On this occasion, we are asked about which factors have the greatest influence in order to carry out adjuvant chemotherapy in colorectal cancer. In order to do so, we must know which are the poor prognostic factors in this pathology where obstruction or intestinal perforation due to the lesion, invasion of adjacent organs, elevation of tumor markers such as CEA and the histology of the neoplasm stand out. Among these, less importance is given to the size of the lesion than to its degree of invasion of the intestinal wall or other adjacent structures, a criterion that must be taken into account for staging by TNM or Astler-Coller classification, which guide the indication of adjuvant treatment after the surgical approach.

On this occasion, we are asked about which factors have the greatest influence in order to carry out adjuvant chemotherapy in colorectal cancer. In order to do so, we must know which are the poor prognostic factors in this pathology where obstruction or intestinal perforation due to the lesion, invasion of adjacent organs, elevation of tumor markers such as CEA and the histology of the neoplasm stand out. Among these, [HIDDEN] than to its degree of invasion of the intestinal wall or other adjacent structures, a criterion that must be taken into account for staging by TNM or Astler-Coller classification, which guide the indication of adjuvant treatment after the surgical approach.

A 52-year-old man was referred to the gastroenterology department for hematochezia, tenesmus and reduction of stool diameter. A series of tests were performed and a diagnosis of adenocarcinoma of the sigma without distant metastasis was made. The patient underwent surgery and was referred to the medical oncology department for evaluation of complementary chemotherapy treatment. Which of the following is a poor prognostic factor after surgical resection and should be taken into account when planning chemotherapy treatment?

The existence of a family history of colorectal cancer.

The size of the primary lesion and histological differentiation.

Perforation or adhesion of the tumor to adjacent organs.


In a woman with delayed puberty and short stature we should always think about and rule out Turner syndrome, whose diagnosis is made by karyotyping (45X0).

15-year-old female presenting with delayed menarche and short stature. She does not have intellectual disability. Which of the following genetic tests would be routinely used for the diagnosis of this patient:


We are told of a case of a 95-year-old patient with a displaced intracapsular (subcapital) hip fracture. In this case, the surgical options may be the use of cannulated screws or hip arthroplasty. Cannulated screws are reserved for cases of non-displaced fractures (Wrong answer 2) so the most indicated option would be arthroplasty, in this case hemiarthroplasty (Correct answer 1). Trochanteric pins are reserved for extracapsular fractures (Wrong answer 2) and conservative treatment is only considered in patients with very low functional demand or surgical contraindication (Wrong answer 4).

We are told of a case of a 95-year-old patient with a displaced intracapsular (subcapital) hip fracture. In this case, the surgical options may be the use of cannulated screws or hip arthroplasty. Cannulated screws are reserved for cases of non-displaced fractures ([HIDDEN]) so the most indicated option would be arthroplasty, in this case hemiarthroplasty ([HIDDEN]). Trochanteric pins are reserved for extracapsular fractures ([HIDDEN]) and conservative treatment is only considered in patients with very low functional demand or surgical contraindication ([HIDDEN]).

95-year-old woman living in a nursing home, independent for her basic activities of daily living, goes out to the garden for walks. She has a history of hypertension, dyslipidemia, osteoporosis and mild cognitive impairment. She suffers a fall when getting up at night to go to the bathroom. X-ray shows a displaced subcapital fracture of the right hip. What is the recommended treatment?


The patient is suffering from anaphylactic shock secondary to peanut ingestion. The treatment of anaphylaxis and anaphylactic shock of first choice is intramuscular adrenaline 1mg/ml (dose 0.01 mg/kg, in adults 0.5 mg maximum). Followed by symptomatic treatment to stabilize the airway with 100% high flow O2, ensure large caliber venous access, fluid replacement and continuous monitoring (HR, BP, SatO2 , diuresis). As adjuvant treatment, an inhaled bronchodilator such as SABA, intramuscular dexchlorpheniramine or corticosteroids such as hydrocortisone IV or methylprednisolone IV can be administered. Adrenaline can be repeated at the same doses every 5 minutes a maximum of 3 times and if after 15 minutes there is no response, IV adrenaline infusion should be started, Glucagon (if treatment with beta-blockers), Atropine (if prolonged bradycardia) or Vasopressors (if refractory hypotension). The laboratory marker that should be requested if anaphylaxis is suspected is serum tryptase in the first hour for a basal determination and another at 4-6 hours to observe its elevation curve. It is not an emergency marker but it is very useful for future allergological study.

A 25-year-old woman with a history of allergic bronchial asthma due to sensitization to grass pollens and atopic dermatitis. She suddenly presents hypotension, tachycardia, urticaria and bronchospasm after ingesting peanuts and is transferred to the emergency department. What would be the order of drugs to be administered and what laboratory test could be requested for further evaluation?

Intramuscular adrenaline, followed by an inhaled bronchodilator of the SABA type and intramuscular dexchlorpheniramine. Then request serum tryptase.

An inhaled SABA-type bronchodilator, followed by intramuscular dexchlorpheniramine and intramuscular adrenaline. Then order serum tryptase.

Intramuscular dexchlorpheniramine, followed by an inhaled bronchodilator of the SABA type and intramuscular adrenaline. Then request eosinophil cationic protein.

Intramuscular adrenaline, followed by an inhaled bronchodilator of the SABA type and intramuscular dexchlorpheniramine. Then request eosinophil cationic protein.


Although mucus is usually more frightening in the consultation, it falls within the Rome II criteria for the diagnosis of Irritable Bowel Syndrome. All the rest are typical signs of organicity, although I think the question is poorly phrased, since any of these data (especially age) can be found in patients who in the end have nothing, what happens is that in these cases we must always look for organicity.

Which of the following clinical data, recorded during the clinical history taking of a patient with diarrhea of more than 4 weeks of evolution, can be found in people without organic pathology:

Weight loss with or without rectorrhagia.

Persistence of diarrhea during the night.

Presence of dermatitis and/or arthritis during the examination.

Expulsion of mucus in more than 25% of defecations.


On average, if 100 patients like this woman are treated with warfarin, the number of strokes is reduced by 3 (from 5.2 untreated to 3.2 treated). Therefore, if you treat 33.3 patients like this woman with warfarin, you reduce the number of strokes by 1: the NNT is 33.3.

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


The clinical picture is typical of spondyloarthritis, and together with the digestive symptoms it is probably associated with inflammatory bowel disease.

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

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

I would perform a digestive study to rule out tumor pathology. The lumbar pain may be due to visceral pathology.

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

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


The pain is of mechanical characteristics, and the most frequent cause of mechanical back pain in adolescents is mechanical overload. There is no data in the statement to suggest any of the other etiologies.

A 13-year-old boy presents dorsal pain of several months of evolution, only on standing and walking, what diagnosis should we consider?


You are describing a Schönlein-Henoch purpura which is a vasculitic phenomenon, so the lesions are not due to plateletopenia. Scrotal edema (sometimes even torsion of Morgani's capsid of the testis) is not exceptional in males with S. Schönlein-Henoch.

A 4-year-old boy consulted for the appearance over the last three days of skin lesions on the legs and buttocks. His parents reported that his pediatrician had diagnosed an upper respiratory tract infection 10 days earlier. In the last 12 hours she presented intense colicky abdominal pain and had two diarrheal stools. Afebrile. No weight loss. On examination she has numerous petechiae and palpable purpuric lesions predominantly on the buttocks and lower extremities. Good general condition although she has intense abdominal pain. Abdominal palpation is difficult to assess due to diffuse pain. No visceromegaly. No other findings of interest on examination. Which of the following data does NOT support your diagnostic suspicion?


They refer to a concept that has emerged relatively recently and is not present in all clinical guidelines as uncomplicated symptomatic diverticular disease. In these cases, the therapeutic trial with rifaximin is recommended, being the true number 1. The absence of acute phase reactants in the CBC suggests that she does not have acute diverticulitis at the time of consultation that would lead us to request an imaging test to rule it out.

They refer to a concept that has emerged relatively recently and is not present in all clinical guidelines as uncomplicated symptomatic diverticular disease. In these cases, the therapeutic trial with rifaximin is recommended, being [HIDDEN]. The absence of acute phase reactants in the CBC suggests that she does not have acute diverticulitis at the time of consultation that would lead us to request an imaging test to rule it out.

83-year-old male who consults for a recurrent picture of abdominal pain in the left iliac fossa, accompanied by diarrhea of up to 6 stools per day without pathological products, of 10-15 days of evolution. No fever or general condition was reported. A recent blood test showed no leukocytosis and a negative fecal occult blood test. On examination there is mild pain on palpation of the left iliac fossa without peritoneal irritation. He had a colonoscopy three years ago in which diverticula were reported along the entire colon, more numerous in the left colon, with no other associated lesions. Which of the following would be the best approach to follow?

Refer to surgery to evaluate sigmoidectomy.


Discontinue lisinopril and initiate sacubitril/valsartan.

75-year-old woman with a history of heart failure with an ejection fraction of 25% who comes for a check-up, being stable in NYHA functional class III. She has an implanted cardioverter defibrillator. Current medication consists of lisinopril, carvedilol and spironolactone at maximum tolerated doses. On physical examination he has BP 118/74 mmHg, HR 78 bpm. On cardiac auscultation a third tone is detected, pulmonary auscultation is normal and there is no edema. Which of the following is the most appropriate step in his management?

Discontinue lisinopril and start sacubitril/valsartan.

Discontinue carvedilol and start ivabradine.


A question that does not seem to have a second intention, as there are no confusing elements. The statement concisely summarizes the description of pilocytic astrocytoma. The Rosenthal fibers may confuse us as they are not very specific, and make us think, for example, of pleomorphic xanthoastrocytoma in which they can also be found, but the cell morphology described (long and thin cytoplasmic processes, which are the ones that give the name "pilocytic") keeps us the first option as the correct one. We can find a good description of the entity, explaining what distinguishes it from other glial tumors in Practical Surgical Neuropathology. A Diagnostic Approach. A. Perry, D.J. Brat. p82-88. Churchill Livingstone Elsevier. 2010. (Philadephia).

A question that does not seem to have a second intention, as there are no confusing elements. The statement concisely summarizes the description of pilocytic astrocytoma. The Rosenthal fibers may confuse us as they are not very specific, and make us think, for example, of pleomorphic xanthoastrocytoma in which they can also be found, but the cell morphology described (long and thin cytoplasmic processes, which are the ones that give the name "pilocytic") [HIDDEN]. We can find a good description of the entity, explaining what distinguishes it from other glial tumors in Practical Surgical Neuropathology. A Diagnostic Approach. A. Perry, D.J. Brat. p82-88. Churchill Livingstone Elsevier. 2010. (Philadelphia).

A 20-year-old man with ataxia, headaches and solid-cystic mass in the right cerebellar hemisphere underwent surgery and a lesion was resected, histologically showing cells with long thin cytoplasmic processes, fascicular and microcystic pattern, numerous vessels and Rosenthal's fibers. The most probable anatomopathologic diagnosis is:


Correct answer 1. 75% of patients with radiculopathy improve with non-surgical treatment, this being the treatment of choice in the initial stages. Magnetic resonance imaging is of choice in certain "red flags": fever, weight loss, nocturnal pain, persistence of symptoms despite conservative treatment and loss of strength (incorrect answer 3).

[HIDDEN] 75% of patients with radiculopathy improve with non-surgical treatment, this being the treatment of choice in the initial stages. Magnetic resonance imaging is of choice in certain "red flags": fever, weight loss, nocturnal pain, persistence of symptoms despite conservative treatment and loss of strength ([HIDDEN]).

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

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

Urgent call to the neurosurgeon for surgical evaluation.

Preferential request for MRI and electromyogram.

Preferential referral to traumatology outpatients.


The sexual route is not a means of transmission of Trypanosoma cruzi. In our environment, since the transmitting vector is not found, the most important means of transmission is the vertical route from mother to child. The woman was already infected by the parasite when she arrived in Spain, it may be correct to suggest that her siblings have a T. cruzi serology test because of the risk that her mother may have transmitted the infection vertically to all her siblings. Likewise, having had two pregnancies in these years of stay in Spain, it should be suggested that her children also be tested for the probable vertical transmission.

The sexual route is not a means of transmission of Trypanosoma cruzi. In our environment, since the transmitting vector is not found, the most important means of transmission is the vertical route from mother to child. The woman was already infected by the parasite when she arrived in Spain, it may be correct to suggest that her siblings have a T. cruzi serology test because of the risk that her mother may have transmitted the infection vertically to all her siblings. Likewise, having had two pregnancies in these years of stay in Spain, it should be suggested that her children also be tested for the [HIDDEN].

A 35-year-old Bolivian woman, 3 months pregnant, who has been living in Spain for 10 years with her partner, who is Spanish and has never traveled to Latin America. The woman has two other children with her partner, born in Spain, and a brother who lives in Bolivia and another in Spain. During her pregnancy she has been diagnosed with Trypanosoma cruzi infection. Which of the following is WRONG?

Recommend that their children have a T. cruzi serology because of the risk of transplacental transmission.

Inform the patient of the risk of T. cruzi transmission and the attitude to be taken during pregnancy, delivery and postpartum.

Recommend that her husband have T. cruzi serology because of the risk of having sexually transmitted the disease to her.

Recommend that her siblings have T. cruzi serology because of the risk of vectorial transmission.


The patient in the case presents a nephrotic syndrome, so far so good. As for the diet, to reduce edema in these patients, it is recommended that it be low-protein and low-salt, so options 1 and 3 would be true. ACE inhibitors are also administered as primary treatment for nephrotic syndrome, since they decrease urinary protein excretion, as do ARA II and loop diuretics, so options 2 and 5 would also be correct. Therefore, simply by discarding, we are left with option 4 as false, and therefore, the correct answer. Moreover, it should stand out from the beginning as the option to be marked, since precisely one of the causes of nephrotic syndrome is the intake of NSAIDs, so how could they be indicated in the treatment?

The patient in the case presents a nephrotic syndrome, so far so good. As for the diet, to reduce edema in these patients, it is recommended that it be low-protein and low-salt, so options 1 and 3 would be [HIDDEN]. ACE inhibitors are also administered as primary treatment for nephrotic syndrome, since they decrease urinary protein excretion, as do ARA II and loop diuretics, so options 2 and 5 would also be [HIDDEN]. Therefore, simply by discarding, we are left with option 4 as [HIDDEN], and therefore, [HIDDEN]. Moreover, it should stand out from the beginning as the option to be marked, since precisely one of the causes of nephrotic syndrome is the intake of NSAIDs, so how could they be indicated in the treatment?

A 42-year-old man came to consultation for edema. Initial tests showed the presence of proteinuria of more than 10 grams/24 hours. Which of the following measures is NOT indicated in the treatment of this patient?

Administration of angiotensin-converting enzyme inhibitors.


Controversial question, since amiodarone (the dose is correct, 300mg), is administered after the third shock, and not after the first defibrillation, which is what we are told in the statement. Although, be careful, that is what the guidelines say. I am sure that more than one of us has administered amiodarone as soon as we have had venous access available in the event of a shockable rhythm. The other options are incorrect.

Controversial question, since amiodarone (the dose is correct, 300mg), is administered after the third shock, and not after the first defibrillation, which is what we are told in the statement. Although, be careful, that is what the guidelines say. I am sure that more than one of us has administered amiodarone as soon as we have had venous access available in the event of a shockable rhythm. [HIDDEN]

A 22-year-old woman presents with sudden cardiac arrest with a rhythm that is considered amenable to defibrillation. Chest compressions and ventilations are being performed, a defibrillator shock has been delivered, and a peripheral venous line has been cannulated. Which of the following would be correct next:

Administration of 150 mg of intravenous amiodarone.

Administration of 300 mg of intravenous amiodarone.

Administration of 1 mg of intravenous atropine.

Administer 2 mg of intravenous atropine.


in thalassemia the ADE is normal.

With the data we are given, the first thing that comes to mind is that it is an arregenerative anemia, since the bone marrow has not responded with an exaltation of erythropoiesis; in this way we have already eliminated the options that speak of regenerative anemia. The next thing that orients us towards the cause is that it is microcytic and hypochromic, which is characteristic of iron deficiency anemia, since folic deficiency gives rise to megaloblastic anemia and active hemorrhage does not give microcytosis or hypochromia, but normocytosis and normochromia. We are almost inclined to answer 5, central arregenerative anemia due to iron deficiency...but there remains answer 1, "thalassemic trait", which makes us uncomfortable and makes us doubt if we are not going for the apparently easy thing...until we remember that in thalassemia the ADE is normal. Definitely, this girl of childbearing age has iron deficiency anemia, something quite common. Those who have doubts can consult "Hematology. Manual básico razonado" by Jesús San Miguel.

With the data we are given, the first thing that comes to mind is that it is an arregenerative anemia, since the bone marrow has not responded with an exaltation of erythropoiesis; [HIDDEN] The next thing that orients us towards the cause is that it is microcytic and hypochromic, which is characteristic of iron deficiency anemia, since folic deficiency gives rise to megaloblastic anemia and active hemorrhage does not give microcytosis or hypochromia, but normocytosis and normochromia. [HIDDEN] [HIDDEN] "thalassemic trait", which makes us uncomfortable and makes us doubt if we are not going for the apparently easy thing...until we remember that in thalassemia the ADE is normal. Definitely, this girl of childbearing age has iron deficiency anemia, something quite common. Those who have doubts can consult "Hematology. Manual básico razonado" by Jesús San Miguel.

A 35-year-old healthy woman consults for asthenia. The CBC shows microcytic and hypochromic anemia (hemoglobin 7 g/dL, mean corpuscular volume 68 fl, mean corpuscular hemoglobin 24 pg) with an elevated red cell distribution amplitude (ADE 20%), decreased reticulocytes (0.3%, 30000/l absolute), decreased hemoglobin content in reticulocytes (17 pg) and discrete thrombocytosis (500000 platelets). With the CBC data, what would be your diagnostic suspicion even without having the patient's biochemistry?

Central anemia, arregenerative, due to folic acid deficiency.

Peripheral, regenerative, hemolytic anemia.

Peripheral anemia, regenerative, due to acute active hemorrhage.

Central anemia, arregenerative, due to iron deficiency.


Obviously, it is the only answer that encompasses all the causes of sudden loss of consciousness and that allows us to somehow filter the diagnosis.

Obviously, [HIDDEN] and that allows us to somehow filter the diagnosis.

A 47-year-old male patient who consults the emergency department for sudden loss of consciousness Which of the following has a higher diagnostic yield?


The maternal grandmother carried the mutation in one copy of the gene on an X chromosome (we are not told that she had the disease, but a son of hers, Isabel's maternal uncle, did have the disease). Isabel's mother continues to carry it, since one of Isabel's brothers has suffered from the disease but not her father. Thus, Isabel has a 50% chance of having inherited the mutated gene from her mother (as her children are all healthy, we are not sure if she is a carrier), and therefore her daughter has a 25% chance of having inherited the mutated gene from her grandmother.

Elizabeth has three sons and one daughter (Mary), all of whom are healthy. A brother and a maternal uncle of Isabel died of Duchenne disease: an X-linked recessive disease. At present, Maria wants to become pregnant and wants to know the risk of transmitting the disease to her offspring. With the data collected, what is the probability that Maria is a carrier of Duchenne disease?


Endometrial biopsy. Peri- or menopause: - Due to the high prevalence of organic pathology during this period it is necessary to systematically perform endometrial biopsy (Cornier or Hysteroscopy).

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

Hormonal assessment with FSH, LH and estradiol.


The correct answer is 1, since the indications for cardiac surgery include the appearance of heart failure or new conduction disorders, and in this case it presents both.

[HIDDEN] since the indications for cardiac surgery include the appearance of heart failure or new conduction disorders, and in this case it presents both.

A 54-year-old patient is admitted for thermometric fever of 38°C in the previous five days and dyspnea at rest (NYHA lV) that appeared 6 hours before coming to the hospital. Examination in the emergency room was compatible with heart failure and the ECG showed complete atrioventricular block with an escape ventricular rate of 45 bpm. Signs of heart failure are refractory to medical treatment and transesophageal echocardiography shows an aortic valve with an effective regurgitant orifice of 0.5 cm2. Serial cultures are positive for Streptococcus gallolyticus. Indicate the best course of action:

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

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

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

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


Paroxetine; complicated question since both hydrochlorothiazide and lisinopril can also produce falls in the elderly, but they would generally be accompanied by dizziness.

An 88-year-old man comes for consultation because he has fallen 3 times in the last 6 months. None of the falls was accompanied by dizziness or syncope. One fall occurred while he was walking in the garden. His medical history includes hypertension without postural changes in blood pressure, gout, osteoarthritis, and depression. She takes 5 medications regularly. Which of the following is most likely to contribute to falls in this patient?


The 1 should not be because although the clinical picture is suggestive, it does not present lymphocytosis. What points to dengue, in addition to the clinical signs, is the plateletopenia.

In this case I believe that the correct answer is 5. The 1 should not be because although the clinical picture is suggestive, it does not present lymphocytosis. It does not seem to be an allergic exanthema from the clinical picture. And certainly she does not have symptoms or clinical signs compatible with malaria or typhoid fever. What points to dengue, in addition to the clinical signs, is the plateletopenia.

In this case I believe that [HIDDEN]. The 1 should not be [HIDDEN] although the clinical picture is suggestive, it does not present lymphocytosis. It does not seem to be an allergic exanthema from the clinical picture. And certainly she does not have symptoms or clinical signs compatible with malaria or typhoid fever. What points to dengue, in addition to the clinical signs, is the plateletopenia.

A 32-year-old woman has traveled to Cuba from where she arrived three days ago. The day after her return, she goes to her family doctor for high fever, intense arthromyalgia and headache that had started before the return trip and he prescribes her paracetamol. Three days later and with no improvement, he presented in the morning with a generalized pruritic maculo-papular rash, which was more intense on the lower limbs where it developed into petechiae, for which he went to the emergency department. There is no relevant data in the EC except platelets 75000/mm3 (htco 36%, leukocytes 4100 79% neutrophils). What is the most likely diagnosis?


A malignant tumor would also hurt at rest. As for Scheuermann and scoliosis, we should be given some physical data because the patient presents with a specific examination that would give us the diagnosis.

A 13-year-old boy presents dorsal pain of several months of evolution, only when standing and walking, what diagnosis should we consider?


Clinical suspicion of chronic compartment syndrome (CCS). The diagnosis is made by obtaining compartment pressures at rest, during exercise and post-exercise.

A 27-year-old male, a regular athlete, complains of pain in the right leg after continuous running. He has visited a physiotherapist on several occasions and has been diagnosed with an overload in the calf muscles. Several months have passed, he has not improved and refers intense pain after physical activity that subsides with rest in the following hours of exercise. What test can help in the diagnosis?

Positron emission tomography with 18 FDG.

Determination of posterior compartment pressure immediately after activity.

Doppler ultrasound to rule out a circulatory disorder of the lower extremity.


If they are talking about a young man 20-30 years old, with tremor and dystonia, whether or not he has a family history, and especially if one of the options tells me about copper in urine, they are telling me to think of Wilson's disease. I do not think of juvenile Parkinson's, nor an epileptic clinic. So the correct answer is 4.

If they are talking about a young man 20-30 years old, with tremor and dystonia, whether or not he has a family history, and especially if one of the options tells me about copper in urine, they are telling me to think of Wilson's disease. I do not think of juvenile Parkinson's, nor an epileptic clinic. So [HIDDEN].

A 25-year-old man consults for tremor. Examination reveals dysarthria and dystonia. He has a family history of psychiatric illness and movement disorders. Which diagnostic test do you consider most accurate?


We describe a young patient with criteria of nephrotic syndrome with excellent response to corticosteroids. Without biopsy, the clinical presentation and evolution suggest a nephropathy with minimal changes, which usually presents with normal or slightly altered renal function together with nephrotic syndrome, and which in 85-90% of cases resolves with steroid treatment. The age is the only data that is a bit shaky, since although it is the most frequent cause of idiopathic nephrotic syndrome in children and adolescents, it is usually recommended to perform a biopsy prior to treatment in those older than 16 years, in any case it does not admit much discussion.

An 18-year-old patient consulted for edema. A complete blood test showed proteinuria of 8 g/day without microhematuria, hypoalbuminemia and hypercholesterolemia with normal renal function. He was empirically administered corticosteroids. After one month, the clinical picture has completely disappeared. What is your diagnostic hypothesis?


To associate a basal insulin dose to the treatment. Expected question on a very important subject: diabetes and its treatment. Patient poorly controlled with metformin and sitagliptin with discrete cardinal symptoms (weight loss, asthenia). The best option is insulin to control cardinal symptoms and decrease HbA1c to < 7%.

A 62-year-old man with type 2 diabetes mellitus of 10 years of evolution is treated with metformin and sitagliptin. He does little physical exercise and follows an adequate diet. In the last 6 months he has lost weight and has more asthenia. Her glycemic controls have deteriorated from baseline blood glucose levels of 110-140 mg/dL to 170-200 mg/dL, as well as her glycosylated hemoglobin which has gone from 7.1 to 8.5%. The most appropriate therapeutic measure to be taken is:

Increase dietary protein and long-chain carbohydrate intake to improve asthenia and weight loss.

Substitute sitagliptin for pioglitazone.


The picture they describe of intense headache with orthostatism that disappears when lying down, although it is true that the most typical presentation is between the first 24-48 hours and in this case it is somewhat earlier. Even so, the rest of the answers are improbable: the first cannot be because we have not been told what the initial headache was like; the third, although it could be due to the time of onset (as I said a little earlier than expected), the reality is that the headache with orthostasis is so typical that it would be the most probable cause; the last one could not be either because SAH does not follow this pattern in relation to orthostasis.

The picture they describe of intense headache with orthostatism that disappears when lying down, although it is true that the most typical presentation is between the first 24-48 hours and in this case it is somewhat earlier. Even so, the rest of the answers are improbable: the first cannot be because we have not been told what the initial headache was like; the third, although it could be due to the time of onset (as I said a little earlier than expected), [HIDDEN]; [HIDDEN].

A 45-year-old patient under study for possible meningitis, with fever, headache and vomiting of 2 days of evolution. A brain MRI and lumbar puncture were performed. Twenty hours later, on getting up to go to the bathroom, he complains of severe headache, very marked when he sits up but disappears when he lies down. She no longer has fever or vomiting. What is most likely the origin of this headache?

Meningitis remains the fundamental cause of her headache, as it is the same type of headache as at the onset of symptoms.

It is necessary to look for a different cause to this headache, because it is not typical of post-lumbar puncture syndrome or meningitis.

Most likely it was not a viral meningitis, but a subarachnoid hemorrhage. For this reason, the initial headache disappears almost completely when lying down.


The correct answer is 2. We are facing a suspicion of endometriosis, due to the symptoms and signs given in the statement. We are asked for a diagnosis of certainty, and the Gold Standard for the diagnosis of this disease is diagnostic laparoscopy.

[HIDDEN] We are facing a suspicion of endometriosis, due to the symptoms and signs given in the statement. We are asked for a diagnosis of certainty, and the Gold Standard for the diagnosis of this disease is diagnostic laparoscopy.

A 27-year-old woman referred to the gynecology office for evaluation referring dyspareunia for about 8 months, along with dyschezia and occasional rectorrhagia coinciding with menstruation for 3-4 months. She also reports dysmenorrhea for years, which she controls well with ibuprofen. She has been trying to get pregnant for 16 months without success. In the gynecological examination she only shows pain when pressing on the posterior vaginal fornix. Which test do you consider would allow you to reach a diagnosis of certainty of her pathology?


The clinical case makes a textbook description of a medial temporal seizure. The aura of ascending epigastric sensation and olfactory alteration and the subsequent description of the seizure with alteration of the level of consciousness (disconnection from the environment) with oral and manual automatisms. The current classification is the 2017 ILAE classification that would describe this seizure as focal seizure with altered level of consciousness, but in the MIR they still use the old terminology (complex is what altered level of consciousness was called).

A 29-year-old woman with a history of febrile seizures and a heavy smoker. She consults for frequent, stereotyped episodes that begin with an ascending epigastric sensation and an unpleasant odor, followed by disconnection from the environment. Family members who are with her observe that she makes sucking movements and repeated opening and closing movements of the left hand. After two minutes the movements subside, but she has difficulty responding appropriately and only partially remembers what happened. Which of the following is the most likely diagnosis?

Transient ischemic attacks in right carotid territory.


After reading the question and the possible answers, we have two tumor and two non-tumor options. At no time are atypical cellular features mentioned, so we can safely rule out tumor lesions, leaving doubts between answers 2 and 3. In this case, we would have to opt for IMMATURE TERATOMA, mentioning the presence of embryonic remains.

After reading the question and the possible answers, we have two tumor and two non-tumor options. At no time are atypical cellular features mentioned, so [HIDDEN], leaving doubts between answers 2 and 3. In this case, we would have to opt for IMMATURE TERATOMA, mentioning the presence of embryonic remains.

A 20-year-old woman with a 15 cm solid-cystic ovarian tumor detected by ultrasound after presenting with non-specific abdominal symptoms. In the anatomopathological 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:


What are these findings in the Holter? If the sinus node fails, the AV node takes over and stimulates the ventricle. In 10% of people there is retrograde conduction, so that beat generated in the AVN stimulates both ventricles and atria, giving a retrograde P as reported in the study. In this sense, no problem. Likewise, there are also no pauses longer than 3 seconds that could cause cardiogenic syncope (which, in fact, he has never suffered). Option 1 is ruled out: it is not a complete AVB. Option 2 cannot be answered either: to exclude, what is said to exclude... It is like never/always. Option 3 does not make much sense: we could suspend those that impair conduction (beta-blockers, calcium antagonists), but drugs that facilitate, as long as we do not give him a perfusion of atropine to take home... In option 4, stating that he has sinoatrial block is a bit of a rap: without an electrophysiological study it cannot be said, he does not necessarily have SA block, and this alone would not indicate the implantation of a pacemaker. So, finally, I would check option 5.

What are these findings in the Holter? If the sinus node fails, the AV node takes over and stimulates the ventricle. In 10% of people there is retrograde conduction, so that beat generated in the AVN stimulates both ventricles and atria, giving a retrograde P as reported in the study. In this sense, no problem. Likewise, there are also no pauses longer than 3 seconds that could cause cardiogenic syncope (which, in fact, he has never suffered). [HIDDEN]. [HIDDEN]. [HIDDEN]. [HIDDEN]. So, finally, I would check [HIDDEN].

An 82-year-old patient presents with sudden and frequent dizziness, without prodromes, of short duration and which subsides spontaneously, without ever presenting syncope. Physical examination and baseline electrocardiogram are normal. In an ambulatory electrocardiogram recording during 24 hours, short phases of absence of P waves prior to QRS with an escape rhythm of the atrioventricular junction with narrow QRS at 40 bpm and a wave at the beginning of the ST segment corresponding to a retrograde P were detected in the vigil period. No asystole periods longer than 3 seconds are detected. Given this you would say:

The patient has a third-degree AVB and requires pacemaker implantation.

The absence of periods of asystole >3 seconds excludes a cardiac cause of dizziness.

Drug treatment to increase conduction in the AV node would be indicated.

The patient presents sinus dysfunction with sinoatrial block and requires pacemaker implantation due to symptoms.

The alterations detected in the ambulatory electrocardiogram are typical of patients of this age and there is no indication for therapeutic intervention.


In a digital hypokratitis of recent onset in a smoking patient, the first option to rule out is bronchopulmonary carcinoma. Other pathologies can also occur but not so suddenly.

A former smoker patient, previously diagnosed with COPD comes in for a checkup. The physical examination reveals digital hypokratism of recent onset. What is the most acceptable explanation for this finding in the clinical context described?


Urinary hydroxyproline: Urinary hydroxyproline excretion reflects the degradation of bone collagen, but is also influenced by the metabolism of other tissues (cartilage, skin) and by the absorption of products rich in collagen, such as meat or gelatins. Due to its diverse tissue origin and metabolic pattern, it correlates poorly with bone resorption.

In a routine workup of a 59-year-old woman, a smoker of 20 cigarettes/day for 25 years, hypercalcemia of 11.3 mg/dL with a phosphorus of 3.4 mg/dL is detected. It would NOT be efficient at the outset:


We have a case of chronic iron deficiency anemia, without obvious bleeding. The first cause of iron deficiency anemia is occult bleeding of digestive origin. The existence of clinical symptoms suggestive of pathology of the upper digestive tract has led us to begin the study with upper endoscopy, but there is no pathology to justify the anemia, so further investigation is necessary, which rules out answers 1 and 2. Between 3 and 4, large bowel lesions are much more common and should be ruled out before small bowel lesions. In fact the recommendations of capsule endoscopy in anemia studies are restricted.

We have a case of chronic iron deficiency anemia, without obvious bleeding. The first cause of iron deficiency anemia is occult bleeding of digestive origin. The existence of clinical symptoms suggestive of pathology of the upper digestive tract has led us to begin the study with upper endoscopy, but there is no pathology to justify the anemia, so further investigation is necessary, [HIDDEN]. Between 3 and 4, large bowel lesions are much more common and should be ruled out before small bowel lesions. In fact the recommendations of capsule endoscopy in anemia studies are restricted.

A 55-year-old postmenopausal woman consults for asthenia and dyspnea on exertion. In the anamnesis she reported slight epigastralgia and occasional heartburn. No metrorrhagia. Laboratory tests: Hb6 gr/dL, MCV 69 fl, sideremia 13 micrograms/dL, ferritin 4 ngr/mL. Gastrointestinal endoscopy: small sliding hiatal hernia with no signs of esophagitis. What is the most correct approach?

Administer oral iron and monitor the evolution of anemia.

Treat with proton pump inhibitors and evaluate at three months.


You present with coxarthrosis (no further imaging tests are needed), and conservative options are exhausted before opting for surgical treatment. Weak opioids are not the initial treatment of choice.

You assess a 66-year-old patient with accentuated groin pain with 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 attitude?

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 of halting disease progression.

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

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


This is spontaneous bacterial peritonitis (SBP), defined by the presence of > 250 polymorphonuclears/mL in the ascitic fluid (in this case there are 1,380, which is 60% of 2,300). It is an indication to start 3rd generation cephalosporins (ceftriaxone or cefotaxime) and albumin. The rest are treatments that can wait for improvement (they do not speak of tension ascites).

A 67-year-old man, diagnosed with cirrhosis of the liver and an active drinker, is admitted for progressive abdominal distension with diffuse malaise, of two weeks of evolution. He reported no fever or other symptoms. On examination, there was a changeable dullness on abdominal percussion, with absence of edema. A diagnostic paracentesis is performed, finding a slightly cloudy fluid, with 2,300 cells/mL, of which 30% are lymphocytes, 60% polymorphonuclear and 10% red blood cells. What is the first therapeutic measure you would prescribe for this patient immediately?

Diuretic treatment with oral spironolactone.

Treatment with a third generation cephalosporin.


We are asked about the management of a very common pathology, diverticulitis. And we are asked about the different therapeutic options depending on how advanced it is. The correct answer is 1, it does not meet the criteria to require drainage by guided puncture (the abscess is not larger than 5-6 cm). Discharge colostomy in this case makes no sense whatsoever, since it is not a question of solving an obstructive condition. Drainage by laparoscopic surgery is not indicated in this case. It could be indicated in the absence of the possibility of percutaneous drainage after failure of conservative treatment, although it is a very controversial option at this time. Sigmoidectomy and anastomosis is also not required. In a high number of cases, after the resolution of the symptoms, the outbreaks are reduced and they can be prevented with diet and hygienic dietary habits.

We are asked about the management of a very common pathology, diverticulitis. And we are asked about the different therapeutic options depending on how advanced it is. [HIDDEN], it does not meet the criteria to require drainage by guided puncture (the abscess is not larger than 5-6 cm). Discharge colostomy in this case makes no sense whatsoever, since it is not a question of solving an obstructive condition. Drainage by laparoscopic surgery is not indicated in this case. It could be indicated in the absence of the possibility of percutaneous drainage after failure of conservative treatment, although it is a very controversial option at this time. Sigmoidectomy and anastomosis is also not required. In a high number of cases, after the resolution of the symptoms, the outbreaks are reduced and they can be prevented with diet and hygienic dietary habits.

An 80-year-old woman comes to the emergency room with abdominal pain starting in the epigastrium and radiating later to the left iliac fossa. An abdominal CT scan is performed, showing inflammation in the walls of the sigma and mesenteric abscess of 2 cm. 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 diagnosis is based on clinical criteria, so muscle biopsy is only performed to rule out other diseases, not to confirm this one. An iron profile, thyroid hormone and vitamin determinations should be performed to rule out other diseases with similar symptomatology. Treatment is symptomatic and is instituted when it interferes with sleep or quality of life, and the first choice treatment is dopamine agonists such as pramipexole and ropirinol.

A 75-year-old woman consults for insomnia. She reports that for years she has been waking up at night with a tingling, burning sensation in the legs and sometimes in the arms; these symptoms also occur in the afternoon. She notices improvement when moving her legs, but the symptoms recur during rest, so she cannot fall asleep again. This picture could lead us to the diagnosis of restless legs syndrome Which of the following is FALSE?

The diagnosis of this affectation is based on clinical criteria.

A basic blood test including iron profile, thyroid hormones and B 12 and folic acid should be performed.

The treatment would be indicated in patients who present alteration of sleep or quality of life but does not alter the course of the disease.

The diagnosis is confirmed by muscle biopsy.

Pramipexole and ropirinol are used in the treatment.


A new approach is currently being developed for the treatment of these patients, which tries to coordinate from the beginning the activity of the different sectors involved, avoiding that the transfer of the patient from one to another takes place at the end of the treatment of each part. This idea gave rise to the so-called orthogeriatric units", which combine the surgeon's surgical activity with that of the patient's immediate rehabilitation and the controls and follow-up of internal medicine. From the very beginning of the process, the social workers and the various vital and support aids are put in place to ensure that recovery is as rapid and complete as possible. ... In most cases, surgery should be performed as soon as possible, as soon as the patient is medically stabilized. There is a contraindication to surgery in patients with unstable medical comorbidity, but several studies have shown that delaying surgery beyond 48 h after admission increases mortality. This is why the ideal time to intervene in these patients is after achieving stabilization of their medical pathologies, taking care that this takes place before 48 h have elapsed." There is no data to suggest that he has any unstable comorbidity at the present time, so surgery in less than 48 hours and orthogeriatric management is of interest.

93-year-old woman with a history of COPD, AHT, dyslipidemia, atrial fibrillation and ischemic heart disease. She lives alone. She has ventricular ejection fraction 53%, creatinine 1.5 mg/dL, normal coagulation. She receives treatment with inhaled bronchodilators and ASA 100 mg per day. She suffers a fall in the street, after which it is impossible for her to stand or sit up, with intense pain in the right hip on mobilization, great shortening and external rotation of the leg. When and how should she be treated?

Admission for transthoracic ultrasound, assessment by Cardiology and then closed reduction and fixation with plate screw.

Admission for evaluation by Nephrology and Cardiology, and then Traumatology will decide whether to use an arthroplasty or a trochanteric nail.

Admission to Internal Medicine / Geriatrics, progressive stabilization of comorbidities, conservative orthopedic treatment.

Closed reduction and fixation of the fracture within 48 hours, very early sedation, orthogeriatric management.


The characterization of cognitive deterioration processes is still clinical, with imaging tests (MRI or PET) being a support tool in some occasions. The first option would be the correct one because it allows us to measure in a standardized way each of the cognitive domains, which will allow us to frame the patient's deficits in a specific syndrome and to monitor the deterioration with repeated scans over time.

The characterization of cognitive deterioration processes is still clinical, with imaging tests (MRI or PET) being a support tool in some occasions. The first option would be [HIDDEN] because it allows us to measure in a standardized way each of the cognitive domains, which will allow us to frame the patient's deficits in a specific syndrome and to monitor the deterioration with repeated scans over time.

A 72-year-old patient presents with progressive memory loss and word finding difficulty of one year's duration. What is the most useful examination to characterize the type of cognitive deficit he presents with?


He describes S1 root involvement by the inability to tiptoe and the absence of the Achilles reflex, in addition to the distribution of pain down the leg. Of our options, the cause that can produce damage to S1 is L5-S1 disc herniation.

He describes S1 root involvement by the inability to tiptoe and the absence of the Achilles reflex, in addition to the distribution of pain down the leg. Of our options, the cause that can produce damage to S1 is [HIDDEN].

A 53-year-old man with no history of interest who after a bad movement in the gym notices low back pain that after a few hours radiates to the back of the right leg and reaches the lateral edge of the foot. On examination he presents positive Lasègue maneuver at 40o, abolished hamstring reflex and he cannot stand on tiptoe. The most probable etiological diagnosis is:


The correct answer is: 3. IgA nephropathy. Given that the clinical presentation of this nephropathy appears in a very unspecific way, to identify the responsible disease we must rely on its epidemiology. Since he is a young male, with a history of previous respiratory infections, a relationship between these infections and renal pathology is established. Based on this we think about IgA nephropathy, which besides being the most frequent glomerulonephritis, it is presented in most of the cases as described.

The [HIDDEN] IgA nephropathy. Given that the clinical presentation of this nephropathy appears in a very unspecific way, to identify the responsible disease we must rely on its epidemiology. Since he is a young male, with a history of previous respiratory infections, a relationship between these infections and renal pathology is established. Based on this we think about IgA nephropathy, which besides being the most frequent glomerulonephritis, it is presented in most of the cases as described.

A 35-year-old man presenting hematuria after respiratory infections for several years, a blood test shows creatinine 1 mg/dl with no other alterations and urine hematocytes 50/field being 80% dysmorphic, with proteinuria of 0.8 grams in 24 hours. What is the most likely diagnosis?

Proliferative and diffuse glomerulonephritis.

Focal and primary segmental glomerulosclerosis.


In principle, this is an easy question, as it deals with a disease that is frequently repeated in the MIR exams. The description is typical of option 2. It is an exudative AMD (although as we said in question 215, with the new classification, we would speak of an advanced AMD in its neovascular variant). In any case, we have an elderly patient with vision loss and metamorphopsia in one eye. In the examination there are lesions in the macula. With that we can rule out acute posterior vitreous detachment, which does not produce visual loss, nor metamorphopsia, nor lesions in the macula. And also non-arteritic anterior ischemic optic neuropathy, because although it produces visual loss and is typical of older people, it does not produce metamorphopsia. And there are no lesions in the macula but papilla edema. In central retinal artery obstruction, metamorphopsia is not particularly characteristic (visual loss and advanced age are), but the lesions in the fundus of the eye vary. In the case of arterial occlusion, there is intracellular edema that is seen as absence of hemorrhages and a whitish, pale fundus. In addition, the entire retina is globally affected, and a cherry-red spot may appear in the macula. In this case the lesions are totally different. They describe hard exudates, deep hemorrhages and localized neurosensory retinal detachment. All this in the macula. These are the characteristic findings of neovascular (or exudative) AMD. As a clue, in the other eye there are abundant soft drusen. Drusen are the typical findings of AMD. So he has AMD in both eyes and in the right eye it has recently become complicated by the appearance of neovascularization.

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

Exudative age-related macular degeneration (AMD).

Non-arteritic anterior ischemic optic neuropathy.


Another gift of a question, the association of S.bovis endocarditis and colon cancer. By the way, it is funny that they give Chest Rx as a test to be performed..... are you telling me that a patient with fever and dyspnea will have an echocardiogram before a simple chest x-ray? And on the other hand... why don't those who write the MIR ask shorter questions without so much back and forth? If what they want is to ask the test to be performed on a patient with S. bovis endocarditis, they could ask the question directly without telling us about the patient's moles...

Another gift of a question, the association of S.bovis endocarditis and colon cancer. By the way, it is funny that they give Chest Rx as a test to be performed..... are you telling me that a patient with fever and dysphea will have an echocardiogram before a simple chest x-ray? And on the other hand... why don't those who write the MIR ask shorter questions without so much back and forth? If what they want is to ask the test to be performed on a patient with S. bovis endocarditis, they could ask the question directly without telling us about the patient's moles...

A 68-year-old man is evaluated for fever, weight loss and dyspnea on exertion. The EP reveals a new aortic diastolic murmur and stigmata of peripheral embolisms. Echocardiography showed a 1 cm vegetation on the aortic valve and two blood cultures isolated penicillin-sensitive Streptococcus bovis. After starting treatment for endocarditis, which of the following examinations could help us in the diagnosis?


Very nice clinical question from MEN. Pancreatic neuroendocrine tumor + pituitary adenoma (prolactinoma) + hyperparathyroidism (renoureteral colic in young people): MEN 1. Medium difficulty because you have to know the MEN triad and recognize the different tumors.

Very nice clinical question from MEN. Pancreatic neuroendocrine tumor + pituitary adenoma (prolactinoma) + hyperparathyroidism (renoureteral colic in young people): [HIDDEN]. Medium difficulty because you have to know the MEN triad and recognize the different tumors.

A 45-year-old woman comes to the clinic referred from surgery with the diagnosis of a neuroendocrine tumor diagnosed after partial pancreatectomy for a 2-cm tumor in the tail of the pancreas. The tumor had been detected by chance in an abdominal CT scan requested to complete the study of a simple hepatic cyst. On questioning the patient, the history of irregular menstruation, amenorrhea for the last 6 months, and repeated renal colic since she was 20 years old, for which she has required lithotripsy on several occasions, stand out. She also has a family history of renoureteral colic. What is her suspected diagnosis?

Multiple endocrine neoplasia type 1 or Wermer's syndrome.

Multiple endocrine neoplasia type 2 A or Sipple's syndrome.


Answer 1 is incorrect because the imaging tests of choice would be ultrasound or CT; answer 3 is incorrect because the laparoscopic approach is indicated from the start; answer 4 is incorrect because the indication in the first episode is for those under 50 years of age, in the rest it is indicated after the second episode or in cases of persistent symptoms or suspected neoplasia; and answer 5 is incorrect because surgery in cases of perforation with peritonitis should always resect the affected segment of colon to control the focus of the infection.

Answer 1 is [HIDDEN] because the imaging tests of choice would be ultrasound or CT; answer 3 is [HIDDEN] because the laparoscopic approach is indicated from the start; answer 4 is [HIDDEN] because the indication in the first episode is for those under 50 years of age, in the rest it is indicated after the second episode or in cases of persistent symptoms or suspected neoplasia; and answer 5 is [HIDDEN] because surgery in cases of perforation with peritonitis should always resect the affected segment of colon to control the focus of the infection.

A 78-year-old woman comes to the emergency department for left iliac fossa pain of 24 hours of evolution associated with fever and occasional vomiting. On examination, there is selective pain on palpation in the left iliac fossa with a feeling of occupation, defense and positive decompression. When acute diverticulitis is suspected, which of the following statements is correct?

The safest and best performing complementary examination is the barium contrast enema.

In case of contained pelvic abscess, percutaneous drainage guided by CT or ultrasound is indicated.

If surgical intervention is required after resolution of the acute episode, the laparoscopic approach is contraindicated.

In case of acute uncomplicated diverticulitis, elective sigmoidectomy is indicated after cure of the first acute episode.

If generalized peritonitis occurs, the most appropriate surgical technique is the practice of a derivative colostomy without resection of the affected sigmoid segment.


The correct answer is: 2. Abdomino-pelvic ultrasound. Abdomino-pelvic ultrasound is undoubtedly the most specific and sensitive test for the diagnosis of polycystic kidney disease and, above all, the cheapest to demonstrate whether or not the patient's sibling has inherited polycystic kidney disease.

The correct answer is: [HIDDEN] Abdomino-pelvic ultrasound is undoubtedly the most specific and sensitive test for the diagnosis of polycystic kidney disease and, above all, the cheapest to demonstrate whether or not the patient's sibling has inherited polycystic kidney disease.

A 52-year-old patient with stage V chronic kidney disease, secondary to autosomal dominant polycystic kidney disease, receives a cadaver donor kidney graft. A 34-year-old brother of his comes to visit him and says he does not know if he has the disease because he has never seen a doctor since he was a teenager. What attitude or test do you think is the most appropriate to recommend at that moment?

Helical computed axial tomography with iodinated contrast.


The best answer to this question is number 5. Most of the lesions identified as L-SIL are associated with HPV infection: for this reason, it is advisable to stop smoking, as this is a factor in the progression of the said infection. On the other hand, according to the latest studies, 70% of the cytologies reported as LSIL will remit, 15% will persist and another 15% will show a more severe cytology, without being able to differentiate whether it is a biological progression or a lesion hidden in the initial cytology. Because of this, it is best to return for a follow-up at 6 months. Given the woman's personal history (more than 5 sexual partners and repeat infections) and her age, a referral for colposcopy would be ideal. However, answer 5 says control in 6 months, but does not specify which control (it could be a colposcopy or cytology).

[HIDDEN]. Most of the lesions identified as L-SIL are associated with HPV infection: for this reason, it is advisable to stop smoking, as this is a factor in the progression of the said infection. On the other hand, according to the latest studies, 70% of the cytologies reported as LSIL will remit, 15% will persist and another 15% will show a more severe cytology, without being able to differentiate whether it is a biological progression or a lesion hidden in the initial cytology. Because of this, it is best to return for a follow-up at 6 months. Given the woman's personal history (more than 5 sexual partners and repeat infections) and her age, a referral for colposcopy would be ideal. However, [HIDDEN].

A 43-year-old woman referred to the Hospital's Lower Genital Tract Pathology Clinic for presenting with a cervico-vaginal cytology reported as "L-SIL" (Low Grade Intraepithelial Lesion). She refers repeated vaginal infections (Trichomoniasis,...) and having had more than 5 sexual partners in her life. The best care strategy for this woman is:

Endocervical curettage with Kevorkian curettage.

Endometrial biopsy with Cornier cannula.

Advise her to stop smoking and contraceptives and to have a control in 6 months.


The endometrium is thickened for a menopausal woman (some guidelines put the limit at 5 and others at 3mm). And the first complementary test to perform would be an endometrial biopsy. If this is not decisive, hysteroscopy will be considered as a second option.

The endometrium is thickened for a menopausal woman (some guidelines put the limit at 5 and others at 3mm). And the first complementary test to perform would be an [HIDDEN]. If this is not decisive, hysteroscopy will be considered as a second option.

A 51-year-old woman, menopausal for a year and a half, who consults for vaginal spotting of 2 weeks' evolution. She reports that the spotting is less than a menstrual period. The ultrasound shows a 7 mm endometrium. Mark the correct option:

The endometrium is thickened and in view of the patient's symptoms, an endometrial biopsy is taken with a Cornier cannula.

The endometrium is not thickened so she is prescribed tranexamic acid and ambulatory follow-up.

Indications for diagnostic hysteroscopy without the need for endometrial biopsy.

The endometrium is not thickened, but since she has clinical signs of metrorrhagia, an endometrial biopsy is indicated.


Reading the case, we are discarding options: child with otalgia, but without fever or acute inflammatory signs: it is neither 1 (recurrent acute otitis media) nor 5 (mastoiditis). On otoscopy, a pinkish and amber eardrum is observed: there are no scales, so it is not 4 (cholesteatomatous chronic otitis media); nor perforations or adhesions, so it is not 3 (simple chronic otitis media). Otoscopy is characteristic of serous otitis media (answer 2 correct). It is known by ENT, pediatricians and family physicians that in the month following an acute otitis media, the middle ear is occupied by a mucous content whose evolution should be monitored. I do not think that this is a contestable issue either.

Reading the case, we are discarding options: child with otalgia, but without fever or acute inflammatory signs: it is neither 1 (recurrent acute otitis media) nor 5 (mastoiditis). On otoscopy, a pinkish and amber eardrum is observed: there are no scales, so it is not 4 (cholesteatomatous chronic otitis media); nor perforations or adhesions, so it is not 3 (simple chronic otitis media). Otoscopy is characteristic of serous otitis media ([HIDDEN]). It is known by ENT, pediatricians and family physicians that in the month following an acute otitis media, the middle ear is occupied by a mucous content whose evolution should be monitored. I do not think that this is a contestable issue either.

A child who comes to the outpatient clinic because he brings his hand to his ear, without fever or acute inflammatory signs and who on examination shows a pinkish/amber eardrum. As history he refers that one month ago he presented an episode of otalgia, fever accompanied by irritability and that he was treated with amoxicillin 40 mg/kg/day. What is the most probable diagnosis?

OTORHINOLARYNGOLOGY AND MAXILLOFACIAL SURGERY


Pretty easy, isn't it? Lung cancer is the most frequent cause of brain metastases and in 20-30% of cases it is as a result of them that the primary tumor is diagnosed (as here).

A 60-year-old man comes to the emergency department for a coma crisis. Ex-smoker for 3 years, with no other history of interest. A CT scan shows multiple metastases. What is the most probable origin?


We are faced with an anaphylactic reaction to metamizole, in which it is necessary to act quickly or the patient could progress to cardiac arrest. It is important to assess the severity of the allergic reactions, since, in this case, early treatment is essential to prevent high mortality if not applied. The treatment of choice is IM adrenaline (only switch to IV if anaphylaxis is refractory), which has been shown to increase survival, and administration can be repeated every 5-15 minutes if symptoms do not subside. As adjuvant treatment, dexchlorpheniramine could be administered. In this particular case, since the patient was previously treated with propranolol, this indicates that the correct answer is 4, which includes the administration of glucagon, which is administered because patients taking beta-blockers can be resistant to treatment with adrenaline and develop refractory hypotension and prolonged bradycardia. The dose in adults is 1 to 2mg, IV or IM, which can be repeated in 5 minutes or followed by an infusion at 5-15mcg/min.

We are faced with an anaphylactic reaction to metamizole, in which it is necessary to act quickly or the patient could progress to cardiac arrest. It is important to assess the severity of the allergic reactions, since, in this case, early treatment is essential to prevent high mortality if not applied. The treatment of choice is IM adrenaline (only switch to IV if anaphylaxis is refractory), which has been shown to increase survival, and administration can be repeated every 5-15 minutes if symptoms do not subside. As adjuvant treatment, dexchlorpheniramine could be administered. In this particular case, since the patient was previously treated with propranolol, this indicates that [HIDDEN], which includes the administration of glucagon, which is administered because patients taking beta-blockers can be resistant to treatment with adrenaline and develop refractory hypotension and prolonged bradycardia. The dose in adults is 1 to 2mg, IV or IM, which can be repeated in 5 minutes or followed by an infusion at 5-15mcg/min.

A 24-year-old woman with a history of migraine, on propranolol and oral contraceptives, presents with severe dyspnea, hoarseness, rash, nausea and vomiting 30 minutes after taking metamizole. His blood pressure is 90/40 mmHg and SatO2 is 90%. The most correct initial treatment would be to administer:

Adrenaline, dexchlorpheniramine and methylprednisolone.

Adrenaline, dexchlorpheniramine and glucagon.


The case is a TIA (transient ischemic attack). The basic etiological study includes echodoppler of supra-aortic trunks +/- cerebral arteries, echocardiogram and directed blood analysis.

61-year-old male, smoker and hypertensive, who comes to the emergency department for sudden loss of strength and tingling sensation in the right hand lasting about 15 minutes, with almost complete recovery afterwards. ECG: sinus rhythm at 93 bpm. In relation to the most probable diagnosis, indicate the FALSE answer:

A probable cause is an arterioarterial embolism due to detachment of a carotid plaque.

Doppler ultrasound of supra-aortic trunks is not very useful for diagnosis.

A cranial CT scan is necessary to assess the impact on the brain parenchyma.

Surgical treatment is indicated if imaging tests reveal carotid stenosis >70%.


Anisakis simplex is a parasite frequently found in fish. To avoid reactions with this parasite, a diet free of fresh and raw fish (anchovies in vinegar, smoked, salted fish, sushi, etc.) should be followed. Deep-frozen fish or fresh fish previously frozen at -20ºC for at least 5 days before cooking can be consumed, as long as it is cooked at high temperatures >60ºC (roasted, fried, etc.), avoiding raw, grilled or microwaved preparations. It is recommended to consume preferably the tails because the larvae of the parasite are usually close to the viscera of the head.

A 35-year-old patient consults to confirm a suspected allergy to Anisakis simplex. She has previously suffered a clinical picture of gastrointestinal anisakiasis after eating fish. The tests performed show specific IgE levels of 10 KU/l against Anisakis simplex. Which of the following would be the dietary recommendation for this patient?

He cannot eat any fish, crustaceans, mollusks or cephalopods.

He can eat fresh fish cooked on the grill.

You can eat fresh marinated or cold smoked fish.


In this question, they insist on the age and comorbidity of the patient, as well as the time of evolution, so the answer will probably not be 1.  In any case, the ideal would be to drain the gallbladder that has not gone up again, so the answer I would give would be 2.

In this question, they insist on the age and comorbidity of the patient, as well as the time of evolution, so [HIDDEN].  In any case, the ideal would be to drain the gallbladder that has not gone up again, so [HIDDEN].

An 87-year-old patient with a history of chronic bronchitis and heart failure has been diagnosed with acute calculous cholecystitis. After 4 days of hospitalization and treatment with absolute diet, piperacillin-tazobactam serum therapy, the patient continues with fever, persistent abdominal pain and leukocytosis. The most appropriate attitude at this time would be:

Biliary drainage by percutaneous cholecystostomy.

Replace piperacillin-tazobactam with metronidazole-cefotaxime.

Replace piperacillin-tazobactam with amikacin-clindamycin.

Add an aminoglycoside such as gentamicin to the treatment.


The correct answer is the first one. It is a typical picture of infectious mononucleosis. Although a similar picture may occur in acute toxoplasmosis, less than 1% of acute toxoplasma infections present as mononucleosis. Characteristic of Epstein-Barr infectious mononucleosis is the appearance of macular rash after treatment with amoxicillin.

[HIDDEN] Although a similar picture may occur in acute toxoplasmosis, less than 1% of acute toxoplasma infections present as mononucleosis. Characteristic of Epstein-Barr infectious mononucleosis is the appearance of macular rash after treatment with amoxicillin.

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


The correct answer is to initiate treatment with L-dopa, since the clinical picture described is of a parkinsonism whose diagnosis is exclusively clinical. The rest of the answers can be made for differential diagnosis, but the performance of complementary tests does not justify delaying the initiation of treatment.

The [HIDDEN] is to initiate treatment with L-dopa, since the clinical picture described is of a parkinsonism whose diagnosis is exclusively clinical. The rest of the answers can be made for differential diagnosis, but the performance of complementary tests does not justify delaying the initiation of treatment.

An 85-year-old woman consults for fatigue and weakness especially in the mornings. She is sometimes unsteady when walking and has to sit down to regain her balance. On two occasions she has had to sit down to keep from falling but denies symptoms of dizziness. She has arterial hypertension, urinary incontinence and osteoarthritis. Her treatment is hydrochlorothiazide (25 mg/d), oxybutynin (10 mg/d), lisinopril (10 mg/d), calcium (1500 mg/d) and paracetamol (3 g/d). On examination he has a blood pressure of 115/70 mm Hg, pulse 80 bpm. His movements are slow. He has a moderate hand tremor. She can get up from the chair slowly but without needing to lean on her arms. She walks slightly leaning forward with little swinging of the arms. Turns slowly but without losing balance. She is unable to stand on one foot. Which of the following possible actions would you perform first?

Measure blood pressure lying down and standing up.


Mature cystic teratoma (common in the ovary of the adult female). Mass with a large cyst occupying most of it; in its cavity there is sebaceous material and hairs. The wall, generally a few millimeters thick, has the structure of skin, with its epidermal surface towards the cavity. Because of this preponderant development of cutaneous structures it is usually called dermoid cyst. The tissues that compose the tumor are well differentiated (mature or adult type); apart from skin structures many other tissues can be observed, particularly in a thickening or spur that eminences into the cavity, in which there are often teeth, cartilage and bone.

20-year-old woman with ovarian tumor of 15 cm, solid-cystic, detected by ultrasound after presenting with unspecific 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:


The most frequent cause of catheter infection is a bacterium that colonizes the skin. The Gram stain tells us that it is a staphylococcus, most of the species of this genus acquired in-hospital are methicillin resistant, so they are considered resistant to Cloxacillin, Cefazolin and there are no clinical data about the efficacy of linezolid for the treatment of systemic infection related to catheter. This, plus the experience with vancomycin use in this setting is considered the empirical choice for vancomycin.

The most frequent cause of catheter infection is a bacterium that colonizes the skin. The Gram stain tells us that it is a staphylococcus, most of the species of this genus acquired in-hospital are methicillin resistant, so they are considered resistant to Cloxacillin, Cefazolin and there are no clinical data about the efficacy of linezolid for the treatment of systemic infection related to catheter. This, plus the experience with vancomycin use in this setting is considered [HIDDEN].

An 85-year-old man with a peripheral venous catheter who, one week after being hospitalized for a stroke, begins with shivering and fever. Blood cultures are performed and microbiology reports that gram-positive cocci are growing in clusters. Pending the antibiogram, what is the most appropriate antibiotic treatment?


Of the proposed drugs, the least likely options would be 3, since metformin very rarely causes lingual angioedema (in March 2020 there was only one case described worldwide) and 4, since, among the adverse reactions of levodopa, angioedema is classified among the very rare ones (frequency less than 0.1%). Of the two remaining options, the drugs most frequently and classically associated with lingual angioedema are ACE inhibitors (frequency around 0.2%), and their association with simvastatin is also less than 0.1%.

Of the proposed drugs, [HIDDEN] since metformin very rarely causes lingual angioedema (in March 2020 there was only one case described worldwide) and [HIDDEN], since, among the adverse reactions of levodopa, angioedema is classified among the very rare ones (frequency less than 0.1%). Of the two remaining options, the drugs most frequently and classically associated with lingual angioedema are ACE inhibitors (frequency around 0.2%), and their association with simvastatin is also less than 0.1%.

A 72-year-old patient presents to the emergency department with severe lingual angioedema. She has no associated urticaria and no history of drug or food allergy. His personal history includes type 2 diabetes mellitus, dyslipidemia, hypertension, hypothyroidism and Parkinson's disease. In regular treatment with metformin, simvastatin, enalapril, thyroxine and levodopa. Which of the following drugs is most likely the causal drug of the clinical picture described?


After a TBI in a patient who is not anticoagulated or antiplatelet, with no known risk factors for hemorrhage, and who does not present alarming data in the anamnesis or physical examination, it is not necessary to perform a cranial imaging test.

A 35-year-old woman referred to the emergency department for head trauma due to a fall on a scooter, with no loss of consciousness or amnesia. The examination shows a closed head injury with concussion and mild headache without nausea and vomiting. The neurological examination is normal and the Glasgow index is 15. In this situation, which imaging test is indicated first?


Direct response question. This is syphilis (both by antecendent and serology) in the secondary stage, so treatment is with Benzathine Penicillin 2.4 MU in a single dose.

A 34-year-old man consults for fever and malaise. The medical history includes a history of homosexual relations for the last 4 months with a new partner. 2 months before the current consultation he had a painless ulcerative lesion on the glans penis with bilateral inguinal lymphadenopathy, all self-limited. Serological studies were requested with the following results: HIV negative, RPR 1/320, HAART 1/128. What treatment would you indicate for this patient?

Intravenous penicillin G, 24 MU every day for 14 days.

Benzathine penicillin 2.4 MU intramuscular, 3 doses in three consecutive weeks.

Ceftriaxone 2 grams intramuscular in a single dose.

Benzathine penicillin 2.4 MU intramuscularly in a single dose.


Vaccination recommendations for HIV+ adults include hepatitis B, influenza, MMR, pneumococcal, Td and Tdap, and for some adults, hepatitis A, or combined A and B, bacterial meningitis, HPV and meningococcal (Source [1]). Considering that the individual has received some vaccines, has a CD4 count >100 (if lower there would be a contraindication) and works in a center that helps AIDS patients (he is equated to "health personnel") answers 2, 4 and 5 are wrong. All four vaccines in option 1 are administrable. In a little more detail: Vaccine against tetanus and diphtheria: all persons should be vaccinated against these two diseases. Hepatitis B vaccine: hepatitis B and HIV viruses share the same routes of transmission, so it is common for HIV-infected patients to also be infected with hepatitis B virus. It is therefore important to know whether the HIV-infected person has markers of hepatitis B infection and to proceed with vaccination if he/she does not have them. Vaccination against hepatitis A: Hepatitis A in a person with hepatitis B, hepatitis C or other liver disease can be very serious. Since these infections are more frequent in HIV-infected patients, vaccination against hepatitis A is recommended. Vaccination against influenza: influenza in a patient with a lack of immune response is more serious and presents a greater risk of complications, so annual vaccination against this disease is indicated. If the patient's immune status is very deteriorated, the response to vaccination is diminished. In this case, it is essential to vaccinate all the people living with the HIV-infected person to prevent them from transmitting the disease. Pneumococcal vaccine: pneumococcal infections (especially pneumonia) are up to 10 times more frequent in HIV-infected persons than in HIV-uninfected adults, so vaccination is recommended, although in patients with counts below 200/mm3 the protective response is usually not sufficient. They should receive a second dose at 3-5 years of age. HIV-infected children should be vaccinated with pneumococcal conjugate vaccine with the corresponding number of doses according to age. Vaccination against Haemophilus Influenzae type b: this bacterium causes pneumonia and meningitis, especially in children. Although in HIV-infected adults it represents a small number of the causes of infection, vaccination is recommended. Vaccination against measles, rubella and mumps (MMR): all three diseases can become more serious in HIV-infected patients, especially measles, so all of them should be vaccinated, provided that immunosuppression is not severe (count less than 200/mm3).

Vaccination recommendations for HIV+ adults include hepatitis B, influenza, MMR, pneumococcal, Td and Tdap, and for some adults, hepatitis A, or combined A and B, bacterial meningitis, HPV and meningococcal (Source [1]). Considering that the individual has received some vaccines, has a CD4 count >100 (if lower there would be a contraindication) and works in a center that helps AIDS patients (he is equated to "health personnel") [HIDDEN]. [HIDDEN]. In a little more detail: Vaccine against tetanus and diphtheria: all persons should be vaccinated against these two diseases. Hepatitis B vaccine: hepatitis B and HIV viruses share the same routes of transmission, so it is common for HIV-infected patients to also be infected with hepatitis B virus. It is therefore important to know whether the HIV-infected person has markers of hepatitis B infection and to proceed with vaccination if he/she does not have them. Vaccination against hepatitis A: Hepatitis A in a person with hepatitis B, hepatitis C or other liver disease can be very serious. Since these infections are more frequent in HIV-infected patients, vaccination against hepatitis A is recommended. Vaccination against influenza: influenza in a patient with a lack of immune response is more serious and presents a greater risk of complications, so annual vaccination against this disease is indicated. If the patient's immune status is very deteriorated, the response to vaccination is diminished. In this case, it is essential to vaccinate all the people living with the HIV-infected person to prevent them from transmitting the disease. Pneumococcal vaccine: pneumococcal infections (especially pneumonia) are up to 10 times more frequent in HIV-infected persons than in HIV-uninfected adults, so vaccination is recommended, although in patients with counts below 200/mm3 the protective response is usually not sufficient. They should receive a second dose at 3-5 years of age. HIV-infected children should be vaccinated with pneumococcal conjugate vaccine with the corresponding number of doses according to age. Vaccination against Haemophilus Influenzae type b: this bacterium causes pneumonia and meningitis, especially in children. Although in HIV-infected adults it represents a small number of the causes of infection, vaccination is recommended. Vaccination against measles, rubella and mumps (MMR): all three diseases can become more serious in HIV-infected patients, especially measles, so all of them should be vaccinated, provided that immunosuppression is not severe (count less than 200/mm3).

30-year-old HIV (+) homosexual male who participates as a volunteer in an AIDS patient support center. According to his medical history he received diphtheria toxoid (Td) 6 years ago, MMR vaccine in childhood and adolescence, and hepatitis B 3 years ago. He is currently asymptomatic with a CD4 count above 200 cls/microliter. Which vaccines should we recommend?

Seasonal influenza, pneumococcal, tetravalent meningitis and hepatitis A.

Seasonal influenza, Td, pneumococcal and tetravalent meningitis.

Tetravalent meningitis, pneumococcal and seasonal flu.

Td, tetravalent meningitis, pneumococcal.

Triple viral, seasonal flu, pneumococcal.


Difficult question in which the correct answer could give rise to discussion. The patient is a 16-year-old male who is admitted for a fairly clear case of mononucleosis due to EBV infection that becomes complicated during admission. The data available to us are: - Pancytopenia. - Hepatopathy. - Coagulopathy. - Absence of infectious focus: negative blood cultures, negative urine cultures, normal X-ray, normal CSF. - CRP and Ferritin elevated / normal Procalcitonin. The possible complications that could have occurred (and that are considered in the answers) are sepsis or a bad evolution of mononucleosis. The clinical data could be consistent with a septic process, however, the main infectious foci have been reasonably ruled out and one of the most sensitive and specific markers of bacteremia (procalcitonin) is in the normal range, which should draw our attention. On the other hand, a complication of the EBV mononucleosis suffered by our patient should be evaluated, among the possible complications are hemolytic anemia, meningoecephalitis (normal CSF) or Guillain-Barré sd. Guillain-Barré syndrome, which are not very consistent with the clinical picture presented to us. Another possible complication of exceptional severity would be hemophagocytic syndrome; this is a rare entity that occurs in certain predisposed subjects and is characterized by an uncontrolled activation and proliferation of histiocytes and T lymphocytes, which produces a state of hypercytokinemia.  The diagnostic criteria, revised in 2004, include persistent high fever, hepatosplenomegaly, cytopenias, hypertriglyceridemia, hyperferritinemia, and hypofibrinogenemia. Hyperferritinemia >3000 in a suggestive clinical context necessitates treatment of the patient (mainly with immunosuppressants and corticosteroids) since mortality is very high and early treatment is essential. The definitive diagnosis is made by microscopic study of an OM biopsy.  Although in this question they do not quantify the value of ferritinemia, it is a remarkable data and given that the clinical picture is suggestive, meeting the diagnostic criteria, it seems to me that answer 5 would be the most accurate.

Difficult question in which the correct answer could give rise to discussion. The patient is a 16-year-old male who is admitted for a fairly clear case of mononucleosis due to EBV infection that becomes complicated during admission. The data available to us are: - Pancytopenia. - Hepatopathy. - Coagulopathy. - Absence of infectious focus: negative blood cultures, negative urine cultures, normal X-ray, normal CSF. - CRP and Ferritin elevated / normal Procalcitonin. The possible complications that could have occurred (and that are considered in the answers) are sepsis or a bad evolution of mononucleosis. The clinical data could be consistent with a septic process, however, the main infectious foci have been reasonably ruled out and one of the most sensitive and specific markers of bacteremia (procalcitonin) is in the normal range, which should draw our attention. On the other hand, a complication of the EBV mononucleosis suffered by our patient should be evaluated, among the possible complications are hemolytic anemia, meningoecephalitis (normal CSF) or Guillain-Barré sd. Guillain-Barré syndrome, which are not very consistent with the clinical picture presented to us. Another possible complication of exceptional severity would be hemophagocytic syndrome; this is a rare entity that occurs in certain predisposed subjects and is characterized by an uncontrolled activation and proliferation of histiocytes and T lymphocytes, which produces a state of hypercytokinemia.  The diagnostic criteria, revised in 2004, include persistent high fever, hepatosplenomegaly, cytopenias, hypertriglyceridemia, hyperferritinemia, and hypofibrinogenemia. Hyperferritinemia >3000 in a suggestive clinical context necessitates treatment of the patient (mainly with immunosuppressants and corticosteroids) since mortality is very high and early treatment is essential. The definitive diagnosis is made by microscopic study of an OM biopsy.  Although in this question they do not quantify the value of ferritinemia, it is a remarkable data and given that the clinical picture is suggestive, meeting the diagnostic criteria, it seems to me that [HIDDEN].

A 16-year-old boy consults for presenting with pustular tonsillitis, fever up to 38.5°C, painful cervical lymphadenopathy, non-pruritic macular rash on the chest and mild hepatosplenomegaly, of 4-5 days of evolution. Paul-Bunnell test and Ig M for Epstein-Barr virus are positive. During his admission he developed continuous fever up to 40ºC, pancytopenia, icteric hepatitis and coagulopathy of progressive intensity. One week after admission, he was transferred to the ICU due to confusion and respiratory failure. Blood cultures and a urine culture were negative, CSF was normal and the chest x-ray showed no infiltrates. Procalcitonin is normal, but CRP and ferritin are very elevated. Of the following statements, which would be the most correct diagnostic and therapeutic approach?

She has a bacterial sepsis of undetermined origin and should be given ceftriaxone and supportive care.

She has bacterial sepsis of undetermined origin and should be given vancomycin, ceftacidime and supportive care.

This is infectious mononucleosis with a severe course and glucocorticoids should be administered.

This is an infectious mononucleosis of severe course and treatment with Acyclovir should be initiated.

I would perform a bone marrow biopsy/aspirate and, if hemophagocytosis is confirmed, initiate treatment with immunosuppressants.


They are not asking about factors that affect oncologic prognosis and therefore imply a change in QT strategy. This question is straightforward. Option 4 is describing to us a T4 stage, either by invasion of adjacent organs or perforation. The T4s carry a much higher chance of recurrence, in fact there are ongoing studies that propose prophylactic HIPEC in T4 and second look surgery + HIPEC in perforated colon tumors.

They are not asking about factors that affect oncologic prognosis and therefore imply a change in QT strategy. This question is straightforward. Option 4 is describing to us a T4 stage, either by invasion of adjacent organs or perforation. The T4s carry a much higher chance of recurrence, [HIDDEN].

A 52-year-old man was referred to the gastroenterology department for hematochezia, tenesmus and reduction of stool diameter. A series of tests were performed and a diagnosis of adenocarcinoma of the sigma without distant metastasis was made. The patient underwent surgery and was referred to the medical oncology department for evaluation of complementary chemotherapy treatment. Which of the following is a poor prognostic factor after surgical resection and should be taken into account when planning chemotherapy treatment?

The existence of a family history of colorectal cancer.

The size of the primary lesion and histological differentiation.

Perforation or adhesion of the tumor to adjacent organs.


In ANCA vasculitis, whatever it is, these antibodies have been shown to be related to the activity of the disease, but at no time are changes in treatment obligatory due to their levels. In this case, with the patient being asymptomatic and with objective evidence of lack of activity, close follow-up should be performed without restarting or modifying treatment.

A 50-year-old man diagnosed with polyangiitis with granulomatosis 10 years earlier and untreated for the past 5 years is asymptomatic at a scheduled check-up. Chest X-ray, blood tests and urine sediment are normal except for positive anti-neutrophil cytoplasmic antibodies (ANCA) at titer 1/320, with anti-proteinase 3 specificity, which had previously been negative. What is the most advisable therapeutic approach?

Initiate treatment with cyclophosphamide.

Initiate treatment with mycophenolate mofetil.


We find a patient with hypoventilation. Glycemia is correct (we rule out hyperosmolar coma and hypoglycemia, option 2 and 4), so, although there is no history of intoxication, we have to go to the most frequent and that we can antagonize with antidotes: benzodiazepines (flumazenil) and opiates (naloxone). If we suspect ethylene glycol intoxication, we would administer thiamine, but there are no data to make us suspect.

We find a patient with hypoventilation. Glycemia is correct (we rule out hyperosmolar coma and hypoglycemia, [HIDDEN]), so, although there is no history of intoxication, we have to go to the most frequent and that we can antagonize with antidotes: benzodiazepines (flumazenil) and opiates (naloxone). If we suspect ethylene glycol intoxication, we would administer thiamine, but there are no data to make us suspect.

A 56-year-old patient is found comatose at home. He has a history of arterial hypertension and diabetes mellitus. He has no toxic habits or any other chronic disease. He is on treatment with irbesartan and empaglifozin. He shows no signs of malnutrition. His blood pressure is 110/60 mmHg, heart rate 110 bpm, 90% SatO2, capillary glucose 120 mg/dl and respiratory rate 7 rpm. Which initial therapeutic approach do you think is the most correct?

Administer naloxone, flumazenil and thiamine.

Administer naloxone, flumazenil and hypertonic glucose.

Administer thiamine and hypertonic glucose.


The correct answer is 3. Easy question if pathology is suspected, which I also think is simple because the clinical description is textbook hypertrophic pyloric stenosis.

[HIDDEN] Easy question if pathology is suspected, which I also think is simple because the clinical description is textbook hypertrophic pyloric stenosis.

Child 28 days old, born at term. History of normal pregnancy and delivery. He has been breastfed since birth. He consults because 8 days ago he started vomiting, initially sporadically and since 5 days ago, after all feedings. He is permanently hungry. The vomiting is of "squirting" food content. On palpation, the abdomen is soft and depressible, without visceromegaly. The blood gas analysis showed pH 7.49, bicarbonate 30 mEq/l, pCO2 53 mmHg, base excess +8 mEq/l. Ions: Na 137 mEq/l, K 3.1 mEq/l, Cl 94 mEq/l. Taking into account the most probable diagnosis in the clinical picture described, what is the complementary test of choice to confirm this clinical diagnosis?


Debut of DM with ketoacidosis. Priority is iv insulin administration and serum therapy. Bicarbonate if pH < 7. Insulin administration should never be delayed.

A 22-year-old female student with no history of pathology or use of medications except anovulatory drugs comes to the emergency department for deterioration of general condition and need to take deep breaths. She reports weight loss in the last 2-3 days, polydipsia, polyuria and nausea. No cough or febrile sensation. Examination: appearance of gravity, blood pressure 100/60 mmHg, deep and rapid breathing (28rpm), level of consciousness preserved, dry mucous membranes. No fever. CBC: blood glucose 420 mg/dL, Na+ 131 mEq/L, K+ normal, pH 7.08, bicarbonate 8 mEq/L and ketonuria (+++) Which answer do you think is more correct?

Debut of type 2 diabetes mellitus, with dyspnea probably due to pneumonia or thromboembolism, since she is taking anovulatory drugs.

It is a diabetic ketoacidosis. It must be treated with intravenous insulin, serum therapy, general measures and search for precipitating cause.

Debut of type 1 diabetes with ketoacidosis. Treat with bicarbonate and after correction of acidosis, add intravenous insulin.

It looks like diabetic ketoacidosis, but it could be alcoholic. BAC should be determined before starting insulin therapy.

Treat with rapid subcutaneous insulin, serum therapy and ask him to drink plenty of fluids.