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A 75 a man is admitted to the hospital because he refuses to eat and has lost 30% of his weight. He has a history of multiple sclerosis which has worsened in recent months. His only family member who was his sister died 3 months ago and since then he has deteriorated. He has become incontinent, has stopped eating and participating in social events. He is suffering from psychotic depression. He is physically able to eat. Psychotropic medication is started and discontinued due to adverse events. If his nutritional status improves it is possible to resume his medications. He refuses intravenous fluids and then accepts them but the IV is started a few hours later. An alternative is to perform a percutaneous endoscopic gastrostomy (PEG) and discharge him to his residence. Which of the following is the most appropriate course of action for this patient?

The correct answer is 1 since the patient is in a situation of psychotic depression and is not able to decide for his life and it does not seem that the patient has filled in the last will and testament, the most convenient thing to do is to present the case to the ethics committee of the center to make a decision on the matter in accordance with the law.

PRIMARY CARE

A 51-year-old man is admitted from the emergency department for macrocytic anemia (Hb 6.3 g/dL, MCV 120 fL). Studies ruled out a deficiency origin. Reticulocytes were 24000/microL. The bone marrow study is compatible with myelodysplastic syndrome (MDS). Cytogenetics shows a 5q deletion. Which is the correct statement regarding this patient?

This is a young patient with no comorbidities and is therefore a candidate for treatment with curative intent, so option 4 is ruled out. Option 3 is also incorrect since we cannot know the patient's IPSS since we do not know the number of blasts and the number of leukocytes and platelets to calculate the risk. Option 2 is also incorrect since the indication for a bone marrow transplant in MDS is those patients with high or intermediate-2 IPSS, and in this case we do not know the risk, the only thing we know about the risk is the cytogenetics which is of good prognosis that would give us 0 points. Therefore the correct one is 1 since it is true that it has a favorable cytogenetics (5q-) and has a specific treatment lenalidomide, also used in other pathologies such as multiple myeloma.

HEMATOLOGY

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

Blood gas analysis shows an acute respiratory acidosis, due to an increase in PCO2 of short evolution time because the kidney has not yet had time to retain bicarbonates (bicarbonate level at the high limit of normality). The patient is not hyperventilating but hypoventilating because PCO2 is elevated. The alveolar arterial oxygen gradient is altered since the patient has a normal PaO2, but because he has a high FiO2. If he were without oxygen, he would be hypoxemic. Respiratory acidosis below 7.20 is a reason to consider noninvasive mechanical ventilation acutely and in principle temporarily in a patient with severe COPD.

PNEUMOLOGY

What therapeutic intervention would you consider in a 67-year-old patient with idiopathic dilated cardiomyopathy, left bundle branch block, left ventricular ejection fraction of 26%, mitral insufficiency grade II-III/IV, undergoing treatment with furosemide, spironolactone, enalapril and bisoprolol and who remains in NYHA functional class III?

We are talking about a patient with heart failure with severe LV dysfunction (EF < 35%), LBBB (wide QRS), who is following optimal medical treatment and who remains in advanced functional class despite this. Coronary revascularization does not appear to be of much benefit in this patient at this time. Nor does mitral valve replacement, firstly because mitral regurgitation is most likely the result of mitral annular dilatation, and secondly because we would need an echocardiographic assessment of the mitral valve to determine whether there is any alteration. Intra-aortic balloon counterpulsation implantation would not be indicated in this patient (it is used in situations of cardiogenic shock, in post-AMI mechanical complications, as a bridge to cardiac Tx...). The ventricular assist device would also not be indicated in this patient. What would really benefit him of all the answers is number 5, the resynchronization device. By achieving simultaneous stimulation of both ventricles, a mechanical synergy is achieved that improves cardiac function. The indications for the application of CRT (cardiac resynchronization therapy) are precisely those mentioned at the beginning: severe ventricular dysfunction, asynchrony demonstrated by the presence of wide QRS in the ECG (usually due to LBBB) and advanced functional class (III-IV) despite optimal medical treatment.

CARDIOLOGY AND VASCULAR SURGERY

A 2-year-old boy, his personal history includes: 3 episodes of acute otitis media, 1 meningococcal meningitis and 2 pneumonias (one middle lobe and one left upper lobe). She has been admitted on 3 occasions for thrombopenic purpura (on three occasions antiplatelet antibodies were negative and bone marrow showed normal megakaryocytes). Several males of the maternal family had died in childhood due to infectious processes. The examination showed typical lesions of atopic dermatitis. The immunological study showed a slight decrease in T lymphocyte subpopulations; elevated IgA and IgE; decreased IgM and IgG at the lower limit of normal. What is the most likely diagnosis?

The correct answer is 1. Wiskott-Aldrich syndrome associates immunodeficiency, thrombopenia and atopic dermatitis with the immunological study described in the statement.

PEDIATRICS

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

It is possibly a temporal arteritis, the clinical picture and a CBC with increased reactants are enough to confirm the suspicion. Then an ocular evaluation should be done to rule out AIN, urgent treatment should be instituted (if there is AIN, 3 boluses of methylprednisolone 1 g, if there is not, prednisone mg/kg) and biopsy should be evaluated.

RHEUMATOLOGY

65-year-old male presenting to the emergency department for appearance of cyanotic mottled lesions on the toes of both feet. Personal history: smoking, hypertension and dyslipidemia. Chest X-ray: mediastinal widening. Thoracic-abdominal-pelvic CT angiography: descending thoracic aortic aneurysm 7 cm in diameter, distal to the left subclavian artery and with mural thrombus. Of the following, indicate the correct option:

Thoracic stent implantation is indicated.

CARDIOLOGY

Patient 76 years old, parity 3-0-3-1, with menopause at age 52. She reports that for at least 4-5 years she has had vulvar pruritus of variable intensity which has been treated sometimes with self-medication and other times on the advice of her general practitioner with topical preparations (creams and washes). The pruritus has evolved intermittently, but for the last 3-4 months she has also noticed a small lump on the left labium majus of the vulva, which has been leaking serohaematically on rubbing for a few days; she therefore consulted a gynecologist. On questioning, she reports occasional dysuria and her general condition is good. What is the most likely diagnosis in this patient?

The correct answer is 5. Vulvar carcinoma is characterized by chronic vulvar itching resistant to multiple treatments, appearance of lumpiness or ulceration, dysuria and urinary urgency, and late pain and bleeding.

GYNECOLOGY AND OBSTETRICS

An 80-year-old woman comes to the emergency department with abdominal pain starting in the epigastrium and radiating later to the left iliac fossa. An abdominal CT scan is performed, showing inflammation of the sigmoid walls and a 2 cm mesenteric abscess. The treatment of choice is:

In this question we are presented with a clinical picture whose manifestations are compatible with acute diverticulitis, already asked on numerous occasions previously. A case of acute diverticulitis complicated with small mesenteric abscess (< 2-3 cm) is presented. Abscesses should be drained by CT-guided percutaneous puncture, since the intra-abdominal approach can spread the contents into the abdominal cavity. However, in small abscesses with Hinchey grade I divertciulitis, in patients without great deterioration of the general condition as in the proposed case, they can be managed by conservative treatment with intravenous antiobiotic therapy and absolute diet, therefore the correct option is 1. The urgent surgical approach should be reserved for cases that present peritonitis (grade III, IV) by resection of the affected segment and primary anastomosis in stable patients or carry out the Hartamn intervention that includes resection with terminal colostomy and closure of the distal rectal stump performing anastomosis in a second surgical time.

GENERAL SURGERY

A 78-year-old woman consults for acute vision loss of the left eye. In the last 3 weeks she has presented with fever, pain in the shoulders, neck and hips, and moderate headache. Funduscopy shows a pale and edematous optic disc. Mobilization of the shoulders and hips produces pain. There are no alterations on palpation of the temporal arteries. Laboratory data: hemoglobin 9.7 g/dL ferritin 450 ng/mL erythrocyte sedimentation rate 115 mm/h. What is the most appropriate immediate action in this patient?

The clinical presentation is strongly suggestive of giant cell arteritis (GCA), with febrile fever, shoulder girdle and pelvic pain, and headache. Age and sex also point to this possibility. Abrupt unilateral visual loss with pale papillary edema is highly indicative of arteritic ischemic optic neuropathy due to GCA. The ESR is elevated, which further clarifies the diagnosis. We have to quickly start corticosteroid treatment. We can already rule out 1 and 5 because they do not contribute anything. 4 could make us doubt, and it is true that we will have to ask for a temporal artery biopsy, but that is not immediate: the statement makes it very clear that we have to act immediately. The current trend is to use megadoses of intravenous corticosteroids, and although aspirin has traditionally been proposed to reduce ischemic events, the evidence currently indicates that antiplatelet agents do not contribute much. An oral corticosteroid dose of around 1mg/kg would also be acceptable. Therefore, if we rule out 3 because the dose is too low, we would have to stay with 2. With reservations, since aspirin has a rather dubious role, and the corticosteroid dose remains ambiguous (we do not know how much the patient weighs). Of all the ophthalmology questions, this is perhaps the one most likely to be contested.

OPHTHALMOLOGY

A 26-year-old woman, with a history of a pregnancy at the age of 24 years ending in spontaneous abortion in the 12th week that did not require curettage, comes to the consultation presenting daily vaginal bleeding of one month of evolution, without fever or pain. Ultrasound showed an increase in the endometrial lining, with an intracavitary image of polypoid appearance. The endometrial biopsy shows intermediate trophoblast proliferation. Which diagnosis is correct?

It elevates chorionic gonadotropin. It has curative treatment.

ONCOLOGY

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

Patients with inflammatory bowel disease (IBD) have an increased risk of colorectal cancer, whether or not they are smokers. It is recommended to start screening 8-10 years after diagnosis of IBD (or earlier if primary sclerosing cholangitis or other events occur during this interval). The recommended techniques are colonoscopy with random biopsies (answer 3) and pancolonic chromoendoscopy with staining, which is currently the gold standard because it detects dysplasia better, although it requires more technical experience.

DIGESTIVE SYSTEM

A 62-year-old man comes to the hospital emergency department with a fever of 38.3″C and chills. He is tachycardic and tachypneic. Blood tests: leukocytosis with left shift. Blood pressure is 90/60 mmHg. No murmurs are heard on cardiac auscultation and chest X-ray rules out pneumonia. As history of interest she refers repeated urinary tract infections. A week ago the primary care physician prescribed cefuroxime, a drug he is currently taking. Two blood cultures were taken and urine was sent for sediment examination and microbiological culture. The sediment was pathological, with intense pyuria, but negative nitrites. After 24 hours, the microbiology laboratory reported that both the urine and the blood cultures were positive, and the results showed gram-positive cocci grouped in chains, pending identification and antibiogram. Pending the definitive result, what would you recommend?

With the urine nitrite test we detect the presence of nitrites in the urine. These appear due to the presence in the urine of a high concentration of bacteria possessing the enzyme nitrate reductase, which is capable of reducing the nitrates present in the urine to nitrites. This enzyme is active in most of the bacteria that most frequently cause urinary tract infection, such as many Gram-negative bacilli. Other microorganisms, relatively frequent causes of urinary tract infection, do not possess this enzyme and do not reduce nitrates, such as enterococci, staphylococci and yeasts. As the Gram stain indicates that the bacteria are grouped in chains, as this is typical of enterococcus, we suggest the need to cover this group of bacteria with antibiotic treatment. Staphylococci are typically seen on Gram stain as Gram-positive cocci forming clusters and yeasts, although with the same staining, have a different typical morphology than Gram-positive cocci.

INFECTIOUS DISEASES AND MICROBIOLOGY

A patient presents with a long history of multiple physical symptoms: memory loss, headache, dizziness, vomiting, genital pain, limb pain, abdominal distention, and menstrual irregularities. The various medical examinations have ruled out any medical illness. Which of the following is most likely to be the case?

According to ICD-10 the criteria for diagnosing Somatization Disorder (F45.0) are: A. History of multiple physical symptoms, which begins before age 30, persists for several years, and compels seeking medical attention or causes significant impairment socially, occupationally, or in other important areas of the individual's activity. B. All of the following criteria must be met, and each symptom can occur at any time during the disturbance: 1. Four painful symptoms: history of pain related to at least four areas of the body or four functions (e.g., head, abdomen, back, joints, extremities, chest, rectum; during menstruation, sexual intercourse, or urination). Two gastrointestinal symptoms: history of at least two gastrointestinal symptoms other than pain (e.g., nausea, bloating, vomiting [not during pregnancy], diarrhea, or intolerance to different foods). 3. A sexual symptom: history of at least one sexual or reproductive symptom other than pain (e.g., sexual indifference, erectile or ejaculatory dysfunction, irregular menses, excessive menstrual leakage, vomiting during pregnancy). 4. A pseudoneurological symptom: History of at least one symptom or deficit suggestive of a neurological disorder not limited to pain (conversion symptoms of the type of impaired psychomotor coordination or balance, localized muscle paralysis or weakness, difficulty swallowing, lump-in-throat sensation, aphonia, urinary retention, hallucinations, loss of tactile and painful sensation, diplopia, blindness, deafness, seizures; dissociative symptoms such as amnesia; or loss of consciousness other than fainting). C. Either of the following two characteristics: 1. Upon adequate examination, none of the symptoms in Criterion B can be explained by the presence of a known medical illness or by the direct effects of a substance (e.g., drugs or medication). 2. If a medical illness is present, the physical symptoms or social or occupational impairment are excessive compared to what would be expected from the history, physical examination, or laboratory findings. D. The symptoms are not intentionally produced and are not simulated (unlike in factitious disorder and simulation). Everything fits with what is described in the statement. Conversive or dissociative disorder is ruled out because these are usually related to psychological factors, associated with the symptom or deficit (not deliberate). The onset or exacerbation of the condition is preceded by conflicts or other triggers, which is not mentioned in the statement. Neither would it be a hypochondriacal disorder because this implies a preoccupation and fear of having, or the conviction of having, a serious illness based on the personal interpretation of somatic symptoms. But it does not involve physical signs or symptoms.

PSYCHIATRY

A 58-year-old woman comes for a follow-up visit for diabetes mellitus and hypertension. She feels well but states that she has stopped taking verapamil because of constipation. She presents with intolerance to ACE inhibitors due to coughing. On examination, blood pressure is 156/92 mm Hg. CBC includes a creatinine of 1.6 mg/dL, 24-hour urine protein excretion of 1.5 g/day, and a creatinine clearance of 45 ml/min. On this basis, what is the most effective treatment to slow the progression of the patient's type 2 diabetic nephropathy?

This question is typical and quite easy. The antihypertensive drugs that have been shown to slow the progression of diabetic nephropathy are the ACE inhibitors and ARAIIs. Specifically, angiotensin II receptor blockers have demonstrated their efficacy in this field for type 2 DM, which together with the side effects that IECAS produce in the patient makes an ARAII the drug of choice. This does not seem to me to be an open question (without going into pharmacoeconomic issues, of course...).

NEPHROLOGY

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 embryonic elements are found in several of the histological preparations. In reference to this case, point out the correct diagnosis:

Teratoma is the most frequent germinal tumor. It presents differentiation in elements of the three embryonic layers: endoderm, mesoderm and ectoderm. Macroscopically they can be cystic or solid, and histologically the tissues composing the tumor can be mature (well differentiated, like adult tissues) or immature (like embryonic tissues).Mature cystic teratoma is the most frequent: they represent on average 10% of ovarian tumors (5-25% depending on the casuistry). They occur at any age. They predominate in ectodermal tissues, such as skin, lining a cavity of keratinous content. In the cavity a spur is recognized from which hair or tooth structures often arise. Frequent tissues include: nervous tissue, usually glial and ependymal epithelium, respiratory and digestive epithelia and various mesodermal structures. They are bilateral in about 10% of cases. The mature cystic teratoma is benign, but in 2% of them a malignant tumor may develop from one of the tissue components (spinocellular carcinoma, carcinoid, adenocarcinoma, thyroid tissue carcinoma, sarcoma). In this case at first we thought that the option was mature cystic teratoma but thanks to Ramón, when we read it more carefully, we found that it had neuroectodermal and embryonal elements in several of the histological preparations, so we consider that the correct answer is 2.

ONCOLOGY (ECTOPIC)

A 60-year-old man, smoker of 40 packs/year, who consults for pain in the ulnar border of the left arm and left palpebral ptosis since one month ago. Chest X-ray shows a mass in the left upper lobe and CT scan confirms the lesion with invasion of the second rib. In relation to the suspected diagnosis, the most appropriate treatment is:

Typical smoker's pancoast, probably an epidermoid, with Horner's sdr. Best would be chemoradio followed by surgical salvage. In the old days it was just RT and surgery. Maybe not far off enter immunotherapy in first line. There are more and more new things.

MEDICAL ONCOLOGY

A 34-year-old patient playing tennis is hit by a ball at the level of the left orbit. On examination he presents significant palpebral hematoma, hyposphagmia, diplopia to superior vision with limitation of the upper version of the eyeball. What would you suspect?

This question has a small typo (one would say "tennis"), but personally I am a little more bothered by the error in the description of the scan. Specifically when they say "diplopia to superior vision with limitation of the superior version of the eyeball". Versions are bilateral conjugated movements of both eyes. That is, a version is composed of the sum of two ductions, since duction is the movement of only one eye. When you explore the versions, specifically the superior version or supraversion, both eyes rotate upward. At that time, you may encounter a limitation of the movement of one eye. In this case, when you scan the supraversion, you suspect or you detect a limitation in the movement of the left eye. And we would call this a limitation to the supraversion of that eye. It doesn't make sense to talk about limitation to the version of the eyeball, because the version is always of both eyeballs. Okay, it is understood, but it is an important misconception that should not be made by the person writing the question (who is supposed to be an expert on the subject), but well, as I do not think it is a reason to challenge the question, let's go on. It is about a patient who has received a blow. All four answers are fractures, so we have a pretty definite picture. The palpebral hematoma and hyposphagma (subconjunctival hemorrhage) does not give us the key data. What is important is that the eye that has received the blow does not go up, and therefore there is double vision in the superior gaze. It might be tempting to answer 3, thinking that because the superior rectus is trapped, it does not work and therefore the eye cannot go up. However, muscles trapped in a fracture do not automatically lose their muscular action. What happens is that they become trapped, they are "hooked", and cannot stretch. The problem is that the inferior wall has been broken, the inferior rectus has been trapped, and when the eye must look up, this inferior rectus cannot stretch as it should. It is not paralysis, but a restrictive problem. This question could also be answered by discarding. Options 2 and 4 can be ignored because they are too far away from the extraocular muscles to produce diplopia. And as for the walls of the orbit, the ones that break most frequently are the inferior and medial wall. The superior wall ruptures very rarely.

OPHTHALMOLOGY

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

We are being presented with a picture of conjunctival inflammation or conjunctivitis and asked which of them is not associated with pre-auricular lymphadenopathy. Adenovirus conjunctivitis can be associated with inflammation of the pre-auricular or ipsilateral sub-mandibular lymph node (option 1 discarded). Allergic conjunctivitis is a hypersensitivity condition that can occur immediately after contact with the triggering stimulus or after 24-72 hours, and is associated with accompanying signs such as eyelid edema and erythema, changes in periocular skin pigmentation, and a key symptom: itching. What it is not associated with is lymphadenopathy (option 2 correct). The oculoglandular syndrome of Parinaud is a picture that by definition is composed of conjunctivitis of infectious cause associated with ipsilateral pre-auricular or latero-cervical lymphadenopathy (one or several), generally produced by bacteria such as Bartonella henselae (cat scratch disease) or Francisella tularensis (tularemia or rabbit fever): option 3 discarded. Chlamydial conjunctivitis can present as 3 very distinct clinical pictures: trachoma, ophthalmia neonatorum or adult inclusion body conjunctivitis. The latter is considered a sexually transmitted disease and is associated with ipsilateral pre-auricular nodes (option 4 discarded).

OPHTHALMOLOGY

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?

Colposcopy with possible biopsy. H-SIL (High-grade squamous intraepithelial lesion)*: includes changes suggestive of CIN2 and CIN3/CIS. The cytologic diagnosis must be confirmed by biopsy, for which it is necessary to perform a directed biopsy by colposcopy.

GYNECOLOGY AND OBSTETRICS

A 40-year-old woman is admitted to the Emergency Department with a fever of 38ºC and right lumbar pain. The CBC shows 25000 leukocytes/mm3 with left deviation and an abdominal ultrasound shows a coralliform lithiasis. What microorganism do we expect to find?

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

INFECTIOUS

A 55-year-old patient diagnosed with hypertension 2 months ago at a company check-up. Laboratory tests: glucose 129 mg/dL, cholesterol 202 mg/dL, LDLc 160 mg/dL, HDLc 38 mg/dL, triglycerides 171 mg/dL, creatinine 1.1 mg/dL. He consults for poor blood pressure control, malleolar edema and dyspnea that is occasionally nocturnal. Physical examination: BMI 38 kg/m2, abdominal perimeter 110 cm, BP 157/93, HR 70 bpm, HR 14 rpm. Systolic murmur with reinforcement of the second sound. Peripheral pulses with discrete asymmetry in right pedius and right posterior tibial pulses that are weaker with respect to the left extremity. Chest X-ray and ECG without alterations Which of the following complementary tests is the least necessary for the detection of lesions in target organs?

HbA1c would be useful in this patient for the diagnosis of diabetes but not for the target organ involvement of hypertension.

ENDOCRINOLOGY

A patient comes to the Emergency Department with fever without focus of 24 h of evolution, hypothyroidism and impression of severity. She underwent a splenectomy 2 years ago for staging of Hosgkin's disease. Which microorganism is most frequently implicated?

Another one on epidemiology. In splenectomized patients, the risk of acquiring serious infections by encapsulated germs is increased, again Pneumococcus being the most frequent.

INFECTIOUS

A 67-year-old patient who in the last 6 months, in two routine analyses, presents progressive lymphocytosis. In the last one, hemoglobin 15.4 g/dL; leukocytes 18.5 x103/μL with 82% of mature lymphocytes that by flow cytometry express CD5/CD19/CD23 antigens and platelets 240 x103/μL. What attitude do you think is correct?

A question that I think can be complicated for a MIR examiner. We are told of a leukocytosis at the expense of lymphocytes with a B-CLL phenotype. It seems that there are no other alarming data. No clinical data are given (so we assume that the patient is asymptomatic). No cytopenias... Conclusion: FOLLOW UP. The main hesitation with the answer should be with option 1. Why do I consider it incorrect? Because the TP53 mutation, although it establishes prognosis, is not indicated at diagnosis, but when treatment is going to be initiated (first line and prior to successive lines in case they are needed). It would be possible to go too far in this question in which the percentage given does not refer directly to clonal lymphocytes, so that it could even be a monoclonal B lymphocytosis. But this is going too far.

HEMATOLOGY

A 59-year-old woman consults a gynecologist for a spontaneous, spontaneous, uniorificial discharge from the right nipple (unilateral) without palpable nodularity. What is the most likely diagnosis?

The correct answer is 2. In the presence of unilateral and uniorificial hematic telorrhea, the most frequent cause is intraductal papilloma (50%), followed by ductal ectasia and carcinoma. When associated with palpable mass, 60% correspond to carcinoma. Paget's disease is of the eczematous type. In hyperprolactinemia, telorrhea is bilateral and pluriorificial. Mammography often does not show papillomas, being more useful ultrasound and galactography.

GYNECOLOGY AND OBSTETRICS

A 17-year-old woman comes to the emergency department with a high fever, pharyngeal pain and cervical lymphadenopathy. She had previously been diagnosed with acute pharyngitis and was treated with amoxicillin, and later presented with a generalized macular skin rash. Laboratory tests showed slight leukocytosis with lymphocytosis and presence of activated lymphocytes, slight thrombopenia and slightly increased transaminases. What would be the most likely diagnosis of this clinical picture?

Of course it is a typical picture (EBV, CMV, VH6, Toxoplasma), of which you will not see so clearly at the emergency room door when you are on call. Be careful with the bad blood in answer 3, because an acute toxoplasmosis can behave like this and also give a macular exanthema, although the one of this girl is related to the intake of amoxicillin. By the way, I add a note, if instead of a girl of 17 years so clear it were a young man/girl with risky sexual relations, do not forget the HIV primoinfection as a cause of mononucleosis syndrome.

INFECTOLOGY

A 45-year-old woman with no history of interest consults for dyspneic sensation of about 4 days of evolution. Examination shows rhythmic tachycardia, without murmurs, and pulmonary auscultation is normal. Arterial blood gases showed a pO2 of 70 mmHg and a pCO2 of 32 mmHg. Hemogram, renal and hepatic function are normal. Prothrombin time 90%, activated partial thromboplastin time (APTT) ratio of 2 to control (N <1.2). Which of the following diagnoses is the most likely:

In this question what they assume is that this is a 45-year-old woman who is diagnosed with pulmonary thromboembolism (PTE). With this diagnosis, options 3 and 4 are directly excluded (also, she is female, so we would not have to think about hemophilia) As an analytical data, it says that there is a lengthening of the aPTT. So, they want you to know, she has positive lupus ac and link it directly to antiphospholipid syndrome (APS). A Leiden's does not alter coagulation, so it is ruled out as well. Anyway, although it is not within the possible answers, lupus positivity can be related to a myriad of clinical situations, syndromes and pathologies. Assuming that a PTE + lupus is a PFS seems to me to be a bit of a stretch, but it is the most likely with the data provided.

HEMATOLOGY

After a traffic accident you attend to an injured person. The patient opens his eyes at your call, but only utters words that are inappropriate. On motor examination, the pain is localized in the right extremities, but spreads on stimulation of the left extremities. How would you describe his condition according to the Glasgow Coma Scale?

The first thing we should know when applying the Glasgow Coma Scale to a patient is that we should always keep the best value in each sphere (ocular response, motor response and verbal response). In this case, we have a patient who has an ocular opening to the call (ocular response 3 out of 4), emits inappropriate words (verbal response 3 out of 5) and localizes pain with right extremities (motor response 5 out of 6). The Glasgow Coma Scale score would be 11 (out of 15). The best value of the examination is taken because in many cases (assessment of a polytraumatized patient, ischemic stroke or spontaneous acute cerebral bleeding), the motor examination may be artifacted by other elements. For example: in a polytraumatized patient (such as the one in question), the response presented with left extremities may be due to localized trauma in that area, and not strictly speaking to an underlying traumatic brain injury. Likewise, sometimes the verbal response may be underestimated in the polytraumatized patient due to airway obstruction (e.g., due to the tongue retreating into the oropharynx). By always assessing the best response, we will have a truer picture of the patient's condition.

CRITICAL AND EMERGENCY CARE

A 55-year-old woman consults for fatigue and polyuria of two years' evolution. Laboratory tests reveal hypercalcemia, increased PTH and increased bone turnover markers. The radiographic study shows subperiosteal resorption and osteoporosis. Sestamibi scintigraphy revealed a parathyroid adenoma. Parathyroidectomy was performed with minimally invasive surgery. Postoperatively, the patient developed severe hypocalcemia and tetany, with PTH below 5 ng/l. The patient responds well to initial treatment with intravenous calcium and later with oral calcium and vitamin D. What is the most likely diagnosis?

Question of very high difficulty, I would not worry about having failed it. It is easy to get confused with the hypoparathyroidism answer. Permanent post-surgical hypoparathyroidism after parathyroidectomy of an adenoma with minimally invasive surgery is rare. I write a brief summary of the hungry bone syndrome that I have found in a clinical case in the Annals of Internal Medicine [1]: "The pathophysiology of the hungry bone syndrome (HBS) is related to an imbalance between bone formation and bone resorption, which is associated with hypocalcemia, hypophosphatemia and hypomagnesemia (1). This syndrome can be observed after surgery in patients with primary hyperparathyroidism (HPT), as well as in tertiary HPT of chronic renal failure, and to a lesser extent after treatment of processes with excess of circulating thyroid hormones (2). In PTH, there is an excess of parathyroid hormone (PTH) which stimulates osteoclastic activity causing demineralization of the bone matrix and releasing calcium into the bloodstream. After parathyroidectomy, serum PTH levels drop dramatically, thus, PTH-induced bone resorption ceases, while osteoblastic activity continues resulting in increased bone uptake of calcium, phosphate and magnesium, thus SHH appears (3)."

ENDOCRINOLOGY

A 4-year-old boy comes to the health center who, 5 minutes before, starts with angioedema in the face, conjunctivitis, nasal congestion and hoarseness, coinciding with the ingestion of a spoonful of yogurt given to him by mistake at school. Among the antecedents, he was diagnosed with cow's milk protein allergy. Examination revealed mild hypotension, heart rate 110 bpm, O2 Sat 93%, pale and slightly sweaty, with scattered wheezing. What is the first treatment of choice?

We are facing a case of Anaphylaxis so the first measure is to administer Adrenaline 1/1000 intramuscular (0.01mg/kg). Subsequently, systemic corticosteroids such as methylprednisolone will be given, which will take a few hours to take effect. So adrenaline first, as it is faster acting, then the rest (Question very similar to one last year, instead of yogurt, it was omelet).

PEDIATRICS

A 72-year-old man presenting since 48 hours with fever of 38.7°C, cough, purulent expectoration and dyspnea. Constants: BP 85/60 mmHg, heart rate 100 bpm, respiratory rate 35 rpm, SatO2 80%. Of note was the presence of confusion and crackles in the left lower lung field. Chest X-ray confirms the existence of pneumonia of the lingula and left lower lobe. What would be the appropriate place of care?

Applying the CURB-65 severity scale (one of the most commonly used in the ED for stratifying the severity of pneumonia, although in this case simply applying common sense, the patient should be admitted to the ICU), we would have a score of at least 4 points (we would be missing the serum urea data), which gives us severity criteria. Since there are no criteria that contraindicate admission to the ICU, admission to the unit would be indicated.

CRITICAL CARE

15-year-old male, admitted after being run over on the public road, resulting in being ejected. He was admitted conscious and oriented, with intense pain in the left hemithorax and dyspnea. Physical examination showed blood pressure 90/60 mmHg, heart rate 130 bpm, basal oxygen saturation 90%, respiratory rate 35 rpm. There is complete hypophonesis in the left hemithorax and dullness to percussion. Chest X-ray shows multiple left costal fractures and massive ipsilateral pleural effusion. Placement of a pleural drain is indicated, with 1700 cc of hematic fluid coming out. What is the decision to be made:

There are two answers that we can immediately rule out if we stick to the initial management of severe chest trauma: 1 (noninvasive ventilation is not indicated because it does not secure the airway) and 3 (observation in these cases, waiting for worsening, only leads to increased morbidity and mortality). Between options 2 and 4 there could be controversy between the literature and the usual clinical practice, in which we usually have to face in a delicate balance the clinical stability of the patient (and what we can "make up" this stability with our life support therapies) and the actions that result in better patient care for the definitive treatment of the lesions. We are dealing with a severe polytraumatized patient. With the data provided by the question, a patient who seems to be in shock (tachycardia, hypoxemia, tachypnea... although we do not receive data, for example, on lactacidemia), and in whom we have to our knowledge a left thoracic trauma, which not only implies bone injury, but may mask other injuries of high severity and which are not diagnosed with a chest X-ray: myocardial contusion, pericardial effusion, splenic injury, diaphragmatic injury... We place a left pleural drain on the patient and obtain a debit of 1700cc of hematic fluid. If we follow the ATLS (ATLS-Advanced Trauma Life Support 10th edition) guidelines for the care of severely polytraumatized patients, they tell us that an immediate bleeding of more than 1500cc of blood is an indication for urgent thoracotomy, and that even in patients with a bleeding of less than 1500cc, if the debit persists at a rate of 200mL/h for 2 to 4h, this indication would also exist. Therefore, the person who asked the MIR question wants us to answer option 2. However, in real life, the course of action will depend on the stability of the patient when we have applied the treatments indicated in option 2: adequate analgesia, oxygen therapy and initiation of blood transfusion. If by optimizing the patient we manage to stabilize him and assess that it is safe to transfer him, the performance of a body CT scan will define in much greater detail the lesions he has, and will help to ensure that the surgery he will probably end up undergoing will be a definitive surgery and not just damage control surgery. In this case, the doubt would arise with option 4, although, as I say, everything will depend on the clinical stability of the patient and the time we have before achieving definitive control of the hemorrhagic focus (which is, after all, what we are after in this situation).

CRITICAL AND EMERGENCY CARE

A 72-year-old man comes to the Emergency Department with a pathological fracture of the left femur. After surgery, a diagnostic study is performed to determine the underlying pathology with the following findings: hemoglobin 9.5 g/dl, total proteins 11 g/dl, (VN: 6-8 g/dl), serum albumin 2 g/dl, (VN 3.5-5.0 g/dl), beta 2 microglobulin 6 mg/l (VN 1.1-2.4 mg/l), serum creatinine 1.8 mg/dl (VN: 0.1-1.4 mg/dl). Indicate which diagnostic tests would be necessary to confirm the most likely diagnosis:

She is going to have myeloma. For diagnosis, a sample (bone marrow) and electrophoresis to determine the type of monoclonal peak. Then, for extension, prognostic value and to decide treatments, the rest, but once diagnosed.

HEMATOLOGY

A 67-year-old man consults for moderate exertional dyspnea of progressive onset in recent years. He has daily whitish expectoration and sometimes breath sounds, especially in winter with respiratory infections. He has been a smoker of about 20 cigarettes a day for the last 45 years. On examination he is eupneic, normocolored, with an oxygen saturation of 94%, and has generalized decreased vesicular murmur on chest auscultation as the only findings of interest. Chest X-ray shows an elongated cardiac silhouette, with signs of hyperinflation or pulmonary air trapping, without other alterations. Spirometry was performed with the following result: FVC 84%, FEV1 58%, FEV1/FVC 61%, unchanged after bronchodilator. Among those indicated, indicate the most appropriate treatment for this patient:

In a patient with a low symptomatic COPD that could probably be classified as GOLD 2, the starting treatment can be either with inhaled tiotropium or with a long-acting beta two. Therefore there is no doubt in the correct answer.

PNEUMOLOGY

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

The correct answer is 3. It defines a typical cerebrospinal fluid of tuberculosis. In clinical practice things might not be so simple......

PEDIATRICS

An 87-year-old patient with a history of chronic bronchitis and heart failure, has been diagnosed with acute calculous cholecystitis . After four days of treatment with absolute diet, serum therapy and piperacillin/tazobactam, the patient continues with fever, persistent abdominal pain and leukocytosis. The most appropriate attitude at this time would be:

I think the correct answer is 2 although the treatment for acute cholecystitis is cholecystectomy, for this it is necessary that the patient is a surgical candidate, in this case it is an elderly patient, with previous diseases that increase the surgical risk and would be an ASA IV for an urgent intervention. In these cases cholecystostomy can cure cholecystitis; and after recovery, assess scheduled surgery according to the patient's situation.

SURGERY

A 61-year-old woman, administrative, with a history of overweight, hypertension, dyslipidemia and metabolic syndrome, who consults for pain in both buttocks, left trochanteric region, lateral aspect of the left thigh up to the knee and left leg up to the middle third. The pain appears when the lower limb is lifted with the knee extended, but is relieved when the knee is flexed. What is the first clinical suspicion?

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

TRAUMATOLOGY

Patient with acute pancreatitis. Computerized Axial Tomography (CAT) performed 72 hours after admission showed necrosis of 50% of the pancreas. At the 3rd week of admission the patient began with high fever and leukocytosis. Urgent chest X-ray and urinary sediment are requested, both being normal. Indicate the next step to follow:

Although the latest recommendations on the management of severe acute pancreatitis advise against FNA because of the risk of infection of sterile necrosis. Current management is governed by stepwise treatment. In the situation described in the question the current treatment is to start antibiotics and assess response.

GENERAL SURGERY

A 54-year-old man who goes for a check-up at his company. A body mass index of 32.8 kg/m2 and fasting blood glucose of 138 mg/l were detected. One month later, glycemia 13 mg/dl. Which therapeutic recommendation would you make first?

Behavioral changes: diet and physical exercise. This is the first thing we do when diagnosed with type 2 diabetes. This is a good question to remember that before any drug, we must insist on changing habits. Then we would prescribe Metformin.

ENDOCRINOLOGY

A 43-year-old man consults for diarrheal syndrome, and refers among his history 3 pneumonias in adulthood. Which of the following immunological studies should we request:

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

GENETICS AND IMMUNOLOGY

A man presents abruptly with asthenia and jaundice with transaminases above 2000 IU/L. Serological markers show the following pattern: anti-HAV IgM negative, HBsAg negative anti-HBc IgM positive, anti-HCV negative. What is the diagnosis?

An interesting one that in general needs to be studied. By the form of presentation, it is clearly an acute hepatitis, so option 1 is ruled out. The negative IgM of HAV rules out 5 and the negative HBs Ag rules out 4 (to have delta virus you need surface antigen B). When having IgM anti HBc we speak of an acute hepatitis B (3), since there is a window period of negativization of the antigen.

DIGESTIVE

55-year-old man who consults for dysphonia. In the anamnesis he refers to a month of asthenia and unquantified weight loss. Chest X-ray shows increased density in the left upper lobe and occupation of the aortopulmonary window. Bronchoscopy shows paralysis of the left vocal cord, without endoscopic image suggestive of neoplasia. What is the most likely diagnosis?

The most frequent cause of recurrent nerve palsy is bronchopulmonary carcinoma. The fact that it is not accessible to endoscopic vision does not mean that it is not there.

PNEUMOLOGY AND THORACIC SURGERY

A 65-year-old female patient debuted two years earlier with an apraxia of speech and has developed rigid-akinetic parkinsonism predominantly in the right hemibody with superimposed myoclonias and alien hand or foreign limb phenomenon.What diagnosis do you consider most likely?

As it is described as an apraxic phenomenon followed by an asymmetric rigid-akinetic parkinsonism and with superimposed myoclonias, it is typical of corticobasal degeneration. Parkinson's disease cannot be because they do not present apraxia as initial feature, Alzheimer's disease does not present an asymmetric parkinsonism and the typical Huntinton's disease is not of so old people and when it debuts with advanced age it behaves like a chorea.

NEUROLOGY

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

The correct answer is 4. The normal range of stool output in young infants is very wide. To suspect aganglionic megacolon there is usually a delay in the evacuation of meconium and often other associated symptoms such as abdominal distension, difficulty in gaining weight, etc.

PEDIATRICS

A 47-year-old woman consults for voiding syndrome. She is diagnosed with uncomplicated urinary tract infection and treated with ciprofloxacin for 5 days. A week later, she consulted again for general malaise, arthralgias and the appearance of a skin rash. In the analytical analysis, the glomerular filtration rate was 45 ml/min (CKD-EPI), whereas 6 months ago it was 100 ml/min. In the sediment leukocytes are identified, being negative for nitrites. Of the following, which is the most probable cause of his renal failure?

General malaise, arthralgias, skin rash, acute renal failure and active sediment with sterile leukocyturia following the intake of a drug is highly suggestive of AIN (option 4 correct). Among drugs, antibiotics are the most frequent cause, and ciprofloxacin is one of the most common. Direct nephrotoxicity is very rare and is characterized by crystallization in the renal tubules (incorrect option 2). Postinfectious glomerulonephritis is more typical of children and adults older than 60 years, and usually manifests with hematuria after streptococcal infections (option 1 incorrect). Acute pyelonephritis would have been presented with high fever and renal fossa pain (option 3 incorrect).

NEPHROLOGY

A 30-year-old woman, asymptomatic, is found to be anemic on routine examination. Physical examination reveals conjunctival jaundice and splenomegaly. The patient refers to a family history of biliary lithiasis at an early age. All this suggests the most probable diagnosis of:

You have probably looked at answer 5, hereditary spherocytosis, associated with biliary lithiasis at an early age. Exactly, that is the correct one. In the statement they have not stopped giving clues: conjunctival jaundice, splenomegaly and family history of biliary lithiasis at an early age. He has reached 30 years of age without suffering a hemolytic crisis, without suffering any symptoms. There was no mention of microcytosis or macrocytosis to suggest thalassemia minor or B12 and/or folic acid deficiency. Nor of hemolytic crisis associated with the consumption of drugs, infections or ingestion of beans or peas. They have not given any clues to stop to think about other possibilities.

HEMATOLOGY

19-year-old woman, weight 60 kg, with acute dehydration due to long exposure to the sun. Blood pressure lying down 100/60 mmHg. Standing 70/50 mmHg with dizziness. Serum sodium levels 155 mmol/L. What is the most correct treatment, in the first 24 hours, taking into account the data available to us?

This question is not an easy one. The available literature is somewhat controversial (some guidelines advise using glucose saline, others absolutely forbid it...) so I have decided to rely on the treatment recommended by Harrison, which is the manual that MIR examiners usually rely on. This girl presents with hypernatremia due to extrarenal free water losses. The goal is to replace the lost water and reduce the natremia at a rate of no more than 12 mmol/day. To calculate fluid therapy, the water deficit must first be calculated. Water def. Water = (Natremia-140/140)xTotal body water. TBW = Weight in kg x 0.4 in females/0.5 in males. In this case, the water deficit is: ([[tel:155-140/140|155-140/140]])x60x0.4 = 2.57 liters. There are only two answers that come close to this figure, but 2 seems more correct, as it is the only one that completely covers the water deficit and uses a hyposodium solution.

NEPHROLOGY

A 43-year-old male with no past history of interest consults for a ten-day history of jaundice of the skin and mucous membranes, choluria and acholia. He does not report abdominal pain, weight loss or other symptoms, except generalized pruritus. She denies alcohol consumption. She does not take any medication except occasional ibuprofen for muscle pain after sports activities. The CBC shows increased bilirubin at the expense of direct bilirubin. An urgent ultrasound shows a normal liver, vesicular cholesterosis and absence of bile duct dilatation, with no other alterations of interest. What is the most likely diagnosis?

We believe that this question is open to challenge. Ibuprofen hepatitis is a rare adverse effect with a prevalence of about 3.7/100,000 users and 1.1/100,000 prescriptions. It appears that it may be related to dose and duration of treatment, but there is little evidence on this. Among the NSAIDs with the highest risk are diclofenac and sulindac. In terms of frequency, the prevalence of cholangiocarcinoma is 2/100,000 patients, a very comparable frequency. The absence of bile duct dilatation in cholangiocarcinomas can be seen in cases of intrahepatic cholangiocarcinomas or in those with mixed histology with hepatocarcinoma. It is true that the acute course and the absence of constitutional syndrome may make us think against this option and tip the balance towards ibuprofen hepatitis. Regarding the other options: acute cholangitis is characterized by the triad of jaundice, abdominal pain and fever; Gilbert's syndrome is an increase in bilirubin at the expense of indirectness.

DIGESTIVE

A 50-year-old patient presenting with a pleural effusion with the following features: straw-like appearance, pH 7.3, pleural protein/serum ratio 0.8, pleural LDH/serum ratio 0.9, Gram and Ziehl's negative, total lipids, cholesterol and triglycerides normal, mesothelial cells <5%, intense lymphocytosis without atypia, ADA 64 U/L. What diagnosis would you suggest?

It is a lymphocytic exudate whose main diagnoses are tumor and tuberculous pleuritis. They do not give the value of glucose which should be lowered, but if the cytology shows absence of malignant cells so we are left with tuberculous pleuritis. Other possible diagnoses such as lymphoma are not mentioned in the answers.

PULMONOLOGY

In a subject over 65 years of age a tuberculin test has shown an induration of 3 mm. The induration on a second test, performed 10 days later, is 13 mm. Point out the correct answer:

Let's see, if that subject was not in any risk group, the positive is in the 15mm, therefore both tests are negative, and as only one answer refers to negative, that's it. But both could be false negatives.

BIOSTATISTICS

A 67-year-old woman diagnosed with 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?

The answer is 2, study of hormone receptors and HER2. This is because no study of first-degree relatives is appropriate, as it does not appear to be hereditary breast cancer since there is no family history of neoplasia. On the other hand, there is no indication for BRCA 1-2 study.

GYNECOLOGY AND OBSTETRICS

A 26-year-old woman diagnosed with systemic lupus erythematosus, on treatment with hydroxychloroquine, consults for a feeling of generalized weakness that has progressively developed in the last 15 days. The physical examination reveals cutaneous pallor and the CBC shows Hb 7.4 g/dL, Hct 31%, MCV 108. Which of the following tests will be most useful in deciding the course of action?

It tells us about a patient with a diagnosis of lupus and macrocytic anemia. In the end, all the data are usually given for a reason. The onset of the picture seems relatively rapid and it is also associated with an autoimmune disease, so it seems that they want you to associate it with an autoimmune hemolytic anemia. The low haptoglobin would tell us it is "hemolytic", the coombs test would tell us it is "autoimmune". Vitamin B12, probably the MCV would be higher than 108 and the onset of the clinical picture would be slower. The ANA would not give us anything in relation to the anemia, since it already has a diagnosis. Therefore, correct answer 2. As a note, autoimmune hemolytic anemias are usually slightly macrocytic due to reticulocytosis. Remember to ask for reticulocytes.

HEMATOLOGY

A 36-year-old man with no PA of interest comes to the emergency department with sudden onset of severe pain in the posterior aspect of the right lower limb extending to the foot. On examination he presented: Positive right Lasège at 10º, decreased strength in plantar flexion of the right foot, hypoesthesia in the external border of the right foot and absence of right Achilles reflex. The simple X-ray of the lumbar spine does not show significant alterations. Which of the following is the most probable diagnosis?

Acute sciatica probably due to disc extrusion. Both the sensory distribution, the paresis for plantar flexion (tiptoe) and the absence of the Achilles reflex are typical of S1 root involvement, which is typically affected with L5/S1 disc herniation (posterolateral). An L1/L2 (posterolateral) herniation would affect the L2 root, an L4/L5 herniation would affect the L5 and cauda equina would involve more symptomatology than simple S1 involvement.

NEUROSURGERY

20-year-old male, who consults for lumbosacral pain of inflammatory rhythm of 4 months of evolution. Also bilateral thalalgia and morning stiffness for 1 hour. In the last 2 months, onset of diarrhea with loss of 4 kg of weight. What is the most correct diagnostic approach?

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

TRAUMATOLOGY AND ORTHOPEDICS

A 30-year-old man suffers a fall from a standing height of 2 meters. On arrival at the emergency room on a stretcher, he is conscious and oriented, with bladder catheterization and clear urine. He shows swelling of the left heel and mild tingling in the anterior aspect of the left thigh and scrotum as well as dysesthesia in both feet. The patient says goodbye to the stretcher-bearer with a handshake and a simultaneous pat on the shoulder. Rotation of the lower limbs on the stretcher grasped by the ankles is painless and compression of the pelvis is asymptomatic. Next:

I believe that the correct answer is 3. The patient, due to the mechanism of injury (foot fall), the calcaneal fracture and the neurological symptoms, suggests a low spinal cord injury due to a fracture of the lumbar spine. The injury is not high because he moves his arms. It also does not appear to be a pelvic injury because of the absence of pain on mobilization or palpation. If there is a suspicion of pelvic injury in the primary evaluation of all polytraumatized (ATLS) a spinal exploration should be performed by rotating the spine en bloc to avoid producing more injury. Abdominal palpation is also part of the initial evaluation. Abdominal ultrasound may be indicated in hemodynamically unstable patients if abdominal injuries are suspected but in any case it is done after the initial evaluation.

SURGERY

35-year-old male, 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:

In this case we describe a case of cervicobrachialgia without alarm signs at the present time, so the most indicated treatment at this time would be conservative, based on NSAIDs, local heat and rest. This is not an urgent case, so answer 2 would not be valid. The performance of an MRI and an electromyogram are valid options for the etiological study of the picture, however, it is necessary to emphasize that we should first perform a correct pain management, so since we are asked about the first attitude, option 1 would be more valid.

TRAUMATOLOGY

A 64-year-old woman, without relevant comorbidities, operated on for a right breast cancer by means of an extended lumpectomy and selective sentinel lymph node biopsy, with the following anatomopathological result: Infiltrating ductal carcinoma poorly dlferentiated (grade 3), size 2.2 cm (pT2), estrogen and progesterone receptor positive, Ki67 25%, HER2 negative. There is macroscopic involvement of the sentinel lymph node, although there is no involvement of the rest of the isolated axillary nodes (pN1). What adjuvant systemic treatment do you consider most appropriate for this patient?

It is a Luminal B. According to the SEGO, this patient is a candidate for chemotherapy treatment because of the high histologic grade and high tumor proliferation.

GYNECOLOGY AND OBSTETRICS

A 10-year-old boy with brief episodes of distractibility (< 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 be with:

Absences behave as brief episodes of abrupt loss of consciousness without alteration of postural control; they typically last seconds and can be repeated many times a day, are usually accompanied by small bilateral motor signs (blinking, chewing) and consciousness is recovered equally abruptly, without subsequent confusion or memory of the episode (MIR 03-04, 248; MIR 97-98, 51). The age of onset is usually between 4 years and early adolescence, being the most frequent cause of seizures in this age range. EEG findings are typically generalized and symmetrical spike-wave discharges at 3 Hz (MIR 99-00F, 67) coinciding with seizures, although in the interictal EEG there are more periods of abnormal activity than clinically visible. The most appropriate drugs for the treatment of absences are Valproate and Ethosuximide (CTO Manual).

NEUROLOGY

35-year-old male, transferred to the emergency department after a traffic accident. On admission, a Glasgow scale score of 15, blood pressure of 140/90 mmHg, respiratory rate of 35 rpm and heart rate of 110 bpm, with a baseline oxygen saturation of 91%. On examination there is right thoracic hypophonesis and tympanism on percussion.What is the presumptive diagnosis? :

This is an easy and classic question that you can also apply to daily clinical practice. Hypophonesis in a hemithorax + tympanism = pneumothorax. If there is dullness on percussion: hemothorax. In either case, in case of hypophonesis of a hemithorax in a severe and unstable polytraumatized patient: thoracic drainage (if possible, large caliber if placed in a hospital environment, since although the predominant lesion is pneumothorax, a hemothorax component can be found which, in case of placing a fine drainage, could obstruct it).

CRITICAL CARE

Patient presenting since 2 weeks ago with a pruritic eruption consisting of multiple polygonal erythematous-violaceous papules, flattened surface, preferentially located on the anterior aspect of wrists, pretibial area and lumbar area. She also presents whitish reticulated lesions in the jugal mucosa. What is the most probable diagnosis?

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

DERMATOLOGY, VENEREOLOGY AND PLASTIC SURGERY

A 73-year-old patient...swallowing a complete neurological dysphagia secondary to a cardioembolic stroke in the left middle cerebral artery territory. will require long-term nutritional support. Of the following treatment modalities, which do you consider most appropriate for this case?

Enteral nutrition is a nutritional support technique that involves administering nutrients directly into the gastrointestinal tract by gavage. The choice of the route of formula administration depends on the nutritional status, age of the patient and the underlying disease. If enteral nutrition is considered to be of short duration, the route of choice is the nasogastric or nasoduodenal- nasojejunal tube... If prolonged nutrition is anticipated the route of choice is gastrostomy (option 3), with jejunostomy being reserved for cases in which it is not possible to use the gastric route.

ENDOCRINOLOGY

A 70-year-old woman with a history of hypertension and moderate heart failure presents with a persistent, dry cough that begins as an itchy sensation in the throat. What is the drug suspected of causing the patient's clinical and laboratory alteration?

These are typical adverse effects of ACEIs, in the case of cough it is usually dry and irritative and appears in up to 3% of patients. Hyperkalemia may also appear in 1%.

PHARMACOLOGY

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

The correct answer is 2. We are dealing with a case of postmenopausal metrorrhagia, whose most frequent cause is genital atrophy in the first place and endometrial cancer in the second place. The data given on obesity should lead us to suspect endometrial cancer, since peripheral fat is converted to estrone, and these estrogens cause the endometrium to proliferate. On the other hand, she provides a normal cytology, which rules out option 3. The hormonal evaluation is not opportune, since we understand that the patient is in menopause. We should not prescribe treatment without first ruling out organic causes.

GYNECOLOGY AND OBSTETRICS

A 62-year-old patient who has had a pericardial bioprosthesis in mitral position for two years. He is admitted urgently for acute coronary syndrome. Two days later and after a favorable evolution, he suddenly presented heart failure with acute pulmonary edema. Select the diagnostic option in this case from the following possibilities:

The valve is biological and, in general, the veils are not sewn to the papillary muscles, so we don't care what happens to them. A ventricular aneurysm depresses LVEF, but does not suddenly put you into PAD. In contrast, a VSD sharply increases flow to the pulmonary bed, causing pulmonary edema, and is also one of the most frequent complications of AMI. Ischemic ASD... I do not deny that it exists, but it does not even appear in the guidelines. And endocarditis would not require so many saddlebags.

CARDIOLOGY AND CARDIOVASCULAR SURGERY

A 64-year-old smoker and heavy drinker reports painless right jugulodigastric lymphadenopathy of progressive growth in the last two months whose fine needle aspiration was reported as squamous cell carcinoma. Which of the following is the most likely location of the primary tumor:

You are in the middle of the ENT block. You have already passed the Pneumology and Digestive blocks. Dermatology is still to come out, but a dermatologist (answer 1) would not ask this. So we are left with parotid and larynx; but parotid squamous cell carcinoma is rare; I would mark 5 and rest easy. Perhaps because all the adenopathies at this level that I have seen have ended up corresponding to carcinomas of the upper aerodigestive tract.

OTOLARYNGOLOGY AND MAXILLOFACIAL SURGERY

A 65-year-old man, a retired office worker and smoker of 1 pack of cigarettes a day, comes to the clinic with a persistent, generally dry cough and progressive dyspnea of 2 years of evolution which is currently grade 2. The patient denies other symptoms. Physical examination shows no relevant data. The attitude to follow would be:

The correct answer is 2 (Perform chest X-ray and spirometry with bronchodilator test). It is probably COPD but we must confirm it and assess the severity of the obstruction with spirometry before starting treatment. He is a patient at risk for lung cancer so it is mandatory to perform a chest X-ray to rule out this or other pathologies that would justify the symptoms, although most likely they are due to the debut of his COPD.

PNEUMOLOGY AND THORACIC SURGERY

A 22-year-old male presents to the emergency department with "almost black" urine for the past 12 hours. He has no past history of interest and is not taking any medications. He refers an upper respiratory catarrhal symptoms since 4-5 days ago for which he has taken paracetamol. Examination: temperature 37.3 ºC, BP 150/95, HR 85 bpm, slight pharyngeal erythema, the rest normal. Laboratory tests showed: Hb 12.8 g/dl, Hcto 39%, leukocytes 10,500/mm3 with normal formula, platelets 250,000/mm3, normal coagulation, urea 25 mg/dl, creatinine 0.8 mg/dl, ions, hepatic, lipid, albumin and total proteins normal. Normal autoimmunity study and negative viral serology. Urine 24 h with proteinuria of 0.75 g/24 h, sediment with 10 erythrocytes per field (90% dysmorphic), no leukocyturia. Renal ultrasound was normal. Which diagnosis do you think is more likely?

A picture of macroscopic hematuria and mild proteinuria with normal creatinine levels, accompanied by an upper tract catarrhal picture, is very suggestive of IgA nephropathy (option 3 correct).

NEPHROLOGY

A 60-year-old man with a history of hypertension and dyslipidemia has recently been diagnosed with heart failure. After performing the relevant tests, it was found that the left ventricular ejection fraction was preserved (>50%). With regard to treatment, indicate the CORRECT answer:

Treatment with diuretics should be started at high doses.

CARDIOLOGY AND VASCULAR SURGERY

In a patient with clinical signs of heart failure who presents with ascites disproportionately elevated in relation to peripheral edema, the most likely etiology would be:

They tell us about clinical symptoms of right failure, with edema and ascites. Therefore, we rule out left heart failure: EAo, dilated with DSVI and a MHO. Of the two we are left with, in constrictive pericarditis we have increased filling pressures in right chambers, which cause retrograde pressure increase with hepatic congestion, ascites, edema, etc. On the contrary, in pulmonary hypertension, the tricuspid valve is responsible (a priori) for "containing" this overpressure.

CARDIOLOGY

A 54-year-old man is diagnosed with a left renal tumor suggestive of renal cell carcinoma. His preoperative workup shows elevated levels of GPT, alkaline phosphatase and alpha-2-globulin and prolonged prothrombin time. The liver is diffusely enlarged, but without defects of hepatic infiltration. The most likely rationale for these findings is due to:

Very easy question in which we are being presented with a patient with Stauffer's syndrome, a paraneoplastic syndrome consisting of liver dysfunction secondary to toxic products secreted by a number of tumors (most frequently, renal cell carcinoma, like the one in this case). As in this case, cholestasis (elevation of alkaline phosphatase), mobilization of hepatic enzymes and lengthening of the prothrombin time indicate liver dysfunction. Metastases are ruled out (there are no defects of hepatic infiltration), intrahepatic tumor thrombosis (it would give another symptomatology and this would be more acute), and acute hepatitis and hemochromatosis (they are not in context nor is it what the author of the question wants us to think).

NEPHROLOGY

12-year-old girl, only child of healthy, non-consanguineous parents. There is no personal or family history of interest. In the clinical examination to start a sports activity, you find a discrete hepatomegaly of normal consistency, so you request a blood test, which highlights an ASAT of 80U / l, ALAT 105 U / l, electrophoretic proteinogram with all protein fractions in normal range and negativity of serology for hepatotropic viruses. What should you rule out and what test would you indicate for it?

In fact, I would not test this patient at this time, and I would check if the transaminase level has normalized at a later time, since the most frequent cause, at least in children, is a transient elevation in the context of viral diseases (most frequently cytomegalovirus and Epstein-Barr virus). The minimal elevation of liver enzymes and the fact that it has a normal protein profile goes against chronicity... If I had to choose I would choose answer 5, which seems to me the least aggressive, and if I had to do analytical tests I would add the determination of alpha-1-antitrypsin (without CT) and markers of celiac disease, because celiac disease can also be associated with some hypertransaminemia.

PEDIATRICS

In a patient with liver cirrhosis and ascites, who develops a pleural effusion with the following data in the pleural fluid: LDH 45 U/L (serum 220 U/L), pleural/serum protein ratio 0.3 and pleural/serum LDH ratio 0.2. What would be the appropriate attitude?

They describe pleural fluid parameters of transudate, so if the patient is not in heart failure it is a hydropic decompensation. No other studies are needed.

PNEUMOLOGY

A 60-year-old diabetic patient is consulting for the first time regarding the treatment of his disease. Which of the following goals would you recommend to him first?

The rest are not indications. The target BP is < 130/85 mmHg.

ENDOCRINOLOGY

A 25-year-old patient, during a tennis match, has intense pain in the neck and in the left eye. The next morning he wakes up with a feeling of gait instability and has palpebral ptosis of the left eye and anisocoria, with the left pupil being smaller than the right. The patient maintains good visual acuity. Where would you most likely locate the lesion?

The picture presented to us is that of a Horner syndrome (miosis with ptosis) so the possibilities are reduced to options 3 or 4, but they specify that the patient presents gait instability, which is not justified by a Horner due to carotid dissection affecting the superior cervical ganglion, which is what they want us to believe when they talk about pain in the neck and in the eye. If the patient really has ataxia, the only possible location would be the spinal cord.

NEUROLOGY

A 67-year-old woman diagnosed with 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?

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

GYNECOLOGY AND OBSTETRICS

A 47-year-old man with myopia magna, who underwent cataract surgery 2 years ago, comes to the emergency room reporting a profound and painless loss of vision in his right eye. Which of the following diagnoses can cause this symptomatology?

He refers to a patient post cataract surgery 2 years ago with deep and painless loss of OD. Post-surgical endophthalmitis is more associated with patients in the immediate postoperative period, besides being very painful with rapidly progressive decrease in visual acuity, so it is not correct. Retinal detachment is consistent with the clinical case because it is also a myopic patient who tend to have a special predisposition to detachment. ARMD usually occurs in older patients and the decrease in vision is progressive. In PVD there may or may not be a slight decrease in visual acuity and the patient usually reports some discomfort or pain at the onset of the clinical picture.

OPHTHALMOLOGY

A 25-year-old woman comes to the ED accompanied by a friend reporting that she was the victim of a sexual assault 4 hours ago. The patient is very affected, answering her questions inconsistently, slowly and not being able to remember how the assault occurred. Her vital signs (blood pressure, heart rate and temperature) are normal. Which of the following would be WRONG:

All the actions detailed are correct except the one detailed in option 2. The collection of samples of legal interest will only be carried out in the presence of the coroner, and, without the presence of the coroner, the woman must give her written consent. In addition, the taking of gynecological samples must be adapted to the psychological state of the victim, so in most cases, it is counterproductive to perform it at this time (even more so when they describe the patient's state as "very affected, answering their questions incongruently, slowly and not being able to remember how the aggression occurred".

CRITICAL AND EMERGENCY CARE

A 31-year-old bricklayer comes to the emergency department with tenosynovitis caused by a penetrating wound. On examination, the ulnar bursa is found to be infected with consequent tendon necrosis. Which tendon will be affected?

Both the flexor carpi radialis and the abductor pollicis longus are anatomically far from the ulnar. The palmaris longus is medial, as is the flexor digitorum profundus. The tendon that runs alongside the ulnar nerve, inserting into the pisiform, is the flexor carpi ulnaris, thus answer 1.

ANATOMY

A patient previously diagnosed with COPD comes to the emergency room for 3 days with increased dyspnea until he is at rest, cough with whitish expectoration and marked drowsiness. After receiving treatment with oxygen at low concentrations, bronchodilators and coticoids, a second arterial blood gas with 28% inspiratory oxygen fraction shows a pH of 7.32, pO2 61 mmHg, pCO2 58 mmHg, HCO3- 29 mmol/l. What would be the interpretation you would make of the arterial blood gas and what treatment would you use?

This is a very bad question, I will bet on one answer, but depending on data that we are not given, three answers could be valid. The trap is that they give us the initial clinical picture WITHOUT GASOMETRY and then they give us the blood gases afterwards WITHOUT CLINIC, so there is no way of knowing what the evolution of the patient has been with our treatment, so it is impossible to know what to do. If the patient initially came with a blood gas with a pH of 7.05 and now has the one we are given, we are doing well (although we are not told the time interval between one thing and the other) and, in this case, it could be worthwhile to continue with the same treatment. If nothing has evolved, the clinical picture is the same and the blood gas at the beginning was similar, something should be done (also depending on the patient's baseline status, which they do not tell us either). If we decide to do something, at present we might decide to use ventilation rather than theophylline, although with "so little" alteration of pH (and even more so if we think that this is a chronic patient who may have a baseline blood gas similar to the one presented to us) it may seem "exaggerated". We have nothing "against" theophylline (we are not told of any contraindication), but nowadays it is rare to resort to it. 1: Wrong, he is a "retentive" patient and increasing O2 flow is highly likely to increase hypercapnia and, therefore, acidosis. 2: We will keep this one as correct. 3: It is not a metabolic acidosis, the bicarbonate is not decreased, on the contrary, it is slightly increased trying to compensate the respiratory acidosis. 4: He does not reach respiratory failure by definition (pO2 60), but he has hypercapnia and slight acidosis. If we knew the first blood gas and she was much worse (i.e. she was doing very well), continuing with the same medication would be an option, but this data is missing!!!, in any case it seems to be a trick answer. 5: At present and -as already mentioned- taking into account that there is no formal contraindication, it is not usually used.

NEUROLOGY AND THORACIC SURGERY

An 82-year-old hypertensive woman on atenolol, hydrochlorothiazide and digoxin. She comes to the emergency room for atrial fibrillation and is administered IV verapamil. The ECG showed complete atrioventricular block. What is the most probable cause of this clinical situation?

He already takes two AV node brakers and you add a third, and are you surprised that he gets complete AV block after messing with drugs from different families but same effect (pharmacodynamics)? Three. And remember that drugs are like drinks when you go to a bar: don't mix!

CARDIOLOGY

A 48-year-old patient referred to the nephrology department for an estimated glomerular filtration rate (eGFR) of 32 ml/min/1.72 mL/min/1.72 mL. Which of the following data would NOT suggest chronic kidney disease?

Adequate corticomedullary differentiation is suggestive of no chronic parenchymal impairment, and is a frequent finding in acute renal failure (option 4 correct). A family history of nephropathy could indicate the existence of a hereditary disorder (incorrect option 2). Small kidneys and hyperphosphatemia are features of chronic kidney disease (option 1 and 3 incorrect).

NEPHROLOGY

A 64-year-old man with Child A liver cirrhosis with no history of decompensation. After detection of a focal hepatic lesion on screening ultrasound, the study is completed with a thoracoabdominal CT scan. This scan showed the presence of 4 liver lesions (one of them up to 6 cm) with uptake pattern typical of hepatocarcinoma, tumor vascular invasion and a metastasis in the right adrenal gland. No ascites is observed. The patient reports only asthenia, but no general syndrome. The treatment of this patient would be:

Comment: The patient presents a good general condition with a recently diagnosed hepatocarcinoma, not giving him any type of treatment other than symptomatic and supportive at this stage would not be the right thing to do. TACE would not be indicated because of extrahepatic involvement. Transplantation would also not be done if he has extrahepatic disease. We are left with answers 3 and 4, both with systemic treatment (indicated because it is metastatic) and the correct answer is 4, for all the reasons given therein.

ONCOLOGY

63-year-old diabetic patient whose family physician has requested a blood test to determine vitamin B12 levels.What is the antidiabetic drug he is taking that warrants such a request:

Metformin is an oral antidiabetic widely used in the treatment of type 2 diabetes mellitus. The best known side effects are gastrointestinal side effects and lactic acidosis; however, vitamin B 12 malabsorption, is less well known. A decrease in vitamin B 12 levels is observed in patients treated with metformin. The mechanism by which this deficit occurs is not clear and it is known to be reversible when treatment is interrupted.

ENDOCRINOLOGY

A 59-year-old woman with recent onset of epileptic seizures comes to the emergency department. The examination showed left pyramidal signs and papillary edema. Brain MRI showed a right hemispheric mass with edema, midline deviation and signs of tentorial herniation. She reports a headache that has been progressing in intensity for the past week. Which of the following features associated with headache seems most likely in this patient?

They describe a recent diagnosis of cerebral LOE with signs of intracranial hypertension (edema, midline deviation, papilledema). The associated headache is typically morning headache, with increasing ICP values at night.

NEUROSURGERY

A 68-year-old woman who wears +4.00 diopter glasses for distance vision in both eyes. She consults because since a few weeks ago she has been having eye pain with headache and blurred vision at night when she is watching television in twilight. Which of the following pathologies is she most likely to present?

We are presented with a 68-year-old woman with moderate hyperopia and no history of cataract surgery. This is not a mere coincidence: the fact that the patient is hyperopic is important, because the eyeballs of hyperopic patients are shorter, with a certain conflict of space in the anterior segment when the crystalline lens undergoes a process of intumescence secondary to age (what patients call incipient cataract). In the clinical case, moreover, the ocular and headache pain occurs in scotopic situations, or in situations of dim ambient lighting, which produces an average mydriasis to optimize the light influx to the eyeball. It is evident, therefore, that the patient suffers from primary angular closure processes that possibly self-resolve when the triggering situation ceases, and not a true acute glaucoma attack. But these intermittent angular closures are contemplated within the spectrum of glaucoma due to primary angular closure (option 1 correct). Migraine, not being a Neurology question, can sometimes be a confounder in the usual clinic; however, patients are usually younger, or at least have a clear history of migraine, and, above all, they present symptomatologic worsening with intense sensory stimuli (photophobia and phonophobia), but symptoms are not worsened precisely in cases of dim lighting (option 2 incorrect). Actinic keratitis occurs precisely in patients exposed to ultraviolet radiation that is not properly filtered before reaching the cornea; it is typical of welders (it is called welder's keratitis), skiers and other people with very intense light exposures and without adequate eye protection (wrong option 3). Dry eye syndrome does not usually produce headache, and ocular discomfort does not go beyond the persistent discomfort that patients might define as pain because of its recently more studied neuropathic component. Some forms of dry eye may be worse in the evening but others are worse in the morning, and it depends mainly on the frequency of blinking. In addition, dry eye syndrome is an outdated term; nowadays it is preferred to speak of dry eye disease (incorrect option 4).

OPHTHALMOLOGY

An 8-year-old patient presenting with superficial pustular lesions, erosions and yellowish crusts around the mouth for the last 3 days:

It is a typical and frequent clinical picture in children. You are describing a contagious impetigo. There is not much dispute. The most frequent causative agent in the bullous form is S. aureus phage II.

DERMATOLOGY, VENEREOLOGY AND PLASTIC SURGERY

A 75-year-old woman, with menopause at age 52, with no family or personal history of fracture, diagnosed with temporal arteritis, who is going to start treatment with high-dose prednisone and expects to be treated for at least one year. The delay of densitometry (DXA) in her center is 4-5 months. Preventive treatment for osteoporosis is considered. Which of the following is the most appropriate approach?

In the data you provide there are no clinical risk factors for osteoporosis prior to the current disease. Since a prolonged and high-dose prednisone regimen will be established, it is advisable, in addition to the non-pharmacological preventive measures, to initiate treatment in any case to minimize the secondary loss of bone mass that occurs with the administration of glucocorticoids (and, above all, in the first months). Therefore, and for this reason alone, options 1, 2 and 5 would be discarded (the three of them have another conditioning factor). In this context, and in the case of a person over 65 years of age, an appropriate attitude would be to administer calcium supplements (corticosteroids are osteopenizantes because they produce, among other mechanisms, a negative balance of this element) and vitamin D. The option of associating a bisphosphonate could also be considered, but calcium supplementation is missing in proposal 3.

RHEUMATOLOGY

34-year-old woman who consults for repeated coitorragia. She brings a cytology with a high grade intraepithelial lesion (U-SIL). Subsequently, colposcopy and biopsy were performed on a mosaic area and histology showed a focus of invasive squamous cell carcinoma of 2 mm in length. Which therapeutic option is the most appropriate for this patient?

According to the SEGO: "Excise the entire lesion so that it can be evaluated histologically. It involves excision of the entire transformation zone. In general, the excision should be adapted to the size and characteristics of the lesion. Three types of excision are distinguished according to the presence of the endocervical component of the lesion. Excision type 1 (applicable in cases with transformation zone type 1, in which the diathermic loop should not include endocervical canal or exceed 8 mm in depth), excision type 2 (indicated in transformation zones type 2, involves resecting a small part of endocervical canal visible by colposcopy) and excision type 3 (indicated in transformation zones type 3, includes part of endocervical epithelium)". When they speak of excision, it is synonymous with conization; as the lesion is less than 8mm deep, this is the indicated treatment.

GYNECOLOGY AND OBSTETRICS

65-year-old woman referred to the ED for fever and alterations in the CBC: 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. A bone marrow examination was performed and the patient was diagnosed with acute leukemia with t(15;17) in 60% of the cells. Which of the following answers is correct?

I think this is a very nice question. There is no doubt about the diagnosis. Because if you don't know the translocation, nothing happens... the answers give you the diagnosis. Now it's time to find out how acute promyelocytic leukemia is currently treated (ATRA aside... which I'm sure you know). As of 2017, the PETHEMA protocol for APL in low to intermediate risk patients (and/or over 70 years of age) is ATO+ATRA. In high risk patients, it is treated with ATRA+chemotherapy. I don't think they want you to know how risk is established in promielos, but it is based on leukocyte and platelet counts. In this case, it doesn't score anything for the score since you have <10,000 leukocytes and >40,000 platelets. That is, it is a low risk. Correct answer 2. Perhaps some people have been confused by option 3. One of the main causes of mortality in the induction of a promyelocyte is coagulopathy, but option 3 is totally incorrect. We could only mess things up even more by putting heparin!!!! I don't know what they are explaining right now in the academies, but it is clear that they wanted you to know that many promyelocytes, since 3 little years ago, are not treated with chemotherapy.

HEMATOLOGY

In a colon cancer screening program, a 52-year-old patient undergoes a colonoscopy. The entire colon is normal except for the finding of a 2 cm pedunculated polyp in the sigma which is removed with a diathermy loop. The anatomopathological result indicates that there is a carcinoma in situ limited to the head of the polyp. She has a thoracoabdominal CT scan reported as normal. Indicate the correct course of action.

Carcinoma in situ is delimited by the basement membrane, i.e. it is not invasive yet, and therefore the treatment is polypectomy, which is already done. Subsequently, an endoscopic follow-up (with biopsies) should be performed at an interval of 3 to 6 months depending on the patient's history, age and concomitant pathologies.

DIGESTIVE TRACT

A 62-year-old man with a history of arterial hypertension under treatment with captopril, duodenal ulcer and uric acid urolithiasis. He consults for typical podagra crisis similar to others presented in the last two years. Examination showed tophi in both pinnae. Analyses show uric acid 10.1 mg/dl, creatine 1.5 mg/dl. Indicate which of the following answers is FALSE in relation to his possible treatment with allopurinol.

Allopurinol is always the treatment of choice, especially in the case of tophaceous gout. Moreover, in this case, uricosuric acid could worsen urolithiasis by increasing uricosuria (sorry for the redundancy...).

RHEUMATOLOGY

We are referred from ophthalmology to a 31-year-old man who consulted for loss of vision and progressive headache. Physical examination showed temporal hemianopsia and pituitary MRI showed a 35 x 30 x 20 mm turnoration compressing chiasm and cavernous sinus. The results of the functional study are cortisol 14 microg/dL, TSH 1.4 microU/ml, T4L 1.2 ng/dL, prolactin 480 microg/L (vn < 15), testosterone 160 ng/dL (vn 300-1200), FSH 1.2 U/I., (vn 5-15) and LH 2 U/L (vn 3-15). What is the initial therapeutic approach?

From what is described it is a macroprolactinoma as it is a pituitary tumor of more than one centimeter, which secretes prolactin and with an insufficiency of the rest of pituitary hormones. The first line treatment of choice is dopaminergic agonists, although when the visual field is affected, surgery may be chosen. In this case, the cavernous sinus is pressured by the mass, so the surgical risk increases. Therefore, in this particular case, the surgical option seems more risky. Taking this into account and the fact that it is a tumor that produces high levels of prolactin, which indicates that it probably responds to pharmacological blockade, the most appropriate option would be option 1, treatment with dopaminergic agonists.

NEUROLOGY

A 45-year-old patient was diagnosed with HIV infection three months ago, presenting at that time with CD4 45 lymphocytes/µl and an HIV-1 viral load of 500,000 copies/ml. At that time he had a negative Mantoux test. He started treatment with an integrase inhibitor and two reverse transcriptase inhibitors, and at one month he had 25,000 copies and CD4 had risen to 80/µL. She consulted for presenting a picture of cervical lymphadenopathy and fever of two weeks of evolution. The puncture of one of the lymph nodes showed isolated acid-fast bacilli and epithelioid granulomas:

We are dealing with a patient with HIV infection in a situation of severe immunosuppression (<50 CD4+) and a very high viral load, who has followed the expected evolution from the immunovirological point of view after the start of treatment (after 12 weeks, the viral load has ostensibly decreased - answer 2 would not be correct, remember that it is desirable that it becomes negative 24 weeks after the start of treatment, although in patients with higher CV like ours, it could take longer - and the CD4+ count has begun to rise). A negative Mantoux test does not rule out tuberculosis (incorrect answer 4), since in patients with severe immunosuppression it can give false negatives. The diagnosis of lymph node tuberculosis is immediate when detecting "isolated acid-fast bacilli and epithelioid granulomas" in the puncture of one of the lymph nodes, however: considering the patient profile, this process will have been clinically unmasked during the immunological reconstitution and the infection is not the consequence of an incomplete immunological recovery (correct answer number 3).

INFECTIOUS DISEASES

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

Typical case of acute mesenteric ischemia, which should be suspected in elderly patients with abdominal pain and distension of sudden onset, diarrhea or vomiting and who present cardiovascular risk factors, especially emboligenic heart disease. In this case we are given characteristic biochemical data (leukocytosis, metabolic acidosis due to lactic acid, hemoconcentration due to loss of fluid to the third space...) and imaging tests (dilated loops, pneumatosis, gas at portal level...) suggestive of mesenteric ischemia.

GENERAL SURGERY

A 25-year-old patient, during a tennis match, has severe pain in his neck and left eye. The next morning he wakes up with a feeling of gait instability and has palpebral ptosis of the left eye and anisocoria, with the left pupil being smaller than the right. The patient maintains good visual acuity, where would you most likely locate the lesion?

Claude-Bernard-Horner syndrome is an old acquaintance of the MIR exam. We do not see it daily in clinical practice, but it appears in many exams. Characteristic is upper eyelid ptosis and miosis of that eye. This occurs due to a deficit of sympathetic innervation of the orbital territory. The sympathetic nervous system innervates the Müller muscle, which is an accessory muscle to the levator of the upper eyelid. If the Müller ceases to function, the eyelid descends slightly. It also innervates the iris dilator muscle. Therefore, the sphincter muscle, its antagonist, is unopposed and the balance of the pupil shifts toward miosis. It explains ptosis and miosis of the left eye, so we suspect Horner's in that eye. She also describes what may have happened: after a possible sudden movement while playing tennis, she has neck pain and a Horner's. We should suspect an aneurysm. We should suspect a dissecting carotid aneurysm, which is one of the best known (and most serious) causes of an acquired Horner's syndrome. The superior cervical ganglion is a ganglion of the sympathetic nervous system located in the sheath of the carotid artery, and at this level it has been affected. We can also try to get this answer right by ruling out. An alteration of the III cranial nerve can produce ptosis, but the pupil, if affected, should be in mydriasis. And damage to the third cranial nerve should also produce some type of ophthalmoplegia, with diplopia. An involvement of the optic chiasm would produce a bilateral loss of vision (probably a bitemporal hemianopsia). We are told in the statement that he maintains good visual acuity. On the other hand, there would also be no ptosis or anisocoria. And finally, an alteration of the medulla oblongata would produce different neurological symptoms not described, and there should be no ptosis or pupillary alterations, because the third pair is located in the midbrain and the sympathetic nuclei in the spinal cord.

OPHTHALMOLOGY (ECTOPIC)

A one-and-a-half year old boy comes to the emergency room with abdominal pain and jaundice. On examination, an abdominal mass is palpated. An ultrasound shows the presence of a common bile duct cyst. What therapeutic approach should we adopt?

The correct answer is 4. A common bile duct cyst is a congenital pathology that usually presents clinically beyond the neonatal period. It is appropriate to have a quality image that delimits the lesion in order to decide the surgical approach.

PEDIATRICS

45-year-old woman. Two previous pregnancies with normal deliveries (G2PN2). Heavy menstrual bleeding for approximately 1 year. Ultrasound shows a 2 cm subserosal myoma that has been stable for several years. Endometrial biopsy was performed and it was normal. The patient has hemoglobin 10 g/dL despite oral ferrotherapy and the amount of menstrual flow has not decreased despite treatment with tranexamic acid and mefenamic acid. Which of the following is the treatment of first choice in this patient?

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

GYNECOLOGY AND OBSTETRICS

A 79-year-old hypertensive woman on treatment with olmesartan comes for consultation for watery diarrhea of 4 to 6 stools per day for the past two months. Three months ago she was treated with nonsteroidal anti-inflammatory drugs for 3 weeks for lumbosciatica. Gastroscopy and colonoscopy were performed, both without macroscopic alterations. Duodenal biopsies were normal, while colon biopsies showed a chronic inflammatory infiltrate of the lamina propria with an irregular band of collagen immediately below the mucosal surface epithelium with a thickness greater than 10 mm and a number of intraepithelial lymphocytes >20 per 100 epithelial cells. Which is the most likely diagnosis?

The diagnostic criteria for microscopic colitis are: a)Chronic or intermittent non-bloody watery diarrhea b)Colonic mucosa assessed by colonoscopy macroscopically normal or near normal c)Characteristic histopathological findings. In our case, the patient presents findings compatible with collagenous colitis (band of collagen underlying the epithelium greater than 10 microns) and lymphocytic (more than 20 intraepithelial lymphocytes). The treatment of this pathology is topical corticosteroids with low oral bioavailability (mainly budesonide). Olmesartan enteropathy produces a picture similar to celiac disease and is characterized by duodenal biopsy with villous atrophy, mucosal inflammation with increased intraepithelial lymphocytes and cryptitis. In this case a normal duodenal biopsy is described, but it would be interesting to keep the concept for future examinations.

DIGESTIVE

A 64-year-old man, diagnosed with myasthenia gravis 1 year ago, treated with low-dose steroids (3 mg/day of deflazacort) and anticholinesterase drugs, asymptomatic for 6 months, consults for mild difficulty in swallowing and evening diplopia for a few days. He was admitted to the hospital for suspected myasthenic crisis and treatment was started. The next day the patient alerts at 03 hours in the morning because the patient makes a strange noise when breathing in, like a soft snoring, the patient is sound asleep and very sweaty, but does not seem to be fatigued. What is the most correct attitude?

This is a patient with decompensated myasthenia with bulbar symptoms (dysphagia) and therefore risk of respiratory muscle involvement. The respiratory symptoms correspond to an exhaustion of the muscles, first inspiratory and then accessory (the patient does not appear fatigued or tachypneic because the muscles are exhausted), progressing to a carbonic coma.

NEUROLOGY AND NEUROSURGERY

A 78-year-old male consults for a year-long history of progressive cognitive impairment with memory and orientation lapses. His family reports recurrent visual hallucinations, occasional falls and striking motor slowing. What is the most likely diagnosis?

Dementia with visual hallucinations at the beginning of the course (in the first 2 years) is very suggestive of Lewy bodies, and is the guiding symptom in these questions. If we add to this the falls and motor slowing suggestive of parkinsonism, it makes the question easier. Therefore, number 3 is correct.

NEUROLOGY AND NEUROSURGERY