QUESTION TYPE: ORTHOPEDIC SURGERY AND TRAUMATOLOGY

CLINICAL CASE:

A 70-year-old woman, diabetic and hypertensive, who suffers a fall at home, presenting a 9 cm wound communicating with a fracture site of the right tibia.

Radiographically, a short oblique fracture of the mid-distal third of the tibia was observed.

An emergency operation was performed by cleaning (Friederich) and placement of an endomedullary steel-plated nail.

At 11 months he presents with atrophic pseudarthrosis of the tibia with suppuration in the wound area.

What will be his best immediate therapeutic option?

1- Triple antibiotherapy (gram-positive, gram-negative and anaerobic) and cleaning of the surgical wound, removing the distal locks to promote bone consolidation.

2- Expectant attitude and antibiotic treatment with quinolones.

3- Autologous graft and growth factors (BMP 2 and 7) to stimulate the bone consolidation process, which is slowing.

4- Removal of the nail, debridement, placement of external fixator and antibiotherapy adjusted to culture results.

CORRECT ANSWER: 4

The first thing is to treat the infection and for this we must remove all the osteosynthesis material, debride and give antibiotherapy.

Fixation in this case is better external to avoid all the material around the affected area, so 4 is correct and 1 and 2 is not.

The 3 would be considered after expiration of the infectious picture.

TREATMENT - Suppressive antibiotic treatment: indicated in patients with Ciemy type C, it consists of prolonged oral antibiotic therapy for at least 6 months to "cool" the exacerbation of the clinical picture.

- Curative treatment: includes a first surgery with aggressive tumor-like debridement of all affected tissues, profuse irrigation, stabilization with external fixator if stability is compromised, and eventual filling of the cavities with antibiotic-releasing substances.

After prolonged periods of antibiotic therapy selected according to the antibiograms of the cultures, and once it is certain that the infection has been cured, special techniques for the reconstruction of the bone defect and to achieve adequate coverage of soft tissues should be considered.

We are dealing with an infection associated with an implant (intramedullary nail) and pseudoarthrosis of the tibia fracture (absence of union after 11 months).

The infection is understood by the clinical manifestations (suppuration, nonunion) and the history of diabetes and open fracture.

Management overlaps with the management of chronic osteomyelitis.

Isolated antibiotherapy (option 2) is indicated only in patients with severe comorbidity in whom surgical treatment would be more aggressive than continuing the disease.

Nail dynamization associated with broad-spectrum antibiotherapy (option 1) is not indicated either, because (a) it has not demonstrated benefit in established pseudarthrosis and (b) we have the same issue as option 1, we do not eliminate biofilm.

Option 3, discussed, would be considered only if there was no associated infection.

B-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise

B-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim B-Marker B-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim

O O B-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim

O B-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim

B-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim

B-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim B-Marker O B-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim O O B-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim


QUESTION TYPE: DERMATOLOGY

CLINICAL CASE:

A 14-year-old female patient in good general condition presents since 4 days ago a very pruritic generalized cutaneous eruption formed by erythematous-edematous plaques between 2 and 15 cm in diameter without desquamation with a tendency to acquire an annular morphology that individually disappear in less than 24 hours.

The mucous membranes are respected.

Your first diagnostic impression would be:

Urticaria.

Rubella.

Toxicoderma.

4- Staphylococcal toxic shock.

Scabies.

CORRECT ANSWER: 1

Acute urticaria: characterized by erythematous-edematous, evanescent, pruritic, evanescent lesions, lasting less than 24 hours, without desquamation.

The general condition is usually preserved.

In children the annular pattern is more frequent.

In both rubella and toxicoderma, the general condition is not preserved.

In staphylococcal shock, the general condition is affected and the lesions are blistering.

Scabies lesions are preferably interdigital, in the form of papulocoses that can follow linear trajectories.

B-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise

B-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim


QUESTION TYPE: ENDOCRINOLOGY

CLINICAL CASE:

A 34-year-old woman is admitted for polyuria and polydipsia.

In the first 24 hours of admission a diuresis of 8.2 liters is found and a blood test shows a glycemia of 96 mg/dL, natremia of 148 mEq/L and plasma osmolality of 309 mOsm/kg with urinary osmolality of 89 mOsmlkg.

What diagnostic test should be performed next?

1- Hypertonic saline infusion test for serial determination of antidiuretic hormone.

2- Dehydration test (Miller test).

3- Administration of desmopressin with serial monitoring of urine osmolality.

4- Determination of antidiuretic hormone in plasma.

CORRECT ANSWER: 3

We are faced with polyuria.

Initially we rule out diabetes mellitus (our patient has a normal blood glucose of 96mg/dl).

The analytical data suggest diabetes insipidus (high plasma osm with low urinary osm).

Now we must differentiate between central diabetes insipidus (lack of ADH) or nephrogenic diabetes insipidus (ADH does not exert its action at the renal level).

This is achieved by the vasopressin test (intravenous administration of ADH and remeasurement of urinary osmolarity).

Therefore, the correct answer is option 3.

B-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise

O B-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim

B-Claim I-Claim I-Claim I-Claim I-Claim I-Claim B-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise

B-Claim I-Claim I-Claim I-Claim I-Claim I-Claim B-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim

B-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim


QUESTION TYPE: DIGESTIVE

CLINICAL CASE:

A 52-year-old woman consulted because she had noticed during the previous week a yellowish discoloration of the conjunctivae.

She does not refer to risky sexual behaviors or epidemiological history of risk of viral hepatitis.

She does not consume alcohol or hepatotoxic drugs.

She reports a one-year history of generalized pruritus, asthenia, dry mouth and absence of lacrimation with no known cause.

Rest of the anamnesis without pathological data.

Physical examination showed scratching lesions, conjunctival jaundice and non-painful hepatomegaly.

The patient brings a blood test carried out in his company with the following pathological results: Bilirubin 3 mg/dl, FA 400 UI/ VSG 40mm 1 hour.

Indicate which would be the best recommendation to establish the etiological diagnosis of the patient's condition:

1- Anti-mitochondrial antibodies.

2- Study of Fe metabolism.

3- Study of copper metabolism.

4- Hepatic MRI.

5- Serology for B and C viruses.

CORRECT ANSWER: 1

Book picture of Primary Biliary Cirrhosis, one of those that do not occur in real life.

The diagnosis would be practically made with the AMA (1).

With 2 we would rule out hemochromatosis, with 3 we would rule out Wilson's disease.

With 4 we could rule out rare diseases such as biliary tract malformations or Caroli's disease and with 5 we could rule out viral hepatitis.

O B-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise

B-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise

B-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim B-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim

B-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim O B-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim


QUESTION TYPE: OPHTHALMOLOGY (ECTOPIC)

CLINICAL CASE:

20-year-old patient who comes to the emergency department after suffering a bicycle accident with facial trauma.

A cranial CT scan was performed showing a fracture of the middle third of the face involving the orbito-malar region.

One of the most frequent complications of this type of fracture is:

1- Temporomandibular ankylosis.

2- Dental malocclusion.

3- Naso-ethmoidal pseudoarthrosis.

Enophthalmos.

CORRECT ANSWER: 4

Fractures of the midface in the orbito-malar region may involve the floor and, to a lesser extent, the lateral wall of the orbit.

Assuming therefore that we are asked which is one of the most frequent complications of the floor of the orbit, two complications should always be highlighted that may indicate surgical treatment, even urgent: diplopia, due to dislocation of the inferior rectus muscle to the underlying maxillary sinus (and even its entrapment); and enophthalmos, which may cause other associated complications in the medium and long term, such as superior palpebral pseudo-ptosis due to loss of orbital volume (option 4 correct).

Temporomandibular ankylosis is not considered because, although relatively close to the orbital cavity, it is not part of the orbito-malar complex (option 1 discarded).

Involvement of the maxilla can lead to dental malocclusion, but usually occurs in fractures located lower than the orbital cavity (option 2 discarded).

Naso-ethmoidal fractures are included in midface fractures, but the bones of the nose are located more anteriorly to the medial orbital rim, and therefore outside the orbit (option 3 discarded).

B-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise

B-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim B-Claim I-Claim I-Claim

B-Claim I-Claim I-Claim I-Claim I-Claim B-Marker B-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim B-Claim I-Claim I-Claim

B-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim B-Claim I-Claim I-Claim

B-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim B-Claim I-Claim I-Claim


QUESTION TYPE: ORTHOPEDIC SURGERY AND TRAUMATOLOGY

CLINICAL CASE:

A 73-year-old woman with a history of obesity, type 2 diabetes mellitus, hypertension and dyslipidemia.

She consults for unbearable pain in the right knee of 5 days of evolution, without previous trauma.

Examination: globular knee, moderate varus, extension and flexion limited by pain, diffuse medial pain.

X-ray shows osteophytes and mild impingement of the medial interlining.

What would be his initial management?

1- Explanation of the diagnosis, relative rest, paracetamol 1g/8h plus metamizol 500 mg/ 8 h rescue naproxen.

2- Preferential referral to Traumatology outpatients for evaluation of total cemented prosthesis.

3- Preferential referral to Traumatology outpatient clinic for arthroscopic debridement.

4- Preferred MRI request for evaluation of meniscopathy, Baker's cyst and/or tendinitis.

CORRECT ANSWER: 1

We are being described an acute pain crisis in a patient with gonarthrosis.

In this situation, the first thing to do is to resolve the pain crisis and to propose an appropriate conservative treatment for this osteoarthritis (1 correct).

A knee arthroplasty is not considered at the outset, so 2 is false.

They are not telling us an infectious clinic to suspect an arthritis that would justify a debridement and washing so 3 is false.

In a patient with gonarthrosis there will always be meniscopathy, it is part of the degenerative changes.

Baker's cyst would only interest us in a severe pain crisis in the differential diagnosis with a deep thrombosis and it is evaluated with an echo-Doppler, in the picture of gonarthrosis it has no value to detect a Baker's cyst.

Tendinitis is diagnosed by examination, not with MRI.

Therefore, 4 is false.

O B-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim

B-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim B-Claim I-Claim

B-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim B-Marker B-Claim I-Claim I-Claim

B-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise B-Marker B-Claim I-Claim I-Claim

B-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim B-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim


QUESTION TYPE: INFECTIOUS DISEASES

CLINICAL CASE:

A 25-year-old man with no past history of interest presents to the emergency department with fever, headache, myalgia, nausea, vomiting, abdominal pain, jaundice and conjunctival injection, 2 weeks after traveling to Thailand to participate in a freshwater regatta.

What is the most likely diagnosis?

Malaria.

Schistosomiasis.

Leptospirosis.

Rabies.

CORRECT ANSWER: 3

The history of contact with fresh water in an endemic area points to leptospirosis, and in the clinical picture we also find jaundice and conjunctival injection which also points to leptospirosis and is not so characteristically related to the other three pathogens.

O B-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise

B-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim O B-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim


QUESTION TYPE: PNEUMOLOGY AND THORACIC SURGERY

CLINICAL CASE:

A 64-year-old patient, farmer, former smoker (5 years), COPD and afflicted with rheumatoid arthritis on corticosteroid therapy.

He consults the emergency department for presenting intense headache of 2 days of evolution with deviation of the oral commissure.

As background, he reports that after a month of influenza, he persists with cough, purulent and occasionally hemoptotic expectoration, febrile fever, anorexia, asthenia and weight loss.

On arrival, the patient had a fever of 38.2ºC, multiple skin abscesses on the hands, back and buttocks (some with fistulous tracts) and right central facial paralysis, apical infiltrates with small associated pleural effusion on chest X-ray and leukocytosis with neutrophilia.

Among the following suspected diagnoses I would consider MOST likely:

1- Lung neoplasm with brain metastases.

2- Disseminated tuberculosis.

Nocardiosis.

Aspergillosis.

CORRECT ANSWER: 4

Nocardia can typically affect immunosuppressed patients, especially those with impaired cell-mediated immunity such as that produced by steroids, and can present with pulmonary involvement, brain abscesses and skin abscesses.

Tuberculosis can affect lung and brain but not cutaneous abscesses.

Aspergillus also does not affect the skin.

O O B-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise

B-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise

O B-Claim I-Claim I-Claim I-Claim I-Claim

B-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim


QUESTION TYPE: PSYCHIATRY

CLINICAL CASE:

68-year-old woman, with a history of 2 major depressive episodes in her lifetime, who consults for symptoms of sadness, depressed mood, anhedonia, asthenia and anorexia compatible with a new depressive episode.

She was prescribed 10 mg of escitalopram and was evaluated 2 weeks later.

In this review the patient reports feeling very well, she wakes up early very hyperactive and with 'a lot of desire to do things', she says she has a lot of energy and is more talkative than usual.

She does not report being irritable and is able to sleep for 6 hours continuously.

Given this situation, what would you think the patient has?

1- Bipolar disorder type I.

2- Drug-induced hypomania.

3- Normal response to escitalopram.

4- Frontal dementia.

CORRECT ANSWER: 3

In this question, one might suspect the possibility of an affective shift after the introduction of the antidepressant drug, according to the patient, but if we look at the patient's ability to maintain sleep, there is a clear fact that "rules out" the hypo/manic shift.

Two weeks is not enough time for the drug to have taken full effect on mood, but an initial activation may appear, which patients sometimes do not cope with very well (something that does not seem to be the case).

In this patient it is indicated to maintain the treatment and reevaluate in no more than one month.

B-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise

B-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim B-Marker B-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim

B-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim B-Marker B-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim


QUESTION TYPE: INFECTIOUS DISEASES

CLINICAL CASE:

A 24-year-old woman consults after noticing inguinal lymphadenopathy.

The interrogation does not reveal the presence of any local discomfort or data suggestive of sexually transmitted infection.

The examination revealed two lymphadenopathies, one in each groin, 1 cm in diameter, soft, mobile, non-painful.

There are no skin lesions on the lower limbs, anus or perineum.

Which test do you consider essential?

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

2- A gynecological examination to rule out ovarian cancer.

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

4- A Paul-Bunnell test should be performed in order to rule out infectious mononucleosis.

CORRECT ANSWER: 3

In healthy adults there may be palpable inguinal nodes up to 2 centimeters that can be considered normal.

A complementary study of these normal lymph nodes is not warranted.

B-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise

O B-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim


QUESTION TYPE: INFECTIOUS

CLINICAL CASE:

A 71-year-old woman with a history of rheumatoid arthritis on sulfasalazine, prednisone and etanercept.

She goes to the emergency room for 72 hours of clinical manifestations compatible with facial herpes zoster affecting the right hemiface, auricular pavilion, respecting the forehead and conjunctival chemosis.

What would be the appropriate treatment?

1- Symptomatic treatment of pain only.

2- Topical treatment with acyclovir.

3- Outpatient treatment with acyclovir, valacyclovir or oral famciclovir.

4- Hospital admission and treatment with acyclovir or famciclovir iv.

5- Parenteral Ig and vaccination.

CORRECT ANSWER: 4

I think this question is not clearly in the Infectious Diseases syllabus, and may overlap with OFT and DERMA, but as I understand it, in an immunocompromised patient and also with data of ocular involvement, admission for intravenous treatment would be indicated due to the high risk of possible complications.

B-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise

O O O O O O O O O O O O O O O O O O O O O O O O B-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim


QUESTION TYPE: NEPHROLOGY

CLINICAL CASE:

A 58-year-old man with a 6-year history of hypertension consults for poor blood pressure control despite treatment with an angiotensin-converting enzyme inhibitor, a diuretic and a calcium antagonist.

On consultation she presented with blood pressure of 149/100 mmHg.

Laboratory tests: creatinine 1.2 mg/dl, potassium 2.2 mEq/l and compensated metabolic alkalosis; the rest of the biochemical study, blood count, coagulation and urinary sediment were normal.

Point out the correct statement:

1- The origin of hypertension in this case is excessive secretion of aldosterone caused by autonomic hyperfunction of the adrenal medulla.

2- In most cases the anatomical substrate is a bilateral hyperplasia of the adrenal cortex.

3- CT scan is part of the diagnostic study in case of biochemical confirmation.

4- Spironolactone is contraindicated in the management of this pathology.

CORRECT ANSWER: 3

We are presented with a patient with resistant arterial hypertension, assuming that he has primary hyperaldosteronism due to hypokalemic metabolic alkalosis.

When the diagnosis is biochemically confirmed, the next test to be performed is a CT scan to determine the subtype and rule out the presence of an adrenal carcinoma (option 3 correct).

Therefore, it is necessary to wait for the imaging test to confirm the etiology (option 1 incorrect).

The most frequent cause is aldosterone-producing adenoma (option 2 incorrect).

Spironolactone is the medical treatment of choice (option 4 incorrect).

B-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise

O B-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim

B-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim B-Claim I-Claim I-Claim

B-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim B-Claim I-Claim I-Claim

B-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim B-Claim I-Claim I-Claim


QUESTION TYPE: DERMATOLOGY, VENEREOLOGY AND PLASTIC SURGERY

CLINICAL CASE:

Gustavo comes to the emergency room with skin lesions and general malaise of several days of evolution.

He has psoriasiform lesions on the trunk with involvement of palms and soles.

He also presents asymmetric non-suppurative joint inflammation and bilateral ocular redness as well as erosions on the glans penis.

In the subsequent anamnesis Gustavo recognizes a risky sexual contact 20 days before.

What is his diagnosis?

1- HIV infection.

2- Secondary syphilis.

3- Reiter's syndrome.

4- Erythema multiforme.

CORRECT ANSWER: 3

He is describing a textbook Reiter's syndrome: palmo-plantar keratoderma, arthritis and ocular manifestations, together with probably a chlamydial urethritis, perhaps asymptomatic (they do not explain urethral exudate).

Of course, the patient may also have HIV infection or even secondary syphilis (in addition to Reiter's).

B-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim B-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise

B-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim


QUESTION TYPE: CRITICAL CARE

CLINICAL CASE:

35-year-old man admitted for severe chest trauma with multiple rib fractures.

After responding favorably to treatment with analgesics and oxygen, he begins to present severe hypoxemia.

Indicate the most probable cause of this deterioration:

1- Chest wall instability due to multiple fractures.

2- Aspiration respiratory infection.

3- Alteration of gas exchange due to pulmonary contusion.

4- Post-traumatic hypovolemia.

CORRECT ANSWER: 3

Pulmonary contusion is the most serious lesion and the one with the worst prognosis in thoracic trauma.

It is also the injury that causes hypoxemia the earliest.

Contrary to what we may think, an unstable thorax due to multiple rib fractures (costal volet) would cause progressive hypoventilation with atelectasis of the pulmonary parenchyma, which would progress on the one hand to hypercapnia and respiratory acidosis, and on the other, to later hypoxemia due to infection associated with atelectasis.

Respiratory infection due to aspiration would also occur later, and does not appear in all cases of severe chest trauma, only if there has been a decrease in the level of consciousness (associated TBI, uncontrolled intubation with bronchoaspiration...).

Post-traumatic hypovolemia (in this case, as there are multiple rib fractures, it could be due to hemothorax) would occur earlier and would be associated in the first place with hemodynamic instability.

B-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise

O B-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim

B-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim


QUESTION TYPE: NEPHROLOGY

CLINICAL CASE:

A 66-year-old woman with type 2 diabetes mellitus.

When assessing her renal function, she presents a G3a/A1 stage.

To which values does this stage correspond, the most frequent in patients with diabetic nephropathy?

Glomerular

filtration

rate

m²

and

albuminuria

mg/ml.

Glomerular

filtration

rate

m²

and

albuminuria

mg/ml.

Glomerular

filtration

rate

m²

and

albuminuria

mg/ml.

Glomerular

filtration

rate

m²

and

albuminuria

mg/ml.

CORRECT ANSWER: 1

Easy question.

Stage G3a corresponds to a filtration rate between 45-59 ml/min.

Stage A1 corresponds to albuminuria less than 30 mg/ml.

Therefore the correct option is 1.

B-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise

O B-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim


QUESTION TYPE: HEMATOLOGY

CLINICAL CASE:

A 29-year-old patient comes to your office with a diagnosis of severe bone marrow aplasia.

What is the treatment of choice?

1- Periodic transfusions and antibiotics.

2- Androgens and platelet transfusions.

3- Allogeneic bone marrow transplantation if HLA identical sibling.

4- Autologous bone marrow transplantation to avoid rejection.

5- Cyclosporin A and antithymocyte globulin.

CORRECT ANSWER: 3

Transfusing this patient and stuffing him with antibiotics is giving him bread for today and hunger for tomorrow.

We want something more lasting.

Androgens and platelet transfusions don't fix the problem either.

We are left with the other three options.

An autologous transplant is not reasonable, since the bone marrow of a patient with bone marrow aplasia is less than 25%, so little can be obtained.

Therefore, we are inclined towards allogeneic bone marrow transplantation if he has an HLA-identical sibling, since this is the treatment of choice according to the protocol of the Spanish Society of Hematology and Hemotherapy for patients under 40 years of age with severe bone marrow aplasia.

Correct answer, 3.

O B-Claim I-Claim I-Claim I-Claim I-Claim

B-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim


QUESTION TYPE: DERMATOLOGY AND PLASTIC SURGERY

CLINICAL CASE:

A young man comes to the emergency room with a second-degree flame burn of 10% of the body surface, affecting the right arm in an extensive and circular manner.

There is no arterial pulse in the hand measured by Doppler.

What is the treatment of choice?

1- Occlusive sulfadiazine-arginine cures and depth assessment at one week.

2- Lymphatic drainage and assess a vascular by-pass.

3- Escharotomy or emergency decompression incisions.

4- Expectant management.

5- Amputation of the extremity.

CORRECT ANSWER: 3

The question is tricky: it speaks of a burn of 10% of the body surface and the treatment of choice for second degree burns less than 20% of the BSA should be topical and monitored.

However, there is a warning sign: there is no arterial pulse and the burn is circumferential to the limb.

This is an emergency that, if allowed to evolve, will compromise the viability of the affected limb and end in amputation: an emergency escharotomy must be performed in order to relieve the pressure of the third space on the arterial vascular trunk.

B-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise

B-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise O B-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim

B-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim B-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim


QUESTION TYPE: PNEUMOLOGY AND THORACIC SURGERY

CLINICAL CASE:

While you are on call in the Emergency Department of your hospital, you have to attend a 64-year-old patient with acute respiratory failure.

His clinical condition is critical, with low oxygen saturation and hemodynamic instability.

An urgent chest X-ray was performed showing atelectasis of 2/3 of the right lung.

Orotracheal intubation and assisted ventilation were performed, with Fi02 of 1.0.

Subsequent arterial blood gas analysis showed pH 7.23, Pa02 60 mmHg and PaC02 30 mmHg.

What was the cause of the hypoxemia?

1- Short circuit.

Hypoventilation.

Low

inspired

pressure.

4- Neuromuscular disease.

CORRECT ANSWER: 1

FiO2 of 1 and hyperventilation with mechanical ventilation, demonstrated by the low PCO2, fail to sufficiently raise PO2, due to a V/Q disturbance, with probable shunt in the area of pulmonary atelectasis, probably acute, since the lung has not been able to create compensatory mechanisms to limit perfusion in the poorly ventilated areas.

O O O O O O O O O O O O O O O O B-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise

B-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise

B-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim


QUESTION TYPE: CARDIOLOGY AND CARDIOVASCULAR SURGERY

CLINICAL CASE:

If in a patient with chronic heart failure we detect prominent v waves in the jugular venous pulse and on cardiac auscultation a holosystolic murmur is auscultated in the area of the xiphoid appendage that is accentuated with deep inspiration.

What is the valvulopathy responsible for this physical examination?

1- Mitral insufficiency.

2- Pulmonary insufficiency.

3- Tricuspid insufficiency.

4- Aortic insufficiency.

5- Aortic stenosis.

CORRECT ANSWER: 3

Basic semiology.

However, emergency reasoning: systolic murmur, something that in systole had to be closed and is not, or had to open, and does not: options 1, 3 and 5.

And if we see repercussion in the jugular pulse, it must be in the right cavities.

Apart from the fact that the v wave appears during systole, while the atria are filling: if the RV flow rises to the RA, what will happen is that the v wave will be very large?

B-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise O B-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise

B-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim


QUESTION TYPE: RHEUMATOLOGY

CLINICAL CASE:

A 42-year-old female patient reports pain with inflammatory features and swelling in both wrists, 2nd and 3rd metacarpophalangeal and proximal interphalangeal joints bilaterally and left ankle of 4 months of evolution accompanied by morning stiffness of more than one hour duration.

Hand X-ray shows an erosion in the styloid process of the ulna in the right carpus.

Laboratory tests showed Hb: 10 g/dL with ESR of 45 mm in the first hour, CRP 16 mg/L, rheumatoid factor 160 IU/ML.

After 6 months of treatment with indomethacin and methotrexate, the patient persists with pain and swelling of both carpals, morning stiffness lasting 30 minutes and a CBC showing an ESR 30 mm in the first hour and a CRP 9 mg/dL.

Regarding the attitude to take, which of the following is true:

1- Suspend the prescribed treatment due to lack of response and initiate prednisone at high doses for symptom control only.

2- Maintain the therapeutic attitude taken since we have only been on it for 6 months and it would be necessary to wait a minimum of 9 months to evaluate therapeutic response.

3- If there is no medical contraindication, consider adding an anti-TNF alpha to the treatment.

4- Start a second disease-modifying drug as soon as possible, since it would not be possible to start treatment with biologic therapy alone after methotrexate.

5- Consider starting treatment with anti-CD20 therapy associated with methotrexate.

CORRECT ANSWER: 2

This is a patient with rheumatoid arthritis.

In my opinion, as in these six months she has shown a clear clinical and biological improvement (decrease in acute phase reactants), I would maintain the therapeutic approach taken and wait for a new evaluation.

However, I consider that this question could have another valid answer, 3.

It depends a little on the attitude of each rheumatologist.

If what you are looking for is a remission of the disease as soon as possible, you could choose to consider associating an anti-TNF alpha?

B-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise

O B-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim

B-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim


QUESTION TYPE: PNEUMOLOGY

CLINICAL CASE:

A 56-year-old woman with a history of well-controlled schizophrenia and no toxic habits.

Admitted for middle lobe pneumonia with a small associated metaneumonic pleural effusion and on treatment with levofloxacin 500 mg/24h .

She presented good clinical evolution except for persistent febrile fever and leukocytosis on the sixth day of treatment.

Microbiological studies are not available.

The most appropriate course of action is:

1- The evolution is normal, treatment should be maintained until completing 10 days.

2- It is considered a therapeutic failure and antibiotic treatment should be modified.

3- Perform thoracentesis to rule out empyema.

4- Add corticosteroids at a dose of 0.5 mg/Kg/day to antibiotic treatment.

5- Bronchoscopy with biopsy, aspiration and bronchoalveolar lavage.

CORRECT ANSWER: 3

As long as fever persists in an evolving pneumonia, there is a risk of empyematization, especially if a small effusion has already occurred at the beginning of the picture.

In principle, antibiotic treatment is correct and before considering changes in treatment, the possibility of empyematization should be evaluated.

B-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise O

O B-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim

B-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim


QUESTION TYPE: NEUROLOGY AND NEUROSURGERY

CLINICAL CASE:

An 18-year-old female patient with a history of absences between 6 and 9 years of age, generalized tonic-clonic seizures of recent onset and violent jumping of the upper limbs at breakfast.

The clinical manifestations worsen with nighttime weekend outings.

An EEG shows acute polyp spike discharges at 6 cycles/second.

The most likely diagnosis is:

1- Great epileptic disease.

2- Lennox-Gastaut syndrome.

3- Symptomatic epilepsy due to mesial temporal sclerosis.

4- Small atypical disease.

5- Juvenile myoclonic epilepsy.

CORRECT ANSWER: 5

A patient of adolescent age with myoclonus ("violent jumps") at breakfast time will almost always lead us to juvenile myoclonic epilepsy (answer 5 correct), a very well characterized entity.

Among other features is the previous history of seizures or absences, the worsening with nighttime departures, and the EEG with generalized polyp spike discharges at a higher frequency than that of absences.

Of the remaining answers, Lennox Gastaut develops at an early age with other symptomatology, 4 is the same as absences, and 3 usually presents with complex partial seizures and either way, the EEG is clearly distinct from a temporal focus.

B-Premise I-Premise I-Premise I-Premise O O B-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise B-Premise I-Premise I-Premise I-Premise I-Premise I-Premise O B-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise

B-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim

O O O O B-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim B-Claim I-Claim I-Claim I-Claim I-Claim I-Claim O B-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim


QUESTION TYPE: DIGESTIVE SYSTEM

CLINICAL CASE:

Indicate the clinical situation in relation to hepatitis B virus infection in a 5-year-old patient from Nigeria, with normal physical examination and the following serology for hepatitis B: HBsAg + / ANTI-HBs - / HbeAg - / ANTI-HBe + / ANTI-HBc IgM - / ANTI-HBc IgG + / DNA HBV +:

1- Acute infection.

2- Chronic infection.

3- Vaccinated patient.

4- Asymptomatic carrier.

CORRECT ANSWER: 4

Having antibodies against the core implies natural contact, and that it is IgG, which is not acute.

The absence of e antigen rules out active replication.

And the persistence of surface antigen (HBsAg) and virus DNA indicates that it is still present.

Together, these indicate an asymptomatic carrier.

Carriers of the pre-core mutant usually have recurrent symptomatic periods and increased liver inflammation.

There would be insufficient data to rule it out completely, but it is not among the answers and indicates a completely normal physical examination.

O O O O O O O B-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise

B-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim

B-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim B-Marker B-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim


QUESTION TYPE: ENDOCRINOLOGY

CLINICAL CASE:

A patient on enteral nutritional support presents 72 hours after starting enteral nutrition with a CBC showing hypophosphoremia and hypokalemia, with clinical signs of heart failure.

The patient is diagnosed with refeeding syndrome.

Indicate which of the following is NOT considered a risk factor for a patient presenting with this condition:

1- Previous caloric malnutrition.

2- Anorexia nervosa.

3- Non-morbid obesity.

Elderly.

5- Prolonged vomiting and diarrhea.

CORRECT ANSWER: 3

Refeeding syndrome occurs in patients with previous malnutrition exposed to either oral, enteral or parenteral nutritional therapy.

All responses are causes of malnutrition except 3.

B-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise

B-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim


QUESTION TYPE: HEMATOLOGY

CLINICAL CASE:

A 32-year-old woman with cerebral palsy from childbirth comes to the emergency department for a few days of dark urine associated with an episode of high fever and dry cough.

On

admission,

the

CBC

showed

S,

L,

M),

hemoglobin

g/dL;

MCV

fl,

In the biochemistry LDH 2408; bilirubin 6.8 mg/dl, (unconjugated bilirubin 6.1 mg/dl), normal GOT and GPT.

The morphological study of blood showed macrocytic anisocytosis with frequent spherocytic forms and polychromatophilia without blasts.

The irregular antibody study is positive for panagglutinin, making crossmatching difficult.

What would be your suspicion and the most appropriate treatment?

1- Medullary aplasia and immunotherapy with thymoglobulin and cyclosporine.

2- Hereditary spherocytosis and splenectomy.

3- Autoimmune hemolytic anemia associated with respiratory infection and corticosteroids.

4- Pernicious anemia and periodic injections of vitamin B12.

5- Acute leukemia and chemotherapy.

CORRECT ANSWER: 3

A long statement full of rather confusing data.

We can attack that question in two ways: by looking at the key data and going all the way to the diagnosis we are considering or by discarding one by one.

The choluria, LDH, presence of panagglutinin and the peripheral blood smear "smells" like hemolytic anemia.

Answer 1 cannot be because a marrow aplasia does not explain the choluria, the elevation of LDH, nor in the study of irregular antibodies is positive in the form of panagglutinin; an aplasia is a marrow failure characterized by a total or partial disappearance of hemopoietic progenitors.

In addition, pancytopenia is not observed, which is what would incline us more towards this pathology.

Answer 2 is not possible either, since a spherocytosis does not justify the presence of panagglutinin.

Answer 3 is the one I consider correct: an autoimmune hemolytic anemia would justify the data given: elevated LDH and bilirubinemia due to red cell destruction, polychromatophilia, spherocytosis and anisocytosis because the marrow is working hard to try to compensate for the anemia, which is regenerative.

The study of irregular antibodies and the presence of panagglutinin also supports this response, since the binding of an antibody to the hematocyte promotes its lysis and destruction.

The girl presents cough and fever, consistent with a respiratory infection.

And the initial treatment is corticosteroids.

This is confirmed by Sans Sabrafens in his book "Clinical Hematology" [1].

Answer 4 gives rise to considerable doubt; it is not possible because a pernicious anemia does not justify the presence of panagglutinin although it would justify the elevation of LDH and bilirubin; moreover, it is an intramedullary, arregenerative hemolysis, there is no reticulocytosis or release into the blood of immature forms in an attempt to compensate and fix the situation.

Answer 5 is not true because no blasts are seen in the blood nor does it explain the presence of panagglutinin.

B-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise

B-Premise I-Premise I-Premise I-Premise I-Premise B-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise B-Premise I-Premise I-Premise I-Premise

O B-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim

O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O

B-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim B-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim

B-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim


QUESTION TYPE: ANESTHESIOLOGY, CRITICAL CARE AND EMERGENCIES

CLINICAL CASE:

A patient admitted for acute pancreatitis starts with tachypnea, tachycardia, sweating and progressive cyanosis.

is

mm

Hg

CXR shows bilateral alveolar pulmonary infiltrates.

Pulmonary capillary wedge pressure is normal.

Oxygen therapy does not improve the situation.

What is the most probable diagnosis:

1- Nosocomial pneumonia.

2- Cardiac failure.

3- Carcinomatous lymphangitis.

4- Pulmonary thromboembolism.

5- Respiratory distress.

CORRECT ANSWER: 5

Direct response question.

The question tells the story of a patient with acute pancreatitis who is developing acute respiratory failure.

The statement lists the criteria for ARDS (acute respiratory distress syndrome): PaO2/fiO2 < 200 + bilateral pulmonary infiltrates + PCP<18.

So the diagnosis is respiratory distress and therefore the correct answer is option 5.

B-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise

B-Claim I-Claim I-Claim I-Claim I-Claim I-Claim O B-Marker B-Claim I-Claim I-Claim I-Claim I-Claim I-Claim


QUESTION TYPE: PEDIATRICS

CLINICAL CASE:

A 13-month-old infant comes to the emergency department with fever up to 39ºC of 48h of evolution with no other associated symptoms.

Examination by organs and devices with no significant findings, highlighting good general condition.

You were going to discharge him home but the Pediatrics attending on duty asks for a systematic urine and urine culture by catheterization.

The urine shows leukocyturia ++, hematuria + and nitrites ++ and the urine Gram-negative bacilli are observed.

In the blood analysis there is no leukocytosis and the C-reactive protein is 50 mg/l.

The attending now tells you that the child does not need to be admitted and to prescribe an oral antibiotic.

State the least appropriate empirical antibiotic treatment in this case:

Amoxicillin.

2- Amoxicillin-clavulanic acid.

Cefuroxime-axetil.

Cotrimoxazole.

Cefixime.

CORRECT ANSWER: 1

Other drugs are a good choice in urinary tract infections caused by large negative bacilli (most likely: E. coli).

The presence of leukocytes + nitrites in the urine is very suggestive of UTI.

And if the urine Gram detects G- bacteria, it is probably a UTI due to E Coli.

Many E Coli are resistant to amoxicillin.

B-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise

B-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim


QUESTION TYPE: UROLOGY

CLINICAL CASE:

12-month-old boy, who in the health examinations practiced since birth presents right testicle in inguinal canal that is not possible to descend to the scrotum.

Mark the CORRECT answer:

1- The most likely diagnosis is retractile testis.

2- Wait until two years of age for spontaneous decrease of the synovial fluid.

3- Human chorionic gonadotropin is the treatment of first choice.

4- The indication for orchidopexy should not be deferred.

CORRECT ANSWER: 4

This is cryptorchidism.

It has to be treated before the age of 2 years, and hormonal treatment is currently in disuse.

The treatment of first choice is orchidopexy.

B-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise

O B-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim

B-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim O B-Claim I-Claim I-Claim I-Claim I-Claim I-Claim


QUESTION TYPE: OPHTHALMOLOGY

CLINICAL CASE:

An 84-year-old woman presents with loss of vision in the left eye of 4 days of evolution accompanied by metamorphopsia.

The macula shows abundant hard exudates, two small deep hemorrhages and a localized neurosensory retinal detachment.

In the contralateral eye there are abundant soft drusen.

Which of the following diagnoses do you think is the most likely?

1- Acute posterior vitreous detachment.

2- Exudative age-related macular degeneration (AMD).

3- Central retinal artery obstruction.

4- Non-arteritic anterior ischemic optic neuropathy.

CORRECT ANSWER: 2

None of the other three options give that clinical picture (DPV is usually asymptomatic, CRVO produces abrupt and total or near total loss of vision with the typical "cherry red spot" in the fundus, and both an arteritic and non-arteritic NOIA would produce papillary edema usually with peripapillary but not macular hemorrhages, and none of these 3 options have any association with drusen in the contralateral eye).

AMD in its exudative form presents with both this clinical presentation (loss of vision and metamorphopsia) and the characteristic fundus described in the question, in addition to the fact that drusen are usually observed in the contralateral eye.

B-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise

B-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim B-Claim I-Claim I-Claim I-Claim B-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim O B-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim O B-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim

B-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim


QUESTION TYPE: OTORHINOLARYNGOLOGY AND MAXILLOFACIAL SURGERY

CLINICAL CASE:

Given a direct trauma to the right side of the face after which the patient presents unilateral palpebral hematoma, diplopia in the vertical gaze and difficulty in opening the mouth, which of the following statements is true?

1- We are with great probability in front of a Lefort I type fracture of the middle third of the face.

2- This is probably a unilateral orbitomalar fracture.

The diagnosis would ideally be verified by CT (computed axial tomography).

3- It is a fracture of the base of the skull at the level of the carotid foramen.

4- The probable diagnosis is fracture with dislocation of the mandibular condyle.

5- A mandibular fracture is probably associated with a Lefort I type midface fracture.

CORRECT ANSWER: 2

Diplopia on vertical gaze is highly suggestive that the bony walls of the orbit are affected.

Lefort type I fracture does not affect the orbital contents.

Knowing this information, the only correct answer is 2.

If we were in doubt about whether or not Lefort's type I fracture affects the orbit, just look at the answers.

Whoever posted the question wanted to make sure that the only valid answer was number 2; that is why they added the tag line "but just in case we check it with a CT scan".

B-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise B-Premise I-Premise I-Premise I-Premise I-Premise O B-Premise I-Premise I-Premise I-Premise I-Premise O O O O O O O

O B-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim

O O O O O O O O O O O O O O O O O O O O O

B-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim


QUESTION TYPE: OPHTHALMOLOGY

CLINICAL CASE:

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

Which of the following diagnoses can cause this symptomatology?

1- Post-surgical endophthalmitis.

2- Retinal detachment.

3- Age-related macular degeneration, wet form.

4- Posterior vitreous detachment.

CORRECT ANSWER: 2

This question could be controversial.

Option 1 is strongly discarded because endophthalmitis typically presents with a lot of pain.

Option 3 of wet form of age-related macular degeneration is also ruled out, because it usually occurs in older patients, although what a patient with myopia magna may present with is myopic macular degeneration (with a similar clinical picture to AMD, but this is a different pathology).

A posterior vitreous detachment (PVD) is usually not very symptomatic, producing myodesopsias but no loss of vision or pain; however, some PVDs are of the hemorrhagic type, by traction of the vessels, producing a vitreous hemorrhage that would cause loss of vision.

In any case, due to the history of myopia magna and previous intraocular surgery, the first diagnosis to rule out would be retinal detachment, since these are two risk factors for this pathology.

Technically, both option 2 and 4 (an acute hemorrhagic DPV) could cause these symptoms, but the most correct option is option 2 (and I am sure it is the one the examiner wants answered).

B-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise

B-Claim I-Claim I-Claim I-Claim I-Claim B-Marker B-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim

B-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim B-Marker B-Claim I-Claim I-Claim I-Claim I-Claim I-Claim B-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim

B-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim B-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim

B-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim

B-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim O O O O O O O O O O O O


QUESTION TYPE: PATHOLOGICAL ANATOMY

CLINICAL CASE:

A 59-year-old woman presenting with chronic watery diarrhea of 4 months' evolution.

In the endoscopy, the mucosa did not show relevant aspects.

In particular, no ulcers or friable areas were observed.

A biopsy of the transverse colon was performed.

Histopathology revealed a thickened area below the superficial lining epithelium, which was more evident by Masson's trichrome technique and involved epithelial atrophy and denudation.

There was also a clear increase in intraepithelial lymphocyte density.

The diagnosis of the intestinal lesion is?

1- Chronic ulcerative colitis.

2- Pseudomembranous colitis.

3- Collagenous colitis.

4- Fibrosing Crohn's disease.

CORRECT ANSWER: 3

In this case, the presence of thickening of the subepithelial collagen layer, more evident with Masson's trichrome (special stain that allows differentiation of the collagen fibers), is pathognomonic of collagenous colitis.

Atrophy together with epithelial denudation are characteristic of this disease, which does not usually cause macroscopic alterations of the mucosa.

An increased density of intraepithelial lymphocytes and the absence of mention of architectural alterations of the crypts (characteristic of ulcerative colitis and Crohn's disease) support this diagnosis.

B-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim

B-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise


QUESTION TYPE: EPIDEMIOLOGY AND PREVENTIVE MEDICINE

CLINICAL CASE:

Luis is a 25-year-old young man who underwent splenectomy after a bicycle accident 1 year ago.

He has a dog that bit him 24 hours ago and has caused a small wound on his right hand.

He went to his health center (located 3 hours from the nearest hospital) for fever of 39ºC, pain in the wound and general malaise.

On examination, BP 100/60 mm Hg, HR 110 beats per minute, slight swelling in the wound without pus.

Which of the following actions is most indicated at this time?

1- Send to hospital for rabies and tetanus vaccination and keep under observation.

2- Clean the wound and administer intramuscular nonspecific ganunaglobulin.

3- Give 400 mg of oral moxifloxacin and send to the hospital.

4- Give clindamycin 600 mg oral every 8 hours and observation.

CORRECT ANSWER: 3

Since a splenectomized patient is considered a "special" patient, he should receive antibiotic treatment as soon as possible, even if the wound does not appear infected.

It is necessary to make sure that the dog is yours (you should ask if the animal is correctly vaccinated) and if the patient is correctly vaccinated (5 doses of tetanus, it would not require tetanus); make a notification of Animal Aggression, for observation of this and take measures in case this is necessary.

B-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise

O B-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim

B-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim B-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim


QUESTION TYPE: GYNECOLOGY AND OBSTETRICS

CLINICAL CASE:

A 67-year-old patient with a history of menopause at 55 years of age, 3 pregnancies with 3 euthyroid deliveries, type 2 diabetes of 6 years of evolution, treatment with nifedipone for hypertension.

She consulted for intermittent scanty metrorrhagia of 2 months of evolution.

The gynecological examination showed external genitalia without lesions, an atrophic cervix, a normal uterus and appendages on palpation and a normal cytological study of the cervix.

The transvaginal ultrasound study shows a 7 mm hyperechogenic endometrium.

Which of the following tests is the most appropriate and most sensitive to establish a diagnosis?

1- Conization of the cervix.

2- Endometrial cytology.

3- Hysteroscopy and endometrial biopsy.

4- Magnetic resonance imaging of the pelvis.

5- Examination under anesthesia of the genital tract and biopsy of the cervix and endometrium.

CORRECT ANSWER: 3

The correct answer is 3.

The study that gives us more information about endometrial pathology is hysteroscopy, which allows us to perform a directed endometrial biopsy.

Endometrial cytology is performed blindly and has a large number of false negatives.

MRI will help us to stage endometrial cancer.

B-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise

O B-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim

B-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim


QUESTION TYPE: NEUROLOGY

CLINICAL CASE:

A 52-year-old man comes to the Emergency Department with headache and fever (37.8°C) of 2 days' evolution.

In the last few hours, he also had difficulty in nomination and comprehension.

The examination did not show nuchal rigidity, the most striking finding being the presence of a mixed aphasia.

The cranial CT shows a faint hypodensity in the left temporal lobe without mass effect and without contrast uptake.

Which of the following statements is correct?

1- Bacterial meningitis is the first diagnostic impression and treatment with 3rd generation cephalosporin should be initiated as soon as possible.

2- Most likely this patient's CSF shows a lymphocyte-predominant pleocytosis with normal glycorrhachia.

3- We would suspect limbic encephalitis.

4- This is an early stage brain abscess.

CORRECT ANSWER: 2

The picture described is typical of a viral meningoencephalitis, more specifically VHZ, with significant tropism by the temporal lobe, causing febrile fever and in many cases aphasia, so the correct option would be 2, since the cerebrospinal fluid normally shows a moderate lymphocytic pleocytosis, with normal glycorrhachia.

The rest are not correct because: The first one because it is not a bacterial meningitis that would present with more fever, the third one because limbic encephalitis usually presents afebrile with behavioral changes and the last one because the image they describe is not an abscess, well delimited.

B-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise

O B-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim

B-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim B-Marker B-Claim I-Claim I-Claim I-Claim I-Claim I-Claim B-Marker B-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim

B-Claim I-Claim I-Claim I-Claim I-Claim B-Marker B-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim B-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim O B-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim


QUESTION TYPE: HEMATOLOGY

CLINICAL CASE:

A 25-year-old woman who wishes to become pregnant and wants to know what treatment she should take during the eventual pregnancy, as she is a heterozygous factor V Leiden carrier.

She has never had any thrombotic phenomena.

The determination of this factor was performed as a family study after an episode of pulmonary embolism in a sibling.

What treatment should be advised?

1- Since pregnancy is a prothrombotic state, there would be a high risk of venous thromboembolism, so pregnancy should be discouraged.

2- Treatment with low molecular weight heparin at prophylactic doses should be carried out in the immediate puerperium, with optional follow-up during pregnancy.

3- Factor V Leiden in heterozygosis is a low-risk thrombophilia and there is no need for any treatment in pregnancy and puerperium.

4- Low-dose aspirin should be advised during pregnancy and puerperium.

5- Treatment with antivitamin K drugs (acenocoumarol) during pregnancy.

CORRECT ANSWER: 3

Reading the answers, the first thing that is clear to us is that acenocoumarol should NOT be given to a pregnant woman because of the risk of teratogenicity.

Anyone who does so during residency should be punished with 100 slaps on the back.

We discard answer 5.

Second: if treatment is given, it should be during the entire pregnancy, prothrombotic status is not only during the puerperium, so answer 2 discarded.

Advise a woman not to become pregnant when there are treatments that ensure a very low risk of thrombosis and/or fetal involvement?

Answer 1 discarded.

We are left with the possibility of not giving any treatment because it is low risk or administering low-dose aspirin.

It is true that factor V Leiden in heterozygosis is classified as low risk, who has not presented a previous thrombotic episode nor is there a combination with another thrombophilia; if we look at the CHEST guide, VIII edition and review what was said at the last congress of the Spanish Society of Gynecology and Obstetrics, we see that aspirin is used in case of phospholipid syndrome and that in the case of this woman, without previous thrombosis, without previous abortions (at least two are needed) and also being heterozygous, treatment is not necessary.

Correct answer, 3.

B-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise

O B-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim

O B-Treatment I-Treatment I-Treatment I-Treatment I-Treatment I-Treatment I-Treatment I-Treatment

B-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim B-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim


QUESTION TYPE: ORTHOPEDIC SURGERY AND TRAUMATOLOGY

CLINICAL CASE:

The most likely diagnosis of a 74-year-old patient who since two months ago begins with lumbar pain radiating to lower limbs, neurogenic claudication and limitation to extension the trunk is:

disc

herniation.

2- Lumbar vertebral fracture.

vertebral

instability.

4- Lumbar canal stenosis.

CORRECT ANSWER: 4

We are being shown a picture of lumbar canal stenosis (Answer 4 correct).

The patient shows the characteristic clinical picture: lumbar pain that is relieved by flexing the trunk forward, radicular pain with lower limb involvement and neurogenic claudication.

Low back pain in a patient over 60 years of age accompanied by leg weakness when walking, which has to be interrupted at a certain distance, called neurogenic claudication, is the typical picture of stenosis.

The patient is relieved by flexing the spine forward because it widens the lumbar canal and worsens with extension...

O O O O O B-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise O

B-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim B-Claim I-Claim I-Claim

B-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise O B-Claim I-Claim I-Claim I-Claim I-Claim

B-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim


QUESTION TYPE: NEUROLOGY AND NEUROSURGERY

CLINICAL CASE:

A 51-year-old woman comes to the emergency department with a sudden decrease in visual acuity, severe headache, nausea and vomiting.

Hypotensive and afebrile.

She presented right ophthalmoparesis due to involvement of the third cranial nerve.

A cranial CT scan shows a mass in the hyperdense selar region with erosion of the anterior clinoid processes.

What is the best approach to follow?

1- Suspect chemical meningitis derived from a ruptured epidermoid tumor and start immediate treatment with corticosteroids.

2- It would indicate the performance of a cerebral angiography to rule out an aneurysm, since it is most likely that we are facing a case of subarachnoid hemorrhage and the mass that is evident in the CT is a thrombosed parasellar aneurysm.

3- Admission to ICU and treatment of the shock suffered by the patient and once stabilized perform brain MRI for scheduled surgery.

4- Urgent biochemistry and hemogram, initiation of high-dose corticosteroid therapy and urgent transsphenoidal surgery.

5- Lumbar puncture to rule out bacterial meningitis after starting empirical antibiotherapy. Once the patient was stabilized, study of the selar mass.

CORRECT ANSWER: 5

Pituitary apoplexy is a syndrome characterized by the sudden onset of headache accompanied by ocular motility disturbances and a variable degree of pituitary insufficiency.

The cause is usually a rapidly growing pituitary mass secondary to a vascular event (infarction or hemorrhage).

General symptoms may range from vomiting or nausea to meningeal irritation.

Compression on the chiasm and optic nerve can cause various campimetric deficits (usually greater bitemporal hemianopsia in the superior quadrants) and decreased visual acuity, even blindness.

If the mass grows lateral to the sella turcica it can compress the oculomotor nerves, with the common motor ocular nerve being the most frequently affected, because of its more medial course in the cavernous sinus.

The test of choice for the diagnosis of pituitary apoplexy is MRI, as CT may not distinguish the region clearly enough to distinguish degenerative or cystic changes from previous bleedings.

The finding of erosion of the anterior clinoid processes in the skull CT may support a chronic lesion, which as a result of an acute vascular phenomenon has caused the symptoms.

The management of these patients involves strict control of water and electrolyte disturbances and correction of hormonal deficits.

In unstable situations as in the case described, with significant visual disturbances, surgical intervention is usually of choice, with transsphenoidal decompression.

B-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise

O B-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim


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- You should not become pregnant until periodic controls and have spent one year with negative BHCG levels.

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

4- It is necessary to perform periodic controls since 40% of the cases will develop a gestational trophoblastic neoplasia.

CORRECT ANSWER: 2

The answer is 2.

According to the SEGO (Spanish Society of Gynecology and Obstetrics) in its 2005 protocol "Gestational trophoblastic disease", the risk of malignization, i.e. of developing a gestational trophoblastic neoplasm, ranges from 5 to 20% depending on whether it is a partial mole or a complete mole, respectively.

According to this protocol: "Patients will be monitored weekly with hcg dosage 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.

Based on the available data, a follow-up of three to six months is recommended for partial mole and 12 months for complete mole." Therefore, subsequent controls are strictly necessary.The risk of a new molar gestation, although increased compared to the normal population, is not 50%.

B-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise

O B-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim

B-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim

B-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim B-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim


QUESTION TYPE: ENDOCRINOLOGY

CLINICAL CASE:

A 52-year-old woman from a village on the Costa Brava notices an otherwise asymptomatic lump in the anterior region when applying cream to her neck; she goes to her general practitioner who confirms the presence of a firm, smooth mass, 2 cm in maximum diameter, which rises with swallowing.

No palpable lymphadenopathy.

What tests would you order at the outset?

1- A determination of thyroglobulin in blood.

2- A cervical CT scan.

3- A determination of circulating antithyroid antibodies (antithyroglubulin and antiperoxidase).

4- A fine needle puncture.

5- A determination of free T3.

CORRECT ANSWER: 4

It refers to a thyroid nodule, and the indicated test is a FNA (fine needle puncture).

I have read the answer Emilio has written on the challenge; the question is in the endocrine block and it seems he is trying to make it clear that it is a nodule.

Ultrasound facilitates FNA but is not mandatory, a 2 cm thyroid nodule can be punctured without echo.

It is important to have an analysis of thyroid function prior to the puncture; but since he is talking about an asymptomatic patient, it seems clear that she is not hyperthyroid.

I do not think it is contested and I think it is a question that most will have answered well.

B-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise

O B-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim

O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O

B-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim


QUESTION TYPE: ONCOLOGY (ECTOPIC)

CLINICAL CASE:

A 67-year-old woman diagnosed with an infiltrating ductal carcinoma of the breast with no family history of neoplasia.

What additional studies should be performed on the tumor because of its clinical and therapeutic implications:

1- Complete phenotypic study by flow cytometry.

2- Study of hormone receptors and HER2.

3- Study of hormone receptors, ecadherin and study of first degree relatives.

4- BRCA l-2 study and study of first-degree relatives.

CORRECT ANSWER: 2

Currently the molecular classification of breast cancer is based on the study of hormone receptors, HER2 and the tumor cell proliferation index (Ki67).

We have four fundamental types: Luminal (A: HR+, HER2- and low Ki67 and B: HR+, HER2+/ - and high Ki67), HER2 + (HR -, HER2 + and high Ki67) and Basal Like or triple negative (HR -, HER2 - and high Ki67).

B-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise

O B-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim

B-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim


QUESTION TYPE: PREVENTIVE MEDICINE

CLINICAL CASE:

An 86-year-old woman in whom nonvalvular atrial fibrillation has been detected.

She has a CHADS2 score of 3 points.

In the literature, similar patients on warfarin therapy have a stroke risk of 2.2% versus 5.2% in patients without warfarin.

What would be the number needed to treat (NNT) to prevent embolic stroke with anticoagulation therapy?

CORRECT ANSWER: 3

The NNT (number needed to treat), means how many patients we would need to treat with an intervention to obtain a benefit; in this question how many patients do we need to treat with warfarin to prevent a stroke.

To calculate this we use the following formula: NNT= 1/RRA (RRA: absolute risk reduction).

RRA= Io - Ie (Io: incidence in those not exposed to warfarin; Ie: incidence in those exposed to warfarin).

RRA:

NNT:

B-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise

O O O B-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim

B-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim B-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim


QUESTION TYPE: NEUROLOGY

CLINICAL CASE:

A 75-year-old woman brought for consultation by her family because they have been finding her depressed and with memory lapses for months.

They are concerned that she may have Alzheimer's disease.

The patient refers that she does not think anything is wrong with her and that she is as usual.

In what order do the following symptoms generally occur in the progression of Alzheimer's disease:

1- Mood changes, behavioral symptoms, cognitive deficits.

2- Behavioral symptoms, motor symptoms, decline of functional independence.

3- Mood changes, cognitive deficit, decline of functional independence.

4- Behavioral symptoms, mood changes, motor symptoms.

CORRECT ANSWER: 3

I answer this question thinking more about what they want to ask than what they are really asking.

There is heterogeneity in the development of Alzheimer's disease symptoms.

There are behavioral variants, but in the MIR they usually want you to think of other types of dementias in the face of behavioral symptoms.

In fact, the appearance of these symptoms in early stages should alert us and open the range of diagnostic possibilities.

Therefore, we discard 2 and 4.

Between 1 and 3, I choose 3 for the same reason and because of the emphasis on the decline of functional independence that occurs in these patients.

B-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise

O B-Claim I-Claim I-Claim I-Claim I-Claim I-Claim

B-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim


QUESTION TYPE: NEPHROLOGY

CLINICAL CASE:

An 80-year-old patient with a history of hypertension and on treatment with enalapril and spironolactone comes to the hospital with asthenia and severe muscle weakness.

Blood pressure is 110/70 mmHg.

In the ECG, there are sharp and elevated T waves, ventricular extrasystoles and short QT.

What is the most likely diagnosis?

Hypercalcemia.

Hyperkalemia.

Hypomagnesemia.

Hypocalcemia.

Hypernatremia.

CORRECT ANSWER: 2

The correct answer is: 2.

Hyperkalemia.

Spironolactone, as a potassium-sparing diuretic, inhibits the action of aldosterone at the renal level, being responsible for a decrease in potassium excretion.

Hyperkalemia produces repolarization disturbances that result in the installation of a large, symmetrical, narrow-based T, visible in the precordial leads.

The QT space is shortened.

These anomalies appear with a kalemia of around 5.5 to 6 mmol/l.

Above 6.5 mmol/L, electrocardiographic changes are constant, and are dominated by conduction disturbances (making ventricular extrasystoles possible).

B-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise

B-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise B-Premise I-Premise O B-Premise I-Premise

B-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim


QUESTION TYPE: GYNECOLOGY AND OBSTETRICS

CLINICAL CASE:

Woman 40 weeks gestation in labor with 6 cm dilation.

She presents a decelerative fetal pattern in cardiotocographic recordings, so it is decided to perform a fetal blood smear to assess fetal well-being. Result 7.22.

The correct conduct is:

1- Severe acidosis. Urgent cesarean section.

2- Pre-pathological value repeat microtome 15-20 minutes.

3- Moderate acidosis. Repeat microtome in 1-2 hours.

4- Value in normal limits, leave natural evolution of labor.

5- Repeat at the time of possible error in obtaining the shot.

CORRECT ANSWER: 2

- pH less than 7.20 Pathological value.

Indication for fetal extraction by the quickest route, in this case a cesarean section.

- pH between 7.20-7.25 Prepathological value.

Repeat microtome in 15-20 min.

- pH greater than 7.25.

Value within the limits of normality. Observation.

B-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise B-Marker B-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise

O B-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim

B-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim


QUESTION TYPE: HEMATOLOGY

CLINICAL CASE:

A 19-year-old girl with no medical history of interest, except for a self-limited case of influenza 3 weeks earlier, who comes to the emergency department with petechiae and ecchymosis of spontaneous onset.

On physical examination the patient was in good general condition, afebrile, normotensive and oriented in time and space.

There were petechiae scattered throughout the lower extremities and abdomen and small ecchymoses in decubitus areas.

No lymphadenopathy or splenomegaly were palpated.

Laboratory tests showed the following findings: Hb 12.6 g/dL, leukocytes 5,500/mm3, platelets 7000/mm3.

The peripheral blood smear showed normal erythrocyte morphology, normal differential leukocyte count and the planetary count was concordant with the autoanalyzer figure without platelet aggregates.

Biochemistry and proteinogram, beta 2 microglobulin and LDH are normal.

Which of the following do you think is the most appropriate initial treatment?

1- Platelet transfusion.

2- Weekly Rituximab.

Cyclophosphamide

in

pulses

every

days.

4- Daily plasmapheresis.

Prednisone

at

mg/day

for

weeks.

CORRECT ANSWER: 1

Idiopathic thrombocytopenic purpura, but with very low platelets, so replenishment is necessary.

The proposed steroid dose is too low.

B-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise

O O O O O O B-Premise I-Premise I-Premise B-Premise I-Premise B-Premise I-Premise

B-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim


QUESTION TYPE: ANATOMY

CLINICAL CASE:

A 42-year-old woman with breast cancer has metastases at the level of the intervertebral foramina between the 4th and 5th cervical vertebrae and between the 4th and 5th thoracic vertebrae.

Which spinal nerves will be injured?

1- Fourth cervical and fourth thoracic nerves.

2- Fifth cervical and fifth thoracic nerves.

3- Fourth cervical and fifth thoracic nerves.

4- Fifth cervical and fourth thoracic nerve.

5- Third cervical and fourth thoracic nerve.

CORRECT ANSWER: 4

The trick to this question is that there are 8 cervical roots for 7 vertebrae, therefore the C1 root exits ABOVE the atlas, and so on up to C8 which exits BETWEEN C7 and T1.

The thoracic roots come out respectively below the vertebra with their same numbering (nerve T1 under T1, T2 under T2, etc.).

Therefore, between C4 and C5 the 5th cervical nerve exits, and between T4 and T5 the 4th thoracic nerve exits.

The correct answer is 4.

B-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise

B-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim


QUESTION TYPE: PATHOLOGICAL ANATOMY

CLINICAL CASE:

A 59-year-old woman presents with chronic watery diarrhea of 4 months' duration.

On endoscopy, the mucosa showed no relevant features.

In particular, no ulcers or friable areas were observed.

A biopsy of the transverse colon was performed.

Histopathology revealed a thickened area below the superficial lining epithelium, which was more evident by Masson's trichrome technique and involved epithelial atrophy and denudation.

There was also a clear increase in intraepithelial lymphocyte density.

The diagnosis of the intestinal lesion is?

1- Chronic ulcerative colitis.

2- Pseudomembranous colitis.

3- Collagenous colitis.

4- Fibrosing Crohn's disease.

CORRECT ANSWER: 3

Everything we are told in this case is typical of COLLAGENOUS COLITIS.

In principle, the clinical and endoscopic findings may leave us a little as at the beginning, but histology is little more than the definition of this pathology.

The specific criterion for the diagnosis of collagenous colitis is the additional presence of an irregular band of collagen just below the surface epithelium of the colonic mucosa in continuity with the basement membrane, visible with trichrome staining (stains type I collagen fibers), which traps superficial capillaries producing lesions in the surface epithelium.

In addition, it is accompanied by a chronic inflammatory infiltrate in the lamina propria, composed mainly of lymphocytes, plasma cells and eosinophils.

B-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise I-Premise

O O O O O O O O O O O O O O O O O O O O O O O O O O O

B-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim I-Claim