', 'request', 'an', 'abdominal', 'ultrasound.'], ['CORRECT', 'ANSWER:', '3'], ['I', 'believe', 'that', 'the', 'correct', 'answer', 'is', '3.'], ['The', 'patient,', 'due', 'to', 'the', 'mechanism', 'of', 'injury', '(foot', 'fall),', 'the', 'calcaneal', 'fracture', 'and', 'the', 'neurological', 'symptoms,', 'suggests', 'a', 'low', 'spinal', 'cord', 'injury', 'due', 'to', 'a', 'fracture', 'of', 'the', 'lumbar', 'spine.'], ['The', 'injury', 'is', 'not', 'high', 'because', 'he', 'moves', 'his', 'arms.'], ['It', 'also', 'does', 'not', 'appear', 'to', 'be', 'a', 'pelvic', 'injury', 'because', 'of', 'the', 'absence', 'of', 'pain', 'on', 'mobilization', 'or', 'palpation.'], ['If', 'there', 'is', 'a', 'suspicion', 'of', 'pelvic', 'injury', 'in', 'the', 'primary', 'evaluation', 'of', 'all', 'polytraumatized', '(ATLS)', 'a', 'spinal', 'exploration', 'should', 'be', 'performed', 'by', 'rotating', 'the', 'spine', 'en', 'bloc', 'to', 'avoid', 'producing', 'more', 'injury.'], ['Abdominal', 'palpation', 'is', 'also', 'part', 'of', 'the', 'initial', 'evaluation.'], ['Abdominal', 'ultrasound', 'may', 'be', 'indicated', 'in', 'hemodynamically', 'unstable', 'patients', 'if', 'abdominal', 'injuries', 'are', 'suspected', 'but', 'in', 'any', 'case', 'it', 'is', 'done', 'after', 'the', 'initial', 'evaluation.']]

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605_113

[['QUESTION', 'TYPE:', 'TRAUMATOLOGY'], ['CLINICAL', 'CASE:'], ['35-year-old', 'male,', 'letter', 'carrier,', 'with', 'no', 'history', 'of', 'interest,', 'who', 'comes', 'to', 'the', 'emergency', 'department', 'for', 'acute', 'cervical', 'pain', 'of', '24', 'hours', 'of', 'evolution,', 'without', 'previous', 'trauma,', 'which', 'radiates', 'to', 'the', 'left', 'arm', 'up', 'to', 'the', 'hand', 'and', 'is', 'accompanied', 'by', 'paresthesia', 'in', 'the', 'radial', 'border', 'of', 'the', 'forearm.'], ['She', 'presents', 'no', 'objectifiable', 'loss', 'of', 'strength,', 'preserves', 'neck', 'mobility', 'although', 'it', 'is', 'painful', 'and', 'contracture', 'of', 'the', 'paravertebral', 'musculature', 'is', 'appreciated.'], ['The', 'first', 'attitude', 'will', 'be:'], ['1-', 'Conservative', 'treatment', 'with', 'non-steroidal', 'anti-inflammatory', 'drugs,', 'local', 'heat', 'and', 'relative', 'rest.'], ['2-', 'Urgent', 'call', 'to', 'the', 'neurosurgeon', 'for', 'surgical', 'evaluation.'], ['3-', 'Preferential', 'request', 'for', 'MRI', 'and', 'electromyogram.'], ['4-', 'Preferential', 'referral', 'to', 'traumatology', 'outpatients.'], ['5-', 'nan'], ['CORRECT', 'ANSWER:', '1'], ['In', 'this', 'case', 'we', 'describe', 'a', 'case', 'of', 'cervicobrachialgia', 'without', 'alarm', 'signs', 'at', 'the', 'present', 'time,', 'so', 'the', 'most', 'indicated', 'treatment', 'at', 'this', 'time', 'would', 'be', 'conservative,', 'based', 'on', 'NSAIDs,', 'local', 'heat', 'and', 'rest.'], ['This', 'is', 'not', 'an', 'urgent', 'case,', 'so', 'answer', '2', 'would', 'not', 'be', 'valid.'], ['The', 'performance', 'of', 'an', 'MRI', 'and', 'an', 'electromyogram', 'are', 'valid', 'options', 'for', 'the', 'etiological', 'study', 'of', 'the', 'picture,', 'however,', 'it', 'is', 'necessary', 'to', 'emphasize', 'that', 'we', 'should', 'first', 'perform', 'a', 'correct', 'pain', 'management,', 'so', 'since', 'we', 'are', 'asked', 'about', 'the', 'first', 'attitude,', 'option', '1', 'would', 'be', 'more', 'valid.']]

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443_102

[['QUESTION', 'TYPE:', 'GYNECOLOGY', 'AND', 'OBSTETRICS'], ['CLINICAL', 'CASE:'], ['A', '64-year-old', 'woman,', 'without', 'relevant', 'comorbidities,', 'operated', 'on', 'for', 'a', 'right', 'breast', 'cancer', 'by', 'means', 'of', 'an', 'extended', 'lumpectomy', 'and', 'selective', 'sentinel', 'lymph', 'node', 'biopsy,', 'with', 'the', 'following', 'anatomopathological', 'result:', 'Infiltrating', 'ductal', 'carcinoma', 'poorly', 'dlferentiated', '(grade', '3),', 'size', '2.2', 'cm', '(pT2),', 'estrogen', 'and', 'progesterone', 'receptor', 'positive,', 'Ki67', '25%,', 'HER2', 'negative.'], ['There', 'is', 'macroscopic', 'involvement', 'of', 'the', 'sentinel', 'lymph', 'node,', 'although', 'there', 'is', 'no', 'involvement', 'of', 'the', 'rest', 'of', 'the', 'isolated', 'axillary', 'nodes', '(pN1).'], ['What', 'adjuvant', 'systemic', 'treatment', 'do', 'you', 'consider', 'most', 'appropriate', 'for', 'this', 'patient?'], ['1-', 'Adjuvant', 'hormone', 'therapy', 'including', 'aromatase', 'inhibitors.'], ['2-', 'Adjuvant', 'chemotherapy,', 'preferably', 'with', 'anthracyclines', 'and', 'taxanes,', 'followed', 'by', 'hormone', 'therapy.'], ['3-', 'Adjuvant', 'chemotherapy', 'in', 'association', 'with', 'the', 'monoclonal', 'antibody', 'trastuzumab,', 'followed', 'by', 'hormone', 'therapy.'], ['4-', 'Adjuvant', 'chemotherapy,', 'preferably', 'with', 'anthracyclines', 'and', 'taxanes.'], ['5-', 'nan'], ['CORRECT', 'ANSWER:', '2'], ['It', 'is', 'a', 'Luminal', 'B.', 'According', 'to', 'the', 'SEGO,', 'this', 'patient', 'is', 'a', 'candidate', 'for', 'chemotherapy', 'treatment', 'because', 'of', 'the', 'high', 'histologic', 'grade', 'and', 'high', 'tumor', 'proliferation.']]

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197_71

[['QUESTION', 'TYPE:', 'NEUROLOGY'], ['CLINICAL', 'CASE:'], ['A', '10-year-old', 'boy', 'with', 'brief', 'episodes', 'of', 'distractibility', '(<', '1', 'minute)', 'in', 'which', 'he', 'does', 'not', 'respond', 'to', 'calls', 'and', 'blinks.'], ['An', 'EEG', 'shows', 'spike-wave', 'discharges', 'at', '3', 'cycles', 'per', 'second.'], ['First-line', 'elective', 'treatment', 'would', 'be', 'with:'], ['1-', 'Valproate.'], ['2-', 'Carbamazepine.'], ['3-', 'Phenytoin.'], ['4-', 'Gabapentin.'], ['5-', 'Clonazepam.'], ['CORRECT', 'ANSWER:', '1'], ['Absences', 'behave', 'as', 'brief', 'episodes', 'of', 'abrupt', 'loss', 'of', 'consciousness', 'without', 'alteration', 'of', 'postural', 'control;', 'they', 'typically', 'last', 'seconds', 'and', 'can', 'be', 'repeated', 'many', 'times', 'a', 'day,', 'are', 'usually', 'accompanied', 'by', 'small', 'bilateral', 'motor', 'signs', '(blinking,', 'chewing)', 'and', 'consciousness', 'is', 'recovered', 'equally', 'abruptly,', 'without', 'subsequent', 'confusion', 'or', 'memory', 'of', 'the', 'episode', '(MIR', '03-04,', '248;', 'MIR', '97-98,', '51).'], ['The', 'age', 'of', 'onset', 'is', 'usually', 'between', '4', 'years', 'and', 'early', 'adolescence,', 'being', 'the', 'most', 'frequent', 'cause', 'of', 'seizures', 'in', 'this', 'age', 'range.'], ['EEG', 'findings', 'are', 'typically', 'generalized', 'and', 'symmetrical', 'spike-wave', 'discharges', 'at', '3', 'Hz', '(MIR', '99-00F,', '67)', 'coinciding', 'with', 'seizures,', 'although', 'in', 'the', 'interictal', 'EEG', 'there', 'are', 'more', 'periods', 'of', 'abnormal', 'activity', 'than', 'clinically', 'visible.'], ['The', 'most', 'appropriate', 'drugs', 'for', 'the', 'treatment', 'of', 'absences', 'are', 'Valproate', 'and', 'Ethosuximide', '(CTO', 'Manual).']]

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478_134

[['QUESTION', 'TYPE:', 'CRITICAL', 'CARE'], ['CLINICAL', 'CASE:'], ['35-year-old', 'male,', 'transferred', 'to', 'the', 'emergency', 'department', 'after', 'a', 'traffic', 'accident.'], ['On', 'admission,', 'a', 'Glasgow', 'scale', 'score', 'of', '15,', 'blood', 'pressure', 'of', '140/90', 'mmHg,', 'respiratory', 'rate', 'of', '35', 'rpm', 'and', 'heart', 'rate', 'of', '110', 'bpm,', 'with', 'a', 'baseline', 'oxygen', 'saturation', 'of', '91%.'], ['On', 'examination', 'there', 'is', 'right', 'thoracic', 'hypophonesis', 'and', 'tympanism', 'on', 'percussion.What', 'is', 'the', 'presumptive', 'diagnosis?'], [':'], ['1-', 'Traumatic', 'cardiac', 'tamponade.'], ['2-', 'Right', 'tension', 'pneumothorax.'], ['3-', 'Massive', 'right', 'hemothorax.'], ['4-', 'Pulmonary', 'contusion.'], ['5-', 'nan'], ['CORRECT', 'ANSWER:', '2'], ['This', 'is', 'an', 'easy', 'and', 'classic', 'question', 'that', 'you', 'can', 'also', 'apply', 'to', 'daily', 'clinical', 'practice.'], ['Hypophonesis', 'in', 'a', 'hemithorax', '+', 'tympanism', '=', 'pneumothorax.'], ['If', 'there', 'is', 'dullness', 'on', 'percussion:', 'hemothorax.'], ['In', 'either', 'case,', 'in', 'case', 'of', 'hypophonesis', 'of', 'a', 'hemithorax', 'in', 'a', 'severe', 'and', 'unstable', 'polytraumatized', 'patient:', 'thoracic', 'drainage', '(if', 'possible,', 'large', 'caliber', 'if', 'placed', 'in', 'a', 'hospital', 'environment,', 'since', 'although', 'the', 'predominant', 'lesion', 'is', 'pneumothorax,', 'a', 'hemothorax', 'component', 'can', 'be', 'found', 'which,', 'in', 'case', 'of', 'placing', 'a', 'fine', 'drainage,', 'could', 'obstruct', 'it).']]

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97_171

[['QUESTION', 'TYPE:', 'DERMATOLOGY,', 'VENEREOLOGY', 'AND', 'PLASTIC', 'SURGERY'], ['CLINICAL', 'CASE:'], ['Patient', 'presenting', 'since', '2', 'weeks', 'ago', 'with', 'a', 'pruritic', 'eruption', 'consisting', 'of', 'multiple', 'polygonal', 'erythematous-violaceous', 'papules,', 'flattened', 'surface,', 'preferentially', 'located', 'on', 'the', 'anterior', 'aspect', 'of', 'wrists,', 'pretibial', 'area', 'and', 'lumbar', 'area.'], ['She', 'also', 'presents', 'whitish', 'reticulated', 'lesions', 'in', 'the', 'jugal', 'mucosa.'], ['What', 'is', 'the', 'most', 'probable', 'diagnosis?'], ['1-', 'Pityriasis', 'versicolor.'], ['2-', 'Mycosis', 'fungoides.'], ['3-', 'Psoriasis', 'in', 'drops.'], ['4-', 'Pityriasis', 'rosea', 'of', 'Gibert.'], ['5-', 'Lichen', 'planus.'], ['CORRECT', 'ANSWER:', '5'], ['They', 'are', 'undoubtedly', 'describing', 'the', 'typical', 'lesions', '(both', 'on', 'skin', 'and', 'oral', 'mucosa)', 'of', 'a', 'lichen', 'planus', '(5).']]

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426_94

[['QUESTION', 'TYPE:', 'ENDOCRINOLOGY'], ['CLINICAL', 'CASE:'], ['A', '73-year-old', 'patient...swallowing', 'a', 'complete', 'neurological', 'dysphagia', 'secondary', 'to', 'a', 'cardioembolic', 'stroke', 'in', 'the', 'left', 'middle', 'cerebral', 'artery', 'territory.', 'will', 'require', 'long-term', 'nutritional', 'support.'], ['Of', 'the', 'following', 'treatment', 'modalities,', 'which', 'do', 'you', 'consider', 'most', 'appropriate', 'for', 'this', 'case?'], ['1-', 'Enteral', 'nutrition', 'by', 'nasogastric', 'tube.'], ['2-', 'Enteral', 'nutrition', 'by', 'nasoduodenal', 'tube.'], ['3-', 'Enteral', 'nutrition', 'by', 'gastrostomy.'], ['4-', 'Enteral', 'nutrition', 'by', 'jejunostomy.'], ['5-', 'nan'], ['CORRECT', 'ANSWER:', '3'], ['Enteral', 'nutrition', 'is', 'a', 'nutritional', 'support', 'technique', 'that', 'involves', 'administering', 'nutrients', 'directly', 'into', 'the', 'gastrointestinal', 'tract', 'by', 'gavage.'], ['The', 'choice', 'of', 'the', 'route', 'of', 'formula', 'administration', 'depends', 'on', 'the', 'nutritional', 'status,', 'age', 'of', 'the', 'patient', 'and', 'the', 'underlying', 'disease.'], ['If', 'enteral', 'nutrition', 'is', 'considered', 'to', 'be', 'of', 'short', 'duration,', 'the', 'route', 'of', 'choice', 'is', 'the', 'nasogastric', 'or', 'nasoduodenal-', 'nasojejunal', 'tube...'], ['If', 'prolonged', 'nutrition', 'is', 'anticipated', 'the', 'route', 'of', 'choice', 'is', 'gastrostomy', '(option', '3),', 'with', 'jejunostomy', 'being', 'reserved', 'for', 'cases', 'in', 'which', 'it', 'is', 'not', 'possible', 'to', 'use', 'the', 'gastric', 'route.']]

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262_58

[['QUESTION', 'TYPE:', 'PHARMACOLOGY'], ['CLINICAL', 'CASE:'], ['A', '70-year-old', 'woman', 'with', 'a', 'history', 'of', 'hypertension', 'and', 'moderate', 'heart', 'failure', 'presents', 'with', 'a', 'persistent,', 'dry', 'cough', 'that', 'begins', 'as', 'an', 'itchy', 'sensation', 'in', 'the', 'throat.'], ['What', 'is', 'the', 'drug', 'suspected', 'of', 'causing', 'the', "patient's", 'clinical', 'and', 'laboratory', 'alteration?'], ['1-', 'Hydrochlorothiazide.'], ['2-', 'Bisoprolol.'], ['3-', 'Furosemide.'], ['4-', 'Enalapril.'], ['5-', 'Hydralazine.'], ['CORRECT', 'ANSWER:', '4'], ['These', 'are', 'typical', 'adverse', 'effects', 'of', 'ACEIs,', 'in', 'the', 'case', 'of', 'cough', 'it', 'is', 'usually', 'dry', 'and', 'irritative', 'and', 'appears', 'in', 'up', 'to', '3%', 'of', 'patients.'], ['Hyperkalemia', 'may', 'also', 'appear', 'in', '1%.']]

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346_159

[['QUESTION', 'TYPE:', 'GYNECOLOGY', 'AND', 'OBSTETRICS'], ['CLINICAL', 'CASE:'], ['69-year-old', 'woman', 'who', 'comes', 'to', 'your', 'office', 'referring', 'genital', 'bleeding', 'of', 'several', 'months', 'of', 'evolution.'], ['She', 'denies', 'hormone', 'replacement', 'therapy', 'and', 'anticoagulation.'], ['She', 'provides', 'normal', 'cervicovaginal', 'cytology.'], ['General', 'and', 'genital', 'physical', 'examination', 'without', 'findings', 'of', 'interest.'], ['BMI', 'of', '38kg/m2.'], ['Indicate', 'the', 'most', 'correct', 'attitude:'], ['1-', 'Prescribe', 'cyclic', 'progesterone.'], ['2-', 'Endometrial', 'biopsy.'], ['3-', 'Random', 'cervical', 'biopsies.'], ['4-', 'Hormonal', 'evaluation', 'with', 'FSH,', 'LH', 'and', 'estradiol.'], ['5-', 'nan'], ['CORRECT', 'ANSWER:', '2'], ['The', 'correct', 'answer', 'is', '2.'], ['We', 'are', 'dealing', 'with', 'a', 'case', 'of', 'postmenopausal', 'metrorrhagia,', 'whose', 'most', 'frequent', 'cause', 'is', 'genital', 'atrophy', 'in', 'the', 'first', 'place', 'and', 'endometrial', 'cancer', 'in', 'the', 'second', 'place.'], ['The', 'data', 'given', 'on', 'obesity', 'should', 'lead', 'us', 'to', 'suspect', 'endometrial', 'cancer,', 'since', 'peripheral', 'fat', 'is', 'converted', 'to', 'estrone,', 'and', 'these', 'estrogens', 'cause', 'the', 'endometrium', 'to', 'proliferate.'], ['On', 'the', 'other', 'hand,', 'she', 'provides', 'a', 'normal', 'cytology,', 'which', 'rules', 'out', 'option', '3.'], ['The', 'hormonal', 'evaluation', 'is', 'not', 'opportune,', 'since', 'we', 'understand', 'that', 'the', 'patient', 'is', 'in', 'menopause.'], ['We', 'should', 'not', 'prescribe', 'treatment', 'without', 'first', 'ruling', 'out', 'organic', 'causes.']]

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170_89

[['QUESTION', 'TYPE:', 'CARDIOLOGY', 'AND', 'CARDIOVASCULAR', 'SURGERY'], ['CLINICAL', 'CASE:'], ['A', '62-year-old', 'patient', 'who', 'has', 'had', 'a', 'pericardial', 'bioprosthesis', 'in', 'mitral', 'position', 'for', 'two', 'years.'], ['He', 'is', 'admitted', 'urgently', 'for', 'acute', 'coronary', 'syndrome.'], ['Two', 'days', 'later', 'and', 'after', 'a', 'favorable', 'evolution,', 'he', 'suddenly', 'presented', 'heart', 'failure', 'with', 'acute', 'pulmonary', 'edema.'], ['Select', 'the', 'diagnostic', 'option', 'in', 'this', 'case', 'from', 'the', 'following', 'possibilities:'], ['1-', 'Acute', 'post-infarction', 'mitral', 'insufficiency.'], ['2-', 'Left', 'ventricular', 'aneurysm.'], ['3-', 'Acute', 'ventricular', 'septal', 'defect.'], ['4-', 'Postinfarction', 'atrial', 'septal', 'defect.'], ['5-', 'Dysfunction', 'of', 'the', 'bioprosthesis', 'due', 'to', 'probable', 'acute', 'endocarditis.'], ['CORRECT', 'ANSWER:', '3'], ['The', 'valve', 'is', 'biological', 'and,', 'in', 'general,', 'the', 'veils', 'are', 'not', 'sewn', 'to', 'the', 'papillary', 'muscles,', 'so', 'we', "don't", 'care', 'what', 'happens', 'to', 'them.'], ['A', 'ventricular', 'aneurysm', 'depresses', 'LVEF,', 'but', 'does', 'not', 'suddenly', 'put', 'you', 'into', 'PAD.'], ['In', 'contrast,', 'a', 'VSD', 'sharply', 'increases', 'flow', 'to', 'the', 'pulmonary', 'bed,', 'causing', 'pulmonary', 'edema,', 'and', 'is', 'also', 'one', 'of', 'the', 'most', 'frequent', 'complications', 'of', 'AMI.'], ['Ischemic', 'ASD...', 'I', 'do', 'not', 'deny', 'that', 'it', 'exists,', 'but', 'it', 'does', 'not', 'even', 'appear', 'in', 'the', 'guidelines.'], ['And', 'endocarditis', 'would', 'not', 'require', 'so', 'many', 'saddlebags.']]

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40_136

[['QUESTION', 'TYPE:', 'OTOLARYNGOLOGY', 'AND', 'MAXILLOFACIAL', 'SURGERY'], ['CLINICAL', 'CASE:'], ['A', '64-year-old', 'smoker', 'and', 'heavy', 'drinker', 'reports', 'painless', 'right', 'jugulodigastric', 'lymphadenopathy', 'of', 'progressive', 'growth', 'in', 'the', 'last', 'two', 'months', 'whose', 'fine', 'needle', 'aspiration', 'was', 'reported', 'as', 'squamous', 'cell', 'carcinoma.'], ['Which', 'of', 'the', 'following', 'is', 'the', 'most', 'likely', 'location', 'of', 'the', 'primary', 'tumor:'], ['1-', 'Scalp.'], ['2-', 'Parotid.'], ['3-', 'Lung.'], ['4-', 'Esophagus.'], ['5-', 'Larynx.'], ['CORRECT', 'ANSWER:', '5'], ['You', 'are', 'in', 'the', 'middle', 'of', 'the', 'ENT', 'block.'], ['You', 'have', 'already', 'passed', 'the', 'Pneumology', 'and', 'Digestive', 'blocks.'], ['Dermatology', 'is', 'still', 'to', 'come', 'out,', 'but', 'a', 'dermatologist', '(answer', '1)', 'would', 'not', 'ask', 'this.'], ['So', 'we', 'are', 'left', 'with', 'parotid', 'and', 'larynx;', 'but', 'parotid', 'squamous', 'cell', 'carcinoma', 'is', 'rare;', 'I', 'would', 'mark', '5', 'and', 'rest', 'easy.'], ['Perhaps', 'because', 'all', 'the', 'adenopathies', 'at', 'this', 'level', 'that', 'I', 'have', 'seen', 'have', 'ended', 'up', 'corresponding', 'to', 'carcinomas', 'of', 'the', 'upper', 'aerodigestive', 'tract.']]

[['O', 'O', 'O', 'O', 'O', 'O'], ['O', 'O'], ['B-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise'], ['O', 'O', 'O', 'O', 'O', 'O', 'O', 'O', 'O', 'O', 'O', 'O', 'O'], ['O', 'B-Claim'], ['O', 'B-Claim'], ['O', 'B-Claim'], ['O', 'B-Claim'], ['O', 'B-Claim'], ['O', 'O', 'O'], ['O', 'O', 'O', 'O', 'O', 'O', 'O', 'O', 'O'], ['B-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim'], ['B-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'B-Marker', 'B-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim'], ['B-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'B-Marker', 'B-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'B-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim'], ['O', 'B-Marker', 'B-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim']]

126_59

[['QUESTION', 'TYPE:', 'PNEUMOLOGY', 'AND', 'THORACIC', 'SURGERY'], ['CLINICAL', 'CASE:'], ['A', '65-year-old', 'man,', 'a', 'retired', 'office', 'worker', 'and', 'smoker', 'of', '1', 'pack', 'of', 'cigarettes', 'a', 'day,', 'comes', 'to', 'the', 'clinic', 'with', 'a', 'persistent,', 'generally', 'dry', 'cough', 'and', 'progressive', 'dyspnea', 'of', '2', 'years', 'of', 'evolution', 'which', 'is', 'currently', 'grade', '2.'], ['The', 'patient', 'denies', 'other', 'symptoms.'], ['Physical', 'examination', 'shows', 'no', 'relevant', 'data.'], ['The', 'attitude', 'to', 'follow', 'would', 'be:'], ['1-', 'Start', 'treatment', 'with', 'inhaled', 'bronchodilators.'], ['2-', 'Chest', 'X-ray', 'and', 'spirometry', 'with', 'bronchodilator', 'test.'], ['3-', 'Prescribe', 'oral', 'corticosteroids.'], ['4-', 'Thoracic', 'CT', 'scan.'], ['5-', 'Perform', 'basal', 'arterial', 'blood', 'gases.'], ['CORRECT', 'ANSWER:', '2'], ['The', 'correct', 'answer', 'is', '2', '(Perform', 'chest', 'X-ray', 'and', 'spirometry', 'with', 'bronchodilator', 'test).'], ['It', 'is', 'probably', 'COPD', 'but', 'we', 'must', 'confirm', 'it', 'and', 'assess', 'the', 'severity', 'of', 'the', 'obstruction', 'with', 'spirometry', 'before', 'starting', 'treatment.'], ['He', 'is', 'a', 'patient', 'at', 'risk', 'for', 'lung', 'cancer', 'so', 'it', 'is', 'mandatory', 'to', 'perform', 'a', 'chest', 'X-ray', 'to', 'rule', 'out', 'this', 'or', 'other', 'pathologies', 'that', 'would', 'justify', 'the', 'symptoms,', 'although', 'most', 'likely', 'they', 'are', 'due', 'to', 'the', 'debut', 'of', 'his', 'COPD.']]

[['O', 'O', 'O', 'O', 'O', 'O'], ['O', 'O'], ['B-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise'], ['B-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise'], ['B-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise'], ['O', 'O', 'O', 'O', 'O', 'O'], ['O', 'B-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim'], ['O', 'B-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim'], ['O', 'B-Claim', 'I-Claim', 'I-Claim'], ['O', 'B-Claim', 'I-Claim', 'I-Claim'], ['O', 'B-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim'], ['O', 'O', 'O'], ['B-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim'], ['B-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim'], ['B-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim']]

568_151

[['QUESTION', 'TYPE:', 'NEPHROLOGY'], ['CLINICAL', 'CASE:'], ['A', '22-year-old', 'male', 'presents', 'to', 'the', 'emergency', 'department', 'with', '"almost', 'black"', 'urine', 'for', 'the', 'past', '12', 'hours.'], ['He', 'has', 'no', 'past', 'history', 'of', 'interest', 'and', 'is', 'not', 'taking', 'any', 'medications.'], ['He', 'refers', 'an', 'upper', 'respiratory', 'catarrhal', 'symptoms', 'since', '4-5', 'days', 'ago', 'for', 'which', 'he', 'has', 'taken', 'paracetamol.'], ['Examination:', 'temperature', '37.3', 'ºC,', 'BP', '150/95,', 'HR', '85', 'bpm,', 'slight', 'pharyngeal', 'erythema,', 'the', 'rest', 'normal.'], ['Laboratory', 'tests', 'showed:', 'Hb', '12.8', 'g/dl,', 'Hcto', '39%,', 'leukocytes', '10,500/mm3', 'with', 'normal', 'formula,', 'platelets', '250,000/mm3,', 'normal', 'coagulation,', 'urea', '25', 'mg/dl,', 'creatinine', '0.8', 'mg/dl,', 'ions,', 'hepatic,', 'lipid,', 'albumin', 'and', 'total', 'proteins', 'normal.'], ['Normal', 'autoimmunity', 'study', 'and', 'negative', 'viral', 'serology.'], ['Urine', '24', 'h', 'with', 'proteinuria', 'of', '0.75', 'g/24', 'h,', 'sediment', 'with', '10', 'erythrocytes', 'per', 'field', '(90%', 'dysmorphic),', 'no', 'leukocyturia.'], ['Renal', 'ultrasound', 'was', 'normal.'], ['Which', 'diagnosis', 'do', 'you', 'think', 'is', 'more', 'likely?'], ['1-', 'Nephropathy', 'with', 'minimal', 'changes.'], ['2-', 'Postinfectious', 'glomerulonephritis.'], ['3-', 'IgA', 'nephropathy.'], ['4-', 'Acute', 'interstitial', 'nephritis.'], ['5-', 'nan'], ['CORRECT', 'ANSWER:', '3'], ['A', 'picture', 'of', 'macroscopic', 'hematuria', 'and', 'mild', 'proteinuria', 'with', 'normal', 'creatinine', 'levels,', 'accompanied', 'by', 'an', 'upper', 'tract', 'catarrhal', 'picture,', 'is', 'very', 'suggestive', 'of', 'IgA', 'nephropathy', '(option', '3', 'correct).']]

[['O', 'O', 'O'], ['O', 'O'], ['B-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise'], ['B-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise'], ['B-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise'], ['B-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise'], ['B-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise'], ['B-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise'], ['B-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise'], ['B-Premise', 'I-Premise', 'I-Premise', 'I-Premise'], ['O', 'O', 'O', 'O', 'O', 'O', 'O', 'O'], ['O', 'B-Claim', 'I-Claim', 'I-Claim', 'I-Claim'], ['O', 'B-Claim', 'I-Claim'], ['O', 'B-Claim', 'I-Claim'], ['O', 'B-Claim', 'I-Claim', 'I-Claim'], ['O', 'O'], ['O', 'O', 'O'], ['B-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'B-Claim', 'I-Claim', 'I-Claim']]

286_60

228_75

[['QUESTION', 'TYPE:', 'CARDIOLOGY'], ['CLINICAL', 'CASE:'], ['In', 'a', 'patient', 'with', 'clinical', 'signs', 'of', 'heart', 'failure', 'who', 'presents', 'with', 'ascites', 'disproportionately', 'elevated', 'in', 'relation', 'to', 'peripheral', 'edema,', 'the', 'most', 'likely', 'etiology', 'would', 'be:'], ['1-', 'Severe', 'aortic', 'stenosis.'], ['2-', 'Dilated', 'cardiomyopathy', 'with', 'significant', 'left', 'ventricular', 'dysfunction.'], ['3-', 'Primary', 'pulmonary', 'hypertension.'], ['4-', 'Obstructive', 'hypertrophic', 'cardiomyopathy.'], ['5-', 'Constrictive', 'pericarditis.'], ['CORRECT', 'ANSWER:', '5'], ['They', 'tell', 'us', 'about', 'clinical', 'symptoms', 'of', 'right', 'failure,', 'with', 'edema', 'and', 'ascites.'], ['Therefore,', 'we', 'rule', 'out', 'left', 'heart', 'failure:', 'EAo,', 'dilated', 'with', 'DSVI', 'and', 'a', 'MHO.'], ['Of', 'the', 'two', 'we', 'are', 'left', 'with,', 'in', 'constrictive', 'pericarditis', 'we', 'have', 'increased', 'filling', 'pressures', 'in', 'right', 'chambers,', 'which', 'cause', 'retrograde', 'pressure', 'increase', 'with', 'hepatic', 'congestion,', 'ascites,', 'edema,', 'etc.'], ['On', 'the', 'contrary,', 'in', 'pulmonary', 'hypertension,', 'the', 'tricuspid', 'valve', 'is', 'responsible', '(a', 'priori)', 'for', '"containing"', 'this', 'overpressure.']]

[['O', 'O', 'O'], ['O', 'O'], ['O', 'B-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'O', 'O', 'O', 'O', 'O', 'O'], ['O', 'B-Claim', 'I-Claim', 'I-Claim'], ['O', 'B-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim'], ['O', 'B-Claim', 'I-Claim', 'I-Claim'], ['O', 'B-Claim', 'I-Claim', 'I-Claim'], ['O', 'B-Claim', 'I-Claim'], ['O', 'O', 'O'], ['B-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise'], ['B-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim'], ['B-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim'], ['B-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim']]

217_122

[['QUESTION', 'TYPE:', 'NEPHROLOGY'], ['CLINICAL', 'CASE:'], ['A', '54-year-old', 'man', 'is', 'diagnosed', 'with', 'a', 'left', 'renal', 'tumor', 'suggestive', 'of', 'renal', 'cell', 'carcinoma.'], ['His', 'preoperative', 'workup', 'shows', 'elevated', 'levels', 'of', 'GPT,', 'alkaline', 'phosphatase', 'and', 'alpha-2-globulin', 'and', 'prolonged', 'prothrombin', 'time.'], ['The', 'liver', 'is', 'diffusely', 'enlarged,', 'but', 'without', 'defects', 'of', 'hepatic', 'infiltration.'], ['The', 'most', 'likely', 'rationale', 'for', 'these', 'findings', 'is', 'due', 'to:'], ['1-', 'Hepatic', 'metastases.'], ['2-', 'Intrahepatic', 'tumor', 'thrombosis.'], ['3-', 'Acute', 'hepatitis.'], ['4-', 'Presence', 'of', 'hepatotoxic', 'substances', 'produced', 'by', 'the', 'tumor.'], ['5-', 'Hemochromatosis.'], ['CORRECT', 'ANSWER:', '4'], ['Very', 'easy', 'question', 'in', 'which', 'we', 'are', 'being', 'presented', 'with', 'a', 'patient', 'with', "Stauffer's", 'syndrome,', 'a', 'paraneoplastic', 'syndrome', 'consisting', 'of', 'liver', 'dysfunction', 'secondary', 'to', 'toxic', 'products', 'secreted', 'by', 'a', 'number', 'of', 'tumors', '(most', 'frequently,', 'renal', 'cell', 'carcinoma,', 'like', 'the', 'one', 'in', 'this', 'case).'], ['As', 'in', 'this', 'case,', 'cholestasis', '(elevation', 'of', 'alkaline', 'phosphatase),', 'mobilization', 'of', 'hepatic', 'enzymes', 'and', 'lengthening', 'of', 'the', 'prothrombin', 'time', 'indicate', 'liver', 'dysfunction.'], ['Metastases', 'are', 'ruled', 'out', '(there', 'are', 'no', 'defects', 'of', 'hepatic', 'infiltration),', 'intrahepatic', 'tumor', 'thrombosis', '(it', 'would', 'give', 'another', 'symptomatology', 'and', 'this', 'would', 'be', 'more', 'acute),', 'and', 'acute', 'hepatitis', 'and', 'hemochromatosis', '(they', 'are', 'not', 'in', 'context', 'nor', 'is', 'it', 'what', 'the', 'author', 'of', 'the', 'question', 'wants', 'us', 'to', 'think).']]

[['O', 'O', 'O'], ['O', 'O'], ['B-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise'], ['B-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise'], ['B-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise'], ['O', 'O', 'O', 'O', 'O', 'O', 'O', 'O', 'O', 'O'], ['O', 'B-Claim', 'I-Claim'], ['O', 'B-Disease', 'I-Disease', 'I-Disease'], ['O', 'B-Claim', 'I-Claim'], ['O', 'B-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim'], ['O', 'B-Claim'], ['O', 'O', 'O'], ['O', 'O', 'O', 'O', 'O', 'B-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise'], ['B-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise'], ['B-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'B-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'B-Claim', 'I-Claim', 'I-Claim', 'B-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'O', 'B-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'B-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise']]

142_138

[['QUESTION', 'TYPE:', 'PEDIATRICS'], ['CLINICAL', 'CASE:'], ['12-year-old', 'girl,', 'only', 'child', 'of', 'healthy,', 'non-consanguineous', 'parents.'], ['There', 'is', 'no', 'personal', 'or', 'family', 'history', 'of', 'interest.'], ['In', 'the', 'clinical', 'examination', 'to', 'start', 'a', 'sports', 'activity,', 'you', 'find', 'a', 'discrete', 'hepatomegaly', 'of', 'normal', 'consistency,', 'so', 'you', 'request', 'a', 'blood', 'test,', 'which', 'highlights', 'an', 'ASAT', 'of', '80U', '/', 'l,', 'ALAT', '105', 'U', '/', 'l,', 'electrophoretic', 'proteinogram', 'with', 'all', 'protein', 'fractions', 'in', 'normal', 'range', 'and', 'negativity', 'of', 'serology', 'for', 'hepatotropic', 'viruses.'], ['What', 'should', 'you', 'rule', 'out', 'and', 'what', 'test', 'would', 'you', 'indicate', 'for', 'it?'], ['1-', 'Deficiency', 'of', 'alpha', '1', 'antitrypsin.', 'Thoracic', 'TAC', 'to', 'confirm', 'emphysema.'], ['2-', 'Mucoviscidosis.', 'Determination', 'of', 'chlorine', 'in', 'sweat.'], ['3-', 'Autoimmune', 'hepatitis.', 'Liver', 'biopsy.'], ['4-', 'Glycogenosis', 'type', 'VI', '(phosphorylase', 'deficiency).', 'Muscle', 'biopsy.'], ['5-', "Wilson's", 'disease.', 'Determine', 'ceruloplasmin', 'and', 'copper', 'in', 'blood', 'and', 'urine.'], ['CORRECT', 'ANSWER:', '5'], ['In', 'fact,', 'I', 'would', 'not', 'test', 'this', 'patient', 'at', 'this', 'time,', 'and', 'I', 'would', 'check', 'if', 'the', 'transaminase', 'level', 'has', 'normalized', 'at', 'a', 'later', 'time,', 'since', 'the', 'most', 'frequent', 'cause,', 'at', 'least', 'in', 'children,', 'is', 'a', 'transient', 'elevation', 'in', 'the', 'context', 'of', 'viral', 'diseases', '(most', 'frequently', 'cytomegalovirus', 'and', 'Epstein-Barr', 'virus).'], ['The', 'minimal', 'elevation', 'of', 'liver', 'enzymes', 'and', 'the', 'fact', 'that', 'it', 'has', 'a', 'normal', 'protein', 'profile', 'goes', 'against', 'chronicity...'], ['If', 'I', 'had', 'to', 'choose', 'I', 'would', 'choose', 'answer', '5,', 'which', 'seems', 'to', 'me', 'the', 'least', 'aggressive,', 'and', 'if', 'I', 'had', 'to', 'do', 'analytical', 'tests', 'I', 'would', 'add', 'the', 'determination', 'of', 'alpha-1-antitrypsin', '(without', 'CT)', 'and', 'markers', 'of', 'celiac', 'disease,', 'because', 'celiac', 'disease', 'can', 'also', 'be', 'associated', 'with', 'some', 'hypertransaminemia.']]

[['O', 'O', 'O'], ['O', 'O'], ['B-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise'], ['B-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise'], ['B-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise'], ['O', 'O', 'O', 'O', 'O', 'O', 'O', 'O', 'O', 'O', 'O', 'O', 'O'], ['O', 'B-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim'], ['O', 'B-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim'], ['O', 'B-Claim', 'I-Claim', 'I-Claim', 'I-Claim'], ['O', 'B-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim'], ['O', 'B-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim'], ['O', 'O', 'O'], ['B-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim'], ['B-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim'], ['B-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'O', 'B-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim']]

267_139

[['QUESTION', 'TYPE:', 'PNEUMOLOGY'], ['CLINICAL', 'CASE:'], ['In', 'a', 'patient', 'with', 'liver', 'cirrhosis', 'and', 'ascites,', 'who', 'develops', 'a', 'pleural', 'effusion', 'with', 'the', 'following', 'data', 'in', 'the', 'pleural', 'fluid:', 'LDH', '45', 'U/L', '(serum', '220', 'U/L),', 'pleural/serum', 'protein', 'ratio', '0.3', 'and', 'pleural/serum', 'LDH', 'ratio', '0.2.'], ['What', 'would', 'be', 'the', 'appropriate', 'attitude?'], ['1-', 'The', 'study', 'of', 'the', 'fluid', 'with', 'cell', 'count,', 'glucose,', 'pH,', 'ADA,', 'cholesterol', 'and', 'culture', 'should', 'be', 'extended.', 'ADA,', 'cholesterol', 'and', 'culture.'], ['2-', 'Blind', 'pleural', 'biopsy.'], ['3-', 'Diagnostic', 'videothoracoscopy.'], ['4-', 'Empirical', 'antibiotherapy', 'for', 'suspected', 'parapneumonic', 'effusion.'], ['5-', 'Continue', 'treatment', 'of', 'his', 'liver', 'disease.'], ['CORRECT', 'ANSWER:', '5'], ['They', 'describe', 'pleural', 'fluid', 'parameters', 'of', 'transudate,', 'so', 'if', 'the', 'patient', 'is', 'not', 'in', 'heart', 'failure', 'it', 'is', 'a', 'hydropic', 'decompensation.'], ['No', 'other', 'studies', 'are', 'needed.']]

[['O', 'O', 'O'], ['O', 'O'], ['B-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise'], ['O', 'O', 'O', 'O', 'O', 'O'], ['O', 'B-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim'], ['O', 'B-Claim', 'I-Claim', 'I-Claim'], ['O', 'B-Claim', 'I-Claim'], ['O', 'B-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim'], ['O', 'B-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim'], ['O', 'O', 'O'], ['B-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'B-Marker', 'B-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim'], ['O', 'O', 'O', 'O', 'O']]

99_84

[['QUESTION', 'TYPE:', 'ENDOCRINOLOGY'], ['CLINICAL', 'CASE:'], ['A', '60-year-old', 'diabetic', 'patient', 'is', 'consulting', 'for', 'the', 'first', 'time', 'regarding', 'the', 'treatment', 'of', 'his', 'disease.'], ['Which', 'of', 'the', 'following', 'goals', 'would', 'you', 'recommend', 'to', 'him', 'first?'], ['1-', 'Maintain', 'blood', 'pressure', 'below', '110/70', 'mmHg.'], ['2-', 'Smoking', 'cessation.'], ['3-', 'Maintain', 'a', 'body', 'mass', 'index', '(BMI)', 'less', 'than', '21.'], ['4-', 'Perform', 'daily', 'basal', 'capillary', 'glycemia.'], ['5-', 'Avoidance', 'of', 'animal', 'fats', 'in', 'the', 'diet.'], ['CORRECT', 'ANSWER:', '2'], ['The', 'rest', 'are', 'not', 'indications.'], ['The', 'target', 'BP', 'is', '<', '130/85', 'mmHg.']]

[['O', 'O', 'O'], ['O', 'O'], ['B-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise'], ['O', 'O', 'O', 'O', 'O', 'O', 'O', 'O', 'O', 'O', 'O'], ['O', 'B-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim'], ['O', 'B-Claim', 'I-Claim'], ['O', 'B-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim'], ['O', 'B-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim'], ['O', 'B-Treatment', 'I-Treatment', 'I-Treatment', 'I-Treatment', 'I-Treatment', 'I-Treatment', 'I-Treatment'], ['O', 'O', 'O'], ['B-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim'], ['B-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim']]

380_135

[['QUESTION', 'TYPE:', 'NEUROLOGY'], ['CLINICAL', 'CASE:'], ['A', '25-year-old', 'patient,', 'during', 'a', 'tennis', 'match,', 'has', 'intense', 'pain', 'in', 'the', 'neck', 'and', 'in', 'the', 'left', 'eye.'], ['The', 'next', 'morning', 'he', 'wakes', 'up', 'with', 'a', 'feeling', 'of', 'gait', 'instability', 'and', 'has', 'palpebral', 'ptosis', 'of', 'the', 'left', 'eye', 'and', 'anisocoria,', 'with', 'the', 'left', 'pupil', 'being', 'smaller', 'than', 'the', 'right.'], ['The', 'patient', 'maintains', 'good', 'visual', 'acuity.'], ['Where', 'would', 'you', 'most', 'likely', 'locate', 'the', 'lesion?'], ['1-', 'III', 'cranial', 'pair.'], ['2-', 'Optic', 'chiasm.'], ['3-', 'Superior', 'cervical', 'ganglion.'], ['4-', 'Spinal', 'bulb.'], ['5-', 'nan'], ['CORRECT', 'ANSWER:', '4'], ['The', 'picture', 'presented', 'to', 'us', 'is', 'that', 'of', 'a', 'Horner', 'syndrome', '(miosis', 'with', 'ptosis)', 'so', 'the', 'possibilities', 'are', 'reduced', 'to', 'options', '3', 'or', '4,', 'but', 'they', 'specify', 'that', 'the', 'patient', 'presents', 'gait', 'instability,', 'which', 'is', 'not', 'justified', 'by', 'a', 'Horner', 'due', 'to', 'carotid', 'dissection', 'affecting', 'the', 'superior', 'cervical', 'ganglion,', 'which', 'is', 'what', 'they', 'want', 'us', 'to', 'believe', 'when', 'they', 'talk', 'about', 'pain', 'in', 'the', 'neck', 'and', 'in', 'the', 'eye.'], ['If', 'the', 'patient', 'really', 'has', 'ataxia,', 'the', 'only', 'possible', 'location', 'would', 'be', 'the', 'spinal', 'cord.']]

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341_33

[['QUESTION', 'TYPE:', 'GYNECOLOGY', 'AND', 'OBSTETRICS'], ['CLINICAL', 'CASE:'], ['A', '67-year-old', 'woman', 'diagnosed', 'with', 'infiltrating', 'ductal', 'carcinoma', 'of', 'the', 'breast', 'with', 'no', 'family', 'history', 'of', 'neoplasia.'], ['What', 'additional', 'studies', 'should', 'be', 'performed', 'on', 'the', 'tumor', 'because', 'of', 'its', 'clinical', 'and', 'therapeutic', 'implications?'], ['1-', 'Complete', 'phenotypic', 'study', 'by', 'flow', 'cytometry.'], ['2-', 'Study', 'of', 'hormone', 'receptors', 'and', 'HER2.'], ['3-', 'Study', 'of', 'hormone', 'receptors,', 'e-cadherin', 'and', 'study', 'of', 'first-degree', 'relatives.'], ['4-', 'Study', 'of', 'BRCA', '1-2', 'and', 'study', 'of', 'first-degree', 'relatives.'], ['5-', 'nan'], ['CORRECT', 'ANSWER:', '2'], ['Study', 'of', 'hormone', 'receptors', 'and', 'HER2.'], ['Both', 'for', 'the', 'type', 'of', 'treatment', 'and', 'to', 'study', 'the', 'prognostic', 'factor', 'and', 'adjuvant', 'treatment,', 'it', 'is', 'necessary', 'to', 'know', 'the', 'different', 'hormonal', 'receptors', '(estrogen', 'and', 'progesterone)', 'as', 'well', 'as', 'HER2-neu.']]

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308_215

[['QUESTION', 'TYPE:', 'OPHTHALMOLOGY'], ['CLINICAL', 'CASE:'], ['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.'], ['Which', 'of', 'the', 'following', 'diagnoses', 'can', 'cause', 'this', 'symptomatology?'], ['1-', 'Post-surgical', 'endophthalmitis.'], ['2-', 'Retinal', 'detachment.'], ['3-', 'Age-related', 'macular', 'degeneration,', 'wet', 'form.'], ['4-', 'Posterior', 'vitreous', 'detachment.'], ['5-', 'nan'], ['CORRECT', 'ANSWER:', '2'], ['He', 'refers', 'to', 'a', 'patient', 'post', 'cataract', 'surgery', '2', 'years', 'ago', 'with', 'deep', 'and', 'painless', 'loss', 'of', 'OD.'], ['Post-surgical', 'endophthalmitis', 'is', 'more', 'associated', 'with', 'patients', 'in', 'the', 'immediate', 'postoperative', 'period,', 'besides', 'being', 'very', 'painful', 'with', 'rapidly', 'progressive', 'decrease', 'in', 'visual', 'acuity,', 'so', 'it', 'is', 'not', 'correct.'], ['Retinal', 'detachment', 'is', 'consistent', 'with', 'the', 'clinical', 'case', 'because', 'it', 'is', 'also', 'a', 'myopic', 'patient', 'who', 'tend', 'to', 'have', 'a', 'special', 'predisposition', 'to', 'detachment.'], ['ARMD', 'usually', 'occurs', 'in', 'older', 'patients', 'and', 'the', 'decrease', 'in', 'vision', 'is', 'progressive.'], ['In', 'PVD', 'there', 'may', 'or', 'may', 'not', 'be', 'a', 'slight', 'decrease', 'in', 'visual', 'acuity', 'and', 'the', 'patient', 'usually', 'reports', 'some', 'discomfort', 'or', 'pain', 'at', 'the', 'onset', 'of', 'the', 'clinical', 'picture.']]

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519_176

63_200

[['QUESTION', 'TYPE:', 'ANATOMY'], ['CLINICAL', 'CASE:'], ['A', '31-year-old', 'bricklayer', 'comes', 'to', 'the', 'emergency', 'department', 'with', 'tenosynovitis', 'caused', 'by', 'a', 'penetrating', 'wound.'], ['On', 'examination,', 'the', 'ulnar', 'bursa', 'is', 'found', 'to', 'be', 'infected', 'with', 'consequent', 'tendon', 'necrosis.'], ['Which', 'tendon', 'will', 'be', 'affected?'], ['1-', 'Tendon', 'of', 'the', 'flexor', 'carpi', 'ulnaris.'], ['2-', 'Tendon', 'of', 'the', 'abductor', 'pollicis', 'longus.'], ['3-', 'Tendon', 'of', 'the', 'deep', 'flexor', 'of', 'the', 'fingers.'], ['4-', 'Radial', 'carpal', 'flexor', 'tendon.'], ['5-', 'Palmaris', 'longus', 'tendon.'], ['CORRECT', 'ANSWER:', '1'], ['Both', 'the', 'flexor', 'carpi', 'radialis', 'and', 'the', 'abductor', 'pollicis', 'longus', 'are', 'anatomically', 'far', 'from', 'the', 'ulnar.'], ['The', 'palmaris', 'longus', 'is', 'medial,', 'as', 'is', 'the', 'flexor', 'digitorum', 'profundus.'], ['The', 'tendon', 'that', 'runs', 'alongside', 'the', 'ulnar', 'nerve,', 'inserting', 'into', 'the', 'pisiform,', 'is', 'the', 'flexor', 'carpi', 'ulnaris,', 'thus', 'answer', '1.']]

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30_61

[['QUESTION', 'TYPE:', 'NEUROLOGY', 'AND', 'THORACIC', 'SURGERY'], ['CLINICAL', 'CASE:'], ['A', 'patient', 'previously', 'diagnosed', 'with', 'COPD', 'comes', 'to', 'the', 'emergency', 'room', 'for', '3', 'days', 'with', 'increased', 'dyspnea', 'until', 'he', 'is', 'at', 'rest,', 'cough', 'with', 'whitish', 'expectoration', 'and', 'marked', 'drowsiness.'], ['After', 'receiving', 'treatment', 'with', 'oxygen', 'at', 'low', 'concentrations,', 'bronchodilators', 'and', 'coticoids,', 'a', 'second', 'arterial', 'blood', 'gas', 'with', '28%', 'inspiratory', 'oxygen', 'fraction', 'shows', 'a', 'pH', 'of', '7.32,', 'pO2', '61', 'mmHg,', 'pCO2', '58', 'mmHg,', 'HCO3-', '29', 'mmol/l.'], ['What', 'would', 'be', 'the', 'interpretation', 'you', 'would', 'make', 'of', 'the', 'arterial', 'blood', 'gas', 'and', 'what', 'treatment', 'would', 'you', 'use?'], ['1-', 'Increase', 'oxygen', 'flow', 'because', 'he', 'has', 'acute', 'respiratory', 'acidosis', 'and', 'hypoxemia.'], ['2-', 'I', 'would', 'initiate', 'noninvasive', 'mechanical', 'ventilation', 'because', 'he', 'has', 'acute', 'hypercapnic', 'respiratory', 'failure', 'with', 'moderate', 'respiratory', 'acidosis.'], ['3-', 'I', 'would', 'add', 'sodium', 'bicarbonate', 'to', 'correct', 'the', 'acute', 'metabolic', 'acidosis.'], ['4-', 'The', 'patient', 'does', 'not', 'have', 'respiratory', 'insufficiency', 'so', 'he', 'would', 'continue', 'with', 'the', 'same', 'pharmacological', 'regimen.'], ['5-', 'I', 'would', 'add', 'intravenous', 'aminophylline', 'as', 'a', 'respiratory', 'stimulant,', 'since', 'I', 'appreciate', 'hypoxemia', 'and', 'hypercapnia.'], ['CORRECT', 'ANSWER:', '4'], ['This', 'is', 'a', 'very', 'bad', 'question,', 'I', 'will', 'bet', 'on', 'one', 'answer,', 'but', 'depending', 'on', 'data', 'that', 'we', 'are', 'not', 'given,', 'three', 'answers', 'could', 'be', 'valid.'], ['The', 'trap', 'is', 'that', 'they', 'give', 'us', 'the', 'initial', 'clinical', 'picture', 'WITHOUT', 'GASOMETRY', 'and', 'then', 'they', 'give', 'us', 'the', 'blood', 'gases', 'afterwards', 'WITHOUT', 'CLINIC,', 'so', 'there', 'is', 'no', 'way', 'of', 'knowing', 'what', 'the', 'evolution', 'of', 'the', 'patient', 'has', 'been', 'with', 'our', 'treatment,', 'so', 'it', 'is', 'impossible', 'to', 'know', 'what', 'to', 'do.'], ['If', 'the', 'patient', 'initially', 'came', 'with', 'a', 'blood', 'gas', 'with', 'a', 'pH', 'of', '7.05', 'and', 'now', 'has', 'the', 'one', 'we', 'are', 'given,', 'we', 'are', 'doing', 'well', '(although', 'we', 'are', 'not', 'told', 'the', 'time', 'interval', 'between', 'one', 'thing', 'and', 'the', 'other)', 'and,', 'in', 'this', 'case,', 'it', 'could', 'be', 'worthwhile', 'to', 'continue', 'with', 'the', 'same', 'treatment.'], ['If', 'nothing', 'has', 'evolved,', 'the', 'clinical', 'picture', 'is', 'the', 'same', 'and', 'the', 'blood', 'gas', 'at', 'the', 'beginning', 'was', 'similar,', 'something', 'should', 'be', 'done', '(also', 'depending', 'on', 'the', "patient's", 'baseline', 'status,', 'which', 'they', 'do', 'not', 'tell', 'us', 'either).'], ['If', 'we', 'decide', 'to', 'do', 'something,', 'at', 'present', 'we', 'might', 'decide', 'to', 'use', 'ventilation', 'rather', 'than', 'theophylline,', 'although', 'with', '"so', 'little"', 'alteration', 'of', 'pH', '(and', 'even', 'more', 'so', 'if', 'we', 'think', 'that', 'this', 'is', 'a', 'chronic', 'patient', 'who', 'may', 'have', 'a', 'baseline', 'blood', 'gas', 'similar', 'to', 'the', 'one', 'presented', 'to', 'us)', 'it', 'may', 'seem', '"exaggerated".'], ['We', 'have', 'nothing', '"against"', 'theophylline', '(we', 'are', 'not', 'told', 'of', 'any', 'contraindication),', 'but', 'nowadays', 'it', 'is', 'rare', 'to', 'resort', 'to', 'it.'], ['1:', 'Wrong,', 'he', 'is', 'a', '"retentive"', 'patient', 'and', 'increasing', 'O2', 'flow', 'is', 'highly', 'likely', 'to', 'increase', 'hypercapnia', 'and,', 'therefore,', 'acidosis.'], ['2:', 'We', 'will', 'keep', 'this', 'one', 'as', 'correct.'], ['3:', 'It', 'is', 'not', 'a', 'metabolic', 'acidosis,', 'the', 'bicarbonate', 'is', 'not', 'decreased,', 'on', 'the', 'contrary,', 'it', 'is', 'slightly', 'increased', 'trying', 'to', 'compensate', 'the', 'respiratory', 'acidosis.'], ['4:', 'He', 'does', 'not', 'reach', 'respiratory', 'failure', 'by', 'definition', '(pO2', '60),', 'but', 'he', 'has', 'hypercapnia', 'and', 'slight', 'acidosis.'], ['If', 'we', 'knew', 'the', 'first', 'blood', 'gas', 'and', 'she', 'was', 'much', 'worse', '(i.e.', 'she', 'was', 'doing', 'very', 'well),', 'continuing', 'with', 'the', 'same', 'medication', 'would', 'be', 'an', 'option,', 'but', 'this', 'data', 'is', 'missing!!!,', 'in', 'any', 'case', 'it', 'seems', 'to', 'be', 'a', 'trick', 'answer.'], ['5:', 'At', 'present', 'and', '-as', 'already', 'mentioned-', 'taking', 'into', 'account', 'that', 'there', 'is', 'no', 'formal', 'contraindication,', 'it', 'is', 'not', 'usually', 'used.']]

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'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim'], ['O', 'B-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim'], ['O', 'B-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim'], ['O', 'B-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim'], ['O', 'B-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim'], ['O', 'O', 'O'], ['O', 'O', 'O', 'O', 'O', 'O', 'O', 'O', 'O', 'O', 'O', 'O', 'O', 'O', 'O', 'O', 'O', 'O', 'O', 'O', 'O', 'B-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim'], ['B-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'B-Marker', 'B-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'B-Marker', 'B-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim'], ['B-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'O', 'B-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim'], ['B-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'B-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'O', 'O', 'O', 'O', 'O', 'O', 'O', 'O', 'O', 'O', 'O', 'O', 'O', 'O'], ['B-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'B-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise'], ['B-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim'], ['B-Claim', 'I-Claim', 'B-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise'], ['B-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim'], ['B-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'B-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise'], ['B-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim'], ['B-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'B-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'I-Premise', 'O', 'O', 'O', 'O', 'O', 'O', 'O', 'O', 'O', 'O'], ['B-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim', 'I-Claim']]

226_71

[['QUESTION', 'TYPE:', 'CARDIOLOGY'], ['CLINICAL', 'CASE:'], ['An', '82-year-old', 'hypertensive', 'woman', 'on', 'atenolol,', 'hydrochlorothiazide', 'and', 'digoxin.'], ['She', 'comes', 'to', 'the', 'emergency', 'room', 'for', 'atrial', 'fibrillation', 'and', 'is', 'administered', 'IV', 'verapamil.'], ['The', 'ECG', 'showed', 'complete', 'atrioventricular', 'block.'], ['What', 'is', 'the', 'most', 'probable', 'cause', 'of', 'this', 'clinical', 'situation?'], ['1-', 'Digitalis', 'intoxication', 'due', 'to', 'pharmacokinetic', 'interaction', 'with', 'verapamil.'], ['2-', 'Hypokalemia', 'due', 'to', 'administration', 'of', 'thiazide', 'and', 'digoxin.'], ['3-', 'Pharmacodynamic', 'interaction', 'of', 'beta-blocker,', 'digoxin', 'and', 'verapamil.'], ['4-', 'Hypotensive', 'effect', 'of', 'thiazide', 'diuretic.'], ['5-', 'Cardiac', 'arrhythmia', 'due', 'to', 'verapamil.'], ['CORRECT', 'ANSWER:', '3'], ['He', 'already', 'takes', 'two', 'AV', 'node', 'brakers', 'and', 'you', 'add', 'a', 'third,', 'and', 'are', 'you', 'surprised', 'that', 'he', 'gets', 'complete', 'AV', 'block', 'after', 'messing', 'with', 'drugs', 'from', 'different', 'families', 'but', 'same', 'effect', '(pharmacodynamics)?'], ['Three.'], ['And', 'remember', 'that', 'drugs', 'are', 'like', 'drinks', 'when', 'you', 'go', 'to', 'a', 'bar:', "don't", 'mix!']]

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565_148

135_38

[['QUESTION', 'TYPE:', 'ONCOLOGY'], ['CLINICAL', 'CASE:'], ['A', '64-year-old', 'man', 'with', 'Child', 'A', 'liver', 'cirrhosis', 'with', 'no', 'history', 'of', 'decompensation.'], ['After', 'detection', 'of', 'a', 'focal', 'hepatic', 'lesion', 'on', 'screening', 'ultrasound,', 'the', 'study', 'is', 'completed', 'with', 'a', 'thoracoabdominal', 'CT', 'scan.'], ['This', 'scan', 'showed', 'the', 'presence', 'of', '4', 'liver', 'lesions', '(one', 'of', 'them', 'up', 'to', '6', 'cm)', 'with', 'uptake', 'pattern', 'typical', 'of', 'hepatocarcinoma,', 'tumor', 'vascular', 'invasion', 'and', 'a', 'metastasis', 'in', 'the', 'right', 'adrenal', 'gland.'], ['No', 'ascites', 'is', 'observed.'], ['The', 'patient', 'reports', 'only', 'asthenia,', 'but', 'no', 'general', 'syndrome.'], ['The', 'treatment', 'of', 'this', 'patient', 'would', 'be:'], ['1-', 'Symptomatic', 'and', 'supportive', 'treatment,', 'since', 'he', 'presented', 'an', 'advanced', 'hepatocarcinoma', 'with', 'vascular', 'invasion', 'and', 'metastasis.'], ['2-', 'Transarterial', 'chemoembolization', '(TACE),', 'since', 'the', 'treatment', 'increases', 'survival', 'in', 'patients', 'with', 'advanced', 'hepatocarcinoma.'], ['3-', 'Systemic', 'chemotherapy', 'with', 'doxorubicin', 'iv', 'since', 'he', 'presents', 'disseminated', 'disease', 'but', 'he', 'is', 'in', 'good', 'general', 'condition.'], ['4-', 'Treatment', 'with', 'oral', 'sorafenib,', 'since', 'this', 'is', 'a', 'patient', 'with', 'good', 'general', 'condition,', 'Child', 'A', 'and', 'advanced', 'stage', 'hepatocarcinoma', 'BCLC-C.'], ['5-', 'The', 'appropriate', 'treatment', 'is', 'liver', 'transplantation', 'as', 'it', 'is', 'the', 'only', 'procedure', 'that', 'completely', 'eliminates', 'the', 'primary', 'tumor', 'and', 'avoids', 'future', 'complications', 'of', 'cirrhosis.'], ['CORRECT', 'ANSWER:', '4'], ['Comment:', 'The', 'patient', 'presents', 'a', 'good', 'general', 'condition', 'with', 'a', 'recently', 'diagnosed', 'hepatocarcinoma,', 'not', 'giving', 'him', 'any', 'type', 'of', 'treatment', 'other', 'than', 'symptomatic', 'and', 'supportive', 'at', 'this', 'stage', 'would', 'not', 'be', 'the', 'right', 'thing', 'to', 'do.'], ['TACE', 'would', 'not', 'be', 'indicated', 'because', 'of', 'extrahepatic', 'involvement.'], ['Transplantation', 'would', 'also', 'not', 'be', 'done', 'if', 'he', 'has', 'extrahepatic', 'disease.'], ['We', 'are', 'left', 'with', 'answers', '3', 'and', '4,', 'both', 'with', 'systemic', 'treatment', '(indicated', 'because', 'it', 'is', 'metastatic)', 'and', 'the', 'correct', 'answer', 'is', '4,', 'for', 'all', 'the', 'reasons', 'given', 'therein.']]

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556_55

[['QUESTION', 'TYPE:', 'ENDOCRINOLOGY'], ['CLINICAL', 'CASE:'], ['63-year-old', 'diabetic', 'patient', 'whose', 'family', 'physician', 'has', 'requested', 'a', 'blood', 'test', 'to', 'determine', 'vitamin', 'B12', 'levels.What', 'is', 'the', 'antidiabetic', 'drug', 'he', 'is', 'taking', 'that', 'warrants', 'such', 'a', 'request:'], ['1-', 'Gliclazide.'], ['2-', 'Metformin.'], ['3-', 'Repaglinide.'], ['4-', 'Pioglitazone.'], ['5-', 'nan'], ['CORRECT', 'ANSWER:', '2'], ['Metformin', 'is', 'an', 'oral', 'antidiabetic', 'widely', 'used', 'in', 'the', 'treatment', 'of', 'type', '2', 'diabetes', 'mellitus.'], ['The', 'best', 'known', 'side', 'effects', 'are', 'gastrointestinal', 'side', 'effects', 'and', 'lactic', 'acidosis;', 'however,', 'vitamin', 'B', '12', 'malabsorption,', 'is', 'less', 'well', 'known.'], ['A', 'decrease', 'in', 'vitamin', 'B', '12', 'levels', 'is', 'observed', 'in', 'patients', 'treated', 'with', 'metformin.'], ['The', 'mechanism', 'by', 'which', 'this', 'deficit', 'occurs', 'is', 'not', 'clear', 'and', 'it', 'is', 'known', 'to', 'be', 'reversible', 'when', 'treatment', 'is', 'interrupted.']]

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448_148

[['QUESTION', 'TYPE:', 'NEUROSURGERY'], ['CLINICAL', 'CASE:'], ['A', '59-year-old', 'woman', 'with', 'recent', 'onset', 'of', 'epileptic', 'seizures', 'comes', 'to', 'the', 'emergency', 'department.'], ['The', 'examination', 'showed', 'left', 'pyramidal', 'signs', 'and', 'papillary', 'edema.'], ['Brain', 'MRI', 'showed', 'a', 'right', 'hemispheric', 'mass', 'with', 'edema,', 'midline', 'deviation', 'and', 'signs', 'of', 'tentorial', 'herniation.'], ['She', 'reports', 'a', 'headache', 'that', 'has', 'been', 'progressing', 'in', 'intensity', 'for', 'the', 'past', 'week.'], ['Which', 'of', 'the', 'following', 'features', 'associated', 'with', 'headache', 'seems', 'most', 'likely', 'in', 'this', 'patient?'], ['1-', 'Predominance', 'in', 'the', 'morning.'], ['2-', 'It', 'does', 'not', 'change', 'with', 'effort.'], ['3-', 'Photophobia.'], ['4-', 'Sonophobia.'], ['5-', 'nan'], ['CORRECT', 'ANSWER:', '1'], ['They', 'describe', 'a', 'recent', 'diagnosis', 'of', 'cerebral', 'LOE', 'with', 'signs', 'of', 'intracranial', 'hypertension', '(edema,', 'midline', 'deviation,', 'papilledema).'], ['The', 'associated', 'headache', 'is', 'typically', 'morning', 'headache,', 'with', 'increasing', 'ICP', 'values', 'at', 'night.']]

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591_64

[['QUESTION', 'TYPE:', 'OPHTHALMOLOGY'], ['CLINICAL', 'CASE:'], ['A', '68-year-old', 'woman', 'who', 'wears', '+4.00', 'diopter', 'glasses', 'for', 'distance', 'vision', 'in', 'both', 'eyes.'], ['She', 'consults', 'because', 'since', 'a', 'few', 'weeks', 'ago', 'she', 'has', 'been', 'having', 'eye', 'pain', 'with', 'headache', 'and', 'blurred', 'vision', 'at', 'night', 'when', 'she', 'is', 'watching', 'television', 'in', 'twilight.'], ['Which', 'of', 'the', 'following', 'pathologies', 'is', 'she', 'most', 'likely', 'to', 'present?'], ['1-', 'Glaucoma', 'due', 'to', 'primary', 'angular', 'closure.'], ['2-', 'Migraine.'], ['3-', 'Actinic', 'keratitis.'], ['4-', 'Dry', 'eye', 'syndrome.'], ['5-', 'nan'], ['CORRECT', 'ANSWER:', '1'], ['We', 'are', 'presented', 'with', 'a', '68-year-old', 'woman', 'with', 'moderate', 'hyperopia', 'and', 'no', 'history', 'of', 'cataract', 'surgery.'], ['This', 'is', 'not', 'a', 'mere', 'coincidence:', 'the', 'fact', 'that', 'the', 'patient', 'is', 'hyperopic', 'is', 'important,', 'because', 'the', 'eyeballs', 'of', 'hyperopic', 'patients', 'are', 'shorter,', 'with', 'a', 'certain', 'conflict', 'of', 'space', 'in', 'the', 'anterior', 'segment', 'when', 'the', 'crystalline', 'lens', 'undergoes', 'a', 'process', 'of', 'intumescence', 'secondary', 'to', 'age', '(what', 'patients', 'call', 'incipient', 'cataract).'], ['In', 'the', 'clinical', 'case,', 'moreover,', 'the', 'ocular', 'and', 'headache', 'pain', 'occurs', 'in', 'scotopic', 'situations,', 'or', 'in', 'situations', 'of', 'dim', 'ambient', 'lighting,', 'which', 'produces', 'an', 'average', 'mydriasis', 'to', 'optimize', 'the', 'light', 'influx', 'to', 'the', 'eyeball.'], ['It', 'is', 'evident,', 'therefore,', 'that', 'the', 'patient', 'suffers', 'from', 'primary', 'angular', 'closure', 'processes', 'that', 'possibly', 'self-resolve', 'when', 'the', 'triggering', 'situation', 'ceases,', 'and', 'not', 'a', 'true', 'acute', 'glaucoma', 'attack.'], ['But', 'these', 'intermittent', 'angular', 'closures', 'are', 'contemplated', 'within', 'the', 'spectrum', 'of', 'glaucoma', 'due', 'to', 'primary', 'angular', 'closure', '(option', '1', 'correct).'], ['Migraine,', 'not', 'being', 'a', 'Neurology', 'question,', 'can', 'sometimes', 'be', 'a', 'confounder', 'in', 'the', 'usual', 'clinic;', 'however,', 'patients', 'are', 'usually', 'younger,', 'or', 'at', 'least', 'have', 'a', 'clear', 'history', 'of', 'migraine,', 'and,', 'above', 'all,', 'they', 'present', 'symptomatologic', 'worsening', 'with', 'intense', 'sensory', 'stimuli', '(photophobia', 'and', 'phonophobia),', 'but', 'symptoms', 'are', 'not', 'worsened', 'precisely', 'in', 'cases', 'of', 'dim', 'lighting', '(option', '2', 'incorrect).'], ['Actinic', 'keratitis', 'occurs', 'precisely', 'in', 'patients', 'exposed', 'to', 'ultraviolet', 'radiation', 'that', 'is', 'not', 'properly', 'filtered', 'before', 'reaching', 'the', 'cornea;', 'it', 'is', 'typical', 'of', 'welders', '(it', 'is', 'called', "welder's", 'keratitis),', 'skiers', 'and', 'other', 'people', 'with', 'very', 'intense', 'light', 'exposures', 'and', 'without', 'adequate', 'eye', 'protection', '(wrong', 'option', '3).'], ['Dry', 'eye', 'syndrome', 'does', 'not', 'usually', 'produce', 'headache,', 'and', 'ocular', 'discomfort', 'does', 'not', 'go', 'beyond', 'the', 'persistent', 'discomfort', 'that', 'patients', 'might', 'define', 'as', 'pain', 'because', 'of', 'its', 'recently', 'more', 'studied', 'neuropathic', 'component.'], ['Some', 'forms', 'of', 'dry', 'eye', 'may', 'be', 'worse', 'in', 'the', 'evening', 'but', 'others', 'are', 'worse', 'in', 'the', 'morning,', 'and', 'it', 'depends', 'mainly', 'on', 'the', 'frequency', 'of', 'blinking.'], ['In', 'addition,', 'dry', 'eye', 'syndrome', 'is', 'an', 'outdated', 'term;', 'nowadays', 'it', 'is', 'preferred', 'to', 'speak', 'of', 'dry', 'eye', 'disease', '(incorrect', 'option', '4).']]

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291_157

[['QUESTION', 'TYPE:', 'DERMATOLOGY,', 'VENEREOLOGY', 'AND', 'PLASTIC', 'SURGERY'], ['CLINICAL', 'CASE:'], ['An', '8-year-old', 'patient', 'presenting', 'with', 'superficial', 'pustular', 'lesions,', 'erosions', 'and', 'yellowish', 'crusts', 'around', 'the', 'mouth', 'for', 'the', 'last', '3', 'days:'], ['1-', 'Exudative', 'erythema', 'multiforme.'], ['2-', 'Contagious', 'impetigo.'], ['3-', 'Infantile', 'acne.'], ['4-', 'Pustular', 'psoriasis.'], ['5-', 'nan'], ['CORRECT', 'ANSWER:', '2'], ['It', 'is', 'a', 'typical', 'and', 'frequent', 'clinical', 'picture', 'in', 'children.'], ['You', 'are', 'describing', 'a', 'contagious', 'impetigo.'], ['There', 'is', 'not', 'much', 'dispute.'], ['The', 'most', 'frequent', 'causative', 'agent', 'in', 'the', 'bullous', 'form', 'is', 'S.', 'aureus', 'phage', 'II.']]

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213_160

[['QUESTION', 'TYPE:', 'RHEUMATOLOGY'], ['CLINICAL', 'CASE:'], ['A', '75-year-old', 'woman,', 'with', 'menopause', 'at', 'age', '52,', 'with', 'no', 'family', 'or', 'personal', 'history', 'of', 'fracture,', 'diagnosed', 'with', 'temporal', 'arteritis,', 'who', 'is', 'going', 'to', 'start', 'treatment', 'with', 'high-dose', 'prednisone', 'and', 'expects', 'to', 'be', 'treated', 'for', 'at', 'least', 'one', 'year.'], ['The', 'delay', 'of', 'densitometry', '(DXA)', 'in', 'her', 'center', 'is', '4-5', 'months.'], ['Preventive', 'treatment', 'for', 'osteoporosis', 'is', 'considered.'], ['Which', 'of', 'the', 'following', 'is', 'the', 'most', 'appropriate', 'approach?'], ['1-', 'Request', 'DXA', 'and', 'wait', 'for', 'the', 'result.'], ['2-', 'Assess', 'absolute', 'risk', 'of', 'fracture', 'using', 'the', 'FRAX', 'questionnaire', 'without', 'BMD', 'and', 'treat', 'only', 'if', 'it', 'is', 'high.'], ['3-', 'Start', 'treatment', 'with', 'bisphosphonates', 'and', 'vitamin', 'D', '(800', 'IU/day).'], ['4-', 'Administer', 'calcium', 'supplementation', '(1g)', 'and', 'vitamin', 'D', '(800', 'IU/day).'], ['5-', 'Assess', 'for', 'osteopenia', 'on', 'radiographs', 'and', 'treat', 'if', 'present.'], ['CORRECT', 'ANSWER:', '4'], ['In', 'the', 'data', 'you', 'provide', 'there', 'are', 'no', 'clinical', 'risk', 'factors', 'for', 'osteoporosis', 'prior', 'to', 'the', 'current', 'disease.'], ['Since', 'a', 'prolonged', 'and', 'high-dose', 'prednisone', 'regimen', 'will', 'be', 'established,', 'it', 'is', 'advisable,', 'in', 'addition', 'to', 'the', 'non-pharmacological', 'preventive', 'measures,', 'to', 'initiate', 'treatment', 'in', 'any', 'case', 'to', 'minimize', 'the', 'secondary', 'loss', 'of', 'bone', 'mass', 'that', 'occurs', 'with', 'the', 'administration', 'of', 'glucocorticoids', '(and,', 'above', 'all,', 'in', 'the', 'first', 'months).'], ['Therefore,', 'and', 'for', 'this', 'reason', 'alone,', 'options', '1,', '2', 'and', '5', 'would', 'be', 'discarded', '(the', 'three', 'of', 'them', 'have', 'another', 'conditioning', 'factor).'], ['In', 'this', 'context,', 'and', 'in', 'the', 'case', 'of', 'a', 'person', 'over', '65', 'years', 'of', 'age,', 'an', 'appropriate', 'attitude', 'would', 'be', 'to', 'administer', 'calcium', 'supplements', '(corticosteroids', 'are', 'osteopenizantes', 'because', 'they', 'produce,', 'among', 'other', 'mechanisms,', 'a', 'negative', 'balance', 'of', 'this', 'element)', 'and', 'vitamin', 'D.'], ['The', 'option', 'of', 'associating', 'a', 'bisphosphonate', 'could', 'also', 'be', 'considered,', 'but', 'calcium', 'supplementation', 'is', 'missing', 'in', 'proposal', '3.']]

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442_100

[['QUESTION', 'TYPE:', 'GYNECOLOGY', 'AND', 'OBSTETRICS'], ['CLINICAL', 'CASE:'], ['34-year-old', 'woman', 'who', 'consults', 'for', 'repeated', 'coitorragia.'], ['She', 'brings', 'a', 'cytology', 'with', 'a', 'high', 'grade', 'intraepithelial', 'lesion', '(U-SIL).'], ['Subsequently,', 'colposcopy', 'and', 'biopsy', 'were', 'performed', 'on', 'a', 'mosaic', 'area', 'and', 'histology', 'showed', 'a', 'focus', 'of', 'invasive', 'squamous', 'cell', 'carcinoma', 'of', '2', 'mm', 'in', 'length.'], ['Which', 'therapeutic', 'option', 'is', 'the', 'most', 'appropriate', 'for', 'this', 'patient?'], ['1-', 'Conization.'], ['2-', 'Total', 'hysterectomy', 'without', 'adnexectomy.'], ['3-', 'Pelvic', 'radiotherapy', 'with', 'curative', 'intent.'], ['4-', 'Repeat', 'a', 'more', 'extensive', 'biopsy.'], ['5-', 'nan'], ['CORRECT', 'ANSWER:', '1'], ['According', 'to', 'the', 'SEGO:', '"Excise', 'the', 'entire', 'lesion', 'so', 'that', 'it', 'can', 'be', 'evaluated', 'histologically.'], ['It', 'involves', 'excision', 'of', 'the', 'entire', 'transformation', 'zone.'], ['In', 'general,', 'the', 'excision', 'should', 'be', 'adapted', 'to', 'the', 'size', 'and', 'characteristics', 'of', 'the', 'lesion.'], ['Three', 'types', 'of', 'excision', 'are', 'distinguished', 'according', 'to', 'the', 'presence', 'of', 'the', 'endocervical', 'component', 'of', 'the', 'lesion.'], ['Excision', 'type', '1', '(applicable', 'in', 'cases', 'with', 'transformation', 'zone', 'type', '1,', 'in', 'which', 'the', 'diathermic', 'loop', 'should', 'not', 'include', 'endocervical', 'canal', 'or', 'exceed', '8', 'mm', 'in', 'depth),', 'excision', 'type', '2', '(indicated', 'in', 'transformation', 'zones', 'type', '2,', 'involves', 'resecting', 'a', 'small', 'part', 'of', 'endocervical', 'canal', 'visible', 'by', 'colposcopy)', 'and', 'excision', 'type', '3', '(indicated', 'in', 'transformation', 'zones', 'type', '3,', 'includes', 'part', 'of', 'endocervical', 'epithelium)".'], ['When', 'they', 'speak', 'of', 'excision,', 'it', 'is', 'synonymous', 'with', 'conization;', 'as', 'the', 'lesion', 'is', 'less', 'than', '8mm', 'deep,', 'this', 'is', 'the', 'indicated', 'treatment.']]

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491_106

[['QUESTION', 'TYPE:', 'HEMATOLOGY'], ['CLINICAL', 'CASE:'], ['65-year-old', 'woman', 'referred', 'to', 'the', 'ED', 'for', 'fever', 'and', 'alterations', 'in', 'the', 'CBC:', 'hemoglobin', '11.4', 'g/dL,', 'leukocytes', '0.86', 'x103/μL,(neutrophils', '41.9', '%,', 'lymphocytes', '55.8', '%),platelets', '48.0', 'x103/μL,', 'fibrinogen', '118', 'mg/dL,D-dimer', '20.2', 'μg/mL.'], ['A', 'bone', 'marrow', 'examination', 'was', 'performed', 'and', 'the', 'patient', 'was', 'diagnosed', 'with', 'acute', 'leukemia', 'with', 't(15;17)', 'in', '60%', 'of', 'the', 'cells.'], ['Which', 'of', 'the', 'following', 'answers', 'is', 'correct?'], ['1-', 'If', 'asymptomatic,', 'transretinoic', 'acid', '(ATRA)', 'will', 'be', 'initiated', 'and', 'controls', 'in', 'day', 'hospital', 'will', 'be', 'recommended.'], ['2-', 'Treatment', 'with', 'arsenic', 'trioxide,', 'ATRA', 'and', 'supportive', 'therapy', 'will', 'be', 'initiated.'], ['3-', 'It', 'is', 'a', 'myeloblastic', 'leukemia', 'type', 'M3,', 'so', 'chemotherapy', 'and', 'heparin', 'treatment', 'will', 'be', 'initiated', 'to', 'control', 'disseminated', 'intravascular', 'coagulation.'], ['4-', 'Antibiotic', 'treatment', 'should', 'be', 'started.', 'When', 'the', 'fever', 'disappears,', 'leukemia', 'treatment', 'should', 'be', 'started.'], ['5-', 'nan'], ['CORRECT', 'ANSWER:', '2'], ['I', 'think', 'this', 'is', 'a', 'very', 'nice', 'question.'], ['There', 'is', 'no', 'doubt', 'about', 'the', 'diagnosis.'], ['Because', 'if', 'you', "don't", 'know', 'the', 'translocation,', 'nothing', 'happens...', 'the', 'answers', 'give', 'you', 'the', 'diagnosis.'], ['Now', "it's", 'time', 'to', 'find', 'out', 'how', 'acute', 'promyelocytic', 'leukemia', 'is', 'currently', 'treated', '(ATRA', 'aside...', 'which', "I'm", 'sure', 'you', 'know).'], ['As', 'of', '2017,', 'the', 'PETHEMA', 'protocol', 'for', 'APL', 'in', 'low', 'to', 'intermediate', 'risk', 'patients', '(and/or', 'over', '70', 'years', 'of', 'age)', 'is', 'ATO+ATRA.'], ['In', 'high', 'risk', 'patients,', 'it', 'is', 'treated', 'with', 'ATRA+chemotherapy.'], ['I', "don't", 'think', 'they', 'want', 'you', 'to', 'know', 'how', 'risk', 'is', 'established', 'in', 'promielos,', 'but', 'it', 'is', 'based', 'on', 'leukocyte', 'and', 'platelet', 'counts.'], ['In', 'this', 'case,', 'it', "doesn't", 'score', 'anything', 'for', 'the', 'score', 'since', 'you', 'have', '<10,000', 'leukocytes', 'and', '>40,000', 'platelets.'], ['That', 'is,', 'it', 'is', 'a', 'low', 'risk.'], ['Correct', 'answer', '2.'], ['Perhaps', 'some', 'people', 'have', 'been', 'confused', 'by', 'option', '3.'], ['One', 'of', 'the', 'main', 'causes', 'of', 'mortality', 'in', 'the', 'induction', 'of', 'a', 'promyelocyte', 'is', 'coagulopathy,', 'but', 'option', '3', 'is', 'totally', 'incorrect.'], ['We', 'could', 'only', 'mess', 'things', 'up', 'even', 'more', 'by', 'putting', 'heparin!!!!'], ['I', "don't", 'know', 'what', 'they', 'are', 'explaining', 'right', 'now', 'in', 'the', 'academies,', 'but', 'it', 'is', 'clear', 'that', 'they', 'wanted', 'you', 'to', 'know', 'that', 'many', 'promyelocytes,', 'since', '3', 'little', 'years', 'ago,', 'are', 'not', 'treated', 'with', 'chemotherapy.']]

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277_226

[['QUESTION', 'TYPE:', 'DIGESTIVE', 'TRACT'], ['CLINICAL', 'CASE:'], ['In', 'a', 'colon', 'cancer', 'screening', 'program,', 'a', '52-year-old', 'patient', 'undergoes', 'a', 'colonoscopy.'], ['The', 'entire', 'colon', 'is', 'normal', 'except', 'for', 'the', 'finding', 'of', 'a', '2', 'cm', 'pedunculated', 'polyp', 'in', 'the', 'sigma', 'which', 'is', 'removed', 'with', 'a', 'diathermy', 'loop.'], ['The', 'anatomopathological', 'result', 'indicates', 'that', 'there', 'is', 'a', 'carcinoma', 'in', 'situ', 'limited', 'to', 'the', 'head', 'of', 'the', 'polyp.'], ['She', 'has', 'a', 'thoracoabdominal', 'CT', 'scan', 'reported', 'as', 'normal.'], ['Indicate', 'the', 'correct', 'course', 'of', 'action.'], ['1-', 'Segmental', 'resection', 'of', 'the', 'affected', 'colon.'], ['2-', 'Periodic', 'endoscopic', 'surveillance.'], ['3-', 'Local', 'resection', 'of', 'the', 'base', 'of', 'the', 'polyp.'], ['4-', 'Sigmoidectomy', 'plus', 'lymphadenectomy.'], ['5-', 'nan'], ['CORRECT', 'ANSWER:', '2'], ['Carcinoma', 'in', 'situ', 'is', 'delimited', 'by', 'the', 'basement', 'membrane,', 'i.e.', 'it', 'is', 'not', 'invasive', 'yet,', 'and', 'therefore', 'the', 'treatment', 'is', 'polypectomy,', 'which', 'is', 'already', 'done.'], ['Subsequently,', 'an', 'endoscopic', 'follow-up', '(with', 'biopsies)', 'should', 'be', 'performed', 'at', 'an', 'interval', 'of', '3', 'to', '6', 'months', 'depending', 'on', 'the', "patient's", 'history,', 'age', 'and', 'concomitant', 'pathologies.']]

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155_83

[['QUESTION', 'TYPE:', 'RHEUMATOLOGY'], ['CLINICAL', 'CASE:'], ['A', '62-year-old', 'man', 'with', 'a', 'history', 'of', 'arterial', 'hypertension', 'under', 'treatment', 'with', 'captopril,', 'duodenal', 'ulcer', 'and', 'uric', 'acid', 'urolithiasis.'], ['He', 'consults', 'for', 'typical', 'podagra', 'crisis', 'similar', 'to', 'others', 'presented', 'in', 'the', 'last', 'two', 'years.'], ['Examination', 'showed', 'tophi', 'in', 'both', 'pinnae.'], ['Analyses', 'show', 'uric', 'acid', '10.1', 'mg/dl,', 'creatine', '1.5', 'mg/dl.'], ['Indicate', 'which', 'of', 'the', 'following', 'answers', 'is', 'FALSE', 'in', 'relation', 'to', 'his', 'possible', 'treatment', 'with', 'allopurinol.'], ['1-', 'Its', 'use', 'is', 'second', 'choice', 'when', 'uricosurics', 'have', 'failed.'], ['2-', 'Its', 'prolonged', 'use', 'is', 'practically', 'obligatory', 'because', 'there', 'are', 'tophi.'], ['3-', 'Its', 'introduction', 'should', 'be', 'delayed', 'until', 'the', 'current', 'attack', 'has', 'resolved', 'with', 'anti-inflammatory', 'drugs', 'or', 'colchicine.'], ['4-', 'Its', 'introduction', 'should', 'be', 'gradual', 'up', 'to', 'a', 'dose', 'that', 'achieves', 'a', 'uricemia', 'below', '6', 'mg/dL.'], ['5-', 'In', 'the', 'first', 'months', 'of', 'treatment', 'it', 'is', 'advisable', 'to', 'associate', 'low', 'doses', 'of', 'colchicine', 'to', 'prevent', 'new', 'attacks.'], ['CORRECT', 'ANSWER:', '1'], ['Allopurinol', 'is', 'always', 'the', 'treatment', 'of', 'choice,', 'especially', 'in', 'the', 'case', 'of', 'tophaceous', 'gout.'], ['Moreover,', 'in', 'this', 'case,', 'uricosuric', 'acid', 'could', 'worsen', 'urolithiasis', 'by', 'increasing', 'uricosuria', '(sorry', 'for', 'the', 'redundancy...).']]

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373_86

[['QUESTION', 'TYPE:', 'NEUROLOGY'], ['CLINICAL', 'CASE:'], ['We', 'are', 'referred', 'from', 'ophthalmology', 'to', 'a', '31-year-old', 'man', 'who', 'consulted', 'for', 'loss', 'of', 'vision', 'and', 'progressive', 'headache.'], ['Physical', 'examination', 'showed', 'temporal', 'hemianopsia', 'and', 'pituitary', 'MRI', 'showed', 'a', '35', 'x', '30', 'x', '20', 'mm', 'turnoration', 'compressing', 'chiasm', 'and', 'cavernous', 'sinus.'], ['The', 'results', 'of', 'the', 'functional', 'study', 'are', 'cortisol', '14', 'microg/dL,', 'TSH', '1.4', 'microU/ml,', 'T4L', '1.2', 'ng/dL,', 'prolactin', '480', 'microg/L', '(vn', '<', '15),', 'testosterone', '160', 'ng/dL', '(vn', '300-1200),', 'FSH', '1.2', 'U/I.,', '(vn', '5-15)', 'and', 'LH', '2', 'U/L', '(vn', '3-15).'], ['What', 'is', 'the', 'initial', 'therapeutic', 'approach?'], ['1-', 'Dopaminergic', 'agonists.'], ['2-', 'Transsphenoidal', 'surgery.'], ['3-', 'External', 'radiotherapy', 'or', 'radiosurgery.'], ['4-', 'Treatment', 'of', 'hypogonadotropic', 'hypogonadism', 'with', 'testosterone.'], ['5-', 'nan'], ['CORRECT', 'ANSWER:', '1'], ['From', 'what', 'is', 'described', 'it', 'is', 'a', 'macroprolactinoma', 'as', 'it', 'is', 'a', 'pituitary', 'tumor', 'of', 'more', 'than', 'one', 'centimeter,', 'which', 'secretes', 'prolactin', 'and', 'with', 'an', 'insufficiency', 'of', 'the', 'rest', 'of', 'pituitary', 'hormones.'], ['The', 'first', 'line', 'treatment', 'of', 'choice', 'is', 'dopaminergic', 'agonists,', 'although', 'when', 'the', 'visual', 'field', 'is', 'affected,', 'surgery', 'may', 'be', 'chosen.'], ['In', 'this', 'case,', 'the', 'cavernous', 'sinus', 'is', 'pressured', 'by', 'the', 'mass,', 'so', 'the', 'surgical', 'risk', 'increases.'], ['Therefore,', 'in', 'this', 'particular', 'case,', 'the', 'surgical', 'option', 'seems', 'more', 'risky.'], ['Taking', 'this', 'into', 'account', 'and', 'the', 'fact', 'that', 'it', 'is', 'a', 'tumor', 'that', 'produces', 'high', 'levels', 'of', 'prolactin,', 'which', 'indicates', 'that', 'it', 'probably', 'responds', 'to', 'pharmacological', 'blockade,', 'the', 'most', 'appropriate', 'option', 'would', 'be', 'option', '1,', 'treatment', 'with', 'dopaminergic', 'agonists.']]

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523_124

[['QUESTION', 'TYPE:', 'INFECTIOUS', 'DISEASES'], ['CLINICAL', 'CASE:'], ['A', '45-year-old', 'patient', 'was', 'diagnosed', 'with', 'HIV', 'infection', 'three', 'months', 'ago,', 'presenting', 'at', 'that', 'time', 'with', 'CD4', '45', 'lymphocytes/µl', 'and', 'an', 'HIV-1', 'viral', 'load', 'of', '500,000', 'copies/ml.'], ['At', 'that', 'time', 'he', 'had', 'a', 'negative', 'Mantoux', 'test.'], ['He', 'started', 'treatment', 'with', 'an', 'integrase', 'inhibitor', 'and', 'two', 'reverse', 'transcriptase', 'inhibitors,', 'and', 'at', 'one', 'month', 'he', 'had', '25,000', 'copies', 'and', 'CD4', 'had', 'risen', 'to', '80/µL.'], ['She', 'consulted', 'for', 'presenting', 'a', 'picture', 'of', 'cervical', 'lymphadenopathy', 'and', 'fever', 'of', 'two', 'weeks', 'of', 'evolution.'], ['The', 'puncture', 'of', 'one', 'of', 'the', 'lymph', 'nodes', 'showed', 'isolated', 'acid-fast', 'bacilli', 'and', 'epithelioid', 'granulomas:'], ['1-', 'It', 'is', 'a', 'lymph', 'node', 'tuberculosis', 'related', 'to', 'an', 'incomplete', 'immunologic', 'recovery.'], ['2-', 'Treatment', 'failure', 'and', 'it', 'is', 'an', 'opportunistic', 'infection.'], ['3-', 'This', 'is', 'an', 'opportunistic', 'infection', 'unmasked', 'within', 'a', 'picture', 'of', 'immune', 'reconstitution.'], ['4-', 'A', 'negative', 'Mantoux', 'test', 'rules', 'out', 'tuberculosis.'], ['5-', 'nan'], ['CORRECT', 'ANSWER:', '3'], ['We', 'are', 'dealing', 'with', 'a', 'patient', 'with', 'HIV', 'infection', 'in', 'a', 'situation', 'of', 'severe', 'immunosuppression', '(<50', 'CD4+)', 'and', 'a', 'very', 'high', 'viral', 'load,', 'who', 'has', 'followed', 'the', 'expected', 'evolution', 'from', 'the', 'immunovirological', 'point', 'of', 'view', 'after', 'the', 'start', 'of', 'treatment', '(after', '12', 'weeks,', 'the', 'viral', 'load', 'has', 'ostensibly', 'decreased', '-', 'answer', '2', 'would', 'not', 'be', 'correct,', 'remember', 'that', 'it', 'is', 'desirable', 'that', 'it', 'becomes', 'negative', '24', 'weeks', 'after', 'the', 'start', 'of', 'treatment,', 'although', 'in', 'patients', 'with', 'higher', 'CV', 'like', 'ours,', 'it', 'could', 'take', 'longer', '-', 'and', 'the', 'CD4+', 'count', 'has', 'begun', 'to', 'rise).'], ['A', 'negative', 'Mantoux', 'test', 'does', 'not', 'rule', 'out', 'tuberculosis', '(incorrect', 'answer', '4),', 'since', 'in', 'patients', 'with', 'severe', 'immunosuppression', 'it', 'can', 'give', 'false', 'negatives.'], ['The', 'diagnosis', 'of', 'lymph', 'node', 'tuberculosis', 'is', 'immediate', 'when', 'detecting', '"isolated', 'acid-fast', 'bacilli', 'and', 'epithelioid', 'granulomas"', 'in', 'the', 'puncture', 'of', 'one', 'of', 'the', 'lymph', 'nodes,', 'however:', 'considering', 'the', 'patient', 'profile,', 'this', 'process', 'will', 'have', 'been', 'clinically', 'unmasked', 'during', 'the', 'immunological', 'reconstitution', 'and', 'the', 'infection', 'is', 'not', 'the', 'consequence', 'of', 'an', 'incomplete', 'immunological', 'recovery', '(correct', 'answer', 'number', '3).']]

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417_76

[['QUESTION', 'TYPE:', 'GENERAL', 'SURGERY'], ['CLINICAL', 'CASE:'], ['78-year-old', 'woman', 'with', 'dementia', 'and', 'institutionalized', 'is', 'brought', 'by', 'her', 'caregivers', 'for', 'significant', 'abdominal', 'pain', 'with', 'deterioration', 'of', 'general', 'condition', 'and', 'abdominal', 'distension.'], ['CBC', 'shows', 'leukocytosis,', 'elevated', 'hematocrit,', 'renal', 'failure', 'and', 'metabolic', 'acidosis.'], ['ECG', 'shows', 'atrial', 'fibrillation.'], ['Abdominal', 'tomography', 'shows', 'edematous', 'small', 'bowel', 'loops,', 'with', 'intestinal', 'and', 'portal', 'accumulation.'], ['The', 'most', 'probable', 'diagnosis', 'is:'], ['1-', 'Perforation', 'of', 'gastric', 'or', 'duodenal', 'ulcus.'], ['2-', 'Biliary', 'leak.'], ['3-', 'Obstructive', 'neoplasia', 'of', 'the', 'sigma', 'with', 'perforation.'], ['4-', 'Mesenteric', 'ischemia.'], ['5-', 'nan'], ['CORRECT', 'ANSWER:', '4'], ['Typical', 'case', 'of', 'acute', 'mesenteric', 'ischemia,', 'which', 'should', 'be', 'suspected', 'in', 'elderly', 'patients', 'with', 'abdominal', 'pain', 'and', 'distension', 'of', 'sudden', 'onset,', 'diarrhea', 'or', 'vomiting', 'and', 'who', 'present', 'cardiovascular', 'risk', 'factors,', 'especially', 'emboligenic', 'heart', 'disease.'], ['In', 'this', 'case', 'we', 'are', 'given', 'characteristic', 'biochemical', 'data', '(leukocytosis,', 'metabolic', 'acidosis', 'due', 'to', 'lactic', 'acid,', 'hemoconcentration', 'due', 'to', 'loss', 'of', 'fluid', 'to', 'the', 'third', 'space...)', 'and', 'imaging', 'tests', '(dilated', 'loops,', 'pneumatosis,', 'gas', 'at', 'portal', 'level...)', 'suggestive', 'of', 'mesenteric', 'ischemia.']]

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403_135

[['QUESTION', 'TYPE:', 'OPHTHALMOLOGY', '(ECTOPIC)'], ['CLINICAL', 'CASE:'], ['A', '25-year-old', 'patient,', 'during', 'a', 'tennis', 'match,', 'has', 'severe', 'pain', 'in', 'his', 'neck', 'and', 'left', 'eye.'], ['The', 'next', 'morning', 'he', 'wakes', 'up', 'with', 'a', 'feeling', 'of', 'gait', 'instability', 'and', 'has', 'palpebral', 'ptosis', 'of', 'the', 'left', 'eye', 'and', 'anisocoria,', 'with', 'the', 'left', 'pupil', 'being', 'smaller', 'than', 'the', 'right.'], ['The', 'patient', 'maintains', 'good', 'visual', 'acuity,', 'where', 'would', 'you', 'most', 'likely', 'locate', 'the', 'lesion?'], ['1-', 'III', 'cranial', 'nerve.'], ['2-', 'Optic', 'chiasm.'], ['3-', 'Upper', 'cervical', 'ganglion.'], ['4-', 'Spinal', 'cord.'], ['5-', 'nan'], ['CORRECT', 'ANSWER:', '3'], ['Claude-Bernard-Horner', 'syndrome', 'is', 'an', 'old', 'acquaintance', 'of', 'the', 'MIR', 'exam.'], ['We', 'do', 'not', 'see', 'it', 'daily', 'in', 'clinical', 'practice,', 'but', 'it', 'appears', 'in', 'many', 'exams.'], ['Characteristic', 'is', 'upper', 'eyelid', 'ptosis', 'and', 'miosis', 'of', 'that', 'eye.'], ['This', 'occurs', 'due', 'to', 'a', 'deficit', 'of', 'sympathetic', 'innervation', 'of', 'the', 'orbital', 'territory.'], ['The', 'sympathetic', 'nervous', 'system', 'innervates', 'the', 'Müller', 'muscle,', 'which', 'is', 'an', 'accessory', 'muscle', 'to', 'the', 'levator', 'of', 'the', 'upper', 'eyelid.'], ['If', 'the', 'Müller', 'ceases', 'to', 'function,', 'the', 'eyelid', 'descends', 'slightly.'], ['It', 'also', 'innervates', 'the', 'iris', 'dilator', 'muscle.'], ['Therefore,', 'the', 'sphincter', 'muscle,', 'its', 'antagonist,', 'is', 'unopposed', 'and', 'the', 'balance', 'of', 'the', 'pupil', 'shifts', 'toward', 'miosis.'], ['It', 'explains', 'ptosis', 'and', 'miosis', 'of', 'the', 'left', 'eye,', 'so', 'we', 'suspect', "Horner's", 'in', 'that', 'eye.'], ['She', 'also', 'describes', 'what', 'may', 'have', 'happened:', 'after', 'a', 'possible', 'sudden', 'movement', 'while', 'playing', 'tennis,', 'she', 'has', 'neck', 'pain', 'and', 'a', "Horner's."], ['We', 'should', 'suspect', 'an', 'aneurysm.'], ['We', 'should', 'suspect', 'a', 'dissecting', 'carotid', 'aneurysm,', 'which', 'is', 'one', 'of', 'the', 'best', 'known', '(and', 'most', 'serious)', 'causes', 'of', 'an', 'acquired', "Horner's", 'syndrome.'], ['The', 'superior', 'cervical', 'ganglion', 'is', 'a', 'ganglion', 'of', 'the', 'sympathetic', 'nervous', 'system', 'located', 'in', 'the', 'sheath', 'of', 'the', 'carotid', 'artery,', 'and', 'at', 'this', 'level', 'it', 'has', 'been', 'affected.'], ['We', 'can', 'also', 'try', 'to', 'get', 'this', 'answer', 'right', 'by', 'ruling', 'out.'], ['An', 'alteration', 'of', 'the', 'III', 'cranial', 'nerve', 'can', 'produce', 'ptosis,', 'but', 'the', 'pupil,', 'if', 'affected,', 'should', 'be', 'in', 'mydriasis.'], ['And', 'damage', 'to', 'the', 'third', 'cranial', 'nerve', 'should', 'also', 'produce', 'some', 'type', 'of', 'ophthalmoplegia,', 'with', 'diplopia.'], ['An', 'involvement', 'of', 'the', 'optic', 'chiasm', 'would', 'produce', 'a', 'bilateral', 'loss', 'of', 'vision', '(probably', 'a', 'bitemporal', 'hemianopsia).'], ['We', 'are', 'told', 'in', 'the', 'statement', 'that', 'he', 'maintains', 'good', 'visual', 'acuity.'], ['On', 'the', 'other', 'hand,', 'there', 'would', 'also', 'be', 'no', 'ptosis', 'or', 'anisocoria.'], ['And', 'finally,', 'an', 'alteration', 'of', 'the', 'medulla', 'oblongata', 'would', 'produce', 'different', 'neurological', 'symptoms', 'not', 'described,', 'and', 'there', 'should', 'be', 'no', 'ptosis', 'or', 'pupillary', 'alterations,', 'because', 'the', 'third', 'pair', 'is', 'located', 'in', 'the', 'midbrain', 'and', 'the', 'sympathetic', 'nuclei', 'in', 'the', 'spinal', 'cord.']]

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42_150

[['QUESTION', 'TYPE:', 'PEDIATRICS'], ['CLINICAL', 'CASE:'], ['A', 'one-and-a-half', 'year', 'old', 'boy', 'comes', 'to', 'the', 'emergency', 'room', 'with', 'abdominal', 'pain', 'and', 'jaundice.'], ['On', 'examination,', 'an', 'abdominal', 'mass', 'is', 'palpated.'], ['An', 'ultrasound', 'shows', 'the', 'presence', 'of', 'a', 'common', 'bile', 'duct', 'cyst.'], ['What', 'therapeutic', 'approach', 'should', 'we', 'adopt?'], ['1-', 'A', 'percutaneous', 'puncture', 'for', 'peritoneal', 'lavage', 'will', 'be', 'performed', 'to', 'verify', 'that', 'the', 'cyst', 'contains', 'bile', 'in', 'order', 'to', 'leave', 'a', 'drainage', 'to', 'improve', 'the', 'abdominal', 'pain.'], ['2-', 'An', 'exploratory', 'laparotomy', 'will', 'be', 'indicated', 'and', 'a', 'radical', 'resection', 'of', 'the', 'entire', 'biliary', 'tract', 'will', 'be', 'performed', 'to', 'replace', 'it', 'with', 'a', 'loop', 'of', 'intestine.'], ['3-', 'A', 'laparotomy', 'will', 'be', 'indicated', 'to', 'drain', 'the', 'cyst', 'and', 'when', 'the', 'dilatation', 'remits', 'the', 'drainage', 'will', 'be', 'removed.'], ['4-', 'A', 'cholangio-resonance', 'will', 'be', 'performed', 'to', 'delimit', 'the', 'cyst', 'and', 'a', 'laparotomy', 'will', 'be', 'indicated', 'for', 'cyst', 'resection', 'and', 'anastomosis', 'of', 'the', 'biliary', 'tract.'], ['5-', 'A', 'HIDA', 'gammagraphic', 'study', 'is', 'necessary', 'to', 'delimit', 'the', 'cyst', 'and', 'to', 'be', 'able', 'to', 'perform', 'percutaneous', 'drainage', 'safely.'], ['CORRECT', 'ANSWER:', '4'], ['The', 'correct', 'answer', 'is', '4.'], ['A', 'common', 'bile', 'duct', 'cyst', 'is', 'a', 'congenital', 'pathology', 'that', 'usually', 'presents', 'clinically', 'beyond', 'the', 'neonatal', 'period.'], ['It', 'is', 'appropriate', 'to', 'have', 'a', 'quality', 'image', 'that', 'delimits', 'the', 'lesion', 'in', 'order', 'to', 'decide', 'the', 'surgical', 'approach.']]

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445_233

[['QUESTION', 'TYPE:', 'GYNECOLOGY', 'AND', 'OBSTETRICS'], ['CLINICAL', 'CASE:'], ['45-year-old', 'woman.'], ['Two', 'previous', 'pregnancies', 'with', 'normal', 'deliveries', '(G2PN2).'], ['Heavy', 'menstrual', 'bleeding', 'for', 'approximately', '1', 'year.'], ['Ultrasound', 'shows', 'a', '2', 'cm', 'subserosal', 'myoma', 'that', 'has', 'been', 'stable', 'for', 'several', 'years.'], ['Endometrial', 'biopsy', 'was', 'performed', 'and', 'it', 'was', 'normal.'], ['The', 'patient', 'has', 'hemoglobin', '10', 'g/dL', 'despite', 'oral', 'ferrotherapy', 'and', 'the', 'amount', 'of', 'menstrual', 'flow', 'has', 'not', 'decreased', 'despite', 'treatment', 'with', 'tranexamic', 'acid', 'and', 'mefenamic', 'acid.'], ['Which', 'of', 'the', 'following', 'is', 'the', 'treatment', 'of', 'first', 'choice', 'in', 'this', 'patient?'], ['1-', 'Total', 'hysterectomy', 'preserving', 'appendages.'], ['2-', 'Combined', 'oral', 'contraceptives.'], ['3-', 'Endometrial', 'ablation.'], ['4-', 'Levonorgestrel', 'IUD.'], ['5-', 'nan'], ['CORRECT', 'ANSWER:', '4'], ['According', 'to', 'the', 'SEGO,', 'in', 'perimenopausal', 'women', 'with', 'heavy', 'and/or', 'prolonged', 'menstrual', 'bleeding', 'who', 'require', 'contraception,', 'the', 'levonorgestrel', 'IUD', '(also', 'called', 'MIRENA', 'IUD)', 'is', 'the', 'first', 'option.']]

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511_152

[['QUESTION', 'TYPE:', 'DIGESTIVE'], ['CLINICAL', 'CASE:'], ['A', '79-year-old', 'hypertensive', 'woman', 'on', 'treatment', 'with', 'olmesartan', 'comes', 'for', 'consultation', 'for', 'watery', 'diarrhea', 'of', '4', 'to', '6', 'stools', 'per', 'day', 'for', 'the', 'past', 'two', 'months.'], ['Three', 'months', 'ago', 'she', 'was', 'treated', 'with', 'nonsteroidal', 'anti-inflammatory', 'drugs', 'for', '3', 'weeks', 'for', 'lumbosciatica.'], ['Gastroscopy', 'and', 'colonoscopy', 'were', 'performed,', 'both', 'without', 'macroscopic', 'alterations.'], ['Duodenal', 'biopsies', 'were', 'normal,', 'while', 'colon', 'biopsies', 'showed', 'a', 'chronic', 'inflammatory', 'infiltrate', 'of', 'the', 'lamina', 'propria', 'with', 'an', 'irregular', 'band', 'of', 'collagen', 'immediately', 'below', 'the', 'mucosal', 'surface', 'epithelium', 'with', 'a', 'thickness', 'greater', 'than', '10', 'mm', 'and', 'a', 'number', 'of', 'intraepithelial', 'lymphocytes', '>20', 'per', '100', 'epithelial', 'cells.'], ['Which', 'is', 'the', 'most', 'likely', 'diagnosis?'], ['1-', 'Microscopic', 'colitis.'], ['2-', 'Enteropathy', 'due', 'to', 'NSAIDs.'], ['3-', 'Olmesartan-associated', 'enteropathy.'], ['4-', 'Irritable', 'bowel', 'syndrome.'], ['5-', 'nan'], ['CORRECT', 'ANSWER:', '1'], ['The', 'diagnostic', 'criteria', 'for', 'microscopic', 'colitis', 'are:', 'a)Chronic', 'or', 'intermittent', 'non-bloody', 'watery', 'diarrhea', 'b)Colonic', 'mucosa', 'assessed', 'by', 'colonoscopy', 'macroscopically', 'normal', 'or', 'near', 'normal', 'c)Characteristic', 'histopathological', 'findings.'], ['In', 'our', 'case,', 'the', 'patient', 'presents', 'findings', 'compatible', 'with', 'collagenous', 'colitis', '(band', 'of', 'collagen', 'underlying', 'the', 'epithelium', 'greater', 'than', '10', 'microns)', 'and', 'lymphocytic', '(more', 'than', '20', 'intraepithelial', 'lymphocytes).'], ['The', 'treatment', 'of', 'this', 'pathology', 'is', 'topical', 'corticosteroids', 'with', 'low', 'oral', 'bioavailability', '(mainly', 'budesonide).'], ['Olmesartan', 'enteropathy', 'produces', 'a', 'picture', 'similar', 'to', 'celiac', 'disease', 'and', 'is', 'characterized', 'by', 'duodenal', 'biopsy', 'with', 'villous', 'atrophy,', 'mucosal', 'inflammation', 'with', 'increased', 'intraepithelial', 'lymphocytes', 'and', 'cryptitis.'], ['In', 'this', 'case', 'a', 'normal', 'duodenal', 'biopsy', 'is', 'described,', 'but', 'it', 'would', 'be', 'interesting', 'to', 'keep', 'the', 'concept', 'for', 'future', 'examinations.']]

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33_65

[['QUESTION', 'TYPE:', 'NEUROLOGY', 'AND', 'NEUROSURGERY'], ['CLINICAL', 'CASE:'], ['A', '64-year-old', 'man,', 'diagnosed', 'with', 'myasthenia', 'gravis', '1', 'year', 'ago,', 'treated', 'with', 'low-dose', 'steroids', '(3', 'mg/day', 'of', 'deflazacort)', 'and', 'anticholinesterase', 'drugs,', 'asymptomatic', 'for', '6', 'months,', 'consults', 'for', 'mild', 'difficulty', 'in', 'swallowing', 'and', 'evening', 'diplopia', 'for', 'a', 'few', 'days.'], ['He', 'was', 'admitted', 'to', 'the', 'hospital', 'for', 'suspected', 'myasthenic', 'crisis', 'and', 'treatment', 'was', 'started.'], ['The', 'next', 'day', 'the', 'patient', 'alerts', 'at', '03', 'hours', 'in', 'the', 'morning', 'because', 'the', 'patient', 'makes', 'a', 'strange', 'noise', 'when', 'breathing', 'in,', 'like', 'a', 'soft', 'snoring,', 'the', 'patient', 'is', 'sound', 'asleep', 'and', 'very', 'sweaty,', 'but', 'does', 'not', 'seem', 'to', 'be', 'fatigued.'], ['What', 'is', 'the', 'most', 'correct', 'attitude?'], ['1-', 'Reassure', 'the', 'nurse', 'and', 'family', 'that', 'the', 'patient', 'is', 'a', 'habitual', 'snorer', 'and', 'is', 'peacefully', 'asleep.', 'The', 'patient', 'should', 'be', 'placed', 'in', 'lateral', 'decubitus.'], ['2-', 'Notify', 'intensive', 'care', 'for', 'suspected', 'acute', 'respiratory', 'failure,', 'to', 'assess', 'possible', 'orotracheal', 'intubation', 'and', 'assisted', 'ventilation.'], ['3-', 'Perform', 'polysomnographic', 'study', 'to', 'rule', 'out', 'sleep', 'apnea.'], ['4-', 'Decrease', 'steroid', 'dose;', 'if', 'he', 'has', 'a', 'steroid', 'myopathy', 'he', 'will', 'improve.'], ['5-', 'Order', 'a', 'thoracic', 'CT', 'scan', 'to', 'rule', 'out', 'compressive', 'thymoma', 'over', 'the', 'trachea', 'associated', 'with', 'myasthenia.'], ['CORRECT', 'ANSWER:', '2'], ['This', 'is', 'a', 'patient', 'with', 'decompensated', 'myasthenia', 'with', 'bulbar', 'symptoms', '(dysphagia)', 'and', 'therefore', 'risk', 'of', 'respiratory', 'muscle', 'involvement.'], ['The', 'respiratory', 'symptoms', 'correspond', 'to', 'an', 'exhaustion', 'of', 'the', 'muscles,', 'first', 'inspiratory', 'and', 'then', 'accessory', '(the', 'patient', 'does', 'not', 'appear', 'fatigued', 'or', 'tachypneic', 'because', 'the', 'muscles', 'are', 'exhausted),', 'progressing', 'to', 'a', 'carbonic', 'coma.']]

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129_81

[['QUESTION', 'TYPE:', 'NEUROLOGY', 'AND', 'NEUROSURGERY'], ['CLINICAL', 'CASE:'], ['A', '78-year-old', 'male', 'consults', 'for', 'a', 'year-long', 'history', 'of', 'progressive', 'cognitive', 'impairment', 'with', 'memory', 'and', 'orientation', 'lapses.'], ['His', 'family', 'reports', 'recurrent', 'visual', 'hallucinations,', 'occasional', 'falls', 'and', 'striking', 'motor', 'slowing.'], ['What', 'is', 'the', 'most', 'likely', 'diagnosis?'], ['1-', 'Multi-infarct', 'vascular', 'dementia.'], ['2-', "Alzheimer's", 'type', 'dementia.'], ['3-', 'Dementia', 'with', 'diffuse', 'Lewy', 'bodies.'], ['4-', 'Frontotemporal', 'dementia.'], ['5-', 'Normal', 'pressure', 'hydrocephalus.'], ['CORRECT', 'ANSWER:', '3'], ['Dementia', 'with', 'visual', 'hallucinations', 'at', 'the', 'beginning', 'of', 'the', 'course', '(in', 'the', 'first', '2', 'years)', 'is', 'very', 'suggestive', 'of', 'Lewy', 'bodies,', 'and', 'is', 'the', 'guiding', 'symptom', 'in', 'these', 'questions.'], ['If', 'we', 'add', 'to', 'this', 'the', 'falls', 'and', 'motor', 'slowing', 'suggestive', 'of', 'parkinsonism,', 'it', 'makes', 'the', 'question', 'easier.'], ['Therefore,', 'number', '3', 'is', 'correct.']]

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