A 57-year-old patient diagnosed with stage T3N1M0 adenocarcinoma of the colon. He was treated with resection followed by postoperative FOLFOX chemotherapy (fluorouracil, leucovorin and oxaliplatin) for 6 months. In a routine control, two years later, carcinoembryonic antigen (CEA) elevation to 30 ng/mL (previously less than 2 ng/mL) was detected. She has no symptoms, physical examination is unremarkable, chest X-ray is normal. CT scan shows a 3 cm mass in the right hepatic lobe that is captured on PET. No other alterations are observed in CT or PET. What is the most correct approach?

We are faced with a situation of probable liver metastasis from a localized colon adenocarcinoma treated 2 years ago. Probable because we do not have histological confirmation, although as it usually happens, what else could it be? As this is a situation of oligometastasis and the treatments for advanced colon adenocarcinoma allow prolonged survival with good quality of life in these patients, if there is nothing to contraindicate surgery, this should be the first option (correct answer 3). I attach the algorithm proposed by the NCCN in situations of recurrence (http://www.nccn.org/professionals/physician_gls/pdf/colon.pdf). In case of an unresectable situation, chemotherapy treatment would be considered with the intention of converting the single metastatic lesion into a resectable one. Since more than 12 months have passed since FOLFOX treatment, the same scheme could be used, although FOLFIRI+bevacizumab would also be useful. Capecitabine monotherapy, in the patient's current situation, would also not be a good starting option, since the responses are lower compared to FOLFOX or FOLFIRI plus antiangiogenic combinations. Hepatic radiotherapy could be considered, since there are SBRT techniques that achieve very good results, but in this case it is best to start by asking for an assessment by the surgeons and if they rule out surgery we would consider RT.

Chemotherapy with FOLFIRI (fluorouracil, leucovorin and irinotecan) plus bevacizumab.

Assessment for surgical resection of the hepatic lesion.


A patient is brought to the ED from a fire occurring inside an enclosed building where polyurethane foams were present. He is conscious, but presents with increasing mental dullness, headache, and severe dyspnea. Oxygen saturation by pulse oximetry is 92% and capillary lactic acid is 8 mEq/l. What specific treatment do you consider most appropriate?

The first thing we need to know is that combustion of polyurethane at high temperature results in the release of cyanide (very intuitive, yes). Knowing this, and that we are dealing with cyanide poisoning, it is easier to answer the question. Among the basic initial treatment measures would be the administration of oxygen therapy with FiO2 1 (not 0.5 as stated in option 1), and an antidote, in this case hydroxycobalamin (this was asked similarly last year). Ventilation with hyperbaric chamber would only be indicated in case of coexistence of carbon monoxide (CO) poisoning. What is stated in option 4 about fluid therapy is not indicated; in case of associated shock, volume would be administered, but in any case not at that rate, but in rapid boluses.

Administration of oxygen by means of a 50% Venturi type mask.

Administration of intravenous hydroxycobalamin.

Fluid therapy with infusion of physiological saline solution at 21 ml/h.


In a 35-year-old patient with a depressive syndrome on treatment with serotonin reuptake inhibitors, the use of the following antimicrobials is contraindicated:

Spontaneous reports of serotonergic syndrome associated with concomitant administration of linezolid and serotonergic agents, including antidepressants such as selective serotonin reuptake inhibitors (SSRIs), have been reported.


A 37-year-old man with no past history of interest comes to the emergency department for syncope while walking. He had started two days earlier with dyspnea on exertion. Examination: weight 75 kg, BP 75/50 mm Hg. SatO2 89%. Pulmonary auscultation was normal. Cardiac auscultation: rhythmic tachycardic tones at 130 bpm. Abdomen normal. Extremities: no alterations. Normal hemogram. Troponin 1.2 ng / ml. ECG: Sensual tachycardia at 130 bpm. Inverted T in V1-V4. Thoracic CT angiography: repletion defect in both main pulmonary arteries. One hour after arrival at the emergency room, BP 70/55 mm Hg persists. What would be the most appropriate initial treatment?

The clinical case is a typical pulmonary thromboembolism. In this case it is associated with persistent arterial hypotension. Option 2 would be correct if the patient were not hypotensive. Option 3 is not correct since diagnostic confirmation is not necessary to initiate anticoagulant therapy in case of PTE without hypotension. Option 4 is not indicated. Option 5 would be correct only if the patient had a contraindication to fibrinolysis. Persistent hypotension in PTE is the most widely accepted indication for fibrinolysis, so the correct option is 1.

ANESTHESIOLOGY, CRITICAL CARE AND EMERGENCIES

Unfractionated heparin, 10,000U iv on clinical suspicion. Fibrinolysis with tPA 100 mg iv once the diagnosis is confirmed.

Enoxaparin: 80 mg sc every 12 hours, starting upon diagnostic suspicion.

Enoxaparin; 80 mg sc every 12 hours, starting upon diagnostic confirmation.

Option 4 is not indicated.


A fall with anterior shoulder fracture-dislocation that was reduced in the emergency department. A sling was placed and its removal was recommended after 3 weeks. On removal of the immobilization, an area of dysesthesia circumscribed to the lateral region of the shoulder was observed. The patient can perform abduction, but only reaches 15 degrees. She has a magnetic resonance imaging study in which the rotator cuff is undamaged. What is the most likely diagnosis of suspicion?

Dysesthesia of the lateral aspect of the deltoid region of the shoulder (area innervated by the axillary nerve) and paralysis of the deltoid (primary muscle for abduction beyond 15°). The rotator cuff is undamaged in the MRI, ruling out option 1 (it would show us tendinopathy of the teres major). Adhesive capsulitis presents with pain and stiffness of the shoulder, especially on active and passive external rotation. The suprascapular nerve innervates the supraspinatus muscle, which contributes to the first 15º of shoulder abduction (preserved in the statement) and does not innervate the skin of the reflected area.


A 64-year-old smoker and heavy drinker with no other history of interest. The picture he explains is odynodysphagia of 3 months of evolution and left otalgia. He provides a dentist's report that rules out a dental cause. He also refers to having been visited by different specialists and provides a head and neck CAT scan (without iodine contrast) which is reported as normal. On examination there was a decrease in the propulsive capacity of the tongue; palpation of the base of the left tongue showed an induration of stony consistency of approximately 3cm and with indirect laryngoscopy no ulceration of the mucosa was observed. Cervical palpation is negative for lymphadenopathy. What is your presumptive diagnosis and course of action?

We are presented with a patient with risk factors for oropharyngeal cancer, but in whom the examination and tests are normal. What is going on here? This question is reverse psychology: what did the questioner want me to know? This question was asked by an otolaryngologist. He already tells you that the dentist "didn't see anything", so he rules out 1. It is not an abscess of the base of the tongue either, because in three months it would have killed him: neither is 2. So we are left with ankyloglossia, tongue base cancer and non-specific inflammation. When there is doubt that it could be cancer, we should not fool around and order a new CT scan and biopsy. Tongue base cancers are very treacherous and it is one of the fears of any otolaryngologist when he suspects a neoplasm. It is not uncommon for them to arise without exophytic masses or ulcerations of the tongue mucosa and they are difficult to detect on CT when contrast is not used. The correct answer is 4 and I do not think it can be challenged.

OTORHINOLARYNGOLOGY AND MAXILLOFACIAL SURGERY

Dental cause / reevaluation by the dentist.

Abscess of the base of the tongue / debridement.

Ankyloglossia / surgical release of the same.

Malignant process of oropharynx / repeat CT scan and biopsy.

Nonspecific inflammation / corticosteroid treatment.


A 28-year-old man comes to the hospital emergency room with gross hematuria. Which of the following urinalysis abnormalities would support a diagnosis of glomerulonephritis?

Glomerulonephritis is typically associated with dysmorphic red blood cells and hematic casts in the sediment (option 1 correct). Proteinuria can also appear in variable range, although it is not usual in the form of isolated microalbuminuria (incorrect option 2), and hematuria with pyuria although it is not characteristic (incorrect option 3). Clots usually appear in the context of alterations of the lower urinary tract (option 4 incorrect).

Dysmorphic red blood cells and/or hematic casts.

Proteinuria of 1 g/day, with negative test strip result and with microalbuminuria greater than 300 mg/24 hours.

Coexistence of hematuria with pyuria without bacteriuria.


An 85-year-old man in permanent atrial fibrillation consults for abrupt pain and coldness in the right foot for 6 hours. On examination he presents plantar cyanosis with partial sensory and mobility deficit. The femoral pulse is palpable, while the popliteal and distal pulses of this extremity are absent. Which of the following is the best therapeutic approach?

Urgent surgical treatment by thromboembolectomy.

Discourage revascularization surgery because of prolonged ischemia time.

Apply heat and notify the on-call vascular surgeon.

Urgent medical treatment with intravenous prostaglandins.


A 12-month-old boy, who in the health examinations performed since birth presents right testicle in the inguinal canal that is not possible to descend to the scrotum. Mark the correct answer:

The retractile testicle is characterized by the testicle being permanently outside the scrotal sac, being possible to descend it manually (although when it is released it automatically returns to its initial location). It is usually due to a short pedicle. In this case we are being told that the teste is always in the inguinal canal (cryptorchidism) so we can discard option 1. Hormonal treatment with HCG has already fallen into disuse, due to its low efficacy, possibility of reascension and because apoptotic and inflammatory phenomena have been described in the teste associated with its use (we discard option 3). Orchidopexy is the treatment of choice when we are faced with cryptorchidism, being desirable to perform it between 6 months and one year of age, and should not be deferred beyond two years of age.

The most probable diagnosis is retractile testicle.

Wait until two years of age for its spontaneous decrease.

Human chorionic gonadotropin is the treatment of first choice.

The indication for orchidopexy should not be deferred.


A 41-year-old male consults for gonalgia of several days' evolution. During the examination, the Thessaly test (pain with internal and external rotation movements with the knee flexed) is positive. Which of the following lesions is most likely to occur?

The Thessaly maneuver consists of the patient, using monopodal support and knee flexion of 5º and then 20º, performing internal and external rotations of the leg. In case this reproduces the pain that the patient refers, the test will be considered as positive. It is a test used for the diagnosis of meniscal pathology (sensitivity greater than 90% and specificity greater than 95%) (Answer 1 correct).

Injury by rupture of the anterior cruciate ligament.

Injury by rupture of the posterior cruciate ligament.


A 60-year-old man with abdominal pain and upper gastrointestinal bleeding was found to have an abdominal tumor related to the gastric wall. Histology shows a spindle cell tumor with few mitoses, positive for CD117. The most likely diagnosis is:

The GI stromal tumor is better known as GIST, positive CD117, ckit, PDGF, manual.


A 41-year-old male consults for gonalgia of several days' evolution. On examination, the Thessaly test (pain with internal and external rotation movements with the knee flexed) is positive. Which of the following injuries is more likely?

Thessaly test. Provocation test performed in suspected meniscal injury.

Injury due to rupture of the anterior cruciate ligament.


A 54-year-old man diagnosed with type 2 diabetes mellitus comes to our office. He reported a fever of 40ºC with chills and shivering, arthromyalgia and headache, for which he started treatment with paracetamol. The symptoms started 24 hours before his return to Spain. Three days later she presented a generalized maculopapular rash that evolved into more intense petechiae on the lower limbs. She presented blood tests with leukopenia with 3,200/mm3 and platelets 91,000/mm3 and severe elevation of aminotransferases. The thick blood drop, peripheral blood smear, PCR and malaria antigen are negative. What is the most likely diagnosis?

It is striking in this question that we are told that our patient has returned to Spain, but not from where (which could help us to make digressions about the possible cause). However, the description of the picture is very exhaustive as well as typical, so the question is easy. It is a disease that produces fever, arthralgias and a generalized exanthema with petechiae on the lower limbs. The CBC shows leukopenia accompanied by plateletopenia and elevated transaminases. Malaria has been ruled out as a possible cause. All the data are highly suggestive of Dengue, especially the plateletopenia and petechiae (suggestive of capillary fragility), answer 3 correct.


A 78-year-old woman with a history of hypertension treated with amlodipine was admitted 3 months ago for heart failure and atrial fibrillation. She came to your office for a cardiological check-up. The discharge report shows the result of the echocardiogram showing moderate left ventricular dysfunction and the discharge treatment: amlodipine was discontinued and furosemide and enalapril were started. The patient reports feeling better, without fatigue and with less leg edema, but she is still not completely well. Physical examination showed no signs of heart failure, but her blood pressure and heart rate were 150/90 mmHg and 120 bpm, respectively. The ECG shows atrial fibrillation at 110-120 bpm. Which treatment is most likely to improve symptoms and reduce mortality from cardiovascular events?

Typical very long and rambling question but not really too complicated... The patient is in heart failure with moderate ventricular dysfunction and also presents atrial fibrillation; she has criteria for anticoagulation, and between the two options that include acenocoumarol we are inclined to choose option 4, since it includes carvedilol, a drug that has been shown to increase survival in heart failure. Verapamil (and calcium antagonists in general) are contraindicated in systolic heart failure: they do not increase survival (they even increase morbidity and mortality) and specifically the non-dihydropyridines (verapamil and diltiazem) should not be associated with beta-blockers due to the increased risk of conduction system blockade.


75-year-old male, hypertensive on treatment with enalapril (20 mg/day), who consults for deterioration of general condition, bitemporal headache and mandibular claudication of 3 weeks of evolution. In addition, in the last hours, he refers two episodes of amaurosis fugax of the left eye. Physical examination revealed thickening and absence of pulse in the left temporal artery. Analysis: CRP 6 mg/dl (VN <1); hemoglobin 10.5 g/dl; ESR 92 mm. Chest X-ray normal. Considering the most likely diagnosis, check the correct option regarding treatment:

Clinical case of giant cell arteritis. Corticosteroid therapy remains the first choice (answer 1 incorrect), to be administered as pulses (doses differ according to the literature, but at least 125 mg/d) in case of ocular involvement (answer 3 incorrect). The current treatment of choice for corticosteroid sparing is Tocilizumab (answer 4 incorrect), which has also been shown to reduce recurrences (answer 2 correct).

Rituximab should be administered, since glucocorticoids have been relegated to second-line treatment due to their side effects.

Tocilizumab has been shown to be effective in reducing recurrences and cumulative prednisone dose in more than 50% of patients.

In the presence of ischemic symptoms, and in order not to worsen the vascular risk of the patient, the use of glucocorticoids at doses higher than 30 mg/day should be avoided.

In conjunction with glucocorticoid boluses of 1 g/day, infliximab should be used as a first-line drug for remission induction.


An 18-year-old patient who comes to the emergency department with epistaxis of several days' evolution, with no personal or family history of interest. On examination he is afebrile, multiple ecchymoses are observed, no splenomegaly is palpable. Laboratory tests: leukocytes 7.2 x103/μL, Hb 12.3 g/dL, platelets 6.0 x103/μL. Thrombocytopenia is confirmed in the smear, where platelets of increased size are observed. Coagulation and biochemistry studies are normal. What do you consider the most likely diagnosis?

This is an easy clinical case only presenting thrombopenia with clinic, petechiae and epistaxis. 1 is false, there would be fever, hemolysis data, neurological symptoms, in the smear there would be schistocytes. In 2 the coagulation must be altered and in this case it is not mentioned.


A 45-year-old woman with no history of interest consults for dyspneic sensation of about 4 days of evolution. Examination shows rhythmic tachycardia, without murmurs and pulmonary auscultation is normal. Arterial blood gases showed a pO2 of 70 mmHg and a pCO2 of 32 mmHg. Hemogram, renal and hepatic function are normal. Prothrombin time 90%, activated partial thromboplastin time (APTT) ratio of 2 to control (N <1.2). Which of the following is the most likely diagnosis?

In this clinical case, we are presented with a woman who rapidly presents dyspnea with hypoxemia, a picture compatible with pulmonary thromboembolism. The prothrombin time of 90% and the aPTT with a ratio of 2, is translating a coagulation problem; and antiphospholipid antibodies can be detected through the prolongation of phospholipid-dependent coagulation tests, correct answer 1. On the other hand, although factor V Leiden has been identified as a common cause of familial thrombosis, it would not alter the clotting time. In the case of hemophilia there would be a problem in blood coagulation but it is not a frequent cause of thromboembolism. Finally, although acute pericarditis could manifest itself in 4 days and with tachycardia, the rest of the symptoms or analytical parameters are not characteristic.


A 35-year-old man comes to the emergency department with pain in his right eye of 3 days' evolution. Biomicroscopic examination of the anterior segment shows, after fluorescein staining, a central corneal ulcer in the form of a dendrite. What is the diagnosis?

Dendritic corneal ulcer is typical of herpes simplex keratitis. It presents with pain, not too striking, and scarce or absent red eye. There are ulcers resembling dendrites that may confuse us in the diagnosis. These pseudodendrites are found in herpes Zoster and in corneal abrasions in resolution. Although in practice we should pay attention to the shape of the dendrite (the true dendrite is deeper and has terminal bulbs at the end of each branch), and pay attention to the evolution of the pain (in the pseudodendrite after abrasion the pain should improve), when answering a MIR question it is simpler: if it is a dendrite, the first thing we have to think is herpes. Fungal and bacterial keratitis have corneal infiltrates. And glaucomatocyclitic crisis (Posner Schlossman syndrome) is a type of idiopathic hypertensive anterior uveitis, which does not present with ulceration.


A patient undergoing chemotherapy for leukemia is admitted for pneumonia for which treatment with cefepime has been prescribed. A chest X-ray/CT scan shows an infiltrate with halo sign and crescentic meniscus. The lesion is peripheral and a transthoracic puncture is indicated for sampling. Pending definitive histologic and microbiologic results, what antimicrobial would you add to the treatment?

Direct response question. This is a patient undergoing chemotherapy with respiratory symptoms and the "halo sign" on X-ray, very suggestive of invasive pulmonary aspergillosis. Treatment is with voriconazole. Aspergillus is resistant to fluconazole, so it would not be a valid option.


A 5-month-old infant exclusively breastfed until the present, who due to maternal work was introduced a bottle with formula and a few days ago was added cereals with and without gluten. Family history: 28-year-old mother with asthma, 32-year-old healthy father and 5-year-old brother with celiac disease and atopic dermatitis. As personal history, pregnancy without incidents and delivery by cesarean section, having been offered a bottle with starter formula on the first day of life in the maternity ward. Since a few days ago she starts with abdominal distension, diarrhea stools, refusal to feed, peribuccal erythema with longer duration after bottle feeding and lately vomiting after feeding, tolerating well the breast. What is the most probable diagnosis?

Child with multiple family history of allergy (asthma, atopy), who has received artificial milk in the first hours of life (sensitization to cow's milk protein) and who, coinciding with the intake of artificial milk, starts digestive symptoms and exanthema = APLV.


Given a patient with poor general condition, fever (axillary temperature 39.5º), bilateral submandibular swelling of six days' evolution, mouth pain and trismus, which of the following statements is correct?

This patient is in serious condition. The trismus and fever suggest a deep cervical space infection and that is not a game because the airway can become obstructed. Knowing this, options 1, 2 and 5 are out of place and I am left with 3 and 4. There may already be mediastinitis; after all, that is the natural history of cervical deep space infections, but answer 4 is more correct and besides, we are in the ENT block, the airway specialty. I like this question because it requires knowledge that is important in clinical practice.

The first diagnostic probability is carcinoma of the floor of the mouth with bilateral cervical metastases.

The therapeutic priority is to ensure the patient's nutrition.

We are almost certainly facing a mediastinitis.

We must consider as a priority the risk of airway obstruction.

We must perform as a first diagnostic measure a cytology by fine needle aspiration puncture.


What is the most likely diagnosis of a newborn with microcephaly, intrauterine growth retardation, congenital heart disease, vertical talus foot and a peculiar facies (microphthalmia, small palpebral fissures, micrognathia and dysplastic ears), hands with the index and little finger above the middle and ring fingers?

You are faithfully describing an Edwards' syndrome. Although the cardiopathies and the alteration of the foot that he describes are common to several chromosomopathies, the alteration of the fingers and toes is very characteristic of Edwards' syndrome.


A 3-year-old girl from Bangladesh consults for intermittent febrile episodes of 3 weeks' duration, associated with weakness and loss of appetite. Physical examination showed marked splenomegaly and mucocutaneous pallor. Complementary tests include: hemoglobin 8.5 mg/dL, hematocrit 26%, MCV 86 fL, MCH 29 pg, leukocytes 2800/mL with 300 neutrophils /ml, platelets 54000/ml, GOT 85 U/l, GPT92 U/l and polyclonal hypergammaglobulinemia in serum proteinogram. Indicate the most probable diagnosis with the data available at this time:

Data such as pancytopenia and hypergammaglobulinemia are very characteristic of kala-azar. The origin of the girl is also indicative of this diagnosis, although it is a disease that also occurs in the Mediterranean area. In the differential diagnosis, it is important to keep in mind the possibility of leukosis.


A 59-year-old woman with a personal history of breast cancer operated on 8 months ago and osteoporosis, suffers a fall and has a fracture of the neck of the right femur. She undergoes surgery and remains in the hospital resting in a cast for 10 days. A week after her discharge, she suddenly feels short of breath, which leads her to consult her family doctor who notices that her right calf has edema and pain on palpation. Which clinical elements would NOT be important in determining that she is at high clinical risk for pulmonary thromboembolism?

The other antecedents and findings are very directly related to the increased risk of thrombotic phenomena. Osteoporosis is not a risk factor for thrombosis.

History of having been at rest for more than 3 days.

Presence of unilateral edema of the right calf.


A 54-year-old patient is admitted for thermometric fever of 38°C in the previous five days and dyspnea at rest (LV) that appeared 6 hours before coming to the hospital. Examination in the emergency room was compatible with heart failure and the ECG showed complete atrioventricular block with an escape ventricular rate of 45 bpm. Signs of heart failure are refractory to medical treatment and transesophageal echocardiography shows an aortic valve with an effective regurgitant orifice of 0.5 cm2_ Serial cultures are positive for Streptococcus gallolyticus. Indicate the best course of action:

Cardiac surgery for aortic valve replacement by mechanical prosthesis with antibiotic therapy according to antibiogram.

Antibiotic therapy according to antibiogram and implantation of intra-aortic balloon counterpulsation and transient pacemaker for up to 3 weeks, after which a permanent pacemaker will be implanted.

Implantation of transient pacemaker, antibiotic therapy according to antibiogram and percutaneous implantation of aortic valve prosthesis.

Urgent implantation of definitive pacemaker with antibiotic therapy according to antibiogram for 6 weeks.


A 32-year-old asymptomatic woman goes for a gynecological health check-up because she wishes to become pregnant. During this check-up, a 4cm uterine myoma is detected, partly intramural and partly subserosal, located on the anterior aspect of the uterus and which does not deform the endometrial cavity. What approach would you recommend?

The correct answer is 5. An asymptomatic myoma of this size that does not deform the endometrial cavity is not a problem for pregnancy.

Myoma embolization by arterial catheterization.

Treatment with Gn-Rh analogues for three months before attempting pregnancy.

Attempting pregnancy without any previous treatment.


A 60-year-old patient diagnosed with breast neoplasia 10 years ago. She underwent treatment with radiochemotherapy and then hormonal therapy for 5 years. A bone scan study performed for polytopic bone pain showed the presence of bone metastases. She is currently under treatment with minor opioids and NSAIDs with good pain control. She consulted for headache that did not subside with the current analgesia and a CT scan of the brain showed images compatible with brain metastases. In relation to the treatment of pain, indicate the CORRECT one:

Brain metastases produce pain due to cranial hypertension. The treatment of choice is corticosteroids. Dexamethasone in oral doses of 4 to 16 mg/day is the treatment of choice.

Extra doses of opioids should be administered as necessary.

Switch to a major opioid and maintain NSAIDs.

The patient should be admitted for intravenous treatment with major opioid.


A 24-year-old woman, primigestation, suffers a spontaneous abortion at 7 weeks of gestation. The anatomopathological study of the abortive remains indicates molar disease. We should inform you that:

Gestational trophoblastic disease should be followed up (regardless of whether the evacuation has been complete or not) and the patient should be advised not to become pregnant again until at least 6 months with negative BHCG titers. The risk of recurrence in another pregnancy is low (1/55) and 90% of cases progress satisfactorily without developing neoplasia.

The risk of a new molar gestation in a future pregnancy is 50%.

She should not become pregnant until she has undergone periodic controls and has spent one year with negative BHCG levels.

Subsequent controls are not necessary if the evacuation of the trophoblastic tissue was complete.

It is necessary to carry out periodic controls since 40% of the cases will develop a gestational trophoblastic neoplasia.


A 24-year-old woman consults after noticing inguinal lymphadenopathy. The interrogation does not reveal any local discomfort or data suggestive of sexually transmitted infection. The examination revealed two lymphadenopathies, one in each groin, 1 cm in diameter, soft, mobile, non-painful. No skin lesions are seen on the lower limbs, anus or perineum. Which test do you consider essential?

The presence of inguinal nodes up to 1-1.5cm may be normal in the absence of symptoms. In this case, they are very nonspecific nodes, without signs of malignancy (mobile, soft, not painful) that do not lead us to suspect neoplastic infiltration and the lack of other clinical signs also leads us to rule out the presence of STD.

A lues serology since it is most likely a Treponema pallidum infection.

A gynecological examination to rule out ovarian cancer.

By the clinical characteristics it seems to be normal lymph nodes and complementary explorations should not be done.

A Paul-Bunell test should be performed to rule out infectious mononucleosis.


79-year-old woman admitted for an osteoporotic hip fracture. Regarding secondary prevention of fragility fractures, point out the WRONG answer:

This question corresponds to the section on traumatology; however, it could be answered with knowledge of rheumatology and with the osteoporosis recommendations of the Spanish Society of Rheumatology. In osteoporosis, one of the main risks associated with increased fracture risk is low adherence to treatment, so answer 1 is correct. Answer 2 is found in the SER guidelines, which confirm that some studies conclude that bone remodeling markers can be useful for early monitoring of adherence and response to treatment. Answer 4 is correct because again in the SER 2019 guidelines they quote: "The current scientific evidence allows us to affirm that neither increasing dietary calcium nor taking calcium supplements alone protects against the appearance of fractures". Therefore, the correct answer to this question is option 3. Patients on pharmacological treatment for OP should use calcium and vitamin D supplements because practically all clinical trials that have demonstrated efficacy of antiosteoporotic drugs routinely include calcium supplements and cholecalciferol (vitamin D3), but not in monotherapy.

Low adherence to treatment is associated with an increased risk of fracture.

Bone remodeling markers may be useful for early monitoring of response to treatment.

Vitamin D monotherapy is effective in reducing such fractures in non-institutionalized elderly.

Increasing dietary calcium or taking calcium supplements alone does not protect against the occurrence of fractures.


A woman diagnosed with type 1 diabetes mellitus for 24 years. She comes to the office with 3 months of clinical evolution of tingling in both feet, with distribution in sock, with paresthetic pain and sensation of hot feet predominantly at night, which significantly interferes with sleep. Which of the following drugs would you use in the first line for the treatment of her pathology?

Duloxetine; the clinical picture described is of diabetic neuropathy. Of the drugs proposed, the first choice would be a dual antidepressant such as duloxetine.


A 78-year-old patient diagnosed with idiopathic dilated cardiomyopathy with mild left ventricular dysfunction (ejection fraction 48%) and chronic atrial fibrillation. Which of the following drugs should be avoided in his treatment?

Digoxin is useful as a symptomatic treatment (it is a positive inotropic) in heart failure, although it does not improve survival. Carvedilol is a very well tolerated aß-blocker (due to its anti-a1 effect) that is associated with symptomatic and survival improvement. Acenocoumarol (Sintrom) would be indicated in this patient with chronic AF to avoid thromboembolic events. Enalapril and ACE inhibitors in general, by inhibiting the renin-angiotensin-aldosterone axis, suppress part of the neurohormonal effects that occur in heart failure; they improve survival in patients with systolic dysfunction. Ibuprofen and NSAIDs in general are contraindicated in patients with heart failure because they inhibit prostaglandin synthesis at the renal level, causing an increase in systemic vascular resistance, reduced renal perfusion, and inhibition of sodium and water excretion, which can precipitate decompensation of heart failure.


The appearance of a high fever of 39°C in a 10-month-old infant that abruptly subsides after 3-5 days, followed by a cephalocaudal morbilliform exanthema with enanthema consisting of reddish papules on the palate, and resolving within a week, associated with good general condition, is usually caused by:

The question of exanthematous diseases that pediatricians and MIR exam takers like so much. By the picture of high fever of several days that suddenly subsides with the appearance of a rash, we have a sudden exanthem, caused by Herpes virus type 6 (remember the mnemonic rule of "sudden Hexanthem"). Parvovirus B19 is the cause of erythema infectiosum or "fifth disease", whose characteristic rash is on the cheeks, giving the appearance of a slapped face. Coxackie A16 causes herpangina and also boca-mano-pie disease, which presents an initially macular rash, which does not respect palms or soles and evolves into bursting vesicles. Finally, EBV infection produces a mononucleosis syndrome with high fever lasting several days, with pharyngeal erythema and grayish exudates on the tonsils. It can present if penicillins are given to treat it (when confused with a streptococcal pharyngotonsillitis) a generalized exanthema. In addition, it also presents with fatigue, hepatic inflammation with increased transaminases and splenomegaly.


An 80-year-old man is admitted for a sudden onset of aphasia and right hemiparesis. His history includes hypertension, well controlled with diet and cognitive deterioration in the last year under study by his neurologist. The emergency cranial CT scan shows a left frontal lobar hematoma without contrast uptake. What is the most probable cause of the hematoma?

Amyloid angiopathy is the most common cause of spontaneous non-hypertensive hemorrhage in elderly patients, and is usually lobar in location (as in the case). They often appear in association with Alzheimer's disease (CTO Manual). The response that may cause the most doubts is 2, hypertension, but the most frequent localizations are: putamen, thalamus, pons and cerebellum. Therefore, most of the time these are deep hemorrhages (CTO Manual). In addition, as a clue it tells us that the patient has well-controlled hypertension without drugs, although this data would not serve to rule out the response. Answer 1, a malformation is typical of young patients, rare in older people. It also decreases the chance of not finding a malformation with contrast-enhanced CT. Answer 4, a brain tumor, does not seem likely since the mass is not seen on CT, and as in the previous case, it is more difficult not to find such a lesion after contrast administration. Answer 3 does not seem correct since vasculitis is a rare entity and more so in older people.

Arteriovenous malformation masked by acute hematoma.

Isolated vasculitis of the nervous system.

Cerebral amyloid angiopathy (congophilic angiopathy).


A 42-year-old woman visits her family physician for gonalgia. Opportunistic use is made of the consultation to assess lifestyles, especially smoking. If you want to follow the health education strategy based on the five "a's" model, which of the following is NOT included in this strategy:

The 5A summarizes the activities that should be performed by healthcare personnel during the brief intervention with the patient to stop smoking and are: find out, advise, analyze, help, accompany or agree. Therefore, the one that is not included in the strategy would be option 2: increase.

Inquire: ask about risk factors and risk behaviors (ask the patient if she smokes).

Increase: increase risk perception to facilitate change (explain the consequences of smoking).

Advise: give clear, specific and personalized advice (advise smoking cessation).

Agree: collaboratively agree on goals for change (assess readiness to make a quit attempt).


65-year-old patient presenting progressive dyspnea of 5 days of evolution until becoming resting, three-pillow orthopnea and episodes of paroxysmal nocturnal dyspnea. Auscultation highlights bilateral crackles, holosystolic murmur radiating to the axilla and gallop rhythm for the third and fourth sounds. Mark the CORRECT statement:

The fourth noise usually appears when there is a certain degree of valvular stenosis.

The third noise coincides with the rapid filling phase of the ventricular diastole of the cardiac cycle.

The most likely diagnosis is heart failure.

The holosystolic murmur may correspond to mitral insufficiency.


65-year-old obese woman who suffers a fall on her hand with her elbow in extension. She presents with arm pain with swelling and functional impotence of the arm and inability to extend the wrist and fingers. It is most likely to present:

We must take into account all the clinical data provided: after trauma we have pain in the arm with soft tissue involvement and the impossibility of extending the wrist and fingers. The only option that includes all the data is 4. Option 1 does not explain the involvement of the wrist and fingers. The elbow dislocation does not explain the lack of finger mobility as well as the diaphyseal fracture of the humerus and double forearm. "Direct mechanism is possible, as is indirect transmission of forces from the elbow and hand...radial nerve involvement is extremely frequent, reaching an incidence of 10-18% of cases." Proximal humerus fracture-dislocation would have greater involvement at the shoulder, elbow dislocation at the elbow, and there is no data to suggest double forearm fracture.

Dislocation fracture of proximal humerus.

Diaphyseal fracture of the humerus associated with double forearm fracture.

Diaphyseal fracture of humerus with radial nerve injury.


A 53-year-old woman with bronchial asthma comes to the allergy clinic for a checkup. She reports repeated exacerbations with nocturnal symptoms, frequent use of rescue medication and dyspnea on exertion when walking on level ground. Spirometry shows a pre-bronchodilator FEV1/FVC ratio of 60% and FEV1 of 55%. Skin tests are positive for mites and total IgE of 150 IU/ml. The patient is being treated with a combination of high-dose salmeterol/budesonide (50/500 mg: 2 puffs twice daily), maintenance oral prednisone (10 mg/day) and theophylline. Of the following options, which is the most advisable therapeutic approach?

The indication of omalizumab in a patient such as the one referred to is a correct indication, although in severe asthma that is difficult to control, there are other prior measures that are not contemplated and that must always be taken into account before resorting to this treatment. It is mandatory to ensure firstly that it is truly asthma and not another disease that simulates asthma, secondly that there are no complications that worsen the evolution as could be the presence of gastroesophageal reflux, bronchiectasis, presence of opportunistic germs given the chronic treatment with steroids, etc; and thirdly, it is necessary to confirm that the patient complies with the treatments correctly, especially the inhaled treatment, etc. Once all of the above has been checked, it would be time to start a trial treatment with omalizumab.

Increase the dose of prednisone to 30 mg/day.

Switch to a combination with high doses of budesonide and formoterol.


A 67-year-old woman with a history of dyslipidemia, who comes to the ED with dysuria and pollakiuria followed by fever, chills, and deterioration of general condition. On arrival she appears severe and is tachycardic, tachypneic, with blood pressure 60/40 mmHg and temperature of 39°C. Which of the following measures would NOT be included in the INITIAL management?

Among the options presented, the only measure not included in the Surviving Sepsis Campaign guidelines on the management of sepsis and septic shock (like the patient we are dealing with) is the administration of IV dobutamine. The appropriate procedure would consist of fluid administration, blood culture extraction, serum lactate measurement and early administration of broad-spectrum antibiotic therapy directed to the suspected septic focus. If we do not obtain mean arterial pressure for adequate perfusion of the organs, we would initiate noradrenaline perfusion, as discussed in question 51.


An asymptomatic 31-year-old woman (Consultant) is asymptomatic and has a 10-week gestation according to ultrasound study (primiparous). Her younger brother (index case) aged 26 years is affected by ataxia and genetically diagnosed as a heterozygous carrier of an expansive mutation of 70 CAG repeats in the SCA3 gene (chromosome 14). The patient is referred to the genetic counseling office where a possible chorionic villus biopsy to study the fetal genotype is evaluated. Is this invasive procedure indicated as a pre-natal diagnosis (PND) in this case?

SCA3 is Spinocerebellar Ataxia type 3 also called Machado-Joseph disease. It is caused by mutations in the ATXN3 gene by the CAG triplet repeat expansion mechanism. Affected individuals have between 52 and 86 CAG triplet repeats in heterozygosis with complete penetrance. The heterozygous mutation carrier has the disease as its inheritance pattern is autosomal dominant. In this clinical case, the one who has the disease and has the mutated gene in heterozygosis is the brother (26 years old) of the pregnant woman. I think that before doing the chorion biopsy, the pregnant woman should be tested to know her ATXN3 gene status. She has a 50% chance of carrying the mutation and having the disease, but since she is 31 years old, I think she should have already had symptoms. Nevertheless, I would do the genetic test on the pregnant woman to be on the safe side. If she came out without the mutation, there would be nothing more to do because the disease would no longer be transmitted. If she came out with the mutation, then I would do a chorionic villus biopsy. Answers 1 and 2 are both true, but I think answer 1 is more true than answer 2.

It is indicated after studying the Consultant's genotype and only if it is heterozygous.

This is not indicated, since SCA3 ataxia is full penetrance and the Consultant is asymptomatic and therefore has not inherited the mutation.

It may be indicated in the next pregnancy, after studying the genotype of the first child and detecting the mutation in it.

SCA3 ataxia is recessively inherited, so there is no appreciable risk of disease transmission and PND is not indicated.

This is indicated regardless of the Consultant's genotype, since SCA3 ataxia is maternally inherited (transmitted by women).


37-week pregnant woman with positive hepatitis B virus surface antigen. She consults about the guidelines to be followed with the newborn and whether she can breastfeed. What advice do you think is most appropriate?

The correct answer is 4. Children born to HBV carrier mothers should be administered hepatitis B vaccine and immunoglobulin at different puncture sites within the first 24 hours of life. Although the virus is excreted in breast milk, the risk of infection by this route is very low and therefore it is not currently a contraindication for breastfeeding.

Administer hepatitis B vaccine at birth. Artificial feeding.

Vaccination and immunoglobulins should be administered at birth. Breastfeeding from one month onwards.

Immunoglobulins at birth and artificial breastfeeding.

Vaccination and immunoglobulins at birth. Maternal feeding.

Artificial feeding and isolation for 4 weeks.


A patient with obesity (body mass index 38) is referred to your office. In the clinical history the patient refers that he/she has been obese since the age of 17 (currently 36 years old), having been on multiple diets with weight loss ranging from 5 to 10 kg but has subsequently regained weight. The patient is currently on a 1500 Kcal diet (self-administered and not restricted in fat) with a good follow-up of this diet, performing one hour of aerobic exercise 4 days a week. She has lost 3 kg but needs an additional loss of 7 kg more. Given the possibility of adding a drug against obesity, which one would you use to reduce fat absorption?

Orlistat acts by decreasing fat absorption; it is currently the only drug approved for use in obesity.


Indicate the clinical situation that, in relation to hepatitis B virus infection, presents a 5-year-old patient from Nigeria, with normal physical examination and with the following serology against hepatitis B: HBsAg + / ANTI- HBs - / HBeAg - / ANTI- Hbe + / ANTI- Hbc IgM - / ANTI- Hbc IgG +/ DNA HBV +:

Question in which having a table in the head comes out alone discarding options: Option 1: The acute infection would be HBeAg + and ANTI-HBe - . In addition the ANTI-HBec would be IgM type (only for this last data, we would have to discard it in a direct way). Option 2: the correct one. It complies with all the characteristics. Option 3: The vaccinated patient cannot have DNA of the virus (the only thing that positivizes in a vaccinated patient is the AntiBs. IgG type). Option 4: The option that could offer more doubts. In the asymptomatic carrier (chronic carrier / seroconverted) the difference is that there is no viral DNA.


A 35-year-old woman, taking contraceptives, comes to the emergency department with febrile syndrome and paresthesias in the left hemibody. Blood tests show Hb 7.5 g/dL, platelets 7,000/microl, normal leukocytes with normal differential count, LDH 1,200 IU/l, reticulocytes 10% (normal 0.5-2%), undetectable serum haptoglobin, negative direct Coombs' test and peripheral blood smear with schistocytes. Coagulation (prothrombin time and APTT) normal. Which of the following is the most likely diagnosis:

The fear of all on-call hematologists... that you will get a TTP. Because, although infrequent, it is the greatest hematologic emergency.  The clinical case is fairly typical. A young person with fever and neurological symptoms that make him go to the emergency department (he is on the run). Laboratory tests show anemia with evidence of hemolysis (increased LDH and retis, presence of schistocytes in peripheral blood) and severe thrombopenia. In addition, coagulation is normal. To distinguish it from the rest of things (although you should not hesitate...) it tells you that the coombs is negative. As a reminder: URGENT TREATMENT: PLASMATIC REPLACEMENTS. The diagnostic confirmation is the ADAMTS 13 deficit, but treatment is started before having that value, which is not usually done urgently. And, as we all know, these things usually come at night and/or weekends, to make things more difficult....

Evans syndrome (hemolytic anemia and immune thrombopenia).


A 35-year-old woman, taking contraceptives, comes to the emergency department with febrile syndrome and paresthesias in the left hemibody. Blood tests showed Hb 7.5 g/dL, platelets 7,000/microl, normal leukocytes with normal differential count, LDH 1,200 IU/l, reticulocytes 10% (normal 0.5-2%), undetectable serum haptoglobin, negative direct Coombs' test and peripheral blood smear with schistocytes. Coagulation (prothrombin time and APTT) normal. Which of the following is the most likely diagnosis:

The patient presents criteria for Thrombotic Thrombocytopenic Purpura (TTP): 1. Neurological alteration. 2. Febrile syndrome (fever). 3. Coombs negative migroangiopathic hemolytic anemia (presence of schistocytes). 4. Thrombopenia.


A 45-year-old woman with a history of heart murmur detected in childhood. She is admitted to the emergency department for palpitations, easy fatigue and malleolar edema. Physical examination revealed absence of cyanosis. Oxygen saturation by pulse oximeter 97% BP 120/80 mmHg. Irregular heart rhythm at 100 bpm. Ejective systolic murmur (2/6) in pulmonary focus. 2nd unfolded noise, wide and fixed. No rales. Slight hepatomeglaia (2-3 cm). Slight malleolar edema. ECG: complete arrhythmia due to atrial fibrillation at 100 bpm. QRS +120º. Conduction disorder of the right bundle branch of the His bundle. What is its diagnostic orientation?

If he has a pediatric murmur, I'm thinking congenital. Hepatomegaly, malleolar edema and BRD, something that overloads the right heart. So we rule out aortic and mitral stenosis. A patent ductus would give cyanosis: ruled out. VSD or ASD? If I am told that he has AF, it is because the atria are of size XL, and a VSD does not produce atrial dilatation.


What examination would you advise in the first place for an 82-year-old patient with exertional angina and a systolic ejection murmur of intensity 3/6 on auscultation?

Ejective murmur, our first suspicion is aortic stenosis. Angina may be due to the stenosis itself or to underlying coronary artery disease (probable, given the age). And with this information, we cannot know if the stenosis is severe. Therefore, the first thing we will have to do will be to study the valve disease: we do not want to put the patient to run or overload him with dobuta and have a syncope, nor do we want to do a catheterization without having first performed another noninvasive test. And cardioTC, in someone 80 years old, is going to tell us what we already know: that he has calcium up to his eyebrows.


In a 70-year-old diabetic man with a history of ischemic heart disease, what is the therapeutic target for LDL cholesterol and glycosylated hemoglobin (Hb A1c)?

Diabetes with ecv ldlc<70.


A 25-year-old man with no known history of interest. He has been presenting with foamy and loaded urine for 2 months, with no other symptoms. Physical examination without findings. Elemental urine: pH 5; glucose negative; hemoglobin ++; protein ++; leukocyte esterase negative; proteinuria 1.5 g/24 hours; urinary Na 60 mEq/L; urinary K 30 mEq/L; urinary Cl 100 mEq/L. Blood biochemistry: creatinine 1.6 mg/dL; urea 80 mg/dL; Na 140 mEq/L; K 3.8 mEq/L. Immunological study: antiDNA negative; ANCA negative; antiMBG negative, rheumatoid factor negative; C3 20 mg/dL (normal 60-120); C4 10 mg/dL (normal 20-40). A renal biopsy is performed. Which of these diagnoses do you think is the most likely to be found in the biopsy?

We are presented with a lot of analytical data but we only have to look at two: the levels of complement fractions C3 and C4 are low. Of the options given, only membranoproliferative glomerulonephritis presents with hypocomplementemia (option 4 correct).

Glomerulonephritis with minimal changes.


A 72-year-old man, ex-smoker, hypertensive and diabetic. History of stroke with residual paresis in the left arm 4 months ago. He comes to the emergency department of a regional hospital with intense precordial pain of 2 hours of evolution; in the physical examination he presents cold and sweaty skin, blood pressure of 80 mm Hg; electrocardiogram with marked ST segment elevation in leads V1-V6, I and aVL. Which of the following treatments of coronary repercussion is the most appropriate?

This question combines several important facts. To begin with, this is a patient with an extensive anterior and lateral AMI, with cardiogenic shock. On the other hand, in the history, we are told that the patient had a stroke 4 months ago. It is evident from the patient's clinical picture that an urgent reperfusion strategy is indicated, which invalidates options 4 and 5. The basic question is whether to choose fibrinolysis (which can be done in a regional hospital) or PCI (for which the patient should be referred to a tertiary center). Option 2 does not make much sense, since in the event that fibrinolysis is indicated, it would only be a waste of time to make the transfer. A history of stroke (presumably ischemic) 4 months ago is a relative contraindication for fibrinolysis (if the time is less than 3 months it is an absolute contraindication), but the definitive factor that tips the balance towards PCI is the extent of AMI and the presence of shock, which are indications for urgent PCI. Therefore, the correct answer is 3.

Immediate systemic fibrinolysis at the regional hospital.

Immediate transfer to a tertiary center for treatment with fibrinolysis.

Immediate transfer to a tertiary center for percutaneous coronary revascularization procedure.

Hemodynamic stabilization and deferred revascularization procedure.

Immediate treatment with fondaparinux and abciximab.


A 79-year-old patient is brought to the ED at 7 pm from a nursing home, but we do not have the referral report and therefore do not know his history. He is disoriented in time and space. He has trouble remembering simple information. Sometimes he becomes very nervous and agitated, because he sees threatening people, even when he is alone. At other times he appears drowsy and inattentive. The main data supporting the diagnosis of delirium as opposed to dementia is:

Little to comment.... is the definition of delirium. Altered state of consciousness.


46-year-old woman with a history of rheumatic valve disease, requiring mitral valve replacement with a mechanical prosthesis. The initial postoperative evolution is favorable. However, after starting treatment with acenocoumarol, she develops a picture of skin necrosis affecting the abdominal region and extremities. Which of the following alterations would justify this picture?

Warfarin-induced skin necrosis is a rare and serious adverse effect of oral anticoagulant therapy, occurring in only 0.01 to 0.1% of patients and is especially related to coagulation protein C and S deficiency.


A 36-year-old man with no past history of interest who, after a high-energy trauma following a fall from a motorcycle, presents with a Gustilo grade II open midshaft fracture of the tibia. Which of the following maneuvers or therapies is most effective for preventing infection?

I believe that the most correct is 2, since Gustilo II fractures are mainly covered with Gram (+) by means of a 1st generation Cepha, and it is not a question of prevention but of treatment (it is considered to be contaminated).

Immediate intravenous broad-spectrum antibiotherapy.

Exhaustive debridement-wound lavage in the operating room with at least 10 liters of saline.

Urgent stabilization of the fracture by external fixation and early wound closure.

Early wound closure with antiseptics and oxygen therapy at two liters per minute.


A 52-year-old woman comes to the emergency room with bilateral paralysis of the upper extremities that had started abruptly two hours earlier. In the interview she is smiling and says she does not understand why her family is so worried. The family refers that the day before her son had been arrested by the police for drug trafficking and they had not yet been able to contact him. Which of the following is the most likely diagnosis?

The nice word to describe this is: "Belle indeference", this woman shows herself with an elegant indifference to a paralysis. The diagnosis.... can be excluded 2,3,4 because the clinical does not match: no delirium, no worry, no sadness. 1 would be if he was making a profit, if he was knowingly simulating and to make a profit he was faking his illness. This is not the case. Conversive would be if the symptom wanted to transmit something to us, that is to say, it was a metaphor of its internal world... The most exact in this case: 5.


A patient with a history of excessive alcohol consumption has been diagnosed with pulmonary tuberculosis due to cough, fever, expectoration, and sputum culture isolation of Mycobacterium tuberculosis. The patient started treatment with isoniazid, rifampicin, ethambutol and pyrazinamide, with adequate tolerance. Twenty days after starting treatment, a report of rifampicin resistance of M. tuberculosis isolated in sputum is received. Which regimen would you select based on this report?

Another question that may generate discussion. When a diagnosis of active tuberculosis infection is made, treatment is initiated with isoniazid, rifampicin and pyrazinamide together with ethambutol in case of suspicion of strains resistant to any of the drugs. Once the existence of resistance has been ruled out, ethambutol can be dispensed with. In case of resistance to rifampicin, rifampicin is withdrawn and treatment is completed with the 3 remaining drugs for 12 months. The option of adding a quinolone during the first two months of treatment (moxifloxacin or levofloxacin) is considered in cases of extensive pulmonary involvement. In this case, they do not tell us anything about extensive pulmonary involvement but they give us a data "excessive alcohol consumption". You know that in the MIR no data is free, and if the person who posted this question wanted to reflect it, probably his intention was that we reflect on it. Alcohol exerts a direct immunosuppressive effect, moreover, alcoholism is related to the affectation of immunity in the respiratory tract. The social context that usually accompanies the alcoholic patient does not help either. All the factors mentioned above make us lean more towards answer number 3, although it is undeniable that number 1 could also be correct.

Isoniazid, ethambutol, pyrazinamide for 12 months.

Isoniazid, ethambutol, pyrazinamide for 12 months and streptomycin for two months.

Isoniazid, ethambutol, pyrazinamide for 12 months and a quinolone for two months.

Isoniazid, ethambutol, pyrazinamide and a quinolone for 18 months.

Isoniazid, ethambutol, pyrazinamide for 18 months and streptomycin and a quinolone for 2 months.


A 47-year-old man, with a history of a right parotid pleomorphic adenoma, treated with surgery (extrafacial parotidectomy) 6 months ago, who comes to our office for presenting pain with sweating and reddening of the skin in the preauricular region during chewing. Which treatment would be the treatment of choice?

This clinical picture is called Frey's syndrome and consists of an anomalous reinnervation of regional structures after parotidectomy due to lesion of the auriculotemporal nerve, so that during mastication, erythema and preauricular sweating occur. The treatment is intradermal botulinum toxin injection.

Extended total parotidectomy on suspicion of tumor recurrence.


A 58-year-old woman, weight 130 kg, height 155 cm, body mass index > 30 with mild hypertension, blood glucose 108 mg/dL and absence of edema in the lower limbs. Blood analysis showed Cr 2.0 mg/dL, Urea 86 mg/dL, Alb 3.8 g/1, Na 142 mEq/L, K 4 mEq/L. In urinalysis: sediment without alterations and in 24 h urine proteinuria of 6.3 g/24 h. Which of the following entities is more likely to be present?

The correct answer is: 2. Focal segmental glomerulonephritis. We are in front of a patient with renal insufficiency whose manifestation is a proteinuria. That places us in the picture of nonproliferative GN (membranous, focal and segmental and minimal changes, discarding the other two). If we also consider that the patient was obese, slightly hypertensive, the most probable is that it is a focal segmental glomerulonephritis.


A 75-year-old patient with significant gonarthrosis with "Genu Varo" that causes marked functional impotence, limited mobility and continuous pain that requires continuous antirheumatic, anti-inflammatory and analgesic medication. What treatment should be indicated in this case?

We are dealing with a patient who has exhausted the pharmacological route given that he takes everything and has two important problems: genu varum and an important gonarthrosis. This means that we can do nothing with an arthroscopy, let alone a synovectomy (1 and 5 false). The genu varum could falsely make us think about an osteotomy, however even if we did it and corrected the varus now the damage is already done and the osteoarthrosis is severe. Perhaps years ago before the osteoarthritis took place it would have been resolutive but not now (4 false). In addition, in order to consider an osteotomy, we should be given more data to know which bone to apply the osteotomy on, the tibia or the femur. Finally, we may think that it is best to first try rehabilitation before considering surgery, but I discard this option because the question emphasizes that we have exhausted pharmacological measures (although it could be considered because they have not specified whether it has been tried or not). In any case with the knee prosthesis we correct the problem of osteoarthritis pain and we can also correct the knee varus.

Abduction supratuberosity tibial supratuberosity tibial osteotomy.


A 33-year-old man, independent in all activities of daily living, with a history of well-controlled hypertension, antiplatelet atrial fibrillation and an adenocarcinoma of the prostate at 73 years of age, currently free of disease. He is brought to the emergency department for clinical aphasia and right hemiparesis of sudden onset, 45 minutes earlier. What is the most correct approach?

The patient suffers an abrupt neurological deficit probably related to a vascular event, so first we will have to perform a cranial CT scan to rule out a hemorrhagic stroke. If the CT scan does not show bleeding, the patient has an acute ischemic stroke, probably cardioembolic due to his cardiac pathology, not anticoagulated. Given that his tumor process is under control, there are no contraindications for the administration of fibrinolysis in this case, since the patient is in a good baseline condition. Although the patient is 88 years old, age is no longer presented as an absolute exclusion criterion, but the general situation of the patient must be taken into account and in this case it is specified that he presents a good baseline situation.

Perform a cranial CT scan and if there are no hemorrhagic lesions or other contraindications in the analysis, start immediate intravenous thrombolysis.

Perform urgent cranial CT scan and if there is no bleeding, start anticoagulation.

Perform cranial CT scan and admission to rehabilitation center, since their attitude will not differ regardless of whether the etiology is ischemic or hemorrhagic.

Cranial CT scan is not necessary, although I would withdraw the antiaggregation.


40-year-old patient, with normal physical examination, in whom a mediastinal mass and a hepatic nodule have been evidenced in the CT scan, and in the CBC a serum elevation of lactic dehydrogenase (LDH), human chorionic betagonadotropin (beta-HCG) and alpha-fetoprotein.What is your diagnostic suspicion. What is your diagnostic suspicion:

Very typical too. In the ED it can be diagnosed with a pregnancy test (in males), because it detects that beta HCG in urine. Hepatocarcinoma can elevate (alone) alpha-fetus, seminoma LDH, lymphoma also LDH.

Metastatic extragonadal nonseminomatous germ cell cancer.


A 41-year-old man comes to the clinic with a nodule in the right thyroid, a fine needle aspiration is performed. Cytological analysis will allow us:

I think the correct answer is 5; FNA does not allow a histological study but a cytological one, therefore questions 1, 2 are eliminated. Question 3 seems to have been put as a filler because it is not relevant. Question 4 could raise doubts if you are not a pathologist but the most logical answer is 5 since papillary carcinoma is the most frequent.

Distinguish between follicular adenoma or minimally invasive follicular carcinoma.

Identify the areas of capsular or vascular invasion of the follicular carcinoma.

Recognize G-cell hyperplasia associated with familial spinal cancer.

Distinguish between a Hurthle cell tumor and an oxyphilic follicular adenoma.

Identify the typical cytologic features of papillary carcinoma.


A 22-year-old boy with hyposmia presents with lack of development of secondary sexual characteristics and infertility. Bilateral testicular volume of 4 mL. Analytically, FSH 1.2 U/L (vn 5-15); LH 0.6 U/L (vn 3-15); testosterone 100 ng/diu (vn 300-1200), prolactin normal. Indicate the treatment you will propose to achieve fertility:

Kallman's syndrome or Morsier's syndrome is a congenital insufficiency associated with hypogonadotropic hypogonadism due to a deficit in GnRH hormone production. Repeated injections of GnRH are performed to restore fertility.

Monthly intramuscular administration of triptorelin.

Intramuscular administration of FSH and LH once a week.


A type 1 diabetic who comes to the emergency room for dyspnea and general malaise. The blood test showed blood glucose 450 mg/dl, Na 142 mEq/l, K 4 mEq/l, pH 7.15, bicarbonate 12 mmol/l. Which treatment would NOT be indicated?

Easy question since the treatment of diabetic ketoacidosis is a very repeated topic in the MIR. Bicarbonate is indicated at pH < 7.

Serum glucose 5% iv when blood glucose is less than 250 mg/dl.

Potassium chloride 100 mEq / day diluted in sera.

Sodium bicarbonate 1M 100 cc iv in 30 minutes.

Bicarbonate is indicated at pH < 7.


A 76-year-old woman consults us because she is concerned about her risk of stroke since her mother died of stroke a year ago. She is diagnosed with arterial hypertension and type 2 diabetes mellitus and is being treated with glipizide, aspirin, enalapril and atorvastatin. She smokes 20 cigarettes a day and leads a sedentary life. The examination revealed a blood pressure of 150/80 mm Hg. The blood test shows a hemoglobin A1C of 8% and LDL cholesterol of 110 mg/dl. Which of the following actions is associated with a greater reduction in the risk of stroke?

The most influential cardiovascular factor for stroke in women over 70 is blood pressure.


A 32-year-old man, ADVP and recently released from prison, has a protein derivative skin test (PPD) with 10 mm of induration. One year ago, the PPD was negative, he is currently asymptomatic, his HIV serology is negative, and his Chest X-ray is normal. Which of the following approaches do you think is most appropriate?

In the face of a PPD conversion within 2 years, and ruling out current TB disease, INH chemoprophylaxis is indicated, although I thought it was for 6 months and not 9. The rest is not questionable.

Do not perform treatment and annual Rx control.

Sputum culture for mycobacteria and treat only if positive.

Treatment with RIF and PRZ for 2 months.


A 40-year-old male, foreign tourist, is referred to the ED for low level of consciousness, temperature of 37.7°C and dyspnea. He has no trauma. Several tests were performed. The most immediate is an ABE without oxygen, showing PH 7.33, PCO2 50, PO2 65, HCO3 27:

Actually, it can be all of them, but the most frequent cause of acute uncompensated respiratory acidosis in a young person is bronchopneumonia.


In a 70-year-old man, hypertensive, with a right hemiplegia of sudden onset with mild dysarthria, without alterations in evocation or language comprehension, what type of stroke do you think is most likely to have suffered?

The closest answer is 1. If we are strict we would be talking about a pure motor lacunar infarction (with mild dysarthria). Since the other 3 options do not give us a clinical picture like the one in the statement. Both options 2 and 3 give us a much more florid and extensive clinical picture.

Left capsular lacunar lacunar infarction.

A cortico-subcortical left frontotemporal sylvian infarction.


A 43-year-old man with no diseases of interest comes to the emergency department for 4 melaenic stools in the last 12 hours. He refers taking NSAIDs in previous days. Physical examination revealed pale skin and mucous membranes. BP 95/65 and HR 110 bpm. The abdomen is not painful and rectal examination shows melenic stools. The CBC shows a Hb of 8.1 gr/dl. After infusion of saline and the start of red blood cell concentrate transfusion, the BP was 120/85 and HR 90 bpm. An endoscopy was performed in which clots were found in the stomach and a 2 cm ulcer in the gastric antrum with fibrin background and a small grayish-white protrusion of 3 mm in the center of the ulcer (visible platelet thrombus vessel). What do you think is the most correct approach?

Question about non-varicose ADH. Young patient, with no previous history, who after taking NSAIDs presents bleeding with hemodynamic instability requiring transfusion.  Answer 1 is not in accordance with what has been said, this is an unstable patient who has bled a lot, who has a Forrest IIa ulcer with a high risk of rebleeding. Answer 2 speaks of somatostatin, which is used for bleeding due to portal hypertension. 4 will only be considered if bleeding is not controlled endoscopically. Between 3 and 5, since there is a high risk of bleeding, endoscopic therapy is recommended, preferably with 2 techniques, so the correct one would be 5.

Since the patient is young, with no associated diseases and the ulcer has stopped bleeding, he can be discharged early with treatment with a PPI and H. Pylori eradication.

Remove the endoscope, place nasogastric tube for continuous aspiration and initiate treatment with a PPI and somatostatin.

Take biopsy for H. Pylori, remove the endoscope taking care not to dislodge the platelet thrombus and continue pharmacological treatment with i.v. PPI.

Consultation to the surgical service to consider urgent surgical treatment.

Endoscopic treatment by injection of adrenaline into the ulcer and placement of clips (metal staples) followed by i.v. administration of PPI.


Elderly woman brought to the ER by her neighbors because they see her somewhat groggy and with stool stains on her clothes. BP 100/60 mmHg, HR 100 bpm, sitting 70/30, HR 105 bpm. PVY normal. Kussmaul's respiration. No neurological focality. Weight 50 kg. Lab: PH 7.25, PCO2 14, Bicarbonate 5, Na 133, K 2.5, Cl 118, Creat 3.4, NUS 60, Prot 8. Which of the following answers is correct?

This is a case of hyperchloremic metabolic acidosis with normal anion gap. Severe metabolic acidosis causes myocardial contractile depression, reduced effectiveness of catecholamines, increased incidence of arrhythmias, vasodilatation and increased capillary permeability, with the consequent reduction of tissue flow, at the cerebral level (leading to states of confusion and even coma), at the renal level, at the hepatic level... These patients frequently present intense tachypnea (Kussmaul's breathing) in an attempt to compensate for MCA by hyperventilation. We must take into account that, in this case, potassium is decreased, so the most frequent cause (supported by the stains on the dress) would be diarrhea, so it is most likely that their renal failure (although they do not give us urine ion data to confirm it) is of prerenal type. The treatment would be water and electrolyte replacement and, in principle, unless the patient worsens and the pH is less than 7.10, we should not administer bicarbonate.

ANESTHESIOLOGY, CRITICAL CARE AND EMERGENCY MEDICINE

The presenting acid-base disorder is a respiratory acidosis.

Compensation to correct the acidosis is inadequate.

With this exploration, we rule out that she is dehydrated.

In any case, we should not put bicarbonate.

She has an acute renal failure of prerenal cause.


A 7-year-old girl who comes for consultation because her parents notice her red face since the previous day and in the last few hours they have noticed red spots on her body. On examination she is afebrile, with tonsils and ears without alterations, normal cardiopulmonary auscultation. He presents a confluent maculo papular rash on both cheeks, respecting the upper lip, resembling a "slapped" face. In the thorax she presents a reticular, lacy, non-pruritic exanthem. What is the most probable clinical diagnosis?

Although this question straddles the line between derma and pediatrics, we would like to do our bit. We are being told about erythema súdenita or fifth disease (also called megaloerythema), caused by parvovirus B19. It is typical that after an episode of high fever an erythema appears on both cheeks in the form of a "slap" that usually has a cranial-caudal extension in the following days.


A 40-year-old male patient, smoker since he was 18 years old, with no history of interest. He consults for symptoms of 24 hours of evolution of chills, thermometric fever of 39ºC and cough with expectoration. Chest X-ray shows an increased density with alveolar pattern in the LSD and the patient is diagnosed with CAP. What is the most frequent etiological agent and therefore of obligatory coverage when choosing empirical atb treatment?

This is a fairly easy epidemiology question, in adults without other data, Pneumococcus is the 1st.


What is the treatment of choice for a 38-year-old man diagnosed with Cushing's disease in relation to a pituitary macroadenoma of 22 mm in diameter?

Although the majority of ACTH-producing adenomas recur, surgery is always the first therapeutic option. The available medications (ketoconazole, somatostatin analogues) are aimed at decreasing the effects of excess cortisol or decreasing ACTH release, but they are not curative.

Initially try medical treatment and, if not effective, resort to surgery.

Selective surgical resection of the adenoma.

Radiotherapy to try to reduce tumor size.


45-year-old woman, mother of 3 children, attends an early diagnosis consultation. The cervicovaginal cytology is compatible with a high-grade squamous intraepithelial lesion. Which of the following options would you choose?

Colposcopy is indicated for all patients with altered cytology (intraepithelial lesion or suspicion of invasive cancer or HPV infection), as a second level of screening. If lesions are observed in this test, a biopsy of the lesion will be performed. There is no point in repeating the cytology (since this is a screening test, not a diagnostic test), performing a hysterectomy for an intraepithelial lesion that has not been confirmed by biopsy is not indicated either, and performing curettage of the endometrial cavity does not provide information since the lesion is from the cervix.

Hysterectomy with bilateral salpinguectomy and ovarian conservation.


A couple with a first male child (index case) with cystic fibrosis (mucoviscidosis) come for genetic counseling. Molecular diagnosis indicates that the index case is homozygous for the F5O8del mutation and his parents are heterozygous carriers. The clinical geneticist will inform them about the mode of transmission of the disease. Which statement is correct?

Both parents are carriers of a mutation (because they are not sick and have already had a homozygous child), and the next offspring has a 50% chance of receiving the mutation from each parent, so the probability of receiving it from both is 50%x50%=25%.

The probability that the next offspring will be affected is 25%.

The probability that the next offspring will be affected is 50%.

Having had an affected child, the next offspring will also be affected.

Having had a homozygous F5O8del child, the next offspring will be heterozygous carriers (67%) or homozygous genotype without the mutation (33%).


A 68-year-old woman who uses +4.00 diopter glasses for distance vision in both eyes. She consults because she has been having eye pain with headache and blurred vision at night when she is watching television in dim light for a few weeks. Which of the following pathologies is she most likely to have?

We are presented with a 68-year-old female patient. At that age the crystalline lens, although it does not normally have a cataract that needs surgery, it usually has increased in thickness. This implies that it projects the iris forward and reduces the depth of the anterior chamber. In an eye with a normal anterior chamber depth this is usually not a problem. But farsighted people already have a narrow anterior chamber. This is the usual combination we find in primary angular closure: farsightedness and age over 50-60 years. Younger hyperopes usually do not have this problem yet. And neither do older people who are emmetropic, myopic or have had cataract surgery. With this narrow angle, what triggers angular closure is mydriasis. That is, when you are in the penumbra, the pupil dilates and the iris thickens in the peripheral part, where it is already very close to the corneal endothelium in the case of a narrow chamber. Mydriasis then triggers angular closure, which is accompanied by ocular pain that may radiate backwards (headache). And increased intraocular pressure produces corneal edema that causes blurred vision. Therefore, option 1 is correct. Migraine does not have to be related to penumbra, and ocular pain and blurred vision is not particularly typical. Actinic keratitis is caused by exposure to ultraviolet radiation (such as solar radiation), and is not related to hyperopia or to being in penumbra. In addition, the history of exposure is usually clear. And finally, dry eye does not produce these symptoms either: it is more a question of burning, foreign body sensation, heaviness, etc. And it is also unrelated to the other elements: penumbra, hyperopia, etc. As a minor detail, I would have worded the question a little better. It is understood that we are asked which pathology is the most probable in relation to the symptoms and the anamnesis. But as it is worded, we are asked about which of the pathologies she is most likely to present, just like that. Actually, a 68-year-old woman is very likely to have dry eye, even if it does not cause the symptoms for which she is presenting.


A 26-year-old man with no history of interest, asymptomatic, presents on examination with a mesosystolic murmur in the aortic focus and left parasternal border that increases with the Valsalva maneuver. BP and peripheral pulses are normal and the ECG shows signs of marked left ventricular enlargement and very deep negative T waves in V3, V4, V5 and V6. What is the most likely diagnosis?

A young male patient with an aortic systolic murmur that increases with the Valsalva maneuver and signs of left ventricular enlargement is practically a "portrait" of the typical findings that can be found in hypertrophic cardiomyopathy. Very easy question.


65-year-old man who consults for dysphagia to solids since two months ago. Esophagoscopy shows a tumor 30 cm from the dental arch, partially stenosing, with pathological anatomy of squamous cell carcinoma. Endoscopic ultrasound and PET-CT scan were requested where no pathological lymphadenopathies were observed. Which of the following options would be the most correct?

Preoperative chemoradio in all the guidelines.

Esophagectomy according to the Ivor-Lewis technique.

Chemotherapy plus preoperative radiotherapy.


A patient diagnosed with bronchial asthma who is being treated with low-dose inhaled steroids (200 micrograms of budesonide every 12 hours) and rescue medication (salbutamol on demand) comes for periodic clinical monitoring. The patient reports that in the last 3 months he has had no exacerbations and that he uses salbutamol once a day. He only has dyspnea when climbing stairs and some nights he sleeps irregularly due to coughing. Which of the following therapeutic options should be considered as the treatment of choice?

Asthma treatment algorithm. We rule out continuing with the same treatment since the patient is symptomatic.

Increase the dose of inhaled corticosteroids to 800 micrograms/day.

Maintain the same pharmacological regimen.

Switch to ocmbined therapy with low-dose inhaled corticosteroids and long-acting beta2-adrenergics.


13-year-old female, with no relevant history, with menarche 3 months ago, followed since the age of 10 years for idiopathic scoliosis that has worsened. In the physical examination she presents a hump of 7 degrees in the Adams test and in the scoliogram a T4-L1 thoracolumbar curve of 35 degrees of Cobb and a Risser 0:

Treatment with a brace in Risser from 0 to 2 can be considered since there is still growth to occur and correction can take place. Its use is considered for curves between 30-40º.

Recommend swimming and review in three months.

Refer to physiotherapy for spine elastification.