There is no doubt that the doctor-patient relationship today transcends the physical environment of the consultation room

Answer that it is important to maintain certain professional boundaries between patients and physicians and that, unfortunately, if you make the request you will not be able to accept it, so it is better not to do so

But we must not forget that we must maintain the same ethical and professional codes as in the real environment

The clinical practice of medicine by means of consultations exclusively by letter, telephone, radio, press or internet, is contrary to the deontological norms

The correct action implies inescapably the personal and direct contact between the doctor and the patient


Diffuse axonal injury produces an early and sustained deterioration of the level of consciousness (as mentioned in the case statement) without a lesion on CT scan to justify the picture

After a traffic accident a 38-year-old patient is admitted to the ICU in coma

After several days the patient does not improve neurologically and a CT scan shows hemorrhagic punctate lesions in the corpus callosum and cortico-subcortical junction

Sometimes, punctate hemorrhages at the level of the corpus callosum, corticosubcortical junction and dorsolateral portion of the brainstem are evidenced in this imaging test


When a severe flare does not respond to iv corticosteroid therapy at full doses (1mg/kg body weight), it is necessary to switch to cyclosporine or infliximab

Etanercept is not approved in Europe for inflammatory bowel disease (for the time being)

Treatment with etanercept (an anti-TNFa antibody) should be considered


Something aortic
this is going to be aortic stenosis...
Support

They give me a gradient, which without knowing the values seems somewhat high (55 mmHg!) and the area, which looks tiny to the naked eye

With the guidelines in hand, that's right: this is a severe stenosis both in terms of area (<1 cm²) and mean gradient (>40 mmHg), with a preserved ejection fraction, and symptomatic

Diuretics and more frequent check-ups by a specialist

In case of increasing dyspnea on exertion, percutaneous dilatation of the aortic valve with a balloon catheter should be performed

Only if the surgical risk is unaffordable, and in that case we would do 5, TAVI implantation

But this is a 52-year-old man, who we assume has good bodywork because he walks to have dyspnea

so to the operating room
Implantation of a percutaneous valve
Attack

The correct thing to do is 3, without a doubt: replace with a prosthesis, preferably mechanical unless the patient has a contraindication for anticoagulation

Replacement of the aortic valve with a prosthesis/bioprosthesis

But it's rare, complex and only done in pediatrics

A homograft? That's the Ross technique, I take the pulmonary and put it where the aortic

Replacement of the aortic valve with a homograft


Patient on her 30th post-transplant day of hematopoietic precursor transplantation, in severe neutropenia who presents with cough with hemoptotic expectoration

This picture is usually seen in infection by Aspergillus spp

We can rule out infection by Staphylococcus aureus because of previous treatment

She starts with cough and hemoptotic expectoration in addition to fever and moderate exertional dyspnea that does not improve despite five days of treatment with amoxicillin-clavulanic acid (875/125 mg/8 h) and levofloxacin (500 mg/12 h)


But if there are data of poor prognosis and the possibility of metastases - as in this case

it is best to complete the thyroidectomy and perform a radioactive iodine scan to rule out metastases or treat them if they are present

This is a follicular carcinoma and requires completion of thyroidectomy

Follicular pattern is an indication for prophylactic cervical lymph node emptying

The report allows us to rule out with total certainty a papillary carcinoma in the remaining thyroid

Measurement of plasma calcitonin will allow us to distinguish between papillary and follicular carcinoma

The statement of 1 is correct in cases of follicular carcinoma without capsular invasion a total thyroidectomy can be performed

As there is no capsular invasion, no further surgery is necessary


Clinical case of SLE with renal involvement, in which positive double-stranded anti-DNA increases the risk of nephritis

Anti-two-stranded or native anti-DNA correlates with the risk of nephritis

As for the rest, anti-Sm are specific to SLE

The anti-Sm antibodies are not specific for this pathology

ANA are detected in more than 90% of cases

ANA (antinuclear antibodies) are detected in 50% of cases

anti-centromere are typical of scleroderma

Anti-centromere antibodies are detected in 90% of cases


Clearly the answer is 4, with a very characteristic clinic of temporary seizures


Answer 4: simply by the way of expressing it, it should already have been ruled out

The report allows to rule out papillary carcinoma with total certainty in the remaining thyroid

Answer 5: you already know that calcitonin is used in medullary carcinoma and not in differentiated carcinoma

Measurement of plasma calcitonin will allow us to differentiate between papillary and follicular carcinoma

Answer 2: prophylactic emptying is indicated in the medullary

The follicular pattern is an indication for prophylactic cervical lymph node emptying

The only ones in which complete thyroidectomy is not recommended are microcarcinomas measuring less than 1 cm

As there is no capsular invasion it is not convenient to perform further surgery

It is a follicular carcinoma and requires completion of thyroidectomy


The correct answer would be 2, HORMONE AND HER2 RECEPTOR STUDY

positive HER2 receptors imply greater aggressiveness of the tumor

Complete phenotypic study by flow cytometry

while answers 3 and 4 should be ruled out

Study of hormone receptors, e-cadherin and study of first degree relatives

Study of BRCA 1-2 and study of first-degree relatives

treatment with trastuzumab and positive hormone receptors would imply the use of hormone therapy

being the first woman in the family with breast carcinoma

the study of the patient's relatives would not be obligatory


we have a blow to the right eye area, with a hematoma on the eyelid

Therefore, something other than the blow has caused hemorrhages in both retinas

The problem is that retinal hemorrhages appear not only in that eye (which in itself is rare, because an external blow to the eye in a child rarely causes bleeding in the retina), but also in the other eye

Characteristic of this syndrome are bilateral retinal hemorrhages, cerebral edema and subdural hematoma

Here we already have the two keys; we have to suspect what is not mentioned in the answers, but which is what the child has: the shaken baby syndrome (shaken baby syndrome)

The cause of shaken baby syndrome is almost always abuse

It is a highly suggestive history of child abuse

It is the normal evolution of a non-perforating intraocular trauma

The most likely diagnosis is Berlin edema

nothing indicates perforating trauma, and it does not explain the hemorrhages in the other eye

And the berlin edema is an edema of the macula and appears as a whitish lesion, which is not described in the statement

However, if we read answer 4 carefully, it does not tell us that if there is child maltreatment Purstcher can occur

Purstcher's retinopathy can also appear in the context of the child of the shaken child, and therefore occur in the case of child abuse

It states that the picture described above (intraretinal hemorrhages, without other findings) is characteristic of Purstcher's angiopathy. It is not

In Purstcher's there are hemorrhages, but also cottony exudates and edema

If there are only hemorrhages, it's not Purstcher's

It is the characteristic picture of Purstcher's traumatic retinal angiopathy


On examination, the nails show the presence of nail pitting and distal yellowish areas in an oil stain

although the description of nail lesions highly suggestive of psoriasis makes this diagnosis the most likely

Any of the 4 options can be the cause of erythroderma


a patient with certain history who has: - Schistocytes in smear

Laboratory tests: creatinine 2.3 mg/dl, Hb 10.3 g/dl and platelets 20000 mm3, with normal coagulation

Bicytopenia: here the causes can be very, very varied

which indicates a massive rupture of red blood cells

Subsequently, he began with progressive deterioration of the level of consciousness and increase of Cr, LDH and unconjugated bilirubin

Answer 1: it cannot be because a hemorrhagic transformation does not give such a brutal elevation of LDH and Cr, in addition to not explaining schistocytosis

New cranial CT in the presence of suspected hemorrhagic transformation of ischemic stroke

Answer 2: urgent plasmapheresis... in case of thrombotic thrombocytopenic purpura, yes

I like this answer because it justifies bicytopenia, since microangiopathic hemolytic anemia is produced by rupture of red blood cells when they are fragmented by ultralong von Willebrand factor multimers in case of deficiency of the ADAMST13 enzyme, resulting in brutal platelet aggregates and the flow cytometer does not count 400 platelets, but a molondron of platelets that form a mass, hence the thrombocytopenia

It also explains the negative direct Coombs, elevated LDH and Cr

Direct Coombs' test was negative
Initiate urgent plasmapheresis
Support

Answer 3: a situation as critical as that patient's indicates that something big is going on and I would not sit and wait for glucocorticoids to take effect...and I do not know right now what pathology gives that symptomatology and has that treatment as standard

Beginning of treatment with glucocorticoids at a dose of 1 mg/kg/day

Answer 4: looking for a trigger for DIC...it would make sense if it were not for the fact that in DIC it is VERY characteristic the consumption of coagulation factors, which is not present in this case

Answer 5: a myeloma does not give schistocytosis nor does it have this symptomatology, they would have to give other data that would support this pathology, such as bone pain and hypercalcemia

Suspected multiple myeloma: bone marrow aspirate


As long as the serological levels of anti-HBs are above 10 IU/l it is not necessary to revaccinate

A 40-year-old orthopedic surgeon who in a routine serology was found to have anti-HBs levels of 30 IU/l

Restart vaccination schedule (0-1-6 months)

Restart vaccination schedule (0-1-2-12 months)

Give anti-hepatitis B immunoglobulin and restart vaccination schedule (0-1-2-12 months)


In this case we are dealing with an elderly patient with chronic treatment with NSAIDs that produces arterial hypertension secondary to renal hypoperfusion

The most reasonable option would be to withdraw ibuprofen and replace it with an analgesic from a group other than NSAIDs (paracetamol, opiates), subsequently monitoring the evolution of blood pressure


In the absence of further information (more complete anamnesis on the current disease, risk factors, personal and family history, extra-articular symptoms or signs, etc.) it can be said that also 1 and 2 (and very exceptionally 5) could debut with a similar clinical and biological picture

With the data provided and taking into account that this is a young male

the most likely option would be bacterial infectious arthritis (that caused by mycobacteria usually have a chronic course)

Acute monoarthritis associated with fever, leukocytosis with neutrophilia and increased acute phase reactants does not always have a septic origin

A 19-year-old man consults for a 24-hour history of pain, swelling and functional impotence of the right knee accompanied by a fever of 38°C

Physical examination reveals inflammatory signs and joint effusion in the right knee

Laboratory tests showed leukocytosis with neutrophilia and elevated C-reactive protein

And above all, because of its implications, the first one to always rule out


All these data are suggestive of visceral Leishmaniasis

an OM biopsy should be performed to look for amastigotes and confirm the diagnosis

We are told about an HIV patient with irregular follow-up of antiretroviral treatment, presenting fever, hepatosplenomegaly, pancytopenia and polyclonal hypergammaglobulinemia

I would perform a bone marrow biopsy, since the most probable diagnosis is visceral leishmaniasis


We first eliminate the most striking "acute" personality disorder.

There are no "acute" characteristics in our personality.

Depressive disorder? There is a time criterion that is not met

it may be sad, but sad is not depression

agoraphobia? if it was something like that we would have been told the context post-traumatic stress reaction?

according to ICD 10: "The stressor may be a devastating traumatic experience involving a serious threat to the safety or physical integrity of the patient or loved one(s) (e.g., natural catastrophes, accidents, battles, muggings, rapes) or an abrupt and threatening change in the individual's rank or social environment (e.g., loss of several loved ones, house fire, etc.). )" or more briefly: "exceptionally threatening or catastrophic nature"

Breaking up with a partner I understand is hard, but not exceptional

The correct term would be post-traumatic stress disorder or acute stress reaction

Diagnoses 1 to 4 would be like calling diabetic the one who has hyperglycemia after eating three muffins


The correct answer is 1
Inject an intravenous anticholinergic
Support

The anticholinergic can be administered intravenously and also intramuscularly if I am not mistaken

The occurrence of dystonia as a side effect is common in children and is one of the main reasons why pediatricians do not usually prescribe some antiemetics in children


It is a definitive promyelocytic leukemia with t(15;17)

as it is well known by all of you the treatment is with arsenic trioxide + ATRA

Start treatment with arsenic trioxide, ATRA and supportive therapy

Option 1 leaves the treatment incomplete

If asymptomatic, transretinoic acid (ATRA) will be started and day hospital controls will be recommended

there is only ATRA and it must be treated as long as the patient's condition allows it, whether or not there are symptoms

Option 3 3 years ago would have been the correct option but nowadays neither chemotherapy nor heparin is used

It is a myeloblastic leukemia type M3, so chemotherapy and heparin will be started to control disseminated intravascular coagulation

that fever is due to the leukemia itself and the priority is to start specific treatment for leukemia

Antibiotic treatment should be started. When the fever disappears, leukemia treatment should be started


at the mir and at the ED door, any elderly person with AF and abdominal pain is emboligenic mesenteric ischemia until proven otherwise

probably an elevated lactic...
ischemia
Support

we could also have been told of intestinal pneumatosis

CT: The finding of portal gas is also highly indicative of mesenteric ischemia

Perforated ulcus: We would have been told of a history of NSAID use, or a history of pain that improves with ingestion, of pneumoperitoneum on chest X-ray

Perforation of gastric or duodenal ulcus

Biliary ileus: There would be a history of biliary colic or pain in the right hypochondrium

they would also speak of aerobilia in the imaging test and dilatation of the small loops with image (or not) of biliary lithiasis in the terminal ileum

Neo sigmoidoscopy: In the myocardial imaging they would speak of weight loss, change of stool habit, pneumoperitoneum in Rx or CT and peritonitic abdominal exploration and may even be able to palpate the mass

Obstructive neoplasm of the sigma with perforation


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

apart from cutaneous structures many other tissues can be seen, particularly in a thickening or spur that eminences into the cavity, in which there are often teeth, cartilage and bone

A 20-year-old woman with a 15-cm solid-cystic ovarian tumor detected by ultrasound after presenting with nonspecific abdominal symptoms

The tissues that make up the tumor are well differentiated (mature or adult-type)

Mature cystic teratoma is a common benign tumor of the ovary in adult women


Several months have passed, she has not improved and refers intense pain after physical activity that subsides with rest in the hours following exercise

Exercise-induced compartment syndrome is an exercise-induced condition of the leg

Diagnosis is made by measuring compartment pressures at rest, during exercise and after exercise

Determination of posterior compartment pressure immediately after activity


Broca's aphasia has preserved comprehension and absence of fluent speech

Wernicke's aphasia is characterized by fluent speech (even in excess) with paraphasias and problems with comprehension, nomination and repetition


In a case like this we must rule out endometrial neoplasia

an endometrial biopsy would be indicated, either by Cornier cannula if possible, or by hysteroscopy

We are being presented with a case of postmenopausal metrorrhagia

A cervical biopsy is not of interest in this case

hormonal assessment is not going to be useful in the diagnosis of endometrial neoplasia

A 69-year-old woman comes to your office reporting genital bleeding of several months' evolution

Finally, prescribing cyclic progesterone is not indicated in a postmenopausal woman


An abdominal ultrasound shows stenosis of both renal arteries

If the renal arteries are stenosed, blood has difficulty reaching the kidneys

If we administer an ACEI, we will provoke the relaxation of this arteriole and the fall of the glomerular filtration rate

And if neither kidney filters, because both have arterial stenosis, we have a problem


Given that this is a displaced subcapital hip fracture, the surgical treatment we should consider is hip joint replacement, given that the injury described presents a high probability of necrosis of the femoral head

The options would be total or partial arthroplasty

Correct Answer 1
Hip hemiarthroplasty
Support

in elderly patients, partial arthroplasty is preferred because it is a shorter and less aggressive surgery than total hip arthroplasty

We would consider this technique in basicervical fractures and trochanteric mass lesions, not in subcapital fractures

Answer 2 incorrect
Trochanteric nail fixation
Attack

We would consider this technique in nondisplaced subcapital fractures in young patients

We would only consider non-surgical treatment in a patient with a very poor baseline general condition: bedridden patients with low life expectancy

Incorrect answer 4
Conservative: bed-chair life
Attack


Laboratory tests: hemoglobin 10.5 g/dL, platelets 98,000/mm3, AST 356 IU/L (0-31), ALT 234 IU/L (0-31), LDH 878 IU/L (125-243)

34-week primigravida with blood pressure of 165/95 and headache of two days of evolution

The laboratory is called because of the presence of schistocytes in the peripheral blood smear

With these weeks of gestation and with the fetus recently matured (she has already been given two doses of corticosteroids), the attitude is immediate termination

She received the second dose of corticosteroids for fetal maturation 24 hours ago

On obstetric ultrasound the estimated fetal weight is in the 1st percentile for gestational age and the umbilical artery Doppler shows absence of end-diastolic flow


It is a pancreatic adenocarcinoma with metastasis, so the treatment should be palliative, so we remove options 1 and 5

Neoadjuvant chemo/radiotherapy, conditioning the option of radical surgery on initial response

Cephalic duodenopancreatectomy, with percutaneous ablation by radiofrequency or alcoholization of the hepatic lesion

the ideal would be to perform a permanent biliary diversion and chemotherapy, option 4 being the one I consider most correct

Metallic biliary prosthesis by endoscopic retrograde cholangiopancreatography with the option of palliative chemotherapy

In principle she is a patient in moderately good general condition


Since the most frequent cause of vaginal bleeding in postmenopausal women is urogenital atrophy, the existence of an endometrial pathology cannot be ruled out

Transvaginal ultrasound and measurement of endometrial thickness. Depending on this, an endometrial biopsy should be taken or not

According to the SEGO: "Abnormal genital bleeding is the main sign of suspicion that should lead us to rule out an endometrial neoplastic pathology, particularly in postmenopausal patients, or those with associated risk factors (...)

Given the sign of suspicion, the performance of a transvaginal ultrasound, or in its absence transrectal, allows us to: rule out organic pathology (fibroids, polyps); measurement of endometrial thickness in a longitudinal cut

It is recommended to use a cut-off point of 3mm for endometrial biopsy in the symptomatic patient


On examination the infant is in good general condition, is well nourished and hydrated and his breathing is eupneic; his weight is 4,730g and has decreased by 70g with respect to the previous week

The baby is not dehydrated and is in good general condition

The abdomen is soft and depressible, without masses or megaliths, and the fontanel is normotensive

Except for the presence of watery rhinorrhea, the rest of the examination by organs and devices is normal

Try to avoid dehydration by replenishing what is being lost, avoiding drastic changes in feeding habits as much as possible

It is advisable to replace losses after each bowel movement with oral rehydration solution and continue with the patient's usual diet

There is also no evidence of lactose intolerance (perianal irritation, frothy and acid stools, etc.) that would advise lactose-free milk

The use of lactose-free formula should be recommended


the patient was operated 20 years ago for a Bilroth II

If it were gastric adenocarcinoma, they would have spoken of constitutional syndrome, extradigestive manifestations (sister Maria Jose node, Krukenberg tumor, Virchow node)

a patient operated, 20 years ago, of gastric ulcer by antrectomy and gastrojejunostomy (Billroth II) who comes to your office referring postpradial abdominal pain, abdominal distension, diarrhea and analytical data of malabsorption of fats and vitamin B12

Rapid gastric emptying syndrome (dumping)

it does not speak of vegetative symptoms (palpitations, facial flushing, etc...)

moreover it is not associated with diarrhea or malabsorption

Biliary reflux gastropathy is an endoscopic diagnosis

there is diarrhea, and if associated with bacterial overgrowth, there is malabsorption of vitamin B12

What has occurred is a stenosis of the afferent loop, so that biliary and pancreatic secretions do not mix with the bolus, they accumulate, produce pain that is relieved by vomiting, fat absorption is not possible (lack of pancreatic lipase)

Afferent loop syndrome with bacterial overgrowth


a young patient from an area with a high rate of TB, a lymphocytic exudate pointing to TB, lymphoma or tumor

Suspicion is very high for tuberculous pleural effusion

Measurement of pleural fluid adenosine deaminase

A 32-year-old man from Cameroon consults for fever cough and left hemithorax pain of 1 month of evolution

Tumor unlikely due to age, negative cytology

A thoracentesis shows a yellowish fluid with the following features: red blood cells 2000/µL, leukocytes 2500/µL with 90% lymphocytes, protein 4.9 g/dL, lactate dehydrogenase 550 VIL, glucose 67 mg/dL, and absence of malignant cells on cytologic study

High adenosine deaminase in LP would point with great certainty to a pleural TB


In this patient the conventional treatment has not worked

it is possible to escalate to specific allergen immunotherapy

Currently the only effective treatment capable of modifying the natural course of respiratory allergy is specific allergen immunotherapy for a minimum of 3 consecutive years

Specific immunotherapy by sublingual or subcutaneous route for a minimum period of 3 years

16-year-old woman diagnosed with allergic rhinoconjunctivitis due to sensitization to grass pollens since she was 10 years old, who does not fully control the symptomatology during the pollination season with oral antihistamines and nasal topical corticosteroids

Omalizumab is a biological treatment that would only be indicated in cases of severe moderate bronchial asthma secondary to respiratory allergy

Omalizumab subcutaneously every 4 weeks for up to 1 year

Omalizumab subcutaneously every 4 weeks for a minimum period of 6 months


C cells, elevated calcitonin, inherited MEN-2nd

Typical medullary thyroid RET
Multifocal medullary carcinoma
Support


The treatment of choice is phlebotomy
Initiate treatment with phlebotomies
Support

This is a patient who already has a diagnosis of hemochromatosis, due to a positive genetic study and data of iron overload (IST >45% and elevated ferritin)

Biopsy would be useful if the diagnosis is uncertain or if we would like to assess liver involvement that is not suspected with this analysis


therefore the correct answer is compulsion

In this question they ask for the name of the symptom, not the disease

This behavior, which she always does when she comes home from work, consists of turning the doorknob of the bathroom on the upper floor of the house before doing anything else, even before greeting her family

According to the DSM-5, a compulsion is a repetitive behavior (e.g., washing hands, tidying up, checking things) or mental act (e.g., praying, counting, repeating words silently) that the subject performs in response to an obsession or in accordance with rules that must be rigidly enforced

Sometimes he has tried to resist doing this but has only succeeded in distressing himself and delaying the behavior for a few minutes

The goal of the behaviors or mental acts is to prevent or decrease anxiety or discomfort, or to avoid some feared event or situation


The infant presents with acute GEA without signs of alarm or severe dehydration

The first step would be to try oral tolerance with oral rehydration saline and continue with normal feeding if well tolerated

Rehydration with low osmolality oral rehydration solution (sodium 60-75 mEq/L) and continue with his usual diet

In this case, intravenous rehydration could be started...

Answer 1 may give rise to doubts, due to the fact that the statement says that the patient "does not tolerate the oral route"

but it would not be advisable to leave the patient on an absolute diet for 8 hours, nor a subsequent astringent diet

Intravenous rehydration, absolute diet 8 hours and start feeding with astringent diet

The rest of the treatments do not provide any benefit

Rehydration with low osmolality oral rehydration solution (sodium 60-75 mEq/L) maintain usual feeding and oral amoxicillin 10 days

Rehydration with low osmolality oral rehydration solution (sodium 60-75 mEq/L) and start feeding with lactose-free formulas

Rehydration with low osmolality oral rehydration solution (sodium 60-75 mEq/L) maintain usual feeding and loperamide 7 days


This case describes an Alzheimer's disease with insidious onset of short-term memory problems

The patient was accompanied by his wife, who reported a slow progressive evolution of memory impairment (e.g., sometimes confused with insulin doses)

Clinically it can be distinguished from other options by the absence of behavioral problems (typical of frontotemporal dementia) and hallucinations (early in Lewy body disease)

There are no hallucinations or behavioral disorder.

Vascular dementia is diagnosed by criteria that include deficits in memory and two other cognitive areas with consequent functional impairment, but cerebral vascular disease based on history, examination and/or neuroimaging tests, which are not indicated in the case

Creutzfeldt-Jacob disease is mostly rapidly progressive and usually presents with other clinical, abnormal neurological examination and MRI alterations.


The clinical case presented is a woman of childbearing age (27 years) presenting dyspareunia + dysmenorrhea + infertility

which should lead us to think of endometriosis

but the diagnosis of certainty is given by direct observation (with or without associated biopsy) of ectopic endometrial tissue implants, either by laparotomy or laparoscopy

The clinical history and ultrasound give a diagnosis of suspicion


The most likely cause is a digitalis intoxication, which would produce this slowing of conduction

Probably secondary to renal failure due to ibuprofen toxicity (but this is a bit of a stretch)


Because of the risk of aspiration pneumonitis

The fact that there is intestinal aeration points to the existence of a fistula of the lower esophageal segment with the trachea or with a bronchus

Chest and abdominal X-ray showed an atresic esophageal pouch, with normal gastrointestinal pneumatization

In this case, pulmonary complications are frequent due to the passage of gastric contents into the airway


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

We are dealing with a case of severe lithium intoxication (lithemia > 3.5 mEq/L is life threatening)

therefore, the therapeutic option of choice is to start hemodialysis urgently

Remember that activated charcoal is NOT indicated in lithium intoxication


For all these reasons, the correct answer is 5

Pericardial effusion with cardiac tamponade

In cardiac tamponade, the deep sinus X is characteristic

In cardiac tamponade, inspiration, which causes an increase in blood flow to the right chambers, increasing their volume, secondarily causes a displacement of the interventricular septum to the left, so that the left heart lodges and expels less blood during systole and the pulse, therefore, decreases

In a normal heart this exaggerated displacement, caused by the pressure exerted by the tamponade on the RV free wall, does not occur

Sinus X represents the systolic collapse of the venous pulse, i.e., the pressure drop due to atrial relaxation (also partly due to a downward displacement of the RV base during systole)

Paradoxical pulse is a drop in blood pressure > 10 mmHg during inspiration

it represents an exaggeration of the physiological phenomenon consisting of inspiratory lowering of BP (normal up to 10 mmHg)


A patient's arterial blood gas result is: pH: 7.40, PaCO2 60 mmHg; bicarbonate 36 mM/L

since a normal pH may suggest that there is no disturbance of acid-base balance

instead it is masking a double disturbance in opposite directions as in this case

The patient presents with respiratory acidosis

Respiratory acidosis and metabolic alkalosis

bicarbonate 36 mmol/l
compensatory metabolic alkalosis
Support

normal to 28
compensatory metabolic alkalosis
Support

This is the typical blood gas of the patient with COPD and compensated chronic respiratory failure


Patients with this disorder voluntarily or accidentally ingest excessive amounts of thyroid hormone, resulting in hyperthyroidism in the absence of goiter

Physical examination showed tachycardia, hyperreflexia and absence of goiter

TSH values are < 0.01 microU/mL, T4 is elevated and thyroglobulin levels are decreased

In contrast to all other causes of hyperthyroidism, serum thyroglobulin is not elevated and is almost always low or at the lower limit of normal

hyperthyroidism
Factitious thyrotoxicosis
Support


his wife is the representative decision maker regarding his medical care and that he does not want extraordinary measures to prolong his life including artificial nutrition

Discharge home with palliative care from the health area

We may appoint a representative to act as an interlocutor with the responsible physician or health care team to ensure that the instructions contained in the declaration are carried out

It thus seems clear that the intended response is 5

In our declaration of advance directives, we can refer to: 1. The expression of personal values, in order to help in the interpretation of the document itself and to guide physicians in making clinical decisions


Triptorelin is a GnRH agonist, which by continuous action reduces FSH and LH, and is used in sex hormone-dependent cancers, as well as precocious puberty

Monthly intramuscular administration of triptorelin

A 22-year-old boy with hyposmia presents lack of development of secondary sexual characteristics and infertility

Analytically, EST-I 1.2 U/L (vn 5-15); LH 0.6 U/L (vn 3-15); testosterone 100 ng/dL (vn 300-1200), prolactin normal

Bromocriptine is a dopaminergic agonist used in hyperPRL (he has normal PRL), pituitary tumors...

To induce testicular maturation, pulsatile GnRH with pump, hCG or FSH+hCG can be used

LH is not used as a treatment, it would be stimulated by intermittent GnRH

Intramuscular administration of FSH and LH once a week


As a psychiatry resident, I wish the MIR questions in my specialty were a bit more thought-provoking and in-depth, although I know that the seconds you will have saved by marking the fourth one directly are very valuable

It describes a patient worried about a non-existent physical defect, whose concern distresses him and prevents him from leaving the house


In case of free wall rupture, there is no palpable frémito

the oximetric jump occurs in the case of septum rupture, as well as fremitus

In case of free wall rupture, there is an oxymetric jump in the right ventricle in the Swan-Ganz catheterization

complications can occur up to the first week

Mechanical complications usually appear on the first post-infarction day


it presents the case with the typical symptoms of dementia due to Lewy bodies, being the guiding symptom visual hallucinations

The correct answer is 2
Dementia due to Lewy bodies
Support

Progressive cognitive impairment, parkinsonian motor signs (inferred from clumsiness of movements) and hypersensitivity to neuroleptics even in small doses are also mentioned


If the ECG shows ischemic changes, we will obviously treat the patient in the emergency room and notify the cardiologist

We will do an ECG in less than 10 minutes

If not, you will be treated as if it were angina and observed, with serial enzymes and treatment in the observation area


The patient has a PSA >4 and a palpation with increased consistency

the need for a transrectal ultrasound-guided biopsy to diagnose whether it is Benign Prostatic Hyperplasia or Prostate Cancer

Suggest to the patient the performance of a transrectal ultrasound and prostate biopsy


Urine system: proteinuria 300 mg/dl, sediment 15 red blood cells per field

The patient presents with thrombotic microangiopathy (TMA) with acute renal failure

This points to HUS, TTP, drug-induced TMA, or TMA mediated by complement, coagulation, or metabolism

Normal ADAMTS-13 levels rule out TTP
incorrect choice 1
Support

Normal ADAMTS-13 levels rule out TTP
Thrombotic thrombocytopenic purpura
Attack

incorrect choice 1
Thrombotic thrombocytopenic purpura
Attack

ADAMTS-13 levels are normal
Normal ADAMTS-13 levels rule out TTP
Support

The absence of gastrointestinal symptoms rules out typical Shiga toxin HUS

incorrect choice 4
Typical hemolytic uremic syndrome
Attack

The history of respiratory infection (not specified, it could be pneumococcal pneumonia) together with the absence of DIC data (no mention of bleeding or altered coagulation tests) makes me think of atypical HUS

option 2 correct
Atypical hemolytic uremic syndrome
Support

A 19-year-old male with no past history of interest comes to the emergency department because after a respiratory infection he presents with asthenia, malaise, oliguria and headache

Pneumococcal infections can also cause HUS, although it is rare and more so in adults


It never ceases to amaze us the strange ways of biology and that the axiom "the longest is the right one" is fulfilled in this case


The correct answer is: 4
Antihypertensive
Support

In particular, hydrochlorothiazide, as a thiazide, is primarily responsible for this patient's hypokalemia

treated for 4 months with Omeprazole, Metformin, Salbutamol, Ipratropium Bromide and Enalapril 20 mg + Hydrochlorothiazide 25 mg


Sometimes amyloid deposits appear on the tongue which can produce macroglossia

If a patient reports having for months now enlargement of the tongue, with no other alterations of the tongue causing constant biting

Amyloidosis is a localized or systemic deposition of fibrillar proteins


Middle-aged male with iron deficiency anemia and increased number of stools

a colonoscopy should be done to rule out colorectal cancer!!!

If the HLA is negative it is very unlikely to be celiac disease (high negative predictive value)

Determination of anti-transglutaminase IgA antibodies


In any case, Barrett's esophagus should follow endoscopic surveillance and lifelong PPI treatment or antireflux surgery to prevent progression

This patient presents Barrett's esophagus with low grade dysplasia

not being with acid production inhibition the dysplasia may be conditioned by inflammation and not be real

Periodic surveillance endoscopies and indefinite treatment with PPI.


Older woman with normocitic anemia and clear ferrokinetic pattern of chronic disorder (hyposideremia but hyperferritinemia)

The only one that fits, and it fits perfectly, is number 3; they only needed to give us a high ESR

Polymyalgia rheumatica
Polymyalgia rheumatica
Support

The determination in a 70-year-old woman of hematocrit 32%, Hb 9.6 g/dL, MCV 85 fL (70-99), Fe 25 ug/dL (37-145) and ferritin 350 ng/mL (15-150)

1: if it is a recent loss, the MCV could remain normal, but the ferritin should be affected, and certainly not elevated

Recent blood loss through the digestive tract

2: the same. If it is due to Fe malabsorption, ferritin should be low

And if it were due to B12 malabsorption, the MCV would be clearly higher

4: 70 tachycardia and normal MCV. This one is too much


It is the male who presents the disease, which we are told is X-linked, so there are only two options left: 2 and 3

Their daughters will not inherit the disease, but all their future sons will be carriers and can transmit the mutation to 50%

Their sons will not inherit the disease, but all their future daughters will be carriers and can transmit the mutation to 50%

2 is not because the males will receive the Y chromosome from the father and the X from the mother, who is healthy, so the daughters will be able to carry the disease (correct option 3)


we will have to perform a capsule endoscopy

It is a study of iron deficiency anemia with normal gastroscopy and colonoscopy, having ruled out possible celiac disease


Amyloidosis presents with proteinuria usually in the nephrotic range, and has a more chronic course

a patient with rheumatoid arthritis on methotrexate, prednisone and indomethacin who acutely presents with edema and increased plasma creatinine with poorly expressive urine sediment and proteinuria less than 100 mg/24 h

GMN associated with rheumatoid arthritis characteristically alters the sediment

Glomerulonephritis secondary to rheumatoid arthritis

renal failure due to NSAIDs has a more chronic course, with papillary necrosis

Renal failure due to nonsteroidal anti-inflammatory drugs

Thus, given the course and the alterations described, interstitial nephritis due to methotrexate is more likely, which is more directly toxic than allergic, hence the absence of pyuria, eosinophilia, fever or other hypersensitivity data

Interstitial nephritis due to methotrexate


A 45-year-old woman diagnosed with stage IV breast cancer with multiple bone metastases on hormonal treatment and iv bisphosphonates

if the patient has bone metastases and may suffer fractures we can control inflammatory pain with ibuprofen

it will also help us to use the antalgic synergy

since she is at almost the maximum pain she can bear

We should change the treatment to a major opioid and treat the disrruptive pain vigorously

Suspend tramadol, maintain ibuprofen and initiate a major opioid such as morphine and oxycodone and at the same time treatment for breakthrough pain with sublingual fentanyl


especially considering that it is only 71 years old, but especially because the patient's "quality of life" is good (and I put "quality of life" because it is a term used erroneously, it is supposed to mean that he maintains a good functional level)

1 and 5: These are diagnostic tests, they are meaningless since you have already made the diagnosis

A trantoracic puncture should be performed

Surgical intervention with curative intent should be contraindicated due to the advanced age of the patient.

3: Presents a very mild respiratory limitation, does not require such a test

An oxygen consumption test should be performed, given the respiratory limitation he presents

Surgical resection (lobectomy of the lower lobe of the right lung) should be indicated directly


although both lesions are resectable
I think the correct answer is 4
Attack

Surgical bypass has more complications than placing a self-expanding metallic prosthesis that has a median patency of 6 months which is similar to the median survival of a patient with hepatic metastases of pancreatic adenocarcinoma

Metallic biliary prosthesis by endoscopic retrograde cholangiography, with the option of palliative chemotherapy

Surgical biliary bypass, with or without prophylactic gastrojejunostomy depending on intraoperative findings

pancreatic adenocarcinoma with synchronous hepatic metastases has no surgical indication

it does not prolong survival and has a high morbidity


The treatment for hypercholesterolemia is statins so we rule out answers 2 and 4

Rule out hypothyroidism or other systemic disease, recommend a healthy lifestyle and treat with fibrates to normalize cholestero

The statin in a patient with cardiovascular disease (such as an AMI) is a lifelong treatment (we discard 1) since it is not taken until LDL levels are normalized.

Treat with statins until cholesterol is normalized and recommend healthy lifestyle (diet, exercise and no smoking)

Rule out secondary dyslipidemia, treat with resins (resincholestyramine) and fibrates and re-commend a healthy lifestyle. Prohibit alcohol

Between 3 and 5, 5 is more complete as it includes treatment and control of other risk factors

Rule out secondary dyslipidemia, request a family study and treat with statins to maintain a good lipid profile. Control of other risk factors

A 57-year-old patient had an acute myocardial infarction and has a blood test with cholesterol 312 mg/dl, LDL 241 mg/dl, HDL 29 and normal TG

Ruling out secondary dyslipidemia is easy with the patient's clinical history and a blood test with thyroid function

He smoked 30 cig/day, was not obese, his blood pressure was 145/90 mm Hg and he did not have diabetes


The correct answer is 2
Colposcopy with possible biopsy
Support

Cervicovaginal cytology is compatible with a high-grade squamous intraepithelial lesion

According to the 2014 SEGO Oncoguide on cervical cancer prevention, when a cytology shows a high-grade squamous intraepithelial lesion, the action to be taken is a colposcopy, with or without biopsy depending on the findings (regardless of the patient's age and parity)

A 45-year-old woman, mother of 3 children, attends an early diagnosis consultation


A 58-year-old man referred a 3-week history of progressive, mildly painful skin lesions on his left arm

The lesions with sporotrichoid or lymphocutaneous pattern described may correspond to sporotrichosis or aquarium granuloma

It had started as an erythematous lesion on his left thumb

Dermatophytosis due to Microsporum gypseum

Cutaneous infection by Staphylococcus aureus

He had been working in his garden but did not remember any injuries

The history of having been working in the garden points more to a sporotrichosis

although the fact that the question asks for the "causative agent" and not the name of the disease misleads a little

Cutaneous infection by Mycobacterium marinum


Therefore, the preferable thing to do in this patient, before increasing the medication, is to change the ibuprofen for paracetamol, which does not have this effect, and to re-evaluate it later

I would change ibuprofen to paracetamol to avoid the possible influence of paracetamol on the effect of hypotensives


A middle-aged woman with Sjögren's-like symptoms (absence of lacrimation, dry mouth), with hyperbilirubinemia, jaundice and hepatomegaly, makes us think of primary biliary cirrhosis

To diagnose it we will use antimitochondrial antibodies (AMA IgG)

Therefore, it would be answer 1
Anti-mitochondrial antibodies
Support


They refer to a partial seizure that is followed by loss of level of consciousness

strictly speaking it would be a symptomatic complex partial seizure, not a secondarily generalized partial seizure (which occurs when tonic-clonic movements extend to the rest of the extremities)

Partial secondarily generalized symptomatic

For this reason the most correct option would be two

it does not specify that it is a simple symptomatic partial seizure, but leaves open the possibility that it is a simple or complex symptomatic partial seizure


The correct answer is: 3
Subcutaneous fat biopsy
Support

The appearance of urinary abnormalities or renal impairment of parenchymal cause are indications for renal biopsy, even with proteinuria ranges lower than those accepted in primary nephropathies

He presents proteinuria of 6 grams per day with hypoalbuminemia and edema

In the urinary sediment no hematuria is detected

In most cases, the relationship is established by an IgA nephropathy, which presents with hematuria, a symptom that claims not to exist in this case

A non-negligible number of patients with evolved AD is amyloidosis, which also matches the patient's symptomatology

Therefore, and given that amyloidosis can be diagnosed with a subcutaneous fat biopsy, it is answer 3 that should be considered valid


A 23-year-old woman comes to the emergency department because she is very nervous after an argument with her partner

The woman is 23 years old and is pissed off

The diagnosis is 1
Borderline personality disorder
Support

The issue is that she cannot stand rejection and has self-injurious gestures

3, 4 and 5 are not even close, there is no clinical picture described in the question

Then in real life exploring well almost certainly there would be dissociative and depersonalization symptoms, as well as depressive symptoms... but symptom is not disorder

The limit: A general pattern of instability in interpersonal relationships, self-image and self-efficacy, and notable impulsivity, beginning in early adulthood and occurring in a variety of contexts, as indicated by five (or more) of the following items

Her medical history shows several similar complaints in the previous year, two of them after a self-injurious gesture

She says she feels misunderstood by everyone, including the psychiatrists attending her

Frantic efforts to avoid real or imagined abandonment

A pattern of unstable and intense interpersonal relationships characterized by alternating between extremes of idealization and devaluation

Identity disturbance: marked and persistently unstable self-image or sense of self

Impulsivity in at least two areas, which is potentially self-harming (e.g., spending, sex, substance abuse, reckless driving, binge eating)

Recurrent suicidal behaviors, attempts or threats, or self-mutilating behavior

Affective instability due to marked mood reactivity (e.g., episodes of intense dysphoria, irritability, or anxiety, usually lasting a few hours and rarely a few days)

Inappropriate and intense anger or difficulties in controlling anger (e.g., frequent displays of temper, constant anger, recurrent physical fights).

Transient stress-related paranoid ideation or severe dissociative symptoms.

Not comfortable in situations where he/she is not the center of attention

The histrionic: A general pattern of excessive emotionality and attention-seeking, beginning in early adulthood and occurring in a variety of contexts, as indicated by five (or more) of the following items

Interaction with others is often characterized by sexually seductive or provocative behavior

Displays a superficial and rapidly changing emotional expression

Constantly uses physical appearance to draw attention to him/herself

Has a way of speaking that is excessively subjective and lacking in nuance

Shows self-dramatization, theatricality and exaggerated emotional expression

Is suggestible, e.g., easily influenced by others or by circumstances

considers his relationships more intimate than they really are


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

a small child who suffers a hemarthrosis without clear trauma

The ultrasound examination is compatible with hemarthrosis

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

An uncle of his had similar problems, so we suspect hereditary disease

in the analysis performed only an APTT lengthening of 52″ (normal 25-35″) stands out

The APTT, which evaluates the intrinsic coagulation pathway (involving factors V, VIII, IX, X, XI and XII) is elongated

Hereditary coagulation problem
We thus discard answers 1, 2 and 5
Support

Hereditary coagulation problem
Marfan syndrome
Attack

Hereditary coagulation problem
Bemard-Soulier disease
Attack

I consider that the correct answer is 4, hemophilia A, since the inheritance pattern is X-linked and its main clinical manifestation is soft tissue bruising and spontaneous hemarthrosis, without apparent trauma, while von Willebrand disease is characterized by bleeding after surgery or trauma and a prolonged bleeding time with a normal platelet count is characteristic (data not mentioned in the statement)

We thus discard answers 1, 2 and 5
Ehlers-Danlos disease
Attack


Treat with L-Tyroxine and determine antithyroid antibodies

If there is no nodule, neither echo nor FNA is indicated

Perform a thyroid ultrasound before starting treatment

Perform thyroid cytology prior to treatment

Determine free T3 and perform a pituitary MRI


Although the diagnosis is clearly osteoarthritis, it does not lead directly to a surgical indication

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

The first step is to try conservative treatment

Osteoarthritis is a degenerative process that opioids certainly do not stop

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

Option four can also be quickly discarded

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

We are talking about a 66-year-old patient with pain on some days, pain of an occasional nature

the statement makes the diagnosis and treatment to follow clear: in this case the MRI will not provide us with any information of interest


Patient with obesity, hypertension and increased HbA1C

In recent studies, Empaglifozin, a highly selective inhibitor of SGLT210, significantly reduces AT, HbA1C and BMI

Its use should be avoided in patients with heart disease

Sitagliptin has been shown to decrease HbA1C but not HT or BMI

His medication includes lisinopril, metoprolol, metformin, ASA and atorvastatin

Acarbose can interact with beta-blockers, such as those taken by our patient


Patient with harmful alcohol consumption (60g and female), high fever, hepatic encephalopathy (disorientation, asterixis), very high direct bilirubin, jaundice, painful hepatomegaly, coagulopathy (elevated prothrombin time) and mild elevation of transaminases (less than 5 times the upper limit of normal)

suggest acute alcohol hepatitis
Alcoholic hepatitis
Support


Both the initially occipital location, the 2-year evolution time, and the sensation of weight lead to answer 4, a tension headache

The pain is like a weight that starts in the occipital area, spreads to both temporal regions and is barely relieved by taking 650 mg paracetamol tablets, so she requests a CT scan (she is convinced that "something must be wrong with her head")

Although she has been having similar episodes for more than a year, in the last 2 months they have worsened considerably

Migraine and vascular disorders, accompanied by other neurological symptoms or nausea, photophobia, etc., are quickly ruled out, as well as the rare temporal arteritis before the age of 50 years

Tumor headache is usually "in crescendo", not recurrent as the case suggests, and is accompanied by other neurological symptoms or intracranial hypertension

A 42-year-old married woman
Temporal artery arteritis
Attack


The rest of the symptoms fall perfectly within the picture

In this question, they give an important piece of information when it comes to suspecting a diagnosis, which is the antitransglutaminase antibodies

A 27-year-old woman under study in the dermatology department for recurrent episodes of oral aphthous ulcers

a blood test showing Hb 11.5 gr/dl Fe 38 AST 52 ALT 64 Ac antitrasglutaminase IgA 177

The patient reported only occasional diffuse abdominal discomfort

She reports no signs of hemorrhage or jaundice

that must lead you to suspect celiac disease

the answer that will give us the diagnosis is 4 (intestinal biopsy)

although probably several of the tests that it says will be done


The characteristics of the fluid described are milky

Chylous ascites due to non-Hodgkin's lymphoma

Taking into account the age of the patient and the constitutional syndrome described

it is most likely to be a non-Hodgkin's lymphoma and not tuberculosis, which also presents with chylous ascitic fluid

there is no mention of infectious symptoms

The rest of the entities offered do not present with chylous ascitic fluid

Hydropic decompensation secondary to liver cirrhosis

Ascites secondary to constrictive pericarditis


Conservative treatment with a success rate of 75%-90%

Conservative treatment with nonsteroidal anti-inflammatory drugs, local heat and relative rest


the patient is in a situation of psychotic depression and is not able to decide for his life and it does not seem that the patient has filled in the last will and testament

the most convenient thing to do is to present the case to the ethics committee of the center to make a decision on the matter in accordance with the law

Ask the hospital ethics committee to help determine the decision that is in the best interest of the patient


This is a young patient with no comorbidities

is therefore a candidate for treatment with curative intent

Treatment in this case would be transfusion only

we cannot know the patient's IPSS
Option 3 is also incorrect
Support

we do not know the number of blasts and the number of leukocytes and platelets to calculate the risk

This is a patient with a high International Prognostic Index (IPSS)

the indication for a bone marrow transplant in MDS is those patients with high or intermediate-2 IPSS

It would be advisable in this patient to perform HLA typing in order to organize an allogeneic transplant

in this case we do not know the risk, the only thing we know about the risk is the cytogenetics which is of good prognosis that would give us 0 points

This deletion (5q-) is an alteration of good prognosis and has a specific treatment (lenalidomide)

it is true that it has a favorable cytogenetics (5q-) and has a specific treatment lenalidomide, also used in other pathologies such as multiple myeloma


A patient with severe COPD comes to the ED with an acute onset and presents an arterial blood gas drawn with Fi02 of 31% at sea level with a Pa02 of 86 mm Hg, PaC02 65 mm Hg, pH 7.13 and Bicarbonate 27 mmol/liter

Blood gas analysis shows an acute respiratory acidosis, due to an increase in PCO2 of short evolution time because the kidney has not yet had time to retain bicarbonates (bicarbonate level at the high limit of normality)

The patient is not hyperventilating but hypoventilating because PCO2 is elevated

The alveolar arterial oxygen gradient is altered since the patient has a normal PaO2, but because he has a high FiO2

The alveolar arterial oxygen gradient is elevated

Respiratory acidosis below 7.20 is a reason to consider noninvasive mechanical ventilation acutely and in principle temporarily in a patient with severe COPD

Initiation of mechanical ventilation should be considered


Coronary revascularization does not appear to be of much benefit in this patient at this time

We are talking about a patient with heart failure with severe LV dysfunction (EF < 35%), LBBB (wide QRS), who is following optimal medical treatment and who remains in advanced functional class despite this

firstly because mitral regurgitation is most likely the result of mitral annular dilatation

secondly because we would need an echocardiographic assessment of the mitral valve to determine whether there is any alteration

Nor does mitral valve replacement
Mitral valve replacement
Attack

it is used in situations of cardiogenic shock, in post-AMI mechanical complications, as a bridge to cardiac Tx

Intra-aortic balloon counterpulsation implantation would not be indicated in this patient

The ventricular assist device would also not be indicated in this patient

Implantation of a ventricular assist device

What would really benefit him of all the answers is number 5, the resynchronization device

Implantation of a cardiac resynchronization system

By achieving simultaneous stimulation of both ventricles, a mechanical synergy is achieved that improves cardiac function

The indications for the application of CRT (cardiac resynchronization therapy) are precisely those mentioned at the beginning: severe ventricular dysfunction, asynchrony demonstrated by the presence of wide QRS in the ECG (usually due to LBBB) and advanced functional class (III-IV) despite optimal medical treatment


The correct answer is 1
Wiskott-Aldrich syndrome
Support

Wiskott-Aldrich syndrome associates immunodeficiency, thrombopenia and atopic dermatitis with the immunological study described in the statement

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

The examination showed typical lesions of atopic dermatitis

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


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

It is possibly a temporal arteritis, the clinical picture and a CBC with increased reactants are enough to confirm the suspicion


The correct answer is 5
Vulvar squamous cell carcinoma
Support

Vulvar carcinoma is characterized by chronic vulvar itching resistant to multiple treatments, appearance of lumpiness or ulceration, dysuria and urinary urgency, and late pain and bleeding

she reports occasional dysuria and her general condition is good

She reports that for at least 4-5 years she has had vulvar pruritus of variable intensity which has been treated sometimes with self-medication and other times on the advice of her general practitioner with topical preparations (creams and washes)

The pruritus has evolved intermittently, but for the last 3-4 months she has also noticed a small lump on the left labium majus of the vulva, which has been leaking serohaematically on rubbing for a few days; she therefore consulted a gynecologist.


A case of acute diverticulitis complicated with small mesenteric abscess (< 2-3 cm) is presented

In this question we are presented with a clinical picture whose manifestations are compatible with acute diverticulitis

the intra-abdominal approach can spread the contents into the abdominal cavity

Abscesses should be drained by CT-guided percutaneous puncture

However, in small abscesses with Hinchey grade I divertciulitis, in patients without great deterioration of the general condition as in the proposed case, they can be managed by conservative treatment with intravenous antiobiotic therapy and absolute diet

Admission to the ward with absolute diet and broad-spectrum antibiotic treatment

The urgent surgical approach should be reserved for cases that present peritonitis (grade III, IV) by resection of the affected segment and primary anastomosis in stable patients or carry out the Hartamn intervention that includes resection with terminal colostomy and closure of the distal rectal stump performing anastomosis in a second surgical time

Urgent surgery with sigmoidectomy and colorectal anastomosis


Age and sex also point to this possibility

The clinical presentation is strongly suggestive of giant cell arteritis (GCA)

febrile fever, shoulder girdle and pelvic pain, and headache

Abrupt unilateral visual loss with pale papillary edema is highly indicative of arteritic ischemic optic neuropathy due to GCA

We have to quickly start corticosteroid treatment.

they do not contribute anything
We can already rule out 1 and 5
Support

Request a Doppler ultrasound of temporal arteries

Request a brain magnetic resonance imaging

if we rule out 3 because the dose is too low, we would have to stay with 2.

Start treatment with prednisone 10 mg per day

Start treatment with prednisone 60mg per day and aspirin 100 mg per day

4 could make us doubt, and it is true that we will have to ask for a temporal artery biopsy, but that is not immediate: the statement makes it very clear that we have to act immediately

With reservations, since aspirin has a rather dubious role

The current trend is to use megadoses of intravenous corticosteroids

The ESR is elevated
which further clarifies the diagnosis
Support

although aspirin has traditionally been proposed to reduce ischemic events, the evidence currently indicates that antiplatelet agents do not contribute much

corticosteroid dose remains ambiguous (we do not know how much the patient weighs)


A 60-year-old man with extensive ulcerative colitis of 15 years of evolution and in clinical remission for the last 3 years, comes to our office to be informed about the risk of colorectal cancer and about the possibility of participating in prevention programs

Patients with inflammatory bowel disease (IBD) have an increased risk of colorectal cancer, whether or not they are smokers

It is recommended to start screening 8-10 years after diagnosis of IBD (or earlier if primary sclerosing cholangitis or other events occur during this interval)

The recommended techniques are colonoscopy with random biopsies (answer 3) and pancolonic chromoendoscopy with staining, which is currently the gold standard

it detects dysplasia better, although it requires more technical experience

In cases such as yours, it is considered appropriate to undergo periodic colonoscopies with multiple biopsies staggered along the entire colon

Ulcerative colitis is only associated with an increased risk of colorectal cancer in smokers


These appear due to the presence in the urine of a high concentration of bacteria possessing the enzyme nitrate reductase, which is capable of reducing the nitrates present in the urine to nitrites

This enzyme is active in most of the bacteria that most frequently cause urinary tract infection, such as many Gram-negative bacilli

Other microorganisms, relatively frequent causes of urinary tract infection, do not possess this enzyme and do not reduce nitrates, such as enterococci, staphylococci and yeasts

As the Gram stain indicates that the bacteria are grouped in chains, as this is typical of enterococcus, we suggest the need to cover this group of bacteria with antibiotic treatment

Switch to a broad-spectrum antimicrobial treatment that covers Enterococcus spp


A patient presents with a long history of multiple physical symptoms: memory loss, headache, dizziness, vomiting, genital pain, limb pain, abdominal distention, and menstrual irregularities

History of multiple physical symptoms, which begins before age 30, persists for several years, and compels seeking medical attention or causes significant impairment socially, occupationally, or in other important areas of the individual's activity

Four painful symptoms: history of pain related to at least four areas of the body or four functions (e.g., head, abdomen, back, joints, extremities, chest, rectum; during menstruation, sexual intercourse, or urination)

Two gastrointestinal symptoms: history of at least two gastrointestinal symptoms other than pain (e.g., nausea, bloating, vomiting [not during pregnancy], diarrhea, or intolerance to different foods)

A sexual symptom: history of at least one sexual or reproductive symptom other than pain (e.g., sexual indifference, erectile or ejaculatory dysfunction, irregular menses, excessive menstrual leakage, vomiting during pregnancy)

Everything fits with what is described in the statement

According to ICD-10 the criteria for diagnosing Somatization Disorder (F45.0)

Conversive or dissociative disorder is ruled out

these are usually related to psychological factors, associated with the symptom or deficit (not deliberate)

The onset or exacerbation of the condition is preceded by conflicts or other triggers, which is not mentioned in the statement

Neither would it be a hypochondriacal disorder

this implies a preoccupation and fear of having, or the conviction of having, a serious illness based on the personal interpretation of somatic symptoms

But it does not involve physical signs or symptoms


Specifically, angiotensin II receptor blockers have demonstrated their efficacy in this field for type 2 DM, which together with the side effects that IECAS produce in the patient makes an ARAII the drug of choice

She presents with intolerance to ACE inhibitors due to coughing


but thanks to Ramón, when we read it more carefully, we found that it had neuroectodermal and embryonal elements in several of the histological preparations

so we consider that the correct answer is 2


Typical smoker's pancoast, probably an epidermoid, with Horner's sdr

Best would be chemoradio followed by surgical salvage

Neoadjuvant chemotherapy with combined chemoradiotherapy, followed by surgery


Versions are bilateral conjugated movements of both eyes

That is, a version is composed of the sum of two ductions, since duction is the movement of only one eye

When you explore the versions, specifically the superior version or supraversion, both eyes rotate upward

At that time, you may encounter a limitation of the movement of one eye

In this case, when you scan the supraversion, you suspect or you detect a limitation in the movement of the left eye

And we would call this a limitation to the supraversion of that eye

What is important is that the eye that has received the blow does not go up

therefore there is double vision in the superior gaze

thinking that because the superior rectus is trapped, it does not work and therefore the eye cannot go up

However, muscles trapped in a fracture do not automatically lose their muscular action

Fracture of the superior wall of the orbit with entrapment of the superior rectus muscle

What happens is that they become trapped, they are "hooked", and cannot stretch

The problem is that the inferior wall has been broken, the inferior rectus has been trapped, and when the eye must look up, this inferior rectus cannot stretch as it should

It is not paralysis, but a restrictive problem

Fracture of the inferior wall of the floor of the orbit with trapping of the inferior rectus muscle

they are too far away from the extraocular muscles to produce diplopia

Options 2 and 4 can be ignored
Zygomatic arch fracture
Attack

Options 2 and 4 can be ignored
Dentoalveolar fracture
Attack

And as for the walls of the orbit, the ones that break most frequently are the inferior and medial wall


Colposcopy with possible biopsy
Colposcopy with possible biopsy
Support

The cytologic diagnosis must be confirmed by biopsy, for which it is necessary to perform a directed biopsy by colposcopy

H-SIL (High-grade squamous intraepithelial lesion)

includes changes suggestive of CIN2 and CIN3/CIS


Coraliform lithiasis are associated with urea-folding germs: Proteus in the first place, Pseudomonas, Klebsiella and some staphylococci

an abdominal ultrasound shows a coralliform lithiasis


In splenectomized patients, the risk of acquiring serious infections by encapsulated germs is increased

She underwent a splenectomy 2 years ago for staging of Hosgkin's disease

Pneumococcus being the most frequent.
Streptococcus pneumoniae
Support


so we assume that the patient is asymptomatic

We are told of a leukocytosis at the expense of lymphocytes with a B-CLL phenotype

It seems that there are no other alarming data

No cytopenias...
Conclusion: FOLLOW UP
Support

New clinical and analytical control in 6 months

But this is going too far
Why do I consider it incorrect?
Support

Because the TP53 mutation, although it establishes prognosis, is not indicated at diagnosis, but when treatment is going to be initiated (first line and prior to successive lines in case they are needed)

It would be possible to go too far in this question in which the percentage given does not refer directly to clonal lymphocytes

so that it could even be a monoclonal B lymphocytosis

Study of TP53 mutations to establish prognosis


The correct answer is 2
Intraductal papilloma
Support

In the presence of unilateral and uniorificial hematic telorrhea, the most frequent cause is intraductal papilloma (50%), followed by ductal ectasia and carcinoma

A 59-year-old woman consults a gynecologist for a spontaneous, spontaneous, uniorificial discharge from the right nipple (unilateral

In hyperprolactinemia, telorrhea is bilateral and pluriorificial

Paget's disease is of the eczematous type

Mammography often does not show papillomas, being more useful ultrasound and galactography.

When associated with palpable mass, 60% correspond to carcinoma


Laboratory tests showed slight leukocytosis with lymphocytosis and presence of activated lymphocytes, slight thrombopenia and slightly increased transaminases

Of course it is a typical picture (EBV, CMV, VH6, Toxoplasma)

Be careful with the bad blood in answer 3, because an acute toxoplasmosis can behave like this and also give a macular exanthema, although the one of this girl is related to the intake of amoxicillin

She had previously been diagnosed with acute pharyngitis and was treated with amoxicillin, and later presented with a generalized macular skin rash

if instead of a girl of 17 years so clear it were a young man/girl with risky sexual relations

do not forget the HIV primoinfection as a cause of mononucleosis syndrome


In this question what they assume is that this is a 45-year-old woman who is diagnosed with pulmonary thromboembolism (PTE)

With this diagnosis, options 3 and 4 are directly excluded

so we would not have to think about hemophilia

As an analytical data, it says that there is a lengthening of the aPTT

So, they want you to know, she has positive lupus ac and link it directly to antiphospholipid syndrome (APS)

A Leiden's does not alter coagulation, so it is ruled out as well

Prothrombin time 90%, activated partial thromboplastin time (APTT) ratio of 2 to control (N <1.2)

Assuming that a PTE + lupus is a PFS seems to me to be a bit of a stretch, but it is the most likely with the data provided


In this case, we have a patient who has an ocular opening to the call (ocular response 3 out of 4), emits inappropriate words (verbal response 3 out of 5) and localizes pain with right extremities (motor response 5 out of 6)

The Glasgow Coma Scale score would be 11 (out of 15)

ocular response 3 out of 4
E3V3M5
Support

verbal response 3 out of 5
E3V3M5
Support

motor response 5 out of 6
E3V3M5
Support

For example: in a polytraumatized patient (such as the one in question), the response presented with left extremities may be due to localized trauma in that area, and not strictly speaking to an underlying traumatic brain injury

The best value of the examination is taken because in many cases (assessment of a polytraumatized patient, ischemic stroke or spontaneous acute cerebral bleeding), the motor examination may be artifacted by other elements

Likewise, sometimes the verbal response may be underestimated in the polytraumatized patient due to airway obstruction (e.g., due to the tongue retreating into the oropharynx)

By always assessing the best response, we will have a truer picture of the patient's condition


Permanent post-surgical hypoparathyroidism after parathyroidectomy of an adenoma with minimally invasive surgery is rare

This syndrome can be observed after surgery in patients with primary hyperparathyroidism (HPT), as well as in tertiary HPT of chronic renal failure, and to a lesser extent after treatment of processes with excess of circulating thyroid hormones (2)

In PTH, there is an excess of parathyroid hormone (PTH) which stimulates osteoclastic activity causing demineralization of the bone matrix and releasing calcium into the bloodstream

After parathyroidectomy, serum PTH levels drop dramatically, thus, PTH-induced bone resorption ceases, while osteoblastic activity continues resulting in increased bone uptake of calcium, phosphate and magnesium, thus SHH appears

Laboratory tests reveal hypercalcemia, increased PTH and increased bone turnover markers

The radiographic study shows subperiosteal resorption and osteoporosis

Postoperatively, the patient developed severe hypocalcemia and tetany, with PTH below 5 ng/l


the first measure is to administer Adrenaline 1/1000 intramuscular (0.01mg/kg)

So adrenaline first, as it is faster acting, then the rest


Since there are no criteria that contraindicate admission to the ICU, admission to the unit would be indicated

Applying the CURB-65 severity scale (one of the most commonly used in the ED for stratifying the severity of pneumonia, although in this case simply applying common sense, the patient should be admitted to the ICU), we would have a score of at least 4 points (we would be missing the serum urea data), which gives us severity criteria


There are two answers that we can immediately rule out if we stick to the initial management of severe chest trauma: 1 (noninvasive ventilation is not indicated because it does not secure the airway) and 3 (observation in these cases, waiting for worsening, only leads to increased morbidity and mortality)

Institute noninvasive mechanical ventilation and request blood transfusion

Orotracheal intubation, request blood transfusion and observation for, in case of worsening, indicate surgical intervention

With the data provided by the question, a patient who seems to be in shock (tachycardia, hypoxemia, tachypnea... although we do not receive data, for example, on lactacidemia), and in whom we have to our knowledge a left thoracic trauma, which not only implies bone injury, but may mask other injuries of high severity and which are not diagnosed with a chest X-ray: myocardial contusion, pericardial effusion, splenic injury, diaphragmatic injury...

We place a left pleural drain on the patient and obtain a debit of 1700cc of hematic fluid

If we follow the ATLS (ATLS-Advanced Trauma Life Support 10th edition) guidelines for the care of severely polytraumatized patients, they tell us that an immediate bleeding of more than 1500cc of blood is an indication for urgent thoracotomy

Therefore, the person who asked the MIR question wants us to answer option 2

even in patients with a bleeding of less than 1500cc, if the debit persists at a rate of 200mL/h for 2 to 4h, this indication would also exist

Analgesia, oxygen therapy, request blood transfusion and indicate urgent surgery

However, in real life, the course of action will depend on the stability of the patient when we have applied the treatments indicated in option 2: adequate analgesia, oxygen therapy and initiation of blood transfusion

If by optimizing the patient we manage to stabilize him and assess that it is safe to transfer him, the performance of a body CT scan will define in much greater detail the lesions he has, and will help to ensure that the surgery he will probably end up undergoing will be a definitive surgery and not just damage control surgery

In this case, the doubt would arise with option 4

although, as I say, everything will depend on the clinical stability of the patient and the time we have before achieving definitive control of the hemorrhagic focus (which is, after all, what we are after in this situation)

Orotracheal intubation and urgent CT scan for accurate assessment of lesions


Then, for extension, prognostic value and to decide treatments, the rest, but once diagnosed

For diagnosis, a sample (bone marrow) and electrophoresis to determine the type of monoclonal peak

Bone marrow aspirate and serum and urine electrophoresis


In a patient with a low symptomatic COPD that could probably be classified as GOLD 2, the starting treatment can be either with inhaled tiotropium or with a long-acting beta two

On examination he is eupneic, normocolored, with an oxygen saturation of 94%, and has generalized decreased vesicular murmur on chest auscultation as the only findings of interest

A 67-year-old man consults for moderate exertional dyspnea of progressive onset in recent years

He has daily whitish expectoration and sometimes breath sounds, especially in winter with respiratory infections

Chest X-ray shows an elongated cardiac silhouette, with signs of hyperinflation or pulmonary air trapping, without other alterations


The correct answer is 3
Tuberculous meningitis
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It defines a typical cerebrospinal fluid of tuberculosis

Given a 7-month-old child with fever and irritability, bulging fontanel and a cerebrospinal fluid study with 110 cells/mm3 (75% lymphocytes), protein 120 mg/dl and glucose 28 mg/dl (serum glycemia 89 mg/dl)


Biliary drainage by percutaneous cholecystostomy.

although the treatment for acute cholecystitis is cholecystectomy

for this it is necessary that the patient is a surgical candidate, in this case it is an elderly patient, with previous diseases that increase the surgical risk and would be an ASA IV for an urgent intervention

In these cases cholecystostomy can cure cholecystitis


The pain appears when the lower limb is lifted with the knee extended, but is relieved when the knee is flexed

Positive Lasegue's sign, reappearance of the symptoms when performing the extension maneuver of the affected limb, compatible with involvement of nerve roots at the lumbosacral spine level


Although the latest recommendations on the management of severe acute pancreatitis advise against FNA because of the risk of infection of sterile necrosis

Fine needle aspiration of pancreatic necrosis guided by ultrasound or CT


This is the first thing we do when diagnosed with type 2 diabetes

Behavioral changes: diet and physical exercise

This is a good question to remember that before any drug, we must insist on changing habits

Behavioral changes. Diet and physical exercise


More than 2 lobar pneumonias make it necessary to rule out an immunologic deficit

Serum immunoglobulin count and antibody production capacity test


By the form of presentation, it is clearly an acute hepatitis

option 1 is ruled out
Chronic hepatitis B
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to have delta virus you need surface antigen B

the negative HBs Ag rules out 4
D (delta) virus superinfection
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The negative IgM of HAV rules out 5
Acute hepatitis A and B
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When having IgM anti HBc we speak of an acute hepatitis B (3)

there is a window period of negativization of the antigen


The fact that it is not accessible to endoscopic vision does not mean that it is not there

The most frequent cause of recurrent nerve palsy is bronchopulmonary carcinoma


it is described as an apraxic phenomenon followed by an asymmetric rigid-akinetic parkinsonism and with superimposed myoclonias

it is typical of corticobasal degeneration

they do not present apraxia as initial feature

Parkinson's disease cannot be
Parkinson's disease
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Alzheimer's disease does not present an asymmetric parkinsonism

A 65-year-old female patient debuted two years earlier with an apraxia of speech and has developed rigid-akinetic parkinsonism predominantly in the right hemibody with superimposed myoclonias and alien hand or foreign limb phenomenon

typical Huntinton's disease is not of so old people and when it debuts with advanced age it behaves like a chorea


It is considered normal intestinal rhythm

The normal range of stool output in young infants is very wide

To suspect aganglionic megacolon there is usually a delay in the evacuation of meconium and often other associated symptoms such as abdominal distension, difficulty in gaining weight, et

Refer to Pediatric Digestive to rule out aganglionic megacolon

A 1 month old infant, exclusively breastfed, consults because he has a bowel movement every 5 or 6 days with straining but with a soft consistency


A week later, she consulted again for general malaise, arthralgias and the appearance of a skin rash

General malaise, arthralgias, skin rash, acute renal failure and active sediment with sterile leukocyturia following the intake of a drug is highly suggestive of AIN

In the sediment leukocytes are identified, being negative for nitrites

option 4 correct
Acute interstitial nephritis
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Among drugs, antibiotics are the most frequent cause, and ciprofloxacin is one of the most common

She is diagnosed with uncomplicated urinary tract infection and treated with ciprofloxacin for 5 days

Direct nephrotoxicity is very rare and is characterized by crystallization in the renal tubules

incorrect option 2
Ciprofloxacin nephrotoxicity
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A 47-year-old woman consults for voiding syndrome

Postinfectious glomerulonephritis is more typical of children and adults older than 60 years, and usually manifests with hematuria after streptococcal infections

option 1 incorrect
Postinfectious glomerulonephritis
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Acute pyelonephritis would have been presented with high fever and renal fossa pain

option 3 incorrect
Acute pyelonephritis
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You have probably looked at answer 5, hereditary spherocytosis, associated with biliary lithiasis at an early age

The patient refers to a family history of biliary lithiasis at an early age

Physical examination reveals conjunctival jaundice and splenomegaly

In the statement they have not stopped giving clues: conjunctival jaundice, splenomegaly and family history of biliary lithiasis at an early age

There was no mention of microcytosis or macrocytosis to suggest thalassemia minor or B12 and/or folic acid deficiency

Vitamin Bl2 and/or folic acid deficiency


The available literature is somewhat controversial (some guidelines advise using glucose saline

Hypertonic saline (3%), 500 ml + 500 ml of 5% glucose

This girl presents with hypernatremia due to extrarenal free water losses

There are only two answers that come close to this figure, but 2 seems more correct, as it is the only one that completely covers the water deficit and uses a hyposodium solution


An urgent ultrasound shows a normal liver, vesicular cholesterosis and absence of bile duct dilatation, with no other alterations of interest

The absence of bile duct dilatation in cholangiocarcinomas can be seen in cases of intrahepatic cholangiocarcinomas or in those with mixed histology with hepatocarcinoma

He does not report abdominal pain, weight loss or other symptoms, except generalized pruritus

It is true that the acute course and the absence of constitutional syndrome may make us think against this option and tip the balance towards ibuprofen hepatitis

acute cholangitis is characterized by the triad of jaundice, abdominal pain and fever

The CBC shows increased bilirubin at the expense of direct bilirubin

Gilbert's syndrome is an increase in bilirubin at the expense of indirectness


It is a lymphocytic exudate whose main diagnoses are tumor and tuberculous pleuritis

They do not give the value of glucose which should be lowered

if the cytology shows absence of malignant cells so we are left with tuberculous pleuritis


therefore both tests are negative, and as only one answer refers to negative, that's it.

that subject was not in any risk group, the positive is in the 15mm


The answer is 2, study of hormone receptors and HER2

it does not appear to be hereditary breast cancer

This is because no study of first-degree relatives is appropriate

Study of hormone receptors, e-cadherin and study of first degree relatives

Study of BRCA 1-2 and study of first-degree relatives

On the other hand, there is no indication for BRCA 1-2 study


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

It tells us about a patient with a diagnosis of lupus and macrocytic anemia

The onset of the picture seems relatively rapid and it is also associated with an autoimmune disease

it seems that they want you to associate it with an autoimmune hemolytic anemia

The ANA would not give us anything in relation to the anemia, since it already has a diagnosis

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

probably the MCV would be higher than 108

the onset of the clinical picture would be slower

Vitamin B12
Therefore, correct answer 2
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the coombs test would tell us it is "autoimmune"

The low haptoglobin would tell us it is "hemolytic"

Therefore, correct answer 2
Coombs test
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On examination he presented: Positive right Lasège at 10º, decreased strength in plantar flexion of the right foot, hypoesthesia in the external border of the right foot and absence of right Achilles reflex

Both the sensory distribution, the paresis for plantar flexion (tiptoe) and the absence of the Achilles reflex are typical of S1 root involvement, which is typically affected with L5/S1 disc herniation (posterolateral)

An L1/L2 (posterolateral) herniation would affect the L2 root

A 36-year-old man with no PA of interest comes to the emergency department with sudden onset of severe pain in the posterior aspect of the right lower limb extending to the foot

cauda equina would involve more symptomatology than simple S1 involvement


The patient presents the clinical features of spondylarthropathy, which is often associated with inflammatory bowel disease, as this case suggests

The clinical picture is very suggestive of spondyloarthritis. Inflammatory bowel disease should be ruled out


The patient will be seated on the stretcher so that the cervical spine can be explored

It also does not appear to be a pelvic injury

Refer to radiology for study of the lower extremities (feet, femurs, pelvis)

The patient, due to the mechanism of injury (foot fall), the calcaneal fracture and the neurological symptoms, suggests a low spinal cord injury due to a fracture of the lumbar spine

We will palpate the abdomen and roll en bloc to palpate the thoracolumbar spine

If there is a suspicion of pelvic injury in the primary evaluation of all polytraumatized (ATLS) a spinal exploration should be performed by rotating the spine en bloc to avoid producing more injury

Abdominal palpation is also part of the initial evaluation

Abdominal ultrasound may be indicated in hemodynamically unstable patients if abdominal injuries are suspected but in any case it is done after the initial evaluation

Rotation of the lower limbs on the stretcher grasped by the ankles is painless

compression of the pelvis is asymptomatic

he moves his arms
The injury is not high
Support

the absence of pain on mobilization or palpation


In this case we describe a case of cervicobrachialgia without alarm signs at the present time

so the most indicated treatment at this time would be conservative, based on NSAIDs, local heat and rest

This is not an urgent case
so answer 2 would not be valid
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Urgent call to the neurosurgeon for surgical evaluation

Conservative treatment with non-steroidal anti-inflammatory drugs, local heat and relative rest

however, it is necessary to emphasize that we should first perform a correct pain management

The performance of an MRI and an electromyogram are valid options for the etiological study of the picture

so since we are asked about the first attitude, option 1 would be more valid

Preferential request for MRI and electromyogram


because of the high histologic grade and high tumor proliferation

According to the SEGO, this patient is a candidate for chemotherapy treatment

A 64-year-old woman, without relevant comorbidities, operated on for a right breast cancer by means of an extended lumpectomy and selective sentinel lymph node biopsy, with the following anatomopathological result: Infiltrating ductal carcinoma poorly dlferentiated (grade 3), size 2.2 cm (pT2), estrogen and progesterone receptor positive, Ki67 25%, HER2 negative

Adjuvant chemotherapy, preferably with anthracyclines and taxanes, followed by hormone therapy


The most appropriate drugs for the treatment of absences are Valproate and Ethosuximide (CTO Manual)

brief episodes of distractibility (< 1 minute) in which he does not respond to calls and blinks

Absences behave as brief episodes of abrupt loss of consciousness without alteration of postural control; they typically last seconds and can be repeated many times a day, are usually accompanied by small bilateral motor signs (blinking, chewing) and consciousness is recovered equally abruptly, without subsequent confusion or memory of the episode (MIR 03-04, 248; MIR 97-98, 51).

The age of onset is usually between 4 years and early adolescence, being the most frequent cause of seizures in this age range

An EEG shows spike-wave discharges at 3 cycles per second

EEG findings are typically generalized and symmetrical spike-wave discharges at 3 Hz (MIR 99-00F, 67) coinciding with seizures, although in the interictal EEG there are more periods of abnormal activity than clinically visible


On examination there is right thoracic hypophonesis and tympanism on percussion

Hypophonesis in a hemithorax + tympanism = pneumothorax

If there is dullness on percussion: hemothorax


They are undoubtedly describing the typical lesions (both on skin and oral mucosa) of a lichen planus (5)


A 73-year-old patient...swallowing a complete neurological dysphagia secondary to a cardioembolic stroke in the left middle cerebral artery territory. will require long-term nutritional support

f enteral nutrition is considered to be of short duration, the route of choice is the nasogastric or nasoduodenal- nasojejunal tube...

If prolonged nutrition is anticipated the route of choice is gastrostomy (option 3), with jejunostomy being reserved for cases in which it is not possible to use the gastric route


in the case of cough it is usually dry and irritative and appears in up to 3% of patients

These are typical adverse effects of ACEIs

A 70-year-old woman with a history of hypertension and moderate heart failure presents with a persistent, dry cough that begins as an itchy sensation in the throat


The correct answer is 2
Endometrial biopsy
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The data given on obesity should lead us to suspect endometrial cancer

peripheral fat is converted to estrone, and these estrogens cause the endometrium to proliferate

which rules out option 3
Random cervical biopsies
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On the other hand, she provides a normal cytology

She provides normal cervicovaginal cytology

The hormonal evaluation is not opportune

Hormonal evaluation with FSH, LH and estradiol

69-year-old woman who comes to your office referring genital bleeding of several months of evolution

We should not prescribe treatment without first ruling out organic causes


A ventricular aneurysm depresses LVEF, but does not suddenly put you into PAD

In contrast, a VSD sharply increases flow to the pulmonary bed, causing pulmonary edema, and is also one of the most frequent complications of AMI

Two days later and after a favorable evolution, he suddenly presented heart failure with acute pulmonary edema

And endocarditis would not require so many saddlebags

Dysfunction of the bioprosthesis due to probable acute endocarditis

Ischemic ASD... I do not deny that it exists, but it does not even appear in the guidelines


all the adenopathies at this level that I have seen have ended up corresponding to carcinomas of the upper aerodigestive tract.

a dermatologist (answer 1) would not ask this

I would mark 5 and rest easy
Larynx
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You have already passed the Pneumology and Digestive blocks


The correct answer is 2 (Perform chest X-ray and spirometry with bronchodilator test)

Chest X-ray and spirometry with bronchodilator test

It is probably COPD but we must confirm it and assess the severity of the obstruction with spirometry before starting treatment

He is a patient at risk for lung cancer so it is mandatory to perform a chest X-ray to rule out this or other pathologies that would justify the symptoms, although most likely they are due to the debut of his COPD

A 65-year-old man, a retired office worker and smoker of 1 pack of cigarettes a day, comes to the clinic with a persistent, generally dry cough and progressive dyspnea of 2 years of evolution which is currently grade 2


A picture of macroscopic hematuria and mild proteinuria with normal creatinine levels, accompanied by an upper tract catarrhal picture, is very suggestive of IgA nephropathy

Urine 24 h with proteinuria of 0.75 g/24 h, sediment with 10 erythrocytes per field (90% dysmorphic), no leukocyturia

Laboratory tests showed: Hb 12.8 g/dl, Hcto 39%, leukocytes 10,500/mm3 with normal formula, platelets 250,000/mm3, normal coagulation, urea 25 mg/dl, creatinine 0.8 mg/dl, ions, hepatic, lipid, albumin and total proteins normal

option 3 correct
IgA nephropathy
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He refers an upper respiratory catarrhal symptoms since 4-5 days ago for which he has taken paracetamol

A 22-year-old male presents to the emergency department with "almost black" urine for the past 12 hours


Therefore, we rule out left heart failure: EAo, dilated with DSVI and a MHO

Dilated cardiomyopathy with significant left ventricular dysfunction

a patient with clinical signs of heart failure who presents with ascites disproportionately elevated in relation to peripheral edema

Of the two we are left with, in constrictive pericarditis we have increased filling pressures in right chambers, which cause retrograde pressure increase with hepatic congestion, ascites, edema, etc


there are no defects of hepatic infiltration

it would give another symptomatology and this would be more acute

they are not in context nor is it what the author of the question wants us to think

Metastases are ruled out
Hepatic metastases
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intrahepatic tumor thrombosis
Intrahepatic tumor thrombosi
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acute hepatitis and hemochromatosis
Acute hepatitis
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acute hepatitis and hemochromatosis
Hemochromatosis
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we are being presented with a patient with Stauffer's syndrome, a paraneoplastic syndrome consisting of liver dysfunction secondary to toxic products secreted by a number of tumors (most frequently, renal cell carcinoma, like the one in this case)

Presence of hepatotoxic substances produced by the tumor

As in this case, cholestasis (elevation of alkaline phosphatase), mobilization of hepatic enzymes and lengthening of the prothrombin time indicate liver dysfunction


If I had to choose I would choose answer 5, which seems to me the least aggressive

Wilson's disease. Determine ceruloplasmin and copper in blood and urine

In the clinical examination to start a sports activity, you find a discrete hepatomegaly of normal consistency, so you request a blood test, which highlights an ASAT of 80U / l, ALAT 105 U / l, electrophoretic proteinogram with all protein fractions in normal range and negativity of serology for hepatotropic viruses

if I had to do analytical tests I would add the determination of alpha-1-antitrypsin (without CT) and markers of celiac disease, because celiac disease can also be associated with some hypertransaminemia

The minimal elevation of liver enzymes and the fact that it has a normal protein profile goes against chronicity


They describe pleural fluid parameters of transudate

if the patient is not in heart failure it is a hydropic decompensation


The picture presented to us is that of a Horner syndrome (miosis with ptosis)

the possibilities are reduced to options 3 or 4

If the patient really has ataxia, the only possible location would be the spinal cord

they specify that the patient presents gait instability

which is not justified by a Horner due to carotid dissection affecting the superior cervical ganglion, which is what they want us to believe when they talk about pain in the neck and in the eye


Both for the type of treatment and to study the prognostic factor and adjuvant treatment, it is necessary to know the different hormonal receptors (estrogen and progesterone) as well as HER2-neu

Study of hormone receptors and HER2
Study of hormone receptors and HER2
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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

Post-surgical endophthalmitis is more associated with patients in the immediate postoperative period

besides being very painful with rapidly progressive decrease in visual acuity

it is not correct
Post-surgical endophthalmitis
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ARMD usually occurs in older patients and the decrease in vision is progressive

Age-related macular degeneration, wet form

In PVD there may or may not be a slight decrease in visual acuity and the patient usually reports some discomfort or pain at the onset of the clinical picture

Retinal detachment is consistent with the clinical case

it is also a myopic patient who tend to have a special predisposition to detachment


Both the flexor carpi radialis and the abductor pollicis longus are anatomically far from the ulnar.

The palmaris longus is medial, as is the flexor digitorum profundus

answer 1
Tendon of the flexor carpi ulnaris
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The tendon that runs alongside the ulnar nerve, inserting into the pisiform, is the flexor carpi ulnaris

Tendon of the deep flexor of the fingers