Free SPEX Practice Test

The Special Purpose Examination (commonly known as the SPEX exam) is a general test of medical knowledge. It is most often used to evaluate already-licensed professionals or individuals who are applying to be re-licensed after not practicing for a time.

There are two different content areas on the SPEX exam: Clinical Encounter Categories and Physician Tasks. The Clinical Encounter Categories include Well-care/Preventive Medicine; Acute, Circumscribed Problems; Ill-defined Presentations or Problems; Chronic or Progressive Illness; Emergency Conditions; Critical Care; and Behavioral/Emotional Problems. The Physician Tasks include Data Gathering; Diagnostic Assessment; Managing Therapy; and Applying Scientific Concepts.

There are four kinds of multiple-choice questions on the SPEX exam: single-item sets (five answer choices, only one best answer); multiple-item sets (several questions based on the same set of information); matching items (in which treatment options and conditions must be paired); and extended matching sets (a situation is presented and you have to choose the best diagnosis, though some wrong answers may be partially correct).

The SPEX exam is divided into eight blocks of 50 questions, each of which takes 52 minutes. The exam is administered by computer in a single day at the test site. The SPEX is a timed test with the test taker being aided by an on-screen prompt displaying a box indicating the amount of time remaining. Before the SPEX exam begins, you will be given a brief tutorial on the testing program procedures. Even those inexperienced in the use of computers should have little trouble navigating the SPEX program.

Practice Questions

1. A 24-year-old man presents with a persistent productive cough and fever of 101°. He states he has had a "cold" for about a week with cough and fever in the 100° to 101° range. He is otherwise healthy, on no medications, and denies smoking, illicit drug use, and homosexual activity. He has never had a "pneumonia shot." He is slightly short of breath with exertion and has mild left-sided pleuritic pain on deep inspiration. He has some crackles and percussion dullness over the left lower lobe. There is no leg swelling or calf tenderness. Oxygen saturation is 93%.

What is the most likely diagnosis?

a. Legionnaire disease
b. Streptococcus pneumoniae pneumonia
c. Pulmonary embolus
d. Mycoplasma pneumonia
e. Pneumocystis pneumonia

2. All of the following would be appropriate in the management of this case EXCEPT:

a. Chest x-ray
b. CBC with differential
c. Hospitalization for intravenous cephalosporin
d. Azithromycin 500 mg as a single dose on the first day followed by 250 mg daily
e. Doxycycline 100 mg orally twice daily

3. A 45-year-old female school teacher complains of pain and tenderness in both hands and wrists for the past 3 to 4 weeks. She also has some diffuse muscle tenderness and notes that she gets extremely fatigued while jogging, her major activity. No other joints are painful and she denies fever, back pain, and ocular, cardiopulmonary, or gastrointestinal symptoms. She has no family history of rheumatic disease. On examination there is warmth and tenderness over the wrist and metacarpal joints with some swelling and limited range of motion. Other joints appear intact and the rest of the exam is negative.

At this point, what is the most likely diagnosis?

a. Systemic lupus erythematosus (SLE)
b. Rheumatoid arthritis (RA)
c. Polymyalgia rheumatica (PR)
d. Fibromyalgia (FM)
e. Osteoarthritis (OA)

4. The patient is sent for blood tests and imaging studies. Which of the following would be most useful in establishing a diagnosis?

a. Joint aspiration and analysis
b. C-reactive protein (CRP)
c. Rheumatoid factor (RF)
d. Plain x-rays of the hands and wrists
e. Anti-cyclic citrullinated protein (anti-CCP)

5. A 50-year-old retired firefighter presents with weight loss, frequent palpitations, and a blood pressure of 170/70. He states his appetite has been good but he sweats a lot and his bowel movement frequency has increased but there has been no diarrhea. On examination he has a lid lag and brisk deep tendon reflexes. His thyroid is diffusely enlarged with an audible bruit but is nontender and no nodules are present. Blood testing reveals the presence of antithyroid antibodies. An ECG shows sinus tachycardia with occasional runs of atrial fibrillation.

Which of these lab results (TSH = thyroid-stimulating hormone and T4= free serum thyroxine) are most consistent with the clinical diagnosis (normal ranges: TSH 0.5 to 5 mcIU/mL and free T4 5 to 15 mcg/dL)?

a. TSH 0.1 mcIU/mL, free T4 20.5 mcg/dL
b. TSH 0.2 mcIU/mL, free T4 15 mcg/dL
c. TSH 7.5 mcIU/mL, free T4 14 mcg/dL
d. TSH 3 mcIU/mL, free T4 7.4 mcg/dL
e. TSH 14.5 mcIU/mL, free T4 2 mcg/dL

Answer Key

1. B. This man appears to have community-acquired pneumonia. Sometimes the pathogen may be suspected by the clinical presentation but there is considerable overlap. The most likely cause is Streptococcus pneumoniae, which still is the most common cause of a community-acquired bacterial pneumonia. The crackles, dullness, and pleuritic pain with slightly low oxygen saturation favor this diagnosis. A mycoplasma etiology cannot be ruled out without further diagnostic testing but this is frequently skipped unless the patient does not respond to empiric antibiotic therapy. Legionella pneumonia is most common in those older than 40 who smoke or are receiving chemotherapy or immunosuppressant drugs. Pneumocystis pneumonia is usually seen in HIV-positive patients or those on prolonged steroid therapy. Pulmonary embolus can sometimes mimic pneumonia but would be very unusual in this young man without predisposing conditions.

2. C. Decisions regarding the management of pneumonia patients are largely based on certain risk factors, such as age, presence of complicating conditions, and extent of disease. This patient is young and otherwise healthy and only mildly impaired physically. A chest x-ray and CBC are always indicated in pneumonia patients to further indicate the extent and severity of the disease and possibly discover additional risk factors. A macrolide antibiotic is usually the first choice for empiric treatment since it covers most of the common community-acquired pathogens. Doxycycline may also be used if the patient is allergic to or does not tolerate macrolides. Intravenous antibiotic therapy is usually not required for this type of patient unless he fails to respond to initial therapy or a complication develops.

3. B. This patient's age, sex, history, and physical findings of joint inflammation are typical of RA. Symmetric synovitis of the wrist and metacarpal joints with morning stiffness and limited range of motion is a common presentation. SLE cannot be ruled out at this point as it often presents with joint pain and swelling, although usually in younger women along with constitutional symptoms. Polymyalgia rheumatica tends to occur in older patients and chiefly presents with head and neck pain and sometimes tenderness over the temporal artery. Fibromyalgia does not show signs of acute inflammation but tenderness over numerous joint and soft tissue spots is present along with constitutional symptoms such as poor sleep, mental "fogginess," and prominent fatigue. Osteoarthritis is a degenerative disorder of joint cartilage, tends to occur in older people, is often asymmetric, and may affect distal joints of the hands or larger joints, such as knees and hips.

4. E. Joint aspiration, if possible, is most useful for distinguishing inflammatory (greater than 2,000 cells/mm3, mostly polys) from noninflammatory (less than 2,000 cells/mm3, mostly mononuclear) arthritis, septic joints (gram stain and culture), and crystal-induced arthritis (gout). CRP is an acute-phase reactant, usually elevated in inflammatory arthritis but not specific for a particular disease though useful for following the degree of inflammation and prognosis. RF is a family of antibodies, usually immunoglobulin M (IgM), that bind to IgG. It is elevated in about 80% of patients with RA but may also be elevated in other immune and inflammatory disorders and in healthy, usually older individuals. Perhaps the immune test most specific for RA is the anti-CCP test, which is positive in 60% to 70% of patients with RA and uncommon in those with other inflammatory disorders. It may even be positive before the onset of symptoms and may be useful for screening those at high risk for the disease. Plain radiographs are an important part of evaluation and progress of all arthritic disorders. While joint space narrowing, erosions, and subluxation of the MCP and PIP joints are common in RA, they may not be seen at the onset of the disease; however, the films are inexpensive, easily obtained, and very useful for following the course of the disease.

5. B. This patient most likely has Graves disease with the presence of thyroid antibodies, which causes predominantly T3 (triiodothyronine) thyrotoxicosis. The TSH will be suppressed, the T3 level increased (greater than 35% resin uptake), and the T4 high normal or borderline elevated. Answer A is more typical of a T4 thyrotoxicosis as seen in subacute thyroiditis. Answer C is most consistent with a TSH-secreting pituitary adenoma where the TSH and the T4 are both elevated. Answer D shows normal values while E is consistent with hypothyroidism.

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Last Updated: 09/22/2017

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