TG, a 72-year-old male, is hospitalized with a pulmonary embolism. He is receiving unfractionated heparin initiated at a rate of 1,000 units/hour. The control value at this hospital is 22-38 seconds. Select the correct test and an appropriate treatment level for this patient:

aPTT, 44 secs

All of the following medications require monitoring of the absolute neutrophil count EXCEPT:

Isocarboxazid

History of Present Illness: SJ is a 41-year-old African American female who is at a 1-month follow-up visit with her PCP after repeat lab testing.

PMH: Depression, anemia, hypertension, tobacco abuse (quit 4 weeks ago), seizure disorder

Allergies: Sulfonamides (hives)

Medications:
Ferrous sulfate 325 mg PO daily
Tri-Sprintec 1 tablet PO daily
Zyban 150 mg PO twice daily
Hydrochlorothiazide 25 mg PO daily
Phenytoin 200 mg PO BID
Aspirin 81 mg PO daily
Celebrex 200 mg PO daily
Cholecalciferol 5,000 units PO daily
Tums E-X 750 1 tablet PO TID
Tessalon Perles 100 mg PO TID PRN
Nicotine gum 4 mg Q1-2H PRN

Which of the following is true regarding the monitoring of SJ's antiepileptic treatment?

The reported phenytoin level is within goal range for safety and efficacy

A 55-year-old female presented to the hospital with weakness and dyspnea. She was diagnosed with pneumonia and severe hemolytic anemia. The Coombs test was positive. The patient received a blood transfusion and was treated with prednisone and clarithromycin for pneumonia.
Home Medications: aspirin, irbesartan, simvastatin, sertraline, rifampin and atenolol.
Medical Conditions: hypertension, dyslipidemia, depression, PPD TB test positive (annual work requirement).
Which medication is most likely to have caused hemolytic anemia?

Rifampin

SS is an 80-year-old Asian female being treated for S. aureus bacteremia. She is receiving daptomycin at a dose of 6 mg/kg daily at 0800 daily. Of the following lab values, which is most essential to monitor in this patient?

Creatinine phosphokinase (CPK)

Which of the following medications is incorrectly matched with its usual therapeutic range?

Phenytoin 4-12 mcg/mL

A pregnant patient is started on methyldopa for blood pressure control. Which laboratory abnormality can occur due to this drug treatment?

Positive ANA

A 44-year-old Asian female with a history of non-Hodgkin's lymphoma received several cycles of chemotherapy. The patient was in remission for 11 years until recently when she experienced a relapse. She was admitted for inpatient chemotherapy. The patient received the CODOX-M/VAC regimen (cyclophosphamide, doxorubicin, methotrexate, etoposide, and cytarabine). During the hospitalization, she developed Streptococcus viridans sepsis and is being treated with levofloxacin 500 mg IV daily. The patient is found to have decreased serum folate levels. The clinical pharmacist participating in medical rounds is asked if any of the patient's medications could have contributed to the low folate levels. Select the best response:

The most likely drug contributing to the decrease in folate is methotrexate

The CRP and ESR are non-specific tests used to identify and evaluate:

Autoimmune diseases

Urine culture results (9/18): E. coli > 100,000 CFU/mLSusceptible to: nitrofurantoin, ceftriaxone, ciprofloxacin, levofloxacin, gentamicin, sulfamethoxazole/trimethoprimResistant to: cefazolin, amoxicillin, ampicillin/sulbactam

Question:
Which antibiotic is best prescribed for BB at discharge?

Levofloxacin

Which of the following drugs can contribute to low serum sodium levels? (Select ALL that apply.)

Torsemide, escitalopram, carbamazepine and oxcarbazepine can all cause hyponatremia.

What is the correct interpretation of LM's coagulation status?

INR = 0.8

Her INR is within reference range

(A normal INR for a patient who is not taking warfarin is < 1.2. A normal range is often not provided for the INR, because the INR target depends on the indication and whether or not the patient is taking warfarin.)

LM presents to her PCP in the clinic. She is known to be sporadically compliant with her medications, but states she has been taking them for the past 3 months since her prescription insurance became active.

Past Medical History: Hypothyroidism, dyslipidemia, hypertension, asthma, peri-menopausal

Medications: Zocor 40 mg daily, levothyroxine 125 mcg daily, Norvasc 10 mg daily, Flovent HFA 88 mcg (2 puffs) BID, multivitamin
Physical/Vitals:Age: 63 Height: 5'3"Weight: 132 pounds BP: 133/83 mmHg

AST (IU/L) = 142 (10 – 40)

ALT (IU/L) = 130 (10 – 40)

T Bili (mg/dL) = 0.8 (0.1 – 1.2)

Which of LM's lab abnormalities is a well-known adverse effect of one of her medications?

Increased LFTs

Medications: Zocor 40 mg daily, levothyroxine 125 mcg daily, Norvasc 10 mg daily, Flovent HFA 88 mcg (2 puffs) BID, multivitamin

TSH (mIU/L) = 0.15 (0.3 – 3)

FT4 (ng/dL) = 4.2 (0.9 – 2.3)

Which of the following is the correct assessment of LM's thyroid function?

She is currently hyperthyroid. Decrease levothyroxine dose.

(Low TSH and increased FT4 indicate hyperthyroidism.)

Which of the following medications are known to contribute to drug-induced hemolysis and would require discontinuation in a patient who developed hemolysis after use of the drug? (Select ALL that apply.)

Methyldopa, quinidine, rasburicase

(The Coombs test is used in the diagnosis of hemolytic anemia. If the Coombs test is positive and a drug-induced cause is suspected, discontinue the offending drug. Drugs with the highest risk of causing hemolytic anemia are also discussed in the Anemia chapter.)

TG, a 72-year-old male, is hospitalized with a pulmonary embolism. He is receiving unfractionated heparin initiated at a rate of 1,000 units/hour. The control value at this hospital is 22-38 seconds. Select the correct monitoring parameters for patients receiving heparin. (Select ALL that apply.)

aPTT, PLTs, Hgb/Hct and signs of bleeding

The pharmacist on rounds has a patient with an acid-base imbalance. The pharmacist has calculated the patient's anion gap. Why is this calculation performed?

To identify if the patient has an anion gap or non-anion gap metabolic acidosis

Which of the following drugs can cause folic acid deficiency? (Select ALL that apply.)

Bactrim, methotrexate

Which of the following drugs should not be dispensed to a patient with known G6PD deficiency? (Select ALL that apply.)

Methylene blue, dapsone, pegloticase

New Orders:Nothing by mouth
Cubicin 6 mg/kg IV dailyDiscontinue IV fluids
Start TPN: 1,800 mL D20W, 750 mL FreAmine 8.5%, 250 mL Intralipid 20%, 50 mL of electrolytes/minerals

Which laboratory value is most essential to monitor given the new orders listed for TP?

CPK

Plt (cells/mm³) = 202 (150 – 450 x 10³)
RBC (cells/mm³) = 3.8 (4.1 – 4.9 x 10⁶)PMNs (%) = 73 (45 – 73)
Bands (%) = 12 (3 – 5)
Eosinophils (%) = 3 (0 – 5)
Basophils (%) = 0 (0 – 1)
Lymphocytes (%) = 10 (20 – 40)
Monocytes (%) = 2 (2 – 8)

TP's laboratory findings show evidence of:

A left shift

The time that is generally preferred to take drug levels (for most drugs) is called:

Steady state

(Steady state occurs when the amount of drug entering the body is equal to the amount leaving the body (through metabolism, excretion).)

A patient has G6PD deficiency. What can occur as a result of this disease if the patient receives primaquine for malaria prophylaxis?

The patient will be at risk for excessive destruction of RBCs

Which diagnosis is most likely based on the lab results from August 6th?

RPR is reactive+

Syphilis

Which lab value obtained on August 6th suggests that BH is malnourished?

Albumin 2.9

Albumin

BH is a 34-year-old female with a history of asthma, type 2 diabetes and hypertension. She presents to her PCP on August 6th for a 3-month follow-up visit. She mentions that she has lost 11 pounds without dieting since her last visit in May.

Medications:Metformin XR 2,000 mg PO daily
Lantus SoloStar 20 units SC daily
Humalog 8 units SC before breakfast and dinner
Invokana 100 mg PO before breakfast
Hyzaar 100/25 mg PO daily
QVAR RediHaler 80 mcg 1 inhalation BID
Yasmin 28 1 tablet PO daily
Ventolin HFA 90 mcg 2 inhalations Q4H PRN
Sumatriptan nasal spray 10 mg in one nostril PRN (can repeat x 1 after 2 hours)

Which medication/s could be contributing to BH's electrolyte abnormality on May 7th? (Select ALL that apply.)

Insulin, ventolin

(same case from above)

What lab-related issues were present on Feb 3rd?

Dehydration and leukocytosis

LC, a 62-year-old male, is hospitalized with a pulmonary embolism. All of his labs were normal upon admission to the hospital and he was taking no medications before admission.
Current Medications: atorvastatin, furosemide, metoprolol, insulin sliding scale, lisinopril, unfractionated heparin drip and 0.45% NaCl at 50 mL/hr.

Platelets: 73 (150 - 420)

Based on the patient's labs, there is a concern for what new medical issue?

HIT

(Heparin-induced thrombocytopenia (HIT) is suspected when platelets drop > 50% from baseline. The scenario stated that the patient's lab values were normal at baseline. All other relevant lab values are within normal limits.)

(same case from above)

Which of the patient's lab values are most indicative of a decline in renal function?

BUN, creatinine, phosphate

WBC (cells/mm³) = 14.3 (4 – 11x10³)

Neut (%) = 88 (45 – 73)

Bands (%) = 7 (3 – 5)

CRP (mg/dL) = 53 (0 – 0.5)

Without knowing JS's medications or past medical history, what is most likely diagnosis based on his labs?

Bacterial infection

A patient presents with a butterfly-shaped rash on her face and achy joints. The physician is concerned for drug-induced lupus. The patient's chronic medications include potassium chloride, furosemide, metoprolol succinate, hydralazine/isosorbide dinitrate, candesartan and eplerenone. Which of the daily medications is most likely contributing to this presentation?

Hydralazine/isosorbide dinitrate

(Isosorbide dinitrate and hydralazine (BiDil) can cause drug-induced lupus due to the hydralazine component.)

A patient's albumin level is 2. Which of the following would need to have the level adjusted due to this albumin level? (Select ALL that apply.)

Calcium, phenytoin, valproate

CRP is a marker for which of the following?

Inflammation

A patient presents with confusion and rapid breathing. A lab report reveals a low serum bicarbonate level and metabolic acidosis. Which of the following medications would most likely cause this abnormality?

Topiramate

When the liver cells (hepatocytes) are acutely damaged these enzymes are released and will be elevated in the serum:

AST and ALT

A drug that is highly protein bound (95% or higher bound to albumin) will have a large change in free drug concentration when the protein level changes. If a patient was using warfarin and the albumin decreased from 2.5 g/dL to 1.5 g/dL what would be expected to happen to the warfarin and the INR result?

The free warfarin level would increase, which would cause the INR to increase

Calcium levels may decrease with chronic use of these drugs: (Select ALL that apply.)

Bumetanide, cinacalcet, alendronate

The pharmacy department received the following parenteral nutrition orders for a 79-year-old patient.
Nutrition Goal: 1,750 total calories per day from all sources

2-in-1 Parenteral Solution
Dextrose 312 grams
Amino acids 62 grams
Sodium chloride 32 mEq
Sodium acetate 12 mEq
Potassium 20 mEq
Magnesium sulfate 10 mEq
Phosphate 28 mmol
Calcium 24.5 mEq
Multivitamins 10 mL
Trace elements 1 mL
Famotidine 10 mg
Regular insulin 10 units
Sterile water qs ad 1,900 mL
30% Intralipid Infuse over 12 hours daily

If the pharmacist becomes concerned that the lipid infusion is causing complications related to hypertriglyceridemia, evaluation of which laboratory tests would be most appropriate?

Amylase and lipase

DL's antiarrhythmic treatment could be contributing to which laboratory abnormality?

TSH

A pharmacist wishes to take a drug level at steady state. The drug is started on Monday at 14:00 hours. It has a half-life of 8 hours and is dosed twice daily. Of the following options, which is the earliest reasonable time to order a steady state drug level?

Wednesday at 6:00

(It takes approximately 5 half-lives to reach steady-state.)

Which medication can cause B12 deficiency when used long-term?

Omeprazole

EK is beginning amiodarone therapy. She is easily stressed and worried about having "racing heart and dizziness" or what her physician said was an "arrhythmia". She uses furosemide and has had hypokalemia in the past. She has been told that her potassium and magnesium need to be within normal limits to keep her heart at a normal rhythm and that she should try to relax. The physician has decided that she wants to check magnesium and potassium and orders a Basic Metabolic Panel (BMP). Select the correct statement:

The physician should also order the magnesium level, this is not included in the BMP

(The BMP includes glucose, sodium, potassium, bicarbonate, chloride, blood urea nitrogen and creatinine.)

A 7-year-old child is receiving the low molecular weight heparin, enoxaparin. The clinical team in the pediatric unit is not sure if the medication is being dosed correctly due to the child's age and body weight. They will order a lab test to check for subtherapeutic, therapeutic or supratherapeutic dosing. Which test should be ordered?

Anti-Xa

The CBC includes each of the following lab values except:

BUN

LM is a 55-year-old female recently diagnosed with multiple myeloma with a history of anxiety, hypertension and rheumatoid arthritis. She has been treated with prednisone and methotrexate. The patient initially presented to her primary care physician with bilateral ankle edema and a 28-pound weight gain. She was found to be in acute kidney failure and was admitted for further evaluation. Abnormal laboratory findings included an elevated serum creatinine, BNP and white blood cell count. The elevated BNP will warrant assessment by the following team:

Cardiology

Select the name of the lab test used to distinguish between a microcytic and macrocytic anemia:

MCV

(The volume (and size) will be lower (low mean corpuscular volume) in a small cell (microcytic) anemia, and larger in a large cell (macrocytic) anemia.)

TY is being seen today in the emergency department. Which of the following is the most likely diagnosis based on his labs?
Labs:WBC (cells/mm³) = 14.3 (4 – 11 x 10³) Hgb (g/dL) = 15.5 (13.5 – 18 male)Hct (%) = 40 (38 – 46 male)Platelets (cells/mm³) = 386 (150 – 450 x 10³)Neutrophils (%) = 41 (45 – 73)
Lymphocytes (%) = 52 (20 – 40) Bands (%) = 3 (3 – 5)Eosinophils (%) = 1 (0 – 5)
Basophils (%) = 1 (0 – 1)
Monocytes (%) = 2 (2 – 8)

Viral infection

A patient with non-small cell lung cancer is receiving cisplatin as part of a chemotherapy treatment regimen. Select the lab test that should be ordered to monitor for leukopenia.

CBC

The BMP includes each of the following lab values except:

Phosphate