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101.- La primera causa de hipertiroidismo en adolescentes es: a) Tiroditis subaguda b) Bocio toxico difuso (enfermedad de Graves) c) Bocio toxico nodular d) Adenoma toxico Respuesta correcta: B, bocio toxico difuso. Thyrotoxicosis is the hypermetabolic condition associated with elevated levels of free thyroxine (FT4), free triiodothyronine (FT3), or both. Hyperthyroidism includes diseases that are a subset of thyrotoxicosis (excludes exogenous thyroid hormone intake and subacute thyroiditis) that is caused by excess synthesis and secretion of thyroid hormone by the thyroid. Most clinicians, exclusive of endocrinologists, use the terms hyperthyroidism and thyrotoxicosis interchangeably. The most common forms of hyperthyroidism include diffuse toxic goiter (Graves disease), toxic multinodular goiter (Plummer disease), and toxic adenoma. The most common cause of thyrotoxicosis is Graves disease (50-60%). Graves disease is an organspecific autoimmune disorder characterized by a variety of circulating antibodies, including common autoimmune antibodies, antithyroperoxidase (anti-TPO), and antithyroglobulin (antiTG) antibodies. The most important autoantibody is thyroid-stimulating immunoglobulin (TSI). TSI is directed toward epitopes of the thyroid-stimulating hormone (TSH) receptor and acts as a TSH-receptor agonist. Similar to TSH, TSI binds to the TSH receptor on the thyroid follicular cells to activate thyroid hormone synthesis and release and thyroid growth (hypertrophy). This results in the characteristic picture of Graves thyrotoxicosis, with a diffusely enlarged thyroid, very high radioactive iodine uptake, and excessive thyroid hormone levels compared to a healthy thyroid with subacute thyroiditis, these conditions constitute 85-90% of all causes of thyrotoxicosis.

102.- El principal neurotransmisor implicado en la de etiopatogenesis de la ansiedad es: a) Noradrenalina b) Serotonina c) GABA

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d) Glutamato. Respuesta correcta: A, serotonina. Serotonin and its receptors have long been implicated in memory and anxiety in both humans and animals. In addition to receptors, other factors include serotonin homeostasis and metabolism. Serotonin is removed from the synaptic cleft by a specific membrane transporter protein (SERT), representing an important target for various manipulations. For example, pharmacological inhibition of SERT leads to elevated hippocampal serotonin levels and improved memory. While genetic ablation of SERT in mice is widely used as a model of anxiety, these mice display increased poststress responsivity, indirectly implying a better memory for aversive stimuli. Clearly, further studies are needed to assess the link between SERT and cognitive abilities in animals, and its relevance to human brain dysfunctions. Overall, human anxiety-related traits seem to generally facilitate cognitive functions (e.g., acquisition of conditioned fear), and such interplay is partially serotonergically mediated. Allan V. Kalueff* Neurobiology of Memory and Anxiety: From Genes to Behavior Neural Plast. 2007; 2007: 78171. 103.- Caso clnico. Un jugador de ftbol soccer que se lesiona al ir corriendo, al parar bruscamente y rotar sobre su propia rodilla, a la exploracin fsica existe signo de tempano de hielo positivo, el diagnstico ms probable es: a) Lesin de meniscos b) Hemartrosis c) Lesin del ligamento cruzado anterior d) Lesin de ligamentos colaterales Respuesta correcta: B, hemartrosis. El futbolista lesionado tiene una rodilla "ocupada" (signo de tempano de hielo positivo) y la nica respuesta probable por la falta de datos especficos es "hemartrosis". Ahora bien, si les dijera que tuvo cajones positivos seria una lesin a ligamentos cruzados, y si les dijeran bostezos positivos seria una lesin de colaterales. La rotacin sobre la rodilla causa lesin meniscal, la carga excesiva en la articulacin de la rodilla al detenerse de manera sbita ocasiona lesin del ligamento cruzado anterior.

Signo de tempano de hielo, producido por lquido en la articulacin. 104.- La lesin ms frecuente en los futbolistas es la lesin de:

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a) b) c) d)

Ligamento cruzado anterior Ligamento cruzado posterior Menisco medial Ligamento colateral medial.

Respuesta correcta: A, ligamento cruzado anterior. Las lesiones del LCA estn frecuentemente asociadas con otras lesiones. El ejemplo clsico es cuando el LCA se desgarra al mismo tiempo que el ligamento cruzado medial y que el menisco medial. Este tipo de lesin es ms frecuente en los futbolistas y en los esquiadores. 105.- Caso clnico. Mujer de 30 aos con un exantema macular en la frente, ulceras bucales, alteraciones en la piel con artritis en manos y pies con factor reumatoide positivo, ANA -. El diagnstico ms probable es: a) b) c) d) LES Dermatomiositis Artritis reumatoide Enfermedad mixta del tejido conjuntivo

Respuesta correcta: A, LES. In lupus the widely recognised presentation of a young woman with inflammatory arthritis and a butterfly facial rash is uncommon. Non-specific symptoms of fatigue, malaise, oral ulcers, arthralgia, photosensitive skin rashes, lymphadenopathy, pleuritic chest pains, headache, paraesthesiae, symptoms of dry eyes and mouth, Raynauds phenomenon, and mild hair loss are more likely presentations. It is not surprising therefore that there is often considerable delay before the diagnosis is considered in patients with low grade disease. Patients may present acutely with major organ dysfunction that can affect virtually any organ, and diagnosis hinges on careful and thorough clinical evaluation and recognition of multisystem involvement. Renal involvement (lupus nephritis) presents insidiously, and if it is not detected early, the risk of progression to renal impairment is high. The key to early diagnosis is clinical evaluation, which should include a complete systems review and examination and investigations guided by the extent of organ involvement. In primary care, a diagnosis of lupus or a related disorder is often apparent after clinical assessment, urinalysis for blood and protein, and basic investigations such as full blood count (often showing anaemia or cytopenia), renal and liver function, and acute phase reactants: a high erythrocyte sedimentation rate (ESR) with a normal C reactive protein (CRP) concentration are characteristic. A search for autoantibodies to nuclear antigens (antinuclear and antiDNA antibodies) and rheumatoid factor are the usual starting points while considering referral to specialist care. Antiphospholipid antibodies (anticardiolipin antibodies and the lupus anticoagulant) should be considered in women with previous morbidity in pregnancy or thrombotic events. In secondary care, more extensive testing is usually considered including detailed assessment of organ dysfunction and further autoantibody testing including complement levels and antibodies to the extractable nuclear antigens (ENA) such as Ro (SS-A), La (SS-B), ribonucleoprotein (RNP), and Sm. It is difficult to predict which patients will progress to severe multisystem disease with a poor outcome. In general morbidity and mortality is higher in patients with extensive multisystem disease and multiple autoantibodies. Prognosis ultimately depends on the amount of damage (permanent scars or irreversible organ dysfunction) accrued over the course of the disease. Treatment therefore aims to eliminate inflammation and thrombosis, minimising damage. Accelerated atherosclerosis is now recognised as a major contributorto premature death through myocardial infarction and cerebrovascular disease.

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D'Cruz D. Systemic lupus erythematosus BMJ 2006;332:890-894 106.- Secretaria con dolor repentino en dedo medio, ndice y pulgar y signo de Tindall positivo, el diagnstico ms probable es lesin del: a) b) c) d) Nervio mediano Nervio radial Nervio cubital Nervio pudendo

Respuesta correcta: A, nervio mediano. El sndrome del tnel del carpo es la neuropata por compresin ms frecuente de todo el organismo. Su cuadro clnico clsico se da en mujeres de edad media avanzada y est dominado por la aparicin de parestesias en primer, segundo, tercer y mitad radial del cuarto dedo, inicialmente de predominio nocturno y casi siempre en la mano dominante. 107.- Caso clnico seriado. Paciente con quemadura en la piel con leja en su trabajo, al momento de la exploracin se observan ampollas y la piel color marrn, sin dolor. Primer enunciado. El tratamiento de eleccin es: a) b) c) d) Irrigacin por 15 minutos Aplicar sustancia neutralizante Observacin Debridacin de rea lesionada

Respuesta correcta: A, irrigacin de la herida por 15 minutos. Al aplicar sustancia neutralizante se podra provocar un dao peor que el de la misma quemadura, esta contraindicado. 108.- Segundo enunciado. El grado de quemadura es: a) b) c) d) Primer grado Segundo grado superficial Segundo grado profunda Tercer grado

Respuesta correcta: B, segundo grado superficial. Las quemaduras por qumicos, ya sea por cido o lcalis, no son frecuentes y suelen presentarse en adultos en su trabajo, o bien en nios en el hogar, por descuido en el manejo de dichas substancias y su almacenamiento. Son quemaduras profundas, hasta de tercer grado (espesor total), porque se mantiene el calor ms tiempo, dependiendo de la concentracin del qumico. Se debe suprimir la permanencia del qumico en la zona afectada, ya que una vez en contacto con los tejidos, estas substancias siguen quemando hasta que se diluyen. Esto se logra mediante lavado intensivo con abundante agua fra en las zonas de contacto con el fin de diluirlo lo ms posible.

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Quemaduras de primer grado. Son eritematosas, secas y muy dolorosas. La lesin es muy superficial y se regenera en lapso de una semana sin dejar cicatriz. El ejemplo ms comn son las quemaduras solares. Segundo Grado Superficial. Cuando presentan flictenas (ampollas), son hmedas, muy dolorosas y al romperse las flictenas muestran un lecho rosado o rojo brillante. La lesin abarca la capa superficial de la dermis (papilar) y se regenera en un lapso de 8 a 14 das sin dejar cicatriz. Los liquidos calientes de baja densidad condicionan este tipo de lesin Segundo Grado Profundo. Cuando se aprecin hmedas, dolorosas, con lechos rosados o rojos opacos o grisceos. La lesin abarca la capa profunda de la dermis (reticular) y se generan a partir de los nexos cutneos (folculos plosos y glndulas sudorparas y sebceas), con facilidad se infectan y por este hecho se profundizan. Pueden regenerarse en un lapso de 21 das si se optimizan las condiciones locales, pero dejan cicatrices hipertrficas. Los lquidos de la densidad pueden condicionar este tipo de lesiones Quemaduras de Tercer Grado. Son secas, deprimidas e insensibles se puede visualizar el trayecto de los vasos superficiales trombosados a travs de la escara. La lesin ocupa el espesor total de la piel y no se pueden regenerar por no existir elementos cutneos para ello. Es necesario cubrirlas por medio de injertos de piel. Las lesiones por electricidad, fuego y qumicos pueden provocar este tipo de lesin. 109.- Paciente femenina de 14 aos con diagnstico de artritis reumatoide juvenil y deformidad articular, el tratamiento de eleccin es: a) b) c) d) Aspirina Metotrexato Primaquina Ciclofosfamida

Respuesta correcta: B, metrotexate. NSAIDs are used to treat all subtypes of juvenile rheumatoid arthritis (JRA). These medications are effective because of inhibition of prostaglandin synthesis. Naproxen is listed below as an example of an NSAID used in treatment; other NSAIDs commonly used include ibuprofen, tolmetin, diclofenac, and indomethacin. In addition, sulfasalazine is sometimes used as a second anti-inflammatory drug in some children with persisting pauciarticular and polyarticular disease. Its use may be considered as an intermediate step prior to adding a second-line drug such as MTX. Aspirin is no longer the drug of first choice because of the increased frequency of gastric toxicity and hepatotoxicity when compared to other NSAID medications. Recently, the discovery that cyclooxygenase (COX) in gastric and intestinal endothelium (ie, COX-1) is different in structure from that in leukocytes (ie, COX-2) has led to the development of antiinflammatory drugs specific for COX-2. COX-2 inhibitors have been found to be effective in treatment of adults with rheumatoid arthritis. Studies of COX-2 inhibitors in persons with JRA are being planned. Besides the benefit of greatly reducing gastric toxicity (although hepatotoxicity remains a possible adverse event), COX-2 inhibitors do not inhibit platelet aggregation. Thus, these agents may find a role in the treatment of inflammatory conditions in which a bleeding diathesis is a potential problem, such as in the postoperative setting. NSAIDs alone are usually adequate for treatment of pauciarticular disease. However, an aggressive arthritis sometimes develops in this subtype, requiring the need to add a second-line drug. Various second-line drugs have been used in addition to first-line NSAIDs. Gold salt injections were used until approximately 15 years ago, when studies by the Pediatric Rheumatology Collaborative Study Group demonstrated the efficacy of PO MTX. Subsequent studies have

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demonstrated that some children with polyarticular arthritis unresponsive to PO MTX benefit from SC or IM administration. The use of high-dose IV steroids in selected patients has been beneficial in some patients, particularly during an early period before MTX may have a full therapeutic effect. Recently, etanercept, a biologic agent administered SC twice weekly and containing a receptor to TNF ligated to an Fc portion of immunoglobulin, has been found to be effective in controlling polyarticular arthritis not controlled by conventional medical treatment. Finally, the treatment of systemic JRA may require, in addition to treatment with NSAIDs, the careful use of either PO or high-dose pulse IV corticosteroids. Such treatment is best reserved for patients in whom definite arthritis has developed to avoid premature treatment in a patient who may prove to have a disease other than JRA. Most children with polyarticular JRA and some with aggressive pauciarticular disease benefit from additional immunosuppressive agents (ie, in particular, MTX). Adams A, Lehman TJ. Update on the pathogenesis and treatment of systemic onset juvenile rheumatoid arthritis Curr Opin Rheumatol 2005;17(5): 612-6 110.- En una poblacin de Pescadores, cerca de una fbrica de plstico aparece una intoxicacin en 24 pobladores sin distincin de edad, con ataxia, el diagnstico ms probable es intoxicacin por: a) b) c) d) Mercurio Vinilo Cloruro Plomo

Respuesta correcta: A, intoxicacin por mercurio. La intoxicacion crnica por mercurio da lugar a debilidad, ataxia, temblores de intencion, irritabilidad y depresion. La exposicion a derivados de alquilo (organicos) de mercurio por pescado contaminado o fungicidas empleados en las semillas produce ataxia, temblores, convulsiones y defectos congenitos catastroficos. 111.- En un recin nacido con choque hipovolmico, a que rgano se desva la sangre primordialmente: a) b) c) d) Suprarrenales Musculoesqueltico Piel Rin

Respuesta correcta: A, suprarrenales. En una hipovolemia la redistribucion del flujo va a preservar el flujo en Corazn, SNC y suprarrenales. 112.- Los hallazgos electrocardiograficos en el infarto agudo al miocardio en cara inferior son: a) b) c) d) DII, DIII y AVF DI, DII y DIII DII, AVF y DI AVF, AVL y AVR

"

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Respuesta correcta: A, DII, DIII y AFV El IAM en cara diafragmtica (inferior) ofrece datos en DII, DIII y AVF, las alteraciones en V1 a V4 son caractersticas de IAM en cara anterior, las alteraciones de V1 a V6 son en cara anterior en infarto extenso, V5, V6 y AVL es IAM en cara lateral alta. Cuando existe IAM en cara diafragmtica hay que poner los electrodos del lado derecho, para ver si hubo afectacin del ventrculo derecho. 113.- El principal componente de las articulaciones es: a) b) c) d) Peptidoglucano Proteglucano Condroitin sulfato Keratin sulfato

Respuesta correcta: B, peptidoglucano. Articular cartilage is composed of hyaline cartilage, which is between 60 and 80% water. The remaining composition consists of macromoleculescollagen, proteoglycans, and noncollagenous proteinswhich are all composed of amino acids and sugars. Type II collagen accounts for approximately 95% of the collagen in articular cartilage. There are three major proteoglycans in articular cartilage that are all polysaccharide chains with a protein core. The two larger proteoglycans are referred to as aggrecans, which, along with water, fill the interfibrillar spaces and give cartilage its mechanical properties. One contains mainly chondroitin sulfate and the other mainly keratin sulfate. A smaller one contains mainly dermatan sulfate. The ground substance of cartilage is rich in proteoglycans consisting of a core protein with numerous- about 100- glycosaminoglycans (GAGs) attached bottle-brush fashion around it. GAGs are made of repeating units of disaccharides, one of which is always a glycosamine (hence the name) such as glucosamine or galactosamine. (Glycosamines are also called hexosamines.) In cartilage, the GAGs attached to the core proteins are chondroitin sulfate and keratan sulfate. The proteoglycans themselves are attached, by special linker proteins to long, rigid molecules of hyaluronic acid (HA). 114.- El medicamento contraindicado en el ataque agudo de gota es: a) b) c) d) Aspirina Alopurinol Indometacina Diureticos

Respuesta correcta: B, alopurinol. The NAIDs are drugs of choice to treat acute inflammation of gout in patients who can safely take these medications. Colchicine can be used to treat acute flares of gout but has an 80% risk for diarrhea and vomiting when used in this manner. More often, it is used at a lower dose as a prophylaxis agent to prevent flares of gout when adding agents that lower uric acid. Corticosteroids agents are potent and effective anti-inflammatory drugs that can be used to treat acute gout in patients who cannot tolerate NSAIDs or colchicine. Steroids can be given PO, IM, IV, intra-articularly, or indirectly via ACTH. The short-burst therapy of corticosteroids necessary to treat an acute flare of gout generally is well tolerated and not associated with the chronic adverse effects seen with long-term steroid use. In many patients, a short course of steroids is the safer option compared to NSAIDs and colchicine. In patients with only 1 or 2 involved joints, intra-articular corticosteroids are a safe and effective treatment option. Uricosuric agents lower uric acid levels by increasing net renal excretion of uric acid. Are better tolerated than allopurinol but are less effective and cannot be used in all circumstances. These agents increase the risk of renal stones. These agents should not be started during an attack of acute gouty arthritis. The goal of therapy is to lower serum uric acid to approximately 5-6 mg/dL without causing renal stones. Xanthine oxidase inhibitors prevent the generation of uric acid and thereby reduce the tissue stores of uric acid. Allopurinol is more likely to be effective than

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uricosuric agents but has an increased risk for significant adverse effects. Allopurinol should not be started during an attack of acute gouty arthritis. The goal of therapy is to lower the serum uric acid level to approximately 5-6 mg/dL. Bieber JD, Terkeltaub RA. Gout: on the brink of novel therapeutic options for an ancient disease Arthritis Rheum 2004;50(8): 2400-14. 115.- La porcin de la nefrona en la que el fluido tubular se encuentra en una concentracin hipertonica respecto al plasma es: a) b) c) d) Tubo colector. Tubo contorneado distal. Asa de Henle. Tubo contorneado prximal.

Respuesta correcta: C, asa de Henle. In the loops of Henle there is a graded increase in the osmolality of the interstitium of the pyramids, the osmolality of the tips of papillae normally being about 1200 mosm/kg of H2O, approximately four times that the plasma. 116.- El medicamento antimicotico con metabolismo renal que adems es nefrotxico es: a) b) c) d) Anfotericina B Nistatina Miconazol Ketoconazol

Respuesta correcta: A, anfotericina B. La anfotericina B es un frmaco potencialmente nefrotxico y, por tanto, en los pacientes con una insuficiencia renal preexistente la funcin renal debe monitorizarse antes de comenzar con el tratamiento, y posteriormente una vez cada semana durante la terapia. En pacientes sometidos a dilisis renal, anfotericina B debe ser administrada despus de finalizar la dilisis o la hemofiltracin. No obstante, si la situacin del paciente lo requiere, anfotericina B se puede administrar durante la dilisis renal o la hemofiltracin. Los niveles de potasio y magnesio en suero deben ser monitorizados regularmente. 117.- El mecanismo de patogenicidad del Streptococo pyogenes es: a) b) c) d) Protena M Lipopolisacaridos Toxina eritrogena Capsula

Respuesta correcta: B, toxina eritrogena. Some strains of S pyogenes possess luxuriant capsules of hyaluronic acid, resulting in large mucoid colonies on blood agar. Luxuriant production of M-protein may also impart a mucoid colony morphology, and this trait has been associated with M-18. The cell wall is composed of a peptidoglycan backbone with integral lipoteichoic acid components. The function of lipoteichoic acid components is not well known; however, both peptidoglycan and lipoteichoic acid components have important interactions with the host. Over 80 different M-protein types of Group A streptococci are currently described. M-protein also protects the organism against phagocytosis by polymorphonuclear leukocytes, although this property can be overcome by type-specific antisera. Streptolysin O belongs to a family of oxygen-labile, thiol-activated cytolysins and causes the broad zone of hemolysis surrounding colonies of S pyogenes on blood agar plates. Thiol-activated cytolysin toxins bind to cholesterol on eukaryotic cell

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membranes, creating toxin-cholesterol aggregates that contribute to cell lysis via a colloidosmotic mechanism. In situations in which serum cholesterol is high, ie, nephrotic syndrome, falsely elevated anti-streptolysin O antibody (ASO) titers may occur because both cholesterol and anti-ASO antibodies will "neutralize Streptolysin O." Striking amino acid homology exists between Streptolysin O and other thiol-activated cytolysin toxins. Streptolysin S is a cellassociated hemolysin and does not diffuse into the agar media. Purification and characterization of this protein have been difficult, and its only role in pathogenesis may be in direct or contact cytotoxicity. Expression of deoxyribonucleases (DNases) in vivo elicits production of anti-DNase antibody following both pharyngeal and skin infection; this is most true for DNase B with Group A streptococci. Hyaluronidase enzyme hydrolyses hyaluronic acid in deeper tissues, facilitating the spread of infection along fascial planes. Antihyaluronidase titers rise following S pyogenes infections, especially those involving the skin. Streptococcal pyrogenic exotoxins types A, B, and C, also called scarlatina or erythrogenic toxins, induce lymphocyte blastogenesis, potentiate endotoxin-induced shock, induce fever, suppress antibody synthesis, and act as superantigens. The identification of these three different types of pyrogenic exotoxins may in part explain why some individuals may have multiple attacks of scarlet fever. Although all strains of Group A streptococci are endowed with genes for streptococcal pyrogenic exotoxin B, not all strains produce it, and even among producing strains, the quantity of toxin synthesized varies greatly from strain to strain. Pyrogenic exotoxin C, like streptococcal pyrogenic exotoxin A, is bacteriophage-mediated, and expression is likewise highly variable. Recently, mild cases of scarlet fever in England and the United States have been associated with streptococcal pyrogenic exotoxin C positive strains. Two new superantigens, mitogenic factor and streptococcal superantigen, have recently been described; however, their roles in pathogenesis have not been fully investigated. 118.- El efecto del glucagn a nivel heptico es: a) Gluclisis y glucogenlisis. b) Aumenta la gluconeognesis y la glucogenolisis. c) Lipolisis y metabolismo anaerobio d) Aumenta la lipolisis y la disminuye la secrecin de insulina Respuesta correcta: B, Aumenta la gluneognesis y la glucogenolisis. Glucagon is glycogenolytic, gluconeogenic, lipolytic, and ketogenic. In the liver, it acts via Gs to activate adenylyl cyclase and increase intracellular cAMP. 119.- Femenina de 38 aos, octava gestacin, anterior-inmediato fue producto gemelar, producto actual 4.200 kg y se utilizaron focerps. Despus del alumbramiento present sangrado profuso transvaginal. El diagnstico ms probable es:

a) Inversin uterina b) Atona uterina $) Ruptura uterina

d) Desgarro uterino Respuesta correcta: B, atona uterina. PPH has many potential causes, but the most common, by a wide margin, is uterine atony, ie, failure of the uterus to contract and retract following delivery of the baby. PPH in a previous pregnancy is a major risk factor and every effort should be made to determine its severity and cause. In a recent randomized trial in the United States, birthweight, labor induction and augmentation, chorioamnionitis, magnesium sulfate use, and previous PPH were all positively associated with increased risk of PPH. A recently published, large population-based study supported these findings with significant risk factors identified using a multivariable analysis. These risk factors are retained placenta (odds ratio [OR] 3.5; 95% confidence interval [CI], 2.15.8), failure to progress during the second stage of labor (OR 3.4; 95% CI, 2.4-4.7), placenta accreta (OR 3.3; 95% CI, 1.7-6.4), lacerations (OR 2.4; 95% CI, 2.0-2.8), instrumental delivery

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(OR 2.3; 95% CI, 1.6-3.4), large for gestational age (LGA) newborn (OR 1.9; 95% CI, 1.6-2.4), hypertensive disorders (OR 1.7; 95% CI, 1.2-2.1), induction of labor (OR 1.4; 95% CI, 1.1-1.7), and augmentation of labor with oxytocin (OR 1.4; 95% CI, 1.2-1.7). As a way of remembering the causes of PPH, several sources have suggested using the 4 T's as a mnemonic: tone, tissue, trauma, and thrombosis (Society of Obstetricians and Gynecologists of Canada, 2002). Uterine atony and failure of contraction and retraction of myometrial muscle fibers can lead to rapid and severe hemorrhage and hypovolemic shock. Overdistension of the uterus, either absolute or relative, is a major risk factor for atony. Overdistension of the uterus can be caused by multifetal gestation, fetal macrosomia, polyhydramnios, or fetal abnormality (eg, severe hydrocephalus); a uterine structural abnormality; or a failure to deliver the placenta or distension with blood before or after placental delivery. Poor myometrial contraction can result from fatigue due to prolonged labor or rapid forceful labor, especially if stimulated. It can also result from the inhibition of contractions by drugs such as halogenated anesthetic agents, nitrates, nonsteroidal anti-inflammatory drugs, magnesium sulfate, beta-sympathomimetics, and nifedipine. Other causes include placental site in the lower uterine segment, bacterial toxins (eg, chorioamnionitis, endomyometritis, septicemia), hypoxia due to hypoperfusion or Couvelaire uterus in abruptio placentae, and hypothermia due to massive resuscitation or prolonged uterine exteriorization. Recent data suggest that grand multiparity is not an independent risk factor for postpartum hemorrhage. 120.- El antipaludico que causa hemolisis es: a) b) c) d) Primaquina Cloroquina Doxorrubicina Dapsona

Respuesta correcta: A, primaquina. Las drogas asociadas a hemlisis por oxidantes (que causan dficit de G6PD) son: Antibiticos: sulfas, nitrofuranos, dapsone, cido nalidxico. Antimalricos: primaquina. Piridium. Doxorrubicina. Son drogas asociadas a hemlisis por mediacin inmunitaria: Anticuerpos droga especficos: penicilina, cefalosporinas, penicilinas sintticas. Combinaciones anticuerpo-hapteno: quinina. Autoanticuerpos a antgenos Rh (a -metildopa). Complejo antgeno-anticuerpo: stibofeno. Anticuerpo fijador de complemento: estreptomicina. 121.- Tipo de ulcera de tubo digestivo mas frecuentemente asociada al hbito tabquico: a) b) c) d) Gastrica Duodenal Yeyunal Esofagica

Respuesta correcta: B, duodenal. La ulcera duodenal es dos veces mas frecuente en los pacientes con tabaquismo que en los no fumadores. 122.- Es la fuente de exposicin mas frecuente en la intoxicacin por mercurio en pacientes peditricos: a) Pilas

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b) Pescado c) Amalgamas d) Pinturas de ltex Respuesta correcta: A, pilas. Las principales fuentes de contaminantes mercuriales han sido la actividad minera, residuos industriales de plantas cloroalcali o de fabricacin de vinilo y fungicidas, pinturas antifngicas, fotografa, pirotecnia, bateras secas y pilas, industrias papeleras y laboratorios mdicoveterinarios y dentales. Ferrer A. Metal Poisoning An Sist Sanit Navar. 2003;26 Suppl 1:141-53 123.- La etiopatogensis de la panarteritis nodosa es: a) b) c) d) Formacin de granulomas Depsito de complejos autoinmunes Inflamacin y necrosis Infiltracin linfocitica

Respuesta correcta: B, deposito de complejos inmunes. The vascular lesion in classic polyarteritis nodosa (PAN) is a necrotizing inflammation of small and medium-sized muscular arteries. The lesions are segmental and tend to involve bifurcations and branchings of arteries. They may spread circumferentially to involve adjacent veins. However, involvement of venules is not seen in classic PAN and, if present, suggests microscopic polyangiitis or the polyangiitis overlap syndrome. In the acute stages of disease, polymorphonuclear neutrophils infiltrate all layers of the vessel wall and perivascular areas, which results in intimal proliferation and degeneration of the vessel wall. Mononuclear cells infiltrate the area as the lesions progress to the subacute and chronic stages. Fibrinoid necrosis of the vessels ensues with compromise of the lumen, thrombosis, infarction of the tissues supplied by the involved vessel, and, in some cases, hemorrhage. As the lesions heal, there is collagen deposition, which may lead to further occlusion of the vessel lumen. Aneurysmal dilatations up to 1 cm in size along the involved arteries are characteristic of classic PAN. Granulomas and substantial eosinophilia with eosinophilic tissue infiltrations are not characteristically found and suggest allergic angiitis and granulomatosis. The presence of hepatitis B antigenemia in approximately 20 to 30% of patients with systemic vasculitis, particularly of the classicPANtype, together with the isolation of circulating immune complexes composed of hepatitis B antigen and immunoglobulin, and the demonstration by immunofluorescence of hepatitis B antigen, IgM, and complement in the blood vessel walls, strongly suggest the role of immunologic phenomena in the pathogenesis of this disease. Hepatitis C infection has been reported in approximately 5% of patients with PAN; however, its pathogenic role in the vasculitis is unclear at present. Hairy cell leukemia can be associated with classic PAN; the pathogenic mechanisms of this association are unclear.

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Poliarteritis nodosa

124.- Paciente femenino de 45 aos de edad, que sufre incontinencia fecal ocasional. A la especuloscopia solo se observa pared posterior redundante. El tratamiento de esta paciente debera ser: a) b) c) d) Colpoperineoplastia Histerectomia Histerectomia con oforectomia Oforectomia

Respuesta correcta: A, colpoperinoplastia. La colpoperinoplastia es un procedimiento para la correccin del descenso vesical y el uretrocele por va vaginal. Alvarado Gay F. Vega Silva E. La ciruga ambulatoria, una buena opcin en pacientes candidatas a colpoperineoplastia. Rev Esp Med Quir 2006;11(2):31-32 125.- Paciente masculino de 2 aos de edad, con retraso para el inicio de la deambulacin, que en la imagen de rayos X en cadera muestra cabeza femoral en hongo y aplanamiento acetabular. El diagnstico ms probable es: a) b) c) d) Necrosis avascular Displasia de cadera Osteondritis de cadera Artritis degenerativa

Respuesta correcta: B, displasia de cadera. La displasia luxacin congnita de cadera se presenta al nacimiento, el Legg-Calv-Perthes o necrosis avascular de la cabeza del femur entre 5 y 10 aos, esa es la base para la diferencia en este diagnstico. 126.- Masculino de 60 aos de edad con diagnstico de fractura de tercio proximal de humero no desplazada, cual es el tratamiento ms adecuado:

a) b) $) d)

Colocacin de placa Clavo centromedular Yeso braquipalmar Cabestrillo y movilizacin temprana

Respuesta correcta: D, cabestrillo y movilizacin temprana. Las fracturas del extremo proximal del humero ocurren principalmente en mujeres con osteoporosis y la mayora se producen con traumatismos moderados, siendo la principal la

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CURSO ELECTRONICO ENARM MODULO 2007 by JD-MD 2 parte

cada desde la posicin erguida. El tratamiento. El 80% de estas fracturas no presentan desplazamiento y se tratan de forma ortopdica mediante cabestrilllo durante tres semanas y rehabilitacin, las fracturas mas complejas y con desplazamiento requieren ciruga RAFI de diversos tipos, prtesis parcial del hombro (cuando mas osteoporotico ms indicada la prtesis parcial). 127.- Paciente peditrica que es trada a urgencias por presentar cuerpo extrao en vas respiratorias altas, el cual se le es extrado. Poco despus presenta sibilancias. El diagnstico ms probable es: a) b) c) d) Fstula traqueoesofagica Estenosis subglotica Neumonia por aspiracin Neumonia nosocomial

Respuesta correcta: B, estenosis subglotica. La estenosis subgltica adquirida (ESA) es la disminucin del dimetro larngeo comprendido entre el borde inferior de las cuerdas vocales y el borde inferior del cartlago cricoides, afectando el tejido blando y/o estructuras cartilaginosas. Se clasifican en: 1- Leve: estenosis menos del 30% 2- Moderada: estenosis mayor de 30% y menor del 60% 3- Severa: estenosis mayor del 60% Etiologa La ESA puede deberse a: 1- Intubacin endotraqueal prolongada. 2- Traumas larngeos externos. 3- Infecciones. 4- Quemaduras. 5- Neoplasias. Indudablemente la causa ms comn es la intubacin endotraqueal prolongada en las unidades de cuidados intensivos, alcanzando el 90% segn la literatura mundial. 128.- La medida teraputica a tomar en una paciente que fue rescatada de un siniestro es: a) b) c) d) Restauracin electroltica Restauracin de lquidos Permeabilizar la va area Oxigeno al 100%

Respuesta correcta: C, permeabilizar va area. Extensive burns may lead to massive edema, obstruction may result from upper airway swelling. Risk of upper airway obstruction increases with massive burns, all patients with deep burns >35-40% TBSA should be endotracheally intubated, burns to the head, and burns inside the mouth. Intubate early if massive burn or signs of obstruction. Intubate if patients require prolonged transport and any concern with potential for obstruction. If any concerns about the airway, it is safer to intubate earlier than when the patient is decompensating. 129.- Caso clnico seriado. Un lactante 30 das de vida con tumoracin en cuello de lado derecho con inclinacin de cabeza a la derecha y barbilla haca lado izquierdo. Primer enunciado. El diagnstico ms probable es:

a) Tumoracin atlanto-axial 13

CURSO ELECTRONICO ENARM MODULO 2007 by JD-MD 2 parte

b) Tortcolis congnita $) Fusin de vertebras cervicales

d) Cuello alado Respuesta correcta: B, tortcolis congnita. Torticollis is an abnormal head posture. Clinical presentation includes ipsilateral tilt and controlateral rotation, and translation. Aetiologies are various including muscular entities, traumatic, inflammatory, infectious, tumour and non-muscular entities ocular, ORL or digestive. Majorities are minor and generally, a complete physical examination is sufficient to eliminate serious entities. Peyrou P, Moulies D. Torticollis in children: diagnostic approach. Arch Pediatr. 2007;14(10):1264-70 130.- Segundo enunciado. El tratamiento correcto corresponde a: a) b) c) d) Ciruga Ejercicios de estiramiento Explicarles a los padres la naturaleza del caso Ninguno

Respuesta correcta: B, ejercicios de estiramiento. El tratamiento inicial consiste en la realizacin de manipulaciones y ejercicios de estiramiento. stos deben hacerse con suavidad, con el nio relajado y un mnimo de 4 veces al da, repitiendo unas 20 veces cada uno de los ejercicios. 131.- Radiloga quien desde hace cerca de 2 meses nota pequea tumoracin en cara anterior de cuello que sigue los movimientos de la deglucin, no dolorosa. Cual seria el estudio mas indicado para confirmar diagnostico? a) b) c) d) Gammagrama Aspiracin y citologa TAC USG

Respuesta correcta: B, aspiracin y citologa. Citologa tiroidea por aspiracin con aguja fina (CTA) se considera el estudio de escrutinio ideal en el diagnstico de pacientes con odulo tiroideo nico o mltiple (NT). Las principales ventajas son: segura; reduce costos de atencin mdica; es rpida en su elaboracin y es el mejor mtodo para seleccionar los pacientes que sern sometidos a tratamiento quirrgico. La CTA es un mtodo confiable, porque puede diferenciar lesiones benignas de malignas, con las limitaciones ya sealadas para los tumores foliculares; no obstante se considera el mejor mtodo diagnstico del NT; el ndice de confiabilidad diagnstica puede ser superior al 94%. Torrez Ambriz P, y Cols. Diagnstico y tratamiento del ndulo tiroideo. Rev Edocrinol Nutr 2000; 8 (3): 87-93 132.- Diagnostico de Leucemia linfocitica aguda (LLA): a) Celulas de Reed Sternberg b) > de 30% de blastos en medula $) < de 5% de blastos en sangre perifrica d) Cromosoma Philadelfia +

CURSO ELECTRONICO ENARM MODULO 2007 by JD-MD 2 parte

Respuesta correcta: B, > de 30% de blastos en la medula. Essential of diagnosis and typical features in acute lymphoblastic leukemia are: Bone marrow aspirate or biopsy shows more than 25% lymphoblasts. Pallor, petechiae, purpura (50%), bone pain (25%). Hepatosplenomegaly (60%), lymphadenopathy (50%). Single or multiple cytopenias: neutropenia, thrombocytopenia, anemia (99%). Leukopenia (15%) or leukocytosis (50%), often with lymphoblasts identifiable on blood smear. Diagnosis confirmed by bone marrow examination. 133.- La acetazolamida se utiliza en el tratamiento del glaucoma ya que disminuye la produccin del humor acuso mediante el bloqueo de: a) b) c) d) Sodio y potasio Sodio y cloro Potasio y cloro Bicarbonato e hidrogeno

Respuesta correcta: D, bicarbonato e hidrogeno. Acetazolamide, sold under the trade name Diamox, is a carbonic anhydrase inhibitor that is used to treat glaucoma, epileptic seizures, benign intracranial hypertension (pseudotumor cerebri), altitude sickness, cystinuria, and dural ectasia. Acetazolamide is available as a generic drug and is also used as a diuretic. This drug will block the formation of CO2 and H2O from H+ and HCO3. The end result is that bicarbonate is excreted in the urine. Indirectly, it will block the Na/H exchanger in the renal proximal tubule by decreasing the conversion of intracellular bicarbonate into a hydrogen ion needed for the Na/H exchanger to reabsorb sodium (and water) back from the tubule lumen. Therefore, there is a natriuretic/diuretic action in addition to the "washing away" of bicarbonate in the urine. The excess luminal water and sodium leads to an increased flow rate that can further disrupt other transporters in the tubule from functioning properly. 134.- Caso clnico seriado. Paciente masculino de 11 aos, que es llevado por su madre a consulta por presentar ginecomastia bilateral, a la exploracin se presentaba mnimo dolor. A la exploracin se corrobora la ginecomastia, adems se encuentra IMC de 30 y talla de 1.70 cms. El diagnstico ms probable es: a) Obesidad b) Ginecomastia puberal fisiolgica $) Sndrome XXY d) Sndrome de Turner Respuesta correcta: B, ginecomastia puberal fisiolgica. Con el trmino ginecomastia, designamos el crecimiento glandular de la mama masculina. Clnicamente se detecta por la presencia de una masa firme o elstica dispuesta, concntricamente, alrededor del pezn. Histolgicamente, la ginecomastia consiste en una proliferacin benigna del tejido glandular de la mama masculina. No confundirla con la adipomastia o lipomastia que es debida a la acumulacin de tejido adiposo, sin aumento del tejido glandular, como se observa con frecuencia en el nio obeso. Salvo la ginecomastia del perodo neonatal, adolescencia y senil, que pueden considerarse hechos fisiolgicos, todo aumento de tamao del tejido mamario en un varn, debe ser considerado como un hecho

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CURSO ELECTRONICO ENARM MODULO 2007 by JD-MD 2 parte

patolgico. Ginecomastia puberal es la hiperplasia benigna del tejido mamario del varn pber. Habitualmente, el tejido glandular suele ser menor de 4 cm de dimetro y se parece a la gemacin de la mama femenina en el estadio I-II Tanner. Es subareolar, mvil, no adherido a piel ni tejidos subyacentes. Bilateral en el 55%.de los casos. Si es mayor de 5 cm y de aspecto parecido a la mama femenina (estadio II-IV Tanner) se denomina macroginecomastia. La situacin clnica habitual, es la de un adolescente sano, obeso, con un ndice de masa corporal superior al P75, no medicado, que presenta un desarrollo sexual equivalente a la fase media del desarrollo puberal, estadio III de Tanner, con un volumen testicular de al menos 8 mL. Su mxima incidencia se presenta entre los 13-14 aos. Las masas no inflamatorias que se observan en el pecho de los adolescentes, prcticamente, siempre, representan ginecomastia.

135.- El tratamiento de inicio consiste en: a) b) c) d) Mastectoma Consejera gentica Mencionarle que es algo pasajero e inocuo Dieta de reduccin de peso y ejercicios

Respuesta correcta: C, mencionarle que es algo pasajero e inocuo. La ginecomastia puberal idioptica, es un cuadro tpicamente transitorio, que slo requiere vigilancia peridica, con controles cada 3-6 meses. Se trata de tranquilizar al paciente, explicndole el problema y prestndole apoyo psicolgico. La ginecomastia puberal regresa espontneamente antes de los 3 aos en el 90% de los casos, si su dimetro es inferior a 4 cm(4). Si el paciente presenta problemas psicolgicos, muy comprensibles en esta etapa de la vida, que interfieren su actividad diaria o escolar (clases de gimnasia, baos, actividad deportiva) est justificado un tratamiento mdico, que suele ser eficaz, si el dimetro de la mama es inferior a 6 cm y el tiempo de evolucin inferior a 2 aos. El tiempo de evolucin de la ginecomastia es uno de los factores mayores a la hora de decidir la terapia de eleccin. Una vez pasados los dos aos de evolucin y entrado en la fase fibrtica es muy improbable que cualquier terapia mdica obtenga resultados. 136.- El tratamiento anticonceptivo para una mujer de 40 aos, G2, con vida sexual activa y antecedentes heredofamiliares de cncer de mama en su madre es: a) b) c) d) DIU Orales Mtodo de barrera Parche

Respuesta correcta: A, DIU. El uso de DIU que contiene levonorgestrel se ha recomendado para los pacientes con Ca de mama tratados con tamoxifeno , para disminuir los episodios de hemorragia genital secundaria a la hiperplasia endometrial e incluso cncer de endometrio. A pesar de que niveles de levorgestrel mayores de 200 pg/mL alteral la efectivididad del tamoxifeno en el cncer de mama, no se ha contraindicado para su uso en pacientes con antecedentes de Ca de mama. 137.- La formula lctea en menores de 6 meses esta modificada en:

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CURSO ELECTRONICO ENARM MODULO 2007 by JD-MD 2 parte

a) b) c) d)

Caseina Lactoalbumina Lactosa Carbohidratos

Respuesta correcta: A, casena. La protena es uno de los nutrimentos ms importantes en la infancia y su cantidad y calidad nutricia en las frmulas para lactantes est regulada por la norma NOM-131-SSA1-1995 de la Secretara de Salud. En dicha norma, la calidad nutricia se ha definido mediante una prueba de su capacidad para sustentar el crecimiento animal, sin considerar mantenimiento. Lo anterior resulta muy discutible porque la protena de la leche humana aparte de sostener el crecimiento, tambin tiene la funcin de defender contra las infecciones y mantener el metabolismo. Adems, la ingestin de protenas diferentes a las de la leche humana puede llevar a desarrollar reacciones de hipersensibilidad y autoinmunidad en ciertos lactantes. Luego entonces, la calidad de un sucedneo de la leche materna estar en funcin de la similitud de sus protenas con las de la leche humana. As, a las frmulas a base de leche de vaca se les adiciona suero a fin de que la elevada proporcin de casena (una de las protenas de la leche) que presentan disminuya a cantidades semejantes a las de la leche humana. De esta manera, se ha instituido como una prctica generalizada que la casena constituya, a lo ms, un 40% de las protenas totales en las frmulas. Caldern de la Barca AM. Y cols. Composicin de protenas de los sucedneos de la leche materna ms utilizados y su regulacin sanitaria. Sal Pub Mex 1996;38(4):268-275 138.- La meningoencefalitis secundaria a un cuadro de sinusitis crnica se debe a: a) b) c) d) La cronicidad Alteracin de la barrera hematoencefalica Patogenicidad del microorganismo Siembra directa

Respuesta correcta: B, alteracin de la barrera hematoencefalica. Intracranial complications, namely, meningitis, subdural empyema, epidural abscess and cerebral abscess may all complicate acute and chronic sinusitis. The ethmoids, frontal, and sphenoid sinusitis primarily responsible. Infection is spread via thrombophlebitis (una forma de alteracin de la barrera hematoencefalica) or less commonly via direct extension of infection. Common symptoms of increased intracranial pressure (ICP) (headache, altered mental status, fever, vomiting, and stiff neck) as well as systemic toxicity usually occur. However, the infection may be "silent" in the frontal lobes with only subtle personality changes until late in the process. High morbidity and mortality despite antibiotics and aggressive treatment still exist. The offending organisms are the same ones implicated in sinusitis (Strep, Staph, anaerobes and GNR). Streptococcal species are most commonly responsible for CNS complications. Exceptions include cerebral abscess and epidural abscess near a focus of osteomyelitis when Staph is more common.

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139.- Paciente femenino de 50 aos, que inicia dolor en epigastrio e hipocondrio derecho que irradia a espalda, despus de la ingesta de comida copiosa y alcohol. La paciente se encuentra ictrica. El US muestra vescula con pared de 6 mm, sin litos aparentes. El diagnstico ms probable es: a) b) c) d) Pancreatitis Colecistitis Colelitiasis Colangitis

Respuesta correcta: B, colecistitis. El dato clave para diferenciar entre pancreatitis y colecistitis es la pared engrosada. Por lo dems no se podra diferenciar entre estas dos entidades. A continuacin una imagen de US que muestra una vescula, con datos caractersticos de inflamacin.

En esta imagen se objetivan al menos 4 signos de colecistitis aguda, la distensin de la vescula biliar, el engrosamiento de la pared vesicular, con una banda hipoecognica central, la presencia de material ecognico en la zona adyacente al infundbulo barro biliar y una pequea coleccin perivesicular (entre el hgado y la vescula biliar).

140.- El principal mediador de la vasoconstriccin es: a) b) c) d) Norepinefrina Epinefrina Acetilcolina Endotelina

Respuesta correcta: D, endotelina.

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CURSO ELECTRONICO ENARM MODULO 2007 by JD-MD 2 parte

Endothelins are 21-amino acid vasoconstricting peptides produced primarily in the endothelium having a key role in vascular homeostasis. Among the strongest vasoconstrictors known, endothelins are implicated in vascular diseases of several organ systems, including the heart, general circulation and brain Agapitov AV, Haynes WG. Role of endothelin in cardiovascular disease J Renin Angiotensin Aldosterone Syst 2002;3(1):1-15 141.- El medicamento contraindicado en un ataque agudo de gota es: a) b) c) d) AINEs Alopurinol Aspirina Conchicina

Respuesta correcta: B, alopurinol. Urate-lowering pharmacotherapy using a xanthine oxidase inhibitor or uricosuric agent is recommended for patients with more than two gouty attacks per year, in patients with tophi, and in patients with joint damage seen on a radiograph. However, this therapy should not commence until the acute phase of gout has completely resolved because fluctuations in serum uric acid levels will exacerbate the inflammatory process. When initiating uratelowering therapy, concurrent prophylaxis with low-dose colchicine (0.6 to 1.2 mg daily) for three to six months has been shown to reduce the risk of flare-ups. Eggebeen AT. Gout: An update Am Fam Physician 2007;76:801-8 142.- La cardiopata mas frecuente en los pacientes alcohlicos es: a) b) c) d) Dilatada Restrictiva Hipertrofica Congnita

Respuesta correcta: A, dilatada. Dilated cardiomyopathies cause about 25% of all cases of CHF. It usually present with symptoms and signs of CHF (most commonly dyspnea). Occasionally, symptomatic ventricular arrhythmias are the presenting event. LV dilation and systolic dysfunction (EF < 50%) are essential for diagnosis. Dilated cardiomyopathy occurs more often in blacks than whites and in men more than women. A growing number of cardiomyopathies due to genetic abnormalities are being recognized, and these may represent up to 25-30% of cases. Often no cause can be identified, but chronic alcohol abuse and unrecognized myocarditis are probably frequent causes. Chronic tachycardia may also precipitate a dilated cardiomyopathy. Amyloidosis, sarcoidosis, hemochromatosis, and diabetes may rarely present as dilated cardiomyopathies, as well as the more classic restrictive picture. The RV may be primarily involved in arrhythmogenic RV dysplasia, an unusual cardiomyopathy with displacement of

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CURSO ELECTRONICO ENARM MODULO 2007 by JD-MD 2 parte

myocardial cells by adipose tissue, or in Uhl's disease, in which there is extreme thinning of the RV walls. Intraventricular thrombus is not uncommon. Histologically, the picture is one of extensive fibrosis unless a specific diagnosis is established. Myocardial biopsy is rarely useful in establishing the diagnosis, though occasionally the underlying cause (eg, sarcoidosis, hemochromatosis) can be discerned. 143.- El tratamiento de la cardiomiopatia dilatada es: a) b) c) d) Betabloqueadores Digitalicos IECAs Vasodilatadores

Respuesta correcta: A y C, betabloqueadores e IECAs. Standard therapy for heart failure should include ACE-I, b-blockers, diuretics, and an aldosterone antagonist. Digoxin is a second-line drug, but remains favored as an adjunct by some. Calcium channel blockers should generally be avoided. Sodium restriction is helpful, especially in acute cardiomyopathy. When atrial fibrillation is present, heart rate control is important if sinus rhythm cannot be established or maintained. Many patients may now be candidates for cardiac synchronization therapy with biventricular pacing and an implantable defibrillator. Few cases of cardiomyopathy are amenable to specific therapy for the underlying cause. Alcohol use should be discontinued. There is often marked recovery of cardiac function following a period of abstinence in alcoholic cardiomyopathy. Endocrine causes (thyroid dysfunction, acromegaly, and pheochromocytoma) should be treated. Immunosuppressive therapy is not indicated in chronic dilated cardiomyopathy. The management of CHF is outlined in the section on heart failure. 144.- La parte anatmica en donde se puede calcular la edad sea en un recin nacido es:

a) b) $) d)

Radiografa de rodilla Radiografa de mano Radiografa de columna Radiografa de pelvis

Respuesta correcta: A, radiografa de rodilla. La edad sea en los recin nacidos se calcula mediante una radiografa de rodilla en el que se observa el fmur distal y la tibia proximal. En los lactantes es en el carpo. 145.- Caso clnico seriado. Recin nacido de 10 das de edad, que naci en su domicilio atendido por partera, se le realiza tamiz neonatal y despus de 10 minutos no cesa el sangrado en el punto de puncin. Primer enunciado. El diagnstico ms probable es: a) Plaquetopenia b) Deficiencia de los factores II, VII, IX y X c) Alteracin en la antrombina d) Efecto residual de la anestesia obstetrica

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CURSO ELECTRONICO ENARM MODULO 2007 by JD-MD 2 parte

Respuesta correcta: B, defieiencia de los factores II, VII, IX y X. La enfermedad hemorrgica por deficiencia de vitamina K (antes llamada enfermedad hemorrgica del recin nacido) se ha definido como todo problema hemorrgico debido a deficiencia de esa vitamina y a la actividad disminuida de los factores II, VII, IX y X, protenas que son sintetizadas y almacenadas en el hgado hasta que son activadas por la vitamina K. sta facilita la carboxilacin postranscripcional de esos factores. En los individuos con deficiencia de vitamina K se producen estos factores, pero no tienen actividad detectable en plasma 3. La vitamina K proviene normalmente de la dieta y de la sntesis bacteriana intestinal. Lpez Candiani C. y Cols. Enfermedad hemorrgica por deficiencia de vitamina K Acta Pediatr Mex 2006;27(1):5-9

146.- Segundo enunciado. El tratamiento consiste en: a) b) c) d) Administrar vitamina K Plasma fresco congelado Crioprecipitados Heparina

Respuesta correcta: A, administrar vitamina K. El tratamiento evidentemente es con vitamina K, que mejora el TP y el TPT en un lapso de cuatro horas. Si la madre ha recibido frmacos cumarnicos, la hemorragia puede no revertir inmediatamente con la vitamina K. En estos casos el uso de plasma fresco puede ser til. La enfermedad hemorrgica cada vez es menos frecuente debido al uso profilctico de vitamina K en el recin nacido. La aplicacin parenteral de vitamina K protege para todas las variedades; la va oral probablemente es menos eficaz para la variedad tarda. En pacientes que reciben vitamina K oral, la enfermedad hemorrgica puede presentarse en forma ms tarda que en los que no la reciben; en especial los nios alimentados exclusivamente con seno materno. Lpez Candiani C. y Cols. Enfermedad hemorrgica por deficiencia de vitamina K Acta Pediatr Mex 2006;27(1):5-9 147.- La complicacin mas frecuente por el uso de ganciclovir en la colitis por citomegalovirus es: a) b) c) d) Inmunodeficiencia Agranulocitosis Proctitis Retinitis

Respuesta correcta: B, agranulocitosis. CMV colitis is the second most common CMV infection in patients with AIDS (after retinitis. Of patients with AIDS who have GI infection caused by CMV, 67% had involvement of the colon. CMV colitis is uncommon in patients who are not severely immunocompromised with only 44 cases described in the literature. GI tract involvement may occur either alone or in the setting of disseminated disease. CMV may complicate steroid-dependent ulcerative colitis (UC), further

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CURSO ELECTRONICO ENARM MODULO 2007 by JD-MD 2 parte

complicating both disease processes. Patients with steroid-dependent UC who present with refractory disease should be evaluated for CMV infection. Up to 59% of patients with steroidrefractory UC have been shown to also have CMV colitis. The prognosis for patients with UC complicated by CMV infection is worse than that for patients with UC alone. Ganciclovir (Cytovene) -- Acyclic nucleoside analogue of 2'deoxyguanasine. Phosphorylates first to monophosphate form by CMV-encoded protein kinase homologue, then to diphosphate and triphosphate forms by cellular kinases, allowing for a 100-fold greater concentration in CMVinfected cells. Thought to inhibit CMV replication by competitive inhibition of viral DNA polymerases and by incorporating itself into viral DNA, causing termination of viral DNA elongation. Like acyclovir, ganciclovir is virostatic and only exerts its effect on replicating virus. Phlebitis or pain may occur at injection site; clinical toxicity includes granulocytopenia, anemia, and thrombocytopenia; because PO ganciclovir is associated with higher rate of CMV retinitis progression compared with IV formulation, use only when benefits outweigh risks (advanced HIV disease); half-life and plasma/serum concentrations may increase as a result of reduced renal clearance; dosages >6 mg/kg IV may result in increased toxicity; rapid infusions may result in increased toxicity; initially, reconstituted solutions of IV ganciclovir have a high pH (11); phlebitis or pain may occur at injection site despite further dilution in IV fluids; administration should be accompanied by adequate hydration; photosensitization (photoallergy or phototoxicity) may occur; myelosuppression is main dose-limiting toxicity; must be used with caution in patients with preexisting cytopenias. 148.- Sangrado rectal en un paciente menor de 2 aos es probable que sea debido a: a) b) c) d) Plipos Invaginacin intestinal Divertculo de Meckel Espasmo anal

Respuesta correcta: C, diverticulo de Meckel. Meckel diverticulum is the most common form of congenital abnormality of the small intestine, resulting from an incomplete obliteration of the vitelline duct (ie, omphalomesenteric duct, yolk stalk). Analysis of the literature suggests that complications of Meckel diverticulum are usually the result of attached bands or ectopic tissue. In one study of 830 patients of all ages, complications included bowel obstruction (35%), hemorrhage (32%), diverticulitis (22%), umbilical fistula (10%), and other umbilical lesions (1%). In children, bleeding is the most common presenting sign. Most children younger than 5 years present with acute lower GI bleeding due to hemorrhage from peptic ulceration, such ulceration is a complication of heterotopic gastric mucosa, and this hemorrhage is usually seen in the form of painless rectal bleeding. However, some patients may present only with pain preceding the onset of hematochezia; this clinical presentation can often obscure the diagnosis. Not all patients have abdominal pain, but, when present, it can be significant. 149.- Caso clnico seriado. Se trata de paciente que presenta incapacidad para realizar ejercicio, palpitaciones, soplo diastlico leve en borde esternal izquierdo en foco pulmonar, chasquido de apertura de la mitral, desdoblamiento del segundo ruido. Primer enunciado. El diagnstico ms probable es: a) Comunicacin interventricular. b) Coartacin aortica.

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c) Comunicacin interauricular. d) Estenosis mitral. Respuesta correcta: D, estenosis mitral. Patients with mitral stenosis usually remain asymptomatic until the area of the valve is reduced to about one third of its normal size of 4 cm2. After the area is decreased to less than 4 cm2, symptoms may begin to develop. The symptoms include dyspnea on exertion and fatigue. As mitral stenosis worsens, dyspnea on exertion (NYHA class II), progresses to orthopnea and paroxysmal nocturnal dyspnea (NYHA class III and IV due to LV failure). Subsequently, RV failure sets in that manifests as ascites and dependent edema. Although mitral stenosis produces characteristic findings on physical examination, the diagnosis is frequently missed because the auscultatory findings may be subtle on inspection. Mitral facies can be seen in some patients. Palpation of the precordium reveals a quiet apical impulse. In pulmonary hypertension and RV hypertrophy, a RV parasternal lift may be encountered. On auscultation, a loud S1 is present because the transmitral gradient holds the mitral valve open throughout diastole until ventricular systole closes the fully opened valve with a loud closing sound (S1). In advanced mitral stenosis, as the mitral leaflets become so damaged that they neither open nor close well, S1 eventually quiets. S2 is physiologically split with a loud pulmonic component (P2) in the presence of pulmonary hypertension. S2 is usually followed by another early diastolic sound, called the opening snap (OS). The interval between S2 and the OS provides a good estimate of LA pressure and thus the severity of the mitral stenosis. When LA pressure is high, the OS closely follows S2 (0.06 s), but when it is normal, the OS occurs later (0.12 s), and it may mimic the S3 gallop. As mitral stenosis worsens, the S2-OS interval shortens. The OS is followed by the characteristic low-pitched early-diastolic murmur. This murmur can be soft in patients with low cardiac output. In such patients, modest exercise, such as isometric handgrip, may increase the intensity of the murmur. A presystolic accentuation of the mitral stenosis murmur is also heard coincident with the atrial contraction. In the presence of pulmonary arterial hypertension, another diastolic murmur of blowing quality due to resultant pulmonary regurgitation (Graham Steell murmur) often becomes audible. Singh VN y Cols. Mitral stenosis eMedicine 2006 150.- En la ecocardiografa podemos encontrar:

a) Aumento del gradiente de apertura de vlvula tricspide b) Aumento del gradiente de apertura de vlvula mitral $) Disminucin del gradiente de apertura de vlvula mitral
d) Disminucin del gradiente de apertura de vlvula tricspide Respuesta correcta: B, aumento del gradiente de apertura de vlvula mitral. Echocardiography generally provides sufficiently detailed images of the mitral valve and is the most important diagnostic tool in establishing the diagnosis. Doppler echocardiography is used to accurately depict the severity of mitral stenosis. Usual 2-dimensional (2D) echocardiographic findings include thickened mitral valve cusps, an enlarged LA with a normal or small LV, and reduced size of the mitral valve orifice in diastole. A diminished E-F slope is noted on M-mode images. Doppler studies demonstrate an increased mean pressure gradient across the mitral orifice and help in quantifying the severity of mitral stenosis. Singh VN y Cols. Mitral stenosis eMedicine 2006

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151.- El factor que perpetua a la hipertensin arterial pulmonar es: a) b) c) d) Obstruccin del lecho vascular pulmonar. Hipoxemia. Remodelacin vascular Ninguna

Respuesta correcta: C, remodelacin vascular. Existe HTP cuando la presin sistlica excede los 30mm Hg y la presin pulmonar media los 25mm de Hg en reposo y los 30mm Hg con ejercicio. En la HTP se pierde la capacidad de acomodar incrementos en el flujo pulmonar. Esta resulta de la reduccin en el calibre de los vasos pulmonares y/o del aumento del flujo sanguneo pulmonar. En condiciones normales la clula del endotelio pulmonar mantiene a la clula muscular lisa en estado de relajacin. En la HTP primaria se postula que existe una anormalidad del endotelio vascular pulmonar en que se produce: un aumento de los mediadores endoteliales vasoconstrictores, de los mediadores plaquetarios vasoconstrictores y una disminucin de la actividad de canales de K del msculo liso, con aumento del calcio intracelular y aumento del tono vascular. Esto resulta en una dificultad para lograr un estado de relajacin del msculo liso, y en un estado procoagulante que facilita la trombosis "in situ". Se encuentra hipertrofia de la media, con hiperplasia y fibrosis intimal, trombosis "in situ", y lesiones plexognicas de los vasos arteriales pulmonares. Los cambios estructurales en el lecho vascular pulmonar que se producen en la HTP secundaria son semejantes e independientes de la etiologa. Los capilares pulmonares se encuentran distendidos, con engrosamiento y rotura de la membrana basal del endotelio y trasudacin de eritrocitos a los espacios alveolares. En etapas avanzadas se aprecian reas hemorrgicas dispersas por los pulmones, edema y cogulos en los alvolos que terminan organizndose con extensa fibrosis. Adems de fibrosis intimal e hipertrofia de las arterias pequeas, arterolas y vnulas. 152.- Este medicamento es el de eleccin para el tratamiento de las metstasis seas, por su efecto al disminuir la angiognesis y disminuir la actividad osteoclstica. a) Bifosfonatos b) Inhibidores de la aromatasa c) Antagonistas del cido flico d) Calcitonina Respuesta correcta: A, bifosfonatos. Los bifosfonatos, como etidronato, pamidronato y clodronato, son anlogos de los pirofosfatos endgenos, los cuales inhiben la reabsorcin sea in vivo. El etidronato, el clodronato y el pamidronato estn disponibles para el manejo de la hipercalcemia por neoplasias. Por su parte reportes anecdticos y ensayos clnicos han demostrado que existe una mejora en el dolor seo y una disminucin en el uso de analgsicos despus de la iniciacin de un bifosfonato. Castro Olidn V. Bifosfonatos Dol Clin Ter 2003;II(5) : 15-18 153.- El tratamiento de la nefrolitiasis por hipocitratria es a base de: a) Diurtico de asa.

CURSO ELECTRONICO ENARM MODULO 2007 by JD-MD 2 parte

b) Potasio. c) Antibitico. d) Bifosfonatos Respuesta correcta: B, potasio. La acidosis tubular renal, el sndrome diarreico crnico, la litiasis clcica hiperuricosrica, la hipocitraturia esencial o secundaria a tiazidas y la hipocitraturia-hipercalciuria son entidades que han sido tratadas con citrato potsico con resultados satisfactorios. Las dosis teraputicas varan entre 20 y 100 mEq/da y con ellas se pretende aumentar la concentracin de los citratos y mejorar la solubilidad urinaria. La dosis empleada depende del grado de hipocitraturia. En pacientes con niveles urinarios inferiores a 100 mg/da suele iniciarse la teraputica con una dosis repartida de 60 mEq/da y a los 3-4 meses se efectua un reajuste de la dosis segn el efecto obtenido. Barcel P y Cols. Hipocitraturia y litiasis renal Actas Fundaci Puigvert 1990; 2: 75 154.- Caso clnico seriado. Paciente femenino de 22 aos, que acude por inflamacin de genitales, a la exploracin fsica se tumoracin en labio mayor izquierdo con severa inflamacin, eritematoso y dolor. Primer enunciado. El diagnstico ms probable es: a) b) c) d) Bartolinitis Hematoma Hidradenoma Lipoma

Respuesta correcta: A, bartolinitis. Bartholin glands are known to form cysts and abscesses in women of reproductive age. Cysts and abscesses are often clinically distinguishable. Bartholin cysts form when the ostium of the duct becomes obstructed, leading to distention of the gland or duct with fluid. Obstruction is usually secondary to nonspecific inflammation or trauma. The cyst is usually 1-3 cm in diameter and often asymptomatic, although larger cysts may be associated with pain and dyspareunia. Bartholin abscesses result from either primary gland infection or infected cyst. Patients with abscesses complain of acute, rapidly progressive vulvar pain. Studies have shown that these abscesses are usually polymicrobial and rarely attributable to sexually transmitted pathogens. Adenocarcinoma of the Bartholin glands is rare, accounting for 1-2% of all vulvar malignancies. Typically, this lesion presents as a gradually enlarging gland in an asymptomatic, postmenopausal woman. Patients with cysts may present with painless labial swelling. Abscesses may present spontaneously or after a painless cyst with the following symptoms: acute, painful unilateral labial swelling, dyspareunia, pain with walking and sitting, sudden relief of pain followed by discharge (highly suggestive of spontaneous rupture) The following physical examination findings are seen in Bartholin abscess: patients typically have an exquisitely tender, fluctuant labial mass with surrounding erythema and edema, in some cases, areas of cellulitis surrounding the abscess may be present, fever, though not typical in healthy patients, may occur, if the abscess has spontaneously ruptured, purulent discharge may be noted. If completely drained, no obvious mass may be observed.

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The following physical examination findings are seen in Bartholin cysts: patients may have a painless, unilateral labial mass without signs of surrounding cellulitis, if large, the cyst may be tender, and discharge from ruptured cyst should be nonpurulent. Uncomplicated Bartholin cysts are filled with nonpurulent mucous. Several studies have aimed to identify the most common bacterial pathogens responsible for Bartholin abscess formation. Studies from the 1970-1980s named Neisseria gonorrhoeae and Chlamydia trachomatis as common pathogens. More recent studies report the predominance of opportunistic bacteria such as Staphylococcus species, Streptococcus species, and most commonly, Escherichia coli.

Abceso de la glandula de Bartholin

Schecter JC. y Cols. Bartholin Gland Diseases eMedicine 2008 155.- Segundo enunciado. El tratamiento correcto es: a) b) c) d) Drenaje Marsupializacin Extirpacin quirrgica Antibioticoterapia

Respuesta correcta: A, drenaje. Emergency department care should include a careful history and physical examination. A patient whose presentation is concerning for malignancy should receive close outpatient gynecologic follow-up for biopsy and possible excision. Those with an uncomplicated, asymptomatic cyst may be discharged with sitz bath instructions. Sitz baths (3 times daily) for several days may promote improvement with resolution or spontaneous rupture with resolution of the cyst. A Bartholin abscess is generally painful, and, thus, usually requires incision and drainage. Several techniques have been described, but no large prospective studies have been performed to determine relative efficacy and complications. The goal of abscess treatment is to allow drainage and to prevent rapid reaccumulation of fluid.

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Marsupialization is reserved for recurrent abscesses. The acute abscess is drained prior to marsupialization. This procedure consists of a wide incision of the mass followed by suturing the inner edge of the incision to external mucosa. This complicated procedure is usually performed by a gynecologist or urologist in the OR. Excision procedure requires excision of the Bartholin gland and surrounding tissue. It is disfiguring, painful, and seldom indicated in the treatment of abscess, although it may be used to treat malignancy. It should be performed only in the OR to ensure appropriate anesthesia. Schecter JC. y Cols. Bartholin Gland Diseases eMedicine 2008 156.- En un paciente comatoso, la respiracin de Kussmaul compensa: a) b) c) d) Acidosis metablica Acidosis respiratoria Alcalosis metablica Alcalosis respiratoria

Respuesta correcta: A, acidosis metablica. La respiracin de Kussmaul es una respiracin anormalmente profunda, muy rpida, jadeante, caracterstica de la acidosis diabtica. 157.- En que capa de la glndula suprarrenal se produce el cortisol: a) b) c) d) Glomerular Fasciculada Reticular Medula

Respuesta correcta: B, fasciculada. La corteza suprarrenal est situada rodeando la circunferencia de la glndula suprarrenal. Su funcin es la de regular varios componentes del metabolismo con la produccin de mineralcorticoides y glucocorticoides que incluyen a la aldosterona y al cortisol. La corteza suprarrenal tambin es un lugar secundario de sntesis de andrgenos. La corteza suprarrenal puede dividirse en tres capas diferentes de tejido basado en los tipos celulares y la funcin que realizan. a) Zona glomerular: Produccin de mineralcorticoides, sobre todo, aldosterona. b) Zona fascicular: Produccin de glucocorticoides, principalmente cortisol, cerca del 95%. c) Zona reticular: Produccin de andrgenos, incluyendo testosterona. 158.- La disminucin de este disminuye la reabsorcin osea: a) b) c) d) Paratohormona Calcitonina Osteoclastos Osteoblastos

Respuesta correcta: A, paratohormona.

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La PTH segregada por las glndulas paratiroides que acta manteniendo una concentracin constante de calcio en el lquido extracelular. Regula la absorcin de calcio a partir del tracto GI, la movilizacin del calcio seo, el depsito de calcio en los huesos y la excrecin de calcio en la leche materna, en las heces, en el sudor y en la orina 159.- El tipo de leucemia ms comn en pacientes con trisomia 21 es: a) b) c) d) LLA LLC LMA LMC

Respuesta correcta: A y C, LLA y LMA. La mayora de los casos de leucemia en el sndrome de Down se da en los primeros 5 aos de vida. En los 3 primeros aos, las leucemias ms frecuentes que en ellos aparecen son las LMA. A diferencia de la poblacin infantil general, la mitad de las leucemias agudas que ocurren en nios con sndrome de Down son de estirpe mieloide y, dentro de ellas, un 50% corresponden a la leucemia megacarioblstica o M-7; en conjunto, se ha llegado a afirmar que la frecuencia de leucemia megacarioblstica o M-7 en la poblacin infantil con sndrome de Down es de 200 a 300 veces mayor que en la poblacin que no lo tiene. Pasados los 3 primeros aos, el 80% de las leucemias se presentan en la forma de LLA y el 20% en la forma de LANL. 160.- Paciente peditrico de 9 aos de edad, acude a su consulta peridica, actualmente asintomtico, ala exploracin fsica se observa TA de 150/90 mmHg. El estudio para corroborar su diagnstico es:

a) Toma de TA 3 veces b) Metanefrinas urinarias

c) TAC de abdomen d) TAC de crneo Respuesta correcta: A, toma de TA 3 veces. Primero debemos corroborar si la TA no es efecto de bata blanca, con tomas seriadas de TA. Despus de esto, se decide, pero primero corroboremos si en realidad el promedio de su Ta correspondera a rangos hipertensivos. 161.- El aminocido precursor de la melanina es: a) b) c) d) Tirosina Serotonina Melatonina Fenilalanina

Respuesta correcta: A, tirosina. La tirosina es precursor de la dopa y esta de la melanina. 162.- La principal causa de hidrocefalia no comunicante es:

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a) b) c) d)

Obstruccin del acueducto de Silvio Malformacin arterio-venosa Evento vascular cerebral Sindrome de Down

Respuesta correcta: A, obstruccin del acueducto de Silvio. La hidrocefalia no comunicante - llamada tambin hidrocefalia "obstructiva" - ocurre cuando el flujo del lquido cerebroespinal se ve bloqueado a lo largo de una o ms de las vas que conectan los ventrculos. Una de las causas ms comunes de hidrocefalia es la "estenosis acuaductal". En este caso, la hidrocefalia resulta de una estrechez del acueducto de Silvio, que comunida el tercer y cuarto ventrculo. 163.- La localizacin mas frecuente de la neurocisticercosis es: a) b) c) d) Parenquima Ventriculos Corteza Cerebelo

Respuesta correcta: A, parnquima. The cysts of cysticercoids usually are located in the gray matter due to the richer vascularization of this tissue, and in the subcortical white matter. In severe cases of parenchymal cysticercosis, the number of parasites may reach several hundreds, but commonly only a scattered few are seen. Cysts also may be found in the subarachnoidal location, and less frequently inside the ventricles and in the spinal cord.

Neuroimaging in neurocysticercosis. Subcortical parenchymatous cysticercosis

Carpio A. Neuroimaging in Neurocysticercosis eMedicine 2006 164.-

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