Although other hemorrhagic diseases can have a prolonged thromboplastin time, due to the intensity of the lesion and the child's sex and family history, the most likely diagnosis is hemophilia

The ultrasound examination is compatible with hemarthrosis and in the analytical analysis only an APTT lengthening of 52'' (normal 25-35'') stands out

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


Knowing that we have taken measures of sleep hygiene, we have explored what provokes him not to sleep, and he does not sleep nine hours and still wants to sleep more,...then the less harmful answer is the 2

Because it is the one with the shortest half-life and he does not want the lady to fall down the next day


The answer is 2, an EMG, which would be the diagnostic test to confirm the diagnostic suspicion of ALS

the imaging tests both CT, but especially MRI would help us to rule out, but would not confirm the diagnosis


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

In this case, when speaking of "reappearance of the symptoms when we lift the lower limb with the knee extended" we are describing the Lasègue Maneuver

This maneuver is positive in cases of lumbosciatic pain, since it causes a stretching of the sciatic nerve

therefore the correct answer is number 3

The rest of the pathologies do not have a positive Lasègue maneuver

so these options would not be correct
Gouty arthritis of left hip
Attack

so these options would not be correct
Left coxofemoral arthrosis
Attack

so these options would not be correct
Claudication due to canal stenosis
Attack


A 32-year-old diabetic patient on insulin therapy with good control of his blood glucose levels comes to your office with tingling in both hands, with a sensation of corking and thermal insensitivity of progressive onset over the course of 2 weeks

He presents a diabetic patient on insulin treatment with good control (although diabetic neuropathies do not only develop in patients with poor control) with a sensory picture limited to the upper limbs and of short onset time, without motor symptoms or at any other level

She does not report visual disturbances, strength deficit, motor clumsiness or other symptoms

On examination she found anesthesia to pain and temperature in both hands and distal forearms; positional and vibratory sensitivity were preserved

In the examination there is a clear dissociation with thermoalgesic anesthesia and preservation of arthrokinetic and vibratory

Muscle reflexes are normal and symmetrical

Reflexes are normal, neither abolished nor exalted

The rest of the neurological examination is strictly normal

In addition, the rest of the examination is strictly normal.

There is no dysmetria, dysdiadochokinesia or intention tremor

With all this I believe that the correct answer is 5, that is a syringomyelic lesion, whose initial characteristic is the sensitive dissociation with anesthesia for the thermoalgesic and conservation of the posterior cord

MS and other spinal cord lesions would be accompanied by other exploratory signs such as exaltation of reflexes

Multiple sclerosis type demyelinating disease

for carpal tunnel the exploration exceeds the territory distal to the carpus

and as for answer 1, although there are forms of peripheral polyneuropathy "pseudosyringomyelic" they are usually of lumbar onset

Peripheral sensitvo symmetric distal peripheral neuropathy of diabetic cause

The short evolution time (2 weeks), the respect of the lower limbs and the preservation of muscle reflexes make me rule out this response despite the distribution being "glove-like"


It is SLE with joint, skin and serositis involvement.

Treatment is EC at moderate-high doses
Glucocorticoids at high doses
Support

Mycophenolate is never a treatment in acute phase but in maintenance, nor has it proved useful in joint involvement


A 75-year-old woman consults for violaceous lesions on the hands and neck together with progressive muscle weakness of 3 months of evolution

Given this clinical picture, one possibility is dermatomyositis

Of the proposed tests, the determination of serum aldolase may be useful

The biopsy should be muscular and not subcutaneous

Anti-smooth muscle antibodies are not characteristic of this disease

Determination of anti-smooth muscle antibodies

Its elevation is characteristic of this disease


Rupture of the interventricular septum
Rupture in the interventricular septum
Support

Mechanical complications are typical in infarctions in elderly women

An 87-year-old woman with a history of hypertension was admitted 48 hours ago to the coronary unit for acute myocardial infarction with ST-segment elevation of anterior location

Examination revealed a systolic murmur with fremitus, radiating to the right sternal border, which was not present on admission

Likewise, a murmur that was not present indicates abnormal blood flow

the most frequent complications are mitral insufficiency, which would present with a musical or piante murmur, and VSD, which presents with a murmur radiating to the right border (think of the direction of blood flow)


We have before us a patient with neuropathic pain, which due to the origin of the tumor, is most likely due to involvement of the celiac plexus

It is important to have a radiological diagnosis in view of a possible local treatment, such as neurolytic treatment or plexus blockade

He is taking WHO step 3 analgesia, which is clearly insufficient,

However, we should not leave the patient without a treatment that can alleviate but rather solve the current situation

although opioids for neuropathic pain are not very effective, we will not reduce the dose but will associate the adjuvants

We would manage the patient with gabapentin and corticosteroids

Administer amitriptyline or gabapentin, dexamethasone and increase the dose of morphine

we would not decrease the dose of morphine

Decrease the dose of morphine as it is ineffective in this type of pain

in the meantime we would ask for a CT scan (or abdominal MRI) to subsequently assess the plexus block


It is a claude bernard horner syndrome and probably the correct one is 1

Sympathetic fibers, at some level that would span from the hypothalamus to the interinedio-lateral Clark's column of the dorsal medulla


Patients will be monitored weekly with hCG dosing until it becomes undetectable, for three consecutive times

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

After that the monitoring will be monthly for six months and then every two months for another six months before a new pregnancy

She should not become pregnant until she has undergone regular check-ups and one year has passed with negative beta-HCG levels

She should not become pregnant until periodic check-ups and after one year with negative BHCG levels


The correct answer is 4
Repeat urine sediment in 15 days
Support

Microhematuria without associated symptoms may be a finding without pathologic significance and must be confirmed in a subsequent new sediment (although I do not know if at 15 days or later)


Cobb angle between 25º - 45º
Orthosis
Support

Orthosis
Prescribe a corset-type orthosis
Support


The patient is already diagnosed with chronic lymphocytic leukemia B (B-CLLL), presents lymphocytosis that is maintained for more than 3 months and by flow cytometry presents a phenotype compatible with it

Therefore, we must first know the risk factors that will indicate with what priority treatment will need to be initiated, their intensity and prognosis

the presence of TP53 mutations or 17p deletions depends on this

The bone marrow aspirate or biopsy is only indicated if there are other accompanying cytopenias that are not justified by the B-CLL itself

Bone aspirate/biopsy to confirm diagnosis

PET-CT is only indicated if Ritcher's syndrome is suspected and we do not have enough data to suspect it

PET/CT to establish the therapeutic attitude

there are no B symptoms, nor is there any mention of LDH elevation

New clinical and analytical control in 6 months


This is a clear clinical case of systemic sclerosis (Raynaud's, esophageal involvement, skin induration) presenting with renal crisis

Apart from anti-proteinase 3 antibodies, which are not related to scleroderma (incorrect answer 3), the most likely ones would be antiRNA polymerase III antibodies, which appear in younger patients with renal crises


both are possible, but the insistence on the patient's atopic burden indicates the likelihood of the latter

18-year-old young man with a history of asthma, allergy to pollens, mites and cat hair, comes to the emergency room referring sensation of food detention at retrosternal level with practical inability to swallow his own saliva


Turner syndrome: low estradiol and elevated gonadotrophins

As she is a girl of pubertal age, it is most likely that her decreased growth and sexual retardation are due to Turner syndrome

Gonadotrophins (FSH and LH) and estradiol are low

brain tumors affecting the hypothalamus-pituitary gland do not give low gonadotrophins

She could have a craniopharyngioma, but it would be rare if she had not shown symptoms before. Also, it would not justify low gonadotrophins and estradiol

it seems obvious that refractive defects do not give hemianopsia

She must not have a hypothalamic tumor because of the absence of polyuria and polydipsia. She probably has constitutional delay and her visual problem is refractive

A growth hormone deficiency may explain the developmental delay and low estradiol. To evaluate if she needs glasses, due to her headaches and visual disturbances


The correct answer is 1
Tolerance
Support

The statement perfectly defines a tolerance phenomenon in which the patient has become "used to" the dose and needs more in order to have the same analgesic effect


A 33-year-old woman consults for repeated epistaxis, petechiae and ecchymosis

The initial presumptive diagnosis is chronic immune thrombocytopenic purpura (ITP)

Laboratory tests show thrombocytopenia with a platelet count of 4000 platelets/microliter.

In the presence of isolated thrombocytopenia we must not lose sight of the physical examination; thus, the presence of lymphadenopathy forces us to rule out the presence of lymphoma, for example

The presence of lymphadenopathy or splenomegaly in the physical examination suggests a different diagnosis of ITP

When performing a bone marrow biopsy-aspirate it is seen that the number of megakaryocytes is normal or even increased, the failure is not in the marrow but in the peripheral blood, where platelets are destroyed

Bone marrow analysis shows a decreased number of megakaryocytes without other alterations


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

It is a typical case of deep endometriosis, with implants in different parts of the pelvis

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

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

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

The definitive diagnosis will be given by the pathological anatomy, so for this we have to do Laparoscopy and send to PA


She starts with a high fever with chills, headache, myalgia and non-productive cough that she interprets as a flu-like process

It presents with a pseudo-flu-like symptomatology (headache, arthralgias, myalgias, fever...) and other symptoms depending on the route of entry

As a possible disease I would consider Brucellosis, typical of cattle (milk, abortion, genital secretions...)

A 38-year-old woman of veterinary profession, in charge of monitoring wild animals and assisting in the delivery of domestic livestock

In our case, when attending animal births, the entry is through the respiratory route

the pulmonary infiltrates and chest pain are due to the bacteria

The treatment varies according to the affectation and mortality is very low, almost null.

Mortality in acute forms is almost nonexistent


According to the described examination the Glasgow is 4 (O1V1M2)

On arrival she is in a Glasgow scale coma of 7

Cerebral perfusion pressure is mean arterial pressure minus intracranial pressure

Cerebral perfusion pressure is mean arterial pressure plus intracranial pressure

In the physical examination he does not open his eyes, does not emit sounds before being intubated and presents extension of extremities to nociceptive stimulus

Cerebral edema in which cellular edema is produced by the introduction of extracellular fluid into the intracellular compartment is cytotoxic

Vasogenic cerebral edema is due to cellular edema, membrane rupture and cell death

Hypercapnia and acidosis produce vasodilatation causing increased cerebral blood flow

Cerebral vascular flow increases with hypercapnia and acidosis


the question is focused on initial management

the most appropriate answer seems to be 2

Answers 1, 2 and 5 are appropriate treatments for dumping syndrome or postgastrectomy

Apply treatment with a somatostatin inhibitor (octreotide)

Indicate surgical treatment to perform an antiperistaltic Roux-en-Y gastrojejunostomy


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

A very effective drug if everyone is forewarned


fever of several days of evolution, exanthema, conjunctival injection, red lips, raspberry tongue, edema of acral parts and adenopathy

There is no doubt, they are not meeting the diagnostic criteria of Kawasaki disease


A 67-year-old man presents with 3 months of asthenia and febrile fever, with nasal obstruction and mucus emission with some clots in the last month

In this patient, he presents with a granulomatosis with polyangiitis formerly known as Wegener's granulomatosis

Physical examination reveals proptosis of the right eyeball and inspection of the nostrils reveals an erythematous mucosa with serohematic crusts

In the clinical case we are told about the otorhinolaryngologic involvement that is present in 92% of patients

At the pulmonary level, we were told that mucus with a clot was present in 85% of the patients

Blood tests (hemogram, renal and hepatic function) are normal, except for an ESR of 65 mm/h; urinalysis shows microhematuria and proteinuria of 520 mg/24h

Also at the end of the case, they comment us the urinalysis with a glomerulonephritis that is present in 77% of the patients


Of the five options, four could be compatible with the referred symptoms

We could initially rule out central serous chorioretinopathy because by definition it occurs in young people (up to 55 years of age, more or less)

The key to differentiate between the other four is that he had soft drusen in the fundus

That while not a "diagnosis" (the question could have been better worded) is a finding related to age-related macular degeneration, or age-related macular degeneration

She reports presenting, since 2 weeks ago, metamorphopsia and significant visual loss in her right eye that prevents her from reading

An epiretinal membrane usually has a slower course

In a macular hole, visual loss is more relevant (metamorphopsia may also be reported, but it is less likely in the acute stage)

In thrombosis of the central retinal vein, visual loss is more important and does not usually explain metamorphopsia (but may have it, due to macular edema)

But the wet or exudative form produces acute or rapidly progressive severe visual loss (usually due to subretinal hemorrhage accompanied by metamorphopsia (image distortion due to retinal lifting)


We all agree that the patient seems to have Cushing's syndrome (we rule out 1)

Postmenopausal osteoporosis, type 2 diabetes mellitus and essential hypertension, with decreased strength due to diabetic polyneuropathy

For the diagnosis we have to measure urinary free cortisol, do a dexamethasone suppression test or measure nocturnal salivary cortisol

Determine urinary free cortisol and basal ACTH, which serves to orient its etiology and select the most appropriate imaging technique

the ACTH measurement indicates the origin: suppressed in hypercortisolism of adrenal origin or prolonged use of corticoids and elevated or normal if the origin is pituitary or by ectopic ACTH secretion

If basal ACTH is high, it may be due to corticosteroid use or an adrenal tumor, and an MRI should be performed

If the basal ACTH is low, he probably has a pituitary micro-adenoma, and a cranial CT scan should be performed

If ACTH is low, a CT scan of the abdomen should be performed to locate the origin

If ACTH is normal or high, a pituitary MRI should be performed (pituitary adenomas responsible for Cushing's syndrome are very small and CT of the pituitary is less sensitive than MRI)

It is very important to perform the order well to arrive at a proper diagnosis: 1st: confirm hypercortisolism or s

Cushing's syndrome, 2nd: measure ACTH to orient etiology

3rd: imaging test according to ACTH levels

Therefore, answer 2 is false (abdominal CT is not a test to rule out s. Cushing's); an imaging test should only be done once a clear diagnosis of hypercortisolism has been made

It is necessary to rule out Cushing's disease by dexamethasone suppression test and perform a cranial CT scan


the treatment of colon cancer is surgical (with neoadjuvant in rectal cancer)

If biopsies confirm adenocarcinoma, there is no need to repeat them

Since the biopsy is superficial, it should be repeated before proceeding with treatment

it is necessary to have the complete specimen

Most colon cancer develops on adenomas
we could eliminate this one
Support

It is unlikely that this tumor has developed over a previous adenoma

Among the other 2, it is important to know that 5 is correct

Microsatellite instability and DNA error repair genes should be studied

they almost always present microsatellite instability even without fulfilling the Amsterdam criteria and have a better prognosis than other poorly differentiated colon cancer


In the presence of acute gouty arthritis (the presence of intracellular crystals with negative birefringence confirms this) in a hyperuricemic patient previously treated with allopurinol, an NSAID should be added until the crisis subsides

Arthrocentesis is performed and polarized light microscopy shows intracellular crystals with negative birefringence

No changes should be made in the hypouricemic treatment during this period because the uric acid metabolic chain is altered and the situation may worsen


According to the patient, 3 weeks ago she had a sexual relationship that could be a risk for contracting the HIV virus

we know that mononucleosis can be an expression of the first phase of HIV infection, especially when we have a history of a risk contact

At first glance, we could directly rule out answer 2

The clinical process that the patient suffers from is not consistent with acute HIV infection

ELISA is a very sensitive but not very specific technique and confirmation with a Western-blot test is ALWAYS necessary

Answers 3 and 4 are also easily ruled out

If the patient's ELISA test was positive, nothing further would be necessary for the diagnosis of HIV infection

The ELISA technique has a high sensitivity for the diagnosis of HIV infection, but its specificity is even higher

it is a very categorical answer ("rule out") that does not quite fit the reality

A negative HIV-1/HIV-2 serology performed by ELISA technique rules out the possibility that the patient has been infected with the HIV virus

As we have said, ELISA is a very sensitive technique, so a negative result could leave us quite calm

however, we all know that there is no medical test that rules out anything with total certainty (unless its sensitivity is 100%, which is not the case)

In addition, it is only 3 weeks since the contact

our patient is probably in the "window period" during which serological techniques may be unprofitable

on the other hand, we could say that in this case we have a high clinical suspicion (the picture is suggestive, and the antecedents are there)

in the window period a viral load may be indicated for diagnosis (positive if there are more than 10,000 copies)

In conclusion, the answer that best fits us would be 5

If the ELISA test to diagnose HIV in the patient was negative, we could determine by PCR technique the viral load in blood

although this test is not done routinely


Conservative treatment with botulinum toxin offers good results

A 47-year-old man, with a history of a right parotid pleomorphic adenoma, treated with surgery (extrafacial parotidectomy) 6 months ago, who comes to our office for presenting pain with sweating and reddening of the skin in the preauricular region during mastication

It is the clinical expression of a vegetative neuropathy caused by mechanical or irritative lesion of the vegetative fibers of the auriculotemporal nerve in its infratemporal pathway

In our environment the most frequent cause is surgery of the split gland with a percentage of occurrence between 10 and 80%

You are asking about auriculotemporal syndrome or Frey's syndrome


The correct answer is the first one
Escherichia coli
Support

The most frequent cause of urinary tract infections is Escherichia coli and in the case of pregnant women as well

She refers repeated urinary tract infections (UTI)


Regarding weight, metformin to a lesser extent, SGLT-2 inhibitors and, above all, GLP-1 agonists have been associated with a significant decrease in weight in patients with DM-2

answers 1,3 and 4 incorrect
Metformin (biguanide)
Attack

Canagliflozin (sodium-glucose cotransporter 2 inhibitor- iSGLT2)

answers 1,3 and 4 incorrect
Liraglutide (GLP-1 receptor agonist)
Attack

On the other hand, pioglitazone, as reflected in its data sheet, can produce dose-dependent weight gain, mainly due to fat accumulation and added, in some cases, to water retention


This is a typical case of cervical incompetence (and this patient has conization as a risk factor)

This pathology consists of dilatation of the cervix in the absence of contractions, requiring cerclage to prevent miscarriage or immature delivery

I would recommend a cervical cerclage at 14 weeks gestation

The cerclage is ideally performed electively, programmed, and not when the patient arrives at the ER "in extemis" (which are also done, but with a lower success rate... the ideal is to do them cold)


The patient presented pulmonary thromboembolism which, in addition to being bilateral, produced severe hemodynamic involvement, shock and required mechanical ventilation

We are not told that he has any contraindication to fibrinolysis, so this would be the most appropriate option due to its rapid administration and action

Systemic fibrinolysis with rt-PA (alteplase) 100 mg intravenous

Angio-CT shows multiple repletion defects occupying both main pulmonary arteries

Sodium heparin is reserved for cases in which the patient is stable

On arrival at the hospital he has hypotension (systolic BP 80 mmHg, diastolic 40 mmHg) and poor perfusion

He is intubated and connected to mechanical ventilation and noradrenaline is started

Echocardiogram shows signs of pulmonary hypertension

Thromboendarterectomy could be performed urgently in selected centers (not available in all) in patients in whom systemic fibrinolysis is contraindicated, or in centers where the experience with this technique is proven and it can be performed quickly

The inferior vena cava filter is a treatment indicated in the acute phase in stable patients, when anticoagulation is contraindicated; or a posteriori, as prophylaxis, in this group of patients

as in the case presented in the question

In the subgroup of high-risk patients (defined by hypotension or cardiogenic shock criteria), the use of systemic fibrinolysis is much clearer


The patient probably presents with bronchiolitis

At this stage, no additional tests should be performed unless there is a clinical worsening

He shows moderate respiratory distress with intercostal and subcostal retraction

Examination: axillary temperature 37.2°C, respiratory rate 40 rpm, heart rate 160 bpm, blood pressure 90/45 mmHg, SatO2 95% on room air

Pulmonary auscultation: scattered expiratory rhonchi, elongated expiration and slight decrease in air entry in both lung fields


jugular venous pressure is elevated with a deep descending sinus X

Low BP with high jugular pressure should always raise the suspicion of cardiac tamponade

Pericardial effusion with cardiac tamponade

A patient with a history of fever and chest pain comes to the hospital with dyspnea and tachypnea

Fever and chest pain with dyspnea and tachypnea should raise suspicion of pericardial effusion with hemodynamic compromise

Paradoxical pulse is a typical finding of cardiac tamponade


we are told that the patient does not have an intellectual disability

she could have several genetic pathologies

an adolescent with pubertal delay and short stature should be a Turner until proven otherwise

Therefore, if that is our first diagnostic suspicion, the HABITUAL test (as the statement says) for diagnosis should be a conventional karyotype (formula: 45, X0)

However, both array and NGS are usually reserved for patients with non-obvious clinical pictures, intellectual disability, or suspicion of a genetic syndrome that requires these specific tests (for example, an array to diagnose a 22q11 deletion syndrome or an NGS panel to diagnose a Noonan syndrome)

A Turner can also be diagnosed with a FISH (there would only be one signal for the X instead of the two that females usually have) or with an array


The rest of the data (seminules in the biopsy, linear IgG deposition) supports the diagnosis

The diagnostic suspicion for the data given (especially the anti-GBM antibodies and the presence of renopulmonary syndrome) is that of Goodpasture's syndrome

option 1 speaks to us of an IgA nephropathy (it is not the case

It is an IgA nephropathy with acute renal failure

option 3 is also discarded
It is a membranous glomerulonephritis
Attack

it is not a primary GMN, like the membranous one, but a secondary glomerulopathy

Mycophenolate mofetil is the initial treatment of choice

the initial treatment is with corticosteroids and cyclophosphamide associated to plasmapheresis

the damage is not due to circulating immunocomplexes, but to antibodies deposited in the glomerular basement membrane

Glomerular involvement is caused by the presence of circulating immunocomplexes

Blood tests show creatinine 7 mg/dL, urea 250 mg/dL and high titer positive anti-GBM (anti-glomerular basement membrane antibodies)

as it has been previously said, the treatment would be performed combining corticosteroids, cyclophosphamide and plasmapheresis

This leaves option 2 as true
Plasmapheresis would be indicated
Support


they do not provide any analytical data and the ultrasound data are ambiguous

It seems that they want to present us with precocious puberty (or premature telarche)

they do not provide any data on ovarian size

we should assume that by a small uterus they are referring to a prepubertal uterus

Strictly speaking, without analytical hormonal data, it seems that we could mark option 1, being necessary to follow the girl closely

Follow-up every 3-4 months, as this is a temporary condition that often resolves on its own

If we take all the above data for granted, we could rule out option 4, which would be the treatment of a central precocious puberty

We are presented with the case of a three-year-old girl with advanced mammary development, in principle without any associated cause

according to the complementary examinations that we are given, it does not seem to be precocious puberty, except for the clinical (Tanner IV)

in principle she does not take drugs that can increase the level of estrogen in the blood, she does not seem to use body creams or eat a lot of chicken meat

Regarding the option of mammography, breast ultrasound is used in pediatrics, and in this case it would be indicated if we were told that there is breast asymmetry

Regarding breast biopsy, it would only be indicated if there are warning signs


A 40-year-old woman consults for approximately 20 episodes per day of intense left periocular pain lasting 15 minutes, accompanied by intense tearing and rhinorrhea

Both the characteristics of the case and the answers suggest that it is a trigemino-autonomic headache (intense, periocular pain with lacrimation and rhinorrhea)

Paroxysmal hemicrania predominates in women, with episodes of pain similar to cluster headache, but with a shorter duration (2-30 min), and a higher frequency (5-30 episodes per day)

Cluster headache predominates in males whose duration can vary between 15-180 minutes, between once every 2 days, up to 8 times a day

As for SUNCT, the crises are much shorter, lasting seconds (5-240 seconds) and are usually refractory to treatment

Therefore the diagnosis would be of a paroxysmal hemicrania and its treatment of choice is indomethacin (which also the answer is a diagnostic criterion)

Therefore correct answer 1 (Indomethacin)


If I am not mistaken, you are describing a Celso's kerion for which the treatment of choice is oral griseofulvin

The correct answer is 3
Griseofulvin orally
Support


We are presented with a case of monocular amaurosis with a vascular profile, also in an older woman with a history of weight loss

what seems to be symptoms of mandibular claudication and polymyalgia rheumatica

the first cause to think about is giant cell arteritis as the cause of NOIA

the correct option would be 2
C Reactive Protein
Support

Option 4 would be considered if we were told of an AINO but with non-arteritic characteristics (without all the accompanying symptomatology)


The picture described is very suggestive of pseudocrisis with asynchronous limb movements, pelvic movements, crying and poor response to antiepileptic drugs

Video-EEG monitoring for diagnosis of pseudocrisis (psychogenic seizures)


All these data, in addition to the analytical data, are describing an immunodeficiency that by the family-maternal history, seems to be X-linked, as several males have died of a similar clinical condition (the father of the patient contributed the Y chromosome, the mother the X)

X-linked severe combined immunodeficiency

Family history of infections with deaths due to infections in males (maternal family)

Among the X-linked immunodeficiencies is Wiskott-Aldrich syndrome, an entity described with an initial triad of symptoms consisting of bleeding (typical BUT absent in the case: heavy bleeding after circumcision, bloody diarrhea), recurrent infections and eczema

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.

Physical examination showed lesions typical 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

The Hyper-IgE option lacks very characteristic clinical data such as bone alterations and skin lesions, which are not atopic dermatitis, since they follow a different pattern (papulopustular rash on the face and scalp)

The option of transient hypogammaglobulinemia of infancy and the common severe and variable combined immunodeficiency fails, among other features, the determination of immunoglobulins G and M, which are at the lower limit, but within normality

Transient hypogammaglobulinemia of childhood


The confusional picture is determined by the dementia that the patient already suffers

Delay surgery until the confusional picture has disappeared

it depends on the type of fracture, which is not specified in the statement: a pertrochanteric fracture would require closed osteosynthesis and a subcapital fracture would require a prosthesis

The elevation of blood pressure is due, in principle, to pain

the stressful situation that leads an already hypertensive patient to increase her blood pressure

Perform closed osteosynthesis, avoiding in any case the implantation of prosthesis

Delay surgery and perform an echocardiogram

Delay surgery until good blood pressure control

Start a beta-blocker and initiate surgery


This is a probably benign finding, since there is less than a 2% chance of cancer. He explains that it requires follow-up every 6-12 months until 24 months or a biopsy

BI-RADS Breast Imaging Reporting and Data System


The halo sign is characteristic of pulmonary aspergillosis, especially in an immuodepressed patient.

But it is not pathognomonic
Aspergillus fumigatus
Attack

it has also been associated with TB, some neoplasms and Wegener's granulomatosis

An immunodeficient patient who presents a pneumonia with meniscus halo sign or crescentic contour on chest X-ray/CT


The first option seems to be the correct one, due to the low probability of P. jirovecii infection in a patient with more than 500 CD4 lymphocytes and undetectable viral load

Cefiriaxone 2 g and azithromycin 500 mg every 24 hours

It is most likely to be a pneumococcal infection that we cover with Ceftriaxone and with azithromycin we cover the so-called "atypical" ones

Meropenem is an antibiotic with too broad a spectrum, which would be an option in in-hospital pneumonia caused by P. aeruginosa, a bacterial agent that can also cause pneumonia in HIV patients, but this is not common

Meropenem I g/8 h and vancomycin I g/l2 h


The first thing is to treat the infection and for this we must remove all the osteosynthesis material, debride and give antibiotherapy

Removal of the nail, debridement, placement of external fixator and antibiotherapy adjusted to culture results

Fixation in this case is better external to avoid all the material around the affected area

Triple antibiotherapy (gram-positive, gram-negative and anaerobic) and cleaning of the surgical wound, removing the distal locks to promote bone consolidation

Expectant attitude and antibiotic treatment with quinolones

The 3 would be considered after expiration of the infectious picture

The infection is understood by the clinical manifestations (suppuration, nonunion) and the history of diabetes and open fracture

We are dealing with an infection associated with an implant (intramedullary nail) and pseudoarthrosis of the tibia fracture (absence of union after 11 months)

An emergency operation was performed by cleaning (Friederich) and placement of an endomedullary steel-plated nail

At 11 months he presents with atrophic pseudarthrosis of the tibia with suppuration in the wound area

Isolated antibiotherapy (option 2) is indicated only in patients with severe comorbidity in whom surgical treatment would be more aggressive than continuing the disease

Nail dynamization associated with broad-spectrum antibiotherapy (option 1) is not indicated either

it has not demonstrated benefit in established pseudarthrosis

we have the same issue as option 1, we do not eliminate biofilm

Option 3, discussed, would be considered only if there was no associated infection

Autologous graft and growth factors (BMP 2 and 7) to stimulate the bone consolidation process, which is slowing


A 14-year-old female patient in good general condition presents since 4 days ago a very pruritic generalized cutaneous eruption formed by erythematous-edematous plaques between 2 and 15 cm in diameter without desquamation with a tendency to acquire an annular morphology that individually disappear in less than 24 hours

The mucous membranes are respected
Urticaria
Support

The general condition is usually preserved

Acute urticaria: characterized by erythematous-edematous, evanescent, pruritic, evanescent lesions, lasting less than 24 hours, without desquamation

In children the annular pattern is more frequent

In both rubella and toxicoderma, the general condition is not preserved

In staphylococcal shock, the general condition is affected and the lesions are blistering

Scabies lesions are preferably interdigital, in the form of papulocoses that can follow linear trajectories


our patient has a normal blood glucose of 96mg/dl

The analytical data suggest diabetes insipidus

Now we must differentiate between central diabetes insipidus (lack of ADH) or nephrogenic diabetes insipidus (ADH does not exert its action at the renal level)

This is achieved by the vasopressin test (intravenous administration of ADH and remeasurement of urinary osmolarity)

Administration of desmopressin with serial monitoring of urine osmolality

Therefore, the correct answer is option 3

In the first 24 hours of admission a diuresis of 8.2 liters is found and a blood test shows a glycemia of 96 mg/dL, natremia of 148 mEq/L and plasma osmolality of 309 mOsm/kg with urinary osmolality of 89 mOsmlkg


The diagnosis would be practically made with the AMA (1)

with 5 we could rule out viral hepatitis


Assuming therefore that we are asked which is one of the most frequent complications of the floor of the orbit, two complications should always be highlighted that may indicate surgical treatment, even urgent: diplopia, due to dislocation of the inferior rectus muscle to the underlying maxillary sinus (and even its entrapment); and enophthalmos, which may cause other associated complications in the medium and long term, such as superior palpebral pseudo-ptosis due to loss of orbital volume

although relatively close to the orbital cavity, it is not part of the orbito-malar complex

Temporomandibular ankylosis is not considered

option 1 discarded
Temporomandibular ankylosis
Attack

A cranial CT scan was performed showing a fracture of the middle third of the face involving the orbito-malar region

Involvement of the maxilla can lead to dental malocclusion, but usually occurs in fractures located lower than the orbital cavity

option 2 discarded
Dental malocclusion
Attack

option 3 discarded
Naso-ethmoidal pseudoarthrosis
Attack

Naso-ethmoidal fractures are included in midface fractures, but the bones of the nose are located more anteriorly to the medial orbital rim, and therefore outside the orbit


In this situation, the first thing to do is to resolve the pain crisis and to propose an appropriate conservative treatment for this osteoarthritis

Explanation of the diagnosis, relative rest, paracetamol 1g/8h plus metamizol 500 mg/ 8 h rescue naproxen

We are being described an acute pain crisis in a patient with gonarthrosis

A knee arthroplasty is not considered at the outset

Preferential referral to Traumatology outpatients for evaluation of total cemented prosthesis

They are not telling us an infectious clinic to suspect an arthritis that would justify a debridement and washing

Preferential referral to Traumatology outpatient clinic for arthroscopic debridement

In a patient with gonarthrosis there will always be meniscopathy, it is part of the degenerative changes

Preferred MRI request for evaluation of meniscopathy, Baker's cyst and/or tendinitis

Baker's cyst would only interest us in a severe pain crisis in the differential diagnosis with a deep thrombosis and it is evaluated with an echo-Doppler

in the picture of gonarthrosis it has no value to detect a Baker's cyst

Tendinitis is diagnosed by examination, not with MRI


The history of contact with fresh water in an endemic area points to leptospirosis

in the clinical picture we also find jaundice and conjunctival injection which also points to leptospirosis and is not so characteristically related to the other three pathogens

25-year-old man with no past history of interest presents to the emergency department with fever, headache, myalgia, nausea, vomiting, abdominal pain, jaundice and conjunctival injection, 2 weeks after traveling to Thailand to participate in a freshwater regatta


On arrival, the patient had a fever of 38.2ºC, multiple skin abscesses on the hands, back and buttocks (some with fistulous tracts) and right central facial paralysis, apical infiltrates with small associated pleural effusion on chest X-ray and leukocytosis with neutrophilia

Aspergillus also does not affect the skin

Tuberculosis can affect lung and brain but not cutaneous abscesses

A 64-year-old patient, farmer, former smoker (5 years), COPD and afflicted with rheumatoid arthritis on corticosteroid therapy

Nocardia can typically affect immunosuppressed patients, especially those with impaired cell-mediated immunity such as that produced by steroids, and can present with pulmonary involvement, brain abscesses and skin abscesses


if we look at the patient's ability to maintain sleep, there is a clear fact that "rules out" the hypo/manic shift

In this question, one might suspect the possibility of an affective shift after the introduction of the antidepressant drug, according to the patient

Two weeks is not enough time for the drug to have taken full effect on mood

an initial activation may appear, which patients sometimes do not cope with very well (something that does not seem to be the case)

In this patient it is indicated to maintain the treatment and reevaluate in no more than one month


In healthy adults there may be palpable inguinal nodes up to 2 centimeters that can be considered normal

By the clinical characteristics it seems to be normal lymph nodes and complementary explorations should not be done

A complementary study of these normal lymph nodes is not warranted


A 71-year-old woman with a history of rheumatoid arthritis on sulfasalazine, prednisone and etanercept

in an immunocompromised patient and also with data of ocular involvement, admission for intravenous treatment would be indicated due to the high risk of possible complications

Hospital admission and treatment with acyclovir or famciclovir iv


When the diagnosis is biochemically confirmed, the next test to be performed is a CT scan to determine the subtype and rule out the presence of an adrenal carcinoma

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

Therefore, it is necessary to wait for the imaging test to confirm the etiology

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

The most frequent cause is aldosterone-producing adenoma

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

Spironolactone is the medical treatment of choice

Spironolactone is contraindicated in the management of this pathology


Of course, the patient may also have HIV infection or even secondary syphilis (in addition to Reiter's)

He is describing a textbook Reiter's syndrome

palmo-plantar keratoderma, arthritis and ocular manifestations, together with probably a chlamydial urethritis, perhaps asymptomatic (they do not explain urethral exudate)


35-year-old man admitted for severe chest trauma with multiple rib fractures

Pulmonary contusion is the most serious lesion and the one with the worst prognosis in thoracic trauma

After responding favorably to treatment with analgesics and oxygen, he begins to present severe hypoxemia

It is also the injury that causes hypoxemia the earliest

Contrary to what we may think, an unstable thorax due to multiple rib fractures (costal volet) would cause progressive hypoventilation with atelectasis of the pulmonary parenchyma, which would progress on the one hand to hypercapnia and respiratory acidosis, and on the other, to later hypoxemia due to infection associated with atelectasis

Chest wall instability due to multiple fractures

Respiratory infection due to aspiration would also occur later, and does not appear in all cases of severe chest trauma, only if there has been a decrease in the level of consciousness (associated TBI, uncontrolled intubation with bronchoaspiration...)

Post-traumatic hypovolemia (in this case, as there are multiple rib fractures, it could be due to hemothorax) would occur earlier and would be associated in the first place with hemodynamic instability

Alteration of gas exchange due to pulmonary contusion


When assessing her renal function, she presents a G3a/A1 stage

Stage G3a corresponds to a filtration rate between 45-59 ml/min

Stage A1 corresponds to albuminuria less than 30 mg/ml

Glomerular filtration rate 45-59 ml/min/1.73 m² and albuminuria <30 mg/ml


Transfusing this patient and stuffing him with antibiotics is giving him bread for today and hunger for tomorrow

Androgens and platelet transfusions don't fix the problem either

An autologous transplant is not reasonable, since the bone marrow of a patient with bone marrow aplasia is less than 25%, so little can be obtained

Autologous bone marrow transplantation to avoid rejection

Therefore, we are inclined towards allogeneic bone marrow transplantation if he has an HLA-identical sibling, since this is the treatment of choice according to the protocol of the Spanish Society of Hematology and Hemotherapy for patients under 40 years of age with severe bone marrow aplasia

Allogeneic bone marrow transplantation if HLA identical sibling


The question is tricky: it speaks of a burn of 10% of the body surface

the treatment of choice for second degree burns less than 20% of the BSA should be topical and monitored

However, there is a warning sign: there is no arterial pulse and the burn is circumferential to the limb

This is an emergency that, if allowed to evolve, will compromise the viability of the affected limb and end in amputation

an emergency escharotomy must be performed in order to relieve the pressure of the third space on the arterial vascular trunk

Escharotomy or emergency decompression incisions


However, emergency reasoning: systolic murmur, something that in systole had to be closed and is not, or had to open, and does not: options 1, 3 and 5

on cardiac auscultation a holosystolic murmur is auscultated in the area of the xiphoid appendage that is accentuated with deep inspiration

If in a patient with chronic heart failure we detect prominent v waves in the jugular venous pulse

And if we see repercussion in the jugular pulse, it must be in the right cavities

Apart from the fact that the v wave appears during systole, while the atria are filling: if the RV flow rises to the RA, what will happen is that the v wave will be very large?


In my opinion, as in these six months she has shown a clear clinical and biological improvement (decrease in acute phase reactants), I would maintain the therapeutic approach taken and wait for a new evaluation

Maintain the therapeutic attitude taken since we have only been on it for 6 months and it would be necessary to wait a minimum of 9 months to evaluate therapeutic response

However, I consider that this question could have another valid answer, 3

If there is no medical contraindication, consider adding an anti-TNF alpha to the treatment

If what you are looking for is a remission of the disease as soon as possible, you could choose to consider associating an anti-TNF alpha


She presented good clinical evolution except for persistent febrile fever and leukocytosis on the sixth day of treatment

As long as fever persists in an evolving pneumonia, there is a risk of empyematization, especially if a small effusion has already occurred at the beginning of the picture

Admitted for middle lobe pneumonia with a small associated metaneumonic pleural effusion and on treatment with levofloxacin 500 mg/24h

In principle, antibiotic treatment is correct and before considering changes in treatment, the possibility of empyematization should be evaluated

Perform thoracentesis to rule out empyema


A patient of adolescent age with myoclonus ("violent jumps") at breakfast time will almost always lead us to juvenile myoclonic epilepsy (answer 5 correct), a very well characterized entity

An 18-year-old female patient
Juvenile myoclonic epilepsy
Support

violent jumping of the upper limbs at breakfast

Among other features is the previous history of seizures or absences, the worsening with nighttime departures, and the EEG with generalized polyp spike discharges at a higher frequency than that of absences

history of absences between 6 and 9 years of age

generalized tonic-clonic seizures of recent onset

The clinical manifestations worsen with nighttime weekend outings

An EEG shows acute polyp spike discharges at 6 cycles/second

Lennox Gastaut develops at an early age with other symptomatology

An 18-year-old female patient
Lennox-Gastaut syndrome
Attack

4 is the same as absences
Small atypical disease
Attack

3 usually presents with complex partial seizures and either way, the EEG is clearly distinct from a temporal focus

Symptomatic epilepsy due to mesial temporal sclerosis


hepatitis B virus infection in a 5-year-old patient from Nigeria, with normal physical examination and the following serology for hepatitis B: HBsAg + / ANTI-HBs - / HbeAg - / ANTI-HBe + / ANTI-HBc IgM - / ANTI-HBc IgG + / DNA HBV +

Having antibodies against the core implies natural contact, and that it is IgG, which is not acute

The absence of e antigen rules out active replication

And the persistence of surface antigen (HBsAg) and virus DNA indicates that it is still present

Together, these indicate an asymptomatic carrier


All responses are causes of malnutrition except 3

A patient on enteral nutritional support presents 72 hours after starting enteral nutrition with a CBC showing hypophosphoremia and hypokalemia, with clinical signs of heart failure

Refeeding syndrome occurs in patients with previous malnutrition exposed to either oral, enteral or parenteral nutritional therapy

The patient is diagnosed with refeeding syndrome


Autoimmune hemolytic anemia associated with respiratory infection and corticosteroids

The irregular antibody study is positive for panagglutinin, making crossmatching difficult

bilirubin 6.8 mg/dl, (unconjugated bilirubin 6.1 mg/dl)

The choluria, LDH, presence of panagglutinin and the peripheral blood smear "smells" like hemolytic anemia

Medullary aplasia and immunotherapy with thymoglobulin and cyclosporine

Answer 1 cannot be because a marrow aplasia does not explain the choluria, the elevation of LDH, nor in the study of irregular antibodies is positive in the form of panagglutinin

On admission, the CBC showed 16900 leukocytes/mm3 (85% S, 11% L, 4% M), hemoglobin 6.3 g/dL; MCV 109 fl, 360000 platelets/mm3

In addition, pancytopenia is not observed, which is what would incline us more towards this pathology.

Hereditary spherocytosis and splenectomy

Answer 2 is not possible either, since a spherocytosis does not justify the presence of panagglutinin

Answer 3 is the one I consider correct: an autoimmune hemolytic anemia would justify the data given: elevated LDH and bilirubinemia due to red cell destruction, polychromatophilia, spherocytosis and anisocytosis because the marrow is working hard to try to compensate for the anemia, which is regenerative.

The morphological study of blood showed macrocytic anisocytosis with frequent spherocytic forms and polychromatophilia without blasts.

The study of irregular antibodies and the presence of panagglutinin also supports this response, since the binding of an antibody to the hematocyte promotes its lysis and destruction

The girl presents cough and fever, consistent with a respiratory infection

A 32-year-old woman with cerebral palsy from childbirth comes to the emergency department for a few days of dark urine associated with an episode of high fever and dry cough

And the initial treatment is corticosteroids

Answer 5 is not true because no blasts are seen in the blood nor does it explain the presence of panagglutinin.

Answer 4 gives rise to considerable doubt; it is not possible because a pernicious anemia does not justify the presence of panagglutinin although it would justify the elevation of LDH and bilirubin; moreover, it is an intramedullary, arregenerative hemolysis, there is no reticulocytosis or release into the blood of immature forms in an attempt to compensate and fix the situation

Pernicious anemia and periodic injections of vitamin B12


So the diagnosis is respiratory distress

the correct answer is option 5
Respiratory distress
Support

The question tells the story of a patient with acute pancreatitis who is developing acute respiratory failure

The statement lists the criteria for ARDS (acute respiratory distress syndrome): PaO2/fiO2 < 200 + bilateral pulmonary infiltrates + PCP<18


Other drugs are a good choice in urinary tract infections caused by large negative bacilli (most likely: E. coli)

Many E Coli are resistant to amoxicillin


It has to be treated before the age of 2 years

The treatment of first choice is orchidopexy

hormonal treatment is currently in disuse

The indication for orchidopexy should not be deferred


None of the other three options give that clinical picture

Non-arteritic anterior ischemic optic neuropathy

DPV is usually asymptomatic
Acute posterior vitreous detachment
Attack

An 84-year-old woman presents with loss of vision in the left eye of 4 days of evolution accompanied by metamorphopsia

The macula shows abundant hard exudates, two small deep hemorrhages and a localized neurosensory retinal detachment

CRVO produces abrupt and total or near total loss of vision with the typical "cherry red spot" in the fundus

both an arteritic and non-arteritic NOIA would produce papillary edema usually with peripapillary but not macular hemorrhages

In the contralateral eye there are abundant soft drusen

none of these 3 options have any association with drusen in the contralateral eye

AMD in its exudative form presents with both this clinical presentation (loss of vision and metamorphopsia) and the characteristic fundus described in the question, in addition to the fact that drusen are usually observed in the contralateral eye

Exudative age-related macular degeneration (AMD)


Diplopia on vertical gaze is highly suggestive that the bony walls of the orbit are affected

Lefort type I fracture does not affect the orbital contents

We are with great probability in front of a Lefort I type fracture of the middle third of the face

Knowing this information, the only correct answer is 2

This is probably a unilateral orbitomalar fracture

Whoever posted the question wanted to make sure that the only valid answer was number 2; that is why they added the tag line "but just in case we check it with a CT scan


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

endophthalmitis typically presents with a lot of pain

Option 1 is strongly discarded
Post-surgical endophthalmitis
Attack

Option 3 of wet form of age-related macular degeneration is also ruled out

although what a patient with myopia magna may present with is myopic macular degeneration (with a similar clinical picture to AMD, but this is a different pathology)

A posterior vitreous detachment (PVD) is usually not very symptomatic, producing myodesopsias but no loss of vision or pain

however, some PVDs are of the hemorrhagic type, by traction of the vessels, producing a vitreous hemorrhage that would cause loss of vision

In any case, due to the history of myopia magna and previous intraocular surgery, the first diagnosis to rule out would be retinal detachment, since these are two risk factors for this pathology

Technically, both option 2 and 4 (an acute hemorrhagic DPV) could cause these symptoms, but the most correct option is option 2


Histopathology revealed a thickened area below the superficial lining epithelium, which was more evident by Masson's trichrome technique and involved epithelial atrophy and denudation

In this case, the presence of thickening of the subepithelial collagen layer, more evident with Masson's trichrome (special stain that allows differentiation of the collagen fibers), is pathognomonic of collagenous colitis

Atrophy together with epithelial denudation are characteristic of this disease, which does not usually cause macroscopic alterations of the mucosa

An increased density of intraepithelial lymphocytes and the absence of mention of architectural alterations of the crypts (characteristic of ulcerative colitis and Crohn's disease) support this diagnosis


Since a splenectomized patient is considered a "special" patient, he should receive antibiotic treatment as soon as possible, even if the wound does not appear infected

Give 400 mg of oral moxifloxacin and send to the hospital


The correct answer is 3.
Hysteroscopy and endometrial biopsy
Support

The study that gives us more information about endometrial pathology is hysteroscopy, which allows us to perform a directed endometrial biopsy

Endometrial cytology is performed blindly and has a large number of false negatives

MRI will help us to stage endometrial cancer

Magnetic resonance imaging of the pelvis


The picture described is typical of a viral meningoencephalitis, more specifically VHZ, with significant tropism by the temporal lobe, causing febrile fever and in many cases aphasia

the cerebrospinal fluid normally shows a moderate lymphocytic pleocytosis, with normal glycorrhachia

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

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

The rest are not correct
We would suspect limbic encephalitis
Attack

The rest are not correct
This is an early stage brain abscess
Attack

The first one because it is not a bacterial meningitis that would present with more fever

A 52-year-old man comes to the Emergency Department with headache and fever (37.8°C) of 2 days' evolution

the third one because limbic encephalitis usually presents afebrile with behavioral changes

the last one because the image they describe is not an abscess, well delimited


Reading the answers, the first thing that is clear to us is that acenocoumarol should NOT be given to a pregnant woman because of the risk of teratogenicity

Treatment with antivitamin K drugs (acenocoumarol) during pregnancy

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

Advise a woman not to become pregnant when there are treatments that ensure a very low risk of thrombosis and/or fetal involvement?

It is true that factor V Leiden in heterozygosis is classified as low risk, who has not presented a previous thrombotic episode nor is there a combination with another thrombophilia;

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

if we look at the CHEST guide, VIII edition and review what was said at the last congress of the Spanish Society of Gynecology and Obstetrics, we see that aspirin is used in case of phospholipid syndrome and that in the case of this woman, without previous thrombosis, without previous abortions (at least two are needed) and also being heterozygous, treatment is not necessary

Low-dose aspirin should be advised during pregnancy and puerperium

A 25-year-old woman who wishes to become pregnant and wants to know what treatment she should take during the eventual pregnancy, as she is a heterozygous factor V Leiden carrier

She has never had any thrombotic phenomena


We are being shown a picture of lumbar canal stenosis

Answer 4 correct
Lumbar canal stenosis
Support

The patient shows the characteristic clinical picture: lumbar pain that is relieved by flexing the trunk forward, radicular pain with lower limb involvement and neurogenic claudication

Low back pain in a patient over 60 years of age accompanied by leg weakness when walking, which has to be interrupted at a certain distance, called neurogenic claudication

The patient is relieved by flexing the spine forward because it widens the lumbar canal and worsens with extension..


A 51-year-old woman comes to the emergency department with a sudden decrease in visual acuity, severe headache, nausea and vomiting

Pituitary apoplexy is a syndrome characterized by the sudden onset of headache accompanied by ocular motility disturbances and a variable degree of pituitary insufficiency

The cause is usually a rapidly growing pituitary mass secondary to a vascular event (infarction or hemorrhage)

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

General symptoms may range from vomiting or nausea to meningeal irritation

Compression on the chiasm and optic nerve can cause various campimetric deficits (usually greater bitemporal hemianopsia in the superior quadrants) and decreased visual acuity, even blindness


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

According to the SEGO (Spanish Society of Gynecology and Obstetrics) in its 2005 protocol "Gestational trophoblastic disease", the risk of malignization, i.e. of developing a gestational trophoblastic neoplasm, ranges from 5 to 20% depending on whether it is a partial mole or a complete mole, respectively

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

The risk of a new molar gestation, although increased compared to the normal population, is not 50%

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

According to this protocol: "Patients will be monitored weekly with hcg dosage until it becomes undetectable, for three consecutive times

Therefore, subsequent controls are strictly necessary

After that the monitoring will be monthly, for six months and then every two months for another six months

Based on the available data, a follow-up of three to six months is recommended for partial mole and 12 months for complete mole

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


It refers to a thyroid nodule, and the indicated test is a FNA (fine needle puncture)

Ultrasound facilitates FNA but is not mandatory, a 2 cm thyroid nodule can be punctured without echo


Currently the molecular classification of breast cancer is based on the study of hormone receptors, HER2 and the tumor cell proliferation index (Ki67)


Behavioral symptoms, motor symptoms, decline of functional independence

Behavioral symptoms, mood changes, motor symptoms

Between 1 and 3, I choose 3 for the same reason and because of the emphasis on the decline of functional independence that occurs in these patients

Mood changes, cognitive deficit, decline of functional independence

There are behavioral variants, but in the MIR they usually want you to think of other types of dementias in the face of behavioral symptoms

In fact, the appearance of these symptoms in early stages should alert us and open the range of diagnostic possibilities


The correct answer is: 2
Hyperkalemia
Support

Hyperkalemia
The correct answer is: 2
Support

short QT
The QT space is shortened
Support

In the ECG, there are sharp and elevated T waves

Hyperkalemia produces repolarization disturbances that result in the installation of a large, symmetrical, narrow-based T, visible in the precordial leads

Above 6.5 mmol/L, electrocardiographic changes are constant, and are dominated by conduction disturbances (making ventricular extrasystoles possible)

These anomalies appear with a kalemia of around 5.5 to 6 mmol/l


pH between 7.20-7.25 Prepathological value

Pre-pathological value repeat microtome 15-20 minutes

Moderate acidosis. Repeat microtome in 1-2 hours


Idiopathic thrombocytopenic purpura, but with very low platelets, so replenishment is necessary


The trick to this question is that there are 8 cervical roots for 7 vertebrae, therefore the C1 root exits ABOVE the atlas, and so on up to C8 which exits BETWEEN C7 and T1

The thoracic roots come out respectively below the vertebra with their same numbering (nerve T1 under T1, T2 under T2, etc.)

Therefore, between C4 and C5 the 5th cervical nerve exits, and between T4 and T5 the 4th thoracic nerve exits

Fifth cervical and fourth thoracic nerve


Everything we are told in this case is typical of COLLAGENOUS COLITIS


Calcium/creatinine urine ratio
Urine calcium/creatinine ratio
Support

In a 30-year-old female patient a calcium level of 11 mg/dl (normal less than 10.5 mg/dl) is found during a routine company examination

This is familial hypocalciuric hypercalcemia or benign familial hypercalcemia

The history is unremarkable except for the fact that the mother and paternal grandfather were diagnosed with hyperparathyroidism and underwent surgery, although they remained hypercalcemic


The surgical criteria depends on the patient's symptoms and failure of medical treatment

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

No medication slows down or modifies the course of the disease

Treatment is medical and sequential, starting with the first analgesic step of the WHO

An MRI is not necessary, it does not contribute anything

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


She does not present weight phobia or body image distortion

As soon as we hear about weight we go to anorexia nervosa, but anorexia nervosa has three features: significant self-induced weight loss, body image distortion and amenorrhea

3 does not make sense in the MIR because of the clinic -in reality the history is different and in psychiatry everything is evolution

4 has to meet temporal criteria that are not met here

There is no anxiety clinic and she also meets the criteria for depression

The poor girl has been diagnosed with depression

The answer is 5
Major depressive disorder
Support

A 19-year-old female university student comes to the clinic accompanied by her parents, reporting feeling progressively more asthenic in the last two months, with loss of appetite and weight and with greater difficulty in concentrating on her studies

The anamnesis also highlights that she has lost interest in going out with friends, has ideas of death without self-harming ideation and pessimistic cognitions of the future


We describe the case of a patient with a hyperkalemic emergency

The first step is the administration of iv calcium gluconate to counteract the cardiac toxicity of hyperkalemia (option 3 correct), giving us more time to initiate hypokalemic treatments (initially saline glucose with insulin, salbutamol, furosemide, and assessing dialysis if there is no good response)

potassium >6.5 mmol/l with ECG alterations

Administration of intravenous calcium gluconate


but what they ask us is what to do to treat the anemia

options 2 and 4 are options to identify the autoimmune disease

so we should suspect that the anemia is secondary to the autoimmune disease

since if it is positive the patient, except in extreme cases, will not be transfused and the primary cause should be treated

therefore request a direct Coombs test
Direct Coombs' test
Support

It also speaks of rapid onset, which in the case of vitamin B12 is more progressive

They comment on the case of a young woman with symptoms of systemic disease of probable autoimmune origin (lupus) who presents with macrocytic anemia


In addition, with this pH (and knowing that the effusion is already loculated), the endothoracic tube is more than indicated

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

During thoracentesis, a yellowish fluid is drawn and analysis shows: leukocytes 15,000/uL, 92% neutrophils, glucose 30 mg/dL, pH 7, lactate dehydrogenase 3500 U/L, adenosine deaminase 45 U/L and absence of germs on GRAM stain

Chest X-ray shows a loculated right pleural effusion occupying two thirds of the hemithorax

since the clinical picture points to a parapneumonic pleural effusion, the macroscopic characteristics of the fluid seem so and the analysis of it shows us that the effusion is also complicated, almost on the verge of being an empyema (very high LDH, cellularity with predominance of PMN, glucose consumption)


In this case, given the antibiotic treatment given and the severity of the diarrhea

it seems that we are dealing with a Clostridium infection

in fact, as much as patients with CAP may have associated diarrhea, it is unlikely that a bacterium is sensitive to an antibiotic at the beginning of the picture and stops being so after 3 days

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

After 4 days of stay in the ward, his evolution is complicated by the appearance of a severe diarrhea


He presents with fork dorsum deformity of the wrist and functional impotence, with normal distal neurovascular status

With the deformity and pain in the distal radius, we expect a fracture at this level

we mark 3
Epiphysiolysis of the distal radius
Support

However, I see it as unquestionable, given that it could also have a concomitant fracture in the ulnar green stalk

although the main lesion is that of the radius


Answer 2 incorrect
Hyperthyroidism due to Graves' disease
Attack

Graves' disease is characterized by hyperthyroidism and one or more of the following features: goiter, exophthalmos and pretibial myxedema

Answer 4 incorrect
Subacute thyroiditis
Attack

The most obvious symptom of subacute thyroiditis is neck pain

Sometimes, the pain may extend to the jaw or ears

In the physical examination she has tachycardia, hyperreflexia and absence of goiter

Painful enlargement of the thyroid gland can last for weeks or months

And you usually have low serum thyroid stimulating hormone (TSH)

In the blood test TSH values are < 0.01 microU/mL, T4 is elevated and thyroglobulin levels are low

High serum thyroglobulin level
Answer 4 incorrect
Support

High serum free T4 level
Answer 4 incorrect
Attack

Ovarian teratoma (ovarian stromal tumor)


They describe a typical hemisection or Brown-Sequard picture

A man presents on neurological examination with a thermoalgesic sensory deficit in the left leg associated with a loss of vibratory and positional sensitivity in the right leg

Ipsilateral posterior motor and chordal involvement with contralateral pain and temperature involvement

At the same time he presents with clumsiness and loss of distal strength in the right leg and a right plantar cutaneous reflex in extension


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


A 10-year-old boy with brief episodes of distractions (< 1 minute) in which he does not respond to calls and blinks

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

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


Given its benign nature, surgery is not recommended, and is reserved only for symptomatic patients or those in whom the nature of the lesion is in doubt after a complete study with CT, MRI and echoendoscopy with biopsy


The clinical and biological picture of this patient raises suspicion of hemolytic anemia in the context of systemic lupus erythematosus

If we have to choose only one diagnostic test, and this should be the first, we are interested in confirming the presence of an autoimmune hemolytic anemia with the direct Coombs' test in order to initiate treatment

A 25-year-old female patient with a history of skin rash after sun exposure and occasional polyarthritis in the joints of the hands, controlled with non-steroidal anti-inflammatory drugs, presents with general malaise, progressive feeling of generalized weakness and pallor for the last 15 days

Laboratory tests showed hemoglobin 7 g/dL, MCV 108 mm/h, 150,000 platelets/mm3, 3000 leukocytes/mm3, elevated LDH, undetectable haptoglobin


This is a woman with abrupt, painless and severe loss (she only sees the movement of the hands) of vision in one eye

We have to rely on systemic symptoms to diagnose the problem

She does not give us much information from the ocular examination, only that there is an afferent pupillary defect

This is an elderly woman with typical symptoms of polymyalgia rheumatica

It is giant cell arteritis or temporal arteritis

the pain in the temporomandibular region is very suggestive

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

The afferent pupillary defect is very characteristic of these severe ischemic optic neuropathies

Suspecting giant cell arteritis, there are three analytical markers that are characteristically high: CRP, ESR and platelet count

The most common ocular manifestation is anterior ischemic optic neuropathy

In the fundus we would certainly see a papillary edema of that eye, with a gypsum white coloration

We will first request one of these parameters and treat it often without waiting for biopsy confirmation

Therefore, option 2 is the correct one
C-reactive protein
Support


they do not give us the quantification of urine protein (they only tell us that urinalysis reveals the presence of kappa light chains, not the amount)

Option 2, nephrotic syndrome, apart from being broad and nonspecific, would not be assessable

A urinalysis reveals the presence of kappa light chains

in amyloidosis, the light chains that are usually deposited are of the lambda type

Option 3 would be unlikely
Amyloidosis
Attack

in IgA myeloma we would expect a monoclonal peak of this Ig, which in this case does not appear

IgA myeloma with Bence-Jones proteinuria

this entity fulfills the characteristics described

absence of monoclonal peak in most cases, acute renal failure and presence of kappa chains in urine

being light chain myeloma a somewhat broader entity

I would opt for 1
Kappa light chain deposition disease
Support


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


A 2-month-old infant with an upper respiratory tract cold of 3 days of evolution, who begins with moderate respiratory distress and pulmonary auscultation with expiratory wheezing

We are presented with a case of RSV-positive bronchiolitis

Respiratory syncytial virus is isolated in the nasopharyngeal exudate

According to current recommendations, it would be indicated to initiate supplemental oxygen therapy


Not only thrombocytopenia but also headache, schistocytes, high LDH and high bilirubin