niryuu/sni-each-converted huggingface dataset:
Question: Question linked to the image nº9 11-year-old boy who attends because 10 days ago he has a daily fever of predominance in the evening. In the last 2 days the fever has been increasing (up to 38.5º C). Has little appetite and has lost weight (2 kg). Three weeks ago he was kicked in the right knee. Although initially he only had pain later he noticed inflammation, which was increasing until it prevented him from walking. Analytical: elevation of PCR (75 mg / L) without other significant alterations. Simple radiology is shown. Which of the following is the most likely diagnosis? 
 Options:  <1> Osteomyelitis. <2> Ossifying myositis <3> Eosinophilic granuloma. <4> Osteosarcoma. <5> Osteoblastoma
Output: 4
Question: Question linked to image # 9 What would be the next step in the clinical management of this patient? 
 Options:  <1> Intravenous antibiotic treatment and radiological control in one month. <2> Perform fine needle aspiration of the lesion for microbiological study. <3> Magnetic resonance of the femur and then, if appropriate, biopsy of the lesion. <4> Anti-inflammatory treatment and clinical-radiological evolutionary control. <5> Perform a bone scan with gallium 67.
Output: 3
Question: Question linked to image nº10 A 4-year-old and 6-month-old boy with a previous normal psychomotor development, which begins to present multiple episodes of medium disconnection with maintained tone and subtle rapid flashing of seconds throughout the day and learning difficulties in the last months. A waking electroencephalogram is performed. An image of the record is shown during the hyperventilation maneuver. What epileptic syndrome corresponds? 
 Options:  <1> Juvenile myoclonic epilepsy. <2> Lennox-Gastaut syndrome. <3> Benign partial epilepsy of childhood with centrotemporal tips. <4> Childhood absence epilepsy. <5> West syndrome.
Output: 4
Question: Question linked to image # 10 In the previous patient, which of the following treatments is of choice? 
 Options:  <1> Carbamazepine <2> Vigabatrin <3> Valproic acid. <4> Topiramate. <5> Levetiracetam
Output: 3
Question: Question linked to image nº11 49-year-old patient without a history of interest. He reports a 2-week history of diffuse abdominal pain independent of ingestion and deposition and accompanied by occasional vomiting, malaise and profuse sweating. Analytical: Hb 12 gr / dL. Leucocytes 10x10 ^ 9 / L (Neutrophil 80%, Lymphocytes 15%, Monocytes 3%, Eosinophils 1%). Platelets 270x10 ^ 9 / L. Glucose 100 mg / dL, Urea 80 mg / dL, Creatinine 1.5 mg / dL, A. Uric 12 mg / dL, LDH 7800 IU / L; GOT, GPT and normal alkaline phosphatase. CT: Large mass (16cm) in retroperitoneum infiltrating pancreas, small bowel loops and right kidney. The biopsy is the one shown in the image. Immunohistochemistry: CD20 (+) CD3 (-) bcl 2 (-), CD10 +, bcl 6 (+), P53 (-), TDT (-) Mib1 (proliferation index) 100%. Genetics: rearrangement of 8q24, c-myc gene. Which is the diagnosis? 
 Options:  <1> Diffuse B-cell large lymphoma. <2> Lymphocytic lymphoma <3> Follicular lymphoma 3b. <4> T-cell lymphoma of the intestinal type. <5> Burkitt lymphoma.
Output: 5
Question: Question linked to image nº11 Which treatment is most appropriate in the previous patient? 
 Options:  <1> Cytoreductive surgery followed by chemotherapy type Rituximab-CHOP until complete remission. <2> Rituximab-CHOP / 21 x 6-8 cycles followed by retroperitoneal radiotherapy. <3> Rituximab-CHOP / 21 x 6-8 cycles followed by intensive QT and stem-cell transplantation (TASPE). <4> Intensive chemotherapy that includes Rituximab, high doses of cyclophosphamide and CNS prophylaxis. <5> Delay treatment until PET-CT and then treat with Rituximab-CHOP / 14 x 6-8 cycles.
Output: 4
Question: Question linked to image # 12 In the CT that is shown, the most likely diagnosis is: 
 Options:  <1> Polycystic kidney disease <2> Retroperitoneal mass. <3> Renal tuberculosis <4> Renal cystic neoplasia. <5> Obstructive uropathy.
Output: 5
Question: Question linked to image # 12 Which of the following is the most likely clinic of this patient's consultation? 
 Options:  <1> Macroscopic hematuria. <2> Poliglobulia, pain and fever. <3> Fever, pain and dark urine. <4> Oligoanuria and pain. <5> Febricule and sterile pyuria.
Output: 3
Question: Question linked to image nº13 A 31-year-old man reported a sudden onset of chills, high fever, joint and muscle pain, maculopapular rash predominantly in the extremities, headache and photophobia. It does not refer to any pathological antecedent of interest or travel abroad in the last two years. He is not aware of the existence of communicable diseases in his immediate environment. He lives in a suburban residential area of ​​the Spanish Levante. Physical examination highlights the blackish eschar that can be seen in the image. Point out the vector transmitter of the disease that the patient most likely presents. 
 Options:  <1> Ixodes ricinus. <2> Rhipicephalus sanguineus. <3> Aedes aegypti. <4> Pediculosis corporis. <5> Dermacentor variabilis.
Output: 2
Question: Question linked to image nº13 Which treatment do you consider most appropriate? 
 Options:  <1> Ceftriaxone 1 g / day parenterally. <2> Doxycycline 100 mg / 12h oral. <3> Paracetamol 500 mg / 6h oral. <4> Chloramphenicol 500 mg / 6h oral. <5> Amoxicillin / clavulanic acid 1 g / 8h oral.
Output: 2
Question: Question linked to image no. 14 A 68-year-old man consults for a loss of general condition in the form of asthenia and anorexia and loss of 12 Kg in the last three months. The physical examination only shows a thin patient and the lesion on the soles of the feet that can be seen in the figure. What do you think is the most likely diagnosis and / or most appropriate attitude? 
 Options:  <1> I would look for immune suppression factors, because the lesion seems to correspond to a Norwegian scabies. <2> The skin lesion looks like a callus in a physiological support area, so for now, I would not consider it related to the loss of the general state. <3> The lesion suggests a palmo-plantar form of psoriasis. <4> It seems a form of diffuse seborrheic keratosis associated with age. <5> It suggests a paraneoplastic plantar keratoderma.
Output: 5
Question: Question linked to image nº14 Suppose that the patient does not refer any family history of interest, has never taken illicit drugs or receives usual medical treatment. An analysis performed in a private mutual shows a microcytic and hypochromic anemia, a normal thyroid function, a serology for HIV negative and a determination of arsenic also negative. The chest x-ray is normal. To continue the study, numerous tests could be carried out. Which do you think could help us more at this time? 
 Options:  <1> A bone marrow aspirate. <2> A complete immunological study with ANA, ANCA and complement. <3> I would not do more tests immediately and follow the clinical evolution for a month. <4> A fibrogastroscopy. <5> A biopsy of the plantar lesion.
Output: 4
Question: Question linked to the image nº15 Patient of 25 years of age transferred to the Rescue Box of the Emergency Service after traffic accident. At admission, he is hypotensive, tachycardic and tachypneic. Portable chest radiography shows right costal fractures from the fourth costal arch to the ninth and right pulmonary contusion image, and the pelvis is attached. What is the best behavior next? 
 Options:  <1> Perform abdominal ultrasound in the emergency box. <2> Request a chest computed tomography. <3> Request pelvic angiography. <4> Request computed tomography of the abdomen and pelvis. <5> Immediately enter the patient in the intensive care unit.
Output: 1
Question: Question linked to image # 15 While we are exploring this patient, he has a sudden worsening of his hemodynamic state and an increase in his tachypnea. Tracheal deviation to the left, distended jugular veins and absence of ventilation in the right hemithorax are observed. The most likely diagnosis is: 
 Options:  <1> Progression of the right pulmonary contusion. <2> Expansive right cervical vascular injury. <3> Cardiac tamponade. <4> Right hemothorax <5> Tension pneumothorax.
Output: 5
Question: Question linked to image n ° 16 Patient of 84 years who presents an ulcerated tumor lesion that shows in the scalp of more than 20 years of evolution. No palpable locoregional adenopathies. Obviously the lesion must be biopsied for diagnostic confirmation but, a priori, which of the following diagnoses seems most likely? 
 Options:  <1> Merkel cell tumor. <2> Basal cell carcinoma. <3> Squamous carcinoma <4> Amelanotic malignant melanoma. <5> Cutaneous B-cell lymphoma
Output: 2
Question: Question linked to image n ° 16 If the patient is treated surgically with adequate resection margins, what prognosis do you consider most likely? 
 Options:  <1> Healing very likely, with moderate possibility of local recurrence and very remote possibility of distant metastasis. <2> Local recurrence with an approximate probability of 50%. <3> Probability of lymph node metastasis greater than 50%. <4> Probability of distant metastasis greater than 30%. <5> In this case, surgical treatment should not be considered as the only therapeutic option.
Output: 1
Question: Question linked to image nº17 You receive a biopsy of the duodenum of a 38-year-old woman with no other clinical information. What is the most likely diagnosis? 
 Options:  <1> Intestinal lymphoma: infiltration of the lamina propria and the superficial epithelium by a monotonous lymphoid cell population. <2> Gluten-sensitive enteropathy (celiac disease): intestinal villi atrophy, increased inflammatory infiltrate and intraepithelial lymphocytosis. <3> Lymphangiectasias: dilatation of lymphatic vessels located in the lamina propria of the mucosa. <4> Whipple's disease: accumulations of macrophages of wide cytoplasm and microvacuolate in the lamina propria of the mucosa. <5> Giardiasis: presence of Giardia lamblia trophozoites on the intestinal surface.
Output: 2
Question: Question linked to image nº17 According to the diagnosis issued in the previous question, what is the best therapeutic option? 
 Options:  <1> Diet rich in proteins and low in fat. <2> Metronidazole <3> Trimethoprim and sulfamethoxazole. <4> Chemotherapy. <5> Gluten-free diet
Output: 5
Question: Which of the following statements is correct with respect to hepatic hemangiomas? 
 Options:  <1> They can be associated with the KasabachMerritt syndrome (thrombocytopenia and consumption coagulopathy), especially giant hemangiomas. <2> Surgical exeresis should be indicated from the moment it is diagnosed if its diameter is greater than 3 cm. <3> Percutaneous embolization is the most recommended therapeutic option for this type of tumor. <4> The best method for its diagnostic confirmation is percutaneous biopsy of the liver lesion. <5> Hepatic MRI does not usually offer much help for its diagnostic characterization.
Output: 1
Question: A 76-year-old woman came to the emergency room referring to pain in the right groin and vomiting for about 6 hours. On examination, a hard consistency tumor is palpable just below the line joining the anterosuperior iliac spine and the pubis (which corresponds to the location of the inguinal ligament). Most likely, it is one: 
 Options:  <1> Direct inguinal hernia. <2> Spiegel hernia. <3> Indirect inguinal hernia. <4> Femoral hernia (crural). <5> Obturator hernia
Output: 4
Question: An 80-year-old man with a history of hypertension, ischemic heart disease and COPD, who underwent a complete rectocolonoscopy due to rectal bleeding, with the following findings: polypoid lesion 3 cm in diameter located 10 cm from the anal margin, occupying the half of the circumference. Rest of exploration without findings until blind. In the polyp biopsy, an adenocarcinoma limited to the submucosa is seen. Endorectal ultrasound: uT1N0. Pelvic MRI: T1N0. TC: No evidence of disease at a distance. What will be the most likely therapeutic decision to be made in the Multidisciplinary Tumor Commission? 
 Options:  <1> Abdominal-perineal rectum amputation. <2> Neoadjuvant radiotherapy and low anterior resection of the rectum by laparoscopy. <3> Transanal endoscopic microsurgery. <4> Anterior low resection of laparotomic rectus. <5> Anterior low resection of laparoscopic rectal route and adjuvant radiotherapy.
Output: 3
Question: A colonoscopy of colorectal cancer screening is performed on a patient with ulcerative colitis with involvement up to the transverse colon. Colonoscopy shows no signs of inflammatory activity. Multiple biopsies were performed every 10 cm. The biopsies were reviewed by 2 expert pathologists demonstrating a focus of high grade dysplasia in one of the biopsies performed in the sigmoid colon. What would you indicate next? 
 Options:  <1> Repeat the colonoscopy to confirm the diagnosis. <2> Intensive surveillance with colonoscopy every 3 to 6 months. <3> Repeat the examination and perform a chromoendoscopy to identify the lesion and perform an endoscopic mucosectomy. <4> Total proctocolectomy. <5> Treatment with mesalazine at doses of 2-3 grams per day and repeat the scan at 3 to 6 months.
Output: 4
Question: Regarding gastroesophageal reflux disease, which of the following statements is true? 
 Options:  <1> The intensity and frequency of heartburn has little relationship with the presence and severity of endoscopic esophagitis. <2> Most patients with gastroesophageal reflux disease have esophagitis at endoscopy. <3> Treatment with proton pump inhibitors usually achieves good control of symptoms but is not superior to placebo in the endoscopic cure of esophagitis. <4> Barrett's esophagus can progress to low-grade epithelial dysplasia, high-grade epithelial dysplasia, and finally squamous cell carcinoma of the esophagus. <5> Endoscopic screening and surveillance programs have unequivocally shown to be able to reduce mortality in patients with Barrett's esophagus.
Output: 1
Question: In which of these patients would the appropriate surgical treatment be the performance of an atypical wedge gastrectomy by laparoscopy without extended lymphadenectomy? 
 Options:  <1> Infiltrating and ulcerated gastric adenocarcinoma at the antro-pylorus level. <2> Subcardial infiltrating gastric adenocarcinoma. <3> Gastrointestinal stromal tumor at the level of the gastric body-greater curvature. <4> Lymphoma MALT. <5> Barrett's esophagus with intestinal metaplasia and dysplasia.
Output: 3
Question: A 25-year-old man consults for jaundice. He practices bodybuilding and has injected anabolic steroids substitutes for 17alkalkyl, three weeks before. For a tonsillitis he had taken amoxicillin-clavulanic acid which he removed 15 days ago. Analytical: AST 1200 IU / L (normal upper limit, lsn 40), ALT 1300 IU / L (lsn 40), GGT 150 IU / L (lsn 50), alkaline phosphatase 180 IU / L (lsn 105), total bililrubin 4 , 8 mg / dL with direct bilirubin predominance. Serology of virus B: Anti-HBs and Anti-HBc positive. Ultrasound suggests grade I steatosis. What is the most likely diagnosis? 
 Options:  <1> Hepatitis by amoxicillin-clavulanic acid. <2> Anabolic steroid hepatitis. <3> Acute hepatitis B virus <4> Non-alcoholic steatohepatitis. <5> Cholestasis due to drugs.
Output: 1
Question: The recommended antibiotic treatment for acute diarrhea caused by Clostridium difficile is: 
 Options:  <1> Administer vancomycin orally. <2> Administer vancomycin intravenously. <3> Administer ciprofloxacin orally. <4> Administer metronidazole orally. <5> Administer rifaximin orally.
Output: 4
Question: In the process of defecation is TRUE: 
 Options:  <1> When the feces penetrate the rectal ampulla, relaxation of the internal anal sphincter occurs consciously. <2> When the feces penetrate the rectal ampulla, the external anal sphincter relaxes unconsciously. <3> The external anal sphincter is controlled by nerve fibers of the pudendal nerve, part of the somatic nervous system, and therefore under voluntary conscious control. <4> The propulsive movements of the colon under normal conditions require one hour to move the chyme through the entire colon from the ileocal valve. <5> During defecation the contraction of the floor of the pelvis occurs.
Output: 3
Question: In relation to intraductal papillary mucinous tumors of the pancreas, point out the WRONG statement: 
 Options:  <1> They are potentially malignant tumors. <2> Its frequency has increased notably in the last decade. <3> Three subtypes are distinguished: main conduit, secondary conduit and mixed conduit. <4> They should be excised as soon as they are diagnosed, except the main duct variety. <5> Its first clinical manifestation can be a picture of acute pancreatitis.
Output: 4
Question: A 49-year-old woman came to the emergency room due to shivering, fever of 39ºC, pain in the right hypochondrium, jaundice and vomiting. The scan reveals TA 100/50 mmHg. FC 110 lpm. Prostration and pain on palpation in the right quadrant, with positive Murphy. The analytical sample shows leukocytosis with left deviation and abdominal ultrasound, cholelithiasis, choledocholithiasis and dilation of the extrahepatic bile duct. Empirical treatment is started with antibiotic and fluid therapy. What is the most effective procedure to perform next? 
 Options:  <1> Maintain antibiotic treatment and support measures with posterior regulated cholecystectomy. <2> Laparoscopic cholecystectomy. <3> Placement of an external biliary drainage. <4> Urgent cholecystectomy with cannulation of the common bile duct. <5> Endoscopic retrograde cholangiopancreatography with sphincterotomy.
Output: 5
Question: A 60-year-old woman, diagnosed with diabetes mellitus type 2 and hypertension, consults for palpitations of weeks of evolution. Provides an electrocardiogram performed a week ago in which he is in atrial fibrillation with an average ventricular rate of 70 beats / min. In the physical examination and in a new electrocardiogram performed in consultation is in sinus rhythm. Is it necessary to anticoagulate it chronically? 
 Options:  <1> It is not necessary to anticoagulate because it has a paroxysmal atrial fibrillation and is not currently in atrial fibrillation. <2> It is not necessary to anticoagulate because it is less than 75 years old and has not had a previous stroke. <3> You must be chronically anticoagulated because you have a CHADS of 2 and a CHADS-VASc of 3. <4> Anticoagulation is not necessary, but antiaggregation with acetylsalicylic acid may be prescribed. <5> Must be anticoagulated only with subcutaneous low molecular weight heparin when in atrial fibrillation.
Output: 3
Question: A 32-year-old man with no history of interest or cardiovascular risk factors. Clinic of dyspnea when climbing a floor of stairs of 1 month of evolution. Consultation due to sudden syncope preceded by exertion. Family history of death not explained abruptly in his brother. On physical examination, a more audible rumen systolic murmur with aortic focus is highlighted. The electrocardiogram performed in the consultation shows a sinus rhythm with a compatible pattern of left ventricular hypertrophy. An echocardiogram was performed to document an important asymmetric hypertrophy of the interventricular septum with a subvalvular dynamic gradient of 70 mmHg with moderate secondary mitral regurgitation and preserved left ventricular ejection fraction. Which therapeutic option is the LESS indicated? 
 Options:  <1> Beta-blockers. <2> Digoxin <3> Calcium-non-dihydropyridine antagonists. <4> Implantable automatic defibrillator. <5> Surgical septal myomectomy of Morrow.
Output: 2
Question: A 65-year-old man, smoker and diabetic, is brought to the Emergency Department for presenting an oppressive, deep-throating sweat for about an hour. In the ECG performed, sinus rhythm was observed at 80 bpm and a complete block of the left branch. What should our attitude be? 
 Options:  <1> Perform an analytical determination of troponin and wait for its result to confirm the presence of an acute myocardial infarction. <2> Treat the patient as if it were an infarction with ST-segment elevation, proposing a reperfusion therapy as early as possible. <3> To implant a transcutaneous pacemaker before the possibility of developing a more advanced block. <4> Perform an urgent CT to rule out the presence of an acute pulmonary embolism. <5> As it could be an acute pericarditis, we will administer NSAIDs.
Output: 2
Question: A patient goes to the hospital for a myocardial infarction with ST segment elevation. Upon arrival, he is hypotensive, presents crackles and a systolic murmur is heard 3/6. What is your diagnostic suspicion? 
 Options:  <1> Cardiogenic shock. <2> Rupture of free wall of left ventricle. <3> Acute mitral failure due to papillary muscle rupture. <4> Cardiac tamponade. <5> Thrombosis of the common trunk.
Output: 3
Question: Man of 55 years, obese, dyslipidemic and active smoker. In study for refractory hypertension without evidence of cardiac or renal damage so far. He refers to morning headache with daytime hypersomnia. ABPM was performed (ambulatory blood pressure monitoring 24 hours) and arterial hypertension was confirmed despite 3 drugs, one of them diuretic, with higher nighttime blood pressures than daytime blood pressure. What diagnostic test would you request next with your clinical suspicion? 
 Options:  <1> Determination of catecholamines in urine 24h. <2> Hormonal determination of renin-aldosterone. <3> Night polysomnography. <4> Doppler ultrasound <5> CT aorta.
Output: 3
Question: One of the following statements about the epidemiology and prognosis of heart failure is INCORRECT. Point it out 
 Options:  <1> Between 60 and 70% of patients die in the first 5 years after establishing the diagnosis of heart failure. <2> The functional situation of the patient with heart failure is the one that best correlates with the expectation of survival. <3> Diastolic dysfunction predominates in elderly women with a history of chronic hypertension. <4> Heart failure due to systolic dysfunction is usually observed in male patients with ischemic heart disease. <5> The prevalence of heart failure is decreasing in the last decade thanks to better control of cardiovascular risk factors.
Output: 5
Question: Patient of 79 years, hypertensive, hyperlipidemic, diabetic and with COPD in treatment with inhaled anticholinergics. He presents chronic atrial fibrillation on anticoagulant treatment with dicumarin. After a 3-day cough, yellow sputum and fever of 38 ° C, presented in the last 24 h progressive worsening with dyspnea of ​​effort, orthopnea and malleolar edema. The examination included a TA of 170/95 mmHg, dyspnea with a respiratory rate of 20 rpm and auscultation with bilateral wheezing and crackling in bases. Tachyarrhythmia at 110 bpm. Discrete malleolar edemas. What is the approach to follow? 
 Options:  <1> The patient probably has pneumonia and the priority is to perform a chest X-ray to confirm it. <2> It is probably an exacerbation of your COPD due to respiratory overinfection. Reinforce the basic treatment with an inhaled beta-2, corticoids and antibiotics and monitor evolution. <3> You probably have a component of left heart failure associated with a febrile respiratory infection. It would be a priority to treat it with vasodilators and diuretics in addition to the treatment that corresponds to their respiratory infection, bronchodilators, etc. <4> The patient is not classified for the severity of his COPD, which would indicate an immediate spirometry to adjust the treatment to the severity of the obstruction. It would also associate an antibiotic given the apparent picture of respiratory overinfection. <5> An echocardiogram would be the first exploration to be performed to rule out a possible component of heart failure associated with the exacerbated COPD episode presented by the patient.
Output: 3
Question: The volume overload of the left ventricle appears in: 
 Options:  <1> Stenosis of heart valves. <2> Coarctation of the aorta. <3> Resting angina. <4> The insufficiencies of the heart valves. <5> Rheumatic fever.
Output: 4
Question: What is the most frequent etiology of aortic stenosis in adults? 
 Options:  <1> Rheumatic <2> Congenital <3> Degenerative or calcified <4> Post endocarditis. <5> Ischemic
Output: 3
Question: In a patient with asthma symptoms, diagnostic confirmation of the disease will be made first by: 
 Options:  <1> The finding of a reversible obstruction of air flow in spirometry. <2> A positive allergic skin test. <3> An increase in the number of eosinophils in the induced sputum. <4> The elevation of nitric oxide in exhaled air (FENO). <5> The presence of a specific IgE in blood to an aeroallergen.
Output: 1
Question: The surgical treatment of COPD, or lung volume reduction surgery, is currently a therapeutic weapon more within the multidisciplinary treatment of it. Which of the following statements is correct? 
 Options:  <1> The indication for surgical treatment will be in those patients who have moderate / severe congestive heart failure at the same time. <2> The presence of a pulmonary artery systolic pressure lower than 45 is an absolute contraindication. <3> COPD with emphysematous predominance in lower and middle lobes associated with pleural pathology is associated with better results. <4> The presence of a diffuse distribution of emphysema with FEV1> 20% and DLCO <20% are indicators of good prognosis. <5> Pre-surgical rehabilitation along with the distribution of emphysema in the upper lobes and the ability to perform postoperative physical exercise makes the results of the surgery beneficial.
Output: 5
Question: Regarding the treatment of patients with COPD, point out the FALSE answer: 
 Options:  <1> The regular use of ipratropium bromide has been associated with a decrease in mortality. <2> In a patient with arterial oxygen saturation of less than 90% and signs of pulmonary hypertension, the use of supplemental oxygen should be considered. <3> The regular use of inhaled corticosteroids does not influence the rate of deterioration of lung function. <4> Long-acting beta-adrenergic agonists provide symptomatic benefits similar to those of ipratropium bromide. <5> In patients hospitalized for exacerbation, corticosteroid therapy has been shown to shorten hospitalization time.
Output: 1
Question: 73-year-old man, ex-smoker, history of hypertension, grade II obesity, type 2 diabetes and severe COPD with chronic home oxygen therapy. He went to the Emergency Department due to a progressive increase in his habitual dyspnea, purulent expectoration and a temperature of 37.9ºC in 4 days of evolution. His family doctor had prescribed moxifloxacin, paracetamol, deflazacort, aerosol therapy and increased oxygen flow 2 days before. On physical examination the patient is in regular general condition, conscious, sleep tendency, tachypneic at 28 rpm and utilization of accessory muscles, temperature 38.2ºC, oxygen saturation of 87%, TA 115/62 mmHg, heart rate 110 lpm; vesicular murmur diminished globally, wheezing and scattered rhonchi and moist crepitations in bases. The analyte highlights 16,500 / uL leukocytes with 14,900 neutrophils, hemoglobin 14 g / dL, glucose 240 mg / dL, urea 56 mg / dL, creatinine 1.3 mg / dL, Na 133 mEq / L, K 3.7 mEq / L. In the ECG, sinus tachycardia was observed. The arterial blood gases show: pH 7.29, pCO2 64 mmHg, pO2 59 mmHg, HCO3 28 mg / dL. The chest radiograph shows no condensation or pleural effusion. Which of the following clinical management options would you establish in the first place? 
 Options:  <1> Start treatment with intravenous diuretics, oxygen with a high-flow 50% mask and continue with the rest of the prescribed treatment. <2> Start treatment with salbutamol and steroid sprays, add a cephalosporin to the antibiotic treatment, intensify oxygen therapy in nasal glasses at 4 liters per minute and maintain deflazacort. <3> Start treatment of acidosis with 1M bicarbonate, correct hyperglycemia, maintain antibiotic treatment and prescribe steroids plus intravenous diuretics. <4> Given the patient's serious situation, orotracheal intubation would be carried out prior to preparation (pre-oxygenation and premedication) and to notify Intensive Care Medicine. <5> Start treatment with non-invasive mechanical ventilation (two-level positive pressure mode), prescribe salbutamol aerosols and intravenous steroids and maintain intravenous antibiotic treatment.
Output: 5
Question: A 58-year-old woman attended the consultation due to dyspnea of ​​medium effort, muscle weakness in the upper extremities and dysphagia to solids of three months of evolution. Physical examination revealed a loss of strength in the upper limbs with preserved sensitivity. Pulmonary auscultation shows generalized hypophisis. A chest x-ray is performed, showing uninspired lungs and laminar atelectasis in the lung bases. Gasometry shows pH 7.39, PCO2 48 mmHg, PO2 63 mmHg, HCO3 28 mmol / L, SatO2 93%. The combination of physiological mechanisms that best explain this gasometry is: 
 Options:  <1> Decrease in FiO2 (inspired fraction of oxygen) and alteration of diffusion. <2> Alteration of diffusion and disturbance of the ventilation / perfusion relationship. <3> Alveolar hypoventilation and decrease in FiO2. <4> Disorder of the ventilation / perfusion relationship and alveolar hypoventilation. <5> Increased pulmonary artery pressure and decreased diffusion.
Output: 4
Question: A 70-year-old man presented with progressive dyspnea and a non-productive cough several years old. In chest X-ray, pleural plaques are seen in the mediastinal and diaphragmatic pleura. On CT, these plaques are confirmed, also appreciating the presence of reticulonodulillar involvement predominantly in lower fields. Among the following, what attitude would you recommend in the first place? 
 Options:  <1> Complete your smoking history. <2> Inquire about occupational exposure. <3> Request blood tests to rule out eosinophilia. <4> Do complete respiratory functional tests. <5> Propose a transbronchial biopsy.
Output: 2
Question: The practice of posteroanterior chest x-ray in forced expiration is very useful for the diagnosis of: 
 Options:  <1> Loculated pleural effusion. <2> Pneumothorax minimum. <3> Hemothorax <4> Pulmonary atelectasis. <5> Pericarditis
Output: 2
Question: A 38-year-old man went to the emergency room for progressive dyspnea and dry cough of a week of evolution. He does not have a history of interest. The vital signs are: temperature 37.8ºC, blood pressure 110/70 mmHg, heart rate 105 bpm and respiratory rate 30 rpm. In the respiratory exploration, percussion dullness, diminution of tactile (vocal) thrill, and diminution of respiratory noises at the base of the right hemithorax stand out. The rest of the physical examination is normal. What is the most likely diagnosis? 
 Options:  <1> Pleural effusion <2> Lobar pneumonia <3> Acute bronchitis. <4> Pulmonary tuberculosis <5> Pneumothorax.
Output: 1
Question: A 68-year-old patient has a tumor mass diagnosed of small cell lung carcinoma in the right main bronchus at 1 cm from the tracheal carina. Mediastinoscopy shows contralateral adenopathies that are positive. The recommended treatment would be: 
 Options:  <1> Chemotherapy with right pneumonectomy. <2> Surgery and subsequent radiotherapy of all affected ganglion chains. <3> Right pneumonectomy and posterior chemotherapy. <4> Chemotherapy and radiotherapy. <5> Radiotherapy.
Output: 4
Question: A patient reporting chest and cervicobrachial pain. Physical examination reveals miosis and unilateral enophthalmos. Chest X-ray shows opacity at the apex and erosion of the first ribs. What is your diagnosis? 
 Options:  <1> Pancoast tumor. <2> Mediastinal tumor. <3> Localized pleural mesothelioma. <4> Bronchioloalveolar tumor. <5> Small cell lung cancer with brain metastases.
Output: 1
Question: A 24-year-old woman with two weekly episodes of headache lasting between one and three days, hemicranial, intense, accompanied by sono and photophobia and nausea. As a preventive treatment, I would NOT consider one of these drugs: 
 Options:  <1> Propranolol <2> Flunarizine <3> Carbamazepine <4> Topiramate. <5> Nadolol
Output: 3
Question: A 30-year-old woman, previously healthy, presents a picture of right facial weakness in the course of about 20 hours, so she can not close her right eye and her mouth has been twisted. Refers to see double with the right lateral gaze. Which of the following diagnostic possibilities seems most likely? 
 Options:  <1> Bell's palsy <2> Ramsay-Hunt syndrome (herpetic facial paralysis). <3> Sarcoidosis <4> Left sylvian infarction with involvement of the rolandic operculum. <5> Protuberant involvement due to an outbreak of multiple sclerosis.
Output: 5
Question: 50-year-old man, mechanic, consulted for a two-year evolution of difficulty in handling the right hand and a feeling of stiffness in the arm. His wife notices his expressionless face and reports that he has very vivid nightmares that wake him up agitated. During the examination, rigidity was observed in the right limbs and slow walking without right arm. What is the most likely diagnosis? 
 Options:  <1> Left thalamic lacunar infarct. <2> Amyotrophic Lateral Sclerosis. <3> Parkinson's disease <4> Cervical plexopathy <5> Corticobasal degeneration.
Output: 3
Question: A 7-year-old boy presents a subacute picture of cerebellar ataxia and intracranial hypertension. Magnetic resonance imaging demonstrates an expansive lesion in the cerebellar vérmix that captures contrast and obstructs the fourth ventricle. The most likely diagnosis is: 
 Options:  <1> Meningioma <2> Cerebellar metastasis. <3> Glioblastoma multiforme. <4> Medulloblastoma <5> Lymphoma
Output: 4
Question: Patient of 70 years with the only antecedent of being ex-alcoholic for 3 years and diagnosed with atrophic gastritis. Consultation for a 4-month evolution that began with distal and symmetrical paresthesias in the lower limbs and progressively added gait difficulty, this being impossible without help, and confusional episodes of paroxysmal presentation. On neurological examination, the cranial nerves are normal, have a slight bradypsychia, failures in deep sensation in four limbs, pseudo-dystonic attitude in the upper limbs, finger-nose dysmetria and bilateral knee heel with closed eyes, extenuated osteotendinous reflexes, bilateral Babinski and distal paresis in upper limbs. Point out the correct answer: 
 Options:  <1> Perform a blood count and determination of B12 when funicular myelosis is suspected. <2> Perform an MRI looking for atrophy of vermis and cerebellar foliae before the high suspicion of alcoholic cerebellar degeneration. <3> Initially, 100 mg of intravenous thiamine should be administered because of suspicion of Wernicke-Korsakoff encephalopathy. <4> The first thing to do would be a determination of natremia to rule out a central pontine myelinolysis. <5> Perform an electromyographic study when there is a high suspicion of primary lateral sclerosis.
Output: 1
Question: A 52-year-old male presents with acute form a confusional syndrome, paresis of both external ocular rectus muscles and gait ataxia. 
 Options:  <1> Hyperglycemic encephalopathy. <2> Korsakoff encephalopathy. <3> Cerebellar infarction. <4> Administer thiamin immediately. <5> Lead poisoning.
Output: 4
Question: A 24-year-old student who, after three weeks of a cold in the upper respiratory tract, visited the doctor for a sensation of numbness in his hands and loss of limb strength in recent days. The picture was preceded by low back pain. In the exploration, it stands out, decrease of asymmetric muscular force in upper and lower extremities, loss of osteotendinous reflexes. In this patient the most likely diagnosis is: 
 Options:  <1> Myasthenia gravis. <2> First outbreak of multiple sclerosis. <3> Acute inflammatory demyelinating polyradiculopathy. <4> Dermatomyositis <5> Amyotrophic Lateral Sclerosis.
Output: 3
Question: A 68-year-old man with a history of diabetes of 20 years of evolution, hypertension and prostatism in treatment, consulted for repeated episodes of syncope. The episodes have occurred while standing, after meals and have been preceded by an oppressive pain in the nape, neck and shoulder girdle. Which of these complementary tests is essential? 
 Options:  <1> Brain and cervical MRI. <2> Angio-MR of the supra-aortic trunks. <3> Nuclear medicine study of cerebral dopamine transporter (SPECT with ioflupane). <4> Measurement of blood pressure in decubitus and standing. <5> 24-hour Holter record of the electrocardiogram.
Output: 4
Question: Which of the following symptoms is NOT present in the Wallemberg syndrome, usually produced by ischemia of the dorsal-lateral region of the bulb? 
 Options:  <1> Diffuse <2> Dysphagia <3> Piramidalism <4> Ataxia. <5> Horner syndrome.
Output: 3
Question: In relation to Hereditary Spherocytosis it is true that: 
 Options:  <1> It is a congenital hemolytic anemia of inheritance linked to the X chromosome that causes severe anemia. <2> It is characterized by a decrease in osmotic fragility. <3> It manifests as episodes of acute medication anemia. <4> Splenectomy is the treatment of choice when it is symptomatic. <5> It is rarely associated with cholelithiasis.
Output: 4
Question: A 45-year-old patient who went to the emergency room for general malaise, headache and progressive tiredness in recent weeks. On physical examination, a slight icteric dye of the skin and mucous membranes was detected and a 2-cm splenomegaly was felt under the costal margin. The analytical presents hemoglobin 8.6 g / dL, VCM 100 fL. The number of reticulocytes is high and anisopoikilocytosis is observed in the blood smear. In the biochemistry highlights LDH 1300 IU / L, bilirubin 2.2 mg / dL and undetectable haptoglobin. Which test is the most appropriate to guide the diagnosis of the patient? 
 Options:  <1> Fecal occult blood test. <2> Test of Coombs. <3> Determination of iron, cobalamin and folic acid. <4> Abdominal ultrasound. <5> Bone marrow aspirate.
Output: 2
Question: 35-year-old woman on hormonal treatment for infertility. He went to the emergency department due to constitutional syndrome and paresthesias in the left side of the body. In blood tests, Hb 7.5 g / dL, reticulocytes 10% (0.52%), platelets 5,000 / uL, normal leukocytes, LDH 1,200 IU / L, direct negative Coombs test, undetectable haptoglobin are detected. Morphology of peripheral blood with abundant schistocytes. Normal coagulation tests. What is the diagnostic suspicion and the most appropriate treatment? 
 Options:  <1> Autoimmune hemolytic anemia. Start steroids. <2> Von Willebrand disease. Administration of desmopressin. <3> Thrombocytopenic purpura. Start steroids and platelet transfusion. <4> Evans syndrome. Start steroids. <5> Thrombotic thrombocytopenic purpura. Treatment with plasmapheresis.
Output: 5
Question: A 70-year-old man should undergo cataract extraction surgery. He has a mitral mechanical prosthesis for 10 years and is being treated with acenocoumarol. The electrocardiogram shows a sinus rhythm. Which of the following recommendations do you find most appropriate? 
 Options:  <1> Perform eye surgery without stopping acenocoumarol. <2> Suspend acenocoumarol 5 days before surgery and restart it the day after it. <3> Suspend acenocoumarol 5 days before surgery, start low molecular weight heparin 3 days before surgery and suspend it 24 hours before surgery. <4> Suspend acenocoumarol 1 day before the intervention and use fresh frozen plasma during it. <5> Suspend acenocoumarol 1 day before the intervention and give vitamin K just before it.
Output: 1
Question: A 29-year-old woman with a history of abundant rules and long-standing iron-deficiency anemia who have required treatment with ferrotherapy since she was 17 years old. Consult because after a tooth extraction you have hemorrhage that has required local hemostatic treatment. He relates that a maternal aunt presents frequent epistaxis. In analytical presents: 8000 leukocytes / uL, Hb 10.7 g / dL, VCM 76 fL, 380,000 platelets / uL; the biochemistry is normal. Prothrombin activity 90%; INR 0.9; Activated Partial Thromboplastin Time (APTT) 48 sec (39 sec) with an APTT ratio of 1.3 and fibrinogen derivative 340 mg / dL. What is the most likely diagnostic suspicion and how would it confirm it? 
 Options:  <1> Hemophilia A and mixtures test. <2> Lupus anticoagulant and ANAS study. <3> Sideroblastic anemia and spinal aspiration. <4> Congenital thrombocytopathy and study of platelet aggregation. <5> Von Willebrand disease and determination of factor vW.
Output: 5
Question: Which of the following statements is FALSE with respect to multiple myeloma? 
 Options:  <1> The cytogenetics and serum levels of albumin and beta2-microglobulin are important data for the prognosis. <2> Bortezomib, thalidomide, lenalidomide and polychemotherapy are very useful therapeutic tools. <3> Autogenic transplantation of hematopoietic progenitors provides a long progression-free survival. <4> Allogeneic transplantation should be considered an experimental procedure (of unproven efficacy). <5> Radiation therapy has no role in the treatment of the disease or its complications.
Output: 5
Question: Patient of 74 years of age, asymptomatic, who in a routine analysis presents platelets 40,000 platelets / μL, the remainder being the normal blood cell count and the complete normal biochemistry. Point out the correct answer: 
 Options:  <1> The most likely diagnosis is an Idiopathic Thrombocytopenic Purpura and steroid treatment should be started as soon as possible. <2> It is a serious thrombocytopenia with a high risk of spontaneous bleeding. <3> A peripheral blood smear should be performed to rule out pseudotrombocytopenia or spurious thrombocytopenia before further measurements are made. <4> The most probable diagnosis is that of a myelodysplastic syndrome, so the initial test to be performed would be a bone marrow study. <5> An initial study should be performed with viral serologies, autoimmunity study and abdominal ultrasound. If all these tests were normal, the study should be completed with a peripheral blood smear.
Output: 3
Question: Pruritus is a typical manifestation of all the following diseases, except: 
 Options:  <1> Hodgkin lymphoma. <2> Polycythemia vera. <3> Mycosis fungoides <4> Systemic mastocytosis. <5> Acute myeloblastic leukemia.
Output: 5
Question: A 34-year-old woman is admitted to the hospital for pulmonary embolism confirmed by angio-CT. He has no history of recent surgery, trauma or travel. He refers to Raynaud's phenomenon for 2 years, and the previous year he had an abortion at 12 weeks of gestation. He has no family history of venous thromboembolic disease. The activated partial thromboplastin time is 56 sg (normal 25-35 sg) and the platelet count is 120000 / uL. Which of the following diagnostic tests would help you most in the diagnosis? 
 Options:  <1> Antithrombin III. <2> Lupus anticoagulant. <3> Factor V of Leiden. <4> Protein C. <5> Protein S.
Output: 2
Question: Patient with diabetes mellitus, weight loss, anemia and necrolytic migraine erythema. The most likely diagnosis is: 
 Options:  <1> Somatostatinoma. <2> Insulinoma <3> Vipoma <4> Gastrinoma <5> Glucagonoma
Output: 5
Question: A 78-year-old woman has recently been diagnosed with diabetes mellitus type 2. She has a history of deep vein thrombosis 5 years ago, high blood pressure, depression and generalized anxiety. Take hydrochlorothiazide, lisinopril, citalopram and aspirin. Live alone in sheltered apartments. Eat little, typically coffee and toast for breakfast, fruit and half a sandwich to eat and salad for dinner. Walk 1.5 km daily. It measures 152 cm and weighs 39 Kg. The blood pressure is 130/80 mmHg and the heart rate is 82 bpm. Laboratory tests included basal glycemia of 147 mg / dL (1 month ago it was 152 mg / dL), creatinine 1.0 mg / dL (estimated glomerular filtration rate 28 ml / min), urea 32 mg / dL and glycosylated hemoglobin 9 ,5%. Which of the following is the best initial treatment for diabetes? 
 Options:  <1> Insulin glargine subcutaneous 8 U per day. <2> Oral metformin at a dose of 850 mg every 12 hours. <3> Oral Glibenclamide 10 mg daily. <4> It does not need pharmacological treatment, only diet. <5> Pioglitazone 15 mg daily.
Output: 1
Question: Metformin is recommended as initial treatment in most consensus of treatment of type 2 diabetes, for efficacy, safety and price; However, its use has some limitations and it is obligatory to suspend it in some clinical situations. In which of the following situations would you NOT consider stopping this treatment? 
 Options:  <1> Introduction of long-acting insulin analogue due to poor metabolic control. <2> Alcohol intake greater than 50 g / day as usual. <3> CT scan with intravenous contrast. <4> Diarrheic picture with elevated plasma Cr at 2.5 mg / dL. <5> Acute ischemia of the lower extremities with significant tissue hypoxia.
Output: 1
Question: In relation to the risk factors of cardiovascular diseases, which of the following statements is NOT correct? 
 Options:  <1> Regarding LDL cholesterol, the therapeutic objective depends on the global cardiovascular risk. <2> Type 2 diabetic patients should be considered at high cardiovascular risk and the objective in terms of LDL cholesterol should be <100 mg / dL. <3> There is not enough evidence that low levels of HDL cholesterol suppose a cardiovascular risk factor. <4> The important thing about the risk associated with hypertension is that it improves when blood pressure is reduced regardless of the type of drug used. <5> The existence of coronary disease in the family is a risk factor for the patient.
Output: 3
Question: A 24-year-old man with hypogonadism of hypothalamic origin secondary to operated craniopharyngioma, undergoing intramuscular treatment with testosterone undecanoate every 12 weeks, which is referred to us from another center for follow-up. The patient interrogates us in the initial visit about the follow-up of his basic pathology, possible adverse events of the hormonal treatment and probabilities of having offspring in the future. Which of the following statements is NOT correct? 
 Options:  <1> Serum testosterone levels should be measured just before each subsequent injection. <2> The goal of treatment is to maintain serum testosterone concentrations in the normal range of normality. <3> It is indicated to check the hematocrit on an annual basis. <4> Treatment with intramuscular testosterone for a prolonged period will increase the chances of conception with your partner. <5> The treatment with testosterone does not require the monitoring of luteinizing hormone concentrations.
Output: 4
Question: A 25-year-old man with no personal or family history of interest, who enters Neurosurgery due to a cranial fracture due to a motorcycle accident. Three days later it begins abruptly with polyuria, polydipsia and intense thirst both during the day and at night. In the study conducted, a urinary volume of 7 liters with urinary osmolarity of 190 mOsm / L (90-1200) and plasma osmolarity of 292 mOsm / L (275-295) was observed. The plasma Na is 143 mmol / L. A water restriction test is performed and after checking that there is no increase in urinary osmolarity, a dose of 2 micrograms of desmopressin subcutaneously is administered. The posterior urinary osmolality is 410 mOsm / kg. What is the most likely diagnosis? 
 Options:  <1> Primary polydipsia. <2> Central diabetes insipidus. <3> Acute adrenal insufficiency. <4> SIADH. <5> Nephrogenic insipid diabetes.
Output: 2
Question: Of the following statements, one is NOT a trigger for abdominopsychoneurological crises in acute porphyria. Indicate which: 
 Options:  <1> The luteal phase of the menstrual cycle. <2> The enzymatic hepatic inducer drugs. <3> The infections <4> A restrictive diet in proteins. <5> The protease inhibitors used in HIV infection.
Output: 4
Question: The gluten-free diet is the cornerstone in the treatment of celiac disease. In this regard, there are numerous products manufactured with an uncertain composition in terms of gluten, often being misleading labeling. Of the following food groups, which one can we consider completely safe in the diet of a celiac patient? 
 Options:  <1> Canned meat: Hamburgers, meatballs. <2> Milk and derivatives: yogurt, cheese, cream, curd. <3> Sauces, condiments and food additives. <4> Integral pasta: noodles, macaroni, noodles. <5> Delicatessen products, sausages, pâtés.
Output: 2