QUESTION TYPE: PEDIATRICS

CLINICAL CASE:

An 18-month-old boy, with complete immunization schedule to date, who consults the Emergency Department for right knee swelling after playing in the park, without obvious trauma.

In the directed anamnesis, the mother refers that an uncle of hers had similar problems.

The ultrasound examination is compatible with hemarthrosis and in the analytical analysis only an APTT lengthening of 52'' (normal 25-35'') stands out.

What is the most probable diagnostic hypothesis?

1- Marfan syndrome.

2- Von-Willebrand's disease.

3- Ehlers-Danlos disease.

4- Hemophilia A.

5- Bernard-Soulier disease.

CORRECT ANSWER: 4

Although other hemorrhagic diseases can have a prolonged thromboplastin time, due to the intensity of the lesion and the child's sex and family history, the most likely diagnosis is hemophilia.

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QUESTION TYPE: PSYCHIATRY

CLINICAL CASE:

We are consulted by an 84-year-old woman for insomnia of conciliation.

After failing sleep hygiene measures, it is decided to initiate pharmacological treatment.

Which of the following drugs would you select for the patient?

Diacepam.

Lormetacepam.

Phenobarbital.

Chlordiazepoxide.

Chloracepate.

CORRECT ANSWER: 2

Knowing that we have taken measures of sleep hygiene, we have explored what provokes him not to sleep, and he does not sleep nine hours and still wants to sleep more,...then the less harmful answer is the 2.

Because it is the one with the shortest half-life and he does not want the lady to fall down the next day.

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QUESTION TYPE: NEUROLOGY

CLINICAL CASE:

A 65-year-old woman consults for weakness in the right hand that has spread in a few months to other muscle territories of both arms and legs, with distal predominance.

On examination there is atrophy and fasciculations in different metameric territories with preserved sensitivity.

There is a bilateral Babinski's sign, what is the diagnostic test that would confirm the suspected diagnosis?

1- Cerebral CT.

2- Electromyographic study.

3- Cerebral MRI.

4- Multimodal evoked potentials.

CORRECT ANSWER: 2

The answer is 2, an EMG, which would be the diagnostic test to confirm the diagnostic suspicion of ALS, the imaging tests both CT, but especially MRI would help us to rule out, but would not confirm the diagnosis.

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QUESTION TYPE: TRAUMATOLOGY

CLINICAL CASE:

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?

1- Gouty arthritis of left hip.

2- Left coxofemoral arthrosis.

3- Radiated low back pain / lumbosciatica.

4- Claudication due to canal stenosis.

CORRECT ANSWER: 3

In this case, when speaking of "reappearance of the symptoms when we lift the lower limb with the knee extended" we are describing the Lasègue Maneuver.

This maneuver is positive in cases of lumbosciatic pain, since it causes a stretching of the sciatic nerve, therefore the correct answer is number 3.

The rest of the pathologies do not have a positive Lasègue maneuver, so these options would not be correct.

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QUESTION TYPE: NEUROLOGY AND NEUROSURGERY

CLINICAL CASE:

A 32-year-old diabetic patient on insulin therapy with good control of his blood glucose levels comes to your office with tingling in both hands, with a sensation of corking and thermal insensitivity of progressive onset over the course of 2 weeks.

She does not report visual disturbances, strength deficit, motor clumsiness or other symptoms.

On examination she found anesthesia to pain and temperature in both hands and distal forearms; positional and vibratory sensitivity were preserved.

There is no muscle atrophy or strength deficit.

Muscle reflexes are normal and symmetrical.

There is no dysmetria, dysdiadochokinesia or intention tremor.

The rest of the neurological examination is strictly normal.

Indicate the most likely diagnosis in this case:

1- Peripheral sensitvo symmetric distal peripheral neuropathy of diabetic cause.

2- Compressive cervical spinal cord injury.

3- Bilateral carpal tunnel syndrome.

4- Multiple sclerosis type demyelinating disease.

5- Central cervical spinal cord injury.

CORRECT ANSWER: 5

This year's Neurology section's burning question.

He presents a diabetic patient on insulin treatment with good control (although diabetic neuropathies do not only develop in patients with poor control) with a sensory picture limited to the upper limbs and of short onset time, without motor symptoms or at any other level.

In the examination there is a clear dissociation with thermoalgesic anesthesia and preservation of arthrokinetic and vibratory.

Reflexes are normal, neither abolished nor exalted.

In addition, the rest of the examination is strictly normal.

With all this I believe that the correct answer is 5, that is a syringomyelic lesion, whose initial characteristic is the sensitive dissociation with anesthesia for the thermoalgesic and conservation of the posterior cord.

MS and other spinal cord lesions would be accompanied by other exploratory signs such as exaltation of reflexes, for carpal tunnel the exploration exceeds the territory distal to the carpus, and as for answer 1, although there are forms of peripheral polyneuropathy "pseudosyringomyelic" they are usually of lumbar onset.

The short evolution time (2 weeks), the respect of the lower limbs and the preservation of muscle reflexes make me rule out this response despite the distribution being "glove-like".

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QUESTION TYPE: RHEUMATOLOGY

CLINICAL CASE:

A 37-year-old man presents with arthritis of the metacarpophalangeal joints of both hands and right pleuritis.

Bilateral malar erythema is seen on examination.

Positive antinuclear antibodies were detected (titer 1/640), with anti native DNA antibodies also positive; anti-Sm negative What would be the initial treatment of choice for this patient?

1- Glucocorticoids at high doses.

2- Glucocorticoids and mycophenolate.

3- Nonsteroidal anti-inflammatory drugs and antimalarials.

4- The picture will probably be self-limited and does not require treatment.

CORRECT ANSWER: 1

It is SLE with joint, skin and serositis involvement.

Treatment is EC at moderate-high doses.

Mycophenolate is never a treatment in acute phase but in maintenance, nor has it proved useful in joint involvement.

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QUESTION TYPE: RHEUMATOLOGY

CLINICAL CASE:

A 75-year-old woman consults for violaceous lesions on the hands and neck together with progressive muscle weakness of 3 months of evolution.

What diagnostic tests, among those indicated, can be useful for the diagnosis?

1- Determination of serum aldolase.

Electroencephalogram.

3- Biopsy of subcutaneous cellular tissue.

4- Determination of anti-smooth muscle antibodies.

5- Genetic study of their descendants.

CORRECT ANSWER: 1

Given this clinical picture, one possibility is dermatomyositis.

Of the proposed tests, the determination of serum aldolase may be useful.

Its elevation is characteristic of this disease.

The biopsy should be muscular and not subcutaneous.

Anti-smooth muscle antibodies are not characteristic of this disease.

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QUESTION TYPE: CARDIOLOGY AND CARDIOVASCULAR SURGERY

CLINICAL CASE:

An 87-year-old woman with a history of hypertension was admitted 48 hours ago to the coronary unit for acute myocardial infarction with ST-segment elevation of anterior location.

She reported dyspnea.

Examination revealed a systolic murmur with fremitus, radiating to the right sternal border, which was not present on admission.

What complication do you suspect?

1- Heart failure due to extensive necrosis.

2- Anterior aneurysm.

3- Left ventricular free wall rupture.

4- Rupture in the interventricular septum.

CORRECT ANSWER: 4

Rupture of the interventricular septum.

Mechanical complications are typical in infarctions in elderly women.

Likewise, a murmur that was not present indicates abnormal blood flow: the most frequent complications are mitral insufficiency, which would present with a musical or piante murmur, and VSD, which presents with a murmur radiating to the right border (think of the direction of blood flow).

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QUESTION TYPE: ONCOLOGY

CLINICAL CASE:

A 66-year-old patient diagnosed with stage IV pancreatic adenocarcinoma 8 months ago.

He follows treatment with delayed release morphine 200 mg/12 hours orally, kerosene and lactulose.

For the last 15 days he has reported paresthesias and occasional lancinating pain in the right lumbar and periumbilical area that does not subside with rescue morphine.

The neurological examination is normal.

Indicate the most appropriate management:

1- Perform computed axial tomography and evaluate nerve compression since it is neuropathic pain.

2- Evaluate neurolytic treatment since neuropathic pain is difficult to control.

3- Decrease the dose of morphine as it is ineffective in this type of pain.

4- Administer amitriptyline or gabapentin, dexamethasone and increase the dose of morphine.

CORRECT ANSWER: 4

We have before us a patient with neuropathic pain, which due to the origin of the tumor, is most likely due to involvement of the celiac plexus.

It is important to have a radiological diagnosis in view of a possible local treatment, such as neurolytic treatment or plexus blockade.

However, we should not leave the patient without a treatment that can alleviate but rather solve the current situation.

He is taking WHO step 3 analgesia, which is clearly insufficient, so he will need adjuvants; although opioids for neuropathic pain are not very effective, we will not reduce the dose but will associate the adjuvants.

We would manage the patient with gabapentin and corticosteroids (true answer 4); we would not decrease the dose of morphine (false answer 3), and in the meantime we would ask for a CT scan (or abdominal MRI) to subsequently assess the plexus block (answers 1 and 2 for future management).

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QUESTION TYPE: PNEUMOLOGY

CLINICAL CASE:

Juan is 60 years old, has been smoking 2 packs/day for years and has reported a persistent cough for the last 6 months.

He notes that his left eyelid is more droopy and that the pupil of this eye is smaller.

John reports that the medial side of his left hand is numb and with less strength.

His physician checks for palpebral ptosis and left miosis; he checks that he can close both eyelids symmetrically and that both pupils respond correctly to light.

In addition, he checks that there is no sweating from the left hemiface, that he feels less prickling on the inner surface of the left hand and that he has less strength in the grip of the left hand.

Regarding the ocular symptomatology, where is the lesion located?

1- Sympathetic fibers, at some level that would span from the hypothalamus to the interinedio-lateral Clark's column of the dorsal medulla.

2- Left common ocular motor nerve in the midbrain.

3- Edinger-Westphal nucleus above the left common ocular motor nerve nucleus.

4- Parasympathetic fibers, at some level ranging from the Edinger-Westphal nucleus to the constrictor muscle of the left pupil.

5- Tarsal muscle exclusively.

CORRECT ANSWER: 1

The question would be more of neurology.

It is a claude bernard horner syndrome and probably the correct one is 1.

But for safety's sake it is better to have it checked by a neurologist.

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QUESTION TYPE: GYNECOLOGY AND OBSTETRICS

CLINICAL CASE:

A 24-year-old woman, primigestation, suffers a spontaneous abortion at 7 weeks gestation.

The anatomopathological study of the abortive remains indicates molar disease.

We should inform you that:

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

2- She should not become pregnant until periodic check-ups and after one year with negative BHCG levels.

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

4- Periodic check-ups are necessary since 40% of cases will develop gestational trophoblastic neoplasia.

CORRECT ANSWER: 2

She should not become pregnant until she has undergone regular check-ups and one year has passed with negative beta-HCG levels.

Patients will be monitored weekly with hCG dosing until it becomes undetectable, for three consecutive times.

After that the monitoring will be monthly for six months and then every two months for another six months before a new pregnancy.

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QUESTION TYPE: PEDIATRICS

CLINICAL CASE:

A 10-year-old girl comes for a health check-up.

Physical examination is normal with weight and height in the 50th percentile and BP 109/65.

A routine urinalysis shows a specific gravity of 1035 pH6 blood 2+ with no protein.

Urine sediment shows 5-10 red blood cells per field.

What would be the most appropriate course of action?

1- Determination of creatinine and nitrogen in blood.

2- Refer the child for cystoscopy.

3- Determine antinuclear antibodies and complement.

4- Repeat urine sediment in 15 days.

5- Abdominal computed axial tomography.

CORRECT ANSWER: 4

The correct answer is 4.

What is not very clear to me is "routine urinalysis" because it is not usually done in an asymptomatic healthy child.

Microhematuria without associated symptoms may be a finding without pathologic significance and must be confirmed in a subsequent new sediment (although I do not know if at 15 days or later).

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QUESTION TYPE: TRAUMATOLOGY

CLINICAL CASE:

A 13-year-old female, with no relevant history, with menarche 3 months ago, followed since the age of 10 years by idiopathic scoliosis that has worsened.

In the physical examination she presents a hump of 7 degrees in the Adams test and in the scoliogram a thoracolumbar curve T4-L1 of 35 degrees of Cobb and a Risser 0.

The correct attitude to take will be:

1- Recommend swimming and revision in three months.

2- Prescribe a corset-type orthosis.

3- Refer to physiotherapy for spine elastification.

4- Review in 6 months with a new X-ray.

CORRECT ANSWER: 2

Orthosis.

Cobb

angle

between

Immature skeleton (Risser 0).

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QUESTION TYPE: HEMATOLOGY

CLINICAL CASE:

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 do you think is the correct approach?

1- Study of TP53 mutations to establish prognosis.

2- Bone aspirate/biopsy to confirm diagnosis.

3- PET/CT to establish the therapeutic attitude.

4- New clinical and analytical control in 6 months.

CORRECT ANSWER: 4

The patient is already diagnosed with chronic lymphocytic leukemia B (B-CLLL), presents lymphocytosis that is maintained for more than 3 months and by flow cytometry presents a phenotype compatible with it.

Therefore, we must first know the risk factors that will indicate with what priority treatment will need to be initiated, their intensity and prognosis; the presence of TP53 mutations or 17p deletions depends on this.

The bone marrow aspirate or biopsy is only indicated if there are other accompanying cytopenias that are not justified by the B-CLL itself, PET-CT is only indicated if Ritcher's syndrome is suspected and we do not have enough data to suspect it, there are no B symptoms, nor is there any mention of LDH elevation.

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QUESTION TYPE: RHEUMATOLOGY

CLINICAL CASE:

A 45-year-old female patient with a history of gastroesophageal reflux has been presenting for the past year with episodes of pallor in some fingers with exposure to cold.

She had recently been prescribed prednisone at a dose of 20 mg/day for joint pain and skin induration in the hands and arms.

For the last 48 hours, she presented with general malaise and intense headache, for which she went to the emergency department.

Examination revealed only a rhythmic tachycardia at 100 bpm, with no neurological focality.

Blood pressure was 200/110 mmHg.

The blood test shows only a creatinine level of 2.5 mg/dL.

Indicate which of the following autoantibodies is best related to the process described:

1- Anti-RNA polymerase III antibodies.

2- Anti-centromere antibodies.

Anti-proteinase

antibodies.

4- Anti-PM-Scl antibodies.

CORRECT ANSWER: 1

This is a clear clinical case of systemic sclerosis (Raynaud's, esophageal involvement, skin induration) presenting with renal crisis.

Apart from anti-proteinase 3 antibodies, which are not related to scleroderma (incorrect answer 3), the most likely ones would be antiRNA polymerase III antibodies, which appear in younger patients with renal crises.

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QUESTION TYPE: DIGESTIVE SYSTEM

CLINICAL CASE:

18-year-old young man with a history of asthma, allergy to pollens, mites and cat hair, comes to the emergency room referring sensation of food detention at retrosternal level with practical inability to swallow his own saliva.

He refers similar episodes on other occasions that have subsided spontaneously within a few minutes.

Which of the following is the most likely diagnosis?

1- Barrett's esophagus.

2- Distal esophageal ring (Schatzki).

3- Infectious esophagitis.

4- Eosinophilic esophagitis.

CORRECT ANSWER: 4

This is intermittent dysphagia.

Barrett's esophagus does not necessarily imply peptic stricture, but assuming it does, it is progressive.

Infectious esophagitis is more typical of immunocompromised patients.

That leaves distal esophageal ring and eosinophilic esophagitis; both are possible, but the insistence on the patient's atopic burden indicates the likelihood of the latter.

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QUESTION TYPE: ENDOCRINOLOGY

CLINICAL CASE:

14-year-old girl who consults for decreased growth for 2-3 years previously normal (provides data) and that other girls her age have greater physical and sexual development.

Lately she has had headaches and visual problems that she notices in class and when studying.

She has not had menarche or polydipsia or polyuria.

Parents with normal height.

Examination: short stature at -2.1 standard deviations, normal body proportions, little pubic hair and breast development.

Campimetry shows left temporal partial hemianopsia.

Bone age: delay of 2 years.

General laboratory tests were normal.

Gonadotrophins (FSH and LH) and estradiol are low.

What do you think is the most appropriate response?

1- Decreased growth and sexual development, delayed bone age, headache and visual alteration suggest hormonal deficit and involvement of the optic chiasm.

2- As she is a girl of pubertal age, it is most likely that her decreased growth and sexual retardation are due to Turner syndrome.

3- She must not have a hypothalamic tumor because of the absence of polyuria and polydipsia. She probably has constitutional delay and her visual problem is refractive.

4- A growth hormone deficiency may explain the developmental delay and low estradiol. To evaluate if she needs glasses, due to her headaches and visual disturbances.

5- She could have a craniopharyngioma, but it would be rare if she had not shown symptoms before. Also, it would not justify low gonadotrophins and estradiol.

CORRECT ANSWER: 1

Answer 2 is false (Turner syndrome: low estradiol and elevated gonadotrophins), brain tumors affecting the hypothalamus-pituitary gland do not give low gonadotrophins (5 false), and it seems obvious that refractive defects do not give hemianopsia (3 and 4 false).

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QUESTION TYPE: PRIMARY CARE

CLINICAL CASE:

The patient comes to the home of an oncology patient whose pain has not been well controlled lately.

On physical examination there appears to be no evidence of tumor progression, and no previously known data of interest is revealed.

In the anamnesis, the main caregiver states that the patient has pain 8 hours after receiving the prescribed basal dose of morphine every 12 hours.

This clinical situation is referred to as:

Tolerance

Hyperalgesia

Dependency

Ineffectiveness

CORRECT ANSWER: 1

The correct answer is 1.

The statement perfectly defines a tolerance phenomenon in which the patient has become "used to" the dose and needs more in order to have the same analgesic effect.

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QUESTION TYPE: HEMATOLOGY

CLINICAL CASE:

A 33-year-old woman consults for repeated epistaxis, petechiae and ecchymosis.

Laboratory tests show thrombocytopenia with a platelet count of 4000 platelets/microliter.

The initial presumptive diagnosis is chronic immune thrombocytopenic purpura (ITP).

Which of the following statements is FALSE regarding the diagnosis of ITP?

1- The presence of lymphadenopathy or splenomegaly in the physical examination suggests a different diagnosis of ITP.

2- Bone marrow analysis shows a decreased number of megakaryocytes without other alterations.

3- Complete blood count shows isolated thrombocytopenia with often large platelets, without anemia unless there is significant bleeding or associated autoimmune hemolysis (Evans syndrome).

4- The diagnosis of ITP is established by exclusion of other processes causing thrombocytopenia.

5- The determination of antiplatelet antibodies is not accurate to establish the diagnosis.

CORRECT ANSWER: 2

In the presence of isolated thrombocytopenia we must not lose sight of the physical examination; thus, the presence of lymphadenopathy forces us to rule out the presence of lymphoma, for example.

1 is correct.

When performing a bone marrow biopsy-aspirate it is seen that the number of megakaryocytes is normal or even increased, the failure is not in the marrow but in the peripheral blood, where platelets are destroyed.

So.

The false answer is 2.

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QUESTION TYPE: GYNECOLOGY AND OBSTETRICS

CLINICAL CASE:

A 27-year-old woman referred to the gynecology office for evaluation referring dyspareunia for about 8 months, along with dyschezia and occasional rectorrhagia coinciding with menstruation for 3-4 months.

She also reports dysmenorrhea for years, which she controls well with ibuprofen.

She has been trying to get pregnant for 16 months without success.

In the gynecological examination she only has pain when pressing on the posterior vaginal fornix.

Which test do you consider would allow you to reach a diagnosis of certainty of her pathology?

1- Transvaginal ultrasound.

2- Diagnostic laparoscopy.

3- Magnetic resonance imaging.

Colonoscopy.

CORRECT ANSWER: 2

Diagnostic laparoscopy.

It is a typical case of deep endometriosis, with implants in different parts of the pelvis.

The definitive diagnosis will be given by the pathological anatomy, so for this we have to do Laparoscopy and send to PA.

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QUESTION TYPE: EPIDEMIOLOGY AND PREVENTIVE MEDICINE

CLINICAL CASE:

A 38-year-old woman of veterinary profession, in charge of monitoring wild animals and assisting in the delivery of domestic livestock.

She starts with a high fever with chills, headache, myalgia and non-productive cough that she interprets as a flu-like process.

She presented with chest pain.

Chest X-ray showed bilateral pulmonary infiltrates in lower fields.

A serologic test was performed with elevated titers of antibodies against phase II antigens.

Which of the following statements is TRUE?

1- This entity is transmitted by ticks.

2- Both doxycycline and hydroxychloroquine are effective in treating acute forms of this disease.

3- In the acute form, the patient also generally has elevated antibodies to phase I antigens.

4- Mortality in acute forms is almost nonexistent.

CORRECT ANSWER: 4

As a possible disease I would consider Brucellosis, typical of cattle (milk, abortion, genital secretions...).

It presents with a pseudo-flu-like symptomatology (headache, arthralgias, myalgias, fever...) and other symptoms depending on the route of entry.

In our case, when attending animal births, the entry is through the respiratory route, so the pulmonary infiltrates and chest pain are due to the bacteria.

The treatment varies according to the affectation and mortality is very low, almost null.

Morbidity and involvement in pregnant women are of greater concern.

Important: it is very frequent in livestock workers (veterinarians, farmers, slaughterhouses...) if you read something like "attends births of livestock animals", "works on a farm", "is a veterinarian" suspect Brucellosis.

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QUESTION TYPE: NEUROLOGY

CLINICAL CASE:

A 49-year-old man is admitted to the ICU for traumatic brain injury after an accident at work.

In the physical examination he does not open his eyes, does not emit sounds before being intubated and presents extension of extremities to nociceptive stimulus.

An intracranial pressure sensor is placed and a decompressive craniotomy must be performed due to intraparenchymal hemorrhage.

Which of the following statements is correct?

1- On arrival she is in a Glasgow scale coma of 7.

2- Cerebral perfusion pressure is mean arterial pressure plus intracranial pressure.

3- Vasogenic cerebral edema is due to cellular edema, membrane rupture and cell death.

4- Cerebral vascular flow increases with hypercapnia and acidosis.

CORRECT ANSWER: 4

Hypercapnia and acidosis produce vasodilatation causing increased cerebral blood flow.

According to the described examination the Glasgow is 4 (O1V1M2).

Cerebral perfusion pressure is mean arterial pressure minus intracranial pressure.

Cerebral edema in which cellular edema is produced by the introduction of extracellular fluid into the intracellular compartment is cytotoxic.

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QUESTION TYPE: GENERAL SURGERY

CLINICAL CASE:

A 45-year-old man undergoes a truncal vagotomy and antrectomy with Billroth II reconstruction for chronic peptic ulcer disease with pyloro-duodenal stricture.

Six weeks after the surgery she reports that shortly after (less than half an hour) after ingestions she presents nausea, asthenia and sweating, dizziness and abdominal cramps usually accompanied by diarrhea.

Which of the following is the most appropriate approach for her initial management?

1- Apply treatment with a somatostatin inhibitor (octreotide).

2- Follow specific dietary measures.

3- Trial treatment with a benzodiazepine.

4- Search for a probable neuroendocrine tumor (e.g. carcinoid).

5- Indicate surgical treatment to perform an antiperistaltic Roux-en-Y gastrojejunostomy.

CORRECT ANSWER: 2

Answers 1, 2 and 5 are appropriate treatments for dumping syndrome or postgastrectomy, but the question is focused on initial management, so the most appropriate answer seems to be 2.

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QUESTION TYPE: PSYCHIATRY

CLINICAL CASE:

A 46-year-old man with bipolar disorder is brought to the emergency department after an over-ingestion of lithium carbonate.

Examination reveals severe tremor, ataxia, dysarthria, myoclonus and fasciculations.

Lithemia is 4.1 mEq/L (toxicity > 1.6 mEq/L).

Which of the following therapeutic options would be most indicated?

1- Aminophylline associated with a cathartic.

2- Activated charcoal.

Hemodialysis.

4- Forced diuresis.

CORRECT ANSWER: 3

Be careful with lithium.

Intoxications have been seen with normal lithium.

It is not rare -especially due to interactions-.

A very effective drug if everyone is forewarned.

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QUESTION TYPE: DERMATOLOGY

CLINICAL CASE:

A 4-year-old girl presenting with a high fever of 6 days' evolution.

On clinical examination she presents an erythematous maculopapular rash on the trunk and genital area, with a tendency to confluence, without becoming scarlatiniform; conjunctival injection without secretions and red lips with raspberry tongue.

She also presents erythema with edema in hands and feet and a unilateral cervical adenopathy of 2 cm in diameter.

The most likely clinical diagnosis of suspicion is:

1- Kawasaki disease.

Measles.

Rubella.

4- Scarlet fever.

CORRECT ANSWER: 1

There is no doubt, they are not meeting the diagnostic criteria of Kawasaki disease (fever of several days of evolution, exanthema, conjunctival injection, red lips, raspberry tongue, edema of acral parts and adenopathy).

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QUESTION TYPE: RHEUMATOLOGY

CLINICAL CASE:

A 67-year-old man presents with 3 months of asthenia and febrile fever, with nasal obstruction and mucus emission with some clots in the last month.

In the last few days she noticed pain in the right eye and asymmetry with respect to the contralateral eye.

Physical examination reveals proptosis of the right eyeball and inspection of the nostrils reveals an erythematous mucosa with serohematic crusts.

The rest of the examination was normal.

Blood tests (hemogram, renal and hepatic function) are normal, except for an ESR of 65 mm/h; urinalysis shows microhematuria and proteinuria of 520 mg/24h.

What is the most probable initial diagnosis?

1- Eosinophilic granulomatosis with polyangiitis.

2- Microscopic polyangiitis.

3- Granulomatosis with polyangiitis.

4- Polyarteritis nodosa.

CORRECT ANSWER: 3

In this patient, he presents with a granulomatosis with polyangiitis formerly known as Wegener's granulomatosis.

In the clinical case we are told about the otorhinolaryngologic involvement that is present in 92% of patients.

At the pulmonary level, we were told that mucus with a clot was present in 85% of the patients.

Also at the end of the case, they comment us the urinalysis with a glomerulonephritis that is present in 77% of the patients.

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QUESTION TYPE: OPHTHALMOLOGY

CLINICAL CASE:

75-year-old woman diagnosed 3 years ago with soft drusen in the fundus.

She reports presenting, since 2 weeks ago, metamorphopsia and significant visual loss in her right eye that prevents her from reading.

Indicate the most probable diagnosis:

1- Macular epiretinal membrane.

2- Macular hole.

3- Thrombosis of the central retinal vein.

4- Senile macular degeneration.

5- Central serous chorioretinopathy.

CORRECT ANSWER: 4

Of the five options, four could be compatible with the referred symptoms.

We could initially rule out central serous chorioretinopathy because by definition it occurs in young people (up to 55 years of age, more or less).

The key to differentiate between the other four is that he had soft drusen in the fundus.

That while not a "diagnosis" (the question could have been better worded) is a finding related to age-related macular degeneration, or age-related macular degeneration.

The dry or atrophic form presents with slowly progressive visual loss.

But the wet or exudative form produces acute or rapidly progressive severe visual loss (usually due to subretinal hemorrhage accompanied by metamorphopsia (image distortion due to retinal lifting).

An epiretinal membrane usually has a slower course.

In a macular hole, visual loss is more relevant (metamorphopsia may also be reported, but it is less likely in the acute stage).

In thrombosis of the central retinal vein, visual loss is more important and does not usually explain metamorphopsia (but may have it, due to macular edema).

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QUESTION TYPE: ENDOCRINOLOGY

CLINICAL CASE:

A 56-year-old female patient consulted for dorso-lumbar spine pain and progressive difficulty in performing usual tasks.

In the last 5 years she gained weight, she has ecchymosis easily and arterial hypertension was detected.

Physical examination: Obesity of central predominance, rounded facies, increased supraclavicular fat, decreased proximal muscle strength and some reddish striae in the abdomen.

She has a blood glucose of 136 mg/dL and the radiological study showed osteoporosis and vertebral crushing.

What do you think is the most coherent interpretation and attitude?

1- Postmenopausal osteoporosis, type 2 diabetes mellitus and essential hypertension, with decreased strength due to diabetic polyneuropathy.

2- It is necessary to rule out Cushing's disease by dexamethasone suppression test and perform a cranial CT scan.

3- Suggest Cushing's.

Determine urinary free cortisol and basal ACTH, which serves to orient its etiology and select the most appropriate imaging technique.

4- It looks like Cushing's.

If basal ACTH is high, it may be due to corticosteroid use or an adrenal tumor, and an MRI should be performed.

5- Probably has Cushing's.

If the basal ACTH is low, he probably has a pituitary micro-adenoma, and a cranial CT scan should be performed.

CORRECT ANSWER: 3

This question is a bit convoluted for the diagnosis of Cushing's syndrome but easy if the steps are clear.

We all agree that the patient seems to have Cushing's syndrome (we rule out 1).

For the diagnosis we have to measure urinary free cortisol, do a dexamethasone suppression test or measure nocturnal salivary cortisol.

If hypercortisolism is confirmed, the origin should be sought; the ACTH measurement indicates the origin: suppressed in hypercortisolism of adrenal origin or prolonged use of corticoids and elevated or normal if the origin is pituitary or by ectopic ACTH secretion.

(Therefore, 4 and 5 are false).

If ACTH is low, a CT scan of the abdomen should be performed to locate the origin.

If ACTH is normal or high, a pituitary MRI should be performed (pituitary adenomas responsible for Cushing's syndrome are very small and CT of the pituitary is less sensitive than MRI).

It is very important to perform the order well to arrive at a proper diagnosis: 1st: confirm hypercortisolism or s.

Cushing's syndrome, 2nd: measure ACTH to orient etiology.

3rd: imaging test according to ACTH levels.

Therefore, answer 2 is false (abdominal CT is not a test to rule out s. Cushing's); an imaging test should only be done once a clear diagnosis of hypercortisolism has been made.

Therefore, the true one is 3.

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QUESTION TYPE: DIGESTIVE

CLINICAL CASE:

During a colonoscopy, a 5-cm tumor located in the right colon is detected in a 48-year-old man.

No other lesions were found.

His maternal grandmother also suffered from colon cancer.

The biopsies are superficial and show a poorly differentiated tumor with abundant inflammatory cells in the stroma that is diagnosed as a medullary type carcinoma.

1- Chemotherapy is the treatment of choice.

2- Since the biopsy is superficial, it should be repeated before proceeding with treatment.

3- The prognosis of the tumor depends mainly on its high degree of anaplasia.

4- It is unlikely that this tumor has developed over a previous adenoma.

5- Microsatellite instability and DNA error repair genes should be studied.

CORRECT ANSWER: 5

Complicated question about an unusual adenocarcinoma.

By rule 1 would be easy to eliminate, the treatment of colon cancer is surgical (with neoadjuvant in rectal cancer).

If biopsies confirm adenocarcinoma, there is no need to repeat them, since it is necessary to have the complete specimen.

Most colon cancer develops on adenomas, so we could eliminate this one.

Among the other 2, it is important to know that 5 is correct since they almost always present microsatellite instability even without fulfilling the Amsterdam criteria and have a better prognosis than other poorly differentiated colon cancer.

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QUESTION TYPE: RHEUMATOLOGY

CLINICAL CASE:

A hyperuricemic patient who usually takes 100 mg of allopurinol daily comes to the ED with acute pain and inflammatory signs in the right knee.

Arthrocentesis is performed and polarized light microscopy shows intracellular crystals with negative birefringence.

Which of the following therapeutic approaches is the most appropriate in this case?

1- Discontinue allopurinol and start colchicine treatment.

2- Discontinue allopurinol and start NSAIDs.

3- Add an NSAID until the crisis remits.

4- Increase the dose of allopurinol to 300 mg/day.

5- Substitute allopurinol for uricosuric acid.

CORRECT ANSWER: 3

In the presence of acute gouty arthritis (the presence of intracellular crystals with negative birefringence confirms this) in a hyperuricemic patient previously treated with allopurinol, an NSAID should be added until the crisis subsides.

No changes should be made in the hypouricemic treatment during this period because the uric acid metabolic chain is altered and the situation may worsen.

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QUESTION TYPE: INFECTIOUS DISEASES

CLINICAL CASE:

A 20-year-old girl comes to the clinic with an acute fever, cervical lymphadenopathy and skin rash.

According to the patient, 3 weeks ago she had a sexual relationship that could be a risk for contracting the HIV virus.

Indicate which of the following answers is true:

1- A negative HIV-1/HIV-2 serology performed by ELISA technique rules out the possibility that the patient has been infected with the HIV virus.

2- The clinical process that the patient suffers from is not consistent with acute HIV infection.

3- If the patient's ELISA test was positive, nothing further would be necessary for the diagnosis of HIV infection.

4- The ELISA technique has a high sensitivity for the diagnosis of HIV infection, but its specificity is even higher.

5- If the ELISA test to diagnose HIV in the patient was negative, we could determine by PCR technique the viral load in blood.

CORRECT ANSWER: 5

A simple question if we are clear about the diagnostic process of HIV.

At first glance, we could directly rule out answer 2 since we know that mononucleosis can be an expression of the first phase of HIV infection, especially when we have a history of a risk contact.

Answers 3 and 4 are also easily ruled out; ELISA is a very sensitive but not very specific technique and confirmation with a Western-blot test is ALWAYS necessary.

Answers 1 and 5 contradict each other if you notice, so one of the two is correct.

In this case, the false answer is 1, it is a very categorical answer ("rule out") that does not quite fit the reality; As we have said, ELISA is a very sensitive technique, so a negative result could leave us quite calm, however, we all know that there is no medical test that rules out anything with total certainty (unless its sensitivity is 100%, which is not the case) and, on the other hand, we could say that in this case we have a high clinical suspicion (the picture is suggestive, and the antecedents are there).

In addition, it is only 3 weeks since the contact, so our patient is probably in the "window period" during which serological techniques may be unprofitable.

In conclusion, the answer that best fits us would be 5, in the window period a viral load may be indicated for diagnosis (positive if there are more than 10,000 copies), although this test is not done routinely.

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QUESTION TYPE: OTOLARYNGOLOGY AND MAXILLOFACIAL SURGERY

CLINICAL CASE:

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

What treatment would be the treatment of choice?

1- Extended total parotidectomy on suspicion of tumor recurrence.

Pregabalin.

3- Intradermal botulinum toxin injection.

4- Broad-spectrum antibiotherapy.

CORRECT ANSWER: 3

You are asking about auriculotemporal syndrome or Frey's syndrome.

It is the clinical expression of a vegetative neuropathy caused by mechanical or irritative lesion of the vegetative fibers of the auriculotemporal nerve in its infratemporal pathway.

In our environment the most frequent cause is surgery of the split gland with a percentage of occurrence between 10 and 80%.

Conservative treatment with botulinum toxin offers good results.

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QUESTION TYPE: MICROBIOLOGY

CLINICAL CASE:

Pregnant woman, 27 years old, 30 weeks of gestation.

She comes to the emergency room because she noticed pain in the left lumbar region and dysuria since yesterday.

She has no febrile sensation.

She refers repeated urinary tract infections (UTI).

Urinalysis shows Hb 3+, leukocytes 3+, nitrites 2+, sediment: 15-20 leukocytes per field and 5-10 red blood cells per field.

Which of the following microorganisms is the most frequent culprit in pregnant women?

1- Escherichia coli.

2- Enterococcus faecalis.

3- Streptococcus agalactiae.

4- Proteus mirabilis.

5- Satphylococcus saprophyticus.

CORRECT ANSWER: 1

The correct answer is the first one.

The most frequent cause of urinary tract infections is Escherichia coli and in the case of pregnant women as well.

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QUESTION TYPE: ENDOCRINOLOGY

CLINICAL CASE:

A 66-year-old woman diagnosed with type 2 diabetes mellitus since three months ago.

She has a BMI of 31 kg/m2 and presents poor glycemic control despite a program of non-pharmacological measures (healthy diet, exercise).

Which of the following hypoglycemic drugs is associated with weight gain and should we avoid in this patient?:

1- Metformin (biguanide).

2- Pioglitazone (thiazolidinedione).

Canagliflozin

(sodium-glucose

cotransporter

inhibitor-

Liraglutide

receptor

agonist).

CORRECT ANSWER: 2

A somewhat more complicated question than the previous one.

Regarding weight, metformin to a lesser extent, SGLT-2 inhibitors and, above all, GLP-1 agonists have been associated with a significant decrease in weight in patients with DM-2 (answers 1,3 and 4 incorrect).

On the other hand, pioglitazone, as reflected in its data sheet, can produce dose-dependent weight gain, mainly due to fat accumulation and added, in some cases, to water retention.

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QUESTION TYPE: GYNECOLOGY AND OBSTETRICS

CLINICAL CASE:

A 32-year-old woman requests preconception counseling.

The patient reports that she underwent cervical conization for a high-grade intraepithelial lesion (H-SIL) and subsequently had three miscarriages between 20 and 22 weeks gestation.

She has no living children.

On all three occasions she came to the emergency department with a feeling of weight in the hypogastrium, where she was found to be 8 cm dilated and with prominent amniotic membranes.

She had never felt contractions before, what advice would you give her for the next pregnancy?

1- I would prescribe oral atosiban prophylaxis throughout the pregnancy.

2- I would offer lung maturation with corticosteroids from 19-20 weeks of gestation.

3- I would recommend a cervical cerclage at 14 weeks gestation.

4- I would advise her not to attempt any more pregnancies because of the high risk of recurrence.

5- I would recommend resorting to assisted reproductive techniques.

CORRECT ANSWER: 3

This is a typical case of cervical incompetence (and this patient has conization as a risk factor).

This pathology consists of dilatation of the cervix in the absence of contractions, requiring cerclage to prevent miscarriage or immature delivery.

The cerclage is ideally performed electively, programmed, and not when the patient arrives at the ER "in extemis" (which are also done, but with a lower success rate... the ideal is to do them cold).

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QUESTION TYPE: CRITICAL CARE AND EMERGENCIES

CLINICAL CASE:

A 58-year-old man, three weeks after a severe ankle sprain presents, rapidly progressive, with dyspnea at rest, dizziness and syncope.

On arrival at the hospital he has hypotension (systolic BP 80 mmHg, diastolic 40 mmHg) and poor perfusion.

He is intubated and connected to mechanical ventilation and noradrenaline is started.

Echocardiogram shows signs of pulmonary hypertension.

Angio-CT shows multiple repletion defects occupying both main pulmonary arteries.

Which of the following treatments would be associated with the most rapid hemodynamic improvement in this case?

1- Intravenous perfused sodium heparin.

Thromboendartectomy.

3- Systemic fibrinolysis with rt-PA (alteplase) 100 mg intravenous.

4- Inferior vena cava filter.

CORRECT ANSWER: 3

The patient presented pulmonary thromboembolism which, in addition to being bilateral, produced severe hemodynamic involvement, shock and required mechanical ventilation.

We are not told that he has any contraindication to fibrinolysis, so this would be the most appropriate option due to its rapid administration and action.

Sodium heparin is reserved for cases in which the patient is stable.

Thromboendarterectomy could be performed urgently in selected centers (not available in all) in patients in whom systemic fibrinolysis is contraindicated, or in centers where the experience with this technique is proven and it can be performed quickly.

The inferior vena cava filter is a treatment indicated in the acute phase in stable patients, when anticoagulation is contraindicated; or a posteriori, as prophylaxis, in this group of patients.

The indications for fibrinolysis in the last SEPAR consensus document included patients at intermediate risk (they could benefit from it) and high risk.

They classify intermediate risk as PESIs ≥ 1 or PESI III-IV.

In this subgroup, patients with right ventricular dysfunction, troponin or BNP above the cutoff and deep vein thrombosis appear to benefit most from fibrinolysis.

In the subgroup of high-risk patients (defined by hypotension or cardiogenic shock criteria), the use of systemic fibrinolysis is much clearer, as in the case presented in the question.

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QUESTION TYPE: PEDIATRICS

CLINICAL CASE:

6-month-old infant presenting to the emergency department for respiratory distress.

Examination: axillary temperature 37.2°C, respiratory rate 40 rpm, heart rate 160 bpm, blood pressure 90/45 mmHg, SatO2 95% on room air.

He shows moderate respiratory distress with intercostal and subcostal retraction.

Pulmonary auscultation: scattered expiratory rhonchi, elongated expiration and slight decrease in air entry in both lung fields.

Cardiac auscultation: no murmurs.

It is decided to keep the patient under observation in the hospital for a few hours.

What do you consider the most appropriate attitude at this time with regard to the complementary tests?

1- Request venous blood gas, leukocyte count and acute phase reactants.

2- Request chest X-ray.

3- Request arterial blood gases and acute phase reactants.

4- Do not request complementary tests.

CORRECT ANSWER: 4

The patient probably presents with bronchiolitis.

At this stage, no additional tests should be performed unless there is a clinical worsening.

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QUESTION TYPE: ANESTHESIOLOGY, CRITICAL CARE AND EMERGENCIES

CLINICAL CASE:

A patient with a history of fever and chest pain comes to the hospital with dyspnea and tachypnea.

On physical examination, the blood pressure cyphrads are low, jugular venous pressure is elevated with a deep descending sinus X, and he has a pulsus paradoxus.

What pathology should be suspected?

1- Ischemic heart disease.

2- Dilated cardiomyopathy.

3- Severe aortic valve stenosis.

4- Constrictive pericarditis.

5- Pericardial effusion with cardiac tamponade.

CORRECT ANSWER: 5

Low BP with high jugular pressure should always raise the suspicion of cardiac tamponade.

Fever and chest pain with dyspnea and tachypnea should raise suspicion of pericardial effusion with hemodynamic compromise.

Paradoxical pulse is a typical finding of cardiac tamponade.

Therefore, the correct answer is 5.

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QUESTION TYPE: GENETICS

CLINICAL CASE:

15-year-old female presenting with delayed menarche and short stature.

She does not have intellectual disability.

Which of the following genetic tests would be routinely used for the diagnosis of this patient:

1- Massive sequencing (NGS).

FISH.

3- DNA and/or RNA microarrays.

Karyotype.

CORRECT ANSWER: 4

This question may be a little more difficult, as the clinical case presented to us is very vague.

An adolescent with pubertal delay and short stature; nothing more.

With this information, she could have several genetic pathologies, but this is the MIR and we are told that the patient does not have an intellectual disability.

In the MIR, an adolescent with pubertal delay and short stature should be a Turner until proven otherwise (there were two questions in 2017).

Therefore, if that is our first diagnostic suspicion, the HABITUAL test (as the statement says) for diagnosis should be a conventional karyotype (formula: 45, X0).

A Turner can also be diagnosed with a FISH (there would only be one signal for the X instead of the two that females usually have) or with an array.

However, both array and NGS are usually reserved for patients with non-obvious clinical pictures, intellectual disability, or suspicion of a genetic syndrome that requires these specific tests (for example, an array to diagnose a 22q11 deletion syndrome or an NGS panel to diagnose a Noonan syndrome).

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QUESTION TYPE: NEPHROLOGY

CLINICAL CASE:

A 38-year-old man consults for dyspnea and hemoptysis.

Blood tests show creatinine 7 mg/dL, urea 250 mg/dL and high titer positive anti-GBM (anti-glomerular basement membrane antibodies).

Renal biopsy shows crescents in 75% of the glomeruli and immunofluorescence shows a linear Ig deposition pattern.

Which of the following is the correct answer?

1- It is an IgA nephropathy with acute renal failure.

2- Plasmapheresis would be indicated.

3- It is a membranous glomerulonephritis.

4- Mycophenolate mofetil is the initial treatment of choice.

5- Glomerular involvement is caused by the presence of circulating immunocomplexes.

CORRECT ANSWER: 2

The diagnostic suspicion for the data given (especially the anti-GBM antibodies and the presence of renopulmonary syndrome) is that of Goodpasture's syndrome.

The rest of the data (seminules in the biopsy, linear IgG deposition) supports the diagnosis.

Knowing this, the options are easily discarded: option 1 speaks to us of an IgA nephropathy (it is not the case because the deposits are of IgG); option 3 is also discarded, because it is not a primary GMN, like the membranous one, but a secondary glomerulopathy; option 4 is also false: the initial treatment is with corticosteroids and cyclophosphamide associated to plasmapheresis; and option 5 is also false, since the damage is not due to circulating immunocomplexes, but to antibodies deposited in the glomerular basement membrane.

This leaves option 2 as true: as it has been previously said, the treatment would be performed combining corticosteroids, cyclophosphamide and plasmapheresis.

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QUESTION TYPE: PEDIATRICS

CLINICAL CASE:

A woman comes to the office with her 3 year old daughter because she has detected a slight mammary development since 3 months without taking any medication or any relevant history.

Indeed, the physical examination shows a Tanner stage IV, with no growth of pubic or axillary hair.

The external genitalia are normal.

Ultrasonography reveals a small uterus and radiology reveals a bone age of 3 years.

What attitude should be adopted?

1- Follow-up every 3-4 months, as this is a temporary condition that often resolves on its own.

2- Breast biopsy.

Mammography.

4- Administration of GnRh analogues.

CORRECT ANSWER: 1

It seems that they want to present us with precocious puberty (or premature telarche) but they do not provide any analytical data and the ultrasound data are ambiguous (we should assume that by a small uterus they are referring to a prepubertal uterus, but they do not provide any data on ovarian size).

We are presented with the case of a three-year-old girl with advanced mammary development, in principle without any associated cause (in principle she does not take drugs that can increase the level of estrogen in the blood, she does not seem to use body creams or eat a lot of chicken meat).

If we follow the diagnostic scheme for a premature telarche or suspicion of precocious puberty, we request bone age and abdominal ultrasound (the EO is not advanced as in precocious puberty, and we assume that with a small uterus they mean a prepubertal uterus); according to the complementary examinations that we are given, it does not seem to be precocious puberty, except for the clinical (Tanner IV).

Strictly speaking, without analytical hormonal data, it seems that we could mark option 1, being necessary to follow the girl closely.

If we take all the above data for granted, we could rule out option 4, which would be the treatment of a central precocious puberty.

Regarding the option of mammography, breast ultrasound is used in pediatrics, and in this case it would be indicated if we were told that there is breast asymmetry (we discard option 3).

Regarding breast biopsy, it would only be indicated if there are warning signs.

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QUESTION TYPE: NEUROLOGY

CLINICAL CASE:

A 40-year-old woman consults for approximately 20 episodes per day of intense left periocular pain lasting 15 minutes, accompanied by intense tearing and rhinorrhea.

Her examination and MRI are normal.

His treatment of choice would be:

Indomethacin.

Lamotrigine.

Verapamil.

Prednisone.

5- Lithium carbonate.

CORRECT ANSWER: 1

In this question we are presented with a case to deduce a diagnosis and then indicate which would be the treatment of choice.

Both the characteristics of the case and the answers suggest that it is a trigemino-autonomic headache (intense, periocular pain with lacrimation and rhinorrhea).

The idea is to make a differential diagnosis mainly between a cluster headache (whose treatments include answers 2, 3, 4 and 5), a paroxysmal hemicrania (whose treatment of choice is the indomethacin of answer 1) and a SUNCT (unilateral neuralgiform headache with conjunctival injection and lacrimation).

Cluster headache predominates in males whose duration can vary between 15-180 minutes, between once every 2 days, up to 8 times a day.

Paroxysmal hemicrania predominates in women, with episodes of pain similar to cluster headache, but with a shorter duration (2-30 min), and a higher frequency (5-30 episodes per day).

As for SUNCT, the crises are much shorter, lasting seconds (5-240 seconds) and are usually refractory to treatment.

Therefore the diagnosis would be of a paroxysmal hemicrania and its treatment of choice is indomethacin (which also the answer is a diagnostic criterion).

Therefore correct answer 1 (Indomethacin).

All data provided are based on the Diagnostic Criteria of the International Headache Society.

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QUESTION TYPE: PEDIATRICS

CLINICAL CASE:

A 6-year-old boy comes to the clinic accompanied by the monitor of a day care center in our neighborhood because of a painful lump 3 cm in diameter on palpation in the right occipital area of the scalp.

He suffers from alopecia in this area and 3 adenomegalies of quite hard consistency in the right posterior cervical region.

What would be the most appropriate treatment?

1- Incision and drainage.

2- Topical Mupirocin.

3- Griseofulvin orally.

4- Intravenous cefazolin.

5- Topical Ketoconazole.

CORRECT ANSWER: 3

The correct answer is 3.

If I am not mistaken, you are describing a Celso's kerion for which the treatment of choice is oral griseofulvin.

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QUESTION TYPE: NEUROLOGY

CLINICAL CASE:

A 70-year-old woman with a history of anorexia, weight loss, discomfort in the muscles and proximal joints and 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

We are presented with a case of monocular amaurosis with a vascular profile, also in an older woman with a history of weight loss and what seems to be symptoms of mandibular claudication and polymyalgia rheumatica, so the first cause to think about is giant cell arteritis as the cause of NOIA, so the correct option would be 2.

Option 4 would be considered if we were told of an AINO but with non-arteritic characteristics (without all the accompanying symptomatology).

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QUESTION TYPE: NEUROLOGY AND NEUROSURGERY

CLINICAL CASE:

In a patient diagnosed with epilepsy who presents with episodes of unresponsiveness to external stimuli, irregular movements of all four limbs, closed eyes, crying and pelvic movements, lasting five to twenty seconds and unresponsive to treatment with antiepileptic drugs, which complementary study is most likely to clarify the diagnosis?

1- Video-EEG monitoring for diagnosis of pseudocrisis (psychogenic seizures).

2- Holter ECG for diagnosis of arrhythmic heart disease.

3- Routine EEG to diagnose the type of epilepsy (generalized or foc).

4- Brain MRI to detect epileptogenic lesions (cortical dysplasia, tumor, medial temporal sclerosis).

5- Determine capillary blood glucose for diagnosis of hypoglycemia.

CORRECT ANSWER: 1

Correct answer 1: The picture described is very suggestive of pseudocrisis with asynchronous limb movements, pelvic movements, crying and poor response to antiepileptic drugs.

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QUESTION TYPE: GENETICS AND IMMUNOLOGY

CLINICAL CASE:

boy.

His personal history includes 3 episodes of acute otitis media, 1 meningococcal meningitis and 2 pneumonias (one middle lobe and one left upper lobe).

She has been admitted on 3 occasions for thrombopenic purpura (on three occasions antiplatelet antibodies were negative and bone marrow showed normal megakaryocytes).

Several males of the maternal family had died in childhood due to infectious processes.

Physical examination showed lesions typical of atopic dermatitis.

The immunological study showed a slight decrease in T-lymphocyte subpopulations; elevated IgA and IgE; decreased IgM and IgG at the lower limit of normal.

What is the most likely diagnosis?

1- Wiskott-Aldrich syndrome.

2- Hyper IgE syndrome.

3- Transient hypogammaglobulinemia of childhood.

4- X-linked severe combined immunodeficiency.

5- Common variable immunodeficiency.

CORRECT ANSWER: 4

To correctly answer this question it should be emphasized that among the symptomatology that is exposed we find: - 2-year-old child.

- ENT infections.

- Pulmonary infections.

- Hospital admissions.

PTI.

- Family history of infections with deaths due to infections in males (maternal family).

- Atopic Dermatitis.

All these data, in addition to the analytical data, are describing an immunodeficiency that by the family-maternal history, seems to be X-linked, as several males have died of a similar clinical condition (the father of the patient contributed the Y chromosome, the mother the X).

Among the X-linked immunodeficiencies is Wiskott-Aldrich syndrome, an entity described with an initial triad of symptoms consisting of bleeding (typical BUT absent in the case: heavy bleeding after circumcision, bloody diarrhea), recurrent infections and eczema.

In addition to thrombocytopenia, they are at increased risk for autoimmune phenomena and lymphoid neoplasms.

The Hyper-IgE option lacks very characteristic clinical data such as bone alterations and skin lesions, which are not atopic dermatitis, since they follow a different pattern (papulopustular rash on the face and scalp).

The option of transient hypogammaglobulinemia of infancy and the common severe and variable combined immunodeficiency fails, among other features, the determination of immunoglobulins G and M, which are at the lower limit, but within normality.

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QUESTION TYPE: ANESTHESIOLOGY AND CRITICAL CARE

CLINICAL CASE:

We are consulted to assess an 83-year-old woman admitted to the Trauma service for a hip fracture 6 hours ago.

She has AP of hypertension, LBP, moderate dementia and lives in a nursing home.

Her usual treatment is thiazide, atorvastatin, donepezil, Calcium and vitamin D.

EF: Confused patient, pulse 90 bpm, respiratory rate 20 rpm, T art 170/88, jugular venous pressure normal.

The CBC and chest X-ray are normal and the ECG shows sinus rhythm without ischemic alterations.

Which of the following is the most correct therapeutic approach?

1- Delay surgery until the confusional picture has disappeared.

2- Delay surgery and perform an echocardiogram.

3- Delay surgery until good blood pressure control.

4- Start a beta-blocker and initiate surgery.

5- Perform closed osteosynthesis, avoiding in any case the implantation of prosthesis.

CORRECT ANSWER: 4

The confusional picture is determined by the dementia that the patient already suffers, so no matter how much we delay surgery, we are not going to achieve anything.

The elevation of blood pressure is due, in principle, to pain (so the first option is an analgesic) and then to the stressful situation that leads an already hypertensive patient to increase her blood pressure, so labetalol could help us.

The last answer is not correct because it depends on the type of fracture, which is not specified in the statement: a pertrochanteric fracture would require closed osteosynthesis and a subcapital fracture would require a prosthesis.

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QUESTION TYPE: ONCOLOGY

CLINICAL CASE:

A 40-year-old woman consults because she has noticed a lump in the superoexternal quadrant of the right breast for the past month.

She provides a mammography report describing a BIRADS 3 lesion.

What is the best course of action?

1- Reassure him, since an imaging test has already been done and malignancy has been ruled out.

2- This classification probably implies surgery since the probability of cancer is greater than 10%. He explains it to you and refers you preferentially to the Breast Unit.

3- This is a probably benign finding, since there is less than a 2% chance of cancer. He explains that it requires follow-up every 6-12 months until 24 months or a biopsy.

4- The findings are of low suspicion of cancer (between 2 and 10 %) but a biopsy is necessary.

CORRECT ANSWER: 3

BI-RADS Breast Imaging Reporting and Data System.

BI-RADS 3 is defined by answer 3.

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QUESTION TYPE: INFECTIOUS

CLINICAL CASE:

An immunodeficient patient who presents a pneumonia with meniscus halo sign or crescentic contour on chest X-ray/CT suggests infection by a microorganism:

1- Staphylococcus aureus.

2- Streptococcus pneumoniae.

3- Candida albicans.

4- Pseudomonas aeruginosa.

5- Aspergillus fumigatus.

CORRECT ANSWER: 5

The halo sign is characteristic of pulmonary aspergillosis, especially in an immuodepressed patient.

But it is not pathognomonic; it has also been associated with TB, some neoplasms and Wegener's granulomatosis.

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QUESTION TYPE: INFECTIOUS DISEASES AND MICROBIOLOGY

CLINICAL CASE:

A 45-year-old man consults for a productive cough, pleuritic pain in the right flank and fever of 48 h of evolution.

He has a baseline O2 saturation of 88% and rales in the right base.

Chest X-ray shows a right basal consolidation.

She has a history of HIV infection well controlled with antiretroviral drugs (CD4 lymphocytes 550 ce/uL and undetectable HIV viral load).

Which of the following empirical antimicrobial treatments do you consider most appropriate?

Cefiriaxone

g

and

azithromycin

mg

every

hours.

2- Cefiriaxone 2 g, azithrornicin 500 mg every 24 h and trimethoprim-sulfamethoxazole 5 mg/kg/8 h (based on trimethoprim doses).

3- Methyl-prednisolone 40 mg/day, cefiriaxone 2 g IV 124 h and trimethoprim-sulfamethoxazole 5 mg/kg/8 h (based on trimethoprim doses).

4- Meropenem I g/8 h and vancomycin I g/l2 h.

CORRECT ANSWER: 1

The first option seems to be the correct one, due to the low probability of P. jirovecii infection in a patient with more than 500 CD4 lymphocytes and undetectable viral load.

It is most likely to be a pneumococcal infection that we cover with Ceftriaxone and with azithromycin we cover the so-called "atypical" ones.

Meropenem is an antibiotic with too broad a spectrum, which would be an option in in-hospital pneumonia caused by P. aeruginosa, a bacterial agent that can also cause pneumonia in HIV patients, but this is not common.

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