Inglés Clase 2

English Clinical Cases
PUEP - ENARM
Dr. Julio Herrera-Zamora Dr. Julio Herrera-Zamora
Case 1
A 27 years old man arrives to your office due to the presence of numbness and cramping in both
hands and one day later presented ascending weakness of the 4 limbs until reaching bedridden
status. On interrogation his wife reports that he was previously healthy with a possible episode of
gastroenteritis two weeks ago. On physical examination bilateral facial diplegia and weakness of
the 4 limbs with areflexia.
Case 1
A 27 years old man arrives to your office due to the presence of numbness and cramping in both
hands and one day later presented ascending weakness of the 4 limbs until reaching bedridden
status. On interrogation his wife reports that he was previously healthy with a possible episode of
gastroenteritis two weeks ago. On physical examination bilateral facial diplegia and weakness of
the 4 limbs with areflexia.
Case 1
Numbness: Entumecimiento o adormecimiento
Cramping: Calambres o espasmos
Weakness: Debilidad
Limbs: Extremidades
Bedridden: Postración
Facial diplegia: Diplejía facial
Case 1
Q1. Which is the most likely diagnosis?
A) Myasthenia gravis
B) Lambert-Eaton Syndrome
C) Botulism
D) Guillain-Barré Syndrome
Case 1-Q1. Review
Guillain Barré syndrome is an acute demyelinating disease that causes the rapid development of
weakness of the extremities and often of the facial, respiratory and swallowing muscles.
Clinically it is characterized by the presence of flaccid paralysis with areflexia, variable sensory
disorder and elevation of proteins in the CSF.
CSF (cerebrospinal fluid): LCR (líquido cefalorraquídeo)

Literature:
Guía de Práctica Clínica: Diagnóstico y Tratamiento Síndrome de Guillain-Barré en el Segundo y Tercer Nivel de Atención. 2016.
Revisión Caso 1 – P1
Síndrome de Guillain Barré es una enfermedad desmielinizante aguda que causa el rápido
desarrollo de debilidad de las extremidades y a menudo de los músculos faciales, respiratorios y
de deglución.
Clínicamente se caracterizapor la presencia de una parálisis flácida con arreflexia, trastorno
sensorial variable y elevación de las proteínas en el líquido cefalorraquídeo.
Bibliografía:
Case 1
Q2. Which is the second infectious agent related to this patient's disease disease?
A) Haemophylus influenzae
B) Campylobacter jejuni
C) Cytomegalovirus
D) Mycoplasma pneumoniae
Case 1-Q2. Review
According to the Clinical Practice Guide: Diagnosis and Treatment Guillain-Barré Syndrome in
the Second and Third Level of Care. In patients with Guillain Barré syndrome, in whom a history
of an infectious process was identified, the following microorganisms were associated:
Campylobacter jejuni: 20-50%, Cytomegalovirus: 5-22%, Haemophylus influenzae: 2-13%,
Epstein Barr: 10% and Mycoplasma pneumoniae: 5%.
Literature:
De acuerdo a la Guía de Práctica Clínica: Diagnóstico y Tratamiento Síndrome de Guillain-Barré
en el Segundo y Tercer Nivel de Atención. En pacientes con síndrome de Guillain Barré, en
quienes se identificó el antecedente de un proceso infeccioso, se asociaron los siguientes
microorganismos: Campylobacter jejuni: 20-50%, Citomegalovirus: 5-22%, Haemophylus
influenzae: 2-13%, virus de Epstein Barr: 10% y Mycoplasma pneumoniae: 5%.
Bibliografía:
Case 1
Q3. At what time does the lumbar puncture is more sensitive?
A) In the first 24 hours

B) In the first 48 hours
C) In the first 72 hours
D) After the first week
Case 1-Q3. Review
In the majority of patients with Guillain Barré syndrome, the cerebrospinal fluid study may not
show alterations in the first 48 hours.
It has been shown that 25% of cases present dissociation in the first week and 90% in the
second week; observed high levels of proteins in the cerebrospinal fluid.
Literature:
En la mayoría de pacientes con síndrome de Guillain Barré, el estudio de líquido cefalorraquídeo
puede no mostrar alteraciones en las primeras 48 horas.
Se ha demostrado que 25% de los casos presentan disociación en la primera semana y 90%, en
la segunda semana; observándose niveles altos de proteínas en el líquido cefalorraquídeo.
Bibliografía:
Case 1
Q4. Which percentage of patients with this disease will require mechanical intubation?
A) 5%
B) 10%
C) 15%
D) 20%
Case 1-Q4. Review
The estimated mortality of Guillain Barré Syndrome is variable and even with the advent of an
effective therapy it is still from 4 to 8%, it is considered that more than 20% of the patients will
require assisted ventilation and that around 40% of those who merited hospitalization will
require rehabilitation
Literature:
La mortalidad estimada del Síndrome de Guillain Barré es variable y aún con el advenimiento de
una terapia efectiva sigue siendo de 4 a 8%, se considera que más de 20% de los pacientes van a
llega a requerir ventilación asistida y que alrededor del 40% de aquellos que ameritaron
hospitalización requerirán rehabilitación.
Bibliografía:
Case 1
Q5. Which of the following is a sign or symptom of alarm in this disease?
A) Blurred vision
B) Sialorrhea
C) Palpitation
D) Paralysis
Blurred vision: Visión borrosa

Case 1-Q5. Review
The symptoms and signs in patients with Guillain Barré syndrome can be classified into:
A. Typical:
- Symmetric and ascending weakness or loss of muscular function (paralysis), areflexia or osteotendinous hyporeflexia,
changes or decrease in tenderness, numbness, muscle pain (may be similar to cramping pain).
B. Additional: (which may appear during the illness, not necessarily specific)
- Blurred vision, difficulty moving of the muscles of the face, torpid walk and falls, palpitations (tactile sensation of the
beats of the heart), muscular contractions
C. Alarm:
- Dysphagia, sialorrhea, dyspnea, apnea or inability to breathe deeply, collapse
Tenderness: Sensibilidad
Beats: Latidos
Deeply: Profundamente
Literature:
Los síntomas y signos en pacientes con síndrome de Guillain Barré, pueden clasificarse en:
A. Típicos:
- Debilidad o pérdida de la función muscular simétrica y ascendente (parálisis), arreflexia o hiporreflexia osteotendinosa,
cambios o disminución de la sensibilidad, entumecimiento, dolor muscular (puede ser similar al dolor por calambres).
B. Adicionales: (que pueden aparecer durante la enfermedad, no necesariamente específicos)
- Visión borrosa, dificultad para mover los músculos de la cara, marcha tórpida y caídas, palpitaciones (sensación táctil de
los latidos delcorazón), contracciones musculares.
C. De alarma:
- Disfagia, sialorrea, disnea, apnea o incapacidad para respirar profundamente, lipotimia.
Bibliografía:
Case 2
A 72 year old man arrives to your office due to a six-month tremor in the right arm that reaches
the four extremities when he becomes nervous. His family noticed him not very expressive and
with less initiative for his daily activities. On physical examination gait disturbances.
Case 2
A 72 year old man arrives to your office due to a six-month tremor in the right arm that reaches
the four extremities when he becomes nervous. His family noticed him not very expressive and
with less initiative for his daily activities. On physical examination gait disturbances.
Case 2
Tremor: Temblor
Reaches: Alcanzar
Less: Menor
Gait disturbances : Trastorno de la marcha
Case 2
a) Alzheimer's disease
b) Dementia due to Lewy bodies
c) Parkinson's disease
d) Huntington
Case 2-Q1. Review
Parkinson's disease is a disorder characterized by motor symptoms such as tremor at rest,
bradykinesia, stiffness and gait disturbances. Non-motor symptoms are also known, such as
autonomic, sexual, sleep and neuropsychiatric alterations. These symptoms are a consequence
of the loss of dopaminergic neurons, mainly from the nigrostriate route.
Literature:
Guía de Práctica Clínica: Diagnóstico y Tratamiento de la Enfermedad de Parkinson Inicial y Avanzada en el Tercer Nivel de Atención.
La Enfermedad de Parkinson es un trastorno caracterizado por síntomas motores como temblor
en reposo, bradicinesia, rigidez y alteraciones en la marcha. También se conocen síntomas no
motores, como alteraciones autonómicas, sexuales, del sueño y neuropsiquiátricas. Estos
síntomas son consecuencia de la pérdida de neuronas dopaminérgicas, principalmente de la vía
nigroestriada.
Bibliografía:
Case 2
Q2. Which percentage of patients will present levodopa-induced dyskinesias at 4 years?
a) 15%
b) 30%
c) 45%
d) 60%
Case 2-Q2. Review
Levodopa-induced dyskinesias may occur within a short time (months) of treatment with
levodopa, although usually these are observed later. It is estimated that 60% of patients present
after 3 or 4 years of treatment with levodopa.
Although: Aunque
Literature:
Las discinesias inducidas por levodopa pueden presentarse al poco tiempo (meses) de iniciado
el tratamiento con levodopa aunque habitualmente estas se observan más tardíamente. Se
estima que se presentan en el 60% pacientes después de 3 o 4 años de iniciado el manejo con
levodopa.
Bibliografía:
Case 2
Q3. Which of the following is not a positive predictive criterion for Parkinson's disease?
A) Unilateral start
B) Bilateral symptoms involvement
C) Excellent response to Levodopa
D) Severe Korea induced by Levodopa
Case 2-Q3. Review
Three or more are required for the diagnosis of defined Parkinson's disease:
1. Unilateral start
2. Presence of resting tremor
3. Progressive disorder
4. Persistent asymmetry, affecting more to the initial side
5. Excellent response to Levodopa
6. Severe chorea induced by Levodopa
7. Response to L-dopa for five years or more
8. Clinical course of 10 years or more
Resting tremor: Temblor en reposo

Literature:
Se requieren tres o más para el diagnóstico de enfermedad de Parkinson definida:
1. Inicio unilateral
2. Presencia de temblor de reposo
3. Trastorno progresivo
4. Asimetría persistente, afectando más al lado inicial
5. Respuesta excelente a Levodopa
6. Corea severa inducida por Levodopa
7. Respuesta a la L-dopa durante cinco años o más
8. Curso clínico de 10 años o más
Bibliografía:
Case 2
Q4. Which stage of the classification of Hoehn and Yahr will this patient have if alteration of the
postural reflexes is observed?
A) Stage 2
B) Stage 3
C) Stage 4
D) Stage 5
Case 2-Q4. Review
• Stage 1: Unilateral, exclusively disease, without functional affectation or with minimal
affectation.
• Stage 2: Bilateral or axial involvement (midline), without alteration of balance.
• Stage 3: Bilateral disease, mild to moderate disability, alteration of postural reflexes.
• Stage 4: Severely disabling disease, still able to walk or stand without help.
• Stage 5: Bedridden status or in a wheelchair without help.
Mild: Leve
Disabling disease: Enfermedad discapacitante
Wheelchair: Silla de ruedas
Literature:
• Estadio 1: Enfermedad exclusivamente unilateral, sin afectación funcional o con mínima
afectación.
• Estadio 2: Afectación bilateral o axial (línea media), sin alteración del equilibrio.
• Estadio 3: Enfermedad bilateral, discapacidad leve a moderada, alteración de los reflejos
posturales.
• Estadio 4: Enfermedad gravemente discapacitante, aún capaz de caminar o de permanecer en
pie sin ayuda.
• Estadio 5: Confinamiento en cama o en silla de ruedas si no tiene ayuda.
Bibliografía:
Case 2
Q5. Which of the following is not an exclusion criterion for Parkinson's disease?
A) History of repeat cranial traumas

B) More than one affected family member
C) Babinski's sign
D) Rest tremor of 4-6 Hz
Case 2-Q5. Review
The absence of all is required for the diagnosis of defined Parkinson's disease:
1. History of recurrent cerebral infarcts with sudden progression of parkinsonian features. 2. History of repetitive cranial traumas
3. History of diagnosed encephalitis 4. Oculogyric crisis
5. Neuroleptic treatment at the beginning of the symptoms 6. More than one affected family member
7. Maintained remission of symptoms 8. Strictly unilateral symptoms after three years of evolution
9. Supranuclear gaze palsy 10. Cerebellar signs
11. Early severe autonomic involvement 12. Early severe dementia with language, memory and praxia disorders
13.Presence of brain tumors or communicating hydrocephalus on computed tomography 14. Babinski's sign
15. Absence of response to large doses of levodopa (excluding malabsorption) 16. Exposure to MPTP
Sudden: Repentino
Supranuclear gaze palsy: Parálisis supranuclear de la mirada
Language: Habla o lenguaje
Literature:
La ausencia de todos es necesaria para el diagnóstico de la enfermedad de Parkinson definida:
1. Historia de infartos cerebrales recurrentes con progresión repentina de rasgos parkinsonianos. 2. Antecedentes de traumas craneales repetitivos.
3. Antecedentes de encefalitis diagnosticada. 4. Crisis oculogírica.
5. Tratamiento neuroléptico al inicio de los síntomas. 6. Más de un familiar afectado.
7. Remisión mantenida de los síntomas. 8. Síntomas estrictamente unilaterales después de tres años de evolución.
9. Parálisis supranuclear de la mirada. 10. Signos cerebelosos
11. temprana participación autonómica severa 12. Demencia temprana precoz con trastornos del lenguaje, memoria y praxia.
13. El signo de Babinski. 14. Presencia de tumores cerebrales o hidrocefalia comunicante en tomografía computarizada
15. Ausencia de respuesta a grandes dosis de levodopa (excluyendo malabsorción) 16. Exposición a MPTP
Bibliografía:
Case 3
A 58 year old woman arrives to the Emergency Department of your hospital complaining about
the worst headache of her life, nausea and vomiting. Her vitals are normal except for mild
hypertension (146/90). Her neurological examination reveals drowsiness, nuchal stiffness, right
third nerve palsy and slight right arm weakness.
Case 3
A 58 year old woman arrives to the Emergency Department of your hospital complaining about
the worst headache of her life, nausea and vomiting. Her vitals are normal except for mild
hypertension (146/90). Her neurological examination reveals drowsiness, nuchal stiffness, right
third nerve palsy and slight right arm weakness.
Case 3
Worst headache of her life : Peor dolor de cabeza de su vida
Drowsiness : somnolencia
Palsy : parálisis
Slight : leve o ligero
Case 3
A) Hemorragic stroke
B) Ischaemic stroke
C) Subarachnoid hemorrage
D) Migraine
Case 3-Q1. Review
Patients with subarachnoid hemorrhage experience abrupt-onset severe headache (“the worst
headache of my life” or “thunderclap” headache) that is often associated with nausea and
vomiting. There may also be a decrease of the level of consciousness and focal neurologic
deficits.
Abrupt-onset: Inicio abrupto

Headache: Dolor de cabeza
Thunderclap: cefalea en trueno
Literature:
Manual CTO de Medicina y Cirugía. 4ta Ed. ENARM-México, Neurología. 2019
Los pacientes con hemorragia subaracnoidea experimentan cefalea severa de inicio brusco ("el
peor dolor de cabeza de mi vida" o cefalea de "trueno") que a menudo se asocia con náuseas y
vómitos. También puede haber una disminución del nivel de conciencia y déficits neurológicos
focales.
Bibliografía:
Case 3
Q2. Which of the following descriptions best defines a complete 3rd nerve palsy with pupillary
involvement?
A) Ptosis, an inward deviated eye, midriatic pupil

B) Ptosis, an outward deviated eye, normal pupil
C) Ptosis, an outward deviated eye, midriatic pupil
D) Ptosis, an inward deviated eye, miotic pupil
Inward: Hacia dentro o interior
Outward: Hacia fuera o exterior
Case 3-Q2. Review
Ptosis is due to an affection of the eyelid elevator (III cranial nerve), exotropia due to weakness
for adduction (lack of opposition to the VI cranial nerve) and mydriasis due to damage to the
parasympathetic fibers that travel together with nerve motor fibers.
Eyelid: Párpado
Literature:
La ptosis es por afección del elevador del párpado (III nervio craneal), la exotropia por debilidad
para la aducción (falta de oposición al VI nervio craneal) y la midriasis por el daño a las fibras
parasimpáticas que viajan junto con las fibras motoras del nervio.
Bibliografía:
Case 3
Q3. Which is her Hunt and Hess score?
A) 1
B) 2
C) 3
D) 4
Case 3-Q3. Review
Classification of Hunt and Hess of subarachnoid hemorrhage:
Stage 0: Intact aneurysm
Stage I: Asymptomatic or minimal headache. Light nuchal stiffness.
Stage IA: No meningeal or cerebral reaction, but with established neurological deficit.
Stage II: Moderate or severe headache. Nuchal stiffness. No serious neurological deficits except for involvement of
cranial nerves.
Stage III: Drowsiness, confusion or mild focal deficits.
Stage IV: Stupor. Moderate or severe hemiparesis. Vegetative alterations and possibly of premature decerebrate rigidity.
Stage V: Deep coma. Decerebrate rigidity, dying appearance.
Dying appearance: Apariencia moribunda

Literature:
La clasificación de Hunt y Hess de la hemorragia subaracnoidea:
Estadio 0: Aneurisma intacto
Estadio I: Asintomático o mínima cefalea. Rigidez nucal ligera.
Estadio IA: Sin reacción meníngea o cerebral, pero con déficit neurológico establecido.
Estadio II: Cefalea moderada o grave. Rigidez nucal. Sin déficit neurológicos graves a excepción de afectación de pares
craneales.
Estadio III: Somnolencia, confusión o déficit focales leves.
Estadio IV: Estupor. Hemiparesia moderada o grave. Alteraciones vegetativas y posiblemente rigidez de descerebración
precoz.
Estadio V: Coma profundo. Rigidez de descerebración, apariencia moribunda.
Bibliografía:
Case 3
Q4. Which is the next step in the diagnosis?
A) Lumbar puncture
B) Non-enhanced computed tomography
C) Contrast-enhanced computed tomography
D) Angiography
Non-enhanced: No contrastada
Case 3-Q4. Review
In clinical suspicion of subarachnoid hemorrhage, non-enhanced computed tomography scan is
the procedure of choice and the first test to confirm the diagnosis. It reveals blood in the basal
cisterns in> 95% of the cases within the first 48 hours.
Contrast should never be given in the tomography because it decreases the diagnostic yield.
Lumbar puncture is reserved for negative scans. The angiography and angio-resonance studies
are useful later to look for the aneurysm.
Yield: Rendimiento
Literature:
Ante la sospecha clínica de hemorragía subaracnoidea, la tomografía craneal sin contraste es el
procedimiento de elección y la primera prueba para confirmar el diagnóstico. Revela sangre en
las cisternas basales en en >95% de los casos dentro de las primeras 48 horas.
Nunca debe administrarse contraste en la tomografía porque disminuye el rendimiento
diagnóstico. La punción lumbar se reserva para las tomografías negativas. Los estudios de
angiografía y angiorresonancia son útiles posteriormente para buscar el aneurisma.
Bibliografía:
Case 3
Q5. The previous test confirmed your diagnosis, which is the next step in management of this
patient?
A) Anti-hypertensive control
B) Intubation and mechanical ventilation
C) Secure the aneurism
D) Oral nifedipine
Case 3-Q5. Review
The treatment priority is to secure the aneurysm as soon as possible, as the risk of rebleeding is
significant in the first 48 hours. Currently, aneurysms are treated with either endovascular or
neurosurgical clipping.
Literature:
La prioridad del tratamiento es asegurar el aneurisma lo antes posible, ya que el riesgo de
resangrado es significativo en las primeras 48 horas. Actualmente, los aneurismas se tratan con
clipaje endovascular o neuroquirúrgico.
Bibliografía:
Case 4
A 21 year old woman arrives to your office complaining about generalized weakness, double
vision, left eyelid droop, and difficulty swallowing; specially at the end of the day. Her pupils and
deep tendon reflexes are normal on examination.
Case 4
A 21 year old woman arrives to your office complaining about generalized weakness, double
vision, left eyelid droop, and difficulty swallowing; specially at the end of the day. Her pupils and
deep tendon reflexes are normal on examination.
Case 4
Difficulty swallowing : Dificultad para tragar
Case 4
A) Multiple sclerosis
B) Lambert-Eaton
C) Myasthenia gravis
D) Myopathy
Case 4-Q1. Review
Myasthenia gravis is a chronic autoimmune neuromuscular disease that affects individuals of all
ages and causes a significant deterioration in the quality of life of patients. The main symptoms
are fluctuating muscle weakness and fatigue of voluntary striated muscles, which generate a
significant deterioration of physical abilities, as well as a serious impact on the quality of life of
the patient. Muscle weakness increases during periods of activity and decreases after periods of
rest.
Literature:
Guía de Práctica Clínica: Tratamiento de la Miastenia Gravis en el adulto.
La miastenia gravis constituye una enfermedad neuromuscular autoinmune y crónica, que afecta
a individuos de todas las edades y produce un deterioro importante en la calidad de vida de los
pacientes. Los síntomas principales son debilidad muscular fluctuante y fatiga de músculos
estriados voluntarios, los cuales generan un deterioro importante de las capacidades físicas, así
como un grave impacto en la calidad de vida del paciente. La debilidad muscular aumenta
durante los períodos de actividad y disminuye después de períodos de reposo.
Bibliografía:
Case 4
Q2. Which is the most specific and sensitive diagnostic test?
A) Tensilon test (edrophonium)

B) Repetitive nerve stimulation test
C) Single fiber electromyography
D) Anti-acetylcholine receptor antibodies
Case 4-Q2. Review
Myasthenia gravis is a chronic autoimmune neuromuscular disease mediated by autoantibodies
against the nicotinic acetylcholine receptor.
Literature:
La miastenia gravis es una enfermedad neuromuscular autoinmune y crónica, mediada por
autoanticuerpos contra el receptor nicotínico de acetilcolina.
Bibliografía:
Case 4
Q3. In which percentage does the anti-acetylcholine receptor antibodies are positive in
ocular myasthenia?
A) 30%
B) 40%
C) 50%
D) 70%
Case 4-Q3. Review
50 to 60% of patients with ocular myasthenia have positive antibodies, detected by
radioimmunoassay against the acetylcholine receptor.
Literature:
50 a 60% de los pacientes con miastenia ocular tienen anticuerpos positivos, detectados
mediante radioinmunoensayo contra el receptor de acetilcolina.
Bibliografía:
Case 4
Q4. Which is the best treatment in the case of an acute myasthenic crisis?
A) High dose of piridostigmine

B) Intravenous steroids
C) Intravenouscyclophosphamide
D) Plasmapheresis
Case 4-Q4. Review
Intravenous immunoglobulin is a therapeutic intervention of first choice in the treatment of
myasthenic crisis, the short-term management of myasthenia gravis and prior to performing
thymectomy.
Short-term : A corto plazo
Literature:
La inmunoglobulina intravenosa es una intervención terapéutica de primera elección en el
tratamiento de la crisis miasténica, el manejo a corto plazo de la miastenia grave y previo a la
realización de timectomía.
Bibliografía:
Case 4
Q5. What Osserman Classification receives a patient with ocular myasthenia gravis with
progression to the involvement of bulbar muscles?
A) Stage 1
B) Stage 2
C) Stage 3
D) Stage 4
Case 4-Q5. Review
Osserman Classification
Stage 1: Localized non-progressive disease (ocular myasthenia).
Stage 2: Generalized disease of gradual presentation (involves more than one group of striated, skeletal and bulbar
muscles)
Stage 3: Acute fulminant generalized disease with severe bulbar involvement.
Stage 4: Severe late disease (usually develops 2 years or more after symptoms in category 1 or 2).
Stage 5: Muscular atrophy (not due to obsolescence) in late generalized disease, restricted to skeletal muscles and
usually related to the duration of the disease and clinical severity (myasthenic myopathy).
Non-progressive disease : Enfermedad no progresiva

Obsolescence: falta de uso
Literature:
Clasificación de Osserman
Estadio 1: Enfermedad localizada no progresiva (miastenia ocular).
Estadio 2: Enfermedad generalizada de presentación gradual (involucra mas de un grupo de
músculos estriados, esquelético y bulbar)
Estadio 3: Enfermedad generalizada aguda fulminante con involucro bulbar grave.
Estadio 4: Enfermedad grave tardía (usualmente se desarrolla 2 años o más después de los
síntomas en la categoría 1 o 2).
Estadio 5: Atrofia muscular (no debido a desuso) en enfermedad generalizada tardía, restringida
a músculos esqueléticos y usualmente relacionada con la duración de la enfermedad y severidad
clínica (miopatía miasténica).
Bibliografía:
Case 5
A 65 year old man arrives to the Emergency Department of your hospital due to a headache that
progressed to neck stiffness, nausea, vomiting, and an inability to look at bright lights. On
physical examination temperture 39.5 oC, blood pressure is 130/85 mmHg, and respirations rate
20 rpm. Extreme pain is elicited upon flexion of the patient's neck and the patient's legs.
Case 5
A 65 year old man arrives to the Emergency Department of your hospital due to a headache that
progressed to neck stiffness, nausea, vomiting, and an inability to look at bright lights. On
physical examination temperture 39.5 oC, blood pressure is 130/85 mmHg, and respirations rate
20 rpm. Extreme pain is elicited upon flexion of the patient's neck and the patient's legs.
Case 5
Elicited upon flexion : obtenido en la flexión
Case 5
Q1. Which is the most likely diagnosis.
A) Brain abscess
B) Viral encephalitis
C) Meningitis
D) Meningoencephalitis
Case 5-Q1. Review
The most frequent symptoms in patients with acute bacterial meningitis are characterized by
the classic triad constituted by fever, neck stiffness and alterations of the mental state. This triad
is more common in patients with bacterial meningitis of pneumococcal and meningococcal
origin. Other frequent signs and symptoms are headache, nausea, vomiting, photophobia,
seizures and focal neurological deficit (aphasia, hemiparesis, cranial nerve palsies).
Seizures : convulsiones
Literature:
Guía de Práctica Clínica: Diagnóstico, Tratamiento y Prevención de la Meningitis Bacteriana Aguda en Adultos Inmunocompetentes.
Los síntomas más frecuentes en pacientes con meningitis bacteriana aguda se caracterizan por
la tríada clásica constituida por fiebre, rigidez de cuello y alteraciones del estado mental. Esta
triada es más común en los pacientes con meningitis bacteriana de origen neumocócica y
meningocócica. Otros signos y síntomas frecuentes son cefalea, náusea, vómito, fotofobia,
convulsiones y déficit neurológico focal (afasia, hemiparesia, parálisis de pares craneales).
Bibliografía:
Case 5
Q2. Which infectious agent should be suspected in pregnancy and puerperium?
A) Streptococcus pneumoniae
B) Neisseria meningitidis
C) Listeria monocytogenes
D) Haemophilus influenzae
Pregnancy: embarazo
Case 5-Q2. Review
Listeria monocytogenes should be suspected in elderly (over 55 years), pregnant (may cause
fetal death) and puerperal, patients with some degree of cellular immunosuppression
(prolonged corticotherapy, AIDS, cirrhosis, solid organ transplant recipients or Hodgkin) and
whenever the cerebrospinal fluid is Gram positive bacilli or the clinical course with
rhombencephalitis (brainstem encephalitis).
Elderly: anciano
Acquired Immune Deficiency Syndrome (AIDS): Síndrome de Inmuno-Deficiencia Adquirida (SIDA)
Literature:
Se debe sospechar de Listeria monocytogenes en edades avanzadas (mayores de 55 años),
embarazadas (pudiendo producir muerte fetal) y puérperas, pacientes con algún grado de
inmunosupresión celular (corticoterapia prolongada, SIDA, cirrosis, receptores de trasplante de
órgano sólido o enfermedad de Hodgkin) y siempre que en el líquido cefalorraquídeo se
obtienen bacilos Gram positivos o el cuadro curse con rombencefalitis (encefalitis del tronco
cerebral).
Bibliografía:
Case 5
Q3. Which of the following is not a chemoprophylactic drug for the contacts of a patient with
meningitis?
A) Rifampin
B) Ciprofloxacin
C) Ceftriaxone
D) Chloramphenicol
Case 5-Q3. Review
The recommended chemoprophylaxis scheme can be any of the following:
- Rifampicin, in doses of 600 mg every 12 hours for 2 days (4 doses).
- Ciprofloxacin, 500 mg, single dose.
- Ceftriaxone 250 mg, 1 gram intramuscular or intravenous in single dose.
Literature:
El esquema de quimioprofilaxis recomendado puede ser cualquiera de los siguientes:
- Rifampicina, en dosis de 600 mg cada 12 horas durante 2 días (4 dosis).

- Ciprofloxacino, 500 mg, dosis única.
- Ceftriaxona 250 mg, a 1 gramo intramuscular o endovenoso en dosis única.
Bibliografía:
Case 5
Q4. Which of the following is not an indication for requesting a CT scan before lumbar puncture?
A) Seizures
B) Papiledema
C) Glasgow of 10 points
D) Severe immunocompetence
Request: solicitar
Case 5-Q4. Review
The following are indications for requesting a CT scan before lumbar puncture:
1. History of central nervous system disease

2. Seizures of recent onset
3. Papiledema
4. Alterations of consciousness (Glasgow <10 points)
5. Presence of focal neurological deficit
6. Severe immunocompetence
Before: antes
Onset: comienzo
Literature:
Las siguientes son indicación para solicitar tomografía de cráneo antes de la punción lumbar:
1. Antecedentes de enfermedad del sistema nervioso central

2. Crisis convulsivas de reciente inicio
3. Papiledema
4. Alteraciones de la conciencia (Glasgow < 10 puntos)
5. Presencia de déficti neurológico focal
6. Inmunocompetencia grave
Bibliografía:
Case 5
Q5. Which of following cerebrospinal fluid findings is not characteristic of this disease:
a) Glucose levels less tan 40 mg/dL

b) Protein content greater than 50 mg/dL
c) Neutrophils greater than 60%
d) Opening pressure lesser than 180 mm H2O
Case 5-Q5. Review
The characteristics of cerebrospinal fluid in bacterial meningitis are:
Turbid or purulent appearance, opening pressure greater than 180 mmH2O, Leukocytes 1,000-
10,000 cel/mm3, neutrophils> 60%, proteins greater than 50 g/dL, glucose <45 mg/dL.
Literature:
Las caracteristicas del líquido cefalorraquídeo en una meningitis bacteriana son:
Apariecnia turbia o purulenta, presión de apertura >180 mmH2O, Leucocitos 1,000-10,000
cel/mm3, neutrófilos >60%, proteínas > 50 g/dL, glucosa <45 mg/dL.
Bibliografía:
Case 6
An 85 year old man arrives to your office accompanied by his wife. She says that her husband has
been losing memory for the last five years, he first started by having minor forgetfulness, but lately
he has been having trouble remembering names. He gets lost in a conversation and sometimes
repeats the same question over and over again. She also says he is more irritable and participates
less in family activities.
Case 6
An 85 year old man arrives to your office accompanied by his wife. She says that her husband has
been losing memory for the last five years, he first started by having minor forgetfulness, but
lately he has been having trouble remembering names. He gets lost in a conversation and
sometimes repeats the same question over and over again. She also says he is more irritable and
participates less in family activities.
Case 6
Losing memory : Perdiendo la memoria
Forgetfulness : Olvidadizo
Remembering : Recordar
Case 6
A) Vascular dementia
B) Lewy body dementia
C) Fronto-temporal dementia
D) Alzheimer´s disease
Case 6-Q1. Review
Alzheimer's disease is a neuro-degenerative disease and is the first worldwide cause of
dementia, up to 60% of cases of dementia correspond to it. It is a disease of insidious onset and
slow progression, with an average evolution of about eight to ten years from onset to death.
Alzheimer's disease usually presents with a preclinical period characterized by specific memory
errors, later alteration of recent memory and learning ability.
Learning ability: Capacidad de aprendizaje
Literature:
Guía de Práctica Clínica: Diagnóstico y Tratamiento de la Enfermedad de Alzheimer. 2017
La enfermedad de Alzheimer es un padecimiento neuro-degenerativo y es la primer causa de
demencia a nivel mundial, hasta el 60% de los casos de demencia corresponden a ésta. Se trata
de una enfermedad de inicio insidioso y progresión lenta, con una evolución media de unos
ocho a diez años desde el inicio hasta la muerte. La enfermedad de Alzheimer suele presentarse
con un periodo preclínico caracterizado por errores puntuales de memoria, posteriormente
alteración de la memoria reciente y de la capacidad de aprendizaje.
Bibliografía:
Case 6
Q2. Which of the following is a symptom of moderate Alzheimer's disease?
A) Loss of recent memory.

B) Reduced attention time.
C) Weight loss.
D) Urinary and fecal incontinence.
Case 6-Q2. Review
Moderate Alzheimer's disease:
- Major deterioration of memory and confusion. - Reduced attention time.
- Difficulty to recognize friends and family. - Decrease in the number of words and fluency of the language.
- Difficulties with reading, writing or calculating. - Difficulty organizing thoughts and thinking logically.
- Inability to learn new things or to face new or unexpected situations.
- Restlessness, agitation, anxiety, crying, wandering, especially in the afternoon or at night. Repetitive movements; Occasional muscle contractions
- Hallucinations, delusions, suspicions or paranoia ("they steal your things"). - Irritability.
- Loss of impulse control: behaviors such as undressing at inappropriate times or places or in vulgar language.
- Executive dysfunction and visual-spatial impairment: such as problems getting out of a chair or setting the table.
Thoughts: Pensamientos
Restlessness : Inquietud
Wandering : Distraído
Literature:
Enfermedad de Alzheimer moderada:
- Deterioro mayor de la de memoria y confusión. - Tiempo de atención reducido.
- Dificultad para reconocer a amigos y familiares. - Disminución de la cantidad de palabras y fluidez del lenguaje.
- Dificultades con la lectura, escritura o cálculo. - Dificultad para organizar pensamientos y pensar lógicamente.
- Incapacidad para aprender cosas nuevas o para hacer frente a situaciones nuevas o inesperadas.
- Inquietud, agitación, ansiedad, llanto, vagabundeo, especialmente en la tarde o por la noche. Movimientos repetitivos; Contracciones musculares ocasionales.
- Alucinaciones, delirios, sospechas o paranoia (“le roban sus cosas”). - Irritabilidad.
- Pérdida del control de los impulsos: conductas tales como desvestirse en momentos o lugares inapropiados o en lenguaje vulgar.
- Disfunción ejecutiva y el deterioro visuo-espacial:
tales como problemas para salir de una silla o poner la mesa.
Bibliografía:
Case 6
Q3. All of the following have an important role for this disease evaluation except:
A) Mental status assesment

B) Laboratory studies
C) Lumbar puncture
D) Electroencephalogram
Case 6-Q3. Review
The diagnosis of Alzheimer's disease should include a formal objective cognitive evaluation with
validated instruments and studies that rule out other diseases. In this case the
electroencephalogram would be the least useful tool for diagnosis, since it would surely show
nonspecific data as a slowing of the base rhythm.
Rule out : Descartar

Least useful: Menos útil
Literature:
El diagnóstico de Enfermedad de Alzheimer debe incluir una evaluación cognoscitiva objetiva
formal mediante instrumentos validados y estudios que descarten otras enfermedades. En este
caso el electroencefalograma sería la herramienta menos útil para el diagnóstico, ya que
seguramente mostraría datos inespecíficos como enlentecimiento del ritmo de base.
Bibliografía:
Case 6
Q4. Which of the following is not a risk factor for Alzheimer's disease?
A) Depression
B) Hypertension in the young adult
C) Obesity (BMI> 30kg / m2)
D) Alcoholism
Case 6-Q4. Review
The modifiable risk factors for developing Alzheimer's disease are: Depression, physical
inactivity, hypertension in the young adult, obesity (BMI> 30kg / m2, smoking, low educational
level and diabetes.
Literature:
Los factores de riesgo modificables para desarrollar Enfermedad de Alzheimer son: Depresión,
inactividad física, hipertensión en el adulto joven, obesidad (IMC >30kg/m2, tabaquismo, bajo
nivel educativo y diabetes.
Bibliografía:
Case 6
Q5. Which is the non-modifiable factor with the highest risk for Alzheimer's disease?
A) Old age
B) First-degree relatives with disease
C) Existence of autosomal dominant genes for the early onset of the disease
D) Presence of E4 allele of apolipoprotein E (Apo E)
Case 6-Q5. Review
Among the non-modifiable risk factors, the highest risk for Alzheimer's disease is the presence
of E4 allele of apolipoprotein E (Apo E), it is more significant in Asians compared to African-
Americans.
Literature:
Dentro de los factor de riesgo no modificable, el de mayor riesgo para Enfermedad de Alzheimer
es la presencia de alelo E4 de la apoliproteina E (Apo E), es más significativo en asiáticos en
comparación con afroamericanos.
Bibliografía:
Case 7
A 42 year old secretary arrives to your office due to a two-month history of proximal
interphalangeal pain and morning joint stiffness for more than 30 minutes, interfering with her
work. On physical examination, the patient has symmetric synovitis of the metacarpophalangeal
and wrist joints.
Case 7
A 42 year old secretary arrives to your office due to a two-month history of proximal
interphalangeal pain and morning joint stiffness for more than 30 minutes, interfering with her
work. On physical examination, the patient has symmetric synovitis of the metacarpophalangeal
and wrist joints.
Case 7
Wrist: Muñeca
Case 7
A) Gout disease
B) Osteoartitis.
C) Rheumatoid arthritis
D) Ankylosing spondylitis
Case 7-Q1. Review
Rheumatoid arthritis is an inflammatory, chronic, autoimmune and systemic disease of unknown
etiology; its main target organ is the synovial membrane; It is characterized by polyarticular and
symmetric inflammation of small and large joints, with possible systemic involvement at any
time during its evolution.
Recent-onset rheumatoid arthritis should be suspected in patients with signs and symptoms of
at least 6 weeks and less than 12 months of evolution, including 3 or more swollen joints,
arthritis in hands (proximal interphalangeal, metacarpophalangeal, carpal) , morning joint
stiffness of 30 minutes or more, pain at compression of metacarpophalangeal and
metatarsophalangeal joints, with symmetric affection.
Target: Blanco
Swollen: Hinchado
Literature:
Guía de Práctica Clínica: Diagnóstico y Tratamiento de Artritis Reumatoide del Adulto.
La artritis reumatoide es una enfermedad inflamatoria, crónica, autoinmune y sistémica de
etiología desconocida; su principal órgano blanco es la membrana sinovial; se caracteriza por
inflamación poliarticular y simétrica de pequeñas y grandes articulaciones, con posible
compromiso sistémico en cualquier momento de su evolución.
La artritis reumatoide de inicio reciente se debe sospechar en el paciente con signos y síntomas
de al menos 6 semanas de duración y de menos de 12 meses de evolución, que incluya 3 o más
articulaciones inflamadas, artritis en manos (IFP, MCF, carpos), rigidez articular matutina de 30
minutos o más, dolor a la compresión de articulaciones metacarpofalángicas y
metatarsofalángicas, con afección simétrica.
Bibliografía:
Case 7
Q2. Which study would you request to complete the diagnosis?
A) C-reactive protein
B) Anti-CCP
C) HLA-B27
D) X-ray of the wrist
Case 7-Q2. Review
Anti-CCP antibodies (anti citrullinated cyclic peptide) have a superior probability ratio for the
diagnosis of Rheumatoid Arthritis than the rheumatoid factor. Anti-CCP antibodies are a useful
tool in the diagnosis of patients with recent onset rheumatoid arthritis
Useful: útil
Literature:
Los anticuerpos anti-CCP (anti péptido cíclico citrulinado) tienen un cociente de probabilidad
para el diagnóstico de Artritis Reumatoide superior al de factor reumatoide. Los anticuerpos
anti-CCP constituyen una herramienta útil en el diagnóstico del paciente con artritis reumatoide
de reciente inicio.
Bibliografía:
Case 7
Q3. Which is the main drug in the treatment of this disease?
A) Methotrexate
B) Sulfasalazine for peripheral manifestations of the disease
C) Paracetamol or NSAID
D) High doses of salicylates + Penicillin for a long time
Case 7-Q3. Review
Methotrexate is currently considered the drug of choice for the treatment of rheumatoid
arthritis due to its efficacy and tolerance. It is administered in a single dose 7.5 to 25 mg week.
The simultaneous use of folic or folinic acid decreases some adverse effects.
Currently: actualmente
Literature:
Metrotexato actualmente es considerado el fármaco de elección para el tratamiento de la
artritis reumatoide debido a su eficacia y tolerancia. Se administra en una única dosis semanala
7.5 a 25 mg. El uso simultáneo de ácido fólico o folínico disminuye algunos efectos adversos.
Bibliografía:
Case 7
Q4. Which will be the chemoprophylaxis drug in case this patient is in contact with someone
infected with tuberculosis?
A) Isoniazid
B) Rifampicin
C) Pyrazinamide
D) Ethambutol
Case 7-Q4. Review
Avoid contact with patients with tuberculosis and do chemoprophylaxis with isoniazid when
appropriate.
Literature:
Se debe evitar contactos con pacientes con tuberculosis y hacer quimioprofilaxis con isoniacida
cuando corresponda.
Bibliografía:
Case 7
Q5. Which of the following is not a preliminary criterion of clinical remission of rheumatoid
arthritis?
A) Rigidity greater than 15 minutes and less than 30 minutes

B) Absence of fatigue
C) Absence of joint pain
D) Sedimentation rate <30 mm in women
Case 7-Q5. Review
Preliminary Criteria for Clinical Remission of Rheumatoid Arthritis
1. Absence of morning stiffness or not exceeding 15 minutes
2. Absence of fatigue
3. Absence of joint pain
4. Absence of joint pain under pressure
5. Absence of synovial and tenosynovial swelling
6. Normal sedimentation rate <30 mm in women and <20 mm in males
Literature:
Criterios preliminares de Remisión Clínica de la Artritis Reumatoide
1. Rigidez matutina ausente o no superior a 15 minutos
2. Ausencia de cansancio
3. Ausencia de dolor articular en la anamnesis
4. Ausencia de dolor articular a la presión
5. Ausencia de tumefacción sinovial y tenosinovial
6. Velocidad de sedimentación normal < 30 mm en mujeres y <20 mm en varones
Bibliografía:
Case 8
A 28 year old man arrives to your office due to a two-year history of worsening lower back
stiffness that is present for a few hours after awakens in the morning, accompanied by buttock
pain throughout the day when he is seated that improves with exercise.
Case 8
A 28 year old man arrives to your office due to a two-year history of worsening lower back
stiffness that is present for a few hours after awakens in the morning, accompanied by buttock
pain throughout the day when he is seated that improves with exercise.
Case 8
Worsening : Empeora
Awakens : Despertar
Buttock : Glúteos
Throughout : Durante todo o en todo
Case 8
A) Reactive arthritis
B) Ankylosing spondylitis
C) Rheumatoid arthritis
D) Herniated disk
Case 8-Q1. Review
Ankylosing spondylitis is a chronic inflammatory systemic disease of unknown etiology, which is
significantly associated with HLA-B27 histocompatibility antigen. It primarily affects the axial
skeleton (spine and sacroiliac joint) and the entheses. It affects the male sex more frequently
and usually occurs during adolescence and adulthood, mainly between 25 and 30 years of age.
Literature:
Guía de Práctica Clínica: Uso de Terapia Biológica en Espondilitis Anquilosante del Adulto
La espondilitis anquilosante es una enfermedad sistémica inflamatoria crónica de etiología
desconocida, que se asocia significativamente al antígeno de histocompatibilidad HLA–B27.
Afecta primariamente al esqueleto axial (columna vertebral y articulación sacroiliaca) y a las
entesis. Afecta con mayor frecuencia al sexo masculino y se presenta habitualmente durante la
adolescencia y en el adulto, principalmente entre los 25 y 30 años de edad.
Bibliografía:
Case 8
Q2. Which of the following is not associated with ankylosing spondylitis?
A) Dactylitis
B) Psoriasis
C) Asymmetric arthritis
D) Ulcerative colitis
Case 8-Q2. Review
A diagnosis of ankylosing spondylitis can be made when there is an association of two of the
following (enthesitis, dactylitis, positive family history, Chron's disease, asymmetric arthritis,
alternating pain in the buttocks, psoriasis, elevation of acute phase reactants, response to
NSAIDs) with inflammatory lumbalgia.
Literature:
Se puede hacer diagnóstico de espondilitis anquilosante, cuando exista asociación de dos de las
siguientes (entesistis, dactilitis, historia familiar positiva, enfermedad de Chron, artritis
asimétrica, dolor alternante en glúteos, psoriasis, elevación de reactantes de fase aguda,
respuesta a AINE) con lumbalgia inflamatoria.
Bibliografía:
Case 8
Q3. Which of the following is not a New York criteria?
A) Lumbar limitation
B) Stiffness > 3 months
C) Unilateral sacroilitis > 2 degree
D) Thoracic expansion limitation
Case 8-Q3. Review
To establish the diagnosis of ankylosing spondylitis, it is recommended to use the modified New
York criteria despite its limitations.
- Clinical criteria: Pain and stiffness in the lower back for more than three months, limitation of
movements of the lumbar spine (sagittal and frontal) and limitation of the thoracic expansion.
- Radiological criteria: bilateral sacroiliitis> 2 degree or unilateral> 3 and 4.
Literature:
Para establecer el diagnóstico de espondilitis anquilosante, se recomienda utilizar los criterios
de Nueva York modificados a pesar de sus limitaciones.
- Criterios clínicos: Dolor y rigidez en la parte baja de la espalda durante más de tres meses,
limitación de movimientos de la columna lumbar (sagital y frontal) y limitación de la expansión
torácica.
- Criterios radiológicos: Sacroileítis bilateral > 2 grado o unilateral >3
Bibliografía:
Case 8
Q4. Which is a chronic complication of this disease?
a) IgA nephropathy
b) Previous Uveitis
c) Amyloidosis
d) Aortic insufficiency
Case 8-Q4. Review
Secondary amyloidosis occurs in 6-8% of chronic forms of the disease. The mortality observed in
patients with ankylosing spondylitis is 1.5 higher than in the general population and is attributed
mainly to cardiac valvular disease, amyloidosis and fractures.
Literature:
La amiloidosis secundaria se llega a producir en el 6-8% de las formas crónicas de la
enfermedad. La mortalidad observada en pacientes con espondilitis anquilosante es 1.5 mayor
que en población general y es atribuida principalmente a enfermedad valvular cardiaca,
amiloidosis y fracturas.
Bibliografía:
Case 8
Q5. In case of failure to the initial treatment you would administer:
A) Methotrexate
B) Infliximab
C) Sulfasalazine
D) Indomethacin
Case 8-Q5. Review
Infliximab produces symptomatic and objective parameters improvement; in addition, it stops
the evolution of the disease. It is indicated if there is activity despite the correct conventional
treatment. The survival of infliximab after two years is of 89%.
Literature:
El infliximab produce mejoría sintomática y de los parámetros objetivos, además de que muy
probablemente detenga la evolución de la enfermedad. Se encuentra indicado si existe actividad
pese al tratamiento convencional correcto. La sobrevida de infliximab después de dos años es
del 89%.
Bibliografía:
Case 9
A 25 years old man arrives to Emergency Department of your Hospital due to epistaxis. On
interrogation he refers recurrent episodes of sinusitis, intermittent night sweats, cough, a 5 kg
weight loss without any recent travel. On physical examination edema of lower limbs. Chest CT
with ground-glass opacities.
Case 9
A 25 years old man arrives to Emergency Department of your Hospital due to epistaxis. On
interrogation he refers recurrent episodes of sinusitis, intermittent night sweats, cough, a 5 kg
weight loss without any recent travel. On physical examination edema of lower limbs. Chest CT
with ground-glass opacities.
Case 9
Night sweats :Sudoración nocturna
Cough :Tos
Case 9
A) c-ANCA-associated vasculitis
B) p-ANCA-associated vasculitis
C) Takayasu's arteritis
D) Giant cell arteritis
Case 9-Q1. Review
Granulomatosis with polyangiitis (Wegener's granulomatosis) is a multisystem disease
characterized by the formation of granulomas and necrotizing inflammation in vessels of the
upper and lower respiratory tract, very frequently associated with glomerulonephritis. This
disease is closely associated with c-ANCA.
Literature:
Manual CTO de Medicina y Cirugía. 4ta Ed. ENARM-México, Reumatología. 2019
La granulomatosis con poliangeítis (Granulomatosis de Wegener) es una enfermedad
multisistémica caracterizada por la formación de granulomas e inflamación necrotizante en los
vasos de las vías respiratorias superior e inferior, muy frecuentemente asociada a
glomerulonefritis. Esta enfermedad tiene estrecha asociación con c-ANCA.
Bibliografía:
Case 9
Q2. In this case you would expect to find:
A) anti-MPO
B) HLA-B27
C) anti-PR3
D) anti-CCP
Case 9-Q2. Review
Depending on the pattern adopted by indirect immunofluorescence, it is known that: c-ANCA
(diffuse cytoplasmic pattern) whose antigen is proteinase 3 (anti-PR3).
Literature:
En función del patrón que adopte la inmunofluorescencia indirecta, se sabe que: c-ANCA (patrón
difuso citoplasmático) cuyo antígeno es la proteinasa 3 (anti-PR3).
Bibliografía:
Case 9
Q3. The data that guides you to the specific diagnosis within the group of diseases is:
a) Age
b) The kidney lung syndrome
c) The upper respiratory condition
d) The presence of edema
Case 9-Q3. Review
The most frequent (95%) and most precociously affected organ is the upper respiratory tract,
where the inflammatory tissue that occupies the paranasal sinuses gives a hemorrhagic or
purulent discharge.
Precociously : precozmente
Literature:
El órgano más frecuente (95%) y más precozmente afectado es la vía respiratoria superior,
donde el tejido inflamatorio que ocupa los senos paranasales da una secreción hemorrágica o
purulenta.
Bibliografía:
Case 9
Q4. Which is the first line treatment?
a) TMP-SMX
b) Cyclophosphamide
c) Mofetil-mycophenolate
d) Methotrexate
Case 9-Q4. Review
Wegener's granulomatosis is vasculitis in which cyclophosphamide has been shown to be more
effective and has modified the prognosis more drastically. Mortality does not exceed 15% and
more than 90% of patients experience clinical improvement (75% complete remission).
Literature:
La granulomatosis de Wegener es la vasculitis en la que la ciclofosfamida se ha mostrado más
eficaz y ha modificado de forma más drástica el pronóstico. La mortalidad no supera el 15% y
más del 90% de los pacientes experimentan mejoría clínica (75% remisión completa).
Bibliografía:
Case 9
Q5. Which will be the best site to confirm the diagnosis of this patient?
a) Request renal biopsy

b) Request a skin biopsy
c) Request paranasal biopsy
d) Request a lung biopsy
Case 9-Q5. Review
Whenever possible, a biopsy should be done to corroborate the diagnosis, which is important to
establish appropriate treatment. The biopsy of the upper respiratory tract can show granulomas
without vasculitis, and in the kidney there will be a glomerulonephritis without granulomas. The
most profitable organ for histologically documenting the disease is the lung.
Whenever possible: De ser posible
Literature:
Siempre que sea posible se debe tener una biopsia para corroborar el diagnóstico, lo cual es
importante para establecer tratamiento apropiado. La biopsia de la vía respiratoria superior
pued mostrar granulomas sin vasculitis, y en el riñón se encontrará una glomerulonefritis sin
granulomas.
El órgano más rentable para documentar histológicamente la enfermeda es el pulmón.
Bibliografía:
Case 10
A 45 year old woman arrives to your office due to a two-year history of diffuse muscular and joint
pain, along with insomnia, fatigue, difficulty concentrating and chronic headaches that are not
relieved by acetaminophen nor ibuprofen. On physical examination, diffuse soft-tissue tenderness
to palpation at multiple sites, but no weakness or synovitis. Laboratory exams are normal.
Case 10
A 45 year old woman arrives to your office due to a two-year history of diffuse muscular and joint
pain, along with insomnia, fatigue, difficulty concentrating and chronic headaches that are not
relieved by acetaminophen nor ibuprofen. On physical examination, diffuse soft-tissue tenderness
to palpation at multiple sites, but no weakness or synovitis. Laboratory exams are normal.
Case 10
Relieved: Aliviar
Soft-tissue tenderness: Tejidos blandos sensibles
Case 10
Q1. Which of the following studies is not useful, to rule out differential diagnoses and reach the
diagnosis?
A) Thyroid function tests

B) Globular sedimentation rate
C) Liver function tests
D) Rheumatoid factor
Case 10-Q1. Review
Fibromyalgia is a painful, non-articulate and idiopathic syndrome characterized by chronic pain
generalized for more than three months and presence of hypersensitive points in the physical
examination, may be accompanied by symptoms such as fatigue, sleep disorders, headache,
paresthesia, syndrome of irritable bowel, behavioral, neuroendocrine and autonomic nervous
system disorders.
It constitutes a multifactorial condition, in which there is an abnormal process of pain.
Laboratory studies are used for differential diagnosis; it is recommended to request tests of
thyroid function, blood cytometry and GSR and/or CRP, transaminases and even serology for
HCV (in patients with risk factors). Routine measurement of rheumatoid factor or antinuclear
antibodies is not indicated.
Painful : Doloroso
Request tests : solicitar pruebas
Literature:
Guía de Práctica Clínica: Diagnóstico y Tratamiento de Fibromialgia en el Adulto. 2009
La fibromialgia es un síndrome doloroso, no articular e idiopático, caracterizado por dolor
crónico generalizado por más de tres meses de duración y presencia de puntos hipersensibles en
el examen físico, puede acompañarse por síntomas como fatiga, trastornos del sueño, cefalea,
parestesias, síndrome de colon irritable, trastornos conductuales, neuroendocrinos y del
sistema nervioso autónomo.
Constituye una condición multifactorial, en la que existe un proceso anormal del dolor. Los
estudios de laboratorio se usan para el diagnóstico diferencial; se recomienda solicitar pruebas
de función tiroidea, citometría hemática y VSG y/o PCR, transaminasas e inclusive serología para
VHC (en pacientes con factores de riesgo). No está indicada la medición de rutina de factor
reumatoide o anticuerpos antinucleares.
Bibliografía:
Case 10
Q2. Which of the following does not correspond to a hypersensitive point?
A) Occiput
B) Lateral epicondyle
C) Third rib
D) Gluteal
Occiput: Occipucio
Case 10-Q2. Review
Pain in > 11 of the 18 hypersensitive points are:
- Occiput
- Low cervical
- Trapezius
- Supraspinatus
- Second rib
- Lateral epicondyle
- Gluteal
- Greater trochanter
- Knee
Literature:
• Dolor en > 11 de los 18 puntos hipersensible son:
• - Occipucio
• - Cervical bajo
• - Trapecio
• - Supraespinoso
• - Segunda costilla
• - Epicóndilo lateral
• - Glúteo
• - Trocánter mayo
• - Rodilla
Bibliografía:
Case 10
Q3. If the diagnosis of fibromyalgia is confirmed, which is the first line drug for this case?
A) Tricyclic antidepressant
B) Benzodiazepines
C) Carbamazepine
D) Serotonin reuptake inhibitors
Case 10-Q3. Review
The treatment of choice is with low doses of amitriptyline (tricyclic antidepressant and an
analgesic).
Literature:
El tratamiento de elección es con dosis bajas de amitriptilina (antidepresivo tricíclico y un
analgésico).
Bibliografía:
Case 10
Q4. Regarding the non-pharmacological treatment, which of the following is not indicated:
A) Cognitive therapy.
B) Behavioral therapy.
C) Exercise programs
D) Confrontation of the patient
Regarding: Con respecto a

Case 10-Q4. Review
The patient should not be confronted, she has a disease and requires appropriate treatment, all
other therapies can benefit in some cases.
Literature:
No se debe confrontar al paciente, ella tiene una enfermedad y requiere el tratamiento
apropiado, todas las demás terapias pueden ser de beneficio en algunos casos.
Bibliografía:
Case 10
Q5. In absence of a therapeutic response with tricyclic antidepressants, which is the
recommended drug for the treatment of fatigue and depression?
A) Monoamine oxidase inhibitors

B) Benzodiazepines
C) Carbamazepine
D) Serotonin reuptake inhibitors
Case 10-Q5. Review
It is recommended for the treatment of fatigue and depression, the administration of serotonin
reuptake inhibitors such as fluoxetine, 20 mg in the morning, in the absence of a therapeutic
response with tricyclic antidepressants.
Literature:
Se recomienda para el tratamiento de la fatiga y depresión, la administración de inhibidores de
la recaptura de serotonina como fluoxetina, 20 mg por la mañana, de no existir respuesta
terapéutica con antidepresivos tricíclicos.
Bibliografía:
Vocabulary Review
L
PUEP - ENARM
Dr. Julio Herrera-Zamora Dr. Julio Herrera-Zamora
Numbness: Entumecimiento o adormecimiento
Cramping: Calambres o espasmos
Weakness: Debilidad
Limbs: Extremidades
Bedridden: Postración
Facial diplegia: Diplejía facial
CSF (cerebrospinal fluid): LCR (líquido cefalorraquídeo)
Blurred vision: Visión borrosa
Tenderness: Sensibilidad
Beats: Latidos
Deeply: Profundamente
Tremor: Temblor
Reaches: Alcanzar
Less: Menor
Gait disturbances : Trastorno de la marcha
Although: Aunque
Resting tremor: Temblor en reposo
Mild: Leve
Disabling disease: Enfermedad discapacitante
Wheelchair: Silla de ruedas
Sudden: Repentino
Supranuclear gaze palsy: Parálisis supranuclear de la mirada
Language: Habla o lenguaje
Worst headache of her life : Peor dolor de cabeza de su vida
Drowsiness : somnolencia
Palsy : parálisis
Slight : leve o ligero
Inward: Hacia dentro o interior
Outward: Hacia fuera o exterior
Eyelid: Párpado
Dying appearance: Apariencia moribunda
Non-enhanced: No contrastada
Yield: Rendimiento
Difficulty swallowing : Dificultad para tragar
Short-term : A corto plazo
Non-progressive disease : Enfermedad no progresiva
Obsolescence: falta de uso
Elicited upon flexion : obtenido en la flexión
Seizures : convulsiones
Pregnancy: embarazo
Elderly: anciano
Acquired Immune Deficiency Syndrome (AIDS): Síndrome de Inmuno-Deficiencia Adquirida (SIDA)
Request: solicitar
Before: antes
Onset: comienzo
Losing memory : Perdiendo la memoria
Forgetfulness : Olvidadizo
Remembering : Recordar
Learning ability: Capacidad de aprendizaje
Thoughts: Pensamientos
Restlessness : Inquietud
Wandering : Distraído
Rule out : Descartar
Least useful: Menos útil
Wrist: Muñeca
Target: Blanco
Swollen: Hinchado
Useful: útil
Currently: actualmente
Worsening : Empeora
Awakens : Despertar
Buttock : Glúteos
Throughout : Durante todo o en todo
Night sweats :Sudoración nocturna
Cough :Tos
Precociously : precozmente
Whenever possible: De ser posible
Relieved: Aliviar
Soft-tissue tenderness: Tejidos blandos sensibles
Painful : Doloroso
Request tests : solicitar pruebas
Occiput: Occipucio
Regarding: Con respecto a

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English Clinical Cases

CSF (cerebrospinal fluid): LCR (líquido cefalorraquídeo)

A) In the first 24 hours

Blurred vision: Visión borrosa

Resting tremor: Temblor en reposo

A) History of repeat cranial traumas

Abrupt-onset: Inicio abrupto

A) Ptosis, an inward deviated eye, midriatic pupil

Dying appearance: Apariencia moribunda

A) Tensilon test (edrophonium)

A) High dose of piridostigmine

Short-term : A corto plazo

Non-progressive disease : Enfermedad no progresiva

- Rifampicina, en dosis de 600 mg cada 12 horas durante 2 días (4 dosis).

1. History of central nervous system disease

1. Antecedentes de enfermedad del sistema nervioso central

a) Glucose levels less tan 40 mg/dL

Learning ability: Capacidad de aprendizaje

A) Loss of recent memory.

A) Mental status assesment

Rule out : Descartar

A) Rigidity greater than 15 minutes and less than 30 minutes

a) Request renal biopsy

Whenever possible: De ser posible

A) Thyroid function tests

Regarding: Con respecto a

A) Monoamine oxidase inhibitors

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