FREE SPEX Assessment Exam Question and Answers
A 33-year-old married guy who suffered severe head injuries in a car accident is brought to the emergency room. He is being kept alive by a ventilator, intravenous hydration, and nutrition while he is in a coma. An electroencephalogram (EEG), neurologic examination, and brain imaging investigations are all consistent with the diagnosis of brain death. He didn't leave a living will or any other instructions for end-of-life treatment, but his driver's license indicated that he wanted to be an organ donor. His parents and brother oppose his wife's request to stop all of his assistance and go forward with organ donation; they want to keep him on life support longer in the hopes of a "miracle" and forbid organ donation. What should the accountable doctor do in these circumstances?
Explanation:
One of the most challenging ethical issues a doctor must deal with is how to treat a patient who is brain dead and on life support, especially if the patient is young and otherwise healthy. When the patient does not leave a living will or even oral instructions to the spouse or other close family members regarding extreme measures at the end of life, the situation gets even more problematic. When there is family conflict and the potential of organ donation, it becomes much more challenging. All interventions are permissible under the law, including stopping artificial breathing, hydration, and feeding. While experts in bioethics and members of the clergy may offer guidance, they cannot make the final choice. Potential donors cannot be managed by the transplant surgeon, and pharmacological interventions cannot hasten death. Although he was found not guilty, the latter action by a transplant specialist in California led to criminal charges. The choice of spouse is final and is overruled by any adult children, parents, siblings, or other available family members. In the well-known Terri Schiavo case, a similar dilemma developed; ultimately, the husband's desires were won following multiple legal fights and federal intervention.
Aspirin and naproxen should be stopped, and the patient should report any visible rectal bleeding. For additional testing, a gastroenterologist is consulted.
What should the following diagnostic process entail?
Explanation:
In individuals with occult blood loss, the upper and lower gastrointestinal tracts should also be checked because there may be several lesions. For patient convenience and to avoid administering anesthetic twice, this is frequently done one after the other. Since colonoscopy can detect bleeding lesions or clots and obtain a biopsy or coagulate them, barium enema procedures are no longer commonly performed. When endoscopy has been ineffective in locating the source or is obstructed by blood, angiography is helpful for bleeding lesions that are moving rapidly (at least 1 mL/min).
A 101° temperature and a chronic, productive cough are both present in a 24-year-old guy. He claims to have had a "cold" for approximately a week, along with a cough and a temperature between 100° and 101°. He claims not to smoke, use illegal drugs, or be homosexual. He is generally healthy and does not use any prescriptions. A "pneumonia shot" has never been given to him. He experiences a small left-sided pleuritic ache on deep inhalation and feels a little bit out of breath with exercise. Over the left lower lobe, he has some crackles and percussive dullness. Both leg swelling and calf discomfort are absent. There is 93% oxygen saturation.
Which diagnosis is more likely?
Explanation:
This individual appears to have pneumonia from a public source. Although there is a lot of overlap, the pathogen may occasionally be suspected based on the clinical presentation. Streptococcus pneumonia, the most typical cause of community-acquired bacterial pneumonia, is the most likely culprit. This diagnosis is supported by the crackles, dullness, and pleuritic discomfort with somewhat low oxygen saturation. Without additional diagnostic testing, a mycoplasma etiology cannot be ruled out; however, this is often omitted unless the patient fails to react to initial antibiotic therapy. The majority of cases of legionella pneumonia occur in people over 40 who smoke, take chemotherapy, or take immunosuppressant medications. Patients with HIV infection or those on long-term steroid therapy are more likely to develop pneumocystis pneumonia. Even though a pulmonary embolism can occasionally mimic pneumonia, it would be extremely unusual for this young man to have one without any risk factors.
A 101° temperature and a chronic, productive cough are both present in a 24-year-old guy. He claims to have had a "cold" for approximately a week, along with a cough and a temperature between 100° and 101°. He claims not to smoke, use illegal drugs, or be homosexual. He is generally healthy and does not use any prescriptions. A "pneumonia shot" has never been given to him. He experiences a small left-sided pleuritic ache on deep inhalation and feels a little bit out of breath with exercise. Over the left lower lobe, he has some crackles and percussive dullness. Both leg swelling and calf discomfort are absent. There is 93% oxygen saturation.
Except for the following, all of the following would be suitable for managing this case:
Explanation:
Many therapeutic choices for pneumonia patients are influenced by risk factors like age, the existence of aggravating illnesses, and the severity of the illness. This patient is young, physically healthy, and only slightly handicapped. Patients with pneumonia should always have a chest x-ray and CBC to help determine the full degree and severity of the illness and maybe identify any other risk factors. Since it protects against the majority of the prevalent community-acquired infections, a macrolide antibiotic is typically the first option for empiric treatment. If a patient cannot tolerate macrolides or has an allergy to them, doxycycline may also be administered. For this kind of patient, intravenous antibiotic medication is typically not necessary until the patient fails to react to initial therapy or a problem arises.
A successful endarterectomy was performed on this patient after cerebral angiography revealed a 95% blockage of the left carotid artery. The brain MRI revealed no signs of a previous stroke, and the cardiac ultrasound confirmed mild left ventricular hypertrophy but revealed no anomalies in wall motion or potential emboli sources.
The appropriate medication(s) for discharge ought to be:
Explanation:
All stroke or TIA patients should receive secondary prophylaxis. The risk of having another stroke maybe 30% lower while using aspirin and other antiplatelet medications. Aspirin dosage cannot be determined with precision in advance. Although aspirin and clopidogrel may be combined, there is no evidence that it is superior to aspirin alone. It is also much more expensive and may raise the risk of bleeding. Clopidogrel may also be administered at a dosage of 75 mg/day. Statins should be used aggressively to treat all individuals with cerebrovascular illness as they have been shown to cut the stroke rate by 25%. Both warfarin and low molecular weight heparin have been proven to be ineffective at preventing strokes and to be highly inconvenient because they both require subcutaneous injection and periodic laboratory testing, respectively.
The young man starts taking an NRTI and a prostate inhibitor. His lover is discovered to be HIV-positive six months later. They acknowledge having multiple instances of unprotected intercourse. She has been referred by her physician for potential therapy and is also five weeks pregnant. She feels fine except for occasional morning sickness and has a basically clean medical background. Her CD4 T-cell count is 500/mL, and she has 20,000 copies of HIV RNA in her blood.
What is the safest course of action for her to take to stop the spread of the infection to the fetus?
Explanation:
Over the past few years, there has been a change in how pregnant women with HIV are treated. For people who have HIV RNA levels above 1,000 copies/mL, combination ART including zidovudine is advised rather than zidovudine or nevirapine monotherapy. There is a minor risk of transmission to the newborn in women with levels below the threshold. While the majority of ART medications are not teratogenic, many have not been sufficiently investigated and others may worsen the negative effects of pregnancy. It is probably safest to hold off until the second trimester.
A standard pre-employment physical is performed on a 30-year-old single male. His medical history shows he had an appendectomy when he was 16 but no other significant illnesses. He experienced a febrile sickness many months ago that included swollen glands, exhaustion, and a fever, but it went away on its own without the need for medical attention. Further investigation finds that he is bisexual, has had intercourse with both men and women, and currently has a committed partner. About using condoms, he is evasive. He denies having any STDs or using drugs intravenously, although he does snort a little cocaine now and then. Except for the scar from the appendectomy, a physical examination is essentially negative. There are no noticeable oropharyngeal abnormalities, lymphadenopathy, or hepatosplenomegaly. An x-ray of the chest is negative. Each of the tests for hepatitis—CBC, liver function, VDRL, and hepatitis—is negative. Western blot confirmation of an HIV screening test's positive result. Tests using pure protein derivatives (PPD) come up negative.
What should the patient's next course of action be?
Explanation:
There is no need to rush into treating this guy because he exhibits no symptoms and has no clear opportunistic illness. It's possible or unlikely that his history of a febrile illness accompanied by lymphadenopathy is connected to the early stages of HIV viremia. The CD4 count and the plasma viral load play a significant role in the therapeutic decisions made in a patient like this who is asymptomatic. For a decision for urgent therapy as well as a baseline for follow-up, both results should be collected. Significant doctors start therapy with CD4 T-cell levels as high as 500/mL; however, there is some debate over the recommendations for treatment based on these numbers. Standard recommendations state that treatment should begin if CD4 T-cell counts are below 200/mL; counts between 200/mL and 350/mL should be actively considered. If the count surpasses 350/mL and the viral load exceeds 100,000 copies, many AIDS specialists will recommend treatment. If the count is greater than 350/mL and the viral load is under 100,000, therapy may be recommended; however, other experts think that viral loads above 55,000 should always be treated, regardless of the CD4 t-cell count. It is advisable to screen the girlfriend and any additional sexual partners mentioned. Recent research suggests that early ART may prevent sexual transmission of the virus to an HIV-negative partner.