Section 1.1. Part 1

A group of parents approach you because they are concerned some student-athletes may be using human growth hormone in an attempt to increase muscle mass. They inquire how to test for this agent. Of the following, what would be your best response?

• A) Currently, there is no definitive test for exogenously administered recombinant HGH and surrogate markers must be utilized.

• B) While there may be some lean mass accretion, there are no data to confirm an actual ergogenic benefit, so the parents should not be concerned.

• C) Currently, there is no definitive test for exogenously administered recombinant HGH; monitoring for a SE profile is the best way to detect its use.

• D) Set up a program and threshold levels and begin measuring serum levels of HGH.

Answer explanation

Explanation:

The correct answer is (A).

 

While isomeric measurement testing is still in developmental stages and may become viable, currently, unless the serum is analyzed within 24 hours of exogenous administration, much speculation and uncertainty exists with regard to identifying illicit use of HGH, thus, surrogate markers such as insulin-like growth factor-1 are used.

Choice (B) is incorrect. While current evidence suggests little, if any, ergogenic effect, and many harmful effects, illicit drug use for performance-enhancing purposes should be discouraged.

Choice (C) is incorrect. Many SE are associated with other drugs as well (eg, fluid retention) and are long term (eg, acromegaly) and so may not be readily apparent.

Choice (D) is incorrect. Measuring serum levels for exogenously administered HGH has not been adequately defined.

46% of users answered correctly.

JD is a 48-year-old male with a past medical history of obesity, hypertension and diabetes. JD has a high LDL- C (188 mg/dL) and a low HDL-C (34 mg/dL) but no previous diagnosis of coronary artery disease. JD is prescribed lisinopril, hctz, aspirin and glipizide. JD's basic metabolic panel and complete blood count are within normal limits. Family history is significant for father having heart attack at age 60. Social history is negative. JD's blood pressure readings for the past month have averaged 151/89.

• A) Less than 100 mg/dL

• B) Less than 130 mg/dL

• C) Less than 160 mg/dL

• D) greater than 60 mg/dL

Answer explanation

Explanation:

The correct answer is (A).

 

For high-risk patients, the National Cholesterol Education Program recommends that LDL-C be lowered to less than 100 mg/dL or by at least 30-40%, but considers a value less than 70 mg/dL an optional goal for patients at very high risk. High risk patients are defined as having CHD or CHD risk equivalents (e.g. diabetes).

Answer (B) is incorrect. An LDL-C less than 130 mg/dL is the goal for patients at moderately high risk (patients with greater than or equal to two risk factors for CHD).

Answer (C) is incorrect. An LDL-C less than 160 mg/dL is the goal for patients at moderately low risk (patients with one or less risk factors for CHD).

Answer (D) is incorrect. Greater than 60 mg/dL refers to HDL-C. A patient with an HDL-C greater than or equal to 60 mg/dL has a negative risk factor for CHD. An HDL-C goal is greater than 45 mg/dL (the higher the better).

73% of users answered correctly.

A nurse is instructing her students about proper administration of antineoplastic agents. They are monitoring a patient receiving paclitaxel. What laboratory value must be monitored and evaluated before administration of paclitaxel?

• A) Glucose

• B) Sodium

• C) Amylase

• D) Neutrophils

Answer explanation

Explanation:

The correct answer is (D).

 

Myelosuppression is a dose-limiting toxicity of several antineoplastics including paclitaxel. Paclitaxel should not be administered if baseline neutrophil count is less than 1500 cells/mm3.

Answers (A), (B) and (C) are incorrect. Paclitaxel does not require monitoring of glucose, sodium or amylase.

74% of users answered correctly.

A patient with anuric acute tubular necrosis has a serum potassium concentration of 6.6 mEq/L with associated electrocardiogram changes of peaked T waves. Which intervention should be initiated first?

• A) Regular insulin 12 U and 25 g of dextrose IV push over two to five minutes

• B) Sodium bicarbonate 50 mEq IV push over two to five minutes

• C) Calcium chloride 1 g IV push over two to five minutes

• D) Sodium polystyrene sulfonate 15 g po

• E) Furosemide 80 mg IV push over two to five minutes

Answer explanation

Explanation:

The correct answer is (C).

 

This patient has signs of cardiotoxicity secondary to hyperkalemia. The most important first step is to antagonize the effect of potassium on the myocardial cells. One gram of calcium (either chloride or gluconate) should be given immediately if any EKG abnormalities are noted.

Answer (A) is incorrect. Insulin stimulates the cellular uptake of potassium, decreasing the extracellular concentration. This is an appropriate step to manage hyperkalemia, though not the first step to take with this patient.

Answer (B) is incorrect. Administering sodium bicarbonate causes the efflux of H+ from within in the cell in exchange for K+. While this might be an appropriate strategy to manage hyperkalemia (especially if the patient had a metabolic acidosis), it is not the first step to take with this patient.

Answer (D) is incorrect. Sodium polystyrene sulfonate is an appropriate adjunctive agent to promote elimination of potassium from the body in the feces. It acts to exchange sodium for potassium ions in the gastrointestinal tract. It does not work immediately, and would not be the first step to take with this patient.

Answer (E) is incorrect. Furosemide, a loop-type diuretic, is an important agent in managing hyperkalemia in patients that are able to urinate. Loop-type diuretics promote kaliuresis and diuresis to enhance potassium elimination from the body. While this is an excellent tool in the management of hyperkalemia, it is not the first step to take with this patient.

47% of users answered correctly.

Which of the following is a gram negative bacterial pathogen that is a common cause of lower respiratory tract infections?

• A) Haemophilus influenzae

• B) Influenza

• C) Parainfluenza

• D) Staphylococcus aureus

Answer explanation

Explanation:

The Correct Answer is: A

 

Haemophilus influenza (A) is a gram-negative coccobacilli that is a common bacterial cause of lower respiratory tract infections.

Influenza (B) is a viral pathogen that is a common cause of lower respiratory tract infections. It is important to be able to recognize and differentiate the difference between Haemophilus influenzae (H. flu) and influenza. Both are causes of lower respiratory tract infections; however, one is a bacteria and the other is a virus.

Parainfluenza (C) is a viral pathogen that is a common cause of lower respiratory tract infections. It is important to be able to recognize and differentiate the difference between Haemophilus influenzae (H. flu) and parainfluenza. Both are causes of lower respiratory tract infections; however, one is a bacteria and the other is a virus. Staphylococcus aureus (D) is a common cause of lower respiratory tract infections; however, it is a gram positive organism.

77% of users answered correctly.

JR is a long-distance cyclist that recently suffered a transient ischemic attack (TIA). He reported to the emergency department (ED) where he related no prescription drug use. His vitals in the ED were: BP 164/90 mm Hg, RR 20 breaths/min, HR 52 beats/min and regular, temperature 99°F. His BUN was 18 mg/dL and his Scr was 1.1 mg/dL. Of note, his hemoglobin was 19 g/dL and his hematocrit was 57.2%. He was assessed as being well hydrated but not fluid overloaded. He was no longer suffering from any neurologic deficit. He did not lose consciousness. A urine test using isoelectric focusing would likely be positive for which exogenously administered substance?

• A) Testosterone

• B) Recombinant human growth

• C) Recombinant erythropoietin

• D) Recombinant human chorionic gonadotropin

Answer explanation

Explanation:

The correct answer is (C).

 

Stimulating erythropoiesis increases RBC mass, which if left unabated, can increase to the point of worsened HTN, increased fluid volume, and thromboembolic events including stroke and TIA. Isoelectric focusing takes advantage of the extra sugar molecules on the recombinant product and this glycosylation allows for separation of exogenous and endogenous erythropoietin in a pH-gradient electrical field, thus, differing isoform patterns.

Choice (A) is partially correct. Testosterone can stimulate endogenous erythropoiesis, but has not been associated with thromboembolic events and stroke. Advanced technological testing for testosterone involves carbon isotope ratio testing or isotope ratio mass spectrometry.

Choice (B) is incorrect. Because recombinant HGH does not contain glycosylation process, isoelectric focusing method developed for recombinant erythropoietin cannot be directly applied to HGH. No definitive test exists currently to detect HGH. Additionally, it has not been associated with embolic events.

Choice (D) is incorrect. Isoelectric focusing is not the method used to test for human chorionic gonadotropin nor is it associated with stroke or TIA.

44% of users answered correctly.

According to national guidelines, what is the recommended age to begin screening for colorectal cancer in a person with average risk?

• A) No later than 21 years old

• B) 40 years old

• C) 45 years old

• D) 50 years old

Answer explanation

Explanation:

The Correct Answer is: D

 

The recommended age to begin screening for colorectal cancer in a person with average risk is 50 years old

(D). The frequency of screening tests depends on the method of screening.

 

Average risk women should receive Pap tests beginning 3 years after first vaginal intercourse, but no later than 21 years old (A). Average risk women should receive annual mammograms starting at age 40 (B). High- risk men, such as African Americans, should be offered prostate cancer screening at age 45 (C), per the American Cancer Society, with careful consultation about the risks and benefits of screening. Of note, other organizations such as the National Comprehensive Cancer Network recommend a baseline evaluation and consultation at age 40.

50% of users answered correctly.

Which patient group should get drug-susceptibility testing?

• A) Latent tuberculosis patients over age 40

• B) All active tuberculosis disease patients

• C) Active tuberculosis patients over age 40

• D) Foreign-born cases of active tuberculosis

Answer explanation

Explanation:

The correct answer is (B).

 

Drug-susceptibility testing should be initially done in all patients with active disease (B), to determine proper drug therapy and to control spread of drug-resistant strains.

Latent TB patients (A) do not need drug-susceptibility testing regardless of age. All active TB patients should receive susceptibility regardless of age (C). A patient being born in a foreign country does not typically affect decisions to do drug-susceptibility testing (D).

64% of users answered correctly.

During interdisciplinary rounds, the medical resident states that a patient on the transplant service has a low WBC count. The patient received a combined kidney-pancreas transplant for juvenile-onset diabetes mellitus 2 months ago and presented 2 days ago with hyperglycemia and elevated amylase and lipase. Acute cellular rejection of the pancreas transplant was confirmed on a subsequent biopsy. Her rejection episode is being treated with rabbit antithymocyte globulin. Her home immunosuppressive regimen consists of tacrolimus, mycophenolate mofetil, and prednisone. She is receiving antiviral prophylaxis with valganciclovir, antibacterial prophylaxis with trimethoprim-sulfamethoxazole and antifungal prophylaxis with nystatin.

• A) Suggest the physician to hold her prednisone until her WBC count normalizes.

• B) Suggest the physician to hold her mycophenolate mofetil until her WBC count normalizes.

• C) Suggest the physician to continue her current therapy, but to closely monitor her WBC count.

• D) Suggest the physician to hold her valganciclovir until her WBC count normalizes.

Answer explanation

Explanation:

The correct answer is (C).

 

This patient's leukopenia is likely caused by rabbit antithymocyte globulin infusion. WBC count along with the rest of hematology labs should be monitored closely. If there is a significant decrease in her WBC or platelet counts, a reduction of or withholding the dose of rabbit antithymocyte globulin may be warranted.

Choice (A) is incorrect. Prednisone usually causes leukocytosis and not leukopenia.

 

Choice (B) is incorrect. While mycophenolate mofetil can cause leukopenia, the likely agent inducing this patient's leukopenia is rabbit antithymocyte globulin. It is important to review the patient's medication administration record in this case to see if her blood sample was drawn during the infusion of rabbit antithymocyte globulin, as this will produce a significant leukopenia. However, even if the blood drawn

occurred after the infusion, the leukopenia is likely due to this agent, and the antiproliferative agent need not be held. This is especially true in light of her current presentation with acute cellular rejection.

Choice (D) is incorrect. While valganciclovir can cause leukopenia, the likely agent inducing this patient's leukopenia is rabbit antithymocyte globulin. During an episode of rejection, patients are treated with immunosuppressive intensification, and therefore are at increased risk for reactivation of latent viral infections. Therefore, care must be taken to not inaccurately hold a patient's antiviral prophylaxis, but thoroughly investigate the cause of leukopenia and act on the most likely cause.

33% of users answered correctly.

A 49-year-old woman with previous peptic ulcer disease was admitted with persistent vomiting. She looked dehydrated, with dry mucus membranes and skin tenting. Her blood results were Na 141 mEq/L, K 2.6 mEq/L, Cl 87 mEq/L, pH 7.51, Pa CO 2 50 mm Hg, and HCO 3 40 mEq/L. What is the primary acid-base disorder?

• A) Increased anion gap metabolic acidosis

• B) Normal anion gap metabolic acidosis

• C) Metabolic alkalosis

• D) Respiratory alkalosis

Answer explanation

Explanation:

The correct answer is (C).

 

Given the patient's presentation of persistent vomiting, we would expect to see a primary metabolic disorder

(C) due to loss of hydrogen ions from the upper GI tract.

 

Looking at the HCO 3 , we see it is markedly elevated, indicating a metabolic alkalosis (A and B). There is no information given to suspect a respiratory disorder (D).

50% of users answered correctly.