This is a grade IIa ulcer (Forrest classification), with a high risk of recurrence

Therefore, endoscopic treatment and hospitalization with intravenous treatment with PPIs (in our setting it is usually omeprazole) for at least 72 hours is clearly indicated

A 52-year-old man with no concomitant diseases comes to the emergency department for melena of 24 hours evolution without hemodynamic repercussions

Surgery is indicated in massive bleeding or bleeding refractory to medical treatment


The most frequent cause of microcytic iron deficiency anemia in young women is chronic gynecologic leaks


Antisuppressants seem to be the most suitable

Immunosuppressive therapy with cyclosporine and antithymocyte immunoglobulin

Severe aplastic anemia and not a candidate for allogeneic transplant because of his age

Chemotherapy and if response autologous transplantation of hematopoietic progenitors


it could also be correct 2 (echocardiogram) in the case of suspicion of associated cardiopathy, less frequent but also possible

The correct answer could be respiratory polygraphy, especially in the case of an obese patient, which we do not know


A cholangioresonance will be performed to delimit the cyst and a laparotomy will be indicated for resection of the cyst and anastomosis of the biliary tract

its treatment is surgical and consists of resection of the cyst and hepaticojejunosotomy

Cholangioresonance is necessary to choose the appropriate technique for the four existing classes of common bile duct cyst (Todani classification)


I have my doubts between 1 and 2
Mycobacterial cellulitis
Attack

I have my doubts between 1 and 2
Erysipelas
Attack

On the other hand, the case may refer to a severe sepsis with poor initial manifestation at first sight, with incipient rhabdomyolysis and muscle pain

in this case it may be a necrotizing fasciitis, where the most frequently implicated germ is S. pyogenes


A 62-year-old man with a history of significant alcohol abuse, carrier of hepatitis C virus, treated with Ibuprofen for tendinitis of the right shoulder, goes to his dermatologist because after spending two weeks on vacation at the beach he notices the appearance of tense blisters on the dorsum of his hands

On examination, in addition to localization and slight malar hypertrichosis

60% of patients with PCT are male, many of them drink alcohol in excess, women who develop it are usually treated with drugs containing estrogens

HCV and HIV infections have been implicated in the precipitation of acquired PCT

Patients with PCT present with blistering of photoexposed skin, most frequently on the dorsum of the hands and scalp

In addition to fragility, they may develop hypertrichosis, hyperpigmentation, cicatricial alopecia and sclerodermal induration

Most are males with signs of iron overload, this overload reduces the activity of the enzyme uroporphyrinogen decarboxylase, which leads to the elevation of uroporphyrins

There is a hereditary form with AD pattern


The correct answer is the fifth one
Trypanosoma cruzi
Support

The cause of Chagas disease is Trypanosoma cruzi.


Examination is normal, except for the presence of bilateral papilledema

Now the guiding symptom is bilateral papilledema which is indicative of intracranial hypertension

Although he does not comment that a space-occupying lesion has been ruled out, given the normal neurological examination and the other symptoms

it is deduced that it is idiopathic intracranial hypertension or pseudotumor cerebri

Other data suggestive of this entity include: women of reproductive age, obesity, and diplopia (due to involvement of the VI cranial nerve)

A 29-year-old obese woman, with no past history of interest, consults for a month of intense, bilateral, pulsating headache, accompanied by horizontal diplopia and episodes of monocular amaurosis lasting seconds

It is characteristic that the headache and visual blurriness suddenly worsen in the mornings when getting up or changing posture, producing transitory blindness (Neurology, Zarranz)

The lumbar puncture invariably shows an increase in cerebrospinal fluid pressure, so the correct answer is 4


A 30-year-old male who consults for unilateral periocular headaches that rapidly progress to become very intense

The pain attacks last 30-60 minutes, occur 2-3 times a day, and are accompanied by tearing in the painful eye and unilateral rhinorrhea

the pain is characteristically unilateral periocular of great intensity, of variable duration, usually minutes, and it associates trigeminoautonomic signs such as rhinorrhea and unilateral conjunctival injection

The preventive treatment par excellence is verapamil associated with a descending corticosteroid regimen, as described in answer 2

Oral prednisone with withdrawal in one month, associated with oral verapamil at a dose of 80-180 mg every 8 hours

They describe a characteristic case of cluster headache


We are presented with a case of PANDAS syndrome, a rare complication of an infection caused by group A beta-hemolytic streptococcus

sudden-onset obsessive-compulsive disorder (OCD) in a 9-year-old boy who also has tics and chorea as neurologic manifestations


A normal spirometry and a negative bronchodilator test does not exclude asthma

a methacholine test would confirm the diagnosis, at least of bronchial hyperresponsiveness

the patient's clinical picture is highly suggestive of asthma


Complementary tests detect the existence of obstructive hypertrophic cardiomyopathy

Our myocardium is thicker than it should be, predominantly in the septum, and it is so thick that it obstructs the LV outflow, producing a "functional" stenosis with a pressure gradient

Our objective will be, first of all, to "relax" the myocardium: for this purpose, a beta-blocker is recommended, whereas digoxin, as a good positive inotrope, increases the gradient and is contraindicated

Digoxin is useful to reduce the subaortic gradient

Sport is not highly recommended, given the increased risk of sudden death associated with this pathology

Abandonment of competitive sport should be recommended

Regarding number 5, it is true: it is convenient to perform a careful exploration and an ECG in the relatives of patients with hypertrophy

Given the hereditary nature of the pathology, a screening study should be performed in the rest of the direct relatives

And if we have a fat septum, which protrudes into the LV cavity, it is not advisable to perform volume depletion, since we would also be increasing the gradient

Diuretics should be avoided or used with great care


In addition, this antiemetic agent provides relief through antagonism of central and peripheral dopamine receptors

Physiologically, it accelerates intestinal transit by increasing the tone and amplitude of gastric contractions, increases lower esophageal sphincter pressure and improves antropyloroduodenal coordination

It acts as a prokinetic by its antagonistic effect on dopamine 2 (D2) receptors promoting gastric emptying and, in addition, binds to the 5-hydroxytryptamine 4 receptor (serotonin 5-HT4) to stimulate cholinergic nerve pathways in the stomach

It was approved as a treatment for gastroparesis by the US Food and Drug Administration (FDA) in 1979 and remains the first-line drug


There is no treatment for this disease, only treatment for flare-ups (colchicine, NSAIDs or corticosteroids)

Once the acute flare-up has passed, treatment with allopurinol should be started to reduce the incidence of new arthritis flare-ups in the future

Allopurinol has not shown any efficacy in this microcrystal arthropathy, but it has shown efficacy in gout


We are presented with the case of a 13 year old patient, with menarche 3 months ago, a T4-L1 thoracolumbar curve of 35º and a Risser 0

As a general rule we could say that below 50º the treatment is usually conservative, with two options: observation or use of a brace to slow down the evolution

In this case, taking into account the remaining growth (menarche 3 months ago and Risser 0) the most indicated would be to use a brace

Answer 2 correct
Prescribe a brace type orthosis
Support


The clue is in the whitish lesions of the jugal mucosa corresponding to Koplik's spots, which are pathognomonic of measles, although as an observation I would say that they usually appear in the prodromal phase of the disease and are often no longer seen when the exanthema appears

On oropharyngeal examination there are whitish spots in the jugal mucosa

In this case you are describing measles complicated by pneumonia


A woman presenting with difficulty walking after gynecologic surgery

The femoral nerve (although rare) may be damaged in a cesarean section, hysterectomy or lower abdominal operation

On examination she has weakness in hip flexion and knee extension, and dysesthesias in the anterior aspect of the thigh

This nerve injury produces hypoesthesia and weakness along its distribution

Femoroneuropathy is manifested by paralysis (25% of cases) of the quadriceps muscles, abolition of patellar reflexes and hypoesthesia of the anterior and inner thigh

Therefore, answer 1 is correct
Femoral nerve neuropathy
Support

She has mild thigh pain and leg failure on support

it would not explain the motor problem of gait

The femoral cutaneous or lateral femoral cutaneous nerve (L2,L3) is only sensitive and is responsible for the sensitivity of the skin of the lateral and anterior aspect of the thigh up to the knee

Meralgia paresthetica of the femoral cutaneous nerve

At the motor level, it invests the obturator externus, pectineus, short approximator, the approximators (adductors) and gracilis

The obturator nerve (L2-L4) is a mixed nerve

At the sensory level the capsule of the coxofemoral joint, medial aspect of the thigh above the knee

Therefore neither affects the sensitivity of the anterior aspect of the thigh nor the extension of the knee so that 3 is false

A lesion of the sciatic nerve at motor level affects to the flexion of the knee not to its extension and at distal level to this one (they do not count anything of distal clinic) and at sensitive level also it is distal in the external face of the leg and in the foot reason why 4 also is false


Neurologic examination shows vertical gaze palsy and MRI shows a contrast-enhancing lesion in the pineal region obstructing the aqueduct of Sylvius

Germinal tumors are the most frequent in children in the pineal region

A 13-year-old boy presents with subacute headache and diplopia

Glioblastomas usually occur in adults at the lobar level

medulloblastomas are the most frequent malignant tumors at the posterior fossa level in children (vermis and roof of the IV ventricle) but rare at the pineal level

meningiomas are rare in children and also in the pineal region


The dog is domestic, known and can be monitored

we would have to wait for the observation period to pass and prophylaxis is not recommended

At this point we will only have to worry about the possible bacteremia that may be occurring in a patient with the possibility of high risk due to asplenia

The treatment of choice in dog bite is amoxicillin/clavulanic acid but it is not available

we can use another treatment such as clindamycin plus cephalosporin or clindamycin + moxifloxacin but it is not contemplated among the alternatives

the correct answer is 3, because of the second part of the question

it is a high risk patient with incipient signs of sepsis

Give 400 mg of oral moxifloxacin and send to hospital

if it was in Ceuta or Melilla the protocol may vary

It could be challenged since they do not say in which community the bite occurred


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

This is due to the characteristics of the tumor: mature teratomas are constituted by adult tissues, coming from the three embryonic leaves, with a clear predominance of ectodermal elements (epidermis, pilosebaceous structures and neural tissue)

In the histopathological study of the corresponding specimen, teeth, hairs, areas of intestinal epithelium, areas of squamous epithelium (15%) and bronchial epithelium, as well as neuroectodermal and embryonic elements are found in several of the histological preparations


tachypnea, tugging, low saturation, cyanosis, diaphoresis, tachycardia, deviated trachea and absence of vesicular murmur

Physical examination suggests a pneumothorax

the rupture of a bulla although it is related to the appearance of abrupt symptoms does not go hand in hand with the other symptoms

you have to look for something that explains everything or almost everything

pneumonia although it is true that it can be related to many of the symptoms does not correlate with the image

Community-acquired necrotizing bacterial pneumonia

the clearest option goes for pneumonia due to P. jirovecii pneumonia

Pulmonary TB could be manifested with all of the above and cause a pneumothorax

a patient with a respiratory picture with more than 7 days of evolution that is complicated abruptly,

In patients with Pneumocystis, 10%, pneumatoceles appear which can sometimes open into the pleural space producing a spontaneous pneumothorax

s a reminder, the most frequent germs in pulmonary involvement in patients with HIV/AIDS infection are P. jiroveci (alone or associated with tuberculosis or other mycobacteria), S. pneumoniae, H. influenzae, S. aureus, cytomegalovirus, Legionella, staphylococci and gram-negative bacilli (Pseudomonas)


the clinical picture is not one of heart failure

Option 2 is immediately ruled out
Cardiac failure
Attack

it does not fit with the clinical picture

in addition HSD would give neurological symptoms with locality

obstructive renal failure does not give polyuria, dysuria or the rest of the clinical picture

Option 3 is also discarded
Subdural hematoma
Attack

Option 4 is discarded
Obstructive renal failure
Attack

Option 5 is less likely
Diabetic ketoacidosis with coma
Attack

diabetic ketoacidosis is more typical of type 1 DM

Hyperglycemic hyperosmolar non-ketotic hyperglycemic coma


Abdominal X-ray is the first imaging study to be performed because it is fast, simple and practically innocuous (except in children and pregnant women)

However, it has a lower yield than the others

It is a mandatory test in any suspicion of colic pain

90% of the stones are radiopaque and therefore visible, but the sensitivity of this test, used in isolation, decreases to 45-59%

A 45-year-old male patient with a history of uric lithiasis with repeated expulsive nephritic colic for 25 years, comes to the ED referring palpitations and intense right lumbar pain since 2 hours before

Although the urological history speaks of uric lithiasis (radiotransparent), with an acid pH that reaffirms the diagnosis of uric origin, we can never rule out calcium oxalate lithiasis that can appear synchronously

Urinalysis showed a pH of 5.5 and leukocyturia without proteinuria

IVUS seems to me to be one of the best performing options

It will give us diagnostic clarity of obstruction, its magnitude and its renal repercussions

It has long been considered the examination of choice for the study of patients with renal lithiasis.

It is a test with high sensitivity and specificity (87-90% and 94-100%, respectively), relatively innocuous, and available in all hospitals

It informs us of the number, size, shape and location of the stone, as well as the functional status of the affected kidney

Contrast-enhanced CT seems to me to be the most efficient option

It serves to discover lithiasis that other tests cannot find and gives us a global image of the rest of the structures

Great performance but also more expensive, more time, more radiation

It has been confirmed as a high sensitivity and specificity scan, surpassing previous tests (94-100% and 92-100%, respectively, for the detection of ureteral calculi) and with its numerous advantages it has become the reference test and is expected to replace IVUS and ultrasound worldwide

It performs a helical scan with 5 mm slices allowing the detection of stones up to 2 mm

With the administration of contrast, it allows the evaluation of renal function

Ultrasound is a fast, cheap and innocuous test, but very radiologist-dependent

It gives great renal information on obstructive repercussions, but less quality in terms of finding a lithiasis.

Ultrasonography only detects calculi larger than 4 mm, located in the pyelo-ureteral junction or the uretero-vesical junction, while the lumbar and pelvic ureter is not very accessible due to the interposition of the intestinal loops

Therefore, ultrasound performed in isolation is not very sensitive (20-45%) for the detection of calculi, but associated with simple abdominal radiography increases its sensitivity and specificity

Doppler echocardiography has no use in urological diagnosis

My answer would be CT with ev contrast and excretory phase (answer (c)), in terms of performance, sensitivity and specificity

Without forgetting that abdominal X-ray should always be done in the suspicion of colic


The relative mildness of the symptoms, which do not seriously interfere with daily activities, excludes in principle the diagnosis of major depression

There is no evidence of hypomanic phases to justify a bipolar II disorder

Dysthymia requires a duration of at least two years

what used to be cyclothymics are now called bipolar, contributing to one of the multiple psychiatric epidemics of our time

Cyclothymia is a very rare diagnosis nowadays

But there are no data on such oscillations

which consists of oscillations between the depressive pole and the manifest, mild

The correct answer is, in all probability, 3

The adaptive disorder appears within 3 months after the stressful event and does not last more than 6 months if the stressful event or its consequences have ceased (which is not the case because the brother of the imaginary patient is still dead)

He reports presenting with anxious symptoms and depressive mood for the last 10 months


Of the microorganisms discussed, Microsporum gypseum does not usually manifest dissemination of infection of a lymphangitic aspect

in general keratinophilic fungi (dermatophytes) do not have any ability to invade deep tissues

we ruled out this option
Dermatophytosis by Microsporum gypseum
Attack

Staphylococcus aureus infection can affect superficial and deep tissue layers, they can spread following a lymphangitic path, but it is not usual such a long evolution, it is usually acute (days) and usually accompanied by systemic symptoms

Cutaneous infection by Staphylococcus aureus

Our patient has no history of exposure to fish or water (they don't say)

considering that usually the diagnosis is based on a high index of suspicion and specifically asking for this history, our case is far from this possibility

Cutaneous infection by Mycobacterium marinum

Infection in humans occurs by direct contact with fish or contaminated water in the presence of a loss of continuity in the skin of the host.

The patient carries out an activity in contact with soil and plants (which are not provided free of charge)

The Sporothrix schenckii complex is the causative agent of Sporotrichosis, this dimorphic fungus is located in the soil, the complex is formed by 5 species, S. schenckii sensu strictu, S. brasiliensis and S. globosa, capable of causing human and animal disease; the other two are S. mexicana and S. albicana not associated with any disease

Patients are usually infected by exposure to soil by means of a sharp object (thorns, stems, animal claws, etc.) and have a slow evolution, affect deep tissues and their dissemination typically follows a pathway as described in the question


The separate findings are: normal pH but with alkalosis tendency, acute respiratory failure, hypocapnia and normal bicarbonate

The most appropriate answer seems to me to be 1

the patient does not present a metabolic alkalosis (bicarbonate would be higher), much less an acidosis (bicarbonate would be low)

The alkalosis is not mixed either, but is mainly respiratory

The patient is probably hyperventilating because of her respiratory failure

the kidney which always compensates later is starting to retain HCO3 to compensate and maintain pH

Hypoxemic respiratory failure with compensated respiratory alkalosis

Acute metabolic alkalosis with hypoxemic and hypocapnic respiratory failure

Chronic hypoxemic respiratory failure with compensated metabolic acidosis

Hypoxemic respiratory failure with compensated mixed alkalosis


Everything points to adhesive capsulitis, as you say

The age, the sex, the clinic... the DM....

A 60-year-old, insulin-dependent diabetic woman presents with right-sided, nocturnal-predominant omalgia of several weeks' duration


Thyroglobulin is synthesized in the follicular cells and then secreted into the circulation

therefore, after total thyroidectomy it should disappear

if this does not occur we must think about the existence of remnants of metastatic tissue

Delay initiation of TSH replacement-suppressive treatment with levothyroxine and refer the patient to the Nuclear Medicine service for administration of an ablative dose of 100 mCi of I131


In this case there are important data such as the history of intestinal resection, hypocalcemia and hypophosphoremoia; this should lead us to think in a vitamin D deficit due to malabsorption and therefore, in an osteomalacia

The rest of the data: previous fracture, pain and the X-ray support the diagnosis

He had suffered a Colles' fracture three months earlier.

A 74-year-old patient with bowel resection following mesenteric thrombosis comes to consult for fatigue and bone pain

Radiographs of the femur show radiolucent bands perpendicular to the cortex on the inner side of the upper femur


The first step is to detect the mutation and once detected, if the mother is a carrier, to proceed with PGD.

t is indicated after detection of the causative mutation in the index case and eventually in his mother


A woman with pancytopenia
Acute promyelocytic leukemia
Support

A bone marrow showing massive infiltration by immature elements that are proliferating non-stop...with Auer's canes

Acute promyelocytic leukemia
Acute promyelocytic leukemia
Support

Those rods are the fusion of primary granules of developing myelocytes


From the symptoms reported, tingling in the anterior thigh, scrotum and dysesthesia in the feet

there seems to be a vertebral involvement at L2-3 and sacral roots

the correct thing to do would be to perform a radiological examination without mobilizing the patient

But it is necessary to mobilize him to explore him, obviously, en bloc

the patient mobilizes both arms adequately, without paresthesia

The cervical spine seems to be undamaged

Palpate the abdomen and rotate it en bloc to palpate the thoracolumbar spine

We will sit him on the stretcher to be able to explore the cervical spine


Bile duct atresia is the main indication for infant liver transplantation

The increase in direct bilirubin immediately rules out the rest of the options

the increase in total bilirubin would be at the expense of indirect bilirubin


Elderly patient with clinical dyspnea and syncope, and systolic murmur radiating to carotids and tip, all typical of this disease

They are describing the "portrait" of a degenerative aortic stenosis


The treatment of choice for Clostridioides difficile infection is vancomycin orally 125mg/6h for 10 days

Change metronidazole for oral vancomycin (125 mg, four times a day for 10 days)

Metronidazole has been relegated to situations where vancomycin is not available

He was diagnosed with Clostridium difficile colitis, amoxicillin/clavulanic acid was discontinued and metronidazole was prescribed


If they wanted us to answer that it is a TTP (answer 1) they would probably associate anemia and in the smear they would surely tell us about schistocytes

Not to say that the patient's symptoms would probably be much more than epistaxis


She currently has a creatinine of 3.2 mg/dL with estimated glomerular filtration rate (CKD-EPI) 14 ml/min

A glomerular filtration rate of less than 15 ml/min is classified as stage 5 (G5)

He has stage 5 chronic kidney disease and renal replacement therapy should be considered

the initiation of replacement therapy should be considered

the renal disease is end-stage
option 2 true
Support

the renal disease is end-stage
option 1 false
Support

He presents stage 3 chronic kidney disease and should initiate phosphorus chelators

In this situation, good glycemic control is not expected to reverse renal damage, although it may help to delay progression

Good glycemic control can reverse renal failure

These patients usually present stage A3 albuminuria (above 300 mg/24 h), and may reach the nephrotic range

It is unlikely to present proteinuria higher than 500 mg/24 h


Laboratory tests show normal ALT, AST, GGT and FA, with total bilirubin of 3.2 mg/dl and direct bilirubin of 0.4 mg/dl

An increase in indirect bilirubin less than 5 (intermittently, under stress) in a young healthy boy should make us think of Gilbert's syndrome

A 17-year-old boy, athletic and with no history of interest, comes to the doctor for occasional conjunctival jaundice

In Rotor syndrome, Dubin-Johnson syndrome and choledocholithiasis there is an increase in direct bilirubin

In the case of acute hepatitis there should be an elevation of transaminases


For this, the best option would be to request reticulocytes, however, as it is not among the options, we should request a Coombs' test

the correct answer is 2
Coombs test
Support

Although they want to confuse us with a MCV 108

so that we think of a megaloblastic anemia

the MCV is not excessively high, the onset of anemia in our patient has been rapid and would not fit with SLE or the form of presentation

26-year-old woman diagnosed with systemic lupus erythematosus, on treatment with hydroxychloroquine, who consults for a feeling of generalized weakness that has progressively set in over the last 15 days

In this question, we are presented with a patient with systemic lupus erythematosus presenting with autoimmune hemolytic anemia

The physical examination reveals cutaneous pallor and the CBC shows Hb 7.4 g/dL, Hct 31%, MCV 108

Antinuclear antibodies are used for diagnosis, but not for monitoring SLE


A 75-year-old woman on sertraline treatment who comes to the emergency department with confusional symptoms

We are presented with a patient with moderate euvolemic hyponatremia, suggesting a syndrome of inadequate antidiuresis (SIAD) secondary to sertraline, although it would be necessary to have urinary osmolality to confirm this

The blood test shows Na 126 mEq/l and K 4 mEq/l, natriuria is 45 mEq/l and diuretic intake has been ruled out

Primary adrenal insufficiency produces hypovolemic hyponatremia

It is Addison's disease and corticosteroids should be administered immediately

Diabetes insipidus is the opposite of this pathology, usually presenting with hypernatremia

Request brain MRI, since it is probably diabetes insipidus

With natremia above 125 mmol/l it is not indicated to treat with HSS unless the patient has severe neurological symptoms, which does not seem to be the case

Administer hypertonic saline to restore natremia as soon as possible

that would be a moderate hyponatremic encephalopathy

it is not indicated to restore natremia as soon as possible (due to the risk of osmotic demyelination syndrome)

Therefore, the correct answer would be 3

Indicate water restriction and if natremia does not rise, switch to slow infusion of saline

since in this case the use of furosemide, tolvaptan or urea should be considered, not saline

What I do not like about this answer is that the second part ("if natraemia does not rise, switch to slow infusion of saline") is incorrect

and it does not indicate tonicity either, since isotonic is not the same as hypertonic


An 11-year-old, 6-month-old, premenarchal girl with known idiopathic scoliosis

In the juvenile and adolescent forms, treatment depends on the degree of deformity

The current x-ray shows a Cobb angle of 28º, with an iliac crest maturation (Risser's sign) of 2

- 20-50°: thermoplastic corsets (Boston, Cheneau or Milwaukee, according to where the apex of the main curve is located)

40-50°: with Risser less than 3, surgical arthrodesis would be indicated; with Risser greater than or equal to 3, the remaining growth potential of the curve is low and observation may be considered in case it tends to progress in adulthood


The apnea-hypopnea index obtained in the polysomnography was 18

With an Apneas-Hypopnea Index of less than 30, and in the absence of striking symptoms of OSAHS and in the absence of risk professions such as professional drivers, etc., the correct thing to do is to control weight and the rest of the hygienic-dietary measures, with periodic follow-up

Hygienic-dietary measures and evolution control


The answer is surgical sphincteroplasty 3

Medical treatment with hygienic and dietary norms

2 is not effective for an organic lesion with normal electromyography

4 is not necessary
Surgical repair of the pelvic floor
Attack

since the lesion is only of the external sphincter

5 is not indicated in a lesion that can be repaired with surgery with good results


The changes described in the question statement correspond to an early precirrhotic situation

It is important to reduce weight and adequately control diabetes to avoid the possible development of cirrhosis

A 56-year-old man, diabetic and moderately overweight, presents a discrete hepatomegaly

Diabetes mellitus causes similar hepatic alterations: fat accumulation in hepatocytes, centroacinar fibrosis, inflammatory infiltrate by polymorphonuclear neutrophils and hyaline degeneration of perinuclear mallory

we can rule out the second question (they are intracellular fat accumulations, not glycogen) and the fourth (if diabetes also produces this situation, there is no reason to mistrust the patient)

Diagnosis is hepatic glycogenosis associated with diabetes

The injury is clearly caused by alcohol despite the patient's refusal

it is not necessary to repeat a liver biopsy that would not expand information, discarding the first question

Biopsy should be repeated to see if the changes are diffuse

Based on the primum non nocere and not having special relevance for the treatment if it is a focal or generalized disease

Fortunately for the hypothetical patient, in the initial phase these changes are reversible when the noxa disappears

Although alcohol is the most frequent toxicant that causes this condition, it is not the exclusive cause

A liver biopsy shows accumulations of clear cytoplasmic vacuoles in 50% of the hepatocytes

Multiple inflammatory foci with neutrophils, Mallory's hyaline degeneration and fibrosis around the terminal hepatic venules


radical thyroidectomy is usually recommended before the age of 5 years

Genetic study of the RET c634 proto-oncogene mutation, and if positive, prophylactic radical thyroidectomy will be performed at this age

Proto-oncogene carriers usually have early thyroid tumors


In the case of suspected compartment syndrome, the urgent invasive measure to perform would be to measure the intracompartmental pressure and, depending on the result, proceed with treatment


Chronic hypertension is defined as hypertension that is present before pregnancy or that is diagnosed before the 20th week of gestation

A pregnant woman, 10 weeks pregnant, comes to the emergency room with a blood pressure of 160/105 mmHg

In this case, the patient is 10 weeks pregnant

the correct answer is 3
Chronic hypertension
Support


In this case what you describe is an oral tumor growing locally and infiltrating the mandibular canal, I believe

Diagnosis of carcinoma with infiltration of the mandibular canal


Biopsy skin areas away from the injured areas and prescribe entry opioid analgesics

Suspect bilateral lower extremity ischemia of drug origin

They are explaining erythema nodosum
2 and 4 are discarded alone
Support

Recommend relative rest and warm cloths on both legs and add antidepressant treatment

They are explaining erythema nodosum
we would recommend relative rest
Support

antidepressants do not make any sense
we would recommend relative rest
Attack

antidepressants do not make any sense
so we also rule out (1)
Support

if the picture is also accompanied by a flare-up of inflammatory bowel disease, the last option (5) seems the most correct

in a 17-year-old boy it would be extremely rare

Although erythema nodosum can be secondary to a malignant process, it is more frequent that it is due to Crohn's disease itself


Assessing capacity is not about taking away the patient's autonomy, but making sure that the patient understands and is aware of the consequences of his decisions

Formal evaluation of the capacity to make decisions concerning their health

This is not done by a psychiatrist, but by the attending physician

In fact, it is a protective measure for the most fragile patients to ensure the best care


It is a genetic disease of autosomal dominant inheritance by mutation of the NOTCH3 gene

He has a history of migraines and some episode of self-limited neurological focality for which he has never consulted

They describe a characteristic case of CADASIL (Cerebral Autosomal Dominant Arteriopathy with Sub-cortical Infarcts and Leukoencephalopathy)

A 45-year-old male brought to the consultation by his relatives for a one-year history of memory loss, which has progressed to the point of needing help with some activities of daily living

Migraines, cerebrovascular disease and cognitive impairment at early ages stand out, as shown in the clinical case of the question

The neuropsychological examination is compatible with an initial dementia and the brain MRI shows a severe leukoencephalopathy

This mutation causes vascular involvement of small vessel that generates severe leukoencephalopathy early, which generates various symptoms


The Thessaly test is a meniscal exploration maneuver

Answer 1 correct
Meniscal injury
Support

During the examination, the Thessaly test is performed (pain with internal and external rotation movements with the knee flexed), which is positive

The statement focuses exclusively on this part of the examination and also explains that it is indeed positive

which leads to the suspicion of a meniscal lesion

At no time do they describe any exploration maneuvers of the anterior cruciate ligament, nor do they mention any trauma that may have injured it

Injury due to rupture of the anterior cruciate ligament

At no time do they describe any exploration maneuvers of the posterior cruciate ligament, nor do they mention any trauma that could have injured it

Injury due to rupture of the posterior cruciate ligament

Although it could occur, it is not to be expected in a 41 year old person with an acutely established clinical condition

Wrong answer 4
Injury due to degenerative arthropathy
Attack


In the past, beta-blockers were the first choice, but nowadays they have been displaced by the group that lowers intraocular pressure the most: prostaglandins

Their efficacy and more convenient dosage (once a day) generally make them the group of choice

Beta-blockers would remain as a second choice in cases in which the side effects of prostaglandins (change in eye color, increase in eyelash size) make us initially leave them aside

A 67-year-old man, diabetic and asthmatic, with primary open-angle glaucoma in both eyes

Since the patient is asthmatic, we should rule out beta-blockers (wrong answer 2)

Also, since we need a significant drop in intraocular pressure because the numbers are high (34 and 31), we can also rule out carbonic anhydrase inhibitors and alpha-2 agonists (options 1 and 3 incorrect)

And opt for the group that can lower intraocular pressure the most

Answer 4 correct.
Prostaglandin derivatives
Support


Technically the patient is in a grade II hemorrhage according to the ATLS classification

in principle this means a loss of between 750 and 1500mL of blood and the indicated action is resuscitation with crystalloids

An 18-year-old man arrives at the hospital emergency department transported by a basic life support unit

however, in the guidelines for the care of severe polytraumatized patients, the early use of blood products is increasingly recommended, especially in borderline cases like this one, and in young patients, who may not be able to translate the severity of the blood loss until it becomes much more significant

On arrival he has a heart rate of 115 bpm, a blood pressure of 110/75 mmHg, a palpable radial pulse, a capillary refill of 2.5 seconds and a respiratory rate of 25 rpm

The patient has lost 15 to 30% of blood volume and requires volume replacement

I would therefore hesitate between options 1 and 2

She has lost more than 30% of volemia and needs volume and blood replacement