QUESTION TYPE: ENDOCRINOLOGY

CLINICAL CASE:

In a 30-year-old female patient a calcium level of 11 mg/dl (normal less than 10.5 mg/dl) is found during a routine company examination.

PTH determination was 45 pg/ml (VN 10-55 pg/ml).

The history is unremarkable except for the fact that the mother and paternal grandfather were diagnosed with hyperparathyroidism and underwent surgery, although they remained hypercalcemic.

Which test is most useful in confirming the diagnosis?

D.

3- Urine calcium/creatinine ratio.

4- Phosphate tubular reabsorption.

PTHrP.

CORRECT ANSWER: 3

Calcium/creatinine urine ratio.

This is familial hypocalciuric hypercalcemia or benign familial hypercalcemia.

Autosomal dominant disorder.

Asymptomatic.

Not cured after surgical treatment; it is due to mutation of the calcium-sensitive receptor.

Difficult question since it is necessary to know data of a disease that is not usually asked in the MIR.

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QUESTION TYPE: RHEUMATOLOGY

CLINICAL CASE:

You evaluate a 66-year-old patient with groin pain accentuated by prolonged standing for a few days per month.

A plain radiograph of the hips shows narrowing of the femoroacetabular joint space, sclerosis and ostephytes.

1- I make the diagnosis of coxarthrosis and send to the traumatologist to place a hip prosthesis.

2- Start treatment with weak opioids that have shown evidence in stopping the progression of the disease.

3- Treatment with paracetamol, explaining that the evolution is very variable and the surgical indication depends on the functionality and pain control.

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

CORRECT ANSWER: 3

It is a coxarthrosis.

The surgical criteria depends on the patient's symptoms and failure of medical treatment.

No medication slows down or modifies the course of the disease.

An MRI is not necessary, it does not contribute anything.

Treatment is medical and sequential, starting with the first analgesic step of the WHO.

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QUESTION TYPE: PSYCHIATRY

CLINICAL CASE:

A 19-year-old female university student comes to the clinic accompanied by her parents, reporting feeling progressively more asthenic in the last two months, with loss of appetite and weight and with greater difficulty in concentrating on her studies.

The anamnesis also highlights that she has lost interest in going out with friends, has ideas of death without self-harming ideation and pessimistic cognitions of the future.

Her weight is 90% of that considered ideal for age and gender.

She does not present weight phobia or body image distortion.

The most appropriate diagnosis is:

1- Anorexia nervosa.

2- Anxiety disorder.

3- Borderline personality disorder.

Dysthymia.

5- Major depressive disorder.

CORRECT ANSWER: 5

As soon as we hear about weight we go to anorexia nervosa, but anorexia nervosa has three features: significant self-induced weight loss, body image distortion and amenorrhea.

So we remove 1.

One loses weight when one gets sad, worries, etc...

3 does not make sense in the MIR because of the clinic -in reality the history is different and in psychiatry everything is evolution-.

4 has to meet temporal criteria that are not met here.

So we are between 2 and 5.

Depression or anxiety?

There is no anxiety clinic and she also meets the criteria for depression.

The poor girl has been diagnosed with depression.

The answer is 5 (another option is that she was studying the MIR).

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QUESTION TYPE: NEPHROLOGY

CLINICAL CASE:

In a patient with known advanced chronic kidney disease (CKD G4, eGFR 20 ml/min) who comes to the emergency department for general weakness and is found to have severe hyperkalemia (K 7 mEq/l) with electrocardiographic abnormalities.

What would be the first measure to take?

1- Administration of cation exchange resins.

2- Placement of a catheter to initiate dialysis.

3- Administration of intravenous calcium gluconate.

4- Administration of oral furosemide.

CORRECT ANSWER: 3

We describe the case of a patient with a hyperkalemic emergency (potassium >6.5 mmol/l with ECG alterations).

The first step is the administration of iv calcium gluconate to counteract the cardiac toxicity of hyperkalemia (option 3 correct), giving us more time to initiate hypokalemic treatments (initially saline glucose with insulin, salbutamol, furosemide, and assessing dialysis if there is no good response).

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QUESTION TYPE: HEMATOLOGY

CLINICAL CASE:

A 26-year-old woman consults for a feeling of generalized weakness that has progressively set in over the course of three weeks, becoming particularly intense in the last two days.

For the last couple of years, she reports episodes of joint pain in the hands that have required the use of anti-inflammatory drugs, as well as the appearance of an erythematous lesion of unclear cause in the neckline area, mainly in summer.

In the physical examination there was only an evident cutaneous-mucosal pallor and a heart rate of 100 bpm.

The

hemogram

shows:

Hb

gr/dL,

Hto

MCV

fL,

platelets

Biochemistry: AST 30 IU/L, ALT 35 IU/L, GGT 59 IU/L, alkaline phosphatase 105 IU/L, LDH 490 IU/L, urea 20 mg/dL, creatinine 0.8 mg/dL.

Taking into account the available information, indicate which of the following additional analytical parameters you would need to know in order to make the most appropriate immediate decision:

Vitamin

2- Antinuclear antibodies.

3- Direct Coombs' test.

4- Anti-DNA antibodies.

CORRECT ANSWER: 3

They comment on the case of a young woman with symptoms of systemic disease of probable autoimmune origin (lupus) who presents with macrocytic anemia, options 2 and 4 are options to identify the autoimmune disease but what they ask us is what to do to treat the anemia, so we should suspect that the anemia is secondary to the autoimmune disease and therefore request a direct Coombs test, since if it is positive the patient, except in extreme cases, will not be transfused and the primary cause should be treated.

It also speaks of rapid onset, which in the case of vitamin B12 is more progressive.

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QUESTION TYPE: INFECTOLOGY

CLINICAL CASE:

A 64-year-old male presents with fever, cough, dyspnea and right pleuritic pain of 1 week's evolution.

Chest X-ray shows a loculated right pleural effusion occupying two thirds of the hemithorax.

During thoracentesis, a yellowish fluid is drawn and analysis shows: leukocytes 15,000/uL, 92% neutrophils, glucose 30 mg/dL, pH 7, lactate dehydrogenase 3500 U/L, adenosine deaminase 45 U/L and absence of germs on GRAM stain.

What is the most appropriate next course of action in this patient?

1- Intravenous antibiotic therapy.

2- Intravenous antibiotic therapy and repeat diagnostic thoracentesis in 24 hours.

3- Intravenous antibiotic therapy and repeat diagnostic thoracentesis if there is no improvement in 48 hours.

4- Intravenous antibiotic therapy and evacuative (therapeutic) thoracentesis if any germ is isolated in the pleural fluid culture.

5- Intravenous antibiotic therapy and placement of a chest tube or catheter to drain all pleural fluid.

CORRECT ANSWER: 5

In this question there should not be much doubt either (by the way, I think it is more of Pneumology than mine, but well, with this fever my friend Emilienko has deviated), since the clinical picture points to a parapneumonic pleural effusion, the macroscopic characteristics of the fluid seem so and the analysis of it shows us that the effusion is also complicated, almost on the verge of being an empyema (very high LDH, cellularity with predominance of PMN, glucose consumption).

In addition, with this pH (and knowing that the effusion is already loculated), the endothoracic tube is more than indicated.

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QUESTION TYPE: INFECTIOUS

CLINICAL CASE:

A 52-year-old patient is admitted to the Hospital for severe pneumonia.

With appropriate antibiotic treatment, the patient's respiratory symptoms improved.

After 4 days of stay in the ward, his evolution is complicated by the appearance of a severe diarrhea.

What is the most frequent microorganism responsible for this condition?

1- Salmonella enterica.

2- The bacterium itself causing pneumonia that has become resistant to the antibiotic.

3- Campylobacter jejuni.

4- Clostridium difficile.

5- Yersinia enterocolitica.

CORRECT ANSWER: 4

In this case, given the antibiotic treatment given and the severity of the diarrhea, it seems that we are dealing with a Clostridium infection.

Option 2 is not very credible, in fact, as much as patients with CAP may have associated diarrhea, it is unlikely that a bacterium is sensitive to an antibiotic at the beginning of the picture and stops being so after 3 days.

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QUESTION TYPE: ORTHOPEDIC SURGERY AND TRAUMATOLOGY

CLINICAL CASE:

A 7-year-old boy brought to the emergency department after falling off a swing onto his right hand.

He has no history of interest.

He presents with fork dorsum deformity of the wrist and functional impotence, with normal distal neurovascular status.

What lesion would you expect to find on the urgent x-ray you request?

1- Fracture - dislocation of Monteggia.

2- Radial head fracture.

3- Epiphysiolysis of the distal radius.

4- Fracture in green stem of ulna.

CORRECT ANSWER: 3

With the deformity and pain in the distal radius, we expect a fracture at this level, so we mark 3.

However, I see it as unquestionable, given that it could also have a concomitant fracture in the ulnar green stalk, although the main lesion is that of the radius.

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QUESTION TYPE: ENDOCRINOLOGY

CLINICAL CASE:

A 30-year-old woman comes to the clinic reporting anxiety, weight loss of about 6 kg and a feeling of "nervousness" in the last three months.

In the physical examination she has tachycardia, hyperreflexia and absence of goiter.

In the blood test TSH values are < 0.01 microU/mL, T4 is elevated and thyroglobulin levels are low.

A scintigraphy shows an absence of uptake in the thyroid region.

What seems to you the most likely diagnosis?

1- Factitious thyrotoxicosis.

2- Hyperthyroidism due to Graves' disease.

3- Ovarian teratoma (ovarian stromal tumor).

4- Subacute thyroiditis.

CORRECT ANSWER: 1

Answer 2 incorrect: Graves' disease is characterized by hyperthyroidism and one or more of the following features: goiter, exophthalmos and pretibial myxedema.

Answer 4 incorrect: The most obvious symptom of subacute thyroiditis is neck pain.

Sometimes, the pain may extend to the jaw or ears.

Painful enlargement of the thyroid gland can last for weeks or months.

And you usually have low serum thyroid stimulating hormone (TSH).

High serum free T4 level.

High serum thyroglobulin level.

Incorrect answer 4: Very rare tumor.

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QUESTION TYPE: NEUROSURGERY

CLINICAL CASE:

A man presents on neurological examination with a thermoalgesic sensory deficit in the left leg associated with a loss of vibratory and positional sensitivity in the right leg.

At the same time he presents with clumsiness and loss of distal strength in the right leg and a right plantar cutaneous reflex in extension.

Which of the following statements is correct:

1- It is a centromedullary syndrome type syringomyelia.

2- It is a hemimedullary syndrome.

3- It is a pattern of transverse medullary lesion.

4- It is a pattern of lateral bulbar lesion.

CORRECT ANSWER: 2

They describe a typical hemisection or Brown-Sequard picture.

Ipsilateral posterior motor and chordal involvement with contralateral pain and temperature involvement.

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QUESTION TYPE: PNEUMOLOGY

CLINICAL CASE:

65-year-old man with a history of pancreatic neoplasm undergoing chemotherapy.

What diagnostic test is more cost-effective to confirm the diagnostic suspicion?

D-dimer.

2- Magnetic resonance imaging.

Phlebography.

4- Venous Doppler ultrasound.

5- Helical CT.

CORRECT ANSWER: 4

Dopler ultrasound is the most accurate test and allows subsequent non-invasive monitoring of the evolution of the disease.

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QUESTION TYPE: PEDIATRICS

CLINICAL CASE:

A 10-year-old boy with brief episodes of distractions (< 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 with:

Valproate.

Carbamazepine.

Phenytoin.

Gabapentin.

Clonazepam.

CORRECT ANSWER: 1

The seizures described and the EEG correspond to typical absence seizures and the initial treatment of choice is valproic acid.

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QUESTION TYPE: DIGESTIVE

CLINICAL CASE:

A 72-year-old woman with no past history of interest.

After a complicated renal colic, a 2 cm cystic lesion in the tail of the pancreas, together with multiple bilateral renal cystic lesions, is found by chance in the abdominal CT scan.

Endoscopic ultrasonography shows a polycystic lesion formed by multiple vesicles with central calcification in the tail of the pancreas with no connection to the duct of Wirsung.

Fluid analysis is compatible with a serous cystadenoma.

Of the following, which is the most correct attitude regarding the management of this patient:

1- Surgical resection (corporocaudal pancreatectomy).

2- Endoscopic ultrasonography-guided puncture and ethanolization of the puncture.

3- Follow-up of the lesion by MRI.

4- Kidney-pancreas transplant.

CORRECT ANSWER: 3

Serous cystoadenoma of the pancreas is a benign, often polycystic entity (also called microcystic adenoma) formed by collagen-producing (non-mucinous) cells.

It is usually asymptomatic and is discovered as an incidental finding.

Given its benign nature, surgery is not recommended, and is reserved only for symptomatic patients or those in whom the nature of the lesion is in doubt after a complete study with CT, MRI and echoendoscopy with biopsy.

It is frequently sporadic, but can be associated with Von-Hippel-Lindau syndrome.

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QUESTION TYPE: RHEUMATOLOGY

CLINICAL CASE:

A 25-year-old female patient with a history of skin rash after sun exposure and occasional polyarthritis in the joints of the hands, controlled with non-steroidal anti-inflammatory drugs, presents with general malaise, progressive feeling of generalized weakness and pallor for the last 15 days.

Laboratory

tests

showed

hemoglobin

g/dL,

MCV

mm/h,

elevated

LDH,

undetectable

haptoglobin.

In the case of choosing a single diagnostic test indicate which of the following determinations should be performed first:

1- Direct Coombs test.

2- Antinuclear antibodies (ANA).

Vitamin

Ferritin.

5- Folic acid.

CORRECT ANSWER: 1

The clinical and biological picture of this patient raises suspicion of hemolytic anemia in the context of systemic lupus erythematosus.

If we have to choose only one diagnostic test, and this should be the first, we are interested in confirming the presence of an autoimmune hemolytic anemia with the direct Coombs' test in order to initiate treatment.

The other tests can wait...

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QUESTION TYPE: OPHTHALMOLOGY (ECTOPIC)

CLINICAL CASE:

A 70-year-old woman with a history of anorexia, weight loss, discomfort in the musculature and proximal joints plus pain in the temporomandibular region who comes to the emergency department for unilateral loss of vision (hand movement), sudden and painless onset (afferent pupillary defect).

What test would you request first for diagnostic purposes?

1- Lumbar puncture.

2- C-reactive protein.

3- Magnetic Resonance Angiography.

4- Carotid ultrasound.

CORRECT ANSWER: 2

This is a woman with abrupt, painless and severe loss (she only sees the movement of the hands) of vision in one eye.

She does not give us much information from the ocular examination, only that there is an afferent pupillary defect.

We have to rely on systemic symptoms to diagnose the problem.

This is an elderly woman with typical symptoms of polymyalgia rheumatica, and the pain in the temporomandibular region is very suggestive.

It is giant cell arteritis or temporal arteritis.

The most common ocular manifestation is anterior ischemic optic neuropathy.

In the fundus we would certainly see a papillary edema of that eye, with a gypsum white coloration.

The afferent pupillary defect is very characteristic of these severe ischemic optic neuropathies.

Suspecting giant cell arteritis, there are three analytical markers that are characteristically high: CRP, ESR and platelet count.

We will first request one of these parameters and treat it often without waiting for biopsy confirmation.

Therefore, option 2 is the correct one.

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QUESTION TYPE: NEPHROLOGY

CLINICAL CASE:

A 68-year-old patient consults for edema and asthenia.

Laboratory tests showed creatinine 5 mg/dL, hemoglobin 10 g/dL and marked hypogammaglobulinemia in serum at the expense of IgG, IgA and IgM.

A urinalysis reveals the presence of kappa light chains.

What is your diagnostic suspicion?

1- Kappa light chain deposition disease.

2- Nephrotic syndrome.

Amyloidosis.

4- IgA myeloma with Bence-Jones proteinuria.

5- Light chain myeloma.

CORRECT ANSWER: 1

This question is mixed hemato-nephro.

It is complicated, so we are going to rule out options one by one.

Option 2, nephrotic syndrome, apart from being broad and nonspecific, would not be assessable, since they do not give us the quantification of urine protein (they only tell us that urinalysis reveals the presence of kappa light chains, not the amount).

Option 3 would be unlikely; in amyloidosis, the light chains that are usually deposited are of the lambda type.

Option 4 also seems unlikely, since in IgA myeloma we would expect a monoclonal peak of this Ig, which in this case does not appear.

The doubt that arises is between 1 and 5; I would opt for 1, because this entity fulfills the characteristics described (absence of monoclonal peak in most cases, acute renal failure and presence of kappa chains in urine), being light chain myeloma a somewhat broader entity, but option 5 could also be considered valid.

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QUESTION TYPE: PNEUMOLOGY

CLINICAL CASE:

A 24-year-old woman is found lying in the street by passers-by.

On arrival of the emergency team she was found with an oxygen saturation of 88% breathing room air and on examination with pinpoint pupils.

She was transferred to the emergency room of the nearest hospital, where the baseline arterial blood gases showed: pH 7.25, PaC02 60 mmHg, Pa02 58 mmHg, bicarbonate 26 mEq/1 and base excess of -1.

In

blood

sodium

was

and

chloride

1- Partial respiratory failure.

2- Metabolic acidosis.

3- Pure respiratory acidosis.

4- Respiratory alkalosis due to lack of chloride.

5- Blood gases can only be venous blood.

CORRECT ANSWER: 3

The acidosis with elevated PCO2, hypoxemia and normal bicarbonate suggests an acute respiratory acidosis of rapid onset probably due to drug intoxication.

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QUESTION TYPE: PEDIATRICS

CLINICAL CASE:

A 2-month-old infant with an upper respiratory tract cold of 3 days of evolution, who begins with moderate respiratory distress and pulmonary auscultation with expiratory wheezing.

Oxygen saturation is 89 %.

Respiratory syncytial virus is isolated in the nasopharyngeal exudate.

Which of the following treatments do you consider more indicated for this condition?

1- Oral rivabirin.

2- Nebulized salbutamol.

3- Supplemental oxygen.

4- Intravenous corticosteroids.

CORRECT ANSWER: 3

We are presented with a case of RSV-positive bronchiolitis.

According to current recommendations, it would be indicated to initiate supplemental oxygen therapy.

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QUESTION TYPE: HEMATOLOGY

CLINICAL CASE:

A 67-year-old female patient on ticlopidine treatment comes to the emergency department with headache, asthenia and petechiae in the lower extremities.

Laboratory tests showed hemoglobin 8.2 g/dL, MCV 100 fl, platelets 25000/ul and leukocytes 7500/ul with normal formula.

The reticulocyte count was elevated and the blood smear showed numerous schistocytes.

Coagulation studies (APTT, PT and fibrinogen) are normal.

The biochemistry shows LDH 2700 IU/l and bilirubin 2.6 mg/dl.

What is the most likely diagnosis?

1- Autoimmune thrombocytopenic purpura.

2- Thrombotic thrombocytopenic purpura.

3- Bone marrow aplasia.

4- Drug-induced thrombopenia.

5- Disseminated intravascular coagulation.

CORRECT ANSWER: 2

Typical of ticlopidine.

Not only thrombocytopenia but also headache, schistocytes, high LDH and high bilirubin.

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