FREE SPEX Analysis Exam Question and Answers

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A 75-year-old woman who has been experiencing palpitations and shortness of breath for the past day is examined in the emergency room. She is discovered to be in atrial fibrillation (AF), with 100 ventricular beats per minute and a 100/70 millimeter-Hg blood pressure. Heparin is used to prevent clotting, and intravenous diltiazem is used to restore her heartbeat to a normal sinus rhythm. There are no signs of severe coronary artery disease, heart failure, or left atrial thrombi in the clinical, imaging, or laboratory data.

Which of the following drugs would be appropriate for discharge?

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Explanation:
The most prevalent persistent arrhythmia is AF, which is more prevalent in elderly people. It might be intermittent or constant, and it might or might not cause overt symptoms. Palpitations, chest discomfort, and dyspnea are common in patients. Acute sinus rhythm restoration may be accomplished with the aid of cardioversion, intravenous beta-blockers, or specific calcium channel blockers. Anticoagulation is required to lower the risk of a stroke brought on by thrombus embolization, which frequently occurs in the left atrial appendage. Transesophageal echocardiography may be used to identify a stroke and, if one is present, recommend anticoagulation for three weeks prior to elective cardioversion, according to certain sources. Warfarin must be used for a long time to prevent bleeding, although there are also easier-to-manage anticoagulants undergoing active clinical trials. The most likely medication to maintain sinus rhythm is amiodarone, however, due to its multiple side effects, many doctors will first try sotalol or propafenone. With beta-blockers, diltiazem, or digoxin, rate control can be attempted. There is strong evidence that rate control is just as helpful in patient management as rhythm control. Radiofrequency ablation of AF focus, typically in the pulmonary veins, has had a lot of success recently, but it is still only a secondary treatment. Finally, stopping anticoagulation may be possible if a filter is positioned with a catheter above the aperture of the left atrial appendage to prevent clot embolization.

A 20-year-old woman comes to see you for menorrhagia and easy bruising. Her gynecologist notes that the pelvic exam was normal. Additional medical history includes bruises from minor childhood injuries, sporadic spontaneous epistaxis, and heavy periods ever since menarche at age 13. She hasn't undergone surgery, but the dentist suggested a workup for a bleeding issue because she had chronic bleeding following dental extraction. She hasn't experienced any joint or deep intramuscular hemorrhage. She doesn't use any medications that affect platelet function, such as aspirin. Her family history is missing because she was adopted. Other than a few bruises on her extremities, her physical examination was normal. There is a slight iron deficient anemia.

Which of the subsequent laboratory tests has the greatest chance of supporting the clinical diagnosis?

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Explanation:
The young woman has a history of type 1 von Willebrand disease, which is the common form (vWD). This is the most prevalent bleeding disease, affecting 1% to 3% of people overall and affecting both sexes. The gene for the vWD factor, a sizable multimeric glycoprotein, is found on chromosome 12. In type 1 vWD, which accounts for 75% to 80% of cases, is inherited as an autosomal dominant trait. Due to the absence or irregularity of the vWF protein, which normally binds with factor VIII and hinders its clearance from circulation, the PTT may be increased and the factor VIII level reduced. Typically, the PT is normal or hardly raised. Normal platelet counts are present. The hemophilias are uncommon in females due to their x-linked method of inheritance, albeit a mutation could take place. Hemophilia cannot be diagnosed if there is no profound bleeding in the muscles or joints; vWD hemorrhage typically occurs on the skin or mucous membranes, and postpubertal females frequently experience menorrhagia. The most accurate and sensitive diagnostic test for vWF is the ristocetin cofactor assay. In the low ristocetin dose assay, RIPA is significantly diminished or nonexistent whereas it may only be modestly reduced in the normal assay.

A 35-year-old married woman contacts you since her older sister recently received a breast cancer diagnosis and her mother passed away from the disease in her 40s. She is Jewish, and her Polish-born grandparents are. She is interested in learning what she may do to reduce her risk of contracting the illness. She has a child who is 5 years old, is in good health, and plans to have one or two more children in the future. It's normal to examine your breasts. She tested positive for the BRCA2 gene, according to genetic testing. Though it is brought up, she declines to consider a bilateral mastectomy.

What would be the most effective strategy for handling her case?

Correct! Wrong!

Explanation:
Less than 5% of breast cancer patients have a BRCA1 or BRCA2 gene mutation, while up to 40% of hereditary breast cancer patients have, with a frequency of 1 in 40 in Ashkenazi Jewish women. This woman has a lifetime risk of ovarian cancer of 10% to 20% and a chance of breast cancer of 56% to 85%. MRI screening is thought to be superior to traditional mammography or ultrasonography in BRCA individuals. Tamoxifen 20 mg daily has been found to lower the risk of both invasive and benign breast cancer by 50% for high-risk premenopausal women. Raloxifene may also be utilized since it reduces risk at a similar pace to tamoxifen while having less side effects. Many more medications are undergoing clinical testing. Right now, neither chemotherapy nor radiation would be appropriate.

The patient is given bed rest and is under strict observation, but her blood pressure remains high and at 32 weeks, her urine still reveals 1+ to 2+ proteinuria.

What do you suggest right now?

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Explanation:
Preeclampsia and gestational hypertension can both be treated with delivery, however the risk of premature must be considered most heavily. Most obstetricians won't perform an abortion before 36 weeks unless the blood pressure becomes unmanageable or there are signs of end-organ failure. Although it is not recommended for preeclampsia or gestational hypertension, magnesium sulfate is beneficial for controlling eclampsia seizures. For any future pregnancies this lady may have, calcium supplements and low-dose aspirin should be taken into consideration as they are most effective at preventing preeclampsia. Pregnant women should not take ACE inhibitors or angiotensin II receptor blockers since they may harm the fetus' kidney development or even result in fetal mortality or deformity. Methyldopa has a very high safety record, lowers vascular resistance while maintaining cardiac output and uteroplacental perfusion, and has been used widely in pregnant hypertension patients. Beta- and alpha-blockers are also an option.

A mole on the student's back has changed in size and color, and he is a 24-year-old medical student. He has no family history of skin cancer and is in good health. Although he has fair skin and served as a lifeguard for two summers while in college, he cannot recall ever getting a bad sunburn. Recently, the mole has occasionally itched, which has drawn his attention to it. The 0.8 cm-long lesion has an uneven border and is located on the left upper back, slightly below the shoulder. No nodule is palpable, however, there are minor color variations. On examination with a magnifying lens, no ulceration was found. Except for a few benign-looking skin nevi, the rest of his physical evaluation is ordinary. Lymphadenopathy is not seen in the cervical, supraclavicular, or axillary areas. There is a wide excisional biopsy of the mole.

Which of the following pathologies and clinical findings is most crucial for determining prognosis?

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Explanation:
The strongest indicator of survival is the thickness of the melanoma, regardless of whether it has spread locally, regionally, or far. Strong indicators of prognosis include the extent of the ulceration and the tumor cells' rate of mitosis. A more aggressive tumor with a higher likelihood of lymph node involvement and lower survival is suggested by ulceration and an elevated mitotic rate. Despite being employed as a prognostic indicator for many years, the depth of penetration is less accurate than the actual thickness of the melanoma and/or the presence of ulceration. The head, neck, and trunk primary have a worse survival rate than those on the extremities, and men generally have a worse prognosis than women. As people get older, their chances of survival decrease as well.

A 72-year-old guy seeks your advice due to fatigue and sleep issues. He has trouble going to sleep, and he frequently wakes up early. He claims that since his wife passed away from cancer two years ago, he has been in a depressed mood and has trouble concentrating. She is constantly on his mind. He no longer finds enjoyment in activities he formerly did, such as swimming, hiking, and hanging out with friends. Although he had fleeting suicidal thoughts, he never actually tried to end his life. He also didn't have any delusions, hallucinations, or sporadic mood changes. He avoids using other illicit drugs and lives alone. He consumes two to three alcoholic drinks every day. He has two adult children, but since they reside out of state, he rarely sees them. He uses the alpha-adrenergic blocker tamsulosin to treat his benign prostatic hypertrophy and moderate hypertension (Flomax).

What type of treatment should be started and what is the most likely diagnosis?

Correct! Wrong!

Explanation:
When depressed patients visit their primary care physician for somatic concerns, the underlying depressive condition is frequently overlooked. Major depression in this situation is indicated by the dismal mood, lack of focus, and interest in formerly enjoyable activities. Particularly concerning are suicidal thoughts, even if they are fleeting and not followed through. A psychiatrist should be consulted as soon as feasible for older persons who are socially isolated and who take drugs to an extreme degree. A selective serotonin reuptake inhibitor (SSRI), such as fluoxetine (Prozac), sertraline (Zoloft), or paroxetine (Paxil), may be prescribed to other patients. If the SSRI doesn't work as expected, psychotherapy may then be added. Many depressed people benefit most from combined medication and psychosocial therapy, according to several studies. Although depressive symptoms are infrequent, flomax may make you feel lightheaded. Beyond dysthymia, the diagnosis includes suicidal ideation. Trazodone is helpful for sleep and can be used as a second medication, although it is better to be referred to a specialist. Bipolar disorder is unlikely because there is no prior history of mood swings or manic conduct.

Prednisone 40 mg/day was prescribed to the patient, and during the following two weeks, his symptoms significantly improved. But when the dosage is reduced to 20 mg per day, the illness worsens.

What will happen with this patient's care after that?

Correct! Wrong!

Explanation:
Although the major treatments for Crohn's disease that induce remission are corticosteroids administered orally or intravenously, these treatments cannot be sustained permanently due to their significant side effects. As a first line of treatment, antibiotics like ciprofloxacin and/or metronidazole may also be employed. The best course of action is to temporarily raise the steroid dose and then add an immunosuppressant if the condition flares up while drugs are being tapered. After several weeks on the immunosuppressant medication, steroid tapering may then be attempted once more. Only patients who are resistant to medicinal therapy or who develop a fistula, abscess, or intestinal blockage usually require surgery early in the course of the disease. Sulfasalazine and olsalazine are 5-aminosalicylic acid-containing medications that can be used for maintenance therapy in remission-bound Crohn's patients, although they work better for ulcerative colitis. Belladonna and powdered opium are antidiarrheal and antispasmodic drugs that may reduce symptoms but do not treat the underlying condition. NSAIDs should be avoided if at all feasible since they can occasionally make inflammatory bowel disease worse.

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