The fact that the place of residence is mentioned already gives us many clues. A "bite" that transforms into a lesion in an uncovered area with a crusty surface and that bothers little or nothing... in the Mediterranean basin this is cutaneous leishmaniasis or oriental button. And while it is true that the lesion is < 4 cm and unique, we are told that the patient is being treated with adalimumab, an anti-TNF monoclonal antibody. With the exception of meglumine antimoniate, none of the other treatments proposed in the different options are indicated in leishmaniasis, so it is clear. The only thing that is more debatable is that, as this is an immunosuppressed patient, systemic treatment would probably be more appropriate. I don't know if for that reason contestable, but at least, debatable.

The fact that the place of residence is mentioned already gives us many clues. A "bite" that transforms into a lesion in an uncovered area with a crusty surface and that bothers little or nothing... in the Mediterranean basin this is cutaneous leishmaniasis or oriental button. And while it is true that the lesion is < 4 cm and unique, we are told that the patient is being treated with adalimumab, an anti-TNF monoclonal antibody. With the exception of meglumine antimoniate, none of the other treatments proposed in the different options are indicated in leishmaniasis, so [HIDDEN]. The only thing that is more debatable is that, as this is an immunosuppressed patient, systemic treatment would probably be more appropriate. I don't know if for that reason contestable, but at least, debatable.

33-year-old patient, resident of Valencia, who consults for presenting on the right cheek an erythematous-orange plaque after an insect bite that has been growing slowly until reaching 1.5 cm and that in the last weeks has ulcerated and covered with a scammocostra. The lesion only causes discrete discomfort if scratched. The patient has a history of plaque psoriasis treated with subcutaneous adalimumab. She is in good general condition and does not take any other drugs and does not report any drug allergies. Indicate the treatment you would use:


We present a case of chronic compartment syndrome. For its diagnosis it is necessary to measure the pressure of the affected compartments at rest and after activity (answer 2 correct).

We present a case of chronic compartment syndrome. For its diagnosis it is necessary to measure the pressure of the affected compartments at rest and after activity ([HIDDEN]).

A 27-year-old male, a regular athlete, refers pain in the right leg after continuous running. He has visited a physiotherapist on several occasions and has been diagnosed with calf overload. 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.


Question in which the clinical picture must be recognized: cardiovascular anomalies - Tetralogy of Fallot -; thymic aplasia/hypoplasia - leading to primary T-cell immunodeficiency; parathyroid aplasia/hypoplasia - hence hypocalcemia -; palatal anomalies - nasal voice; psychomotor retardation. In my opinion, just with the words "thymic dysfunction", hypocalcemia and cardiopathy, we would have to go straight to DiGeorge syndrome. Indeed, the genetic defect is a 22q11.2 deletion (which if we know it, the better, but with the clinic it would be enough for us). The only option with which there could be doubt is Noonan syndrome, which can also be associated with cardiopathy, but above all it is characterized by short stature, cardiopathy and bone alterations; moreover, in most cases it is caused by an alteration in the PTPN11 gene, not in those mentioned in the question.

Question in which the clinical picture must be recognized: cardiovascular anomalies - Tetralogy of Fallot -; thymic aplasia/hypoplasia - leading to primary T-cell immunodeficiency; parathyroid aplasia/hypoplasia - hence hypocalcemia -; palatal anomalies - nasal voice; psychomotor retardation. In my opinion, just with the words "thymic dysfunction", hypocalcemia and cardiopathy, we would have to go straight to DiGeorge syndrome. [HIDDEN] The only option with which there could be doubt is Noonan syndrome, which can also be associated with cardiopathy, but above all it is characterized by short stature, cardiopathy and bone alterations; moreover, in most cases it is caused by an alteration in the PTPN11 gene, not in those mentioned in the question.

Amalia is a 3-year-old girl who has undergone surgery for tetralogy of Fallot. She also presented thymic dysfunction in the neonatal period and hypocalcemia as well as a nasal voice and psychomotor retardation. Which genetic test do you consider most appropriate to reach an etiological diagnosis?

22q11 deletion study (Di George or Velo-cardio-facial syndrome).

Study of FMR1 gene expansion, responsible for Fragile X syndrome.

Sequencing of genes related to HRAS (Noonan syndrome).

Genetic study of Williams Beuren syndrome.


Given this clinical picture and without having complementary tests available, the most likely diagnosis is reactive arthritis. The only problem is that the statement speaks of joint pain and not arthritis... Reiter's syndrome (triad of conjunctivitis, urethritis and arthritis) is one of the forms in which reactive arthritis can present. In Behçet's disease oral and genital aphthous ulcers may occur but urethritis is not a feature. And the characteristic ocular condition is uveitis.

A 40-year-old patient who comes to the emergency room with aphthous stomatitis, conjunctivitis, urethritis, balanitis and joint pain. Which of the following diagnoses is the most likely?


We are talking about a patient with 3-vessel coronary artery disease and, very importantly, with severe ventricular dysfunction. Under these conditions, the treatment of choice would be surgical (myocardial revascularization surgery or by-pass). In the case of a patient with preserved LV function, the choice of surgical vs. percutaneous treatment would be more questionable, since today, thanks to drug-eluting stents, the differences in terms of morbidity and mortality between by-pass surgery and angioplasty are minimal.

We are talking about a patient with 3-vessel coronary artery disease and, very importantly, with severe ventricular dysfunction. Under these conditions, [HIDDEN]. In the case of a patient with preserved LV function, [HIDDEN], since today, thanks to drug-eluting stents, [HIDDEN].

A 60-year-old man reports precordial pain after medium exertion. Coronary angiography shows significant stenosis in the proximal segments of the three main vessels with good distal bed. Ventricular function is depressed (<30%). What is the best therapeutic option?

Implantation of balloon counterpulsation.


We are dealing with a severe patient, with target lesions and Nikolsky's sign in > 30% of the body surface area. Together with the history of treatment with carbamazepine, the suspicion will be of toxic epidermal necrolysis (answer 4). If the epidermal detachment is less than 10% then we would be dealing with Stevens-Johnson (and intermediate cases are referred to as overlap, since it is a whole spectrum). Incidentally, we would recommend immediate admission to a major burn unit.

We are dealing with a severe patient, with target lesions and Nikolsky's sign in > 30% of the body surface area. Together with the history of treatment with carbamazepine, the suspicion will be of toxic epidermal necrolysis ([HIDDEN]). If the epidermal detachment is less than 10% then we would be dealing with Stevens-Johnson (and intermediate cases are referred to as overlap, since it is a whole spectrum). Incidentally, we would recommend immediate admission to a major burn unit.

A 60-year-old man on carbamazepine treatment for epilepsy presenting with fever (38.8°C), odynophagia, conjunctivitis, brownish skin lesions spread over a large body surface, target-like in appearance and accompanied by epidermal detachment (greater than 30%) at the slightest friction. It is very likely that she is presenting a clinical picture of:

Acute urticaria of pharmacological cause.

Erythema minor exudative secondary to drugs.


This is a very simple question and very useful for the management of PTE in the ED. There is no need to worry: a patient with advanced renal failure (stage 5) is contraindicated for any imaging study that requires the administration of IV contrast, such as CT angiography. All other examinations do not require it and therefore would be more than indicated in the presence of a PTE.

A 72-year-old woman with type 2 diabetes and stage 5 chronic renal insufficiency. Given the suspicion of pulmonary thromboembolism, indicate which diagnostic test is contraindicated:


Vasospasm as a complication of subarachnoid hemorrhage usually occurs early, in the week after the hemorrhage. The progressive deterioration with alteration of the level of consciousness makes us suspect one of the complications that can occur in this condition: hydrocephalus. The diagnostic technique of choice in this case is neuroimaging with cranial CT.

A 55-year-old male who suffers a subarachnoid hemorrhage due to a ruptured middle cerebral artery aneurysm. He is treated surgically. After a good evolution in which he recovers the ability to walk, one month after suffering the hemorrhage, he presents a progressive deterioration, becoming cloudy and with difficulty to obey orders. Mark the correct statement:

She is in the moment of evolution in which vasospasm is more frequent.

This progressive deterioration is probably secondary to aneurysm rebleeding.

Subacute deterioration is most likely due to hydrocephalus.

The diagnostic technique of choice is cerebral angiography.


The key in the question is "stopping the clinical course", as Hungtinton's disease, Tourette's and Parkinson's disease do not have treatments that can stop the clinical course. Sydenham's chorea is typical of younger children with a history of streptococcal infection and resolution is usually spontaneous. On the other hand, in clinical cases it is recommended to rule out Wilson's disease in young patients with movement and neuropsychiatric disorders.

In a patient presenting in the second decade of life with a progressive picture of parkinsonism, tremor, dystonia and behavioral alteration, you should always perform a study to rule out the presence of a disease whose appropriate treatment can improve neurological symptoms and stop the clinical course. What disease is it?


Paralytic ileus is a failure of intestinal propulsion that appears acutely in the absence of mechanical obstruction; it is secondary to various causes and affects intestinal contractility. Therefore, parenteral administration is necessary.

In a hospitalized patient who is unable to feed orally for more than 6 days, in which of the following clinical situations are we necessarily to use parenteral nutrition?

Cardioembolic stroke with complete neurologic dysphagia.

Cachexia due to chronic empyema in immunocompromised patient.

Advanced Alzheimer's disease with severe risk of bronchial aspiration.


Chancroid is a solitary lesion.

Chancroid is a solitary lesion. Secondary syphilis usually occurs as a generalized rash or as characteristic lesions on palms and soles (syphilitic nails) with a longer latency period. Trichomonas balanitis is always associated with urethritis, which is not referred to in the question. Therefore, the answer is 1. However, the clinical picture suggests herpes simplex rather than candidiasis and 5 also refers to fungi (although dermatophytes do not cause balanitis).... from our point of view, even if we consider 1 to be correct, the question is misleading and could be open to challenge. Moreover, genital candidiasis is not necessarily sexually transmitted.

Chancroid is a solitary lesion. Secondary syphilis usually occurs as a generalized rash or as characteristic lesions on palms and soles (syphilitic nails) with a longer latency period. Trichomonas balanitis is always associated with urethritis, which is not referred to in the question. Therefore, [HIDDEN]. However, the clinical picture suggests herpes simplex rather than candidiasis and [HIDDEN] (although dermatophytes do not cause balanitis).... from our point of view, even if we consider [HIDDEN], the question is misleading and could be open to challenge. Moreover, genital candidiasis is not necessarily sexually transmitted.

A 24-year-old young man who 3 days after a risky sexual contact presents numerous pustular lesions, small, very pruritic and evolving to tiny erosions affecting the entire glans and the inner face of the foreskin. Which of the following is the most likely diagnostic approach?


This is because in early ovarian failure FSH and LH are elevated. This is confirmed by the SEGO protocol called Early Menoguia. The rest of the diagnoses are consistent with these analytical parameters.

A 21-year-old woman comes for consultation with a hormonal study showing FSH 0.29 mUl/mL (normal in follicular phase = 3.50-12.50 mUl/mL) and LH < 0.1 mUl/mL (normal in follicular phase 2.40-12.60 mUl/mL). We should make a differential diagnosis between the following clinical situations EXCEPT:

Administration of combined oral contraceptives.


Prerenal acute renal failure due to NSAIDs seems the most plausible option in this case. Tubulointerstitial nephritis due to methotrexate is less likely due to the absence of rash, fever or eosinophilia, which although rare in the MIR usually appear. Although GMN and renal amyloidosis are relatively frequent in RA, the anodyne urine sediment and the absence of proteinuria make these options unlikely.

Prerenal acute renal failure due to NSAIDs seems [HIDDEN]. Tubulointerstitial nephritis due to methotrexate is less likely due to the absence of rash, fever or eosinophilia, which although rare in the MIR usually appear. Although GMN and renal amyloidosis are relatively frequent in RA, the anodyne urine sediment and the absence of proteinuria make these options unlikely.

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

Glomerulonephritis secondary to rheumatoid arthritis.

Renal failure due to non-steroidal anti-inflammatory drugs.

Interstitial nephritis due to methotrexate.


In a polytraumatized patient, the first cause of shock is blood loss (hemorrhagic shock). The guidelines to follow should always contemplate the replenishment of blood volume (if possible, with blood products as early as possible) and control of the focus. In this case, given the vital compromise, the need for transfusion is very urgent, so the indication is emergency blood transfusion (O Rh negative).

A 34-year-old male is involved in a traffic accident and is attended at the scene of the accident. The medical personnel observe that he is pale, sweaty, has a thready pulse with a blood pressure of 90/50 mmHg, a heart rate of 127 bpm, a respiratory rate of 28 rpm and an oxygen saturation of 92%. He was infused with 20 ml/kg of crystalloids. During his transfer to the hospital his vital signs improve transiently and then deteriorate on arrival at the hospital. Point out the correct answer:

Type-specific blood transfusion required.

Requires emergency blood transfusion (O Rh negative).

A possible blood transfusion with crossmatching tests should be prepared.

Try again infusion of another 20 ml/kg of crystalloids.


Angioedema is a type of profound urticaria that can be of drug etiology (not IgE-mediated) and in this case, ACEIs (such as enalapril) are considered the most frequent pharmacological cause, so in this case it would be the correct answer (if we speak in probabilistic terms).

Angioedema is a type of profound urticaria that can be of drug etiology (not IgE-mediated) and in this case, ACEIs (such as enalapril) are considered the most frequent pharmacological cause, so in this case it would be [HIDDEN] (if we speak in probabilistic terms).

A 72-year-old patient comes to the emergency department for presenting with severe and significant lingual angioedema. She does not present associated urticaria and has no history of drug or food allergy. His personal history includes type 2 diabetes mellitus, dyslipidemia, hypertension, hypothyroidism and Parkinson's disease. She is on 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?


We describe a picture of typical peripheral facial paralysis, with dysgeusia, hyperacusis and mastoid pain. In this case the treatment is corticoid. The first one would not be correct because although within the age range of multiple sclerosis debut, the presentation is usually gradual over days and the nuclear involvement of the VII cranial nerve (which could simulate a peripheral facial) would not cause dysgeusia, hyperacusis or mastoid pain. In the third answer they propose us that it is a vascular picture and therefore that the facial paralysis is central, so it is discarded and the last one is not correct because most of the idiopathic peripheral facial paralysis (Bell's palsy) heal without sequelae.

We describe a picture of typical peripheral facial paralysis, with dysgeusia, hyperacusis and mastoid pain. In this case the treatment is corticoid. The first one would not be [HIDDEN] because although within the age range of multiple sclerosis debut, the presentation is usually gradual over days and the nuclear involvement of the VII cranial nerve (which could simulate a peripheral facial) would not cause dysgeusia, hyperacusis or mastoid pain. In the third answer they propose us that it is a vascular picture and therefore that the facial paralysis is central, so it is [HIDDEN] and the last one is not [HIDDEN] because most of the idiopathic peripheral facial paralysis (Bell's palsy) heal without sequelae.

A 20-year-old girl comes to the emergency department because she has noticed after getting up, when looking in the mirror, weakness in the right half of the face (including the forehead, closing the eyelid and smiling). She is accompanied by dysgeusia, with a sensation of metallic taste of food as well as hyperacusis and ipsilateral mastoid pain. On examination there is no evidence of strength deficits or sensory deficits in the extremities or speech or language disorders. In this case, which of the following statements is correct?

The most probable diagnosis is a demyelinating plaque in the contralateral hemiprotuberance, the most necessary complementary exploration would be a cranial MRI.

Oral corticosteroids are the treatment of choice for the patient.

Intravenous fibrinolysis should be considered if the evolution time is less than 3h.

Most likely the picture is irreversible.


In this case, he is describing the cardinal symptoms of polymyalgia rheumatica. Older patient, over 50 years of age, presenting with pain and stiffness in both girdles, associated with an elevation of acute phase reactants. He presents all the indispensable criteria: age equal to or greater than 50 years, bilateral omalgia and increased acute phase reactants. Of the optional criteria, he presents stiffness, pain or limitation in the hip. Initial treatment is corticosteroids at medium doses.

A 70-year-old woman who has been complaining for 1 month of pain and stiffness in the shoulder girdle and pelvic girdle, which predominates when she gets up and improves with mobilization, without fever, headache or general condition. Physical examination showed stiffness and pain on mobilization of the shoulders and hips. Laboratory tests show elevated ESR and C-reactive protein. What is the most likely diagnosis and what treatment would you prescribe?

Rheumatoid arthritis, would initiate treatment with methotrexate.

Fibromyalgia, would initiate treatment with duloxetine.

Polymyalgia rheumatica, would initiate treatment with corticosteroids.

Ankylosing spondylitis, I would initiate treatment with non-steroidal anti-inflammatory drugs.


It is the classic exploration: he had a fever and pain, he had pericarditis with effusion, and now this is causing tamponade. Hence the hypotension (his heart cannot fill well with blood and pump), jugular engorgement and dependence on respiration to achieve preload and cardiac output (i.e. paradoxical pulse).

A 45-year-old man with a history of febrile illness and chest pain comes to the hospital with dyspnea and tachypnea. On physical examination his blood pressure is low, jugular venous pressure is elevated with a prominent descending sinus x and he has a paradoxical pulse. What diagnosis would you suspect?

Pericardial effusion with cardiac tamponade.


They give to know of a patient with SLE in treatment with Hydroxychloroquine. She has a hb of 7.4 and a MCV over 100, adding pallor and weakness, we would be dealing with a macrocytic anemia. In my opinion, the most suitable would be alternative 2, since hydroxyloroquine has been reported to decrease the absorption of folic acid, and since she has a complication of SLE, in this case, we could be dealing with an autoimmune hemolytic anemia with folic acid consumption. And for this it would be first to determine with the direct coombs.

A 26-year-old woman diagnosed with systemic lupus erythematosus, on treatment with hydroxychloroquine, who consults for a feeling of generalized weakness that has progressively set in over the last 15 days. The physical examination reveals cutaneous pallor and the CBC shows Hb 7.4 g/dL, Hct 31%, MCV 108. Which of the following tests will be most useful in deciding the course of action?


The correct answer is 3. In the inguinal region, the lymph nodes can acquire a size of up to 1.5 cm being normal. In addition, the rest of the data of the inguinal exploration (no pain, mobile, soft, etc.) corroborates this. On the other hand, there are no signs or symptoms that make us think of a sexually transmitted infection.

[HIDDEN] In the inguinal region, the lymph nodes can acquire a size of up to 1.5 cm being normal. In addition, the rest of the data of the inguinal exploration (no pain, mobile, soft, etc.) corroborates this. On the other hand, there are no signs or symptoms that make us think of a sexually transmitted infection.

A 24-year-old woman consults after noticing inguinal lymphadenopathies. The interrogation does not show any local discomfort or data suggestive of sexually transmitted infection. The examination revealed two lymphadenopathies, one in each groin, 1 cm in diameter, soft, mobile, non-painful. No skin lesions are seen on the lower limbs, anus or perineum. Which test do you consider essential?

A lupus serology since it is most likely a Treponema pallidum infection.

A gynecological examination to rule out ovarian cancer.

From the clinical features it seems to be normal lymph nodes and complementary explorations should not be performed.

A Paul-Bunell test should be performed to rule out infectious mononucleosis.


Ivabradine, in fact, is contraindicated in patients with atrial fibrillation. Initially (although evidence has recently emerged that qualifies this information) ivabradine was said to be selective over the sodium If current in the sinus node. If the patient is in AF, it makes no sense to act on the sinus node.

An 84-year-old man with chronic heart failure in functional grade II secondary to ischemic heart disease with severe non-revascularizable systolic dysfunction, stage 3 chronic kidney disease (glomerular filtration rate 45-50 mL/min) and permanent atrial fibrillation with heart rate >80 beats per minute. Which of the following drugs does NOT provide benefit to the patient according to the currently available evidence?

Angiotensin converting enzyme inhibitors.


Question always involves the brainstem. We have a right hemiparesis and involvement of the left facial nucleus, since it has affected the upper and lower facial; therefore we have a crossed clinical picture, having to think about brainstem involvement. If we have in a quick diagram where the nuclei of the cranial pairs start from: the first 4 above the pons, the next 4 in the pons, and the last 4 below the pons, we have that the facial nucleus is in the middle 4. That is, left facial nucleus, left pons, so answer 4.

Question always involves the brainstem. We have a right hemiparesis and involvement of the left facial nucleus, since it has affected the upper and lower facial; therefore we have a crossed clinical picture, having to think about brainstem involvement. If we have in a quick diagram where the nuclei of the cranial pairs start from: the first 4 above the pons, the next 4 in the pons, and the last 4 below the pons, we have that the facial nucleus is in the middle 4. That is, left facial nucleus, left pons, so answer [HIDDEN].

An individual presents with "muscle weakness" (spastic hemiparesis) of both right extremities, with hyperreflexia and Babinski's sign, along with a "facial flaccid paralysis" of the left hemiface, with inability to close the left eye or retract the left side of the mouth, in addition to other alterations. From the data described, it is an alteration that affects, among other elements, the motor fascicles: cortico-spinal and cortico-nuclear, but at what level of the neuroaxis would the lesion be located?

At the level of the area 4 of Brodmann of the cerebral cortex of the right side.

In the internal capsule, posterior arm on the right side.

In the medial portion of the caudal protuberance of the left side.

In the medulla oblongata before decussation of the right cortico-spinal fascicle.


Overuse of the drugs he is taking should be suspected. Olanzapine has no antidote, so, in principle, we should antagonize the effect of benzodiazepines. If the patient continues to be drowsy and does not respond to stimuli, we should proceed to intubate to secure the airway.

A 30-year-old woman with a drug addiction PD in a current detoxification period is brought to the ED with profound somnolence, with no other symptoms. We find out that her treatment includes olanzapine and benzodiazepines. What should we do first?

ANESTHESIOLOGY, CRITICAL CARE AND EMERGENCY MEDICINE


We are not given any further data on the patient except that she is in shock (tissue hypoperfusion) and on introducing a Swan-Ganz catheter we find a low cardiac index (<2), elevated PCP (25mmHg) and elevated systemic resistances (normal: 600-1200 dyne/m2). These data are compatible with cardiogenic origin of shock.

Woman with hypotension and tissue hypoperfusion in whom the following parameters are objectified after insertion of a Swan-Ganz catheter: cardiac index 1.4 L/min/m2, pulmonary capillary wedge pressure 25 mmHg and systemic vascular resistances 2000 dynes/m2. The type of shock presented by the patient is:


The data provided on the characteristics of the murmur (it DECREASES with Valsalva) and the data on left ventricular hypertrophy, lead us to the diagnosis of severe aortic stenosis.

A 58-year-old hypertensive man comes to the emergency department for a 30-second syncope while jogging, with spontaneous recovery and no sequelae. Blood pressure is 135/65 mmHg. Cardiac auscultation shows a loud, intense systolic murmur, which is reduced with Valsalva maneuvers and an attenuated second tone. The ECG shows sinus rhythm at 72 bpm, with criteria of left ventricular hypertrophy and inverted T waves in anterior face. Point out the correct statement:

The clinical picture suggests pulmonary thromboembolism.

The data provided indicate hypertrophic cardiomyopathy with severe obstruction of the left ventricular outflow tract.

These data correspond to severe aortic stenosis.

Aortic dissection should be excluded by contrast-enhanced computed tomography.


VVI pacemaker (ventricular unicameral).

82-year-old woman with chronic atrial fibrillation of 10 years of evolution and preserved biventricular systolic function who presents with episodes of symptomatic complete atrioventricular block, so it is decided to implant a definitive cardiac pacing system. Which of the following is indicated:

AAI pacemaker (single-chamber atrial pacemaker).

Ventricular resynchronization therapy (CRT).


We are faced with a situation of probable liver metastasis from a localized colon adenocarcinoma treated 2 years ago. Probable because we do not have histological confirmation, although as it usually happens, what else could it be? As this is a situation of oligometastasis and the treatments for advanced colon adenocarcinoma allow prolonged survival with good quality of life in these patients, if there is nothing to contraindicate surgery, this should be the first option (correct answer 3). I attach the algorithm proposed by the NCCN in situations of recurrence (http://www.nccn.org/professionals/physician_gls/pdf/colon.pdf). In case of an unresectable situation, chemotherapy treatment would be considered with the intention of converting the single metastatic lesion into a resectable one. Since more than 12 months have passed since FOLFOX treatment, the same scheme could be used, although FOLFIRI+bevacizumab would also be useful. Capecitabine monotherapy, in the patient's current situation, would also not be a good starting option, since the responses are lower compared to FOLFOX or FOLFIRI plus antiangiogenic combinations. Hepatic radiotherapy could be considered, since there are SBRT techniques that achieve very good results, but in this case it is best to start by asking for an assessment by the surgeons and if they rule out surgery we would consider RT.

We are faced with a situation of probable liver metastasis from a localized colon adenocarcinoma treated 2 years ago. Probable because we do not have histological confirmation, although as it usually happens, what else could it be? As this is a situation of oligometastasis and the treatments for advanced colon adenocarcinoma allow prolonged survival with good quality of life in these patients, if there is nothing to contraindicate surgery, this should be the first option ([HIDDEN]). I attach the algorithm proposed by the NCCN in situations of recurrence (http://www.nccn.org/professionals/physician_gls/pdf/colon.pdf). In case of an unresectable situation, chemotherapy treatment would be considered with the intention of converting the single metastatic lesion into a resectable one. Since more than 12 months have passed since FOLFOX treatment, the same scheme could be used, although FOLFIRI+bevacizumab would also be useful. Capecitabine monotherapy, in the patient's current situation, would also not be a good starting option, since the responses are lower compared to FOLFOX or FOLFIRI plus antiangiogenic combinations. Hepatic radiotherapy could be considered, since there are SBRT techniques that achieve very good results, but in this case it is best to start by asking for an assessment by the surgeons and if they rule out surgery we would consider RT.

A 57-year-old patient diagnosed with stage T3N1M0 adenocarcinoma of the colon. He was treated with resection followed by postoperative FOLFOX chemotherapy (fluorouracil, leucovorin and oxaliplatin) for 6 months. In a routine control, two years later, carcinoembryonic antigen (CEA) elevation to 30 ng/mL (previously less than 2 ng/mL) was detected. She has no symptoms, physical examination is unremarkable, chest X-ray is normal. CT scan shows a 3 cm mass in the right hepatic lobe that is captured on PET. No other alterations are observed in CT or PET. What is the most correct approach?

Chemotherapy with FOLFIRI (fluorouracil, leucovorin and irinotecan) plus bevacizumab.

Assessment for surgical resection of the hepatic lesion.


The first thing we need to know is that combustion of polyurethane at high temperature results in the release of cyanide (very intuitive, yes). Knowing this, and that we are dealing with cyanide poisoning, it is easier to answer the question. Among the basic initial treatment measures would be the administration of oxygen therapy with FiO2 1 (not 0.5 as stated in option 1), and an antidote, in this case hydroxycobalamin (this was asked similarly last year). Ventilation with hyperbaric chamber would only be indicated in case of coexistence of carbon monoxide (CO) poisoning. What is stated in option 4 about fluid therapy is not indicated; in case of associated shock, volume would be administered, but in any case not at that rate, but in rapid boluses.

The first thing we need to know is that combustion of polyurethane at high temperature results in the release of cyanide (very intuitive, yes). Knowing this, and that we are dealing with cyanide poisoning, it is easier to answer the question. Among the basic initial treatment measures would be the administration of oxygen therapy with FiO2 1 (not 0.5 as stated in [HIDDEN]), and an antidote, in this case hydroxycobalamin (this was asked similarly last year). Ventilation with hyperbaric chamber would only be indicated in case of coexistence of carbon monoxide (CO) poisoning. What is stated in [HIDDEN] about fluid therapy is not indicated; in case of associated shock, volume would be administered, but in any case not at that rate, but in rapid boluses.

A patient is brought to the ED from a fire occurring inside an enclosed building where polyurethane foams were present. He is conscious, but presents with increasing mental dullness, headache, and severe dyspnea. Oxygen saturation by pulse oximetry is 92% and capillary lactic acid is 8 mEq/l. What specific treatment do you consider most appropriate?

Administration of oxygen by means of a 50% Venturi type mask.

Administration of intravenous hydroxycobalamin.

Fluid therapy with infusion of physiological saline solution at 21 ml/h.


Spontaneous reports of serotonergic syndrome associated with concomitant administration of linezolid and serotonergic agents, including antidepressants such as selective serotonin reuptake inhibitors (SSRIs), have been reported.

In a 35-year-old patient with a depressive syndrome on treatment with serotonin reuptake inhibitors, the use of the following antimicrobials is contraindicated:


Option 4 is not indicated.

The clinical case is a typical pulmonary thromboembolism. In this case it is associated with persistent arterial hypotension. Option 2 would be correct if the patient were not hypotensive. Option 3 is not correct since diagnostic confirmation is not necessary to initiate anticoagulant therapy in case of PTE without hypotension. Option 4 is not indicated. Option 5 would be correct only if the patient had a contraindication to fibrinolysis. Persistent hypotension in PTE is the most widely accepted indication for fibrinolysis, so the correct option is 1.

The clinical case is a typical pulmonary thromboembolism. In this case it is associated with persistent arterial hypotension. Option 2 would be [HIDDEN] if the patient were not hypotensive. Option 3 is [HIDDEN] since diagnostic confirmation is not necessary to initiate anticoagulant therapy in case of PTE without hypotension. Option 4 is [HIDDEN]. Option 5 would be [HIDDEN] only if the patient had a contraindication to fibrinolysis. Persistent hypotension in PTE is the most widely accepted indication for fibrinolysis, so [HIDDEN].

A 37-year-old man with no past history of interest comes to the emergency department for syncope while walking. He had started two days earlier with dyspnea on exertion. Examination: weight 75 kg, BP 75/50 mm Hg. SatO2 89%. Pulmonary auscultation was normal. Cardiac auscultation: rhythmic tachycardic tones at 130 bpm. Abdomen normal. Extremities: no alterations. Normal hemogram. Troponin 1.2 ng / ml. ECG: Sensual tachycardia at 130 bpm. Inverted T in V1-V4. Thoracic CT angiography: repletion defect in both main pulmonary arteries. One hour after arrival at the emergency room, BP 70/55 mm Hg persists. What would be the most appropriate initial treatment?

Unfractionated heparin, 10,000U iv on clinical suspicion. Fibrinolysis with tPA 100 mg iv once the diagnosis is confirmed.

Enoxaparin: 80 mg sc every 12 hours, starting upon diagnostic suspicion.

Enoxaparin; 80 mg sc every 12 hours, starting upon diagnostic confirmation.

ANESTHESIOLOGY, CRITICAL CARE AND EMERGENCIES


Dysesthesia of the lateral aspect of the deltoid region of the shoulder (area innervated by the axillary nerve) and paralysis of the deltoid (primary muscle for abduction beyond 15°). The rotator cuff is undamaged in the MRI, ruling out option 1 (it would show us tendinopathy of the teres major). Adhesive capsulitis presents with pain and stiffness of the shoulder, especially on active and passive external rotation. The suprascapular nerve innervates the supraspinatus muscle, which contributes to the first 15º of shoulder abduction (preserved in the statement) and does not innervate the skin of the reflected area.

Dysesthesia of the lateral aspect of the deltoid region of the shoulder (area innervated by the axillary nerve) and paralysis of the deltoid (primary muscle for abduction beyond 15°). The rotator cuff is undamaged in the MRI, [HIDDEN]. Adhesive capsulitis presents with pain and stiffness of the shoulder, especially on active and passive external rotation. The suprascapular nerve innervates the supraspinatus muscle, which contributes to the first 15º of shoulder abduction (preserved in the statement) and does not innervate the skin of the reflected area.

A fall with anterior shoulder fracture-dislocation that was reduced in the emergency department. A sling was placed and its removal was recommended after 3 weeks. On removal of the immobilization, an area of dysesthesia circumscribed to the lateral region of the shoulder was observed. The patient can perform abduction, but only reaches 15 degrees. She has a magnetic resonance imaging study in which the rotator cuff is undamaged. What is the most likely diagnosis of suspicion?


We are presented with a patient with risk factors for oropharyngeal cancer, but in whom the examination and tests are normal. What is going on here? This question is reverse psychology: what did the questioner want me to know? This question was asked by an otolaryngologist. He already tells you that the dentist "didn't see anything", so he rules out 1. It is not an abscess of the base of the tongue either, because in three months it would have killed him: neither is 2. So we are left with ankyloglossia, tongue base cancer and non-specific inflammation. When there is doubt that it could be cancer, we should not fool around and order a new CT scan and biopsy. Tongue base cancers are very treacherous and it is one of the fears of any otolaryngologist when he suspects a neoplasm. It is not uncommon for them to arise without exophytic masses or ulcerations of the tongue mucosa and they are difficult to detect on CT when contrast is not used. The correct answer is 4 and I do not think it can be challenged.

We are presented with a patient with risk factors for oropharyngeal cancer, but in whom the examination and tests are normal. What is going on here? This question is reverse psychology: what did the questioner want me to know? This question was asked by an otolaryngologist. He already tells you that the dentist "didn't see anything", so [HIDDEN]. It is not an abscess of the base of the tongue either, because in three months it would have killed him: [HIDDEN]. So we are left with ankyloglossia, tongue base cancer and non-specific inflammation. When there is doubt that it could be cancer, we should not fool around and order a new CT scan and biopsy. Tongue base cancers are very treacherous and it is one of the fears of any otolaryngologist when he suspects a neoplasm. It is not uncommon for them to arise without exophytic masses or ulcerations of the tongue mucosa and they are difficult to detect on CT when contrast is not used. [HIDDEN] and I do not think it can be challenged.

A 64-year-old smoker and heavy drinker with no other history of interest. The picture he explains is odynodysphagia of 3 months of evolution and left otalgia. He provides a dentist's report that rules out a dental cause. He also refers to having been visited by different specialists and provides a head and neck CAT scan (without iodine contrast) which is reported as normal. On examination there was a decrease in the propulsive capacity of the tongue; palpation of the base of the left tongue showed an induration of stony consistency of approximately 3cm and with indirect laryngoscopy no ulceration of the mucosa was observed. Cervical palpation is negative for lymphadenopathy. What is your presumptive diagnosis and course of action?

Dental cause / reevaluation by the dentist.

Abscess of the base of the tongue / debridement.

Ankyloglossia / surgical release of the same.

Malignant process of oropharynx / repeat CT scan and biopsy.

Nonspecific inflammation / corticosteroid treatment.

OTORHINOLARYNGOLOGY AND MAXILLOFACIAL SURGERY


Glomerulonephritis is typically associated with dysmorphic red blood cells and hematic casts in the sediment (option 1 correct). Proteinuria can also appear in variable range, although it is not usual in the form of isolated microalbuminuria (incorrect option 2), and hematuria with pyuria although it is not characteristic (incorrect option 3). Clots usually appear in the context of alterations of the lower urinary tract (option 4 incorrect).

Glomerulonephritis is typically associated with dysmorphic red blood cells and hematic casts in the sediment ([HIDDEN]). Proteinuria can also appear in variable range, although it is not usual in the form of isolated microalbuminuria ([HIDDEN]), and hematuria with pyuria although it is not characteristic ([HIDDEN]). Clots usually appear in the context of alterations of the lower urinary tract ([HIDDEN]).

A 28-year-old man comes to the hospital emergency room with gross hematuria. Which of the following urinalysis abnormalities would support a diagnosis of glomerulonephritis?

Dysmorphic red blood cells and/or hematic casts.

Proteinuria of 1 g/day, with negative test strip result and with microalbuminuria greater than 300 mg/24 hours.

Coexistence of hematuria with pyuria without bacteriuria.


Urgent surgical treatment by thromboembolectomy.

An 85-year-old man in permanent atrial fibrillation consults for abrupt pain and coldness in the right foot for 6 hours. On examination he presents plantar cyanosis with partial sensory and mobility deficit. The femoral pulse is palpable, while the popliteal and distal pulses of this extremity are absent. Which of the following is the best therapeutic approach?

Discourage revascularization surgery because of prolonged ischemia time.

Apply heat and notify the on-call vascular surgeon.

Urgent medical treatment with intravenous prostaglandins.


The retractile testicle is characterized by the testicle being permanently outside the scrotal sac, being possible to descend it manually (although when it is released it automatically returns to its initial location). It is usually due to a short pedicle. In this case we are being told that the teste is always in the inguinal canal (cryptorchidism) so we can discard option 1. Hormonal treatment with HCG has already fallen into disuse, due to its low efficacy, possibility of reascension and because apoptotic and inflammatory phenomena have been described in the teste associated with its use (we discard option 3). Orchidopexy is the treatment of choice when we are faced with cryptorchidism, being desirable to perform it between 6 months and one year of age, and should not be deferred beyond two years of age.

The retractile testicle is characterized by the testicle being permanently outside the scrotal sac, being possible to descend it manually (although when it is released it automatically returns to its initial location). It is usually due to a short pedicle. In this case we are being told that the teste is always in the inguinal canal (cryptorchidism) so we can [HIDDEN]. Hormonal treatment with HCG has already fallen into disuse, due to its low efficacy, possibility of reascension and because apoptotic and inflammatory phenomena have been described in the teste associated with its use ([HIDDEN]). Orchidopexy is the treatment of choice when we are faced with cryptorchidism, being desirable to perform it between 6 months and one year of age, and should not be deferred beyond two years of age.

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

The most probable diagnosis is retractile testicle.

Wait until two years of age for its spontaneous decrease.

Human chorionic gonadotropin is the treatment of first choice.

The indication for orchidopexy should not be deferred.


The Thessaly maneuver consists of the patient, using monopodal support and knee flexion of 5º and then 20º, performing internal and external rotations of the leg. In case this reproduces the pain that the patient refers, the test will be considered as positive. It is a test used for the diagnosis of meniscal pathology (sensitivity greater than 90% and specificity greater than 95%) (Answer 1 correct).

The Thessaly maneuver consists of the patient, using monopodal support and knee flexion of 5º and then 20º, performing internal and external rotations of the leg. In case this reproduces the pain that the patient refers, the test will be considered as positive. It is a test used for the diagnosis of meniscal pathology (sensitivity greater than 90% and specificity greater than 95%) ([HIDDEN]).

A 41-year-old male consults for gonalgia of several days' evolution. During the examination, the Thessaly test (pain with internal and external rotation movements with the knee flexed) is positive. Which of the following lesions is most likely to occur?

Injury by rupture of the anterior cruciate ligament.

Injury by rupture of the posterior cruciate ligament.


The GI stromal tumor is better known as GIST, positive CD117, ckit, PDGF, manual.

A 60-year-old man with abdominal pain and upper gastrointestinal bleeding was found to have an abdominal tumor related to the gastric wall. Histology shows a spindle cell tumor with few mitoses, positive for CD117. The most likely diagnosis is:


Thessaly test. Provocation test performed in suspected meniscal injury.

A 41-year-old male consults for gonalgia of several days' evolution. On examination, the Thessaly test (pain with internal and external rotation movements with the knee flexed) is positive. Which of the following injuries is more likely?

Injury due to rupture of the anterior cruciate ligament.


It is striking in this question that we are told that our patient has returned to Spain, but not from where (which could help us to make digressions about the possible cause). However, the description of the picture is very exhaustive as well as typical, so the question is easy. It is a disease that produces fever, arthralgias and a generalized exanthema with petechiae on the lower limbs. The CBC shows leukopenia accompanied by plateletopenia and elevated transaminases. Malaria has been ruled out as a possible cause. All the data are highly suggestive of Dengue, especially the plateletopenia and petechiae (suggestive of capillary fragility), answer 3 correct.

It is striking in this question that we are told that our patient has returned to Spain, but not from where (which could help us to make digressions about the possible cause). However, the description of the picture is very exhaustive as well as typical, so the question is easy. It is a disease that produces fever, arthralgias and a generalized exanthema with petechiae on the lower limbs. The CBC shows leukopenia accompanied by plateletopenia and elevated transaminases. Malaria has been ruled out as a possible cause. All the data are highly suggestive of Dengue, especially the plateletopenia and petechiae (suggestive of capillary fragility), [HIDDEN].

A 54-year-old man diagnosed with type 2 diabetes mellitus comes to our office. He reported a fever of 40ºC with chills and shivering, arthromyalgia and headache, for which he started treatment with paracetamol. The symptoms started 24 hours before his return to Spain. Three days later she presented a generalized maculopapular rash that evolved into more intense petechiae on the lower limbs. She presented blood tests with leukopenia with 3,200/mm3 and platelets 91,000/mm3 and severe elevation of aminotransferases. The thick blood drop, peripheral blood smear, PCR and malaria antigen are negative. What is the most likely diagnosis?


Typical very long and rambling question but not really too complicated... The patient is in heart failure with moderate ventricular dysfunction and also presents atrial fibrillation; she has criteria for anticoagulation, and between the two options that include acenocoumarol we are inclined to choose option 4, since it includes carvedilol, a drug that has been shown to increase survival in heart failure. Verapamil (and calcium antagonists in general) are contraindicated in systolic heart failure: they do not increase survival (they even increase morbidity and mortality) and specifically the non-dihydropyridines (verapamil and diltiazem) should not be associated with beta-blockers due to the increased risk of conduction system blockade.

Typical very long and rambling question but not really too complicated... The patient is in heart failure with moderate ventricular dysfunction and also presents atrial fibrillation; she has criteria for anticoagulation, and between the two options that include acenocoumarol we are inclined to choose [HIDDEN], since it includes carvedilol, a drug that has been shown to increase survival in heart failure. Verapamil (and calcium antagonists in general) are contraindicated in systolic heart failure: they do not increase survival (they even increase morbidity and mortality) and specifically the non-dihydropyridines (verapamil and diltiazem) should not be associated with beta-blockers due to the increased risk of conduction system blockade.

A 78-year-old woman with a history of hypertension treated with amlodipine was admitted 3 months ago for heart failure and atrial fibrillation. She came to your office for a cardiological check-up. The discharge report shows the result of the echocardiogram showing moderate left ventricular dysfunction and the discharge treatment: amlodipine was discontinued and furosemide and enalapril were started. The patient reports feeling better, without fatigue and with less leg edema, but she is still not completely well. Physical examination showed no signs of heart failure, but her blood pressure and heart rate were 150/90 mmHg and 120 bpm, respectively. The ECG shows atrial fibrillation at 110-120 bpm. Which treatment is most likely to improve symptoms and reduce mortality from cardiovascular events?


Clinical case of giant cell arteritis. Corticosteroid therapy remains the first choice (answer 1 incorrect), to be administered as pulses (doses differ according to the literature, but at least 125 mg/d) in case of ocular involvement (answer 3 incorrect). The current treatment of choice for corticosteroid sparing is Tocilizumab (answer 4 incorrect), which has also been shown to reduce recurrences (answer 2 correct).

Clinical case of giant cell arteritis. Corticosteroid therapy remains the first choice ([HIDDEN]), to be administered as pulses (doses differ according to the literature, but at least 125 mg/d) in case of ocular involvement ([HIDDEN]). The current treatment of choice for corticosteroid sparing is Tocilizumab ([HIDDEN]), which has also been shown to reduce recurrences ([HIDDEN]).

75-year-old male, hypertensive on treatment with enalapril (20 mg/day), who consults for deterioration of general condition, bitemporal headache and mandibular claudication of 3 weeks of evolution. In addition, in the last hours, he refers two episodes of amaurosis fugax of the left eye. Physical examination revealed thickening and absence of pulse in the left temporal artery. Analysis: CRP 6 mg/dl (VN <1); hemoglobin 10.5 g/dl; ESR 92 mm. Chest X-ray normal. Considering the most likely diagnosis, check the correct option regarding treatment:

Rituximab should be administered, since glucocorticoids have been relegated to second-line treatment due to their side effects.

Tocilizumab has been shown to be effective in reducing recurrences and cumulative prednisone dose in more than 50% of patients.

In the presence of ischemic symptoms, and in order not to worsen the vascular risk of the patient, the use of glucocorticoids at doses higher than 30 mg/day should be avoided.

In conjunction with glucocorticoid boluses of 1 g/day, infliximab should be used as a first-line drug for remission induction.


This is an easy clinical case only presenting thrombopenia with clinic, petechiae and epistaxis. 1 is false, there would be fever, hemolysis data, neurological symptoms, in the smear there would be schistocytes. In 2 the coagulation must be altered and in this case it is not mentioned.

This is an easy clinical case only presenting thrombopenia with clinic, petechiae and epistaxis. [HIDDEN], there would be fever, hemolysis data, neurological symptoms, in the smear there would be schistocytes. In [HIDDEN] the coagulation must be altered and in this case it is not mentioned.

An 18-year-old patient who comes to the emergency department with epistaxis of several days' evolution, with no personal or family history of interest. On examination he is afebrile, multiple ecchymoses are observed, no splenomegaly is palpable. Laboratory tests: leukocytes 7.2 x103/μL, Hb 12.3 g/dL, platelets 6.0 x103/μL. Thrombocytopenia is confirmed in the smear, where platelets of increased size are observed. Coagulation and biochemistry studies are normal. What do you consider the most likely diagnosis?


In this clinical case, we are presented with a woman who rapidly presents dyspnea with hypoxemia, a picture compatible with pulmonary thromboembolism. The prothrombin time of 90% and the aPTT with a ratio of 2, is translating a coagulation problem; and antiphospholipid antibodies can be detected through the prolongation of phospholipid-dependent coagulation tests, correct answer 1. On the other hand, although factor V Leiden has been identified as a common cause of familial thrombosis, it would not alter the clotting time. In the case of hemophilia there would be a problem in blood coagulation but it is not a frequent cause of thromboembolism. Finally, although acute pericarditis could manifest itself in 4 days and with tachycardia, the rest of the symptoms or analytical parameters are not characteristic.

In this clinical case, we are presented with a woman who rapidly presents dyspnea with hypoxemia, a picture compatible with pulmonary thromboembolism. The prothrombin time of 90% and the aPTT with a ratio of 2, is translating a coagulation problem; and antiphospholipid antibodies can be detected through the prolongation of phospholipid-dependent coagulation tests, [HIDDEN]. On the other hand, although factor V Leiden has been identified as a common cause of familial thrombosis, it would not alter the clotting time. In the case of hemophilia there would be a problem in blood coagulation but it is not a frequent cause of thromboembolism. Finally, although acute pericarditis could manifest itself in 4 days and with tachycardia, the rest of the symptoms or analytical parameters are not characteristic.

A 45-year-old woman with no history of interest consults for dyspneic sensation of about 4 days of evolution. Examination shows rhythmic tachycardia, without murmurs and pulmonary auscultation is normal. Arterial blood gases showed a pO2 of 70 mmHg and a pCO2 of 32 mmHg. Hemogram, renal and hepatic function are normal. Prothrombin time 90%, activated partial thromboplastin time (APTT) ratio of 2 to control (N <1.2). Which of the following is the most likely diagnosis?


Dendritic corneal ulcer is typical of herpes simplex keratitis. It presents with pain, not too striking, and scarce or absent red eye. There are ulcers resembling dendrites that may confuse us in the diagnosis. These pseudodendrites are found in herpes Zoster and in corneal abrasions in resolution. Although in practice we should pay attention to the shape of the dendrite (the true dendrite is deeper and has terminal bulbs at the end of each branch), and pay attention to the evolution of the pain (in the pseudodendrite after abrasion the pain should improve), when answering a MIR question it is simpler: if it is a dendrite, the first thing we have to think is herpes. Fungal and bacterial keratitis have corneal infiltrates. And glaucomatocyclitic crisis (Posner Schlossman syndrome) is a type of idiopathic hypertensive anterior uveitis, which does not present with ulceration.

A 35-year-old man comes to the emergency department with pain in his right eye of 3 days' evolution. Biomicroscopic examination of the anterior segment shows, after fluorescein staining, a central corneal ulcer in the form of a dendrite. What is the diagnosis?


Direct response question. This is a patient undergoing chemotherapy with respiratory symptoms and the "halo sign" on X-ray, very suggestive of invasive pulmonary aspergillosis. Treatment is with voriconazole. Aspergillus is resistant to fluconazole, so it would not be a valid option.

A patient undergoing chemotherapy for leukemia is admitted for pneumonia for which treatment with cefepime has been prescribed. A chest X-ray/CT scan shows an infiltrate with halo sign and crescentic meniscus. The lesion is peripheral and a transthoracic puncture is indicated for sampling. Pending definitive histologic and microbiologic results, what antimicrobial would you add to the treatment?


Child with multiple family history of allergy (asthma, atopy), who has received artificial milk in the first hours of life (sensitization to cow's milk protein) and who, coinciding with the intake of artificial milk, starts digestive symptoms and exanthema = APLV.

A 5-month-old infant exclusively breastfed until the present, who due to maternal work was introduced a bottle with formula and a few days ago was added cereals with and without gluten. Family history: 28-year-old mother with asthma, 32-year-old healthy father and 5-year-old brother with celiac disease and atopic dermatitis. As personal history, pregnancy without incidents and delivery by cesarean section, having been offered a bottle with starter formula on the first day of life in the maternity ward. Since a few days ago she starts with abdominal distension, diarrhea stools, refusal to feed, peribuccal erythema with longer duration after bottle feeding and lately vomiting after feeding, tolerating well the breast. What is the most probable diagnosis?


This patient is in serious condition. The trismus and fever suggest a deep cervical space infection and that is not a game because the airway can become obstructed. Knowing this, options 1, 2 and 5 are out of place and I am left with 3 and 4. There may already be mediastinitis; after all, that is the natural history of cervical deep space infections, but answer 4 is more correct and besides, we are in the ENT block, the airway specialty. I like this question because it requires knowledge that is important in clinical practice.

This patient is in serious condition. The trismus and fever suggest a deep cervical space infection and that is not a game because the airway can become obstructed. Knowing this, options 1, 2 and 5 are [HIDDEN] and I am left with 3 and 4. There may already be mediastinitis; after all, that is the natural history of cervical deep space infections, but answer 4 is [HIDDEN] and besides, we are in the ENT block, the airway specialty. I like this question because it requires knowledge that is important in clinical practice.

Given a patient with poor general condition, fever (axillary temperature 39.5º), bilateral submandibular swelling of six days' evolution, mouth pain and trismus, which of the following statements is correct?

The first diagnostic probability is carcinoma of the floor of the mouth with bilateral cervical metastases.

The therapeutic priority is to ensure the patient's nutrition.

We are almost certainly facing a mediastinitis.

We must consider as a priority the risk of airway obstruction.

We must perform as a first diagnostic measure a cytology by fine needle aspiration puncture.


You are faithfully describing an Edwards' syndrome. Although the cardiopathies and the alteration of the foot that he describes are common to several chromosomopathies, the alteration of the fingers and toes is very characteristic of Edwards' syndrome.

What is the most likely diagnosis of a newborn with microcephaly, intrauterine growth retardation, congenital heart disease, vertical talus foot and a peculiar facies (microphthalmia, small palpebral fissures, micrognathia and dysplastic ears), hands with the index and little finger above the middle and ring fingers?


Data such as pancytopenia and hypergammaglobulinemia are very characteristic of kala-azar. The origin of the girl is also indicative of this diagnosis, although it is a disease that also occurs in the Mediterranean area. In the differential diagnosis, it is important to keep in mind the possibility of leukosis.

A 3-year-old girl from Bangladesh consults for intermittent febrile episodes of 3 weeks' duration, associated with weakness and loss of appetite. Physical examination showed marked splenomegaly and mucocutaneous pallor. Complementary tests include: hemoglobin 8.5 mg/dL, hematocrit 26%, MCV 86 fL, MCH 29 pg, leukocytes 2800/mL with 300 neutrophils /ml, platelets 54000/ml, GOT 85 U/l, GPT92 U/l and polyclonal hypergammaglobulinemia in serum proteinogram. Indicate the most probable diagnosis with the data available at this time:


The other antecedents and findings are very directly related to the increased risk of thrombotic phenomena. Osteoporosis is not a risk factor for thrombosis.

A 59-year-old woman with a personal history of breast cancer operated on 8 months ago and osteoporosis, suffers a fall and has a fracture of the neck of the right femur. She undergoes surgery and remains in the hospital resting in a cast for 10 days. A week after her discharge, she suddenly feels short of breath, which leads her to consult her family doctor who notices that her right calf has edema and pain on palpation. Which clinical elements would NOT be important in determining that she is at high clinical risk for pulmonary thromboembolism?

History of having been at rest for more than 3 days.

Presence of unilateral edema of the right calf.


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

A 54-year-old patient is admitted for thermometric fever of 38°C in the previous five days and dyspnea at rest (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:

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.


The correct answer is 5. An asymptomatic myoma of this size that does not deform the endometrial cavity is not a problem for pregnancy.

[HIDDEN] An asymptomatic myoma of this size that does not deform the endometrial cavity is not a problem for pregnancy.

A 32-year-old asymptomatic woman goes for a gynecological health check-up because she wishes to become pregnant. During this check-up, a 4cm uterine myoma is detected, partly intramural and partly subserosal, located on the anterior aspect of the uterus and which does not deform the endometrial cavity. What approach would you recommend?

Myoma embolization by arterial catheterization.

Treatment with Gn-Rh analogues for three months before attempting pregnancy.

Attempting pregnancy without any previous treatment.


Brain metastases produce pain due to cranial hypertension. The treatment of choice is corticosteroids. Dexamethasone in oral doses of 4 to 16 mg/day is the treatment of choice.

Brain metastases produce pain due to cranial hypertension. The treatment of choice is corticosteroids. Dexamethasone in oral doses of 4 to 16 mg/day is [HIDDEN].

A 60-year-old patient diagnosed with breast neoplasia 10 years ago. She underwent treatment with radiochemotherapy and then hormonal therapy for 5 years. A bone scan study performed for polytopic bone pain showed the presence of bone metastases. She is currently under treatment with minor opioids and NSAIDs with good pain control. She consulted for headache that did not subside with the current analgesia and a CT scan of the brain showed images compatible with brain metastases. In relation to the treatment of pain, indicate the CORRECT one:

Extra doses of opioids should be administered as necessary.

Switch to a major opioid and maintain NSAIDs.

The patient should be admitted for intravenous treatment with major opioid.


Gestational trophoblastic disease should be followed up (regardless of whether the evacuation has been complete or not) and the patient should be advised not to become pregnant again until at least 6 months with negative BHCG titers. The risk of recurrence in another pregnancy is low (1/55) and 90% of cases progress satisfactorily without developing neoplasia.

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

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

She should not become pregnant until she has undergone periodic controls and has spent one year with negative BHCG levels.

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

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


The presence of inguinal nodes up to 1-1.5cm may be normal in the absence of symptoms. In this case, they are very nonspecific nodes, without signs of malignancy (mobile, soft, not painful) that do not lead us to suspect neoplastic infiltration and the lack of other clinical signs also leads us to rule out the presence of STD.

The presence of inguinal nodes up to 1-1.5cm may be normal in the absence of symptoms. In this case, they are very nonspecific nodes, without signs of malignancy (mobile, soft, not painful) that [HIDDEN] and the lack of other clinical signs also leads us [HIDDEN].

A 24-year-old woman consults after noticing inguinal lymphadenopathy. The interrogation does not reveal any local discomfort or data suggestive of sexually transmitted infection. The examination revealed two lymphadenopathies, one in each groin, 1 cm in diameter, soft, mobile, non-painful. No skin lesions are seen on the lower limbs, anus or perineum. Which test do you consider essential?

A lues serology since it is most likely a Treponema pallidum infection.

A gynecological examination to rule out ovarian cancer.

By the clinical characteristics it seems to be normal lymph nodes and complementary explorations should not be done.


This question corresponds to the section on traumatology; however, it could be answered with knowledge of rheumatology and with the osteoporosis recommendations of the Spanish Society of Rheumatology. In osteoporosis, one of the main risks associated with increased fracture risk is low adherence to treatment, so answer 1 is correct. Answer 2 is found in the SER guidelines, which confirm that some studies conclude that bone remodeling markers can be useful for early monitoring of adherence and response to treatment. Answer 4 is correct because again in the SER 2019 guidelines they quote: "The current scientific evidence allows us to affirm that neither increasing dietary calcium nor taking calcium supplements alone protects against the appearance of fractures". Therefore, the correct answer to this question is option 3. Patients on pharmacological treatment for OP should use calcium and vitamin D supplements because practically all clinical trials that have demonstrated efficacy of antiosteoporotic drugs routinely include calcium supplements and cholecalciferol (vitamin D3), but not in monotherapy.

This question corresponds to the section on traumatology; however, it could be answered with knowledge of rheumatology and with the osteoporosis recommendations of the Spanish Society of Rheumatology. In osteoporosis, one of the main risks associated with increased fracture risk is low adherence to treatment, so [HIDDEN]. Answer 2 is found in the SER guidelines, which confirm that some studies conclude that bone remodeling markers can be useful for early monitoring of adherence and response to treatment. [HIDDEN] because again in the SER 2019 guidelines they quote: "The current scientific evidence allows us to affirm that neither increasing dietary calcium nor taking calcium supplements alone protects against the appearance of fractures". Therefore, [HIDDEN]. Patients on pharmacological treatment for OP should use calcium and vitamin D supplements because practically all clinical trials that have demonstrated efficacy of antiosteoporotic drugs routinely include calcium supplements and cholecalciferol (vitamin D3), but not in monotherapy.

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

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

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

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

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


Duloxetine; the clinical picture described is of diabetic neuropathy. Of the drugs proposed, the first choice would be a dual antidepressant such as duloxetine.

A woman diagnosed with type 1 diabetes mellitus for 24 years. She comes to the office with 3 months of clinical evolution of tingling in both feet, with distribution in sock, with paresthetic pain and sensation of hot feet predominantly at night, which significantly interferes with sleep. Which of the following drugs would you use in the first line for the treatment of her pathology?


Digoxin is useful as a symptomatic treatment (it is a positive inotropic) in heart failure, although it does not improve survival. Carvedilol is a very well tolerated aß-blocker (due to its anti-a1 effect) that is associated with symptomatic and survival improvement. Acenocoumarol (Sintrom) would be indicated in this patient with chronic AF to avoid thromboembolic events. Enalapril and ACE inhibitors in general, by inhibiting the renin-angiotensin-aldosterone axis, suppress part of the neurohormonal effects that occur in heart failure; they improve survival in patients with systolic dysfunction. Ibuprofen and NSAIDs in general are contraindicated in patients with heart failure because they inhibit prostaglandin synthesis at the renal level, causing an increase in systemic vascular resistance, reduced renal perfusion, and inhibition of sodium and water excretion, which can precipitate decompensation of heart failure.

A 78-year-old patient diagnosed with idiopathic dilated cardiomyopathy with mild left ventricular dysfunction (ejection fraction 48%) and chronic atrial fibrillation. Which of the following drugs should be avoided in his treatment?


The question of exanthematous diseases that pediatricians and MIR exam takers like so much. By the picture of high fever of several days that suddenly subsides with the appearance of a rash, we have a sudden exanthem, caused by Herpes virus type 6 (remember the mnemonic rule of "sudden Hexanthem"). Parvovirus B19 is the cause of erythema infectiosum or "fifth disease", whose characteristic rash is on the cheeks, giving the appearance of a slapped face. Coxackie A16 causes herpangina and also boca-mano-pie disease, which presents an initially macular rash, which does not respect palms or soles and evolves into bursting vesicles. Finally, EBV infection produces a mononucleosis syndrome with high fever lasting several days, with pharyngeal erythema and grayish exudates on the tonsils. It can present if penicillins are given to treat it (when confused with a streptococcal pharyngotonsillitis) a generalized exanthema. In addition, it also presents with fatigue, hepatic inflammation with increased transaminases and splenomegaly.

The question of exanthematous diseases that pediatricians and MIR exam takers like so much. By the picture of high fever of several days that suddenly subsides with the appearance of a rash, we have a sudden exanthem, caused by Herpes virus type 6 (remember the mnemonic rule of "sudden Hexanthem"). Parvovirus B19 is the cause of erythema infectiosum or "fifth disease", whose characteristic rash is on the cheeks, giving the appearance of a slapped face. Coxsackie A16 causes herpangina and also boca-mano-pie disease, which presents an initially macular rash, which does not respect palms or soles and evolves into bursting vesicles. Finally, EBV infection produces a mononucleosis syndrome with high fever lasting several days, with pharyngeal erythema and grayish exudates on the tonsils. It can present if penicillins are given to treat it (when confused with a streptococcal pharyngotonsillitis) a generalized exanthema. In addition, it also presents with fatigue, hepatic inflammation with increased transaminases and splenomegaly.

The appearance of a high fever of 39°C in a 10-month-old infant that abruptly subsides after 3-5 days, followed by a cephalocaudal morbilliform exanthema with enanthema consisting of reddish papules on the palate, and resolving within a week, associated with good general condition, is usually caused by:


Amyloid angiopathy is the most common cause of spontaneous non-hypertensive hemorrhage in elderly patients, and is usually lobar in location (as in the case). They often appear in association with Alzheimer's disease (CTO Manual). The response that may cause the most doubts is 2, hypertension, but the most frequent localizations are: putamen, thalamus, pons and cerebellum. Therefore, most of the time these are deep hemorrhages (CTO Manual). In addition, as a clue it tells us that the patient has well-controlled hypertension without drugs, although this data would not serve to rule out the response. Answer 1, a malformation is typical of young patients, rare in older people. It also decreases the chance of not finding a malformation with contrast-enhanced CT. Answer 4, a brain tumor, does not seem likely since the mass is not seen on CT, and as in the previous case, it is more difficult not to find such a lesion after contrast administration. Answer 3 does not seem correct since vasculitis is a rare entity and more so in older people.

Amyloid angiopathy is the most common cause of spontaneous non-hypertensive hemorrhage in elderly patients, and is usually lobar in location (as in the case). They often appear in association with Alzheimer's disease (CTO Manual). The response that may cause the most doubts is 2, hypertension, but [HIDDEN] are: putamen, thalamus, pons and cerebellum. Therefore, most of the time these are deep hemorrhages (CTO Manual). In addition, as a clue it tells us that the patient has well-controlled hypertension without drugs, although this data would not serve to [HIDDEN]. Answer 1, a malformation is typical of young patients, rare in older people. It also decreases the chance of not finding a malformation with contrast-enhanced CT. Answer 4, a brain tumor, does not seem likely since [HIDDEN], and as in the previous case, it is more difficult not to find such a lesion after contrast administration. Answer 3 does not seem [HIDDEN] since vasculitis is a rare entity and more so in older people.

An 80-year-old man is admitted for a sudden onset of aphasia and right hemiparesis. His history includes hypertension, well controlled with diet and cognitive deterioration in the last year under study by his neurologist. The emergency cranial CT scan shows a left frontal lobar hematoma without contrast uptake. What is the most probable cause of the hematoma?

Arteriovenous malformation masked by acute hematoma.

Isolated vasculitis of the nervous system.

Cerebral amyloid angiopathy (congophilic angiopathy).


The 5A summarizes the activities that should be performed by healthcare personnel during the brief intervention with the patient to stop smoking and are: find out, advise, analyze, help, accompany or agree. Therefore, the one that is not included in the strategy would be option 2: increase.

The 5A summarizes the activities that should be performed by healthcare personnel during the brief intervention with the patient to stop smoking and are: find out, advise, analyze, help, accompany or agree. Therefore, the one that is not included in the strategy would be option 2: [HIDDEN].

A 42-year-old woman visits her family physician for gonalgia. Opportunistic use is made of the consultation to assess lifestyles, especially smoking. If you want to follow the health education strategy based on the five "a's" model, which of the following is NOT included in this strategy:

Inquire: ask about risk factors and risk behaviors (ask the patient if she smokes).

Increase: increase risk perception to facilitate change (explain the consequences of smoking).

Advise: give clear, specific and personalized advice (advise smoking cessation).

Agree: collaboratively agree on goals for change (assess readiness to make a quit attempt).


The fourth noise usually appears when there is a certain degree of valvular stenosis.

65-year-old patient presenting progressive dyspnea of 5 days of evolution until becoming resting, three-pillow orthopnea and episodes of paroxysmal nocturnal dyspnea. Auscultation highlights bilateral crackles, holosystolic murmur radiating to the axilla and gallop rhythm for the third and fourth sounds. Mark the CORRECT statement:

The third noise coincides with the rapid filling phase of the ventricular diastole of the cardiac cycle.

The most likely diagnosis is heart failure.

The holosystolic murmur may correspond to mitral insufficiency.


We must take into account all the clinical data provided: after trauma we have pain in the arm with soft tissue involvement and the impossibility of extending the wrist and fingers. The only option that includes all the data is 4. Option 1 does not explain the involvement of the wrist and fingers. The elbow dislocation does not explain the lack of finger mobility as well as the diaphyseal fracture of the humerus and double forearm. "Direct mechanism is possible, as is indirect transmission of forces from the elbow and hand...radial nerve involvement is extremely frequent, reaching an incidence of 10-18% of cases." Proximal humerus fracture-dislocation would have greater involvement at the shoulder, elbow dislocation at the elbow, and there is no data to suggest double forearm fracture.

We must take into account all the clinical data provided: after trauma we have pain in the arm with soft tissue involvement and the impossibility of extending the wrist and fingers. [HIDDEN] Option 1 does not explain the involvement of the wrist and fingers. The elbow dislocation does not explain the lack of finger mobility as well as the diaphyseal fracture of the humerus and double forearm. "Direct mechanism is possible, as is indirect transmission of forces from the elbow and hand...radial nerve involvement is extremely frequent, reaching an incidence of 10-18% of cases." Proximal humerus fracture-dislocation would have greater involvement at the shoulder, elbow dislocation at the elbow, and there is no data to suggest double forearm fracture.

65-year-old obese woman who suffers a fall on her hand with her elbow in extension. She presents with arm pain with swelling and functional impotence of the arm and inability to extend the wrist and fingers. It is most likely to present:

Dislocation fracture of proximal humerus.

Diaphyseal fracture of the humerus associated with double forearm fracture.

Diaphyseal fracture of humerus with radial nerve injury.


The indication of omalizumab in a patient such as the one referred to is a correct indication, although in severe asthma that is difficult to control, there are other prior measures that are not contemplated and that must always be taken into account before resorting to this treatment. It is mandatory to ensure firstly that it is truly asthma and not another disease that simulates asthma, secondly that there are no complications that worsen the evolution as could be the presence of gastroesophageal reflux, bronchiectasis, presence of opportunistic germs given the chronic treatment with steroids, etc; and thirdly, it is necessary to confirm that the patient complies with the treatments correctly, especially the inhaled treatment, etc. Once all of the above has been checked, it would be time to start a trial treatment with omalizumab.

The indication of omalizumab in a patient such as the one referred to is [HIDDEN], although in severe asthma that is difficult to control, there are other prior measures that are not contemplated and that must always be taken into account before resorting to this treatment. It is mandatory to ensure firstly that it is truly asthma and not another disease that simulates asthma, secondly that there are no complications that worsen the evolution as could be the presence of gastroesophageal reflux, bronchiectasis, presence of opportunistic germs given the chronic treatment with steroids, etc; and thirdly, it is necessary to confirm that the patient complies with the treatments correctly, especially the inhaled treatment, etc. Once all of the above has been checked, it would be time to start a trial treatment with omalizumab.

A 53-year-old woman with bronchial asthma comes to the allergy clinic for a checkup. She reports repeated exacerbations with nocturnal symptoms, frequent use of rescue medication and dyspnea on exertion when walking on level ground. Spirometry shows a pre-bronchodilator FEV1/FVC ratio of 60% and FEV1 of 55%. Skin tests are positive for mites and total IgE of 150 IU/ml. The patient is being treated with a combination of high-dose salmeterol/budesonide (50/500 mg: 2 puffs twice daily), maintenance oral prednisone (10 mg/day) and theophylline. Of the following options, which is the most advisable therapeutic approach?

Increase the dose of prednisone to 30 mg/day.

Switch to a combination with high doses of budesonide and formoterol.


Among the options presented, the only measure not included in the Surviving Sepsis Campaign guidelines on the management of sepsis and septic shock (like the patient we are dealing with) is the administration of IV dobutamine. The appropriate procedure would consist of fluid administration, blood culture extraction, serum lactate measurement and early administration of broad-spectrum antibiotic therapy directed to the suspected septic focus. If we do not obtain mean arterial pressure for adequate perfusion of the organs, we would initiate noradrenaline perfusion, as discussed in question 51.

Among the options presented, the only measure not included in the Surviving Sepsis Campaign guidelines on the management of sepsis and septic shock (like the patient we are dealing with) is [HIDDEN]. The appropriate procedure would consist of fluid administration, blood culture extraction, serum lactate measurement and early administration of broad-spectrum antibiotic therapy directed to the suspected septic focus. If we do not obtain mean arterial pressure for adequate perfusion of the organs, we would initiate noradrenaline perfusion, as discussed in question 51.

A 67-year-old woman with a history of dyslipidemia, who comes to the ED with dysuria and pollakiuria followed by fever, chills, and deterioration of general condition. On arrival she appears severe and is tachycardic, tachypneic, with blood pressure 60/40 mmHg and temperature of 39°C. Which of the following measures would NOT be included in the INITIAL management?


SCA3 is Spinocerebellar Ataxia type 3 also called Machado-Joseph disease. It is caused by mutations in the ATXN3 gene by the CAG triplet repeat expansion mechanism. Affected individuals have between 52 and 86 CAG triplet repeats in heterozygosis with complete penetrance. The heterozygous mutation carrier has the disease as its inheritance pattern is autosomal dominant. In this clinical case, the one who has the disease and has the mutated gene in heterozygosis is the brother (26 years old) of the pregnant woman. I think that before doing the chorion biopsy, the pregnant woman should be tested to know her ATXN3 gene status. She has a 50% chance of carrying the mutation and having the disease, but since she is 31 years old, I think she should have already had symptoms. Nevertheless, I would do the genetic test on the pregnant woman to be on the safe side. If she came out without the mutation, there would be nothing more to do because the disease would no longer be transmitted. If she came out with the mutation, then I would do a chorionic villus biopsy. Answers 1 and 2 are both true, but I think answer 1 is more true than answer 2.

SCA3 is Spinocerebellar Ataxia type 3 also called Machado-Joseph disease. It is caused by mutations in the ATXN3 gene by the CAG triplet repeat expansion mechanism. Affected individuals have between 52 and 86 CAG triplet repeats in heterozygosis with complete penetrance. The heterozygous mutation carrier has the disease as its inheritance pattern is autosomal dominant. In this clinical case, the one who has the disease and has the mutated gene in heterozygosis is the brother (26 years old) of the pregnant woman. I think that before doing the chorion biopsy, the pregnant woman should be tested to know her ATXN3 gene status. She has a 50% chance of carrying the mutation and having the disease, but since she is 31 years old, I think she should have already had symptoms. Nevertheless, I would do the genetic test on the pregnant woman to be on the safe side. If she came out without the mutation, there would be nothing more to do because the disease would no longer be transmitted. If she came out with the mutation, then I would do a chorionic villus biopsy. [HIDDEN]

An asymptomatic 31-year-old woman (Consultant) is asymptomatic and has a 10-week gestation according to ultrasound study (primiparous). Her younger brother (index case) aged 26 years is affected by ataxia and genetically diagnosed as a heterozygous carrier of an expansive mutation of 70 CAG repeats in the SCA3 gene (chromosome 14). The patient is referred to the genetic counseling office where a possible chorionic villus biopsy to study the fetal genotype is evaluated. Is this invasive procedure indicated as a pre-natal diagnosis (PND) in this case?

It is indicated after studying the Consultant's genotype and only if it is heterozygous.

This is not indicated, since SCA3 ataxia is full penetrance and the Consultant is asymptomatic and therefore has not inherited the mutation.

It may be indicated in the next pregnancy, after studying the genotype of the first child and detecting the mutation in it.

SCA3 ataxia is recessively inherited, so there is no appreciable risk of disease transmission and PND is not indicated.

This is indicated regardless of the Consultant's genotype, since SCA3 ataxia is maternally inherited (transmitted by women).


The correct answer is 4. Children born to HBV carrier mothers should be administered hepatitis B vaccine and immunoglobulin at different puncture sites within the first 24 hours of life. Although the virus is excreted in breast milk, the risk of infection by this route is very low and therefore it is not currently a contraindication for breastfeeding.

[HIDDEN] Children born to HBV carrier mothers should be administered hepatitis B vaccine and immunoglobulin at different puncture sites within the first 24 hours of life. Although the virus is excreted in breast milk, the risk of infection by this route is very low and therefore it is not currently a contraindication for breastfeeding.

37-week pregnant woman with positive hepatitis B virus surface antigen. She consults about the guidelines to be followed with the newborn and whether she can breastfeed. What advice do you think is most appropriate?

Administer hepatitis B vaccine at birth. Artificial feeding.

Vaccination and immunoglobulins should be administered at birth. Breastfeeding from one month onwards.

Immunoglobulins at birth and artificial breastfeeding.

Vaccination and immunoglobulins at birth. Maternal feeding.

Artificial feeding and isolation for 4 weeks.


Orlistat acts by decreasing fat absorption; it is currently the only drug approved for use in obesity.

A patient with obesity (body mass index 38) is referred to your office. In the clinical history the patient refers that he/she has been obese since the age of 17 (currently 36 years old), having been on multiple diets with weight loss ranging from 5 to 10 kg but has subsequently regained weight. The patient is currently on a 1500 Kcal diet (self-administered and not restricted in fat) with a good follow-up of this diet, performing one hour of aerobic exercise 4 days a week. She has lost 3 kg but needs an additional loss of 7 kg more. Given the possibility of adding a drug against obesity, which one would you use to reduce fat absorption?


Question in which having a table in the head comes out alone discarding options: Option 1: The acute infection would be HBeAg + and ANTI-HBe - . In addition the ANTI-HBec would be IgM type (only for this last data, we would have to discard it in a direct way). Option 2: the correct one. It complies with all the characteristics. Option 3: The vaccinated patient cannot have DNA of the virus (the only thing that positivizes in a vaccinated patient is the AntiBs. IgG type). Option 4: The option that could offer more doubts. In the asymptomatic carrier (chronic carrier / seroconverted) the difference is that there is no viral DNA.

Question in which having a table in the head comes out alone discarding options: Option 1: The acute infection would be HBeAg + and ANTI-HBe - . In addition the ANTI-HBec would be IgM type (only for this last data, we would have to discard it in a direct way). Option 2: [HIDDEN]. It complies with all the characteristics. Option 3: The vaccinated patient cannot have DNA of the virus (the only thing that positivizes in a vaccinated patient is the AntiBs. IgG type). Option 4: The option that could offer more doubts. In the asymptomatic carrier (chronic carrier / seroconverted) the difference is that there is no viral DNA.

Indicate the clinical situation that, in relation to hepatitis B virus infection, presents a 5-year-old patient from Nigeria, with normal physical examination and with the following serology against hepatitis B: HBsAg + / ANTI- HBs - / HBeAg - / ANTI- Hbe + / ANTI- Hbc IgM - / ANTI- Hbc IgG +/ DNA HBV +:


The fear of all on-call hematologists... that you will get a TTP. Because, although infrequent, it is the greatest hematologic emergency.  The clinical case is fairly typical. A young person with fever and neurological symptoms that make him go to the emergency department (he is on the run). Laboratory tests show anemia with evidence of hemolysis (increased LDH and retis, presence of schistocytes in peripheral blood) and severe thrombopenia. In addition, coagulation is normal. To distinguish it from the rest of things (although you should not hesitate...) it tells you that the coombs is negative. As a reminder: URGENT TREATMENT: PLASMATIC REPLACEMENTS. The diagnostic confirmation is the ADAMTS 13 deficit, but treatment is started before having that value, which is not usually done urgently. And, as we all know, these things usually come at night and/or weekends, to make things more difficult....

A 35-year-old woman, taking contraceptives, comes to the emergency department with febrile syndrome and paresthesias in the left hemibody. Blood tests show Hb 7.5 g/dL, platelets 7,000/microl, normal leukocytes with normal differential count, LDH 1,200 IU/l, reticulocytes 10% (normal 0.5-2%), undetectable serum haptoglobin, negative direct Coombs' test and peripheral blood smear with schistocytes. Coagulation (prothrombin time and APTT) normal. Which of the following is the most likely diagnosis:

Evans syndrome (hemolytic anemia and immune thrombopenia).


The patient presents criteria for Thrombotic Thrombocytopenic Purpura (TTP): 1. Neurological alteration. 2. Febrile syndrome (fever). 3. Coombs negative migroangiopathic hemolytic anemia (presence of schistocytes). 4. Thrombopenia.

A 35-year-old woman, taking contraceptives, comes to the emergency department with febrile syndrome and paresthesias in the left hemibody. Blood tests showed Hb 7.5 g/dL, platelets 7,000/microl, normal leukocytes with normal differential count, LDH 1,200 IU/l, reticulocytes 10% (normal 0.5-2%), undetectable serum haptoglobin, negative direct Coombs' test and peripheral blood smear with schistocytes. Coagulation (prothrombin time and APTT) normal. Which of the following is the most likely diagnosis:


If he has a pediatric murmur, I'm thinking congenital. Hepatomegaly, malleolar edema and BRD, something that overloads the right heart. So we rule out aortic and mitral stenosis. A patent ductus would give cyanosis: ruled out. VSD or ASD? If I am told that he has AF, it is because the atria are of size XL, and a VSD does not produce atrial dilatation.

If he has a pediatric murmur, I'm thinking congenital. Hepatomegaly, malleolar edema and BRD, something that overloads the right heart. So we rule out aortic and mitral stenosis. A patent ductus would give cyanosis: [HIDDEN]. VSD or ASD? If I am told that he has AF, it is because the atria are of size XL, and a VSD does not produce atrial dilatation.

A 45-year-old woman with a history of heart murmur detected in childhood. She is admitted to the emergency department for palpitations, easy fatigue and malleolar edema. Physical examination revealed absence of cyanosis. Oxygen saturation by pulse oximeter 97% BP 120/80 mmHg. Irregular heart rhythm at 100 bpm. Ejective systolic murmur (2/6) in pulmonary focus. 2nd unfolded noise, wide and fixed. No rales. Slight hepatomeglaia (2-3 cm). Slight malleolar edema. ECG: complete arrhythmia due to atrial fibrillation at 100 bpm. QRS +120º. Conduction disorder of the right bundle branch of the His bundle. What is its diagnostic orientation?


Ejective murmur, our first suspicion is aortic stenosis. Angina may be due to the stenosis itself or to underlying coronary artery disease (probable, given the age). And with this information, we cannot know if the stenosis is severe. Therefore, the first thing we will have to do will be to study the valve disease: we do not want to put the patient to run or overload him with dobuta and have a syncope, nor do we want to do a catheterization without having first performed another noninvasive test. And cardioTC, in someone 80 years old, is going to tell us what we already know: that he has calcium up to his eyebrows.

What examination would you advise in the first place for an 82-year-old patient with exertional angina and a systolic ejection murmur of intensity 3/6 on auscultation?


Diabetes with ecv ldlc<70.

In a 70-year-old diabetic man with a history of ischemic heart disease, what is the therapeutic target for LDL cholesterol and glycosylated hemoglobin (Hb A1c)?


We are presented with a lot of analytical data but we only have to look at two: the levels of complement fractions C3 and C4 are low. Of the options given, only membranoproliferative glomerulonephritis presents with hypocomplementemia (option 4 correct).

We are presented with a lot of analytical data but we only have to look at two: the levels of complement fractions C3 and C4 are low. Of the options given, only membranoproliferative glomerulonephritis presents with hypocomplementemia ([HIDDEN]).

A 25-year-old man with no known history of interest. He has been presenting with foamy and loaded urine for 2 months, with no other symptoms. Physical examination without findings. Elemental urine: pH 5; glucose negative; hemoglobin ++; protein ++; leukocyte esterase negative; proteinuria 1.5 g/24 hours; urinary Na 60 mEq/L; urinary K 30 mEq/L; urinary Cl 100 mEq/L. Blood biochemistry: creatinine 1.6 mg/dL; urea 80 mg/dL; Na 140 mEq/L; K 3.8 mEq/L. Immunological study: antiDNA negative; ANCA negative; antiMBG negative, rheumatoid factor negative; C3 20 mg/dL (normal 60-120); C4 10 mg/dL (normal 20-40). A renal biopsy is performed. Which of these diagnoses do you think is the most likely to be found in the biopsy?

Glomerulonephritis with minimal changes.