The patient did not have associated nerve damage prior to external manoeuvring reduction of the glenohumeral joint. The review of awareness after reduction is not changed. You set up an immobiliatlon by an elbow brace to the body. You see the patient again a month later. On clinical examination, you notice the following: passive mobility is not diminished, the right arm in anterior elevation and internal rotation, the patient can not resist the force of abbaissement that you exert, when he wants to bring his hand to the mouth, you observe that the patient is forced to raise his elbow laterally above the level of his hand. In addition, the arm placed in external rotation elbows to the body, there is an automatic internal rotation. Passive external rotation is not increased. The patient retains the possibility of taking off the hand placed in the back at the lumbosacral junction. There is no abnormality during thwarted active flexion of the elbow when the palms are up. Given the data of the clinical examination, you mention the possibility of a rupture of one or more of the following elements: (one or more true propositions)


Context: A 50-year-old mason consults for pain in the right shoulder evolving for 6 months. He is an unweaned 40 PA smoker and a carrier of ischemic heart disease on antiplatelet agents. There is irradiation in the right upper limb poorly systematized.

Given the functional discomfort, rotator cuff repair surgery is offered to the patient. While waiting for the consultation of the anaesthetist, the patient asks you a few questions. Which of the following answers you could give is correct?

For this scheduled procedure, the anesthesia consultation can take place until the day before the intervention

You will see either a doctor or a nurse anaesthetist for this consultation

You will not necessarily have to take a blood test before the procedure

If you do not wish to have locoregional anesthesia, you can refuse it

As you are taking aspirin for the heart, it will in any case be necessary to stop it between 5 and 7 days before the procedure


The patient is now in the post-interventional monitoring room following his surgery, which took place without incident anesthetic and surgically. He expresses pain at 8 out of 10 on the numerical scale and asks to be relieved. Which multimodal analgesia(s) are indicated in this context, among the analgesia represented in the figure below? PCA: patient-controlled analgesia (or PDA)


Morphine titration was initiated because it was severe pain. It was relayed by patient-controlled analgesia (PCA) with paracetamol and nefopam as part of multimodal postoperative analgesia. It has been effective. The ACP was arrested on the second day. On the third day, the patient again complains of pain, the intensity of which is measured at 54 mm on a visual analogue scale, and he wishes to be relieved. His current analgesic treatment includes paracetamol and nefopam. Which treatment(s) is (are) indicated in the context of multimodal analgesia in this context?

Transcutaneous electrical nerve stimulation (TENS)


After 5 months of rehabilitation, the patient has regained satisfactory active and passive mobility and he hardly complains of pain. He questions you about the resumption of his work because he fears that he will not be able to continue his activity. In agreement with your patient, you wish to contact his occupational physician. Which element(s) is (are) relevant to transmit to the occupational physician?

None, so as not to break medical confidentiality

A certificate of aptitude for his position

Possible extra-occupational risk factors


Context: A 54-year-old woman is hospitalized orthopedically following a fall at home that resulted in a scalp wound and an uncomplicated extra-articular fracture of the lower end of the radius that required reduction under general anesthesia and percutaneous embroidery surgical treatment. The following night, when a discharge is scheduled for the next day, the patient must be escorted back to her room several times by the health care team to whom she makes increasingly disjointed remarks. She thinks she is at home, walks through the ward and then tries to lock herself in the caregivers' rest room. When we talk to her, we have to repeat the questions several times because she seems elsewhere. She ends up talking about cameras in her room. She only agrees to return to it if the light is left on to, she says, "scare away cockroaches". Just when she seemed to have calmed down, she burst into the care station again, brandishing a fork that she pointed at the night shift and said she was not going to "let it happen".

Which of the following clinical elements is present in the observation?

'You have to repeat it several times because it seems elsewhere'


Faced with this state of agitation, which of the following elements present in the observation, which one (directs) towards a delirium rather than an acute psychotic state?

Abrupt onset in a post-operative context

The postoperative context points much more towards confusion (known link between confusion and surgery) than towards EPA (no known link between EPA and surgery)

Anxiety is found in both etiologies. This is a characteristic of agitation.

The EPA does not fluctuate, or does not fluctuate, or little


Which of the following clinical elements would be in favor of delirium syndrome?

Visual (rather than auditory) hallucinations are often found in confusion.


The agitation is fluctuating but she does not repeat her hetero-aggressive threats and agrees to be escorted back to her room. She remains disoriented in space and time. At this stage, which of the following additional examinations is essential to carry out immediately?

Any acute and non-systematized neurological signs should be investigated for hypoglycemia as a first-line treatment.


Capillary blood glucose is 3.8 mmol/L. Which of the following causes should be mentioned in front of the clinical picture presented by the patient?


Physical examination shows sweating, tachycardia and tremor of extremities. The neurological examination cannot be continued due to increased agitation. The patient nevertheless accepts oral treatment. What do you recommend?

We start on an alcoholic withdrawal in view of the clinical description and the context of the patient.

Brain scan without injection as soon as possible


Given the delirium syndrome and the context of fall with scalp wound, a brain scan is prescribed urgently after benzodiazepine sedation. The brain scan is normal but biology shows a moderate elevation of gamma-glutamyl-transpeptidase (GGT) and transaminases (predominant on AST) contrasting with a normal level of alkaline phosphatase, as well as an elevation of mean corpuscular volume. The blood ionogram and serum calcium are normal. CPKs are quietly increased. The temperature is 37.8 °C.  The patient is no longer agitated but still disoriented, anxious and continues to make delusional remarks. What do you recommend in the immediate future? (one or more responses)


You have set up intravenous hydration treatment and administration of vitamin B1 and Diazepam. Which of the following clinical and biological elements is part of the monitoring of delirium tremens?

The patient is subfebrile. The normalization of its temperature is monitored. This parameter is not part of the Cushman score (but it is still checked in the delirium tremens) 😉


The evolution of delirium is favorable in a few days and an addictological consultation is organized. The patient reports excessive daily alcohol consumption but says she has not lost control of her consumption and does not need addiction management. Which of the following attitudes you could adopt to promote patient adherence, which are specifically motivational interviewing techniques?

Explain the link between alcohol consumption and delirium tremens episode

Explain other risks associated with alcohol consumption

Ask the patient what her alcohol consumption brings

Talk about ambivalence to change as normal

Introduce drug treatments to help maintain abstinence

Motivational interviewing meets a very specific definition.


The patient is followed by her general practitioner with a goal of complete abstinence. However, she was unable to stop drinking for more than five days. Which of the following classes of drugs can be prescribed as an aid to maintain abstinence?

A selective serotonin reuptake inhibitor


Management by the general practitioner continues, but without a significant reduction in alcohol consumption. She continues to drink one and a half bottles of wine a day. The patient often comes to the consultations having been drinking. She then cries a lot, says she is sad, lacking appetite and blaming herself. What therapeutic strategy(s) is (are) indicated for this patient?

The description does not meet the DSM-5 criteria for depression.

Scheduled hospitalization for alcohol withdrawal


The patient is cared for in a CSAPA (center for care, support and prevention in addiction) and a scheduled withdrawal has made it possible to obtain complete abstinence from alcohol for 3 months. Despite this, she continues to suffer from a deep malaise and tells her doctor that she can no longer bear to live alone, that she feels tired in the morning and needs several hours to prepare. It is very difficult to make decisions, she is incompetent in all areas and has a strong tendency to eat between meals to the point of having gained 5 kilos for 2 months. In addition, she worries almost all day and excessively for various reasons and takes more than an hour before falling asleep. She goes out little and sees very few people because she dreads all the encounters and is afraid of not being up to it. What diagnostic criterion(s) of severe depression do you identify among the symptoms presented by this patient:

Feeling lonely is not a DSM-5 criterion. Wicked trap 🙈


What other diagnosis(s) does the patient's clinical picture suggest?


A prescription of antidepressant monotherapy (escitalopram) was implemented 4 months ago and has achieved complete remission of the depressive episode for 3 months now. The patient remained abstinent in alcohol 🍷. However, she remains very anxious in many situations of everyday life. What therapeutic orientation(s) is (are) indicated at this stage?


After 12 months of treatment with escitalopram and maintenance of a complete and stable remission of the depressive episode, what argument(s) can justify the extension of this long-term treatment?

Identification of a history of depressive episodes

Identification of a history of manic episode

Signs of drug withdrawal occurring when you forget to take


The patient consults a year later. She has not taken an antidepressant for 6 months, but takes alprazolam in varying doses prescribed by another doctor every day. What therapeutic strategy(s) can be proposed to limit the risk of benzodiazepine dependence in this patient?

Information on the risks of chronic benzodiazepine use

Participation in a mutual aid group (GEM)

Doubt on this question: there is no mention of these GEM in the college 🤷 ♂ But we decide to tick it just since it seems logical.

Extension of the prescription of alprazolam at a stable dose to achieve complete remission

Replacement of alprazolam with a benzodiazepine with a shorter half-life

The shorter the half-life, the higher the risk.

Information on non-drug therapeutic alternatives


Context: A 17-year-old woman is referred by the SAMU to the emergency reception service because she had lost consciousness on the public road an hour earlier. Bystanders noticed convulsive movements and called the UAS. He arrived fifteen minutes after the loss of consciousness and tells you that the patient was confused. It reports urine loss. When you examine it, it is perfectly conscious, well oriented in time and space. She doesn't remember anything and asks you why she was hospitalized. Your clinical examination is normal.

Regarding the confusion in this situation, what is(are) the exact answer(s)? (one or more true propositions)

This is called post-critical confusion, which lasts a few minutes to a few hours.

It may be followed by persistent cognitive impairment

It is manifested by a spontaneous language disorder

Its association with temporospatial disorientation is constant

It is manifested in particular by behavioral disorders


Regarding the mechanism of this loss of knowledge, what is (are) the right proposal(s)? (one or more true propositions)

You mention the diagnosis of tonic-clonic seizure because witnesses report convulsive movements

You retain the diagnosis of tonic-clonic seizure since the patient reported a loss of urine

The absence of tongue bite makes it possible to rule out the diagnosis of tonic-clonic seizure

The fact that the patient says she does not remember anything supports a psychogenic origin of the loss of consciousness

The existence of confusion during the management by the SAMU makes you evoke a tonic-clonic epileptic seizure


What element(s) would be in favor of convulsive syncope?

Immediate resumption of normal consciousness

Duration of loss of consciousness of at least five minutes


During the interrogation, you learn that the patient is sometimes surprised in the morning by jolts of the upper limbs. She even suddenly dropped the cup of coffee she was holding as the movement was so abrupt. Regarding this symptom, you mention:


You integrate this symptom into your syndromic reasoning. What is the exact proposal(s):

This symptom calls into question the diagnosis of an epileptic mechanism concerning the episode of loss of consciousness

This symptom associated with the clinical suspicion of tonic-clonic seizure is in favor of secondarily generalized partial epilepsy

This symptom associated with clinical suspicion of tonic-clonic seizure is in favor of idiopathic generalized epilepsy

This symptom requires psychiatric advice

This symptom should cause the interrogation to look for photosensitivity


You remember the existence of epileptic myoclonus. Regarding epileptic myoclonus, which is (are) the exact proposal(s)?

They can be observed during generalized epilepsy

They can be observed during partial epilepsies

They are favored by intermittent light stimulation

They can occur in the absence of concomitant epileptic discharge on the electroencephalogram


In the first hours of your care, which additional examination(s) for etiological purposes will you perform?

Not in the first hours but it is systematic in a second time.

The repetition of symptoms is not in favor of an infectious origin.

We will look for a background 😉 activity

The repetition of symptoms is not in favor.

We can consider a CT scan, but not a CT angiography (we do not think of ischemia in front of this table).


You have to perform an electroencephalogram one hour after admission. What characteristic(s) do you remember at the seventh second of the recording?

One landfill recorded on all leads (lines)

A discharge characteristic of a partial crisis


A brain MRI is performed remotely, what do you expect (indicate the exact proposal(s))?

It will be normal in case of idiopathic generalized epilepsy

An MRI abnormality is not necessarily responsible for epilepsy

An MRI abnormality will prove that the patient's symptoms are epileptic

The absence of abnormalities on MRI will make it possible to reject the diagnosis of epilepsy in this patient

The presence of an abnormality on MRI will prove that epilepsy is of partial origin in this patient


Brain MRI is normal. What is the diagnosis?


You have retained the diagnosis of benign juvenile myoclonic epilepsy. You discuss with the patient the initiation of background antiepileptic therapy. What is the exact proposal(s)?

There is no indication for background anti-epileptic treatment as she had only one generalized seizure

The benign nature of epilepsia justifies therapeutic abstention

The prescription of background anti-epileptic treatment must be accompanied by therapeutic education

Prescription of background antiepileptic therapy contraindicates oral contraception

The prescription must be maintained over the long term to prevent the recurrence of its pathology


Treated for 18 months with lamotrigine, she has never reoffended. She wants to pass her driver's license. What is the exact answer(s) regarding driving?

Driving a public transit vehicle is definitely contraindicated

Driving a light vehicle is possible without restriction

The physician must inform the patient of the regulatory procedures

Driving will be possible with a certificate from the attending physician

Taking antiepileptic treatment prohibits driving


She asks you about her contraception. What is the exact answer(s)?

Lamotrigine is an enzyme inducer of estrogen-progestin contraceptives

You recommend stopping antiepileptic treatment

You authorize the contraception of his choice

You recommend a change in antiepileptic treatment


Five years later, the patient expresses a desire for pregnancy and wishes to have information. What is the exact answer(s)?

The context of pregnancy makes you offer dual therapy

Close ultrasound monitoring will be necessary during the last trimester of pregnancy

Under treatment the risk of malformation is higher than that of the general population


Context: Mr. B. is brought to the emergency room by an SMUR team for trauma to the right upper limb following a fight. The initial lesion assessment carried out by the out-of-hospital medical team suspects a closed fracture of the right wrist. There are also several superficial wounds on both forearms, heavily soiled with mud, which require stitches. He is 45 years old and of Afghan nationality, arrived on French territory 4 months ago, in an irregular situation. He speaks and understands only a few words of French. You benefit from a French-Afghan translator in the emergency room. He lives in a camp with the aim of crossing to the United Kingdom and has therefore not taken any steps to obtain a residence permit in France. With the help of an association, he has been domiciled with the communal centre for social action since his arrival. He has active smoking, regular alcohol and cannabis use. He has no other known history other than a proven allergy to egg protein.

In the emergency room, the patient is taken care of. The clinical examination, supplemented by imaging, confirms a closed fracture of the right wrist requiring surgery. The wounds of the upper limbs are to be sutured. The caregiver washes his hands according to the following steps. Which of the following suggestions for standard hygiene precautions for performing sutures in emergency rooms is correct?

Wearing a surgical mask for the operator is recommended

The friction of the hands in 6 steps with a hydro-alcoholic solution, before the treatment, is in accordance with the recommendations

The duration of hand rubbing should last at least one minute

Wearing a pair of goggles is recommended


The wounds were sutured. You ask the patient about his vaccination status that he does not know. What modality(s) of prevention of the risk of infection do you implement?

You give him an injection of 250 IU of tetanus immunoglobulins in the emergency room

You give him an injection of a dose of vaccine containing tetanus valence in the emergency room

You start antibiotic therapy with amoxicillin and clavulanic acid for a period of 10 days

You are planning a tetanus vaccination booster for this patient

You are planning a new consultation for wound healing monitoring in a week 1 1


You inform the patient of the need for surgery followed by hospitalization to treat their wrist fracture. The patient refuses surgery and hospitalization. Which of the following proposals regarding patient information and consent is accurate?

The patient's low level of understanding of the French language exempts the physician from obtaining the patient's consent

The doctor must inform this patient of the expected benefits and possible risks of the surgical procedure

The status of illegal alien exempts the doctor from obtaining the patient's consent

The physician must ensure the patient's understanding by asking him to say what he has understood

The presence of the interpreter is recommended during the interview with the patient


The exchange with the patient highlights that his refusal is mainly motivated by the cost of surgery and hospitalization. His hospitalization costs will be covered under which device?

Complementary Universal Health Coverage (CMUc)

Assistance to complementary health (ACS)


This patient meets the conditions to benefit from the State Medical Aid (AME) but he has not, to date, submitted an application. Which of the following proposals for AME is correct?

The AME application must have been filed on the day of hospitalization

The hospital fee will remain the responsibility of the patient because he had not submitted an application for AME prior to his entry into the hospital

The AME will only allow him to access free emergency care

The AME will allow him to be reimbursed 100% of a medical consultation but he will have to advance the costs

The AME will allow him to be exempted from the medical deductible


Following the information provided, the patient finally accepts the surgery and hospitalization. He was therefore taken to the operating room for an orthopedic procedure. Arriving at the operating room, the team uses the patient safety checklist << the operating room >> (2016 version) of the High Authority for Health (HAS). Which of the following proposals regarding the patient safety <<checklist in the >> operating room is which one is correct?

The checklist is a barrier to recovery according to Reason's model

The checklist checks safety points of care at 4 key moments of surgery: before anesthetic induction, before, during and after surgery

The checklist promotes the sharing of information through cross-checking

The checklist significantly reduces postoperative morbidity and mortality

The checklist must be co-signed by the surgeon, anaesthetist and patient as soon as they wake up


The immediate aftermath of surgery is simple. The patient is now hospitalized. He is quickly seen by the mobile addiction team. The patient's clinical condition is stable and satisfactory. Postoperative pain is well controlled. There are no other notable clinical signs. Which of the following addiction consumption evaluation questionnaires is indicated in this patient?


During the appointment with the addictologist, in the presence of the translator, the patient reports an alcohol consumption equivalent to 6 standard drinks every day. He feels the need to have a first drink in the morning and has already been injured in a context of alcoholization in the last 12 months. The addictologist uses the AUDIT test. These elements of consumption are in favor (one or more possible answers):

The indication of a brief intervention only


As part of the prevention of alcohol withdrawal syndrome, the doctor of the department prescribes treatment with diazepam. The doctor on call is called during the following night because the patient has a state of convulsive status requiring a transfer to intensive care for 48 hours, lengthening the duration of hospitalization of this patient. Consultation of the patient's file during management by the doctor on duty shows that the patient has not received his diazepam treatment. You have no further information at this stage. How can we qualify this situation (one or more possible answers)?


As part of the quality approach within the department, it is decided to investigate the causes responsible for the occurrence of this adverse event. Which method(s) is (are) suitable?

An analysis of failure modes, their effects and criticality


The analysis of this event in mortality and morbidity review aims to (one or more possible responses):

Setting a priori the optimal care pathway

The MMR (Mortality and Morbidity Review) is carried out a posteriori, that is to say after the event has taken place.

Carry out a collective analysis integrating all the professionals concerned by the event

Identify the culprit(s) at the origin of the fault

This is absolutely not the objective of quality approaches.

Implement prevention, recovery or mitigation actions


The ALARM method was used to identify the causes of this care-associated adverse event. The causes identified are as follows. First, a computer failure did not make it possible to carry out a computerized prescription. The prescription was made in a paper file that turned out to be that of a patient other than Mr. B. The prescription was made at the end of the morning nurses' shift. However, the computer failure was quickly resolved and the afternoon shift nurses were not informed of the computer failure. In the end, the computer failure concerned only Mr B.'s prescriptions. The prescriptions of the other patients of the department could be made on computer as is customary in this department. The patient did not speak French, and in the absence of an interpreter during hospitalization, there was a lack of communication. The nursing team was understaffed due to multiple work stoppages in the context of an influenza epidemic. The analysis of causes finds related factors (one or more possible answers):


Following this adverse event associated with care, what should be done (one or more possible responses):

Inform the patient that they have experienced an unwanted event

Explain to the patient that this event would not have occurred if they did not consume so much alcohol daily

Inform the patient that every effort has been made to understand the causes of this event and prevent it from happening again

Minimize the importance of this event as it has no sequelae


Context: A 42-year-old patient visits the emergency department for acute abdominal pain. She is a hostess, has no personal or family medical history apart from a balanced migraine pathology under treatment. She underwent surgery at the age of 14 for acute appendicitis. She is on oral contraception. The pain came abruptly while she was at her workstation. It began in the periumbilical region and then spread to the entire abdomen. She was not relieved by taking paracetamol (1g) or by the 2 vomiting or diarrheal episode she had. She has no fever. On inspection, the patient lies down like a gun dog. The physical examination finds diffuse abdominal pain without contracture or defense on palpation. The pain is rated at 8/10 on the EVA scale.

Which of the following clinical signs are the ones that immediately point to a surgical emergency:

The criteria for a surgical emergency include: high and sudden abdominal pain, contracture (defense to a lesser extent), signs of hypovolemic shock (tachycardia, hypotension), signs of septic shock (fever), etc.

Periumbilical pain is not a worrying localization


Which of the following diagnoses you think is most likely (an expected answer):

The location of pain is not in favor (classically in left iliac fossa / left flank)

Ileitis is much less likely than occlusion.

The localization of the pain is not in favor (classically in right hypochondrium)

We think rather of a digestive pathology here.


The pulse is at 98 beats per minute, the BP at 110/80 mmHg and the temperature at 37.8 °C.  Regarding emergency care, what is (are) the real proposal(s)? (one or more true answers)

Systematics in case of suspected occlusion


Which examination(s) do you think are useful for the management of this patient?

Abdominopelvic CT scan with contrast injection

X-ray of abdomen without face preparation


An abdomino-pelvic CT scan is performed. Which of the following is correct?

It is an abdominal CT scan with injection, arterial time

The spleen is no longer tabby 👉 it is not arterial

The superior mesenteric artery is clouded and visible on this picture


The CT scan confirms the hypothesis of a small bowel occlusion on flange with suffering of a small loop and presence of a peritoneal effusion. What do you propose at this stage?

Check the blood ionogram to adapt the ionic intake

Hospitalization, fasting, continuation of analgesic treatment and transit accelerators, clinical and biological reassessment at 24 h

Occlusion on flange + digestive suffering does not allow to wait

Contact the surgical and anesthetic team for emergency intervention

Starting intravenous probabilistic antibiotic therapy

Perform a rectosigmoidoscopy to lift the flange

Can be done in the volvulus of the sigmoid


You decide to operate on the patient. A laparotomy is performed, you discover a flange responsible for strangulation of the ileum with ischemia of the small intestine for about 1 meter. Which of the following suggestions regarding your care is true?

Section as quickly as possible of the flange responsible for strangulation

Rapid resection of the ischemic digestive segment to avoid bacterial translocation

Installation of moist and warm compresses in contact with the ischemic intestine and reassess its recoloration and vitality after a few minutes

The entire small intestine should be unwound to look for other flanges that may cause occlusions

You have informed the patient of the possibility of a stoma after the procedure


You perform a resection-anastomosis of the hail. The patient is renourished on day 2. On the 5th day, she complains of diffuse abdominal pain, predominant at the periumbilical level. The temperature is 38.5 °C.  The examination finds a painful arch at the level of the operative scar. Which of the following diagnoses can you mention?


What test(s) do you request to support your diagnosis? (one or more responses)

A rectosigmoidoscopy to remove an anastomotic fistula


The abdominal CT scan ordered urgently shows a wall abscess. The abscess is evacuated. The patient leaves the ward with local care at home with a 5-week absence from work. Why should she see the occupational physician again when resuming (one or more possible answers):

Because the event occurred in the workplace

Because it's a stop of more than 30 days

The three situations that require a follow-up visit are: occupational disease, stoppage > 30J, maternity leave.

To approve!' Imputability of the accident at work

To determine the rate of disability related to the work-related accident


She is seen again in consultation at his request 6 months later for the appearance of a << ball >> in front of his scar. On examination, there is an impulsive cough swelling, not painful. Which of the following diagnoses can be mentioned?

The peritoneum does not 👉 hold evisceration. According to the College of Digestive Surgery: 'Early post-operative injury'

The peritoneum holds 👉 ventration. According to the College of Digestive Surgery: 'Hernia through an opening secondary to a previous incision'


Given the impulsive nature of coughing and not painful, you evoke an uncomplicated eventration. Do you inform the patient that?

Wearing a restraint belt for 6 months prevents their occurrence

An eventration always occurs on an acquired aponeurotic orifice

Surgery is responsible for venting in the majority of cases

She should have had a work stoppage of at least 3 months to prevent the ventration

The occurrence of a parietal abscess is a risk factor for the occurrence of eventration


You propose to the patient a surgical cure of the eventration. But she refuses this intervention. Three years later, she was admitted urgently for acute abdominal pain. Which of the following proposals will direct you towards the diagnosis of strangled ventration?


You make the diagnosis of strangulated ventration and the patient is operated urgently. There is no digestive suffering and the fascia is closed by a simple suture. The postoperative follow-up is simple and the patient leaves the service at 5 quality of general practitioner, you see the patient again 8 days later at home and you inform her

That, in its situation, the aponeurotic suture guarantees the absence of recurrence in 90% of cases

That the wearing of a restraint belt is recommended 24 hours a day

That it would be advisable to contact the occupational physician of his company

That in case of recurrence of its eventration, the installation of a parietal reinforcement prosthesis would be recommended

That you cannot ask his surgeon for his entire hospitalization file because of medical confidentiality


Context: You are on duty at the telephone regulation service of the UAS, you are given the call of the mother of an 18-month-old child. She worries because her child went back to sleep at 10am and she can't wake her up. The child had gotten up around 7 a.m. and was fine. This child has no notable history, she was born eutrophic at term after a normal pregnancy.

Which of the following are the clinically severe symptoms(s) you are looking for in this child:

In both children and adults, it is a sign of clinical seriousness

She has fever and a rash that persists on vitropressure

The rash that persists with vitropressure is purpura, i.e. blood extravasation (blood coming out of the vessels). Any febrile purpura is a fulminans purpura until proven otherwise, and requires the introduction of antibiotic therapy as a matter of absolute urgency (even before bacteriological sampling if these delay management).


There is no rash or fever. In the absence of a verbal and motor response described by the mother as well as breathing that you hear as very slow and noisy, you send a team home. On the spot the doctor notes: a heart rate at 80 / min, a respiratory rate at 10 / min, a pink but sleepy child with a Glasgow score at 11, the temperature is at 36.2 ° C, skin recoloration is immediate and blood pressure is 102/61 mmHg. The pupils are symmetrical and responsive, the nape is flexible. The mother does not report any unusual items in the previous days (no fever, no trauma). Which diagnosis(s) are compatible with this clinical picture?

a pink but sleepy child with a Glasgow score of 11


Regarding the hypothesis of a inflicted head trauma, what is (are) the exact proposal(s) in this pathology?

The absence of impact on the skull excludes this diagnosis

The break of the cranial perimeter curve is suggestive


As a general rule, under what circumstances can bradypnea be observed in children?


The arterial gas balance made under oxygen is as follows: pH 7.26, PCO2 66 mmHg, Bicarbonates 24 mmol / L, HbCO 3%, PO2 90 mmHg. How do you interpret this balance sheet (only one answer)?

Acidosis because pH<7.35 (or 7.38 depending on the source). Respiratory because the drop in pH is caused by the increase in pCO2 (which is > 45). Not compensated because the pH is acidic.


The child is admitted to the emergency room where you decide to perform a brain scan and prescribe a urine toxicity test. Which symptom(s) is compatible with drug poisoning? (one or more exact propositions)


Here are the growth curves that you reconstitute in the health record. What diagnostic hypothesis(s) can (s) be evoked when reading these curves?


The search for toxic substances finds cannabis. The mother reports that her husband had friends the day before and that it is possible that they had left cannabis resin on the coffee table that the child would have ingested at the time. You also note on clinical examination gingival hypertrophy, cavities, pallor, some petechiae in the lower limbs. What first-line investigation(s) is (are) necessary in view of these growth charts and clinical signs?


The complete blood count shows a hemoglobin of 9.8 g/dL, with a MCV of 68 fL, the platelet count of 525 G/L. Which of the following do you think is the most likely diagnosis based on history, clinical signs and laboratory results?


The dietary survey confirms your hypothesis of serious deficiency on an inadequate diet, since the child drinks only semi-skimmed cow's milk, sugary drinks and nibbles cakes. Regarding the recommended dietary and vitamin allowances at this age, which is (are) accurate?

Fluoride supplementation is recommended for all children from birth

A vitamin C supplement is necessary in winter

Growing up milk can be replaced by cow's milk from 18 months

Breastfeeding provides adequate iron intake at this age

Infant formulas are fortified with vitamin D


You consult his health record. At 2 months: hexavalent and pneumococcal conjugate vaccine with 13 valences. at 6 months: hexavalent and pneumococcal conjugate vaccine with 13 valences. At 7 months: meningococcal C. vaccination at 12 months: hexavalent and pneumococcal conjugate vaccine with 13 valences. There has been no medical examination since the age of 12 months. Regarding the vaccination recommendations in force for this 18-month-old infant, what is the exact proposal(s)? (one or more true propositions)

One dose of hepatitis vaccine is missing

At least one dose of measles/mumps/rubella (MMR) vaccine is missing

One dose of 23-valent pneumococcal polysaccharide vaccine is missing

No mandatory varicella vaccine, nor recommended at this age (it is in adolescents and adults who were not infected in childhood)


You are also worried about the psychomotor development of this 18-month-old child, who has very little stimulation from parents and spends her days in front of the television screen. Which of these propositions is (are) accurate?

Their language must be at least 100 words long


This child's language is dissyllabic, she does not associate two words and does not react to the call of her name. She stands alone and takes a few steps when invited but is spontaneously << very calm >>. Which of the following investigations should be carried out in the first line?

Deafness must be eliminated in front of this clinical description. It is a common cause of delayed psychomotor development.


The ENT consultation finds normal hearing, you retain a deficiency origin to this psychomotor delay. Faced with this table of accidental poisoning and serious deficiency of food intake, irregular medical monitoring (with vaccination delay), what step(s) do you think is necessary? (one or more true propositions)

Worrying information at the High Authority of Health (HAS)

A phone call to the child's doctor and the Maternal Child Protection


You write a judicial report. Which of the following is correct?

The name of the medical writer(s) must remain anonymous

He must suggest the person responsible for the abuse

Parents may be informed, unless the child is in the best interests of the contrary

It must mention the identity of the persons holding parental authority

Unless otherwise interested of the child


Context: A couple consults for infertility. The woman is 28 years old and has no family history. She has never traveled or had unprotected sex except with her current partner, and has a personal history of recurrent epistaxis, active smoking for 10 packs years, allergy to pollen and dust mites, and abdominal surgery for appendectomy at the age of 21. The spouse is 36 years old, has smoked 1 pack a day since the age of 17 and occasionally uses cannabis. He has no medical-surgical history. They have been living in a relationship for 6 years, have not used contraception for 14 months and have sex several weeks. The gynaecologist who treats the patient did not find any ovarian or uterine abnormalities. The patient's hormonal balance is normal.

What element(s) do you look for in the clinical examination of the patient who may participate in infertility?

We do not think of acute orchitis in this context


The patient has already made a spermogram after 4 days of abstinence of which he shows you the results: ejaculated volume at 5 ml, sperm concentration: 2 million / ml, total sperm motility: 10%, 75% spermatozoa, 1% normal forms. What are the exact proposal(s)?

Well, we don't know what the 75% means (are these normal or dead spermatozoa?), so we don't tick


No etiology is found to these spermogram abnormalities explaining infertility and pregnancy is obtained by intracytoplasmic injection of spermatozoa. The 1 trimester of pregnancy passes without difficulty except for nausea and some bleeding of red blood. The patient consults at 27 SA because her last two urine strips showed the presence of leukocytes and nitrites. She has no fever, no urinary symptoms apart from slight cough leakage. She has had a recurrent cough since the beginning of winter. She therefore restricts herself from drinking to limit leakage. What is the most likely diagnosis? (only one answer expected)


You have a cytobacteriological examination of urine performed which shows: 42000 red blood cells / ml, 12000 leukocytes per mL, and 10 power 5 E. Coli / mL in culture. What do you do?

Amoxicillin treatment should be started as a first-line treatment

First-line fosfomycin-trometamol therapy should be started

It is necessary to wait for the results of the susceptibility test to treat

Intravenous dual antibiotic therapy is needed

There is a risk of acute pyelonephritis if left untreated


Escherichia coli colonization recurs several times during pregnancy and required 4 lines of antibiotic treatment. The patient gives birth at 38 SA+ 4 J of a little girl of 4180 g vaginally without episiotomy. Three weeks later, she consults for an alteration of the general condition, a fever at 38.8 ° C, urinary functional signs such as pollakiuria and leakage with effort and pain that she has difficulty systematizing but predominant in the right hemiabdomen. Her daughter is formula-fed and is doing well. What diagnosis(s) are possible at this stage?


On clinical examination the vaginal touch is painless, the breasts are flexible, there is pain at the shaking of the right lumbar fossa with a painful path radiating in addition pubic. Cardiopulmonary auscultation finds a decrease in vesicular murmur in the right base. The patient is febrile at 38.7°C, heart rate is 132/min and blood pressure is 87/53 mmHg. Which exam(s) are you asking for as a first line?

Cytobacteriological examination of urine


The imagery is as follows. Which proposal(s) is the exact proposal(s): (one or more expected proposals)

These are cuts of abdominal-pelvic CT scan after injection of contrast medium

There is dilation of the right pyelocalicial cavities

There is a syndrome of right kidney mass


The abdominopelvic CT scan therefore shows a dilation of the right pyelocalicial cavities upstream of a 7 mm ureteral stone. Direct examination of urine shows the presence of leukocytes, red blood cells and gram-negative bacilli. As she returned from the CT scan, the patient's blood pressure dropped to 65/30 mmHg and the lumbar fossa pain intensified. Her state of consciousness is normal, she has some mottling on her knees. What therapeutic measure(s) is possible in the first line?

No measures should delay surgical management

Parenteral bi-antibiotic therapy with fluoroquinolone and aminoglycoside

Parenteral bi-antibiotic therapy with beta-lactam and aminoglycoside

Administration of vasopressive drug type noradrenaline


The patient responds well to crystalloid filling and her blood pressure is now stabilized at 100/58 mmHg. What additional therapeutic measure do you propose in this context? (only one answer expected)

Ureteroscopy for stone extraction after 48 h of effective antibiotic therapy

Ureteral drainage by JJ tube after 48 h of effective antibiotic therapy


After the placement of a JJ tube (non-purulent urine) and 72 hours of adapted antibiotic therapy, the patient's clinical condition improves and she can go home. You see it again in consultation 1 month later and the CT scan without injection shows that the stone has been pushed back into the upper calyx. It always measures 7 mm and its density is 1050 UH. The JJ tube is quite poorly tolerated with pollakiuria and almost permanent pain. What are the possible measures for the continuation of the care (one or more correct answers):


You finally decide to perform a flexible ureteroscopy with extraction of all the lithiasic fragments that are sent for analysis. Given the elements at your disposal, what is the most likely majority component of this calculation?


Infrared spectrophotometry concludes that it is a calculation composed of 75% whewellite (calcium oxalate monohydrate), 25% wedellite (calcium oxalate dihydrate). What can be the contributing factor(s) of such a calculation in this patient?


The first-line etiological assessment you prescribed is normal. What recurrence prevention measure(s) are you putting in place?

Hydration for a diuresis volume of about 1 L


The patient comes back to see you 4 years later because she thinks her stones are recurring. However, she experienced a second pregnancy without lithiasis recurrence and gave birth without difficulty to a little boy weighing 3560 grams 18 months ago. For the past few weeks, she has felt embarrassed by a bladder stone that frequently makes her want to urinate day and night. She feels pelvic heaviness aggravated by prolonged standing. Her needs are so urgent that she can't always restrain herself. On the other hand, his cough leaks disappeared except possibly in the morning when he woke up. Sexual intercourse is unpleasant. What is the most likely diagnostic hypothesis?


Your clinical examination confirms the presence of a grade 3 anterior colpocele. What is the most plausible explanation for the disappearance of stress urinary incontinence: (one exact proposition)

Plication of the urethra by the colpocele

Urethral calcification by calcium oxalate


Context: A 36-year-old patient comes to consult urgently for moderate metrorrhagia and delayed menstruation of 2 weeks. She is 1m65 tall and weighs 89 kg. She is a smoker (25 packs year). She has a history of phlebitis of the lower right limb after orthopedic treatment for right ankle sprain. His mother developed a pulmonary embolism postpartum. His father died. He had bilateral hearing loss and had a kidney transplant. She provides contraception with condoms. She performed a urine pregnancy test which is positive.

What is the most relevant information to look for during the interview or clinical examination?

The main question is: is it a GEU? The absence of abdominal pain would then be very reassuring.

An exacerbation of sympathetic signs of pregnancy


In this patient, physical examination reveals moderate pain caused in the defenseless right iliac fossa. Blood pressure is at 130/70 mmHg. The heart rate is at 80 bpm. The uterus is impalpable due to the patient's overweight. On examination under speculum, moderate red bleeding comes from the endocervix. At vaginal touch, there is no mass, but palpation of the right cul-de-sac triggers moderate pain. Which diagnosis do you prefer at this stage of management?

Priority is always given to the most serious and urgent 😉


Following your clinical examination, you decide to perform an endovaginal pelvic ultrasound. Which ultrasound sign(s) would be compatible with the diagnosis of ectopic pregnancy?

Absence of effusion in the rectouterine cul-de-sac (Douglas)

Absence of visible right laterouterine mass

Hypoechoic intrauterine image without hyperechoic crown


The pelvic ultrasound you perform shows uterine emptiness, no intra-abdominal effusion and no visible adnexal mass. Plasma HCG is measured at 900 IU/L. What therapeutic strategy do you adopt (only one expected response)?

Intramuscular injection of methotrexate on an outpatient basis

Administration of oral misoprostol on an outpatient basis

Expectancy and reassessment within 48 h with new HCG assay and control ultrasound

Endorish aspiration with sending of samples in anatomical pathology for chorionic villus testing


You see the patient again two days later. She still feels a slight pain in the right iliac fossa. Minimal metrorrhagia persist. The HCGs are at 1200 in the same laboratory. The control ultrasound reveals this time a hematosalpinx of 20mm on the right, without visible embryo and without abdominal effusion. Your increased suspicion of ectopic pregnancy therefore leads you to prescribe methotrexate. Which proposals are correct?

Folic acid should be systematically combined

It may be accompanied by hand-foot syndrome

The success rate is correlated with the HCG rate


What advice(s) do you give to the patient?

Absolute contraindication to microprogestogens

Need for early pelvic ultrasound in case of new pregnancy

We have not found this notion even if it would seem logical 🤔 to us

Respect a minimum of 6 months after the injection of methotrexate to start a new pregnancy

Perform a hysterosalpingography to assess tubal patency


Two years after the management of this ectopic pregnancy, the patient returns to consult as part of the follow-up of a new pregnancy. This pregnancy is desired. It is at 12 SA. She has no symptoms. It brings you the result of the early pregnancy assessment prescribed by its general practitioner: blood group O rhesus negative, negative search for irregular agglutinins, rubella serology IgG +, serology toxoplasmosis IgG + / lgM-, HBsAg-, TPHA-VDRL-, HIV serology- You take the opportunity to perform a urine strip, it reveals 2 blood crosses and 2 protein crosses, no leukocytes or nitrites. Blood pressure is measured at 130/80 mmHg. What is (are) your prescription(s)?

Quantification of urinary red blood cells by ECBU

Positive BU -> ECBU of confirmation and precision


The next day (12+1 SA), you receive the results of the prescribed examinations. The ECBU is sterile 3 but confirms a red blood cell rate of 10 red blood cells/mm. The proteinuria/creatinine ratio is 40 mg/mmol. Ultrasound shows the absence of kidney malformation and normal-sized kidneys without macroscopic cysts as well as a bladder without abnormalities. The plasma creatinine assay is 50 micromoL/L. What etiology(ies) is (are) compatible with the whole picture presented by this patient?


Given the probable existence of nephropathy pre-existing to pregnancy, a consultation with a nephrologist is scheduled. In the absence of renal failure, the latter provides for a renal biopsy to be performed once the pregnancy is over.
The monitoring of pregnancy subsequently proves satisfactory, especially in terms of blood pressure. At 31 weeks, the patient consults for decreased fetal active movements. She is also asymptomatic. Its temperature is 37 °C.  His blood pressure is 140/80 mmHg. The uterine height is measured at 26 cm. His osteotendinous reflexes are normal. Fetal cardio monitoring is normal.
You perform a fetal ultrasound. Fetal biometrics include: biparietal diameter at 258 percentile, cephalic perimeter at 308 percentile, abdominal perimeter at 58 percentile, femur length 48 percentile, fetal weight estimate at 38 percentile. The uterine Doppler has a decreased diastole on both sides, without notch. The umbilical Doppler has zero diastole. The cerebral Doppler has an increased diastole. There is no visible fetal malformation. The amount of amniotic fluid is decreased.
What argument(s) support(s) the hypothesis of a vasculo-placental cause that can explain these biometrics?

It is a present notch that directs us to a vascular cause


Given this small fetus for gestational age, you decide to hospitalize the patient for fetal heart rate monitoring 3 times a day. What therapeutic measure(s) do you decide to implement?

Fetal lung maturation corticosteroid therapy

< 32 SA if imminent delivery for the baby potit or if neuros signs in front of pre-eclampsia for the mother potitis


After 24 hours of hospitalization, the patient's condition deteriorates. Blood pressure is now measured at 150/100 mmHg. The patient complains of headache and epigastric pain. His diuresis is quantified at 200 ml since his hospitalization. The reflexes are sharp, diffused and polykinetic. Cardiofetal monitoring is not very oscillating with decelerations. You perform an emergency biological assessment, the results are as follows: platelets 60 G / L, hemoglobin 9 g / dL, schizocytes positive, haptoglobin 0.2 g / l, asat 230 IU / L, ALAT 340 IU / L. What are the priority therapeutic measures (one or more exact answers)?

Prevention of eclampsia by magnesium sulfate


An emergency caesarean section is performed. The patient gives birth to a 1020 g girl cared for by the neonatal team. Breastfeeding is maternal. At 72 hours, maternal progress is satisfactory. High blood pressure has disappeared, as have headaches. Osteotendinous reflexes have normalized. Diuresis resumed normally. Maternal work-up also improved in the first 48 hours after delivery with the disappearance of HELLP syndrome. On day 4, the patient presents with fever at 38.5°C and significant hypogastric pelvic pain. His blood pressure is 130/70 mmHg and his pulse is 90 bpm. Examination with the speculum reveals smelly lochia mixed with blood in small quantities. The caesarean section scar is clean. The breasts are tense, painful as a whole, without inflammatory cupboard or palpable mass. There is no axillary lymphadenopathy. The patient has not had a venous route or urinary catheter for 48 hours. No preventive anticoagulant therapy was initially initiated due to HELLP syndrome. What is the diagnosis you mention first?


You perform a pelvic ultrasound in front of this suspicion of endometritis. A small placental retention measured 15 mm in sagittal section of the uterus is observed. What is (are) the element(s) of your therapeutic management?

Ceftriaxone and intravenous metronidazole

Endouterine aspiration in the operating room

Low molecular weight heparin at prophylactic dose


Three days after starting treatment with antibiotics and heparin therapy at a prophylactic dose, pelvic pain persists, as does fever. The patient is still bloated. You request a CT scan with contrast injection. What is the most likely diagnosis?

Urolithiasis enclosed in the lower right ureter


In addition to the patient's personal and family thrombotic history, what additional risk factor(s) do you identify in this context of right ovarian vein thrombosis?


Knowing that serum creatinine is controlled at 70 micromol / L and that the patient wishes to continue breastfeeding, what is your anticoagulant prescription for this thrombophlebitis of the right ovarian vein


Context: A 36-year-old Caucasian patient is referred to her general practitioner for the discovery of a three-cross hematuria on the urine strip in occupational medicine, with a blood pressure of 155/90 mmHg. The patient's main history is an appendectomy and frequent cystitis (3 to 4 per year, the last 3 months ago treated with fluoroquinolones). She had 2 pregnancies and 2 vaginal deliveries at age 25 and 30 (the last pregnancy complicated by pre-eclampsia). She currently wears an IUD. She has a smoking rate of 10 packs/year unweaned. She does not take any long-term treatment except ibuprofen occasionally for menstrual pain in particular. It weighs 60 kg for 1.68 m. She works in finance in a position of high responsibility and is under great stress.

In view of the context, which diagnosis is to be mentioned in the first intention?


What is (are) the element(s) to be collected during the interrogation in this context of discovery of hematuria? (one or more true propositions)

We do not start at all on a bladder cancer, which is not a hereditary pathology


The ECBU you prescribed to the patient currently finds: red blood cells 150,000/ml; leukocytes< 1,000/ml, sterile culture. There was a proteinuria with 2 crosses to the strip but the urine was concentrated. Her blood pressure is currently at 150/90 mmHg in your consulting room. Her urinary beta-HCG is negative (the last menstrual period started 8 days ago). What biological examination(s) do you prescribe for this patient at this stage: (one or more expected proposals)

Serum creatinine with glomerular filtration rate calculation

Proteinuria and creatinineuria on urine specimen


What imaging test(s) do you prescribe for this patient at this stage?


What is the action to take in the face of the discovery of this high blood pressure in this patient? (One or more correct answers)

Prescription of amlodipine pending the results of biological tests

Request for outpatient self-measurement of blood pressure measurements

Need to see the patient again within 48 hours for blood pressure control

Reassessment of blood pressure after discontinuation of ibuprofen


The results of the prescribed examinations are as follows: Na 142 mmol/L; K 4 mmol/L, 2); proteinuria 2.5 g/24 h, selective; serum creatinine 90 μmol/L (DFG CKD-EPI at 71 mL/min/1.73 m^2 ECBU red blood cells 200,000/mL, leukocytes< 1,000/ml. Renal ultrasound finds kidneys of 118 mm and 122 mm respectively on the right and left with a cyst of the upper right pole of 1 cm. They are well differentiated, the cortical thickness is 22 mm, homogeneous. His ambulatory blood pressure is 150/90 mmHg on average despite stopping ibuprofen. She describes asthenia and a recent loss of her hair that she links to strong tensions at work. You refer the patient to a nephrologist with other laboratory tests. Which examination(s) is the most relevant exam(s) given the context in this patient?

Determination of parathyroid hormone and 250H vitamin D

Anti-nuclear factors, anti-DNA antibodies


Your additional assessment is as follows: leukocytes 3.50 G / L, Hb 9 g / dL, VGM 92 fi; e platelets 200 G/L, reticulocytes 250 G/L, anti-nuclear factors positive at 1/160 with native anti-DNA antibodies at 40 Ul/ml, C3 0.5 g/L (0.8-1.6); C4 0.08 g/L (0.17-0.53), CH50 40 50 CRP 7 mg/L; HCV and HIV negative serologies; HBV serology: anti-HBs 100 Ul/ml antibodies, negative anti-HBc antibodies. What is (are) in favor of a diagnosis of systemic lupus?


What are the possible causes of this anemia in this context (one or more correct answers)?


What extrarenal clinical signs will you look for in the context of this probable lupus flare-up? (One or more correct answers)


The patient has non-erosive mouth ulcers and arthritis of the hands and you are diagnosed with systemic lupus. What is the most appropriate course of action for this patient at this stage? (Only one response is expected.)

Performing a transparietal renal biopsy puncture

No need for renal histological confirmation in this context of leupic nephropathy


You decide to perform a kidney biopsy on this patient. She is hospitalized in nephrology. His clinical examination regained a blood pressure of 155/90 mmHg. She is apyretic but has had voiding burns for 48 hours. Its biological balance finds: leukocytes 3.8 G / L, Hb 9.4 g / dL, VGM 88 fL, platelets 220 G / L, Na 142 mmol / L, K 3.7 mmol / L; 2 ); serum creatinine 99 μmol/L (glomerular filtration rate CKD-EPI at 63 ml/min/1.73 m^2 proteinuria 2.2 g/24 h, selective; ECBU red blood cells 300,000/ml; leukocytes 20,000/ml; many live Gram-negative bacilli. You decide to treat 48 hours this probable cystitis before performing the renal biopsy puncture and normalizing his blood pressure. What are the elements of your therapeutic care? (One or more correct answers)


What are the possible basic histological elements in this patient given her clinicobiological presentation? (One or more correct answers)

Dominant mesangial deposits of immunoglobulin A and complement

Extramembranous immunoglobulin and complement deposits in immunofluorescence


Here is the report of your patient's renal biopsy: 8 mm renal cortical fragment containing 15 glomeruli including 1 sealing loaf; Optical microscopy: 10 glomeruli out of 15 are the site of endocapillary proliferation, presence of extra-capillary proliferations on 3 glomeruli, voluminous endomembranous deposits along the glomerular capillaries making << wireloops >>; - polymorphic interstitial infiltrate on about 30% of the cortical surface; - no vascular lesions or tubular lesions, presence of haematic cylinders in some tubular lumen; - immunofluorescence:  granular deposits of Ig G, lgM, C3 and C1q to 3+ mesangial and 2+ endomembranous on all glomeruli, no extramembranous deposits, fibrin deposits on 4 out of 18 glomeruli. What is your diagnosis?

Diffuse proliferative lupus glomerulonephritis

Focal proliferative lupus glomerulonephritis


Your patient therefore has a systemic lupus flare-up with hemolytic anemia, polyarthritis, canker sores, alopecia and class IV lupus glomerulonephritis (diffuse proliferative). What are the treatment options for attack therapy in this patient? (One or more correct answers)

bolus of methylprednisolone then prednisone 1 mg/kg


You start the attack treatment which is well tolerated including corticosteroid therapy in high doses. His blood pressure is 145/90 mmHg on ramipril that you started before the kidney biopsy. His renal assessment before discharge is as follows: serum creatinine 97 μmol / L (filtration rate 2 glomerular CKD-EPI at 65 ml / min / 1.73 m ^ 2 ), proteinuria 2.2 g / 24 h; ECBU red blood cells 350000/ml. What are the different possible therapeutic measures before returning home? (one or more correct answers)

Hydrochlorothiazide in combination with ramipril

Candesartan in combination with ramipril


Context: Mr. M, 45 years old, SNCF controller, comes to see you for "increase of red blood cells". He is an occasional blood donor and was rejected because of too high a hemoglobin. He does not know the results of the blood count. He is 1.72m tall and weighs 93 kg (BMI = 31) with facial erythrosis, but says he has always looked "good". He has been taking amlodipine for hypertension for 5 years, and pravastatin for hypercholesterolemia.

What are you looking for in interrogation to explore this anomaly? (One or more correct answers)


On clinical examination, what signs would point you to primary polycythemia? (one or more possible answers)


You make a blood count that shows: GR 6.9 T/L; haemoglobin 18.7 g/dL, haematocrit 57%; MCV 83 fL, MCHC 33 g/dL, reticulocytes 80 G/L, leukocytes 12.6 G/L, neutrophils 10.4 G/L, eosinophil polynuclear 0.3 G/L, basophilic polynuclear 0.05 G/L, lymphocytes 1.25 G/L, monocytes 0.6 G/L, platelets 534 G/L. What does this blood count show? (one or more possible answers)


You find on examination a splenomegaly with a costal overhang of 2 cm and the notion of aquagenic pruritus. Which of the following tests are useful in this patient to support the diagnosis of polycythemia vera (one or more answers are possible)?


You see the patient again with the results of your tests. He has a JAK2 mutation and erythropoietin levels are plummeted. The patient, worried, asks you about complications that may occur. What do you say to him (One or more possible answers here)?


About polycythemia vera, which propositions are true? (One or more possible answers)

It is a clonal disease of mature hematopoietic cells

There is an erythroblastic maturation blockade

There is spontaneous growth of erythroblastic progenitors in vitro


The patient asks you about the principles of treatment. What kind of care do you discuss with him? (One or more correct answers)


The patient had initial bleeding and is currently on antiaggregants. Three months later, your patient comes to see you 48 hours after returning from vacation in the West Indies. He has a painful left calf that has been swollen for 24 hours. What clinical elements will support your suspicion of deep vein thrombosis (phlebitis)? (One or more possible answers)


What are the risk factors for phlebitis in this patient? (One or more correct answers)


The clinical examination is not very specific. Which tests are useful for diagnosis? (One or more possible answers)


Doppler ultrasound confirmed the existence of sural phlebitis. What therapeutic attitudes are possible in this patient? (One or more possible answers)


You have opted for LMWH treatment with early relay with vitamin K antagonist (warfarin). What recommendations do you give your patient in relation to this treatment? (one or more possible answers)

Wearing a card mentioning the treatment on oneself

This is not a strict diet: just avoid a few foods that interfere with hepatic enzyme metabolism.


During his follow-up, the patient calls you because his control INR is 5.5. He found no bleeding signs. What do you do?


Your patient has been transferred to a city 500 km from your home. You have no news for several years. Then, a doctor who sees him for the first time calls you because the patient is referred to him for discomfort. The blood count shows: Hb 10 g/dL, MCV 83 fL, leukocytes 3 G/L, PNN 0.8 G/L, lymphocytes 1 G/L, monocytes 0.2 G/L, blast cells 1 G/L, platelets 86 G/L. What abnormalities do you see on this blood count? (One or more correct answers)


What diagnoses do you mention in this context? (One or more possible answers)

Transformation into chronic myelogenous leukemia


Context: You welcome an 84-year-old patient directly into the geriatric ward following a fall. The patient complains of dyspnea. You do not currently have any information about his background.

The nurse on the unit gives you the following information: blood pressure at 95/55mmHg, temperature at 39°C and heart rate at 110/min. Dyspnea is in the foreground. On pulmonary auscultation, you find a decrease in the vesicular murmur of the base of the left lung. Which of the following proposals is (are) the element(s) in favor of pleural effusion in this patient?

Noise added to left one-sided crackling type


You get more information for this patient who lives alone at home independently. He has a history of NYHA stage III heart failure on ischemic and hypertensive heart disease. The nurse had her daughter on the phone telling her that her father has not been elected as usual for 48 hours, with incoherent words.
At careful pulmonary auscultation, you find noises added to type of unilateral crackles in the left base. Vocal vibrations are increased in the left base. He has no signs of right heart failure.
Which of the following is the most likely etiology(s) of the pulmonary picture? (one or more exact propositions)


To assess the seriousness of this patient, which element seems most important?

Looking for a sign of neurological focus


The patient has a respiratory rate of 35/min and his saturation is measured at 94% in ambient air. You suspect acute lobar pneumonia. Which of the following additional examinations should be carried out immediately? (one or more exact propositions)


Biological samples are in progress and chest X-ray shows alveolar opacity of the left base associated with low pleural effusion. Arterial blood gases show: PaO 62 mmHg; PaCO 28 mmHg; lactate 1.3 mmol/L; pH 7.46. Which of the following propositions in this patient is(s) the correct statement(s)?

You immediately think of a pulmonary embolism

You think it's consistent with the diagnosis of pneumonia

You think the value of lactate points to acute community-acquired pneumonia

You think pleural effusion may explain the gasometric shunt effect


Given the context of falling, you examine the musculoskeletal system. Your exam finds pain in your right hip. You suspect a fracture of the right femoral neck because there are: (one or more possible answers)

Functional impotence of the right lower limb

Pain on palpation of the right great trochanter


The hip X-ray does not show a fracture of the femoral neck. The blood count shows leukocytes at 15 G/L, hemoglobin at 10 g/dL and platelets at 349 G/L. The serum creatinine is 75 micromol/L. What care do you start with this patient?

Low molecular weight heparin at preventive dose

Isotonic saline in venous infusion 3 liters / day


Which of the following other measures is the most important to put in place?

It is an early complication and carries great morbidity


During the first 24 hours of hospitalization, the patient has incoherent words. He believes he is in 1939. At times, on the contrary, it seems well suited. It is most often drowsy. When you enter the room, he does not remember seeing you in the morning and does not know that he is hospitalized. You mention a delirium syndrome. Which semiological element(s) present in the observation is (are) in favor of this diagnostic hypothesis?


The patient was put on oxygen and antibiotic therapy was started. The next morning the nurse finds that the patient is getting worse. What sign(s) would be in favor of hypercapnia?


Finally, the patient evolves favorably on the respiratory plan in your 3 days with apyrexia and a reduction in respiratory rate. However, he has not eaten anything in the last 3 days and you fear the presence of protein-energy malnutrition (MPE). Which of the following proposals regarding its nutritional status is the right proposal(s)?

His nutritional status may not have deteriorated sufficiently in 3 days

The determination of blood albumin is essential to determine the nutritional status

Lack of power over the last 3 days can define an MPE

MPE can be defined according to HAS by weight loss over the past year

A body mass index < 21 kg/m^2 defines MPE


On the 4th day, your patient can get up but the bipodal support is painful preventing walking and the unipodal support on the right is impossible. A second hip X-ray is re-read normally.
Which of the following proposals regarding his condition is(s) the correct statement(s) at this stage? (one or more exact propositions)

You are looking for an ilio- or ischiopubic branch fracture

You prescribe a scanograhie of the pelvis and hips

You prescribe an X-ray of the right knee


The CT scan revealed a fracture of the right iliopubic branch. The evolution is favorable under analgesic treatment and active early mobilization in one week. You plan to return home. What element(s) should be assessed before considering a return home?


You have assessed their basic activities of daily living (ADL score). What element(s) constitutes this score?

Its ability to answer the phone without aids

Its ability to use public transport without aids

Their ability to manage medications without aids


You measure their current ADL (Basic Activities of Daily Living) score at 4/6, and their iso-resource group (GIR) at 4. What is the correct interpretation(s)?

The ADL score shows that there is an addiction for one's instrumental activities of daily living

The GIR is associated with the ADL level

The ADL score does not measure the presence of a cognitive disorder

Cognitive impairment is taken into account in the measurement of the GIR

It seems likely that he will obtain financial assistance for his home helpers


Context: A 66-year-old patient consults his general practitioner for dyspnea of effort evolving for 2 months. He is still an active chef. He is overweight with a body mass index of 28 kg/m2, type 2 diabetic and hypertensive. He has been weaned from smoking (35 packs.years) for 1 year, date of the discovery of diabetes. He drinks 2 to 3 glasses of wine a day. He receives irbesartan, metformin and rosuvastatin.

What semeiological element(s) are you looking for in favor of a cardiac cause of dyspnea in this patient?

Gravity of the hypochondrium right to effort


The patient lives on the 38th floor with elevator. He does not present respiratory discomfort for everyday gestures. On the other hand, it signals dyspnea when walking uphill at normal speed (4 km / h).
At what stage of the NYHA does this description fit?


The patient has NYHA stage II dyspnea. Cardiac auscultation reveals mitral insufficiency. On which auscultatory anomaly(ies) is this diagnosis based?


The general practitioner refers the patient to a cardiology consultation. While waiting for his appointment, the patient is admitted to the emergency room for acute dyspnea. The emergency physician evokes an acute edema of the lung (OAP) cardigenic. What is the main semeiological argument for this diagnosis?


The clinical examination finds bilateral crackling rales going back to mid-field. Routine laboratory tests (blood count, platelets, blood ionogram, urea and serum creatinine) have been taken and you are waiting for the results. What is (are) the additional examination(s) essential before starting treatment?


A chest X-ray is performed. What abnormality(s) present on this picture is (are) in favor of the diagnosis of heart failure?


The electrocardiogram does not show an argument in favor of an acute coronary syndrome. The presence of orthopnea, diffuse subcrackling rales halfway up the pulmonary fields with bilateral radiological alveolar syndrome was sufficient for the diagnosis of acute pulmonary edema. Blood pressure is at 140/90 mmHg, heart rate is at 110 beats/min, there is no mottling or cooling of the extremities. Treatment with furosemide and oxygen therapy are started. Which complementary treatment(s) should be prescribed urgently?

Nitrates by intravenous infusion with an electric syringe

Dobutamine intravenous infusion with an electric syringe

Unfractionated intravenous heparin for 2.5x control ACT


The response to treatment is quickly favorable. An electrocardiogram is recorded again. What is the interpretation of this electrocardiogram?

Left posterior hemibloc (fascicular block)


An echocardiogram is performed with the following results: - dilation of the left ventricle with alteration of the ejection fraction to 30%; - Akinesia of the lower wall with hypokinesia of the lateral wall of the left ventricle; - dilation of the left atrium and right ventricle; - elevation of the filling pressures of the left ventricle; - moderate mitral leakage (grade II) of restrictive mechanism associated with dilation of the mitral ring. Systolic pulmonary arterial pressure is estimated to be elevated. What is (are) the contribution(s) of this echocardiography concerning the diagnosis?

The patient presented with an unnoticed myocardial infarction

The current picture of heart failure is due to ischemic heart disease

The current picture of heart failure is valvular cause

The patient developed pulmonary embolism


It is an ischemic heart disease with mitral leakage secondary to an unnoticed inferior myocardial infarction, complicated by heart failure with impaired ejection fraction. Which of the following decisions is, at this stage, the most important for this patient?

Confirmation of pulmonary hypertension by right catheterization

Search for viability and myocardial ischemia of the left ventricle

Analysis of the possibility of mitral plasty surgery

Metabolic stress test (with gas analysis and V02 calculation)


The search for myocardial ischemia is positive in the anteroseptal territory and leads to the realization of a coronary angiography. This examination reveals critical stenosis of the anterior interventricular coronary artery that is treated by angioplasty (percutaneous coronary intervention) and placement of a stent (stent).
What is (are) the therapeutic adaptation(s) to be made before returning home?

Introduce a bradycardial calcium channel blocker (diltiazem or verapamil)

Initiate triple antithrombotic therapy (e.g. aspirin+apixaban+clopidogrel)

Introduce a beta oral blocker in progressive doses


The patient discharges the hospital with carvedilol, enalapril, aspirin, prasugrel, rosuvastatin, furosemide, potassium salts and metformin. It is reviewed periodically to gradually increase the doses of carvedilol and enalapril to the target doses. Four months after revascularization, he is still dyspneic on exertion at NYHA stage II. He describes a first episode of brief loss of consciousness when climbing stairs, 30 minutes after taking his treatment. The search for orthostatic arterial hypotension is negative. The electrocardiogram is not changed. Echocardiography shows the persistence of systolic dysfunction with a stationary left ventricle ejection fraction at 30%, mitral leakage has not evolved and remains moderate (grade II). What is (are) the therapeutic adaptation(s) to be made to manage heart failure and its consequences?

Introduce a mineralocorticoid receptor antagonist

Reduce the dosages of enalapril and carvedilol

Implement ventricular resynchronization by biventricular stimulator


A few months later the patient presents a brutal, intense pain in the lower right limb which wakes him up at 6 am. He consults you at noon. The pain is intolerable agitating the patient, the foot is livid and cold with functional impotence. You will only find the femoral pulse in the right lower limb. You observe a discrete bilateral perimalleolar edema, taking the bucket. Skin sensitivity is decreased on the right side of the knee to the foot. Palpation of the calf is painful. What is the diagnosis to evoke in this patient?


In front of this brutal clinical picture you retain the occurrence of acute limb ischemia. What is (are) the sign(s) of gravity?

The presence of a sensory and motor deficit


What additional diagnostic examination do you propose to this patient before entrusting him to the surgical team?


The surgical team will immediately take care of the patient to perform emergency revascularization. What is (are) the modality(s) of care to be put in place immediately?

This will further decrease the arterial influx. On the contrary, they must be put in the unslid position.

Unfractionated heparin with an electric syringe after an intravenous bolus

Protection of the limb by avoiding compression points

Intravenous arterial vasodilator therapy


What risk(s) is (s) to which the patient is exposed due to the occurrence of this acute ischemia?


Context: A 68-year-old patient, a tobacco maker, is referred for dysphonia that has been evolving for 4 months. There is a history of atrial fibrillation treated with an anti-vitamin K. The last INR check performed 10 days ago was at 2.4. He started treatment including amoxicillin at a dose of 1g x 3/day in self-medication which he continued for 3 days without any improvement. The clinical examination carried out reveals moderate dysphonia. The blood pressure measurement is 120/85 mmHg, the height is 172 cm and the weight is stable at 75 Kg.

What are the diagnoses to evoke in front of dysphonia (one or more expected responses) in this patient?


Which of the following risk factors promote the development of vocal fold cancer (one or more expected responses)?


The patient is seen in consultation with 0RL. Among the following tests, which are those that make it possible to evoke the diagnosis of laryngeal cancer during a 0RL consultation (one or more expected answers):

Panendoscopy of the upper aerodigestive tract


You are moving towards the diagnosis of laryngeal cancer. Which of the following functional signs is related to a significant spread of cancer (one or more expected responses)?

Swallowing disorders with false routes mainly when ingesting fluids


During the clinical examination of the patient, what are the essential gestures to be performed (one or more expected answers)?

Complete inspection of the oropharynx and oral cavity


You highlight cervical lymphadenopathy. What are the elements to be specified during the clinical examination (one or more expected answers)?

Compression of the internal jugular vein


At the end of your clinical examination, you perform a pharyngolaryngeal nasofibroscopy. You highlight a tumor of the right hemilarynx with the presence of several right cervical lymphadenopathy. What are the important elements missing from the description of your clinical examination (one or more expected answers)?


For this patient, what are the examinations you request as part of the locoregional and general extension assessment (one or more expected answers)?

Panendoscopy of the upper aerodigestive tract under general anesthesia


You decide to perform a panendoscopy of the upper aerodigestive tract under general anesthesia. An anesthesia consultation is mandatory. What are the characteristics of this consultation (one or more expected answers)?

It is governed by a decree of the Public Health Code

It is performed by the anaesthetist who will practice anesthesia during surgery

Informing the patient about the anesthesia procedure is mandatory

It is performed by any doctor regardless of his specialty

It is performed at least 48 hours before panendoscopy


Which of the following biological examinations is essential before performing panendoscopy?

Haemostasis assessment including INR, TCA, p lacquettes


The cervico-thoracic CT scan was performed. What are the exact proposals (one or more expected answers)?

3 refers to the sternocleidostoid muscle


At the end of all the examinations performed, the final diagnosis is a moderately differentiated squamous cell carcinoma of the right hemianx classified T3N2bM0. What are the mandatory rules to respect for the management of a patient with carcinoma (one or more expected responses)?

Decision on taking charge in a multidisciplinary consultation meeting (RCP)

Management defined in agreement with the patient

Application for inclusion on the list of long-term conditions made by the attending physician


During the multidisciplinary consultation meeting, it was decided to propose a laryngeal preservation strategy with two chemotherapy courses combining cisplatin, 5FU, Docetaxel. Which of the following complications could be related to cisplatin (one or more expected responses)?

The college of oncology does not report it! We were as surprised as you probably are now 😖.


Because of the 5FU treatment, what toxicity do you monitor first? (Only one answer expected)


After two courses of chemotherapy, a regression of tumor volume greater than 50% associated with remobilization of the right hemilarynx was highlighted. was decided to perform cetuximab-sensitized radiotherapy. What are the complications of radiotherapy that could be observed in the medium or long term (one or more expected responses)?


Context: A 67-year-old man consults for right calf pain occurring after a walk that the patient estimates to be 350 meters away. He is a retired and sedentary taxi driver. This patient has been smoking a pack of cigarettes a day since the age of 30. You follow it for high blood pressure discovered by a systematic and balanced examination by perindopril. Blood sugar is normal as well as lipid balance.

What is your main diagnostic hypothesis?

Obliterating arterial disease of the lower limbs


You suspect arterial disease obliterating the lower limbs. Which of the following semiological elements will guide the diagnosis towards this hypothesis?

This is the description of the famous shopping cart sign, found in the narrowed lumbar canal

Disappearance of pain gradually for several hours

Decrease in pain at cessation of exertion in PAD. It is the onset of pain that is progressive.

Faster onset of symptoms when the patient climbs a slope


The interrogation confirms the appearance of a pain when walking with a cramp type localized in the right calf. The pain manifests itself early when the patient climbs a slope, thus supporting your diagnostic hypothesis of arterial obliterating disease of the lower limbs. On clinical examination, the patient measures 1.77 m, weighs 70 kg and the blood pressure is 134/68 mmHg in both arms. Abdominal palpation does not perceive pulsatile or expansive mass. At the level of the lower left limb all peripheral pulses are found, the popliteal pulse seems however too well perceived. At the level of the lower right limb, only the femoral pulse is found. At auscultation you will find only a right cervical murmur and a murmur in the upper 1/3 of the left thigh. On the data of this clinical examination, which is(are) the arterial atheromatous lesion(s) that you should suspect?

Stenosis of the right external iliac artery

The perception of a murmur on auscultation points to stenosis of the artery. Not to be confused with an obliteration, which corresponds to a total stenosis, that is to say that the blood does not pass at all. At the auscultation of an obliteration, we do not find a breath. On palpation of an obliteration, no pulse is found.


You mention the existence of a stenosis of the left femoral artery, a left popliteal aneurysm and a right femoral obliteration-reinjection. To confirm the diagnosis of obliterating arterial disease of the lower limbs you perform a measurement of the Systolic Pressure Index (SPI) in the ankle. The SPI is 0.67 at the lower right limb and 0.85 at the left lower limb. What are the semiological value and limitations of this parameter? (one or more correct answers).

When the SNI is less than 0.90, it confirms the diagnosis of peripheral arterial disease

The SPI standard is between 0.9 and 1.3 (1.4 is found as the higher standard in some sources). Below 0.9, he signs an AOMI. Above 1.3 (or 1.4), it signs arterial incompressibility (found in diabetic patients and chronic renal failure dialysis) due to mediacalcosis (calcification of the media, the intermediate tunica of the vessels, between the intima and the weed). An IPS below 0.7 indicates severe PAD.

When the SNI is less than 0.90, it indicates an over-risk of cardiovascular morbidity and mortality

When the SPI is greater than 1.40, it indicates arterial stiffness associated with mediacalcosis

The presence of a mediacalcosis requires the use of toe pressure and not ankle pressure for the calculation of the IPS

This is the way we have found to counter the mediacalcolsis. The arteries of the toe are less prone to medicalcolsis. However, it should not be forgotten that it is physiological that the pressure of the toe is lower than the pressure of the ankle. The standard is therefore lower. Indeed, in case of taking the voltage of the ortel, the standard of the IPS is then 0.7

ABI should be measured in patients suspected of acute sensory-motor ischemia to confirm diagnosis

Acute limb ischemia is a medical-surgical, functional and even vital emergency. No examination should slow down management.


To specify the arterial lesion assessment, which is (are) the additional first-line examination(s) you are requesting?

arteriography of the aorta and lower limbs

Doppler ultrasound of the abdominal aorta and arteries of the lower limbs

Makes it possible to precisely identify lesions, to evaluate the degree of stenosis and to objectify functional adaptation.

a Doppler ultrasound of arterial axes for cervico-encephalic purposes

In the previous questions, the patient has a cervical murmur. It must therefore be explored.

angio-MRI of the arterial axes for cervico-encephalic

CT angiography of the aorta and lower limbs

Is done pre-operatively of a revascularization


You asked in first intention the realization of a Doppler ultrasound of the axes for cervico-encephalic use, the aorta and the lower limbs to specify the arterial lesions. This objective examination an atheromatous overload at the level of the arterial axes of the supra-aortic trunks without significant stenosis. The abdominal aorta is regular and measures 28 mm in anteroposterior diameter. There is an obliteration of the right femoral artery with reinjection of the popliteal artery. There is also stenosis in the middle third of the left femoral artery. The left popliteal artery is regular and measures 13 mm in diameter in its widest dimension. Given the absence of a threatening lesion, you decide to treat this patient medically. What therapeutic measure(s) are you going to put in place?

Drug treatment of intermittent claudication is based on anti-platelet aggregation (by aspirin at anti-aggregating dose), an inhibitor of the converting enzyme (ACE inhibitor, the patient is already on perindopril for his hypertension, so we will keep it), and a statin (with an LDLc goal of less than 0.7 g / L because we are in secondary prevention,  the lesions are already there). It is associated with therapeutic education (sports activity, smoking cessation, Mediterranean diet, ...) and rehabilitation to progressive effort. Finally, we can discuss a gesture of revascularization.

ACE inhibitor is the treatment of choice in PAD

Treatment formally indicated from the stage of intermittent claudication. It is discussed in case of completely asymptomatic PAD (rare case).

We are not dealing with a coagulation problem. Neither AOD nor Heparin are therefore indicated. Indeed, in the arterial circuit, it is mainly a problem of primary hemostasis (platelet aggregation and formation of a thrombus) that may arise.


In addition to drug treatment, what advice(s) will you give to your patient?

His high blood pressure seems to be under control. Even if this were not the case, we would potentially advise a low-sodium (<6g/D) and unsodized (<4g/D) diet. The latter, the soda diet, is reserved for cases of cirrhosis with refractory ascites for example.

That's 150 minutes of physical activity per week


You see the patient again after 6 months of treatment and prescribe a treadmill walking test. Regarding this review, what is the exact proposal(s)?

It makes it possible to assess the disability related to arterial disease obliterans of the lower limbs

The shorter the patient can walk, the greater the disability.

It makes it possible to measure in a standardized way the distance traveled in 6 minutes

This proposal refers to the 6-minute walking test (TM6), useful in pulmonology. It consists of measuring the distance that a patient can travel in 6 minutes. Here, the test of walking on a treadmill is something else entirely: the patient puts himself on a treadmill advancing at 3.2km/h with a slope of 10%, and he walks as long as possible (no time limit).

It allows a reassessment of SNPs after walking

The SPI is evaluated after walking and compared to that at rest.

It is only intended for patients with mediacalcosis

There is no real connection with medicalcosis 😅

It allows the evaluation of the functional value of collateral circulation

The longer the patient can walk, the more the collateral circulation ensures a satisfactory locum function.


The walking test shows only moderate functional disability, compatible with continued medical treatment. The cardiologist consulted beforehand performed a stress ultrasound on dobutamine which does not show signs of myocardial ischemia. Resting echocardiography is also normal, with the exception of the presence of dilatation of the left atrium. Smoking cessation is ongoing. The patient is treated with atorvastatin, aspirin and perindopril. A year later, he consulted the cardiologist for palpitations that had been evolving episodically for several weeks. What is the possible cause(s) of palpitations in this patient?

Atrial tachycardia can cause palpitations (this is what you can feel after a 100m sprint at the end of D4 🤭 #vecu).

If there are many and as a result, it is possible to feel palpitations. This is also the case for ventricular extrasystoles.

We find rather a bradycardia. It is not a cause of palpitation.

First etiology to look for in case of palpitations.

Ventricular fibrillation never returns to normal on its own, and leads to cardiorespiratory arrest quickly and death if left untreated. If the patient had had VF, we would know.


An electrocardiogram is performed, of which here is the trace.


Which factor(s) were considered to assess the thromboembolic risk of atrial fibrillation in this patient?

History of high blood pressure (hypertension)

The recent nature of atrial fibrillation (AF)


Renal function is normal and treatment with direct oral anticoagulant with apixaban is started due to age over 65 years, high blood pressure and peripheral arterial disease. The very reliable interrogation of the patient makes it possible to specify that palpitations occur in episodes whose duration varies between 6 and 72 hours. How to qualify this atrial fibrillation according to the data collected (only one answer)?

Spontaneous reduction in less than 7 days (here 'between 6 and 72 hours' according to the statement).


This is paroxysmal atrial fibrillation. You decide to prescribe a beta-blocker to slow the frequency of atrial fibrillation. After 3 days of treatment, the patient presents to the emergency room for lipothymia and exertional dyspnea. The electrocardiogram shows only sinus bradycardia at 42 beats / minute. Blood pressure is normal, the patient is asymptomatic to decubitus, there is no sign of low flow, diuresis is preserved, pulmonary auscultation is normal. What is your care?

Modification of treatment and return home

Suspension of beta-blocker and resumed at reduced doses

It is probably the introduction of the beta-blocker that is at the origin of bradycardia, therefore of the patient's symptomatology. We therefore stop the offending drug, with a wash-out period, then resume in small doses when the patient stabilizes, finding a dose that optimizes the benefit/risk balance.

Placement of a percutaneous electrosystolic training probe


This is an adverse reaction of the beta-blocker whose dosage was not adequate. After dose reduction, the situation stabilizes favorably. Treatment with direct oral anticoagulant is continued. A few weeks later, the patient presents again for an attack of atrial fibrillation prolonged for more than 4 days but perfectly well tolerated under beta-blocker. You offer him an electrical cardioversion scheduled for the coming weeks. What will be the condition(s) for achieving this electrical cardioversion?

ETO is not useful if cardioversion is covered by 3 weeks of anticoagulation before.

Relay of direct oral anticoagulant by low molecular weight heparin at curative dose

We are very happy with the AOD 😊. Furthermore, LMWHs do not have MA in atrial fibrillation. So, at the ECN, you should never tick them! The HnF will then be used.

Realization at low energy under light sedation by midazolam

Must be done under general anesthesia (an external electric shock, it hurts a lot!). 😰

The medico-legal delay of an anesthesia consultation is at least 48 hours. The pre-anesthetic visit is carried out a few hours before.

Weekly INR check for a target between 2 and 3

DOACs do not have biological monitoring parameters, which is sometimes problematic (when one needs to measure its effect exactly, for example when introducing a drug known for its enzymatic inducing effect).


Electrical cardioversion is successfully performed two weeks later. Antiarrhythmic treatment is undertaken by flecainide which makes the symptoms disappear. The patient asks you about stopping direct oral anticoagulant therapy now that the atrial fibrillation has disappeared. What do you say to him (one correct answer)?

Discontinuation of direct oral anticoagulant therapy 4 weeks after cardioversion

This proposition would have been true if he had a CHADS-VASc at 0, or if he was under 65 and a purely isolated AF.

Discontinuation of direct oral anticoagulant therapy if long-term Holter recording is normal

Indefinite maintenance of direct oral anticoagulant therapy

Its CHADS-VASc at 3 requires long-term anticoagulation.

Discontinuation of direct oral anticoagulant therapy after 12 months without documented relapse of atrial fibrillation

Discontinuation of direct oral anticoagulant therapy if echocardiography shows haemodynamic efficacy of atrial systole


You continued the anticoagulant treatment. The patient asks you about the reasons for the occurrence of atrial fibrillation in his case. What do you say (one or more exact answers)?

It is an arrhythmia frequently associated with arterial disease obliterans of the lower limbs

Questionable proposal. Smoking is indeed a predisposing factor to heart disease, but establishing a direct link between FA tobacco 👉 seems too bold.

It is a common arrhythmia in case of high blood pressure

High blood pressure is the leading cause of atrial fibrillation.

It is an arrhythmia favored by its sedentary lifestyle

No report, especially in this patient who is neither diabetic nor overweight.

It is an arrhythmia frequently associated with sleep apnea syndrome.


Context: A 62-year-old patient consults for pelvic pain of progressive onset evolving for several weeks with recent occurrence of minimal vaginal bleeding. She had a normal pregnancy at the age of 42. She went through menopause at the age of 50 without hormone replacement therapy. She does not smoke, and has a body mass index of 36 kg/m 2. Her main history is right breast cancer at the age of 45, the management of which consisted of a lumpectomy with sentinel lymph node testing followed by chemotherapy, radiotherapy and hormone therapy for 5 years. Her family history includes breast cancer in her mother at age 75, ovarian cancer in a maternal aunt at age 63 and colon cancer in her maternal uncle at age 49.

What pathology(s) does the gynecological clinical examination (inspection, speculum examination and vaginal examination) allow you to eliminate with certainty?

The diagnosis of cervical dyaplsia is pathological pathology.


On examination, the vaginal wall is unremarkable and the cervix is normal. Which additional exam(s) do you prescribe as a first-line treatment?

An x-ray of the abdomen without preparation

The king first-line examination in gynecology 👑

Abdominopelvic magnetic resonance imaging


A pelvic ultrasound is performed. It reveals a cystic right ovarian mass of about 6 cm with vascularized vegetation, a left hydrosalpinx and a left ovary carrying cystic formation with pure fluid content. The endometrial thickness is 18 mm with hypervascularization. There is also minimal peritoneal fluid effusion. What argument(s) is (or are) in favor of a malignant pathology?

The size less than 7cm is a reassuring element.

The existence of vascularized vegetation on the right annex

The intense vascularization of a lesion is often in favor of malignancy (by secretion of VEGF from tumor cells).


In this context, the right ovarian lesion as well as the endometrial thickness worry you. What other imaging exam(s) will you perform?

Abdominopelvic magnetic resonance imaging with Gadolinium injection

Fluoro-Deoxy-Glucose positron emission tomography


Along with the MRI you request. What biological marker(s) will you dose for this patient?

Look at the patient's 😉 age (and don't blame yourself for checking it, but make sure you NEVER get caught up in this trap 🤗)

Marker of ovarian cancer. ACE and HE4 would be added. Note that the use of these markers is discussed.


The results of the markers:

CA 15.3: 25U/mL

CA 125: 40 Ul/ml.

A pelvic MRI is performed. The radiologist confirms the strong suspicion of malignant lesion of the right ovary and endometrium, as well as the a priori benign nature of the lesions of the left appendix. What do you do to support the diagnosis? (one or more possible answer(s))

Puncture of the peritoneal effusion vaginally

Right ultrasound-guided ovarian biopsy vaginally


Laparoscopy is performed. What do you expect? (one or more possible answer(s))

The endometrium is not removed directly.

Assessment of the resectability of lesions

Assessment of peritoneal extension of the disease