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-1,"Teenager, after attempted suicide with intake of tricyclic antidepressant, manifested cardiorespiratory arrest. During resuscitation cardiopulmonary, the following rhythm was observed in heart monitor. The analysis of the cardiac monitor allows us to confirm that the electrocardiographic tracing demonstrates rhythm of","ventricular tachycardia, which may be responsive to shock and the use of atropine.","ventricular fibrillation, which may be responsive to cardioversion (shock in synchronized mode).","ventricular fibrillation, which may be responsive to defi brillation (shock in synchronized mode).","ventricular tachycardia, which may be responsive to cardioversion (shock in synchronized mode).",,D,test
-2,"Patient, 49 years old, male, farmer, comes to the consultation complaining of a lesion on the face that started as a papule, later evolving into painless ulceration. The first lesion appeared 3 months ago, followed by two more with the same characteristics. Associated with the appearance of the lesions, he developed weight loss, which he was unable to quantify, but he noticed that his clothes were looser than usual. He hasn't presented a similar picture before. He reports smoking and alcohol consumption since childhood. Does not mention medication use. During the physical examination, ulcerated lesions with raised edges and a grainy background were seen in the lower labial and mental region. A scraping was taken for direct examination and biopsy of the lesion. In both exams, yeast-like forms with multiple small, rudder-wheel buddings were found. Negative Montenegro reaction. What is the diagnosis and treatment of choice?",Paracoccidioidomycosis and itraconazole.,Sporotrichosis and saturated iodide solution potassium.,Squamous cell carcinoma and surgery.,Cutaneous tuberculosis and R (Rifampicin) – H (Isoniazid) – Z (Pyrazinamide) – E (Ethambutol).,,A,test
-3,"A 57-year-old male patient arrives at the emergency room complaining of palpitations that began three days ago, associated with dizziness and dyspnea. She reports using methimazole 10 mg/day for a month due to a diagnosis of hyperthyroidism. He has also been taking enalapril 20 mg for high blood pressure since he was 45 years old. On examination: Blood pressure = 110 x 70 mmHg; Heart rate = 160 BPM; Respiratory rate = 26 irmp; tachycardic, irregular heart rhythm, in two beats, without murmurs; physiological breath sounds with bibasal crackles; abdomen free, painless, positive bowel sounds; locomotor system without changes. Peripheral oxygen saturation of 87%. ECG requested in figure 1. Oxygen supplementation and cardiac monitoring installed. Select the alternative that identifies the arrhythmia and the action to be taken in the emergency room.",Atrial flutter and amiodarone.,Paroxysmal supraventricular tachycardia and procainamide.,Wolff-Parkinson-White syndrome and beta blocker.,Multifocal atrial tachycardia and calcium channel blockers.,,D,test
-4,"A 57-year-old patient goes to the Basic Health Unit complaining of the appearance, a month ago, of a reddish lesion on his right arm. She sought medical attention, when she was prescribed nystastin cream for 14 days and fluconazole 150 mg in a single dose, with no improvement in her condition. He reports that he subsequently developed pain in his right elbow, and was diagnosed with tendinitis and prescribed anti-inflammatory drugs. He reports that he has no other illness and does not use medication. Physical examination shows an erythematous macule with raised erythematous edges and an atrophic center. What is the diagnostic hypothesis and workup to be carried out?",Psoriasis and clinical diagnosis.,Paracoccidioidomycosis and scraping of the lesion.,Chromomycosis and biopsy.,Leprosy and Mitsuda intradermal reaction.,,D,test
-5,"A 14-year-old female patient receives medical care due to macroscopic hematuria accompanied by mild myalgia, adynamia and mild hyperthermia (axillary temperature = 37.8°C). The mother informs that the patient had an upper airway infection about a month ago, which resolved after treatment with amoxicillin for seven days. At the time of this first consultation, the patient presents with arterial hypertension (Blood pressure = 150x110 mmHg), the fundus is normal and there are no other changes on the physical examination. The patient is hospitalized because the first laboratory tests already show elevated serum creatinine (8.4 mg/dL) and she quickly progresses to oligoanuria, edema and worsening renal function. The macroscopic hematuria regresses, but microscopic hematuria persists, with the presence of hematic casts and the patient also starts to present proteinuria (3g/24 h). Clinical-laboratory investigation does not show the presence of vasculitis or systemic disease. Serum complement dosage (C3, CH50) is normal; antinuclear antibodies absent, negative antinuclear factor test. The patient underwent a renal biopsy - a fragment with 30 glomeruli, with proliferation of Bownan's capsule epithelial cells and infiltration by macrophages and lymphocytes, configuring the presence of epithelial crescents in 70% of the glomeruli, some with a fibrocellular appearance. The immunofluorescence of the renal biopsy, reproduced below, shows linear deposition of IgG - there are no mesangial deposits; Negative immunofluorescence for IgM, IgA and C3. Based on the clinical history, evolution and renal biopsy and immunofluorescence, the question is what is the mechanism responsible for glomerular damage? ",In situ antigen-antibody reaction along the glomerular basement membrane.,Deposition of circulating immune complexes along the glomerular basement membrane.,"Changes in cellular immunity, notably macrophages and T helper lymphocytes.",Antineutrophil cytoplasmic antigen antibody deposition.,,A,test
-6,"Patient, 25 years old, second pregnancy, with previous cesarean section (G2P1C1), uneventful prenatal care, was admitted in labor and presents progress according to the partogram, shown below. In the tenth hour of evolution, she presents regular uterine activity of 5 contractions/45 seconds/10 minutes/strong and fetal heartbeat of 150 bpm. Analyzing the partogram, what is the diagnosis and management of the case?",Secondary stop of descent and forceps.,Secondary arrest of dilation and oxytocin.,Secondary stop of dilation and forceps.,Secondary arrest of descent and cesarean section.,,D,test
-7,"A 24-year-old woman has been presenting progressive dyspnea on exertion, dry cough, sputum with occasional streaks of blood. Denies feverish episode. On physical examination, he presented blood pressure = 110 x 70 mmHg; radial pulse = 110 bpm; jugular stasis. On lung auscultation, fine crackles were evident at the lung bases; cardiac auscultation with hypophonesis of B1, splitting and hyperphonesis of B2, soft diastolic murmur on the left sternal border and diastolic rumbling murmur in the mitral focus. Upon examination of the abdomen, the liver was palpable 4 cm from the right costal margin and the spleen was impalpable. Perimalleolar edema was detected in the extremities. The patient underwent a chest X-ray in a posteroanterior view, which is illustrated below. The finding marked by the arrow on the chest x-ray is indicative of",aortic dilation.,pulmonary thromboembolism.,left hilar lymphadenopathy.,left atrial hypertrophy.,,D,test
-8,"A 12-month-old infant is taken to the Emergency Room by his mother with reports of intense crying, swelling in the leg and falling out of his crib approximately 8 hours ago. He has a history of TBI two months ago, also due to falling from his crib, according to his mother. An x-ray was taken, the image of which is reproduced below. The indication for hospitalization for this child will be made considering the most likely diagnosis to be",Munchausen syndrome.,Legg-Perthes disease.,osteogenesis imperfecta.,cortical hyperostosis.,,D,test
-9,"A male patient, 55 years old, smoker 60 packs/year, with a chronic cough for more than 10 years, reports that about three months ago he observed the presence of blood in the secretion eliminated by coughing. She also reports loss of around 15% of her usual weight in the same period, anorexia, adynamia and night sweats. The chest x-ray taken at the time of the consultation is shown below. What is the most likely diagnostic hypothesis in this case?",Pulmonary aspergillosis.,Lung carcinoma.,Cavitary tuberculosis.,Bronchiectasis with infection.,,B,test
-10,"A 48-year-old man, hypertensive, obese, arrives at the Emergency Room complaining of episodes of precordial chest pain, without irradiation, which started in the last two days, and has worsened for 24 hours. The pain lasts from 5 to 15 minutes, being precipitated by intense exertion, such as climbing stairs, and is relieved by rest. The patient reports not feeling pain at the time of the anamnesis. Use captopril and oral hypoglycemic medication regularly. He denies any history of coronary disease and an electrocardiogram was considered normal by his cardiologist at his last appointment, 6 months ago. On examination, he appears anxious, but in good general condition, pulse = 85 bpm, regular, full, BP = 140x80 mmHg, peripheral pulses are palpable and symmetrical, extremities are well perfused. Lung and heart auscultations are within normal limits. His electrocardiogram on admission shows the following findings. What is the most appropriate approach for the patient?",Carry out anti-ischemic and antithrombotic treatments administered immediately and simultaneously.,Observe in the Coronary Care Unit and administer symptomatic medications until cardiac catheterization is performed.,Observe in the Emergency Room for 12 hours and refer to the cardiologist for an exercise stress test if asymptomatic remains.,"Perform immediate anti-ischemic treatment, followed by antithrombotic therapy in case of changes in the ST segment on the ECG within the next 12 hours.",,A,test
-11,"A 24-year-old patient, first pregnancy, goes to a prenatal medical appointment at the health center. At this prenatal consultation, the doctor calculated the gestational age considering her first ultrasound at 12 weeks, concluding that she is 41 weeks and 6 days pregnant. During the pelvic examination, the uterine cervix was observed to be soft, posterior, 30% effaced, closed external os, high and mobile presentation. During the fetal palpation maneuver (Leopold-Zweifel), it was noticed that there was good fetal mobility, signaling a normal amount of amniotic fluid. Fearing postdatism, the doctor sent the patient to be admitted to the Maternity Hospital. Once there, she underwent cardiotocography, the image of which is reproduced below. What action should be proposed for this patient?",Cesarean section due to the non-reassuring pattern of cardiotocography.,Cervical ripening with misoprostol.,Elective induction of labor with oxytocin.,Detachment of the amniotic sac.,,B,test
-12,"A 25-year-old first pregnancy comes to the Maternity Hospital when labor begins at 1 p.m. and its progress is recorded in the partogram below. The patient completes the first period of labor at 6:30 pm. The second period had already lasted 45 minutes, when the fetus began to show type II decelerations. What is the diagnosis of this case and the most appropriate obstetric management?",Prolonged pelvic period; forceps for rotation dystocia.,Tachytocic labor; acute tocolysis with subcutaneous terbutaline.,Secondary descent stop; cesarean section due to cephalopelvic disproportion.,Prolonged active phase; administration of oxytocin to increase metro-systoles.,,A,test
-13,"An 81-year-old woman, a smoker for 60 years, was admitted to a general hospital with severe dyspnea, which resulted in death two days after admission. Upon admission, a diagnosis of pulmonary embolism and deep vein thrombosis in the right lower limb was made. Properly filling out the death certificate is:",Part I: a. pulmonary embolism; b. deep vein thrombosis; w. smoking. Part II: (unfilled).,Part I: a. intense dyspnea; b. deep vein thrombosis; w. smoking. Part II: pulmonary embolism.,Part I: a. pulmonary embolism; b. deep vein thrombosis. Part II: smoking.,Part I: a. intense dyspnea; b. deep vein thrombosis. Part II: smoking.,,C,test
-14,"A three-year-old child, born at term, not regularly monitored in Child Care, was taken by the mother for an appointment at the Basic Health Unit after suffering a fracture in her right forearm two months ago. After medical evaluation, it was observed: low stature for age, scoliosis, disproportion of the upper and lower segment relationship, muscular hypotonia and small umbilical hernia. The doctor requested x-rays of the hand, wrist and lower limbs, shown below. The diagnosis and the radiological alteration that confirms it are, respectively:",osteopenia and loss of bone density.,hypothyroidism and delayed bone age.,phosphorus deficiency and osteomalacia.,bone dysplasia and metaphyseal dysplasia.,,D,test
-15,"A 54-year-old man, with a history of dyslipidemia, high blood pressure and a history of early familial cardiovascular disease (father had a myocardial infarction at age 50), was admitted to the Emergency Room of a hospital with a history of pain in the epigastric region for approximately five hours, in tightness, of strong intensity, unrelated to food and without factors for improvement, accompanied by nausea and vomiting. He had received 200 mg of AAS at the hospital of origin. On examination, he was pale, sweaty and drowsy. Axillary temperature = 35.8 oC, blood pressure = 80x50 mmHg, heart rate = 118 bpm, respiratory rate = 16 bpm. Decreased peripheral perfusion. Heart auscultation revealed normophonetic sounds, without murmurs. There was jugular turgidity at 45°. Lung auscultation revealed no rales. The admission electrocardiogram is shown below. Given the patient's clinical condition, the diagnostic hypothesis, the probable cause of shock and the recommended initial treatment are, respectively:",inferior wall ST elevation myocardial infarction; cardiac tamponade; pericardiocentesis.,anterior wall ST elevation myocardial infarction; systemic inflammatory response; norepinephrine.,inferior wall ST elevation myocardial infarction; right ventricular infarction; hydration with saline solution.,anterior wall ST elevation myocardial infarction; papillary muscle rupture; intra-balloon placement aortic.,,C,test
-17,"A 64-year-old man, suffering from high blood pressure and diabetes for over 20 years, sought the Emergency Department with complaints of dyspnea on medium exertion, which progressed to dyspnea on light exertion, in addition to paroxysmal nocturnal dyspnea, emergence of limb edema lower, soft, cold and ascending and also palpitations, for about two days. The patient states that he had stopped taking chronic medications 30 days ago and consumed alcohol and food in excess three days ago. Denies chest pain. The physical examination showed the patient to be in good general condition, conscious and oriented, slightly tachypneic at rest. Axillary temperature = 36 oC, blood pressure = 135x75 mmHg, heart rate = 122 bpm, respiratory rate = 22 bpm, capillary blood glucose = 321 mg/dL. Cardiac auscultation revealed normophonetic sounds, irregular heart rhythm in three beats, with the presence of B3, with a heart rate of 122 bpm, with a systolic murmur of tricuspid regurgitation. Jugular turgidity at 45th present. Lung auscultation revealed crackling rales at the bases. In the lower limbs there was 2+/4+ edema, soft, cold and painless. The patient had an echocardiogram performed three months ago with the following findings: enlargement of the heart chambers, concentric hypertrophy of the left ventricle, moderate tricuspid insufficiency and an ejection fraction of 35%. The electrocardiogram from the current admission is reproduced below. Based on the data presented, it can be stated that:",The patient's arrhythmia is due to decompensation of heart failure and no specific treatment is required.,heart failure is due to an acute arrhythmia and the patient must undergo immediate electrical cardioversion,the patient must undergo anticoagulation with heparin and immediate chemical reversal of the arrhythmia with amiodarone.,the patient must receive digoxin for heart rate control and low molecular weight heparin for anticoagulation.,,D,test
-18,"A 42-year-old man, a street vendor, was admitted to formal employment in commerce and seeks the Basic Health Unit to find out how to proceed in relation to a change identified in the admission exams, reproduced in the chest x-ray shown above. In the anamnesis, he reports a dry cough for more than six months, constant, daily, never treated. He denies fever, dyspnea, hemoptysis and weight loss. He has no other complaints. He has high blood pressure, controlled with hydrochlorothiazide. He has been a smoker, with a smoking history of 20 packs/year, for 22 years. His family history includes a brother with pulmonary tuberculosis who was treated last year. Denies any other pathological history or family history of the disease. The physical examination is normal. The most appropriate management for this patient at this time is:",start trial treatment for tuberculosis.,request a computed tomography.,stop smoking and observe.,repeat chest x-ray.,,B,test
-19,"Regarding the Rede Cegonha indicators, the Family Health Strategy teams in your city presented the graph above. The management goal is to reach 80% of registered pregnant women. The consultant from the Department of Health, which has limited financial resources, recommends an awareness and training workshop in order to reverse the current situation. Among the team members, which is the preferred target audience for the workshop to have the most effect?",Doctors,Nurses,Community Health Agents.,Nursing Assistants and Technicians.,,C,test
-20,"A 56-year-old woman, former smoker (40 packs/year), presents with dyspnea on exertion and a morning cough with clear sputum. He uses inhaled salbutamol to relieve dyspnea. On physical examination, the patient has a pulse = 85 bpm, respiratory rate = 24 bpm, pulmonary auscultation shows reduced vesicular sounds at the base, without adventitious sounds. No other changes on physical examination. Come to the outpatient review appointment with a chest X-ray and arterial blood gas analysis on room air. After evaluating the exams, pharmacological treatment was prescribed and prolonged home oxygen therapy was indicated – 1L/min for at least 15h/day. Based on this information, the gasometric result that justified the indication of oxygen therapy is:",pH 7.45; PaCO 33 mmHg; PaO2 58 mmHg; HCO3 22 mEq/L.,pH 7.34; PaCO2 45 mmHg; PaO2 57 mmHg; HCO3 26 mEq/L,pH 7.35; PaCO2 43 mmHg; PaO2 60 mmHg; HCO3 24 mEq/L,pH 7.38; PaCO2 36 mmHg; PaO2 62 mmHg; HCO3 24 mEq/L.,,D,test
-21,"A 30-year-old first pregnancy, 38 weeks of gestation and uneventful prenatal care, is admitted to the Maternity Hospital in labor. On physical examination upon admission, blood pressure = 100 x 60 mmHg, uterine height = 35 cm, uterine dynamics - 2 contractions in 10 minutes, fetal heart rate = 140 bpm. Upon vaginal examination, thin cervix, 3 cm dilation, cephalic presentation, intact pouch. Analyzing the evolution of labor, according to the partogram shown above, the diagnostic hypothesis and correct conduct, after 10 hours of observation, are, respectively:",prolonged active phase; administer oxytocin.,secondary descent stop; perform a cesarean section.,secondary stop of dilation; perform a cesarean section.,secondary stop of dilation; administer oxytocin.,,C,test
-22,"A 6-month-old infant arrives at the Emergency Room with a history of irritability and a fever of 38 C for two days. The mother states that today she noticed reddish and vesicular lesions throughout the head and oropharynx. When investigating the family history, the mother says that the grandmother, who lives with the family, had lesions on her left face similar to those shown in the figure below. Based on the assessment of the grandmother's injuries, the diagnosis and treatment for this infant are, respectively:",shingles; hospitalization for administration of intravenous analgesics and corticosteroids and topical lidocaine.,herpes simplex; hospitalization for administration of intravenous antiviral medication and corticosteroids.,coxsackiosis; home treatment with antibiotics and oral embrocation with anesthetic.,varicella; outpatient monitoring and prescription of symptomatic drugs.,,D,test
-23,"A 60-year-old woman, with hypertension, goes to an appointment at a Basic Health Unit because she presented with paresthesias and hemiparesis in the left upper limb for a week, with complete spontaneous reversal within 12 hours. Blood pressure = 180x110 mmHg, cardiac auscultation with irregular rhythm, in 2 stages, neurological examination without significant changes. Bring a computed tomography of the head without contrast, performed on the day of symptoms, which is normal. An electrocardiogram was performed as shown below - IBD (brings a similar test carried out 60 days ago). Which other drug, in addition to antihypertensive treatment, is the most suitable for this patient as a measure with the greatest impact in preventing new episodes of the neurological condition?",Warfarin,Clopidogrel,Ticlopidine,Atorvastatin,,A,test
-24,"Woman, 25 years old, comes to the Gynecology Outpatient Clinic to undergo her ""preventive"" (sic). Reports regular menstrual cycles every 28 - 30 days. She reports that in the days before menstruation she feels more bloated, with mastalgia and that, in the first two days of menstrual flow, she feels cramps. When performing the speculum exam on the patient, the doctor visualizes the finding shown in the figure above, which is clinically compatible with:",use of combined hormonal contraception.,diagnosis of nonspecific cervicitis.,existence of low estrogen levels.,immediate pre-ovulatory period.,,D,test
-25,"A first-time pregnant woman, at 37 weeks of gestation, complains of lower limb edema for a week. The prenatal card has notes as shown in the following figure. On physical examination, she presents good general condition, blood pressure = 150 × 90 mmHg, uterine height = 34 cm, absent uterine dynamics, fetal auscultation = 140 bpm, without decelerations, lower limb edema ++/4+. Vaginal touch: thick and impervious cervix. Ribbon proteinuria +/4+. What is the correct diagnosis and the most appropriate management?",Gestational hypertension; requesting tests to assess fetal well-being and prenatal follow-up.,"Mild pre-eclampsia; hospitalization for relative rest, normal sodium diet and assessment of fetal well-being.",Mild pre-eclampsia; requesting tests to assess fetal well-being and prenatal follow-up.,Severe pre-eclampsia; hospitalization to resolve the pregnancy by induction of labor or cesarean section,,B,test
-26,"A 24-year-old patient, university student, seeks a Basic Health Unit reporting a sudden onset of “high fever” for two days, chest pain on deep inspiration and a productive cough, with yellowish sputum. Denies significant pathological history. On examination, the patient appears lucid, oriented, with normal-colored, normal-hydrated mucous membranes, anicteric sclera. Respiratory system: audible vesicular murmur, except in the middle third of the right hemithorax, where a tubal murmur can be heard. There is an increase in thoraco-vocal fremitus in this same region. Cardiovascular system: regular heart rhythm in two beats with normophonetic sounds, without murmurs. Flaccid abdomen, absence of visceromegaly. Lower limbs unchanged. Vital signs: blood pressure = 120 × 80 mmHg, respiratory rate = 24 bpm, heart rate = 98 bpm and axillary temperature = 39.0C. The chest x-ray performed during care is shown below.  The most appropriate therapeutic approach for this patient is",cephalexin orally.,azithromycin orally.,levofloxacin orally or intravenously.,intravenous or intramuscular ceftriaxone + oral azithromycin.,,B,test
-27,"A first-time pregnant woman, 36 weeks pregnant, comes to the Maternity Hospital complaining of pain in her lower abdomen. On examination: good general condition, afebrile, uterine height of 33 cm, uterine dynamics present (three to four contractions every 10 minutes, moderate), fetal heartbeat present. On vaginal examination: thin cervix, dilated to 4 cm, intact pouch, cephalic presentation. The input cardiotocography is shown in the figure below. Select the alternative that presents the interpretation of cardiotocography and the recommended course of action.",Normal pattern; inhibition of preterm labor.,Pathological pattern; prophylactic antibiotic therapy and resolution of pregnancy by cesarean section.,Non-reassuring pattern; inhibition of preterm labor and prophylaxis for streptococcus B.,Suspicious pattern; labor assistance with continuous monitoring of fetal heart rate.,,D,test
-28,"A 50-year-old patient diagnosed with idiopathic pulmonary hypertension, with a history of prior hospitalization a year ago, due to dyspnea on exertion and anasarca, he was admitted to the Emergency Room due to an episode of syncope during sexual intercourse. He reports using diltiazen regularly and reports that in the last two months his dyspnea has progressed to mild exertion and lethargy has appeared. In the last two weeks, he has been developing abdominal pain in the right hypochondrium and edema of the lower limbs and has also presented three episodes of tight chest pain, without irradiation, triggered by great exertion. On physical examination, the patient appears to be in a regular general condition, eupneic at rest, oriented, without neurological deficits. Cardiac auscultation reveals a regular rhythm, with B2 hyperphonosis, no murmurs, heart rate = 92 bpm, blood pressure = 100x65 mmHg. Jugular distension was observed at 45° and lung auscultation was normal. Palpation of the liver edge, approximately 5 cm from the right costal margin, is mildly painful. There is edema of the lower limbs, reaching up to the thigh and abdominal wall, +++/4+, cold and painless. A chest x-ray (postero-anterior view) and an electrocardiogram (ECG) were performed, shown below. The findings of these exams are:","chest x-ray: bulging of the pulmonary artery trunk and reduction of the peripheral pulmonary vascular network; ECG: right bundle branch block, cardiac axis deviation to the right and strain-type ventricular repolarization pattern.","chest x-ray: bulging of the pulmonary artery trunk and redistribution of the vascular network to the pulmonary apices; ECG: left bundle branch block, deviation of the cardiac axis to the right and ventricular repolarization pattern of the strain type.","chest x-ray: enlargement of both cardiac ventricles and reduction of the peripheral pulmonary vascular network; ECG: left bundle branch block, cardiac axis deviation to the right and nonspecific repolarization changes ventricular.","chest x-ray: enlargement of both ventricles and redistribution of the vascular network to the lung apices; ECG: right bundle branch block, deviation of the cardiac axis to the right and nonspecific changes in ventricular repolarization.",,A,test
-29,"A 22-year-old woman, sexually active, has had yellow-green leucorrhoea for the past month, of foul odor. Reports new sexual partner three months ago. Regularly uses combined oral contraceptives. During the gynecological examination, the images shown above are observed. The etiological agent responsible for this patient's clinical condition is",Trichomonas vaginalis.,Chlamydia trachomatis.,Neisseria gonorrhea.,Candida albicans.,,A,test
-30,"A 35-year-old man, an alcoholic for 20 years, seeks the Basic Health Unit complaining of moderate pain in the right upper quadrant, fever not measured, and chills for 15 days. On physical examination, he presents an axillary temperature of 38 oC, an enlarged liver and pain on abdominal palpation in the right hypochondrium. An abdominal ultrasound image is shown below. The correct diagnosis and the next step in the management of this patient are",alcoholic cirrhosis; the patient must be referred to a liver transplant service.,intrahepatic lithiasis; the patient should be referred for transparietohepatic drainage.,alcoholic hepatitis; the patient must be referred for detox and psychiatric treatment.,liver abscess; The patient should be referred for abscess drainage as quickly as possible. possible.,,D,test
-31,"A 25-year-old woman comes to the Outpatient Clinic and reports the appearance, 10 days ago, of an untreated wound. painful sensation in the vulva, shown in the photo below. Reports unprotected sexual intercourse for 30 days. Denies pain or fever. On examination, a single, ulcerated lesion with hard edges was observed. Considering the most likely etiology, the test that should be requested for diagnostic confirmation is",bacterioscopy of a smear of the lesion stained by the Gram method.,dark field research of the etiological agent.,fresh bacteriological research.,culture of secretion from the lesion.,,B,test
-32,"A 20-year-old woman presents to the Basic Health Unit with the lesion on her hallux shown below, which appeared seven days ago, after manipulation of the nail by a manicurist. The patient reports throbbing pain, but denies fever or other symptoms. On examination, there is: absence of purulent secretion; absence of regional adenopathy.  The appropriate approach to resolve the condition presented by the patient is",the prescription of broad-spectrum antibiotics for 10 days.,"cleaning the finger with soap and water, degerming with povidone and removing the entire nail with local anesthesia.","the removal of an ellipse of skin and subcutaneous tissue from the edge with granulation tissue, suturing with nylon.",the removal of a segment of the nail with anesthesia of the region performed through digital block with lidocaine with vasoconstrictor.,,C,test
-33,"A three-year-old child, malnourished, who had been hospitalized ten days ago, is taken to the Medical Emergency Department. The child has had an unchecked fever, cough and difficulty breathing for two days. The mother reports that the patient is unable to drink liquids and has vomited several times in the last 24 hours. Upon physical examination, the doctor observed that the child had a regular general condition, fever of 38.5 oC, mild dehydration, tachydyspnea, with intercostal insufficiency, presence of crackling rales and decreased breath sounds in the left hemithorax; heart rate = 130 bpm, respiratory rate = 64 bpm and oxygen saturation = 91%. The chest x-ray is shown below. The etiological agent and treatment of pneumonia presented by the child are",Haemophilus influenzae; crystalline penicillin.,Streptococcus pneumoniae; procaine penicillin.,Staphylococcus aureus; ceftriaxone associated with oxacillin.,Mycoplasma pneumoniae; antibiotic therapy with macrolides.,,C,test
-34,"A 36-year-old man had been treated at the Basic Health Unit for several months due to tuberculosis. During this period, he was also diagnosed with the HIV virus. There was no other manifestation until ten months ago, when he started to have a fever, intense weight loss and a lot of coughing. As his symptoms worsened three days ago, he required urgent hospital admission with radiologically confirmed bronchopneumonia. As his clinical condition progressively worsened, he went into respiratory failure and died after successive cardiorespiratory arrests. No autopsy was performed. What underlying cause of death should be included in this patient's death certificate (Causes of Death – Part I – item d)?",Respiratory failure.,Bronchopneumonia.,Tuberculosis.,AIDS,,D,test
-35,"A 27-year-old pregnant woman, tertigravid, with a history of a cesarean section seven years ago and a natural birth three years ago, underwent prenatal care during the current pregnancy, with seven consultations, without any complications. She was admitted to labor and is progressing according to the chart below.  The analysis of the partogram indicates that the diagnosis and obstetric management indicated are",secondary stop of dilation; forceps delivery.,secondary descent stop; cesarean birth.,cephalo-pelvic disproportion; forceps delivery.,prolonged active phase; cesarean birth.,,B,test
-37,"In one city, there were several cases of a notifiable disease, enough to exceed the upper endemic limit in a given period. The Epidemilogical Surveillance team, after carrying out an investigation, prepared the graph illustrated below, which considers the distribution of the number of cases (vertical axis) as a function of time (horizontal axis), in addition to the maximum incubation period of this disease (thicker line , below the horizontal axis). Based on the data presented, how should this epidemic be characterized?","Massive exposure, from a common and prolonged source.","Massive exposure, from a common source, short duration or explosive.","Multiple exposure, progressive or propagated epidemic.","Massive exposure, from multiple sources, followed by secondary cases.",,B,test
-38,"An 8-month-old infant born prematurely at 32 weeks of gestation is seen in the Emergency Room with a history of coughing for three days. The mother reports that, today, the child is paler, drowsier and has difficulty breathing, to the point of preventing food intake. On physical examination, the infant appears irritable, in a regular general condition, cyanotic, afebrile, with wheezing and an increased respiratory rate for her age, with intercostal and subcostal incision. Chest X-ray in the anteroposterior position is reproduced below.  What is the appropriate conduct in this situation?",Determine hospitalization to start oxygen therapy due to signs of severity.,Determine hospitalization for immediate initiation of broad-spectrum antibiotic therapy.,Administer corticosteroids and bronchodilators and maintain observation in the Emergency Room.,"Recommend returning home, considering that the family has an inhaler to use the medication.",,A,test
-39,"The following graph shows the evolution of infant mortality in a given region, over time, breaking down its two components: neonatal infant mortality and post-neonatal or late infant mortality. Graph analysis reveals the evolution pattern of a region","in development, with a drop in infant mortality represented by the green line, at the expense of the neonatal (blue line) and post-neonatal (red line) component.","developed, with stabilization of infant mortality represented by the blue line, at the expense of the neonatal (green line) and post-neonatal (red line) components.","in development, with a drop in infant mortality represented by the red line, at the expense of the neonatal (green line) and post-neonatal (blue line) component.","developed, with infant mortality represented by the red line, at the expense of the neonatal (blue) and post-neonatal (green line) components.",,A,test
-40,"A 42-year-old man, homeless, user of crack and illicit injectable drugs, presents to the Family Health Unit with a productive cough and fever at the end of the day, for 2 months. She reports waking up in the early hours of the morning due to sweating, loss of appetite and weight loss of 20 kg during the period. On physical examination, he was conscious, oriented, pale (+/4+), anicteric, dehydrated, feverish (axillary temperature = 37.8°C), with heart rate = 120 bpm and blood pressure = 120 x 60 mmHg. Respiratory system with bilateral intercostal retraction and global reduction in breath sounds. Cardiovascular system: regular heart rhythm in 2 beats and hyperphonetic sounds. Painless abdomen on superficial palpation and slightly painful on deep palpation over the hepatic pocket, hepatimetry 2 cm from the right costal margin, with a smooth consistency and blunt edge. Spleen palpable 1.5 cm from the left costal margin. Test results: rapid test for HIV positive; complete blood count - hemoglobin = 8.0 g/dL (normal 12 to 15 g/dL), hemotcrit = 24% (normal = 35 to 45%) and leukopenia = 800 leukocytes/mm3 (normal between 4,000 and 11,000/mm3) ; Negative AFB test in 3 sputum samples. A chest computed tomography was performed, reproduced in the figure below. Based on the clinical and laboratory findings and the image presented, what would be an appropriate therapeutic approach?","Start treatment with antiretroviral (lamivudine + efavirenz + tenofovir) and, after 2 weeks, RIPE (rifampicin + isoniazid + pyrazinamide + ethambutol) for 6 months.","Start treatment with antiretroviral medication (lamivudine + zidovudine + efavirenz), simultaneously with the structured antituberculosis regimen, with rifabutin, for 6 months.","Start treatment with RIPE (rifampicin + isoniazid + pyrazinamide + ethambutol) lasting 6 months and, after 4 weeks, introduce treatment with antiretrovirals (lamivudine + tenofovir + efavirenz).","Start treatment with RIPE (rifampicin + isoniazid + pyrazinamide + ethambutol) recommended for 6 months and, after 1 week, introduce antiretroviral treatment (lamivudine + zidovudine + lopinavir with ritonavir).",,C,test
-41,"A boy aged 7 years and nine months arrives at the Basic Health Unit accompanied by his mother. At the last appointment, a month ago, the mother was worried, as she said that “he was not growing like others of the same age”. He was exclusively breastfed until the sixth month of life, with no history of acute or chronic illness to date. Has a good appetite and eats well. The doctor requested an x-ray of the wrist, which showed a bone age of 5 years and 9 months. The height of the father and mother respectively are 167 cm and 154 cm. The physical examination was normal. The height and weight graphs are illustrated in the following figure. Considering the data presented, what is the most likely cause of this child's short stature?",Nutritional,Hormonal,Constitutional,Genetic disease.,,C,test
-42,"A 23-year-old woman was admitted to the Emergency Room in labor, with a ruptured uterine sac. She was in the 40th week of pregnancy and had a blood pressure of 170 x 100 mmHg. Two hours after giving birth, she developed a seizure, which was controlled with medication. An hour later, he developed a new seizure, which progressed to coma, followed by irreversible cardiac arrest and death. The following figure shows the form for the death certificate. How should the death certificate be properly completed?",Part I: a - eat; b - convulsive crisis; c - hypertensive crisis. Part II: (unfilled)., Part I: a - cardiac arrest; b - eat; c - cerebral edema; d - convulsive crisis. Part II: eclampsia., Part I: a - cardiac arrest; b - eat; c - convulsive crisis; d - hypertensive crisis. Part II: hypertension.,Part I: a - eat; b - cerebral edema; c - convulsive crisis; d - eclampsia in the postpartum period. Part II: 40 week gestation.,,D,test
-43,"A 19-year-old patient was playing handball in a college competition when, while jumping to throw the ball, she lost her balance and “stepped wrong”. He complains of a lot of pain in the area. On local physical examination, edema (+2/4+), slight hematoma and pain on palpation of the lateral malleolus were noted. He is unable to place his foot on the floor due to the pain. The two images below show two plain x-ray views of the patient's ankle. The most appropriate approach for this patient is considered to be:",referral to an orthopedic hospital for possible surgical treatment due to the fracture.,referral to an orthopedic hospital for possible conservative management with the use of plaster due to the fracture.,"use of ice on the site (up to 3 times a day for 30 minutes), non-steroidal anti-inflammatories and use of a splint for analgesic immobilization for 5 to 7 days.","guidance on relative rest, use of ice on site (3 times a day for 30 minutes) and non-steroidal anti-inflammatories, freeing the patient to go home.",,C,test
-44,"A 35-year-old man sought the Emergency Department due to fever and muscle pain for 3 days. The pain is mainly concentrated in the lower limbs. He reported that for approximately 24 hours he had been observing darkening of the urine, without a reduction in urinary volume and that he had two episodes of hemoptysis during this period. He denied chronic illnesses and reported that he does not use medication. The clinical examination revealed: regular general condition, jaundice (++/4+), hypocolored (++/4+), heart rate = 90 bpm, blood pressure = 130 x 80 mmHg, respiratory rate = 36 bpm, axillary temperature = 39.2°C. Lung auscultation allowed the detection of audible breath sounds with diffuse crackles. The abdomen was painful on palpation in the mesogastrium and left hypochondrium. Laboratory tests showed: Ht = 28% (VR = 35 - 45%); Hb = 10 g/dL (VR = 11.5 - 15g/dL); Leukocytes = 15,200/mm3 (S = 82%; B = 8%; L = 9%; M = 1%) (VR = 4,000 - 11,000 mm3); Platelets = 98,000/mm3 (VR = 100,000 - 400,000 mm3); Urea = 190 mg/dL (reference value = 10 - 20 mg/dL); Creatinine = 8.9 mg/dL (reference value = 1.5 mg/dL); Na = 135 mEq/L (reference value = 136 - 145 mEq/L); K = 2.5 mEq/L (reference value = 3.5 - 5 mEq/L); CPK = 1,250 IU/L (reference value = 60 - 400 IU/L); Total bilirubin = 8.2 mg/dL (reference value = 03 - 1 mg/dL); Direct bilirubin = 64 mg/dL (reference value = 0.1 - 0.3 mg/dL); Indirect bilirubin = 1.7 mg/dL (reference value = 0.2 - 0.7 mg/dL); AST = 120 IU/L (reference value = 10 - 37 U/L); ALT = 130UI/L (reference value = 11 - 45 U/L). The chest x-ray, performed on admission, is illustrated below. According to the table described and the information presented, select the alternative that presents, respectively, the diagnostic hypothesis and the conduct to be established from that moment on.",Leptospirosis; potassium replacement and early peritoneal dialysis.,"Pneumocystosis; vigorous hydration, trimethoprim-sulfamethoxazole.","Typhoid; vigorous hydration, aminopenicillins and fluoroquinolones.",Primary Sclerosing Cholangitis; endoscopic retrograde cholangiography.,,A,test
-45,"A 45-year-old man comes to the emergency room of a hospital complaining of retrosternal chest discomfort associated with nausea and dyspnea. According to him, the symptoms started at rest, after the meal, about 30 minutes ago, without relief. The patient has no previous history of chronic diseases and does not use any medication. On physical examination, he is anxious, BP = 140 x 90 mmHg, HR = 130 bpm, cardiac auscultation with a regular two-beat rhythm, normophonetic heart sounds, crackling rales on pulmonary auscultation and peripheral pulses are present, full and symmetrical. The ECG was performed, presented below. Subsequently, a troponin I assessment was performed, which was positive. Therefore, after the examination, in the emergency room, oxygen therapy, morphine, acetylsalicylic acid, nitroglycerin and metoprolol were administered. At this moment, which medications should be associated with the therapy already instituted for this patient?","Ticlopidine, girofibran and verapamil.","Clopidogrel, enoxaparin and enalapril.","Alteplase, enoxaparin and valsartan.","Heparin, streptokinase and esmolol.",,B,test
-47,"A 26-year-old man is treated in the hospital Emergency Room after being the victim of an attack and suffering multiple blunt injuries to his scalp and face. At the time of the initial assessment, he does not open his eyes even to pain, localizes the painful stimulus and only verbalizes incomprehensible sounds. The doctor on duty requests a computed tomography of the skull, the image of which is shown below. Considering the clinical picture described and the image presented, what is the most likely diagnostic hypothesis for the case?",Epidural hematoma.,Subdural hematoma.,Intraparenchymal hemorrhage.,Coalescing brain contusions.,,A,test
-48,"A 52-year-old man, hypertensive, using amlodipine, seeks the Emergency Care Unit (UPA) with left anterior chest pain, radiating to the epigastrium, with tightness, of intensity 8/10, with a sudden onset about 1 hour after meal. On examination, he is anxious and sweaty; blood pressure = 100 x 60 mmHg; heart rate = 72 bpm; respiratory rate = 24 rpm, with no other findings on physical examination. An electrocardiogram was performed, the results of which are presented below. ""The patient was monitored, received acetylsalicylic acid (AAS), morphine and oxygen, and a support hospital was contacted for transfer. As there was no vacancy forecast for the next few hours, it was decided to perform thrombolysis with alteplase followed by anticoagulation with enoxaparin Blood pressure remained at 100 x 60 mmHg. The conduct to be adopted in this case is the administration of """,losartan orally.,clopidogrel orally., metoprolol intravenously.,intravenous nitroglycerin.,,B,test
-49,"A 29-year-old woman seeks the Basic Health Unit (UBS), reporting that for 2 months she has noticed a change in the pattern of a spot on her skin, located in the dorsal region. She also reports that the spot has been itching and occasional bleeding. The patient is concerned due to the fact that her mother had melanoma at the age of 45 in the dorsal region, having undergone resection of this melanoma with a wide safety margin and axillary dissection. On physical examination, the patient can observe the lesion shown in the image below. Considering the clinical picture presented, the UBS doctor should","perform excision of the lesion under local anesthesia on an outpatient basis, at the UBS, and send the tissue for histopathological examination.","reassure the patient, explaining that the lesion presents evidence of benignity and that there is no greater risk for melanoma, despite the familial factor.",refer the patient to a specialized center for excisional biopsy and subsequent surgical completion according to the results of the histopathological examination.,"reevaluate the patient in 6 months to observe the evolution of the pigmented lesion under dermoscopy and, if there are no changes, monitor the patient annually.",,C,test
-50,"The following graph shows the evolution of the incidence rate of congenital syphilis in children under 1 year of age, per thousand live births, in Brazil and its regions, between 2004 and 2013. Considering the epidemiological data presented in the graph above and the reality Brazilian population in the period evaluated, it is correct to state that congenital syphilis in the country presents"," increasing incidence rates due to pregnant women actively seeking prenatal care and, consequently, early diagnosis of the disease in pregnant women.","increasing incidence rates due to the low rate of adequate treatment for pregnant women during prenatal care, which reflects the maintenance of the vertical transmission chain of the disease.","increasing incidence rates due to the low rate of adequate treatment for pregnant women during prenatal care, which reflects the maintenance of the vertical transmission chain of the disease.","controlled epidemiological situation, with an increase in the incidence rate of the disease in recent years due to the increase in the capture and diagnosis of pregnant women following the expansion of primary care coverage",,B,test
-51,"A 40-year-old man, a chronic smoker and alcoholic, seeks medical assistance reporting general malaise, nausea and vomiting. She reports that she has had progressive jaundice for 4 months and lost 8 kg of weight in the same period. He states that he sought medical services on other occasions, motivated by the dark color of his urine and yellowish skin, but that he did not perform the tests requested on those occasions. The doctor orders an abdominal tomography and laboratory tests, which show the following result: hemoglobin = 8.2 g/dL (reference value: 13.0 to 16.5 g/dL); hematocrit = 26% (reference value: 36 to 54%); total leukocytes = 13,000/mm3 (reference value: 3,600 to 11,000/mm3); fasting blood glucose = 210 mg/dL (reference value: 70 to 99 mg/dL); LDH = 350 U/L (reference value: 50 to 115 U/L); aspartate amino transferase = 60 U/L (reference value: less than 34U/L); alanine amino transferase = 66 U/L (reference value: 10 to 49 U/L); gamma glutamyl transferase = 200 U/L (reference value: less than 73 U/L); total bilirubin = 7.0 mg/dL (reference value: 0.3 to 1.2 mg/dL); direct bilirubin = 5.8 mg/dL (reference value: up to 0.35 mg/dL); indirect bilirubin = 1.2 mg/dL (reference value: up to 1.0 mg/dL); alkaline phosphatase = 250 U/L (reference value: 13 to 43 U/L). The abdominal tomography is shown below. Select the option in which the diagnosis and appropriate management for the case are presented.",Gallbladder neoplasm; clarify the patient about the disease and indicate laparoscopic surgery.,Gallbladder neoplasm; indicate endoscopic treatment (endoscopic prosthesis) and inform the patient about the prognosis of the disease.,Pancreatic head neoplasm; clarify the patient about the disease and its prognosis and indicate surgery (hepaticojejunostomy and gastrojejunostomy).,Pancreatic head neoplasm; indicate surgery (gastroduodenopancreatectomy with resection of the superior mesenteric artery and primary anastomosis) and discuss prognosis with the patient.,,C,test
-53,"During the shift at a General Hospital, several victims of a bus accident arrive and, after assessment, are sent for emergency surgery. It was necessary to call the general practitioner to perform a laparotomy. The figure below represents the assembly reference for the instrumentation table to be followed by the doctor. In this situation, the scrub doctor must position","the cutting instruments in quadrant 3, because they are the first to be used.","the retractors next to the diaeresis material, because they are essential accessories during this surgical procedure.","the synthesis instruments, grouped, in quadrants 2 and 4, as they will be the most used during the procedure.","hemostasis instruments with the tip facing quadrants 1 or 2, facilitating their passage into the hands of surgeons.",,A,test
-54,"In 1993, tuberculosis became recognized by the World Health Organization as a global emergency, having been included in international health policies. In 2000, the goal of reducing the incidence rate of the disease by 2015 was included in the eight Millennium Development Goals (MDGs) of the United Nations. The graph below shows the evolution of the tuberculosis incidence rate, from 1990 to 2013, in Brazil and some other countries. Select the alternative that presents the correct analysis of the graph above, in the context of the data series presented.","Brazil and 4 other countries reached the MDG target, with Cuba being the country with the highest percentage of reduction in the incidence of tuberculosis.","Brazil and 4 other countries reached the MDG target, with Cuba being the country with the highest percentage of reduction in the incidence of tuberculosis.","Brazil and 5 other countries reached the MDG target, with Ecuador being the country with the highest percentage of reduction in the incidence of tuberculosis.","Brazil and 5 other countries reached the MDG target, with Portugal being the country with the highest percentage of reduction in the incidence of tuberculosis.",,C,test
-55,"A woman, primiparous, 21 years old and 38 weeks gestational age, goes into labor. The examination carried out when the patient was admitted to the hospital showed that there were no systemic changes; uterine height = 34 cm; uterine dynamics = 4 contractions of 45 seconds in 10 minutes; cephalic presentation; fetal heart rate = 144 bpm, with transient acceleration present. During vaginal examination, the uterine cervix was dilated to 4 cm, thin and anterior. The evolution is presented in the graph illustrated below. The situation described and the analysis of the graph above indicate the occurrence of",prolonged pelvic period.,secondary stop of dilation., secondary descent stop., normal course of labor.,,D,test
-56,"A 50-year-old man, without comorbidities, with a history of midline xiphopubic laparotomy due to a gunshot wound 4 years ago, reports that he has been experiencing diffuse abdominal pain accompanied by vomiting and abdominal distension, with cessation of gas elimination. and stool 2 days ago. On physical examination, he is dehydrated, flushed, tachypneic and afebrile. His abdomen is distended, tympanic, painful on deep palpation, without pain on sudden decompression. Upon abdominal auscultation, bowel sounds are present and increased, with a metallic timbre. The patient underwent a simple abdominal x-ray in an upright position, the image of which is shown below. The main diagnostic hypothesis for this case is",paralytic ileus.,colon neoplasm.,midgut volvulus.,intestinal obstruction by bridles.,,D,test
-57,"A 57-year-old woman is taken by family members to an Emergency Care Unit with a “fainting” condition, which occurred a few hours ago. The patient regained consciousness and started complaining of palpitations and dizziness. She denies fever, headache, dyspnea or chest pain and similar previous episodes. The patient reports having hypertension, controlled only with diuretics, and denies smoking or alcohol consumption. On physical examination, she appears lucid, oriented, collaborative, pale, sweaty and slightly tachypneic. Lung auscultation is normal. The results of the cardiovascular examination show an irregular heart rhythm, in two beats, normophonetic sounds, without murmurs; blood pressure = 80 x 40 mmHg; heart rate = 200 bpm on average; respiratory rate = 24 rpm. The other aspects of the physical examination do not present significant changes. The patient immediately underwent an electrocardiogram, the results of which are reproduced below. When caring for this patient, the recommended approach is","administration of intravenous heparin, immediate electrical cardioversion, initiation of post-cardioversion oral anticoagulation and subsequent maintenance therapy with amiodarone.","administration of intravenous heparin, initiation of oral anticoagulation or antiaggregation, subsequent electrical or chemical cardioversion and maintenance therapy with amiodarone.","immediate administration of intravenous beta-blocker, initiation of oral anticoagulation or antiaggregation, monitoring of the electrocardiogram and observation of progress.","immediate administration of amiodarone, initiation of oral anticoagulation or antiaggregation, catheter ablation of arrhythmogenic foci and suspension of post-ablation drugs.",,A,test
-58,"A 38-year-old woman was admitted to an Emergency Unit with dyspnea and chest pain. The condition began 5 days earlier with a dry cough, chest pain on the right and high fever. The day after the onset of the condition, she sought medical assistance and was prescribed treatment with levofloxacin for community bacterial pneumonia. The patient reported progress with maintenance of fever and other complaints; Later, she also started to feel tired, dyspneic and with pleuritic chest pain. As he saw no improvement in the condition, he sought out the Emergency Unit where he is currently located. During the first visit to the Emergency Unit, the patient denied smoking, drinking alcohol and using illicit drugs. His past pathological history reveals only recurrent cystitis, with the last episode 2 months ago, always treated with oral quinolones. On physical examination, he presented blood pressure = 85 x 40 mmHg; heart rate = 120 bpm; respiratory rate = 28 rpm; temperature = 38.7 oC; lung examination compatible with lobar condensation on the right. Oxygen therapy was initiated under a mask and the diagnosis of sepsis was considered using the classic criteria (systemic inflammatory response syndrome with proven or suspected infection). Blood cultures were collected, serum lactate was measured, the antibiotic regimen was changed to third-generation cephalosporin + macrolide and generous volume rescue was initiated. The complementary tests carried out confirm the existence of serious organ dysfunction, with the presence of 3 dysfunctions in the SOFA (sequential organ-failure assessment) score: severe kidney injury, with serum creatinine = 5.8 mg/dL; marked hyperkalemia, with serum K+ = 7.2 mEq/L; significant metabolic acidosis, with pH = 7.18 and serum bicarbonate = 12 mEq/L. Intensive therapeutic measures were then instituted to control organic dysfunctions, but, the following morning, shortly after carrying out the electrocardiographic recording illustrated below, the patient presented cardiorespiratory arrest with pulseless electrical activity, which was reversed with the performance of support maneuvers. basics of life and intermittent administration of adrenaline, sodium bicarbonate and calcium gluconate. After the patient's hemodynamic stabilization, immediate dialysis support was indicated. Considering that the electrocardiographic record presented indicates the cause of the patient's cardiorespiratory arrest, what motivated the institution of dialysis therapy?",Marked and refractory hyperkalemia.,Severe and refractory metabolic acidosis.,Uremic pericarditis with tamponade.,Volume overload with pulmonary congestion.,,A,test
-59,"The following graph shows proportional mortality cause in Brazil, from 1930 to 2004. From the analysis of the graph above, it is inferred that",The existence of public safety policies and projects to reduce land transport accidents contributes to explaining the reduction in proportional mortality from external causes.,The significant increase in the number of dengue cases from the 1990s onwards helps to explain the significant increase in mortality from communicable diseases from that period onwards., Inadequate completion of death certificates is one of the factors that contributes to explaining the persistence of proportional mortality from cardiovascular causes throughout the period studied.,sedentary lifestyle and being overweight are among the factors that contribute to explaining the continuous increase in the proportion of deaths due to diseases non-transmissible chronicles from 1950 onwards.,,D,test
-60,"A 6-year-old boy was admitted to an Emergency Care Unit, accompanied by his mother. He reports that he fell from his bunk, from a height of approximately 1 meter, 3 hours ago. Upon admission, he appears tearful, with functional impotence in the right wrist and intense local pain. The result of the x-ray of the child's right wrist is shown in the image below. In this case, diagnosis and management are","fracture of the distal radius through the growth plate and metaphysis, sparing the epiphysis; closed local reduction, with plaster placement."," fracture of the distal ulna through the growth plate and metaphysis; closed local reduction, with plaster placement.","fracture of the distal radius, affecting the epiphysis; immobilization with a sling and oral anti-inflammatory administration.","fracture of the distal ulna through the growth plate and metaphysis; open reduction of the injury, with placement of an external fixator.",,A,test
-61,"An 8-year-old boy appears at the Basic Health Unit, accompanied by his mother, to annual consultation. When asked about physical activity, the mother reports that the child attends school. morning and does not like to carry out activities that require physical effort at school and, at home, has the habit of play video games and games on your cell phone. In the dietary recall, a high carbohydrate intake was observed. THE anthropometric assessment shows height of 130 cm and weight of 37 kg. Based on the situation and the table presented and according to the Body Mass Index (BMI) for the age, what is the classification of the boy’s nutritional status?",Obesity,Overweight,Severe obesity,Risk of overweight,,A,test
-62,"A 62-year-old man arrives at the emergency room of a hospital with an installation board Abrupt, approximately 1 hour ago, of right upper monoparesis associated with non-fluent aphasia. The patient, who has a history of type 2 diabetes mellitus, has been using metformin 850 mg twice a day, in addition to acid acetylsalicylic acid (AAS), due to the occurrence of recurrent paroxysmal atrial fibrillation, having one point in the score CHA2DS2-VASc. There are no other morbidities or allergies. Upon admission to hospital, the patient maintains the deficit, which appears to have worsened a little in the last few minutes. He is awake, distressed by the undeniable non-fluent aphasia (Broca) and the moderate decrease in strength in the right upper limb. Presents BP = 160 x 100 mmHg, HR = 110 bpm, with irregular heart rhythm and with anisocardiosphigmia. At this moment, he has capillary blood glucose = 300 mg/dL. The patient is immediately referred for a non-contrast computed tomography of the skull, the image of which is presented in the following figure, with the report being released approximately 2 hours and 30 minutes after the start of the neurological picture. Given this situation, what are the appropriate diagnosis and medical management at this time?",Transient ischemic attack; start full intravenous anticoagulation in association with AAS.,Ischemic stroke; proceed with immediate thrombolysis with rtPA., Ischemic stroke; contraindicate thrombolytic therapy.,Transient ischemic attack; associate clopidogrel with AAS.,,B,test
-63,"The following table presents data on mortality in Brazilian capitals due to COVID-19 and the population who lives on less than US$5.5 a day, the range that defines the poverty line, according to the World Bank. Based on the information in the table presented, select the correct alternative.","The capitals with the highest mortality rates from COVID-19 have a larger estimated population, indicating greater demographic concentration and, therefore, greater risk of contagion.","There is no association between COVID-19 mortality and the poorest population rate, as the occurrence of death from the disease is related to age and the presence of comorbidities.","There is a large difference in mortality from COVID-19, being higher where the proportion of poorer people, which reinforces the social determination of health.",The capitals with the highest mortality rates from COVID-19 have lower proportions of people with family income below the poverty line.,,C,test
-64,"A 34-year-old patient, victim of a car accident, presenting with abdominal trauma contused without evidence of injuries to other body segments, she was taken to the emergency room of the Center tertiary-level Trauma Referral Center for care. During on-scene assistance by the advanced support from the Mobile Emergency Care Service (SAMU), 500 mL of lactated ringer. During the patient's physical examination, the following results were obtained: HR = 110 bpm, filling capillary = 6 seconds, BP = 100 x 70 mmHg, Glasgow = 15. There was normalization of vital signs after the infusion of another 500 mL of crystalloid solution in the initial care. Laboratory tests showed the following results: Hb = 10.5 g/dL (reference value: 12 to 14 g/dL), Ht = 31 % (reference value: 35 to 45 %), lactate = 2.8 mmol/L (reference value: < 2.0 mmol/L), INR = 1.0 (reference value: 0.8 to 1.2), fibrinogen = 200 mg/dL (reference value: 185.0 to 400.0 mg/dL), platelets = 120,000/mm3 (reference value: reference: 100,000 to 424,000/mm3). Abdominal computed tomography with intravenous contrast is shown in the following image. No other injuries were found in the abdomen. Based on the clinical history, physical examination data and tomography image, appropriate medical management is to indicate",urgent exploratory laparotomy to treat liver injury.,serial clinical-laboratory control and non-operative treatment.,angiography and embolization for treatment of liver injury.,emergency laparoscopy for hemostasis of the liver lesion.,,C,test
-65,"A 25-year-old patient was the victim of penetrating gunshot wound in left hemithorax. The physical examination showed signs normal vitals. On examination of the left hemithorax, it was evidenced entry hole in the anterior axillary line 1.5 cm above the nipple line and exit hole in posterior region just above the angle of the scapula same side. Lung auscultation showed abolition from vesicular murmur and dullness to percussion. THE chest x-ray, performed with the patient standing, is displayed below. The diagnosis and initial management indicated for this patient are",hemopneumothorax and water seal drainage in the fifth intercostal space.,hemothorax and water seal drainage in the fifth intercostal space.,hemopneumothorax and thoracentesis in the fifth intercostal space.,diaphragmatic hernia and exploratory laparotomy.,,A,test
-66,"A 25-year-old woman goes to the outpatient clinic of gynecology complaining of pelvic pain for 24 hours. It has regular cycles of 28 days (3 to 4 days) and your last menstrual period was 3 weeks ago. On clinical examination, BP = 110 x 70 mmHg was observed and pulse = 84 bpm. Pain was noted on deep palpation in the left iliac fossa and hypogastric region, Negative Blumberg. No other abnormalities during the physical examination. Ultrasonography was performed transvaginal examination that revealed cystic structure in the ovary left, measuring 7.0 x 6.5 cm, without flow on study Doppler, as shown in the following image. Considering the clinical case presented and the hypothesis most likely diagnosis, what should be the conduct doctor?",Request an MRI of the pelvis., Refer for exploratory laparoscopy.,Advise repeat ultrasound after menstruation.,Request tumor markers such as antigen carcino-embryonic and CA-125.,,C,test
-67,"A 45-year-old patient complains of asthenia, malaise and persistent dry cough. She sought medical assistance at a Basic Unit of Health. On his physical examination, lymph node enlargement was noted. bilateral cervical, without other findings. It was carried out the chest x-ray, as shown in the image. In outpatient care, a biopsy was performed of one of the nodules that revealed giant cells, multinucleated cells with an “owl’s eyes” appearance and nodular sclerosis subtype. According to the radiographic findings and histopathological findings, the recommended approach is to refer patient to", UNACON/CACON cancer care network.,tertiary hospital for specialized treatment in Infectology.,tertiary hospital for specialized treatment in Thoracic Surgery., tertiary hospital for specialized treatment in Head and Neck Surgery.,,A,test
-68,"A 50-year-old man carries out investigation outpatient due to increased transaminases: AST = 122 U/L (reference value: < 38 U/L) and ALT = 142 U/L (reference value: < 41 U/L) shown in a routine examination. The patient consumes 5 cans of beer daily and denies the use of illicit drugs. There are no clinical complaints. Laboratory tests requested for the investigation demonstrated what is presented in the following table. Based on clinical and laboratory aspects, the diagnosis and management at this time should be, respectively,",chronic hepatitis B; indicate vaccination.,acute hepatitis B; start pegylated alpha interferon., cured hepatitis C; guide cessation of alcohol consumption.,chronic hepatitis B; guide cessation of alcohol consumption.,,D,test
-69,"The following figure shows proportional mortality due to some cause groups in males and selected age groups. Based on the data shown in the graphs, it is concluded that",Assaults and external causes of undetermined intent are responsible for at least 50% of deaths occurring in the age group of 15 to 29 years.,"in the age group of 60 years and over, proportional mortality from ischemic heart disease is lower than in the age group of 30 to 59 years.","Respiratory diseases, in the age group of 60 years and over, cause more deaths than diseases of the circulatory system.",Educational activities aimed at reducing excessive consumption of alcoholic beverages would have less impact on mortality indicators for the age groups from 15 to 59 years than in the age group of 60 years and over.,,A,test
-70,"A 40-year-old man, who works with forest extractivism in the interior of the state of Amazonas, where he spends most of the year, sought medical attention at a Basic Health Unit due to a lesion exulcerated on his chest 6 months ago, evolving with progressive increase . On physical examination, there are no changes, except for the single lesion below, which was biopsied. The result of the histopathological examination expected for this case and the proposed treatment must be",neutrophilic infiltrate with an apple green appearance when stained with Congo Red; fluconazole.,Kupffer cells accompanied by regenerative nodules with areas of fibrosis; prednisone.,nonspecific inflammatory infiltrate with Hürthle cells and presence of vascular invasion; benznidazole.,granulomas and rounded structures compatible with amastigote forms; N-methylglucamine.,,D,test
-71,"A 55-year-old woman seeks the referred emergency unit complaining of tight chest pain for 12 hours. Personal history: type 2 diabetic, for 12 years, using metformin 1,500 mg per day and glicazide 30 mg per day, high blood pressure, for 8 years, using captopril 150 mg per day. Physical examination on admission: BP = 100 x 60 mmHg, HR = 70 bpm, RR = 18 bpm, Sat = 92%. Regular heart rhythm in 2 beats without murmurs, symmetrical vesicular murmur with crackling rales at the base, globular abdomen, liver 4 cm from the right costal margin, spleen not percussible. Extremities: decreased peripheral pulses, 3+/4+ edema. ECG below.  Given the situation presented, diagnosis and treatment are",acute myocardial infarction and thrombolysis with ateplase.,advanced myocardial infarction and catheterization. ,acute coronary syndrome and intra-aortic balloon pump.,acute pericarditis and colchicine.,,B,test
-72,"A 24-year-old primigravida attends a routine prenatal medical appointment at 38 weeks. Reports cramping pain associated with uterine contractions. During the obstetric examination, she presented positive uterine dynamics and, after Leopold's maneuvers, the back was noted on the right, with the cephalic pole in the pelvis, as shown in the following figure. Based on this information, the situation, presentation and position of the fetus are, respectively, ","cephalic situation, longitudinal presentation, variety of occipital-left-posterior position.","cephalic situation, longitudinal presentation, variety of occiput-right-posterior position.","longitudinal situation, cephalic presentation, occiput-right-posterior variety of position.","longitudinal situation, cephalic presentation, variety of nasal-left-posterior position.",,C,test
-73,"A 64-year-old patient was taken by family members to the emergency unit shortly after experiencing an episode of syncope. According to the patient, he had already experienced 2 other episodes in the last 3 months, always preceded by a feeling of “dizziness”, and, eventually, he has felt the impression of weakness, “dimming of vision” and a feeling of imminent fall. There is no relevant data on the patient's past pathological history, as he does not use any medication regularly. On physical examination, the patient was bradycardic (42 beats per minute), normotensive, with a regular heart rhythm in 3 beats (B4), without murmurs. His jugular venous pulse revealed the presence of intermittent “cannon a” waves. An electrocardiogram was performed, which revealed a pattern similar to that illustrated in the figure below. The emergency physician treating this patient should explain to him that it will be necessary to carry out",electrical cardioversion.,ablation of anomalous pathway. , permanent pacemaker implantation. ,electrical isolation of the pulmonary tract. ,,C,test
-74,"A 55-year-old man reports bilious vomiting, colicky abdominal pain and cessation of gas and feces elimination for about 3 hours. He had surgery for a perforated peptic ulcer 5 years ago. His physical examination shows: scar from the median xiphopubian incision, abdomen that is slightly distended and painful on deep palpation, with no signs of peritoneal irritation. It was not possible to palpate masses and/or visceromegaly. The image below corresponds to the abdominal x-ray of this patient. In this case, besides water and electrolyte replacement, what is the most appropriate approach?  ",Diagnostic videolaparoscopy.,Emergency exploratory laparotomy.,Nasogastric tube and clinical observation.,Colonic decompression by rectosigmoidoscopy. ,,C,test
-75,"A 30-year-old male patient was seen in the emergency room, complaining of itchy eyes and watering for two days. On physical examination, he presented conjunctival hyperemia, with swollen eyelids and ulcerated and crusted edges, as shown in the image below. Considering the main diagnostic hypothesis, what is the most common etiological agent? ",Adenovirus. ,Herpes simplex. ,Staphylococcus aureus. ,Chlamydia trachomatis.,,C,test
-76,"Figures 1 and 2, below, were extracted from an epidemiological bulletin from the Ministry of Health published on April 20, 2020, at the beginning of the covid-19 pandemic in Brazil. According to the data in the graphs presented, select the correct option regarding the race/ethnicity of people with SARS due to Covid-19, at that time of the pandemic.  ",There were more deaths of indigenous people than of people of yellow race/ethnicity. ,White people had better survival than people of other races/ethnicities combined.,"Among people of black race/ethnicity, there were a greater number of hospitalizations than among mixed-race people. ","People of yellow and indigenous race/ethnicity, together, were subjected to more hospitalizations than people of black race/ethnicity.",,B,test
-77,"A 69-year-old woman was seen complaining of colicky abdominal pain for 3 days, accompanied by distension, nausea, hyporexia and cessation of flatus and feces elimination. He reported that, for five months, he had been losing weight and had episodes of abdominal pain, associated with constipation. He has a history of systemic arterial hypertension and is taking losartan 50 mg/day. On physical examination, she was conscious, contacting, pale ++/4, dehydrated +/4, distended, globular abdomen, hypertympanic on the upper floor, slightly painful, with a palpable mass in the hypogastrium, negative sudden decompression. Laboratory tests and an abdominal x-ray were performed, the image of which is presented below. Considering the information from this case and the previous image, select the option that correctly indicates the diagnosis and the image finding, respectively.",Intestinal obstruction; distension of small intestine and colon loops.,Obstructive acute abdomen; pneumoperitoneum and absence of air in the rectal ampulla.,Low intestinal obstruction; colonic distension and competent ileocecal valve.,Intestinal constipation; air in the rectal ampulla and distension of the colon and small intestine.,,C,test
-78,"A patient at 39 weeks and 2 days of gestation arrives at the emergency care unit for obstetric evaluation and, after anamnesis and general physical examination, a fetal presentation was found in the vaginal examination as illustrated in the photo below. Regarding the photo, it is correct to say that it is a cephalic presentation ","1st degree deflection, bregmatic.","2nd degree deflection, from the forehead. ","3rd degree deflection, facing. ","flexed, occipital",,C,test
-79,"A 20-year-old patient was treated in the emergency room of a secondary hospital, victim of an accidental burn to the upper limbs and anterior part of the chest, which occurred 30 minutes ago. Conscious and oriented, she complains of pain at the burn site and nausea. On physical examination, upper limbs are observed with hyperemia and blisters throughout; blood pressure of 80 × 50 mmHg, heart rate of 120 beats per minute, respiratory rate of 35 breaths per minute, body mass index of 40 kg/m2. An attempt was made to obtain central venous access in the right femoral vein, without success. Successful right subclavian central access. Approximately 25 minutes after starting hydration and intravenous analgesia, the patient reported ""shortness of breath"". A chest X-ray was requested, which showed the following image. Considering the most frequent complication in deep venous access via the subclavian route in the context of the case presented, the image shows  ","pneumothorax, requiring immediate intervention for drainage and decompression. ","hemothorax, compressing structures and imposing immediate intervention for drainage and decompression. ","hydrothorax, a new contralateral puncture, via the jugular route, is recommended to establish a new central access route.","right diaphragmatic elevation, due to phrenic paralysis, a new contralateral puncture, via the jugular route, is recommended to establish a new central access route.",,A,test
-80,"A doctor started working in a Family Health team (ESF) in a large urban center. In the first team meeting, he questioned how workers organized their work process to understand the specificities and needs of the population in the area, from the point of view of social determinants of health (DSS). The professionals participating in the meeting were unable to answer this question. The social determinants of health (DSS) model proposed by Dahlgren and Whitehead is presented below.  Considering the model of social determination of health presented, professionals in this ESF should ","consider that only genetic factors, lifestyle and social and community networks should be evaluated to recognize the specificities of the population in the area covered. ","understand that, although living and working conditions are important for the DSS, they do not influence or guide the activities carried out in the territory. ","consider hereditary factors; lifestyle; general socioeconomic, cultural and environmental conditions are the most important factors in determining their actions.","understand that individuals and their individual characteristics of age, sex and hereditary factors are at the basis of the model, and individual lifestyles are situated on the threshold between individual factors and the DSS.",,D,test
-81,"A 19-year-old man, previously healthy, comes to the health unit for consultation reporting the appearance, a few weeks ago, of a single lesion on his right hand. Initially, the lesion was like a papule, which progressively increased until it had its current appearance. The patient is a military man, mixed race, serving in the Amazon forest, single, born in Belém do Pará. He denies pain. On examination, the lesion has a firm consistency and appearance as shown in the image. Given this information, what are, respectively, the most likely diagnosis and appropriate treatment for this patient?",Blastomycosis; prescription for oral itraconazole.,Squamous cell carcinoma; performing surgical excision of the lesion. ,"Leprosy; administration of rifampicin, clofazimine and dapsone.",Cutaneous leishmaniasis; treatment with antimoniate N-methylglucamine.,,D,test
-82,"A 58-year-old man, a construction worker, comes to the clinic with a clinical history of facial injury for approximately 4 years, with growth for 2 months, as shown in the following figure. He denies other skin lesions or other comorbidities. The physical examination was unremarkable. Based on this information, what is the most likely diagnostic hypothesis? ",Melanoma,Melanocytic nevus. ,Seborrheic keratosis.,Squamous cell carcinoma.,,A,test
-83,"The case of a 72-year-old man is evaluated at a team meeting at the basic health unit after a home visit carried out by the community health agent (CHA). The 68-year-old wife, upon noticing a worsening of urinary incontinence, associated with significant weight loss over 8 months, took the elderly man to a urologist, who had abandoned his previous follow-up for benign prostatic hyperplasia (BPH). The visit was requested because upon receiving the diagnosis of advanced prostate cancer with no possibility of cure, the wife noticed the elderly man's lack of interest in carrying out daily tasks and in taking a shower, getting out of bed and getting dressed, in addition to the lack of support, in regarding the care of the father, of the couple's daughter, a 33-year-old woman who is a lot of work, according to the mother. The ecomap shown below was constructed by team members, considering other information collected by the ACS during the home visit. Based on the information presented in the text and on the ecomap, the family health team should","develop a definitive singular therapeutic project for the wife to guide and follow, as the elderly man has no prospect of a cure. ","suggest compulsory hospitalization for treatment of the couple's daughter, reducing the number of problems that the elderly man's wife will need to manage at this stage.","recognize the dynamics of family functioning, detecting dysfunctionalities and planning early interventions in the search for rebalancing this structure of relationships.",suggest the hospitalization of the elderly person in a palliative care service to enable a prepared palliative care team to manage the care provided.,,C,test
-84,"In relation to the assumptions and characteristics of the Unified Health System (SUS) and Primary Health Care (PHC), the cartoon presented is related to problems of ","decentralization and hierarchization, since many people would like to be served at the same time, in one place. ","accessibility and management, since underfunding and undermanagement can explain the long queues to access the system. ","resolubility and completeness, since patients who are seen first will have a greater chance of having their problems resolved. ","universality and coordination of care, since the “least sick” patient or with the least care needs is at the end of the queue. ",,B,test
-85,"A late premature newborn of 36 weeks gestational age was born by cesarean section after rupture of the amniotic membranes without progressing to labor. In the immediate postpartum period, the newborn developed tachypnea, presenting a respiratory rate of 70 breaths per minute, intercostal retraction, sternal retraction, cyanosis and need for oxygen therapy. Chest x-rays were taken at 1 hour, 12 hours and 24 hours of life, which are shown, respectively, below. Considering the patient's radiological evolution, it is correct to state that the diagnosis is compatible with ",congenital pneumonia.,hyaline membrane disease. ,meconium aspiration syndrome. ,transient tachypnea of ​​the newborn. ,,D,test
-86,"A 58-year-old man is taken to the emergency room due to severe, squeezing, retrosternal pain radiating to the left arm, which began 1 hour ago. He is hypertensive, diabetic and a smoker. He underwent angioplasty via cardiac catheterization, with resolution of his symptoms. On the second day after angioplasty, during a visit from a family member, the level of consciousness suddenly decreased and the patient remained with a central pulse. The cardiac monitor showed the following tracing. Given the clinical picture presented, the action to be adopted immediately is ",perform electrical cardioversion.,perform a new cardiac catheterization.,administer intravenous metoprolol. ,administer intravenous lidocaine. ,,A,test
-87,"A full-term newborn, appropriate for gestational age, evolved without meconium elimination in the first 48 hours of life. Afterwards, he developed vomiting, showing hypoactivity, refusing to breastfeed and abdominal distension. On physical examination, he is dehydrated, pale, with a distended and painful abdomen, with decreased bowel sounds. During rectal examination, an unchanged anus is noted, with a large amount of meconium being eliminated. An abdominal x-ray was performed, shown below. Based on the case presented and the radiological image, select the correct propaedeutic.  ",Colonoscopy without emergency biopsy is indicated for diagnostic confirmation. ,The double bubble sign present on a plain abdominal x-ray suggests the diagnosis. ,"Detailed clinical examination, associated with abdominal ultrasound confirms the diagnosis. ","Barium retention barium enema, 24 to 36 hours after the exam, suggests the diagnosis. ",,D,test
-88,"A 25-year-old patient, 34 weeks pregnant, attends a prenatal consultation at the basic health unit. Her pregnancy is classified as normal risk and all her routine prenatal laboratory tests are normal. The doctor then performs an obstetric physical examination, including the uterine height, which measures 31 cm. Obstetric palpation and fetal statics are represented in Figure 1, while the uterine height graph for the week of gestation is presented in Figure 2. Based on the analysis of the information presented, it is correct to state that fetal statics and height measurement uterus meet the longitudinal fetus, and ","cephalic, back on the right and uterine height appropriate for gestational age.","cormic, back to the right and uterine height reduced for gestational age.","cormic, dorsum on the left and uterine height reduced for gestational age. ","cephalic, back on the left and uterine height appropriate for gestational age.",,D,test
-89,"A police officer takes a homeless man, approximately 55 years old, to the emergency room, who has a fever (armpit temperature of 38.8 °C) and a cough with copious putrid sputum that started several weeks ago. The patient is an alcoholic, crack user and does not know how to report any previous illnesses. A chest x-ray was performed, which can be seen below. Based on this clinical picture, select the option that indicates, respectively, the most likely diagnosis and the most appropriate initial management. ",Pulmonary thromboembolism; start anticoagulation. ,Lung abscess; start empirical antibiotic therapy.,Primary lung neoplasm; wait for bronchoscopy and biopsy. ,Pulmonary tuberculosis; wait for culture results M. tuberculosis. ,,B,test
-90,"A 3-month-old infant has had intestinal constipation since birth, with a 48-hour delay in meconium elimination. The patient was diagnosed with aganglionosis throughout the sigmoid and is awaiting surgery. The day before, he had an episode of large amounts of bloody diarrhea, with fever, abdominal distension and cessation of gas and feces elimination. He arrived at the emergency department in poor general condition, pale, hypotensive, sweating, tachycardic, with significant abdominal distension and an axillary temperature of 38 °C. At this time, volume replacement, decompression with a nasogastric and rectal tube were performed and broad-spectrum antibiotics were administered to cover aerobic and anaerobic organisms. Next, the results of the imaging exam brought by the patient's mother to the emergency room are reproduced. Based on this information, it is correct to state that, after the patient's clinical stabilization, definitive treatment is ",endoanal colon lowering without colostomy.,abdominoperineal colon lowering with colostomy. ,decompressive colostomy in the colon dilation zone.,Abdominoperineal sigmoidectomy with definitive colostomy.,,A,test
-91,"A 2-month-old baby is taken by his mother to the emergency room at the region's referral hospital. She complains that her son is not moving his legs and that he cries a lot during diaper changes. His mother denies that he suffered trauma, violence or that he had a fever. The baby was born at 36 weeks, in an uneventful home birth. The pregnancy took place without prenatal care. There was also no heel prick test (neonatal screening). On physical examination, the baby was noted to be crying, pale, jaundiced, with no skin lesions. On ocular examination, a translucent and symmetrical red reflex is noted. Examination of the respiratory and cardiovascular systems is unremarkable. His abdomen is globular, with a palpable liver 3.5 cm from the right costal margin. Regarding neuropsychomotor development, it is noted that the patient observes the doctor's face during the examination, raises his head in a prone position, does not open his hands, does not smile when stimulated and reacts to sounds, but does not emit them. Below, you can see the results of the lower limb x-ray, carried out after this initial treatment. Considering the clinical case and the available work-up, what are, respectively, the likely diagnosis and the most appropriate medical management in this situation?  ",Neonatal hepatitis; request a full abdominal ultrasound. ,Congenital syphilis; request serology and start crystalline penicillin.,Shaken baby syndrome; carry out notification of violence. ,Hypothyroidism with developmental delay; order TSH and T4 tests,,B,test
-92,"A 37-year-old man, homeless for a long time, with poor personal hygiene conditions, a history of alcohol and crack abuse, seeks treatment at an emergency unit due to an unmeasured intermittent low-grade fever, productive cough with greenish sputum streaked with blood and a foul odor, general weakness and weight loss. He states that the condition has been evolving for around 3 weeks. Once the exams were carried out, the rapid molecular test showed an undetectable result for mycobacteria and the result of the simple chest x-ray is reproduced in the image below. The patient is then referred to hospital, and an antimicrobial regimen is started with Ceftriaxone and Metronidazole intravenously. After 20 days of treatment, the patient continues episodes of intermittent low-grade fever, but with less intensity, and reports that the symptoms initially described persist, except for the reduction in hemoptysis. A new simple chest x-ray was performed and it was noted that the image showed maintenance of the initial changes. The recommended course of action in this case is",change the treatment regimen to antibiotics with coverage for multidrug-resistant bacteria.,"initiate empirical treatment for pulmonary tuberculosis, considering the high clinical and epidemiological probability. ",maintain the use of antibiotics and indicate a surgical approach with removal of the lesion and the affected lung segment. ,"maintain the antibiotic regimen and monitor clinical evolution, considering a slow and favorable response.",,C,test
-93,"A second pregnant woman with a previous vaginal birth and no comorbidities arrives at the maternity ward in labor. Ten minutes after midnight, after evaluating the labor process, normal progress was observed. A physical examination was carried out on the patient, showing a positive plane presentation (+2), cervix 100% effaced, 8 centimeters dilated, ruptured pouch. Upon auscultation of the fetal heartbeat, the attending physician notices a drop in the heartbeat and, therefore, chooses to perform a cardiotocography, the results of which are shown below. In view of the cardiotocographic tracing, select the correct option.","The baseline is between 100 and 150 bpm, variability is increased, decelerations are of the early type, therefore, intrauterine resuscitation should be the approach. ","The baseline is between 110 and 160 bpm, the variability is moderate, the decelerations are of the late type, therefore, the management should be changing the mother's position and intravenous hydration.","The baseline is between 110 and 160 bpm, the variability is moderate, the decelerations are of the early type, therefore, the management must follow the monitoring of labor and delivery. ","The baseline is between 100 and 150 bpm, variability is increased, decelerations are of the variable type with unfavorable characteristics, therefore, the management should be administration of oxygen and sound stimulation.",,C,test