ANXIETY, DEPRESSION LINKED TO ANGINA FREQUENCY IN HEART PATIENTS

NEW RESEARCH SHOWS THAT ISCHEMIC HEART DISEASE PATIENTS WHO

SUFFER SIGNIFICANT ANXIETY HAVE CLOSE TO A 5-FOLD INCREASED RISK OF
EXPERIENCING FREQUENT ANGINA AND THOSE WITH DEPRESSION HAVE MORE
THAN A 3-FOLD INCREASED RISK FOR THESE EPISODES. THIS OBSERVED LINK
BETWEEN PSYCHIATRIC SYMPTOMS AND ANGINA UNDERLINES THE
IMPORTANCE OF TREATING ANXIETY AND DEPRESSION IN CARDIAC PATIENTS.
PSYCHOSOCIAL FACTORS: THE RESEARCHERS EXAMINED 5 PSYCHOSOCIAL
FACTORS THAT MIGHT AFFECT ANGINA FREQUENCY: ANXIETY; DEPRESSION;
NEUROTICISM (TENDENCY TO EXPERIENCE NEGATIVE EMOTIONS SUCH AS
SADNESS, ANGER, OR GUILT); ALEXITHYMIA (IMPAIRED ABILITY TO EXPRESS
INNER FEELINGS); AND SOMATOSENSORY AMPLIFICATION (TENDENCY TO
EXPERIENCE A SOMATIC SENSATION AS INTENSE, NOXIOUS, AND DISTURBING).
THERE WAS MORE ANXIETY AND DEPRESSION AMONG PATIENTS WITH
FREQUENT ANGINA. FOR INSTANCE, 22% OF PATIENTS WITH NO ANGINA HAD
CLINICALLY SIGNIFICANT ANXIETY, DEFINED AS A SCORE OF 16 OR GREATER ON
THE BECK ANXIETY INVENTORY SCALE, COMPARED WITH 38% FOR PATIENTS
WITH MONTHLY ANGINA AND 64% FOR THOSE WITH WEEKLY OR DAILY ANGINA.
OTHER PSYCHOSOCIAL FACTORS WERE ALSO INCREASED AMONG PATIENTS
WITH MORE FREQUENT ANGINA. FOR EXAMPLE, 38% OF PATIENTS WITH
WEEKLY OR DAILY ANGINA HAD A HIGH LEVEL OF ALEXITHYMIA COMPARED
WITH 17% OF PATIENTS WITH MONTHLY ANGINA AND 14% OF THOSE WITHOUT
ANGINA. HOWEVER, AFTER ADJUSTMENT FOR DEGREE OF MYOCARDIAL
ISCHEMIA, GREATER ANXIETY SCORE (ODDS RATIO, 1.39 PER HALFSTANDARD
DEVIATION INCREASE IN ANXIETY SCORE) AND GREATER DEPRESSION SCORE
(OR, 1.51 PER HALFSTANDARD DEVIATION INCREASE IN DEPRESSION SCORE)
WERE THE ONLY PSYCHOSOCIAL FACTORS SIGNIFICANTLY ASSOCIATED WITH
MORE FREQUENT ANGINA. AS EXPECTED, PREVIOUS CORONARY
REVASCULARIZATION WAS ALSO SIGNIFICANTLY ASSOCIATED WITH FREQUENT
ANGINA. PATIENTS WITH AT LEAST MODERATE ANXIETY SYMPTOMS
EXPERIENCED A 4.7-FOLD INCREASED RISK OF HAVING MORE FREQUENT
ANGINA. PATIENTS WITH CLINICALLY RELEVANT DEPRESSIVE SYMPTOMS HAD A
3.2-FOLD INCREASED RISK OF EXPERIENCING MORE FREQUENT ANGINA.
BIOLOGICAL FACTORS: NOT EVERY PATIENT WITH CORONARY ARTERY DISEASE
DEVELOPS ANGINA. UP TO 45% OF THESE PATIENTS HAVE ASYMPTOMATIC
ISCHEMIA. SEVERAL BIOLOGICAL FACTORS MIGHT EXPLAIN THE DISCREPANCY
BETWEEN CORONARY ARTERY DISEASE AND ANGINA SEVERITY, ACCORDING TO
THE AUTHORS. FOR EXAMPLE, METABOLIC NEUROPATHY OR ISCHEMIC
REGIONAL NERVE INJURY MAY INFLUENCE PAIN LEVELS.

3.- WHAT HAS NEW RESEARCH DEMONSTRATED ABOUT ISCHEMIC HEART

DISEASE PATIENTS WITH DEPRESSION?

a) THIS PATIENTS HAVE MORE INCREASED RISK OF EXPERIENCING FREQUENT

ANGINA.
b) THIS PATIENTS HAVE MORE INCREASED RISK OF THIS EPISODES.
c) A PATIENTS HEART DISEASE IS NOT RELATED WITH ANY PSYCHIATRIC
DISEASE.
d) THERE IS NO OBSERVED LINK BETWEEN PSYCHIATRIC SYMPTOMS AND
ANGINA.

4.- WHAT RELATIONSHIP WAS FOUND BETWEEN PSYCHIATRIC SYMPTOMS AND

PATIENTS WITH FREQUENT ANGINA?

a) THIS PATIENTS HAD CLINICALLY SIGNIFICANT ANXIETY.

b) THIS PATIENTS HAD A 16 SCORE OR GREATER ON THE BECK ANXIETY
INVENTORY SCALE.
c) THIS PATIENTS SUFFERED FROM WEEKLY OR DAILY ANGINA.
d) THIS PATIENTS HAD MORE ANXIETY AND DEPRESSION.

5.- WHAT PSYCHOSOCIAL FACTORS INCREASED AMONG PATIENTS WHO

SUFFERED OF FREQUENT ANGINA?

a) ALEXITHYMIA.
b) ANXIETY.
c) SOMATOSENSORY AMPLIFICATION.
d) NOXIOUS.

6.- WHAT ADJUSTMENT FOR DEGREE WAS THERE AFTER MYOCHARDIAL

ISCHEMIA?

a) ANXIETY AND DEPRESSION DECREASED.

b) DEPRESSION AND ANXIETY INCREASED.
c) ANXIETY AND DEPRESSION REMAINED THE SAME.
d) THERE WAS NO SIGNIFICANT CHANGES.

7.- WHAT BIOLOGICAL FACTORS EFFECTS PATIENTS WITH ANGINA?

a) EVERY PATIENT WITH CORONARY ARTERY DISEASE DEVELOPS ANGINA.

b) PREVIOUS CORONARY REVASCULARIZATION WAS ALSO ASSOCIATED WITH
FREQUENT ANGINA.
c) SOME OF THIS PATIENTS HAVE ASYMPTOMATIC ISQUEMIA.
d) METABOLIC NEUROPATHY OR ISCHEMIC REGIONAL NERVE INJURY ARE NOT
RELATED.

MUJER DE 31 AOS. ES ATENDIDA EN CONSULTA POR PRESENTAR ACTIVIDAD

UTERINA REGULAR Y DOLOROSA. ACTUALMENTE CURSA EMBARAZO GEMELAR
DE 33 SEMANAS . NIEGA SANGRADO TRANSVAGINAL, SALIDA DE LQUIDO
TRANSVAGINAL. REFIERE MOVIMIENTOS FETALES PRESENTES. ANTECEDENTES:
G:3, P:2, DIABETES GESTACIONAL MANEJADA CON DIETA Y METFORMINA CON
BUEN CONTROL GLICMICO. E.F.: PRODUCTO NICO LONGITUDINAL PLVICO,
DORSO DERECHA. CON FCF 130 LPM. TACTO VAGINAL 1 CM DE DILATACIN
CON 80% BORRRAMIENTO.

8.- EL TRATAMIENTO DE PRIMERA ELECCIN PARA ESTA PACIENTE ES:

a) INHIBIDORES DE LA SINTESIS DE PROSTAGLANDINAS.

b) BETAMIMTICOS.
c) NIFEDIPINO.
d) REPOSO.

NIA DE 4 AOS, INGRESA AL SERVICIO DE URGENCIAS POR DOLOR

ABDOMINAL CONSTANTE DE 48 HORAS DE EVOLUCIN. SU MADRE LE DI
PARACETAMOL AYER, SIN EMBARGO EL DOLOR PERSISTE Y SE AGREGARON
VMITO VERDOSO Y FIEBRE DE 39C. ANTECEDENTES: OPERADA DE
HIPERTROFIA PILRICA A LOS 2 MESES. E.F.: TA/ 100/60, FC 120LPM, FR 30
RPM, TEMPERATURA 38.7C. ABDOMEN CON DOLOR A LA PALPACIN MEDIA Y
RESISTENCIA, TIMPNICO, PERISTALSIS NULA.

9.- EL DIAGNSTICO DE MS PROBABILIDAD ES:

a) OCLUSIN INTESTINAL BAJA.

b) INVAGINACIN INTESTINAL.
c) OCLUSION POR ADHERENCIAS.
d) APENDICITIS COMPLICADA.

10.- EL TRATAMIENTO INMEDIATO PARA ESTA PACIENTE ES:

a) ADMINISTRAR SONDA A DERIVACIN.

b) LAPAROTOMIA EXPLORADORA.
c) SOLUCIONES PARENTERALES.
d) OBSERVACIN.

HOMBRE DE 45 AOS. ATENDIDO EN LA CONSULTA POR PRESENTAR

EXPECTORACIN CON SANGRE. ANTECEDENTES: TABAQUISMO POSITIVO, 42
CAJETILLAS AL AO. TOS CRNICA CON EXPECTORACIN MUCOSA
ABUNDANTE, DE 3 AOS DE EVOLUCIN. E.F.: TA 130/80 MM HG, FC 88 LPM, FR
14 RPM, TEMP 37C. DISMINUCIN DE AMPLEXIN Y AMPLEXACIN. RX DE
TRAX MUESTRA OPACIDAD HILIAR DERECHA.

11.- EL SIGUIENTE ESTUDIO QUE SE DEBE REALIZAR EN ESTE PACIENTE PARA

CONFIRMAR EL DIAGNSTICO ES:

a) CITOLOGA EN EXPECTORACIN.
b) LAVADO, CEPILLADO BRONQUIAL POR BRONCOSCOPA.
c) TOMA DE BIOPSIA TRANSBRONQUIAL POR BRONCOSCOPIA.
d) TOMA DE BIOPSIA TRANSTORCICA CON AGUJA FINA.

12.- EN ESTE PACIENTE EL REPORTE ANATOMOPATOLGICO MS PROBABLE ES:

a) CARCINOMA EPIDERMOIDE.
b) ADENOCARCINOMA.
c) LINFOMA DE HODGKIN.
d) CARCINOMA DE CELULAS PEQUEAS.

13.- EN ESTE PACIENTE, UNA VEZ TRATADO, USTED ESPERA QUE PUEDA TENER:

a) EDEMA DE MIEMBROS INFERIORES.

b) ASCITIS.
c) CRISIS CONVULSIVAS.

d) ARRITMIAS CARDIACAS.

HOMBRE DE 40 AOS. ATENDIDO EN LA CONSULTA EXTERNA POR DOLOR

INTENSO EN PRIMER ORTEJO DEL PIE DERECHO Y FIEBRE. ANTECEDENTES: SE
ENCUENTRA EN QUIMIOTERAPIA POR PADECER DE LEUCEMIA GRANULOCTICA
CRNICA. E.F.: TA 130/70 MM HG, FC 120 LPM, FR 14 RPM, TEMP 38C. EL DEDO
REFERIDO ESTA INFLAMADO MUY DOLOROSO AL MENOR ESTMULO.
LABORATORIO: LEUCOCITOS 25,000/MM3, CIDO RICO 14 MG/DL. CREATININA
SERICA 0.9 MG/DL.

14.- LA EXPLICACIN MS PROBABLE DE ESTE CUADRO CLNICO ES:

a) INGESTIN ABUNDANTE DE CARNES ROJAS.

b) AUMENTO DE RECAMBIO TISULAR.
c) DISMINUCIN EN LA ELIMINACIN RENAL DE CIDO RICO.
d) CONSECUENCIA DEL TRATAMIENTO ANTINEOPLASICO.

LACTANTE DE 2 MESES DE EDAD. ES ATENDIDO EN LA CONSULTA POR

PRESENTAR ADENOMEGALIA EN REGIN AXILAR DERECHA CON DOLOR E
INMOVILIZACIN DE LA ARTICULACIN. REFIERE LA MADRE QUE TIENE
ESQUEMA COMPLETO DE VACUNACIN. E.F.: MASA DE 3 CM EN AXILA CON
CAMBIOS DE COLOR Y AUMENTO DE TEMPERATURA EN LA REGIN.
TEMPERATURA 37.3, FC. 124LPM, FR 36 RPM.

15.- LA PRINCIPAL SOSPECHA CLNICA EN ESTE CASO ES:

a) ABSCESO AXILAR.
b) TUBERCULOMA.
c) LIPOMA.
d) INFECCIN.

16.- ESTUDIO MAS SENSIBLE PARA REALIZAR EL DIAGNSTICO:

a) REVISAR EL ESQUEMA DE VACUNACIN.

b) TOMA DE BIOPSIA.
c) APLICACIN DE PPD.
d) BAAR POR SONDA OROGSTRICA.
SUDDEN CARDIAC DEATH (SCD) IS DEFINED AS THE UNEXPECTED NATURAL
DEATH FROM CARDIAC CAUSES WITHIN A SHORT TIME PERIOD IN A PERSON
WITHOUT A CARDIAC CONDITION THAT WOULD APPEAR FATAL. SCD IS
RESPONSIBLE FOR APPROXIMATELY 300,000 FATALITIES IN THE UNITED STATES
ALONE. IT IS ESTIMATED THAT 50% OF ALL CARDIAC DEATHS ARE SUDDEN,
AND THIS PROPORTION HAS REMAINED CONSTANT DESPITE THE OVERALL
DECLINE IN CARDIOVASCULAR MORTALITY DURING THE LAST DECADES. IN
APPROXIMATELY THREE FOURTHS OF CASES, SCD IS CAUSED BY VENTRICULAR
TACHYCARDIA (VT) AND FIBRILLATION (VF), ALTHOUGH IN PATIENTS WHO HAVE
UNDERLYING CONGESTIVE HEART FAILURE (CHF), A SIGNIFICANT PROPORTION
OF SCD IS THE CONSEQUENCE OF BRADYCARDIC EVENTS OR
ELECTROMECHANICAL DISSOCIATION. THIS ARTICLE SUMMARIZES THE
CURRENT KNOWLEDGE ON RISK STRATIFICATION IN PATIENTS WHO HAVE
STRUCTURAL HEART DISEASE, NOTABLY CORONARY ARTERY DISEASE AND
NONISCHEMIC CARDIOMYOPATHY. ALTHOUGH OTHER TYPES OF STRUCTURAL
HEART DISEASE AND INHERITED ION CHANNEL ABNORMALITIES ARE ALSO
ASSOCIATED WITH A RISK OF SCD, THE RISK STRATIFICATION STRATEGIES AND
DATA IN THESE ENTITIES ARE DIVERSE AND BEYOND THE SCOPE OF THIS
ARTICLE. THE MAGNITUDE OF THE PROBLEM IN SPECIFIC SUBGROUPS OF
PATIENTS PRONE TO SCD WAS ADDRESSED BY MYERBURG IN A REVIEW OF THE
POPULATION IMPACT OF EMERGING IMPLANTABLE
CARDIOVERTER/DEFIBRILLATOR (ICD) TRIALS. THE HIGHEST INCIDENCE OF SCD
OCCURRED IN SURVIVORS OF OUT-OF-HOSPITAL CARDIAC DEATH AND HIGHRISK POST INFARCTION SUBGROUPS, BUT THE GREATEST ABSOLUTE NUMBER
OF SCD EVENTS (POPULATION ATTRIBUTABLE RISK) OCCURRED IN LARGER
SUBGROUPS OF PATIENTS AT SOMEWHAT LOWER RISK, INCLUDING PATIENTS
WITH LEFT VENTRICULAR DYSFUNCTION, CHF, OR ANY PRIOR CORONARY
EVENTS. THE CHALLENGE IS TO IDENTIFY RISK FACTORS FOR SCD AMONG THE
LARGE GROUP OF PATIENTS AT RELATIVELY LOW RISK, WHICH APPLIES, FOR
EXAMPLE, DIRECTLY TO SURVIVORS OF MYOCARDIAL INFARCTION, IN AN ERA
WHEN THE PROGNOSIS HAS IMPROVED SUBSTANTIALLY IN COMPARISON WITH
PRIOR SERIES ANTEDATING THE WIDESPREAD USE OF REPERFUSION THERAPY.

AMONG PATIENTS SUFFERING FROM CARDIAC ARREST, MOST HAVE SOME FORM
OF STRUCTURAL HEART DISEASE, WITH MOST PATIENTS SUFFERING FROM
CORONARY ARTERY DISEASE, BUT ACUTE MYOCARDIAL INFARCTION IS SEEN IN
LESS THAN HALF. IN A SERIES OF 151 HEARTS FROM MEN WHO DIED FROM
SUDDEN CARDIAC DEATH, THE PRESENCE OF ACUTE THROMBUS/PLAQUE
RUPTURE OR EROSION WAS NOTED IN 67% OF PATIENTS AGED 30 TO 39, BUT
THIS PROPORTION DECLINED WITH AGE AND WAS PRESENT IN ONLY 31% OF
PATIENTS AGES 60 TO 69.

17.- IN MOST CASES SCD WAS

a) CAUSED BY VENTRICULAR TACHYCARDIA (VT)

b) CAUSED BY FIBRILLATION (VF)
c) CAUSED BY VENTRICULAR TACHYCARDIA (VT) AND FIBRILLATION (VF)
d) CAUSED BY BRADYARDIC EVENTS AND ELECTROMECHANICAL DISSOCIATION

18.- THE RISK STRATIFICATION STRATEGIES AND DATA OF SCD

a) ARE INCLUDED WITH DETAIL AND EXAMPLES IN THIS ARTICLE

b) COMPARATIVE DETAILS AND EXAMPLES ARE INCLUDED IN THIS ARTICLE
c) ONLY SCD RISK STRATEGIES ARE INCLUDED IN THIS ARTICLE
d) SCD RISK STRATIFICATION STRATEGIES AND INFORMATION IS NOT THE
OBJECTIVE OF THIS ARTICLE

19.- THE GREATEST NUMBER OF SCD OCURRED IN

a) LARGER SUBGROUPS OF PATIENTS AT SOMEWHAT HIGHER RISK, INCLUDING

PATIENTS WITH LEFT VENTRICULAR DYSFUNCTION, CHF, OR ANY PRIOR
CORONARY EVENTS.
b) LARGER SUBGROUPS OF PATIENTS AT SOMEWHAT LOWER AND HIGHER RISK,
INCLUDING PATIENTS WITH LEFT VENTRICULAR DYSFUNCTION, CHF, OR ANY
PRIOR CORONARY EVENTS.
c) LARGER SUBGROUPS OF PATIENTS AT SOMEWHAT LOWER RISK, INCLUDING
PATIENTS WITH RIGHT VENTRICULAR DYSFUNCTION, CHF, OR ANY PRIOR
CORONARY EVENTS.
d) LARGER SUBGROUPS OF PATIENTS AT SOMEWHAT LOWER RISK, INCLUDING
PATIENTS WITH LEFT VENTRICULAR DYSFUNCTION, CHF, OR ANY PRIOR
CORONARY EVENTS

20.- THE CHALLENGE IS TO IDENTIFY

a) RISK FACTORS FOR SCD AMONG THE SMALL GROUP OF PATIENTS AT

RELATIVELY LOW RISK
b) RISK FACTORS FOR SCD AMONG THE LARGE GROUP OF PATIENTS AT
RELATIVELY HIGH RISK
c) RISK FACTORS FOR SCD AMONG THE LARGE GROUP OF PATIENTS AT
RELATIVELY LOW RISK
d) NON-RISK FACTORS FOR SCD AMONG THE LARGE GROUP OF PATIENTS AT
RELATIVELY LOW RISK

21.- THE HIGHEST RISK GROUP OF PATIENTS SUFFERING FROM CARDIAC

ARREST WHO HAD SOME FORM OF STRUCTURAL HEART DISEASE AND
CORONARY ARTERY DISEASE WERE

a) YOUNGER MEN
b) MIDDLE AGED MEN

c) OLDER MEN
d) OF ALL ADULT AGES

MUJER 82 AOS. ATENDIDA EN URGENCIAS POR DOLOR EN EPIGASTRIO

INTENSO QUE SE ACOMPAA DE NUSEA Y VMITO EN POZOS EN CAF. HA
TENIDO EVACUACIONES MELNICAS Y CON SANGRE FRESCA AS COMO
DISTENSIN ABDOMINAL . TIENE ANTECEDENTES DE ENFERMEDAD ARTICULAR
DEGENERATIVA TRATADA CON AINES. E.F.: TA 80/40 MMHG, FC 120 LPM, RCR,
CAMPOS PULMONARES CLAROS, ABDOMEN DOLOROSO A LA PALPACIN, CON
REBOTE POSITIVO Y PERISTALSIS AUSENTE.

22.- EL ESTUDIO INICIAL PARA CORROBORAR EL DIAGNSTICO ES:

a) RX DE ABDOMEN DE PIE Y DECBITO.

b) ENDOSCOPA.
c) TAC DE ABDOMEN.
d) COLONOSCOPA.

23.- EL TRATAMIENTO DEFINITIVO EN ESTE PACIENTE ES:

a) BLOQUEADORES DE BOMBA DE PROTONES.

b) LAVADO GSTRICO.
c) CIRUGA.
d) SUSPENDER AINES.

APPENDICITIS: SELECTIVE USE OF ABDOMINAL CT REDUCES NEGATIVE

APPENDECTOMY RATE APPENDICITIS ACCOUNTS FOR OVER 3% OF THE
DISEASES THAT INVOLVE THE DIGESTIVE SYSTEM, IS THE MOST COMMON
ACUTE SURGICAL PROBLEM OF THE ABDOMEN, AND APPENDECTOMY IS THE

FIFTH MOST COMMON SURGICAL PROCEDURE PERFORMED ON THE

GASTROINTESTINAL TRACT. IT IS ALSO ONE OF THE MOST DIFFICULT DISEASE
PROCESSES TO DIAGNOSE ACCURATELY. RATES OF NEGATIVE APPENDECTOMY
RANGE FROM 20% TO 44%. THESE RATES ARE EVEN HIGHER IN WOMEN OF
CHILDBEARING AGE, RANGING FROM 25% TO AS HIGH AS 52%. REPORTED
PERFORATION RATES RANGE FROM 15% TO 37%. THESE RATES OF NEGATIVE
APPENDECTOMY HAVE BEEN CONSIDERED ACCEPTABLE BECAUSE THE
MORBIDITY ASSOCIATED WITH COMPLICATED APPENDICITIS IS SIGNIFICANTLY
HIGHER THAN THAT OF NON-THERAPEUTIC APPENDECTOMY. NUMEROUS
DIAGNOSTIC TOOLS HAVE BEEN IMPLEMENTED IN AN EFFORT TO REDUCE THE
HIGH RATE OF NEGATIVE APPENDECTOMY WHILE AT THE SAME TIME NOT
INCREASE THE PERFORATION RATE. SOME OF THESE TOOLS INCLUDE CLINICAL
SCORING SYSTEMS, ULTRASOUND, COMPUTERIZED DECISION SUPPORT,
VARIOUS LABORATORY TESTS, AND OTHER, NON-TRADITIONAL METHODS.
THESE VARIOUS MODALITIES HAVE ALL YIELDED MIXED RESULTS AS TO THEIR
USEFULNESS IN CLINICAL PRACTICE. STUDIES HAVE SHOWN THAT HELICAL
COMPUTERIZED TOMOGRAPHY (CT) SCANNING OF THE ABDOMEN HAS BEEN
SUCCESSFUL IN REDUCING NONTHERAPEUTIC APPENDECTOMY RATES TO AS
LOW AS 3%. THESE RESULTS PROVIDE EVIDENCE THAT THERE MAY FINALLY BE
A DIAGNOSTIC TOOL THAT CAN BE EFFECTIVE IN REDUCING RATES OF
NONTHERAPEUTIC APPENDECTOMY WHILE NOT INCREASING THE MORBIDITY
AND MORTALITY ASSOCIATED WITH APPENDICITIS.

24.- WHAT IS RELATION OF APPENDICITIS WITH OTHER GASTROINTESTINAL

TRACT DISEASES?

a) IS ONE OF THE LESS COMMON SURGICAL PROCEDURES OF THE

GASTROINTESTINAL TRACT.
b) IT HAS NO RELATION WITH OTHER GASTROINTESTINAL TRACT DISEASES.
c) IT HAS THE HIGHEST INDEX OF MORBILITY.
d) IS THE FIFTH MOST COMMON SURGICAL PROCEDURE OF THE
GASTROINTESTINAL TRACT.

25.- WHY CAN APPENDICITIS END IN A COMPLICATED PERFORATION?

a) BECAUSE IS THE MOST COMMON ACUTE SURGICAL PROBLEM OR THE

ABDOMEN.
b) BECAUSE IT IS ONE OF THE MOST DIFFICULT DISEASE PROCESSES TO
DIAGNOSE ACURATELY.
c) BECAUSE APPENDECTOMY IS THE FIFTH MOST COMMON SURGICAL
PROCEDURE PERFORMED ON THE GASTROINTESTINAL TRACT.
d) BECAUSE OF THE LACK OF DIAGNOSTIC TOOLS.

26.- WHAT ARE THE RATES OF NEGATIVE APPENDECTOMY?

a) THESE RATES ARE EVEN LOWER IN WOMEN OF CHILDBEARING AGE.

b) THESE RATES ARE NOT CONSIDERED ACCEPTABLE.
c) THESE RATES ARE EVEN HIGHER IN WOMEN WHO ARE NOT IN CHILDBEARING
AGE.
d) THESE RATES ARE EVEN HIGHER IN WOMEN OF CHILDBEARING AGE.

27.- WHICH OF THE NEXT DIAGNOSTIC TOOLS HAS SUCCESFULLY REDUCED

NONTHERAPEUTIC APPENDECTOMY?

a) SCORING SYSTEMS.
b) HELICAL COMPUTERIZED TOMOGRAPHY.
c) ULTRASOUND.
d) LABORATORY TESTS.

28.- WHAT IS THE FINAL RESULT OF THIS STUDY?

a) THE HELICAL COMPUTERIZED TOMOGRAPHY CAN PREVENT

NONTHERAPEUTICAL APPENDECTOMY.
b) THE RATES OF NONTHERAPEUTICAL APPENDECTOMY HAVE INCREASED.
c) APPENDICITIS IS THE FIFTH MOST COMMON SURGICAL PROCEDURE
PERFORMED ON THE GASTROINTESTINAL TRACT.
d) NUMEROUS DIAGNOSTIC TOOL HAVE BEEN IMPLEMENTED IN AN EFFORT TO
REDUCE THE RISK OF NONTHERAPEUTICAL APPENDECTOMY.

MUJER DE 23 AOS. ASISTE A URGENCIAS POR PRESENTAR SALIDA DE LQUIDO

TRANSVAGINAL DE INICIO SBITO POSTERIOR A UNA RELACIN SEXUAL.
ACTUALMENTE CURSA SU PRIMER EMBARAZO Y EST EN LA SEMANA 39 DE
GESTACIN. E.F.: PRODUCTO LONGITUDINAL CEFLICO DORSO IZQUIERDA. FCF
EN 140 LPM. GENITALES HMEDOS. SE VISUALIZA CRVIX CERRADO FORMADO
Y POSTERIOR. NO HAY LQUIDO EN FONDO DE SACO.

29.- EL MTODO MS SENSIBLE Y ESPECFICO PARA ESTABLER EL DIAGNSTICO

EN ESTA PACIENTE ES:

a) CRISTALOGRAFA .
b) INYECCIN DE PIGMENTO POR AMNIOCENTESIS Y OBSERVACIN DE FUGA
HACIA CANAL VAGINAL.
c) PRUEBA DE NITRAZINA.
d) PH VAGINAL.
MUJER DE 25 AOS. ES ATENDIDA EN CONSULTA PARA CONTROL PRENATAL. 13
SEMANAS DE GESTACIN POR FUR. ULTRASONIDO TRANSABDOMINAL SE
OBSERVA LA PRESENCIA DE DOS FETOS DENTRO DE UN SACO GESTACIONAL.
SE APRECIA UNA MEMBRANA DIVISORIA DELGADA QUE AL UNIRSE A LA
PLACENTA FORMA UNA IMAGEN EN T.

30.- LA CAUSA MS PROBABLE DE ESTE HALLAZGO ES:

a) SEPARACIN ANTES DE LA DIFERENCIACIN DEL TROFOBLASTO (ANTES DA

3).
b) SEPARACIN DESPUS DE LA DIFERENCIACIN DEL TROFOBLASTO PERO
ANTES DE LA FORMACIN DEL AMNIOS (DIA 3 .
c) SEPARACIN DE TROFOBLASTO Y DIVISIN POSTERIOR A LA FORMACIN
DEL AMNIOS (DIA 8-13) .
d) SEPARACION POSTERIOR A LA FORMACIN DEL AMNIOS (DAS 10 A 15).

A 71-YEAR-OLD MAN PRESENTED WITH A 2-WEEK HISTORY OF PAIN AND

SWELLING OF HIS LEFT ARM. EXAMINATION REVEALED A CRAGGY, MOBILE
MASS WITH IRREGULAR BORDERS IN THE EXTENSOR COMPARTMENT OF THE
LEFT ARM MEASURING 6 4 CM. ULTRASONOGRAPHY OF THE LEFT ARM
DEMONSTRATED THE PRESENCE OF DEEP OVOID HYPERECHOIC MASS LOCATED
IN THE LONG AXIS OF THE LEFT TRICEPS MUSCLE, MEASURING 5 3 CM. THIS
LED TO FURTHER RADIOLOGIC EVALUATION IN THE FORM OF MRI OF THE LEFT
ARM. MRI SHOWED INTERMEDIATE SIGNAL MASS IN THE TRICEPS
MUSCULATURE ON T1-WEIGHTED IMAGES WITH FAT SATURATION. THIS LESION
IS CONFINED TO THE EXTENSOR COMPARTMENT OF THE ARM. A PRESUMPTIVE
DIAGNOSIS OF SOFT TISSUE SARCOMA WAS MADE. AN INCISIONAL BIOPSY WAS
PERFORMED. THIS WAS FOUND TO BE CONSISTENT WITH METASTATIC
SQUAMOUS CELL CARCINOMA WITH A POSSIBLE LUNG PRIMARY, FURTHER
SUPPORTED DUE TO A POSITIVE CK7 AND NEGATIVE CK20 STAIN ON
IMMUNOHISTOCHEMISTRY. CT SCAN OF THE CHEST REVEALED A LESION
MEASURING 4 2 CM IN THE LEFT UPPER LOBE. FIBER-OPTIC BRONCHOSCOPY
AND BIOPSY CONFIRMED THE DIAGNOSIS OF STAGE IV SQUAMOUS CELL
CARCINOMA OF THE LUNG. HE UNDERWENT PALLIATIVE RADIOTHERAPY TO THE
MASS IN THE ARM, 20 GY IN 4 FRACTIONS. THIS PROVIDED GOOD RELIEF FROM
PAIN AND SWELLING WITHIN 2 WEEKS OF COMPLETING TREATMENT. SYSTEMIC
THERAPY WAS NOT OFFERED ON THE BASIS OF POOR AND DETERIORATING
PERFORMANCE STATUS. UNFORTUNATELY, THE PATIENT DIED WITHIN 10 WEEKS
OF PRESENTATION. INTRAMUSCULAR METASTASES IN CANCER PATIENTS ARE
RARE. THIS IN ITSELF IS QUITE PECULIAR BECAUSE MUSCULAR MASS
ACCOUNTS FOR APPROXIMATELY 50% OF TOTAL BODY WEIGHT. IT IS THOUGHT
THAT MUSCULAR CONTRACTILE ACTIONS, LOCAL PH ENVIRONMENT, AND
ACCUMULATION OF LACTIC ACID AND OTHER METABOLITES CONTRIBUTE TO
THE RARE OCCURRENCE OF THIS PHENOMENON. THE TRUE INCIDENCE OF
MUSCULAR METASTASIS REMAINS UNKNOWN, BUT AN AUTOPSY SERIES
SUGGESTS THAT ITS INCIDENCE COULD BE AS LOW AS 0.8%. LUNG CARCINOMA
SEEMS TO BE THE UNDERLYING PRIMARY CANCER IN MOST OF THESE CASES.
MANY OTHER TUMORS, SUCH AS KIDNEY, STOMACH, PANCREAS, THYROID

GLAND, BREAST, OVARY, PROSTATE, AND BLADDER CANCERS HAVE ALSO BEEN
SPORADICALLY DESCRIBED IN ASSOCIATION WITH INTRAMUSCULAR
SECONDARIES. HOWEVER, PRIMARY PRESENTATION OF AN INTRAMUSCULAR
METASTASIS, SUCH AS DEMONSTRATED BY OUR PATIENT, REMAINS AN
EXCEPTIONALLY UNUSUAL OCCURRENCE. THE MOST FREQUENT PRESENTATION
OF MUSCULAR METASTASIS IS PAIN WITH OR WITHOUT SWELLING. DIAGNOSIS,
EVEN WITH RADIOLOGIC IMAGING IS OFTEN TRICKY BECAUSE IT CAN BE
CONFUSED WITH AN ABSCESS OR SOFT TISSUE TUMORS.

31.- WHY WAS THE RADIOLOGIC EVALUATION DONE?

a) BECAUSE OF THE PRESENCE OF DEEP OVOID HYPERECHOIC MASS LOCATED

IN THE LONG AXIS OF THE RIGHT TRICEPS MUSCLE.
b) BECAUSE OF THE RESULTS OF THE ULTRASONOGRAPHY
c) BECAUSE DIAGNOSIS WITH RADIOLOGIC IMAGING IS OFTEN TRICKY.
d) BECAUSE OF THE CLINICAL HISTORY OF THE PATIENT.

32.- WHY ARE THE INTRAMUSCULAR METASTASES IN CANCER PATIENTS RARE?

a) BECAUSE THE AMOUNT OF THE MUSCULAR MASS ACCOUNTS FOR

APPROXIMATELY 50% OF THE TOTAL BODY WEIGHT.
b) DUE TO THE MUSCULAR CONTRACTILE ACTIONS, LOCAL PH ENVIRONMENT,
AND ACCUMULATION OF LACTIC ACID AND OTHER METASTASIS.
c) BECAUSE THE PATIENTS DIE WITHIN 10 WEEKS OF PRESENTATION
d) BECAUSE PATIENTS LEAD AN ACTIVE LIFE

33.- WHAT KIND OF CANCER DID THE 71-YEAR-OLD PATIENT HAVE?

a) LUNG CARCINOMA.
b) KIDNEY CANCER
c) PROSTATE CANCER
d) BREAST CANCER

34.- HOW WAS THE PATIENTS CANCER CONFIRMED?

a) THROUGH THE MRI.

b) WITH IMMUNOHISTOCHEMISTRY
c) THROUGH FIBER-OPTIC BRONCHOSCOPY AND BIOPSY
d) THROUGH OBSERVATION OF THE SWELLING AND THE PAIN PRESENTED BY
THE PATIENT

35.- WHY WASNT SYSTEMATIC THERAPY OFFERED?

a) BECAUSE THE PATIENT WAS TOO OLD TO RESIST THE THERAPY

b) BECAUSE THE PALLIATIVE RADIOTHERAPY PROVIDED GOOD RELIEF FROM
PAIN AND SWELLING.
c) BECAUSE THE PATIENT SHOWED VERY LITTLE IMPROVEMENT.
d) THE PATIENT DIED 10 WEEKS AFTER THE FIRST PRESENTATION.
NIO DE 5 AOS. ES ATENDIDO EN LA CONSULTA POR PRESENTAR MORETONES
EN PIERNAS SIN ANTECEDENTE DE TRAUMATISMO. ANTECEDENTES: HACE 2
MESES CON HIPOREXIA, BAJA DE PESO, SANO PREVIAMENTE. E.F.: TA 110/65
MM HG, FC 120 LPM, FR 28 RPM. PLIDO ++, HIPOACTIVO. SE PALPA HGADO A
DOS CENTMETROS POR ABAJO DEL BORDE COSTAL. LABORATORIO: HB 9G/DL,
LEUCOCITOS 25, 000 PREDOMINO DE LINFOCITOS 50%, PLAQUETAS 100,000.

36.- EL DIAGNSTICO MAS PROBABLE CON ESTE PACIENTE ES:

a) ANEMIA APLSICA.
b) HISTIOCITOSIS X.
c) LEUCEMIA LINFOBLSTICA.
d) PRPURA TROMBTICA.

37.- EL SIGUIENTE PASO EN LA ATENCIN DE ESTE PACIENTE QUE DEBE

REALIZAR USTED ES:

a) INICIAR ESQUEMA DE QUIMIOTERAPIA.

b) TRANSFUNDIRLE PAQUETE GLOBULAR.
c) DERIVAR AL HEMATLOGO.
d) ANLISIS MDULA SEA.
ENDOMETRIAL CANCER IN THE UNITED STATES ENDOMETRIAL CANCER REFERS
TO SEVERAL TYPES OF MALIGNANCY WHICH ARISE FROM THE ENDOMETRIUM,
OR LINING OF THE UTERUS. ENDOMETRIAL CANCERS ARE THE MOST COMMON
GYNECOLOGIC CANCERS IN THE UNITED STATES, WITH OVER 35,000 WOMEN
DIAGNOSED EACH YEAR IN THE U.S. THE MOST COMMON SUBTYPE,
ENDOMETRIOID ADENOCARCINOMA, TYPICALLY OCCURS WITHIN A FEW
DECADES OF MENOPAUSE, IS ASSOCIATED WITH EXCESSIVE ESTROGEN
EXPOSURE, OFTEN DEVELOPS IN THE SETTING OF ENDOMETRIAL HYPERPLASIA,
AND PRESENTS MOST OFTEN WITH VAGINAL BLEEDING. ENDOMETRIAL
CARCINOMA IS THE THIRD MOST COMMON CAUSE OF GYNECOLOGIC CANCER
DEATH (BEHIND OVARIAN AND CERVICAL CANCER CLINICAL EVALUATION:
ROUTINE SCREENING OF ASYMPTOMATIC WOMEN IS NOT INDICATED, SINCE
THE DISEASE IS HIGHLY CURABLE IN ITS EARLY STAGES. RESULTS FROM A
PELVIC EXAMINATION ARE FREQUENTLY NORMAL, ESPECIALLY IN THE EARLY
STAGES OF DISEASE. CHANGES IN THE SIZE, SHAPE OR CONSISTENCY OF THE
UTERUS AND/OR ITS SURROUNDING, SUPPORTING STRUCTURES MAY EXIST
WHEN THE DISEASE IS MORE ADVANCED. A PAP SMEAR MAY BE EITHER
NORMAL OR SHOW ABNORMAL CELLULAR CHANGES. ENDOMETRIAL
CURETTAGE IS THE TRADITIONAL DIAGNOSTIC METHOD. BOTH ENDOMETRIAL

AND ENDOCERVICAL MATERIAL SHOULD BE SAMPLED. IF ENDOMETRIAL

CURETTAGE DOES NOT YIELD SUFFICIENT DIAGNOSTIC MATERIAL, A DILATION
AND CURETTAGE (D&C) IS NECESSARY FOR DIAGNOSING THE CANCER.
HYSTEROSCOPY ALLOWS THE DIRECT VISUALIZATION OF THE UTERINE CAVITY
AND CAN BE USED TO DETECT THE PRESENCE OF LESIONS OR TUMOURS. IT
ALSO PERMITS THE DOCTOR TO OBTAIN CELL SAMPLES WITH MINIMAL DAMAGE
TO THE ENDOMETRIAL LINING (UNLIKE BLIND D&C). ENDOMETRIAL BIOPSY OR
ASPIRATION MAY ASSIST THE DIAGNOSIS. TRANSVAGINAL ULTRASOUND TO
EVALUATE THE ENDOMETRIAL THICKNESS IN WOMEN WITH POSTMENOPAUSAL
BLEEDING IS INCREASINGLY BEING USED TO EVALUATE FOR ENDOMETRIAL
CANCER. RECENTLY, A NEW METHOD OF TESTING HAS BEEN INTRODUCED
CALLED THE TRUTEST, OFFERED THROUGH GYNECOR. IT USES THE SMALL
FLEXIBLE TAO BRUSH TO BRUSH THE ENTIRE LINING OF THE UTERUS. THIS
METHOD IS LESS PAINFUL THAN A PIPELLE BIOPSY AND HAS A LARGER
LIKELIHOOD OF PROCURING ENOUGH TISSUE FOR TESTING. SINCE IT IS
SIMPLER AND LESS INVASIVE, THE TRUTEST CAN BE PERFORMED AS OFTEN,
AND AT THE SAME TIME AS, A ROUTINE PAP SMEAR, THUS ALLOWING FOR
EARLY DETECTION AND TREATMENT. ONGOING RESEARCH SUGGESTS THAT
SERUM P53 ANTIBODY MAY HOLD VALUE IN IDENTIFYING HIGH-RISK
ENDOMETRIAL CANCER.[4]

38.- ENDOMETRIAL CANCER REFERS TO:

a) SPECIFIC TYPES OF MALIGNANCY WHICH ARISE FROM THE ENDOMETRIUM,

OR LINING OF THE UTERUS.
b) SEVERAL TYPES OF MALIGNANCY WHICH NEVER ARISE FROM THE
ENDOMETRIUM, OR LINING OF THE UTERUS.
c) ALL TYPES OF MALIGNANCY WHICH ARISE FROM THE ENDOMETRIUM.
d) SEVERAL TYPES OF MALIGNANCY WHICH ARISE FROM THE ENDOMETRIUM,
OR LINING OF THE UTERUS.

39.- ENDOMETRIOID ADENOCARCINOMA, TYPICALLY OCCURS WITHIN:

a) EXCESSIVE ESTROGEN.

b) A LOT OF DECADES OF MENOPAUSE.

c) ALWAYS PRESENTS VAGINAL BLEEDING.
d) ALWAYS DEVELOPS IN THE SETTING OF ENDOMETRIAL HYPERPLASIA.

40.- RESULTS FROM A PELVIC EXAMINATION ARE:

a) ALWAYS CHANGES IN THE SIZE AND NEVER IN SHAPE

b) SOMETIMES NORMAL, ESPECIALLY IN THE EARLY STAGES OF THE DISEASE.
c) CHANGES IN THE SIZE, SOMETIMES THE SHAPE BUT NEVER THE
CONSISTENCY OF THE UTERUS
d) CHANGES IN THE SIZE, SHAPE BUT NEVER IN THE CONSISTENCY OF THE
UTERUS

41.- CLINICAL METHOD FOR EVALUATION:

a) A PAP IS THE BEST OPTION YOU CAN USE.

b) ENDOMETRIAL CURETTAGE IS NOT THE TRADITIONAL DIAGNOSTIC METHOD.
c) HYSTEROSCOPY ALLOWS THE DIRECT VISUALIZATION OF THE UTERINE
CAVITY.
d) ENDOMETRIAL BIOPSY OR ASPIRATION ALWAYS ASSIST IN THE DIAGNOSIS.

42.- HOW IS THE DEVELOPEMENT OF THIS NEW METHOD?

a) IT USES THE HUGE FLEXIBLE TAO BRUSH TO BRUSH THE ENTIRE LINING OF
THE UTERUS.

b) IT USES THE SMALL UNFLEXIBLE TAO BRUSH TO BRUSH THE UTERUS.

c) IT USES THE SMALL UNFLEXIBLE TAO BRUSH TO BRUSH THE ENTIRE LINING
OF THE UTERUS.
d) IT USES THE SMALL FLEXIBLE TAO BRUSH TO BRUSH THE ENTIRE LINING OF
THE UTERUS.

MUJER DE 25 AOS. TRABAJA EN UN ASILO DE ANCIANOS. ES ATENDIDA EN

URGENCIAS POR PRESENTAR DESDE HACE 24 HORAS, MALESTAR GENERAL,
CEFALEA INTENSA, VMITO, DIARREA, MIALGIAS Y FIEBRE. G:2 , C:1. CURSA
CON EMBARZO DE 22 SEMANAS. E.F.: PESO 63 KGS. TEMP. 38.3 C . FCF: 128
LPM.

43.- LO MS PROBABLE ES QUE EL AGENTE CAUSAL SEA:

a) ROTAVIRUS.
b) ADENOVIRUS INTESTINAL.
c) ASTROVIRUS.
d) NOROVIRUS.
MUJER DE 33 AOS. EMBARAZADA, INGRESA A URGENCIAS CON ACTIVIDAD
UTERINA. REFIERE HABER INICIADO CON CEFALEA HACE 4 HORAS Y ACTIVIDAD
UTERINA REGULAR. G: 4, P:3. CURSA CON EMBARZO DE 35.4 SEMANAS, TOMA
HIDRALAZINA Y ALFAMETILDOPA E.F.: PESO 74 KGS. TA 140/90 MM/HG. FU: 32
CMS. PRODUCTO CEFLICO CON FCF: 128 LPM. TACTO VAGINAL: CERVIX,
SEMIBORRADO SIN DILATACIN.

44.- PARA CORROBORAR EL DIAGNSTICO SE DEBE DE REALIZAR :

a) PRUEBAS DE FUNCION HEPTICA.

b) DEPURACIN DE CREATININA.
c) DETERMINACIN DE CIDO RICO.
d) PROTENAS EN ORINA.

HOMBRE DE 89 AOS. LLEVADO A URGENCIAS POR UN VECINO YA QUE

PRESENTA DESDE HACE UNA SEMANA TOS CON EXPECTORACIN VERDEAMARILLENTA. HA PRESENTADO ALTERACIONES EN EL ESTADO DE CONCIENCIA,
FIEBRE, ASTENIA, ADINAMIA E HIPOREXIA Y OLIGURIA DE 5 DIAS DE
EVOLUCIN. E.F.: PESO 45KG, TEMP 39 C, FC 110 LPM, MUCOSAS ORALES
DESHIDRATADAS, RCR DE BAJA INTENSIDAD, CAMPOS PULMONARES CON
ESTERTORES CREPITANTES DISEMINADOS. GIORDANO DUDOSO BILATERAL,
EXTREMIDADES INFERIORES Y SUPERIORES HIPOTRFICAS Y ESCARA EN
REGIN SACRA.

45.- EL PRINCIPAL PROBLEMA DE ESTE PACIENTE ES:

a) ISQUEMIA CEREBRAL TRANSITORIA.

b) DEMENCIA SENIL.
c) INFECCIN DE VIAS URINARIAS.
d) SNDROME DE ABANDONO.

46.- EL MANEJO MDICO INICIAL EN ESTE PACIENTE ES:

a) HOSPITALIZACIN, HIDRATACIN Y PENICILINA BENZATNICA Y

DESINFLAMATORIOS.
b) HIDRATACIN Y MANEJO DE LA INFECCIN DE VAS RESPIRATORIAS.
c) HIDRATACIN Y MANEJO DE LA INFECCIN DE VAS URINARIAS.
d) HOSPITALIZACIN Y OBSERVACIN.

RECIN NACIDO DE TRMINO. ES ATENDIDO EN LA CONSULTA A LOS 3 DAS

POR NOTAR LA MADRE ENROJECIMIENTO INTENSO DE SU OMBLIGO Y LLANTO
CONSTANTE. ANTECEDENTES: NACIDO CON PARTERA. E.F.: TA 94/52 MM HG, FC
160 LPM, FR 50 POR MINUTO, TEMPERATURA DE 39C. DECADO, RECHAZA EL
PECHO, LLENADO CAPILAR DE 4 SEGUNDOS.

47.- EL DIAGNSTICO MAS PROBABLE EN ESTE CASO ES:

a) ONFALITIS.
b) PERITONITIS.
c) SEPSIS.
d) ERITEMA DEL NEONATO.

48.- LOS MICROORGANISMOS MAS COMUNES EN ESTOS CASOS SON:

a) ANAEROBIOS.
b) GRAM POSITIVOS.
c) GRAM NEGATIVOS.
d) VIRUS.
RECIN NACIDO DE 40 SEMANAS DE GESTACIN. APGAR DE 3 AL MINUTO.
ANTECEDENTES: MADRE SIN CONTROL PRENATAL, OBRERA, GESTA 8, LLEG A
URGENCIAS POR NO SENTIR MOVIMIENTOS DEL BEB. E.F.: TA 50/20 MM HG, FC
< 100 LPM, FR 10 RPM, TEMPERATURA 37.5C. LLENADO CAPILAR > 4 SEG.

49.- EL MANEJO INMEDIATO PARA ESTE PACIENTE ES:

a) HABLARLE AL PEDIATRA E INICIAR MANIOBRAS.

b) ADMINISTRAR ADRENALINA E INICIAR MANIOBRAS.
c) ADMINISTRAR ATROPINA E INICIAR MANIOBRAS.
d) VENTILACIN Y COMPRESIN CARDIACA