This question combines several important facts. To begin with, this is a patient with an extensive anterior and lateral AMI, with cardiogenic shock. On the other hand, in the history, we are told that the patient had a stroke 4 months ago. It is evident from the patient's clinical picture that an urgent reperfusion strategy is indicated, which invalidates options 4 and 5. The basic question is whether to choose fibrinolysis (which can be done in a regional hospital) or PCI (for which the patient should be referred to a tertiary center). Option 2 does not make much sense, since in the event that fibrinolysis is indicated, it would only be a waste of time to make the transfer. A history of stroke (presumably ischemic) 4 months ago is a relative contraindication for fibrinolysis (if the time is less than 3 months it is an absolute contraindication), but the definitive factor that tips the balance towards PCI is the extent of AMI and the presence of shock, which are indications for urgent PCI. Therefore, the correct answer is 3.

This question combines several important facts. To begin with, this is a patient with an extensive anterior and lateral AMI, with cardiogenic shock. On the other hand, in the history, we are told that the patient had a stroke 4 months ago. It is evident from the patient's clinical picture that an urgent reperfusion strategy is indicated, which invalidates options 4 and 5. The basic question is whether to choose fibrinolysis (which can be done in a regional hospital) or PCI (for which the patient should be referred to a tertiary center). [HIDDEN] since in the event that fibrinolysis is indicated, it would only be a waste of time to make the transfer. A history of stroke (presumably ischemic) 4 months ago is a relative contraindication for fibrinolysis (if the time is less than 3 months it is an absolute contraindication), but the definitive factor that tips the balance towards PCI is the extent of AMI and the presence of shock, which are indications for urgent PCI. Therefore, [HIDDEN].

A 72-year-old man, ex-smoker, hypertensive and diabetic. History of stroke with residual paresis in the left arm 4 months ago. He comes to the emergency department of a regional hospital with intense precordial pain of 2 hours of evolution; in the physical examination he presents cold and sweaty skin, blood pressure of 80 mm Hg; electrocardiogram with marked ST segment elevation in leads V1-V6, I and aVL. Which of the following treatments of coronary repercussion is the most appropriate?

Immediate systemic fibrinolysis at the regional hospital.

Immediate transfer to a tertiary center for treatment with fibrinolysis.

Immediate transfer to a tertiary center for percutaneous coronary revascularization procedure.

Hemodynamic stabilization and deferred revascularization procedure.

Immediate treatment with fondaparinux and abciximab.


Little to comment.... is the definition of delirium. Altered state of consciousness.

A 79-year-old patient is brought to the ED at 7 pm from a nursing home, but we do not have the referral report and therefore do not know his history. He is disoriented in time and space. He has trouble remembering simple information. Sometimes he becomes very nervous and agitated, because he sees threatening people, even when he is alone. At other times he appears drowsy and inattentive. The main data supporting the diagnosis of delirium as opposed to dementia is:


Warfarin-induced skin necrosis is a rare and serious adverse effect of oral anticoagulant therapy, occurring in only 0.01 to 0.1% of patients and is especially related to coagulation protein C and S deficiency.

46-year-old woman with a history of rheumatic valve disease, requiring mitral valve replacement with a mechanical prosthesis. The initial postoperative evolution is favorable. However, after starting treatment with acenocoumarol, she develops a picture of skin necrosis affecting the abdominal region and extremities. Which of the following alterations would justify this picture?


I believe that the most correct is 2, since Gustilo II fractures are mainly covered with Gram (+) by means of a 1st generation Cepha, and it is not a question of prevention but of treatment (it is considered to be contaminated).

I believe that [HIDDEN], since Gustilo II fractures are mainly covered with Gram (+) by means of a 1st generation Cepha, and it is not a question of prevention but of treatment (it is considered to be contaminated).

A 36-year-old man with no past history of interest who, after a high-energy trauma following a fall from a motorcycle, presents with a Gustilo grade II open midshaft fracture of the tibia. Which of the following maneuvers or therapies is most effective for preventing infection?

Immediate intravenous broad-spectrum antibiotherapy.

Exhaustive debridement-wound lavage in the operating room with at least 10 liters of saline.

Urgent stabilization of the fracture by external fixation and early wound closure.

Early wound closure with antiseptics and oxygen therapy at two liters per minute.


The nice word to describe this is: "Belle indeference", this woman shows herself with an elegant indifference to a paralysis. The diagnosis.... can be excluded 2,3,4 because the clinical does not match: no delirium, no worry, no sadness. 1 would be if he was making a profit, if he was knowingly simulating and to make a profit he was faking his illness. This is not the case. Conversive would be if the symptom wanted to transmit something to us, that is to say, it was a metaphor of its internal world... The most exact in this case: 5.

The nice word to describe this is: "Belle indeference", this woman shows herself with an elegant indifference to a paralysis. The diagnosis.... can be excluded 2,3,4 because the clinical does not match: no delirium, no worry, no sadness. 1 would be if he was making a profit, if he was knowingly simulating and to make a profit he was faking his illness. This is not the case. Conversive would be if the symptom wanted to transmit something to us, that is to say, it was a metaphor of its internal world... The most exact in this case: [HIDDEN].

A 52-year-old woman comes to the emergency room with bilateral paralysis of the upper extremities that had started abruptly two hours earlier. In the interview she is smiling and says she does not understand why her family is so worried. The family refers that the day before her son had been arrested by the police for drug trafficking and they had not yet been able to contact him. Which of the following is the most likely diagnosis?


Another question that may generate discussion. When a diagnosis of active tuberculosis infection is made, treatment is initiated with isoniazid, rifampicin and pyrazinamide together with ethambutol in case of suspicion of strains resistant to any of the drugs. Once the existence of resistance has been ruled out, ethambutol can be dispensed with. In case of resistance to rifampicin, rifampicin is withdrawn and treatment is completed with the 3 remaining drugs for 12 months. The option of adding a quinolone during the first two months of treatment (moxifloxacin or levofloxacin) is considered in cases of extensive pulmonary involvement. In this case, they do not tell us anything about extensive pulmonary involvement but they give us a data "excessive alcohol consumption". You know that in the MIR no data is free, and if the person who posted this question wanted to reflect it, probably his intention was that we reflect on it. Alcohol exerts a direct immunosuppressive effect, moreover, alcoholism is related to the affectation of immunity in the respiratory tract. The social context that usually accompanies the alcoholic patient does not help either. All the factors mentioned above make us lean more towards answer number 3, although it is undeniable that number 1 could also be correct.

Another question that may generate discussion. When a diagnosis of active tuberculosis infection is made, treatment is initiated with isoniazid, rifampicin and pyrazinamide together with ethambutol in case of suspicion of strains resistant to any of the drugs. Once the existence of resistance has been ruled out, ethambutol can be dispensed with. In case of resistance to rifampicin, rifampicin is withdrawn and treatment is completed with the 3 remaining drugs for 12 months. The option of adding a quinolone during the first two months of treatment (moxifloxacin or levofloxacin) is considered in cases of extensive pulmonary involvement. In this case, they do not tell us anything about extensive pulmonary involvement but they give us a data "excessive alcohol consumption". You know that in the MIR no data is free, and if the person who posted this question wanted to reflect it, probably his intention was that we reflect on it. Alcohol exerts a direct immunosuppressive effect, moreover, alcoholism is related to the affectation of immunity in the respiratory tract. The social context that usually accompanies the alcoholic patient does not help either. All the factors mentioned above make us lean more towards [HIDDEN], although it is undeniable that [HIDDEN].

A patient with a history of excessive alcohol consumption has been diagnosed with pulmonary tuberculosis due to cough, fever, expectoration, and sputum culture isolation of Mycobacterium tuberculosis. The patient started treatment with isoniazid, rifampicin, ethambutol and pyrazinamide, with adequate tolerance. Twenty days after starting treatment, a report of rifampicin resistance of M. tuberculosis isolated in sputum is received. Which regimen would you select based on this report?

Isoniazid, ethambutol, pyrazinamide for 12 months.

Isoniazid, ethambutol, pyrazinamide for 12 months and streptomycin for two months.

Isoniazid, ethambutol, pyrazinamide for 12 months and a quinolone for two months.

Isoniazid, ethambutol, pyrazinamide and a quinolone for 18 months.

Isoniazid, ethambutol, pyrazinamide for 18 months and streptomycin and a quinolone for 2 months.


This clinical picture is called Frey's syndrome and consists of an anomalous reinnervation of regional structures after parotidectomy due to lesion of the auriculotemporal nerve, so that during mastication, erythema and preauricular sweating occur. The treatment is intradermal botulinum toxin injection.

A 47-year-old man, with a history of a right parotid pleomorphic adenoma, treated with surgery (extrafacial parotidectomy) 6 months ago, who comes to our office for presenting pain with sweating and reddening of the skin in the preauricular region during chewing. Which treatment would be the treatment of choice?

Extended total parotidectomy on suspicion of tumor recurrence.

OTORHINOLARYNGOLOGY AND MAXILLOFACIAL SURGERY


The correct answer is: 2. Focal segmental glomerulonephritis. We are in front of a patient with renal insufficiency whose manifestation is a proteinuria. That places us in the picture of nonproliferative GN (membranous, focal and segmental and minimal changes, discarding the other two). If we also consider that the patient was obese, slightly hypertensive, the most probable is that it is a focal segmental glomerulonephritis.

The [HIDDEN]. We are in front of a patient with renal insufficiency whose manifestation is a proteinuria. That places us in the picture of nonproliferative GN (membranous, focal and segmental and minimal changes, discarding the other two). If we also consider that the patient was obese, slightly hypertensive, the most probable is that it is a focal segmental glomerulonephritis.

A 58-year-old woman, weight 130 kg, height 155 cm, body mass index > 30 with mild hypertension, blood glucose 108 mg/dL and absence of edema in the lower limbs. Blood analysis showed Cr 2.0 mg/dL, Urea 86 mg/dL, Alb 3.8 g/1, Na 142 mEq/L, K 4 mEq/L. In urinalysis: sediment without alterations and in 24 h urine proteinuria of 6.3 g/24 h. Which of the following entities is more likely to be present?


We are dealing with a patient who has exhausted the pharmacological route given that he takes everything and has two important problems: genu varum and an important gonarthrosis. This means that we can do nothing with an arthroscopy, let alone a synovectomy (1 and 5 false). The genu varum could falsely make us think about an osteotomy, however even if we did it and corrected the varus now the damage is already done and the osteoarthrosis is severe. Perhaps years ago before the osteoarthritis took place it would have been resolutive but not now (4 false). In addition, in order to consider an osteotomy, we should be given more data to know which bone to apply the osteotomy on, the tibia or the femur. Finally, we may think that it is best to first try rehabilitation before considering surgery, but I discard this option because the question emphasizes that we have exhausted pharmacological measures (although it could be considered because they have not specified whether it has been tried or not). In any case with the knee prosthesis we correct the problem of osteoarthritis pain and we can also correct the knee varus.

We are dealing with a patient who has exhausted the pharmacological route given that he takes everything and has two important problems: genu varum and an important gonarthrosis. This means that we can do nothing with an arthroscopy, let alone a synovectomy ([HIDDEN]). The genu varum could falsely make us think about an osteotomy, however even if we did it and corrected the varus now the damage is already done and the osteoarthrosis is severe. Perhaps years ago before the osteoarthritis took place it would have been resolutive but not now ([HIDDEN]). In addition, in order to consider an osteotomy, we should be given more data to know which bone to apply the osteotomy on, the tibia or the femur. Finally, we may think that it is best to first try rehabilitation before considering surgery, but I discard this option because the question emphasizes that we have exhausted pharmacological measures (although it could be considered because they have not specified whether it has been tried or not). In any case with the knee prosthesis we correct the problem of osteoarthritis pain and we can also correct the knee varus.

A 75-year-old patient with significant gonarthrosis with "Genu Varo" that causes marked functional impotence, limited mobility and continuous pain that requires continuous antirheumatic, anti-inflammatory and analgesic medication. What treatment should be indicated in this case?

Abduction supratuberosity tibial supratuberosity tibial osteotomy.


The patient suffers an abrupt neurological deficit probably related to a vascular event, so first we will have to perform a cranial CT scan to rule out a hemorrhagic stroke. If the CT scan does not show bleeding, the patient has an acute ischemic stroke, probably cardioembolic due to his cardiac pathology, not anticoagulated. Given that his tumor process is under control, there are no contraindications for the administration of fibrinolysis in this case, since the patient is in a good baseline condition. Although the patient is 88 years old, age is no longer presented as an absolute exclusion criterion, but the general situation of the patient must be taken into account and in this case it is specified that he presents a good baseline situation.

A 33-year-old man, independent in all activities of daily living, with a history of well-controlled hypertension, antiplatelet atrial fibrillation and an adenocarcinoma of the prostate at 73 years of age, currently free of disease. He is brought to the emergency department for clinical aphasia and right hemiparesis of sudden onset, 45 minutes earlier. What is the most correct approach?

Perform a cranial CT scan and if there are no hemorrhagic lesions or other contraindications in the analysis, start immediate intravenous thrombolysis.

Perform urgent cranial CT scan and if there is no bleeding, start anticoagulation.

Perform cranial CT scan and admission to rehabilitation center, since their attitude will not differ regardless of whether the etiology is ischemic or hemorrhagic.

Cranial CT scan is not necessary, although I would withdraw the antiaggregation.


Very typical too. In the ED it can be diagnosed with a pregnancy test (in males), because it detects that beta HCG in urine. Hepatocarcinoma can elevate (alone) alpha-fetus, seminoma LDH, lymphoma also LDH.

40-year-old patient, with normal physical examination, in whom a mediastinal mass and a hepatic nodule have been evidenced in the CT scan, and in the CBC a serum elevation of lactic dehydrogenase (LDH), human chorionic betagonadotropin (beta-HCG) and alpha-fetoprotein.What is your diagnostic suspicion. What is your diagnostic suspicion:

Metastatic extragonadal nonseminomatous germ cell cancer.


I think the correct answer is 5; FNA does not allow a histological study but a cytological one, therefore questions 1, 2 are eliminated. Question 3 seems to have been put as a filler because it is not relevant. Question 4 could raise doubts if you are not a pathologist but the most logical answer is 5 since papillary carcinoma is the most frequent.

I think [HIDDEN]; FNA does not allow a histological study but a cytological one, therefore questions [HIDDEN]. Question 3 seems to have been put as a filler because it is not relevant. Question 4 could raise doubts if you are not a pathologist but [HIDDEN] since papillary carcinoma is the most frequent.

A 41-year-old man comes to the clinic with a nodule in the right thyroid, a fine needle aspiration is performed. Cytological analysis will allow us:

Distinguish between follicular adenoma or minimally invasive follicular carcinoma.

Identify the areas of capsular or vascular invasion of the follicular carcinoma.

Recognize G-cell hyperplasia associated with familial spinal cancer.

Distinguish between a Hurthle cell tumor and an oxyphilic follicular adenoma.

Identify the typical cytologic features of papillary carcinoma.


Kallman's syndrome or Morsier's syndrome is a congenital insufficiency associated with hypogonadotropic hypogonadism due to a deficit in GnRH hormone production. Repeated injections of GnRH are performed to restore fertility.

A 22-year-old boy with hyposmia presents with lack of development of secondary sexual characteristics and infertility. Bilateral testicular volume of 4 mL. Analytically, FSH 1.2 U/L (vn 5-15); LH 0.6 U/L (vn 3-15); testosterone 100 ng/diu (vn 300-1200), prolactin normal. Indicate the treatment you will propose to achieve fertility:

Monthly intramuscular administration of triptorelin.

Intramuscular administration of FSH and LH once a week.


Bicarbonate is indicated at pH < 7.

Easy question since the treatment of diabetic ketoacidosis is a very repeated topic in the MIR. Bicarbonate is indicated at pH < 7.

A type 1 diabetic who comes to the emergency room for dyspnea and general malaise. The blood test showed blood glucose 450 mg/dl, Na 142 mEq/l, K 4 mEq/l, pH 7.15, bicarbonate 12 mmol/l. Which treatment would NOT be indicated?

Serum glucose 5% iv when blood glucose is less than 250 mg/dl.

Potassium chloride 100 mEq / day diluted in sera.

Sodium bicarbonate 1M 100 cc iv in 30 minutes.


The most influential cardiovascular factor for stroke in women over 70 is blood pressure.

A 76-year-old woman consults us because she is concerned about her risk of stroke since her mother died of stroke a year ago. She is diagnosed with arterial hypertension and type 2 diabetes mellitus and is being treated with glipizide, aspirin, enalapril and atorvastatin. She smokes 20 cigarettes a day and leads a sedentary life. The examination revealed a blood pressure of 150/80 mm Hg. The blood test shows a hemoglobin A1C of 8% and LDL cholesterol of 110 mg/dl. Which of the following actions is associated with a greater reduction in the risk of stroke?


In the face of a PPD conversion within 2 years, and ruling out current TB disease, INH chemoprophylaxis is indicated, although I thought it was for 6 months and not 9. The rest is not questionable.

In the face of a PPD conversion within 2 years, and ruling out current TB disease, INH chemoprophylaxis is indicated, although I thought it was for 6 months and not 9. The rest is [HIDDEN].

A 32-year-old man, ADVP and recently released from prison, has a protein derivative skin test (PPD) with 10 mm of induration. One year ago, the PPD was negative, he is currently asymptomatic, his HIV serology is negative, and his Chest X-ray is normal. Which of the following approaches do you think is most appropriate?

Do not perform treatment and annual Rx control.

Sputum culture for mycobacteria and treat only if positive.

Treatment with RIF and PRZ for 2 months.


Actually, it can be all of them, but the most frequent cause of acute uncompensated respiratory acidosis in a young person is bronchopneumonia.

A 40-year-old male, foreign tourist, is referred to the ED for low level of consciousness, temperature of 37.7°C and dyspnea. He has no trauma. Several tests were performed. The most immediate is an ABE without oxygen, showing PH 7.33, PCO2 50, PO2 65, HCO3 27:


The closest answer is 1. If we are strict we would be talking about a pure motor lacunar infarction (with mild dysarthria). Since the other 3 options do not give us a clinical picture like the one in the statement. Both options 2 and 3 give us a much more florid and extensive clinical picture.

[HIDDEN] If we are strict we would be talking about a pure motor lacunar infarction (with mild dysarthria). Since the other 3 options do not give us a clinical picture like the one in the statement. Both options 2 and 3 give us [HIDDEN] extensive clinical picture.

In a 70-year-old man, hypertensive, with a right hemiplegia of sudden onset with mild dysarthria, without alterations in evocation or language comprehension, what type of stroke do you think is most likely to have suffered?

Left capsular lacunar lacunar infarction.

A cortico-subcortical left frontotemporal sylvian infarction.


Question about non-varicose ADH. Young patient, with no previous history, who after taking NSAIDs presents bleeding with hemodynamic instability requiring transfusion.  Answer 1 is not in accordance with what has been said, this is an unstable patient who has bled a lot, who has a Forrest IIa ulcer with a high risk of rebleeding. Answer 2 speaks of somatostatin, which is used for bleeding due to portal hypertension. 4 will only be considered if bleeding is not controlled endoscopically. Between 3 and 5, since there is a high risk of bleeding, endoscopic therapy is recommended, preferably with 2 techniques, so the correct one would be 5.

Question about non-varicose ADH. Young patient, with no previous history, who after taking NSAIDs presents bleeding with hemodynamic instability requiring transfusion. Answer 1 is [HIDDEN], this is an unstable patient who has bled a lot, who has a Forrest IIa ulcer with a high risk of rebleeding. Answer 2 speaks of somatostatin, which is used for bleeding due to portal hypertension. 4 will only be considered if bleeding is not controlled endoscopically. Between 3 and 5, since there is a high risk of bleeding, endoscopic therapy is recommended, preferably with 2 techniques, so [HIDDEN].

A 43-year-old man with no diseases of interest comes to the emergency department for 4 melaenic stools in the last 12 hours. He refers taking NSAIDs in previous days. Physical examination revealed pale skin and mucous membranes. BP 95/65 and HR 110 bpm. The abdomen is not painful and rectal examination shows melenic stools. The CBC shows a Hb of 8.1 gr/dl. After infusion of saline and the start of red blood cell concentrate transfusion, the BP was 120/85 and HR 90 bpm. An endoscopy was performed in which clots were found in the stomach and a 2 cm ulcer in the gastric antrum with fibrin background and a small grayish-white protrusion of 3 mm in the center of the ulcer (visible platelet thrombus vessel). What do you think is the most correct approach?

Since the patient is young, with no associated diseases and the ulcer has stopped bleeding, he can be discharged early with treatment with a PPI and H. Pylori eradication.

Remove the endoscope, place nasogastric tube for continuous aspiration and initiate treatment with a PPI and somatostatin.

Take biopsy for H. Pylori, remove the endoscope taking care not to dislodge the platelet thrombus and continue pharmacological treatment with i.v. PPI.

Consultation to the surgical service to consider urgent surgical treatment.

Endoscopic treatment by injection of adrenaline into the ulcer and placement of clips (metal staples) followed by i.v. administration of PPI.


This is a case of hyperchloremic metabolic acidosis with normal anion gap. Severe metabolic acidosis causes myocardial contractile depression, reduced effectiveness of catecholamines, increased incidence of arrhythmias, vasodilatation and increased capillary permeability, with the consequent reduction of tissue flow, at the cerebral level (leading to states of confusion and even coma), at the renal level, at the hepatic level... These patients frequently present intense tachypnea (Kussmaul's breathing) in an attempt to compensate for MCA by hyperventilation. We must take into account that, in this case, potassium is decreased, so the most frequent cause (supported by the stains on the dress) would be diarrhea, so it is most likely that their renal failure (although they do not give us urine ion data to confirm it) is of prerenal type. The treatment would be water and electrolyte replacement and, in principle, unless the patient worsens and the pH is less than 7.10, we should not administer bicarbonate.

This is a case of hyperchloremic metabolic acidosis with normal anion gap. Severe metabolic acidosis causes myocardial contractile depression, reduced effectiveness of catecholamines, increased incidence of arrhythmias, vasodilatation and increased capillary permeability, with the consequent reduction of tissue flow, at the cerebral level (leading to states of confusion and even coma), at the renal level, at the hepatic level... These patients frequently present intense tachypnea (Kussmaul's breathing) in an attempt to compensate for MCA by hyperventilation. We must take into account that, in this case, potassium is decreased, so [HIDDEN], so it is most likely that their renal failure (although they do not give us urine ion data to confirm it) is of prerenal type. The treatment would be water and electrolyte replacement and, in principle, unless the patient worsens and the pH is less than 7.10, we should not administer bicarbonate.

Elderly woman brought to the ER by her neighbors because they see her somewhat groggy and with stool stains on her clothes. BP 100/60 mmHg, HR 100 bpm, sitting 70/30, HR 105 bpm. PVY normal. Kussmaul's respiration. No neurological focality. Weight 50 kg. Lab: PH 7.25, PCO2 14, Bicarbonate 5, Na 133, K 2.5, Cl 118, Creat 3.4, NUS 60, Prot 8. Which of the following answers is correct?

The presenting acid-base disorder is a respiratory acidosis.

Compensation to correct the acidosis is inadequate.

With this exploration, we rule out that she is dehydrated.

In any case, we should not put bicarbonate.

She has an acute renal failure of prerenal cause.

ANESTHESIOLOGY, CRITICAL CARE AND EMERGENCY MEDICINE


Although this question straddles the line between derma and pediatrics, we would like to do our bit. We are being told about erythema súdenita or fifth disease (also called megaloerythema), caused by parvovirus B19. It is typical that after an episode of high fever an erythema appears on both cheeks in the form of a "slap" that usually has a cranial-caudal extension in the following days.

A 7-year-old girl who comes for consultation because her parents notice her red face since the previous day and in the last few hours they have noticed red spots on her body. On examination she is afebrile, with tonsils and ears without alterations, normal cardiopulmonary auscultation. He presents a confluent maculo papular rash on both cheeks, respecting the upper lip, resembling a "slapped" face. In the thorax she presents a reticular, lacy, non-pruritic exanthem. What is the most probable clinical diagnosis?


This is a fairly easy epidemiology question, in adults without other data, Pneumococcus is the 1st.

This is a fairly easy epidemiology question, in adults without other data, Pneumococcus is the [HIDDEN].

A 40-year-old male patient, smoker since he was 18 years old, with no history of interest. He consults for symptoms of 24 hours of evolution of chills, thermometric fever of 39ºC and cough with expectoration. Chest X-ray shows an increased density with alveolar pattern in the LSD and the patient is diagnosed with CAP. What is the most frequent etiological agent and therefore of obligatory coverage when choosing empirical atb treatment?


Although the majority of ACTH-producing adenomas recur, surgery is always the first therapeutic option. The available medications (ketoconazole, somatostatin analogues) are aimed at decreasing the effects of excess cortisol or decreasing ACTH release, but they are not curative.

What is the treatment of choice for a 38-year-old man diagnosed with Cushing's disease in relation to a pituitary macroadenoma of 22 mm in diameter?

Initially try medical treatment and, if not effective, resort to surgery.

Selective surgical resection of the adenoma.

Radiotherapy to try to reduce tumor size.


Colposcopy is indicated for all patients with altered cytology (intraepithelial lesion or suspicion of invasive cancer or HPV infection), as a second level of screening. If lesions are observed in this test, a biopsy of the lesion will be performed. There is no point in repeating the cytology (since this is a screening test, not a diagnostic test), performing a hysterectomy for an intraepithelial lesion that has not been confirmed by biopsy is not indicated either, and performing curettage of the endometrial cavity does not provide information since the lesion is from the cervix.

[HIDDEN], as a second level of screening. If lesions are observed in this test, a biopsy of the lesion will be performed. [HIDDEN], performing a hysterectomy for an intraepithelial lesion that has not been confirmed by biopsy is not indicated either, and performing curettage of the endometrial cavity does not provide information since the lesion is from the cervix.

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

Hysterectomy with bilateral salpinguectomy and ovarian conservation.


Both parents are carriers of a mutation (because they are not sick and have already had a homozygous child), and the next offspring has a 50% chance of receiving the mutation from each parent, so the probability of receiving it from both is 50%x50%=25%.

A couple with a first male child (index case) with cystic fibrosis (mucoviscidosis) come for genetic counseling. Molecular diagnosis indicates that the index case is homozygous for the F5O8del mutation and his parents are heterozygous carriers. The clinical geneticist will inform them about the mode of transmission of the disease. Which statement is correct?

The probability that the next offspring will be affected is 25%.

The probability that the next offspring will be affected is 50%.

Having had an affected child, the next offspring will also be affected.

Having had a homozygous F5O8del child, the next offspring will be heterozygous carriers (67%) or homozygous genotype without the mutation (33%).


We are presented with a 68-year-old female patient. At that age the crystalline lens, although it does not normally have a cataract that needs surgery, it usually has increased in thickness. This implies that it projects the iris forward and reduces the depth of the anterior chamber. In an eye with a normal anterior chamber depth this is usually not a problem. But farsighted people already have a narrow anterior chamber. This is the usual combination we find in primary angular closure: farsightedness and age over 50-60 years. Younger hyperopes usually do not have this problem yet. And neither do older people who are emmetropic, myopic or have had cataract surgery. With this narrow angle, what triggers angular closure is mydriasis. That is, when you are in the penumbra, the pupil dilates and the iris thickens in the peripheral part, where it is already very close to the corneal endothelium in the case of a narrow chamber. Mydriasis then triggers angular closure, which is accompanied by ocular pain that may radiate backwards (headache). And increased intraocular pressure produces corneal edema that causes blurred vision. Therefore, option 1 is correct. Migraine does not have to be related to penumbra, and ocular pain and blurred vision is not particularly typical. Actinic keratitis is caused by exposure to ultraviolet radiation (such as solar radiation), and is not related to hyperopia or to being in penumbra. In addition, the history of exposure is usually clear. And finally, dry eye does not produce these symptoms either: it is more a question of burning, foreign body sensation, heaviness, etc. And it is also unrelated to the other elements: penumbra, hyperopia, etc. As a minor detail, I would have worded the question a little better. It is understood that we are asked which pathology is the most probable in relation to the symptoms and the anamnesis. But as it is worded, we are asked about which of the pathologies she is most likely to present, just like that. Actually, a 68-year-old woman is very likely to have dry eye, even if it does not cause the symptoms for which she is presenting.

We are presented with a 68-year-old female patient. At that age the crystalline lens, although it does not normally have a cataract that needs surgery, it usually has increased in thickness. This implies that it projects the iris forward and reduces the depth of the anterior chamber. In an eye with a normal anterior chamber depth this is usually not a problem. But farsighted people already have a narrow anterior chamber. This is the usual combination we find in primary angular closure: farsightedness and age over 50-60 years. Younger hyperopes usually do not have this problem yet. And neither do older people who are emmetropic, myopic or have had cataract surgery. With this narrow angle, what triggers angular closure is mydriasis. That is, when you are in the penumbra, the pupil dilates and the iris thickens in the peripheral part, where it is already very close to the corneal endothelium in the case of a narrow chamber. Mydriasis then triggers angular closure, which is accompanied by ocular pain that may radiate backwards (headache). And increased intraocular pressure produces corneal edema that causes blurred vision. Therefore, [HIDDEN]. Migraine does not have to be related to penumbra, and ocular pain and blurred vision is not particularly typical. Actinic keratitis is caused by exposure to ultraviolet radiation (such as solar radiation), and is not related to hyperopia or to being in penumbra. In addition, the history of exposure is usually clear. And finally, dry eye does not produce these symptoms either: it is more a question of burning, foreign body sensation, heaviness, etc. And it is also unrelated to the other elements: penumbra, hyperopia, etc. As a minor detail, I would have worded the question a little better. It is understood that we are asked which pathology is the most probable in relation to the symptoms and the anamnesis. But as it is worded, we are asked about which of the pathologies she is most likely to present, just like that. Actually, a 68-year-old woman is very likely to have dry eye, even if it does not cause the symptoms for which she is presenting.

A 68-year-old woman who uses +4.00 diopter glasses for distance vision in both eyes. She consults because she has been having eye pain with headache and blurred vision at night when she is watching television in dim light for a few weeks. Which of the following pathologies is she most likely to have?


A young male patient with an aortic systolic murmur that increases with the Valsalva maneuver and signs of left ventricular enlargement is practically a "portrait" of the typical findings that can be found in hypertrophic cardiomyopathy. Very easy question.

A young male patient with an aortic systolic murmur that increases with the Valsalva maneuver and signs of left ventricular enlargement is practically a "portrait" of the typical findings that can be found in hypertrophic cardiomyopathy. [HIDDEN]

A 26-year-old man with no history of interest, asymptomatic, presents on examination with a mesosystolic murmur in the aortic focus and left parasternal border that increases with the Valsalva maneuver. BP and peripheral pulses are normal and the ECG shows signs of marked left ventricular enlargement and very deep negative T waves in V3, V4, V5 and V6. What is the most likely diagnosis?


Preoperative chemoradio in all the guidelines.

65-year-old man who consults for dysphagia to solids since two months ago. Esophagoscopy shows a tumor 30 cm from the dental arch, partially stenosing, with pathological anatomy of squamous cell carcinoma. Endoscopic ultrasound and PET-CT scan were requested where no pathological lymphadenopathies were observed. Which of the following options would be the most correct?

Esophagectomy according to the Ivor-Lewis technique.

Chemotherapy plus preoperative radiotherapy.


Asthma treatment algorithm. We rule out continuing with the same treatment since the patient is symptomatic.

A patient diagnosed with bronchial asthma who is being treated with low-dose inhaled steroids (200 micrograms of budesonide every 12 hours) and rescue medication (salbutamol on demand) comes for periodic clinical monitoring. The patient reports that in the last 3 months he has had no exacerbations and that he uses salbutamol once a day. He only has dyspnea when climbing stairs and some nights he sleeps irregularly due to coughing. Which of the following therapeutic options should be considered as the treatment of choice?

Increase the dose of inhaled corticosteroids to 800 micrograms/day.

Maintain the same pharmacological regimen.

Switch to ocmbined therapy with low-dose inhaled corticosteroids and long-acting beta2-adrenergics.


Treatment with a brace in Risser from 0 to 2 can be considered since there is still growth to occur and correction can take place. Its use is considered for curves between 30-40º.

13-year-old female, with no relevant history, with menarche 3 months ago, followed since the age of 10 years for idiopathic scoliosis that has worsened. In the physical examination she presents a hump of 7 degrees in the Adams test and in the scoliogram a T4-L1 thoracolumbar curve of 35 degrees of Cobb and a Risser 0:

Recommend swimming and review in three months.

Refer to physiotherapy for spine elastification.