Laparoscopy did not show peritoneal extension. The histological results of the endometrial sample are: grade II invasive endometrioid adenocarcinoma. The histological results of the right adnexal swab: an intraovarian endometrioid adenocarcinoma lesion without extension to the surface or tubal wall. What treatment should be performed?

A total hysterectomy with bilateral appendectomy

Expanded colpohysterectomy with bilateral appendectomy

The cervix is healthy. There is no indication to remove it.

Abdominopelvic external beam radiation therapy combined with concomitant chemotherapy


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.

Regarding the epidemiological data of the type of endometrial cancer (endometrioid) of this patient, what is(are) the exact statement(s)?

It is the most common gynecological (pelvic) cancer


The patient's file is presented at a multidisciplinary consultation meeting (RCP). Regarding CPR, what is(es) the correct answer(s)?

Except in very special cases (emergency for example), CPR is mandatory

It is the referring surgeon who proposes a therapeutic strategy

Doctors from three different specialties must be present

The decision is based on the objective data of science


The patient's attending physician applies for admission to a long-term condition (ALDI. Which of the following is correct?

The care protocol must be drawn up by the attending physician, in consultation with the patient and the other corresponding physician(s) involved in the follow-up.

ALD recognition allows 100% coverage of all health costs

The patient will be able to enjoy the benefits of her ALD for life

ALD recognition commits the patient to respond to the controls carried out by her health insurance organization

Part of the fee overruns billed by health professionals may be covered by the ALD.


Given the carcinological history of the patient and her family, what is (or are) the exact proposal(s)?

A family predisposition is strongly suspected

A pelvic ultrasound is indicated in her daughter

A CA15.3 assay is indicated in his daughter

An onco-genetic consultation should be recommended

A search for microsatellite instability is done on operating room

Lynch syndrome is suspected. We therefore look for the corresponding mutations on the operating room.


Which familial form do you suspect first?


At the end of her treatment, the patient is considered in complete remission. What monitoring do you put in place for the first two years? (one or more possible answers)

A semi-annual assay of the serum marker CA 15.3

This is the CA 125 test for ovarian 🤭 cancer

An annual pelvic thoracoabdomino CT scan

She had breast cancer 👉 Annual mammogram for life.


Context: You receive in consultation of general medicine the young Theo, aged 3 years, in the company of his mother, for sleep disorders. Theo is the only child of this single mother, her spouse having left him at the birth of the child. Theo does not know his father. The mother has no job, and has had to move twice since Theo was born, especially after a recent affair with an abusive man. Theo refuses to go to bed and every night he cries. He only manages to fall asleep late, in the bed of his mother who tells you she is exhausted. In addition, he snores and wakes up several times a night, restless. During the day, between phases of drowsiness, he is irritable and angry. The start of the school year in kindergarten is imminent and Theo's mother is worried about her son's troubles.

In front of this sleep disorder, you must look for Theo:

It cannot be eliminated in the face of compatible symptoms and lack of information on the duration of the disorders. There are many possible triggering factors (domestic violence, moving, entry into a small section).

Sleep disorders are against this diagnosis. Irritability and anger do not seem to be taken to extremes and can be explained by lack of sleep.


Among the symptoms presented by Theo, which is an obstructive sleep apnea syndrome?


In the context of this sleep disorder, what do you recommend at first?

A prescription of anti-histamine for hypnotic purposes


You gave Theo's mother advice about sleep hygiene and how to behave with him. Six months later, you see the child again in consultation because the drowsiness is more and more marked. His school entry went well but, at times, he falls asleep in class. These phases are interspersed with phases of significant irritability associated with relational difficulties with other students. This boy is now 3 years and 6 months old, 1 meter tall and weighs 22 kilograms. The rest of the somatic clinical examination is normal. Faced with this drowsiness, among the following proposals, which is the most relevant in the first line?


The ENT consultation diagnoses obstructive sleep apnea syndrome and finds tonsillar hypertrophy and vegetations. Theo is operated on and the drowsiness disappears. Two years later, you see Theo again in consultation at the request of the teacher who describes a very difficult behavior: he never sits, does not wait his turn in class activities, does not respect the instructions and is very slow in his school work. The mother reports that he very often loses his belongings. Theo now sleeps in his own bed but demands a night light. Besides, he wets the bed. During your consultation, he does not hold in place and cuts you off. You suspect attention deficit hyperactivity disorder (ADHD). Your diagnostic hypothesis for ADHD is based on:

About 10% of children with isolated primary nocturnal enuresis have attention deficit hyperactivity disorder (ADHD).


Apart from being overweight, the rest of your physical exam is normal. To support your diagnosis of ADHD, you propose:

A questionnaire to be completed by the mother

A questionnaire to be completed by the teacher


The diagnosis of ADHD is confirmed. There is no associated learning disability. At this stage, you recommend:

This treatment is only possible from the age of 6. Theo is only 5 years old at this question. In addition, it is proposed as a second intention.

AEMO is decided by a juvenile judge in special cases such as abuse.


Six months later, Theo is 6 years old and faced with the little evolution of his disorders, you decide to prescribe methylphenidate. This molecule:

28 days, no limit on the total duration of treatment.

Can be renewed by the general practitioner

Today, this proposition is true. Since 2021, the prescription and renewal of methylphenidate can be initiated by any neurologist, psychiatry or pediatrician and renewed by any doctor.

Is prescribed without taking into account school holidays


A few weeks after the introduction of the treatment, you see Theo and his mother again in consultation. Which of the following symptoms reported by his mother can methylphenidate be attributed to?


Three years later, Theo is admitted to the pediatric emergency room for a major attack of agitation at home. In a fit of anger, he broke his tablet and threatened to jump out of the window. He has just learned from his mother that his father, whom he did not know, committed suicide. You learn on this occasion that his mother lives with a new spouse and that intra-family relations are very tense, especially between Theo and his stepfather. Theo is now 9 years old and is enrolled in CE2. When you meet him, alone, he is calm and tells you about his discomfort. Overweight is manifest and badly experienced. Between sobs, he says: <<I'm tired of it, it's been going on too long. I can't take it anymore. >> In pediatric emergencies, management includes:

A prescription of an anti-histamine for anxiolytic purposes

A prescription of a benzodiazepine for anxiolytic purposes


Which of the following proposals is one or more of Theo's emergency hospitalization objectives?

This is not an indication for emergency hospitalization


Theo is hospitalized in pediatrics. During an interview, he described sexual touching by his stepfather but refused to be told about it to his mother. Faced with this situation

You make a report even if the mother objects

You make a report even without Theo's agreement

You identify the father-in-law on your certificate as responsible for the facts

You avoid transcribing Theo's words word for word


To the social worker of the paediatric department


The mother's spouse admits the facts and is incarcerated. A few weeks after his release from the hospital, Theo says he is reassured but remains sad and worried about his future. He is still treated with methylphenidate, which allows him to be calmer, but still has great academic difficulties. He has few classmates and often misses school due to somatic complaints. In view of this clinical picture, which diagnosis(s) should be mentioned?

A minor patient is not diagnosed with a personality disorder.


Which of the following measures, due to his situation and his difficulties at school, which can be put in place for Theo?

An individualized reception project (PAI)

The PAI makes it possible to arrange Theo's reception by informing his pedagogical managers of his pathology.

Theo has been put in danger and his current social context is difficult. Mentioning an AEMO will allow the juvenile judge to assess the need for support for Theo.

An allowance for the education of disabled children (AEEH)

The PAP concerns learning disabilities, from which Theo seems to suffer.


Context: A 53-year-old woman, a chartered accountant in an international company, consults your office in September for the appearance for 5 days of a lesion on her left leg (photo). She has a history of active smoking, non-insulin-dependent diabetes, high blood pressure, right sural phlebitis on an old venous insufficiency 7 years ago and arterial disease of the lower limbs known for 3 years. His current treatment includes anti-hypertensive therapy and oral antidiabetics. His diabetes has been less well balanced for several weeks. She also says she regularly takes nonsteroidal anti-inflammatory drugs due to chronic low back pain. The clinical examination found a fever at 38 ° 2 C, a pulse at 100 / min, a blood pressure at 15/9, a weight at 83 kg for a height of 1m65. There is no pain when palpating the left calf.

What is the BMI (body mass index) in rounded value of this patient?


Which is (are) the most likely diagnostic hypothesis(s) in front of this clinical picture?


What clinical characteristic(s) is (are) in favor of non-necrotizing bacterial dermohypodermatitis?


What comorbidity(ies) present in this patient is(are) a risk factor(s) for the occurrence of bacterial dermohypoderma?

Risk factor for necrotizing dermohypodermitis.


You have several elements to orient you towards bacterial dermohypodermatitis especially as you find an intertrigo of the 2 feet. What gesture(s) do you perform in front of this lesion?

Search for an increase in local skin temperature

Stripping of a small bullous detachment within the erythematous zone

Bacteriological swab of the most inflammatory area of erythema


Palpation of the inguinal folds objective left inguinal lymphadenopathy. What is (are) the most likely cause(s) of this left inguinal lymphadenopathy?

Concomitant inflammatory pathology of the small pelvis

Concomitant inflammatory pathology of the perineal region

Satellite lymphadenopathy of dermohypodermatitis


What is essential to achieve before starting the therapeutic management of this dermohypodermitis? (only one answer expected)

Namely: blood cultures are positive in less than 5% of cases and are only to be performed in a particular context (bite, travel, occurring in an aquatic environment, post-traumatic, immunosuppression, nosocomial context, signs of clinical or biological seriousness).

The form is typical and uncomplicated 👉 no additional examination. The diagnosis is clinical.


Which infectious agent(s) is (are) most likely to be involved?

These are low-virulent staphylococci that are present on the skin commensally. These are often contaminants (S. Epidermidis ++).


What is your first-line anti-infectious therapeutic option(s) (knowing that you decide to treat her at home because of the lack of signs of severity and that she has no known allergy)?

It is a treatment to be used in case of allergy to amoxicillin.

3rd generation cephalosporin as intramuscular injection


What associated treatment do you prescribe?

This helps to evacuate the edema that accompanies the inflammatory phenomenon.


You treat it with amoxicillin and paracetamol and plan to see it again 2 days later. Indeed, this patient is exposed to the risk of evolution to a necrotizing form. What is (are) the risk factor(s) of such a development?

According to HAS, the risk factors for progression to a necrotizing form are: diabetes, nonsteroidal anti-inflammatory drugs, immunosuppression (corticosteroids, chemotherapy, immunosuppressants, chronic renal failure, cirrhosis), malnutrition, age over 60 years, intravenous drug addiction, venous insufficiency, peripheral arterial disease (PAD) and obesity. In children, chickenpox is the main risk factor for DHBN. The recommendation is here: https://www.has-sante.fr/upload/docs/application/pdf/2019-04/prise_en_charge_des_infections_cutanees_bacteriennes_courantes_recommandations.pdf

Taking nonsteroidal anti-inflammatory drugs


Under treatment, dermohypodermatitis disappears. You see the patient again 3 months later because her company sends her to do an accounting in Abidjan in Côte d'Ivoire for 3 weeks. She has never traveled to Africa. What vaccination(s) do you offer?

Update of its diphtheria-tetanus-polio vaccines

This proposal is contentious. This vaccine is indicated in case of close and prolonged contact with the local population in an epidemic/endemic area. Is this the case in the case of public accounting? It's hard to know 🤷 ♂.


You decide to prescribe atovaquone-proguanil for malaria chemoprophylaxis for this 3-week trip. How long do you write on the prescription? (only one answer expected)

Atovaquone-Proguanil: Length of stay + 1 week (daily dose)

Mefloquine: 1 week before + Length of stay + 3 weeks (weekly intake).

Doxycycline: Length of stay + 4 weeks/1 month (daily intake)


Upon her return from Côte d'Ivoire, the patient consults you again. She is doing well and the stay went well. She was even able to spend the last weekend in a bush camp. She describes rudimentary facilities with poor hygiene conditions, especially on bedding. Since her return, she has slept poorly due to pruritus of her forearms, wrists and fingers. One of her colleagues with whom she shared the same room has the same symptoms. On examination you see especially scratching lesions especially in interdigital spaces. She did not change personal care products. Which pathology do you think is most likely in this context? (only one answer expected)


You mention a scabies that is confirmed by the visualization of parasites with a dermoscope. What do you recommend? (one or more correct answers)

Washing clothes at least 60 °C in a long cycle

Treatment at the same time of his colleague

Eviction from the community is up to 3 days after the start of treatment if common scabies (which seems to be the case here).


Context: Mr R, 40, is an engineer and works a lot. He has smoked about a pack a day for 20 years, drinks occasionally and takes no medication. He consults today because for about a week he feels an unusual fatigue, and he has a lump in his tongue that bothers him.

You notice the lesion opposite. You mention (one or more possible answers)

The lesion is regular. The patient is young. The area of attack is not classic.


This is an oral hemorrhagic bubble. Given this lesion, which etiology is most likely?

Willebrand disease is a pathology of primary hemostasis that is accompanied by a normal platelet count. This is a possible etiology but unlikely given the age of the patient.


You mention severe thrombocytopenia. What other bleeding signs are you looking for? (one or more possible answers)

Purpura will then be thrombocytopenic: petechial, mucocutaneous, non-infiltrated, on the trunk and upper limbs as well as on the lower limbs.

Hemarthrosis is deep bleeding. It therefore evokes a pathology of coagulation.

Melena testifies to mucosal involvement, which is readily found in thrombocytopenia.


On examination, you actually find purpura. What are the expected characteristics of purpura in this context? (one or more possible answers)


What first-line exams will you request? (one or more possible answers)

We want to know hemoglobin. Be careful, the NFS does not provide information on the platelets (it is the NFS-P that counts the platelets!).

We have no arguments for a potential DICV here.


The CBC shows: red blood cells 2.24 T/L, hemoglobin 76 g/L, hematocrit 22.1%, MCV 98.7 fL, MCDC 34.4 g/dL, leukocytes 1.3 G/L, neutrophils 0.4 G/L, lymphocytes 0.5 G/L, monocytes 0.05 G/L, blasts 0.35 G/L, platelets 9 G/L, reticulocytes 45 T/L. Describe this NFS:

neutrophils 0.4 G/L when normal is > 1.5 G/L

lymphocytes 0.5 G/L when normal is > 1.5 G/L

Normochrome because CCMH between 32 and 36

reticulocytes 45 T/L while we speak of regenerative above 120-150.


What diagnoses do you mention? (one or more possible answers)

The circulating blasts direct us directly to leukemia.


You receive the hemostasis assessment. It shows: TP at 50%, TCA ratio 1.1, fibrinogen 0.88 g / l. How do you complete the hemostasis assessment? (one or more possible answers)

The TP is decreased, the TCA begins to increase, the fibrinogen is low 👉 red alert CIVD! The dosage of D-Dimer will allow us to base the diagnosis.

The search for circulating anticoagulant

The TP is low, so factor VII is decreased. The determination of factor V will allow us to know if the decrease in factor VII comes from the liver (hepatocellular insufficiency) or from the synthesis of vitamin-dependent factors (X, IX, VII, II).


You suspect acute myelogenous leukemia. You perform a myelogram. What are you waiting for? (one or more possible answers)

The presence of more than 20% of myeloblasts

An increase in the number of myelocytes and metamyelocytes

Myelocytes and metamyelocytes are greatly reduced


Mr. R. does have acute myelogenous leukemia. What should you do? (one or more possible answers)

A multidisciplinary consultation meeting to decide on therapeutic conduct


Mr. R.'s file was presented in PCR, which offers him to participate in a randomized phase therapeutic protocol. He is given information with a consent form. Who should sign it? (one or more possible answers)

There are two signatures: that of the patient and that of his investigator.

The pharmacist who dispenses the study products


Treatment is started and he needs a red blood cell transfusion. What biological tests should be performed before transfusion? (one or more possible answers)


Mr. R.'s uncle was infected during a transfusion in 1984. Mr. R. therefore wished to know what checks had been carried out on the red blood cells. Which of the following are true? (one or more possible answers)

For the premature, for the patient in SCID (and not DICV), ...

Products are tested for hepatitis B and C

The products are tested for HIV, HTLV, HCV, HBV, and syphilis.


What are the legal provisions for transfusion? (one or more possible answers)

The nurse must verify the conformity of the product received

Pellets must be transfused within one hour of arrival in the department

The nurse checks the identity match between the patient and the group card

The nurse checks the match between the group card and the cap pocket


You prescribe the transfusion of 2 phenotyped red blood cells. The nurse performs the test on a test cardboard before the transfusion. The result is: {pos = presence of agglutinates, neg = absence of agglutinates}. Which propositions are true? (one or more possible answers)

The card contains anti-A antibodies. They react with the patient's 👉 blood it is group 🅰 .

The red blood cell group is identical to that of the patient

The red blood cell is compatible with the patient

The patient can be transfused without further prior examination


Context: A 71-year-old patient is admitted to the emergency room following a fall from her height while shopping in a supermarket. She slipped on a vegetable with a forced abduction of the lower right limb responsible for a very violent pain. The patient was transported to the emergency department. She vomits during transport. She complains of no longer being able to raise and lower her foot, of having felt a stroke of electricity pain in the lower right limb to the foot, of feeling her right foot and leg "cotton". There was no loss of consciousness. The inspection does not find a vicious attitude of the lower limb. The patient has no treatment. His history includes an appendectomy, tonsillectomy, and colpo-suspension procedure in 2015. She also has ophthalmological follow-up for age-related macular degeneration.

In view of this clinical picture, which is (are) the diagnostic hypothesis(s) to evoke?

The patient's symptoms are: foot levator/lowering deficit, electrical pain + paresthesia of the right lower limb. These symptoms can be part of the nosological framework of damage to the L5-S1 roots, following a fracture of the sacrum or femur.

Statement: 'The inspection does not find a vicious attitude of the lower limb.'

Trauma in abduction 👉 possible tearing of the adductors.

Removal of the distal insertion of the iliopsoas


Which exam(s) should I request in the first line?

She probably fell on her back and she has a pain in the lower 👉 limb lower lumbar vertebral fracture?


After a 2-hour decubitus rest in the emergency room, the patient wants to get back on her feet. She says she finds her right leg and foot still numb. She still can't lift or extend her foot. X-rays of the pelvis and thoracolumbar spine are performed. Given the clinical and radiological evidence available for this patient, what is the most likely diagnostic hypothesis?

A fracture of the upper end of the femur

This nerve arises from the L2, L3 and L4 roots of the lumbar plexus. His sensory-motor innervation stops at the knee.


On X-rays, no fractures were observed. Nerve damage has been suggested. The patient was discharged from the emergency room the same day and you will see her at home 3 days after her fall. On inspection, you notice visible skin signs in the following photo. On clinical examination, the patient complains of having a cotton leg and right foot and localized pain in the sole of the right foot. The right patellar reflex is present, the right Achilles absent while it is present on the left. In distality, there is difficulty raising and lowering the tip of the right foot. Motor testing during knee extension, abduction and right hip extension are possible against resistance and are normal. You notice weakness in the flexion of the leg on the right thigh. She has hypoaesthesia of her right leg. There is no vesico-sphincter disorder. Given the clinical evidence you have, what type(s) of neurological impairment(s) can you discuss?

The involvement of a single root (L5 or S1) does not explain all the symptomatology. The infringement is therefore more distorted.

The involvement of several roots would give a more proximal symptomatology.

Absent right Achilles reflex (carried by the root S1) + difficulty raising and lowering the tip of the foot (involvement of the fibular nerve, branch of the sciatic nerve, which comes from the root L5) = involvement of the sciatic nerve = monotroncular involvement.

Paraparesis is bilateral. However, the symptoms here are one-sided.

No sphincter bladder disorders, no proximal involvement, no arguments 😅.


Three days after the trauma, in the context of sciatic monotroncular involvement, which examination would be most likely to change the management of this patient? (only one answer expected)

An ultrasound of the right buttock and right thigh

The patient has a hematoma of the thigh, probably compressible 👉 we will try to see if this is really the case 😉


Ultrasound of the right buttock showed a hematoma that was evacuated because it compressed the sciatic nerve. You want to prescribe a right foot lifter-type technical aid. Which of the following regulatory elements for non-molded orthotics is(are) accurate:

They require a request for prior agreement

They are prescribed on a major appliance form.

They are prescribed on a simple prescription

They are fully reimbursed by the health insurance fund


You decide to prescribe rehabilitation sessions on an outpatient basis at home. Among these elements, which is (are) mandatory on the prescription for the physiotherapist:

The region and/or pathology to be treated


You follow your patient in regular consultation every month. Which of the following clinical or paraclinical elements is useful for monitoring recovery from this traumatic truncal nerve injury?

As for most peripheral nerve damage, the EMG will make it possible to follow the (potention of) evolution with the monitoring of the speeds / amplitudes of the impulse.


You see the patient again in consultation 3 months after the initial trauma. She always has an abnormal gait. In the oscillating phase of walking on flat ground, the tip of the right foot is constantly lowered, it raises the knee higher than it does at the same phase on the left side. Which of these statements is (are) accurate?


The patient is increasingly anxious about walking due to her right sciatica neurological injury. She clings the tip of her right foot into a loose carpet at home, as she walked through a dark hallway. She stumbles and falls again. She can no longer support the right side because of pain. Here is the x-ray of the pelvis taken in the emergency room. What can you say from the X-ray? (one or more correct answers)

Garden 3 fracture of the right femoral neck


Which of the various factors that may have contributed to this patient's fall, which do you consider to be an intrinsic factor(s) of falling?

The orthosis (calf-plant lifter) ineffective


Which of the following is considered an activity limitation in this patient?

A decrease in the range of motion of the right hip

A sensory disorder of the sole of the right foot


You want to improve the patient's balance and walking disorders. Which of the following health professionals will contribute to the improvement of these symptoms?


Given the patient's age, which insurance organization(s) will contribute to the patient's care?

Aid for the autonomy of the departmental council

National Fund for Solidarity and Autonomy


Context: Mrs. X., 32 years old, executive secretary, has been consulting you for finger pain for several months. These pains occur in episodes, last about ten minutes, and affect the fingers of the 2 hands.

Among the following acrosyndromes, and at this stage of the semiological description, which one (or which) is (are) compatible with the clinical picture reported by Mrs. X.?


She tells you that these episodes are clearly triggered by the cold, and presents you at the consultation a photograph taken during one of these episodes. With this new information, the possible diagnosis(s) is:


You are diagnosed with Raynaud's phenomenon. What elements are to be looked for during the interrogation? (one or more expected answers)


On physical examination of the patient, you note:

- whitening of the hand after compression of the ulnar and radial arteries and << pumping maneuvers >>, then obtaining a recoloration of the hand in 3 seconds following the relaxation of the ulnar artery; and in 4 seconds after the relaxation of the radial artery;

- the absence of paresthesias of the fingers at the percussion of the anterior surface of the wrist or during the forced flexion of the wrist.

The patient's physical examination favours (one or more correct answers)

From compression of the median nerve to carpal tunnel


What semiological element(s) are you looking for in favor of a secondary Raynaud's phenomenon?

Telangiectasias would be part of cutaneous scleroderma (CREST syndrome).


When questioned by Mrs. X., she explains that these symptoms began around the age of 30, and occur every winter. She has no notable personal history, but her sister and mother have the same type of clinical manifestations. Thumbs are spared. It does not describe any other symptoms. On physical examination, you do not find trophic disorder, sclerodactyly or telangiectasia, peripheral pulses are perceived in all 4 limbs, and you do not notice audible murmur on auscultation of arterial pathways. Which clinical element(s) is compatible with Raynaud's disease (essential Raynaud's phenomenon)?

We start to ask ourselves questions after 35 years.


In the clinical situation of Mrs. X., which additional examination(s) do you prescribe?

X-ray of the spine from the front centered on C7

Ultrasound-Doppler of the arteries of the upper limbs


Antinuclear antibodies are 1/80. You retain the diagnosis of essential Raynaud's phenomenon (Raynaud's disease) and propose symptomatic management. Five years later, Mrs. X. is referred to you by her doctor for a fever that has been evolving for 4 weeks. This fever is irregular, oscillating with a temperature of 37.9 ° C in the morning but higher in the evening, can rise up to 39 ° C and associated with sweating. Mrs. X. is tired, she has lost 2 kg since the beginning of this fever. She has no other symptoms. She lives in an urban setting, has never travelled abroad, and does not take any treatment. The clinical picture currently presented by the patient is compatible with: (one or more exact answers)

The picture does not stick: it is rather that of a teenager.


In the clinical situation of the patient, what biological abnormality(s) would be suggestive of an inflammatory syndrome?

Increase in all proteins except transport proteins: albumin, transferrin and transtyretrin.


On physical examination of the patient in the supine position, you perceive a mass of the left hypochondrium lowering on deep inhalation. Which of the following proposals do you think is accurate given this new clinical element?

This clinical finding is common in a young, thin patient

This clinical finding makes an infectious cause less likely

Many infections can be accompanied by splenomegaly: mononucleosis syndrome (HIV, CMV, toxoplasmosis, ...), endocarditis, hepatitis, malaria, ...

This clinical finding makes an autoimmune cause less likely

Lupus, sarcoidosis and rheumatoid arthritis (to name only the less rare) are often accompanied by splenomegaly.

This clinical finding can be observed in cases of liver disease

👉 This is a sign of portal hypertension.

This clinical finding should suggest a haemological pathy


On cardiac auscultation of Mrs. X., you perceive a systolic murmur at 2/6. This heart murmur was not known until now. There is no associated diastolic murmur, heart sounds are regular, there are no signs of associated heart failure. You suspect infective endocarditis. What element(s) are you looking for to support your suspected diagnosis?

Vascular pupura is an immunological manifestation

Purplish nodules of the pulp of the fingers

This is called Osler's False Panaris (pathognomonic sign of infective endocarditis).

Roth's nodules can be observed at the back of the eye, but without affecting the anterior chamber.


At this stage of the treatment, which examination(s) do you think are justified?


Three blood cultures with aero-anaerobic cultures remain sterile, the good quality transthoracic cardiac ultrasound is normal, showing no vegetation image or significant valve abnormality. Which of the following proposals do you think is correct?

The realization of a trans-esophageal cardiac ultrasound is justified

The description of ETT is very reassuring. Blood cultures are negative. It is lawful to stop there.

The realization of a thoraco-abdomino-pelvic CT scan is justified

The realization of viral serologies (HIV and EBV) is justified

A therapeutic test with corticosteroids is justified

A therapeutic test with antibiotics is justified


HIV serology is negative, and EBV serology supports ancient immunity. A thoraco-abdomino-pelvic CT scan shows supracentimetric mediastinal lymphadenopathy and splenomegaly. Which of the following tests do you think is the most relevant way to advance in the diagnostic investigation of the patient? (only one answer expected)

Search for anti-neutrophil cytoplasmic antibodies (ANCA)

A spleen is not biopsied because there is too great a risk of bleeding.


A diagnosis of diffuse large cell B-cell lymphoma is made by a lymph node biopsy performed by mediastinoscopy. An implantable chamber is placed and immunochemotherapy treatment with R-CHOP (rituximab - cyclophosphamide, hydroxydoxorubicin, vincristine and prednisone) is started.

While the first 2 treatment cycles were uncomplicated, the patient ° presents on Day 10 of the 3rd treatment cycle a fever at 39 ° C with chills. You see her in an emergency consultation. Blood pressure is 130/70 mmHg, heart rate is 95/minute. The patient does not have a neurological disorder, the skin examination, especially with regard to the implantable chamber is normal, there is no obvious functional or physical respiratory, digestive or urinary sign. Your physical exam is normal. A blood count taken in town the same morning shows the following results: white blood cells 1.8 G/L, hemoglobin 104 g/L, mean corpuscular volume 85 fL, platelets 97 G/L, leukocyte formula: neutrophils 0.4 G/L eosinophilic polynuclear 0.1 G/L, basophilic polynuclear 0.9 G/L, lymphocytes 0.9 G/L, monocytes 0.3 G/L. What examination(s) do you perform before starting antibiotic therapy in your patient?

Blood cultures on the periphery and on the central venous catheter


Outpatient care is offered. Treatment with amoxicillin/clavulanic acid + ciprofloxacin is started urgently. The fever disappears within 24 hours. Samples taken before the start of treatment remain sterile, and treatment is continued for 7 days.

Three weeks later, the patient sees you again because of the onset of a fever at 39.5°C associated with the next rash. Which of the following may be present in your patient in case of drug reaction syndrome with eosinophilia and systemic signs (DRESS)? (one or more expected answers)

elevation of transaminases with decrease of TP


Context: A 55-year-old patient visits the emergency department for retrosternal chest pain. This pain radiates to the base of the neck and jaw. The anamnesis allows you to find in the personal history: active smoking at 10 pack-years and two caesarean sections

Which additional examination should be carried out first at this stage?


In the event of a myocardial infarction, which early life-threatening complication should you keep in mind as a priority during your initial management?

It is less early, less serious, and less common than ventricular fibrillation.


The interrogation reveals that the pain is chronic, evolving crescendo for 3 months. The electrocardiogram performed immediately does not show an argument in favor of acute coronary syndrome. On physical examination, you find dyspnea at the slightest effort with appearance of edema of the bilateral lower limbs, a gain of 6 kg in 10 days as well as jugular turgor with hepatojugular reflux. The life constants are: BP 95/65 mmHg, heart rate 112 beats/min, OPS 98% ambient air, temperature 36.6 °C.  What are the two most likely diagnoses compatible with this clinical picture?

There would be no signs of right heart failure (OMI, TJ, RHJ).


By resuming your physical examination, the intern reports observing a paradoxical pulse. Which of the following proposals corresponds to the description of a paradoxical pulse?

Pulse attenuated one out of two heartbeats

Pulse perception after the second heart sound


Inspiratory pulse depression confirms the paradoxical pulse. In this context, you ask for a front chest X-ray and echocardiography. What anomaly(s) do you identify on this shot taken in bed

Protrusion of the lower left arch of the cardiac silhouette

We asked a radiology PU-PH for his opinion on these two proposals. His answer: the protrusions of the heart arches correspond to cardiomegaly, but only when it is the heart that exceeds its usual size. We can not speak strictly of protrusion here, since the paradoxical pulse directs you to a pericardial effusion.

Protrusion of the lower right arch of the cardiac silhouette


On echocardiography, there is a circumferential pericardial effusion of great abundance with hemodynamic impact and a scalloped appearance of the serosa. You retain the diagnosis of pericardial tamponade. What element(s) is (are) involved in the pathophysiology of tamponade?

Decreased systolic ejection volume of the left ventricle


What is (are) the therapeutic measure(s) to be applied urgently in front of this tamponade?

Infusion of catecholamines (dobutamine or noradrenaline)


You transfer the patient for emergency drainage to the cardiac surgery block. 1,000 mL of bloody fluid was punctured. The pathologist identifies the presence of tumor cells of adenocarcinomatous nature. She was then admitted to intensive care. Which underlying primary tumor can you end up with a significant probability? (one or more correct answer(s))


A chest CT scan identifies in addition to neoplastic pericarditis in particular: a left hilar tumor mass extending to the apico-dorsal segment of the culmen associated with homolateral mediastinal adenomegaly, bilateral pleural effusion. What is the stage of the disease?


In the case of primary stage IV bronchial adenocarcinoma, what extension assessment do you request in the absence of a new symptom (one or more correct response(s))?

The tumour is stage IV (disseminated). The extension assessment has no therapeutic impact.


What is the reference oncological treatment for this stage IV bronchial cancer (one or more possible response(s))?


The general condition being preserved, you retain an indication of systemic treatment of metastatic first-line associated with palliative care. What will you look for on the pathological report of pericardial drainage fluid to guide the choice of systemic treatment (one or more possible answers)?

Nothing in particular, chemotherapy being based on a doublet of conventional drugs


In the absence of targetable molecular alteration and expression of PDL1, you retain the indication of chemotherapy with carboplatin / paclitaxel. What is(s) the main expected side effect(s) of carboplatin of which you inform the patient?


Finally the situation is complicated with a DICD not allowing to start chemotherapy. You move towards exclusive palliative care and decide to hospitalize the patient in a palliative care unit. Regarding palliative care units (PHUs), what is(are) the exact statement(s)?

Their mission is to admit patients in end-of-life situations and who present a complex situation of care

The essential criterion for a patient to be admitted to USP is that his survival is estimated at less than three months

The main objective of a USP treatment is to improve the patient's quality of life

Chemotherapy treatments can be continued even while the patient is hospitalized in USP

The visit of children under 10 years old is not allowed in USP


After a few days of hospitalization in the palliative care unit, the situation, although precarious, stabilized and the patient expressed the wish to return home. What element(s) could jeopardize the organization of this return home?

Physical or moral exhaustion of loved ones

A refusal of the family to consider death at home

The need for morphine treatment at a high dosage

A lack of mobilization of the attending physician


Context: Mr. R, 58, is referred by his doctor to an endocrinologist before the discovery of diabetes. He is a tobacconist, rather sedentary. He has a history of active smoking at 45 pack-years and high blood pressure treated with amlodipine 5 mg for 5 years. He weighs 110 kg for 1m74 (BMI 36 kg/m 2). His attending physician performed a blood test in front of the presence of asthenia and the result shows a fasting blood glucose of 2 g / L and a glycosylated hemoglobin of 8.5%. On clinical examination, his blood pressure is 170/100 mmHg and his heart rate is 86/min.

What therapeutic care do you offer for this diabetes? (one or more correct answers)

Low-calorie diet (30% reduction in current intake) and low in fast sugars

We always start with hygiene measures in type 2 diabetes.

Treatment with slow insulin and basal bolus


You recover the following balance: creatinine at 130 μmol / L or a glomerular filtration rate CKD-PPE estimated at 52 ml / min / 1.73 m ^2
Urine strip: protein three cross, red blood cells three cross, leukocytes negative, nitrites negative, ketone bodies negative. What biological tests are needed at this stage? (one or more correct answers)

Cytobacteriological examination of urine

Anti-neutrophil cytoplasmic antibodies (ANCA)


The results are as follows:
ECBU: red blood cells at 80,000/ml, leukocytes< 1000/ml, negative culture over 24 h.
24-hour proteinuria: 2.5 g/d composed of 70% albumin.
What are the additional examinations to be carried out in the face of these anomalies? (one or more correct answers)

Vesicorenal ultrasound with arterial Doppler


The fundus finds arterial stiffness with sign of crossing without further lesion. Renal Doppler ultrasound finds normal-sized kidneys without dilation of the pyelocalicial cavities. There is a simple kidney cyst of 1 cm on the right and one of 4 mm on the left. The Doppler analysis is not very contributory given the morphotype of the patient but the radiologist indicates that he does not find an indirect sign for significant renal arterial stenosis.
There is a 12 mm tissue-like image at the lower bladder bottom. In addition, despite the appropriate hygiene measures, diabetes control is unsatisfactory and you start treatment with metformin at a dose of 500 mg at a frequency of 3 times / day. Given these results, what can be the causes of this hematuria (one or more correct answers)?

Hematuria is not found in diabetic glomerular nephropathy

The ultrasound imagining orients us somewhat.


What tests are needed to explore this hematuria at this stage? (one or more correct answers)

Urinary cytology on fresh urine with histopathological examination

Ascending urethrocystography and voiding


You decide to do urinary cytology and bladder fibroscopy.
Regarding the possible realization of the uroscanner in your patient, which proposals are accurate (one or more correct answers)

This examination is contraindicated in this patient

Metformin should be stopped on the day of the exam

Hydration by glucose solute is to be expected before the examination

Oral hydration is to be expected before the examination

There is a risk of acute interstitial nephritis

There is a risk of acute tubular necrosis.


The uroscanner did not find any other urothelial lesions. Cystoscopy confirmed the existence of the polyp and a transurethral resection of the bladder polyp was performed. Anatomical pathology has shown that it is a low-grade urothelial carcinoma pTa. What is the exact proposal regarding his tumor? (an expected response)

It is an invasive tumor infiltrating the muscle


In the absence of diabetic retinopathy, you decide to perform a kidney biopsy. The pathology report is as follows:
8 mm renal cortical fragment containing 12 glomeruli including 2 sclerotic glomeruli.
The remaining 10 glomeruli exhibit nodular mesangial expansion with thickening of the basement membranes.
There is moderate arteriolar hyalinosis and interstitial fibrosis affecting 20% of the parenchyma of the biopsy.
The coloration by Congo red is negative.
The immunofluorescence study does not find significant deposits in the glomeruli.
What is the most likely diagnosis (only one response expected)


Your patient therefore has diabetic glomerulosclerosis. Its renal function stabilizes at 135 μmol/I (DFG CKD EPI = 50 ml/min/1.73 m^22). What is the stage of his chronic kidney disease? (an expected response)


What are the treatment targets in this patient at this stage? (one or more correct answers)

Hematuria is not a nephrological cause. It comes from his tumor.

Blood pressure less than or equal to 120/70 mmHg


Which of the following molecules can be prescribed as a first-line treatment for this patient for high blood pressure? (one or more correct answers)

Angiotensin II receptor antagonist (ARA2)

Angiotensin-thiazide receptor antagonist association

As a second line (amlodipine does not seem to be sufficient here).


What therapies are possible in this patient to reduce cardiovascular risk? (one or more correct answers)


You have prescribed an angiotensin 2-thiazide receptor antagonist combination. You see him again in nephrology consultation two months later with a control biological assessment. He tells you that he was bedridden for a few days due to sciatica and that he took ibuprofen in self-medication. His blood pressure is 122/73 mmHg, his heart rate is 82/min. The electrocardiogram is normal. The blood test is as follows: Na 140 mmol/L, K 5.5 mmol/L, HCO3 21 mmol/L, urea 18 mmol/L, creatinine 212 μmol/L. What are the factors that may have favored this acute renal failure (one or more exact responses)

Taking nonsteroidal anti-inflammatory drugs

Treatment with angiotensin 2 and thiazide receptor antagonist


What is your therapeutic attitude? (one or more correct answers)

Suspend angiotensin receptor antagonist 2

Infusion of calcium gluconate ampoule IVD


Her kidney function has improved thanks to your treatment and her serum creatinine has stabilized at 140 μmol/L. You want to formally rule out stenosis of the renal arteries. What imaging tests are appropriate for this patient at this stage? (one or more correct answers)


You have performed the following radiological examination. What are the exact proposals? (one or more correct answers)

Arrow 1 corresponds to the small intestine

It is rather the colon (the colonist is the most peripheral, if there is nothing on the right 👉 it is the colon 💩!).

Arrow 2 corresponds to the superior mesenteric vein

This is the pancreas. We are too low for the stomach.

Arrow 4 corresponds to the right renal artery

The examination is done at an arterial phase


The examination performed does not find significant stenosis. What advice do you give to your patient following this episode? (one or more correct answers)

Drinks of at least 1 liter/day and suitable for 24-hour diuresis

Suspend angiotensin II receptor antagonist and thiazide in dehydration

Hydration by low mineralized water 2 liters / day

Formal contraindication to nonsteroidal anti-inflammatory drugs


Context: Mrs. D, 28, consults in March because she wants to lose weight before the summer. Indeed, she has as her only antecedent a long-standing obesity, with a family history of obesity since her parents and two brothers are also affected. She has already tried several diets without much success and this time wants to be accompanied by a health professional. Clinically, weight is measured at 105 kg for a height of 170 cm, or a body mass index of 36.3 kg/m 2. Waist circumference is measured at 102 cm and hip circumference at 128 cm. Over the year, his weight increased by 2 kg. She is nulliparous, amenorrhea for 6 months.

During your first consultation, what element(s) could guide you towards secondary obesity?

Acanthosis nigricans is an aspecific sign of insulin resistance.

Colored stretch marks from the root of the limbs

Extracellular hyperhydration is not classic.


Waist circumference is measured at 102 cm and hip circumference at 128 cm. There is no acanthosis nigricans. You notice some stretch marks that the patient reports as related to her weight changes. His blood pressure is measured at 140/84 mmHg. You prescribe an initial biological assessment. What will it include in the first intention? (one or more correct answers)

Uricemia is part of the list of the systematic bio assessment in front of adult obesity in the college 🤷 ♂ (page 357 of the 2021 edition).


You see her again a month later, the weight is the same and the patient explains that she is very interested in bariatric surgery and wants more information. Which proposal(s) is (are) accurate?

he sleep apnea syndrome is a contraindication to performing bariatric surgery

bariatric surgery has no indication when the BMI is less than 35 kg/m2

Gastric banding is the technique that has shown the most effective

bariatric surgery cannot be performed until summer

Gastric bypass is responsible for weight loss through both restriction and malabsorption


It presents the results of the prescribed biological assessment:

natremia 138 mmol/L;

serum potassium level 3.2 mmol/L;

fasting blood glucose 1.16 g/L (6.38 mmol/L);

total cholesterol 1.83 g/L (N: 1.8-2.4);

triglycerides 2.58 g/L (N: 0.7-1.5);

HDL-cholesterol 0.40 g/L (N: 0.45-0.90);

LDL-cholesterol 0.91 g/L (N: 0.6-1.6);

AST 38 IU/L (N < 20); ALT 65 IU/L (N< 40).

You suspect Cushing's syndrome. What arguments point to this hypothesis? (one or more correct answers)

Hyperglycemia can quite fit into the nosological framework of a common obesity and does not particularly point to a Cushing's syndrome.

Hypertriglyceridemia can quite fit into the nosological framework of a common obesity and does not particularly point to a Cushing's syndrome.

Cytolysis can quite fit into the nosological framework of a common obesity and does not particularly point to a Cushing's syndrome.


What biological tests can you order to support your diagnostic hypothesis? (one or more correct answers)


She tells you that she had an abdominal CT scan a few weeks ago because of abdominal pain. Two sections are reproduced below. Arrows with numbers represent anatomical structures. What is the exact answer(s)?

Stomach (we are too high to see the transverse colon, we do not see small intestine or right/left colon).

This is the aorta. The VCI is very prominent.


The abdominal CT scan she performed was normal. The report you gave him gives the following results: salivary cortisol at midnight at 4 times normal. You have confirmed hypercortisolism by a 24-hour urine free cortisol assay with a result of 245 μg/24 hours (N < 60). ACTH was dosed at 85 pg/mL (N: 10-50). Which exam(s) can you now prescribe?

The increase in cortisol after a CRH injection may confirm the pituitary origin of the hypersecretion (versus a paraneoplastic origin).


The CRH test shows a marked elevation of ACTH and cortisol. A section of the pituitary MRI you prescribed is reproduced below. Arrows with letters represent anatomical structures. Which structure(s) is correctly identified?

E represents the left internal carotid artery

She makes a little bow of families (that's why we see her twice 🥐)


In front of this pituitary macroadenoma, you want to complete your biological assessment. Which of the following proposals do you think is relevant to prescribe in this context?

DHA is secreted by the post-pituitary gland.


The complementary balance shows: TSH 1.1 mIU/L (N: 0.4-4); T4 14.8 pmol/L (N: 8-20); estradiol 10 pg/ml (N: 40-150); FSH 0, 1 IU/L (N: 2-6); LH 0.5 IU/L (N: 2-8); prolactin 30 μg/L (N 25). What elements do you mention about this assessment? (one or more correct answers)

We speak of disconnection because < 100 μg/L. Beyond that, we can talk about a prolactinoma.

To check each time you have a deficiency of a lineage, it is an anterior pituitary insufficiency. Not to be confused with panhypopituitarism.


To assess the impact of this Cushing's syndrome, you prescribe a bone densitometry, the results of which are reproduced below.
Which of the following is correct?

The disorders observed may be increased by estrogenic deficiency

The observed disorders may be increased by hyperprolactinemia

The observed disorders may be increased by obesity

Obesity does not lead to osteoporosis. It is even sometimes considered a protective factor: more fatty 👉 tissue more protection of the bone in case of trauma.


You retain the diagnosis of corticotropic macro-adenoma and entrust the patient to your neurosurgeon colleague who practices his public activity at the CHU. He performed a rhinoseptal resection of this adenoma a few days later. There is no intraoperative incident and the neurosurgeon considers its excision satisfactory. In the recovery room, the patient quickly desaturates and presents a state of shock. Resuscitation measures are started immediately. However, the patient died a few minutes later. In this context, the neurosurgeon would like to perform a scientific autopsy to know the exact causes of death. What is (are) the procedure(s) to be carried out before this autopsy can be carried out

Querying the automated national register of refusals

Judicial report to the public prosecutor

Obtaining the approval of a pathologist to perform the autopsy

Search for an organ donor card in the patient

Interview with the family to seek the non-opposition of the patient during her lifetime


The patient's family wishes to obtain a medical certificate. For what reason(s) can the doctor write it?

To provide a comprehensive list of the patient's history


The scientific autopsy performed reveals a massive proximal pulmonary embolism of both branches of the pulmonary artery. The family decides to initiate proceedings. What type(s) of responsibility can be engaged then?

It will be engaged in case of detachable fault of the establishment.

Administrative responsibility of the institution

Disciplinary responsibility of the physician


Context: The parents of Romain, two weeks old, come to consult you urgently for the appearance for a few days of a lesion on the face of the child. The pregnancy proceeded without any particular problem, with a birth at 39 weeks, a birth weight of 3200 grams and a height of 50 cm. The infant is eating normally (artificial feeding) and there is no deterioration in general condition or fever.

Which diagnosis do you mention as a priority?


You suspect an infantile hemangioma. What is (are) the semiological element(s) that you will find at Romain's clinical examination?

Hypertrophy of the hemiface on inspection


Romain's parents ask you about the evolution and possible complications to expect from this infantile hemangioma. What do you say to them? (one or more correct answers)

A histological examination of the lesion makes it possible to better specify the chances of spontaneous involution

A growth phase may occur during the next few months

Given the location of this hemangioma, there is a risk that it covers the eye of little Theo and that this leads to functional 😥 amblyopia.

Complete disappearance without sequelae occurs in 50% of cases


Parents are concerned about the risk of growth of the lesion and the risk of functional amblyopia by occlusion of the cleft palpebral, and ask if treatment will then be offered for Romain. What do you say to them? (one or more correct answers)

Treatment with propranolol will be offered

Pulsed dye laser treatment will be offered

Embolization treatment in interventional radiology will be proposed

Low molecular weight heparin therapy will be proposed


Following a phase of growth of the lesion and the risk of impact on the palpebral opening, treatment with propranolol was put in place, allowing the complete disappearance of the lesion, without sequelae. You see Romain again in consultation at the age of 18 months because he has for several weeks an itchy skin involvement predominant on the face, and his sleep is disturbed. It is apyretic with conservation of the general condition. What semiological element(s) do you identify on this image?


Which of the following interrogation elements is relevant, if present, to support the diagnosis you suspect in Romain?

Psoriasis is not affected by atopic risk.

Cow's milk protein allergy in Romain's brother

Recent pruritus in several family members

We are not looking for scabies but rather eczema (= atopic dermatitis) 😅

Frequent herpetic recurrences in Romain's mother


You are diagnosed with atopic dermatitis motivating local corticosteroid therapy. What attitude(s) of prevention and prophylaxis do you put in place?

Adapt the vaccination schedule according to the evolution of the pathology

Prophylaxis of herpes superinfections with aciclovir

Prevention of superinfection by regular use of antiseptics

Daily use of fragrance-free emollients on body and face


You see again urgently Romain 1 month later for a predominant rash on the trunk, appeared the night before, in a context of fever up to 39 ° C for 2 days, without alteration of the general condition. The temperature measured in the office is 37.2 ° C (last taken of paracetamol 24 hours ago). The clinical examination, apart from the skin examination, is unremarkable. What diagnosis(s) do you mention?


You mention an infantile roseola (or sudden exanthema of the infant). What is the causative infectious agent?


What recommendation(s) and/or prescription(s) do you make to parents regarding the management of Romain roseola?

Realization of a urine strip for proteinuria in 3 weeks

Prescription of paracetamol 15 mg/kg every 4 to 6 hours, if fever rises

Prescription of a 17-butyrate hydrocortisone cream with 1 application per day on the body for 5 days


After this intercurrent infectious episode, atopic dermatitis experienced a spontaneously favorable evolution. Now 5 years old and enrolled in kindergarten, he is brought to you by his parents for skin and hair lesions evolving for a few weeks. What diagnosis(s) do you evoke in front of these facial and scalp lesions?


Examination with Wood's lamp shows yellow-green fluorescence of the hairs in favor of microsporic ringworm. What do you do while waiting for the result of cultivation? (only one answer expected)

To be introduced after sampling to maximize their profitability.

Prescription of systemic antifungals only

Prescription of local and systemic antifungals


In front of this microsporic ringworm with a very extensive alopecic plaque associated with several lesions of dermatophytosis of the hairless skin, you begin, without waiting for the results of the culture, a treatment combining local and systemic antifungals. Which systemic antifungal will you prescribe, as a first intention, to Romain?

Treatment of moths of choice in children.


The result of the culture comes back positive 3 weeks later to Microsporum canis. How could Romain be contaminated?


Context: Ms. X, a 37-year-old woman, presented to the emergency room of a public hospital at 10 p.m. for pain in her left cheekbone. She states that she accidentally fell down the stairs the day before, after tripping. She came to the hospital because she had time available for herself, her two children having gone to snow class, and her spouse also a few days in a professional seminar. On examination, the doctor notes several traumatic lesions: a reddish hematoma of the left cheekbone, a purplish bruise of the lower left eyelid, two centimetric reddish rounded bruises on the right lateral surface of the neck, a greenish bruise 4 cm in diameter on the right breast, three purplish bruises on the back of the right hand,  several yellowish bruises measuring between 1 and 2 cm on the inner and outer surfaces of both arms. The rest of the clinical examination is normal. This is a woman whose only history is a voluntary termination of pregnancy at the age of 18, and two pregnancies carried to term 12 and 8 years ago. She doesn't have usual treatment, but having been waking up at night for a few weeks, her best friend gave her a few zopiclone tablets.

The doctor evokes the hypothesis of domestic violence. Which element(s) of the statement is (are) in favor of this hypothesis?

The presence of bruises of different ages

An incompatibility between a fall from stairs and the lesions observed


Ms. X confirms that she was physically abused by her spouse the day before. She states that he took her by the neck, that she tried to protect herself by putting his hand in front of her face, but took several punches to the left hemiface. During this episode there was forced sex. Mrs. X came tonight because she was home alone, but does not plan to file a complaint because she does not want marital separation. The doctor considers whether to notify the public prosecutor. What criteria in the statement support compliance with the patient's choice not to file a complaint? (one or more correct answers)

The occurrence of sexual violence associated with physical violence


As Mrs. X is of age, without physical or psychological vulnerability, and not wishing to file a complaint, the doctor decided to respect her request and not to make a judicial report. What paraclinical element(s) can (s) be part of the management of this patient in the emergency room?

Taking photographic photographs to document traumatic bodily injuries

Whole-body X-rays looking for fractures of different ages

Traumatic brain injury without loss of consciousness, without headache, without Master > 1 criteria.


Here is the picture of the arm of the outer face of the left arm. Which proposal(s) is true?

This lesion may correspond to the imprint of the pulp of a finger on the arm.

This lesion is older than those found in the left hemiface

This lesion may correspond to friction of the arm against a hard plane

This injury may correspond to a direct blow with an object on the arm.


The doctor proposes to make a descriptive medical certificate. What should be mentioned? (one or more correct answers)

The alleged date of the last episode of violence suffered by Ms X

The objective account of the violence suffered by Mrs. X

Description of all visible traumatic injuries

The psychological symptoms resulting from the violence suffered by Ms X


The psychological repercussions resulting from the violence must be investigated and mentioned on the descriptive medical certificate. What symptoms should the doctor look for when questioning Mrs. X to assess these repercussions and manage them? (one or more correct answers)


During the interrogation, Mrs. X explains that she has been disturbed for several months in a disturbed sleep, with bad dreams where she sees herself pursued by a threatening shadow. She wakes up early, little rested, but cannot sleep during the day, always awake, jumping at the slightest noise. She gets angry more easily with her children. During the day, when she goes shopping, she makes detours to avoid passing in front of her husband's work and gym, to be sure not to cross him. Eventually, she ends up falling asleep, exhausted, in front of the television at night.
Mrs. X puts all this down to tensions in her work, and a recent family bereavement.
She explains that apart from a few episodes of slapping and forced sex, she has never been a victim of violence by her husband. When she hears about domestic violence, she doesn't feel concerned.
Among the elements of the interrogation, what symptoms are suggestive of post-traumatic stress disorder? (one or more correct answers)


After a full information provided by the doctor, Mrs. X agrees to file a complaint. The doctor calls the judicial police officer on duty at the police station, who goes to the hospital to receive Ms. X's complaint. A gynaecological examination as well as medico-legal samples are requested on judicial requisition. These samples:

Are analyzed urgently at the hospital laboratory at the request of the medical examiner

Aim to highlight the DNA of the perpetrator

Are placed under seal by the judicial police officer


In the requisition, the judicial police officer asks you to set the ITT resulting from the violence. What does this acronym mean?

To avoid melting, we now speak of Total Functional Deficit (FTD).


What will be the purpose of the ITT (total incapacity for work) assessment for a victim of violence? (one or more correct answers)

To classify the criminal offence of which she was a victim

Obtain emergency social housing more quickly if they leave home

To determine the duration of the prescribed absence from work following his injuries

To enable the magistrate to know the repercussions of the violence suffered on the state of health

To determine the competent court to try the perpetrator of the violence


In the case of Ms. X, solicitor-client privilege: (one or more correct answers)

Is, unless otherwise specified, an obligation of the health professional

Allows the transmission of medical information about her to a police officer by telephone

Allows the transmission of medical information concerning her to her spouse

Persists in case of judicial requisition for all medical information that does not concern the questions of requisition

Allows the patient to be personally transmitted of the descriptive medical certificate upon discharge from the hospital if she does not wish to file a complaint


Three weeks after Ms. X went to the emergency room, her husband, from whom she had separated, sent a letter to the hospital to complain about the medical certificate drawn up on requisition, which had been sent to her by her lawyer. He explains that the doctor did not put the story of the violence in the conditional and that he considers himself wrongly accused. In this context, what medical liability(s) can (s) be engaged?

If the fault is detachable from the service.


Eleven weeks later, Ms. X returned to the hospital because she knew she was pregnant as a result of the sexual violence she had reported during admission. She wishes to benefit from a voluntary termination of pregnancy. What is the real proposal(s)?

The doctor is obliged to inform the police of this pregnancy

A voluntary medical termination of pregnancy may be proposed to Mrs. X

Two consultations are offered before the voluntary termination of pregnancy

The consent of Mrs X's spouse is required for the initiation of the procedure

The agreement of the public prosecutor is necessary for the initiation of the procedure


Context: You see a 4-month-old infant in the emergency room with a fever of 39.3°C.  He was born at term and had two bronchiolitis at 1 and 3 months. He was never breastfed. Parents report that he has been drinking less than half of his bottles for 24 hours and has vomited the last bottles. Clinical examination reveals a child with plaintive cry, rhinitis, his heart rate is 200 beats per minute, his respiratory rate is 70 per minute, his skin recoloration time is 2 seconds.

What is (are) the criterion(s) of severity in this febrile child?

The severity criteria for acute bronchiolitis in infants are: FR > 60/min, HR > 180/min, pauses in breathing, signs of struggle, SpO2 < 92%, anorexia.


Given this clinical picture, what action do you take immediately? (only one answer expected)


You have done vascular filling with 0.9% NaCl. Fifteen minutes later, his constants are as follows: heart rate 150 beats per minute, respiratory rate 70 per minute, temperature 39.1 ° C, skin recoloration time at 1 second. Chest auscultation regains a symmetrical vesicular murmur and a systolic murmur at 2/6. Abdominal palpation is normal and otoscopy shows a hypervascularized right eardrum. The child is reactive, without hypotonia.
What is the most likely diagnosis?

High fever and lack of sibilants point more towards pneumonia.


You mention pneumococcal pneumonia. Which of the following is(s) in favor of this diagnosis?


Chest X-ray shows systematized opacity of the right upper lobe with an aerial bronchogram. What is your assessment?

Pneumococcal PCR on nasopharyngeal secretions


The blood test shows the following results:

hemoglobin 115 g/L,

leukocytes 20 G/L with 75% neutrophils,

platelets 400 G/L,

CRP 250 mg/l,

natremia 129 mmol/l, potassium 3.7 mmol/l,

urea 1.5 mmol/l, creatinine 30 micromoles/l.

What pathophysiological elements are likely involved in this hyponatremia? (one or more correct answers)


You mention acute hyponatremia in a context of possible extracellular dehydration and DHA secretion complicating acute pneumonia. You set up an infusion adapted to ionic disorders. Which of the following offers do you offer antibiotic therapy?


You have started treatment with amoxicillin 90 mg/kg/day intravenously. 72 hours later, the infant remains feverish at 39.5°C.  You make an X-ray of the chest, interpret the images you see.

Presence of right fluid pleural effusion

We do not see a Damoiseau line because the child is lying, so the fluid is behind the pulmonary parenchyma and corresponds to the opacity of the lung.

Abnormal enlargement of the upper mediastinum


You carry the diagnosis of purulent pleurisy and adapt your antibiotic therapy. Which germ(s) should or should be covered by this antibiotic therapy?

Staphylococcus aureus infection is a common cause of purulent pleurisy.


The evolution is favorable under antibiotic therapy and the child is released from hospitalization 7 days later. He returned to the emergency room at 9 months of age for cough with fever at 38.2°C and difficulty breathing. The parents report that he presented with a febrile cough at the age of 7 months treated with oral antibiotic therapy. Weight gain between 6 and 9 months was 750 g.

At auscultation, you hear bilateral sibillants. You perform a chest X-ray that shows a systematized focus of the lower left lobe with aerial bronchogram. Faced with this recurrence, what is (are) the cause(s) to evoke?

Infant asthma has a new definition: three episodes of wheezing dyspnea before 12 months, or two episodes + atopy (personal or family) before 12 months.


What additional examination(s) do you do on this child?

He is a little young to blow into a tube 😇. EFRs, in fact, are not feasible for 3 to 6 years.


For the exploration of an immune deficiency, what is your first-line assessment?

Lymphocyte phenotyping detects membrane antigens (CD4, CD8, CD19, CD20, etc.) of lymphocytes to know if they are B, T, NK lymphocytes or other. It is, in this situation, a second-line examination.


To explore the possibility of immune deficiency, the assessment includes a weight assay of immunoglobulins and post-vaccination serologies. The complete blood count was normal. Here are the results available at this stage: IgG 1 g/L (N 3.3-6.2), lgA 0.2 g/L (N 0.2-0.8), lgM 0.7 g/L (0.5-1.3). Post-vaccination serologies reveal a defect in the production of specific antibodies. Which diagnosis do you think is most likely? (only one answer expected)


You confirm the diagnosis of variable common immunodeficiency. As the vaccination schedule was respected until the age of 9 months, which vaccine(s) are indicated for this child for the next 6 months?

This vaccine is a live attenuated vaccine. It is contraindicated in case of immunosuppression.


Context: A 43-year-old woman is hospitalized in the emergency department for a painful left shoulder since an undetermined malaise with loss of consciousness. The discomfort would have occurred the day before. It is only in front of the functional impotence of the shoulder that she travels to the emergency room. The objective clinical examination a dislocation of the left shoulder. The general skin condition is poor with multiple dermabrasions and some hematomas on the limbs. His social situation is precarious. She says she doesn't take any medication. The ECG performed does not reveal any conduction anomaly.

Which of the following proposals concerning the etiology of malaise would you provide discriminating information?

Urine loss is not to be considered as a distinguishing element between the cardiac or epileptic origin of the malaise.

The localization of hematomas of the limbs

The bite of the lateral edge of the tongue


The dislocation is managed orthopedically. You hospitalize him for monitoring and assessment of the malaise.

The first night of hospitalization is difficult with constant wandering. The next morning, the staff noticed agitation and she tore off her drip. She does not see the point and wants to leave the institution. You notice a tremor of the upper limbs when maintaining the attitude. Objective examination (difficult given the patient's weak cooperation) seems normal except for an abolition of Achilles reflexes. The interrogation is difficult. Spontaneously, his speech is disjointed and incoherent. Which of the following suggestions regarding your diagnostic orientation on its current condition is compatible with this table?


What additional biological examination(s) are you performing at this stage to advance on the etiological context of this patient?

An increase in OGT/AST greater than that of TGP/ALT may indicate chronic alcohol poisoning.


The patient remains agitated and not very compliant. At this stage, biological results show MCV at 114μm (N < 100), TGO (aspartame aminotransferase) at 155 (N < 40), TGP (alanine aminotransferase) at 63 (N < 40), zero ethylemia and natremia at 134 mmol / L. What non-biological examination should be performed at this stage and during the day (only one response expected):

Abdominal ultrasound could give arguments for cirrhosis (bumpy liver, increased hepatic arrow, hyperechogenicity of the parenchyma, signs of portal hypertension) but, in front of the neurological signs and the context of fall (and potential head trauma), brain scan is more priority.


The brain scan reveals diffuse and age-significant atrophy. An electroencephalogram is performed but is artefacted by the patient's movements and does not allow reliable interpretation. Which of the following therapeutic proposals are you putting in place at this stage?

Glucose increases the use of vitamin B1 and therefore the risk of Gayet-Wernicke encephalopathy. The patient must be hydrated with 0.9% NaCl.

The patient appears to have symptoms of alcohol withdrawal, which therefore requires an emergency pharmacological prerisk. The patient's lack of compliance and the need for rehydration (so the patient will have a venous line in all cases) directs us towards a parenteral route.


Concomitantly with the placement of the venous line, she presents a loss of consciousness with a period of generalized hypertonia and movements of the 4 limbs. She is receiving an intravenous benzodiazepine. The awakening is gradual.

In the hours that followed, confusion and agitation increased; The patient is covered in sweat, she makes incoherent remarks. Blood pressure is at 180/110 mmHg. The heart rate is at 110/min. The temperature is 38.5 °C.  The clinical examination is difficult but finds no obvious signs of neurological focus.

Which of the following diagnostic proposals is (are) accurate?

The first part of the statement refers to an epileptic seizure secondary to alcohol withdrawal.

Confusion, agitation, sweating, and incoherent remarks point to a delirium tremens.


The clinical course under treatment is partially favorable. The patient is less agitated but confusion persists. You have contacted his doctor who confirms a significant and daily alcohol consumption, active smoking and social precariousness. By putting the patient in orthostatism, standing appears very unstable and walking is impossible without the help of a third party. During the examination, you notice multidirectional nystagmus and bilateral limitation of eye abduction.

Which of the following diagnostic hypotheses is compatible with the clinical picture?

Status epilepticus with confusional expression


You mention the diagnosis of Gayet-Wernicke encephalopathy. In general, concerning the pathophysiological mechanism(s) that could explain or increase the symptoms of this pathology, which proposal(s) is(are) accurate?


A brain MRI is performed. What is the sequence shown below?

The gray matter (in the periphery) is white, the white matter (in medial) is gray 👉 It is a T2. The liquids are black 👉 It is a T2 FLAIR.

The median hypersignal that we see is not CSF, it is a hypersignal of the mammillary bodies that is readily found in deficiency encephalopathies.


Which of the following proposals for these MRIs is the visible anomaly?

The thalami (plural of thalamus) are just opposite the lateral ventricles and the third ventricle. We can see in the first axial section that they are in hypersignal.

Hypersignal in the periphery of the third ventricle

This hypersignal indicates an attack of the thalami.

The Sylvius aqueduct (synonymous with the midbrain aqueduct) is the small pipe that allows CSF communication between the third ventricle (located in the brain) and the fourth ventricle (located between the cerebellum and the brainstem). It is observed on the second axial section: it is in hypersignal (= we have a problem 😥).

The protuberance is synonymous with the bridge, which is the intermediate structure of the brainstem, making the link between the medulla elongata (synonym of myelencephalon) and the midbrain. We see it in the coronal cup: no hyper/hypo-signal, everything is fine 👌

The white substance is gray on all cuts: there is no hypersignal, everything is fine 👌


You have been diagnosed with Gayet-Wernicke encephalopathy. Which of the following processing proposals are you putting in place now?


The clinical course is favorable after three weeks of hospitalization. She therefore presented neurological complications of chronic alcoholism. Biological parameters are standardized except for MCV at 104 μm3. She seems to you to have understood the need for a definitive and total weaning. She keeps an abnormal neuropsychological assessment for her age with some visuospatial disorders, judgment and working memory. Walking is limited in terms of perimeter, cautious with widening of the lifting polygon, and tendency to hang the forefoot.

What is (are) your hypothesis(s) to explain the gait disorders presented by this patient?

Argued by the enlargement of the lift polygon


You have been able to gather some social information: the patient lives alone, has no close relative, has been unemployed for 9 months. Regarding medico-social care, what approach(s) will you take?

Application for a disabled adult allowance

The AAH concerns people who have never worked, with a very high rate of disability. That is not the case here.

Application for long-term illness with Social Security

Temporary suspension of driver's licence


You have not heard from this patient again. Six months later, your psychiatrist colleague calls you about him. She is treated in psychiatric emergency for << delirium >>. You go to see it and see a seemingly normal reasoning but you are amazed by its familiarity. It presents significant memory disorders predominant on recent facts but also on older facts. The patient repeatedly asks you about her immediate future when you have already answered the same question several times.

Which of the following diagnostic proposals is accurate?


Which of the following propositions, are the semiological argument(s) that characterize Korsakoff syndrome?


Context: A 72-year-old woman presents to the emergency room for an epistaxis that began a few days ago and has been interrupted several times. Since this morning, there is no possibility to stop it, bleeding persists. The patient is on anti-vitamin K therapy for complete arrhythmia by paroxysmal atrial fbrillation with regular INR check-ups.

After quickly collecting the history and circumstances of occurrence of epistaxis, what is (are) the gesture (s) that you practice quickly?

Digital nasal compression for ten minutes

Assessment of the presence of posterior hemorrhage by pharyngeal examination


Regarding the vascularization of the nasal cavities, what is(are) the exact answer(s)?

Branches of the internal carotid artery vascularize the lower turbinate

Vascularization comes mainly from the branches of the external carotid artery

The main artery is the sphenopalatine artery

The anterior ethmoidal artery is the terminal branch of the external carotid artery

The facial artery participates in the vascularization of the nasal cavities


Which element(s) are you looking for during the interrogation?

The unilateral or bilateral nature of the bleeding

A history of perforation of the nasal septum


On clinical examination, the patient is pale and sweaty. The epistaxis is both anterior and posterior. Blood pressure is at 150/95 mmHg with a regular heart rate at 124/min. The temperature is 37.5 °C and oxygen saturation is 98%.

What is (are) the element(s) in favor of severe epistaxis in this patient?


You take a biological sample. Which biological parameter(s) are you asking for at this stage?

Coagulation assessment including TP, INR, TCA


A few minutes later, blood pressure is 85/55 mmHg and heart rate is 130/min. The patient has some mottling at the knees. What measure(s) do you propose at this stage? (one or more correct answers)

That is not the urgency here. The patient who appears to be in hemorrhagic shock must first be stabilized.

Introducing intravenous noradrenaline as a continuous infusion

It is (almost) never possible to perform interventional radiology on an unstable patient.


Vascular filling stabilized hemodynamics. The mottling has disappeared. You want to locate the origin of epistaxis at the level of the nasal cavities.

What step(s) is necessary to localize the bleeding? (one or more correct answers)

You blow the patient's nose to evacuate the clots

You introduce a wick impregnated with local vasoconstrictor into the hemorrhagic nasal cavity

You request a non-injected CT scan of the facial mass


The patient is calm and after your endonasal examination you observe unilateral bleeding from the vascular spot. The INR is at 2.5. The rest of the balance sheet is pending. What is (are) the possible option(s) to stop the bleeding?

Primary electrical cauterization of hemorrhagic vessels

This is a bleeding of the vascular 👉 task cauterization is to be done in first intention.

The IV route is used here because it is a serious hemorrhage. The patient is not asymptomatic.

The return home will be authorized in the absence of recurrence of the epistaxis after a surveillance of a few hours


You performed cauterization of the vascular spot. Despite this, epistaxis persisted. You observe significant bleeding without being able to locate the exact origin. What is your immediate attitude? (only one exact answer)

Previous tamponade with a greasy strand or hemostatic swab

Anteroposterior buffering by double balloon probe

Discontinuation of vitamin K antagonists

It's been a long time since we stopped them (and even poured them out).

Arteriography with selective embolization


Despite a well-performed previous tamponade, you observe an early recurrence of epistaxis. What is your attitude? (only one exact answer)

Endonasal ligation of the sphenopalatine artery


You have managed to dry up epistaxis, and you decide to look for the etiology. Regarding epistaxis << >> symptom, which is (are) the diagnosis(s) that you can evoke?

It is necessary to differentiate epistaxis << symptom >> (local cause) from epistaxis << epiphenomenon >> (general cause) of which Willebrand and Rendu-Osler disease are part.


Regarding epistaxis of general origin (<< epistaxis epiphenomenon >>), what is (are) the diagnosis (s) that you can evoke?

Bleeding disorders are expressed more by deep bleeding. In addition, the advanced age and the fact that it is a woman lead us to count this false proposition.


During the etiological assessment, you ask for a scan of the sinuses. On this coronal CT scan of the sinuses, which is (are) the exact proposal(s):

4 represents the left posterior turbeach


Context: You see in consultation a 61-year-old woman, night nurse in a pulmonology department. She has a history of smoking started at the age of 18 and continued with a current consumption of more than one pack of 20 cigarettes a day. She has smoked the same amount for at least the last 25 years. 18 months ago, she developed chest pain that led to the discovery of coronary stenosis that required a stent. She had no medical follow-up prior to this episode. At this time, hypercholesterolemia and high blood pressure were also detected. Since then, she has been treated with an antiaggregant, a selective cardio-blocker, a statin and an ACE inhibitor.

She consults for a rather dry cough evolving for 3 months. This cough has become very disabling and wakes her up at night. You mention the possibility of a cough with ACE inhibitors. Which of the following answers is correct about IEC cough?

It contraindicates angiotensin inhibitors II

It can affect 5% or more of patients treated with ACE inhibitors

It usually occurs after an infectious episode


You stop its ACE inhibitor and replace it with an angiotensin II inhibitor. The cough decreases in a few days and will disappear in less than 15 days. She has no sputum. The patient nevertheless complains of discomfort during exercise with a feeling of shortness of breath when walking flat quickly and when she climbs a slight slope, which she has noticed for several months when she returns home. You rate his dyspnea in his medical record by the chronic dyspnea scale of modified MRC (modified scale of Medical Research Counci/). This scale assesses the impact of physical activity on dyspnea. What is the mMRC stage of this patient?

everything is fine we are oklm (important effort like everyone else, even Benzema)

a feeling of shortness of breath when walking flat fast and when climbing a slight slope = mMRC 1

a feeling of shortness of breath when walking with people of his age

a feeling of shortness of breath when walking after a few minutes flat

a feeling of shortness of breath preventing him from going out


You examine the patient. Cardiac auscultation is normal. Pulmonary auscultation finds a diffuse decrease in vesicular murmur without sibilant or crackling. Vocal vibrations are transmitted. The percussion of the thorax is generally tympanic. There is no sign of heart failure either right or left. She weighs 44 kg and is 1.55 m tall. Which clinical sign(s) testify to chest distention?

When the patient inhales, the transverse diameter (from right to left) of the chest decreases, whereas normally it should increase.


You carry out a spirometry of which here is the report. Which of the following proposal(s) is correct:

You can affirm the existence of an obstructive syndrome

There is a significant lack of reversibility

You can claim chronic respiratory failure


You complete the examinations with a front chest x-ray and more complete pulmonary function tests (RFS). Taking into account clinical history, clinical examination, imaging and EFRs, it is true that:


Given the clinical chest distension, chest distension on the lung X-ray with flattening of the diaphragmatic cupolas and EFRs you retain the diagnosis of COPD, probably in connection with emphysema, especially since there is an impairment of the diffusion. You explain to the patient that this disease is directly related to smoking and that quitting smoking will be essential. You assess his pharmacological/nicotine dependence via the Fagerström test.

Which element(s) is (are) in favor of a strong pharmacological dependence?

Smoking a cigarette as soon as you wake up


After assessing her tobacco use and conducting a motivational interview, you find that the patient is motivated to quit smoking completely. She has a significant pharmacological dependence on nicotine with the first cigarette smoked within 5 minutes after waking up and again between 21 and 30 cigarettes a day. She does not consume other psychoactive products. You first prescribe nicotine substitutes in oral form.

What is the exact proposal(s)?

He will have to be prescribed a dose of 10 mg per day of nicotine

Nicotine substitutes have few side effects

Nicotine replacement therapy is more effective than placebo in cases of physical dependence

Nicotine substitutes are prescribed in his off-label case because of the cardiovascular history


The patient will be able to quit smoking overnight, thanks in part to nicotine substitutes that you will be able to stop very gradually. She has never had an acute episode of worsening respiratory disease to date. As part of the treatment of his GCP0, what measure(s) to accompany the pharmacological management will you put in place?

Annual influenza and pneumococcal vaccinations


You carry out the necessary vaccinations. Regarding his drug treatments, what is (are) the exact proposal(s)?

You contraindicate its beta-blocker treatment

You prescribe a short-acting bronchodilator on demand

Every COPD patient should carry their BDCA.

You prescribe a long-acting bronchodilator once or twice a day

You prescribe an inhaled corticosteroid as part of a fixed combination

You prescribe loop diuretics in moderate doses


Despite the treatments put in place, the patient still has dyspnea of the mMRC stage. You are considering pulmonary rehabilitation. Regarding the latter, its effectiveness has been demonstrated on:


The patient benefited greatly from pulmonary rehabilitation. Two years later, she is retired and comes to see you again in consultation because she feels much more breathless for a few days while her condition was quite stable until then. This increase in dyspnea is associated with the reappearance of a cough and purulent sputum. You suspect an exacerbation of COPD. What is the exact proposal(s)?

The majority of COPD exacerbations are infectious (viral, bacterial, or mixed)

The first exacerbation is usually not serious

The diagnosis of exacerbation is based on increased dyspnea, cough and/or sputum

The main argument in favor of a bacterial infection is sputum purulence

The bacteria most often involved are Haemophilus influenzae, Pseudomonas aeruginosa and Moraxella catarrhalis

The 3 bacteria to know are: Haemophilus influenzae, Streptococcus pneumoniae and Moraxella catarrhalis. Pseudomonas aeruginosa is rarer, but more serious.


She was admitted to the emergency room of the hospital. The nurse who takes care of her calls you because she is worried. You will find paradoxical abdominal breathing on clinical examination. Regarding paradoxical abdominal breathing, what is (are) the true proposition(s)?

It is defined as the receding of the anterior wall of the abdomen during inspiration instead of the expected abdominal expansion

Its presence indicates the absence of participation of the diaphragm in the ventilation which is then taken care of by the extra-diaphragmatic inspiratory muscles

Its finding requires the admission of the patient to a structure where ventilatory assistance can be set up without delay.

Its presence raises fears of short-term failure


You will immediately transfer the patient to respiratory intensive care. Chest X-ray does not find an infectious focus or pneumothorax. Analysis of blood gases in ambient air shows a pH of 7.35, a PaO at 50 mmHg and a PaCO2 at 48 mmHg, HCO3- at 26 mmol / L.  What treatment(s) will you put in place?

The patient shows signs of severity. This is an indication for antibiotic therapy.

Chest physiotherapy is offered acutely in case of significant bronchial secretions.

Oxygen therapy with a titrated oxygen flow rate to obtain a pulsed oxygen saturation (Sp02) between 88% and 92%


The evolution is favorable with the treatment implemented without the need for mechanical ventilation. She can be discharged from hospital 8 days later. She gradually returns to her usual state. You see her again 6 months later because she has just presented some sputum of pure blood during a coughing effort. She has no other symptoms elsewhere. His dyspnea is not increased. What is the exact proposal(s)?

In the context of this patient, bronchial cancer must be ruled out until proven otherwise.

The administration of vitamin K should be carried out as a matter of urgency as a matter of principle

Taking the antiaggregant may be the cause of hemoptysis in this context of COPD

⚠ Recurrent pitfall: COPD is not a cause of hemoptysis.

Chest computed tomography injected with arterial time is the key examination and will be performed if possible even before a bronchial endoscopy.

Despite good tolerance, management should be considered an emergency


Context: A 37-year-old patient, a mechanic, has been suffering from mid-back pain for 2 months. He has difficulty falling asleep and the pain wakes him up in the second part of the night. The pain improves after an hour of activity in the morning while lying down rest does not relieve it. His history includes: high blood pressure, active smoking at 20 packs-year, a perforated gastric ulcer two years ago, penicillin allergy and childhood eczema. Until then, he had been running regularly, twice an hour a week.

What element(s) are you looking for questioning about these pains to advance in your diagnostic hypotheses?


In this patient, what etiology(s) should you mention?

Sequelae of vertebral growth epiphysitis


The pain settled gradually over two months. Which element(s) point to the inflammatory nature of the pain in this patient?

Improvement after one hour of activity in the morning


On clinical examination, the pain is maximum on palpation of the spinous located opposite the two points of scapula. At what spinal level does this localization correspond?


In front of this inflammatory back pain located at the level of the 7th thoracic vertebra, what are you looking for in priority at the clinical examination? (one or more correct answers)


What exam(s) do you prescribe in the first line for this patient?


There is no inflammatory syndrome and the CBC is without abnormalities. A systematic ECG is normal. Why do you decide to do imaging tests?


In this patient with inflammatory back pain with a normal biological assessment, which imaging examination seems most relevant to you at this stage? (only one answer expected)


MRI of the entire spine performed quickly is normal. At the follow-up consultation one month later, the back pain gradually and spontaneously improved within a month. The patient makes an appointment with you three months later because he has had pain in his right knee for 2 days. What are you looking for on the physical exam? (one or more correct answers)

Pain of the lateral edge of the knee during its extension (sign of the windshield wiper)


There is patellar shock of the right knee. The patient has a temperature of 37.3 °C. You are wondering about performing a knee puncture. What is the true statement?

It is necessary to puncture the knee because there is an effusion

Do not puncture the knee because the pain has been evolving for less than 7 days

Do not puncture the knee because the temperature is normal

Do not puncture the knee because the patient is young

Do not puncture the knee because there is a risk of infecting the knee


You decide to perform a joint puncture of the right knee. Which statement(s) is the correct statement(s)?

The procedure requires an antiseptic skin preparation

Prophylactic antibiotic therapy is needed

Cytological examination of the fluid is essential

Written consent from the patient must be obtained prior to the procedure

There are very few actions that require written consent. Punctures are not part of it (except genetic test).


The joint puncture fluid has 5500/mm3 leukocytes. Germs are not found on direct examination or after cultivation. There are no microcrystals.
Which etiology(ies) is(are) the most likely?


You suspect spondyloarthritis. What are you doing to support this diagnosis? (one or more correct answers)

Looking for a history of finger in << sausage>>

Ulcer history makes prescribing NSAIDs somewhat annoying 🤭


The search for the HLA B27 gene is positive. The patient is worried and asks you questions. What do you say to him? (one or more correct answers)

The presence of HLA B27 in the blood is variable over the course of life

Either the protein is there or it is not.

The presence of HLA B27 requires the protection of your partner during sexual intercourse

You have to do the research in your children

HLA B27 is present in more than 90% of patients with ankylosing spondylitis

The vast majority of HLA B27+ subjects will never have spondyloarthritis


The patient asks you for advice regarding his long-term management. What measure(s) do you recommend?

Nonsteroidal anti-inflammatory drugs for flare-ups

He cannot be recommended NSAIDs per se because of his history of ulcer.


Context: A 25-year-old man is consulting for bloody diarrhea that has been progressing for a week after returning from a trip to Brazil. The patient has no medical or surgical history. He does not smoke or drink alcohol

What elements of the interrogation are you looking for to support this diagnosis? (one or more expected answers)


The patient reports spurs relieved by glairo-bloody emissions, which reinforces your hypothesis of proctitis. You learn that the patient has unprotected sex with episodic male partners. What arguments are you looking for in favor of an infectious etiology? (one or more expected answers)


The patient describes tenesmus but no muco-purulent discharge. There is no fever or deterioration in the general condition. The weight is 65 kg for a height of 1m70. The clinical examination does not find inguinal lymphadenopathy. The abdominal wall is not sensitive. What, at this stage, are the etiological hypotheses concerning this suspicion of proctitis? (one or more expected answers)


What are the additional first-line examinations to be performed? (one or more expected answers)

Microbiological collection by rectal swab

Recto-sigmoidoscopy with biopsy for histopathological examination


Rectal swab with PCR examination does not find Chlamydia trachomatis or Neisseria gonorrhoeae. HIV serology is negative. Parasitological examination of stool is negative. Endoscopic examination shows a rectal mucosa of granite appearance with erosions that bleed on contact with the endoscope. The lesions do not extend beyond the rectosigmoid hinge and the sigmoid mucosa is normal. Histological examination shows glandular distortions, cryptic abscesses and an inflammatory infiltrate of the chorion, consisting of lymphoplasmocytes and polynuclear cells. The diagnosis of ulcerative colitis is retained. You propose treatment with 5-amino-salicylates rectally. What information do you give the patient about their illness? (one or more expected answers)

Treatment can cure the disease permanently

The risk of colorectal cancer is increased compared to the general population

The risk of primary biliary cirrhosis is increased compared to the general population

The risk of diverticular disease is increased compared to the general population