QUESTION TYPE: ONCOLOGY

CLINICAL CASE:

Faced with a patient presenting with an ulcerovegetating lesion on the mandibular gingiva at the level of the molar region of 5 months of evolution, the appearance of hypoesthesia in the mentonian region requires ruling out:

1- Paraneoplastic neuropathy.

2- Diagnosis of sarcoidosis with "on the scale" facial paralysis.

3- Herpes virus infection in immunosuppressed patient.

4- Diagnosis of carcinoma with infiltration of the mandibular canal.

CORRECT ANSWER: 4

Mentonian paresthesias (Roger's sign) are associated with bone metastases (it is not paraneoplastic but direct infiltration).

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

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QUESTION TYPE: DERMATOLOGY, VENEREOLOGY AND PLASTIC SURGERY

CLINICAL CASE:

A 17-year-old boy with Crohn's disease with colonic involvement of 2 years of evolution, in maintenance treatment with azathioprine, consults for the appearance for 5 days of subcutaneous purplish red, hot, painful, bilateral, pretibial localization nodules, associated with an increase in the number of stools and abdominal pain.

The most appropriate approach in this case is:

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

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

3- Suspect the existence of a malignant intestinal tumor lesion as a trigger of the cutaneous process.

4- Suspect bilateral lower extremity ischemia of drug origin.

5- Adjustment of bowel disease treatment.

CORRECT ANSWER: 5

2 and 4 are discarded alone.

They are explaining erythema nodosum, so we would recommend relative rest (but antidepressants do not make any sense, so we also rule out (1)).

Although erythema nodosum can be secondary to a malignant process, it is more frequent that it is due to Crohn's disease itself (moreover, in a 17-year-old boy it would be extremely rare), so if the picture is also accompanied by a flare-up of inflammatory bowel disease, the last option (5) seems the most correct.

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QUESTION TYPE: PSYCHIATRY

CLINICAL CASE:

An 80-year-old man is brought to the ER by the police to find him at night, on the street, several blocks from his home, somewhat lost.

He tells the ER doctor "I feel fine, I was walking and I got lost".

The examination, by systems, is anodyne.

When asked about his medication, he does not remember.

His history includes glipizide, atenolol and acenocoumarol.

She has been to the ER 3 times in the last three months for "dizziness", low back pain and an INR of 5.

She reports independence in basic and instrumental activities of daily living.

There is no evidence of family or close friends.

Several references from the social work in the area indicate that she refuses medical or nursing aids or visits.

In the physical examination, only temperature of 37.7, BMI of 16, BP of 160/90, HR of 90 and SO2 of 99% stand out.

He has global loss of muscle mass.

He is dressed in his robe and smells of urine.

He refuses to answer Minimental's questions.

Laboratory tests include 13,000 leukocytes, blood glucose 300, glycosylated hemoglobin 11%, INR 0.9, urine over 50 leukocytes/field, nitrites+ and urine culture > 100,000 Gram negative bacilli.

He is admitted to the hospital, receives antibiotics, insulin and restarts acenocoumarol with good evolution.

He is stable and wants to go home.

The ward nurse says he is unable to self-administer insulin.

Which of the following is the next step in determining the patient's safety at home?

1- Refer to Primary Care and social work in the area to determine safety at home.

2- Formal evaluation of the capacity to make decisions concerning their health.

3- Evaluation to rule out dementia.

4- Evaluation to rule out depression.

CORRECT ANSWER: 2

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

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

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

There are several tests or semi-structured interviews to assess the capacity of patients, and all physicians should be familiar with these instruments.

It is important that it is the attending physician who performs this assessment, because he/she is the one who previously informs the patient (informed consent) of the therapeutic plan and is the one who is best able to assess whether the patient has understood everything: what the medical problem is, what treatment is proposed, the alternatives if any, whether to accept or reject any of them and why, the consequences of making these decisions (also those of not wanting treatment), even assessing psychopathology susceptible to an ICP to Psychiatry.

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QUESTION TYPE: NEUROLOGY

CLINICAL CASE:

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

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

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

Which test should be ordered?

1- Lumbar puncture to analyze amyloid and tau protein in CSF.

Genetic

study

for

presenilin

Genetic

study

for

4- Genetic study for progranulin.

CORRECT ANSWER: 3

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

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

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

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

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QUESTION TYPE: TRAUMATOLOGY

CLINICAL CASE:

A 41-year-old male consults for gonalgia of several days' evolution.

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

Which of the following lesions is more probable?

1- Meniscal injury.

2- Injury due to rupture of the anterior cruciate ligament.

3- Injury due to rupture of the posterior cruciate ligament.

4- Injury due to degenerative arthropathy.

CORRECT ANSWER: 1

Answer 1 correct: The Thessaly test is a meniscal exploration maneuver.

The statement focuses exclusively on this part of the examination and also explains that it is indeed positive, which leads to the suspicion of a meniscal lesion.

"The Thessaly test is a dynamic reproduction of load transmission in the knee joint and is performed at 5° and 20° of flexion.

The examiner supports the patient by holding his or her outstretched hands while the patient stands flatfooted on the floor.

The patient then rotates his or her knee and body, internally and externally, three times, keeping the knee in slight flexion (5°).

Then the same procedure is carried out with the knee flexed at 20°.

Patients with suspected meniscal tears experience medial or lateral joint-line discomfort and may have a sense of locking or catching.

The theory behind the test is that, with this maneuver, the knee with a meniscal tear is subjected to excessive loading conditions and almost certainly will have the same symptoms that the patient reported.

The test is always performed first on the normal knee so that the patient may be trained, especially with regard to how to keep the knee in 5° and then in 20° of flexion and how to recognize, by comparison, a possible positive result in the symptomatic knee." Answer 2 incorrect: At no time do they describe any exploration maneuvers of the anterior cruciate ligament, nor do they mention any trauma that may have injured it.

Answer 3 incorrect: At no time do they describe any exploration maneuvers of the posterior cruciate ligament, nor do they mention any trauma that could have injured it.

Wrong answer 4: Although it could occur, it is not to be expected in a 41 year old person with an acutely established clinical condition.

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QUESTION TYPE: OPHTHALMOLOGY

CLINICAL CASE:

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

He has an ocular pressure of 34 mmHg in his right eye and 31 mmHg in his left eye.

Which of the following pharmacological groups is the most indicated as first choice as hypotensive treatment?

1- Carbonic anhydrase inhibitors.

Beta-blockers.

agonists.

4- Prostaglandin derivatives.

CORRECT ANSWER: 4

We are asked about the first choice treatment for glaucoma.

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

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

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

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

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

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

Answer 4 correct.

And then a couple of nuances of the statement.

It would be more correct to talk about intraocular pressure and not "ocular pressure".

And the wording could be improved so as not to repeat the word "as" in the last sentence.

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QUESTION TYPE: CRITICAL CARE

CLINICAL CASE:

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

He has been hit by a car while riding a bicycle.

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

What do these data tell us:

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

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

3- He has lost more than 40% of blood volume and will require surgical treatment.

4- Has lost more than 50% of volemia and requires volume and blood replacement.

CORRECT ANSWER: 1

Technically the patient is in a grade II hemorrhage according to the ATLS classification, in principle this means a loss of between 750 and 1500mL of blood and the indicated action is resuscitation with crystalloids; however, in the guidelines for the care of severe polytraumatized patients, the early use of blood products is increasingly recommended, especially in borderline cases like this one, and in young patients, who may not be able to translate the severity of the blood loss until it becomes much more significant.

I would therefore hesitate between options 1 and 2.

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