He is describing a textbook Reiter's syndrome: palmo-plantar keratoderma, arthritis and ocular manifestations, together with probably a chlamydial urethritis, perhaps asymptomatic (they do not explain urethral exudate). Of course, the patient may also have HIV infection or even secondary syphilis (in addition to Reiter's).

Gustavo comes to the emergency room with skin lesions and general malaise of several days of evolution. He has psoriasiform lesions on the trunk with involvement of palms and soles. He also presents asymmetric non-suppurative joint inflammation and bilateral ocular redness as well as erosions on the glans penis. In the subsequent anamnesis Gustavo recognizes a risky sexual contact 20 days before. What is his diagnosis?

DERMATOLOGY, VENEREOLOGY AND PLASTIC SURGERY


Pulmonary contusion is the most serious lesion and the one with the worst prognosis in thoracic trauma. It is also the injury that causes hypoxemia the earliest. Contrary to what we may think, an unstable thorax due to multiple rib fractures (costal volet) would cause progressive hypoventilation with atelectasis of the pulmonary parenchyma, which would progress on the one hand to hypercapnia and respiratory acidosis, and on the other, to later hypoxemia due to infection associated with atelectasis. Respiratory infection due to aspiration would also occur later, and does not appear in all cases of severe chest trauma, only if there has been a decrease in the level of consciousness (associated TBI, uncontrolled intubation with bronchoaspiration...). Post-traumatic hypovolemia (in this case, as there are multiple rib fractures, it could be due to hemothorax) would occur earlier and would be associated in the first place with hemodynamic instability.

Pulmonary contusion is the most serious lesion and the one with the worst prognosis in thoracic trauma. It is also the injury that causes hypoxemia the earliest. Contrary to what we may think, an unstable thorax due to multiple rib fractures (costal volet) would cause progressive hypoventilation with atelectasis of the pulmonary parenchyma, which would progress on the one hand to hypercapnia and respiratory acidosis, and on the other, to [HIDDEN] due to infection associated with atelectasis. Respiratory infection due to aspiration would also occur later, and does not appear in all cases of severe chest trauma, only if there has been a decrease in the level of consciousness (associated TBI, uncontrolled intubation with bronchoaspiration...). [HIDDEN] (in this case, as there are multiple rib fractures, it could be due to hemothorax) would occur earlier and would be associated in the first place with hemodynamic instability.

35-year-old man admitted for severe chest trauma with multiple rib fractures. After responding favorably to treatment with analgesics and oxygen, he begins to present severe hypoxemia. Indicate the most probable cause of this deterioration:

Chest wall instability due to multiple fractures.

Alteration of gas exchange due to pulmonary contusion.


Easy question. Stage G3a corresponds to a filtration rate between 45-59 ml/min. Stage A1 corresponds to albuminuria less than 30 mg/ml. Therefore the correct option is 1.

Easy question. Stage G3a corresponds to a filtration rate between 45-59 ml/min. Stage A1 corresponds to albuminuria less than 30 mg/ml. Therefore [HIDDEN].

A 66-year-old woman with type 2 diabetes mellitus. When assessing her renal function, she presents a G3a/A1 stage. To which values does this stage correspond, the most frequent in patients with diabetic nephropathy?

Glomerular filtration rate 45-59 ml/min/1.73 m² and albuminuria <30 mg/ml.

Glomerular filtration rate 30-44 ml/min/1.73 m² and albuminuria <30 mg/ml.

Glomerular filtration rate 45-59 ml/min/1.73 m² and albuminuria 30-300 mg/ml.

Glomerular filtration rate 15-29 ml/min/1.73 m² and albuminuria <30 mg/ml.


Transfusing this patient and stuffing him with antibiotics is giving him bread for today and hunger for tomorrow. We want something more lasting. Androgens and platelet transfusions don't fix the problem either. We are left with the other three options. An autologous transplant is not reasonable, since the bone marrow of a patient with bone marrow aplasia is less than 25%, so little can be obtained. Therefore, we are inclined towards allogeneic bone marrow transplantation if he has an HLA-identical sibling, since this is the treatment of choice according to the protocol of the Spanish Society of Hematology and Hemotherapy for patients under 40 years of age with severe bone marrow aplasia. Correct answer, 3.

Transfusing this patient and stuffing him with antibiotics is giving him bread for today and hunger for tomorrow. We want something more lasting. Androgens and platelet transfusions don't fix the problem either. We are left with the other three options. An autologous transplant is not reasonable, since the bone marrow of a patient with bone marrow aplasia is less than 25%, so little can be obtained. Therefore, we are inclined towards allogeneic bone marrow transplantation if he has an HLA-identical sibling, since this is the treatment of choice according to the protocol of the Spanish Society of Hematology and Hemotherapy for patients under 40 years of age with severe bone marrow aplasia. [HIDDEN]

A 29-year-old patient comes to your office with a diagnosis of severe bone marrow aplasia. What is the treatment of choice?

Allogeneic bone marrow transplantation if HLA identical sibling.

Autologous bone marrow transplantation to avoid rejection.

Cyclosporin A and antithymocyte globulin.


The question is tricky: it speaks of a burn of 10% of the body surface and the treatment of choice for second degree burns less than 20% of the BSA should be topical and monitored. However, there is a warning sign: there is no arterial pulse and the burn is circumferential to the limb. This is an emergency that, if allowed to evolve, will compromise the viability of the affected limb and end in amputation: an emergency escharotomy must be performed in order to relieve the pressure of the third space on the arterial vascular trunk.

A young man comes to the emergency room with a second-degree flame burn of 10% of the body surface, affecting the right arm in an extensive and circular manner. There is no arterial pulse in the hand measured by Doppler. What is the treatment of choice?

Occlusive sulfadiazine-arginine cures and depth assessment at one week.

Lymphatic drainage and assess a vascular by-pass.

Escharotomy or emergency decompression incisions.


FiO2 of 1 and hyperventilation with mechanical ventilation, demonstrated by the low PCO2, fail to sufficiently raise PO2, due to a V/Q disturbance, with probable shunt in the area of pulmonary atelectasis, probably acute, since the lung has not been able to create compensatory mechanisms to limit perfusion in the poorly ventilated areas.

FiO2 of 1 and hyperventilation with mechanical ventilation, demonstrated by the low PCO2, [HIDDEN], due to a V/Q disturbance, with probable shunt in the area of pulmonary atelectasis, probably acute, since the lung has not been able to create compensatory mechanisms to limit perfusion in the poorly ventilated areas.

While you are on call in the Emergency Department of your hospital, you have to attend a 64-year-old patient with acute respiratory failure. His clinical condition is critical, with low oxygen saturation and hemodynamic instability. An urgent chest X-ray was performed showing atelectasis of 2/3 of the right lung. Orotracheal intubation and assisted ventilation were performed, with Fi02 of 1.0. Subsequent arterial blood gas analysis showed pH 7.23, Pa02 60 mmHg and PaC02 30 mmHg. What was the cause of the hypoxemia?


Basic semiology. However, emergency reasoning: systolic murmur, something that in systole had to be closed and is not, or had to open, and does not: options 1, 3 and 5. And if we see repercussion in the jugular pulse, it must be in the right cavities. Apart from the fact that the v wave appears during systole, while the atria are filling: if the RV flow rises to the RA, what will happen is that the v wave will be very large?

If in a patient with chronic heart failure we detect prominent v waves in the jugular venous pulse and on cardiac auscultation a holosystolic murmur is auscultated in the area of the xiphoid appendage that is accentuated with deep inspiration. What is the valvulopathy responsible for this physical examination?


This is a patient with rheumatoid arthritis. In my opinion, as in these six months she has shown a clear clinical and biological improvement (decrease in acute phase reactants), I would maintain the therapeutic approach taken and wait for a new evaluation. However, I consider that this question could have another valid answer, 3. It depends a little on the attitude of each rheumatologist. If what you are looking for is a remission of the disease as soon as possible, you could choose to consider associating an anti-TNF alpha?

This is a patient with rheumatoid arthritis. In my opinion, as in these six months she has shown a clear clinical and biological improvement (decrease in acute phase reactants), I would maintain the therapeutic approach taken and wait for a new evaluation. However, I consider that this question could have another valid answer, [HIDDEN]. It depends a little on the attitude of each rheumatologist. If what you are looking for is a remission of the disease as soon as possible, you could choose to consider associating an anti-TNF alpha?

A 42-year-old female patient reports pain with inflammatory features and swelling in both wrists, 2nd and 3rd metacarpophalangeal and proximal interphalangeal joints bilaterally and left ankle of 4 months of evolution accompanied by morning stiffness of more than one hour duration. Hand X-ray shows an erosion in the styloid process of the ulna in the right carpus. Laboratory tests showed Hb: 10 g/dL with ESR of 45 mm in the first hour, CRP 16 mg/L, rheumatoid factor 160 IU/ML. After 6 months of treatment with indomethacin and methotrexate, the patient persists with pain and swelling of both carpals, morning stiffness lasting 30 minutes and a CBC showing an ESR 30 mm in the first hour and a CRP 9 mg/dL. Regarding the attitude to take, which of the following is true:

Suspend the prescribed treatment due to lack of response and initiate prednisone at high doses for symptom control only.

Maintain the therapeutic attitude taken since we have only been on it for 6 months and it would be necessary to wait a minimum of 9 months to evaluate therapeutic response.

If there is no medical contraindication, consider adding an anti-TNF alpha to the treatment.

Start a second disease-modifying drug as soon as possible, since it would not be possible to start treatment with biologic therapy alone after methotrexate.

Consider starting treatment with anti-CD20 therapy associated with methotrexate.


As long as fever persists in an evolving pneumonia, there is a risk of empyematization, especially if a small effusion has already occurred at the beginning of the picture. In principle, antibiotic treatment is correct and before considering changes in treatment, the possibility of empyematization should be evaluated.

As long as fever persists in an evolving pneumonia, there is a risk of empyematization, especially if a small effusion has already occurred at the beginning of the picture. In principle, antibiotic treatment is [HIDDEN] and before considering changes in treatment, the possibility of empyematization should be evaluated.

A 56-year-old woman with a history of well-controlled schizophrenia and no toxic habits. Admitted for middle lobe pneumonia with a small associated metaneumonic pleural effusion and on treatment with levofloxacin 500 mg/24h . She presented good clinical evolution except for persistent febrile fever and leukocytosis on the sixth day of treatment. Microbiological studies are not available. The most appropriate course of action is:

The evolution is normal, treatment should be maintained until completing 10 days.

It is considered a therapeutic failure and antibiotic treatment should be modified.

Perform thoracentesis to rule out empyema.

Add corticosteroids at a dose of 0.5 mg/Kg/day to antibiotic treatment.

Bronchoscopy with biopsy, aspiration and bronchoalveolar lavage.


4 is the same as absences,

A patient of adolescent age with myoclonus ("violent jumps") at breakfast time will almost always lead us to juvenile myoclonic epilepsy (answer 5 correct), a very well characterized entity. Among other features is the previous history of seizures or absences, the worsening with nighttime departures, and the EEG with generalized polyp spike discharges at a higher frequency than that of absences. Of the remaining answers, Lennox Gastaut develops at an early age with other symptomatology, 4 is the same as absences, and 3 usually presents with complex partial seizures and either way, the EEG is clearly distinct from a temporal focus.

A patient of adolescent age with myoclonus ("violent jumps") at breakfast time will almost always lead us to juvenile myoclonic epilepsy ([HIDDEN]), a very well characterized entity. Among other features is the previous history of seizures or absences, the worsening with nighttime departures, and the EEG with generalized polyp spike discharges at a higher frequency than that of absences. Of the remaining answers, Lennox Gastaut develops at an early age with other symptomatology, 4 is the same as absences, and 3 usually presents with complex partial seizures and either way, the EEG is clearly distinct from a temporal focus.

An 18-year-old female patient with a history of absences between 6 and 9 years of age, generalized tonic-clonic seizures of recent onset and violent jumping of the upper limbs at breakfast. The clinical manifestations worsen with nighttime weekend outings. An EEG shows acute polyp spike discharges at 6 cycles/second. The most likely diagnosis is:

Symptomatic epilepsy due to mesial temporal sclerosis.


Having antibodies against the core implies natural contact, and that it is IgG, which is not acute. The absence of e antigen rules out active replication. And the persistence of surface antigen (HBsAg) and virus DNA indicates that it is still present. Together, these indicate an asymptomatic carrier. Carriers of the pre-core mutant usually have recurrent symptomatic periods and increased liver inflammation. There would be insufficient data to rule it out completely, but it is not among the answers and indicates a completely normal physical examination.

Having antibodies against the core implies natural contact, and that it is IgG, which is not acute. The absence of e antigen rules out active replication. And the persistence of surface antigen (HBsAg) and virus DNA indicates that it is still present. Together, these indicate an asymptomatic carrier. Carriers of the pre-core mutant usually have recurrent symptomatic periods and increased liver inflammation. There would be insufficient data to rule it out completely, but [HIDDEN] and indicates a completely normal physical examination.

Indicate the clinical situation in relation to hepatitis B virus infection in a 5-year-old patient from Nigeria, with normal physical examination and the following serology for hepatitis B: HBsAg + / ANTI-HBs - / HbeAg - / ANTI-HBe + / ANTI-HBc IgM - / ANTI-HBc IgG + / DNA HBV +:


Refeeding syndrome occurs in patients with previous malnutrition exposed to either oral, enteral or parenteral nutritional therapy. All responses are causes of malnutrition except 3.

Refeeding syndrome occurs in patients with previous malnutrition exposed to either oral, enteral or parenteral nutritional therapy. All responses are causes of malnutrition except [HIDDEN].

A patient on enteral nutritional support presents 72 hours after starting enteral nutrition with a CBC showing hypophosphoremia and hypokalemia, with clinical signs of heart failure. The patient is diagnosed with refeeding syndrome. Indicate which of the following is NOT considered a risk factor for a patient presenting with this condition:


A long statement full of rather confusing data. We can attack that question in two ways: by looking at the key data and going all the way to the diagnosis we are considering or by discarding one by one. The choluria, LDH, presence of panagglutinin and the peripheral blood smear "smells" like hemolytic anemia. Answer 1 cannot be because a marrow aplasia does not explain the choluria, the elevation of LDH, nor in the study of irregular antibodies is positive in the form of panagglutinin; an aplasia is a marrow failure characterized by a total or partial disappearance of hemopoietic progenitors. In addition, pancytopenia is not observed, which is what would incline us more towards this pathology. Answer 2 is not possible either, since a spherocytosis does not justify the presence of panagglutinin. Answer 3 is the one I consider correct: an autoimmune hemolytic anemia would justify the data given: elevated LDH and bilirubinemia due to red cell destruction, polychromatophilia, spherocytosis and anisocytosis because the marrow is working hard to try to compensate for the anemia, which is regenerative. The study of irregular antibodies and the presence of panagglutinin also supports this response, since the binding of an antibody to the hematocyte promotes its lysis and destruction. The girl presents cough and fever, consistent with a respiratory infection. And the initial treatment is corticosteroids. This is confirmed by Sans Sabrafens in his book "Clinical Hematology" [1]. Answer 4 gives rise to considerable doubt; it is not possible because a pernicious anemia does not justify the presence of panagglutinin although it would justify the elevation of LDH and bilirubin; moreover, it is an intramedullary, arregenerative hemolysis, there is no reticulocytosis or release into the blood of immature forms in an attempt to compensate and fix the situation. Answer 5 is not true because no blasts are seen in the blood nor does it explain the presence of panagglutinin.

A long statement full of rather confusing data. We can attack that question in two ways: by looking at the key data and going all the way to the diagnosis we are considering or by discarding one by one. The choluria, LDH, presence of panagglutinin and the peripheral blood smear "smells" like hemolytic anemia. Answer 1 cannot be because a marrow aplasia does not explain the choluria, the elevation of LDH, nor in the study of irregular antibodies is positive in the form of panagglutinin; an aplasia is a marrow failure characterized by a total or partial disappearance of hemopoietic progenitors. In addition, pancytopenia is not observed, which is what would incline us more towards this pathology. [HIDDEN], since a spherocytosis does not justify the presence of panagglutinin. [HIDDEN]: an autoimmune hemolytic anemia would justify the data given: elevated LDH and bilirubinemia due to red cell destruction, polychromatophilia, spherocytosis and anisocytosis because the marrow is working hard to try to compensate for the anemia, which is regenerative. The study of irregular antibodies and the presence of panagglutinin also supports this response, since the binding of an antibody to the hematocyte promotes its lysis and destruction. The girl presents cough and fever, consistent with a respiratory infection. And the initial treatment is corticosteroids. This is confirmed by Sans Sabrafens in his book "Clinical Hematology" [1]. [HIDDEN]; it is not possible because a pernicious anemia does not justify the presence of panagglutinin although it would justify the elevation of LDH and bilirubin; moreover, it is an intramedullary, arregenerative hemolysis, there is no reticulocytosis or release into the blood of immature forms in an attempt to compensate and fix the situation. [HIDDEN].

A 32-year-old woman with cerebral palsy from childbirth comes to the emergency department for a few days of dark urine associated with an episode of high fever and dry cough. On admission, the CBC showed 16900 leukocytes/mm3 (85% S, 11% L, 4% M), hemoglobin 6.3 g/dL; MCV 109 fl, 360000 platelets/mm3. In the biochemistry LDH 2408; bilirubin 6.8 mg/dl, (unconjugated bilirubin 6.1 mg/dl), normal GOT and GPT. The morphological study of blood showed macrocytic anisocytosis with frequent spherocytic forms and polychromatophilia without blasts. The irregular antibody study is positive for panagglutinin, making crossmatching difficult. What would be your suspicion and the most appropriate treatment?

Medullary aplasia and immunotherapy with thymoglobulin and cyclosporine.

Hereditary spherocytosis and splenectomy.

Autoimmune hemolytic anemia associated with respiratory infection and corticosteroids.

Pernicious anemia and periodic injections of vitamin B12.


Direct response question. The question tells the story of a patient with acute pancreatitis who is developing acute respiratory failure. The statement lists the criteria for ARDS (acute respiratory distress syndrome): PaO2/fiO2 < 200 + bilateral pulmonary infiltrates + PCP<18. So the diagnosis is respiratory distress and therefore the correct answer is option 5.

Direct response question. The question tells the story of a patient with acute pancreatitis who is developing acute respiratory failure. The statement lists the criteria for ARDS (acute respiratory distress syndrome): PaO2/fiO2 < 200 + bilateral pulmonary infiltrates + PCP<18. So the diagnosis is respiratory distress and therefore [HIDDEN].

A patient admitted for acute pancreatitis starts with tachypnea, tachycardia, sweating and progressive cyanosis. PaO2 is 55 mm Hg (PaO2/FiO2 ratio<200). CXR shows bilateral alveolar pulmonary infiltrates. Pulmonary capillary wedge pressure is normal. Oxygen therapy does not improve the situation. What is the most probable diagnosis:

ANESTHESIOLOGY, CRITICAL CARE AND EMERGENCIES


Other drugs are a good choice in urinary tract infections caused by large negative bacilli (most likely: E. coli). The presence of leukocytes + nitrites in the urine is very suggestive of UTI. And if the urine Gram detects G- bacteria, it is probably a UTI due to E Coli. Many E Coli are resistant to amoxicillin.

A 13-month-old infant comes to the emergency department with fever up to 39ºC of 48h of evolution with no other associated symptoms. Examination by organs and devices with no significant findings, highlighting good general condition. You were going to discharge him home but the Pediatrics attending on duty asks for a systematic urine and urine culture by catheterization. The urine shows leukocyturia ++, hematuria + and nitrites ++ and the urine Gram-negative bacilli are observed. In the blood analysis there is no leukocytosis and the C-reactive protein is 50 mg/l. The attending now tells you that the child does not need to be admitted and to prescribe an oral antibiotic. State the least appropriate empirical antibiotic treatment in this case:


This is cryptorchidism. It has to be treated before the age of 2 years, and hormonal treatment is currently in disuse. The treatment of first choice is orchidopexy.

This is cryptorchidism. It has to be treated before the age of 2 years, and hormonal treatment is currently in disuse. The treatment of first choice is [HIDDEN].

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

The most likely diagnosis is retractile testis.

Wait until two years of age for spontaneous decrease of the synovial fluid.

Human chorionic gonadotropin is the treatment of first choice.

The indication for orchidopexy should not be deferred.


None of the other three options give that clinical picture (DPV is usually asymptomatic, CRVO produces abrupt and total or near total loss of vision with the typical "cherry red spot" in the fundus, and both an arteritic and non-arteritic NOIA would produce papillary edema usually with peripapillary but not macular hemorrhages, and none of these 3 options have any association with drusen in the contralateral eye). AMD in its exudative form presents with both this clinical presentation (loss of vision and metamorphopsia) and the characteristic fundus described in the question, in addition to the fact that drusen are usually observed in the contralateral eye.

An 84-year-old woman presents with loss of vision in the left eye of 4 days of evolution accompanied by metamorphopsia. The macula shows abundant hard exudates, two small deep hemorrhages and a localized neurosensory retinal detachment. In the contralateral eye there are abundant soft drusen. Which of the following diagnoses do you think is the most likely?

Exudative age-related macular degeneration (AMD).

Non-arteritic anterior ischemic optic neuropathy.


Diplopia on vertical gaze is highly suggestive that the bony walls of the orbit are affected. Lefort type I fracture does not affect the orbital contents. Knowing this information, the only correct answer is 2. If we were in doubt about whether or not Lefort's type I fracture affects the orbit, just look at the answers. Whoever posted the question wanted to make sure that the only valid answer was number 2; that is why they added the tag line "but just in case we check it with a CT scan".

Diplopia on vertical gaze is highly suggestive that the bony walls of the orbit are affected. Lefort type I fracture does not affect the orbital contents. Knowing this information, [HIDDEN]. If we were in doubt about whether or not Lefort's type I fracture affects the orbit, just look at the answers. Whoever posted the question wanted to make sure that [HIDDEN]; that is why they added the tag line "but just in case we check it with a CT scan".

Given a direct trauma to the right side of the face after which the patient presents unilateral palpebral hematoma, diplopia in the vertical gaze and difficulty in opening the mouth, which of the following statements is true?

We are with great probability in front of a Lefort I type fracture of the middle third of the face.

This is probably a unilateral orbitomalar fracture. The diagnosis would ideally be verified by CT (computed axial tomography).

It is a fracture of the base of the skull at the level of the carotid foramen.

The probable diagnosis is fracture with dislocation of the mandibular condyle.

A mandibular fracture is probably associated with a Lefort I type midface fracture.

OTORHINOLARYNGOLOGY AND MAXILLOFACIAL SURGERY


This question could be controversial. Option 1 is strongly discarded because endophthalmitis typically presents with a lot of pain. Option 3 of wet form of age-related macular degeneration is also ruled out, because it usually occurs in older patients, although what a patient with myopia magna may present with is myopic macular degeneration (with a similar clinical picture to AMD, but this is a different pathology). A posterior vitreous detachment (PVD) is usually not very symptomatic, producing myodesopsias but no loss of vision or pain; however, some PVDs are of the hemorrhagic type, by traction of the vessels, producing a vitreous hemorrhage that would cause loss of vision. In any case, due to the history of myopia magna and previous intraocular surgery, the first diagnosis to rule out would be retinal detachment, since these are two risk factors for this pathology. Technically, both option 2 and 4 (an acute hemorrhagic DPV) could cause these symptoms, but the most correct option is option 2 (and I am sure it is the one the examiner wants answered).

This question could be controversial. Option 1 is strongly discarded because endophthalmitis typically presents with a lot of pain. Option 3 of wet form of age-related macular degeneration is also ruled out, because it usually occurs in older patients, although what a patient with myopia magna may present with is myopic macular degeneration (with a similar clinical picture to AMD, but this is a different pathology). A posterior vitreous detachment (PVD) is usually not very symptomatic, producing myodesopsias but no loss of vision or pain; however, some PVDs are of the hemorrhagic type, by traction of the vessels, producing a vitreous hemorrhage that would cause loss of vision. In any case, due to the history of myopia magna and previous intraocular surgery, the first diagnosis to rule out would be retinal detachment, since these are two risk factors for this pathology. Technically, [HIDDEN].

A 47-year-old man with myopia magna, who underwent cataract surgery 2 years ago, comes to the emergency room reporting a profound and painless loss of vision in his right eye. Which of the following diagnoses can cause this symptomatology?

Age-related macular degeneration, wet form.


In this case, the presence of thickening of the subepithelial collagen layer, more evident with Masson's trichrome (special stain that allows differentiation of the collagen fibers), is pathognomonic of collagenous colitis. Atrophy together with epithelial denudation are characteristic of this disease, which does not usually cause macroscopic alterations of the mucosa. An increased density of intraepithelial lymphocytes and the absence of mention of architectural alterations of the crypts (characteristic of ulcerative colitis and Crohn's disease) support this diagnosis.

A 59-year-old woman presenting with chronic watery diarrhea of 4 months' evolution. In the endoscopy, the mucosa did not show relevant aspects. In particular, no ulcers or friable areas were observed. A biopsy of the transverse colon was performed. Histopathology revealed a thickened area below the superficial lining epithelium, which was more evident by Masson's trichrome technique and involved epithelial atrophy and denudation. There was also a clear increase in intraepithelial lymphocyte density. The diagnosis of the intestinal lesion is?


Since a splenectomized patient is considered a "special" patient, he should receive antibiotic treatment as soon as possible, even if the wound does not appear infected. It is necessary to make sure that the dog is yours (you should ask if the animal is correctly vaccinated) and if the patient is correctly vaccinated (5 doses of tetanus, it would not require tetanus); make a notification of Animal Aggression, for observation of this and take measures in case this is necessary.

Since a splenectomized patient is considered a "special" patient, he should receive antibiotic treatment as soon as possible, even if the wound does not appear infected. It is necessary to make sure that the dog is yours (you should ask if the animal is correctly vaccinated) and if the patient is correctly vaccinated (5 doses of tetanus, [HIDDEN]); make a notification of Animal Aggression, for observation of this and take measures in case this is necessary.

Luis is a 25-year-old young man who underwent splenectomy after a bicycle accident 1 year ago. He has a dog that bit him 24 hours ago and has caused a small wound on his right hand. He went to his health center (located 3 hours from the nearest hospital) for fever of 39ºC, pain in the wound and general malaise. On examination, BP 100/60 mm Hg, HR 110 beats per minute, slight swelling in the wound without pus. Which of the following actions is most indicated at this time?

Send to hospital for rabies and tetanus vaccination and keep under observation.

Clean the wound and administer intramuscular nonspecific ganunaglobulin.

Give 400 mg of oral moxifloxacin and send to the hospital.

Give clindamycin 600 mg oral every 8 hours and observation.


The correct answer is 3. The study that gives us more information about endometrial pathology is hysteroscopy, which allows us to perform a directed endometrial biopsy. Endometrial cytology is performed blindly and has a large number of false negatives. MRI will help us to stage endometrial cancer.

The [HIDDEN] The study that gives us more information about endometrial pathology is hysteroscopy, which allows us to perform a directed endometrial biopsy. Endometrial cytology is performed blindly and has a large number of false negatives. MRI will help us to stage endometrial cancer.

A 67-year-old patient with a history of menopause at 55 years of age, 3 pregnancies with 3 euthyroid deliveries, type 2 diabetes of 6 years of evolution, treatment with nifedipone for hypertension. She consulted for intermittent scanty metrorrhagia of 2 months of evolution. The gynecological examination showed external genitalia without lesions, an atrophic cervix, a normal uterus and appendages on palpation and a normal cytological study of the cervix. The transvaginal ultrasound study shows a 7 mm hyperechogenic endometrium. Which of the following tests is the most appropriate and most sensitive to establish a diagnosis?

Magnetic resonance imaging of the pelvis.

Examination under anesthesia of the genital tract and biopsy of the cervix and endometrium.


The picture described is typical of a viral meningoencephalitis, more specifically VHZ, with significant tropism by the temporal lobe, causing febrile fever and in many cases aphasia, so the correct option would be 2, since the cerebrospinal fluid normally shows a moderate lymphocytic pleocytosis, with normal glycorrhachia. The rest are not correct because: The first one because it is not a bacterial meningitis that would present with more fever, the third one because limbic encephalitis usually presents afebrile with behavioral changes and the last one because the image they describe is not an abscess, well delimited.

The picture described is typical of a viral meningoencephalitis, more specifically VHZ, with significant tropism by the temporal lobe, causing febrile fever and in many cases aphasia, so [HIDDEN], since the cerebrospinal fluid normally shows a moderate lymphocytic pleocytosis, with normal glycorrhachia. The rest are [HIDDEN]: The first one because it is not a bacterial meningitis that would present with more fever, [HIDDEN] limbic encephalitis usually presents afebrile with behavioral changes and [HIDDEN] the image they describe is not an abscess, well delimited.

A 52-year-old man comes to the Emergency Department with headache and fever (37.8°C) of 2 days' evolution. In the last few hours, he also had difficulty in nomination and comprehension. The examination did not show nuchal rigidity, the most striking finding being the presence of a mixed aphasia. The cranial CT shows a faint hypodensity in the left temporal lobe without mass effect and without contrast uptake. Which of the following statements is correct?

Bacterial meningitis is the first diagnostic impression and treatment with 3rd generation cephalosporin should be initiated as soon as possible.

Most likely this patient's CSF shows a lymphocyte-predominant pleocytosis with normal glycorrhachia.


Reading the answers, the first thing that is clear to us is that acenocoumarol should NOT be given to a pregnant woman because of the risk of teratogenicity. Anyone who does so during residency should be punished with 100 slaps on the back. We discard answer 5. Second: if treatment is given, it should be during the entire pregnancy, prothrombotic status is not only during the puerperium, so answer 2 discarded. Advise a woman not to become pregnant when there are treatments that ensure a very low risk of thrombosis and/or fetal involvement? Answer 1 discarded. We are left with the possibility of not giving any treatment because it is low risk or administering low-dose aspirin. It is true that factor V Leiden in heterozygosis is classified as low risk, who has not presented a previous thrombotic episode nor is there a combination with another thrombophilia; if we look at the CHEST guide, VIII edition and review what was said at the last congress of the Spanish Society of Gynecology and Obstetrics, we see that aspirin is used in case of phospholipid syndrome and that in the case of this woman, without previous thrombosis, without previous abortions (at least two are needed) and also being heterozygous, treatment is not necessary. Correct answer, 3.

Reading the answers, the first thing that is clear to us is that acenocoumarol should NOT be given to a pregnant woman because of the risk of teratogenicity. Anyone who does so during residency should be punished with 100 slaps on the back. We discard answer 5. Second: if treatment is given, it should be during the entire pregnancy, prothrombotic status is not only during the puerperium, so answer 2 discarded. Advise a woman not to become pregnant when there are treatments that ensure a very low risk of thrombosis and/or fetal involvement? Answer 1 discarded. We are left with the possibility of not giving any treatment because it is low risk or administering low-dose aspirin. It is true that factor V Leiden in heterozygosis is classified as low risk, who has not presented a previous thrombotic episode nor is there a combination with another thrombophilia; if we look at the CHEST guide, VIII edition and review what was said at the last congress of the Spanish Society of Gynecology and Obstetrics, we see that aspirin is used in case of phospholipid syndrome and that in the case of this woman, without previous thrombosis, without previous abortions (at least two are needed) and also being heterozygous, treatment is not necessary. [HIDDEN].

A 25-year-old woman who wishes to become pregnant and wants to know what treatment she should take during the eventual pregnancy, as she is a heterozygous factor V Leiden carrier. She has never had any thrombotic phenomena. The determination of this factor was performed as a family study after an episode of pulmonary embolism in a sibling. What treatment should be advised?

Since pregnancy is a prothrombotic state, there would be a high risk of venous thromboembolism, so pregnancy should be discouraged.

Treatment with low molecular weight heparin at prophylactic doses should be carried out in the immediate puerperium, with optional follow-up during pregnancy.

Factor V Leiden in heterozygosis is a low-risk thrombophilia and there is no need for any treatment in pregnancy and puerperium.

Low-dose aspirin should be advised during pregnancy and puerperium.

Treatment with antivitamin K drugs (acenocoumarol) during pregnancy.


We are being shown a picture of lumbar canal stenosis (Answer 4 correct). The patient shows the characteristic clinical picture: lumbar pain that is relieved by flexing the trunk forward, radicular pain with lower limb involvement and neurogenic claudication. Low back pain in a patient over 60 years of age accompanied by leg weakness when walking, which has to be interrupted at a certain distance, called neurogenic claudication, is the typical picture of stenosis. The patient is relieved by flexing the spine forward because it widens the lumbar canal and worsens with extension...

We are being shown a picture of lumbar canal stenosis ([HIDDEN]). The patient shows the characteristic clinical picture: lumbar pain that is relieved by flexing the trunk forward, radicular pain with lower limb involvement and neurogenic claudication. Low back pain in a patient over 60 years of age accompanied by leg weakness when walking, which has to be interrupted at a certain distance, called neurogenic claudication, is the typical picture of stenosis. The patient is relieved by flexing the spine forward because it widens the lumbar canal and worsens with extension...

The most likely diagnosis of a 74-year-old patient who since two months ago begins with lumbar pain radiating to lower limbs, neurogenic claudication and limitation to extension the trunk is:


Pituitary apoplexy is a syndrome characterized by the sudden onset of headache accompanied by ocular motility disturbances and a variable degree of pituitary insufficiency. The cause is usually a rapidly growing pituitary mass secondary to a vascular event (infarction or hemorrhage). General symptoms may range from vomiting or nausea to meningeal irritation. Compression on the chiasm and optic nerve can cause various campimetric deficits (usually greater bitemporal hemianopsia in the superior quadrants) and decreased visual acuity, even blindness. If the mass grows lateral to the sella turcica it can compress the oculomotor nerves, with the common motor ocular nerve being the most frequently affected, because of its more medial course in the cavernous sinus. The test of choice for the diagnosis of pituitary apoplexy is MRI, as CT may not distinguish the region clearly enough to distinguish degenerative or cystic changes from previous bleedings. The finding of erosion of the anterior clinoid processes in the skull CT may support a chronic lesion, which as a result of an acute vascular phenomenon has caused the symptoms. The management of these patients involves strict control of water and electrolyte disturbances and correction of hormonal deficits. In unstable situations as in the case described, with significant visual disturbances, surgical intervention is usually of choice, with transsphenoidal decompression.

A 51-year-old woman comes to the emergency department with a sudden decrease in visual acuity, severe headache, nausea and vomiting. Hypotensive and afebrile. She presented right ophthalmoparesis due to involvement of the third cranial nerve. A cranial CT scan shows a mass in the hyperdense selar region with erosion of the anterior clinoid processes. What is the best approach to follow?

Suspect chemical meningitis derived from a ruptured epidermoid tumor and start immediate treatment with corticosteroids.

It would indicate the performance of a cerebral angiography to rule out an aneurysm, since it is most likely that we are facing a case of subarachnoid hemorrhage and the mass that is evident in the CT is a thrombosed parasellar aneurysm.

Admission to ICU and treatment of the shock suffered by the patient and once stabilized perform brain MRI for scheduled surgery.

Urgent biochemistry and hemogram, initiation of high-dose corticosteroid therapy and urgent transsphenoidal surgery.

Lumbar puncture to rule out bacterial meningitis after starting empirical antibiotherapy. Once the patient was stabilized, study of the selar mass.


The answer is 2. According to the SEGO (Spanish Society of Gynecology and Obstetrics) in its 2005 protocol "Gestational trophoblastic disease", the risk of malignization, i.e. of developing a gestational trophoblastic neoplasm, ranges from 5 to 20% depending on whether it is a partial mole or a complete mole, respectively. According to this protocol: "Patients will be monitored weekly with hcg dosage until it becomes undetectable, for three consecutive times. After that the monitoring will be monthly, for six months and then every two months for another six months. Based on the available data, a follow-up of three to six months is recommended for partial mole and 12 months for complete mole." Therefore, subsequent controls are strictly necessary.The risk of a new molar gestation, although increased compared to the normal population, is not 50%.

[HIDDEN] According to the SEGO (Spanish Society of Gynecology and Obstetrics) in its 2005 protocol "Gestational trophoblastic disease", the risk of malignization, i.e. of developing a gestational trophoblastic neoplasm, ranges from 5 to 20% depending on whether it is a partial mole or a complete mole, respectively. According to this protocol: "Patients will be monitored weekly with hcg dosage until it becomes undetectable, for three consecutive times. After that the monitoring will be monthly, for six months and then every two months for another six months. Based on the available data, a follow-up of three to six months is recommended for partial mole and 12 months for complete mole." Therefore, subsequent controls are strictly necessary.The risk of a new molar gestation, although increased compared to the normal population, is not 50%.

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

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

You should not become pregnant until periodic controls and have spent one year with negative BHCG levels.

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

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


A 27-year-old woman, 10 weeks pregnant, with persistent severe allergic asthma. She is currently adequately controlled with daily inhaled budesonide and rescue inhaled salbutamol on demand. She comes to your office concerned about the possible teratogenic effects of her anti-asthma medication. Which of the following would be the correct approach?

Given that asthma improves during pregnancy in most patients, the best thing for the patient and the fetus is to suspend anti-asthma treatment.

Discontinue budesonide because it has been associated with an increased risk of fetal malformations and replace it with an oral anti-leukotriene (montelukast).

Withdraw current treatment and replace it with oral prednisone at the lowest possible dose.

Maintain the current treatment and reassure the patient about its side effects and the need for adequate asthma control during pregnancy.

Replace budesonide with an anti-IgE monoclonal antibody (omalizumab) because of its greater safety in pregnancy since it is not a drug.


It refers to a thyroid nodule, and the indicated test is a FNA (fine needle puncture). I have read the answer Emilio has written on the challenge; the question is in the endocrine block and it seems he is trying to make it clear that it is a nodule. Ultrasound facilitates FNA but is not mandatory, a 2 cm thyroid nodule can be punctured without echo. It is important to have an analysis of thyroid function prior to the puncture; but since he is talking about an asymptomatic patient, it seems clear that she is not hyperthyroid. I do not think it is contested and I think it is a question that most will have answered well.

It refers to a thyroid nodule, and the indicated test is a FNA (fine needle puncture). I have read the answer Emilio has written on the challenge; the question is in the endocrine block and it seems he is trying to make it clear that it is a nodule. Ultrasound facilitates FNA but is not mandatory, a 2 cm thyroid nodule can be punctured without echo. It is important to have an analysis of thyroid function prior to the puncture; but since he is talking about an asymptomatic patient, it seems clear that she is not hyperthyroid. I do not think it is contested and I think [HIDDEN].

A 52-year-old woman from a village on the Costa Brava notices an otherwise asymptomatic lump in the anterior region when applying cream to her neck; she goes to her general practitioner who confirms the presence of a firm, smooth mass, 2 cm in maximum diameter, which rises with swallowing. No palpable lymphadenopathy. What tests would you order at the outset?

A determination of thyroglobulin in blood.

A determination of circulating antithyroid antibodies (antithyroglubulin and antiperoxidase).


Currently the molecular classification of breast cancer is based on the study of hormone receptors, HER2 and the tumor cell proliferation index (Ki67). We have four fundamental types: Luminal (A: HR+, HER2- and low Ki67 and B: HR+, HER2+/ - and high Ki67), HER2 + (HR -, HER2 + and high Ki67) and Basal Like or triple negative (HR -, HER2 - and high Ki67).

A 67-year-old woman diagnosed with an 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:

Complete phenotypic study by flow cytometry.

Study of hormone receptors, ecadherin and study of first degree relatives.

BRCA l-2 study and study of first-degree relatives.


The NNT (number needed to treat), means how many patients we would need to treat with an intervention to obtain a benefit; in this question how many patients do we need to treat with warfarin to prevent a stroke. To calculate this we use the following formula: NNT= 1/RRA (RRA: absolute risk reduction). RRA= Io - Ie (Io: incidence in those not exposed to warfarin; Ie: incidence in those exposed to warfarin). RRA: 5,2%- 2,2%= 3= 0,03. NNT: 1/0.03= 33.3.

The NNT (number needed to treat), means how many patients we would need to treat with an intervention to obtain a benefit; in this question how many patients do we need to treat with warfarin to prevent a stroke. To calculate this we use the following formula: NNT= 1/RRA (RRA: absolute risk reduction). RRA= Io - Ie (Io: incidence in those not exposed to warfarin; Ie: incidence in those exposed to warfarin). RRA: 5,2%- 2,2%= [HIDDEN]. NNT: 1/0.03= [HIDDEN].

An 86-year-old woman in whom nonvalvular atrial fibrillation has been detected. She has a CHADS2 score of 3 points. In the literature, similar patients on warfarin therapy have a stroke risk of 2.2% versus 5.2% in patients without warfarin. What would be the number needed to treat (NNT) to prevent embolic stroke with anticoagulation therapy?


Patient with familial adenomatous polyposis. All statements are correct except 2. Treatment should be surgical when polyposis is observed. At 40 years of age is the usual point of incidence of cancer.

Patient with familial adenomatous polyposis. All statements are correct except [HIDDEN]. Treatment should be surgical when polyposis is observed. At 40 years of age is the usual point of incidence of cancer.

A 30-year-old man with a family history of a father who died at 38 years of age from colon cancer. A colonoscopy is performed and shows hundreds of adenomas throughout the colon. Which of the following statements is false?

The patient has familial adenomatous polyposis.

The most appropriate management is annual follow-up colonoscopy and colectomy at age 40.

If the patient does not undergo surgical treatment, he/she will almost certainly develop colorectal cancer.

First degree relatives should be studied.

The patient's children have a 50% risk of suffering the same disease.


I answer this question thinking more about what they want to ask than what they are really asking. There is heterogeneity in the development of Alzheimer's disease symptoms. There are behavioral variants, but in the MIR they usually want you to think of other types of dementias in the face of behavioral symptoms. In fact, the appearance of these symptoms in early stages should alert us and open the range of diagnostic possibilities. Therefore, we discard 2 and 4. Between 1 and 3, I choose 3 for the same reason and because of the emphasis on the decline of functional independence that occurs in these patients.

I answer this question thinking more about what they want to ask than what they are really asking. There is heterogeneity in the development of Alzheimer's disease symptoms. There are behavioral variants, but in the MIR they usually want you to think of other types of dementias in the face of behavioral symptoms. In fact, the appearance of these symptoms in early stages should alert us and open the range of diagnostic possibilities. Therefore, we [HIDDEN] Between 1 and 3, I [HIDDEN] for the same reason and because of the emphasis on the decline of functional independence that occurs in these patients.

A 75-year-old woman brought for consultation by her family because they have been finding her depressed and with memory lapses for months. They are concerned that she may have Alzheimer's disease. The patient refers that she does not think anything is wrong with her and that she is as usual. In what order do the following symptoms generally occur in the progression of Alzheimer's disease:

Mood changes, behavioral symptoms, cognitive deficits.

Behavioral symptoms, motor symptoms, decline of functional independence.

Mood changes, cognitive deficit, decline of functional independence.

Behavioral symptoms, mood changes, motor symptoms.


The correct answer is: 2. Hyperkalemia. Spironolactone, as a potassium-sparing diuretic, inhibits the action of aldosterone at the renal level, being responsible for a decrease in potassium excretion. Hyperkalemia produces repolarization disturbances that result in the installation of a large, symmetrical, narrow-based T, visible in the precordial leads. The QT space is shortened. These anomalies appear with a kalemia of around 5.5 to 6 mmol/l. Above 6.5 mmol/L, electrocardiographic changes are constant, and are dominated by conduction disturbances (making ventricular extrasystoles possible).

[HIDDEN] Hyperkalemia. Spironolactone, as a potassium-sparing diuretic, inhibits the action of aldosterone at the renal level, being responsible for a decrease in potassium excretion. Hyperkalemia produces repolarization disturbances that result in the installation of a large, symmetrical, narrow-based T, visible in the precordial leads. The QT space is shortened. These anomalies appear with a kalemia of around 5.5 to 6 mmol/l. Above 6.5 mmol/L, electrocardiographic changes are constant, and are dominated by conduction disturbances (making ventricular extrasystoles possible).

An 80-year-old patient with a history of hypertension and on treatment with enalapril and spironolactone comes to the hospital with asthenia and severe muscle weakness. Blood pressure is 110/70 mmHg. In the ECG, there are sharp and elevated T waves, ventricular extrasystoles and short QT. What is the most likely diagnosis?


- pH less than 7.20 Pathological value. Indication for fetal extraction by the quickest route, in this case a cesarean section. - pH between 7.20-7.25 Prepathological value. Repeat microtome in 15-20 min. - pH greater than 7.25. Value within the limits of normality. Observation.

- pH less than 7.20 Pathological value. [HIDDEN], in this case a cesarean section.
- pH between 7.20-7.25 Prepathological value. Repeat microtome in 15-20 min.
- pH greater than 7.25. Value within the limits of normality. Observation.

Woman 40 weeks gestation in labor with 6 cm dilation. She presents a decelerative fetal pattern in cardiotocographic recordings, so it is decided to perform a fetal blood smear to assess fetal well-being. Result 7.22. The correct conduct is:

Severe acidosis. Urgent cesarean section.

Pre-pathological value repeat microtome 15-20 minutes.

Moderate acidosis. Repeat microtome in 1-2 hours.

Value in normal limits, leave natural evolution of labor.

Repeat at the time of possible error in obtaining the shot.


The proposed steroid dose is too low.

Idiopathic thrombocytopenic purpura, but with very low platelets, so replenishment is necessary. The proposed steroid dose is too low.

A 19-year-old girl with no medical history of interest, except for a self-limited case of influenza 3 weeks earlier, who comes to the emergency department with petechiae and ecchymosis of spontaneous onset. On physical examination the patient was in good general condition, afebrile, normotensive and oriented in time and space. There were petechiae scattered throughout the lower extremities and abdomen and small ecchymoses in decubitus areas. No lymphadenopathy or splenomegaly were palpated. Laboratory tests showed the following findings: Hb 12.6 g/dL, leukocytes 5,500/mm3, platelets 7000/mm3. The peripheral blood smear showed normal erythrocyte morphology, normal differential leukocyte count and the planetary count was concordant with the autoanalyzer figure without platelet aggregates. Biochemistry and proteinogram, beta 2 microglobulin and LDH are normal. Which of the following do you think is the most appropriate initial treatment?

Cyclophosphamide in 4-day pulses every 21 days.


The trick to this question is that there are 8 cervical roots for 7 vertebrae, therefore the C1 root exits ABOVE the atlas, and so on up to C8 which exits BETWEEN C7 and T1. The thoracic roots come out respectively below the vertebra with their same numbering (nerve T1 under T1, T2 under T2, etc.). Therefore, between C4 and C5 the 5th cervical nerve exits, and between T4 and T5 the 4th thoracic nerve exits. The correct answer is 4.

The trick to this question is that there are 8 cervical roots for 7 vertebrae, therefore the C1 root exits ABOVE the atlas, and so on up to C8 which exits BETWEEN C7 and T1. The thoracic roots come out respectively below the vertebra with their same numbering (nerve T1 under T1, T2 under T2, etc.). Therefore, between C4 and C5 the 5th cervical nerve exits, and between T4 and T5 the 4th thoracic nerve exits. [HIDDEN]

A 42-year-old woman with breast cancer has metastases at the level of the intervertebral foramina between the 4th and 5th cervical vertebrae and between the 4th and 5th thoracic vertebrae. Which spinal nerves will be injured?

Fourth cervical and fourth thoracic nerves.

Fifth cervical and fifth thoracic nerves.

Fourth cervical and fifth thoracic nerves.

Fifth cervical and fourth thoracic nerve.

Third cervical and fourth thoracic nerve.


Everything we are told in this case is typical of COLLAGENOUS COLITIS. In principle, the clinical and endoscopic findings may leave us a little as at the beginning, but histology is little more than the definition of this pathology. The specific criterion for the diagnosis of collagenous colitis is the additional presence of an irregular band of collagen just below the surface epithelium of the colonic mucosa in continuity with the basement membrane, visible with trichrome staining (stains type I collagen fibers), which traps superficial capillaries producing lesions in the surface epithelium. In addition, it is accompanied by a chronic inflammatory infiltrate in the lamina propria, composed mainly of lymphocytes, plasma cells and eosinophils.

A 59-year-old woman presents with chronic watery diarrhea of 4 months' duration. On endoscopy, the mucosa showed no relevant features. In particular, no ulcers or friable areas were observed. A biopsy of the transverse colon was performed. Histopathology revealed a thickened area below the superficial lining epithelium, which was more evident by Masson's trichrome technique and involved epithelial atrophy and denudation. There was also a clear increase in intraepithelial lymphocyte density. The diagnosis of the intestinal lesion is?


Aortic stenosis.

A 78-year-old patient with no past history who consults for asthenia and dyspnea of 3 months of evolution, which has progressed to rest in the last few days. In the previous days he also refers chest pain with anginal characteristics with small efforts. On examination, blood pressure of 110/80 mmHg, heart rate of 85 bpm and auscultation with a rough systolic murmur in the right second intercostal space and crackles in both lung bases. Which of the following is the most likely diagnosis?

Dilated cardiomyopathy of ischemic origin.


Calcium/creatinine urine ratio. This is familial hypocalciuric hypercalcemia or benign familial hypercalcemia. Autosomal dominant disorder. Asymptomatic. Not cured after surgical treatment; it is due to mutation of the calcium-sensitive receptor. Difficult question since it is necessary to know data of a disease that is not usually asked in the MIR.

Calcium/creatinine urine ratio. This is familial hypocalciuric hypercalcemia or benign familial hypercalcemia. Autosomal dominant disorder. Asymptomatic. Not cured after surgical treatment; it is due to mutation of the calcium-sensitive receptor. [HIDDEN] since it is necessary to know data of a disease that is not usually asked in the MIR.

In a 30-year-old female patient a calcium level of 11 mg/dl (normal less than 10.5 mg/dl) is found during a routine company examination. PTH determination was 45 pg/ml (VN 10-55 pg/ml). The history is unremarkable except for the fact that the mother and paternal grandfather were diagnosed with hyperparathyroidism and underwent surgery, although they remained hypercalcemic. Which test is most useful in confirming the diagnosis?


CT scan is part of the diagnostic workup in case there is biochemical confirmation.

A 58-year-old male with a history of arterial hypertension of 6 years of evolution, who consults for poor control of blood pressure figures despite receiving treatment with an angiotensin-converting enzyme inhibitor, a diuretic and a calcium antagonist. On consultation she presented with blood pressure of 149/100 mmHg. Laboratory tests: creatinine 1.2 mg/dl, potassium 2.2 mEq/l and compensated metabolic alkalosis; the rest of the biochemical study, blood count, coagulation and urinary sediment were normal. Mark the correct statement:

The origin of hypertension in this case is excessive aldosterone secretion caused by autonomic hyperfunction of the adrenal medulla.

In most cases the anatomical substrate is bilateral hyperplasia of the adrenal cortex.

CT scan is part of the diagnostic study in case of biochemical confirmation.

Spironolactone is contraindicated in the management of this pathology.


It is a coxarthrosis. The surgical criteria depends on the patient's symptoms and failure of medical treatment. No medication slows down or modifies the course of the disease. An MRI is not necessary, it does not contribute anything. Treatment is medical and sequential, starting with the first analgesic step of the WHO.

You evaluate a 66-year-old patient with groin pain accentuated by prolonged standing for a few days per month. A plain radiograph of the hips shows narrowing of the femoroacetabular joint space, sclerosis and ostephytes.

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.

Treatment with paracetamol, explaining 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.


As soon as we hear about weight we go to anorexia nervosa, but anorexia nervosa has three features: significant self-induced weight loss, body image distortion and amenorrhea. So we remove 1. One loses weight when one gets sad, worries, etc... 3 does not make sense in the MIR because of the clinic -in reality the history is different and in psychiatry everything is evolution-. 4 has to meet temporal criteria that are not met here. So we are between 2 and 5. Depression or anxiety? There is no anxiety clinic and she also meets the criteria for depression. The poor girl has been diagnosed with depression. The answer is 5 (another option is that she was studying the MIR).

As soon as we hear about weight we go to anorexia nervosa, but anorexia nervosa has three features: significant self-induced weight loss, body image distortion and amenorrhea. So we remove 1. One loses weight when one gets sad, worries, etc... [HIDDEN] -in reality the history is different and in psychiatry everything is evolution-. [HIDDEN]. So we are between 2 and 5. Depression or anxiety? There is no anxiety clinic and she also meets the criteria for depression. The poor girl has been diagnosed with depression. [HIDDEN] (another option is that she was studying the MIR).

A 19-year-old female university student comes to the clinic accompanied by her parents, reporting feeling progressively more asthenic in the last two months, with loss of appetite and weight and with greater difficulty in concentrating on her studies. The anamnesis also highlights that she has lost interest in going out with friends, has ideas of death without self-harming ideation and pessimistic cognitions of the future. Her weight is 90% of that considered ideal for age and gender. She does not present weight phobia or body image distortion. The most appropriate diagnosis is:


We describe the case of a patient with a hyperkalemic emergency (potassium >6.5 mmol/l with ECG alterations). The first step is the administration of iv calcium gluconate to counteract the cardiac toxicity of hyperkalemia (option 3 correct), giving us more time to initiate hypokalemic treatments (initially saline glucose with insulin, salbutamol, furosemide, and assessing dialysis if there is no good response).

We describe the case of a patient with a hyperkalemic emergency (potassium >6.5 mmol/l with ECG alterations). The first step is the administration of iv calcium gluconate to counteract the cardiac toxicity of hyperkalemia ([HIDDEN]), giving us more time to initiate hypokalemic treatments (initially saline glucose with insulin, salbutamol, furosemide, and assessing dialysis if there is no good response).

In a patient with known advanced chronic kidney disease (CKD G4, eGFR 20 ml/min) who comes to the emergency department for general weakness and is found to have severe hyperkalemia (K 7 mEq/l) with electrocardiographic abnormalities. What would be the first measure to take?

Administration of cation exchange resins.

Placement of a catheter to initiate dialysis.

Administration of intravenous calcium gluconate.


They comment on the case of a young woman with symptoms of systemic disease of probable autoimmune origin (lupus) who presents with macrocytic anemia, options 2 and 4 are options to identify the autoimmune disease but what they ask us is what to do to treat the anemia, so we should suspect that the anemia is secondary to the autoimmune disease and therefore request a direct Coombs test, since if it is positive the patient, except in extreme cases, will not be transfused and the primary cause should be treated. It also speaks of rapid onset, which in the case of vitamin B12 is more progressive.

They comment on the case of a young woman with symptoms of systemic disease of probable autoimmune origin (lupus) who presents with macrocytic anemia, [HIDDEN], but what they ask us is what to do to treat the anemia, so we should suspect that the anemia is secondary to the autoimmune disease and therefore request a direct Coombs test, since if it is positive the patient, except in extreme cases, will not be transfused and the primary cause should be treated. It also speaks of rapid onset, which in the case of vitamin B12 is more progressive.

A 26-year-old woman consults for a feeling of generalized weakness that has progressively set in over the course of three weeks, becoming particularly intense in the last two days. For the last couple of years, she reports episodes of joint pain in the hands that have required the use of anti-inflammatory drugs, as well as the appearance of an erythematous lesion of unclear cause in the neckline area, mainly in summer. In the physical examination there was only an evident cutaneous-mucosal pallor and a heart rate of 100 bpm. The hemogram shows: Hb 6 gr/dL, Hto 27 %, MCV 105 fL, 3,420 leukocytes/mm3 (2300 neutrophils/mm3, 800 lymphocytes/mm3, 250 monocytes/mm3, 50 eosinophils/mm3, 20 basophils/mm3), platelets 170,000/mm3. Biochemistry: AST 30 IU/L, ALT 35 IU/L, GGT 59 IU/L, alkaline phosphatase 105 IU/L, LDH 490 IU/L, urea 20 mg/dL, creatinine 0.8 mg/dL. Taking into account the available information, indicate which of the following additional analytical parameters you would need to know in order to make the most appropriate immediate decision:


In this question there should not be much doubt either (by the way, I think it is more of Pneumology than mine, but well, with this fever my friend Emilienko has deviated), since the clinical picture points to a parapneumonic pleural effusion, the macroscopic characteristics of the fluid seem so and the analysis of it shows us that the effusion is also complicated, almost on the verge of being an empyema (very high LDH, cellularity with predominance of PMN, glucose consumption). In addition, with this pH (and knowing that the effusion is already loculated), the endothoracic tube is more than indicated.

A 64-year-old male presents with fever, cough, dyspnea and right pleuritic pain of 1 week's evolution. Chest X-ray shows a loculated right pleural effusion occupying two thirds of the hemithorax. During thoracentesis, a yellowish fluid is drawn and analysis shows: leukocytes 15,000/uL, 92% neutrophils, glucose 30 mg/dL, pH 7, lactate dehydrogenase 3500 U/L, adenosine deaminase 45 U/L and absence of germs on GRAM stain. What is the most appropriate next course of action in this patient?

Intravenous antibiotic therapy and repeat diagnostic thoracentesis in 24 hours.

Intravenous antibiotic therapy and repeat diagnostic thoracentesis if there is no improvement in 48 hours.

Intravenous antibiotic therapy and evacuative (therapeutic) thoracentesis if any germ is isolated in the pleural fluid culture.

Intravenous antibiotic therapy and placement of a chest tube or catheter to drain all pleural fluid.


In this case, given the antibiotic treatment given and the severity of the diarrhea, it seems that we are dealing with a Clostridium infection. Option 2 is not very credible, in fact, as much as patients with CAP may have associated diarrhea, it is unlikely that a bacterium is sensitive to an antibiotic at the beginning of the picture and stops being so after 3 days.

In this case, given the antibiotic treatment given and the severity of the diarrhea, it seems that we are dealing with a Clostridium infection. Option 2 is [HIDDEN], in fact, as much as patients with CAP may have associated diarrhea, it is unlikely that a bacterium is sensitive to an antibiotic at the beginning of the picture and stops being so after 3 days.

A 52-year-old patient is admitted to the Hospital for severe pneumonia. With appropriate antibiotic treatment, the patient's respiratory symptoms improved. After 4 days of stay in the ward, his evolution is complicated by the appearance of a severe diarrhea. What is the most frequent microorganism responsible for this condition?

The bacterium itself causing pneumonia that has become resistant to the antibiotic.


With the deformity and pain in the distal radius, we expect a fracture at this level, so we mark 3. However, I see it as unquestionable, given that it could also have a concomitant fracture in the ulnar green stalk, although the main lesion is that of the radius.

With the deformity and pain in the distal radius, we expect a fracture at this level, so we mark [HIDDEN]. However, I see it as [HIDDEN], given that it could also have a concomitant fracture in the ulnar green stalk, although the main lesion is that of the radius.

A 7-year-old boy brought to the emergency department after falling off a swing onto his right hand. He has no history of interest. He presents with fork dorsum deformity of the wrist and functional impotence, with normal distal neurovascular status. What lesion would you expect to find on the urgent x-ray you request?


Answer 2 incorrect: Graves' disease is characterized by hyperthyroidism and one or more of the following features: goiter, exophthalmos and pretibial myxedema. Answer 4 incorrect: The most obvious symptom of subacute thyroiditis is neck pain. Sometimes, the pain may extend to the jaw or ears. Painful enlargement of the thyroid gland can last for weeks or months. And you usually have low serum thyroid stimulating hormone (TSH). High serum free T4 level. High serum thyroglobulin level. Incorrect answer 4: Very rare tumor.

Answer 2 [HIDDEN]: Graves' disease is characterized by hyperthyroidism and one or more of the following features: goiter, exophthalmos and pretibial myxedema. Answer 4 [HIDDEN]: The most obvious symptom of subacute thyroiditis is neck pain. Sometimes, the pain may extend to the jaw or ears. Painful enlargement of the thyroid gland can last for weeks or months. And you usually have low serum thyroid stimulating hormone (TSH). High serum free T4 level. High serum thyroglobulin level. [HIDDEN]: Very rare tumor.

A 30-year-old woman comes to the clinic reporting anxiety, weight loss of about 6 kg and a feeling of "nervousness" in the last three months. In the physical examination she has tachycardia, hyperreflexia and absence of goiter. In the blood test TSH values are < 0.01 microU/mL, T4 is elevated and thyroglobulin levels are low. A scintigraphy shows an absence of uptake in the thyroid region. What seems to you the most likely diagnosis?

Ovarian teratoma (ovarian stromal tumor).


They describe a typical hemisection or Brown-Sequard picture. Ipsilateral posterior motor and chordal involvement with contralateral pain and temperature involvement.

A man presents on neurological examination with a thermoalgesic sensory deficit in the left leg associated with a loss of vibratory and positional sensitivity in the right leg. At the same time he presents with clumsiness and loss of distal strength in the right leg and a right plantar cutaneous reflex in extension. Which of the following statements is correct:

It is a centromedullary syndrome type syringomyelia.

It is a pattern of transverse medullary lesion.

It is a pattern of lateral bulbar lesion.


Dopler ultrasound is the most accurate test and allows subsequent non-invasive monitoring of the evolution of the disease.

Doppler ultrasound is the most accurate test and allows subsequent non-invasive monitoring of the evolution of the disease.

65-year-old man with a history of pancreatic neoplasm undergoing chemotherapy. What diagnostic test is more cost-effective to confirm the diagnostic suspicion?


The seizures described and the EEG correspond to typical absence seizures and the initial treatment of choice is valproic acid.

A 10-year-old boy with brief episodes of distractions (< 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 with:


Serous cystoadenoma of the pancreas is a benign, often polycystic entity (also called microcystic adenoma) formed by collagen-producing (non-mucinous) cells. It is usually asymptomatic and is discovered as an incidental finding. Given its benign nature, surgery is not recommended, and is reserved only for symptomatic patients or those in whom the nature of the lesion is in doubt after a complete study with CT, MRI and echoendoscopy with biopsy. It is frequently sporadic, but can be associated with Von-Hippel-Lindau syndrome.

A 72-year-old woman with no past history of interest. After a complicated renal colic, a 2 cm cystic lesion in the tail of the pancreas, together with multiple bilateral renal cystic lesions, is found by chance in the abdominal CT scan. Endoscopic ultrasonography shows a polycystic lesion formed by multiple vesicles with central calcification in the tail of the pancreas with no connection to the duct of Wirsung. Fluid analysis is compatible with a serous cystadenoma. Of the following, which is the most correct attitude regarding the management of this patient:

Surgical resection (corporocaudal pancreatectomy).

Endoscopic ultrasonography-guided puncture and ethanolization of the puncture.


The other tests can wait...

The other tests can wait...

The other tests can wait...

The other tests can wait...

The clinical and biological picture of this patient raises suspicion of hemolytic anemia in the context of systemic lupus erythematosus. If we have to choose only one diagnostic test, and this should be the first, we are interested in confirming the presence of an autoimmune hemolytic anemia with the direct Coombs' test in order to initiate treatment. The other tests can wait...

A 25-year-old female patient with a history of skin rash after sun exposure and occasional polyarthritis in the joints of the hands, controlled with non-steroidal anti-inflammatory drugs, presents with general malaise, progressive feeling of generalized weakness and pallor for the last 15 days. Laboratory tests showed hemoglobin 7 g/dL, MCV 108 mm/h, 150,000 platelets/mm3, 3000 leukocytes/mm3, elevated LDH, undetectable haptoglobin. In the case of choosing a single diagnostic test indicate which of the following determinations should be performed first:


This is a woman with abrupt, painless and severe loss (she only sees the movement of the hands) of vision in one eye. She does not give us much information from the ocular examination, only that there is an afferent pupillary defect. We have to rely on systemic symptoms to diagnose the problem. This is an elderly woman with typical symptoms of polymyalgia rheumatica, and the pain in the temporomandibular region is very suggestive. It is giant cell arteritis or temporal arteritis. The most common ocular manifestation is anterior ischemic optic neuropathy. In the fundus we would certainly see a papillary edema of that eye, with a gypsum white coloration. The afferent pupillary defect is very characteristic of these severe ischemic optic neuropathies. Suspecting giant cell arteritis, there are three analytical markers that are characteristically high: CRP, ESR and platelet count. We will first request one of these parameters and treat it often without waiting for biopsy confirmation. Therefore, option 2 is the correct one.

This is a woman with abrupt, painless and severe loss (she only sees the movement of the hands) of vision in one eye. She does not give us much information from the ocular examination, only that there is an afferent pupillary defect. We have to rely on systemic symptoms to diagnose the problem. This is an elderly woman with typical symptoms of polymyalgia rheumatica, and the pain in the temporomandibular region is very suggestive. It is giant cell arteritis or temporal arteritis. The most common ocular manifestation is anterior ischemic optic neuropathy. In the fundus we would certainly see a papillary edema of that eye, with a gypsum white coloration. The afferent pupillary defect is very characteristic of these severe ischemic optic neuropathies. Suspecting giant cell arteritis, there are three analytical markers that are characteristically high: CRP, ESR and platelet count. We will first request one of these parameters and treat it often without waiting for biopsy confirmation. Therefore, [HIDDEN].

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


This question is mixed hemato-nephro. It is complicated, so we are going to rule out options one by one. Option 2, nephrotic syndrome, apart from being broad and nonspecific, would not be assessable, since they do not give us the quantification of urine protein (they only tell us that urinalysis reveals the presence of kappa light chains, not the amount). Option 3 would be unlikely; in amyloidosis, the light chains that are usually deposited are of the lambda type. Option 4 also seems unlikely, since in IgA myeloma we would expect a monoclonal peak of this Ig, which in this case does not appear. The doubt that arises is between 1 and 5; I would opt for 1, because this entity fulfills the characteristics described (absence of monoclonal peak in most cases, acute renal failure and presence of kappa chains in urine), being light chain myeloma a somewhat broader entity, but option 5 could also be considered valid.

This question is mixed hemato-nephro. It is complicated, so we are going to rule out options one by one. [HIDDEN], nephrotic syndrome, apart from being broad and nonspecific, would not be assessable, since they do not give us the quantification of urine protein (they only tell us that urinalysis reveals the presence of kappa light chains, not the amount). [HIDDEN]; in amyloidosis, the light chains that are usually deposited are of the lambda type. [HIDDEN], since in IgA myeloma we would expect a monoclonal peak of this Ig, which in this case does not appear. The doubt that arises is between 1 and 5; [HIDDEN], because this entity fulfills the characteristics described (absence of monoclonal peak in most cases, acute renal failure and presence of kappa chains in urine), being light chain myeloma a somewhat broader entity, but [HIDDEN].

A 68-year-old patient consults for edema and asthenia. Laboratory tests showed creatinine 5 mg/dL, hemoglobin 10 g/dL and marked hypogammaglobulinemia in serum at the expense of IgG, IgA and IgM. A urinalysis reveals the presence of kappa light chains. What is your diagnostic suspicion?

IgA myeloma with Bence-Jones proteinuria.


The acidosis with elevated PCO2, hypoxemia and normal bicarbonate suggests an acute respiratory acidosis of rapid onset probably due to drug intoxication.

A 24-year-old woman is found lying in the street by passers-by. On arrival of the emergency team she was found with an oxygen saturation of 88% breathing room air and on examination with pinpoint pupils. She was transferred to the emergency room of the nearest hospital, where the baseline arterial blood gases showed: pH 7.25, PaC02 60 mmHg, Pa02 58 mmHg, bicarbonate 26 mEq/1 and base excess of -1. In blood sodium was 137 mEq/1 and chloride 100 mEq/1:

Respiratory alkalosis due to lack of chloride.


We are presented with a case of RSV-positive bronchiolitis. According to current recommendations, it would be indicated to initiate supplemental oxygen therapy.

A 2-month-old infant with an upper respiratory tract cold of 3 days of evolution, who begins with moderate respiratory distress and pulmonary auscultation with expiratory wheezing. Oxygen saturation is 89 %. Respiratory syncytial virus is isolated in the nasopharyngeal exudate. Which of the following treatments do you consider more indicated for this condition?


Typical of ticlopidine. Not only thrombocytopenia but also headache, schistocytes, high LDH and high bilirubin.

A 67-year-old female patient on ticlopidine treatment comes to the emergency department with headache, asthenia and petechiae in the lower extremities. Laboratory tests showed hemoglobin 8.2 g/dL, MCV 100 fl, platelets 25000/ul and leukocytes 7500/ul with normal formula. The reticulocyte count was elevated and the blood smear showed numerous schistocytes. Coagulation studies (APTT, PT and fibrinogen) are normal. The biochemistry shows LDH 2700 IU/l and bilirubin 2.6 mg/dl. What is the most likely diagnosis?