Mixed Deck — All SPEX Topics Flashcards

Which medication used for acne treatment is absolutely contraindicated in pregnancy due to teratogenicity?

Answer: Oral isotretinoin

Oral isotretinoin is a Category X teratogen causing severe birth defects and requires enrollment in the iPLEDGE program for all patients.

A pharmacy technician accepts a faxed prescription for a Schedule II controlled substance. What is the pharmacist's appropriate response?

Answer: Inform the technician that Schedule II drugs require an original written or electronic prescription, with limited emergency exceptions

Federal law requires Schedule II controlled substances to be dispensed only with an original written or valid electronic prescription; faxes serve only as a record with limited emergency exceptions.

A 66-year-old man presents with fluctuating cognition, vivid visual hallucinations of animals, and parkinsonism. He was given haloperidol by an emergency physician for agitation and developed profound rigidity and decreased consciousness within 24 hours. Which mechanism BEST explains his severe neuroleptic sensitivity reaction?

Answer: Blockade of D2 receptors in a nigrostriatal system already depleted of dopaminergic neurons

This is Dementia with Lewy Bodies (DLB). Patients with DLB have profound presynaptic dopaminergic deficiency in the striatum due to alpha-synuclein pathology. D2 receptor blockade by typical antipsychotics (like haloperidol) in an already critically dopamine-depleted system causes catastrophic worsening — severe parkinsonism, reduced consciousness, autonomic instability, and potentially fatal neuroleptic sensitivity in up to 50% of DLB patients. Atypical antipsychotics (quetiapine, clozapine) with low D2 affinity are used cautiously if necessary.

A 58-year-old man with type 2 diabetes and stage 3b CKD (eGFR 38 mL/min/1.73m²) presents with HbA1c of 8.9%. He is currently on metformin 1000 mg BID and glipizide 10 mg BID. Which modification to his diabetes regimen is most appropriate?

Answer: Discontinue metformin and initiate a GLP-1 receptor agonist such as semaglutide

Metformin is contraindicated when eGFR falls below 30 and requires dose reduction/caution at eGFR <45. SGLT-2 inhibitors like empagliflozin lose glycemic efficacy at eGFR <45 (though empagliflozin retains cardiorenal benefit at lower eGFRs, it's not the primary fix here). GLP-1 agonists like semaglutide are safe in CKD stage 3b and provide cardiovascular protection plus improved glycemic control — making them the most appropriate addition/switch. Glyburide is the worst sulfonylurea choice in CKD due to accumulation of active metabolites causing prolonged hypoglycemia.

A 65-year-old man has a pearly, telangiectatic papule on his nose that has slowly enlarged over 2 years. Biopsy shows palisading nuclei at the periphery of tumor islands. What is the diagnosis?

Answer: Basal cell carcinoma

Basal cell carcinoma characteristically shows palisading of nuclei at the periphery of tumor nests on histology, with a pearly, telangiectatic clinical appearance.

In evaluating a new occupational health screening program, an investigator notes that employees found to have early-stage disease through screening appear to survive longer than historical controls diagnosed after symptom onset — even though no effective treatment exists for the condition. This observation MOST likely reflects which bias?

Answer: Lead-time bias

Lead-time bias occurs when screening detects disease earlier in its natural history, advancing the time of diagnosis without altering the biological course or time of death. Survival appears longer because the clock starts earlier, not because the patient lives longer. Length-biased sampling (a related but distinct concept) refers to screening preferentially detecting slower-progressing, less aggressive disease — but the key signal here (no effective treatment yet longer apparent survival) most directly implicates lead-time bias.

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?

Answer: Stop all life support per the wife's wishes and proceed with the organ donation

In cases of brain death, the patient is legally and medically deceased. The driver's license indicating organ donation serves as a legally binding advanced directive for organ donation, reflecting the patient's autonomous wishes. The wife, as the legal next of kin, has the authority to make decisions regarding the cessation of life support for a deceased individual, especially when aligned with the patient's expressed wishes. The family's opposition, while emotionally understandable, does not override these legal and medical determinations.

A patient asks their physician to provide a fraudulent sick note to avoid work. What is the appropriate physician response?

Answer: Refuse, as providing false documentation violates medical ethics

Providing fraudulent documentation is a breach of medical ethics and professional integrity, and constitutes fraud.

A 29-year-old G2P1 at 22 weeks gestation undergoes amniocentesis for elevated AFP on quad screen. The amniotic fluid AFP is markedly elevated and acetylcholinesterase is present. Fetal ultrasound reveals a normal-appearing fetus with no visible neural tube defect. What is the most likely explanation?

Answer: Fetal sacrococcygeal teratoma

The combination of elevated amniotic fluid AFP AND positive acetylcholinesterase (AChE) confirms fetal origin rather than contamination. AChE is present in fetal neural tissue and exposed skin/gut. When the neural tube appears intact on ultrasound, other open fetal defects must be considered — sacrococcygeal teratoma is a classic cause of elevated AFP with positive AChE and no visible NTD. Blood contamination would not produce AChE. Placental mesenchymal dysplasia can elevate AFP but does not produce AChE. Confined placental mosaicism does not elevate AChE.

A 28-year-old woman presents with episodic severe unilateral headache with allodynia, ptosis, and miosis ipsilateral to the pain. Attacks last 15–180 minutes and recur up to 8 times daily in clusters. Unlike migraine, the attacks are associated with prominent ipsilateral autonomic features and extreme agitation. She reports that indomethacin provides no benefit, but high-flow 100% oxygen aborts attacks within 15 minutes. Which condition best fits, and what is the first-line preventive therapy?

Answer: Cluster headache; verapamil

Cluster headache is distinguished by attacks lasting 15–180 minutes (up to 8/day), severe unilateral periorbital pain, ipsilateral cranial autonomic features (ptosis, miosis, lacrimation, rhinorrhea), and characteristic patient agitation/restlessness. High-flow oxygen (100% at 12–15 L/min) is first-line abortive therapy. Verapamil is the gold-standard preventive agent. Paroxysmal hemicrania is exquisitely indomethacin-responsive — its absence here rules it out. SUNCT features shorter, more frequent attacks (seconds duration) and is treated with lamotrigine.

A patient taking phenelzine for depression presents to the ER after self-administering dextromethorphan (DXM) from an OTC cough syrup. Which syndrome is the primary concern and what is its mechanism?

Answer: Serotonin syndrome via excess serotonergic activity from MAO inhibition plus DXM's serotonin reuptake inhibition

DXM is a sigma-1 receptor agonist and a weak serotonin reuptake inhibitor (SERT inhibitor). When combined with an irreversible MAO inhibitor like phenelzine, which prevents serotonin degradation, the two mechanisms converge to cause serotonin syndrome: hyperthermia, clonus, hyperreflexia, diaphoresis, and agitation. This combination is absolutely contraindicated. DXM does have weak mu-opioid activity, but this is not the dominant clinical concern with MAOI co-administration.

In communicable disease control, 'herd immunity threshold' is calculated as 1 − (1/R₀). For measles with an R₀ of 15, what percentage of the population must be immune?

Answer: 93%

1 − (1/15) = 1 − 0.067 ≈ 0.933, meaning approximately 93% of the population must be immune.

During a laparoscopic cholecystectomy, intraoperative cholangiography demonstrates a Type E4 (Strasberg) bile duct injury with complete transection of the common hepatic duct at the hepatic confluence. The patient is hemodynamically stable. What is the most appropriate immediate next step?

Answer: Place closed-suction drains, close, and arrange urgent transfer to a hepatobiliary center

A Strasberg E4 injury (injury at or above the hepatic confluence) is a complex, high-level biliary injury that carries significant morbidity. When recognized intraoperatively by a non-hepatobiliary surgeon, the safest strategy is damage control: place closed-suction drains to control bile leakage, close, and urgently transfer to a hepatobiliary center with expertise in complex biliary reconstruction. Attempting primary repair or Roux-en-Y reconstruction without hepatobiliary expertise leads to higher rates of stricture, cholangitis, and secondary biliary cirrhosis. ERCP/stenting cannot bridge a complete transection at the confluence. Outcomes are significantly better when complex reconstruction is performed electively by experienced hepatobiliary surgeons.

A client with borderline personality disorder frequently calls the psychologist after hours in crisis. The most appropriate initial response is to:

Answer: Collaboratively develop a crisis plan within sessions to guide after-hours contact

Establishing a structured, collaborative crisis plan within therapy sessions is consistent with DBT and other evidence-based approaches, setting limits while ensuring safety.

A 45-year-old woman presents with a 3-year history of recurrent episodes of painful, erythematous nodules on the anterior shins that resolve with bruise-like discoloration without ulceration. She has a chronic dry cough and elevated serum ACE levels. A punch biopsy of a fresh nodule reveals septal panniculitis without vasculitis. Which of the following best characterizes the underlying histologic finding and its significance?

Answer: Septal panniculitis with Miescher radial granulomas — pathognomonic for the associated systemic disease

This presentation is classic for erythema nodosum (EN) associated with sarcoidosis (elevated ACE, chronic cough). The histologic hallmark of EN is septal panniculitis (inflammation primarily in the fibrous septa between fat lobules) without vasculitis. Miescher's radial granulomas — small, nodular aggregates of histiocytes arranged radially around a central stellate cleft — are considered pathognomonic for erythema nodosum and help distinguish it from other forms of panniculitis. Their presence on biopsy, combined with the elevated ACE and pulmonary symptoms, strongly supports sarcoidosis-associated EN (Löfgren syndrome when accompanied by bilateral hilar adenopathy and arthritis). Treatment is primarily NSAIDs or potassium iodide; addressing the underlying sarcoidosis is key.

In SPEX practice, what is the best approach to quality improvement in emergency medicine?

Answer: Use data-driven methods with measurable outcomes

Data-driven quality improvement with measurable outcomes ensures that changes actually produce the intended improvements and can be verified.

What is the preferred conduit for coronary artery bypass grafting (CABG) to the left anterior descending artery, due to its superior long-term patency?

Answer: Left internal mammary artery

The left internal mammary artery (LIMA) to LAD bypass demonstrates 90-95% patency at 10 years, far superior to saphenous vein grafts, making it the gold standard conduit.

A child weighing 22 kg needs amoxicillin for otitis media. The standard pediatric dose is 90 mg/kg/day in 2 divided doses. What is the correct dose per administration?

Answer: 990 mg

90 mg/kg/day × 22 kg = 1980 mg/day ÷ 2 doses = 990 mg per dose.

Which of the following is the preferred treatment for onychomycosis caused by Trichophyton rubrum?

Answer: Oral terbinafine for 12 weeks

Oral terbinafine for 12 weeks is the first-line treatment for toenail onychomycosis due to its superior mycological cure rates against dermatophytes.

A 28-year-old male veteran presents with nightmares, hypervigilance, and emotional numbing 14 months after a combat deployment. He has failed two adequate SSRI trials. He now reports passive suicidal ideation without plan or intent. Which pharmacologic agent has the STRONGEST evidence as an augmentation strategy specifically targeting PTSD nightmares?

Answer: Prazosin

Prazosin, an alpha-1 adrenergic antagonist, has the most robust randomized controlled trial evidence specifically for PTSD-related nightmares and sleep disturbance. It reduces noradrenergic activity during REM sleep. Quetiapine has limited evidence as augmentation. Topiramate has some data but is not FDA-indicated and evidence is mixed. Nabilone (a cannabinoid) has preliminary data in treatment-resistant PTSD nightmares but far less evidence than prazosin.