FREE SPEX Exam Question and Answers
The patient mentioned above had a CD4 T-cell count of 400/mL and plasma HIV RNA of 75,000 as the results of the follow-up tests. Although his girlfriend's HIV was not detected, one male sexual contact was revealed to be positive. He was advised to use latex condoms for safe sex and, if at all possible, steer clear of homosexual encounters. Following up after six months revealed a reduction in CD 4 T cells to 340/mL and an increase in viral load to 110,000. He is still symptom-free.
Now, how ought he to be handled?
In order to prevent the formation of resistant strains, HAART therapy should be started with combination medication therapy for new HIV-positive patients. Each major drug category has a large number of products available, and many 2 and 3-drug combinations make it simpler to take them. Before starting therapy, the patient must carefully look over lists of each medication's potential side effects. Authorities advise combining an NRTI with a PI and NNRTI. Therefore, appropriate combinations could include efavirenz (NNRTI) with zidovudine/lamivudine or atazanavir and ritonavir (PI) with zidovudine/lamivudine (NRTI). In new patients, three medication treatments seem to be just as effective as four. By week four and week eight of treatment, the HIV viral load should have decreased by 0.5 to 0.75 log. By four to six months, the infection shouldn't be found. A growing CD4 T-cell count frequently accompanies a reduction in the viral RNA.
Upper and lower endoscopy are performed on the patient, but neither procedure reveals any bleeding lesions or clots. No gastric or duodenal ulcer is visible and the esophageal mucosa appears intact. He has a few minor colonic polyps that were surgically removed and were determined to be benign as well as a few dispersed diverticula. While occult blood in the stool tests continues to be positive, a repeat EGD remains negative.
What should the next diagnostic procedure entail?
In cases of occult bleeding where standard endoscopy has been unsuccessful in detecting a lesion, capsule endoscopy—in which the patient eats a small camera inside of an ingestible capsule—had a good diagnostic yield (60% to 90%). Angiography is especially helpful in cases of severe bleeding. Isotope-tagged red blood cell scintigraphy may identify the site of gastrointestinal bleeding at lower blood flows (0.1 mL/min) but cannot pinpoint the cause. If the bleeding is not severe, push enteroscopy of the small intestine may be used, which has a yield of 38% to 75%. If none of the aforementioned methods can identify the cause of the bleeding, surgery with intraoperative enteroscopy may be tried. Iron therapy and follow-up hemoglobin readings should always be done, and transfusions should be used if necessary.
A significant branch of the left anterior descending artery in the aforementioned patient's angiography reveals a 90% blockage (LAD). It seems like fewer than 30% of the other arteries are blocked. After balloon angioplasty and placement of a drug-eluting stent in the severely blocked artery, the patient reports having pain-free rest and exercise. Since the isotopic stress test revealed no signs of myocardial ischemia, the resting electrocardiogram is now normal.
With the exception of All of the following medications, the patient may be discharged:
Except in cases where atrial fibrillation or venous thromboembolism are complications, warfarin is typically not recommended for CAD patients. The platelet inhibitor clopidogrel is typically administered to reduce the risk of stent thrombosis, although some individuals (15–48% of them) may be resistant and greater doses or a new medication, prasugrel, may be needed. Even if the LDL cholesterol is within the normal level, a statin is unquestionably needed. Many cardiologists agree that in patients like this one, the LDL cholesterol level should be lowered to less than 70 mg/dL. Unless there is a history of gastrointestinal bleeding or another bleeding risk, low-dose aspirin is frequently added. In addition to their antihypertensive effects, ACE inhibitors have been demonstrated to have impacts on these patients.
The patient's routine blood tests reveal a normal CBC and platelet count, 150 mg/dL fasting hyperglycemia, and modest transaminase increases. A borderline larger cardiac profile and clean lung fields can be seen on a chest x-ray. When reading an ECG, normal sinus rhythm is identified along with a left hemiblock but not ST change or Q waves.
The subsequent diagnostic step should be:
Duplex scanning of the carotids is a reasonable initial noninvasive test because carotid stenosis leading to transient ischemic episodes is the presumptive diagnosis. It combines range-gated pulsed Doppler and B-mode ultrasonography. Although just the part of the carotid circulation between the clavicles and mandible may be seen, it often reveals the luminal diameter and blood velocity. The results of this investigation should be available if a consultation with a vascular or neurosurgeon is necessary, thus it is usually advisable to have it done before the referral. Before an endarterectomy, cerebral angiography is typically done to see if the patient may benefit from the operation. The patient is exposed to both ionizing radiation and contrast medium. MR angiography tends to overestimate the degree of stenosis and is more beneficial for large lesions than smaller ones. In order to rule out a potential cardiac source of emboli and because there is a hint of left ventricular prominence, this patient should also have a cardiac ultrasound. In order to rule out a past stroke or other brain lesions, a brain CT or MRI should also be performed.
The patient mentioned above awakens two days later with excruciating, ongoing chest discomfort. Mild diaphoresis is present, but there is no nausea or vomiting. The paramedics administer him two chewable aspirin tablets and nitroglycerin spray before transporting him to the emergency room. His blood pressure is now 160/90, and his ECG displays sinus tachycardia with some inverted T waves in the lateral precordial leads and some ST depressions.
His chest pain has considerably lessened. What activity would be the next most logical step?
This individual has an acute coronary syndrome (ACS), most likely a non-ST-segment elevation myocardial infarction, based on his clinical presentation (NSTEMI). According to recent research, ST depression has a worse prognostic impact than T-wave inversion alone. The myocardial injury will be indicated by an elevated troponin level, and data are now readily available. It has been demonstrated that the degree of troponin I increase is inversely correlated with 30-day mortality. He should subsequently be sent to the catheterization laboratory for coronary angiography as soon as feasible, along with balloon angioplasty and stenting if necessary, given that he falls into the high-risk category. Although angiography continues to be the "gold standard" for the identification of CAD, high-resolution CT scans may be able to detect coronary calcifications. Patients with ACS whose catheterization is postponed by more than 24 hours should take clopidogrel. However, cardiac ultrasound will merely put off obligatory heart catheterization. Cardiac ultrasound may reveal some anomalies of wall motion.
The 65-year-old woman visits her doctor because she has experienced multiple periods of weakness in her right arm and hand, which have been accompanied by slurred speech. No loss of conscience exists. The experiences continue for 5 to 15 minutes, following which she returns to her normal state. She is right-handed, widowed, and independent. She has been taking a diuretic, an angiotensin receptor blocker (ARB), metformin, and other medications for the past 5 years to control her diabetes and high blood pressure. She disputes having heart problems, seizures, vertigo, or any other neurological condition. 6.6% was her most recent hemoglobin A1c. Her pulse is steady, and her blood pressure is 150/80. Over the left carotid artery, a bruit can be heard. At the cardiac base, there is a grade 2/6 mid-systolic murmur but no additional abnormalities. The nerves in her skull are unharmed.
What medical condition most closely resembles her symptoms?
The woman has been having transient ischemia events, which are probably caused by left carotid artery vascular disease. The duration of these attacks, which can last up to an hour or two before ending, suggests a full stroke, but their continued occurrence after 24 hours. Her diabetes and hypertension are cerebrovascular disease risk factors, and the bruit points to a vessel narrowing. Her signs and symptoms rule out a seizure disorder. Vertigo, visual complaints or drop episodes must not be present to rule out vertebrobasilar illness. She may have some aortic stenosis, but this should not be the only factor in interpreting her constellation of symptoms.
A 55-year-old guy visits his doctor because of his sporadic chest problems. It occasionally happens during effort and occasionally at rest, and it typically lasts 5 to 10 minutes. With some radiation to the throat, it is midsternal. He has a history of hypertension. He ceased smoking roughly at age 50. His only prescription is 10 mg of amlodipine daily. His type 2 diabetes and hypertension run in the family and his height is 70 inches, his weight is 210 pounds, and his blood pressure is 135/85. His pulse is also regular at 76. There are no cardiac rubs or murmurs audible, and his chest is clear. The overall evaluation is unfavorable. He has a normal electrocardiogram (ECG).
What logical step would result in the best chance of a diagnosis?
Finding out if this man has coronary artery disease is the main goal (CAD). Although his history of smoking, high blood pressure, and potentially diabetes puts him at a heightened risk for the condition, a lipid profile may still show him to be at risk. The latter will be revealed by the hemoglobin A1c, but not by CAD. To rule out an upper gastrointestinal cause of his symptoms, including gastroesophageal reflux disease or esophageal spasm, an EGD may be helpful. Identifying the existence of coronary disease is crucial. An isotope stress test is preferred over urgent angiography since the patient is stable and pain-free.