If the ECG shows ischemic changes, we will obviously treat the patient in the emergency room and notify the cardiologist. If not, you will be treated as if it were angina and observed, with serial enzymes and treatment in the observation area.

A 64-year-old man with a history of hypertension and ischemic heart disease comes to the emergency department for oppressive chest pain while watching television. In the ED triage consultation, T. art values of 155/95 mmHg and a capillary O2 saturation of 95% are detected. Which of the following is the most correct course of action?

Instruct her to go to the waiting room. You will be notified for tests.

This patient should be treated in the vital emergency room (shock room).

We will notify the cardiologist on duty to evaluate the patient.

From the Triage consultation, the patient will be referred to the Coronary Unit.

We will do an ECG in less than 10 minutes.


The patient has a PSA >4 and a palpation with increased consistency, which implies the need for a transrectal ultrasound-guided biopsy to diagnose whether it is Benign Prostatic Hyperplasia or Prostate Cancer.

Faced with a 49-year-old man, asymptomatic, with a family history of a father who died of prostate cancer, who in a routine company control is identified a PSA (Prostate Specific Antigen) of 5.9 ng / ml, with a ratio of free PSA / total PSA of 11% and that a rectal examination shows increased consistency in the right prostatic lobe, what is the following clinical indication?

Suggest to the patient the performance of a transrectal ultrasound and prostate biopsy.

Initiate treatment with 5 alpha Reductase Inhibitors to reduce PSA levels by half.

Initiate combined treatment of LHRH analogues and antiandrogens.


Difficult question. The patient presents with thrombotic microangiopathy (TMA) with acute renal failure. This points to HUS, TTP, drug-induced TMA, or TMA mediated by complement, coagulation, or metabolism. Normal ADAMTS-13 levels rule out TTP (incorrect choice 1). The absence of gastrointestinal symptoms rules out typical Shiga toxin HUS (incorrect choice 4). Pneumococcal infections can also cause HUS, although it is rare and more so in adults. The history of respiratory infection (not specified, it could be pneumococcal pneumonia) together with the absence of DIC data (no mention of bleeding or altered coagulation tests) makes me think of atypical HUS (option 2 correct).

Difficult question. The patient presents with thrombotic microangiopathy (TMA) with acute renal failure. This points to HUS, TTP, drug-induced TMA, or TMA mediated by complement, coagulation, or metabolism. Normal ADAMTS-13 levels rule out TTP ([HIDDEN]). The absence of gastrointestinal symptoms rules out typical Shiga toxin HUS ([HIDDEN]). Pneumococcal infections can also cause HUS, although it is rare and more so in adults. The history of respiratory infection (not specified, it could be pneumococcal pneumonia) together with the absence of DIC data (no mention of bleeding or altered coagulation tests) makes me think of atypical HUS ([HIDDEN]).

A 19-year-old male with no past history of interest comes to the emergency department because after a respiratory infection he presents with asthenia, malaise, oliguria and headache. Physical examination: BP 210/120 mmHg, fundus with hypertensive retinopathy grade III. Laboratory tests: Hb 7.4 g/dl, platelets 85,000/mm3, 2-3 schistocytes in the peripheral blood smear, LDH 950 IU/ml, serum creatinine 8.75 mg/dl. Urine system: proteinuria 300 mg/dl, sediment 15 red blood cells per field. ADAMTS-13 levels are normal. Given these findings, what would be your main diagnostic suspicion?


There is a large literature on this subject. It never ceases to amaze us the strange ways of biology and that the axiom "the longest is the right one" is fulfilled in this case.

There is a large literature on this subject. It never ceases to amaze us the strange ways of biology and that the axiom "the longest is [HIDDEN]" is fulfilled in this case.

Faced with sudden-onset obsessive-compulsive disorder (OCD) in a 9-year-old boy who also presents with tics and chorea as neurological manifestations, infection by:


There are doubts regarding the efficacy of calcium or vitamin D administered in monotherapy for the treatment of osteoporosis; they point out that "administered together they seem to have a certain degree of efficacy in the prevention of non-vertebral fractures, which is clearer in people who are deficient in them, as may be the case of elderly people living in residences. There is practically no evidence of their efficacy in the prevention of vertebral fractures.

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

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

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

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

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


The correct answer is: 4. Antihypertensive. In particular, hydrochlorothiazide, as a thiazide, is primarily responsible for this patient's hypokalemia.

The [HIDDEN] Antihypertensive. In particular, hydrochlorothiazide, as a thiazide, is primarily responsible for this patient's hypokalemia.

A 60-year-old woman diagnosed with chronic bronchopathy, diabetes mellitus, hypertension and treated for 4 months with Omeprazole, Metformin, Salbutamol, Ipratropium Bromide and Enalapril 20 mg + Hydrochlorothiazide 25 mg comes to your office for fatigue, decreased appetite, with slight dyspnea and occasional cough, variable stools, sometimes soft and without urinary symptoms. Blood tests show leukocytes 10,000/mm³, Ht 35%, MCV 80, Glucose 150 mg/dl, Urea 80 mg/dl, Creatinine 1.6 mg/dl, Sodium 133 mEq/l and Potassium 2.9 mEq/l. What is the most likely cause of hypokalemia?


In a severe asthma crisis all options are indicated or may be indicated before more aggressive options. In the case of a bad evolution with acidosis etc., the patient would be tributary to invasive medication.

A 55-year-old asthmatic patient comes to the ED with an exacerbation. One hour after administration of supplemental oxygen and two nebulizations of salbutamol the patient does not improve. On examination, he breathes at 42 rpm with supraclavicular pull v with scattered inspiratory and expiratory wheezing. Peak flow has decreased from 310 to 220 L/min. A blood gas drawn with 28% oxygen shows a p02 of 54 mmHg and a pC02 of 35 mm Hg. Which of the following do you think is LEAST indicated?

Administer 80 mg of methylprednisolone iv.

Nebulize ipratropium bromide together with salbutamol every 20 minutes.

Start noninvasive mechanical ventilation.


Question shared with ENT. Amyloidosis is a localized or systemic deposition of fibrillar proteins. It can be primary or secondary. The most frequently affected organs are the kidneys and the heart. Sometimes amyloid deposits appear on the tongue which can produce macroglossia.

If a patient reports having for months now enlargement of the tongue, with no other alterations of the tongue causing constant biting, which disease would you think of the following:


Middle-aged male with iron deficiency anemia and increased number of stools, a colonoscopy should be done to rule out colorectal cancer!!! If the HLA is negative it is very unlikely to be celiac disease (high negative predictive value).

Middle-aged male with iron deficiency anemia and increased number of stools, a colonoscopy should be done to rule out colorectal cancer!!! If the HLA is negative it is [HIDDEN] (high negative predictive value).

A 55-year-old man, father of a celiac child, with iron-deficiency anemia and a recent increase in the stool rhythm, has been tested negative for HLA-DQ2 and HLA-DQ8 alleles. Which diagnostic test is the most appropriate in this case?

Determination of anti-transglutaminase IgA antibodies.


This patient presents Barrett's esophagus with low grade dysplasia. I do not like the question, since not being with acid production inhibition the dysplasia may be conditioned by inflammation and not be real. In any case, Barrett's esophagus should follow endoscopic surveillance and lifelong PPI treatment or antireflux surgery to prevent progression. The correct answer is 4.

This patient presents Barrett's esophagus with low grade dysplasia. I do not like the question, since not being with acid production inhibition the dysplasia may be conditioned by inflammation and not be real. In any case, Barrett's esophagus should follow endoscopic surveillance and lifelong PPI treatment or antireflux surgery to prevent progression. [HIDDEN]

A 66-year-old man reports daily heartburn since youth, which he treats with alkalis. An upper endoscopy shows mild erosive esophagitis and displaced squamous columnar junction approximately 7 cm. The esophageal biopsies showed mild erosive esophagitis and a columnar squamous junction displaced approximately 7 cm from the most proximal portion of the gastric folds. Biopsies of the distal esophagus reveal that the normal squamous epithelium has been replaced by intestinal-type columnar epithelium with low-grade dysplasia What is the most appropriate management option for this patient?

Given that the esophagitis is mild and the dysplasia is low grade, it is advisable to continue treatment with alkalines.

Indefinite treatment with high doses of PPI since it has been demonstrated that this prevents the progression of Barrett's esophagus to adenocarcinoma, making endoscopic surveillance unnecessary.

Periodic surveillance endoscopies and treatment with PPIs for less than 12 weeks, since prolonged treatment is associated with a high risk of gastrinoma development.

Periodic surveillance endoscopies and indefinite treatment with PPI.


Polymyalgia rheumatica. Classic example I suppose, and it is seen in the clinic in droves. Older woman with normocitic anemia and clear ferrokinetic pattern of chronic disorder (hyposideremia but hyperferritinemia). The only one that fits, and it fits perfectly, is number 3; they only needed to give us a high ESR. 1: if it is a recent loss, the MCV could remain normal, but the ferritin should be affected, and certainly not elevated. 2: the same. If it is due to Fe malabsorption, ferritin should be low. And if it were due to B12 malabsorption, the MCV would be clearly higher. 4: 70 tachycardia and normal MCV. This one is too much.

Polymyalgia rheumatica. Classic example I suppose, and it is seen in the clinic in droves. Older woman with normocitic anemia and clear ferrokinetic pattern of chronic disorder (hyposideremia but hyperferritinemia). [HIDDEN] they only needed to give us a high ESR. [HIDDEN] 2: the same. [HIDDEN] And if it were due to B12 malabsorption, the MCV would be clearly higher. [HIDDEN] This one is too much.

The determination in a 70-year-old woman of hematocrit 32%, Hb 9.6 g/dL, MCV 85 fL (70-99), Fe 25 ug/dL (37-145) and ferritin 350 ng/mL (15-150), is more suggestive of:

Recent blood loss through the digestive tract.


It is the male who presents the disease, which we are told is X-linked, so there are only two options left: 2 and 3. 2 is not because the males will receive the Y chromosome from the father and the X from the mother, who is healthy, so the daughters will be able to carry the disease (correct option 3).

It is the male who presents the disease, which we are told is X-linked, so there are only two options left: 2 and 3. 2 is not because the males will receive the Y chromosome from the father and the X from the mother, who is healthy, so the daughters will be able to carry the disease ([HIDDEN]).

A man has a partial deletion in the dystrophin gene (chromosome Xp21) which causes the semiology of Becker muscular dystrophy. He goes to the genetic consultation with his wife, to assess the risks of transmission of the disease. What correct information will be provided in the course of the genetic counseling?

According to autosomal dominant inheritance, half of her children will inherit the disease and without distinction of sexes.

Their daughters will not inherit the disease, but all their future sons will be carriers and can transmit the mutation to 50%.

Their sons will not inherit the disease, but all their future daughters will be carriers and can transmit the mutation to 50%.

There is no risk: the inheritance of the disease is of the mitochondrial type, never transmitted by males.

According to autosomal recessive inheritance, 25% of their children will manifest the disease in childhood, regardless of sex.


It is a study of iron deficiency anemia with normal gastroscopy and colonoscopy, having ruled out possible celiac disease. We have yet to see jejunum and ileum, so we will have to perform a capsule endoscopy. In iron deficiency anemia, a digestive cause must always be ruled out.

A 65-year-old woman with a history of joint pain and under treatment with anti-inflammatory drugs is referred for anemia. In the complementary studies she presented red blood cells 3,164,000, Hto. 32%, Hb 11g/dl, MCV 69 fl, Leukocytes 7800, Platelets 370,000, CRP 0.29 mg/dl, Fe 20ng/ml, Ferritin 18 ng/ml, Glucose 105 mg/dl, GOT, GPT, GGT, Alkaline F, total Bilirubin, Cholesterol, Creatinine, Calcium and Phosphorus normal. Negative antitransglutaminase and antigliadin antibodies. Gastroscopy: hiatus hernia of 3 cm, the rest without alterations. Colonoscopy: up to cecum, isolated diverticula in sigma. Intestinal transit without alterations. Ultrasound of the abdomen without alterations. Which of the following examinations do you consider most appropriate to complete the study?


Amyloidosis presents with proteinuria usually in the nephrotic range, and has a more chronic course. GMN associated with rheumatoid arthritis characteristically alters the sediment, and renal failure due to NSAIDs has a more chronic course, with papillary necrosis. Thus, given the course and the alterations described, interstitial nephritis due to methotrexate is more likely, which is more directly toxic than allergic, hence the absence of pyuria, eosinophilia, fever or other hypersensitivity data.

Amyloidosis presents with proteinuria usually in the nephrotic range, and has a more chronic course. GMN associated with rheumatoid arthritis characteristically alters the sediment, and renal failure due to NSAIDs has a more chronic course, with papillary necrosis. Thus, given the course and the alterations described, interstitial nephritis due to methotrexate is [HIDDEN], which is more directly toxic than allergic, hence the absence of pyuria, eosinophilia, fever or other hypersensitivity data.

In a patient with rheumatoid arthritis on methotrexate, prednisone and indomethacin who acutely presents with edema and increased plasma creatinine with poorly expressive urine sediment and proteinuria less than 100 mg/24 h the most likely cause is:

Glomerulonephritis secondary to rheumatoid arthritis.

Renal failure due to nonsteroidal anti-inflammatory drugs.

Interstitial nephritis due to methotrexate.


A first episode of acute low back pain (less than 6 weeks duration), does not require imaging tests in the absence of "red flags" that may indicate an underlying process, such as a fracture, infection or malignant tumor.

A 45-year-old patient who presents with a first episode of low back pain of 3 weeks' evolution that prevents him from carrying out his normal life. She does not refer trauma or other underlying pathology. In the physical examination there is no neurological deficit. Which imaging test would be indicated?

As this is the first episode of low back pain, only a simple X-ray of the lumbar spine.

MRI, which provides more information on soft tissue and possible herniations.

CT scan, to better assess the bone structure and possible fractures.


The correct answer is 4 because if the patient has bone metastases and may suffer fractures we can control inflammatory pain with ibuprofen and it will also help us to use the antalgic synergy. We should change the treatment to a major opioid and treat the disrruptive pain vigorously since she is at almost the maximum pain she can bear.

[HIDDEN] if the patient has bone metastases and may suffer fractures we can control inflammatory pain with ibuprofen and it will also help us to use the antalgic synergy. We should change the treatment to a major opioid and treat the disrruptive pain vigorously since she is at almost the maximum pain she can bear.

A 45-year-old woman diagnosed with stage IV breast cancer with multiple bone metastases on hormonal treatment and iv bisphosphonates. She comes to your office referring intense bone pain (VAS=7), in several locations without associated neurological symptoms and exarcerbations of pain (VAS=9) several times a day that force her to remain at rest. In the treatment with ibuprofen (600 mg every 8 h) and tramadol (150 mg per day), what treatment would you consider most appropriate in this patient to improve the pain?

Suspend ibuprofen and tramadol and start a major opioid such as morphine or oxycodone.

Suspend tramadol, maintain ibuprofen and initiate a major opioid such as morphine and oxycodone.

Discontinue ibuprofen and tramadol and start a major opioid such as morphine or oxycodone and at the same time start treatment of breakthrough pain with sublingual fentanyl.

Suspend tramadol, maintain ibuprofen and initiate a major opioid such as morphine and oxycodone and at the same time treatment for breakthrough pain with sublingual fentanyl.


1 and 5: These are diagnostic tests, they are meaningless since you have already made the diagnosis. 2: Age should not be a limiting factor, especially considering that it is only 71 years old, but especially because the patient's "quality of life" is good (and I put "quality of life" because it is a term used erroneously, it is supposed to mean that he maintains a good functional level). 3: Presents a very mild respiratory limitation, does not require such a test. 4: Is the correct one.

1 and 5: These are diagnostic tests, they are meaningless since you have already made the diagnosis. 2: Age should not be a limiting factor, especially considering that it is only 71 years old, but especially because the patient's "quality of life" is good (and I put "quality of life" because it is a term used erroneously, it is supposed to mean that he maintains a good functional level). 3: Presents a very mild respiratory limitation, does not require such a test. 4: Is [HIDDEN].

A 71-year-old patient, smoker of 2 packs of cigarettes/day for 50 years, with good quality of life and no other pathologic history of interest, consults for cough and hemoptotic expectoration. Physical examination revealed no significant pathological findings. Chest X-ray showed a mass of 4x3.4 cm lower right, a finding that was confirmed in the thoracoabdominal CT scan, which located the lesion in the lower lobe and found no adenopathy or metastasis. Bronchoscopy showed an infiltrating lesion in the right basal pyramid, biopsied as a well-differentiated squamous cell carcinoma. As for respiratory function tests, the FVC is 3,300 cc (84%) and the FEV 1 is 2,240 cc (80%). What should be the next step to follow in this patient?

Surgical intervention with curative intent should be contraindicated due to the advanced age of the patient.

An oxygen consumption test should be performed, given the respiratory limitation he presents.

Surgical resection (lobectomy of the lower lobe of the right lung) should be indicated directly.

A trantoracic puncture should be performed.


I think the correct answer is 4, although both lesions are resectable, pancreatic adenocarcinoma with synchronous hepatic metastases has no surgical indication because it does not prolong survival and has a high morbidity. Surgical bypass has more complications than placing a self-expanding metallic prosthesis that has a median patency of 6 months which is similar to the median survival of a patient with hepatic metastases of pancreatic adenocarcinoma.

I think [HIDDEN], although both lesions are resectable, pancreatic adenocarcinoma with synchronous hepatic metastases has no surgical indication because it does not prolong survival and has a high morbidity. Surgical bypass has more complications than placing a self-expanding metallic prosthesis that has a median patency of 6 months which is similar to the median survival of a patient with hepatic metastases of pancreatic adenocarcinoma.

A 76-year-old woman with no history other than hypertension consults for painless jaundice and pruritus with anorexia. Laboratory tests show a bilirubin level of 12 mg/dl (with 9.5 direct bilirubin). Abdominal ultrasound shows dilatation of the intrahepatic and extrahepatic biliary tract, together with a single 2 cm nodule located peripherally in the anterior aspect of the left lobe. CT scan confirms the findings, also demonstrating the presence of a 3.5 cm mass in the head of the pancreas. Fine needle aspiration confirms the diagnosis of adenocarcinoma. Indicate the best therapeutic option:

Adjuvant chemo/radiotherapy, conditioning radical surgery to the initial response.

Percutaneous external drainage is palliative, with eventual conversion to internal drainage in case of intolerance or complications.

Surgical biliary bypass, with or without prophylactic gastrojejunostomy depending on intraoperative findings.

Metallic biliary prosthesis by endoscopic retrograde cholangiography, with the option of palliative chemotherapy.

Cephalic duodenopancreatectomy with radiofrequency ablation or alcoholization of the liver lesion.


Perform urgent coronary angiography.

A 72-year-old woman presents to the hospital with oppressive chest pain of 2 hours' duration. Blood pressure is 68/32 mm Hg, heart rate is 124 beats/min, respiratory rate is 32 breaths/min, oxygen saturation is 91% with oxygen at 50%, bilateral crackles on pulmonary auscultation. An ECG shows a subepicardial lesion in the anterior face, with a specular image in the inferior face. Chest X-ray shows bilateral alveolar pattern. What is your therapeutic decision?

Perform fibrinolysis with tenecteplase (TNK).


Question on a fashionable topic in recent years: dyslipidemia; I would answer it by rule out. The treatment for hypercholesterolemia is statins so we rule out answers 2 and 4. The statin in a patient with cardiovascular disease (such as an AMI) is a lifelong treatment (we discard 1) since it is not taken until LDL levels are normalized. Between 3 and 5, 5 is more complete as it includes treatment and control of other risk factors. Ruling out secondary dyslipidemia is easy with the patient's clinical history and a blood test with thyroid function.

Question on a fashionable topic in recent years: dyslipidemia; I would answer it by rule out. The treatment for hypercholesterolemia is statins so we [HIDDEN]. The statin in a patient with cardiovascular disease (such as an AMI) is a lifelong treatment [HIDDEN] since it is not taken until LDL levels are normalized. Between 3 and 5, [HIDDEN] as it includes treatment and control of other risk factors. [HIDDEN] is easy with the patient's clinical history and a blood test with thyroid function.

A 57-year-old patient had an acute myocardial infarction and has a blood test with cholesterol 312 mg/dl, LDL 241 mg/dl, HDL 29 and normal TG. He smoked 30 cig/day, was not obese, his blood pressure was 145/90 mm Hg and he did not have diabetes. When asked about family history, he mentioned that an uncle on his mother's side died suddenly at 53 years of age. Which answer do you agree with the most?

Treat with statins until cholesterol is normalized and recommend healthy lifestyle (diet, exercise and no smoking).

Rule out hypothyroidism or other systemic disease, recommend a healthy lifestyle and treat with fibrates to normalize cholesterol.

It is not necessary to rule out secondary dyslipidemia because it is infrequent. A family lipid profile should be performed.

Rule out secondary dyslipidemia, treat with resins (resincholestyramine) and fibrates and re-commend a healthy lifestyle. Prohibit alcohol.

Rule out secondary dyslipidemia, request a family study and treat with statins to maintain a good lipid profile. Control of other risk factors.


The correct answer is 2. According to the 2014 SEGO Oncoguide on cervical cancer prevention, when a cytology shows a high-grade squamous intraepithelial lesion, the action to be taken is a colposcopy, with or without biopsy depending on the findings (regardless of the patient's age and parity).

The [HIDDEN]. According to the 2014 SEGO Oncoguide on cervical cancer prevention, when a cytology shows a high-grade squamous intraepithelial lesion, the action to be taken is a colposcopy, with or without biopsy depending on the findings (regardless of the patient's age and parity).

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

Hysterectomy with bilateral salpinguectomy and ovarian conservation.


The lesions with sporotrichoid or lymphocutaneous pattern described may correspond to sporotrichosis or aquarium granuloma, so the first two would be ruled out. The history of having been working in the garden points more to a sporotrichosis, although the fact that the question asks for the "causative agent" and not the name of the disease misleads a little, so that if we consider sporotrichosis in reality the answer should be Sporothrix schenckii Despite this, knowing that this question will be correct for many examinees although it is poorly worded -which cancels it directly- the challenge will not be promoted.

The lesions with sporotrichoid or lymphocutaneous pattern described may correspond to sporotrichosis or aquarium granuloma, so the first two would be [HIDDEN]. The history of having been working in the garden points more to a sporotrichosis, although the fact that the question asks for the "causative agent" and not the name of the disease misleads a little, so that if we consider sporotrichosis in reality the answer should be Sporothrix schenckii Despite this, knowing that this question will be [HIDDEN] although it is poorly worded -which cancels it directly- the challenge will not be promoted.

A 58-year-old man referred a 3-week history of progressive, mildly painful skin lesions on his left arm. It had started as an erythematous lesion on his left thumb. He had visible reddish striae as connecting lines between the lesions. The patient had no fever or other general symptoms. He had been working in his garden but did not remember any injuries. The etiologic diagnosis was made by culture of a skin biopsy. What is the most likely causative agent of this process?

Dermatophytosis due to Microsporum gypseum.

Cutaneous infection by Staphylococcus aureus.

Cutaneous infection by Mycobacterium marinum.

DERMATOLOGY, VENEREOLOGY AND PLASTIC SURGERY


One of the mechanisms that produce the hypotensive effect of ACE inhibitors such as perindopril is the increased action of vasodilator prostaglan-dins on the kidney, which decreases hydrosaline retention and therefore increases diuresis and lowers blood pressure. NSAIDs inhibit prostaglandin synthesis and decrease renal perfusion, thus antagonizing the hypotensive effect of many antihypertensives, including ACE inhibitors. Therefore, the preferable thing to do in this patient, before increasing the medication, is to change the ibuprofen for paracetamol, which does not have this effect, and to re-evaluate it later.

An 87-year-old man with a history of hypertension and gonarthrosis. Baseline situation with full functional and cognitive autonomy that allows him to continue living alone in the community. He is receiving regular treatment with perindopril and thiazide diuretic for blood pressure control and routinely takes ibuprofen 1800 mg/day to control the symptoms derived from his gonarthrosis. After routine control, a persistent blood pressure of 190 and TAD 80 mmHg was observed. What would be the most reasonable therapeutic modification to achieve blood pressure control?

I would increase the dose of hydrochlorothiazide to 25 mg/day.

I would change ibuprofen to paracetamol to avoid the possible influence of paracetamol on the effect of hypotensives.

I would add an alpha-blocker because of the high prevalence of prostatic syndrome in males of this age.


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

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

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

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

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

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

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


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

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

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


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

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

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

Partial secondarily generalized symptomatic.


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

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

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

To initiate corticoids for suspicion of minimal change glomerular disease.

Treat with cyclophosphamide for suspected membranous glomerulopathy.

Glucose overload test to rule out diabetic nephropathy.


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

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

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


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

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

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


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

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

Perform a thyroid ultrasound before starting treatment.

Determine free T3 and perform a pituitary MRI.

Treat with L-triiodothyronine and a statin.

Treat with L-Tyroxine and determine antithyroid antibodies.

Perform thyroid cytology prior to treatment.


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

We are talking about a 66-year-old patient with pain on some days, pain of an occasional nature. Although the diagnosis is clearly osteoarthritis, it does not lead directly to a surgical indication. The first step is to try conservative treatment [HIDDEN]. Osteoarthritis is a degenerative process that opioids certainly do not stop, [HIDDEN]. [HIDDEN]: the statement makes the diagnosis and treatment to follow clear: in this case the MRI will not provide us with any information of interest.

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

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

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

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

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


You are describing sarcoidosis.

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


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

The rest of the answers are [HIDDEN]. With a BIRADS 3 this is [HIDDEN] attitude to follow.

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

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

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

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

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


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

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


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

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


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

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

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


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

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

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


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

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

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

Hydropic decompensation secondary to liver cirrhosis.

Chylous ascites due to non-Hodgkin's lymphoma.

Peritoneal metastasis of adenocarcinoma.

Ascites secondary to constrictive pericarditis.


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

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

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

Urgent call to the neurosurgeon for surgical evaluation.

Preferential request for MRI and electromyogram.

Preferential referral to outpatient traumatology consultations.


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

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

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


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

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

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

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

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

Enrolling the patient in terminal palliative care.


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

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

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

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

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

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

Treatment in this case would be transfusion only.


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

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

The alveolar arterial oxygen gradient is elevated.

Initiation of mechanical ventilation should be considered.


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

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

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

Implantation of a ventricular assist device.

Implantation of a cardiac resynchronization system.


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

[HIDDEN] Wiskott-Aldrich syndrome associates immunodeficiency, thrombopenia and atopic dermatitis with the immunological study described in the statement.

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

Transient hypogammaglobulinemia of infancy.

Severe X-associated combined immunodeficiency.


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

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

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


Thoracic stent implantation is indicated.

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

Statin therapy is indicated to stabilize the thrombus.

Urgent diagnostic aortography is necessary.

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


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

[HIDDEN] Vulvar carcinoma is characterized by chronic vulvar itching resistant to multiple treatments, appearance of lumpiness or ulceration, dysuria and urinary urgency, and late pain and bleeding.

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


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

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

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

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

Urgent surgery with sigmoidectomy and colorectal anastomosis.


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

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

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

Request a Doppler ultrasound of temporal arteries.

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

Start treatment with prednisone 10 mg per day.

Request a brain magnetic resonance imaging.


It elevates chorionic gonadotropin.

It elevates chorionic gonadotropin. It has curative treatment.

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


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

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

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

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

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

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

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


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

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

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

Change to ertapenem, considering the possibility of multiresistant microorganisms.

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

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


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

According to ICD-10 the criteria for diagnosing Somatization Disorder (F45.0) are: A. History of multiple physical symptoms, which begins before age 30, persists for several years, and compels seeking medical attention or causes significant impairment socially, occupationally, or in other important areas of the individual's activity. B. All of the following criteria must be met, and each symptom can occur at any time during the disturbance: 1. Four painful symptoms: history of pain related to at least four areas of the body or four functions (e.g., head, abdomen, back, joints, extremities, chest, rectum; during menstruation, sexual intercourse, or urination). Two gastrointestinal symptoms: history of at least two gastrointestinal symptoms other than pain (e.g., nausea, bloating, vomiting [not during pregnancy], diarrhea, or intolerance to different foods). 3. A sexual symptom: history of at least one sexual or reproductive symptom other than pain (e.g., sexual indifference, erectile or ejaculatory dysfunction, irregular menses, excessive menstrual leakage, vomiting during pregnancy). 4. A pseudoneurological symptom: History of at least one symptom or deficit suggestive of a neurological disorder not limited to pain (conversion symptoms of the type of impaired psychomotor coordination or balance, localized muscle paralysis or weakness, difficulty swallowing, lump-in-throat sensation, aphonia, urinary retention, hallucinations, loss of tactile and painful sensation, diplopia, blindness, deafness, seizures; dissociative symptoms such as amnesia; or loss of consciousness other than fainting). C. Either of the following two characteristics: 1. Upon adequate examination, none of the symptoms in Criterion B can be explained by the presence of a known medical illness or by the direct effects of a substance (e.g., drugs or medication). 2. If a medical illness is present, the physical symptoms or social or occupational impairment are excessive compared to what would be expected from the history, physical examination, or laboratory findings. D. The symptoms are not intentionally produced and are not simulated (unlike in factitious disorder and simulation). Everything fits with what is described in the statement. Conversive or dissociative disorder is ruled out because these are usually related to psychological factors, associated with the symptom or deficit (not deliberate). The onset or exacerbation of the condition is preceded by conflicts or other triggers, which is not mentioned in the statement. [HIDDEN] because this implies a preoccupation and fear of having, or the conviction of having, a serious illness based on the personal interpretation of somatic symptoms. But it does not involve physical signs or symptoms.

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


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

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

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

Angiotensin converting enzyme inhibitor.


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

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

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


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

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

Neoadjuvant chemotherapy with combined chemoradiotherapy, followed by surgery.

Neoadjuvant chemotherapy without surgery, followed by radiotherapy.

Surgery followed by combined chemoradiotherapy.

Radiotherapy without chemotherapy, followed by surgery.


The superior wall ruptures very rarely.

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

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

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

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

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