he is a "retentive" patient and increasing O2 flow is highly likely to increase hypercapnia and, therefore, acidosis

the bicarbonate is not decreased, on the contrary, it is slightly increased trying to compensate the respiratory acidosis

If we knew the first blood gas and she was much worse (i.e. she was doing very well), continuing with the same medication would be an option

4: He does not reach respiratory failure by definition (pO2 60), but he has hypercapnia and slight acidosis

The trap is that they give us the initial clinical picture WITHOUT GASOMETRY and then they give us the blood gases afterwards WITHOUT CLINIC

there is no way of knowing what the evolution of the patient has been with our treatment

If the patient initially came with a blood gas with a pH of 7.05 and now has the one we are given, we are doing well (although we are not told the time interval between one thing and the other)

in this case, it could be worthwhile to continue with the same treatment

If nothing has evolved, the clinical picture is the same and the blood gas at the beginning was similar

If we decide to do something, at present we might decide to use ventilation rather than theophylline

although with "so little" alteration of pH (and even more so if we think that this is a chronic patient who may have a baseline blood gas similar to the one presented to us) it may seem "exaggerated"

We have nothing "against" theophylline (we are not told of any contraindication), but nowadays it is rare to resort to it

5: At present and -as already mentioned- taking into account that there is no formal contraindication, it is not usually used

The patient does not have respiratory insufficiency so he would continue with the same pharmacological regimen

I would add intravenous aminophylline as a respiratory stimulant, since I appreciate hypoxemia and hypercapnia

I would initiate noninvasive mechanical ventilation because he has acute hypercapnic respiratory failure with moderate respiratory acidosis

Increase oxygen flow because he has acute respiratory acidosis and hypoxemia

I would add sodium bicarbonate to correct the acute metabolic acidosis


He already takes two AV node brakers and you add a third, and are you surprised that he gets complete AV block after messing with drugs from different families but same effect (pharmacodynamics)?

Pharmacodynamic interaction of beta-blocker, digoxin and verapamil


The patient presents a good general condition with a recently diagnosed hepatocarcinoma, not giving him any type of treatment other than symptomatic and supportive at this stage would not be the right thing to do

Symptomatic and supportive treatment, since he presented an advanced hepatocarcinoma with vascular invasion and metastasis

TACE would not be indicated because of extrahepatic involvement

Transarterial chemoembolization (TACE), since the treatment increases survival in patients with advanced hepatocarcinoma

Transplantation would also not be done if he has extrahepatic disease

The appropriate treatment is liver transplantation as it is the only procedure that completely eliminates the primary tumor and avoids future complications of cirrhosis

the correct answer is 4, for all the reasons given therein

Treatment with oral sorafenib, since this is a patient with good general condition, Child A and advanced stage hepatocarcinoma BCLC-C

answers 3 and 4, both with systemic treatment (indicated because it is metastatic)

Systemic chemotherapy with doxorubicin iv since he presents disseminated disease but he is in good general condition

This scan showed the presence of 4 liver lesions (one of them up to 6 cm) with uptake pattern typical of hepatocarcinoma, tumor vascular invasion and a metastasis in the right adrenal gland


A decrease in vitamin B 12 levels is observed in patients treated with metformin

63-year-old diabetic patient whose family physician has requested a blood test to determine vitamin B12 levels

however, vitamin B 12 malabsorption, is less well known


They describe a recent diagnosis of cerebral LOE with signs of intracranial hypertension

The associated headache is typically morning headache, with increasing ICP values at night

She reports a headache that has been progressing in intensity for the past week


A 68-year-old woman who wears +4.00 diopter glasses for distance vision in both eyes

We are presented with a 68-year-old woman with moderate hyperopia and no history of cataract surgery

This is not a mere coincidence: the fact that the patient is hyperopic is important, because the eyeballs of hyperopic patients are shorter, with a certain conflict of space in the anterior segment when the crystalline lens undergoes a process of intumescence secondary to age (what patients call incipient cataract)

She consults because since a few weeks ago she has been having eye pain with headache and blurred vision at night when she is watching television in twilight

In the clinical case, moreover, the ocular and headache pain occurs in scotopic situations, or in situations of dim ambient lighting, which produces an average mydriasis to optimize the light influx to the eyeball

It is evident, therefore, that the patient suffers from primary angular closure processes that possibly self-resolve when the triggering situation ceases, and not a true acute glaucoma attack

But these intermittent angular closures are contemplated within the spectrum of glaucoma due to primary angular closure

however, patients are usually younger, or at least have a clear history of migraine, and, above all, they present symptomatologic worsening with intense sensory stimuli (photophobia and phonophobia), but symptoms are not worsened precisely in cases of dim lighting

Migraine, not being a Neurology question, can sometimes be a confounder in the usual clinic

Actinic keratitis occurs precisely in patients exposed to ultraviolet radiation that is not properly filtered before reaching the cornea

it is typical of welders (it is called welder's keratitis), skiers and other people with very intense light exposures and without adequate eye protection

Dry eye syndrome does not usually produce headache

ocular discomfort does not go beyond the persistent discomfort that patients might define as pain because of its recently more studied neuropathic component

incorrect option 4
Dry eye syndrome
Attack


You are describing a contagious impetigo


the three of them have another conditioning factor

Therefore, and for this reason alone, options 1, 2 and 5 would be discarded

a prolonged and high-dose prednisone regimen will be established

it is advisable, in addition to the non-pharmacological preventive measures, to initiate treatment in any case to minimize the secondary loss of bone mass that occurs with the administration of glucocorticoids (and, above all, in the first months)

there are no clinical risk factors for osteoporosis prior to the current disease

Assess absolute risk of fracture using the FRAX questionnaire without BMD and treat only if it is high

Assess for osteopenia on radiographs and treat if present

an appropriate attitude would be to administer calcium supplements (corticosteroids are osteopenizantes because they produce, among other mechanisms, a negative balance of this element) and vitamin D

Administer calcium supplementation (1g) and vitamin D (800 IU/day)

calcium supplementation is missing in proposal 3

The option of associating a bisphosphonate could also be considered

Start treatment with bisphosphonates and vitamin D (800 IU/day)


According to the SEGO: "Excise the entire lesion so that it can be evaluated histologically

When they speak of excision, it is synonymous with conization

as the lesion is less than 8mm deep, this is the indicated treatment

It involves excision of the entire transformation zone


Now it's time to find out how acute promyelocytic leukemia is currently treated

In this case, it doesn't score anything for the score since you have <10,000 leukocytes and >40,000 platelets

In high risk patients, it is treated with ATRA+chemotherapy

Treatment with arsenic trioxide, ATRA and supportive therapy will be initiated

As of 2017, the PETHEMA protocol for APL in low to intermediate risk patients (and/or over 70 years of age) is ATO+ATRA

One of the main causes of mortality in the induction of a promyelocyte is coagulopathy, but option 3 is totally incorrect

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

We could only mess things up even more by putting heparin!!!!

I don't know what they are explaining right now in the academies, but it is clear that they wanted you to know that many promyelocytes, since 3 little years ago, are not treated with chemotherapy


Carcinoma in situ is delimited by the basement membrane, i.e. it is not invasive yet

therefore the treatment is polypectomy, which is already done

Subsequently, an endoscopic follow-up (with biopsies) should be performed at an interval of 3 to 6 months depending on the patient's history, age and concomitant pathologies


Allopurinol is always the treatment of choice, especially in the case of tophaceous gout

Its use is second choice when uricosurics have failed

Moreover, in this case, uricosuric acid could worsen urolithiasis by increasing uricosuria


it is a pituitary tumor of more than one centimeter, which secretes prolactin and with an insufficiency of the rest of pituitary hormones

From what is described it is a macroprolactinoma

The first line treatment of choice is dopaminergic agonists

the surgical risk increases
Transsphenoidal surgery
Attack

In this case, the cavernous sinus is pressured by the mass

although when the visual field is affected, surgery may be chosen

Therefore, in this particular case, the surgical option seems more risky

Taking this into account and the fact that it is a tumor that produces high levels of prolactin, which indicates that it probably responds to pharmacological blockade, the most appropriate option would be option 1, treatment with dopaminergic agonists


A 45-year-old patient was diagnosed with HIV infection three months ago, presenting at that time with CD4 45 lymphocytes/µl and an HIV-1 viral load of 500,000 copies/ml

We are dealing with a patient with HIV infection in a situation of severe immunosuppression (<50 CD4+) and a very high viral load, who has followed the expected evolution from the immunovirological point of view after the start of treatment (after 12 weeks, the viral load has ostensibly decreased

Treatment failure and it is an opportunistic infection

although in patients with higher CV like ours, it could take longer - and the CD4+ count has begun to rise

remember that it is desirable that it becomes negative 24 weeks after the start of treatment

A negative Mantoux test does not rule out tuberculosis

A negative Mantoux test rules out tuberculosis

since in patients with severe immunosuppression it can give false negatives

however: considering the patient profile, this process will have been clinically unmasked during the immunological reconstitution and the infection is not the consequence of an incomplete immunological recovery

The diagnosis of lymph node tuberculosis is immediate when detecting "isolated acid-fast bacilli and epithelioid granulomas" in the puncture of one of the lymph nodes

This is an opportunistic infection unmasked within a picture of immune reconstitution

It is a lymph node tuberculosis related to an incomplete immunologic recovery


78-year-old woman with dementia and institutionalized is brought by her caregivers for significant abdominal pain with deterioration of general condition and abdominal distension

Typical case of acute mesenteric ischemia, which should be suspected in elderly patients with abdominal pain and distension of sudden onset, diarrhea or vomiting and who present cardiovascular risk factors, especially emboligenic heart disease

CBC shows leukocytosis, elevated hematocrit, renal failure and metabolic acidosis

suggestive of mesenteric ischemia
Mesenteric ischemia
Support


The next morning he wakes up with a feeling of gait instability and has palpebral ptosis of the left eye and anisocoria, with the left pupil being smaller than the right

Characteristic is upper eyelid ptosis and miosis of that eye

It explains ptosis and miosis of the left eye

The sympathetic nervous system innervates the Müller muscle, which is an accessory muscle to the levator of the upper eyelid

Therefore, the sphincter muscle, its antagonist, is unopposed and the balance of the pupil shifts toward miosis

If the Müller ceases to function, the eyelid descends slightly

It also innervates the iris dilator muscle

She also describes what may have happened: after a possible sudden movement while playing tennis, she has neck pain and a Horner's

We should suspect a dissecting carotid aneurysm, which is one of the best known (and most serious) causes of an acquired Horner's syndrome

The superior cervical ganglion is a ganglion of the sympathetic nervous system located in the sheath of the carotid artery, and at this level it has been affected

This occurs due to a deficit of sympathetic innervation of the orbital territory

but the pupil, if affected, should be in mydriasis

An alteration of the III cranial nerve can produce ptosis

And damage to the third cranial nerve should also produce some type of ophthalmoplegia, with diplopia

The patient maintains good visual acuity

We are told in the statement that he maintains good visual acuity

An involvement of the optic chiasm would produce a bilateral loss of vision (probably a bitemporal hemianopsia)

On the other hand, there would also be no ptosis or anisocoria

And finally, an alteration of the medulla oblongata would produce different neurological symptoms not described, and there should be no ptosis or pupillary alterations, because the third pair is located in the midbrain and the sympathetic nuclei in the spinal cord


A common bile duct cyst is a congenital pathology that usually presents clinically beyond the neonatal period

It is appropriate to have a quality image that delimits the lesion in order to decide the surgical approach

A cholangio-resonance will be performed to delimit the cyst and a laparotomy will be indicated for cyst resection and anastomosis of the biliary tract

An ultrasound shows the presence of a common bile duct cyst

A one-and-a-half year old boy comes to the emergency room with abdominal pain and jaundice


Heavy menstrual bleeding for approximately 1 year

According to the SEGO, in perimenopausal women with heavy and/or prolonged menstrual bleeding who require contraception, the levonorgestrel IUD (also called MIRENA IUD) is the first option


A 79-year-old hypertensive woman on treatment with olmesartan comes for consultation for watery diarrhea of 4 to 6 stools per day for the past two months

The diagnostic criteria for microscopic colitis are: a)Chronic or intermittent non-bloody watery diarrhea b)Colonic mucosa assessed by colonoscopy macroscopically normal or near normal c)Characteristic histopathological findings

In our case, the patient presents findings compatible with collagenous colitis (band of collagen underlying the epithelium greater than 10 microns) and lymphocytic (more than 20 intraepithelial lymphocytes)

Gastroscopy and colonoscopy were performed, both without macroscopic alterations

The treatment of this pathology is topical corticosteroids with low oral bioavailability (mainly budesonide)

Olmesartan enteropathy produces a picture similar to celiac disease and is characterized by duodenal biopsy with villous atrophy, mucosal inflammation with increased intraepithelial lymphocytes and cryptitis

Duodenal biopsies were normal, while colon biopsies showed a chronic inflammatory infiltrate of the lamina propria with an irregular band of collagen immediately below the mucosal surface epithelium with a thickness greater than 10 mm and a number of intraepithelial lymphocytes >20 per 100 epithelial cells

In this case a normal duodenal biopsy is described

but it would be interesting to keep the concept for future examinations


He was admitted to the hospital for suspected myasthenic crisis

This is a patient with decompensated myasthenia with bulbar symptoms (dysphagia) and therefore risk of respiratory muscle involvement

A 64-year-old man, diagnosed with myasthenia gravis 1 year ago, treated with low-dose steroids (3 mg/day of deflazacort) and anticholinesterase drugs, asymptomatic for 6 months, consults for mild difficulty in swallowing and evening diplopia for a few days

The respiratory symptoms correspond to an exhaustion of the muscles, first inspiratory and then accessory (the patient does not appear fatigued or tachypneic because the muscles are exhausted), progressing to a carbonic coma

Notify intensive care for suspected acute respiratory failure, to assess possible orotracheal intubation and assisted ventilation


Dementia with visual hallucinations at the beginning of the course (in the first 2 years) is very suggestive of Lewy bodies, and is the guiding symptom in these questions

His family reports recurrent visual hallucinations

If we add to this the falls and motor slowing suggestive of parkinsonism, it makes the question easier.

occasional falls and striking motor slowing

Therefore, number 3 is correct
Dementia with diffuse Lewy bodies
Support


In the male, the onset of puberty is considered normal from the age of 9 years

therefore in this case it is a premature puberty

the testicular size has not increased
we can rule out options 1 and 2
Support

we can rule out options 1 and 2
Central precocious puberty
Attack

we can rule out options 1 and 2
Peripheral precocious puberty
Attack

The onset of puberty is defined as an increase in testicular volume (greater than or equal to 4cc)

The excessive secretion of androgens produced by an adrenal tumor would cause a greater amount of hair and an increase in penile size, which our patient does not present

Therefore, the correct option is early adrenarche

An 8-year-old boy consults for the appearance of pubic hair at the base of the penis for the last 12 months

The testicle has not increased in volume and the penis has not increased in size


The determination of ADA, in the presence of a pneumonia of long evolution that does not improve with antibiotic treatment, with an effusion with abundant leukocytes and lymphocytic predominance, in which the presence of neoplasia is ruled out, with values higher than 70 UI/L, should lead us to have a high degree of suspicion about tuberculous etiology and send the pleural fluid to microbiology for tuberculosis study

Measurement of adenosine deaminase in pleural fluid


Coxiella infection is not transmitted by ticks

The way of transmission of this entity is by ticks

The contact can be with high probability at the time of delivery of an infected farm animal, in which the bacterium is disseminated in aerosols

A serologic test was performed with elevated antibody titers against phase I antigens

elevation of antibodies against phase I antigens is observed and carries a higher risk of mortality

The combination of doxycycline plus hicroxychloroquine can be used, but for chronic Q fever

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

In its acute form it also presents, generally, elevation of antibodies against phase I antigens

The treatment of choice is with doxycycline in the acute phase

Mortality in acute forms is almost nonexistent


Health care providers should prescribe the shorter treatments, which are more convenient, whenever possible

The shortest combination would be Isoniazid + Rifapentine for three months or Rifampicin for four months

Isoniazid and rifapentine, for three months

As of 2018, there are four dosing schedules for treatment of latent TB infection recommended by the CDC using isoniazid (INH), rifapentine (RPT) or rifampin (RIF)

However, the fact that he is taking acenocoumarol means that the indication for this patient is Isoniazid for 9 months, since there is interaction between the rifamycin derivatives (rifapentine and rifampicin)


we can objectively assess the severity of the disease with the use of bloodless techniques

The most important is the ankle-brachial index

answer 2 is correct
Ankle-brachial index
Support

Although the diagnosis of peripheral arteriopathy is fundamentally clinical (in this patient the picture is very typical)

Imaging techniques (arteriography, angioCT or angioMRI) are used when surgical repair of arterial occlusion is considered

Computerized axial tomography with vascular reconstruction of lower extremities


Given her circumstances and taking into account that she is exclusively breastfeeding, the best thing to do would be to prescribe only gestagens

She has a history of an emergency cesarean section 7 months ago, giving birth to a 3,550 g baby girl

He explains that she could use a gestagen-only hormonal method


It is a headache in the context of papilledema

In this case the papilledema is due to increased intracranial pressure due to a tumor

A brain MRI shows a right hemispheric mass with edema, midline deviation and signs of tentorial herniation

On examination she presents left pyramidal signs and papillary edema

it increases with Valsalva maneuvers and when bending down

The headache due to increased intracranial pressure is of positional type

so option 2 is not correct
It does not change with effort
Attack

In addition, it is predominantly morning

option 1 is correct
Morning predominance
Support

in the morning intracranial pressure naturally rises

But this headache is not a migraine headache

Migraine-type headaches may be associated with photophobia or sonophobia (answers 3 and 4)


digoxin and non-dihydropyridine calcium channel blockers (e.g., verapamil, diltiazem) are contraindicated

Heart rate slowing drugs, commonly used in atrial fibrillation, are ineffective

IV procainamide or amiodarone is preferred, but any class Ia, Ic or III antiarrhythmic drug can be used


Dehydration may be due to diarrhea of other etiologies

We have to understand that the growth of Pseudomona aeruginosa is in the culture of bronchial secretions

Because clearly the indication to perform a sweat chlorine (to rule out FQP) are the HIPOnatremic dehydrations and not the hypernatremic ones as the answer says


The laboratory reports the visualization of Plasmodium falciparum in the blood with a parasitemia level of 6%

In severe cases of Plasmodium infection, the greatest risk of mortality occurs in the first 24 hours of clinical presentation

Treatment with parenteral or intramuscular artesunate is more indicated in severe Plasmodium infection, both in adults and children and in pregnant women


Microhematuria, proteinuria and sensorineural hearing loss in a young male with a family history of women with hematuria


Calcium gluconate has no effect on blood potassium levels

therefore options 1, 2 and 3 are ruled out

Encourage the displacement of potassium from the plasma space to the intracellular space

Chelate circulating potassium to favor its hepatic elimination

Chelate circulating potassium to favor its renal elimination

Its function is to decrease the excitability of cardiac myocytes to decrease the likelihood of developing heart rhythm disorders

Antagonize the action of potassium on the myocardial cell membrane


The patient is a man with pneumonia with isolated germ in blood culture and antibiogram

According to the data provided, it is a pneumococcus sensitive to penicillin (MIC < 0.125)

treatment is started with penicillin at high doses every 4 h, despite which the fever persists

the germ is totally sensitive to the drug and the dosage is adequate

If we analyze the case carefully, the treatment should be effective

so that high concentrations of the drug should be maintained at all times, remember that the efficacy of beta-lactams is time-dependent and the antibiotic concentrations in blood should be above the MIC permanently to achieve effectiveness and avoid the production of resistance

it is not reaching the infectious focus adequately

although the antibiotic is the right one

We should rule out the existence of an empyema and drain it while continuing with the antibiotic treatment

It would rule out the presence of pleural empyema

If the dosage had not been adequate and the presence of drug resistance was possible, one option could have been to treat with ceftriaxone at high doses

I would change the treatment to ceftriaxone because of its greater efficacy

we should remember that streptococcus does not produce beta-lactamase and beta-lactam resistance is produced by another mechanism

using amoxicillin-clavulanate would not provide us with anything

I would switch to amoxicillin/clavulanic acid

With quinolone we do not increase the spectrum

I would add a quinolone to the treatment

it is evident that the poor evolution of the patient is not only a problem of time

I would continue with the same treatment, assuming it is simply a timing issue


Triplet expansion diseases, such as this one, can have the anticipation phenomenon whereby females with premutations (between 55-200 repeats) can have children with full mutations (more than 200 repeats of the triplet) and more obvious, more severe and/or earlier clinical, in both males and females (Fragile X syndrome, early ovarian failure, tremor/ataxia associated with Fragile X)

There is a phenomenon of genetic anticipation, so their offspring will present more severe and earlier symptoms

Also, on the same concept as question 44, the phenomenon of genetic anticipation


given the lack of survival benefit with early initiation of treatment, the NCCN guidelines recommend waiting and seeing, unless GELF criteria are met to initiate treatment: GELF criteria (Follicular Lymphoma Study Group)

There may be debate about whether to start Rituximab with another cytostatic drug or in monotherapy


If a conventional right hemicolectomy type surgery is performed, the chances of recurrence are higher than 30%

The age and right location data lead us to answer 4: total colectomy with ileorectal anastomosis

Total colectomy with ileorectal anatomosis


normal figures in consultation and elevated on AMPA or ABPM

The patient described is the definition of masked HT

He comes in showing blood pressure recordings taken at home over several weeks with values above 140/90 mmHg

Her blood pressure has been taken repeatedly at the doctor's and nurse's office, presenting figures below 140/90 mmHg

option 2 correct
Presents masked arterial hypertension
Support

It is not secondary HT because no study has been done to confirm it

option 1 incorrect
She has secondary hypertension
Attack

the elevated figures are maintained for several weeks

It is not isolated HT
option 3 incorrect
Support

It is not refractory HT because it has not yet been treated

Presents refractory arterial hypertension


The hormonal profile we are told is in menopausal range

the patient has systemic vasomotor symptoms

Therefore, it would be more appropriate to administer systemic estrogens

Transdermal estrogens in a continuous regimen


The treatment of choice is intramuscular adrenaline, and effectively, without wasting too much time

The first thing is INTRAMUSCULAR adrenaline NOW

A 15-month-old boy, who during dinner, after eating a bite of tortilla, suddenly presented with facial reddening predominantly perioral, habonous lesions on the trunk and extremities and cough.

She is describing egg anaphylaxis, a potentially fatal condition

On arrival at the center, the patient was conscious and, in addition to what was described above, the following were observed: suprasternal twitching, abundant watery rhinorrhea, bilateral hypoventilation without wheezing and capillary refill of less than 2 seconds

Intramuscular adrenaline should be administered without further delay

The venous route, corticosteroids, antihistamines, etc. will come later

The priority is to cannulate a venous line

Intramuscular methylprednisolone is the treatment of choice

It is a picture of urticaria associated with asthma, and should be treated with antihistamines and inhaled bronchodilators


in this case we will use bisoprolol
Bisoprolol
Support

In a patient with multiple CVRF with concomitant heart and renal failure (presumably of multiple etiology: renal hypoperfusion, arteriosclerosis...)

we must be very careful when using diuretics and ACEI/ARA-II

we can worsen renal function and/or increase potassium levels (among diuretics, spironolactone and eplerenone are "potassium-sparing")


On examination she has a palpable neck mass and a blood test shows plasma calcium levels of 15 mg/dL

therefore, the option of medullary thyroid cancer is ruled out

it does not affect the level of calcemia

Palpable mass in the neck
suspect thyroid/parathyroid pathology
Support

To think of MEN type I we should associate other pathologies (pituitary, pancreatic or duodenal tumors)

The presence of a calcemia higher than 13mgr/dl, together with dysphonia, indicates a malignant tumor (higher calcemia level and infiltration)

therefore we opt for option 1
Parathyroid carcinoma
Support

A 45-year-old woman comes to the emergency department with confusional symptoms accompanied by dysphonia


In this case the MRI already places the origin of the symptoms in the pineal gland

The most frequent tumor in this region is the germ cell tumor (answer 3)


Diagnostic Criteria for DM according to ISPAD 2018 *Classic symptoms of diabetes with blood glucose > 200mgr/dl or: * Fasting glycemia ≥ 126mgr/dl (fasting at least 8h) or * Glycemia at 2h SOG ≥ 200mgr/dl (on 2 occasions) or * HbA1C ≥ 6.5%

Already meets diagnostic criteria for diabetes mellitus


It does not explain pyramidalism
Answer 1 incorrect
Support

We would lack data to think of a Brown Sequard hemimedullary syndrome

It could explain the difficulty in dorsiflexion and plantar flexion of the foot, but not the pyramidalism

it could explain part of the clinical picture, but not the pyramidalism

It would explain the pyramidalism, but we would be missing data suggestive of this picture such as a contralateral hypoesthesia

Mononeuropathy of the right common peroneal nerve

Right hemimedullary involvement (Brown-Sequard)

Multiple mononeuropathy with involvement of the common peroneal and right posterior tibial nerve.


The answer is obviously 4
Perform electrocardiogram
Support

Had there been a fifth option it would have been that nothing needs to be done, which might have generated some doubt in the student, but since the question does not exist it is a piece of candy

Although there are many protocols on preoperative procedures, almost as many as there are hospitals, the question makes it easy by putting a very old patient, 80 years old

The age range from which it is considered mandatory to request an ECG varies between 45, 50, 60 or even some say 70 years

An 80-year-old man comes to your office for evaluation of a scheduled cholecystectomy by laparoscopy


Fracture of the roof is much less frequent

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

entrapment of the superior rectus would cause limitation for infraduction

As the mechanical function of the left inferior rectus is compromised, it would not allow to complete the supraduccion movement generating vertical diplopia, this plus the traumatic antecedent allows to suspect a fracture of the orbital floor with muscular entrapment of the inferior rectus

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


Discontinue sulfonylurea because of Risk of hypoglycemia


2 is absurd: sitting down to avoid angina?

Expectorant with rigorous rest, since decreasing myocardial oxygen demand should decrease angina

although I miss statins, ACE inhibitors and antiplatelet agents, and I have too many vasodilators (nitrates are class IIb, if my memory serves me correctly)

Medical with vasodilators and beta-blockers to avoid angina

That's like cutting down the forest to prevent fires

3 to 5 are about revascularization: since it is a single vessel and not a proximal LAD, revascularization would have to be percutaneous

Surgical revascularization of the ischemic myocardium by means of a left mammary artery bypass distal to the lesion in the diseased coronary artery

Between 4 and 5, the fifth is more complete

Therapeutic catheterization to dilate the lesion of the diseased artery and implantation of a stent in the dilated area

not only would it be necessary to dilate, but also to implant a stent

and this is what would be done in any hospital nowadays: a suboccluded artery is dilated directly

Applying the general rules of response in the MIR, if two options are similar except in one detail, the correct one is one of these

Dilatation of the coronary artery lesion by therapeutic catheterization

I would mark 5... but I would not be surprised if it was 1


the febrile fever and the limitation of mobility of the spine with the acute course give the key

We suspect spondylodiscitis
the indicated test is the MRI
Support

Pyogenic spondylodiscitis with magnetic resonance imaging (MRI)

"The most demonstrative test is magnetic resonance imaging (MRI), which is positive even in the first 2 weeks of the picture, which facilitates early diagnosis, with a sensitivity of 90%"

In addition, there is no data in the history pointing to bone metastases (oncologic history, weight loss etc)

Bone metastases with technetium bone scan

Vertebral crushing would be seen in the simple X-ray, as well as vertebral ankylosing hyperostosis and many metastases

Vertebral crush with computed tomography (CT)


Clinically, it is characterized by marked skin fragility with the appearance of erosions, vesicles and blisters after minimal trauma

Porphyria cutanea tarda (PCT) is the most common porphyria and can present with three major clinical forms: familial, sporadic and toxic

The picture is accompanied by skin fragility

Histopathologically there is a subepidermal blister with PAS+ deposits in and around the superficial dermal vessels

60-year-old male patient who refers 10 days ago the appearance of blistering lesions on dorsum of hands after sun exposure

The most frequent sites are the back of the hands and the face, i.e. the areas of greatest photoexposure


A 61-year-old woman, administrative, with a history of overweight, hypertension, dyslipidemia and metabolic syndrome, who consults for pain in both buttocks, left trochanteric region, lateral aspect of the left thigh up to the knee and left leg up to the middle third

The most common symptomatology of a patient with coxarthrosis includes: hip pain that limits ambulation, nocturnal discomfort and even at rest, hip stiffness and locking

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

Coxo-femoral osteoarthrosis presents with a negative Lasegue test

Wrong answer 2
Left coxofemoral arthrosis
Attack

Low back pain of a neuropathic nature usually presents with unilateral and distributed radiculopathy according to dermatomes

The recognized risk factors are most frequently: women, obesity, smoking and sedentary lifestyle or situations of prolonged sitting

The lumbosciatica is usually referred to the buttock, posterior aspect of the thighs and even inguinal

The clinical case describes the Lasegue maneuver or test

a provocation test that evidences radicular irritation in the lumbosacral region

Claudication due to canal stenosis typically presents with pain that worsens with trunk extension (walking, standing) and is relieved with flexion (sitting, sleeping in the fetal position...)

Wrong answer 4
Claudication due to canal stenosis
Attack


It is a semiology question that helps us to remember the types of aphasia

The following aspects should be taken into account: language emission (fluent, non-fluent, non-emission), comprehension (yes or no), repetition (yes or no) and nomination

On arrival at the hospital, an unknown atrial fibrillation is observed, and on examination she presents fluent speech with a tendency to slurred speech, poor language comprehension, inability to repeat and dysnomia

Wernicke's aphasia or sensitive aphasia has a fluent language, does not understand, does not repeat and does not nominate, just like the patient in the question

Sensory transcortical aphasia differs from sensory aphasia in that patients are able to repeat

Conduction aphasia differs from sensory aphasia in that comprehension is preserved, all else being equal

Finally, in broca's aphasia the language is non-fluent, comprehension is preserved, it does not repeat and does not nominate


The urine is normal (without hematuria, caused by the lithiasis as it progresses)

In principle, what you tell us does not fit with a nephritic colic

the Creat is normal (it can rise up to 1.9 in nephritic colic)

which, in addition, being a 45-year-old male, with no previous history, does not seem to respond to an underlying structural heart disease together with right lumbar pain, which could correspond to irritation of the pleura at the level of the right lumbar spine

In this case, we have an important risk factor for embolism, which is atrial fibrillation

The increase in LDH is non-specific and can be found in hepatic parenchymal lesions, AMI or pulmonary embolism, as well as in many other less frequent cases (tumors, myopathies, etc.)

It can also provide an alternative diagnosis in case PTE is not confirmed

it would be a very useful test
Spiral CT with contrast
Support

Spiral CT with contrast has acquired great value in the diagnosis of PTE

Doppler ultrasound would be the most useful test to diagnose the source of the emboli

it could also be a valid answer depending on what they mean by "useful"

Its limitations are the assessment of infrapopliteal thrombi and, in many cases, in patients who are not thin, of the iliac and cava veins


Treatment of the disease and its control usually improves the cutaneous lesions

Adjustment of the treatment of the disease

Biopsy skin areas away from the injured areas and prescribe opioid analgesics at the beginning

It appears that the patient has erythema nodosum lesions associated with a flare of his disease, which is common


most of these situations resolve spontaneously with conservative treatment

Initial management should be conservative, with serum therapy, nasogastric aspiration and periodic clinical, analytical and radiographic monitoring


We are presented with an adolescent patient who is overweight with pain in the thigh and knee, a length discrepancy of 1 cm and the limb in external rotation

He has been complaining of mechanical pain in the right thigh and knee for 4 months

Clinical examination reveals a 1 cm discrepancy in the length of the lower extremities and an attitude of the right lower extremity in external rotation with loss of internal rotation

This picture should automatically lead us to mark epiphysiolysis capitis femoris (proximal femoral epiphysiolysis, the fact of reading it in Latin nomina is a bit of a misunderstanding but it should not mislead us

We should think of this one because it is the most frequent and possible (correct answer 2)

If they were sequelae of hip dysplasia, it would not have this 4-month onset and the age of onset would be earlier

Sequelae of developmental dysplasia of the hip

Complications of dysplasia are dislocations and subluxations that may require surgery and avascular necrosis of the head (false answer 5)

Perthes disease occurs in younger children (4-9 years) with episodes of limping and pain in the hip and knee (false answer 4)

In a child the most typical would be a fracture at the level of the physis, not at the level of the femoral neck, so we discard 3.

Fracture of the femoral neck due to overload

As for juvenile chronic arthritis, it is a rheumatoid option surrounded by trauma options

They do not speak to us of rheumatologic factors in an analytical analysis, nor of a polyarticular picture

Perhaps we could think about this one because they talk about pain in the right knee, but this picture that they present us is limited to the right lower limb, they do not talk about other joints or fever or other accompanying systemic symptoms, so it is not an option to evaluate, especially with the other options presented to us that would be more likely in view of the picture presented to us (option 1 false)

In addition, the knee pain in this case refers to a referred pain of the hip, without involvement of the knee


Chemoprophylaxis with INH, 8-12 weeks. Repeat PT. If negative, stop treatment. If positive, perform chest X-ray to decide whether or not there is disease

If the result of the repeat PT is still negative, the child should not be tested again

If it is positive, the X-ray (or pulmonary CT in younger children) should be repeated


values above 20ngr/ml are considered hyperprolectinemia

Analytically, the estradiol concentration is below normal and the prolactin value is 12 ng/mL

For its diagnosis we will ask for a basal FSH

They tell us that the estrogen level is low

In this case we should suspect early ovarian failure

in cases of premature ovarian failure it would be elevated


At least for me, as a family physician, I usually start with the least invasive and most cost-effective tests, and in the case described, an ischemic problem in the lower limbs is the ankle-brachial index


The fact of being a photoinduced picture, the histology and the age make the diagnosis of PCT more probable (3)

The rest of the answers do not fit with the clinical picture or the histology

A 60-year-old male patient who reported 10 days ago the appearance of blistering lesions on the dorsum of the hands after sun exposure

Histopathologically there is a subepidermal blister with PAS+ deposits in and around the superficial dermal vessels

The picture is accompanied by skin fragility


Acute hemolytic transfusion reactions can occur within minutes

5-10 minutes after starting the transfusion, she begins with fever, chills, hypotension and pain in the lumbar region

Clinically they are characterized by chills, fever, urticaria, tachycardia, nausea and vomiting, lumbar pain, hemorrhage due to disseminated intravascular coagulation (DIC).....

We are told of a patient who, within minutes of starting a transfusion, presented with an acute and very serious condition (with shock)

Such an acute and severe situation only fits option 4


she does not have a family history of neoplasia

The study of relatives and the BCRA gene is not indicated

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

All breast carcinomas should be accompanied by the study of hormone receptors and HER-2 for the prognostic implications of the tumor, as well as the adequacy of the treatment of the same, since depending on the result will apply some drugs or others

Complete phenotypic study by flow cytometry

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


Suspect anorexia nervosa and inquire about intake, body image, etc

The symptoms and signs described are the biological findings associated with anorexia nervosa

A 13-year-old girl consults us for weight loss, asthenia, secondary amenorrhea and constipation

Examination revealed a temperature of 35ºC, weight below the 3rd percentile, bradycardia and orthostatic hypotension.

on the electrocardiogram a flattened T wave with ST-segment elevation and prolonged QTc

The ECG disturbances are derived from electrolyte disturbances.


This is hypertension that is detected before pregnancy or before the 20th week of pregnancy and/or persists at 12 weeks postpartum

A pregnant woman, 10 weeks pregnant, comes to the emergency room with a blood pressure of 160/105 mmHg

Chronic hypertension
Chronic hypertension
Support


That is why today, anthracyclines (does not suffer from heart) and taxanes before RT

Chemotherapy based on anthracyclines and taxanes, and radiotherapy

High grade, and no hormone receptors or her2 (the dreaded triple negative)

I was there when there were no taxanes or herceptin and I was in the trials that showed that more and more are being cured, unfortunately still not all


The SEGO in its 2006 protocol "Hypertensive disorders of pregnancy" refers that this is chronic hypertension, although diagnosed in pregnancy

This is because it has been diagnosed at 10 weeks of gestation

Above 20 weeks' gestation, we would be talking about preeclampsia (if HT + proteinuria or uterine artery pulsatility index above the 95th percentile), pregnancy-induced hypertension (only HT) or eclampsia (a form of severe preeclampsia)

The correct answer is 3
Chronic hypertension
Support


the usefulness of antidepressants in this picture has not been described

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

About 10% of cases of erythema nodosum are associated with inflammatory bowel disease, both ulcerative colitis and Crohn's disease

When associated with inflammatory bowel disease, erythema nodosum usually resolves with treatment of the intestinal flare, and recurs with disease recurrences


there would be infectious signs
1 cannot be
Support

the radiotherapy that the patient received would be oriented on the breast and not on the mandible

bisphosphonates create mandibular necrosis

it is not a case of dental root involvement

Answer 2 is possible
Osteonecrosis due to bisphosphonates
Support

3 seems unlikely to me
Osteoradionecrosis
Attack

I rule out number 4
Dental root included
Attack

5 is possible
Metastasis of breast carcinoma
Support

between two possible answers you have to always answer, and between 2 and 5, you have to check 2, which is more likely


a young patient with a frequent history of dysphagia to solids and liquids with repeated food impactions, without symptoms of heartburn and in whom oral endoscopy shows multiple concentric esophageal rings with normal mucosa (trachealized appearance)

The endoscopic appearance of trachealized esophagus is very typical of eosinophilic esophagitis, which presents with dysphagia and repeated food impactions


the answer is CT
An adrenal CT scan
Support

before doing the CT scan, ACTH should be measured and, once ACTH is suppressed, the CT scan should be done

Anyway, I think that the clinical case is poorly stated


Lichen planus is a very common dermatosis of unknown etiology characterized by the appearance of pruritic polygonal papules, with a purplish color and shiny surface, preferentially located in the distal areas of the extremities

The patient presents since 2 weeks ago a pruritic eruption consisting of multiple polygonal erythematous-violaceous papules, with flattened surface, preferentially located on the anterior aspect of the wrists, pretibial area and lumbar area

Characteristically these papules show a symmetrical distribution and are preferentially located on the anterior aspect of the wrists (Figure 1) and ankles

She also presents whitish reticulated lesions in the jugal mucosa

Oral mucosal involvement is very frequent, and approximately 75% of patients with lichen planus show an asymptomatic whitish reticulation affecting the jugal or lingual mucosa


In young contacts, chemoprophylaxis should be started even if the mantoux test is negative and repeated after 2-3 months to decide whether to continue treatment for 6 months (if it turns positive) or to stop it

Start chemoprophylaxis and repeat skin test after 3 months

A 14-year-old asymptomatic boy whose father has just been diagnosed with pulmonary TB undergoes a Mantoux test, with a negative result


Among these, less importance is given to the size of the lesion than to its degree of invasion of the intestinal wall or other adjacent structures, a criterion that must be taken into account for staging by TNM or Astler-Coller classification, which guide the indication of adjuvant treatment after the surgical approach

The size of the primary lesion and histological differentiation

Perforation or adhesion of the tumor to adjacent organs

we must know which are the poor prognostic factors in this pathology

obstruction or intestinal perforation due to the lesion, invasion of adjacent organs, elevation of tumor markers such as CEA and the histology of the neoplasm stand out


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

In a woman with delayed puberty and short stature we should always think about and rule out Turner syndrome, whose diagnosis is made by karyotyping (45X0)


We are told of a case of a 95-year-old patient with a displaced intracapsular (subcapital) hip fracture

In this case, the surgical options may be the use of cannulated screws or hip arthroplasty

Cannulated screws are reserved for cases of non-displaced fractures

Wrong answer 2
Fixation with cannulated screws
Attack

so the most indicated option would be arthroplasty, in this case hemiarthroplasty

Correct answer 1
Hip hemiarthroplasty
Support

Trochanteric pins are reserved for extracapsular fractures

Wrong answer 2
Trochanteric nail fixation
Attack

conservative treatment is only considered in patients with very low functional demand or surgical contraindication

Wrong answer 4
Conservative: bed-chair life
Attack


She suddenly presents hypotension, tachycardia, urticaria and bronchospasm after ingesting peanuts and is transferred to the emergency department

The patient is suffering from anaphylactic shock secondary to peanut ingestion

The treatment of anaphylaxis and anaphylactic shock of first choice is intramuscular adrenaline 1mg/ml (dose 0.01 mg/kg, in adults 0.5 mg maximum)

Followed by symptomatic treatment to stabilize the airway with 100% high flow O2, ensure large caliber venous access, fluid replacement and continuous monitoring (HR, BP, SatO2 , diuresis)

Intramuscular adrenaline, followed by an inhaled bronchodilator of the SABA type and intramuscular dexchlorpheniramine. Then request serum tryptase

As adjuvant treatment, an inhaled bronchodilator such as SABA, intramuscular dexchlorpheniramine or corticosteroids such as hydrocortisone IV or methylprednisolone IV can be administered

Adrenaline can be repeated at the same doses every 5 minutes a maximum of 3 times and if after 15 minutes there is no response, IV adrenaline infusion should be started, Glucagon (if treatment with beta-blockers), Atropine (if prolonged bradycardia) or Vasopressors (if refractory hypotension)

The laboratory marker that should be requested if anaphylaxis is suspected is serum tryptase in the first hour for a basal determination and another at 4-6 hours to observe its elevation curve


Although mucus is usually more frightening in the consultation, it falls within the Rome II criteria for the diagnosis of Irritable Bowel Syndrome

Expulsion of mucus in more than 25% of defecations

All the rest are typical signs of organicity

Weight loss with or without rectorrhagia

Persistence of diarrhea during the night

Presence of dermatitis and/or arthritis during the examination

since any of these data (especially age) can be found in patients who in the end have nothing, what happens is that in these cases we must always look for organicity

although I think the question is poorly phrased


On average, if 100 patients like this woman are treated with warfarin, the number of strokes is reduced by 3 (from 5.2 untreated to 3.2 treated)

Therefore, if you treat 33.3 patients like this woman with warfarin, you reduce the number of strokes by 1


In the last 2 months, onset of diarrhea with loss of 4 kg of weight

The clinical picture is typical of spondyloarthritis, and together with the digestive symptoms it is probably associated with inflammatory bowel disease


There is no data in the statement to suggest any of the other etiologies

the most frequent cause of mechanical back pain in adolescents is mechanical overload

The pain is of mechanical characteristics


You are describing a Schönlein-Henoch purpura which is a vasculitic phenomenon, so the lesions are not due to plateletopenia

Scrotal edema (sometimes even torsion of Morgani's capsid of the testis) is not exceptional in males with S. Schönlein-Henoch


83-year-old male who consults for a recurrent picture of abdominal pain in the left iliac fossa, accompanied by diarrhea of up to 6 stools per day without pathological products, of 10-15 days of evolution

They refer to a concept that has emerged relatively recently and is not present in all clinical guidelines as uncomplicated symptomatic diverticular disease

In these cases, the therapeutic trial with rifaximin is recommended, being the true number 1

On examination there is mild pain on palpation of the left iliac fossa without peritoneal irritation

The absence of acute phase reactants in the CBC suggests that she does not have acute diverticulitis at the time of consultation that would lead us to request an imaging test to rule it out

No fever or general condition was reported


The statement concisely summarizes the description of pilocytic astrocytoma

The Rosenthal fibers may confuse us as they are not very specific, and make us think, for example, of pleomorphic xanthoastrocytoma in which they can also be found

the cell morphology described (long and thin cytoplasmic processes, which are the ones that give the name "pilocytic") keeps us the first option as the correct one


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

75% of patients with radiculopathy improve with non-surgical treatment, this being the treatment of choice in the initial stages

Urgent call to the neurosurgeon for surgical evaluation

Magnetic resonance imaging is of choice in certain "red flags": fever, weight loss, nocturnal pain, persistence of symptoms despite conservative treatment and loss of strength

Preferential request for MRI and electromyogram


Although, be careful, that is what the guidelines say

Controversial question, since amiodarone (the dose is correct, 300mg), is administered after the third shock, and not after the first defibrillation

I am sure that more than one of us has administered amiodarone as soon as we have had venous access available in the event of a shockable rhythm

Administration of 300 mg of intravenous amiodarone

Administration of 150 mg of intravenous amiodarone

Administration of 1 mg of intravenous atropine


A 35-year-old healthy woman consults for asthenia

the first thing that comes to mind is that it is an arregenerative anemia, since the bone marrow has not responded with an exaltation of erythropoiesis; in this way we have already eliminated the options that speak of regenerative anemia

Central anemia, arregenerative, due to iron deficiency

Central anemia, arregenerative, due to folic acid deficiency

Peripheral, regenerative, hemolytic anemia

Peripheral anemia, regenerative, due to acute active hemorrhage

The next thing that orients us towards the cause is that it is microcytic and hypochromic, which is characteristic of iron deficiency anemia, since folic deficiency gives rise to megaloblastic anemia and active hemorrhage does not give microcytosis or hypochromia, but normocytosis and normochromia

The CBC shows microcytic and hypochromic anemia (hemoglobin 7 g/dL, mean corpuscular volume 68 fl, mean corpuscular hemoglobin 24 pg

with an elevated red cell distribution amplitude (ADE 20%)

decreased reticulocytes (0.3%, 30000/l absolute)

decreased hemoglobin content in reticulocytes (17 pg)

discrete thrombocytosis (500000 platelets)

We are almost inclined to answer 5, central arregenerative anemia due to iron deficiency...but there remains answer 1, "thalassemic trait", which makes us uncomfortable and makes us doubt if we are not going for the apparently easy thing...until we remember that in thalassemia the ADE is normal

Definitely, this girl of childbearing age has iron deficiency anemia, something quite common


that encompasses all the causes of sudden loss of consciousness and that allows us to somehow filter the diagnosis

Obviously, it is the only answer
Clinical history
Support


one of Isabel's brothers has suffered from the disease but not her father

The maternal grandmother carried the mutation in one copy of the gene on an X chromosome

her children are all healthy
we are not sure if she is a carrier
Support

Thus, Isabel has a 50% chance of having inherited the mutated gene from her mother

therefore her daughter has a 25% chance of having inherited the mutated gene from her grandmother


Endometrial biopsy
Endometrial biopsy
Support

Peri- or menopause
Endometrial biopsy
Support

Due to the high prevalence of organic pathology during this period it is necessary to systematically perform endometrial biopsy (Cornier or Hysteroscopy)


Examination in the emergency room was compatible with heart failure and the ECG showed complete atrioventricular block with an escape ventricular rate of 45 bpm

the indications for cardiac surgery include the appearance of heart failure or new conduction disorders, and in this case it presents both

Cardiac surgery for aortic valve replacement by mechanical prosthesis with antibiotic therapy according to antibiogram


both hydrochlorothiazide and lisinopril can also produce falls in the elderly, but they would generally be accompanied by dizziness


although the clinical picture is suggestive, it does not present lymphocytosis

What points to dengue, in addition to the clinical signs, is the plateletopenia

In this case I believe that the correct answer is 5

It does not seem to be an allergic exanthema from the clinical picture

certainly she does not have symptoms or clinical signs compatible with malaria or typhoid fever

platelets 75000/mm3 (htco 36%, leukocytes 4100 79% neutrophils)


the patient presents with a specific examination that would give us the diagnosis

As for Scheuermann and scoliosis, we should be given some physical data

A malignant tumor would also hurt at rest


If they are talking about a young man 20-30 years old, with tremor and dystonia, whether or not he has a family history, and especially if one of the options tells me about copper in urine

they are telling me to think of Wilson's disease

So the correct answer is 4
Copper in urine of 24
Support

I do not think of juvenile Parkinson's, nor an epileptic clinic


After one month, the clinical picture has completely disappeared

We describe a young patient with criteria of nephrotic syndrome with excellent response to corticosteroids

A complete blood test showed proteinuria of 8 g/day without microhematuria, hypoalbuminemia and hypercholesterolemia with normal renal function

He was empirically administered corticosteroids

Without biopsy, the clinical presentation and evolution suggest a nephropathy with minimal changes, which usually presents with normal or slightly altered renal function together with nephrotic syndrome, and which in 85-90% of cases resolves with steroid treatment

since although it is the most frequent cause of idiopathic nephrotic syndrome in children and adolescents, it is usually recommended to perform a biopsy prior to treatment in those older than 16 years

The age is the only data that is a bit shaky

in any case it does not admit much discussion


To associate a basal insulin dose to the treatment

Patient poorly controlled with metformin and sitagliptin with discrete cardinal symptoms (weight loss, asthenia)

The best option is insulin to control cardinal symptoms and decrease HbA1c to < 7%


A 45-year-old patient under study for possible meningitis, with fever, headache and vomiting of 2 days of evolution

we have not been told what the initial headache was like

The picture they describe of intense headache with orthostatism that disappears when lying down, although it is true that the most typical presentation is between the first 24-48 hours and in this case it is somewhat earlier

SAH does not follow this pattern in relation to orthostasis

Most likely it was not a viral meningitis, but a subarachnoid hemorrhage. For this reason, the initial headache disappears almost completely when lying down

the third, although it could be due to the time of onset (as I said a little earlier than expected), the reality is that the headache with orthostasis is so typical that it would be the most probable cause

It is necessary to look for a different cause to this headache, because it is not typical of post-lumbar puncture syndrome or meningitis

Meningitis remains the fundamental cause of her headache, as it is the same type of headache as at the onset of symptoms

Even so, the rest of the answers are improbable


The correct answer is 2
Diagnostic laparoscopy
Support

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

We are facing a suspicion of endometriosis, due to the symptoms and signs given in the statement

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

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

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


The clinical case makes a textbook description of a medial temporal seizure

The aura of ascending epigastric sensation and olfactory alteration and the subsequent description of the seizure with alteration of the level of consciousness (disconnection from the environment) with oral and manual automatisms


we can safely rule out tumor lesions, leaving doubts between answers 2 and 3

In this case, we would have to opt for IMMATURE TERATOMA, mentioning the presence of embryonic remains

At no time are atypical cellular features mentioned


it is not a complete AVB
Option 1 is ruled out
Support

The patient has a third-degree AVB and requires pacemaker implantation

Option 2 cannot be answered either: to exclude, what is said to exclude...

The absence of periods of asystole >3 seconds excludes a cardiac cause of dizziness

Likewise, there are also no pauses longer than 3 seconds that could cause cardiogenic syncope

we could suspend those that impair conduction (beta-blockers, calcium antagonists)

but drugs that facilitate, as long as we do not give him a perfusion of atropine to take home...

In option 4, stating that he has sinoatrial block is a bit of a rap: without an electrophysiological study it cannot be said

this alone would not indicate the implantation of a pacemaker.

The patient presents sinus dysfunction with sinoatrial block and requires pacemaker implantation due to symptoms

Drug treatment to increase conduction in the AV node would be indicated

The alterations detected in the ambulatory electrocardiogram are typical of patients of this age and there is no indication for therapeutic intervention

If the sinus node fails, the AV node takes over and stimulates the ventricle


A former smoker patient, previously diagnosed with COPD comes in for a checkup

In a digital hypokratitis of recent onset in a smoking patient, the first option to rule out is bronchopulmonary carcinoma

The physical examination reveals digital hypokratism of recent onset


We have a case of chronic iron deficiency anemia, without obvious bleeding

The existence of clinical symptoms suggestive of pathology of the upper digestive tract has led us to begin the study with upper endoscopy,

The first cause of iron deficiency anemia is occult bleeding of digestive origin

there is no pathology to justify the anemia

further investigation is necessary, which rules out answers 1 and 2

Administer oral iron and monitor the evolution of anemia

Treat with proton pump inhibitors and evaluate at three months

In fact the recommendations of capsule endoscopy in anemia studies are restricted

Between 3 and 4, large bowel lesions are much more common and should be ruled out before small bowel lesions

Laboratory tests: Hb6 gr/dL, MCV 69 fl, sideremia 13 micrograms/dL, ferritin 4 ngr/mL

A 55-year-old postmenopausal woman consults for asthenia and dyspnea on exertion

Gastrointestinal endoscopy: small sliding hiatal hernia with no signs of esophagitis


Weak opioids are not the initial treatment of choice

Start treatment with weak opioids that have shown evidence of halting disease progression

conservative options are exhausted before opting for surgical treatment

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

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

I instigate treatment with paracetamol, explain that the evolution is very variable and the surgical indication depends on functionality and pain control


in this case there are 1,380, which is 60% of 2,300

This is spontaneous bacterial peritonitis (SBP), defined by the presence of > 250 polymorphonuclears/mL in the ascitic fluid

It is an indication to start 3rd generation cephalosporins (ceftriaxone or cefotaxime) and albumin

Treatment with a third generation cephalosporin


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

it does not meet the criteria to require drainage by guided puncture

it is not a question of solving an obstructive condition

Discharge colostomy in this case makes no sense whatsoever,

Drainage by laparoscopic surgery is not indicated in this case

although it is a very controversial option at this time

It could be indicated in the absence of the possibility of percutaneous drainage after failure of conservative treatment

Sigmoidectomy and anastomosis is also not required

Urgent surgery with sigmoidectomy and colorectal anastomosis

In a high number of cases, after the resolution of the symptoms, the outbreaks are reduced and they can be prevented with diet and hygienic dietary habits


There is no data to suggest that he has any unstable comorbidity at the present time

surgery in less than 48 hours and orthogeriatric management is of interest

Closed reduction and fixation of the fracture within 48 hours, very early sedation, orthogeriatric management

In most cases, surgery should be performed as soon as possible, as soon as the patient is medically stabilized

There is a contraindication to surgery in patients with unstable medical comorbidity, but several studies have shown that delaying surgery beyond 48 h after admission increases mortality

This is why the ideal time to intervene in these patients is after achieving stabilization of their medical pathologies, taking care that this takes place before 48 h have elapsed

Admission to Internal Medicine / Geriatrics, progressive stabilization of comorbidities, conservative orthopedic treatment


The first option would be the correct one

it allows us to measure in a standardized way each of the cognitive domains, which will allow us to frame the patient's deficits in a specific syndrome and to monitor the deterioration with repeated scans over time

The characterization of cognitive deterioration processes is still clinical, with imaging tests (MRI or PET) being a support tool in some occasions


the inability to tiptoe and the absence of the Achilles reflex, in addition to the distribution of pain down the leg

Of our options, the cause that can produce damage to S1 is L5-S1 disc herniation


The correct answer is: 3
IgA nephropathy
Support

Since he is a young male, with a history of previous respiratory infections, a relationship between these infections and renal pathology is established

Based on this we think about IgA nephropathy, which besides being the most frequent glomerulonephritis, it is presented in most of the cases as described

A 35-year-old man presenting hematuria after respiratory infections for several years, a blood test shows creatinine 1 mg/dl with no other alterations and urine hematocytes 50/field being 80% dysmorphic, with proteinuria of 0.8 grams in 24 hours


Exudative age-related macular degeneration (AMD)

although as we said in question 215, with the new classification, we would speak of an advanced AMD in its neovascular variant

In any case, we have an elderly patient with vision loss and metamorphopsia in one eye

With that we can rule out acute posterior vitreous detachment, which does not produce visual loss, nor metamorphopsia, nor lesions in the macula

In the examination there are lesions in the macula

although it produces visual loss and is typical of older people, it does not produce metamorphopsia

And also non-arteritic anterior ischemic optic neuropathy

Non-arteritic anterior ischemic optic neuropathy

And there are no lesions in the macula but papilla edema

In central retinal artery obstruction, metamorphopsia is not particularly characteristic (visual loss and advanced age are), but the lesions in the fundus of the eye vary

In this case the lesions are totally different

In addition, the entire retina is globally affected, and a cherry-red spot may appear in the macula

In the case of arterial occlusion, there is intracellular edema that is seen as absence of hemorrhages and a whitish, pale fundus

They describe hard exudates, deep hemorrhages and localized neurosensory retinal detachment

These are the characteristic findings of neovascular (or exudative) AMD

As a clue, in the other eye there are abundant soft drusen

Drusen are the typical findings of AMD
Acute posterior vitreous detachment
Support

So he has AMD in both eyes and in the right eye it has recently become complicated by the appearance of neovascularization


By the way, it is funny that they give Chest Rx as a test to be performed..... are you telling me that a patient with fever and dyspnea will have an echocardiogram before a simple chest x-ray?

Another gift of a question, the association of S.bovis endocarditis and colon cancer


Pancreatic neuroendocrine tumor + pituitary adenoma (prolactinoma) + hyperparathyroidism (renoureteral colic in young people)

Multiple endocrine neoplasia type 1 or Wermer's syndrome


the imaging tests of choice would be ultrasound or CT

the laparoscopic approach is indicated from the start

the indication in the first episode is for those under 50 years of age, in the rest it is indicated after the second episode or in cases of persistent symptoms or suspected neoplasia

surgery in cases of perforation with peritonitis should always resect the affected segment of colon to control the focus of the infection

The safest and best performing complementary examination is the barium contrast enema

If surgical intervention is required after resolution of the acute episode, the laparoscopic approach is contraindicated

In case of acute uncomplicated diverticulitis, elective sigmoidectomy is indicated after cure of the first acute episode

A 78-year-old woman comes to the emergency department for left iliac fossa pain of 24 hours of evolution associated with fever and occasional vomiting

If generalized peritonitis occurs, the most appropriate surgical technique is the practice of a derivative colostomy without resection of the affected sigmoid segment


The correct answer is: 2
Abdomino-pelvic ultrasound
Support

Abdomino-pelvic ultrasound is undoubtedly the most specific and sensitive test for the diagnosis of polycystic kidney disease and, above all, the cheapest to demonstrate whether or not the patient's sibling has inherited polycystic kidney disease


Most of the lesions identified as L-SIL are associated with HPV infection

for this reason, it is advisable to stop smoking, as this is a factor in the progression of the said infection

The best answer to this question is number 5

On the other hand, according to the latest studies, 70% of the cytologies reported as LSIL will remit, 15% will persist and another 15% will show a more severe cytology, without being able to differentiate whether it is a biological progression or a lesion hidden in the initial cytology

Because of this, it is best to return for a follow-up at 6 months

Given the woman's personal history (more than 5 sexual partners and repeat infections) and her age

a referral for colposcopy would be ideal

Advise her to stop smoking and contraceptives and to have a control in 6 months

However, answer 5 says control in 6 months, but does not specify which control (it could be a colposcopy or cytology)


A 51-year-old woman, menopausal for a year and a half, who consults for vaginal spotting of 2 weeks' evolution

The endometrium is thickened for a menopausal woman

The endometrium is thickened and in view of the patient's symptoms, an endometrial biopsy is taken with a Cornier cannula

some guidelines put the limit at 5 and others at 3mm

And the first complementary test to perform would be an endometrial biopsy


child with otalgia, but without fever or acute inflammatory signs: it is neither 1 (recurrent acute otitis media) nor 5 (mastoiditis)

On otoscopy, a pinkish and amber eardrum is observed: there are no scales, so it is not 4 (cholesteatomatous chronic otitis media); nor perforations or adhesions, so it is not 3 (simple chronic otitis media)

Otoscopy is characteristic of serous otitis media (answer 2 correct)

on examination shows a pinkish/amber eardrum

It is known by ENT, pediatricians and family physicians that in the month following an acute otitis media, the middle ear is occupied by a mucous content whose evolution should be monitored

As history he refers that one month ago he presented an episode of otalgia, fever accompanied by irritability and that he was treated with amoxicillin 40 mg/kg/day


Lung cancer is the most frequent cause of brain metastases and in 20-30% of cases it is as a result of them that the primary tumor is diagnosed (as here)

A CT scan shows multiple metastases
Lung cancer
Support


A 24-year-old woman with a history of migraine, on propranolol and oral contraceptives, presents with severe dyspnea, hoarseness, rash, nausea and vomiting 30 minutes after taking metamizole

We are faced with an anaphylactic reaction to metamizole, in which it is necessary to act quickly or the patient could progress to cardiac arrest

In this particular case, since the patient was previously treated with propranolol

this indicates that the correct answer is 4, which includes the administration of glucagon

patients taking beta-blockers can be resistant to treatment with adrenaline and develop refractory hypotension and prolonged bradycardia

Adrenaline, dexchlorpheniramine and glucagon

The treatment of choice is IM adrenaline (only switch to IV if anaphylaxis is refractory), which has been shown to increase survival, and administration can be repeated every 5-15 minutes if symptoms do not subside

As adjuvant treatment, dexchlorpheniramine could be administered


Anisakis simplex is a parasite frequently found in fish

To avoid reactions with this parasite, a diet free of fresh and raw fish (anchovies in vinegar, smoked, salted fish, sushi, etc.) should be followed

Deep-frozen fish or fresh fish previously frozen at -20ºC for at least 5 days before cooking can be consumed, as long as it is cooked at high temperatures >60ºC (roasted, fried, etc.), avoiding raw, grilled or microwaved preparations


In this question, they insist on the age and comorbidity of the patient, as well as the time of evolution

In any case, the ideal would be to drain the gallbladder that has not gone up again, so the answer I would give would be 2

Biliary drainage by percutaneous cholecystostomy


It is a typical picture of infectious mononucleosis

Although a similar picture may occur in acute toxoplasmosis, less than 1% of acute toxoplasma infections present as mononucleosis

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

Characteristic of Epstein-Barr infectious mononucleosis is the appearance of macular rash after treatment with amoxicillin


The correct answer is to initiate treatment with L-dopa, since the clinical picture described is of a parkinsonism whose diagnosis is exclusively clinical

the performance of complementary tests does not justify delaying the initiation of treatment


20-year-old woman with ovarian tumor of 15 cm, solid-cystic, detected by ultrasound after presenting with unspecific abdominal symptoms

Mature cystic teratoma (common in the ovary of the adult female)

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 embryonic elements are found in several of the histological preparations

Mass with a large cyst occupying most of it; in its cavity there is sebaceous material and hairs

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

The tissues that compose the tumor are well differentiated (mature or adult type)

The wall, generally a few millimeters thick, has the structure of skin, with its epidermal surface towards the cavity

Because of this preponderant development of cutaneous structures it is usually called dermoid cyst


they are considered resistant to Cloxacillin, Cefazolin and there are no clinical data about the efficacy of linezolid for the treatment of systemic infection related to catheter

The Gram stain tells us that it is a staphylococcus, most of the species of this genus acquired in-hospital are methicillin resistant

This, plus the experience with vancomycin use in this setting is considered the empirical choice for vancomycin


Of the proposed drugs, the least likely options would be 3

A 72-year-old patient presents to the emergency department with severe lingual angioedema

metformin very rarely causes lingual angioedema (in March 2020 there was only one case described worldwide)

among the adverse reactions of levodopa, angioedema is classified among the very rare ones (frequency less than 0.1%)

Of the two remaining options, the drugs most frequently and classically associated with lingual angioedema are ACE inhibitors (frequency around 0.2%), and their association with simvastatin is also less than 0.1%


After a TBI in a patient who is not anticoagulated or antiplatelet, with no known risk factors for hemorrhage, and who does not present alarming data in the anamnesis or physical examination, it is not necessary to perform a cranial imaging test


This is syphilis (both by antecendent and serology) in the secondary stage

treatment is with Benzathine Penicillin 2.4 MU in a single dose

Benzathine penicillin 2.4 MU intramuscularly in a single dose


the individual has received some vaccines, has a CD4 count >100 (if lower there would be a contraindication) and works in a center that helps AIDS patients (he is equated to "health personnel")

Seasonal influenza, Td, pneumococcal and tetravalent meningitis

Td, tetravalent meningitis, pneumococcal

Triple viral, seasonal flu, pneumococcal

All four vaccines in option 1 are administrable

Seasonal influenza, pneumococcal, tetravalent meningitis and hepatitis A

Vaccine against tetanus and diphtheria: all persons should be vaccinated against these two diseases

Hepatitis B vaccine: hepatitis B and HIV viruses share the same routes of transmission, so it is common for HIV-infected patients to also be infected with hepatitis B virus

It is therefore important to know whether the HIV-infected person has markers of hepatitis B infection and to proceed with vaccination if he/she does not have them

Vaccination against hepatitis A: Hepatitis A in a person with hepatitis B, hepatitis C or other liver disease can be very serious

Since these infections are more frequent in HIV-infected patients, vaccination against hepatitis A is recommended

Vaccination against influenza: influenza in a patient with a lack of immune response is more serious and presents a greater risk of complications

annual vaccination against this disease is indicated

Pneumococcal vaccine: pneumococcal infections (especially pneumonia) are up to 10 times more frequent in HIV-infected persons than in HIV-uninfected adults

although in patients with counts below 200/mm3 the protective response is usually not sufficient

They should receive a second dose at 3-5 years of age

Although in HIV-infected adults it represents a small number of the causes of infection, vaccination is recommended

Vaccination against measles, rubella and mumps (MMR): all three diseases can become more serious in HIV-infected patients, especially measles

all of them should be vaccinated, provided that immunosuppression is not severe (count less than 200/mm3)

He is currently asymptomatic with a CD4 count above 200 cls/microliter


the main infectious foci have been reasonably ruled out

The clinical data could be consistent with a septic process

one of the most sensitive and specific markers of bacteremia (procalcitonin) is in the normal range

She has a bacterial sepsis of undetermined origin and should be given ceftriaxone and supportive care

She has bacterial sepsis of undetermined origin and should be given vancomycin, ceftacidime and supportive care

which are not very consistent with the clinical picture presented to us

among the possible complications are hemolytic anemia, meningoecephalitis (normal CSF) or Guillain-Barré sd. Guillain-Barré syndrome

this is a rare entity that occurs in certain predisposed subjects and is characterized by an uncontrolled activation and proliferation of histiocytes and T lymphocytes, which produces a state of hypercytokinemia

Another possible complication of exceptional severity would be hemophagocytic syndrome

The diagnostic criteria, revised in 2004, include persistent high fever, hepatosplenomegaly, cytopenias, hypertriglyceridemia, hyperferritinemia, and hypofibrinogenemia

Hyperferritinemia >3000 in a suggestive clinical context necessitates treatment of the patient (mainly with immunosuppressants and corticosteroids) since mortality is very high and early treatment is essential

A 16-year-old boy consults for presenting with pustular tonsillitis, fever up to 38.5°C, painful cervical lymphadenopathy, non-pruritic macular rash on the chest and mild hepatosplenomegaly, of 4-5 days of evolution

Although in this question they do not quantify the value of ferritinemia, it is a remarkable data and given that the clinical picture is suggestive, meeting the diagnostic criteria, it seems to me that answer 5 would be the most accurate

I would perform a bone marrow biopsy/aspirate and, if hemophagocytosis is confirmed, initiate treatment with immunosuppressants


Option 4 is describing to us a T4 stage, either by invasion of adjacent organs or perforation

Perforation or adhesion of the tumor to adjacent organs

The T4s carry a much higher chance of recurrence

in fact there are ongoing studies that propose prophylactic HIPEC in T4 and second look surgery + HIPEC in perforated colon tumors


In this case, with the patient being asymptomatic and with objective evidence of lack of activity, close follow-up should be performed without restarting or modifying treatment

A 50-year-old man diagnosed with polyangiitis with granulomatosis 10 years earlier and untreated for the past 5 years is asymptomatic at a scheduled check-up

In ANCA vasculitis, whatever it is, these antibodies have been shown to be related to the activity of the disease, but at no time are changes in treatment obligatory due to their levels


His blood pressure is 110/60 mmHg, heart rate 110 bpm, 90% SatO2, capillary glucose 120 mg/dl and respiratory rate 7 rpm

A 56-year-old patient is found comatose at home

we rule out hyperosmolar coma and hypoglycemia, option 2 and 4

Administer naloxone, flumazenil and hypertonic glucose

Administer thiamine and hypertonic glucose

so, although there is no history of intoxication, we have to go to the most frequent and that we can antagonize with antidotes: benzodiazepines (flumazenil) and opiates (naloxone)

but there are no data to make us suspect

If we suspect ethylene glycol intoxication, we would administer thiamine

Administer naloxone, flumazenil and thiamine


The correct answer is 3
Abdominal ultrasound
Support

the clinical description is textbook hypertrophic pyloric stenosis


It is a diabetic ketoacidosis. It must be treated with intravenous insulin, serum therapy, general measures and search for precipitating cause

Priority is iv insulin administration and serum therapy

Insulin administration should never be delayed


33-year-old patient, resident of Valencia, who consults for presenting on the right cheek an erythematous-orange plaque after an insect bite that has been growing slowly until reaching 1.5 cm and that in the last weeks has ulcerated and covered with a scammocostra

The fact that the place of residence is mentioned already gives us many clues

A "bite" that transforms into a lesion in an uncovered area with a crusty surface and that bothers little or nothing..

in the Mediterranean basin this is cutaneous leishmaniasis or oriental button

And while it is true that the lesion is < 4 cm and unique, we are told that the patient is being treated with adalimumab, an anti-TNF monoclonal antibody

With the exception of meglumine antimoniate, none of the other treatments proposed in the different options are indicated in leishmaniasis

it is clear
Intralesional meglumine antimoniate
Support


For its diagnosis it is necessary to measure the pressure of the affected compartments at rest and after activity

We present a case of chronic compartment syndrome

Determination of posterior compartment pressure immediately after activity


Question in which the clinical picture must be recognized: cardiovascular anomalies - Tetralogy of Fallot -; thymic aplasia/hypoplasia - leading to primary T-cell immunodeficiency; parathyroid aplasia/hypoplasia - hence hypocalcemia -; palatal anomalies - nasal voice; psychomotor retardation

In my opinion, just with the words "thymic dysfunction", hypocalcemia and cardiopathy, we would have to go straight to DiGeorge syndrome

22q11 deletion study (Di George or Velo-cardio-facial syndrome)

Indeed, the genetic defect is a 22q11.2 deletion (which if we know it, the better, but with the clinic it would be enough for us)

moreover, in most cases it is caused by an alteration in the PTPN11 gene, not in those mentioned in the question

Sequencing of genes related to HRAS (Noonan syndrome)

The only option with which there could be doubt is Noonan syndrome, which can also be associated with cardiopathy

but above all it is characterized by short stature, cardiopathy and bone alterations


Given this clinical picture and without having complementary tests available, the most likely diagnosis is reactive arthritis

The only problem is that the statement speaks of joint pain and not arthritis

A 40-year-old patient who comes to the emergency room with aphthous stomatitis

Reiter's syndrome (triad of conjunctivitis, urethritis and arthritis) is one of the forms in which reactive arthritis can present

In Behçet's disease oral and genital aphthous ulcers may occur but urethritis is not a feature

And the characteristic ocular condition is uveitis


Under these conditions, the treatment of choice would be surgical (myocardial revascularization surgery or by-pass)

We are talking about a patient with 3-vessel coronary artery disease and, very importantly, with severe ventricular dysfunction

since today, thanks to drug-eluting stents, the differences in terms of morbidity and mortality between by-pass surgery and angioplasty are minimal

In the case of a patient with preserved LV function, the choice of surgical vs. percutaneous treatment would be more questionable


A 60-year-old man on carbamazepine treatment for epilepsy presenting with fever (38.8°C), odynophagia, conjunctivitis, brownish skin lesions spread over a large body surface, target-like in appearance and accompanied by epidermal detachment (greater than 30%) at the slightest friction

We are dealing with a severe patient, with target lesions and Nikolsky's sign in > 30% of the body surface area

Together with the history of treatment with carbamazepine, the suspicion will be of toxic epidermal necrolysis (answer 4)

If the epidermal detachment is less than 10% then we would be dealing with Stevens-Johnson (and intermediate cases are referred to as overlap, since it is a whole spectrum)

Incidentally, we would recommend immediate admission to a major burn unit


After a good evolution in which he recovers the ability to walk, one month after suffering the hemorrhage, he presents a progressive deterioration, becoming cloudy and with difficulty to obey orders

Vasospasm as a complication of subarachnoid hemorrhage usually occurs early, in the week after the hemorrhage

She is in the moment of evolution in which vasospasm is more frequent

The progressive deterioration with alteration of the level of consciousness makes us suspect one of the complications that can occur in this condition: hydrocephalus

Subacute deterioration is most likely due to hydrocephalus

The diagnostic technique of choice in this case is neuroimaging with cranial CT

The diagnostic technique of choice is cerebral angiography

This progressive deterioration is probably secondary to aneurysm rebleeding


The key in the question is "stopping the clinical course", as Hungtinton's disease, Tourette's and Parkinson's disease do not have treatments that can stop the clinical course

a patient presenting in the second decade of life

you should always perform a study to rule out the presence of a disease whose appropriate treatment can improve neurological symptoms and stop the clinical course

progressive picture of parkinsonism, tremor, dystonia and behavioral alteration

Sydenham's chorea is typical of younger children with a history of streptococcal infection and resolution is usually spontaneous

On the other hand, in clinical cases it is recommended to rule out Wilson's disease in young patients with movement and neuropsychiatric disorders


Paralytic ileus is a failure of intestinal propulsion that appears acutely in the absence of mechanical obstruction

Therefore, parenteral administration is necessary

it is secondary to various causes and affects intestinal contractility


A 24-year-old young man who 3 days after a risky sexual contact presents numerous pustular lesions, small, very pruritic and evolving to tiny erosions affecting the entire glans and the inner face of the foreskin

Chancroid is a solitary lesion
Chancroid
Attack

Secondary syphilis usually occurs as a generalized rash or as characteristic lesions on palms and soles (syphilitic nails) with a longer latency period

Therefore, the answer is 1
Genital candidiasis
Support

which is not referred to in the question

Trichomonas balanitis is always associated with urethritis

Moreover, genital candidiasis is not necessarily sexually transmitted

However, the clinical picture suggests herpes simplex rather than candidiasis and 5 also refers to fungi

although dermatophytes do not cause balanitis

from our point of view, even if we consider 1 to be correct, the question is misleading and could be open to challenge


Prerenal acute renal failure due to NSAIDs seems the most plausible option in this case

Renal failure due to non-steroidal anti-inflammatory drugs

Tubulointerstitial nephritis due to methotrexate is less likely due to the absence of rash, fever or eosinophilia

Interstitial nephritis due to methotrexate

the anodyne urine sediment and the absence of proteinuria make these options unlikely

Although GMN and renal amyloidosis are relatively frequent in RA

Glomerulonephritis secondary to rheumatoid arthritis


In a polytraumatized patient, the first cause of shock is blood loss (hemorrhagic shock)

The guidelines to follow should always contemplate the replenishment of blood volume (if possible, with blood products as early as possible) and control of the focus

In this case, given the vital compromise, the need for transfusion is very urgent

so the indication is emergency blood transfusion (O Rh negative)

During his transfer to the hospital his vital signs improve transiently and then deteriorate on arrival at the hospital

A 34-year-old male is involved in a traffic accident and is attended at the scene of the accident

The medical personnel observe that he is pale, sweaty, has a thready pulse with a blood pressure of 90/50 mmHg, a heart rate of 127 bpm, a respiratory rate of 28 rpm and an oxygen saturation of 92%

Requires emergency blood transfusion (O Rh negative)


Angioedema is a type of profound urticaria that can be of drug etiology (not IgE-mediated)

in this case, ACEIs (such as enalapril) are considered the most frequent pharmacological cause

so in this case it would be the correct answer (if we speak in probabilistic terms)


We describe a picture of typical peripheral facial paralysis, with dysgeusia, hyperacusis and mastoid pain

Oral corticosteroids are the treatment of choice for the patient

although within the age range of multiple sclerosis debut, the presentation is usually gradual over days and the nuclear involvement of the VII cranial nerve (which could simulate a peripheral facial) would not cause dysgeusia, hyperacusis or mastoid pain

The most probable diagnosis is a demyelinating plaque in the contralateral hemiprotuberance, the most necessary complementary exploration would be a cranial MRI

In the third answer they propose us that it is a vascular picture

therefore that the facial paralysis is central

Intravenous fibrinolysis should be considered if the evolution time is less than 3h

most of the idiopathic peripheral facial paralysis (Bell's palsy) heal without sequelae


Older patient, over 50 years of age, presenting with pain and stiffness in both girdles, associated with an elevation of acute phase reactants

In this case, he is describing the cardinal symptoms of polymyalgia rheumatica

He presents all the indispensable criteria: age equal to or greater than 50 years, bilateral omalgia and increased acute phase reactants

Of the optional criteria, he presents stiffness, pain or limitation in the hip

Initial treatment is corticosteroids at medium doses

Polymyalgia rheumatica, would initiate treatment with corticosteroids


It is the classic exploration: he had a fever and pain, he had pericarditis with effusion, and now this is causing tamponade

Pericardial effusion with cardiac tamponade

Hence the hypotension (his heart cannot fill well with blood and pump), jugular engorgement and dependence on respiration to achieve preload and cardiac output (i.e. paradoxical pulse)


She has a hb of 7.4 and a MCV over 100, adding pallor and weakness

we would be dealing with a macrocytic anemia

They give to know of a patient with SLE in treatment with Hydroxychloroquine

In my opinion, the most suitable would be alternative 2

since hydroxyloroquine has been reported to decrease the absorption of folic acid

in this case, we could be dealing with an autoimmune hemolytic anemia with folic acid consumption

And for this it would be first to determine with the direct coombs


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

In the inguinal region, the lymph nodes can acquire a size of up to 1.5 cm being normal

On the other hand, there are no signs or symptoms that make us think of a sexually transmitted infection

A lupus serology since it is most likely a Treponema pallidum infection

From the clinical features it seems to be normal lymph nodes and complementary explorations should not be performed

In addition, the rest of the data of the inguinal exploration (no pain, mobile, soft, etc.) corroborates this


An individual presents with "muscle weakness" (spastic hemiparesis) of both right extremities, with hyperreflexia and Babinski's sign, along with a "facial flaccid paralysis" of the left hemiface, with inability to close the left eye or retract the left side of the mouth, in addition to other alterations

We have a right hemiparesis and involvement of the left facial nucleus, since it has affected the upper and lower facial

therefore we have a crossed clinical picture, having to think about brainstem involvement

If we have in a quick diagram where the nuclei of the cranial pairs start from: the first 4 above the pons, the next 4 in the pons, and the last 4 below the pons, we have that the facial nucleus is in the middle 4

That is, left facial nucleus, left pons, so answer 4

In the medial portion of the caudal protuberance of the left side


in principle, we should antagonize the effect of benzodiazepines


We are not given any further data on the patient except that she is in shock (tissue hypoperfusion) and on introducing a Swan-Ganz catheter we find a low cardiac index (<2), elevated PCP (25mmHg) and elevated systemic resistances (normal: 600-1200 dyne/m2)

These data are compatible with cardiogenic origin of shock


Cardiac auscultation shows a loud, intense systolic murmur, which is reduced with Valsalva maneuvers and an attenuated second tone

The data provided on the characteristics of the murmur (it DECREASES with Valsalva) and the data on left ventricular hypertrophy, lead us to the diagnosis of severe aortic stenosis

The ECG shows sinus rhythm at 72 bpm, with criteria of left ventricular hypertrophy and inverted T waves in anterior face

These data correspond to severe aortic stenosis


As this is a situation of oligometastasis and the treatments for advanced colon adenocarcinoma allow prolonged survival with good quality of life in these patients, if there is nothing to contraindicate surgery, this should be the first option

Assessment for surgical resection of the hepatic lesion

the responses are lower compared to FOLFOX or FOLFIRI plus antiangiogenic combinations

Capecitabine monotherapy, in the patient's current situation, would also not be a good starting option

there are SBRT techniques that achieve very good results

Hepatic radiotherapy could be considered

but in this case it is best to start by asking for an assessment by the surgeons and if they rule out surgery we would consider RT

although FOLFIRI+bevacizumab would also be useful

Chemotherapy with FOLFIRI (fluorouracil, leucovorin and irinotecan) plus bevacizumab