I think this is a very nice question. There is no doubt about the diagnosis. Because if you don't know the translocation, nothing happens... the answers give you the diagnosis. Now it's time to find out how acute promyelocytic leukemia is currently treated (ATRA aside... which I'm sure you know). As of 2017, the PETHEMA protocol for APL in low to intermediate risk patients (and/or over 70 years of age) is ATO+ATRA. In high risk patients, it is treated with ATRA+chemotherapy. I don't think they want you to know how risk is established in promielos, but it is based on leukocyte and platelet counts. In this case, it doesn't score anything for the score since you have <10,000 leukocytes and >40,000 platelets. That is, it is a low risk. Correct answer 2. Perhaps some people have been confused by option 3. One of the main causes of mortality in the induction of a promyelocyte is coagulopathy, but option 3 is totally incorrect. We could only mess things up even more by putting heparin!!!! I don't know what they are explaining right now in the academies, but it is clear that they wanted you to know that many promyelocytes, since 3 little years ago, are not treated with chemotherapy.

I think this is a very nice question. There is no doubt about the diagnosis. Because if you don't know the translocation, nothing happens... the answers give you the diagnosis. Now it's time to find out how acute promyelocytic leukemia is currently treated (ATRA aside... which I'm sure you know). As of 2017, the PETHEMA protocol for APL in low to intermediate risk patients (and/or over 70 years of age) is ATO+ATRA. In high risk patients, it is treated with ATRA+chemotherapy. I don't think they want you to know how risk is established in promielos, but it is based on leukocyte and platelet counts. In this case, it doesn't score anything for the score since you have <10,000 leukocytes and >40,000 platelets. That is, it is a low risk. [HIDDEN] Perhaps some people have been confused by option 3. One of the main causes of mortality in the induction of a promyelocyte is coagulopathy, but option 3 is [HIDDEN] We could only mess things up even more by putting heparin!!!! I don't know what they are explaining right now in the academies, but it is clear that they wanted you to know that many promyelocytes, since 3 little years ago, are not treated with chemotherapy.

65-year-old woman referred to the ED for fever and alterations in the CBC: hemoglobin 11.4 g/dL, leukocytes 0.86 x103/μL,(neutrophils 41.9 %, lymphocytes 55.8 %),platelets 48.0 x103/μL, fibrinogen 118 mg/dL,D-dimer 20.2 μg/mL. A bone marrow examination was performed and the patient was diagnosed with acute leukemia with t(15;17) in 60% of the cells. Which of the following answers is correct?

If asymptomatic, transretinoic acid (ATRA) will be initiated and controls in day hospital will be recommended.

Treatment with arsenic trioxide, ATRA and supportive therapy will be initiated.

It is a myeloblastic leukemia type M3, so chemotherapy and heparin treatment will be initiated to control disseminated intravascular coagulation.

Antibiotic treatment should be started. When the fever disappears, leukemia treatment should be started.


Carcinoma in situ is delimited by the basement membrane, i.e. it is not invasive yet, and therefore the treatment is polypectomy, which is already done. Subsequently, an endoscopic follow-up (with biopsies) should be performed at an interval of 3 to 6 months depending on the patient's history, age and concomitant pathologies.

In a colon cancer screening program, a 52-year-old patient undergoes a colonoscopy. The entire colon is normal except for the finding of a 2 cm pedunculated polyp in the sigma which is removed with a diathermy loop. The anatomopathological result indicates that there is a carcinoma in situ limited to the head of the polyp. She has a thoracoabdominal CT scan reported as normal. Indicate the correct course of action.

Segmental resection of the affected colon.

Local resection of the base of the polyp.


Allopurinol is always the treatment of choice, especially in the case of tophaceous gout. Moreover, in this case, uricosuric acid could worsen urolithiasis by increasing uricosuria (sorry for the redundancy...).

A 62-year-old man with a history of arterial hypertension under treatment with captopril, duodenal ulcer and uric acid urolithiasis. He consults for typical podagra crisis similar to others presented in the last two years. Examination showed tophi in both pinnae. Analyses show uric acid 10.1 mg/dl, creatine 1.5 mg/dl. Indicate which of the following answers is FALSE in relation to his possible treatment with allopurinol.

Its use is second choice when uricosurics have failed.

Its prolonged use is practically obligatory because there are tophi.

Its introduction should be delayed until the current attack has resolved with anti-inflammatory drugs or colchicine.

Its introduction should be gradual up to a dose that achieves a uricemia below 6 mg/dL.

In the first months of treatment it is advisable to associate low doses of colchicine to prevent new attacks.


From what is described it is a macroprolactinoma as it is a pituitary tumor of more than one centimeter, which secretes prolactin and with an insufficiency of the rest of pituitary hormones. The first line treatment of choice is dopaminergic agonists, although when the visual field is affected, surgery may be chosen. In this case, the cavernous sinus is pressured by the mass, so the surgical risk increases. Therefore, in this particular case, the surgical option seems more risky. Taking this into account and the fact that it is a tumor that produces high levels of prolactin, which indicates that it probably responds to pharmacological blockade, the most appropriate option would be option 1, treatment with dopaminergic agonists.

From what is described it is a macroprolactinoma as it is a pituitary tumor of more than one centimeter, which secretes prolactin and with an insufficiency of the rest of pituitary hormones. The first line treatment of choice is dopaminergic agonists, although when the visual field is affected, surgery may be chosen. In this case, the cavernous sinus is pressured by the mass, so the surgical risk increases. Therefore, in this particular case, the surgical option seems more risky. Taking this into account and the fact that it is a tumor that produces high levels of prolactin, which indicates that it probably responds to pharmacological blockade, [HIDDEN].

We are referred from ophthalmology to a 31-year-old man who consulted for loss of vision and progressive headache. Physical examination showed temporal hemianopsia and pituitary MRI showed a 35 x 30 x 20 mm turnoration compressing chiasm and cavernous sinus. The results of the functional study are cortisol 14 microg/dL, TSH 1.4 microU/ml, T4L 1.2 ng/dL, prolactin 480 microg/L (vn < 15), testosterone 160 ng/dL (vn 300-1200), FSH 1.2 U/I., (vn 5-15) and LH 2 U/L (vn 3-15). What is the initial therapeutic approach?

Treatment of hypogonadotropic hypogonadism with testosterone.


We are dealing with a patient with HIV infection in a situation of severe immunosuppression (<50 CD4+) and a very high viral load, who has followed the expected evolution from the immunovirological point of view after the start of treatment (after 12 weeks, the viral load has ostensibly decreased - answer 2 would not be correct, remember that it is desirable that it becomes negative 24 weeks after the start of treatment, although in patients with higher CV like ours, it could take longer - and the CD4+ count has begun to rise). A negative Mantoux test does not rule out tuberculosis (incorrect answer 4), since in patients with severe immunosuppression it can give false negatives. The diagnosis of lymph node tuberculosis is immediate when detecting "isolated acid-fast bacilli and epithelioid granulomas" in the puncture of one of the lymph nodes, however: considering the patient profile, this process will have been clinically unmasked during the immunological reconstitution and the infection is not the consequence of an incomplete immunological recovery (correct answer number 3).

We are dealing with a patient with HIV infection in a situation of severe immunosuppression (<50 CD4+) and a very high viral load, who has followed the expected evolution from the immunovirological point of view after the start of treatment (after 12 weeks, the viral load has ostensibly decreased - [HIDDEN], remember that it is desirable that it becomes negative 24 weeks after the start of treatment, although in patients with higher CV like ours, it could take longer - and the CD4+ count has begun to rise). A negative Mantoux test does not rule out tuberculosis ([HIDDEN]), since in patients with severe immunosuppression it can give false negatives. The diagnosis of lymph node tuberculosis is immediate when detecting "isolated acid-fast bacilli and epithelioid granulomas" in the puncture of one of the lymph nodes, however: considering the patient profile, this process will have been clinically unmasked during the immunological reconstitution and [HIDDEN].

A 45-year-old patient was diagnosed with HIV infection three months ago, presenting at that time with CD4 45 lymphocytes/µl and an HIV-1 viral load of 500,000 copies/ml. At that time he had a negative Mantoux test. He started treatment with an integrase inhibitor and two reverse transcriptase inhibitors, and at one month he had 25,000 copies and CD4 had risen to 80/µL. She consulted for presenting a picture of cervical lymphadenopathy and fever of two weeks of evolution. The puncture of one of the lymph nodes showed isolated acid-fast bacilli and epithelioid granulomas:

It is a lymph node tuberculosis related to an incomplete immunologic recovery.

Treatment failure and it is an opportunistic infection.

This is an opportunistic infection unmasked within a picture of immune reconstitution.

A negative Mantoux test rules out tuberculosis.


Typical case of acute mesenteric ischemia, which should be suspected in elderly patients with abdominal pain and distension of sudden onset, diarrhea or vomiting and who present cardiovascular risk factors, especially emboligenic heart disease. In this case we are given characteristic biochemical data (leukocytosis, metabolic acidosis due to lactic acid, hemoconcentration due to loss of fluid to the third space...) and imaging tests (dilated loops, pneumatosis, gas at portal level...) suggestive of mesenteric ischemia.

78-year-old woman with dementia and institutionalized is brought by her caregivers for significant abdominal pain with deterioration of general condition and abdominal distension. CBC shows leukocytosis, elevated hematocrit, renal failure and metabolic acidosis. ECG shows atrial fibrillation. Abdominal tomography shows edematous small bowel loops, with intestinal and portal accumulation. The most probable diagnosis is:

Perforation of gastric or duodenal ulcus.

Obstructive neoplasia of the sigma with perforation.


Claude-Bernard-Horner syndrome is an old acquaintance of the MIR exam. We do not see it daily in clinical practice, but it appears in many exams. Characteristic is upper eyelid ptosis and miosis of that eye. This occurs due to a deficit of sympathetic innervation of the orbital territory. The sympathetic nervous system innervates the Müller muscle, which is an accessory muscle to the levator of the upper eyelid. If the Müller ceases to function, the eyelid descends slightly. It also innervates the iris dilator muscle. Therefore, the sphincter muscle, its antagonist, is unopposed and the balance of the pupil shifts toward miosis. It explains ptosis and miosis of the left eye, so we suspect Horner's in that eye. She also describes what may have happened: after a possible sudden movement while playing tennis, she has neck pain and a Horner's. We should suspect an aneurysm. We should suspect a dissecting carotid aneurysm, which is one of the best known (and most serious) causes of an acquired Horner's syndrome. The superior cervical ganglion is a ganglion of the sympathetic nervous system located in the sheath of the carotid artery, and at this level it has been affected. We can also try to get this answer right by ruling out. An alteration of the III cranial nerve can produce ptosis, but the pupil, if affected, should be in mydriasis. And damage to the third cranial nerve should also produce some type of ophthalmoplegia, with diplopia. An involvement of the optic chiasm would produce a bilateral loss of vision (probably a bitemporal hemianopsia). We are told in the statement that he maintains good visual acuity. On the other hand, there would also be no ptosis or anisocoria. And finally, an alteration of the medulla oblongata would produce different neurological symptoms not described, and there should be no ptosis or pupillary alterations, because the third pair is located in the midbrain and the sympathetic nuclei in the spinal cord.

A 25-year-old patient, during a tennis match, has severe pain in his neck and left eye. The next morning he wakes up with a feeling of gait instability and has palpebral ptosis of the left eye and anisocoria, with the left pupil being smaller than the right. The patient maintains good visual acuity, where would you most likely locate the lesion?


The correct answer is 4. A common bile duct cyst is a congenital pathology that usually presents clinically beyond the neonatal period. It is appropriate to have a quality image that delimits the lesion in order to decide the surgical approach.

[HIDDEN] A common bile duct cyst is a congenital pathology that usually presents clinically beyond the neonatal period. It is appropriate to have a quality image that delimits the lesion in order to decide the surgical approach.

A one-and-a-half year old boy comes to the emergency room with abdominal pain and jaundice. On examination, an abdominal mass is palpated. An ultrasound shows the presence of a common bile duct cyst. What therapeutic approach should we adopt?

A percutaneous puncture for peritoneal lavage will be performed to verify that the cyst contains bile in order to leave a drainage to improve the abdominal pain.

An exploratory laparotomy will be indicated and a radical resection of the entire biliary tract will be performed to replace it with a loop of intestine.

A laparotomy will be indicated to drain the cyst and when the dilatation remits the drainage will be removed.

A cholangio-resonance will be performed to delimit the cyst and a laparotomy will be indicated for cyst resection and anastomosis of the biliary tract.

A HIDA gammagraphic study is necessary to delimit the cyst and to be able to perform percutaneous drainage safely.


According to the SEGO, in perimenopausal women with heavy and/or prolonged menstrual bleeding who require contraception, the levonorgestrel IUD (also called MIRENA IUD) is the first option.

According to the SEGO, in perimenopausal women with heavy and/or prolonged menstrual bleeding who require contraception, the levonorgestrel IUD (also called MIRENA IUD) is [HIDDEN].

45-year-old woman. Two previous pregnancies with normal deliveries (G2PN2). Heavy menstrual bleeding for approximately 1 year. Ultrasound shows a 2 cm subserosal myoma that has been stable for several years. Endometrial biopsy was performed and it was normal. The patient has hemoglobin 10 g/dL despite oral ferrotherapy and the amount of menstrual flow has not decreased despite treatment with tranexamic acid and mefenamic acid. Which of the following is the treatment of first choice in this patient?

Total hysterectomy preserving appendages.


The diagnostic criteria for microscopic colitis are: a)Chronic or intermittent non-bloody watery diarrhea b)Colonic mucosa assessed by colonoscopy macroscopically normal or near normal c)Characteristic histopathological findings. In our case, the patient presents findings compatible with collagenous colitis (band of collagen underlying the epithelium greater than 10 microns) and lymphocytic (more than 20 intraepithelial lymphocytes). The treatment of this pathology is topical corticosteroids with low oral bioavailability (mainly budesonide). Olmesartan enteropathy produces a picture similar to celiac disease and is characterized by duodenal biopsy with villous atrophy, mucosal inflammation with increased intraepithelial lymphocytes and cryptitis. In this case a normal duodenal biopsy is described, but it would be interesting to keep the concept for future examinations.

A 79-year-old hypertensive woman on treatment with olmesartan comes for consultation for watery diarrhea of 4 to 6 stools per day for the past two months. Three months ago she was treated with nonsteroidal anti-inflammatory drugs for 3 weeks for lumbosciatica. Gastroscopy and colonoscopy were performed, both without macroscopic alterations. Duodenal biopsies were normal, while colon biopsies showed a chronic inflammatory infiltrate of the lamina propria with an irregular band of collagen immediately below the mucosal surface epithelium with a thickness greater than 10 mm and a number of intraepithelial lymphocytes >20 per 100 epithelial cells. Which is the most likely diagnosis?


This is a patient with decompensated myasthenia with bulbar symptoms (dysphagia) and therefore risk of respiratory muscle involvement. The respiratory symptoms correspond to an exhaustion of the muscles, first inspiratory and then accessory (the patient does not appear fatigued or tachypneic because the muscles are exhausted), progressing to a carbonic coma.

A 64-year-old man, diagnosed with myasthenia gravis 1 year ago, treated with low-dose steroids (3 mg/day of deflazacort) and anticholinesterase drugs, asymptomatic for 6 months, consults for mild difficulty in swallowing and evening diplopia for a few days. He was admitted to the hospital for suspected myasthenic crisis and treatment was started. The next day the patient alerts at 03 hours in the morning because the patient makes a strange noise when breathing in, like a soft snoring, the patient is sound asleep and very sweaty, but does not seem to be fatigued. What is the most correct attitude?

Reassure the nurse and family that the patient is a habitual snorer and is peacefully asleep. The patient should be placed in lateral decubitus.

Notify intensive care for suspected acute respiratory failure, to assess possible orotracheal intubation and assisted ventilation.

Perform polysomnographic study to rule out sleep apnea.

Decrease steroid dose; if he has a steroid myopathy he will improve.

Order a thoracic CT scan to rule out compressive thymoma over the trachea associated with myasthenia.


Dementia with visual hallucinations at the beginning of the course (in the first 2 years) is very suggestive of Lewy bodies, and is the guiding symptom in these questions. If we add to this the falls and motor slowing suggestive of parkinsonism, it makes the question easier. Therefore, number 3 is correct.

Dementia with visual hallucinations at the beginning of the course (in the first 2 years) is very suggestive of Lewy bodies, and is the guiding symptom in these questions. If we add to this the falls and motor slowing suggestive of parkinsonism, it makes the question easier. Therefore, [HIDDEN].

A 78-year-old male consults for a year-long history of progressive cognitive impairment with memory and orientation lapses. His family reports recurrent visual hallucinations, occasional falls and striking motor slowing. What is the most likely diagnosis?


In the male, the onset of puberty is considered normal from the age of 9 years, therefore in this case it is a premature puberty. The onset of puberty is defined as an increase in testicular volume (greater than or equal to 4cc); by specifying that the testicular size has not increased, we can rule out options 1 and 2. The excessive secretion of androgens produced by an adrenal tumor would cause a greater amount of hair and an increase in penile size, which our patient does not present. Therefore, the correct option is early adrenarche.

In the male, the onset of puberty is considered normal from the age of 9 years, therefore in this case it is a premature puberty. The onset of puberty is defined as an increase in testicular volume (greater than or equal to 4cc); by specifying that the testicular size has not increased, we can rule out options 1 and 2. The excessive secretion of androgens produced by an adrenal tumor would cause a greater amount of hair and an increase in penile size, which our patient does not present. Therefore, the [HIDDEN] option is early adrenarche.

An 8-year-old boy consults for the appearance of pubic hair at the base of the penis for the last 12 months. The testicle has not increased in volume and the penis has not increased in size. There is no increase in growth rate in the last year. The bone age is one year older than the chronological age. What is the most likely diagnosis?


The determination of ADA, in the presence of a pneumonia of long evolution that does not improve with antibiotic treatment, with an effusion with abundant leukocytes and lymphocytic predominance, in which the presence of neoplasia is ruled out, with values higher than 70 UI/L, should lead us to have a high degree of suspicion about tuberculous etiology and send the pleural fluid to microbiology for tuberculosis study.

A 32-year-old man from Cameroon consults for fever cough and left hemithorax pain of 1 month's evolution. He took amoxicillin-clavulanic acid for 1 week without improvement of symptoms. A blood test showed a white blood cell count of 8000/microL and a hemoglobin of 12.8 g/dL. Chest X-ray showed a loculated left pleural effusion occupying one third of the hemithorax. A thoracentesis shows a yellowish fluid with the following features: red blood cells 2000/uL, leukocytes 2500/uL, with 90% lymphocytes, protein 4.9 g/dL, lactate dehydrogenase 550 U/L, glucose 67 mg/dL, and absence of malignant cells on cytology. Which of the following tests would be most useful in diagnosing the cause of the pleural effusion?

A thoracic computed tomography (CT) scan.

Measurement of adenosine deaminase in pleural fluid.


Acute infection by Coxiella burnetii manifested in this case by Pneumonia. Coxiella infection is not transmitted by ticks. The contact can be with high probability at the time of delivery of an infected farm animal, in which the bacterium is disseminated in aerosols. The treatment of choice is with doxycycline in the acute phase (if meningitis is present, quinolones are preferred due to penetration of the blood-brain barrier). The combination of doxycycline plus hicroxychloroquine can be used, but for chronic Q fever (which is where elevation of antibodies against phase I antigens is observed and carries a higher risk of mortality).

Acute infection by Coxiella burnetii manifested in this case by Pneumonia. Coxiella infection is not transmitted by ticks. The contact [HIDDEN], in which the bacterium is disseminated in aerosols. The treatment of choice is with doxycycline [HIDDEN]. The combination of doxycycline plus hicroxychloroquine can be used, but for chronic Q fever (which [HIDDEN]).

A 38-year-old woman of veterinary profession, in charge of monitoring wild animals and assisting in the delivery of domestic livestock. She starts with a high fever with chills, headache, myalgia and non-productive cough that she interprets as a flu-like process. She presented with chest pain. Chest X-ray showed bilateral pulmonary infiltrates in lower fields. A serologic test was performed with elevated antibody titers against phase I antigens. Which of the following statements is TRUE?

The way of transmission of this entity is by ticks.

Both doxycycline and hydroxychloroquine are effective in treating acute forms of this disease.

In its acute form it also presents, generally, elevation of antibodies against phase I antigens.

Mortality in acute forms is almost nonexistent.


As of 2018, there are four dosing schedules for treatment of latent TB infection recommended by the CDC using isoniazid (INH), rifapentine (RPT) or rifampin (RIF). All treatments are effective. Health care providers should prescribe the shorter treatments, which are more convenient, whenever possible. The shortest combination would be Isoniazid + Rifapentine for three months or Rifampicin for four months. However, the fact that he is taking acenocoumarol means that the indication for this patient is Isoniazid for 9 months, since there is interaction between the rifamycin derivatives (rifapentine and rifampicin).

As of 2018, there are four dosing schedules for treatment of latent TB infection recommended by the CDC using isoniazid (INH), rifapentine (RPT) or rifampin (RIF). All treatments are effective. Health care providers should prescribe the shorter treatments, which are more convenient, whenever possible. The shortest combination would be Isoniazid + Rifapentine for three months or Rifampicin for four months. However, the fact that he is taking acenocoumarol means that the indication for this patient is Isoniazid for 9 months, [HIDDEN].

A 62-year-old patient who consults because of close contact in recent weeks with a person with active tuberculosis. Mantoux test is positive (12 mm). His history includes treatment with oral anticoagulants (acenocoumarol) for a deep vein thrombosis a few months ago. He does not report fever or cough and is asymptomatic. Chest X-ray is normal. Which of the following treatments is the most advisable?

Isoniazid and rifampicin, for three months.

Isoniazid and rifapentine, for three months.


Although the diagnosis of peripheral arteriopathy is fundamentally clinical (in this patient the picture is very typical), we can objectively assess the severity of the disease with the use of bloodless techniques. The most important is the ankle-brachial index. Therefore, answer 2 is correct. Imaging techniques (arteriography, angioCT or angioMRI) are used when surgical repair of arterial occlusion is considered.

Although the diagnosis of peripheral arteriopathy is fundamentally clinical (in this patient the picture is very typical), we can objectively assess the severity of the disease with the use of bloodless techniques. The most important is the ankle-brachial index. Therefore, [HIDDEN]. Imaging techniques (arteriography, angioCT or angioMRI) are used when surgical repair of arterial occlusion is considered.

A 64-year-old man consults for right calf pain when climbing hills and stairs and when walking on level ground for a prolonged period of time. He reports that the pain becomes so intense with exertion that he is forced to stand up, which causes the pain to improve in a matter of minutes. As personal history, the patient is a smoker of 20 cigarettes a day, diabetic on metformin and hypertensive. On examination, there is good peripheral perfusion of the right foot, but the patient has a decreased pedal pulse. Which of the following complementary tests should be ordered initially for the diagnosis and assessment of the severity of the patient's disease?

Computerized axial tomography with vascular reconstruction of lower extremities.


Given her circumstances and taking into account that she is exclusively breastfeeding, the best thing to do would be to prescribe only gestagens.

A 30-year-old woman requesting a contraceptive method. She has a history of an emergency cesarean section 7 months ago, giving birth to a 3,550 g baby girl. She is exclusively breastfeeding. Point out the correct statement:

Explain to her that, if she is amenorrheic, she does not require another contraceptive method since breastfeeding is sufficient as a contraceptive method.

He informed her that the levonogestrel IUD is contraindicated because she had a cesarean section less than a year ago.

He explains that she could use a gestagen-only hormonal method.

She is offered combined hormonal contraception.


It is a headache in the context of papilledema. In this case the papilledema is due to increased intracranial pressure due to a tumor. The headache due to increased intracranial pressure is of positional type (it increases with Valsalva maneuvers and when bending down), so option 2 is not correct. In addition, it is predominantly morning (option 1 is correct) because in the morning intracranial pressure naturally rises. Migraine-type headaches may be associated with photophobia or sonophobia (answers 3 and 4). But this headache is not a migraine headache.

It is a headache in the context of papilledema. In this case the papilledema is due to increased intracranial pressure due to a tumor. The headache due to increased intracranial pressure is of positional type (it increases with Valsalva maneuvers and when bending down), so option 2 is [HIDDEN]. In addition, it is predominantly morning (option 1 is [HIDDEN]) because in the morning intracranial pressure naturally rises. Migraine-type headaches may be associated with photophobia or sonophobia (answers 3 and 4). But this headache is not a migraine headache.

A 59-year-old woman with recent onset of epileptic seizures comes to the emergency department. On examination she presents left pyramidal signs and papillary edema. A brain MRI shows a right hemispheric mass with edema, midline deviation and signs of tentorial herniation. She reports that for the past week she has been suffering from headache that has been progressing in intensity. Which of the following features associated with headache seems most likely for this patient?


Procainamide. The treatment of choice for Wolff-Parkinson-White syndrome is cardioversion with direct current. Heart rate slowing drugs, commonly used in atrial fibrillation, are ineffective, and digoxin and non-dihydropyridine calcium channel blockers (e.g., verapamil, diltiazem) are contraindicated because they may increase the ventricular rate and cause ventricular fibrillation. If cardioversion is not possible, drugs that prolong the refractory period of accessory connection should be used. IV procainamide or amiodarone is preferred, but any class Ia, Ic or III antiarrhythmic drug can be used.

A 23-year-old male diagnosed with Wolff-Parkinson-White syndrome who comes to the emergency department for palpitations. The ECG shows an irregular wide QRS tachycardia, with a heart rate of 205 bpm, compatible with pre-excited atrial fibrillation. Which of the following drugs do you consider appropriate to stop the tachycardia:


Dehydration may be due to diarrhea of other etiologies. I have doubts about answer 3 since it does not specify which secretions are involved. We have to understand that the growth of Pseudomona aeruginosa is in the culture of bronchial secretions. Because clearly the indication to perform a sweat chlorine (to rule out FQP) are the HIPOnatremic dehydrations and not the hypernatremic ones as the answer says.

Dehydration may be due to diarrhea of other etiologies. I have doubts about answer 3 since it does not specify which secretions are involved. We have to understand that the growth of Pseudomona aeruginosa is in the culture of bronchial secretions. Because clearly the indication to perform a sweat chlorine (to rule out FQP) are the HIPOnatremic dehydrations and not the hypernatremic ones as [HIDDEN].

In a 3-month-old infant all the clinical manifestations outlined below would make it necessary to rule out cystic fibrosis, EXCEPT:

Isolation of secretions of Pseudomonas aeruginosa.

Deterioration/detention of the weight curve.


In severe cases of Plasmodium infection, the greatest risk of mortality occurs in the first 24 hours of clinical presentation, so treatment should be started immediately. Treatment with parenteral or intramuscular artesunate is more indicated in severe Plasmodium infection, both in adults and children and in pregnant women.

In severe cases of Plasmodium infection, the greatest risk of mortality occurs in the first 24 hours of clinical presentation, so treatment should be started immediately. Treatment with parenteral or intramuscular artesunate is [HIDDEN] in severe Plasmodium infection, both in adults and children and in pregnant women.

A 38-year-old man comes to the emergency department with fever above 39ºC and deterioration of consciousness after a trip to Equatorial Guinea without antimalarial prophylaxis. Laboratory tests showed creatinine 3.4 mg/dL, AST 764 UlL, ALT 678 UlL. The laboratory reports the visualization of Plasmodium falciparum in the blood with a parasitemia level of 6%. What treatment would you initiate at this time?


Textbook case, little to add. Microhematuria, proteinuria and sensorineural hearing loss in a young male with a family history of women with hematuria = Alport syndrome.

Textbook case, little to add. Microhematuria, proteinuria and sensorineural hearing loss in a young male with a family history of women with hematuria = [HIDDEN].

24-year-old male presenting with dysmorphic microhematuria, proteinuria of 3 g/24 h, eGFR (CKD-EPI) 85 ml/min and sensorineural hearing loss. He reports that his maternal grandmother required dialysis at 70 years of age and both his mother and younger sister have isolated microhematuria. Which of the following diseases is more likely?

Autosomal dominant polycystic kidney disease.


Calcium gluconate has no effect on blood potassium levels (therefore options 1, 2 and 3 are ruled out). Its function is to decrease the excitability of cardiac myocytes to decrease the likelihood of developing heart rhythm disorders.

Calcium gluconate has no effect on blood potassium levels (therefore [HIDDEN]). Its function is to decrease the excitability of cardiac myocytes to decrease the likelihood of developing heart rhythm disorders.

A 5-year-old boy diagnosed with chronic renal failure. He comes to the emergency department with vomiting, malaise, and palpitations. An electrocardiogram was performed with T-wave elevation and blood tests showed potassium levels of 5.9 mEq/L. Immediate administration of calcium gluconate is decided. What is the purpose of this treatment?

Encourage the displacement of potassium from the plasma space to the intracellular space.

Chelate circulating potassium to favor its hepatic elimination.

Chelate circulating potassium to favor its renal elimination.

Antagonize the action of potassium on the myocardial cell membrane.


The patient is a man with pneumonia with isolated germ in blood culture and antibiogram. According to the data provided, it is a pneumococcus sensitive to penicillin (MIC < 0.125), so treatment is started with penicillin at high doses every 4 h, despite which the fever persists. If we analyze the case carefully, the treatment should be effective since the germ is totally sensitive to the drug and the dosage is adequate (so that high concentrations of the drug should be maintained at all times, remember that the efficacy of beta-lactams is time-dependent and the antibiotic concentrations in blood should be above the MIC permanently to achieve effectiveness and avoid the production of resistance). In such a case, what could be happening, probably, although the antibiotic is the right one, it is not reaching the infectious focus adequately because an empyema has probably occurred. We should rule out the existence of an empyema and drain it while continuing with the antibiotic treatment. If the dosage had not been adequate and the presence of drug resistance was possible, one option could have been to treat with ceftriaxone at high doses, since we should remember that streptococcus does not produce beta-lactamase and beta-lactam resistance is produced by another mechanism (using amoxicillin-clavulanate would not provide us with anything). With quinolone we do not increase the spectrum and it is evident that the poor evolution of the patient is not only a problem of time.

The patient is a man with pneumonia with isolated germ in blood culture and antibiogram. According to the data provided, it is a pneumococcus sensitive to penicillin (MIC < 0.125), so treatment is started with penicillin at high doses every 4 h, despite which the fever persists. If we analyze the case carefully, the treatment should be effective since the germ is totally sensitive to the drug and the dosage is adequate (so that high concentrations of the drug should be maintained at all times, remember that the efficacy of beta-lactams is time-dependent and the antibiotic concentrations in blood should be above the MIC permanently to achieve effectiveness and avoid the production of resistance). In such a case, what could be happening, probably, [HIDDEN] [HIDDEN] it is not reaching the infectious focus adequately because an empyema has probably occurred. We should rule out the existence of an empyema and drain it while continuing with the antibiotic treatment. If the dosage had not been adequate and the presence of drug resistance was possible, [HIDDEN], [HIDDEN] since we should remember that streptococcus does not produce beta-lactamase and beta-lactam resistance is produced by another mechanism (using amoxicillin-clavulanate would not provide us with anything). [HIDDEN] [HIDDEN] it is evident that the poor evolution of the patient is not only a problem of time.

A 50-year-old man with chronic bronchitis is admitted for pneumonia with positive blood culture for Streptococcus pneumoniae, with an MIC to penicillin of 0.0125 mg/l. Treatment was started with penicillin 2 million every 4h. On the fifth day, she still has a fever of 38ºC. Which of the following decisions do you think is correct?

I would change the treatment to ceftriaxone because of its greater efficacy.

I would add a quinolone to the treatment.

I would switch to amoxicillin/clavulanic acid.

It would rule out the presence of pleural empyema.

I would continue with the same treatment, assuming it is simply a timing issue.


Another classic MIR, asked in 2019 and in 2017, fragile X syndrome. Also, on the same concept as question 44, the phenomenon of genetic anticipation. Triplet expansion diseases, such as this one, can have the anticipation phenomenon whereby females with premutations (between 55-200 repeats) can have children with full mutations (more than 200 repeats of the triplet) and more obvious, more severe and/or earlier clinical, in both males and females (Fragile X syndrome, early ovarian failure, tremor/ataxia associated with Fragile X).

What genetic and reproductive counseling would you indicate to a 30-year-old woman who consults because she is a carrier of a premutation in the FMR1 gene, responsible for Fragile X syndrome, and who wishes to have offspring. Point out the correct answer:

All her male children will be carriers and, therefore, will manifest the disease.

There is a phenomenon of genetic anticipation, so their offspring will present more severe and earlier symptoms.

Preimplantation genetic diagnosis for sex selection of embryos by fluorescence in situ hybridization (FISH) is the best option for healthy offspring.

50% of her daughters will be carriers, but will not present clinical manifestations of the disease.


There may be debate about whether to start Rituximab with another cytostatic drug or in monotherapy, but given the lack of survival benefit with early initiation of treatment, the NCCN guidelines recommend waiting and seeing, unless GELF criteria are met to initiate treatment: GELF criteria (Follicular Lymphoma Study Group): - Involvement of ≥3 nodal areas, each with a diameter ≥ 3 cm. - Any nodal or extranodal mass with a diameter ≥ 7 cm. - B symptoms. - Splenomegaly. - Pleural effusion or ascites. - Cytopenias (leukocytes < 1.0 x 109 / L and/or platelets < 100 x 109 / L). - Leukemia (> 5.0 x 109 /L of malignant cells).

There may be debate about whether to start Rituximab with another cytostatic drug or in monotherapy, but given the [HIDDEN], the NCCN guidelines recommend waiting and seeing, unless GELF criteria are met to initiate treatment: GELF criteria (Follicular Lymphoma Study Group): - Involvement of ≥3 nodal areas, each with a diameter ≥ 3 cm. - Any nodal or extranodal mass with a diameter ≥ 7 cm. - B symptoms. - Splenomegaly. - Pleural effusion or ascites. - Cytopenias (leukocytes < 1.0 x 109 / L and/or platelets < 100 x 109 / L). - Leukemia (> 5.0 x 109 /L of malignant cells).

A 78-year-old woman with a history of type 2 diabetes treated with oral antidiabetics, hypertension treated with beta-blockers and ACE inhibitors, and NYHA grade 1 congestive heart failure with LVEF of 48%, and currently asymptomatic. Functional status: ECOG 0. History of 2 years of evolution of small lumps in the neck. Biopsy of cervical adenopathy: follicular lymphoma grade 2. Extension study: Hb 12 g/dL, Leukocytes 6,900/microL (Neutrophils 60%, Lymphocytes 27%, Monocytes 6%, Eosinophils 4%, Basophils 4%), Platelets 220,000/microL. MO: infiltrate by follicular lymphoma. Creatinine 1.5 mg/dL, LDH 235 U/L, Beta2 microglobulin 2.1 microg/mL. CT: lymphadenopathies less than 3 cm in cervical, axillary, retroperitoneal, iliac and inguinal territories; liver and spleen are normal. Which of the following treatments is the most appropriate?

Rituximab-CHOP (Cyclophosphamide, Adriamycin, Vincristine, Prednisone).

Rituximab-CVP (Cyclophosphamide, Vincristine, Prednisone).

Do not treat and monitor (wait and see).


The statement with the family history indicates that this is a case of hereditary nonpolyposis colorectal cancer (Lynch syndrome). The age and right location data lead us to answer 4: total colectomy with ileorectal anastomosis. If a conventional right hemicolectomy type surgery is performed, the chances of recurrence are higher than 30%. Excision of the rectum is not necessary prophylactically.

The statement with the family history indicates that [HIDDEN]. The age and right location data lead us to [HIDDEN]. If a conventional right hemicolectomy type surgery is performed, the chances of recurrence are higher than 30%. Excision of the rectum is not necessary prophylactically.

A 35-year-old woman is diagnosed with colon cancer located in the hepatic angle. She has a family history of colon cancer in her mother, an aunt at the age of 45 and a grandfather. The most accepted surgical intervention is:

Total colectomy with ileorectal anatomosis.


The patient described is the definition of masked HT, normal figures in consultation and elevated on AMPA or ABPM (option 2 correct). It is not secondary HT because no study has been done to confirm it (option 1 incorrect). It is not isolated HT because the elevated figures are maintained for several weeks (option 3 incorrect). It is not refractory HT because it has not yet been treated (option 4 incorrect).

The patient described is the definition of masked HT, normal figures in consultation and elevated on AMPA or ABPM ([HIDDEN]). It is not secondary HT because no study has been done to confirm it ([HIDDEN]). It is not isolated HT because the elevated figures are maintained for several weeks ([HIDDEN]). It is not refractory HT because it has not yet been treated ([HIDDEN]).

53-year-old woman with a personal history of obesity and migraine. Her blood pressure has been taken repeatedly at the doctor's and nurse's office, presenting figures below 140/90 mmHg. However, an approved blood pressure measuring device has been purchased and she has been taught how to use it correctly. He comes in showing blood pressure recordings taken at home over several weeks with values above 140/90 mmHg. Mark the correct answer:

Presents isolated clinical hypertension.

Presents refractory arterial hypertension.


The hormonal profile we are told is in menopausal range (FSH >20; estradiol <5) and the patient has systemic vasomotor symptoms. Therefore, it would be more appropriate to administer systemic estrogens. To compensate, she already has a local uterine progestin (levonorgestrel IUD).

A 43-year-old woman with a levonorgestrel intrauterine device who consults for lack of rest at night with the appearance of heat and palpitations. In the analytical analysis highlights free T4 10.5 pmol/L (9-19), thyrotropin 2.1 mIU/L (0.30-5.00), FSH 95.6 IU/L (1.38-16.7), LH 21 IU/L (2.4-9.3), estradiol < 0.07 nmol/L (0.07 - 1.14). What is the most appropriate treatment?

Oral estrogens and progestogens in continuous regimen.

Transdermal estrogens in a continuous regimen.


She is describing egg anaphylaxis, a potentially fatal condition. The treatment of choice is intramuscular adrenaline, and effectively, without wasting too much time. The first thing is INTRAMUSCULAR adrenaline NOW! The venous route, corticosteroids, antihistamines, etc. will come later.

A 15-month-old boy, who during dinner, after eating a bite of tortilla, suddenly presented with facial reddening predominantly perioral, habonous lesions on the trunk and extremities and cough. On arrival at the center, the patient was conscious and, in addition to what was described above, the following were observed: suprasternal twitching, abundant watery rhinorrhea, bilateral hypoventilation without wheezing and capillary refill of less than 2 seconds. Of the following statements, indicate the CORRECT answer:

The priority is to cannulate a venous line.

Intramuscular methylprednisolone is the treatment of choice.

It is a picture of urticaria associated with asthma, and should be treated with antihistamines and inhaled bronchodilators.

Parents should be advised to transfer to a hospital emergency department.

Intramuscular adrenaline should be administered without further delay.


In a patient with multiple CVRF with concomitant heart and renal failure (presumably of multiple etiology: renal hypoperfusion, arteriosclerosis...), we must be very careful when using diuretics and ACEI/ARA-II, since we can worsen renal function and/or increase potassium levels (among diuretics, spironolactone and eplerenone are "potassium-sparing"). Therefore, in this case we will use bisoprolol.

A 75-year-old man, hypertensive and dyslipidemic with a history of heart failure due to left ventricular systolic dysfunction (EF < 30%). He comes to our office for worsening of his usual dyspnea in recent weeks. His systolic blood pressure is 160/95 mmHg with a heart rate of 65 bpm. In the physical examination no crackles were heard and his jugular venous pressure was normal. He provides a creatinine determination that is 3.7 mg/dL with ions within normal. Which of the following drugs is the most appropriate to improve the prognosis of his heart failure?


Palpable mass in the neck: suspect thyroid/parathyroid pathology. It is associated with hypercalcemia, therefore, the option of medullary thyroid cancer is ruled out (it does not affect the level of calcemia). To think of MEN type I we should associate other pathologies (pituitary, pancreatic or duodenal tumors). The presence of a calcemia higher than 13mgr/dl, together with dysphonia, indicates a malignant tumor (higher calcemia level and infiltration), therefore we opt for option 1.

Palpable mass in the neck: suspect thyroid/parathyroid pathology. It is associated with hypercalcemia, therefore, the option of medullary thyroid cancer is ruled out (it does not affect the level of calcemia). To think of MEN type I we should associate other pathologies (pituitary, pancreatic or duodenal tumors). The presence of a calcemia higher than 13mgr/dl, together with dysphonia, indicates a malignant tumor (higher calcemia level and infiltration), therefore we opt for [HIDDEN].

A 45-year-old woman comes to the emergency department with confusional symptoms accompanied by dysphonia. On examination she has a palpable neck mass and a blood test shows plasma calcium levels of 15 mg/dL (normal up to 10.2 mg/dL). Given these findings, which of the following diagnoses should be suspected?


Diplopia is usually caused by acute or secondary strabismus. Vertical gaze palsy is due to a midbrain lesion. In this case the MRI already places the origin of the symptoms in the pineal gland. The most frequent tumor in this region is the germ cell tumor (answer 3).

Diplopia is usually caused by acute or secondary strabismus. Vertical gaze palsy is due to a midbrain lesion. In this case the MRI already places the origin of the symptoms in the pineal gland. The most frequent tumor in this region is the germ cell tumor ([HIDDEN]).

A 13-year-old boy presents with subacute headache and diplopia. Neurologic examination shows vertical gaze palsy and MRI shows a contrast-enhancing lesion in the pineal region obstructing the aqueduct of Sylvian. The most likely diagnosis is:


Diagnostic Criteria for DM according to ISPAD 2018 *Classic symptoms of diabetes with blood glucose > 200mgr/dl or: * Fasting glycemia ≥ 126mgr/dl (fasting at least 8h) or * Glycemia at 2h SOG ≥ 200mgr/dl (on 2 occasions) or * HbA1C ≥ 6.5%.

58-year-old male, obese, asymptomatic, moderate drinker, who presents a first baseline blood glucose of 153 mg/d with negative glycosuria. In the following weeks he has had two other baseline blood glucose readings of 118 and 136 mg/dl. Which of the following is the most appropriate approach to confirm the diagnosis of diabetes mellitus:

Practice a blood glucose curve with 75 g of glucose.

Already meets diagnostic criteria for diabetes mellitus.

Request a determination of basal insulinemia or C-peptide.

Request a determination of glycosylated hemoglobin.


It does not explain pyramidalism.

Answer 1 incorrect: It does not explain pyramidalism. Answer 2 correct: A nonspecific answer, but probably the correct answer. Answer 3 incorrect: We would lack data to think of a Brown Sequard hemimedullary syndrome. It would explain the pyramidalism, but we would be missing data suggestive of this picture such as a contralateral hypoesthesia. Incorrect answer 4: It could explain the difficulty in dorsiflexion and plantar flexion of the foot, but not the pyramidalism. Incorrect answer 5: In a similar way to the previous one, it could explain part of the clinical picture, but not the pyramidalism.

Answer 1 [HIDDEN]: It does not explain pyramidalism. Answer 2 [HIDDEN]: A nonspecific answer, but probably [HIDDEN]. Answer 3 [HIDDEN]: We would lack data to think of a Brown Sequard hemimedullary syndrome. It would explain the pyramidalism, but we would be missing data suggestive of this picture such as a contralateral hypoesthesia. [HIDDEN]: It could explain the difficulty in dorsiflexion and plantar flexion of the foot, but not the pyramidalism. [HIDDEN]: In a similar way to the previous one, it could explain part of the clinical picture, but not the pyramidalism.

A 56-year-old patient with no personal or family history of interest is studied because he has been having difficulty walking with his right leg for six months. He reports no other symptoms. The examination shows a 4/5 weakness for dorsal flexion and eversion of the foot and 4/5 for flexion and inversion of the foot, with increased muscle reflexes and Babinski present, the rest being normal. The syndromic diagnosis would be:

Mononeuropathy of the right common peroneal nerve.

Focal involvement of the first motor neuron and probably of the second.

Right hemimedullary involvement (Brown-Sequard).

Multiple mononeuropathy with involvement of the common peroneal and right posterior tibial nerve.


This is a completely gratuitous question, from a healthier gentleman than me who is going to undergo low-risk surgery on a scheduled basis. The answer is obviously 4. Had there been a fifth option it would have been that nothing needs to be done, which might have generated some doubt in the student, but since the question does not exist it is a piece of candy. Although there are many protocols on preoperative procedures, almost as many as there are hospitals, the question makes it easy by putting a very old patient, 80 years old. The age range from which it is considered mandatory to request an ECG varies between 45, 50, 60 or even some say 70 years. For example: > 50 years: always, except if a previous ECG is available < 50 years: only if there is known or suspected heart disease (CVRF), severe DM, hyperthyroidism or severe COPD.

This is a completely gratuitous question, from a healthier gentleman than me who is going to undergo low-risk surgery on a scheduled basis. The answer is [HIDDEN]. Had there been a fifth option it would have been that nothing needs to be done, which might have generated some doubt in the student, but since the question does not exist it is a piece of candy. Although there are many protocols on preoperative procedures, almost as many as there are hospitals, the question makes it easy by putting a very old patient, 80 years old. The age range from which it is considered mandatory to request an ECG varies between 45, 50, 60 or even some say 70 years. For example: > 50 years: always, except if a previous ECG is available < 50 years: only if there is known or suspected heart disease (CVRF), severe DM, hyperthyroidism or severe COPD.

An 80-year-old man comes to your office for evaluation of a scheduled cholecystectomy by laparoscopy. He has a history of arterial hypertension under treatment for 10 years. He denies heart or pulmonary disease. She has no chest pain. She has an active life and goes daily to the gym where she alternates swimming and walking on the treadmill for at least one hour. Usual treatment: nebivolol 5 mg every 24 hours and hydrochlorothiazide 12.5 mg daily. Physical examination: weight 73 kgs; height 179 cm; blood pressure 138/80 mmHg; heart rate 60 beats/minute. No murmurs are auscultated Which of the following is the most appropriate preoperative approach?

Perform a thallium and dipyridamole scan.


The statement describes diplopia to superior vision with limitation of upper eyeball extension. As the mechanical function of the left inferior rectus is compromised, it would not allow to complete the supraduccion movement generating vertical diplopia, this plus the traumatic antecedent allows to suspect a fracture of the orbital floor with muscular entrapment of the inferior rectus. Fracture of the roof is much less frequent and the entrapment of the superior rectus would cause limitation for infraduction.

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

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

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


Discontinue sulfonylurea because of Risk of hypoglycemia.

A 49-year-old man who consults for severe polyuria and polydipsia and unintentional weight loss of 10 kg and is diagnosed with diabetes mellitus due to a plasma blood glucose of 322 mg/dL and a glycosylated hemoglobin of 9.8%. His physician gave him dietary recommendations, the convenience of physical exercise, and he started treatment with metformin 850 mg/12 hours and glimepiride 6 mg/day. In the following weeks the glycemic controls are progressively reduced. At 4 months glycemia is 94 mg/dL and HbA1c is 5.9%. The patient complains of frequent episodes of dizziness, epigastric pain, blurred vision, sweating and tremor, which improve with food and occur mainly in the late morning and late afternoon. What modification would you propose in his treatment?

Review dietary carbohydrate distribution.

Substitute metformin with a DPP4 inhibitor.


Stable angina in diabetics: this question is a nod to the BARI-2D study (NEJM 2009), which showed that medical management was not inferior to revascularization (in fact, the new guidelines reflect the trend that not all coronary stenosis should be systematically opened). Answer 1 is along these lines, although I miss statins, ACE inhibitors and antiplatelet agents, and I have too many vasodilators (nitrates are class IIb, if my memory serves me correctly). 2 is absurd: sitting down to avoid angina? That's like cutting down the forest to prevent fires. 3 to 5 are about revascularization: since it is a single vessel and not a proximal LAD, revascularization would have to be percutaneous, so we discard 3. Between 4 and 5, the fifth is more complete: not only would it be necessary to dilate, but also to implant a stent. So the doubt would be between 1 and 5. Applying the general rules of response in the MIR, if two options are similar except in one detail, the correct one is one of these, so we would mark 5 (and this is what would be done in any hospital nowadays: a suboccluded artery is dilated directly). On the other hand, and although 1 is incomplete, I suppose the author wanted to be clever and show that he has read the latest articles. Conclusion: I would mark 5... but I would not be surprised if it was 1.

Stable angina in diabetics: this question is a nod to the BARI-2D study (NEJM 2009), which showed that medical management was not inferior to revascularization (in fact, the new guidelines reflect the trend that not all coronary stenosis should be systematically opened). Answer 1 is along these lines, although I miss statins, ACE inhibitors and antiplatelet agents, and I have too many vasodilators (nitrates are class IIb, if my memory serves me correctly). 2 is absurd: sitting down to avoid angina? That's like cutting down the forest to prevent fires. 3 to 5 are about revascularization: since it is a single vessel and not a proximal LAD, revascularization would have to be percutaneous, so [HIDDEN]. Between 4 and 5, [HIDDEN]. So the doubt would be between 1 and 5. Applying the general rules of response in the MIR, if two options are similar except in one detail, [HIDDEN]. On the other hand, and although 1 is incomplete, I suppose the author wanted to be clever and show that he has read the latest articles. Conclusion: [HIDDEN]... but I would not be surprised if [HIDDEN].

In a 60-year-old diabetic patient with stable angina secondary to ischemic heart disease due to subtotal obstruction in the middle third of the anterior descending coronary artery, what treatment would you propose?

Medical with vasodilators and beta-blockers to avoid angina.

Expectorant with rigorous rest, since decreasing myocardial oxygen demand should decrease angina.

Surgical revascularization of the ischemic myocardium by means of a left mammary artery bypass distal to the lesion in the diseased coronary artery.

Dilatation of the coronary artery lesion by therapeutic catheterization.

Therapeutic catheterization to dilate the lesion of the diseased artery and implantation of a stent in the dilated area.


We suspect spondylodiscitis - the febrile fever and the limitation of mobility of the spine with the acute course give the key -, and the indicated test is the MRI. "The most demonstrative test is magnetic resonance imaging (MRI), which is positive even in the first 2 weeks of the picture, which facilitates early diagnosis, with a sensitivity of 90%". Vertebral crushing would be seen in the simple X-ray, as well as vertebral ankylosing hyperostosis and many metastases. In addition, there is no data in the history pointing to bone metastases (oncologic history, weight loss etc).

We suspect spondylodiscitis - the febrile fever and the limitation of mobility of the spine with the acute course give the key -, and the indicated test is the MRI. "[HIDDEN]", which facilitates early diagnosis, with a sensitivity of 90%". Vertebral crushing would be seen in the simple X-ray, as well as vertebral ankylosing hyperostosis and many metastases. In addition, there is no data in the history pointing to bone metastases (oncologic history, weight loss etc).

A 70-year-old man consults for non-radiating lumbar pain of 1 week's duration, of progressive intensity, accompanied by marked limitation of spinal mobility and febrile fever. The lumbar spine X-ray shows no alterations. What diagnosis should we rule out first and with what technique?

Vertebral crush with computed tomography (CT).

Bone metastases with technetium bone scan.

Vertebral ankylosing hyperostosis with dorsolumbar spine x-ray.

Pyogenic spondylodiscitis with magnetic resonance imaging (MRI).


Porphyria cutanea tarda (PCT) is the most common porphyria and can present with three major clinical forms: familial, sporadic and toxic. Clinically, it is characterized by marked skin fragility with the appearance of erosions, vesicles and blisters after minimal trauma. The most frequent sites are the back of the hands and the face, i.e. the areas of greatest photoexposure. Clinically, the most important differential diagnosis should be established with pseudoporphyria or phototoxic bullous dermatitis, in which the blisters and cutaneous erosions are produced by photosensitivity, induced by drugs such as tetracyclines, sulfonamides, etc. However, unlike porphyria, porphyrin levels in serum, feces and urine are normal. The histopathological differential diagnosis should be established with those diseases showing dermal hyaline deposits, such as: hyalinosis cutis, in which unlike porphyria, PAS-positive hyaline deposits are extensive and massively occupy the deep dermis and subcutaneous cellular tissue; Milium colloid in which hyaline material, usually PAS negative expands the papillary dermis, forming characteristic clefts and fissures; and lipoid proteinosis, in which the material is deposited throughout the dermis, has a distribution not only perivascular but more extensive than in porphyria, and usually affects sweat glands.

60-year-old male patient who refers 10 days ago the appearance of blistering lesions on dorsum of hands after sun exposure. The picture is accompanied by skin fragility. Histopathologically there is a subepidermal blister with PAS+ deposits in and around the superficial dermal vessels. The most plausible diagnosis is:

DERMATOLOGY, VENEREOLOGY AND PLASTIC SURGERY


The most common symptomatology of a patient with coxarthrosis includes: hip pain that limits ambulation, nocturnal discomfort and even at rest, hip stiffness and locking. Coxo-femoral osteoarthrosis presents with a negative Lasegue test. Wrong answer 2. Low back pain of a neuropathic nature usually presents with unilateral and distributed radiculopathy according to dermatomes. The recognized risk factors are most frequently: women, obesity, smoking and sedentary lifestyle or situations of prolonged sitting. The lumbosciatica is usually referred to the buttock, posterior aspect of the thighs and even inguinal. The clinical case describes the Lasegue maneuver or test; a provocation test that evidences radicular irritation in the lumbosacral region (Answer 3 correct). Claudication due to canal stenosis typically presents with pain that worsens with trunk extension (walking, standing) and is relieved with flexion (sitting, sleeping in the fetal position...) Wrong answer 4.

The most common symptomatology of a patient with coxarthrosis includes: hip pain that limits ambulation, nocturnal discomfort and even at rest, hip stiffness and locking. Coxo-femoral osteoarthrosis presents with a negative Lasegue test. [HIDDEN]. Low back pain of a neuropathic nature usually presents with unilateral and distributed radiculopathy according to dermatomes. The recognized risk factors are most frequently: women, obesity, smoking and sedentary lifestyle or situations of prolonged sitting. The lumbosciatica is usually referred to the buttock, posterior aspect of the thighs and even inguinal. The clinical case describes the Lasegue maneuver or test; a provocation test that evidences radicular irritation in the lumbosacral region ([HIDDEN]). Claudication due to canal stenosis typically presents with pain that worsens with trunk extension (walking, standing) and is relieved with flexion (sitting, sleeping in the fetal position...) [HIDDEN].

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?


It is a semiology question that helps us to remember the types of aphasia. The following aspects should be taken into account: language emission (fluent, non-fluent, non-emission), comprehension (yes or no), repetition (yes or no) and nomination. Wernicke's aphasia or sensitive aphasia has a fluent language, does not understand, does not repeat and does not nominate, just like the patient in the question. Sensory transcortical aphasia differs from sensory aphasia in that patients are able to repeat. Conduction aphasia differs from sensory aphasia in that comprehension is preserved, all else being equal. Finally, in broca's aphasia the language is non-fluent, comprehension is preserved, it does not repeat and does not nominate.

An 80-year-old woman with a history of arterial hypertension and diabetes mellitus who suddenly presents with language impairment. On arrival at the hospital, an unknown atrial fibrillation is observed, and on examination she presents fluent speech with a tendency to slurred speech, poor language comprehension, inability to repeat and dysnomia. Semiologically she presents a picture compatible with:


In principle, what you tell us does not fit with a nephritic colic. The urine is normal (without hematuria, caused by the lithiasis as it progresses), the Creat is normal (it can rise up to 1.9 in nephritic colic). The increase in LDH is non-specific and can be found in hepatic parenchymal lesions, AMI or pulmonary embolism, as well as in many other less frequent cases (tumors, myopathies, etc.). In this case, we have an important risk factor for embolism, which is atrial fibrillation, which, in addition, being a 45-year-old male, with no previous history, does not seem to respond to an underlying structural heart disease together with right lumbar pain, which could correspond to irritation of the pleura at the level of the right lumbar spine. Spiral CT with contrast has acquired great value in the diagnosis of PTE, due to its rapidity and good sensitivity, higher than 83-92% in most studies, and according to some it can reach 100% for central thrombi, located in main, lobar or segmental pulmonary arteries. Its specificity is greater than 90%. Nodes can produce false positives. It can also provide an alternative diagnosis in case PTE is not confirmed, so it would be a very useful test. Doppler ultrasound would be the most useful test to diagnose the source of the emboli, so it could also be a valid answer depending on what they mean by "useful". It is a noninvasive technique that has demonstrated its good sensitivity and specificity in the diagnosis of DVT compared to phlebography. It also allows the diagnosis of other pathologies that could justify the patient's symptoms. Its limitations are the assessment of infrapopliteal thrombi and, in many cases, in patients who are not thin, of the iliac and cava veins.

A 45-year-old male patient with a history of uric lithiasis and repeated expulsive nephritic colic for the past 25 years comes to the emergency room reporting palpitations and severe right lumbar pain for the past 2 hours. Urinalysis shows a pH of 5.5 and leukocyturia without proteinuria. The electrocardiogram confirms a previously unknown AF. Blood biochemistry shows a Creat of 0.9, Ca of 11 and LDH of 950. What is the most useful diagnostic maneuver to perform?

ANESTHESIOLOGY, CRITICAL CARE AND EMERGENCY MEDICINE


It appears that the patient has erythema nodosum lesions associated with a flare of his disease, which is common. Treatment of the disease and its control usually improves the cutaneous lesions. The lesions should not be biopsied.

A 17-year-old boy with Crohn's disease with colonic involvement of 2 years of evolution, in maintenance treatment with azathioprine, consults for the appearance since 5 days ago of purplish-red, hot, painful, bilateral subcutaneous nodules of pretibial location, associated with an increase in the number of stools and abdominal pain. The most appropriate approach in this case is:

Recommend relative rest and warm cloths on both legs and add antidepressant treatment.

Biopsy skin areas away from the injured areas and prescribe opioid analgesics at the beginning.

Suspect bilateral lower extremity ischemia of drug origin.

Adjustment of the treatment of the disease.


Pelvic inflammatory disease is suspected, given the patient's symptoms. According to the 2006 SEGO protocol for Pelvic Inflammatory Disease, answer 2 is the false answer and, therefore, the one that should be marked. This is because hysterosalpingography can spread the infection to the pelvic and abdominal cavity. The rest of the answers are correct.

Pelvic inflammatory disease is suspected, given the patient's symptoms. According to the 2006 SEGO protocol for Pelvic Inflammatory Disease, answer 2 is [HIDDEN] and, therefore, the one that should be marked. This is because hysterosalpingography can spread the infection to the pelvic and abdominal cavity. The rest of the answers are [HIDDEN].

A 24-year-old woman consults for lower abdominal pain of two weeks of evolution that has worsened with the last sexual intercourse. She reports having a recent partner with whom she only occasionally uses a condom. On examination, she was in fair general condition. Temperature 38.6ºC, leukocytes 16,000/uL (85% neutrophils); CRP 30 mg/L. Speculum examination shows abundant abnormal vaginal discharge and painful cervical mobilization. Indicate the FALSE answer:

We would start antibiotic treatment as soon as we suspect the diagnosis.

We would indicate as a preferential complementary test a hysterosalpingography for tubal assessment.

Delay in diagnosis and treatment increases the occurrence of sequelae.

The presence of abscess would be a criterion for hospitalization.


This is a typical description of a picture of intestinal obstruction due to bridging or adhesions due to previous surgery. The correct answer is 5 and not 1 because most of these situations resolve spontaneously with conservative treatment.

This is a typical description of a picture of intestinal obstruction due to bridging or adhesions due to previous surgery. The [HIDDEN] and not 1 because most of these situations resolve spontaneously with conservative treatment.

55-year-old woman, operated on for appendicitis 24 years ago, who comes in because while previously well, she has started with repeated vomiting after breakfast, about 12 hours ago, associated with abdominal distention. She presented a diarrhea stool a few hours after the onset of the symptoms. Examination revealed abdominal distension, tympanism and increased bowel sounds, but no peritoneal irritation. Laboratory tests showed no abnormalities. The abdominal X-ray showed dilatation of the small bowel loops, without gas in the rectal ampulla. Regarding this case it is true that:

This is a picture of intestinal flange obstruction requiring emergency laparotomy.

Most likely we are facing a case of obstruction at the level of the large intestine.

The fact that the patient presented a diarrheal stool allows us to exclude the diagnosis of intestinal obstruction. Further imaging studies are necessary to ensure a diagnosis.

We should indicate the practice of a decompressive colonoscopy.

Initial management should be conservative, with serum therapy, nasogastric aspiration and periodic clinical, analytical and radiographic monitoring.


We are presented with an adolescent patient who is overweight with pain in the thigh and knee, a length discrepancy of 1 cm and the limb in external rotation. This picture should automatically lead us to mark epiphysiolysis capitis femoris (proximal femoral epiphysiolysis, the fact of reading it in Latin nomina is a bit of a misunderstanding but it should not mislead us). We should think of this one because it is the most frequent and possible (correct answer 2). The other options are not impossible but they are less frequent and they would not ask us this if they wanted us to choose another option. If they were sequelae of hip dysplasia, it would not have this 4-month onset and the age of onset would be earlier. Complications of dysplasia are dislocations and subluxations that may require surgery and avascular necrosis of the head (false answer 5). Perthes disease occurs in younger children (4-9 years) with episodes of limping and pain in the hip and knee (false answer 4). In a child the most typical would be a fracture at the level of the physis, not at the level of the femoral neck, so we discard 3. For us to consider this option we would have to have been presented with a bone cyst, something that would justify a weakness in the femoral neck area. As for juvenile chronic arthritis, it is a rheumatoid option surrounded by trauma options. They do not speak to us of rheumatologic factors in an analytical analysis, nor of a polyarticular picture. Perhaps we could think about this one because they talk about pain in the right knee, but this picture that they present us is limited to the right lower limb, they do not talk about other joints or fever or other accompanying systemic symptoms, so it is not an option to evaluate, especially with the other options presented to us that would be more likely in view of the picture presented to us (option 1 false). In addition, the knee pain in this case refers to a referred pain of the hip, without involvement of the knee.

We are presented with an adolescent patient who is overweight with pain in the thigh and knee, a length discrepancy of 1 cm and the limb in external rotation. This picture should automatically lead us to mark epiphysiolysis capitis femoris (proximal femoral epiphysiolysis, the fact of reading it in Latin nomina is a bit of a misunderstanding but it should not mislead us). We should think of this one because it is the most frequent and possible [HIDDEN]. The other options are not impossible but they are less frequent and they would not ask us this if they wanted us to choose another option. If they were sequelae of hip dysplasia, it would not have this 4-month onset and the age of onset would be earlier. Complications of dysplasia are dislocations and subluxations that may require surgery and avascular necrosis of the head [HIDDEN]. Perthes disease occurs in younger children (4-9 years) with episodes of limping and pain in the hip and knee [HIDDEN]. In a child the most typical would be a fracture at the level of the physis, not at the level of the femoral neck, so we discard [HIDDEN]. For us to consider this option we would have to have been presented with a bone cyst, something that would justify a weakness in the femoral neck area. As for juvenile chronic arthritis, it is a rheumatoid option surrounded by trauma options. They do not speak to us of rheumatologic factors in an analytical analysis, nor of a polyarticular picture. Perhaps we could think about this one because they talk about pain in the right knee, but this picture that they present us is limited to the right lower limb, they do not talk about other joints or fever or other accompanying systemic symptoms, so it is not an option to evaluate, especially with the other options presented to us that would be more likely in view of the picture presented to us [HIDDEN]. In addition, the knee pain in this case refers to a referred pain of the hip, without involvement of the knee.

Obese 12-year-old boy (87 kg). He has been complaining of mechanical pain in the right thigh and knee for 4 months. Clinical examination reveals a 1 cm discrepancy in the length of the lower extremities and an attitude of the right lower extremity in external rotation with loss of internal rotation. We should suspect that he presents:

Fracture of the femoral neck due to overload.

Sequelae of developmental dysplasia of the hip.


The correct answer is 5. The mother should be isolated for the first 2-4 weeks of treatment, after which she would no longer be contagious. If the result of the repeat PT is still negative, the child should not be tested again. If it is positive, the X-ray (or pulmonary CT in younger children) should be repeated.

The [HIDDEN] The mother should be isolated for the first 2-4 weeks of treatment, after which she would no longer be contagious. If the result of the repeat PT is still negative, the child should not be tested again. If it is positive, the X-ray (or pulmonary CT in younger children) should be repeated.

A 1-year-old boy whose mother has just been diagnosed with bacilliferous pulmonary tuberculosis, having started correct treatment. The child is asymptomatic with a normal examination, negative tuberculin test (PT) and normal chest Rx. What would be the attitude to adopt in the child?

Only separate him from the mother until her treatment is completed (at least 6 months).

Perform a high-resolution CT scan of the lung, and if normal, repeat PT at 8-12 weeks.

Chemoprophylaxis with isoniazid (INH) until the mother's smear test is negative.

Chemoprophylaxis with INH 6-9 months. New PT and chest X-ray at the end of treatment, to decide whether or not to conclude treatment.

Chemoprophylaxis with INH, 8-12 weeks. Repeat PT. If negative, stop treatment. If positive, perform chest X-ray to decide whether or not there is disease.


Vasoactive intestinal peptide (VIP). VIPoma-diarrhea. The 3.

A 40-year-old woman, with no personal or family history of interest, presents several days of watery diarrhea, very abundant, accompanied by loss of 10 kg of weight, flushing and facial reddening, together with lipothymias and colicky abdominal pain, with hypokalemia in the laboratory data. An abdominal ultrasound shows a mass of 1.5 cm in diameter in the pancreatic tail. Among the following, your primary diagnostic suspicion is:


A gram negative stain never rules out the presence of infection.

A 41-year-old man comes to the Emergency Department with three days of swelling and pain in the right knee, with functional impotence and fever Two weeks earlier he had had a self-limited diarrhea. On examination there is joint effusion, so we proceed to perform an arthrocentesis and obtain 50 cc of cloudy liquid, with decreased viscosity and the following analytical parameters: leukocytes 40. 000/microL (85% of neutrophils), glucose 40 mg/dL, absence of crystals, Gram stain: no microorganisms are observed. Which of the following statements about this patient is WRONG:

Treatment with cloxacillin and ceftriaxone should be initiated pending the result of the fluid culture.

It is advisable to perform daily arthrocentesis to relieve symptoms and prevent joint destruction.

If the culture is negative, it is likely to be reactive arthritis.

Negative Gram stain rules out septic arthritis.


Young woman with secondary amenorrhea, with no history of interest. Prolactin values are normal (values above 20ngr/ml are considered hyperprolectinemia), thus ruling out hyperprolactinemia as the cause of amenorrhea. They tell us that the estrogen level is low. In this case we should suspect early ovarian failure. For its diagnosis we will ask for a basal FSH (in cases of premature ovarian failure it would be elevated).

Young woman with secondary amenorrhea, with no history of interest. Prolactin values are normal (values above 20ngr/ml are considered hyperprolectinemia), thus [HIDDEN] as the cause of amenorrhea. They tell us that the estrogen level is low. In this case we should suspect early ovarian failure. For its diagnosis we will ask for a basal FSH (in cases of premature ovarian failure it would be elevated).

A 27-year-old woman consults for secondary amenorrhea of one year of evolution. She has no iatrogenic history. Analytically, the estradiol concentration is below normal and the prolactin value is 12 ng/mL. Indicate which of the following examinations would you request as a first step to try to identify the origin of the disorder:


At least for me, as a family physician, I usually start with the least invasive and most cost-effective tests, and in the case described, an ischemic problem in the lower limbs is the ankle-brachial index.

A 70-year-old woman, hypertensive and diabetic, who has worked as a sales clerk all her life. She consults for an internal malleolar lesion in the right leg with intense pain throughout the day that worsens at night. On examination, there are uncomplicated varicose cords in both extremities and normal femoral and popliteal pulses with absence of distal pulses. What examination should we perform first?


The fact of being a photoinduced picture, the histology and the age make the diagnosis of PCT more probable (3). The rest of the answers do not fit with the clinical picture or the histology.

The fact of being a photoinduced picture, the histology and the age make the diagnosis of PCT more probable [HIDDEN]. The rest of the answers do not fit with the clinical picture or the histology.

A 60-year-old male patient who reported 10 days ago the appearance of blistering lesions on the dorsum of the hands after sun exposure. The picture is accompanied by skin fragility. Histopathologically there is a subepidermal blister with PAS+ deposits in and around the superficial dermal vessels. The most plausible diagnosis is:


In resection margins, we have: intralesional → marginal (option 3) → Extended → Radical (options 1 and 4). This is a high-grade tumor, in which extended resection including tumor-free margins is indicated. Radical amputation surgery has not been shown to improve survival being reserved for selected cases (invasion of neurovascular structures, pathologic fracture...). Therefore, we discard both option 1 and 4; option 3 is also discarded, because it is a smaller margin than the extended one; by elimination we are left with option 2.

In resection margins, we have: intralesional → marginal (option 3) → Extended → Radical (options 1 and 4). This is a high-grade tumor, in which extended resection including tumor-free margins is indicated. Radical amputation surgery has not been shown to improve survival being reserved for selected cases (invasion of neurovascular structures, pathologic fracture...). Therefore, we discard both option 1 and 4; [HIDDEN], because it is a smaller margin than the extended one; by elimination we are left with [HIDDEN].

44-year-old patient with a rapidly growing lesion (16x8x12 cm) involving the soft tissues of the proximal third of the right thigh. He reports that he has started to notice the mass, which has a hard consistency and is adhered to deep planes, in the last 6 months. Previously, she had been a regular athlete and had even finished a marathon. On examination, collateral circulation was observed, but no right inguinal lymph nodes were palpable. After biopsy it was confirmed to be a high-grade undifferentiated pleomorphic sarcoma, which in the imaging studies was found proximal to the lesser trochanter. The extension CT scan is negative. What would be the therapeutic approach?

Treatment with ifosfamide and tamoxifen for 6 cycles prior to resection surgery to reduce the size of the lesion.

Marginal surgery removing the pseudocapsule that these tumors usually form in response to their rapid growth.


Acute hemolytic transfusion reactions can occur within minutes. Clinically they are characterized by chills, fever, urticaria, tachycardia, nausea and vomiting, lumbar pain, hemorrhage due to disseminated intravascular coagulation (DIC)..... We are told of a patient who, within minutes of starting a transfusion, presented with an acute and very serious condition (with shock). Such an acute and severe situation only fits option 4.

Acute hemolytic transfusion reactions can occur within minutes. Clinically they are characterized by chills, fever, urticaria, tachycardia, nausea and vomiting, lumbar pain, hemorrhage due to disseminated intravascular coagulation (DIC)..... We are told of a patient who, within minutes of starting a transfusion, presented with an acute and very serious condition (with shock). Such an acute and severe situation only fits [HIDDEN].

A 35-year-old patient who, due to hematemesis due to ulcus, receives a transfusion of 2 packed red blood cells. 5-10 minutes after starting the transfusion, she begins with fever, chills, hypotension and pain in the lumbar region. What would be the most likely diagnosis?

Febrile reaction secondary to transfusion.

Febrile reaction due to plasma contaminating red blood cells.


All breast carcinomas should be accompanied by the study of hormone receptors and HER-2 for the prognostic implications of the tumor, as well as the adequacy of the treatment of the same, since depending on the result will apply some drugs or others. The study of relatives and the BCRA gene is not indicated since she does not have a family history of neoplasia.

[HIDDEN] [HIDDEN] [HIDDEN] [HIDDEN] [HIDDEN] [HIDDEN] [HIDDEN] [HIDDEN] [HIDDEN] [HIDDEN] [HIDDEN] [HIDDEN] [HIDDEN] [HIDDEN] [HIDDEN] [HIDDEN] [HIDDEN] [HIDDEN] [HIDDEN] [HIDDEN] [HIDDEN] [HIDDEN] [HIDDEN] [HIDDEN] [HIDDEN] [HIDDEN] [HIDDEN].

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

Complete phenotypic study by flow cytometry.

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

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


The correct answer is 1. The symptoms and signs described are the biological findings associated with anorexia nervosa. The ECG disturbances are derived from electrolyte disturbances.

[HIDDEN] The symptoms and signs described are the biological findings associated with anorexia nervosa. The ECG disturbances are derived from electrolyte disturbances.

A 13-year-old girl consults us for weight loss, asthenia, secondary amenorrhea and constipation. Examination revealed a temperature of 35ºC, weight below the 3rd percentile, bradycardia and orthostatic hypotension. Laboratory tests showed anemia with mild leukopenia, cholesterol of 230 mg/dL and on the electrocardiogram a flattened T wave with ST-segment elevation and prolonged QTc. What process would you suspect and what would you do next?

Suspect anorexia nervosa and inquire about intake, body image, etc.

Suspect hypothyroidism and request TSH and thyroid hormones.

Suspect cardiomyopathy and request echocardiography.

I would suspect celiac disease and request anti-transglutaminase IgA antibodies.

Suspect panhypopituitarism and request a cranial CT scan.


Chronic hypertension. This is hypertension that is detected before pregnancy or before the 20th week of pregnancy and/or persists at 12 weeks postpartum.

A pregnant woman, 10 weeks pregnant, comes to the emergency room with a blood pressure of 160/105 mmHg. She is in good general condition, with only mild headache, which is the reason for taking her blood pressure. After 4 hours of rest she presented with a blood pressure of 150/95mmHg. A complete blood count is normal and proteinuria is negative. What type of hypertension does she have?


Typical question, conservative surgery implies radiate, for sure. High grade, and no hormone receptors or her2 (the dreaded triple negative). I was there when there were no taxanes or herceptin and I was in the trials that showed that more and more are being cured, unfortunately still not all. That is why today, anthracyclines (does not suffer from heart) and taxanes before RT. My specialty is beautiful, and will be more so in the coming years.

65-year-old woman with no comorbidities, undergoing left breast-conserving surgery with selective sentinel lymph node biopsy. The pathological anatomy of the specimen shows an infiltrating ductal carcinoma grade III of 11 mm, two negative sentinel nodes, estrogen receptors: 0%, progesterone receptors: 0%, Ki 67: 70%, HER2: negative. The extension study is negative. Adjuvant treatment would be:

Chemotherapy based on anthracyclines and taxanes, radiotherapy and trastuzumab.

Chemotherapy based on anthracyclines and taxanes, radiotherapy and tamoxifen.

Chemotherapy based on anthracyclines and taxanes, and radiotherapy.

Chemotherapy based on anthracyclines and taxanes, radiotherapy and aromatase inhibitors, since it is postmenopausal.


The correct answer is 3. The SEGO in its 2006 protocol "Hypertensive disorders of pregnancy" refers that this is chronic hypertension, although diagnosed in pregnancy. This is because it has been diagnosed at 10 weeks of gestation. Above 20 weeks' gestation, we would be talking about preeclampsia (if HT + proteinuria or uterine artery pulsatility index above the 95th percentile), pregnancy-induced hypertension (only HT) or eclampsia (a form of severe preeclampsia).

The [HIDDEN] The SEGO in its 2006 protocol "Hypertensive disorders of pregnancy" refers that this is chronic hypertension, although diagnosed in pregnancy. This is because it has been diagnosed at 10 weeks of gestation. Above 20 weeks' gestation, we would be talking about preeclampsia (if HT + proteinuria or uterine artery pulsatility index above the 95th percentile), pregnancy-induced hypertension (only HT) or eclampsia (a form of severe preeclampsia).

A pregnant woman, 10 weeks pregnant, comes to the emergency room with a blood pressure of 160/105 mmHg. She is in good general condition, with only mild headache, which is the reason for taking her blood pressure. After 4 hours of rest she presented with a blood pressure of 150/95mmHg. A complete blood count is normal and proteinuria is negative. What type of hypertension is present?


The patient's presenting picture is presumably erythema nodosum. About 10% of cases of erythema nodosum are associated with inflammatory bowel disease, both ulcerative colitis and Crohn's disease. As mentioned, in most cases, erythema nodosum has a self-limited course. When associated with inflammatory bowel disease, erythema nodosum usually resolves with treatment of the intestinal flare, and recurs with disease recurrences. Local measures include elevation of the legs and bed rest. In particularly severe cases, oral administration of potassium iodide has been shown to be helpful. Although the use of aspirin and other NSAIDs is effective for erythema nodosum, their use in patients with inflammatory bowel disease should be limited, as they may worsen the intestinal picture, the usefulness of antidepressants in this picture has not been described, so answer nº1 would not be correct.

The patient's presenting picture is presumably erythema nodosum. About 10% of cases of erythema nodosum are associated with inflammatory bowel disease, both ulcerative colitis and Crohn's disease. As mentioned, in most cases, erythema nodosum has a self-limited course. When associated with inflammatory bowel disease, erythema nodosum usually resolves with treatment of the intestinal flare, and recurs with disease recurrences. Local measures include elevation of the legs and bed rest. In particularly severe cases, oral administration of potassium iodide has been shown to be helpful. Although the use of aspirin and other NSAIDs is effective for erythema nodosum, their use in patients with inflammatory bowel disease should be limited, as they may worsen the intestinal picture, the usefulness of antidepressants in this picture has not been described, so answer nº1 would [HIDDEN]

A 17-year-old boy with Crohn's disease with colonic involvement of 2 years of evolution, in maintenance treatment with azathioprine, consults for the appearance for 5 days of subcutaneous red purplish, hot, painful, bilateral, pretibial localization nodules, associated with an increase in the number of stools and abdominal pain. The most appropriate approach in this case is:

Biopsy areas of skin away from the injured areas and prescribe opioid analgesics for entry.

Suspect the existence of a malignant intestinal tumor lesion as a trigger of the cutaneous process.

Suspect bilateral lower extremity ischemia of drug-induced origin.


This one has been difficult for me, we are going to rule it out. 1 cannot be, because there would be infectious signs. Answer 2 is possible because bisphosphonates create mandibular necrosis. 3 seems unlikely to me because the radiotherapy that the patient received would be oriented on the breast and not on the mandible. I rule out number 4, as it is not a case of dental root involvement. 5 is possible; after all, the patient already has bone metastases. So, I hesitate between 2 and 5, which one to choose? I am certainly not sure what a bone sclerosis means on a CT scan, but a bone metastasis would be more destructive than sclerotizing. On the other hand, using reverse psychology, what did the questioner want me to know? That bisphosphonates can create mandibular necrosis? Or that a woman with several bone metastases can have a metastasis also in the mandible? The latter seems too simple, and would make me lean more towards 2, but it's not clear to me. Be that as it may, between two possible answers you have to always answer, and between 2 and 5, you have to check 2, which is more likely.

This one has been difficult for me, we are going to rule it out. 1 cannot be, because [HIDDEN]. Answer 2 is possible because bisphosphonates create mandibular necrosis. 3 seems unlikely to me because [HIDDEN]. I rule out number 4, as [HIDDEN]. 5 is possible; after all, the patient already has bone metastases. So, I hesitate between 2 and 5, which one to choose? I am certainly not sure what a bone sclerosis means on a CT scan, but [HIDDEN]. On the other hand, using reverse psychology, what did the questioner want me to know? That bisphosphonates can create mandibular necrosis? Or that [HIDDEN]? The latter seems too simple, and [HIDDEN], but it's not clear to me. Be that as it may, between two possible answers you have to always answer, and between 2 and 5, [HIDDEN].

60-year-old woman, diagnosed with breast cancer treated with surgery and radiotherapy 10 years ago. Currently with metastases in the dorsal spine and sacroiliac joint, for which she has received monthly treatment with i.v. zoledronic acid for the last two years. The patient presented spontaneous bone exposure at the level of the mandibular bone of approximately 2 cm. There are no signs of acute infection and the gum around the bone exposure is strictly normal. The mandibular CT scan shows an area of bone sclerosis. What would be the diagnosis?

OTORHINOLARYNGOLOGY AND MAXILLOFACIAL SURGERY


The endoscopic appearance of trachealized esophagus is very typical of eosinophilic esophagitis, which presents with dysphagia and repeated food impactions.

What disease would we suspect in a young patient with a frequent history of dysphagia to solids and liquids with repeated food impactions, without symptoms of heartburn and in whom oral endoscopy shows multiple concentric esophageal rings with normal mucosa (trachealized appearance)?


Anyway, I think that the clinical case is poorly stated, since before doing the CT scan, ACTH should be measured and, once ACTH is suppressed, the CT scan should be done. But since the question is "what would you do to confirm the diagnosis of suspected ACTH independent Cushing's syndrome", the answer is CT.

Anyway, I think that the clinical case is poorly stated, since before doing the CT scan, ACTH should be measured and, once ACTH is suppressed, the CT scan should be done. But since the question is "what would you do to confirm the diagnosis of suspected ACTH independent Cushing's syndrome", [HIDDEN].

In a 42-year-old obese woman, cortisol levels in blood, urine and saliva are determined and in all the determinations they are elevated. After performing the nocturnal suppression test with dexamethasone, cortisol levels in blood remain elevated, so ACTH independent Cushing's syndrome is suspected, what additional test would you request to confirm the diagnosis at this time?

A gammagraphy with labeled somatostatin (Octreoscan).


Patient with suspected meningococcal sepsis. Stabilization with fluids (hypotension) according to ABCDE is essential. Blood culture can be obtained together with the initial blood test. Early initiation of antibiotic therapy (cefotaxime) is essential. However, in an unstable patient such as ours, a lumbar puncture is not indicated.

A 23-month-old boy presenting with fever, hypotension, repeated vomiting, meningeal signs, petechiae, and ecchymosis. The CBC shows 25,000 leukocytes (75% neutrophils, 10% white blood cells) and 12,000 platelets/microL, and the coagulation study shows a prothrombin activity of 35%. Which option is NOT appropriate for management?


Lichen planus is a very common dermatosis of unknown etiology characterized by the appearance of pruritic polygonal papules, with a purplish color and shiny surface, preferentially located in the distal areas of the extremities. Characteristically these papules show a symmetrical distribution and are preferentially located on the anterior aspect of the wrists (Figure 1) and ankles. Oral mucosal involvement is very frequent, and approximately 75% of patients with lichen planus show an asymptomatic whitish reticulation affecting the jugal or lingual mucosa.

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


In young contacts, chemoprophylaxis should be started even if the mantoux test is negative and repeated after 2-3 months to decide whether to continue treatment for 6 months (if it turns positive) or to stop it.

A 14-year-old asymptomatic boy whose father has just been diagnosed with pulmonary TB undergoes a Mantoux test, with a negative result. What is the appropriate course of action?

Start chemoprophylaxis and repeat skin test after 3 months.

A sputum study should be performed before starting chemoprophylaxis with Isoniazid for 1 year.


We are being presented with a case of eosinophilic esophagitis (adolescent male, with heartburn and dysphagia, and a history of atopic dermatitis). Of all the tests proposed to us, the least indicated in this case would be option 3.

We are being presented with a case of eosinophilic esophagitis (adolescent male, with heartburn and dysphagia, and a history of atopic dermatitis). Of all the tests proposed to us, the least indicated in this case would be [HIDDEN].

A 13-year-old boy presents to the pediatrics office with a feeling of heartburn during and after meals and occasional dysphagia, which increases with the ingestion of solid foods such as meat. In the family history, his mother is diagnosed with hiatal hernia. In the personal history she refers to allergy to pollens, mites and latex. Physical examination shows no significant findings except for eczematous lesions in the popliteal and antecubital hollows. Which of the following complementary tests would you NOT perform according to the most probable diagnoses?

Carbon 13 breath test for Helicobacter pylori.