A 34-year-old man referred to the clinic for persistent LDL cholesterol levels above 250 mg/dL. The patient is asymptomatic but on examination there are whitish indurated spots on elbows, knees and eyelids. His BP is 135/85 mmHg. Her father died of myocardial infarction at the age of 48 years. The fasting blood test shows a total cholesterol of 346 mg/dl, LDL cholesterol of 278 mg/dl, HDL cholesterol of 42 mg/dl, triglycerides of 130 mg/dl and glucose of 93 mg/dl. Regarding the disease from which this patient suffers, one of the following statements is FALSE. Point out which one:

This is a heterozygous familial hypercholesterolemia. We must know how to recognize the disease and know the criteria. It seems to me to be of high difficulty.

It is an autosomal codominant hereditary disease, with a high penetrance, so it is frequent that some of the parents and siblings of the individual also suffer from it.

The genetic disorder affects the gene encoding the LDL cholesterol receptor and more than 900 mutations have been described.

The genetic disorder also affects the synthesis of triglycerides, causing in the advanced stages of the disease, an increase in triglycerides, which is usually higher than 500 mg/dl.

Untreated males have a near 50% chance of a coronary event before age 60, and women with the disease have a higher prevalence of ischemic heart disease than the general female population.

Statins are effective in the treatment of the heterozygous form of the disease, but often need to be combined with cholesterol absorption inhibitors to achieve therapeutic goals and disease control.


A 52-year-old woman consults for having noticed during the previous week a yellowish discoloration of the conjunctivae. She does not refer to risky sexual behavior or epidemiological history of risk of viral hepatitis. She does not consume alcohol or hepatotoxic drugs. She reports a one-year history of generalized pruritus, asthenia, dry mouth and absence of lacrimation with no known cause. Rest of the anamnesis without pathological data. Physical examination showed scratching lesions conjunctival jaundice and non-painful hepatomegaly. The patient brings a blood test carried out in his company with the following pathological results: total bilirubin 3 mg/dl alkaline phosphatase 400 UI sedimentation rate 40 mm at the first hour. Indicate which would be the best recommendation to establish the etiological diagnosis of the patient's condition:

A middle-aged woman with Sjögren's-like symptoms (absence of lacrimation, dry mouth), with hyperbilirubinemia, jaundice and hepatomegaly, makes us think of primary biliary cirrhosis. To diagnose it we will use antimitochondrial antibodies (AMA IgG). Therefore, it would be answer 1.


A 39-year-old man who in the last 3 months has had two episodes of wide and involuntary jumping movements of the left limbs, which in about two minutes lead to loss of consciousness. In the neuroradiological study a right frontal expansive lesion suggestive of cerebral glioma was found.How would you classify this patient's epilepsy?

They refer to a partial seizure that is followed by loss of level of consciousness, so strictly speaking it would be a symptomatic complex partial seizure, not a secondarily generalized partial seizure (which occurs when tonic-clonic movements extend to the rest of the extremities). For this reason the most correct option would be two because it does not specify that it is a simple symptomatic partial seizure, but leaves open the possibility that it is a simple or complex symptomatic partial seizure.

Partial secondarily generalized symptomatic.


A 66-year-old man with a history of ankylosing spondylitis of long evolution. He presents proteinuria of 6 grams per day with hypoalbuminemia and edema. In the urinary sediment no hematuria is detected. His plasma creatinine is 1.6 mg/dL and his glomerular filtration rate is 45 mL/min. Glycemia 110 mg/dL. His severe spinal deformity makes it difficult to perform percutaneous renal biopsy. What is the correct initial approach?

The correct answer is: 3. Subcutaneous fat biopsy. Lupus erythematosus, some vasculitides, Goodpasture's disease and other systemic diseases (ankylosing spondylitis is one of them) affect the kidney and condition its prognosis. The appearance of urinary abnormalities or renal impairment of parenchymal cause are indications for renal biopsy, even with proteinuria ranges lower than those accepted in primary nephropathies. The determination of anti-GBM antibodies and ANCAS are helpful for diagnosis, but they do not replace renal biopsy, since they lack prognostic value and do not help to plan treatment. In this case, in which we are led to think that renal biopsy is not possible, we must relate AE to renal failure. In most cases, the relationship is established by an IgA nephropathy, which presents with hematuria, a symptom that claims not to exist in this case. A non-negligible number of patients with evolved AD is amyloidosis, which also matches the patient's symptomatology. Therefore, and given that amyloidosis can be diagnosed with a subcutaneous fat biopsy, it is answer 3 that should be considered valid.

To initiate corticoids for suspicion of minimal change glomerular disease.

Treat with cyclophosphamide for suspected membranous glomerulopathy.

Glucose overload test to rule out diabetic nephropathy.


A 23-year-old woman comes to the emergency department because she is very nervous after an argument with her partner. Her medical history shows several similar complaints in the previous year, two of them after a self-injurious gesture. Frequent conflicts in the couple's relationship, job changes and family arguments are also noted. She says she feels misunderstood by everyone, including the psychiatrists attending her. The diagnosis is:

The woman is 23 years old and is pissed off. She needs support and a lot of emotional education to curb her impulsivity... she feels misunderstood... maybe she is right... The issue is that she cannot stand rejection and has self-injurious gestures. The diagnosis is 1. 3, 4 and 5 are not even close, there is no clinical picture described in the question. Then in real life exploring well almost certainly there would be dissociative and depersonalization symptoms, as well as depressive symptoms... but symptom is not disorder. Why not 2? It could also be very punctilious and spinning very fine... here the discussion is served. I put the criteria of each one and we talk about it,... but the intention of the examiner was the 1 and I see it well defended. It cannot be challenged. - The limit: A general pattern of instability in interpersonal relationships, self-image and self-efficacy, and notable impulsivity, beginning in early adulthood and occurring in a variety of contexts, as indicated by five (or more) of the following items: 1. Frantic efforts to avoid real or imagined abandonment. Note: Do not include suicidal or self-mutilating behaviors covered in Criterion 5. 2. A pattern of unstable and intense interpersonal relationships characterized by alternating between extremes of idealization and devaluation. 3. Identity disturbance: marked and persistently unstable self-image or sense of self. Impulsivity in at least two areas, which is potentially self-harming (e.g., spending, sex, substance abuse, reckless driving, binge eating). Note: Do not include suicidal or self-mutilating behaviors listed in Criterion 5. 5. Recurrent suicidal behaviors, attempts or threats, or self-mutilating behavior. Affective instability due to marked mood reactivity (e.g., episodes of intense dysphoria, irritability, or anxiety, usually lasting a few hours and rarely a few days). 7. Chronic feelings of emptiness. 8. Inappropriate and intense anger or difficulties in controlling anger (e.g., frequent displays of temper, constant anger, recurrent physical fights). 9. Transient stress-related paranoid ideation or severe dissociative symptoms. - The histrionic: A general pattern of excessive emotionality and attention-seeking, beginning in early adulthood and occurring in a variety of contexts, as indicated by five (or more) of the following items: 1. Not comfortable in situations where he/she is not the center of attention. Interaction with others is often characterized by sexually seductive or provocative behavior. 3. 3. Displays a superficial and rapidly changing emotional expression. 4. Constantly uses physical appearance to draw attention to him/herself. 5. Has a way of speaking that is excessively subjective and lacking in nuance. 6. Shows self-dramatization, theatricality and exaggerated emotional expression. 7. Is suggestible, e.g., easily influenced by others or by circumstances. 8. considers his relationships more intimate than they really are.


18-month-old boy, with complete vaccination schedule to date, who consults the Emergency Department for swelling of the right knee after playing in the park, without obvious trauma. In the directed anamnesis, the mother refers that an uncle of hers had similar problems. The ultrasound examination is compatible with hemarthrosis and in the analysis performed only an APTT lengthening of 52″ (normal 25-35″) stands out. What is the most likely diagnostic hypothesis?

In this question they also do not stop dropping clues to throw us headlong into the correct diagnosis. Let's review: a small child who suffers a hemarthrosis without clear trauma. An uncle of his had similar problems, so we suspect hereditary disease. The APTT, which evaluates the intrinsic coagulation pathway (involving factors V, VIII, IX, X, XI and XII) is elongated. Hereditary coagulation problem. We thus discard answers 1, 2 and 5. We are left with von Willebrand's disease and hemophilia A. I consider that the correct answer is 4, hemophilia A, since the inheritance pattern is X-linked and its main clinical manifestation is soft tissue bruising and spontaneous hemarthrosis, without apparent trauma, while von Willebrand disease is characterized by bleeding after surgery or trauma and a prolonged bleeding time with a normal platelet count is characteristic (data not mentioned in the statement).


A 24-year-old man reports progressive asthenia for at least 6 months, hoarse voice, slow speech, drowsiness and swelling of the hands, feet and face. Examination: pulse at 52 beats per minute, abotarada face and dry and pale skin. CBC: mild anemia, cholesterol 385 mg/dL (normal <220), creatinine 1.3 mg/dL (normal: 0.5-1.1), negative proteinuria, TSH 187μIU/mL (normal 0.35-5.5) and Free T4 0.2 ng/dL (normal 0.85-1.86). What strategy do you think is most appropriate?

This is severe primary hypothyroidism. Treatment is with thyroxine. If there is no nodule, neither echo nor FNA is indicated.

Perform a thyroid ultrasound before starting treatment.

Determine free T3 and perform a pituitary MRI.

Treat with L-triiodothyronine and a statin.

Treat with L-Tyroxine and determine antithyroid antibodies.

Perform thyroid cytology prior to treatment.


You evaluate a 66-year-old patient with groin pain accentuated by prolonged standing a few days a month. A plain radiograph of the hips shows narrowing of the femoroacetabular joint space, sclerosis and osteophytes. What is your approach?

We are talking about a 66-year-old patient with pain on some days, pain of an occasional nature. Although the diagnosis is clearly osteoarthritis, it does not lead directly to a surgical indication. The first step is to try conservative treatment (we ruled out the first option). Osteoarthritis is a degenerative process that opioids certainly do not stop, so we rule out option two. Option four can also be quickly discarded: the statement makes the diagnosis and treatment to follow clear: in this case the MRI will not provide us with any information of interest.

I make the diagnosis of coxarthrosis and send to the traumatologist to place a hip prosthesis.

Start treatment with weak opioids that have shown evidence in stopping the progression of the disease.

I insist treatment with paracetamol, explain that the evolution is very variable and the surgical indication depends on the functionality and pain control.

Because of the radiological features described, I need a hip MRI before making a therapeutic decision.


A 30-year-old donkey man undergoes a chest X-ray to formalize an employment contract in a company. The X-ray shows a bilateral interstitial pattern of reticular type, bilateral hilar and mediastinal adenopathies. Bronchofibroscopy with bronchoalveolar lavage is indicated and the cell count shows the following results: lymphocytes 50%, histiocytes 40%, eosinophils 2%, polymorphonuclear 8% and CD4/Cd8 ratio 5 What is the most likely diagnosis?

You are describing sarcoidosis.


A 40-year-old woman consults because she has noticed a lump in the superoexternal quadrant of the right breast for the past month. She provides a report of a mammography that describes a BIRADS 3 lesion:

The rest of the answers are incorrect. With a BIRADS 3 this is the correct attitude to follow.

Reassure her, since an imaging test has already been done and malignancy has been ruled out.

This classification probably implies surgery, given that the probability of cancer is greater than 10%. He explains it to her and refers her preferentially to the Breast Unit.

This is a probably benign finding, given that there is less than a 2% chance of cancer. He explains that it requires follow-up every 6-12 months until 24 months or a biopsy.

The findings are of low suspicion of cancer (between 2 and 10%) but a biopsy is necessary.


A 58-year-old man comes for a scheduled check-up for type 2 diabetes mellitus diagnosed 6 years ago. He has a personal history of hypertension, dyslipidemia, ischemic heart disease and pancreatitis of biliary origin. His medication includes lisinopril, metoprolol, metformin, ASA and atorvastatin. Physical examination showed blood pressure 151/93 mmHg, BMI 27.1 kg/m2. Glycated hemoglobin is 8.3%. Which of the following is the most appropriate treatment for this patient?

Patient with obesity, hypertension and increased HbA1C. In recent studies, Empaglifozin, a highly selective inhibitor of SGLT210, significantly reduces AT, HbA1C and BMI. Glipizide is of the sulfonylurea group. Its use should be avoided in patients with heart disease. Acarbose can interact with beta-blockers, such as those taken by our patient. Sitagliptin has been shown to decrease HbA1C but not HT or BMI.


A 50-year-old woman comes to the emergency department with asthenia, anorexia, weight loss, jaundice, fever and abdominal pain. She has no recent history of blood transfusion, risky sexual contacts or addiction to parenteral drugs. Habitual consumption of 60 grams of alcohol per day during the last five years, consumption that has increased during the previous month due to family problems. Temperature 38.5ºC, blood pressure 100/60 mmHg. Physical examination showed temporal and spatial disorientation, malnutrition, asterixis, jaundice and painful hepatomegaly. No ascites or evidence of peritoneal irritation. Laboratory tests include leukocytes 15,000/microliter with 90% polymorphonuclear, red blood cells 3 million/mm3, hemoglobin 10g/dl, mean corpuscular volume 115 fl, bilirubin 15 mg/dl direct predominance, AST (GOT) 300 IU/L, ALT (GPT) 120 IU/L, GGT 635 IU/L, prothrombin time prolongation greater than 50%. What is the most likely diagnosis of the patient's condition?

Patient with harmful alcohol consumption (60g and female), high fever, hepatic encephalopathy (disorientation, asterixis), very high direct bilirubin, jaundice, painful hepatomegaly, coagulopathy (elevated prothrombin time) and mild elevation of transaminases (less than 5 times the upper limit of normal) suggest acute alcohol hepatitis.


A 42-year-old married woman with 2 school-age children consults her family physician for a severe headache of about 7 days' evolution. Although she has been having similar episodes for more than a year, in the last 2 months they have worsened considerably. The pain is like a weight that starts in the occipital area, spreads to both temporal regions and is barely relieved by taking 650 mg paracetamol tablets, so she requests a CT scan (she is convinced that "something must be wrong with her head"). Which of the following is the most plausible cause of her headache?

Just as last year they wanted to paint a nurse as bad for waking us up for a patient with myasthenia, this year they entertain us by presenting a patient asking for a CT scan. I interpret that they show a patient stressed by her children with recurrent headaches of occipital location that she previously relieved with a low dose of paracetamol and now she does not. Both the initially occipital location, the 2-year evolution time, and the sensation of weight lead to answer 4, a tension headache. Migraine and vascular disorders, accompanied by other neurological symptoms or nausea, photophobia, etc., are quickly ruled out, as well as the rare temporal arteritis before the age of 50 years. Tumor headache is usually "in crescendo", not recurrent as the case suggests, and is accompanied by other neurological symptoms or intracranial hypertension.


A 27-year-old woman under study in the dermatology department for recurrent episodes of oral aphthous ulcers. She was referred to the gastrointestinal department for a blood test showing Hb 11.5 gr/dl Fe 38 AST 52 ALT 64 Ac antitrasglutaminase IgA 177. The patient reported only occasional diffuse abdominal discomfort. She reports no signs of hemorrhage or jaundice. The physical examination is normal. Which of the following tests do you consider to be the most appropriate to make the diagnosis?

In this question, they give an important piece of information when it comes to suspecting a diagnosis, which is the antitransglutaminase antibodies that must lead you to suspect celiac disease. The rest of the symptoms fall perfectly within the picture and although probably several of the tests that it says will be done, the answer that will give us the diagnosis is 4 (intestinal biopsy).


An 80-year-old woman consults for presenting, since 1 month ago, a progressive increase in abdominal perimeter. During the previous 4-5 months she noted asthenia, anorexia and unspecified weight loss. Physical examination revealed tension ascites and malleolar edema, with no other relevant signs. An ultrasound and CT scan of the abdomen showed the presence of ascites, of homogeneous density, without peritoneal implants or abdominal or pelvic masses. Liver, pancreas, adrenal, spleen and kidneys without significant findings. Paracentesis is performed through a thick needle, obtaining with difficulty a somewhat yellowish, dense and gelatinous fluid. What is the most probable etiology?

The characteristics of the fluid described are milky, i.e., chylous ascitic fluid. Taking into account the age of the patient and the constitutional syndrome described, it is most likely to be a non-Hodgkin's lymphoma and not tuberculosis, which also presents with chylous ascitic fluid, since there is no mention of infectious symptoms. The rest of the entities offered do not present with chylous ascitic fluid.

Hydropic decompensation secondary to liver cirrhosis.

Chylous ascites due to non-Hodgkin's lymphoma.

Peritoneal metastasis of adenocarcinoma.

Ascites secondary to constrictive pericarditis.


A 35-year-old man, a letter carrier, with no history of interest, who comes to the emergency department for acute cervical pain of 24 hours of evolution, without previous trauma, which radiates to the left arm up to the hand and is accompanied by paresthesia in the radial border of the forearm. She presents no objectifiable loss of strength, preserves neck mobility although it is painful and contracture of the paravertebral musculature is appreciated. The first attitude will be:

Cervicalgia without alarm signs. Conservative treatment with a success rate of 75%-90%.

Conservative treatment with nonsteroidal anti-inflammatory drugs, local heat and relative rest.

Urgent call to the neurosurgeon for surgical evaluation.

Preferential request for MRI and electromyogram.

Preferential referral to outpatient traumatology consultations.


A 25-year-old woman presents to the emergency department with ecchymosis and petechiae in the lower extremities and gingivorrhage in the last few days. Her blood count showed the following data: Hb 13 g/dL, leukocytes 8,500/microL with normal leukocyte formula and platelets 9,000/mm3. The determination of coagulation times is normal. Which of the following diagnostic tests should NOT be performed?

The first thing is to know the diagnosis of the clinical case that we are presented with, it is a primary immune thrombocytopenia (ITP), only the platelet series is altered with normal coagulation. The first test to be performed is a peripheral blood smear to check if these platelets are real and there is no pseudothrombopenia due to platelet aggregates. In the enlargement study, antinuclear antibodies (ANA) are requested to rule out autoimmune pathologies that may be the cause of the thrombopenia and another test that would be indicated although in this case the patient is young and does not present signs of seriousness (leukopenia, anemia, no response to first line treatment...) is the performance of a bone marrow aspirate, to see if there are thromboforming megakaryocytes and thus confirm that the platelet destruction is of peripheral origin. But what is not indicated is the determination of the JAK-2 mutation, which is used in the diagnosis of chronic myeloproliferative syndromes, which is not the case here.


A 75 a man is admitted to the hospital because he refuses to eat and has lost 30% of his weight. He has a history of multiple sclerosis which has worsened in recent months. His only family member who was his sister died 3 months ago and since then he has deteriorated. He has become incontinent, has stopped eating and participating in social events. He is suffering from psychotic depression. He is physically able to eat. Psychotropic medication is started and discontinued due to adverse events. If his nutritional status improves it is possible to resume his medications. He refuses intravenous fluids and then accepts them but the IV is started a few hours later. An alternative is to perform a percutaneous endoscopic gastrostomy (PEG) and discharge him to his residence. Which of the following is the most appropriate course of action for this patient?

The correct answer is 1 since the patient is in a situation of psychotic depression and is not able to decide for his life and it does not seem that the patient has filled in the last will and testament, the most convenient thing to do is to present the case to the ethics committee of the center to make a decision on the matter in accordance with the law.

Ask the hospital ethics committee to help determine the decision that is in the best interest of the patient.

Assess whether the residence will take the patient if PEG is not performed.

Enrolling the patient in terminal palliative care.


A 51-year-old man is admitted from the emergency department for macrocytic anemia (Hb 6.3 g/dL, MCV 120 fL). Studies ruled out a deficiency origin. Reticulocytes were 24000/microL. The bone marrow study is compatible with myelodysplastic syndrome (MDS). Cytogenetics shows a 5q deletion. Which is the correct statement regarding this patient?

This is a young patient with no comorbidities and is therefore a candidate for treatment with curative intent, so option 4 is ruled out. Option 3 is also incorrect since we cannot know the patient's IPSS since we do not know the number of blasts and the number of leukocytes and platelets to calculate the risk. Option 2 is also incorrect since the indication for a bone marrow transplant in MDS is those patients with high or intermediate-2 IPSS, and in this case we do not know the risk, the only thing we know about the risk is the cytogenetics which is of good prognosis that would give us 0 points. Therefore the correct one is 1 since it is true that it has a favorable cytogenetics (5q-) and has a specific treatment lenalidomide, also used in other pathologies such as multiple myeloma.

This deletion (5q-) is an alteration of good prognosis and has a specific treatment (lenalidomide).

It would be advisable in this patient to perform HLA typing in order to organize an allogeneic transplant.

This is a patient with a high International Prognostic Index (IPSS).

Treatment in this case would be transfusion only.


A patient with severe COPD comes to the ED with an acute onset and presents an arterial blood gas drawn with Fi02 of 31% at sea level with a Pa02 of 86 mm Hg, PaC02 65 mm Hg, pH 7.13 and Bicarbonate 27 mmol/liter. Which of the following statements is FALSE?

Blood gas analysis shows an acute respiratory acidosis, due to an increase in PCO2 of short evolution time because the kidney has not yet had time to retain bicarbonates (bicarbonate level at the high limit of normality). The patient is not hyperventilating but hypoventilating because PCO2 is elevated. The alveolar arterial oxygen gradient is altered since the patient has a normal PaO2, but because he has a high FiO2. If he were without oxygen, he would be hypoxemic. Respiratory acidosis below 7.20 is a reason to consider noninvasive mechanical ventilation acutely and in principle temporarily in a patient with severe COPD.

The alveolar arterial oxygen gradient is elevated.

Initiation of mechanical ventilation should be considered.


What therapeutic intervention would you consider in a 67-year-old patient with idiopathic dilated cardiomyopathy, left bundle branch block, left ventricular ejection fraction of 26%, mitral insufficiency grade II-III/IV, undergoing treatment with furosemide, spironolactone, enalapril and bisoprolol and who remains in NYHA functional class III?

We are talking about a patient with heart failure with severe LV dysfunction (EF < 35%), LBBB (wide QRS), who is following optimal medical treatment and who remains in advanced functional class despite this. Coronary revascularization does not appear to be of much benefit in this patient at this time. Nor does mitral valve replacement, firstly because mitral regurgitation is most likely the result of mitral annular dilatation, and secondly because we would need an echocardiographic assessment of the mitral valve to determine whether there is any alteration. Intra-aortic balloon counterpulsation implantation would not be indicated in this patient (it is used in situations of cardiogenic shock, in post-AMI mechanical complications, as a bridge to cardiac Tx...). The ventricular assist device would also not be indicated in this patient. What would really benefit him of all the answers is number 5, the resynchronization device. By achieving simultaneous stimulation of both ventricles, a mechanical synergy is achieved that improves cardiac function. The indications for the application of CRT (cardiac resynchronization therapy) are precisely those mentioned at the beginning: severe ventricular dysfunction, asynchrony demonstrated by the presence of wide QRS in the ECG (usually due to LBBB) and advanced functional class (III-IV) despite optimal medical treatment.

Implantation of a ventricular assist device.

Implantation of a cardiac resynchronization system.


A 2-year-old boy, his personal history includes: 3 episodes of acute otitis media, 1 meningococcal meningitis and 2 pneumonias (one middle lobe and one left upper lobe). She has been admitted on 3 occasions for thrombopenic purpura (on three occasions antiplatelet antibodies were negative and bone marrow showed normal megakaryocytes). Several males of the maternal family had died in childhood due to infectious processes. The examination showed typical lesions of atopic dermatitis. The immunological study showed a slight decrease in T lymphocyte subpopulations; elevated IgA and IgE; decreased IgM and IgG at the lower limit of normal. What is the most likely diagnosis?

The correct answer is 1. Wiskott-Aldrich syndrome associates immunodeficiency, thrombopenia and atopic dermatitis with the immunological study described in the statement.

Transient hypogammaglobulinemia of infancy.

Severe X-associated combined immunodeficiency.


A 70-year-old woman with a history of anorexia, weight loss, muscle and proximal joint discomfort and pain in the temporomandibular region comes to the emergency department for unilateral vision loss (hand movement), sudden and painless onset (afferent pupillary defect). What test would you order first for diagnostic purposes?

It is possibly a temporal arteritis, the clinical picture and a CBC with increased reactants are enough to confirm the suspicion. Then an ocular evaluation should be done to rule out AIN, urgent treatment should be instituted (if there is AIN, 3 boluses of methylprednisolone 1 g, if there is not, prednisone mg/kg) and biopsy should be evaluated.


65-year-old male presenting to the emergency department for appearance of cyanotic mottled lesions on the toes of both feet. Personal history: smoking, hypertension and dyslipidemia. Chest X-ray: mediastinal widening. Thoracic-abdominal-pelvic CT angiography: descending thoracic aortic aneurysm 7 cm in diameter, distal to the left subclavian artery and with mural thrombus. Of the following, indicate the correct option:

Thoracic stent implantation is indicated.

Statin therapy is indicated to stabilize the thrombus.

Urgent diagnostic aortography is necessary.

At surgery, the aneurysmal segment is replaced by a tubular prosthesis with reimplantation of the supra-aortic trunks.


Patient 76 years old, parity 3-0-3-1, with menopause at age 52. She reports that for at least 4-5 years she has had vulvar pruritus of variable intensity which has been treated sometimes with self-medication and other times on the advice of her general practitioner with topical preparations (creams and washes). The pruritus has evolved intermittently, but for the last 3-4 months she has also noticed a small lump on the left labium majus of the vulva, which has been leaking serohaematically on rubbing for a few days; she therefore consulted a gynecologist. On questioning, she reports occasional dysuria and her general condition is good. What is the most likely diagnosis in this patient?

The correct answer is 5. Vulvar carcinoma is characterized by chronic vulvar itching resistant to multiple treatments, appearance of lumpiness or ulceration, dysuria and urinary urgency, and late pain and bleeding.


An 80-year-old woman comes to the emergency department with abdominal pain starting in the epigastrium and radiating later to the left iliac fossa. An abdominal CT scan is performed, showing inflammation of the sigmoid walls and a 2 cm mesenteric abscess. The treatment of choice is:

In this question we are presented with a clinical picture whose manifestations are compatible with acute diverticulitis, already asked on numerous occasions previously. A case of acute diverticulitis complicated with small mesenteric abscess (< 2-3 cm) is presented. Abscesses should be drained by CT-guided percutaneous puncture, since the intra-abdominal approach can spread the contents into the abdominal cavity. However, in small abscesses with Hinchey grade I divertciulitis, in patients without great deterioration of the general condition as in the proposed case, they can be managed by conservative treatment with intravenous antiobiotic therapy and absolute diet, therefore the correct option is 1. The urgent surgical approach should be reserved for cases that present peritonitis (grade III, IV) by resection of the affected segment and primary anastomosis in stable patients or carry out the Hartamn intervention that includes resection with terminal colostomy and closure of the distal rectal stump performing anastomosis in a second surgical time.

Admission to the ward with absolute diet and broad-spectrum antibiotic treatment.

Urgent surgery with sigmoidectomy and colorectal anastomosis.


A 78-year-old woman consults for acute vision loss of the left eye. In the last 3 weeks she has presented with fever, pain in the shoulders, neck and hips, and moderate headache. Funduscopy shows a pale and edematous optic disc. Mobilization of the shoulders and hips produces pain. There are no alterations on palpation of the temporal arteries. Laboratory data: hemoglobin 9.7 g/dL ferritin 450 ng/mL erythrocyte sedimentation rate 115 mm/h. What is the most appropriate immediate action in this patient?

The clinical presentation is strongly suggestive of giant cell arteritis (GCA), with febrile fever, shoulder girdle and pelvic pain, and headache. Age and sex also point to this possibility. Abrupt unilateral visual loss with pale papillary edema is highly indicative of arteritic ischemic optic neuropathy due to GCA. The ESR is elevated, which further clarifies the diagnosis. We have to quickly start corticosteroid treatment. We can already rule out 1 and 5 because they do not contribute anything. 4 could make us doubt, and it is true that we will have to ask for a temporal artery biopsy, but that is not immediate: the statement makes it very clear that we have to act immediately. The current trend is to use megadoses of intravenous corticosteroids, and although aspirin has traditionally been proposed to reduce ischemic events, the evidence currently indicates that antiplatelet agents do not contribute much. An oral corticosteroid dose of around 1mg/kg would also be acceptable. Therefore, if we rule out 3 because the dose is too low, we would have to stay with 2. With reservations, since aspirin has a rather dubious role, and the corticosteroid dose remains ambiguous (we do not know how much the patient weighs). Of all the ophthalmology questions, this is perhaps the one most likely to be contested.

Request a Doppler ultrasound of temporal arteries.

Start treatment with prednisone 60mg per day and aspirin 100 mg per day.

Start treatment with prednisone 10 mg per day.

Request a brain magnetic resonance imaging.


A 26-year-old woman, with a history of a pregnancy at the age of 24 years ending in spontaneous abortion in the 12th week that did not require curettage, comes to the consultation presenting daily vaginal bleeding of one month of evolution, without fever or pain. Ultrasound showed an increase in the endometrial lining, with an intracavitary image of polypoid appearance. The endometrial biopsy shows intermediate trophoblast proliferation. Which diagnosis is correct?

It elevates chorionic gonadotropin. It has curative treatment.

It elevates chorionic gonadotropin.


A 60-year-old man with extensive ulcerative colitis of 15 years of evolution and in clinical remission for the last 3 years, comes to our office to be informed about the risk of colorectal cancer and about the possibility of participating in prevention programs. It is correct to inform him that:

Patients with inflammatory bowel disease (IBD) have an increased risk of colorectal cancer, whether or not they are smokers. It is recommended to start screening 8-10 years after diagnosis of IBD (or earlier if primary sclerosing cholangitis or other events occur during this interval). The recommended techniques are colonoscopy with random biopsies (answer 3) and pancolonic chromoendoscopy with staining, which is currently the gold standard because it detects dysplasia better, although it requires more technical experience.

Ulcerative colitis is only associated with an increased risk of colorectal cancer in smokers.

In her case, given that she is in long-term remission, the screening advised to the general population is considered appropriate.

In cases such as yours, it is considered appropriate to undergo periodic colonoscopies with multiple biopsies staggered along the entire colon.

In cases such as yours, screening with periodic fecal occult blood tests is considered appropriate, but with a higher frequency than that used in screening the general population.


A 62-year-old man comes to the hospital emergency department with a fever of 38.3″C and chills. He is tachycardic and tachypneic. Blood tests: leukocytosis with left shift. Blood pressure is 90/60 mmHg. No murmurs are heard on cardiac auscultation and chest X-ray rules out pneumonia. As history of interest she refers repeated urinary tract infections. A week ago the primary care physician prescribed cefuroxime, a drug he is currently taking. Two blood cultures were taken and urine was sent for sediment examination and microbiological culture. The sediment was pathological, with intense pyuria, but negative nitrites. After 24 hours, the microbiology laboratory reported that both the urine and the blood cultures were positive, and the results showed gram-positive cocci grouped in chains, pending identification and antibiogram. Pending the definitive result, what would you recommend?

With the urine nitrite test we detect the presence of nitrites in the urine. These appear due to the presence in the urine of a high concentration of bacteria possessing the enzyme nitrate reductase, which is capable of reducing the nitrates present in the urine to nitrites. This enzyme is active in most of the bacteria that most frequently cause urinary tract infection, such as many Gram-negative bacilli. Other microorganisms, relatively frequent causes of urinary tract infection, do not possess this enzyme and do not reduce nitrates, such as enterococci, staphylococci and yeasts. As the Gram stain indicates that the bacteria are grouped in chains, as this is typical of enterococcus, we suggest the need to cover this group of bacteria with antibiotic treatment. Staphylococci are typically seen on Gram stain as Gram-positive cocci forming clusters and yeasts, although with the same staining, have a different typical morphology than Gram-positive cocci.

Continue with cefuroxime while awaiting the definitive result, since the patient has undergone multiple treatments and we should not make a mistake in his current treatment.

Change to ertapenem, considering the possibility of multiresistant microorganisms.

Switch to a broad-spectrum antimicrobial treatment that covers Enterococcus spp.

Switch to broad-spectrum antimicrobial therapy containing imipenem, considering the possibility of Staphylococcus aureus, since our hospital has a high incidence of methicillin-resistant S. aureus (MRSA).


A patient presents with a long history of multiple physical symptoms: memory loss, headache, dizziness, vomiting, genital pain, limb pain, abdominal distention, and menstrual irregularities. The various medical examinations have ruled out any medical illness. Which of the following is most likely to be the case?

According to ICD-10 the criteria for diagnosing Somatization Disorder (F45.0) are: A. History of multiple physical symptoms, which begins before age 30, persists for several years, and compels seeking medical attention or causes significant impairment socially, occupationally, or in other important areas of the individual's activity. B. All of the following criteria must be met, and each symptom can occur at any time during the disturbance: 1. Four painful symptoms: history of pain related to at least four areas of the body or four functions (e.g., head, abdomen, back, joints, extremities, chest, rectum; during menstruation, sexual intercourse, or urination). Two gastrointestinal symptoms: history of at least two gastrointestinal symptoms other than pain (e.g., nausea, bloating, vomiting [not during pregnancy], diarrhea, or intolerance to different foods). 3. A sexual symptom: history of at least one sexual or reproductive symptom other than pain (e.g., sexual indifference, erectile or ejaculatory dysfunction, irregular menses, excessive menstrual leakage, vomiting during pregnancy). 4. A pseudoneurological symptom: History of at least one symptom or deficit suggestive of a neurological disorder not limited to pain (conversion symptoms of the type of impaired psychomotor coordination or balance, localized muscle paralysis or weakness, difficulty swallowing, lump-in-throat sensation, aphonia, urinary retention, hallucinations, loss of tactile and painful sensation, diplopia, blindness, deafness, seizures; dissociative symptoms such as amnesia; or loss of consciousness other than fainting). C. Either of the following two characteristics: 1. Upon adequate examination, none of the symptoms in Criterion B can be explained by the presence of a known medical illness or by the direct effects of a substance (e.g., drugs or medication). 2. If a medical illness is present, the physical symptoms or social or occupational impairment are excessive compared to what would be expected from the history, physical examination, or laboratory findings. D. The symptoms are not intentionally produced and are not simulated (unlike in factitious disorder and simulation). Everything fits with what is described in the statement. Conversive or dissociative disorder is ruled out because these are usually related to psychological factors, associated with the symptom or deficit (not deliberate). The onset or exacerbation of the condition is preceded by conflicts or other triggers, which is not mentioned in the statement. Neither would it be a hypochondriacal disorder because this implies a preoccupation and fear of having, or the conviction of having, a serious illness based on the personal interpretation of somatic symptoms. But it does not involve physical signs or symptoms.


A 58-year-old woman comes for a follow-up visit for diabetes mellitus and hypertension. She feels well but states that she has stopped taking verapamil because of constipation. She presents with intolerance to ACE inhibitors due to coughing. On examination, blood pressure is 156/92 mm Hg. CBC includes a creatinine of 1.6 mg/dL, 24-hour urine protein excretion of 1.5 g/day, and a creatinine clearance of 45 ml/min. On this basis, what is the most effective treatment to slow the progression of the patient's type 2 diabetic nephropathy?

This question is typical and quite easy. The antihypertensive drugs that have been shown to slow the progression of diabetic nephropathy are the ACE inhibitors and ARAIIs. Specifically, angiotensin II receptor blockers have demonstrated their efficacy in this field for type 2 DM, which together with the side effects that IECAS produce in the patient makes an ARAII the drug of choice. This does not seem to me to be an open question (without going into pharmacoeconomic issues, of course...).

Angiotensin converting enzyme inhibitor.


A 20-year-old woman with a 15-cm solid-cystic ovarian tumor detected by ultrasound after presenting with nonspecific abdominal symptoms. In the histopathological study of the corresponding specimen, teeth, hairs, areas of intestinal epithelium, areas of squamous epithelium (15%) and bronchial epithelium, as well as neuroectodermal and embryonic elements are found in several of the histological preparations. In reference to this case, point out the correct diagnosis:

Teratoma is the most frequent germinal tumor. It presents differentiation in elements of the three embryonic layers: endoderm, mesoderm and ectoderm. Macroscopically they can be cystic or solid, and histologically the tissues composing the tumor can be mature (well differentiated, like adult tissues) or immature (like embryonic tissues).Mature cystic teratoma is the most frequent: they represent on average 10% of ovarian tumors (5-25% depending on the casuistry). They occur at any age. They predominate in ectodermal tissues, such as skin, lining a cavity of keratinous content. In the cavity a spur is recognized from which hair or tooth structures often arise. Frequent tissues include: nervous tissue, usually glial and ependymal epithelium, respiratory and digestive epithelia and various mesodermal structures. They are bilateral in about 10% of cases. The mature cystic teratoma is benign, but in 2% of them a malignant tumor may develop from one of the tissue components (spinocellular carcinoma, carcinoid, adenocarcinoma, thyroid tissue carcinoma, sarcoma). In this case at first we thought that the option was mature cystic teratoma but thanks to Ramón, when we read it more carefully, we found that it had neuroectodermal and embryonal elements in several of the histological preparations, so we consider that the correct answer is 2.


A 60-year-old man, smoker of 40 packs/year, who consults for pain in the ulnar border of the left arm and left palpebral ptosis since one month ago. Chest X-ray shows a mass in the left upper lobe and CT scan confirms the lesion with invasion of the second rib. In relation to the suspected diagnosis, the most appropriate treatment is:

Typical smoker's pancoast, probably an epidermoid, with Horner's sdr. Best would be chemoradio followed by surgical salvage. In the old days it was just RT and surgery. Maybe not far off enter immunotherapy in first line. There are more and more new things.

Neoadjuvant chemotherapy with combined chemoradiotherapy, followed by surgery.

Neoadjuvant chemotherapy without surgery, followed by radiotherapy.

Surgery followed by combined chemoradiotherapy.

Radiotherapy without chemotherapy, followed by surgery.


A 34-year-old patient playing tennis is hit by a ball at the level of the left orbit. On examination he presents significant palpebral hematoma, hyposphagmia, diplopia to superior vision with limitation of the upper version of the eyeball. What would you suspect?

This question has a small typo (one would say "tennis"), but personally I am a little more bothered by the error in the description of the scan. Specifically when they say "diplopia to superior vision with limitation of the superior version of the eyeball". Versions are bilateral conjugated movements of both eyes. That is, a version is composed of the sum of two ductions, since duction is the movement of only one eye. When you explore the versions, specifically the superior version or supraversion, both eyes rotate upward. At that time, you may encounter a limitation of the movement of one eye. In this case, when you scan the supraversion, you suspect or you detect a limitation in the movement of the left eye. And we would call this a limitation to the supraversion of that eye. It doesn't make sense to talk about limitation to the version of the eyeball, because the version is always of both eyeballs. Okay, it is understood, but it is an important misconception that should not be made by the person writing the question (who is supposed to be an expert on the subject), but well, as I do not think it is a reason to challenge the question, let's go on. It is about a patient who has received a blow. All four answers are fractures, so we have a pretty definite picture. The palpebral hematoma and hyposphagma (subconjunctival hemorrhage) does not give us the key data. What is important is that the eye that has received the blow does not go up, and therefore there is double vision in the superior gaze. It might be tempting to answer 3, thinking that because the superior rectus is trapped, it does not work and therefore the eye cannot go up. However, muscles trapped in a fracture do not automatically lose their muscular action. What happens is that they become trapped, they are "hooked", and cannot stretch. The problem is that the inferior wall has been broken, the inferior rectus has been trapped, and when the eye must look up, this inferior rectus cannot stretch as it should. It is not paralysis, but a restrictive problem. This question could also be answered by discarding. Options 2 and 4 can be ignored because they are too far away from the extraocular muscles to produce diplopia. And as for the walls of the orbit, the ones that break most frequently are the inferior and medial wall. The superior wall ruptures very rarely.

Fracture of the inferior wall of the floor of the orbit with trapping of the inferior rectus muscle.

Fracture of the superior wall of the orbit with entrapment of the superior rectus muscle.

The superior wall ruptures very rarely.


A 36-year-old male who consults for conjunctival hyperemia and foreign body sensation. Which of the following pathologies does NOT correspond to the above mentioned examination?

We are being presented with a picture of conjunctival inflammation or conjunctivitis and asked which of them is not associated with pre-auricular lymphadenopathy. Adenovirus conjunctivitis can be associated with inflammation of the pre-auricular or ipsilateral sub-mandibular lymph node (option 1 discarded). Allergic conjunctivitis is a hypersensitivity condition that can occur immediately after contact with the triggering stimulus or after 24-72 hours, and is associated with accompanying signs such as eyelid edema and erythema, changes in periocular skin pigmentation, and a key symptom: itching. What it is not associated with is lymphadenopathy (option 2 correct). The oculoglandular syndrome of Parinaud is a picture that by definition is composed of conjunctivitis of infectious cause associated with ipsilateral pre-auricular or latero-cervical lymphadenopathy (one or several), generally produced by bacteria such as Bartonella henselae (cat scratch disease) or Francisella tularensis (tularemia or rabbit fever): option 3 discarded. Chlamydial conjunctivitis can present as 3 very distinct clinical pictures: trachoma, ophthalmia neonatorum or adult inclusion body conjunctivitis. The latter is considered a sexually transmitted disease and is associated with ipsilateral pre-auricular nodes (option 4 discarded).


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

Colposcopy with possible biopsy. H-SIL (High-grade squamous intraepithelial lesion)*: includes changes suggestive of CIN2 and CIN3/CIS. The cytologic diagnosis must be confirmed by biopsy, for which it is necessary to perform a directed biopsy by colposcopy.

Hysterectomy with bilateral salpinguectomy and ovarian conservation.


A 40-year-old woman is admitted to the Emergency Department with a fever of 38ºC and right lumbar pain. The CBC shows 25000 leukocytes/mm3 with left deviation and an abdominal ultrasound shows a coralliform lithiasis. What microorganism do we expect to find?

Epidemiology question shared with URO. Coraliform lithiasis are associated with urea-folding germs: Proteus in the first place, Pseudomonas, Klebsiella and some staphylococci.


A 55-year-old patient diagnosed with hypertension 2 months ago at a company check-up. Laboratory tests: glucose 129 mg/dL, cholesterol 202 mg/dL, LDLc 160 mg/dL, HDLc 38 mg/dL, triglycerides 171 mg/dL, creatinine 1.1 mg/dL. He consults for poor blood pressure control, malleolar edema and dyspnea that is occasionally nocturnal. Physical examination: BMI 38 kg/m2, abdominal perimeter 110 cm, BP 157/93, HR 70 bpm, HR 14 rpm. Systolic murmur with reinforcement of the second sound. Peripheral pulses with discrete asymmetry in right pedius and right posterior tibial pulses that are weaker with respect to the left extremity. Chest X-ray and ECG without alterations Which of the following complementary tests is the least necessary for the detection of lesions in target organs?

HbA1c would be useful in this patient for the diagnosis of diabetes but not for the target organ involvement of hypertension.

Determination of glycosylated hemoglobin.


A patient comes to the Emergency Department with fever without focus of 24 h of evolution, hypothyroidism and impression of severity. She underwent a splenectomy 2 years ago for staging of Hosgkin's disease. Which microorganism is most frequently implicated?

Another one on epidemiology. In splenectomized patients, the risk of acquiring serious infections by encapsulated germs is increased, again Pneumococcus being the most frequent.


A 67-year-old patient who in the last 6 months, in two routine analyses, presents progressive lymphocytosis. In the last one, hemoglobin 15.4 g/dL; leukocytes 18.5 x103/μL with 82% of mature lymphocytes that by flow cytometry express CD5/CD19/CD23 antigens and platelets 240 x103/μL. What attitude do you think is correct?

A question that I think can be complicated for a MIR examiner. We are told of a leukocytosis at the expense of lymphocytes with a B-CLL phenotype. It seems that there are no other alarming data. No clinical data are given (so we assume that the patient is asymptomatic). No cytopenias... Conclusion: FOLLOW UP. The main hesitation with the answer should be with option 1. Why do I consider it incorrect? Because the TP53 mutation, although it establishes prognosis, is not indicated at diagnosis, but when treatment is going to be initiated (first line and prior to successive lines in case they are needed). It would be possible to go too far in this question in which the percentage given does not refer directly to clonal lymphocytes, so that it could even be a monoclonal B lymphocytosis. But this is going too far.

Study of TP53 mutations to establish prognosis.

Bone aspirate/biopsy to confirm the diagnosis.

PET/CT to establish the therapeutic attitude.

New clinical and analytical control in 6 months.


A 59-year-old woman consults a gynecologist for a spontaneous, spontaneous, uniorificial discharge from the right nipple (unilateral) without palpable nodularity. What is the most likely diagnosis?

The correct answer is 2. In the presence of unilateral and uniorificial hematic telorrhea, the most frequent cause is intraductal papilloma (50%), followed by ductal ectasia and carcinoma. When associated with palpable mass, 60% correspond to carcinoma. Paget's disease is of the eczematous type. In hyperprolactinemia, telorrhea is bilateral and pluriorificial. Mammography often does not show papillomas, being more useful ultrasound and galactography.

Given the hematic nature of the discharge, the most likely diagnosis is infiltrating ductal carcinoma.

Mammography will indicate the diagnosis.


A 17-year-old woman comes to the emergency department with a high fever, pharyngeal pain and cervical lymphadenopathy. She had previously been diagnosed with acute pharyngitis and was treated with amoxicillin, and later presented with a generalized macular skin rash. Laboratory tests showed slight leukocytosis with lymphocytosis and presence of activated lymphocytes, slight thrombopenia and slightly increased transaminases. What would be the most likely diagnosis of this clinical picture?

Of course it is a typical picture (EBV, CMV, VH6, Toxoplasma), of which you will not see so clearly at the emergency room door when you are on call. Be careful with the bad blood in answer 3, because an acute toxoplasmosis can behave like this and also give a macular exanthema, although the one of this girl is related to the intake of amoxicillin. By the way, I add a note, if instead of a girl of 17 years so clear it were a young man/girl with risky sexual relations, do not forget the HIV primoinfection as a cause of mononucleosis syndrome.

It is a typical picture of infectious mononucleosis.


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 diagnoses is the most likely:

In this question what they assume is that this is a 45-year-old woman who is diagnosed with pulmonary thromboembolism (PTE). With this diagnosis, options 3 and 4 are directly excluded (also, she is female, so we would not have to think about hemophilia) As an analytical data, it says that there is a lengthening of the aPTT. So, they want you to know, she has positive lupus ac and link it directly to antiphospholipid syndrome (APS). A Leiden's does not alter coagulation, so it is ruled out as well. Anyway, although it is not within the possible answers, lupus positivity can be related to a myriad of clinical situations, syndromes and pathologies. Assuming that a PTE + lupus is a PFS seems to me to be a bit of a stretch, but it is the most likely with the data provided.


After a traffic accident you attend to an injured person. The patient opens his eyes at your call, but only utters words that are inappropriate. On motor examination, the pain is localized in the right extremities, but spreads on stimulation of the left extremities. How would you describe his condition according to the Glasgow Coma Scale?

The first thing we should know when applying the Glasgow Coma Scale to a patient is that we should always keep the best value in each sphere (ocular response, motor response and verbal response). In this case, we have a patient who has an ocular opening to the call (ocular response 3 out of 4), emits inappropriate words (verbal response 3 out of 5) and localizes pain with right extremities (motor response 5 out of 6). The Glasgow Coma Scale score would be 11 (out of 15). The best value of the examination is taken because in many cases (assessment of a polytraumatized patient, ischemic stroke or spontaneous acute cerebral bleeding), the motor examination may be artifacted by other elements. For example: in a polytraumatized patient (such as the one in question), the response presented with left extremities may be due to localized trauma in that area, and not strictly speaking to an underlying traumatic brain injury. Likewise, sometimes the verbal response may be underestimated in the polytraumatized patient due to airway obstruction (e.g., due to the tongue retreating into the oropharynx). By always assessing the best response, we will have a truer picture of the patient's condition.


A 55-year-old woman consults for fatigue and polyuria of two years' evolution. Laboratory tests reveal hypercalcemia, increased PTH and increased bone turnover markers. The radiographic study shows subperiosteal resorption and osteoporosis. Sestamibi scintigraphy revealed a parathyroid adenoma. Parathyroidectomy was performed with minimally invasive surgery. Postoperatively, the patient developed severe hypocalcemia and tetany, with PTH below 5 ng/l. The patient responds well to initial treatment with intravenous calcium and later with oral calcium and vitamin D. What is the most likely diagnosis?

Question of very high difficulty, I would not worry about having failed it. It is easy to get confused with the hypoparathyroidism answer. Permanent post-surgical hypoparathyroidism after parathyroidectomy of an adenoma with minimally invasive surgery is rare. I write a brief summary of the hungry bone syndrome that I have found in a clinical case in the Annals of Internal Medicine [1]: "The pathophysiology of the hungry bone syndrome (HBS) is related to an imbalance between bone formation and bone resorption, which is associated with hypocalcemia, hypophosphatemia and hypomagnesemia (1). This syndrome can be observed after surgery in patients with primary hyperparathyroidism (HPT), as well as in tertiary HPT of chronic renal failure, and to a lesser extent after treatment of processes with excess of circulating thyroid hormones (2). In PTH, there is an excess of parathyroid hormone (PTH) which stimulates osteoclastic activity causing demineralization of the bone matrix and releasing calcium into the bloodstream. After parathyroidectomy, serum PTH levels drop dramatically, thus, PTH-induced bone resorption ceases, while osteoblastic activity continues resulting in increased bone uptake of calcium, phosphate and magnesium, thus SHH appears (3)."


A 4-year-old boy comes to the health center who, 5 minutes before, starts with angioedema in the face, conjunctivitis, nasal congestion and hoarseness, coinciding with the ingestion of a spoonful of yogurt given to him by mistake at school. Among the antecedents, he was diagnosed with cow's milk protein allergy. Examination revealed mild hypotension, heart rate 110 bpm, O2 Sat 93%, pale and slightly sweaty, with scattered wheezing. What is the first treatment of choice?

We are facing a case of Anaphylaxis so the first measure is to administer Adrenaline 1/1000 intramuscular (0.01mg/kg). Subsequently, systemic corticosteroids such as methylprednisolone will be given, which will take a few hours to take effect. So adrenaline first, as it is faster acting, then the rest (Question very similar to one last year, instead of yogurt, it was omelet).


A 72-year-old man presenting since 48 hours with fever of 38.7°C, cough, purulent expectoration and dyspnea. Constants: BP 85/60 mmHg, heart rate 100 bpm, respiratory rate 35 rpm, SatO2 80%. Of note was the presence of confusion and crackles in the left lower lung field. Chest X-ray confirms the existence of pneumonia of the lingula and left lower lobe. What would be the appropriate place of care?

Applying the CURB-65 severity scale (one of the most commonly used in the ED for stratifying the severity of pneumonia, although in this case simply applying common sense, the patient should be admitted to the ICU), we would have a score of at least 4 points (we would be missing the serum urea data), which gives us severity criteria. Since there are no criteria that contraindicate admission to the ICU, admission to the unit would be indicated.

Admission to an emergency observation unit.


15-year-old male, admitted after being run over on the public road, resulting in being ejected. He was admitted conscious and oriented, with intense pain in the left hemithorax and dyspnea. Physical examination showed blood pressure 90/60 mmHg, heart rate 130 bpm, basal oxygen saturation 90%, respiratory rate 35 rpm. There is complete hypophonesis in the left hemithorax and dullness to percussion. Chest X-ray shows multiple left costal fractures and massive ipsilateral pleural effusion. Placement of a pleural drain is indicated, with 1700 cc of hematic fluid coming out. What is the decision to be made:

There are two answers that we can immediately rule out if we stick to the initial management of severe chest trauma: 1 (noninvasive ventilation is not indicated because it does not secure the airway) and 3 (observation in these cases, waiting for worsening, only leads to increased morbidity and mortality). Between options 2 and 4 there could be controversy between the literature and the usual clinical practice, in which we usually have to face in a delicate balance the clinical stability of the patient (and what we can "make up" this stability with our life support therapies) and the actions that result in better patient care for the definitive treatment of the lesions. We are dealing with a severe polytraumatized patient. With the data provided by the question, a patient who seems to be in shock (tachycardia, hypoxemia, tachypnea... although we do not receive data, for example, on lactacidemia), and in whom we have to our knowledge a left thoracic trauma, which not only implies bone injury, but may mask other injuries of high severity and which are not diagnosed with a chest X-ray: myocardial contusion, pericardial effusion, splenic injury, diaphragmatic injury... We place a left pleural drain on the patient and obtain a debit of 1700cc of hematic fluid. If we follow the ATLS (ATLS-Advanced Trauma Life Support 10th edition) guidelines for the care of severely polytraumatized patients, they tell us that an immediate bleeding of more than 1500cc of blood is an indication for urgent thoracotomy, and that even in patients with a bleeding of less than 1500cc, if the debit persists at a rate of 200mL/h for 2 to 4h, this indication would also exist. Therefore, the person who asked the MIR question wants us to answer option 2. However, in real life, the course of action will depend on the stability of the patient when we have applied the treatments indicated in option 2: adequate analgesia, oxygen therapy and initiation of blood transfusion. If by optimizing the patient we manage to stabilize him and assess that it is safe to transfer him, the performance of a body CT scan will define in much greater detail the lesions he has, and will help to ensure that the surgery he will probably end up undergoing will be a definitive surgery and not just damage control surgery. In this case, the doubt would arise with option 4, although, as I say, everything will depend on the clinical stability of the patient and the time we have before achieving definitive control of the hemorrhagic focus (which is, after all, what we are after in this situation).

Institute noninvasive mechanical ventilation and request blood transfusion.

Analgesia, oxygen therapy, request blood transfusion and indicate urgent surgery.

Orotracheal intubation, request blood transfusion and observation for, in case of worsening, indicate surgical intervention.

Orotracheal intubation and urgent CT scan for accurate assessment of lesions.


A 72-year-old man comes to the Emergency Department with a pathological fracture of the left femur. After surgery, a diagnostic study is performed to determine the underlying pathology with the following findings: hemoglobin 9.5 g/dl, total proteins 11 g/dl, (VN: 6-8 g/dl), serum albumin 2 g/dl, (VN 3.5-5.0 g/dl), beta 2 microglobulin 6 mg/l (VN 1.1-2.4 mg/l), serum creatinine 1.8 mg/dl (VN: 0.1-1.4 mg/dl). Indicate which diagnostic tests would be necessary to confirm the most likely diagnosis:

She is going to have myeloma. For diagnosis, a sample (bone marrow) and electrophoresis to determine the type of monoclonal peak. Then, for extension, prognostic value and to decide treatments, the rest, but once diagnosed.

Radiological bone series and bone marrow aspirate.

Serum and urine electrophoresis and renal function tests.

Bone marrow aspirate and serum calcium concentration.

Bone marrow aspirate and serum and urine electrophoresis.

Biopsy of the pathological fracture and radiological bone series.


A 67-year-old man consults for moderate exertional dyspnea of progressive onset in recent years. He has daily whitish expectoration and sometimes breath sounds, especially in winter with respiratory infections. He has been a smoker of about 20 cigarettes a day for the last 45 years. On examination he is eupneic, normocolored, with an oxygen saturation of 94%, and has generalized decreased vesicular murmur on chest auscultation as the only findings of interest. Chest X-ray shows an elongated cardiac silhouette, with signs of hyperinflation or pulmonary air trapping, without other alterations. Spirometry was performed with the following result: FVC 84%, FEV1 58%, FEV1/FVC 61%, unchanged after bronchodilator. Among those indicated, indicate the most appropriate treatment for this patient:

In a patient with a low symptomatic COPD that could probably be classified as GOLD 2, the starting treatment can be either with inhaled tiotropium or with a long-acting beta two. Therefore there is no doubt in the correct answer.

Home oxygen therapy with portable oxygen source for ambulation.


Given a 7-month-old child with fever and irritability, bulging fontanel and a cerebrospinal fluid study with 110 cells/mm3 (75% lymphocytes), protein 120 mg/dl and glucose 28 mg/dl (serum glycemia 89 mg/dl), what is the most reasonable diagnostic suspicion?

The correct answer is 3. It defines a typical cerebrospinal fluid of tuberculosis. In clinical practice things might not be so simple......


An 87-year-old patient with a history of chronic bronchitis and heart failure, has been diagnosed with acute calculous cholecystitis . After four days of treatment with absolute diet, serum therapy and piperacillin/tazobactam, the patient continues with fever, persistent abdominal pain and leukocytosis. The most appropriate attitude at this time would be:

I think the correct answer is 2 although the treatment for acute cholecystitis is cholecystectomy, for this it is necessary that the patient is a surgical candidate, in this case it is an elderly patient, with previous diseases that increase the surgical risk and would be an ASA IV for an urgent intervention. In these cases cholecystostomy can cure cholecystitis; and after recovery, assess scheduled surgery according to the patient's situation.

Surgical treatment (urgent cholecystectomy).

Biliary drainage by percutaneous cholecystostomy.

Substitute metronidazole + cefotaxime for piperacillin/tazobactam.

Replace piperacillin/tazobactam with amikacin+clindamycin.


A 61-year-old woman, administrative, with a history of overweight, hypertension, dyslipidemia and metabolic syndrome, who consults for pain in both buttocks, left trochanteric region, lateral aspect of the left thigh up to the knee and left leg up to the middle third. The pain appears when the lower limb is lifted with the knee extended, but is relieved when the knee is flexed. What is the first clinical suspicion?

Positive Lasegue's sign, reappearance of the symptoms when performing the extension maneuver of the affected limb, compatible with involvement of nerve roots at the lumbosacral spine level.


Patient with acute pancreatitis. Computerized Axial Tomography (CAT) performed 72 hours after admission showed necrosis of 50% of the pancreas. At the 3rd week of admission the patient began with high fever and leukocytosis. Urgent chest X-ray and urinary sediment are requested, both being normal. Indicate the next step to follow:

Although the latest recommendations on the management of severe acute pancreatitis advise against FNA because of the risk of infection of sterile necrosis. Current management is governed by stepwise treatment. In the situation described in the question the current treatment is to start antibiotics and assess response.

Fine needle aspiration of pancreatic necrosis guided by ultrasound or CT.

Bronchoalveolar aspirate, urine culture and blood cultures.

Echoendoscopy with puncture of the necrosis.


A 54-year-old man who goes for a check-up at his company. A body mass index of 32.8 kg/m2 and fasting blood glucose of 138 mg/l were detected. One month later, glycemia 13 mg/dl. Which therapeutic recommendation would you make first?

Behavioral changes: diet and physical exercise. This is the first thing we do when diagnosed with type 2 diabetes. This is a good question to remember that before any drug, we must insist on changing habits. Then we would prescribe Metformin.

Behavioral changes. Diet and physical exercise.

Take acarbose at night, before going to bed.


A 43-year-old man consults for diarrheal syndrome, and refers among his history 3 pneumonias in adulthood. Which of the following immunological studies should we request:

More than 2 lobar pneumonias make it necessary to rule out an immunologic deficit.

Serum immunoglobulin count and antibody production capacity test.

Phagocytosis test and oxidative metabolism of neutrophils.

Apoptosis test (programmed cell death) in the patient's circulating lymphocytes.

Study of the repertoire and clonality of T lymphocytes (alpha/beta).

In this patient it would not be appropriate to request any immunological study.


A man presents abruptly with asthenia and jaundice with transaminases above 2000 IU/L. Serological markers show the following pattern: anti-HAV IgM negative, HBsAg negative anti-HBc IgM positive, anti-HCV negative. What is the diagnosis?

An interesting one that in general needs to be studied. By the form of presentation, it is clearly an acute hepatitis, so option 1 is ruled out. The negative IgM of HAV rules out 5 and the negative HBs Ag rules out 4 (to have delta virus you need surface antigen B). When having IgM anti HBc we speak of an acute hepatitis B (3), since there is a window period of negativization of the antigen.

The negative IgM of HAV rules out 5


55-year-old man who consults for dysphonia. In the anamnesis he refers to a month of asthenia and unquantified weight loss. Chest X-ray shows increased density in the left upper lobe and occupation of the aortopulmonary window. Bronchoscopy shows paralysis of the left vocal cord, without endoscopic image suggestive of neoplasia. What is the most likely diagnosis?

The most frequent cause of recurrent nerve palsy is bronchopulmonary carcinoma. The fact that it is not accessible to endoscopic vision does not mean that it is not there.


A 65-year-old female patient debuted two years earlier with an apraxia of speech and has developed rigid-akinetic parkinsonism predominantly in the right hemibody with superimposed myoclonias and alien hand or foreign limb phenomenon.What diagnosis do you consider most likely?

As it is described as an apraxic phenomenon followed by an asymmetric rigid-akinetic parkinsonism and with superimposed myoclonias, it is typical of corticobasal degeneration. Parkinson's disease cannot be because they do not present apraxia as initial feature, Alzheimer's disease does not present an asymmetric parkinsonism and the typical Huntinton's disease is not of so old people and when it debuts with advanced age it behaves like a chorea.


A 1 month old infant, exclusively breastfed, consults because he has a bowel movement every 5 or 6 days with straining but with a soft consistency, what would our attitude be?

The correct answer is 4. The normal range of stool output in young infants is very wide. To suspect aganglionic megacolon there is usually a delay in the evacuation of meconium and often other associated symptoms such as abdominal distension, difficulty in gaining weight, etc.

Supplement breastfeeding with anti-constipation formula.

It is considered normal intestinal rhythm.

Refer to Pediatric Digestive to rule out aganglionic megacolon.


A 47-year-old woman consults for voiding syndrome. She is diagnosed with uncomplicated urinary tract infection and treated with ciprofloxacin for 5 days. A week later, she consulted again for general malaise, arthralgias and the appearance of a skin rash. In the analytical analysis, the glomerular filtration rate was 45 ml/min (CKD-EPI), whereas 6 months ago it was 100 ml/min. In the sediment leukocytes are identified, being negative for nitrites. Of the following, which is the most probable cause of his renal failure?

General malaise, arthralgias, skin rash, acute renal failure and active sediment with sterile leukocyturia following the intake of a drug is highly suggestive of AIN (option 4 correct). Among drugs, antibiotics are the most frequent cause, and ciprofloxacin is one of the most common. Direct nephrotoxicity is very rare and is characterized by crystallization in the renal tubules (incorrect option 2). Postinfectious glomerulonephritis is more typical of children and adults older than 60 years, and usually manifests with hematuria after streptococcal infections (option 1 incorrect). Acute pyelonephritis would have been presented with high fever and renal fossa pain (option 3 incorrect).


A 30-year-old woman, asymptomatic, is found to be anemic on routine examination. Physical examination reveals conjunctival jaundice and splenomegaly. The patient refers to a family history of biliary lithiasis at an early age. All this suggests the most probable diagnosis of:

You have probably looked at answer 5, hereditary spherocytosis, associated with biliary lithiasis at an early age. Exactly, that is the correct one. In the statement they have not stopped giving clues: conjunctival jaundice, splenomegaly and family history of biliary lithiasis at an early age. He has reached 30 years of age without suffering a hemolytic crisis, without suffering any symptoms. There was no mention of microcytosis or macrocytosis to suggest thalassemia minor or B12 and/or folic acid deficiency. Nor of hemolytic crisis associated with the consumption of drugs, infections or ingestion of beans or peas. They have not given any clues to stop to think about other possibilities.

Glucose 6-phosphate dehydrogenase deficiency.

Vitamin Bl2 and/or folic acid deficiency.


19-year-old woman, weight 60 kg, with acute dehydration due to long exposure to the sun. Blood pressure lying down 100/60 mmHg. Standing 70/50 mmHg with dizziness. Serum sodium levels 155 mmol/L. What is the most correct treatment, in the first 24 hours, taking into account the data available to us?

This question is not an easy one. The available literature is somewhat controversial (some guidelines advise using glucose saline, others absolutely forbid it...) so I have decided to rely on the treatment recommended by Harrison, which is the manual that MIR examiners usually rely on. This girl presents with hypernatremia due to extrarenal free water losses. The goal is to replace the lost water and reduce the natremia at a rate of no more than 12 mmol/day. To calculate fluid therapy, the water deficit must first be calculated. Water def. Water = (Natremia-140/140)xTotal body water. TBW = Weight in kg x 0.4 in females/0.5 in males. In this case, the water deficit is: ([[tel:155-140/140|155-140/140]])x60x0.4 = 2.57 liters. There are only two answers that come close to this figure, but 2 seems more correct, as it is the only one that completely covers the water deficit and uses a hyposodium solution.

Hypertonic saline (3%), 500 ml + 500 ml of 5% glucose.


A 43-year-old male with no past history of interest consults for a ten-day history of jaundice of the skin and mucous membranes, choluria and acholia. He does not report abdominal pain, weight loss or other symptoms, except generalized pruritus. She denies alcohol consumption. She does not take any medication except occasional ibuprofen for muscle pain after sports activities. The CBC shows increased bilirubin at the expense of direct bilirubin. An urgent ultrasound shows a normal liver, vesicular cholesterosis and absence of bile duct dilatation, with no other alterations of interest. What is the most likely diagnosis?

We believe that this question is open to challenge. Ibuprofen hepatitis is a rare adverse effect with a prevalence of about 3.7/100,000 users and 1.1/100,000 prescriptions. It appears that it may be related to dose and duration of treatment, but there is little evidence on this. Among the NSAIDs with the highest risk are diclofenac and sulindac. In terms of frequency, the prevalence of cholangiocarcinoma is 2/100,000 patients, a very comparable frequency. The absence of bile duct dilatation in cholangiocarcinomas can be seen in cases of intrahepatic cholangiocarcinomas or in those with mixed histology with hepatocarcinoma. It is true that the acute course and the absence of constitutional syndrome may make us think against this option and tip the balance towards ibuprofen hepatitis. Regarding the other options: acute cholangitis is characterized by the triad of jaundice, abdominal pain and fever; Gilbert's syndrome is an increase in bilirubin at the expense of indirectness.


A 50-year-old patient presenting with a pleural effusion with the following features: straw-like appearance, pH 7.3, pleural protein/serum ratio 0.8, pleural LDH/serum ratio 0.9, Gram and Ziehl's negative, total lipids, cholesterol and triglycerides normal, mesothelial cells <5%, intense lymphocytosis without atypia, ADA 64 U/L. What diagnosis would you suggest?

It is a lymphocytic exudate whose main diagnoses are tumor and tuberculous pleuritis. They do not give the value of glucose which should be lowered, but if the cytology shows absence of malignant cells so we are left with tuberculous pleuritis. Other possible diagnoses such as lymphoma are not mentioned in the answers.

Pleural effusion due to heart failure (transudate).

Effusion secondary to pulmonary infarction.


In a subject over 65 years of age a tuberculin test has shown an induration of 3 mm. The induration on a second test, performed 10 days later, is 13 mm. Point out the correct answer:

Let's see, if that subject was not in any risk group, the positive is in the 15mm, therefore both tests are negative, and as only one answer refers to negative, that's it. But both could be false negatives.

The second reaction is a false positive.


A 67-year-old woman diagnosed with infiltrating ductal carcinoma of the breast with no family history of neoplasia. What additional studies should be performed on the tumor because of its clinical and therapeutic implications?

The answer is 2, study of hormone receptors and HER2. This is because no study of first-degree relatives is appropriate, as it does not appear to be hereditary breast cancer since there is no family history of neoplasia. On the other hand, there is no indication for BRCA 1-2 study.

Complete phenotypic study by flow cytometry.

Study of hormone receptors, e-cadherin and study of first degree relatives.

Study of BRCA 1-2 and study of first-degree relatives.


A 26-year-old woman diagnosed with systemic lupus erythematosus, on treatment with hydroxychloroquine, consults for a feeling of generalized weakness that has progressively developed in the last 15 days. The physical examination reveals cutaneous pallor and the CBC shows Hb 7.4 g/dL, Hct 31%, MCV 108. Which of the following tests will be most useful in deciding the course of action?

It tells us about a patient with a diagnosis of lupus and macrocytic anemia. In the end, all the data are usually given for a reason. The onset of the picture seems relatively rapid and it is also associated with an autoimmune disease, so it seems that they want you to associate it with an autoimmune hemolytic anemia. The low haptoglobin would tell us it is "hemolytic", the coombs test would tell us it is "autoimmune". Vitamin B12, probably the MCV would be higher than 108 and the onset of the clinical picture would be slower. The ANA would not give us anything in relation to the anemia, since it already has a diagnosis. Therefore, correct answer 2. As a note, autoimmune hemolytic anemias are usually slightly macrocytic due to reticulocytosis. Remember to ask for reticulocytes.


A 36-year-old man with no PA of interest comes to the emergency department with sudden onset of severe pain in the posterior aspect of the right lower limb extending to the foot. On examination he presented: Positive right Lasège at 10º, decreased strength in plantar flexion of the right foot, hypoesthesia in the external border of the right foot and absence of right Achilles reflex. The simple X-ray of the lumbar spine does not show significant alterations. Which of the following is the most probable diagnosis?

Acute sciatica probably due to disc extrusion. Both the sensory distribution, the paresis for plantar flexion (tiptoe) and the absence of the Achilles reflex are typical of S1 root involvement, which is typically affected with L5/S1 disc herniation (posterolateral). An L1/L2 (posterolateral) herniation would affect the L2 root, an L4/L5 herniation would affect the L5 and cauda equina would involve more symptomatology than simple S1 involvement.

an L4/L5 herniation would affect the L5


20-year-old male, who consults for lumbosacral pain of inflammatory rhythm of 4 months of evolution. Also bilateral thalalgia and morning stiffness for 1 hour. In the last 2 months, onset of diarrhea with loss of 4 kg of weight. What is the most correct diagnostic approach?

The patient presents the clinical features of spondylarthropathy, which is often associated with inflammatory bowel disease, as this case suggests.

Given the patient's age, he most likely suffers from non-specific low back pain and tendonitis of the feet. If the diarrhea persists, a digestive study would be performed.

Perform a digestive study to rule out tumor pathology. Low back pain may be due to visceral pathology.

The clinical picture is very suggestive of spondyloarthritis. Inflammatory bowel disease should be ruled out.

I would request a lumbar MRI to rule out disc herniation and if diarrhea persists, a digestive study.


A 30-year-old man suffers a fall from a standing height of 2 meters. On arrival at the emergency room on a stretcher, he is conscious and oriented, with bladder catheterization and clear urine. He shows swelling of the left heel and mild tingling in the anterior aspect of the left thigh and scrotum as well as dysesthesia in both feet. The patient says goodbye to the stretcher-bearer with a handshake and a simultaneous pat on the shoulder. Rotation of the lower limbs on the stretcher grasped by the ankles is painless and compression of the pelvis is asymptomatic. Next:

I believe that the correct answer is 3. The patient, due to the mechanism of injury (foot fall), the calcaneal fracture and the neurological symptoms, suggests a low spinal cord injury due to a fracture of the lumbar spine. The injury is not high because he moves his arms. It also does not appear to be a pelvic injury because of the absence of pain on mobilization or palpation. If there is a suspicion of pelvic injury in the primary evaluation of all polytraumatized (ATLS) a spinal exploration should be performed by rotating the spine en bloc to avoid producing more injury. Abdominal palpation is also part of the initial evaluation. Abdominal ultrasound may be indicated in hemodynamically unstable patients if abdominal injuries are suspected but in any case it is done after the initial evaluation.

The patient will be seated on the stretcher so that the cervical spine can be explored.

Refer to radiology for study of the lower extremities (feet, femurs, pelvis).

We will palpate the abdomen and roll en bloc to palpate the thoracolumbar spine.

We will place a cervical collar and refer to radiology for imaging of the lower extremities and cervical spine.

We will request an abdominal ultrasound.


35-year-old male, letter carrier, with no history of interest, who comes to the emergency department for acute cervical pain of 24 hours of evolution, without previous trauma, which radiates to the left arm up to the hand and is accompanied by paresthesia in the radial border of the forearm. She presents no objectifiable loss of strength, preserves neck mobility although it is painful and contracture of the paravertebral musculature is appreciated. The first attitude will be:

In this case we describe a case of cervicobrachialgia without alarm signs at the present time, so the most indicated treatment at this time would be conservative, based on NSAIDs, local heat and rest. This is not an urgent case, so answer 2 would not be valid. The performance of an MRI and an electromyogram are valid options for the etiological study of the picture, however, it is necessary to emphasize that we should first perform a correct pain management, so since we are asked about the first attitude, option 1 would be more valid.

Conservative treatment with non-steroidal anti-inflammatory drugs, local heat and relative rest.

Urgent call to the neurosurgeon for surgical evaluation.

Preferential request for MRI and electromyogram.

Preferential referral to traumatology outpatients.


A 64-year-old woman, without relevant comorbidities, operated on for a right breast cancer by means of an extended lumpectomy and selective sentinel lymph node biopsy, with the following anatomopathological result: Infiltrating ductal carcinoma poorly dlferentiated (grade 3), size 2.2 cm (pT2), estrogen and progesterone receptor positive, Ki67 25%, HER2 negative. There is macroscopic involvement of the sentinel lymph node, although there is no involvement of the rest of the isolated axillary nodes (pN1). What adjuvant systemic treatment do you consider most appropriate for this patient?

It is a Luminal B. According to the SEGO, this patient is a candidate for chemotherapy treatment because of the high histologic grade and high tumor proliferation.

Adjuvant hormone therapy including aromatase inhibitors.

Adjuvant chemotherapy, preferably with anthracyclines and taxanes, followed by hormone therapy.

Adjuvant chemotherapy in association with the monoclonal antibody trastuzumab, followed by hormone therapy.

Adjuvant chemotherapy, preferably with anthracyclines and taxanes.


A 10-year-old boy with brief episodes of distractibility (< 1 minute) in which he does not respond to calls and blinks. An EEG shows spike-wave discharges at 3 cycles per second. First-line elective treatment would be with:

Absences behave as brief episodes of abrupt loss of consciousness without alteration of postural control; they typically last seconds and can be repeated many times a day, are usually accompanied by small bilateral motor signs (blinking, chewing) and consciousness is recovered equally abruptly, without subsequent confusion or memory of the episode (MIR 03-04, 248; MIR 97-98, 51). The age of onset is usually between 4 years and early adolescence, being the most frequent cause of seizures in this age range. EEG findings are typically generalized and symmetrical spike-wave discharges at 3 Hz (MIR 99-00F, 67) coinciding with seizures, although in the interictal EEG there are more periods of abnormal activity than clinically visible. The most appropriate drugs for the treatment of absences are Valproate and Ethosuximide (CTO Manual).


35-year-old male, transferred to the emergency department after a traffic accident. On admission, a Glasgow scale score of 15, blood pressure of 140/90 mmHg, respiratory rate of 35 rpm and heart rate of 110 bpm, with a baseline oxygen saturation of 91%. On examination there is right thoracic hypophonesis and tympanism on percussion.What is the presumptive diagnosis? :

This is an easy and classic question that you can also apply to daily clinical practice. Hypophonesis in a hemithorax + tympanism = pneumothorax. If there is dullness on percussion: hemothorax. In either case, in case of hypophonesis of a hemithorax in a severe and unstable polytraumatized patient: thoracic drainage (if possible, large caliber if placed in a hospital environment, since although the predominant lesion is pneumothorax, a hemothorax component can be found which, in case of placing a fine drainage, could obstruct it).


Patient presenting since 2 weeks ago with a pruritic eruption consisting of multiple polygonal erythematous-violaceous papules, flattened surface, preferentially located on the anterior aspect of wrists, pretibial area and lumbar area. She also presents whitish reticulated lesions in the jugal mucosa. What is the most probable diagnosis?

They are undoubtedly describing the typical lesions (both on skin and oral mucosa) of a lichen planus (5).

DERMATOLOGY, VENEREOLOGY AND PLASTIC SURGERY


A 73-year-old patient...swallowing a complete neurological dysphagia secondary to a cardioembolic stroke in the left middle cerebral artery territory. will require long-term nutritional support. Of the following treatment modalities, which do you consider most appropriate for this case?

Enteral nutrition is a nutritional support technique that involves administering nutrients directly into the gastrointestinal tract by gavage. The choice of the route of formula administration depends on the nutritional status, age of the patient and the underlying disease. If enteral nutrition is considered to be of short duration, the route of choice is the nasogastric or nasoduodenal- nasojejunal tube... If prolonged nutrition is anticipated the route of choice is gastrostomy (option 3), with jejunostomy being reserved for cases in which it is not possible to use the gastric route.


A 70-year-old woman with a history of hypertension and moderate heart failure presents with a persistent, dry cough that begins as an itchy sensation in the throat. What is the drug suspected of causing the patient's clinical and laboratory alteration?

These are typical adverse effects of ACEIs, in the case of cough it is usually dry and irritative and appears in up to 3% of patients. Hyperkalemia may also appear in 1%.


69-year-old woman who comes to your office referring genital bleeding of several months of evolution. She denies hormone replacement therapy and anticoagulation. She provides normal cervicovaginal cytology. General and genital physical examination without findings of interest. BMI of 38kg/m2. Indicate the most correct attitude:

The correct answer is 2. We are dealing with a case of postmenopausal metrorrhagia, whose most frequent cause is genital atrophy in the first place and endometrial cancer in the second place. The data given on obesity should lead us to suspect endometrial cancer, since peripheral fat is converted to estrone, and these estrogens cause the endometrium to proliferate. On the other hand, she provides a normal cytology, which rules out option 3. The hormonal evaluation is not opportune, since we understand that the patient is in menopause. We should not prescribe treatment without first ruling out organic causes.

Hormonal evaluation with FSH, LH and estradiol.


A 62-year-old patient who has had a pericardial bioprosthesis in mitral position for two years. He is admitted urgently for acute coronary syndrome. Two days later and after a favorable evolution, he suddenly presented heart failure with acute pulmonary edema. Select the diagnostic option in this case from the following possibilities:

The valve is biological and, in general, the veils are not sewn to the papillary muscles, so we don't care what happens to them. A ventricular aneurysm depresses LVEF, but does not suddenly put you into PAD. In contrast, a VSD sharply increases flow to the pulmonary bed, causing pulmonary edema, and is also one of the most frequent complications of AMI. Ischemic ASD... I do not deny that it exists, but it does not even appear in the guidelines. And endocarditis would not require so many saddlebags.

Acute post-infarction mitral insufficiency.

Dysfunction of the bioprosthesis due to probable acute endocarditis.


A 64-year-old smoker and heavy drinker reports painless right jugulodigastric lymphadenopathy of progressive growth in the last two months whose fine needle aspiration was reported as squamous cell carcinoma. Which of the following is the most likely location of the primary tumor:

You are in the middle of the ENT block. You have already passed the Pneumology and Digestive blocks. Dermatology is still to come out, but a dermatologist (answer 1) would not ask this. So we are left with parotid and larynx; but parotid squamous cell carcinoma is rare; I would mark 5 and rest easy. Perhaps because all the adenopathies at this level that I have seen have ended up corresponding to carcinomas of the upper aerodigestive tract.

OTOLARYNGOLOGY AND MAXILLOFACIAL SURGERY


A 65-year-old man, a retired office worker and smoker of 1 pack of cigarettes a day, comes to the clinic with a persistent, generally dry cough and progressive dyspnea of 2 years of evolution which is currently grade 2. The patient denies other symptoms. Physical examination shows no relevant data. The attitude to follow would be:

The correct answer is 2 (Perform chest X-ray and spirometry with bronchodilator test). It is probably COPD but we must confirm it and assess the severity of the obstruction with spirometry before starting treatment. He is a patient at risk for lung cancer so it is mandatory to perform a chest X-ray to rule out this or other pathologies that would justify the symptoms, although most likely they are due to the debut of his COPD.

Start treatment with inhaled bronchodilators.

Chest X-ray and spirometry with bronchodilator test.


A 22-year-old male presents to the emergency department with "almost black" urine for the past 12 hours. He has no past history of interest and is not taking any medications. He refers an upper respiratory catarrhal symptoms since 4-5 days ago for which he has taken paracetamol. Examination: temperature 37.3 ºC, BP 150/95, HR 85 bpm, slight pharyngeal erythema, the rest normal. Laboratory tests showed: Hb 12.8 g/dl, Hcto 39%, leukocytes 10,500/mm3 with normal formula, platelets 250,000/mm3, normal coagulation, urea 25 mg/dl, creatinine 0.8 mg/dl, ions, hepatic, lipid, albumin and total proteins normal. Normal autoimmunity study and negative viral serology. Urine 24 h with proteinuria of 0.75 g/24 h, sediment with 10 erythrocytes per field (90% dysmorphic), no leukocyturia. Renal ultrasound was normal. Which diagnosis do you think is more likely?

A picture of macroscopic hematuria and mild proteinuria with normal creatinine levels, accompanied by an upper tract catarrhal picture, is very suggestive of IgA nephropathy (option 3 correct).


A 60-year-old man with a history of hypertension and dyslipidemia has recently been diagnosed with heart failure. After performing the relevant tests, it was found that the left ventricular ejection fraction was preserved (>50%). With regard to treatment, indicate the CORRECT answer:

Treatment with diuretics should be started at high doses.

Initial treatment should be directed to the underlying pathological process.

If nitrate treatment is required, it should be started at low doses.

Dyspnea can be treated by reducing neurohormonal activation with angiotensin converting enzyme inhibitors or angiotensin receptor antagonists.


In a patient with clinical signs of heart failure who presents with ascites disproportionately elevated in relation to peripheral edema, the most likely etiology would be:

They tell us about clinical symptoms of right failure, with edema and ascites. Therefore, we rule out left heart failure: EAo, dilated with DSVI and a MHO. Of the two we are left with, in constrictive pericarditis we have increased filling pressures in right chambers, which cause retrograde pressure increase with hepatic congestion, ascites, edema, etc. On the contrary, in pulmonary hypertension, the tricuspid valve is responsible (a priori) for "containing" this overpressure.

Dilated cardiomyopathy with significant left ventricular dysfunction.


A 54-year-old man is diagnosed with a left renal tumor suggestive of renal cell carcinoma. His preoperative workup shows elevated levels of GPT, alkaline phosphatase and alpha-2-globulin and prolonged prothrombin time. The liver is diffusely enlarged, but without defects of hepatic infiltration. The most likely rationale for these findings is due to:

Very easy question in which we are being presented with a patient with Stauffer's syndrome, a paraneoplastic syndrome consisting of liver dysfunction secondary to toxic products secreted by a number of tumors (most frequently, renal cell carcinoma, like the one in this case). As in this case, cholestasis (elevation of alkaline phosphatase), mobilization of hepatic enzymes and lengthening of the prothrombin time indicate liver dysfunction. Metastases are ruled out (there are no defects of hepatic infiltration), intrahepatic tumor thrombosis (it would give another symptomatology and this would be more acute), and acute hepatitis and hemochromatosis (they are not in context nor is it what the author of the question wants us to think).

Presence of hepatotoxic substances produced by the tumor.