We are being presented with a picture of conjunctival inflammation or conjunctivitis and asked which of them is not associated with pre-auricular lymphadenopathy. Adenovirus conjunctivitis can be associated with inflammation of the pre-auricular or ipsilateral sub-mandibular lymph node (option 1 discarded). Allergic conjunctivitis is a hypersensitivity condition that can occur immediately after contact with the triggering stimulus or after 24-72 hours, and is associated with accompanying signs such as eyelid edema and erythema, changes in periocular skin pigmentation, and a key symptom: itching. What it is not associated with is lymphadenopathy (option 2 correct). The oculoglandular syndrome of Parinaud is a picture that by definition is composed of conjunctivitis of infectious cause associated with ipsilateral pre-auricular or latero-cervical lymphadenopathy (one or several), generally produced by bacteria such as Bartonella henselae (cat scratch disease) or Francisella tularensis (tularemia or rabbit fever): option 3 discarded. Chlamydial conjunctivitis can present as 3 very distinct clinical pictures: trachoma, ophthalmia neonatorum or adult inclusion body conjunctivitis. The latter is considered a sexually transmitted disease and is associated with ipsilateral pre-auricular nodes (option 4 discarded).

We are being presented with a picture of conjunctival inflammation or conjunctivitis and asked which of them is not associated with pre-auricular lymphadenopathy. Adenovirus conjunctivitis can be associated with inflammation of the pre-auricular or ipsilateral sub-mandibular lymph node ([HIDDEN]). Allergic conjunctivitis is a hypersensitivity condition that can occur immediately after contact with the triggering stimulus or after 24-72 hours, and is associated with accompanying signs such as eyelid edema and erythema, changes in periocular skin pigmentation, and a key symptom: itching. What it is not associated with is lymphadenopathy ([HIDDEN]). The oculoglandular syndrome of Parinaud is a picture that by definition is composed of conjunctivitis of infectious cause associated with ipsilateral pre-auricular or latero-cervical lymphadenopathy (one or several), generally produced by bacteria such as Bartonella henselae (cat scratch disease) or Francisella tularensis (tularemia or rabbit fever): [HIDDEN]. Chlamydial conjunctivitis can present as 3 very distinct clinical pictures: trachoma, ophthalmia neonatorum or adult inclusion body conjunctivitis. The latter is considered a sexually transmitted disease and is associated with ipsilateral pre-auricular nodes ([HIDDEN]).

A 36-year-old male who consults for conjunctival hyperemia and foreign body sensation. Which of the following pathologies does NOT correspond to the above mentioned examination?


Colposcopy with possible biopsy. H-SIL (High-grade squamous intraepithelial lesion)*: includes changes suggestive of CIN2 and CIN3/CIS. The cytologic diagnosis must be confirmed by biopsy, for which it is necessary to perform a directed biopsy by colposcopy.

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

Hysterectomy with bilateral salpinguectomy and ovarian conservation.


Epidemiology question shared with URO. Coraliform lithiasis are associated with urea-folding germs: Proteus in the first place, Pseudomonas, Klebsiella and some staphylococci.

A 40-year-old woman is admitted to the Emergency Department with a fever of 38ºC and right lumbar pain. The CBC shows 25000 leukocytes/mm3 with left deviation and an abdominal ultrasound shows a coralliform lithiasis. What microorganism do we expect to find?


HbA1c would be useful in this patient for the diagnosis of diabetes but not for the target organ involvement of hypertension.

A 55-year-old patient diagnosed with hypertension 2 months ago at a company check-up. Laboratory tests: glucose 129 mg/dL, cholesterol 202 mg/dL, LDLc 160 mg/dL, HDLc 38 mg/dL, triglycerides 171 mg/dL, creatinine 1.1 mg/dL. He consults for poor blood pressure control, malleolar edema and dyspnea that is occasionally nocturnal. Physical examination: BMI 38 kg/m2, abdominal perimeter 110 cm, BP 157/93, HR 70 bpm, HR 14 rpm. Systolic murmur with reinforcement of the second sound. Peripheral pulses with discrete asymmetry in right pedius and right posterior tibial pulses that are weaker with respect to the left extremity. Chest X-ray and ECG without alterations Which of the following complementary tests is the least necessary for the detection of lesions in target organs?

Determination of glycosylated hemoglobin.


Another one on epidemiology. In splenectomized patients, the risk of acquiring serious infections by encapsulated germs is increased, again Pneumococcus being the most frequent.

A patient comes to the Emergency Department with fever without focus of 24 h of evolution, hypothyroidism and impression of severity. She underwent a splenectomy 2 years ago for staging of Hosgkin's disease. Which microorganism is most frequently implicated?


A question that I think can be complicated for a MIR examiner. We are told of a leukocytosis at the expense of lymphocytes with a B-CLL phenotype. It seems that there are no other alarming data. No clinical data are given (so we assume that the patient is asymptomatic). No cytopenias... Conclusion: FOLLOW UP. The main hesitation with the answer should be with option 1. Why do I consider it incorrect? Because the TP53 mutation, although it establishes prognosis, is not indicated at diagnosis, but when treatment is going to be initiated (first line and prior to successive lines in case they are needed). It would be possible to go too far in this question in which the percentage given does not refer directly to clonal lymphocytes, so that it could even be a monoclonal B lymphocytosis. But this is going too far.

A question that I think can be complicated for a MIR examiner. We are told of a leukocytosis at the expense of lymphocytes with a B-CLL phenotype. It seems that there are no other alarming data. No clinical data are given (so we assume that the patient is asymptomatic). No cytopenias... Conclusion: FOLLOW UP. The main hesitation with the answer should be with option 1. Why do I consider it [HIDDEN]? Because the TP53 mutation, although it establishes prognosis, is not indicated at diagnosis, but when treatment is going to be initiated (first line and prior to successive lines in case they are needed). It would be possible to go too far in this question in which the percentage given does not refer directly to clonal lymphocytes, so that it could even be a monoclonal B lymphocytosis. But this is going too far.

A 67-year-old patient who in the last 6 months, in two routine analyses, presents progressive lymphocytosis. In the last one, hemoglobin 15.4 g/dL; leukocytes 18.5 x103/μL with 82% of mature lymphocytes that by flow cytometry express CD5/CD19/CD23 antigens and platelets 240 x103/μL. What attitude do you think is correct?

Study of TP53 mutations to establish prognosis.

Bone aspirate/biopsy to confirm the diagnosis.

PET/CT to establish the therapeutic attitude.

New clinical and analytical control in 6 months.


The correct answer is 2. In the presence of unilateral and uniorificial hematic telorrhea, the most frequent cause is intraductal papilloma (50%), followed by ductal ectasia and carcinoma. When associated with palpable mass, 60% correspond to carcinoma. Paget's disease is of the eczematous type. In hyperprolactinemia, telorrhea is bilateral and pluriorificial. Mammography often does not show papillomas, being more useful ultrasound and galactography.

[HIDDEN] In the presence of unilateral and uniorificial hematic telorrhea, the most frequent cause is intraductal papilloma (50%), followed by ductal ectasia and carcinoma. When associated with palpable mass, 60% correspond to carcinoma. Paget's disease is of the eczematous type. In hyperprolactinemia, telorrhea is bilateral and pluriorificial. Mammography often does not show papillomas, being more useful ultrasound and galactography.

A 59-year-old woman consults a gynecologist for a spontaneous, spontaneous, uniorificial discharge from the right nipple (unilateral) without palpable nodularity. What is the most likely diagnosis?

Given the hematic nature of the discharge, the most likely diagnosis is infiltrating ductal carcinoma.

Mammography will indicate the diagnosis.


Of course it is a typical picture (EBV, CMV, VH6, Toxoplasma), of which you will not see so clearly at the emergency room door when you are on call. Be careful with the bad blood in answer 3, because an acute toxoplasmosis can behave like this and also give a macular exanthema, although the one of this girl is related to the intake of amoxicillin. By the way, I add a note, if instead of a girl of 17 years so clear it were a young man/girl with risky sexual relations, do not forget the HIV primoinfection as a cause of mononucleosis syndrome.

Of course it is a typical picture (EBV, CMV, VH6, Toxoplasma), of which you will not see so clearly at the emergency room door when you are on call. Be careful with the bad blood in [HIDDEN], because an acute toxoplasmosis can behave like this and also give a macular exanthema, although the one of this girl is related to the intake of amoxicillin. By the way, I add a note, if instead of a girl of 17 years so clear it were a young man/girl with risky sexual relations, do not forget the HIV primoinfection as a cause of mononucleosis syndrome.

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

It is a typical picture of infectious mononucleosis.


In this question what they assume is that this is a 45-year-old woman who is diagnosed with pulmonary thromboembolism (PTE). With this diagnosis, options 3 and 4 are directly excluded (also, she is female, so we would not have to think about hemophilia) As an analytical data, it says that there is a lengthening of the aPTT. So, they want you to know, she has positive lupus ac and link it directly to antiphospholipid syndrome (APS). A Leiden's does not alter coagulation, so it is ruled out as well. Anyway, although it is not within the possible answers, lupus positivity can be related to a myriad of clinical situations, syndromes and pathologies. Assuming that a PTE + lupus is a PFS seems to me to be a bit of a stretch, but it is the most likely with the data provided.

In this question what they assume is that this is a 45-year-old woman who is diagnosed with pulmonary thromboembolism (PTE). With this diagnosis, options 3 and 4 are directly [HIDDEN] (also, she is female, so we would not have to think about hemophilia) As an analytical data, it says that there is a lengthening of the aPTT. So, they want you to know, she has positive lupus ac and link it directly to antiphospholipid syndrome (APS). A Leiden's does not alter coagulation, so it is [HIDDEN]. Anyway, although it is not within the possible answers, lupus positivity can be related to a myriad of clinical situations, syndromes and pathologies. Assuming that a PTE + lupus is a PFS seems to me to be [HIDDEN], but it is the most likely with the data provided.

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 diagnoses is the most likely:


The first thing we should know when applying the Glasgow Coma Scale to a patient is that we should always keep the best value in each sphere (ocular response, motor response and verbal response). In this case, we have a patient who has an ocular opening to the call (ocular response 3 out of 4), emits inappropriate words (verbal response 3 out of 5) and localizes pain with right extremities (motor response 5 out of 6). The Glasgow Coma Scale score would be 11 (out of 15). The best value of the examination is taken because in many cases (assessment of a polytraumatized patient, ischemic stroke or spontaneous acute cerebral bleeding), the motor examination may be artifacted by other elements. For example: in a polytraumatized patient (such as the one in question), the response presented with left extremities may be due to localized trauma in that area, and not strictly speaking to an underlying traumatic brain injury. Likewise, sometimes the verbal response may be underestimated in the polytraumatized patient due to airway obstruction (e.g., due to the tongue retreating into the oropharynx). By always assessing the best response, we will have a truer picture of the patient's condition.

After a traffic accident you attend to an injured person. The patient opens his eyes at your call, but only utters words that are inappropriate. On motor examination, the pain is localized in the right extremities, but spreads on stimulation of the left extremities. How would you describe his condition according to the Glasgow Coma Scale?


Question of very high difficulty, I would not worry about having failed it. It is easy to get confused with the hypoparathyroidism answer. Permanent post-surgical hypoparathyroidism after parathyroidectomy of an adenoma with minimally invasive surgery is rare. I write a brief summary of the hungry bone syndrome that I have found in a clinical case in the Annals of Internal Medicine [1]: "The pathophysiology of the hungry bone syndrome (HBS) is related to an imbalance between bone formation and bone resorption, which is associated with hypocalcemia, hypophosphatemia and hypomagnesemia (1). This syndrome can be observed after surgery in patients with primary hyperparathyroidism (HPT), as well as in tertiary HPT of chronic renal failure, and to a lesser extent after treatment of processes with excess of circulating thyroid hormones (2). In PTH, there is an excess of parathyroid hormone (PTH) which stimulates osteoclastic activity causing demineralization of the bone matrix and releasing calcium into the bloodstream. After parathyroidectomy, serum PTH levels drop dramatically, thus, PTH-induced bone resorption ceases, while osteoblastic activity continues resulting in increased bone uptake of calcium, phosphate and magnesium, thus SHH appears (3)."

A 55-year-old woman consults for fatigue and polyuria of two years' evolution. Laboratory tests reveal hypercalcemia, increased PTH and increased bone turnover markers. The radiographic study shows subperiosteal resorption and osteoporosis. Sestamibi scintigraphy revealed a parathyroid adenoma. Parathyroidectomy was performed with minimally invasive surgery. Postoperatively, the patient developed severe hypocalcemia and tetany, with PTH below 5 ng/l. The patient responds well to initial treatment with intravenous calcium and later with oral calcium and vitamin D. What is the most likely diagnosis?


We are facing a case of Anaphylaxis so the first measure is to administer Adrenaline 1/1000 intramuscular (0.01mg/kg). Subsequently, systemic corticosteroids such as methylprednisolone will be given, which will take a few hours to take effect. So adrenaline first, as it is faster acting, then the rest (Question very similar to one last year, instead of yogurt, it was omelet).

A 4-year-old boy comes to the health center who, 5 minutes before, starts with angioedema in the face, conjunctivitis, nasal congestion and hoarseness, coinciding with the ingestion of a spoonful of yogurt given to him by mistake at school. Among the antecedents, he was diagnosed with cow's milk protein allergy. Examination revealed mild hypotension, heart rate 110 bpm, O2 Sat 93%, pale and slightly sweaty, with scattered wheezing. What is the first treatment of choice?


Applying the CURB-65 severity scale (one of the most commonly used in the ED for stratifying the severity of pneumonia, although in this case simply applying common sense, the patient should be admitted to the ICU), we would have a score of at least 4 points (we would be missing the serum urea data), which gives us severity criteria. Since there are no criteria that contraindicate admission to the ICU, admission to the unit would be indicated.

A 72-year-old man presenting since 48 hours with fever of 38.7°C, cough, purulent expectoration and dyspnea. Constants: BP 85/60 mmHg, heart rate 100 bpm, respiratory rate 35 rpm, SatO2 80%. Of note was the presence of confusion and crackles in the left lower lung field. Chest X-ray confirms the existence of pneumonia of the lingula and left lower lobe. What would be the appropriate place of care?

Admission to an emergency observation unit.


There are two answers that we can immediately rule out if we stick to the initial management of severe chest trauma: 1 (noninvasive ventilation is not indicated because it does not secure the airway) and 3 (observation in these cases, waiting for worsening, only leads to increased morbidity and mortality). Between options 2 and 4 there could be controversy between the literature and the usual clinical practice, in which we usually have to face in a delicate balance the clinical stability of the patient (and what we can "make up" this stability with our life support therapies) and the actions that result in better patient care for the definitive treatment of the lesions. We are dealing with a severe polytraumatized patient. With the data provided by the question, a patient who seems to be in shock (tachycardia, hypoxemia, tachypnea... although we do not receive data, for example, on lactacidemia), and in whom we have to our knowledge a left thoracic trauma, which not only implies bone injury, but may mask other injuries of high severity and which are not diagnosed with a chest X-ray: myocardial contusion, pericardial effusion, splenic injury, diaphragmatic injury... We place a left pleural drain on the patient and obtain a debit of 1700cc of hematic fluid. If we follow the ATLS (ATLS-Advanced Trauma Life Support 10th edition) guidelines for the care of severely polytraumatized patients, they tell us that an immediate bleeding of more than 1500cc of blood is an indication for urgent thoracotomy, and that even in patients with a bleeding of less than 1500cc, if the debit persists at a rate of 200mL/h for 2 to 4h, this indication would also exist. Therefore, the person who asked the MIR question wants us to answer option 2. However, in real life, the course of action will depend on the stability of the patient when we have applied the treatments indicated in option 2: adequate analgesia, oxygen therapy and initiation of blood transfusion. If by optimizing the patient we manage to stabilize him and assess that it is safe to transfer him, the performance of a body CT scan will define in much greater detail the lesions he has, and will help to ensure that the surgery he will probably end up undergoing will be a definitive surgery and not just damage control surgery. In this case, the doubt would arise with option 4, although, as I say, everything will depend on the clinical stability of the patient and the time we have before achieving definitive control of the hemorrhagic focus (which is, after all, what we are after in this situation).

There are two answers that we can immediately rule out if we stick to the initial management of severe chest trauma: 1 (noninvasive ventilation is not indicated because it does not secure the airway) and 3 (observation in these cases, waiting for worsening, only leads to increased morbidity and mortality). Between options 2 and 4 there could be controversy between the literature and the usual clinical practice, in which we usually have to face in a delicate balance the clinical stability of the patient (and what we can "make up" this stability with our life support therapies) and the actions that result in better patient care for the definitive treatment of the lesions. We are dealing with a severe polytraumatized patient. With the data provided by the question, a patient who seems to be in shock (tachycardia, hypoxemia, tachypnea... although we do not receive data, for example, on lactacidemia), and in whom we have to our knowledge a left thoracic trauma, which not only implies bone injury, but may mask other injuries of high severity and which are not diagnosed with a chest X-ray: myocardial contusion, pericardial effusion, splenic injury, diaphragmatic injury... We place a left pleural drain on the patient and obtain a debit of 1700cc of hematic fluid. If we follow the ATLS (ATLS-Advanced Trauma Life Support 10th edition) guidelines for the care of severely polytraumatized patients, they tell us that an immediate bleeding of more than 1500cc of blood is an indication for urgent thoracotomy, and that even in patients with a bleeding of less than 1500cc, if the debit persists at a rate of 200mL/h for 2 to 4h, this indication would also exist. Therefore, [HIDDEN]. However, in real life, the course of action will depend on the stability of the patient when we have applied the treatments indicated in [HIDDEN]: adequate analgesia, oxygen therapy and initiation of blood transfusion. If by optimizing the patient we manage to stabilize him and assess that it is safe to transfer him, the performance of a body CT scan will define in much greater detail the lesions he has, and will help to ensure that the surgery he will probably end up undergoing will be a definitive surgery and not just damage control surgery. In this case, the doubt would arise with [HIDDEN], although, as I say, everything will depend on the clinical stability of the patient and the time we have before achieving definitive control of the hemorrhagic focus (which is, after all, what we are after in this situation).

15-year-old male, admitted after being run over on the public road, resulting in being ejected. He was admitted conscious and oriented, with intense pain in the left hemithorax and dyspnea. Physical examination showed blood pressure 90/60 mmHg, heart rate 130 bpm, basal oxygen saturation 90%, respiratory rate 35 rpm. There is complete hypophonesis in the left hemithorax and dullness to percussion. Chest X-ray shows multiple left costal fractures and massive ipsilateral pleural effusion. Placement of a pleural drain is indicated, with 1700 cc of hematic fluid coming out. What is the decision to be made:

Institute noninvasive mechanical ventilation and request blood transfusion.

Analgesia, oxygen therapy, request blood transfusion and indicate urgent surgery.

Orotracheal intubation, request blood transfusion and observation for, in case of worsening, indicate surgical intervention.

Orotracheal intubation and urgent CT scan for accurate assessment of lesions.


She is going to have myeloma. For diagnosis, a sample (bone marrow) and electrophoresis to determine the type of monoclonal peak. Then, for extension, prognostic value and to decide treatments, the rest, but once diagnosed.

A 72-year-old man comes to the Emergency Department with a pathological fracture of the left femur. After surgery, a diagnostic study is performed to determine the underlying pathology with the following findings: hemoglobin 9.5 g/dl, total proteins 11 g/dl, (VN: 6-8 g/dl), serum albumin 2 g/dl, (VN 3.5-5.0 g/dl), beta 2 microglobulin 6 mg/l (VN 1.1-2.4 mg/l), serum creatinine 1.8 mg/dl (VN: 0.1-1.4 mg/dl). Indicate which diagnostic tests would be necessary to confirm the most likely diagnosis:

Radiological bone series and bone marrow aspirate.

Serum and urine electrophoresis and renal function tests.

Bone marrow aspirate and serum calcium concentration.

Bone marrow aspirate and serum and urine electrophoresis.

Biopsy of the pathological fracture and radiological bone series.


In a patient with a low symptomatic COPD that could probably be classified as GOLD 2, the starting treatment can be either with inhaled tiotropium or with a long-acting beta two. Therefore there is no doubt in the correct answer.

In a patient with a low symptomatic COPD that could probably be classified as GOLD 2, the starting treatment can be either with inhaled tiotropium or with a long-acting beta two. Therefore there is [HIDDEN].

A 67-year-old man consults for moderate exertional dyspnea of progressive onset in recent years. He has daily whitish expectoration and sometimes breath sounds, especially in winter with respiratory infections. He has been a smoker of about 20 cigarettes a day for the last 45 years. On examination he is eupneic, normocolored, with an oxygen saturation of 94%, and has generalized decreased vesicular murmur on chest auscultation as the only findings of interest. Chest X-ray shows an elongated cardiac silhouette, with signs of hyperinflation or pulmonary air trapping, without other alterations. Spirometry was performed with the following result: FVC 84%, FEV1 58%, FEV1/FVC 61%, unchanged after bronchodilator. Among those indicated, indicate the most appropriate treatment for this patient:

Home oxygen therapy with portable oxygen source for ambulation.


The correct answer is 3. It defines a typical cerebrospinal fluid of tuberculosis. In clinical practice things might not be so simple......

[HIDDEN] It defines a typical cerebrospinal fluid of tuberculosis. In clinical practice things might not be so simple......

Given a 7-month-old child with fever and irritability, bulging fontanel and a cerebrospinal fluid study with 110 cells/mm3 (75% lymphocytes), protein 120 mg/dl and glucose 28 mg/dl (serum glycemia 89 mg/dl), what is the most reasonable diagnostic suspicion?


I think the correct answer is 2 although the treatment for acute cholecystitis is cholecystectomy, for this it is necessary that the patient is a surgical candidate, in this case it is an elderly patient, with previous diseases that increase the surgical risk and would be an ASA IV for an urgent intervention. In these cases cholecystostomy can cure cholecystitis; and after recovery, assess scheduled surgery according to the patient's situation.

I think [HIDDEN] although the treatment for acute cholecystitis is cholecystectomy, for this it is necessary that the patient is a surgical candidate, in this case it is an elderly patient, with previous diseases that increase the surgical risk and would be an ASA IV for an urgent intervention. In these cases cholecystostomy can cure cholecystitis; and after recovery, assess scheduled surgery according to the patient's situation.

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

Surgical treatment (urgent cholecystectomy).

Biliary drainage by percutaneous cholecystostomy.

Substitute metronidazole + cefotaxime for piperacillin/tazobactam.

Replace piperacillin/tazobactam with amikacin+clindamycin.


Positive Lasegue's sign, reappearance of the symptoms when performing the extension maneuver of the affected limb, compatible with involvement of nerve roots at the lumbosacral spine level.

A 61-year-old woman, administrative, with a history of overweight, hypertension, dyslipidemia and metabolic syndrome, who consults for pain in both buttocks, left trochanteric region, lateral aspect of the left thigh up to the knee and left leg up to the middle third. The pain appears when the lower limb is lifted with the knee extended, but is relieved when the knee is flexed. What is the first clinical suspicion?


Although the latest recommendations on the management of severe acute pancreatitis advise against FNA because of the risk of infection of sterile necrosis. Current management is governed by stepwise treatment. In the situation described in the question the current treatment is to start antibiotics and assess response.

Patient with acute pancreatitis. Computerized Axial Tomography (CAT) performed 72 hours after admission showed necrosis of 50% of the pancreas. At the 3rd week of admission the patient began with high fever and leukocytosis. Urgent chest X-ray and urinary sediment are requested, both being normal. Indicate the next step to follow:

Fine needle aspiration of pancreatic necrosis guided by ultrasound or CT.

Bronchoalveolar aspirate, urine culture and blood cultures.

Echoendoscopy with puncture of the necrosis.


Behavioral changes: diet and physical exercise. This is the first thing we do when diagnosed with type 2 diabetes. This is a good question to remember that before any drug, we must insist on changing habits. Then we would prescribe Metformin.

Behavioral changes: diet and physical exercise. This is the first thing we do when diagnosed with type 2 diabetes. This is a good question to remember that before any drug, we must insist on changing habits. [HIDDEN]

A 54-year-old man who goes for a check-up at his company. A body mass index of 32.8 kg/m2 and fasting blood glucose of 138 mg/l were detected. One month later, glycemia 13 mg/dl. Which therapeutic recommendation would you make first?

Behavioral changes. Diet and physical exercise.

Take acarbose at night, before going to bed.


More than 2 lobar pneumonias make it necessary to rule out an immunologic deficit.

A 43-year-old man consults for diarrheal syndrome, and refers among his history 3 pneumonias in adulthood. Which of the following immunological studies should we request:

Serum immunoglobulin count and antibody production capacity test.

Phagocytosis test and oxidative metabolism of neutrophils.

Apoptosis test (programmed cell death) in the patient's circulating lymphocytes.

Study of the repertoire and clonality of T lymphocytes (alpha/beta).

In this patient it would not be appropriate to request any immunological study.


The negative IgM of HAV rules out 5

An interesting one that in general needs to be studied. By the form of presentation, it is clearly an acute hepatitis, so option 1 is ruled out. The negative IgM of HAV rules out 5 and the negative HBs Ag rules out 4 (to have delta virus you need surface antigen B). When having IgM anti HBc we speak of an acute hepatitis B (3), since there is a window period of negativization of the antigen.

An interesting one that in general needs to be studied. By the form of presentation, it is clearly an acute hepatitis, so [HIDDEN]. The negative IgM of HAV rules out [HIDDEN] and the negative HBs Ag rules out [HIDDEN] (to have delta virus you need surface antigen B). When having IgM anti HBc we speak of an acute hepatitis B [HIDDEN], since there is a window period of negativization of the antigen.

A man presents abruptly with asthenia and jaundice with transaminases above 2000 IU/L. Serological markers show the following pattern: anti-HAV IgM negative, HBsAg negative anti-HBc IgM positive, anti-HCV negative. What is the diagnosis?


The most frequent cause of recurrent nerve palsy is bronchopulmonary carcinoma. The fact that it is not accessible to endoscopic vision does not mean that it is not there.

55-year-old man who consults for dysphonia. In the anamnesis he refers to a month of asthenia and unquantified weight loss. Chest X-ray shows increased density in the left upper lobe and occupation of the aortopulmonary window. Bronchoscopy shows paralysis of the left vocal cord, without endoscopic image suggestive of neoplasia. What is the most likely diagnosis?


As it is described as an apraxic phenomenon followed by an asymmetric rigid-akinetic parkinsonism and with superimposed myoclonias, it is typical of corticobasal degeneration. Parkinson's disease cannot be because they do not present apraxia as initial feature, Alzheimer's disease does not present an asymmetric parkinsonism and the typical Huntinton's disease is not of so old people and when it debuts with advanced age it behaves like a chorea.

A 65-year-old female patient debuted two years earlier with an apraxia of speech and has developed rigid-akinetic parkinsonism predominantly in the right hemibody with superimposed myoclonias and alien hand or foreign limb phenomenon.What diagnosis do you consider most likely?


The correct answer is 4. The normal range of stool output in young infants is very wide. To suspect aganglionic megacolon there is usually a delay in the evacuation of meconium and often other associated symptoms such as abdominal distension, difficulty in gaining weight, etc.

[HIDDEN] The normal range of stool output in young infants is very wide. To suspect aganglionic megacolon there is usually a delay in the evacuation of meconium and often other associated symptoms such as abdominal distension, difficulty in gaining weight, etc.

A 1 month old infant, exclusively breastfed, consults because he has a bowel movement every 5 or 6 days with straining but with a soft consistency, what would our attitude be?

Supplement breastfeeding with anti-constipation formula.

It is considered normal intestinal rhythm.

Refer to Pediatric Digestive to rule out aganglionic megacolon.


General malaise, arthralgias, skin rash, acute renal failure and active sediment with sterile leukocyturia following the intake of a drug is highly suggestive of AIN (option 4 correct). Among drugs, antibiotics are the most frequent cause, and ciprofloxacin is one of the most common. Direct nephrotoxicity is very rare and is characterized by crystallization in the renal tubules (incorrect option 2). Postinfectious glomerulonephritis is more typical of children and adults older than 60 years, and usually manifests with hematuria after streptococcal infections (option 1 incorrect). Acute pyelonephritis would have been presented with high fever and renal fossa pain (option 3 incorrect).

General malaise, arthralgias, skin rash, acute renal failure and active sediment with sterile leukocyturia following the intake of a drug is highly suggestive of AIN ([HIDDEN]). Among drugs, antibiotics are the most frequent cause, and ciprofloxacin is one of the most common. Direct nephrotoxicity is very rare and is characterized by crystallization in the renal tubules ([HIDDEN]). Postinfectious glomerulonephritis is more typical of children and adults older than 60 years, and usually manifests with hematuria after streptococcal infections ([HIDDEN]). Acute pyelonephritis would have been presented with high fever and renal fossa pain ([HIDDEN]).

A 47-year-old woman consults for voiding syndrome. She is diagnosed with uncomplicated urinary tract infection and treated with ciprofloxacin for 5 days. A week later, she consulted again for general malaise, arthralgias and the appearance of a skin rash. In the analytical analysis, the glomerular filtration rate was 45 ml/min (CKD-EPI), whereas 6 months ago it was 100 ml/min. In the sediment leukocytes are identified, being negative for nitrites. Of the following, which is the most probable cause of his renal failure?


You have probably looked at answer 5, hereditary spherocytosis, associated with biliary lithiasis at an early age. Exactly, that is the correct one. In the statement they have not stopped giving clues: conjunctival jaundice, splenomegaly and family history of biliary lithiasis at an early age. He has reached 30 years of age without suffering a hemolytic crisis, without suffering any symptoms. There was no mention of microcytosis or macrocytosis to suggest thalassemia minor or B12 and/or folic acid deficiency. Nor of hemolytic crisis associated with the consumption of drugs, infections or ingestion of beans or peas. They have not given any clues to stop to think about other possibilities.

You have probably looked at answer 5, hereditary spherocytosis, associated with biliary lithiasis at an early age. [HIDDEN]. In the statement they have not stopped giving clues: conjunctival jaundice, splenomegaly and family history of biliary lithiasis at an early age. He has reached 30 years of age without suffering a hemolytic crisis, without suffering any symptoms. There was no mention of microcytosis or macrocytosis to suggest thalassemia minor or B12 and/or folic acid deficiency. Nor of hemolytic crisis associated with the consumption of drugs, infections or ingestion of beans or peas. They have not given any clues to stop to think about other possibilities.

A 30-year-old woman, asymptomatic, is found to be anemic on routine examination. Physical examination reveals conjunctival jaundice and splenomegaly. The patient refers to a family history of biliary lithiasis at an early age. All this suggests the most probable diagnosis of:

Glucose 6-phosphate dehydrogenase deficiency.

Vitamin Bl2 and/or folic acid deficiency.


This question is not an easy one. The available literature is somewhat controversial (some guidelines advise using glucose saline, others absolutely forbid it...) so I have decided to rely on the treatment recommended by Harrison, which is the manual that MIR examiners usually rely on. This girl presents with hypernatremia due to extrarenal free water losses. The goal is to replace the lost water and reduce the natremia at a rate of no more than 12 mmol/day. To calculate fluid therapy, the water deficit must first be calculated. Water def. Water = (Natremia-140/140)xTotal body water. TBW = Weight in kg x 0.4 in females/0.5 in males. In this case, the water deficit is: ([[tel:155-140/140|155-140/140]])x60x0.4 = 2.57 liters. There are only two answers that come close to this figure, but 2 seems more correct, as it is the only one that completely covers the water deficit and uses a hyposodium solution.

This question is not an easy one. The available literature is somewhat controversial (some guidelines advise using glucose saline, others absolutely forbid it...) so I have decided to rely on the treatment recommended by Harrison, which is the manual that MIR examiners usually rely on. This girl presents with hypernatremia due to extrarenal free water losses. The goal is to replace the lost water and reduce the natremia at a rate of no more than 12 mmol/day. To calculate fluid therapy, the water deficit must first be calculated. Water def. Water = (Natremia-140/140)xTotal body water. TBW = Weight in kg x 0.4 in females/0.5 in males. In this case, the water deficit is: ([[tel:155-140/140|155-140/140]])x60x0.4 = 2.57 liters. There are only two answers that come close to this figure, but [HIDDEN], as it is the only one that completely covers the water deficit and uses a hyposodium solution.

19-year-old woman, weight 60 kg, with acute dehydration due to long exposure to the sun. Blood pressure lying down 100/60 mmHg. Standing 70/50 mmHg with dizziness. Serum sodium levels 155 mmol/L. What is the most correct treatment, in the first 24 hours, taking into account the data available to us?

Hypertonic saline (3%), 500 ml + 500 ml of 5% glucose.


We believe that this question is open to challenge. Ibuprofen hepatitis is a rare adverse effect with a prevalence of about 3.7/100,000 users and 1.1/100,000 prescriptions. It appears that it may be related to dose and duration of treatment, but there is little evidence on this. Among the NSAIDs with the highest risk are diclofenac and sulindac. In terms of frequency, the prevalence of cholangiocarcinoma is 2/100,000 patients, a very comparable frequency. The absence of bile duct dilatation in cholangiocarcinomas can be seen in cases of intrahepatic cholangiocarcinomas or in those with mixed histology with hepatocarcinoma. It is true that the acute course and the absence of constitutional syndrome may make us think against this option and tip the balance towards ibuprofen hepatitis. Regarding the other options: acute cholangitis is characterized by the triad of jaundice, abdominal pain and fever; Gilbert's syndrome is an increase in bilirubin at the expense of indirectness.

We believe that this question is open to challenge. Ibuprofen hepatitis is a rare adverse effect with a prevalence of about 3.7/100,000 users and 1.1/100,000 prescriptions. It appears that it may be related to dose and duration of treatment, but there is little evidence on this. Among the NSAIDs with the highest risk are diclofenac and sulindac. In terms of frequency, the prevalence of cholangiocarcinoma is 2/100,000 patients, a very comparable frequency. The absence of bile duct dilatation in cholangiocarcinomas can be seen in cases of intrahepatic cholangiocarcinomas or in those with mixed histology with hepatocarcinoma. [HIDDEN] Regarding the other options: acute cholangitis is characterized by the triad of jaundice, abdominal pain and fever; Gilbert's syndrome is an increase in bilirubin at the expense of indirectness.

A 43-year-old male with no past history of interest consults for a ten-day history of jaundice of the skin and mucous membranes, choluria and acholia. He does not report abdominal pain, weight loss or other symptoms, except generalized pruritus. She denies alcohol consumption. She does not take any medication except occasional ibuprofen for muscle pain after sports activities. The CBC shows increased bilirubin at the expense of direct bilirubin. An urgent ultrasound shows a normal liver, vesicular cholesterosis and absence of bile duct dilatation, with no other alterations of interest. What is the most likely diagnosis?


It is a lymphocytic exudate whose main diagnoses are tumor and tuberculous pleuritis. They do not give the value of glucose which should be lowered, but if the cytology shows absence of malignant cells so we are left with tuberculous pleuritis. Other possible diagnoses such as lymphoma are not mentioned in the answers.

A 50-year-old patient presenting with a pleural effusion with the following features: straw-like appearance, pH 7.3, pleural protein/serum ratio 0.8, pleural LDH/serum ratio 0.9, Gram and Ziehl's negative, total lipids, cholesterol and triglycerides normal, mesothelial cells <5%, intense lymphocytosis without atypia, ADA 64 U/L. What diagnosis would you suggest?

Pleural effusion due to heart failure (transudate).

Effusion secondary to pulmonary infarction.


Let's see, if that subject was not in any risk group, the positive is in the 15mm, therefore both tests are negative, and as only one answer refers to negative, that's it. But both could be false negatives.

Let's see, if that subject was not in any risk group, the positive is in the 15mm, therefore both tests are negative, and as only one answer refers to negative, [HIDDEN]. But both could be false negatives.

In a subject over 65 years of age a tuberculin test has shown an induration of 3 mm. The induration on a second test, performed 10 days later, is 13 mm. Point out the correct answer:

The second reaction is a false positive.


The answer is 2, study of hormone receptors and HER2. This is because no study of first-degree relatives is appropriate, as it does not appear to be hereditary breast cancer since there is no family history of neoplasia. On the other hand, there is no indication for BRCA 1-2 study.

The answer is [HIDDEN], study of hormone receptors and HER2. This is because no study of first-degree relatives is appropriate, as it does not appear to be hereditary breast cancer since there is no family history of neoplasia. On the other hand, there is no indication for BRCA 1-2 study.

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

Complete phenotypic study by flow cytometry.

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

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


It tells us about a patient with a diagnosis of lupus and macrocytic anemia. In the end, all the data are usually given for a reason. The onset of the picture seems relatively rapid and it is also associated with an autoimmune disease, so it seems that they want you to associate it with an autoimmune hemolytic anemia. The low haptoglobin would tell us it is "hemolytic", the coombs test would tell us it is "autoimmune". Vitamin B12, probably the MCV would be higher than 108 and the onset of the clinical picture would be slower. The ANA would not give us anything in relation to the anemia, since it already has a diagnosis. Therefore, correct answer 2. As a note, autoimmune hemolytic anemias are usually slightly macrocytic due to reticulocytosis. Remember to ask for reticulocytes.

It tells us about a patient with a diagnosis of lupus and macrocytic anemia. In the end, all the data are usually given for a reason. The onset of the picture seems relatively rapid and it is also associated with an autoimmune disease, so it seems that they want you to associate it with an autoimmune hemolytic anemia. The low haptoglobin would tell us it is "hemolytic", the coombs test would tell us it is "autoimmune". Vitamin B12, probably the MCV would be higher than 108 and the onset of the clinical picture would be slower. The ANA would not give us anything in relation to the anemia, since it already has a diagnosis. Therefore, [HIDDEN]. As a note, autoimmune hemolytic anemias are usually slightly macrocytic due to reticulocytosis. Remember to ask for reticulocytes.

A 26-year-old woman diagnosed with systemic lupus erythematosus, on treatment with hydroxychloroquine, consults for a feeling of generalized weakness that has progressively developed in 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?


an L4/L5 herniation would affect the L5

Acute sciatica probably due to disc extrusion. Both the sensory distribution, the paresis for plantar flexion (tiptoe) and the absence of the Achilles reflex are typical of S1 root involvement, which is typically affected with L5/S1 disc herniation (posterolateral). An L1/L2 (posterolateral) herniation would affect the L2 root, an L4/L5 herniation would affect the L5 and cauda equina would involve more symptomatology than simple S1 involvement.

A 36-year-old man with no PA of interest comes to the emergency department with sudden onset of severe pain in the posterior aspect of the right lower limb extending to the foot. On examination he presented: Positive right Lasège at 10º, decreased strength in plantar flexion of the right foot, hypoesthesia in the external border of the right foot and absence of right Achilles reflex. The simple X-ray of the lumbar spine does not show significant alterations. Which of the following is the most probable diagnosis?


The patient presents the clinical features of spondylarthropathy, which is often associated with inflammatory bowel disease, as this case suggests.

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

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

Perform a digestive study to rule out tumor pathology. Low back pain may be due to visceral pathology.

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

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


I believe that the correct answer is 3. The patient, due to the mechanism of injury (foot fall), the calcaneal fracture and the neurological symptoms, suggests a low spinal cord injury due to a fracture of the lumbar spine. The injury is not high because he moves his arms. It also does not appear to be a pelvic injury because of the absence of pain on mobilization or palpation. If there is a suspicion of pelvic injury in the primary evaluation of all polytraumatized (ATLS) a spinal exploration should be performed by rotating the spine en bloc to avoid producing more injury. Abdominal palpation is also part of the initial evaluation. Abdominal ultrasound may be indicated in hemodynamically unstable patients if abdominal injuries are suspected but in any case it is done after the initial evaluation.

I believe that the [HIDDEN]. The patient, due to the mechanism of injury (foot fall), the calcaneal fracture and the neurological symptoms, suggests [HIDDEN] due to a fracture of the lumbar spine. The injury is not high because he moves his arms. It also does not appear to be a pelvic injury because of the absence of pain on mobilization or palpation. If there is a suspicion of pelvic injury in the primary evaluation of all polytraumatized (ATLS) a spinal exploration should be performed by rotating the spine en bloc to avoid producing more injury. Abdominal palpation is also part of the initial evaluation. Abdominal ultrasound may be indicated in hemodynamically unstable patients if abdominal injuries are suspected but in any case it is done after the initial evaluation.

A 30-year-old man suffers a fall from a standing height of 2 meters. On arrival at the emergency room on a stretcher, he is conscious and oriented, with bladder catheterization and clear urine. He shows swelling of the left heel and mild tingling in the anterior aspect of the left thigh and scrotum as well as dysesthesia in both feet. The patient says goodbye to the stretcher-bearer with a handshake and a simultaneous pat on the shoulder. Rotation of the lower limbs on the stretcher grasped by the ankles is painless and compression of the pelvis is asymptomatic. Next:

The patient will be seated on the stretcher so that the cervical spine can be explored.

Refer to radiology for study of the lower extremities (feet, femurs, pelvis).

We will palpate the abdomen and roll en bloc to palpate the thoracolumbar spine.

We will place a cervical collar and refer to radiology for imaging of the lower extremities and cervical spine.

We will request an abdominal ultrasound.


In this case we describe a case of cervicobrachialgia without alarm signs at the present time, so the most indicated treatment at this time would be conservative, based on NSAIDs, local heat and rest. This is not an urgent case, so answer 2 would not be valid. The performance of an MRI and an electromyogram are valid options for the etiological study of the picture, however, it is necessary to emphasize that we should first perform a correct pain management, so since we are asked about the first attitude, option 1 would be more valid.

In this case we describe a case of cervicobrachialgia without alarm signs at the present time, so the most indicated treatment at this time would be conservative, based on NSAIDs, local heat and rest. This is not an urgent case, so answer 2 would be [HIDDEN]. The performance of an MRI and an electromyogram are valid options for the etiological study of the picture, however, it is necessary to emphasize that we should first perform a correct pain management, so since we are asked about the first attitude, option 1 would be [HIDDEN].

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

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

Urgent call to the neurosurgeon for surgical evaluation.

Preferential request for MRI and electromyogram.

Preferential referral to traumatology outpatients.


It is a Luminal B. According to the SEGO, this patient is a candidate for chemotherapy treatment because of the high histologic grade and high tumor proliferation.

A 64-year-old woman, without relevant comorbidities, operated on for a right breast cancer by means of an extended lumpectomy and selective sentinel lymph node biopsy, with the following anatomopathological result: Infiltrating ductal carcinoma poorly dlferentiated (grade 3), size 2.2 cm (pT2), estrogen and progesterone receptor positive, Ki67 25%, HER2 negative. There is macroscopic involvement of the sentinel lymph node, although there is no involvement of the rest of the isolated axillary nodes (pN1). What adjuvant systemic treatment do you consider most appropriate for this patient?

Adjuvant hormone therapy including aromatase inhibitors.

Adjuvant chemotherapy, preferably with anthracyclines and taxanes, followed by hormone therapy.

Adjuvant chemotherapy in association with the monoclonal antibody trastuzumab, followed by hormone therapy.

Adjuvant chemotherapy, preferably with anthracyclines and taxanes.


Absences behave as brief episodes of abrupt loss of consciousness without alteration of postural control; they typically last seconds and can be repeated many times a day, are usually accompanied by small bilateral motor signs (blinking, chewing) and consciousness is recovered equally abruptly, without subsequent confusion or memory of the episode (MIR 03-04, 248; MIR 97-98, 51). The age of onset is usually between 4 years and early adolescence, being the most frequent cause of seizures in this age range. EEG findings are typically generalized and symmetrical spike-wave discharges at 3 Hz (MIR 99-00F, 67) coinciding with seizures, although in the interictal EEG there are more periods of abnormal activity than clinically visible. The most appropriate drugs for the treatment of absences are Valproate and Ethosuximide (CTO Manual).

A 10-year-old boy with brief episodes of distractibility (< 1 minute) in which he does not respond to calls and blinks. An EEG shows spike-wave discharges at 3 cycles per second. First-line elective treatment would be with:


This is an easy and classic question that you can also apply to daily clinical practice. Hypophonesis in a hemithorax + tympanism = pneumothorax. If there is dullness on percussion: hemothorax. In either case, in case of hypophonesis of a hemithorax in a severe and unstable polytraumatized patient: thoracic drainage (if possible, large caliber if placed in a hospital environment, since although the predominant lesion is pneumothorax, a hemothorax component can be found which, in case of placing a fine drainage, could obstruct it).

35-year-old male, transferred to the emergency department after a traffic accident. On admission, a Glasgow scale score of 15, blood pressure of 140/90 mmHg, respiratory rate of 35 rpm and heart rate of 110 bpm, with a baseline oxygen saturation of 91%. On examination there is right thoracic hypophonesis and tympanism on percussion.What is the presumptive diagnosis? :


They are undoubtedly describing the typical lesions (both on skin and oral mucosa) of a lichen planus (5).

They are undoubtedly describing the typical lesions (both on skin and oral mucosa) of a lichen planus ([HIDDEN]).

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

DERMATOLOGY, VENEREOLOGY AND PLASTIC SURGERY


Enteral nutrition is a nutritional support technique that involves administering nutrients directly into the gastrointestinal tract by gavage. The choice of the route of formula administration depends on the nutritional status, age of the patient and the underlying disease. If enteral nutrition is considered to be of short duration, the route of choice is the nasogastric or nasoduodenal- nasojejunal tube... If prolonged nutrition is anticipated the route of choice is gastrostomy (option 3), with jejunostomy being reserved for cases in which it is not possible to use the gastric route.

Enteral nutrition is a nutritional support technique that involves administering nutrients directly into the gastrointestinal tract by gavage. The choice of the route of formula administration depends on the nutritional status, age of the patient and the underlying disease. If enteral nutrition is considered to be of short duration, the route of choice is the nasogastric or nasoduodenal- nasojejunal tube... If prolonged nutrition is anticipated the route of choice is [HIDDEN], with jejunostomy being reserved for cases in which it is not possible to use the gastric route.

A 73-year-old patient...swallowing a complete neurological dysphagia secondary to a cardioembolic stroke in the left middle cerebral artery territory. will require long-term nutritional support. Of the following treatment modalities, which do you consider most appropriate for this case?


These are typical adverse effects of ACEIs, in the case of cough it is usually dry and irritative and appears in up to 3% of patients. Hyperkalemia may also appear in 1%.

A 70-year-old woman with a history of hypertension and moderate heart failure presents with a persistent, dry cough that begins as an itchy sensation in the throat. What is the drug suspected of causing the patient's clinical and laboratory alteration?


The correct answer is 2. We are dealing with a case of postmenopausal metrorrhagia, whose most frequent cause is genital atrophy in the first place and endometrial cancer in the second place. The data given on obesity should lead us to suspect endometrial cancer, since peripheral fat is converted to estrone, and these estrogens cause the endometrium to proliferate. On the other hand, she provides a normal cytology, which rules out option 3. The hormonal evaluation is not opportune, since we understand that the patient is in menopause. We should not prescribe treatment without first ruling out organic causes.

[HIDDEN] We are dealing with a case of postmenopausal metrorrhagia, whose most frequent cause is genital atrophy in the first place and endometrial cancer in the second place. The data given on obesity should lead us to suspect endometrial cancer, since peripheral fat is converted to estrone, and these estrogens cause the endometrium to proliferate. On the other hand, she provides a normal cytology, which [HIDDEN] The hormonal evaluation is not opportune, since we understand that the patient is in menopause. We should not prescribe treatment without first ruling out organic causes.

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

Hormonal evaluation with FSH, LH and estradiol.


The valve is biological and, in general, the veils are not sewn to the papillary muscles, so we don't care what happens to them. A ventricular aneurysm depresses LVEF, but does not suddenly put you into PAD. In contrast, a VSD sharply increases flow to the pulmonary bed, causing pulmonary edema, and is also one of the most frequent complications of AMI. Ischemic ASD... I do not deny that it exists, but it does not even appear in the guidelines. And endocarditis would not require so many saddlebags.

A 62-year-old patient who has had a pericardial bioprosthesis in mitral position for two years. He is admitted urgently for acute coronary syndrome. Two days later and after a favorable evolution, he suddenly presented heart failure with acute pulmonary edema. Select the diagnostic option in this case from the following possibilities:

Acute post-infarction mitral insufficiency.

Dysfunction of the bioprosthesis due to probable acute endocarditis.


You are in the middle of the ENT block. You have already passed the Pneumology and Digestive blocks. Dermatology is still to come out, but a dermatologist (answer 1) would not ask this. So we are left with parotid and larynx; but parotid squamous cell carcinoma is rare; I would mark 5 and rest easy. Perhaps because all the adenopathies at this level that I have seen have ended up corresponding to carcinomas of the upper aerodigestive tract.

You are in the middle of the ENT block. You have already passed the Pneumology and Digestive blocks. Dermatology is still to come out, but a dermatologist (answer 1) would not ask this. So we are left with parotid and larynx; but parotid squamous cell carcinoma is rare; I would mark [HIDDEN] and rest easy. Perhaps because all the adenopathies at this level that I have seen have ended up corresponding to carcinomas of the upper aerodigestive tract.

A 64-year-old smoker and heavy drinker reports painless right jugulodigastric lymphadenopathy of progressive growth in the last two months whose fine needle aspiration was reported as squamous cell carcinoma. Which of the following is the most likely location of the primary tumor:

OTOLARYNGOLOGY AND MAXILLOFACIAL SURGERY


The correct answer is 2 (Perform chest X-ray and spirometry with bronchodilator test). It is probably COPD but we must confirm it and assess the severity of the obstruction with spirometry before starting treatment. He is a patient at risk for lung cancer so it is mandatory to perform a chest X-ray to rule out this or other pathologies that would justify the symptoms, although most likely they are due to the debut of his COPD.

[HIDDEN] It is probably COPD but we must confirm it and assess the severity of the obstruction with spirometry before starting treatment. He is a patient at risk for lung cancer so it is mandatory to perform a chest X-ray to rule out this or other pathologies that would justify the symptoms, although [HIDDEN].

A 65-year-old man, a retired office worker and smoker of 1 pack of cigarettes a day, comes to the clinic with a persistent, generally dry cough and progressive dyspnea of 2 years of evolution which is currently grade 2. The patient denies other symptoms. Physical examination shows no relevant data. The attitude to follow would be:

Start treatment with inhaled bronchodilators.

Chest X-ray and spirometry with bronchodilator test.


A picture of macroscopic hematuria and mild proteinuria with normal creatinine levels, accompanied by an upper tract catarrhal picture, is very suggestive of IgA nephropathy (option 3 correct).

A picture of macroscopic hematuria and mild proteinuria with normal creatinine levels, accompanied by an upper tract catarrhal picture, is very suggestive of IgA nephropathy ([HIDDEN]).

A 22-year-old male presents to the emergency department with "almost black" urine for the past 12 hours. He has no past history of interest and is not taking any medications. He refers an upper respiratory catarrhal symptoms since 4-5 days ago for which he has taken paracetamol. Examination: temperature 37.3 ºC, BP 150/95, HR 85 bpm, slight pharyngeal erythema, the rest normal. Laboratory tests showed: Hb 12.8 g/dl, Hcto 39%, leukocytes 10,500/mm3 with normal formula, platelets 250,000/mm3, normal coagulation, urea 25 mg/dl, creatinine 0.8 mg/dl, ions, hepatic, lipid, albumin and total proteins normal. Normal autoimmunity study and negative viral serology. Urine 24 h with proteinuria of 0.75 g/24 h, sediment with 10 erythrocytes per field (90% dysmorphic), no leukocyturia. Renal ultrasound was normal. Which diagnosis do you think is more likely?


Treatment with diuretics should be started at high doses.

A 60-year-old man with a history of hypertension and dyslipidemia has recently been diagnosed with heart failure. After performing the relevant tests, it was found that the left ventricular ejection fraction was preserved (>50%). With regard to treatment, indicate the CORRECT answer:

Initial treatment should be directed to the underlying pathological process.

If nitrate treatment is required, it should be started at low doses.

Dyspnea can be treated by reducing neurohormonal activation with angiotensin converting enzyme inhibitors or angiotensin receptor antagonists.


They tell us about clinical symptoms of right failure, with edema and ascites. Therefore, we rule out left heart failure: EAo, dilated with DSVI and a MHO. Of the two we are left with, in constrictive pericarditis we have increased filling pressures in right chambers, which cause retrograde pressure increase with hepatic congestion, ascites, edema, etc. On the contrary, in pulmonary hypertension, the tricuspid valve is responsible (a priori) for "containing" this overpressure.

In a patient with clinical signs of heart failure who presents with ascites disproportionately elevated in relation to peripheral edema, the most likely etiology would be:

Dilated cardiomyopathy with significant left ventricular dysfunction.


Very easy question in which we are being presented with a patient with Stauffer's syndrome, a paraneoplastic syndrome consisting of liver dysfunction secondary to toxic products secreted by a number of tumors (most frequently, renal cell carcinoma, like the one in this case). As in this case, cholestasis (elevation of alkaline phosphatase), mobilization of hepatic enzymes and lengthening of the prothrombin time indicate liver dysfunction. Metastases are ruled out (there are no defects of hepatic infiltration), intrahepatic tumor thrombosis (it would give another symptomatology and this would be more acute), and acute hepatitis and hemochromatosis (they are not in context nor is it what the author of the question wants us to think).

A 54-year-old man is diagnosed with a left renal tumor suggestive of renal cell carcinoma. His preoperative workup shows elevated levels of GPT, alkaline phosphatase and alpha-2-globulin and prolonged prothrombin time. The liver is diffusely enlarged, but without defects of hepatic infiltration. The most likely rationale for these findings is due to:

Presence of hepatotoxic substances produced by the tumor.


In fact, I would not test this patient at this time, and I would check if the transaminase level has normalized at a later time, since the most frequent cause, at least in children, is a transient elevation in the context of viral diseases (most frequently cytomegalovirus and Epstein-Barr virus). The minimal elevation of liver enzymes and the fact that it has a normal protein profile goes against chronicity... If I had to choose I would choose answer 5, which seems to me the least aggressive, and if I had to do analytical tests I would add the determination of alpha-1-antitrypsin (without CT) and markers of celiac disease, because celiac disease can also be associated with some hypertransaminemia.

In fact, I would not test this patient at this time, and I would check if the transaminase level has normalized at a later time, since the most frequent cause, at least in children, is a transient elevation in the context of viral diseases (most frequently cytomegalovirus and Epstein-Barr virus). The minimal elevation of liver enzymes and the fact that it has a normal protein profile goes against chronicity... If I had to choose I would [HIDDEN], which seems to me the least aggressive, and if I had to do analytical tests I would add the determination of alpha-1-antitrypsin (without CT) and markers of celiac disease, because celiac disease can also be associated with some hypertransaminemia.

12-year-old girl, only child of healthy, non-consanguineous parents. There is no personal or family history of interest. In the clinical examination to start a sports activity, you find a discrete hepatomegaly of normal consistency, so you request a blood test, which highlights an ASAT of 80U / l, ALAT 105 U / l, electrophoretic proteinogram with all protein fractions in normal range and negativity of serology for hepatotropic viruses. What should you rule out and what test would you indicate for it?

Deficiency of alpha 1 antitrypsin. Thoracic TAC to confirm emphysema.

Mucoviscidosis. Determination of chlorine in sweat.

Glycogenosis type VI (phosphorylase deficiency). Muscle biopsy.

Wilson's disease. Determine ceruloplasmin and copper in blood and urine.


They describe pleural fluid parameters of transudate, so if the patient is not in heart failure it is a hydropic decompensation. No other studies are needed.

In a patient with liver cirrhosis and ascites, who develops a pleural effusion with the following data in the pleural fluid: LDH 45 U/L (serum 220 U/L), pleural/serum protein ratio 0.3 and pleural/serum LDH ratio 0.2. What would be the appropriate attitude?

The study of the fluid with cell count, glucose, pH, ADA, cholesterol and culture should be extended. ADA, cholesterol and culture.

Empirical antibiotherapy for suspected parapneumonic effusion.

Continue treatment of his liver disease.


The rest are not indications. The target BP is < 130/85 mmHg.

The rest are not indications.

The rest are not indications.

The rest are not indications.

The rest are not indications.

A 60-year-old diabetic patient is consulting for the first time regarding the treatment of his disease. Which of the following goals would you recommend to him first?

Maintain blood pressure below 110/70 mmHg.

Maintain a body mass index (BMI) less than 21.


The picture presented to us is that of a Horner syndrome (miosis with ptosis) so the possibilities are reduced to options 3 or 4, but they specify that the patient presents gait instability, which is not justified by a Horner due to carotid dissection affecting the superior cervical ganglion, which is what they want us to believe when they talk about pain in the neck and in the eye. If the patient really has ataxia, the only possible location would be the spinal cord.

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


Study of hormone receptors and HER2. Both for the type of treatment and to study the prognostic factor and adjuvant treatment, it is necessary to know the different hormonal receptors (estrogen and progesterone) as well as HER2-neu.

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

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


He refers to a patient post cataract surgery 2 years ago with deep and painless loss of OD. Post-surgical endophthalmitis is more associated with patients in the immediate postoperative period, besides being very painful with rapidly progressive decrease in visual acuity, so it is not correct. Retinal detachment is consistent with the clinical case because it is also a myopic patient who tend to have a special predisposition to detachment. ARMD usually occurs in older patients and the decrease in vision is progressive. In PVD there may or may not be a slight decrease in visual acuity and the patient usually reports some discomfort or pain at the onset of the clinical picture.

He refers to a patient post cataract surgery 2 years ago with deep and painless loss of OD. Post-surgical endophthalmitis is more associated with patients in the immediate postoperative period, besides being very painful with rapidly progressive decrease in visual acuity, so it is [HIDDEN]. Retinal detachment is consistent with the clinical case because it is also a myopic patient who tend to have a special predisposition to detachment. ARMD usually occurs in older patients and the decrease in vision is progressive. In PVD there may or may not be a slight decrease in visual acuity and the patient usually reports some discomfort or pain at the onset of the clinical picture.

A 47-year-old man with myopia magna, who underwent cataract surgery 2 years ago, comes to the emergency room reporting a profound and painless loss of vision in his right eye. Which of the following diagnoses can cause this symptomatology?

Age-related macular degeneration, wet form.


All the actions detailed are correct except the one detailed in option 2. The collection of samples of legal interest will only be carried out in the presence of the coroner, and, without the presence of the coroner, the woman must give her written consent. In addition, the taking of gynecological samples must be adapted to the psychological state of the victim, so in most cases, it is counterproductive to perform it at this time (even more so when they describe the patient's state as "very affected, answering their questions incongruently, slowly and not being able to remember how the aggression occurred".

All the actions detailed are [HIDDEN] The collection of samples of legal interest will only be carried out in the presence of the coroner, and, without the presence of the coroner, the woman must give her written consent. In addition, the taking of gynecological samples must be adapted to the psychological state of the victim, so in most cases, it is counterproductive to perform it at this time (even more so when they describe the patient's state as "very affected, answering their questions incongruently, slowly and not being able to remember how the aggression occurred".

A 25-year-old woman comes to the ED accompanied by a friend reporting that she was the victim of a sexual assault 4 hours ago. The patient is very affected, answering her questions inconsistently, slowly and not being able to remember how the assault occurred. Her vital signs (blood pressure, heart rate and temperature) are normal. Which of the following would be WRONG:

Immediate gynecological examination with cervical cytology.

Administer 500 mg of intramuscular ceftriaxone, 1 g of azithromycin orally and 2 g of tinidazole orally in single doses.

Administer 1500 mg of levonorgestrel orally in a single dose.


Both the flexor carpi radialis and the abductor pollicis longus are anatomically far from the ulnar. The palmaris longus is medial, as is the flexor digitorum profundus. The tendon that runs alongside the ulnar nerve, inserting into the pisiform, is the flexor carpi ulnaris, thus answer 1.

Both the flexor carpi radialis and the abductor pollicis longus are anatomically far from the ulnar. The palmaris longus is medial, as is the flexor digitorum profundus. The tendon that runs alongside the ulnar nerve, inserting into the pisiform, is the flexor carpi ulnaris, thus [HIDDEN].

A 31-year-old bricklayer comes to the emergency department with tenosynovitis caused by a penetrating wound. On examination, the ulnar bursa is found to be infected with consequent tendon necrosis. Which tendon will be affected?

Tendon of the deep flexor of the fingers.


This is a very bad question, I will bet on one answer, but depending on data that we are not given, three answers could be valid. The trap is that they give us the initial clinical picture WITHOUT GASOMETRY and then they give us the blood gases afterwards WITHOUT CLINIC, so there is no way of knowing what the evolution of the patient has been with our treatment, so it is impossible to know what to do. If the patient initially came with a blood gas with a pH of 7.05 and now has the one we are given, we are doing well (although we are not told the time interval between one thing and the other) and, in this case, it could be worthwhile to continue with the same treatment. If nothing has evolved, the clinical picture is the same and the blood gas at the beginning was similar, something should be done (also depending on the patient's baseline status, which they do not tell us either). If we decide to do something, at present we might decide to use ventilation rather than theophylline, although with "so little" alteration of pH (and even more so if we think that this is a chronic patient who may have a baseline blood gas similar to the one presented to us) it may seem "exaggerated". We have nothing "against" theophylline (we are not told of any contraindication), but nowadays it is rare to resort to it. 1: Wrong, he is a "retentive" patient and increasing O2 flow is highly likely to increase hypercapnia and, therefore, acidosis. 2: We will keep this one as correct. 3: It is not a metabolic acidosis, the bicarbonate is not decreased, on the contrary, it is slightly increased trying to compensate the respiratory acidosis. 4: He does not reach respiratory failure by definition (pO2 60), but he has hypercapnia and slight acidosis. If we knew the first blood gas and she was much worse (i.e. she was doing very well), continuing with the same medication would be an option, but this data is missing!!!, in any case it seems to be a trick answer. 5: At present and -as already mentioned- taking into account that there is no formal contraindication, it is not usually used.

This is a very bad question, I will bet on one answer, but depending on data that we are not given, three answers could be valid. The trap is that they give us the initial clinical picture WITHOUT GASOMETRY and then they give us the blood gases afterwards WITHOUT CLINIC, so there is no way of knowing what the evolution of the patient has been with our treatment, so it is impossible to know what to do. If the patient initially came with a blood gas with a pH of 7.05 and now has the one we are given, we are doing well (although we are not told the time interval between one thing and the other) and, in this case, it could be worthwhile to continue with the same treatment. If nothing has evolved, the clinical picture is the same and the blood gas at the beginning was similar, something should be done (also depending on the patient's baseline status, which they do not tell us either). If we decide to do something, at present we might decide to use ventilation rather than theophylline, although with "so little" alteration of pH (and even more so if we think that this is a chronic patient who may have a baseline blood gas similar to the one presented to us) it may seem "exaggerated". We have nothing "against" theophylline (we are not told of any contraindication), but nowadays it is rare to resort to it. 1: Wrong, he is a "retentive" patient and increasing O2 flow is highly likely to increase hypercapnia and, therefore, acidosis. 2: [HIDDEN] 3: It is not a metabolic acidosis, the bicarbonate is not decreased, on the contrary, it is slightly increased trying to compensate the respiratory acidosis. 4: He does not reach respiratory failure by definition (pO2 60), but he has hypercapnia and slight acidosis. If we knew the first blood gas and she was much worse (i.e. she was doing very well), continuing with the same medication would be an option, but this data is missing!!!, in any case it seems to be a trick answer. 5: At present and -as already mentioned- taking into account that there is no formal contraindication, it is not usually used.

A patient previously diagnosed with COPD comes to the emergency room for 3 days with increased dyspnea until he is at rest, cough with whitish expectoration and marked drowsiness. After receiving treatment with oxygen at low concentrations, bronchodilators and coticoids, a second arterial blood gas with 28% inspiratory oxygen fraction shows a pH of 7.32, pO2 61 mmHg, pCO2 58 mmHg, HCO3- 29 mmol/l. What would be the interpretation you would make of the arterial blood gas and what treatment would you use?

Increase oxygen flow because he has acute respiratory acidosis and hypoxemia.

I would initiate noninvasive mechanical ventilation because he has acute hypercapnic respiratory failure with moderate respiratory acidosis.

I would add sodium bicarbonate to correct the acute metabolic acidosis.

The patient does not have respiratory insufficiency so he would continue with the same pharmacological regimen.

I would add intravenous aminophylline as a respiratory stimulant, since I appreciate hypoxemia and hypercapnia.


He already takes two AV node brakers and you add a third, and are you surprised that he gets complete AV block after messing with drugs from different families but same effect (pharmacodynamics)? Three. And remember that drugs are like drinks when you go to a bar: don't mix!

He already takes two AV node brakers and you add a third, and are you surprised that he gets complete AV block after messing with drugs from different families but same effect (pharmacodynamics)? [HIDDEN] And remember that drugs are like drinks when you go to a bar: don't mix!

An 82-year-old hypertensive woman on atenolol, hydrochlorothiazide and digoxin. She comes to the emergency room for atrial fibrillation and is administered IV verapamil. The ECG showed complete atrioventricular block. What is the most probable cause of this clinical situation?

Digitalis intoxication due to pharmacokinetic interaction with verapamil.

Hypokalemia due to administration of thiazide and digoxin.

Pharmacodynamic interaction of beta-blocker, digoxin and verapamil.

Hypotensive effect of thiazide diuretic.


Adequate corticomedullary differentiation is suggestive of no chronic parenchymal impairment, and is a frequent finding in acute renal failure (option 4 correct). A family history of nephropathy could indicate the existence of a hereditary disorder (incorrect option 2). Small kidneys and hyperphosphatemia are features of chronic kidney disease (option 1 and 3 incorrect).

Adequate corticomedullary differentiation is suggestive of no chronic parenchymal impairment, and is a frequent finding in acute renal failure ([HIDDEN]). A family history of nephropathy could indicate the existence of a hereditary disorder ([HIDDEN]). Small kidneys and hyperphosphatemia are features of chronic kidney disease ([HIDDEN]).

A 48-year-old patient referred to the nephrology department for an estimated glomerular filtration rate (eGFR) of 32 ml/min/1.72 mL/min/1.72 mL. Which of the following data would NOT suggest chronic kidney disease?

Good ultrasound differentiation of renal cortex and medulla.


Comment: The patient presents a good general condition with a recently diagnosed hepatocarcinoma, not giving him any type of treatment other than symptomatic and supportive at this stage would not be the right thing to do. TACE would not be indicated because of extrahepatic involvement. Transplantation would also not be done if he has extrahepatic disease. We are left with answers 3 and 4, both with systemic treatment (indicated because it is metastatic) and the correct answer is 4, for all the reasons given therein.

Comment: The patient presents a good general condition with a recently diagnosed hepatocarcinoma, [HIDDEN]. TACE would not be indicated because of extrahepatic involvement. Transplantation would also not be done if he has extrahepatic disease. We are left with answers 3 and 4, both with systemic treatment (indicated because it is metastatic) and [HIDDEN].

A 64-year-old man with Child A liver cirrhosis with no history of decompensation. After detection of a focal hepatic lesion on screening ultrasound, the study is completed with a thoracoabdominal CT scan. This scan showed the presence of 4 liver lesions (one of them up to 6 cm) with uptake pattern typical of hepatocarcinoma, tumor vascular invasion and a metastasis in the right adrenal gland. No ascites is observed. The patient reports only asthenia, but no general syndrome. The treatment of this patient would be:

Symptomatic and supportive treatment, since he presented an advanced hepatocarcinoma with vascular invasion and metastasis.

Transarterial chemoembolization (TACE), since the treatment increases survival in patients with advanced hepatocarcinoma.

Systemic chemotherapy with doxorubicin iv since he presents disseminated disease but he is in good general condition.

Treatment with oral sorafenib, since this is a patient with good general condition, Child A and advanced stage hepatocarcinoma BCLC-C.

The appropriate treatment is liver transplantation as it is the only procedure that completely eliminates the primary tumor and avoids future complications of cirrhosis.


Metformin is an oral antidiabetic widely used in the treatment of type 2 diabetes mellitus. The best known side effects are gastrointestinal side effects and lactic acidosis; however, vitamin B 12 malabsorption, is less well known. A decrease in vitamin B 12 levels is observed in patients treated with metformin. The mechanism by which this deficit occurs is not clear and it is known to be reversible when treatment is interrupted.

Metformin is an oral antidiabetic widely used in the treatment of type 2 diabetes mellitus. The best known side effects are gastrointestinal side effects and lactic acidosis; however, vitamin B12 malabsorption, is less well known. A decrease in vitamin B12 levels is observed in patients treated with metformin. The mechanism by which this deficit occurs is not clear and it is known to be reversible when treatment is interrupted.

63-year-old diabetic patient whose family physician has requested a blood test to determine vitamin B12 levels.What is the antidiabetic drug he is taking that warrants such a request:


They describe a recent diagnosis of cerebral LOE with signs of intracranial hypertension (edema, midline deviation, papilledema). The associated headache is typically morning headache, with increasing ICP values at night.

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


We are presented with a 68-year-old woman with moderate hyperopia and no history of cataract surgery. This is not a mere coincidence: the fact that the patient is hyperopic is important, because the eyeballs of hyperopic patients are shorter, with a certain conflict of space in the anterior segment when the crystalline lens undergoes a process of intumescence secondary to age (what patients call incipient cataract). In the clinical case, moreover, the ocular and headache pain occurs in scotopic situations, or in situations of dim ambient lighting, which produces an average mydriasis to optimize the light influx to the eyeball. It is evident, therefore, that the patient suffers from primary angular closure processes that possibly self-resolve when the triggering situation ceases, and not a true acute glaucoma attack. But these intermittent angular closures are contemplated within the spectrum of glaucoma due to primary angular closure (option 1 correct). Migraine, not being a Neurology question, can sometimes be a confounder in the usual clinic; however, patients are usually younger, or at least have a clear history of migraine, and, above all, they present symptomatologic worsening with intense sensory stimuli (photophobia and phonophobia), but symptoms are not worsened precisely in cases of dim lighting (option 2 incorrect). Actinic keratitis occurs precisely in patients exposed to ultraviolet radiation that is not properly filtered before reaching the cornea; it is typical of welders (it is called welder's keratitis), skiers and other people with very intense light exposures and without adequate eye protection (wrong option 3). Dry eye syndrome does not usually produce headache, and ocular discomfort does not go beyond the persistent discomfort that patients might define as pain because of its recently more studied neuropathic component. Some forms of dry eye may be worse in the evening but others are worse in the morning, and it depends mainly on the frequency of blinking. In addition, dry eye syndrome is an outdated term; nowadays it is preferred to speak of dry eye disease (incorrect option 4).

We are presented with a 68-year-old woman with moderate hyperopia and no history of cataract surgery. This is not a mere coincidence: the fact that the patient is hyperopic is important, because the eyeballs of hyperopic patients are shorter, with a certain conflict of space in the anterior segment when the crystalline lens undergoes a process of intumescence secondary to age (what patients call incipient cataract). In the clinical case, moreover, the ocular and headache pain occurs in scotopic situations, or in situations of dim ambient lighting, which produces an average mydriasis to optimize the light influx to the eyeball. It is evident, therefore, that the patient suffers from primary angular closure processes that possibly self-resolve when the triggering situation ceases, and not a true acute glaucoma attack. But these intermittent angular closures are contemplated within the spectrum of glaucoma due to primary angular closure ([HIDDEN]). Migraine, not being a Neurology question, can sometimes be a confounder in the usual clinic; however, patients are usually younger, or at least have a clear history of migraine, and, above all, they present symptomatologic worsening with intense sensory stimuli (photophobia and phonophobia), but symptoms are not worsened precisely in cases of dim lighting ([HIDDEN]). Actinic keratitis occurs precisely in patients exposed to ultraviolet radiation that is not properly filtered before reaching the cornea; it is typical of welders (it is called welder's keratitis), skiers and other people with very intense light exposures and without adequate eye protection ([HIDDEN]). Dry eye syndrome does not usually produce headache, and ocular discomfort does not go beyond the persistent discomfort that patients might define as pain because of its recently more studied neuropathic component. Some forms of dry eye may be worse in the evening but others are worse in the morning, and it depends mainly on the frequency of blinking. In addition, dry eye syndrome is an outdated term; nowadays it is preferred to speak of dry eye disease ([HIDDEN]).

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

Glaucoma due to primary angular closure.


It is a typical and frequent clinical picture in children. You are describing a contagious impetigo. There is not much dispute. The most frequent causative agent in the bullous form is S. aureus phage II.

An 8-year-old patient presenting with superficial pustular lesions, erosions and yellowish crusts around the mouth for the last 3 days:


In the data you provide there are no clinical risk factors for osteoporosis prior to the current disease. Since a prolonged and high-dose prednisone regimen will be established, it is advisable, in addition to the non-pharmacological preventive measures, to initiate treatment in any case to minimize the secondary loss of bone mass that occurs with the administration of glucocorticoids (and, above all, in the first months). Therefore, and for this reason alone, options 1, 2 and 5 would be discarded (the three of them have another conditioning factor). In this context, and in the case of a person over 65 years of age, an appropriate attitude would be to administer calcium supplements (corticosteroids are osteopenizantes because they produce, among other mechanisms, a negative balance of this element) and vitamin D. The option of associating a bisphosphonate could also be considered, but calcium supplementation is missing in proposal 3.

In the data you provide there are no clinical risk factors for osteoporosis prior to the current disease. Since a prolonged and high-dose prednisone regimen will be established, it is advisable, in addition to the non-pharmacological preventive measures, to initiate treatment in any case to minimize the secondary loss of bone mass that occurs with the administration of glucocorticoids (and, above all, in the first months). Therefore, and for this reason alone, [HIDDEN] (the three of them have another conditioning factor). In this context, and in the case of a person over 65 years of age, an appropriate attitude would be to administer calcium supplements (corticosteroids are osteopenizantes because they produce, among other mechanisms, a negative balance of this element) and vitamin D. The option of associating a bisphosphonate could also be considered, but calcium supplementation is missing in proposal 3.

A 75-year-old woman, with menopause at age 52, with no family or personal history of fracture, diagnosed with temporal arteritis, who is going to start treatment with high-dose prednisone and expects to be treated for at least one year. The delay of densitometry (DXA) in her center is 4-5 months. Preventive treatment for osteoporosis is considered. Which of the following is the most appropriate approach?

Assess absolute risk of fracture using the FRAX questionnaire without BMD and treat only if it is high.

Start treatment with bisphosphonates and vitamin D (800 IU/day).

Administer calcium supplementation (1g) and vitamin D (800 IU/day).

Assess for osteopenia on radiographs and treat if present.


According to the SEGO: "Excise the entire lesion so that it can be evaluated histologically. It involves excision of the entire transformation zone. In general, the excision should be adapted to the size and characteristics of the lesion. Three types of excision are distinguished according to the presence of the endocervical component of the lesion. Excision type 1 (applicable in cases with transformation zone type 1, in which the diathermic loop should not include endocervical canal or exceed 8 mm in depth), excision type 2 (indicated in transformation zones type 2, involves resecting a small part of endocervical canal visible by colposcopy) and excision type 3 (indicated in transformation zones type 3, includes part of endocervical epithelium)". When they speak of excision, it is synonymous with conization; as the lesion is less than 8mm deep, this is the indicated treatment.

According to the SEGO: "Excise the entire lesion so that it can be evaluated histologically. It involves excision of the entire transformation zone. In general, the excision should be adapted to the size and characteristics of the lesion. Three types of excision are distinguished according to the presence of the endocervical component of the lesion. Excision type 1 (applicable in cases with transformation zone type 1, in which the diathermic loop should not include endocervical canal or exceed 8 mm in depth), excision type 2 (indicated in transformation zones type 2, involves resecting a small part of endocervical canal visible by colposcopy) and excision type 3 (indicated in transformation zones type 3, includes part of endocervical epithelium)". When they speak of excision, it is synonymous with conization; as the lesion is less than 8mm deep, [HIDDEN].

34-year-old woman who consults for repeated coitorragia. She brings a cytology with a high grade intraepithelial lesion (U-SIL). Subsequently, colposcopy and biopsy were performed on a mosaic area and histology showed a focus of invasive squamous cell carcinoma of 2 mm in length. Which therapeutic option is the most appropriate for this patient?

Pelvic radiotherapy with curative intent.