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Juan, a second year resident, attends Sofia, a 15 year old girl in the emergency room, who apparently fainted at school without losing consciousness. The patient says that she was due to take an exam, which caused her a lot of anxiety. From the interrogation, it appears that she was being bullied by her classmates and that she may have an eating disorder. Vital signs and neurological examination are normal. Juan keeps Sofia under observation while waiting for her parents to come to the service, periodically taking a look at how the patient is doing. After the initial scare, the patient seems to be increasingly animated and is very friendly. On one occasion, Juan finds her actively chatting on her cell phone. Juan tells her that it would be better for her to put the cell phone down and rest and to reassure her, he tells her that he also uses social networks a lot since college. Sofia apologizes for not knowing that she should have her cell phone turned off, and after turning it off, asks if she can make a friend request on Facebook. What do you think is Juan's best response?

There is no doubt that the doctor-patient relationship today transcends the physical environment of the consultation room. But we must not forget that we must maintain the same ethical and professional codes as in the real environment. The code of ethics Article 26-3. The clinical practice of medicine by means of consultations exclusively by letter, telephone, radio, press or internet, is contrary to the deontological norms. The correct action implies inescapably the personal and direct contact between the doctor and the patient.

PRIMARY CARE AND SOCIAL NETWORKS

After a traffic accident a 38-year-old patient is admitted to the ICU in coma. After several days the patient does not improve neurologically and a CT scan shows hemorrhagic punctate lesions in the corpus callosum and cortico-subcortical junction. What is the diagnosis?

Diffuse axonal injury produces an early and sustained deterioration of the level of consciousness (as mentioned in the case statement) without a lesion on CT scan to justify the picture. Sometimes, punctate hemorrhages at the level of the corpus callosum, corticosubcortical junction and dorsolateral portion of the brainstem are evidenced in this imaging test.

NEUROLOGY

79-year-old woman admitted for an osteoporotic hip fracture. Regarding secondary prevention of fragility fractures, point out the WRONG answer:

In osteoporosis, one of the main risks associated with the increased risk of fracture is low adherence to treatment, so answer 1 is correct. Answer 2 is found in the SER guidelines, which confirm that some studies conclude that bone remodeling markers can be useful for early monitoring of adherence and response to treatment. Answer 4 is correct because again in the SER 2019 guidelines they quote: "The current scientific evidence allows us to affirm that neither increasing dietary calcium nor taking calcium supplements alone protects against the appearance of fractures". Therefore, the correct answer to this question is option 3. Patients on pharmacological treatment for OP should use calcium and vitamin D supplements because practically all clinical trials that have demonstrated efficacy of antiosteoporotic drugs routinely include calcium supplements and cholecalciferol (vitamin D3), but not in monotherapy.

TRAUMATOLOGY

A 41-year-old man comes to the Emergency Department for three days of swelling and pain in the right knee, with functional impotence and fever Two weeks earlier he had had a self-limited diarrhea. On examination there is joint effusion, so we proceed to perform an arthrocentesis and obtain 50 cc of cloudy fluid, with decreased viscosity and the following analytical parameters: leukocytes 40. 000/microL (85% neutrophils), glucose 40 mg/dL, absence of crystals, Gram stain: no microorganisms are observed. Which of the following statements about this patient is 'CORRECT:

Gram negative does NOT rule out infection. We mark four.

TRAUMATOLOGY AND ORTHOPEDICS

A 37-year-old woman with extensive ulcerative colitis presents a severe flare-up for which treatment with prednisone at a dose of 1 mg/kg is started. After one week of treatment, the patient shows no improvement. What is the next therapeutic measure to be taken?

When a severe flare does not respond to iv corticosteroid therapy at full doses (1mg/kg body weight), it is necessary to switch to cyclosporine or infliximab. Etanercept is not approved in Europe for inflammatory bowel disease (for the time being).

DIGESTIVE TRACT

A 52-year-old patient who has been complaining of dyspnea on medium exertion for 6 months. He has not presented angina or syncope. Physical examination and diagnostic tests show a mean aortic transvalvular gradient of 55 mmHg and a calculated area of 0.7 cm². Ejection fraction of 65%. The treatment to be indicated for this patient is:

Something aortic. They give me a gradient, which without knowing the values seems somewhat high (55 mmHg!) and the area, which looks tiny to the naked eye: this is going to be aortic stenosis... And he has dyspnea. Symptomatic aortic stenosis, will the examiner want me to send him for surgery? With the guidelines in hand, that's right: this is a severe stenosis both in terms of area (<1 cm²) and mean gradient (>40 mmHg), with a preserved ejection fraction, and symptomatic. Surgical indication. If we do 1 we take away life expectancy, because we allow the ventricle to claudicate. 2 is outdated: balloon valvuloplasty? Only if the surgical risk is unaffordable, and in that case we would do 5, TAVI implantation (see [1]). But this is a 52-year-old man, who we assume has good bodywork because he walks to have dyspnea, so to the operating room. So to the operating room. A homograft? That's the Ross technique, I take the pulmonary and put it where the aortic. But it's rare, complex and only done in pediatrics. The correct thing to do is 3, without a doubt: replace with a prosthesis, preferably mechanical unless the patient has a contraindication for anticoagulation.

CARDIOLOGY

A 65-year-old woman who underwent hematopoietic precursor transplantation 30 days ago and has severe neutropenia. She starts with cough and hemoptotic expectoration in addition to fever and moderate exertional dyspnea that does not improve despite five days of treatment with amoxicillin-clavulanic acid (875/125 mg/8 h) and levofloxacin (500 mg/12 h). Chest X-ray shows multiple ill-defined pulmonary nodules, some of them cavitated. Among the following, which is the most probable diagnosis of suspicion?

Patient on her 30th post-transplant day of hematopoietic precursor transplantation, in severe neutropenia who presents with cough with hemoptotic expectoration. This picture is usually seen in infection by Aspergillus spp. We can rule out infection by Staphylococcus aureus because of previous treatment, although we do not know if it raises the response also a possible MRSA.

INFECTIOUS DISEASES AND MICROBIOLOGY

A 36-year-old male consults for conjunctival hyperemia and foreign body sensation. Which of the following pathologies does NOT correspond to the above mentioned examination?

The involvement of the preauricular node is the typical lymphadenopathy of conjunctival infectious conditions. It is true that typical bacterial conjunctivitis does not usually present with lymphadenopathy. They have a more rapid and self-resolving course and do not awaken the lymphoid response as adenoviruses typically do. Or some more atypical bacteria that produce chronic conjunctivitis, such as Chlamydia, or much more infrequent bacteria such as those responsible for Parinaud's oculoglandular syndrome (Bartonella henselae, Francisella tularensis, Sporothrix schenckii, etc). Adenopathy being very typical of adenoviral conjunctivitis, this option is the easiest to rule out. Considering that chlamydiae arouse the lymphoid response in a similar way to adenoviruses (they also produce conjunctival follicles, for example), this would be the second easiest option to rule out. Perhaps the difficult thing is to rule out oculoglandular syndrome of Parinaud, because it is a very rare disease. If we do not realize that it is an infectious disease, we could hesitate. In any case, allergic conjunctivitis is not an infectious problem. So it is not going to have adenopathy. Even if we doubt with some of the previous options (especially with Parinaud), if we stay with the basic concepts (allergic conjunctivitis does not present with lymphadenopathies) we can be right. Option 2 is the correct one.

OPHTHALMOLOGY

Ten days after performing a hemithyroidectomy on a patient with a 1.5 cm thyroid nodule you receive the following anatomopathologic report: "very cellular follicular pattern without capsular invasion and infiltrating adjacent blood vessels and nerves". Point out the correct answer:

I think the correct answer is 3 answers 2,4 and 5 are clearly false. The doubt is between 1 and 2. The statement of 1 is correct in cases of follicular carcinoma without capsular invasion a total thyroidectomy can be performed. But if there are data of poor prognosis and the possibility of metastases - as in this case - it is best to complete the thyroidectomy and perform a radioactive iodine scan to rule out metastases or treat them if they are present.

SURGERY

A 27-year-old black woman consults for the appearance of edema in the lower limbs, decreased diuresis, fever and a malar rash in butterfly wings of 20 days of evolution. Laboratory tests showed creatinine 3 mg/dl, leukopenia, hemoglobin 10.5 g/dl (normochromic normocytic), CRP 9 mg/dl and ESR 60 mm. Regarding the pathology presented by this patient, point out the correct answer:

Another question about SLE antibodies. Clinical case of SLE with renal involvement, in which positive double-stranded anti-DNA increases the risk of nephritis. As for the rest, anti-Sm are specific to SLE, ANA are detected in more than 90% of cases, and anti-centromere are typical of scleroderma.

RHEUMATOLOGY

In a woman with an epileptic seizure presenting with the following clinical features: epigastric aura, unpleasant odor, disconnection from the environment, motor automatisms (sucking, swallowing, opening and closing of one hand) and postcritical amnesia, what is your diagnostic suspicion?

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

NEUROLOGY

Ten days after performing a hemithyroidectomy on a patient with a 1.5 cm thyroid nodule you receive the following definitive report from the pathologist: "very cellular follicular pattern without capsular invasion invading adjacent blood vessels and nerves". Point out the correct answer:

I find this question a bit more difficult since you have to have clear concepts of pathologic anatomy. In any case, it is possible to exclude by exclusion and by the way the answers are expressed: Answer 2: prophylactic emptying is indicated in the medullary. Answer 4: simply by the way of expressing it, it should already have been ruled out. Answer 5: you already know that calcitonin is used in medullary carcinoma and not in differentiated carcinoma. Answers 1 and 3 are contrary, one recommends completing thyroidectomy and the other does not. The only ones in which complete thyroidectomy is not recommended are microcarcinomas measuring less than 1 cm.

ENDOCRINOLOGY

A 67-year-old woman diagnosed with an infiltrating ductal carcinoma of the breast and no family history of neoplasia. What additional studies should be performed on the tumor for its clinical-therapeutic implications?

The correct answer would be 2, HORMONE AND HER2 RECEPTOR STUDY, since positive HER2 receptors imply greater aggressiveness of the tumor but treatment with trastuzumab and positive hormone receptors would imply the use of hormone therapy. Answer 1 can be ruled out visu visu, while answers 3 and 4 should be ruled out since, being the first woman in the family with breast carcinoma, the study of the patient's relatives would not be obligatory. Likewise, e-cadherin is important for the differential diagnosis of a lobular breast carcinoma, not a ductal one.

PATHOLOGICAL ANATOMY

A parent comes to the emergency department with his 2-year-old son because he reports that he has hit his right eye while playing. Indeed, a hematoma is observed on the right eyelid, apparently of no importance. The fundus examination showed intraretinal hemorrhages not only in the eye referred by the parents but also in the other eye. It is noteworthy that the child appears drowsy and with little tone. Which of the following statements should you consider regarding this clinical picture?

Easy question in principle, but with a bit of a catch. If you have the right intuition when you read it and go straight to what you think, you will probably get it right. The problem is option 4, which can confuse us. Let's see: we have a blow to the right eye area, with a hematoma on the eyelid. So far so normal. The problem is that retinal hemorrhages appear not only in that eye (which in itself is rare, because an external blow to the eye in a child rarely causes bleeding in the retina), but also in the other eye. Therefore, something other than the blow has caused hemorrhages in both retinas. Then we are told that the child seems drowsy and with little tone. Here we already have the two keys; we have to suspect what is not mentioned in the answers, but which is what the child has: the shaken baby syndrome (shaken baby syndrome). Characteristic of this syndrome are bilateral retinal hemorrhages, cerebral edema and subdural hematoma. There may also be fracture of long bones and other problems. Numbness and hypotonia allow us to suspect intracranial complications. The cause of shaken baby syndrome is almost always abuse, so the answer is 1. Options 2 and 3 are easy to rule out: nothing indicates perforating trauma, and it does not explain the hemorrhages in the other eye. And the berlin edema is an edema of the macula and appears as a whitish lesion, which is not described in the statement. The catch is option 4. Purstcher's retinopathy can also appear in the context of the child of the shaken child, and therefore occur in the case of child abuse. Seeing these two partly related questions, we may hesitate. However, if we read answer 4 carefully, it does not tell us that if there is child maltreatment Purstcher can occur. It states that the picture described above (intraretinal hemorrhages, without other findings) is characteristic of Purstcher's angiopathy. It is not. In Purstcher's there are hemorrhages, but also cottony exudates and edema. If there are only hemorrhages, it's not Purstcher's. Here's the messy bit, but it's really well worded. If he had a Purstcher it could also be for child abuse, but he doesn't.

OPHTHALMOLOGY

A patient comes to the emergency department with erythroderma with fever and general malaise. On examination, the nails show the presence of nail pitting and distal yellowish areas in an oil stain. What is the primary disease that caused the condition?

Any of the 4 options can be the cause of erythroderma, although the description of nail lesions highly suggestive of psoriasis makes this diagnosis the most likely.

DERMATOLOGY, VENEREOLOGY AND PLASTIC SURGERY

A 54-year-old man, with a personal history of DM, hypertension and mild chronic renal insufficiency, presented with somnolence and right hemiparesis. Laboratory tests: creatinine 2.3 mg/dl, Hb 10.3 g/dl and platelets 20000 mm3, with normal coagulation. Cranial CT: ischemic lesions with microhemorrhagic necrosis. Subsequently, he began with progressive deterioration of the level of consciousness and increase of Cr, LDH and unconjugated bilirubin. Direct Coombs' test was negative. Schistocytes in smear. In view of the diagnostic suspicion, the following conduct is to be followed:

Let's see: a patient with certain history who has: - Schistocytes in smear: indicates microangiopathic anemia, red cell rupture of mechanical cause, which can be seen mainly in PTT, autoimmune hemolytic anemia and DIC. - Bicytopenia: here the causes can be very, very varied. - Elevation of LDH and Bilirubin, which indicates a massive rupture of red blood cells. - Negative direct Coombs' test: essential data, indicating that there is no antibody that sticks to the red blood cells. With these wickers we are going to weave the basket: Answer 1: it cannot be because a hemorrhagic transformation does not give such a brutal elevation of LDH and Cr, in addition to not explaining schistocytosis. Answer 2: urgent plasmapheresis... in case of thrombotic thrombocytopenic purpura, yes; I like this answer because it justifies bicytopenia, since microangiopathic hemolytic anemia is produced by rupture of red blood cells when they are fragmented by ultralong von Willebrand factor multimers in case of deficiency of the ADAMST13 enzyme, resulting in brutal platelet aggregates and the flow cytometer does not count 400 platelets, but a molondron of platelets that form a mass, hence the thrombocytopenia. It also explains the negative direct Coombs, elevated LDH and Cr. Answer 3: a situation as critical as that patient's indicates that something big is going on and I would not sit and wait for glucocorticoids to take effect...and I do not know right now what pathology gives that symptomatology and has that treatment as standard. Answer 4: looking for a trigger for DIC...it would make sense if it were not for the fact that in DIC it is VERY characteristic the consumption of coagulation factors, which is not present in this case. Answer 5: a myeloma does not give schistocytosis nor does it have this symptomatology, they would have to give other data that would support this pathology, such as bone pain and hypercalcemia...

NEUROLOGY AND NEUROSURGERY

An 8 year old boy with lameness of the right lower extremity, of insidious presentation and one month of evolution. There is no history of trauma or constitutional signs. On examination there is evidence of restriction to passive mobilization of the limb, especially in abduction and internal rotation. Of the following statements all are true EXCEPT one:

The correct answer is 3. Perthes disease is more common and has a better prognosis in younger children.

PEDIATRICS

A 40-year-old orthopedic surgeon who in a routine serology was found to have anti-HBs levels of 30 IU/l. He refers complete vaccination according to the standard hepatitis B vaccination schedule 4 years ago. It would be advisable:

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

PREVENTIVE MEDICINE AND EPIDEMIOLOGY

87-year-old man with a history of hypertension and gonarthrosis. Baseline situation with full functional and cognitive autonomy that allows him to continue living alone in the community. He is receiving regular treatment with perindopril and thiazide diuretic for blood pressure control and routinely takes ibuprofen 1800 mg/day to control the symptoms derived from his gonarthrosis. After routine control, a persistent blood pressure of 190 and TAD 80 mmHg was observed. What would be the most reasonable therapeutic modification to achieve blood pressure control?

Before intensifying antihypertensive treatment, the potential causes should be resolved. In this case we are dealing with an elderly patient with chronic treatment with NSAIDs that produces arterial hypertension secondary to renal hypoperfusion. The most reasonable option would be to withdraw ibuprofen and replace it with an analgesic from a group other than NSAIDs (paracetamol, opiates), subsequently monitoring the evolution of blood pressure.

NEPHROLOGY

A 19-year-old man consults for a 24-hour history of pain, swelling and functional impotence of the right knee accompanied by a fever of 38°C. Physical examination reveals inflammatory signs and joint effusion in the right knee. Laboratory tests showed leukocytosis with neutrophilia and elevated C-reactive protein. The syndromic diagnosis of acute monoarthritis is made. What is the most likely etiologic diagnosis?

Acute monoarthritis associated with fever, leukocytosis with neutrophilia and increased acute phase reactants does not always have a septic origin. In the absence of further information (more complete anamnesis on the current disease, risk factors, personal and family history, extra-articular symptoms or signs, etc.) it can be said that also 1 and 2 (and very exceptionally 5) could debut with a similar clinical and biological picture. With the data provided and taking into account that this is a young male, the most likely option would be bacterial infectious arthritis (that caused by mycobacteria usually have a chronic course). And above all, because of its implications, the first one to always rule out.

RHEUMATOLOGY

A 53-year-old woman consults for a fever of 15 days of evolution, without symptoms of infectious focality. On examination, a painful hepatomegaly is detected at 5 cm from the costal margin and the spleen is palpated at 14 cm from the left costal margin. The blood count showed Hb 8.5 g/dL, leukocytes 630/ml (lymphocytes 63%, monocytes 20%, neutrophils 17%) and platelets 35,000/ml. Biochemistry shows moderate elevation of liver biochemistry, LDH is normal and polyclonal hypergammaglobulinemia (3.5 g/dL) is observed in the proteinogram. He has a history of known HIV infection for 10 years and irregular adherence to antiretroviral treatment, with recent determinations of CD4 lymphocytes 350 cells/mL and HIV viral load of 154 copies/mL. For the past 3 months she has been treated for seronegative symmetrical polyarthritis with 10-20 mg/day of prednisone. Which of the following statements is correct?

Easy and quite typical question. We are told about an HIV patient with irregular follow-up of antiretroviral treatment, presenting fever, hepatosplenomegaly, pancytopenia and polyclonal hypergammaglobulinemia. All these data are suggestive of visceral Leishmaniasis, so an OM biopsy should be performed to look for amastigotes and confirm the diagnosis.

INFECTIOUS DISEASES

A 31-year-old man with no psychiatric history comes to the emergency room complaining...¨ symptoms of anxiety. Two days ago he experienced another episode of the same symptoms... .... 1 week ago he broke up with his partner... ruled out any organic pathology....:

Here it is good that they tell you their antecedents (we all have antecedents because we all have a life) and that they rule out organic pathology. That is fundamental. Let us not forget that also the hypochondriacs have body. We first eliminate the most striking "acute" personality disorder. Personality accompanies us all our lives. There are no "acute" characteristics in our personality. Depressive disorder? There is a time criterion that is not met, it may be sad, but sad is not depression (1). agoraphobia? if it was something like that we would have been told the context post-traumatic stress reaction? That's a good one. The correct term would be post-traumatic stress disorder or acute stress reaction, and according to ICD 10: "The stressor may be a devastating traumatic experience involving a serious threat to the safety or physical integrity of the patient or loved one(s) (e.g., natural catastrophes, accidents, battles, muggings, rapes) or an abrupt and threatening change in the individual's rank or social environment (e.g., loss of several loved ones, house fire, etc.). )" or more briefly: "exceptionally threatening or catastrophic nature" Breaking up with a partner I understand is hard, but not exceptional. So by elimination 5. Crisis of distress. This is a useful question, common in daily practice, and so we see that we must avoid giving a diagnosis of long evolution for a natural reaction. Diagnoses 1 to 4 would be like calling diabetic the one who has hyperglycemia after eating three muffins. Useful and realistic question.

PSYCHIATRY

A 10-year-old boy is brought to the Emergency Department because for the last 2 hours he has been involuntarily turning his neck to the right associated with marked cervical pain at each turn. The grandmother subsequently tells us that he has been vomiting since yesterday, so she gave him a syrup; what would be the most appropriate therapeutic approach?

The correct answer is 1. The anticholinergic can be administered intravenously and also intramuscularly if I am not mistaken. The occurrence of dystonia as a side effect is common in children and is one of the main reasons why pediatricians do not usually prescribe some antiemetics in children.

PEDIATRICS

A 65-year-old woman referred to the emergency department for fever and alterations in the laboratory tests: hemoglobin 11.4 g/dL, leukocytes 0.86 x103/μL,(neutrophils 41.9%, lymphocytes 55.8%),platelets 48.0 x103/μL, fibrinogen 118 mg/dL,D-dimer 20.2 μg/mL. Bone marrow examination was performed and she was diagnosed with acute leukemia with t(15;17) in 60% of the cells. Which of the following answers is correct?

It is a definitive promyelocytic leukemia with t(15;17), and as it is well known by all of you the treatment is with arsenic trioxide + ATRA. Option 1 leaves the treatment incomplete, there is only ATRA and it must be treated as long as the patient's condition allows it, whether or not there are symptoms. Option 3 3 years ago would have been the correct option but nowadays neither chemotherapy nor heparin is used. And option 4 is false because that fever is due to the leukemia itself and the priority is to start specific treatment for leukemia.

HEMATOLOGY

A 78-year-old woman with dementia and institutionalized is brought in by her caregivers for significant abdominal pain with deterioration of general condition and abdominal distension. CBC shows leukocytosis, elevated hematocrit, renal failure and metabolic acidosis. ECG shows atrial fibrillation. Abdominal tomography shows edematous small bowel loops, with intestinal and portal accumulation. The most probable diagnosis is:

This is a classic picture and the author of the question has taken care to give us enough clues so that we do not miss it. When reading this statement, multiple alarms go off: - Atrial Fibrillation: at the mir and at the ED door, any elderly person with AF and abdominal pain is emboligenic mesenteric ischemia until proven otherwise. - Acute abdominal pain, SIRS, renal failure, metabolic acidosis (ischemia!), probably an elevated lactic... - CT: The finding of portal gas is also highly indicative of mesenteric ischemia, we could also have been told of intestinal pneumatosis. Why are not the other pictures? - Perforated ulcus: We would have been told of a history of NSAID use, or a history of pain that improves with ingestion, of pneumoperitoneum on chest X-ray. - Biliary ileus: There would be a history of biliary colic or pain in the right hypochondrium, they would also speak of aerobilia in the imaging test and dilatation of the small loops with image (or not) of biliary lithiasis in the terminal ileum. - Neo sigmoidoscopy: In the myocardial imaging they would speak of weight loss, change of stool habit, pneumoperitoneum in Rx or CT and peritonitic abdominal exploration and may even be able to palpate the mass.

GENERAL SURGERY

A 9-year-old boy, asymptomatic with an innocent murmur, undergoes an ECG that documents Wolf-Parkinson-White Syndrome. Which of the following statements is FALSE?

The correct answer is 1. It is also answered with the statement that begins by saying that the child is asymptomatic. The error seems to me to be a misconception because for the study of a murmur an ECG is not usually requested but an echocardiography. Heart failure is a complication of Wolf-Parkinson-White syndrome and rarely a debut form of the disease.

PEDIATRICS

A 20-year-old woman with a 15-cm solid-cystic ovarian tumor detected by ultrasound after presenting with nonspecific abdominal symptoms. In the histopathological study of the corresponding specimen, teeth, hairs, areas of intestinal epithelium, areas of squamous epithelium (15%) and bronchial epithelium, as well as neuroectodermal and embryonal elements are found in several of the histological preparations. In reference to this case, point out the correct diagnosis:

Mature cystic teratoma is a common benign tumor of the ovary in adult women. The tissues that make up the tumor are well differentiated (mature or adult-type); apart from cutaneous structures many other tissues can be seen, particularly in a thickening or spur that eminences into the cavity, in which there are often teeth, cartilage and bone.

GYNECOLOGY AND OBSTETRICS

A 27-year-old male, a regular athlete, refers pain in the right leg after continuous running. He has visited a physiotherapist on several occasions and has been diagnosed with calf overload. Several months have passed, she has not improved and refers intense pain after physical activity that subsides with rest in the hours following exercise. What test can help in the diagnosis?

Exercise-induced compartment syndrome is an exercise-induced condition of the leg. It is characterized by reversible ischemia of the muscles of a muscle compartment. Diagnosis is made by measuring compartment pressures at rest, during exercise and after exercise (answer 2 correct). Treatment usually consists of fasciotomies of the affected compartments. Although MRI is not very useful in establishing the diagnosis, it can help in the differential diagnosis.

TRAUMATOLOGY

A 3-month-old infant correctly vaccinated for his age, who after two weeks of rhinorrhea, sneezing and coughing, is admitted for intensification of coughing spells, with cyanosis at the end of them, ending with deep inspiration or inspiratory rooster, requiring stimulation, aspiration of secretions and oxygen to recover from them. According to your diagnostic suspicion and with respect to the vaccine for this disease, all are true EXCEPT:

We are being asked about the pertussis vaccine. Option 1 is correct, it is the diphtheria-tetanus-pertussis vaccine. Option 4 is also correct, since they are inactivated microorganisms. Now we are left with the doubt between 2 and 3... Option 3 is the one that "is not true among all those proposed to us": immunity lasts about 10 years after the last dose.

PEDIATRICS

A patient who presents with problems in understanding spoken and written language, inability to name objects and repeat words that are said to him, incomprehensible fluent speech with semantic and phonemic paraphasias. This is a:

Transcortical have preserved repetition. Broca's aphasia has preserved comprehension and absence of fluent speech. Wernicke's aphasia is characterized by fluent speech (even in excess) with paraphasias and problems with comprehension, nomination and repetition.

NEUROLOGY

A 69-year-old woman comes to your office reporting genital bleeding of several months' evolution. She denies hormone replacement therapy and anticoagulation. She provides normal cervicovaginal cytology. General and genital physical examination without findings of interest. BMI of 38kg/m2. Indicate the most correct attitude:

We are being presented with a case of postmenopausal metrorrhagia. In a case like this we must rule out endometrial neoplasia, so an endometrial biopsy would be indicated, either by Cornier cannula if possible, or by hysteroscopy. A cervical biopsy is not of interest in this case since the cytology is normal and hormonal assessment is not going to be useful in the diagnosis of endometrial neoplasia. Finally, prescribing cyclic progesterone is not indicated in a postmenopausal woman.

GYNECOLOGY AND OBSTETRICS

A 45-year-old woman presents arterial hypertension (190/120 mmHg) accompanied by K 2.5 mEq/l. An abdominal ultrasound shows stenosis of both renal arteries. Indicate which treatment is contraindicated:

If the renal arteries are stenosed, blood has difficulty reaching the kidneys. That is, both are poorly perfused and can only create the pressure gradient necessary for filtration by contraction of the efferent arteriole. If we administer an ACEI, we will provoke the relaxation of this arteriole and the fall of the glomerular filtration rate. And if neither kidney filters, because both have arterial stenosis, we have a problem....

CARDIOLOGY AND CARDIOVASCULAR SURGERY

A 67-year-old woman with a history of dyslipidemia, who comes to the ED with dysuria and pollakiuria followed by fever, chills, and deterioration of general condition. On arrival she appears severe and is tachycardic, tachypneic, with blood pressure 60/40 mmHg and temperature of 39°C. Which of the following measures would NOT be included in the INITIAL management?

Patient presenting with fever+tachypnea+FC>100 = 3 criteria of SIRS (Systemic Inflammatory Response Syndrome). Reminder: sepsis is a SIRS due to infection, which leads to a decrease in SVR, resulting in a decrease in preload and stroke volume leading to hypotension. The first therapeutic measures are the administration of empirical broad-spectrum antibiotics and fluid replacement (answer 4) to try to compensate for this decrease in preload. Of choice, balanced crystalloids and albumin solutions [1] But when this is insufficient, we must try to correct the decrease in PVR by using vasoactive drugs [2]. But the vasoactive drug of choice in the context of septic shock is noradrenaline ([3], [4]) (answer 1 FALSE) A minimum of two blood cultures is mandatory (answer 3), for the diagnosis of bacteremia and facilitating a targeted antibiotic treatment. [2] On the other hand, it is interesting to determine blood lactic acid levels for two purposes: it is currently considered the best marker of tissue hypoperfusion/hypoxia and it predicts the response to treatment[2] (answer 2).

CRITICAL CARE

95-year-old woman living in a nursing home, independent for her basic activities of daily living, goes out to the garden for walks. She has a history of hypertension, dyslipidemia, osteoporosis and mild cognitive impairment. She suffers a fall when getting up at night to go to the bathroom. X-ray shows a displaced subcapital fracture of the right hip. What is the recommended treatment?

Correct Answer 1: Given that this is a displaced subcapital hip fracture, the surgical treatment we should consider is hip joint replacement, given that the injury described presents a high probability of necrosis of the femoral head. The options would be total or partial arthroplasty: in elderly patients, partial arthroplasty is preferred because it is a shorter and less aggressive surgery than total hip arthroplasty. Answer 2 incorrect: We would consider this technique in basicervical fractures and trochanteric mass lesions, not in subcapital fractures. Incorrect Answer 3: We would consider this technique in nondisplaced subcapital fractures in young patients. Incorrect answer 4: We would only consider non-surgical treatment in a patient with a very poor baseline general condition: bedridden patients with low life expectancy.

TRAUMATOLOGY

34-week primigravida with blood pressure of 165/95 and headache of two days of evolution. Laboratory tests: hemoglobin 10.5 g/dL, platelets 98,000/mm3, AST 356 IU/L (0-31), ALT 234 IU/L (0-31), LDH 878 IU/L (125-243). The laboratory is called because of the presence of schistocytes in the peripheral blood smear. She received the second dose of corticosteroids for fetal maturation 24 hours ago. On obstetric ultrasound the estimated fetal weight is in the 1st percentile for gestational age and the umbilical artery Doppler shows absence of end-diastolic flow. Which of the following is the most indicated clinical approach?

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

OBSTETRICS AND GYNECOLOGY

A 76-year-old woman with no history other than hypertension consults for painless jaundice and pruritus with anorexia. Laboratory tests show bilirubin of 12 mg/dl (9.5 direct). Ultrasound shows intrahepatic and extrahepatic biliary dilatation together with a single hepatic nodule smaller than 2 cm located peripherally on the anterior aspect of the left lobe. The CT scan confirms these findings also demonstrating the presence of a pancreatic mass of 3.5 cm. In the pancreatic head. The aspiration puncture of the hepatic nodule is conclusive for adenocarcinoma. Indicate the best therapeutic option:

This case does not seem so easy to me. It is a pancreatic adenocarcinoma with metastasis, so the treatment should be palliative, so we remove options 1 and 5. In principle she is a patient in moderately good general condition, so the ideal would be to perform a permanent biliary diversion and chemotherapy, option 4 being the one I consider most correct.

DIGESTIVE

A 64-year-old woman. Menopause at 54 years of age. Two pregnancies and eutocic deliveries. She does not take any medication. She comes to the emergency department reporting two days of vaginal bleeding with discomfort in the hypogastrium. The clinical examination performed by the gynecologist does not show any lesions in the external genitalia, vagina or cervix. Vaginal examination is inconclusive. Which of the following seems to you to be the most appropriate first diagnostic approach?

Since the most frequent cause of vaginal bleeding in postmenopausal women is urogenital atrophy, the existence of an endometrial pathology cannot be ruled out. According to the SEGO: "Abnormal genital bleeding is the main sign of suspicion that should lead us to rule out an endometrial neoplastic pathology, particularly in postmenopausal patients, or those with associated risk factors (...) Given the sign of suspicion, the performance of a transvaginal ultrasound, or in its absence transrectal, allows us to: rule out organic pathology (fibroids, polyps); measurement of endometrial thickness in a longitudinal cut. It is recommended to use a cut-off point of 3mm for endometrial biopsy in the symptomatic patient".

GYNECOLOGY AND OBSTETRICS

The parents of a 5-month-old infant come because their child, who attends day care, has been presenting for 3 days, coinciding with an upper respiratory tract infection, liquid stools numbering 4 per day, occasional alimentary vomiting, and axillary temperature of 38.3°C. He is being fed with mixed breastfeeding. On examination the infant is in good general condition, is well nourished and hydrated and his breathing is eupneic; his weight is 4,730g and has decreased by 70g with respect to the previous week. The abdomen is soft and depressible, without masses or megaliths, and the fontanel is normotensive. Except for the presence of watery rhinorrhea, the rest of the examination by organs and devices is normal. Of the following statements, indicate the answer that you consider CORRECT:

The baby is not dehydrated and is in good general condition. Try to avoid dehydration by replenishing what is being lost, avoiding drastic changes in feeding habits as much as possible. The rest of the answers touch on many of the "myths" and customs surrounding gastroenteritis. There is also no evidence of lactose intolerance (perianal irritation, frothy and acid stools, etc.) that would advise lactose-free milk.

PEDIATRICS

A 63-year-old woman comes to the emergency department reporting severe headache with signs of meningeal irritation, bilateral visual disturbances and ophthalmoplegia. A CT scan showed a 2 cm space-occupying lesion in the sella turcica compatible with pituitary adenoma with signs of intratumoral hemorrhage, with deviation of the pituitary stalk and compression of the glandular tissue. Mark which of the following answers is WRONG:

Very difficult question of pituitary apoplexy. It is a marginal topic in the MIR and also the answer is complex. Eliminating answers we are left with intervene (answer 4) or not to intervene (answer 2). In patients with hemodynamic instability, decreased level of consciousness, decreased visual acuity and extensive visual field defects, surgical decompression is recommended in the first week after symptom onset. I think the answer is 4, although it is oddly worded. I don't know if the neurosurgeon will support my answer.

ENDOCRINOLOGY

Point out from among the following the most likely complication presented by a patient operated, 20 years ago, of gastric ulcer by antrectomy and gastrojejunostomy (Billroth II) who comes to your office referring postpradial abdominal pain, abdominal distension, diarrhea and analytical data of malabsorption of fats and vitamin B12:

The statement has described the clinical features of this syndrome. It is usually a late complication (the patient was operated 20 years ago for a Bilroth II, remember that it is a partial gastrectomy, closure of the gastric stump and anastomosis of the first jejunal loop to the stump), it is accompanied by postprandial pain, abdominal distension. What has occurred is a stenosis of the afferent loop, so that biliary and pancreatic secretions do not mix with the bolus, they accumulate, produce pain that is relieved by vomiting, fat absorption is not possible (lack of pancreatic lipase), so there is diarrhea, and if associated with bacterial overgrowth, there is malabsorption of vitamin B12. If it were gastric adenocarcinoma, they would have spoken of constitutional syndrome, extradigestive manifestations (sister Maria Jose node, Krukenberg tumor, Virchow node). It is not dumping because it does not speak of vegetative symptoms (palpitations, facial flushing, etc...). Biliary reflux gastropathy is an endoscopic diagnosis, moreover it is not associated with diarrhea or malabsorption.

GENERAL SURGERY

A 32-year-old man from Cameroon consults for fever cough and left hemithorax pain of 1 month of evolution. He took amoxicillin-clavulanic acid for 1 week without improvement of symptoms. A blood test showed a white blood cell count of 8000/microL and a hemoglobin of 12.8 g/dL. Chest X-ray shows a loculated left pleural effusion occupying one third of the hemithorax. A thoracentesis shows a yellowish fluid with the following features: red blood cells 2000/µL, leukocytes 2500/µL with 90% lymphocytes, protein 4.9 g/dL, lactate dehydrogenase 550 VIL, glucose 67 mg/dL, and absence of malignant cells on cytologic study. Which of the following tests would be most useful in diagnosing the cause of the pleural effusion?

Suspicion is very high for tuberculous pleural effusion, in a young patient from an area with a high rate of TB, a lymphocytic exudate pointing to TB, lymphoma or tumor. Tumor unlikely due to age, negative cytology. Lymphoma could be but no evidence of associated nodal pathology. High adenosine deaminase in LP would point with great certainty to a pleural TB although it would be advisable to confirm the diagnosis with a pleural biopsy since it can also occur in lymphomas and empyemas of other origin.

PNEUMOLOGY AND THORACIC SURGERY

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

Currently the only effective treatment capable of modifying the natural course of respiratory allergy is specific allergen immunotherapy for a minimum of 3 consecutive years. In this patient the conventional treatment has not worked, so it is possible to escalate to specific allergen immunotherapy. It is true that it is not necessary to wait 10 years to start it since it is indicated and its use is allowed if there is clinical relevance in patients older than 5 years. Omalizumab is a biological treatment that would only be indicated in cases of severe moderate bronchial asthma secondary to respiratory allergy.

ALLERGOLOGY

A 32-year-old woman with multiple endocrine neoplasia syndrome type 2A (MEN-2A) and carrier of a mutation in RET. In a neck ultrasound a 6 mm hypoechogenic nodule with calcifications inside is identified. It was decided to perform a total thyroidectomy and cervical lymph node removal. In the macroscopic study a total of three nodules were identified, two in the right lobe of 5 and 6 mm, and one in the left lobe of 4 mm. In the microscopic study the three lesions are constituted by a uniform proliferation of rounded cells arranged in a solid pattern and accompanied by calcifications and amyloid deposits. The nuclei are not clear, nor do they show clefts or pseudoinclusions. Immunohistochemical staining for synaptophysin is positive. In the cervical lymph node clearance metastases are identified. What is the pathologic diagnosis of the lesions identified in the total thyroidectomy?

Typical medullary thyroid RET (C cells, elevated calcitonin, inherited MEN-2nd, typical MIR question).

ONCOLOGY

A 52-year-old man who consults for a second opinion on the need to perform a liver biopsy for the study of hypertransaminasemia detected two years ago in routine company analyses. His family history includes the death of his father of an unidentified etiology of epatic cirrhosis. Asymptomatic and performing social and work life without limits. He denies alcohol consumption. Physical examination shows metallic skin pigmentation and minimal non-painful hepatomegaly. The rest of the physical examination was normal, body mass index 23. Laboratory tests showed the following results: billirubin, albumin, transaminases AST and ALT, normal blood count and prothrombin time: glycemia 150 mg/dl; serum ferritin 950; transferrin saturation >45%, negative for hepatotropic virus. Normal abdominal ultrasound. He has undergone HFE genetic study being homozygous for the C282Y mutation. What would be the best recommendation with the available information?

This is a patient who already has a diagnosis of hemochromatosis, due to a positive genetic study and data of iron overload (IST >45% and elevated ferritin). Biopsy would be useful if the diagnosis is uncertain or if we would like to assess liver involvement that is not suspected with this analysis. The treatment of choice is phlebotomy.

DIGESTIVE SYSTEM

Mariano is a 53-year-old man who comes to your office reporting that he has been feeling very unwell for several years. He relates his discomfort to a behavior that he finds absurd but that he is unable to avoid. This behavior, which she always does when she comes home from work, consists of turning the doorknob of the bathroom on the upper floor of the house before doing anything else, even before greeting her family. Sometimes he has tried to resist doing this but has only succeeded in distressing himself and delaying the behavior for a few minutes. This behavior that Mariano performs in an incoercible and automatic way is what is called:

In this question they ask for the name of the symptom, not the disease, so therefore the correct answer is compulsion. According to the DSM-5, a compulsion is a repetitive behavior (e.g., washing hands, tidying up, checking things) or mental act (e.g., praying, counting, repeating words silently) that the subject performs in response to an obsession or in accordance with rules that must be rigidly enforced. The goal of the behaviors or mental acts is to prevent or decrease anxiety or discomfort, or to avoid some feared event or situation; however, these behaviors or mental acts are not realistically connected with those intended to neutralize or prevent or are clearly excessive.

PSYCHIATRY

Previously healthy 10-month-old infant with acute gastroenteritis of one day's evolution and signs of mild dehydration, without blood or mucus in the stool and without oral tolerance. What is the initial treatment of choice in our environment?

The infant presents with acute GEA without signs of alarm or severe dehydration. The first step would be to try oral tolerance with oral rehydration saline and continue with normal feeding if well tolerated. Answer 1 may give rise to doubts, due to the fact that the statement says that the patient "does not tolerate the oral route". In this case, intravenous rehydration could be started... but it would not be advisable to leave the patient on an absolute diet for 8 hours, nor a subsequent astringent diet, so I prefer answer 2. The rest of the treatments do not provide any benefit.

PEDIATRICS

A 77-year-old man with a history of type 2 Diabetes Mellitus was diagnosed 2 years ago with mild cognitive impairment. At that time a Minimental (Folstein) 28/30, abbreviated Yesavage Test 14/15, a CBC with normal TSH and maturation factors along with negative LUES and HIV serologies and a magnetic resonance imaging (MRI) showing diffuse cortical atrophy predominantly in the posterior area. The patient was accompanied by his wife, who reported a slow progressive evolution of memory impairment (e.g., sometimes confused with insulin doses). There are no hallucinations or behavioral disorder. Current Minimental is 24/30 and Yesavage test 14/15, there is no neurological focality, tremor or tone or gait disorders on physical examination. Two months ago he came to the emergency department after a mild traumatic brain injury due to an accidental fall (the only one in 2 years) and a CT scan was performed which did not provide new information compared to the previous MRI. What is the most likely diagnosis in this patient?

This case describes an Alzheimer's disease with insidious onset of short-term memory problems. Clinically it can be distinguished from other options by the absence of behavioral problems (typical of frontotemporal dementia) and hallucinations (early in Lewy body disease). Vascular dementia is diagnosed by criteria that include deficits in memory and two other cognitive areas with consequent functional impairment, but cerebral vascular disease based on history, examination and/or neuroimaging tests, which are not indicated in the case. Creutzfeldt-Jacob disease is mostly rapidly progressive and usually presents with other clinical, abnormal neurological examination and MRI alterations.

NEUROLOGY

A 27-year-old woman referred to a gynecology office for evaluation, reporting dyspareunia for about 8 months, along with dyschezia and occasional rectorrhagia coinciding with menstruation for 3-4 months. She also reports dysmenorrhea for years, which she controls well with ibuprofen. She has been trying to get pregnant for 16 months without success. In the gynecological examination she only shows pain when pressing on the posterior vaginal fornix. Which test do you consider would allow you to reach a diagnosis of certainty of her pathology?

The clinical case presented is a woman of childbearing age (27 years) presenting dyspareunia + dysmenorrhea + infertility, which should lead us to think of endometriosis. The clinical history and ultrasound give a diagnosis of suspicion, but the diagnosis of certainty is given by direct observation (with or without associated biopsy) of ectopic endometrial tissue implants, either by laparotomy or laparoscopy.

GYNECOLOGY AND OBSTETRICS

The daughter of an 82-year-old woman consults us because she has found her mother more confused than usual. The patient is diagnosed with moderate Alzheimer's disease. She also has AF, depression and osteoarthritis. She has been receiving stable treatment for 3 years, including digoxin, acenocoumarol, fluoxetine for the last 4 months and ibuprofen for the last month for joint pain. On examination, her blood pressure is 130/80, heart rate 48 bpm and respiratory rate 10 rpm. Which of the following is the most likely cause of the increased confusion?

The most likely cause is a digitalis intoxication, which would produce this slowing of conduction, which is seen in the heart rate. Probably secondary to renal failure due to ibuprofen toxicity (but this is a bit of a stretch).

ANESTHESIOLOGY, CRITICAL CARE AND EMERGENCY MEDICINE

A newborn of 37 weeks gestational age, with no pathological findings in the prenatal ultrasound, presents in the examination performed in the delivery room a "stop" to the passage of the nasogastric tube. Chest and abdominal X-ray showed an atresic esophageal pouch, with normal gastrointestinal pneumatization. After a diagnostic evaluation that ruled out other anomalies and being in a stable respiratory condition, surgical intervention was decided. On what basis was the priority to intervene in this patient based?

The correct answer is 3. The fact that there is intestinal aeration points to the existence of a fistula of the lower esophageal segment with the trachea or with a bronchus. In this case, pulmonary complications are frequent due to the passage of gastric contents into the airway.

PEDIATRICS

A 46-year-old man with bipolar disorder is brought to the emergency department after an over-ingestion of lithium carbonate. Examination reveals severe tremor, ataxia, dysarthria, myoclonus and fasciculations. Lithemia is 4.1 mEq/L (toxicity > 1.6 mEq/L). Which of the following therapeutic options would be most indicated?

We are dealing with a case of severe lithium intoxication (lithemia > 3.5 mEq/L is life threatening), therefore, the therapeutic option of choice is to start hemodialysis urgently. Remember that activated charcoal is NOT indicated in lithium intoxication.

CRITICAL CARE

A patient with a history of febrile illness and chest pain comes to the hospital with dyspnea and tachypnea. On physical examination his blood pressure is low, jugular venous pressure is elevated with a deep descending sinus "X" and he has a paradoxical pulse. What pathology should you suspect?

Paradoxical pulse is a drop in blood pressure > 10 mmHg during inspiration; it represents an exaggeration of the physiological phenomenon consisting of inspiratory lowering of BP (normal up to 10 mmHg). In cardiac tamponade, inspiration, which causes an increase in blood flow to the right chambers, increasing their volume, secondarily causes a displacement of the interventricular septum to the left, so that the left heart lodges and expels less blood during systole and the pulse, therefore, decreases. In a normal heart this exaggerated displacement, caused by the pressure exerted by the tamponade on the RV free wall, does not occur. Sinus X represents the systolic collapse of the venous pulse, i.e., the pressure drop due to atrial relaxation (also partly due to a downward displacement of the RV base during systole). Sinus Y represents the diastolic collapse of the venous pulse, i.e., the pressure drop that occurs from the moment blood enters the tricuspid valve into the ventricle. In cardiac tamponade, the deep sinus X is characteristic. In constrictive pericarditis, the deep Y sinus. For all these reasons, the correct answer is 5.

CARDIOLOGY AND VASCULAR SURGERY

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

Blood gases can be misleading since a normal pH may suggest that there is no disturbance of acid-base balance, instead it is masking a double disturbance in opposite directions as in this case. The patient presents with respiratory acidosis (PaCO2 60 mmHg; normal to 50) and compensatory metabolic alkalosis (bicarbonate 36 mmol/l; normal to 28). This is the typical blood gas of the patient with COPD and compensated chronic respiratory failure.

NEPHROLOGY

A 30-year-old woman comes to the clinic reporting anxiety, weight loss of about 6 kgs and a feeling of "nervousness" in the last three months. Physical examination showed tachycardia, hyperreflexia and absence of goiter. TSH values are < 0.01 microU/mL, T4 is elevated and thyroglobulin levels are decreased. A scan reveals an absence of uptake in the thyroid region. What seems to you the most likely diagnosis?

Patients with this disorder voluntarily or accidentally ingest excessive amounts of thyroid hormone, resulting in hyperthyroidism in the absence of goiter. In contrast to all other causes of hyperthyroidism, serum thyroglobulin is not elevated and is almost always low or at the lower limit of normal. The fundamental doubt we had with ovarian teratoma (ovarian struma) which is a rare variant of mature monodermal teratoma composed of thyroid tissue described at the beginning of the 20th century. It is so named when the teratoma is predominantly composed of mature thyroid tissue (at least 50%, in order to be classified as struma ovarii). It represents between 2.5 and 5% of ovarian teratomas. In itself, it is a benign tumor, but in up to 5% of cases it can develop a malignant transformation of its elements, classically referred to as malignant struma ovarii. Mostly, the neoplastic tissue developed is a papillary carcinoma, less frequently it corresponds to follicular carcinoma. This malignant transformation arises mostly from classical forms of struma, but is extremely rare in cases of mature cystic teratomas. Its behavior is similar to that of other primary ovarian tumors, tending to metastasize to the peritoneal cavity and hematogenously to bone, liver and brain. The mean age of presentation of thyroid carcinoma on struma ovarii is between 42.9-44 years and between 21 and 63 for the papillary carcinoma variant. Clinically, the predominant form of presentation is as a pelvic mass or abdominal pain (45%), less frequently hyperthyroidism (5-8%) or ascites (17%). It is postulated that the ovarian thyroid tissue in the struma is autonomous in the production of thyroid hormones, so it is essential to measure serum thyroglobulin levels in patients affected by hyperthyroidism, as they point to the extrathyroid production of thyroid hormone.

ONCOLOGY (ECTOPIC)

For the third time in the last 6 months an 84-year-old man with advanced dementia is admitted to a hospital for aspiration pneumonia. He has lost 9.5 kg in the last 10 months. He has a pressure ulcer in the sacrum. He does not communicate verbally, does not ambulate and is dependent for all activities of daily living. His wife cares for him at home and does not want to place him in a nursing home. A swallowing study indicates that he chokes on all types of food consistencies. The hospital physician suggests tube feeding. The patient's "Advance Living Will" states that his wife is the representative decision maker regarding his medical care and that he does not want extraordinary measures to prolong his life including artificial nutrition. Which of the following is the most appropriate recommendation for this patient:

This is perhaps the least scientific of this year's MIR questions, since its answer is based on the interpretation of a law, which is also of an autonomous nature. Probably the spirit of the examiner wants to reflect this law, in an extreme case. Let's see, starting from article 11 of Law 41 /2002, of November 14 (1), basic law regulating patient autonomy and the rights and obligations regarding information and clinical documentation (B.O.E. No. 274, of November 15) of a national nature, in Castilla-La Mancha there is Law 6/2005, of July 7 (2), of Castilla-La Mancha, on the Declaration of Advance Directives in matters of one's own health. (D.O.C.M. No. 141, of July 15) and Decree 15/2006, of February 21 (3), of the Registry of Advance Directives of Castilla-La Mancha (D.O.C.M. No. 42, of February 24). In the summary published by the JCCM (4) it says: "The declaration of advance directives (also known as advance directives or living will) is the written manifestation of a capable person who, acting freely, expresses the instructions to be taken into account regarding the health care he/she wishes to receive in situations that prevent him/her from communicating his/her will personally, or regarding the destination of his/her body or organs once death has occurred. In our declaration of advance directives, we can refer to: 1. The expression of personal values, in order to help in the interpretation of the document itself and to guide physicians in making clinical decisions. 2. Instructions about the care and treatment related to our health that we may or may not wish to receive. 3. We may appoint a representative to act as an interlocutor with the responsible physician or health care team to ensure that the instructions contained in the declaration are carried out. 4. We may also include our decision regarding organ donation. In these cases, the authorization of the family will not be required for the removal or use of the donated organs". It thus seems clear that the intended response is 5.

PALLIATIVE CARE

A 22-year-old boy with hyposmia presents lack of development of secondary sexual characteristics and infertility. Bilateral testicular volume of 4 mL. Analytically, EST-I 1.2 U/L (vn 5-15); LH 0.6 U/L (vn 3-15); testosterone 100 ng/dL (vn 300-1200), prolactin normal. State your proposed treatment to achieve fertility:

This is a Kallman syndrome (hypogonadotropic hypogonadism + olfactory disturbance). Triptorelin is a GnRH agonist, which by continuous action reduces FSH and LH, and is used in sex hormone-dependent cancers, as well as precocious puberty. Bromocriptine is a dopaminergic agonist used in hyperPRL (he has normal PRL), pituitary tumors... We stay between 1 and 3. To induce testicular maturation, pulsatile GnRH with pump, hCG or FSH+hCG can be used. LH is not used as a treatment, it would be stimulated by intermittent GnRH.

UROLOGY

95-year-old woman living in a nursing home, independent for basic activities of daily living, goes out to the garden for walks. She has a history of hypertension, dyslipidemia, osteoporosis and mild cognitive impairment. She suffers a fall when getting up at night to go to the bathroom. X-ray shows a displaced subcapital fracture of the right hip. What is the recommended treatment?

Displaced hip fracture, Garden III-IV. Surgical treatment. Hip hemiarthroplasty. Option 2 treatment for pertrochanteric fractures. Option 3. Non-displaced fractures. Option 4. Non ambulatory patients with minimal pain and high surgical risk.

TRAUMATOLOGY

A 26-year-old single man is brought in by his family because he has been refusing to leave his home for 3 months. The reason given by the patient is the belief that he has an asymmetrical jaw and a crooked face. According to the patient, this situation is progressive and he looks more and more deformed when he looks in the mirror. He is ashamed of his appearance, so he does not want to go out, he gets very anxious when he sees his image and he cannot stop thinking about his deformity all day long. He has consulted several maxillofacial surgeons but they tell him that he does not have facial asymmetry and refer him to a psychiatrist. The patient's diagnosis is:

Another simple question with an immediate answer, which offers no doubt. It describes a patient worried about a non-existent physical defect, whose concern distresses him and prevents him from leaving the house. As a psychiatry resident, I wish the MIR questions in my specialty were a bit more thought-provoking and in-depth, although I know that the seconds you will have saved by marking the fourth one directly are very valuable.

PSYCHIATRY

A 70-year-old female patient is admitted to the ICU after suffering anterior AMI treated by coronary angioplasty and stent placement in the anterior descending artery. Four days later, she suddenly presents hypotension that requires vigorous volume support, initiation of vasoactive drugs, orotracheal intubation and connection to mechanical ventilation. Physical examination revealed a murmur not previously present. Suspecting a mechanical complication of the infarction, transthoracic echocardiography showed pericardial effusion. Mark the CORRECT answer:

Mortality is not so low, the oximetric jump occurs in the case of septum rupture, as well as fremitus (hence the correct answer is 3) and complications can occur up to the first week.

CRITICAL, PALLIATIVE AND EMERGENCY CARE

A 76-year-old man consults for cognitive impairment, slowness and clumsiness of movements, of eight months of evolution. The family reports that the patient had visual hallucinations, so his primary care physician prescribed low doses of risperidone, with a significant worsening of motor status. In view of these data, what is the most likely diagnosis?

The correct answer is 2 because it presents the case with the typical symptoms of dementia due to Lewy bodies, being the guiding symptom visual hallucinations. Progressive cognitive impairment, parkinsonian motor signs (inferred from clumsiness of movements) and hypersensitivity to neuroleptics even in small doses are also mentioned.

NEUROLOGY

A 64-year-old man with a history of hypertension and ischemic heart disease comes to the emergency department for oppressive chest pain while watching television. In the ED triage consultation, T. art values of 155/95 mmHg and a capillary O2 saturation of 95% are detected. Which of the following is the most correct course of action?

If the ECG shows ischemic changes, we will obviously treat the patient in the emergency room and notify the cardiologist. If not, you will be treated as if it were angina and observed, with serial enzymes and treatment in the observation area.

ANESTHESIOLOGY, CRITICAL CARE AND EMERGENCY MEDICINE

Faced with a 49-year-old man, asymptomatic, with a family history of a father who died of prostate cancer, who in a routine company control is identified a PSA (Prostate Specific Antigen) of 5.9 ng / ml, with a ratio of free PSA / total PSA of 11% and that a rectal examination shows increased consistency in the right prostatic lobe, what is the following clinical indication?

The patient has a PSA >4 and a palpation with increased consistency, which implies the need for a transrectal ultrasound-guided biopsy to diagnose whether it is Benign Prostatic Hyperplasia or Prostate Cancer.

UROLOGY

A 19-year-old male with no past history of interest comes to the emergency department because after a respiratory infection he presents with asthenia, malaise, oliguria and headache. Physical examination: BP 210/120 mmHg, fundus with hypertensive retinopathy grade III. Laboratory tests: Hb 7.4 g/dl, platelets 85,000/mm3, 2-3 schistocytes in the peripheral blood smear, LDH 950 IU/ml, serum creatinine 8.75 mg/dl. Urine system: proteinuria 300 mg/dl, sediment 15 red blood cells per field. ADAMTS-13 levels are normal. Given these findings, what would be your main diagnostic suspicion?

Difficult question. The patient presents with thrombotic microangiopathy (TMA) with acute renal failure. This points to HUS, TTP, drug-induced TMA, or TMA mediated by complement, coagulation, or metabolism. Normal ADAMTS-13 levels rule out TTP (incorrect choice 1). The absence of gastrointestinal symptoms rules out typical Shiga toxin HUS (incorrect choice 4). Pneumococcal infections can also cause HUS, although it is rare and more so in adults. The history of respiratory infection (not specified, it could be pneumococcal pneumonia) together with the absence of DIC data (no mention of bleeding or altered coagulation tests) makes me think of atypical HUS (option 2 correct).

NEPHROLOGY

Faced with sudden-onset obsessive-compulsive disorder (OCD) in a 9-year-old boy who also presents with tics and chorea as neurological manifestations, infection by:

There is a large literature on this subject. It never ceases to amaze us the strange ways of biology and that the axiom "the longest is the right one" is fulfilled in this case.

PSYCHIATRY

79-year-old woman admitted for an osteoporotic hip fracture. Regarding secondary prevention of fragility fractures, point out the WRONG answer:

There are doubts regarding the efficacy of calcium or vitamin D administered in monotherapy for the treatment of osteoporosis; they point out that "administered together they seem to have a certain degree of efficacy in the prevention of non-vertebral fractures, which is clearer in people who are deficient in them, as may be the case of elderly people living in residences. There is practically no evidence of their efficacy in the prevention of vertebral fractures.

TRAUMATOLOGY

A 60-year-old woman diagnosed with chronic bronchopathy, diabetes mellitus, hypertension and treated for 4 months with Omeprazole, Metformin, Salbutamol, Ipratropium Bromide and Enalapril 20 mg + Hydrochlorothiazide 25 mg comes to your office for fatigue, decreased appetite, with slight dyspnea and occasional cough, variable stools, sometimes soft and without urinary symptoms. Blood tests show leukocytes 10,000/mm³, Ht 35%, MCV 80, Glucose 150 mg/dl, Urea 80 mg/dl, Creatinine 1.6 mg/dl, Sodium 133 mEq/l and Potassium 2.9 mEq/l. What is the most likely cause of hypokalemia?

The correct answer is: 4. Antihypertensive. In particular, hydrochlorothiazide, as a thiazide, is primarily responsible for this patient's hypokalemia.

NEPHROLOGY

A 55-year-old asthmatic patient comes to the ED with an exacerbation. One hour after administration of supplemental oxygen and two nebulizations of salbutamol the patient does not improve. On examination, he breathes at 42 rpm with supraclavicular pull v with scattered inspiratory and expiratory wheezing. Peak flow has decreased from 310 to 220 L/min. A blood gas drawn with 28% oxygen shows a p02 of 54 mmHg and a pC02 of 35 mm Hg. Which of the following do you think is LEAST indicated?

In a severe asthma crisis all options are indicated or may be indicated before more aggressive options. In the case of a bad evolution with acidosis etc., the patient would be tributary to invasive medication.

PNEUMOLOGY

If a patient reports having for months now enlargement of the tongue, with no other alterations of the tongue causing constant biting, which disease would you think of the following:

Question shared with ENT. Amyloidosis is a localized or systemic deposition of fibrillar proteins. It can be primary or secondary. The most frequently affected organs are the kidneys and the heart. Sometimes amyloid deposits appear on the tongue which can produce macroglossia.

DERMATOLOGY

A 55-year-old man, father of a celiac child, with iron-deficiency anemia and a recent increase in the stool rhythm, has been tested negative for HLA-DQ2 and HLA-DQ8 alleles. Which diagnostic test is the most appropriate in this case?

Middle-aged male with iron deficiency anemia and increased number of stools, a colonoscopy should be done to rule out colorectal cancer!!! If the HLA is negative it is very unlikely to be celiac disease (high negative predictive value).

DIGESTIVE SYSTEM

A 66-year-old man reports daily heartburn since youth, which he treats with alkalis. An upper endoscopy shows mild erosive esophagitis and displaced squamous columnar junction approximately 7 cm. The esophageal biopsies showed mild erosive esophagitis and a columnar squamous junction displaced approximately 7 cm from the most proximal portion of the gastric folds. Biopsies of the distal esophagus reveal that the normal squamous epithelium has been replaced by intestinal-type columnar epithelium with low-grade dysplasia What is the most appropriate management option for this patient?

This patient presents Barrett's esophagus with low grade dysplasia. I do not like the question, since not being with acid production inhibition the dysplasia may be conditioned by inflammation and not be real. In any case, Barrett's esophagus should follow endoscopic surveillance and lifelong PPI treatment or antireflux surgery to prevent progression. The correct answer is 4.

DIGESTIVE

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

Polymyalgia rheumatica. Classic example I suppose, and it is seen in the clinic in droves. Older woman with normocitic anemia and clear ferrokinetic pattern of chronic disorder (hyposideremia but hyperferritinemia). The only one that fits, and it fits perfectly, is number 3; they only needed to give us a high ESR. 1: if it is a recent loss, the MCV could remain normal, but the ferritin should be affected, and certainly not elevated. 2: the same. If it is due to Fe malabsorption, ferritin should be low. And if it were due to B12 malabsorption, the MCV would be clearly higher. 4: 70 tachycardia and normal MCV. This one is too much.

HEMATOLOGY

A man has a partial deletion in the dystrophin gene (chromosome Xp21) which causes the semiology of Becker muscular dystrophy. He goes to the genetic consultation with his wife, to assess the risks of transmission of the disease. What correct information will be provided in the course of the genetic counseling?

It is the male who presents the disease, which we are told is X-linked, so there are only two options left: 2 and 3. 2 is not because the males will receive the Y chromosome from the father and the X from the mother, who is healthy, so the daughters will be able to carry the disease (correct option 3).

GENETICS AND IMMUNOLOGY

A 65-year-old woman with a history of joint pain and under treatment with anti-inflammatory drugs is referred for anemia. In the complementary studies she presented red blood cells 3,164,000, Hto. 32%, Hb 11g/dl, MCV 69 fl, Leukocytes 7800, Platelets 370,000, CRP 0.29 mg/dl, Fe 20ng/ml, Ferritin 18 ng/ml, Glucose 105 mg/dl, GOT, GPT, GGT, Alkaline F, total Bilirubin, Cholesterol, Creatinine, Calcium and Phosphorus normal. Negative antitransglutaminase and antigliadin antibodies. Gastroscopy: hiatus hernia of 3 cm, the rest without alterations. Colonoscopy: up to cecum, isolated diverticula in sigma. Intestinal transit without alterations. Ultrasound of the abdomen without alterations. Which of the following examinations do you consider most appropriate to complete the study?

It is a study of iron deficiency anemia with normal gastroscopy and colonoscopy, having ruled out possible celiac disease. We have yet to see jejunum and ileum, so we will have to perform a capsule endoscopy. In iron deficiency anemia, a digestive cause must always be ruled out.

DIGESTIVE SYSTEM

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

Amyloidosis presents with proteinuria usually in the nephrotic range, and has a more chronic course. GMN associated with rheumatoid arthritis characteristically alters the sediment, and renal failure due to NSAIDs has a more chronic course, with papillary necrosis. Thus, given the course and the alterations described, interstitial nephritis due to methotrexate is more likely, which is more directly toxic than allergic, hence the absence of pyuria, eosinophilia, fever or other hypersensitivity data.

NEPHROLOGY

A 45-year-old patient who presents with a first episode of low back pain of 3 weeks' evolution that prevents him from carrying out his normal life. She does not refer trauma or other underlying pathology. In the physical examination there is no neurological deficit. Which imaging test would be indicated?

A first episode of acute low back pain (less than 6 weeks duration), does not require imaging tests in the absence of "red flags" that may indicate an underlying process, such as a fracture, infection or malignant tumor.

TRAUMATOLOGY

A 45-year-old woman diagnosed with stage IV breast cancer with multiple bone metastases on hormonal treatment and iv bisphosphonates. She comes to your office referring intense bone pain (VAS=7), in several locations without associated neurological symptoms and exarcerbations of pain (VAS=9) several times a day that force her to remain at rest. In the treatment with ibuprofen (600 mg every 8 h) and tramadol (150 mg per day), what treatment would you consider most appropriate in this patient to improve the pain?

The correct answer is 4 because if the patient has bone metastases and may suffer fractures we can control inflammatory pain with ibuprofen and it will also help us to use the antalgic synergy. We should change the treatment to a major opioid and treat the disrruptive pain vigorously since she is at almost the maximum pain she can bear.

PRIMARY CARE

A 71-year-old patient, smoker of 2 packs of cigarettes/day for 50 years, with good quality of life and no other pathologic history of interest, consults for cough and hemoptotic expectoration. Physical examination revealed no significant pathological findings. Chest X-ray showed a mass of 4x3.4 cm lower right, a finding that was confirmed in the thoracoabdominal CT scan, which located the lesion in the lower lobe and found no adenopathy or metastasis. Bronchoscopy showed an infiltrating lesion in the right basal pyramid, biopsied as a well-differentiated squamous cell carcinoma. As for respiratory function tests, the FVC is 3,300 cc (84%) and the FEV 1 is 2,240 cc (80%). What should be the next step to follow in this patient?

1 and 5: These are diagnostic tests, they are meaningless since you have already made the diagnosis. 2: Age should not be a limiting factor, especially considering that it is only 71 years old, but especially because the patient's "quality of life" is good (and I put "quality of life" because it is a term used erroneously, it is supposed to mean that he maintains a good functional level). 3: Presents a very mild respiratory limitation, does not require such a test. 4: Is the correct one.

NEUROLOGY AND THORACIC SURGERY

A 76-year-old woman with no history other than hypertension consults for painless jaundice and pruritus with anorexia. Laboratory tests show a bilirubin level of 12 mg/dl (with 9.5 direct bilirubin). Abdominal ultrasound shows dilatation of the intrahepatic and extrahepatic biliary tract, together with a single 2 cm nodule located peripherally in the anterior aspect of the left lobe. CT scan confirms the findings, also demonstrating the presence of a 3.5 cm mass in the head of the pancreas. Fine needle aspiration confirms the diagnosis of adenocarcinoma. Indicate the best therapeutic option:

I think the correct answer is 4, although both lesions are resectable, pancreatic adenocarcinoma with synchronous hepatic metastases has no surgical indication because it does not prolong survival and has a high morbidity. Surgical bypass has more complications than placing a self-expanding metallic prosthesis that has a median patency of 6 months which is similar to the median survival of a patient with hepatic metastases of pancreatic adenocarcinoma.

SURGERY

A 72-year-old woman presents to the hospital with oppressive chest pain of 2 hours' duration. Blood pressure is 68/32 mm Hg, heart rate is 124 beats/min, respiratory rate is 32 breaths/min, oxygen saturation is 91% with oxygen at 50%, bilateral crackles on pulmonary auscultation. An ECG shows a subepicardial lesion in the anterior face, with a specular image in the inferior face. Chest X-ray shows bilateral alveolar pattern. What is your therapeutic decision?

Perform urgent coronary angiography.

CARDIOLOGY AND VASCULAR SURGERY

A 57-year-old patient had an acute myocardial infarction and has a blood test with cholesterol 312 mg/dl, LDL 241 mg/dl, HDL 29 and normal TG. He smoked 30 cig/day, was not obese, his blood pressure was 145/90 mm Hg and he did not have diabetes. When asked about family history, he mentioned that an uncle on his mother's side died suddenly at 53 years of age. Which answer do you agree with the most?

Question on a fashionable topic in recent years: dyslipidemia; I would answer it by rule out. The treatment for hypercholesterolemia is statins so we rule out answers 2 and 4. The statin in a patient with cardiovascular disease (such as an AMI) is a lifelong treatment (we discard 1) since it is not taken until LDL levels are normalized. Between 3 and 5, 5 is more complete as it includes treatment and control of other risk factors. Ruling out secondary dyslipidemia is easy with the patient's clinical history and a blood test with thyroid function.

ENDOCRINOLOGY

A 45-year-old woman, mother of 3 children, attends an early diagnosis consultation. Cervicovaginal cytology is compatible with a high-grade squamous intraepithelial lesion. Which of the following options would you choose?

The correct answer is 2. According to the 2014 SEGO Oncoguide on cervical cancer prevention, when a cytology shows a high-grade squamous intraepithelial lesion, the action to be taken is a colposcopy, with or without biopsy depending on the findings (regardless of the patient's age and parity).

GYNECOLOGY AND OBSTETRICS

A 58-year-old man referred a 3-week history of progressive, mildly painful skin lesions on his left arm. It had started as an erythematous lesion on his left thumb. He had visible reddish striae as connecting lines between the lesions. The patient had no fever or other general symptoms. He had been working in his garden but did not remember any injuries. The etiologic diagnosis was made by culture of a skin biopsy. What is the most likely causative agent of this process?

The lesions with sporotrichoid or lymphocutaneous pattern described may correspond to sporotrichosis or aquarium granuloma, so the first two would be ruled out. The history of having been working in the garden points more to a sporotrichosis, although the fact that the question asks for the "causative agent" and not the name of the disease misleads a little, so that if we consider sporotrichosis in reality the answer should be Sporothrix schenckii Despite this, knowing that this question will be correct for many examinees although it is poorly worded -which cancels it directly- the challenge will not be promoted.

DERMATOLOGY, VENEREOLOGY AND PLASTIC SURGERY

An 87-year-old man with a history of hypertension and gonarthrosis. Baseline situation with full functional and cognitive autonomy that allows him to continue living alone in the community. He is receiving regular treatment with perindopril and thiazide diuretic for blood pressure control and routinely takes ibuprofen 1800 mg/day to control the symptoms derived from his gonarthrosis. After routine control, a persistent blood pressure of 190 and TAD 80 mmHg was observed. What would be the most reasonable therapeutic modification to achieve blood pressure control?

One of the mechanisms that produce the hypotensive effect of ACE inhibitors such as perindopril is the increased action of vasodilator prostaglan-dins on the kidney, which decreases hydrosaline retention and therefore increases diuresis and lowers blood pressure. NSAIDs inhibit prostaglandin synthesis and decrease renal perfusion, thus antagonizing the hypotensive effect of many antihypertensives, including ACE inhibitors. Therefore, the preferable thing to do in this patient, before increasing the medication, is to change the ibuprofen for paracetamol, which does not have this effect, and to re-evaluate it later.

NEPHROLOGY

A 34-year-old man referred to the clinic for persistent LDL cholesterol levels above 250 mg/dL. The patient is asymptomatic but on examination there are whitish indurated spots on elbows, knees and eyelids. His BP is 135/85 mmHg. Her father died of myocardial infarction at the age of 48 years. The fasting blood test shows a total cholesterol of 346 mg/dl, LDL cholesterol of 278 mg/dl, HDL cholesterol of 42 mg/dl, triglycerides of 130 mg/dl and glucose of 93 mg/dl. Regarding the disease from which this patient suffers, one of the following statements is FALSE. Point out which one:

This is a heterozygous familial hypercholesterolemia. We must know how to recognize the disease and know the criteria. It seems to me to be of high difficulty.

ENDOCRINOLOGY

A 52-year-old woman consults for having noticed during the previous week a yellowish discoloration of the conjunctivae. She does not refer to risky sexual behavior or epidemiological history of risk of viral hepatitis. She does not consume alcohol or hepatotoxic drugs. She reports a one-year history of generalized pruritus, asthenia, dry mouth and absence of lacrimation with no known cause. Rest of the anamnesis without pathological data. Physical examination showed scratching lesions conjunctival jaundice and non-painful hepatomegaly. The patient brings a blood test carried out in his company with the following pathological results: total bilirubin 3 mg/dl alkaline phosphatase 400 UI sedimentation rate 40 mm at the first hour. Indicate which would be the best recommendation to establish the etiological diagnosis of the patient's condition:

A middle-aged woman with Sjögren's-like symptoms (absence of lacrimation, dry mouth), with hyperbilirubinemia, jaundice and hepatomegaly, makes us think of primary biliary cirrhosis. To diagnose it we will use antimitochondrial antibodies (AMA IgG). Therefore, it would be answer 1.

OPHTHALMOLOGY

A 39-year-old man who in the last 3 months has had two episodes of wide and involuntary jumping movements of the left limbs, which in about two minutes lead to loss of consciousness. In the neuroradiological study a right frontal expansive lesion suggestive of cerebral glioma was found.How would you classify this patient's epilepsy?

They refer to a partial seizure that is followed by loss of level of consciousness, so strictly speaking it would be a symptomatic complex partial seizure, not a secondarily generalized partial seizure (which occurs when tonic-clonic movements extend to the rest of the extremities). For this reason the most correct option would be two because it does not specify that it is a simple symptomatic partial seizure, but leaves open the possibility that it is a simple or complex symptomatic partial seizure.

NEUROLOGY

A 66-year-old man with a history of ankylosing spondylitis of long evolution. He presents proteinuria of 6 grams per day with hypoalbuminemia and edema. In the urinary sediment no hematuria is detected. His plasma creatinine is 1.6 mg/dL and his glomerular filtration rate is 45 mL/min. Glycemia 110 mg/dL. His severe spinal deformity makes it difficult to perform percutaneous renal biopsy. What is the correct initial approach?

The correct answer is: 3. Subcutaneous fat biopsy. Lupus erythematosus, some vasculitides, Goodpasture's disease and other systemic diseases (ankylosing spondylitis is one of them) affect the kidney and condition its prognosis. The appearance of urinary abnormalities or renal impairment of parenchymal cause are indications for renal biopsy, even with proteinuria ranges lower than those accepted in primary nephropathies. The determination of anti-GBM antibodies and ANCAS are helpful for diagnosis, but they do not replace renal biopsy, since they lack prognostic value and do not help to plan treatment. In this case, in which we are led to think that renal biopsy is not possible, we must relate AE to renal failure. In most cases, the relationship is established by an IgA nephropathy, which presents with hematuria, a symptom that claims not to exist in this case. A non-negligible number of patients with evolved AD is amyloidosis, which also matches the patient's symptomatology. Therefore, and given that amyloidosis can be diagnosed with a subcutaneous fat biopsy, it is answer 3 that should be considered valid.

NEPHROLOGY

A 23-year-old woman comes to the emergency department because she is very nervous after an argument with her partner. Her medical history shows several similar complaints in the previous year, two of them after a self-injurious gesture. Frequent conflicts in the couple's relationship, job changes and family arguments are also noted. She says she feels misunderstood by everyone, including the psychiatrists attending her. The diagnosis is:

The woman is 23 years old and is pissed off. She needs support and a lot of emotional education to curb her impulsivity... she feels misunderstood... maybe she is right... The issue is that she cannot stand rejection and has self-injurious gestures. The diagnosis is 1. 3, 4 and 5 are not even close, there is no clinical picture described in the question. Then in real life exploring well almost certainly there would be dissociative and depersonalization symptoms, as well as depressive symptoms... but symptom is not disorder. Why not 2? It could also be very punctilious and spinning very fine... here the discussion is served. I put the criteria of each one and we talk about it,... but the intention of the examiner was the 1 and I see it well defended. It cannot be challenged. - The limit: A general pattern of instability in interpersonal relationships, self-image and self-efficacy, and notable impulsivity, beginning in early adulthood and occurring in a variety of contexts, as indicated by five (or more) of the following items: 1. Frantic efforts to avoid real or imagined abandonment. Note: Do not include suicidal or self-mutilating behaviors covered in Criterion 5. 2. A pattern of unstable and intense interpersonal relationships characterized by alternating between extremes of idealization and devaluation. 3. Identity disturbance: marked and persistently unstable self-image or sense of self. Impulsivity in at least two areas, which is potentially self-harming (e.g., spending, sex, substance abuse, reckless driving, binge eating). Note: Do not include suicidal or self-mutilating behaviors listed in Criterion 5. 5. Recurrent suicidal behaviors, attempts or threats, or self-mutilating behavior. Affective instability due to marked mood reactivity (e.g., episodes of intense dysphoria, irritability, or anxiety, usually lasting a few hours and rarely a few days). 7. Chronic feelings of emptiness. 8. Inappropriate and intense anger or difficulties in controlling anger (e.g., frequent displays of temper, constant anger, recurrent physical fights). 9. Transient stress-related paranoid ideation or severe dissociative symptoms. - The histrionic: A general pattern of excessive emotionality and attention-seeking, beginning in early adulthood and occurring in a variety of contexts, as indicated by five (or more) of the following items: 1. Not comfortable in situations where he/she is not the center of attention. Interaction with others is often characterized by sexually seductive or provocative behavior. 3. 3. Displays a superficial and rapidly changing emotional expression. 4. Constantly uses physical appearance to draw attention to him/herself. 5. Has a way of speaking that is excessively subjective and lacking in nuance. 6. Shows self-dramatization, theatricality and exaggerated emotional expression. 7. Is suggestible, e.g., easily influenced by others or by circumstances. 8. considers his relationships more intimate than they really are.

PSYCHIATRY

18-month-old boy, with complete vaccination schedule to date, who consults the Emergency Department for swelling of the right knee after playing in the park, without obvious trauma. In the directed anamnesis, the mother refers that an uncle of hers had similar problems. The ultrasound examination is compatible with hemarthrosis and in the analysis performed only an APTT lengthening of 52″ (normal 25-35″) stands out. What is the most likely diagnostic hypothesis?

In this question they also do not stop dropping clues to throw us headlong into the correct diagnosis. Let's review: a small child who suffers a hemarthrosis without clear trauma. An uncle of his had similar problems, so we suspect hereditary disease. The APTT, which evaluates the intrinsic coagulation pathway (involving factors V, VIII, IX, X, XI and XII) is elongated. Hereditary coagulation problem. We thus discard answers 1, 2 and 5. We are left with von Willebrand's disease and hemophilia A. I consider that the correct answer is 4, hemophilia A, since the inheritance pattern is X-linked and its main clinical manifestation is soft tissue bruising and spontaneous hemarthrosis, without apparent trauma, while von Willebrand disease is characterized by bleeding after surgery or trauma and a prolonged bleeding time with a normal platelet count is characteristic (data not mentioned in the statement).

HEMATOLOGY

A 24-year-old man reports progressive asthenia for at least 6 months, hoarse voice, slow speech, drowsiness and swelling of the hands, feet and face. Examination: pulse at 52 beats per minute, abotarada face and dry and pale skin. CBC: mild anemia, cholesterol 385 mg/dL (normal <220), creatinine 1.3 mg/dL (normal: 0.5-1.1), negative proteinuria, TSH 187μIU/mL (normal 0.35-5.5) and Free T4 0.2 ng/dL (normal 0.85-1.86). What strategy do you think is most appropriate?

This is severe primary hypothyroidism. Treatment is with thyroxine. If there is no nodule, neither echo nor FNA is indicated.

ENDOCRINOLOGY

You evaluate a 66-year-old patient with groin pain accentuated by prolonged standing a few days a month. A plain radiograph of the hips shows narrowing of the femoroacetabular joint space, sclerosis and osteophytes. What is your approach?

We are talking about a 66-year-old patient with pain on some days, pain of an occasional nature. Although the diagnosis is clearly osteoarthritis, it does not lead directly to a surgical indication. The first step is to try conservative treatment (we ruled out the first option). Osteoarthritis is a degenerative process that opioids certainly do not stop, so we rule out option two. Option four can also be quickly discarded: the statement makes the diagnosis and treatment to follow clear: in this case the MRI will not provide us with any information of interest.

TRAUMATOLOGY AND ORTHOPEDICS

A 30-year-old donkey man undergoes a chest X-ray to formalize an employment contract in a company. The X-ray shows a bilateral interstitial pattern of reticular type, bilateral hilar and mediastinal adenopathies. Bronchofibroscopy with bronchoalveolar lavage is indicated and the cell count shows the following results: lymphocytes 50%, histiocytes 40%, eosinophils 2%, polymorphonuclear 8% and CD4/Cd8 ratio 5 What is the most likely diagnosis?

You are describing sarcoidosis.

NEUROLOGY AND THORACIC SURGERY

A 40-year-old woman consults because she has noticed a lump in the superoexternal quadrant of the right breast for the past month. She provides a report of a mammography that describes a BIRADS 3 lesion:

The rest of the answers are incorrect. With a BIRADS 3 this is the correct attitude to follow.

OBSTETRICS AND GYNECOLOGY

A 58-year-old man comes for a scheduled check-up for type 2 diabetes mellitus diagnosed 6 years ago. He has a personal history of hypertension, dyslipidemia, ischemic heart disease and pancreatitis of biliary origin. His medication includes lisinopril, metoprolol, metformin, ASA and atorvastatin. Physical examination showed blood pressure 151/93 mmHg, BMI 27.1 kg/m2. Glycated hemoglobin is 8.3%. Which of the following is the most appropriate treatment for this patient?

Patient with obesity, hypertension and increased HbA1C. In recent studies, Empaglifozin, a highly selective inhibitor of SGLT210, significantly reduces AT, HbA1C and BMI. Glipizide is of the sulfonylurea group. Its use should be avoided in patients with heart disease. Acarbose can interact with beta-blockers, such as those taken by our patient. Sitagliptin has been shown to decrease HbA1C but not HT or BMI.

ENDOCRINOLOGY

A 50-year-old woman comes to the emergency department with asthenia, anorexia, weight loss, jaundice, fever and abdominal pain. She has no recent history of blood transfusion, risky sexual contacts or addiction to parenteral drugs. Habitual consumption of 60 grams of alcohol per day during the last five years, consumption that has increased during the previous month due to family problems. Temperature 38.5ºC, blood pressure 100/60 mmHg. Physical examination showed temporal and spatial disorientation, malnutrition, asterixis, jaundice and painful hepatomegaly. No ascites or evidence of peritoneal irritation. Laboratory tests include leukocytes 15,000/microliter with 90% polymorphonuclear, red blood cells 3 million/mm3, hemoglobin 10g/dl, mean corpuscular volume 115 fl, bilirubin 15 mg/dl direct predominance, AST (GOT) 300 IU/L, ALT (GPT) 120 IU/L, GGT 635 IU/L, prothrombin time prolongation greater than 50%. What is the most likely diagnosis of the patient's condition?

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

DIGESTIVE SYSTEM

A 42-year-old married woman with 2 school-age children consults her family physician for a severe headache of about 7 days' evolution. Although she has been having similar episodes for more than a year, in the last 2 months they have worsened considerably. The pain is like a weight that starts in the occipital area, spreads to both temporal regions and is barely relieved by taking 650 mg paracetamol tablets, so she requests a CT scan (she is convinced that "something must be wrong with her head"). Which of the following is the most plausible cause of her headache?

Just as last year they wanted to paint a nurse as bad for waking us up for a patient with myasthenia, this year they entertain us by presenting a patient asking for a CT scan. I interpret that they show a patient stressed by her children with recurrent headaches of occipital location that she previously relieved with a low dose of paracetamol and now she does not. Both the initially occipital location, the 2-year evolution time, and the sensation of weight lead to answer 4, a tension headache. Migraine and vascular disorders, accompanied by other neurological symptoms or nausea, photophobia, etc., are quickly ruled out, as well as the rare temporal arteritis before the age of 50 years. Tumor headache is usually "in crescendo", not recurrent as the case suggests, and is accompanied by other neurological symptoms or intracranial hypertension.

NEUROLOGY AND NEUROSURGERY

A 27-year-old woman under study in the dermatology department for recurrent episodes of oral aphthous ulcers. She was referred to the gastrointestinal department for a blood test showing Hb 11.5 gr/dl Fe 38 AST 52 ALT 64 Ac antitrasglutaminase IgA 177. The patient reported only occasional diffuse abdominal discomfort. She reports no signs of hemorrhage or jaundice. The physical examination is normal. Which of the following tests do you consider to be the most appropriate to make the diagnosis?

In this question, they give an important piece of information when it comes to suspecting a diagnosis, which is the antitransglutaminase antibodies that must lead you to suspect celiac disease. The rest of the symptoms fall perfectly within the picture and although probably several of the tests that it says will be done, the answer that will give us the diagnosis is 4 (intestinal biopsy).

DIGESTIVE

An 80-year-old woman consults for presenting, since 1 month ago, a progressive increase in abdominal perimeter. During the previous 4-5 months she noted asthenia, anorexia and unspecified weight loss. Physical examination revealed tension ascites and malleolar edema, with no other relevant signs. An ultrasound and CT scan of the abdomen showed the presence of ascites, of homogeneous density, without peritoneal implants or abdominal or pelvic masses. Liver, pancreas, adrenal, spleen and kidneys without significant findings. Paracentesis is performed through a thick needle, obtaining with difficulty a somewhat yellowish, dense and gelatinous fluid. What is the most probable etiology?

The characteristics of the fluid described are milky, i.e., chylous ascitic fluid. Taking into account the age of the patient and the constitutional syndrome described, it is most likely to be a non-Hodgkin's lymphoma and not tuberculosis, which also presents with chylous ascitic fluid, since there is no mention of infectious symptoms. The rest of the entities offered do not present with chylous ascitic fluid.

DIGESTIVE SYSTEM

A 35-year-old man, a letter carrier, with no history of interest, who comes to the emergency department for acute cervical pain of 24 hours of evolution, without previous trauma, which radiates to the left arm up to the hand and is accompanied by paresthesia in the radial border of the forearm. She presents no objectifiable loss of strength, preserves neck mobility although it is painful and contracture of the paravertebral musculature is appreciated. The first attitude will be:

Cervicalgia without alarm signs. Conservative treatment with a success rate of 75%-90%.

TRAUMATOLOGY

A 25-year-old woman presents to the emergency department with ecchymosis and petechiae in the lower extremities and gingivorrhage in the last few days. Her blood count showed the following data: Hb 13 g/dL, leukocytes 8,500/microL with normal leukocyte formula and platelets 9,000/mm3. The determination of coagulation times is normal. Which of the following diagnostic tests should NOT be performed?

The first thing is to know the diagnosis of the clinical case that we are presented with, it is a primary immune thrombocytopenia (ITP), only the platelet series is altered with normal coagulation. The first test to be performed is a peripheral blood smear to check if these platelets are real and there is no pseudothrombopenia due to platelet aggregates. In the enlargement study, antinuclear antibodies (ANA) are requested to rule out autoimmune pathologies that may be the cause of the thrombopenia and another test that would be indicated although in this case the patient is young and does not present signs of seriousness (leukopenia, anemia, no response to first line treatment...) is the performance of a bone marrow aspirate, to see if there are thromboforming megakaryocytes and thus confirm that the platelet destruction is of peripheral origin. But what is not indicated is the determination of the JAK-2 mutation, which is used in the diagnosis of chronic myeloproliferative syndromes, which is not the case here.

HEMATOLOGY