A 52-year-old man comes to the Emergency Department with headache and fever (37.8°C) of 2 days' evolution. In the last few hours, he also had difficulty in nomination and comprehension. The examination did not show nuchal rigidity, the most striking finding being the presence of a mixed aphasia. The cranial CT shows a faint hypodensity in the left temporal lobe without mass effect and without contrast uptake. Which of the following statements is correct?

The picture described is typical of a viral meningoencephalitis, more specifically VHZ, with significant tropism by the temporal lobe, causing febrile fever and in many cases aphasia, so the correct option would be 2, since the cerebrospinal fluid normally shows a moderate lymphocytic pleocytosis, with normal glycorrhachia. The rest are not correct because: The first one because it is not a bacterial meningitis that would present with more fever, the third one because limbic encephalitis usually presents afebrile with behavioral changes and the last one because the image they describe is not an abscess, well delimited.

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

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


A 25-year-old woman who wishes to become pregnant and wants to know what treatment she should take during the eventual pregnancy, as she is a heterozygous factor V Leiden carrier. She has never had any thrombotic phenomena. The determination of this factor was performed as a family study after an episode of pulmonary embolism in a sibling. What treatment should be advised?

Reading the answers, the first thing that is clear to us is that acenocoumarol should NOT be given to a pregnant woman because of the risk of teratogenicity. Anyone who does so during residency should be punished with 100 slaps on the back. We discard answer 5. Second: if treatment is given, it should be during the entire pregnancy, prothrombotic status is not only during the puerperium, so answer 2 discarded. Advise a woman not to become pregnant when there are treatments that ensure a very low risk of thrombosis and/or fetal involvement? Answer 1 discarded. We are left with the possibility of not giving any treatment because it is low risk or administering low-dose aspirin. It is true that factor V Leiden in heterozygosis is classified as low risk, who has not presented a previous thrombotic episode nor is there a combination with another thrombophilia; if we look at the CHEST guide, VIII edition and review what was said at the last congress of the Spanish Society of Gynecology and Obstetrics, we see that aspirin is used in case of phospholipid syndrome and that in the case of this woman, without previous thrombosis, without previous abortions (at least two are needed) and also being heterozygous, treatment is not necessary. Correct answer, 3.

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

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

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

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

Treatment with antivitamin K drugs (acenocoumarol) during pregnancy.


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

We are being shown a picture of lumbar canal stenosis (Answer 4 correct). The patient shows the characteristic clinical picture: lumbar pain that is relieved by flexing the trunk forward, radicular pain with lower limb involvement and neurogenic claudication. Low back pain in a patient over 60 years of age accompanied by leg weakness when walking, which has to be interrupted at a certain distance, called neurogenic claudication, is the typical picture of stenosis. The patient is relieved by flexing the spine forward because it widens the lumbar canal and worsens with extension...


A 51-year-old woman comes to the emergency department with a sudden decrease in visual acuity, severe headache, nausea and vomiting. Hypotensive and afebrile. She presented right ophthalmoparesis due to involvement of the third cranial nerve. A cranial CT scan shows a mass in the hyperdense selar region with erosion of the anterior clinoid processes. What is the best approach to follow?

Pituitary apoplexy is a syndrome characterized by the sudden onset of headache accompanied by ocular motility disturbances and a variable degree of pituitary insufficiency. The cause is usually a rapidly growing pituitary mass secondary to a vascular event (infarction or hemorrhage). General symptoms may range from vomiting or nausea to meningeal irritation. Compression on the chiasm and optic nerve can cause various campimetric deficits (usually greater bitemporal hemianopsia in the superior quadrants) and decreased visual acuity, even blindness. If the mass grows lateral to the sella turcica it can compress the oculomotor nerves, with the common motor ocular nerve being the most frequently affected, because of its more medial course in the cavernous sinus. The test of choice for the diagnosis of pituitary apoplexy is MRI, as CT may not distinguish the region clearly enough to distinguish degenerative or cystic changes from previous bleedings. The finding of erosion of the anterior clinoid processes in the skull CT may support a chronic lesion, which as a result of an acute vascular phenomenon has caused the symptoms. The management of these patients involves strict control of water and electrolyte disturbances and correction of hormonal deficits. In unstable situations as in the case described, with significant visual disturbances, surgical intervention is usually of choice, with transsphenoidal decompression.

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

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

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

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

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


A 24-year-old woman, primigestation, suffers a spontaneous abortion at 7 weeks gestation. The anatomopathological study of the abortive remains indicates molar disease. We should inform you that:

The answer is 2. According to the SEGO (Spanish Society of Gynecology and Obstetrics) in its 2005 protocol "Gestational trophoblastic disease", the risk of malignization, i.e. of developing a gestational trophoblastic neoplasm, ranges from 5 to 20% depending on whether it is a partial mole or a complete mole, respectively. According to this protocol: "Patients will be monitored weekly with hcg dosage until it becomes undetectable, for three consecutive times. After that the monitoring will be monthly, for six months and then every two months for another six months. Based on the available data, a follow-up of three to six months is recommended for partial mole and 12 months for complete mole." Therefore, subsequent controls are strictly necessary.The risk of a new molar gestation, although increased compared to the normal population, is not 50%.

The risk of a new molar gestation in a future pregnancy is 50%.

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

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

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


A 27-year-old woman, 10 weeks pregnant, with persistent severe allergic asthma. She is currently adequately controlled with daily inhaled budesonide and rescue inhaled salbutamol on demand. She comes to your office concerned about the possible teratogenic effects of her anti-asthma medication. Which of the following would be the correct approach?

Given that asthma improves during pregnancy in most patients, the best thing for the patient and the fetus is to suspend anti-asthma treatment.

Discontinue budesonide because it has been associated with an increased risk of fetal malformations and replace it with an oral anti-leukotriene (montelukast).

Withdraw current treatment and replace it with oral prednisone at the lowest possible dose.

Maintain the current treatment and reassure the patient about its side effects and the need for adequate asthma control during pregnancy.

Replace budesonide with an anti-IgE monoclonal antibody (omalizumab) because of its greater safety in pregnancy since it is not a drug.


A 52-year-old woman from a village on the Costa Brava notices an otherwise asymptomatic lump in the anterior region when applying cream to her neck; she goes to her general practitioner who confirms the presence of a firm, smooth mass, 2 cm in maximum diameter, which rises with swallowing. No palpable lymphadenopathy. What tests would you order at the outset?

It refers to a thyroid nodule, and the indicated test is a FNA (fine needle puncture). I have read the answer Emilio has written on the challenge; the question is in the endocrine block and it seems he is trying to make it clear that it is a nodule. Ultrasound facilitates FNA but is not mandatory, a 2 cm thyroid nodule can be punctured without echo. It is important to have an analysis of thyroid function prior to the puncture; but since he is talking about an asymptomatic patient, it seems clear that she is not hyperthyroid. I do not think it is contested and I think it is a question that most will have answered well.

A determination of thyroglobulin in blood.

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


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

Currently the molecular classification of breast cancer is based on the study of hormone receptors, HER2 and the tumor cell proliferation index (Ki67). We have four fundamental types: Luminal (A: HR+, HER2- and low Ki67 and B: HR+, HER2+/ - and high Ki67), HER2 + (HR -, HER2 + and high Ki67) and Basal Like or triple negative (HR -, HER2 - and high Ki67).

Complete phenotypic study by flow cytometry.

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

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


An 86-year-old woman in whom nonvalvular atrial fibrillation has been detected. She has a CHADS2 score of 3 points. In the literature, similar patients on warfarin therapy have a stroke risk of 2.2% versus 5.2% in patients without warfarin. What would be the number needed to treat (NNT) to prevent embolic stroke with anticoagulation therapy?

The NNT (number needed to treat), means how many patients we would need to treat with an intervention to obtain a benefit; in this question how many patients do we need to treat with warfarin to prevent a stroke. To calculate this we use the following formula: NNT= 1/RRA (RRA: absolute risk reduction). RRA= Io - Ie (Io: incidence in those not exposed to warfarin; Ie: incidence in those exposed to warfarin). RRA: 5,2%- 2,2%= 3= 0,03. NNT: 1/0.03= 33.3.


A 30-year-old man with a family history of a father who died at 38 years of age from colon cancer. A colonoscopy is performed and shows hundreds of adenomas throughout the colon. Which of the following statements is false?

Patient with familial adenomatous polyposis. All statements are correct except 2. Treatment should be surgical when polyposis is observed. At 40 years of age is the usual point of incidence of cancer.

The patient has familial adenomatous polyposis.

The most appropriate management is annual follow-up colonoscopy and colectomy at age 40.

If the patient does not undergo surgical treatment, he/she will almost certainly develop colorectal cancer.

First degree relatives should be studied.

The patient's children have a 50% risk of suffering the same disease.


A 75-year-old woman brought for consultation by her family because they have been finding her depressed and with memory lapses for months. They are concerned that she may have Alzheimer's disease. The patient refers that she does not think anything is wrong with her and that she is as usual. In what order do the following symptoms generally occur in the progression of Alzheimer's disease:

I answer this question thinking more about what they want to ask than what they are really asking. There is heterogeneity in the development of Alzheimer's disease symptoms. There are behavioral variants, but in the MIR they usually want you to think of other types of dementias in the face of behavioral symptoms. In fact, the appearance of these symptoms in early stages should alert us and open the range of diagnostic possibilities. Therefore, we discard 2 and 4. Between 1 and 3, I choose 3 for the same reason and because of the emphasis on the decline of functional independence that occurs in these patients.

Mood changes, behavioral symptoms, cognitive deficits.

Behavioral symptoms, motor symptoms, decline of functional independence.

Mood changes, cognitive deficit, decline of functional independence.

Behavioral symptoms, mood changes, motor symptoms.


An 80-year-old patient with a history of hypertension and on treatment with enalapril and spironolactone comes to the hospital with asthenia and severe muscle weakness. Blood pressure is 110/70 mmHg. In the ECG, there are sharp and elevated T waves, ventricular extrasystoles and short QT. What is the most likely diagnosis?

The correct answer is: 2. Hyperkalemia. Spironolactone, as a potassium-sparing diuretic, inhibits the action of aldosterone at the renal level, being responsible for a decrease in potassium excretion. Hyperkalemia produces repolarization disturbances that result in the installation of a large, symmetrical, narrow-based T, visible in the precordial leads. The QT space is shortened. These anomalies appear with a kalemia of around 5.5 to 6 mmol/l. Above 6.5 mmol/L, electrocardiographic changes are constant, and are dominated by conduction disturbances (making ventricular extrasystoles possible).


Woman 40 weeks gestation in labor with 6 cm dilation. She presents a decelerative fetal pattern in cardiotocographic recordings, so it is decided to perform a fetal blood smear to assess fetal well-being. Result 7.22. The correct conduct is:

- pH less than 7.20 Pathological value. Indication for fetal extraction by the quickest route, in this case a cesarean section. - pH between 7.20-7.25 Prepathological value. Repeat microtome in 15-20 min. - pH greater than 7.25. Value within the limits of normality. Observation.

Severe acidosis. Urgent cesarean section.

Pre-pathological value repeat microtome 15-20 minutes.

Moderate acidosis. Repeat microtome in 1-2 hours.

Value in normal limits, leave natural evolution of labor.

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


A 19-year-old girl with no medical history of interest, except for a self-limited case of influenza 3 weeks earlier, who comes to the emergency department with petechiae and ecchymosis of spontaneous onset. On physical examination the patient was in good general condition, afebrile, normotensive and oriented in time and space. There were petechiae scattered throughout the lower extremities and abdomen and small ecchymoses in decubitus areas. No lymphadenopathy or splenomegaly were palpated. Laboratory tests showed the following findings: Hb 12.6 g/dL, leukocytes 5,500/mm3, platelets 7000/mm3. The peripheral blood smear showed normal erythrocyte morphology, normal differential leukocyte count and the planetary count was concordant with the autoanalyzer figure without platelet aggregates. Biochemistry and proteinogram, beta 2 microglobulin and LDH are normal. Which of the following do you think is the most appropriate initial treatment?

Idiopathic thrombocytopenic purpura, but with very low platelets, so replenishment is necessary. The proposed steroid dose is too low.

Cyclophosphamide in 4-day pulses every 21 days.

The proposed steroid dose is too low.


A 42-year-old woman with breast cancer has metastases at the level of the intervertebral foramina between the 4th and 5th cervical vertebrae and between the 4th and 5th thoracic vertebrae. Which spinal nerves will be injured?

The trick to this question is that there are 8 cervical roots for 7 vertebrae, therefore the C1 root exits ABOVE the atlas, and so on up to C8 which exits BETWEEN C7 and T1. The thoracic roots come out respectively below the vertebra with their same numbering (nerve T1 under T1, T2 under T2, etc.). Therefore, between C4 and C5 the 5th cervical nerve exits, and between T4 and T5 the 4th thoracic nerve exits. The correct answer is 4.

Fourth cervical and fourth thoracic nerves.

Fifth cervical and fifth thoracic nerves.

Fourth cervical and fifth thoracic nerves.

Fifth cervical and fourth thoracic nerve.

Third cervical and fourth thoracic nerve.


A 59-year-old woman presents with chronic watery diarrhea of 4 months' duration. On endoscopy, the mucosa showed no relevant features. In particular, no ulcers or friable areas were observed. A biopsy of the transverse colon was performed. Histopathology revealed a thickened area below the superficial lining epithelium, which was more evident by Masson's trichrome technique and involved epithelial atrophy and denudation. There was also a clear increase in intraepithelial lymphocyte density. The diagnosis of the intestinal lesion is?

Everything we are told in this case is typical of COLLAGENOUS COLITIS. In principle, the clinical and endoscopic findings may leave us a little as at the beginning, but histology is little more than the definition of this pathology. The specific criterion for the diagnosis of collagenous colitis is the additional presence of an irregular band of collagen just below the surface epithelium of the colonic mucosa in continuity with the basement membrane, visible with trichrome staining (stains type I collagen fibers), which traps superficial capillaries producing lesions in the surface epithelium. In addition, it is accompanied by a chronic inflammatory infiltrate in the lamina propria, composed mainly of lymphocytes, plasma cells and eosinophils.


A 78-year-old patient with no past history who consults for asthenia and dyspnea of 3 months of evolution, which has progressed to rest in the last few days. In the previous days he also refers chest pain with anginal characteristics with small efforts. On examination, blood pressure of 110/80 mmHg, heart rate of 85 bpm and auscultation with a rough systolic murmur in the right second intercostal space and crackles in both lung bases. Which of the following is the most likely diagnosis?

Dilated cardiomyopathy of ischemic origin.

Aortic stenosis.


In a 30-year-old female patient a calcium level of 11 mg/dl (normal less than 10.5 mg/dl) is found during a routine company examination. PTH determination was 45 pg/ml (VN 10-55 pg/ml). The history is unremarkable except for the fact that the mother and paternal grandfather were diagnosed with hyperparathyroidism and underwent surgery, although they remained hypercalcemic. Which test is most useful in confirming the diagnosis?

Calcium/creatinine urine ratio. This is familial hypocalciuric hypercalcemia or benign familial hypercalcemia. Autosomal dominant disorder. Asymptomatic. Not cured after surgical treatment; it is due to mutation of the calcium-sensitive receptor. Difficult question since it is necessary to know data of a disease that is not usually asked in the MIR.


A 58-year-old male with a history of arterial hypertension of 6 years of evolution, who consults for poor control of blood pressure figures despite receiving treatment with an angiotensin-converting enzyme inhibitor, a diuretic and a calcium antagonist. On consultation she presented with blood pressure of 149/100 mmHg. Laboratory tests: creatinine 1.2 mg/dl, potassium 2.2 mEq/l and compensated metabolic alkalosis; the rest of the biochemical study, blood count, coagulation and urinary sediment were normal. Mark the correct statement:

CT scan is part of the diagnostic workup in case there is biochemical confirmation.

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

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

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

Spironolactone is contraindicated in the management of this pathology.


You evaluate a 66-year-old patient with groin pain accentuated by prolonged standing for a few days per month. A plain radiograph of the hips shows narrowing of the femoroacetabular joint space, sclerosis and ostephytes.

It is a coxarthrosis. The surgical criteria depends on the patient's symptoms and failure of medical treatment. No medication slows down or modifies the course of the disease. An MRI is not necessary, it does not contribute anything. Treatment is medical and sequential, starting with the first analgesic step of the WHO.

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

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

Treatment with paracetamol, explaining that the evolution is very variable and the surgical indication depends on the functionality and pain control.

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


A 19-year-old female university student comes to the clinic accompanied by her parents, reporting feeling progressively more asthenic in the last two months, with loss of appetite and weight and with greater difficulty in concentrating on her studies. The anamnesis also highlights that she has lost interest in going out with friends, has ideas of death without self-harming ideation and pessimistic cognitions of the future. Her weight is 90% of that considered ideal for age and gender. She does not present weight phobia or body image distortion. The most appropriate diagnosis is:

As soon as we hear about weight we go to anorexia nervosa, but anorexia nervosa has three features: significant self-induced weight loss, body image distortion and amenorrhea. So we remove 1. One loses weight when one gets sad, worries, etc... 3 does not make sense in the MIR because of the clinic -in reality the history is different and in psychiatry everything is evolution-. 4 has to meet temporal criteria that are not met here. So we are between 2 and 5. Depression or anxiety? There is no anxiety clinic and she also meets the criteria for depression. The poor girl has been diagnosed with depression. The answer is 5 (another option is that she was studying the MIR).


In a patient with known advanced chronic kidney disease (CKD G4, eGFR 20 ml/min) who comes to the emergency department for general weakness and is found to have severe hyperkalemia (K 7 mEq/l) with electrocardiographic abnormalities. What would be the first measure to take?

We describe the case of a patient with a hyperkalemic emergency (potassium >6.5 mmol/l with ECG alterations). The first step is the administration of iv calcium gluconate to counteract the cardiac toxicity of hyperkalemia (option 3 correct), giving us more time to initiate hypokalemic treatments (initially saline glucose with insulin, salbutamol, furosemide, and assessing dialysis if there is no good response).

Administration of cation exchange resins.

Placement of a catheter to initiate dialysis.

Administration of intravenous calcium gluconate.


A 26-year-old woman consults for a feeling of generalized weakness that has progressively set in over the course of three weeks, becoming particularly intense in the last two days. For the last couple of years, she reports episodes of joint pain in the hands that have required the use of anti-inflammatory drugs, as well as the appearance of an erythematous lesion of unclear cause in the neckline area, mainly in summer. In the physical examination there was only an evident cutaneous-mucosal pallor and a heart rate of 100 bpm. The hemogram shows: Hb 6 gr/dL, Hto 27 %, MCV 105 fL, 3,420 leukocytes/mm3 (2300 neutrophils/mm3, 800 lymphocytes/mm3, 250 monocytes/mm3, 50 eosinophils/mm3, 20 basophils/mm3), platelets 170,000/mm3. Biochemistry: AST 30 IU/L, ALT 35 IU/L, GGT 59 IU/L, alkaline phosphatase 105 IU/L, LDH 490 IU/L, urea 20 mg/dL, creatinine 0.8 mg/dL. Taking into account the available information, indicate which of the following additional analytical parameters you would need to know in order to make the most appropriate immediate decision:

They comment on the case of a young woman with symptoms of systemic disease of probable autoimmune origin (lupus) who presents with macrocytic anemia, options 2 and 4 are options to identify the autoimmune disease but what they ask us is what to do to treat the anemia, so we should suspect that the anemia is secondary to the autoimmune disease and therefore request a direct Coombs test, since if it is positive the patient, except in extreme cases, will not be transfused and the primary cause should be treated. It also speaks of rapid onset, which in the case of vitamin B12 is more progressive.


A 64-year-old male presents with fever, cough, dyspnea and right pleuritic pain of 1 week's evolution. Chest X-ray shows a loculated right pleural effusion occupying two thirds of the hemithorax. During thoracentesis, a yellowish fluid is drawn and analysis shows: leukocytes 15,000/uL, 92% neutrophils, glucose 30 mg/dL, pH 7, lactate dehydrogenase 3500 U/L, adenosine deaminase 45 U/L and absence of germs on GRAM stain. What is the most appropriate next course of action in this patient?

In this question there should not be much doubt either (by the way, I think it is more of Pneumology than mine, but well, with this fever my friend Emilienko has deviated), since the clinical picture points to a parapneumonic pleural effusion, the macroscopic characteristics of the fluid seem so and the analysis of it shows us that the effusion is also complicated, almost on the verge of being an empyema (very high LDH, cellularity with predominance of PMN, glucose consumption). In addition, with this pH (and knowing that the effusion is already loculated), the endothoracic tube is more than indicated.

Intravenous antibiotic therapy and repeat diagnostic thoracentesis in 24 hours.

Intravenous antibiotic therapy and repeat diagnostic thoracentesis if there is no improvement in 48 hours.

Intravenous antibiotic therapy and evacuative (therapeutic) thoracentesis if any germ is isolated in the pleural fluid culture.

Intravenous antibiotic therapy and placement of a chest tube or catheter to drain all pleural fluid.


A 52-year-old patient is admitted to the Hospital for severe pneumonia. With appropriate antibiotic treatment, the patient's respiratory symptoms improved. After 4 days of stay in the ward, his evolution is complicated by the appearance of a severe diarrhea. What is the most frequent microorganism responsible for this condition?

In this case, given the antibiotic treatment given and the severity of the diarrhea, it seems that we are dealing with a Clostridium infection. Option 2 is not very credible, in fact, as much as patients with CAP may have associated diarrhea, it is unlikely that a bacterium is sensitive to an antibiotic at the beginning of the picture and stops being so after 3 days.

The bacterium itself causing pneumonia that has become resistant to the antibiotic.


A 7-year-old boy brought to the emergency department after falling off a swing onto his right hand. He has no history of interest. He presents with fork dorsum deformity of the wrist and functional impotence, with normal distal neurovascular status. What lesion would you expect to find on the urgent x-ray you request?

With the deformity and pain in the distal radius, we expect a fracture at this level, so we mark 3. However, I see it as unquestionable, given that it could also have a concomitant fracture in the ulnar green stalk, although the main lesion is that of the radius.


A 30-year-old woman comes to the clinic reporting anxiety, weight loss of about 6 kg and a feeling of "nervousness" in the last three months. In the physical examination she has tachycardia, hyperreflexia and absence of goiter. In the blood test TSH values are < 0.01 microU/mL, T4 is elevated and thyroglobulin levels are low. A scintigraphy shows an absence of uptake in the thyroid region. What seems to you the most likely diagnosis?

Answer 2 incorrect: Graves' disease is characterized by hyperthyroidism and one or more of the following features: goiter, exophthalmos and pretibial myxedema. Answer 4 incorrect: The most obvious symptom of subacute thyroiditis is neck pain. Sometimes, the pain may extend to the jaw or ears. Painful enlargement of the thyroid gland can last for weeks or months. And you usually have low serum thyroid stimulating hormone (TSH). High serum free T4 level. High serum thyroglobulin level. Incorrect answer 4: Very rare tumor.

Ovarian teratoma (ovarian stromal tumor).


A man presents on neurological examination with a thermoalgesic sensory deficit in the left leg associated with a loss of vibratory and positional sensitivity in the right leg. At the same time he presents with clumsiness and loss of distal strength in the right leg and a right plantar cutaneous reflex in extension. Which of the following statements is correct:

They describe a typical hemisection or Brown-Sequard picture. Ipsilateral posterior motor and chordal involvement with contralateral pain and temperature involvement.

It is a centromedullary syndrome type syringomyelia.

It is a pattern of transverse medullary lesion.

It is a pattern of lateral bulbar lesion.


65-year-old man with a history of pancreatic neoplasm undergoing chemotherapy. What diagnostic test is more cost-effective to confirm the diagnostic suspicion?

Dopler ultrasound is the most accurate test and allows subsequent non-invasive monitoring of the evolution of the disease.


A 10-year-old boy with brief episodes of distractions (< 1 minute) in which he does not respond to calls and blinks. An EEG shows spike-wave discharges at 3 cycles per second. First-line elective treatment would with:

The seizures described and the EEG correspond to typical absence seizures and the initial treatment of choice is valproic acid.


A 72-year-old woman with no past history of interest. After a complicated renal colic, a 2 cm cystic lesion in the tail of the pancreas, together with multiple bilateral renal cystic lesions, is found by chance in the abdominal CT scan. Endoscopic ultrasonography shows a polycystic lesion formed by multiple vesicles with central calcification in the tail of the pancreas with no connection to the duct of Wirsung. Fluid analysis is compatible with a serous cystadenoma. Of the following, which is the most correct attitude regarding the management of this patient:

Serous cystoadenoma of the pancreas is a benign, often polycystic entity (also called microcystic adenoma) formed by collagen-producing (non-mucinous) cells. It is usually asymptomatic and is discovered as an incidental finding. Given its benign nature, surgery is not recommended, and is reserved only for symptomatic patients or those in whom the nature of the lesion is in doubt after a complete study with CT, MRI and echoendoscopy with biopsy. It is frequently sporadic, but can be associated with Von-Hippel-Lindau syndrome.

Surgical resection (corporocaudal pancreatectomy).

Endoscopic ultrasonography-guided puncture and ethanolization of the puncture.


A 25-year-old female patient with a history of skin rash after sun exposure and occasional polyarthritis in the joints of the hands, controlled with non-steroidal anti-inflammatory drugs, presents with general malaise, progressive feeling of generalized weakness and pallor for the last 15 days. Laboratory tests showed hemoglobin 7 g/dL, MCV 108 mm/h, 150,000 platelets/mm3, 3000 leukocytes/mm3, elevated LDH, undetectable haptoglobin. In the case of choosing a single diagnostic test indicate which of the following determinations should be performed first:

The clinical and biological picture of this patient raises suspicion of hemolytic anemia in the context of systemic lupus erythematosus. If we have to choose only one diagnostic test, and this should be the first, we are interested in confirming the presence of an autoimmune hemolytic anemia with the direct Coombs' test in order to initiate treatment. The other tests can wait...

The other tests can wait...

The other tests can wait...

The other tests can wait...

The other tests can wait...


A 70-year-old woman with a history of anorexia, weight loss, discomfort in the musculature and proximal joints plus pain in the temporomandibular region who comes to the emergency department for unilateral loss of vision (hand movement), sudden and painless onset (afferent pupillary defect). What test would you request first for diagnostic purposes?

This is a woman with abrupt, painless and severe loss (she only sees the movement of the hands) of vision in one eye. She does not give us much information from the ocular examination, only that there is an afferent pupillary defect. We have to rely on systemic symptoms to diagnose the problem. This is an elderly woman with typical symptoms of polymyalgia rheumatica, and the pain in the temporomandibular region is very suggestive. It is giant cell arteritis or temporal arteritis. The most common ocular manifestation is anterior ischemic optic neuropathy. In the fundus we would certainly see a papillary edema of that eye, with a gypsum white coloration. The afferent pupillary defect is very characteristic of these severe ischemic optic neuropathies. Suspecting giant cell arteritis, there are three analytical markers that are characteristically high: CRP, ESR and platelet count. We will first request one of these parameters and treat it often without waiting for biopsy confirmation. Therefore, option 2 is the correct one.


A 68-year-old patient consults for edema and asthenia. Laboratory tests showed creatinine 5 mg/dL, hemoglobin 10 g/dL and marked hypogammaglobulinemia in serum at the expense of IgG, IgA and IgM. A urinalysis reveals the presence of kappa light chains. What is your diagnostic suspicion?

This question is mixed hemato-nephro. It is complicated, so we are going to rule out options one by one. Option 2, nephrotic syndrome, apart from being broad and nonspecific, would not be assessable, since they do not give us the quantification of urine protein (they only tell us that urinalysis reveals the presence of kappa light chains, not the amount). Option 3 would be unlikely; in amyloidosis, the light chains that are usually deposited are of the lambda type. Option 4 also seems unlikely, since in IgA myeloma we would expect a monoclonal peak of this Ig, which in this case does not appear. The doubt that arises is between 1 and 5; I would opt for 1, because this entity fulfills the characteristics described (absence of monoclonal peak in most cases, acute renal failure and presence of kappa chains in urine), being light chain myeloma a somewhat broader entity, but option 5 could also be considered valid.

IgA myeloma with Bence-Jones proteinuria.


A 24-year-old woman is found lying in the street by passers-by. On arrival of the emergency team she was found with an oxygen saturation of 88% breathing room air and on examination with pinpoint pupils. She was transferred to the emergency room of the nearest hospital, where the baseline arterial blood gases showed: pH 7.25, PaC02 60 mmHg, Pa02 58 mmHg, bicarbonate 26 mEq/1 and base excess of -1. In blood sodium was 137 mEq/1 and chloride 100 mEq/1:

The acidosis with elevated PCO2, hypoxemia and normal bicarbonate suggests an acute respiratory acidosis of rapid onset probably due to drug intoxication.

Respiratory alkalosis due to lack of chloride.


A 2-month-old infant with an upper respiratory tract cold of 3 days of evolution, who begins with moderate respiratory distress and pulmonary auscultation with expiratory wheezing. Oxygen saturation is 89 %. Respiratory syncytial virus is isolated in the nasopharyngeal exudate. Which of the following treatments do you consider more indicated for this condition?

We are presented with a case of RSV-positive bronchiolitis. According to current recommendations, it would be indicated to initiate supplemental oxygen therapy.


A 67-year-old female patient on ticlopidine treatment comes to the emergency department with headache, asthenia and petechiae in the lower extremities. Laboratory tests showed hemoglobin 8.2 g/dL, MCV 100 fl, platelets 25000/ul and leukocytes 7500/ul with normal formula. The reticulocyte count was elevated and the blood smear showed numerous schistocytes. Coagulation studies (APTT, PT and fibrinogen) are normal. The biochemistry shows LDH 2700 IU/l and bilirubin 2.6 mg/dl. What is the most likely diagnosis?

Typical of ticlopidine. Not only thrombocytopenia but also headache, schistocytes, high LDH and high bilirubin.