Lab Values & Drug Monitoring

Front 1

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

Back 1

BDemadexCLexaproDTrileptalETegretol

Front 2

Leslie McMan 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 mmHgLabs:Labs:Na (mEq/L) = 146 (135 – 145) K (mEq/L) = 4.1 (3.5 – 5) Cl (mEq/L) = 100 (95 – 103) HCO3 (mEq/L) = 25 (24 – 30) BUN (mg/dL) = 16 (7 – 20) SCr (mg/dL) = 0.9 (0.6 – 1.3) Glucose (mg/dL) = 112 (100 – 125) Ca (mg/dL) = 8.2 (8.5 – 10.5) Mg (mEq/L) = 2.1 (1.3 – 2.1) PO4 (mg/dL) = 3.2 (2.3 – 4.7) WBC (cells/mm^3) = 13.6 (4 – 11x10^3) Hgb (g/dL) = 10.8 (12 – 16 female)Hct (%) = 32.1 (36 – 46 female)Plt (cells/mm^3) = 345 (150 – 450x10^3)AST (IU/L) = 142 (10 – 40) ALT (IU/L) = 130 (10 – 40) GGT (units/L) = 32 (9 – 58) T Bili (mg/dL) = 0.8 (0.1 – 1.2)TSH (mIU/L) = 0.15 (0.3 – 3)FT4 (ng/dL) = 4.2 (0.9 – 2.3)Albumin (g/dL) = 2.8 (3.5 – 5) INR = 0.8Question: Calculate Ms. McMan's corrected calcium using the following formula: Ca(corrected) = Ca(serum) + [(4 - albumin) x 0.8]. (Answer must be numeric; no units or commas; round the final answer to the nearest TENTH.)

Back 2

9.2

Front 3

A patient presents with a butterfly-shaped rash on her face and achey joints. The patient's chronic medications include Klor-Con, Lasix, Toprol XL, BiDil, Atacand and Inspra. Which of the daily medication is most likely contributing to this presentation?

Back 3

BiDil

Front 4

Tom Gallon, a 72 year-old male, is hospitalized with a pulmonary embolism. He is receiving unfractionated heparin initiated at a rate of 1000 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.)

Back 4

-aPTT

-Platelets

-Hgb/Hct and signs of bleeding

Front 5

The BMP includes each of the following lab values except:

Back 5

phosphate

Front 6

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

Back 6

MCV

Front 7

A patient has G6PD-deficiency. What will occur if the patient receives primaquine for malaria prophylaxis?

Back 7

The patient will be at risk for serious internal bleeding.

Front 8

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

Back 8

-bumex

-Boniva

-Topamax

Front 9

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?

Back 9

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

Front 10

A young man with immune thrombocytopenia recently had transient intravascular hemolysis during treatment with IVIG. The hemolysis was mediated by anti-A antibody present in the treatment. What signs and symptoms could indicate hemolysis? (Select ALL that apply.)

Back 10

-Positive Direct Coombs test

-Hematuria

Front 11

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.)

Back 11

AnswerAWarfarinBCalciumCPhenytoin EValproate

Front 12

A lab report indicates an elevated CRP. Which of the following causes is most likely?

Back 12

Systemic lupus erythematosus

Front 13

Laura Melroy is a 55 year-old female with a history of anxiety, hypertension and rheumatoid arthritis. She has been treated with prednisone and methotrexate was recently diagnosed with multiple myeloma. 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 renal 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:

Back 13

cardiology

Front 14

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

Back 14

steady-state

Front 15

James Salib is being seen today in the Emergency Department. Physical/Vitals:Age: 47 Height: 5'5"Weight: 172 pounds Labs:Na (mEq/L) = 140 (135 – 145) K (mEq/L) = 5.2 (3.5 – 5) Cl (mEq/L) = 103 (95 – 103) HCO3 (mEq/L) = 30 (24 – 30) BUN (mg/dL) = 18 (7 – 20) SCr (mg/dL) = 1.2 (0.6 – 1.3) Glucose (mg/dL) = 142 (100 – 125) Ca (mg/dL) = 9.1 (8.5 – 10.5) Mg (mEq/L) = 2.1 (1.3 – 2.1) PO4 (mg/dL) = 3.2 (2.3 – 4.7) WBC (cells/mm^3) = 14.3 (4 – 11x10^3) Hgb (g/dL) = 15.5 (13.5 – 18 male)Hct (%) = 40 (38 – 46 male)Plt (cells/mm^3) = 386 (150 – 450x10^3)Neut (%) = 88 (45 – 73)Bands (%) = 7 (3 – 5)Eos (%) = 1 (0 – 5)AST (IU/L) = 39 (10 – 40) ALT (IU/L) = 36 (10 – 40) GGT (units/L) = 42 (9 – 58) CRP (mg/dL) = 53 (0 – 0.5)Albumin (g/dL) = 4.2 (3.5 – 5) INR = 0.8Amylase (units/L) = 152 (60 – 180)Question: Without knowing Mr. Salib's medications or past medical history, what is most likely diagnosis based on his labs?

Back 15

bacterial infection

Front 16

Everette Stanford, an 82 year-old male with COPD, has difficulty breathing. Everette finds little relief from daily use of the Advair Diskus and Spiriva. Which condition is most likely in this patient?

Back 16

respiratory acidosis

Front 17

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

Back 17

Phenytoin: 4 – 12 mcg/mL

Front 18

A patient complains of abdominal pain, nausea, itching, dark urine and jaundice. The physician suspects that the bile ducts may be obstructed (closed). Which of the following tests would help confirm the suspicion?

Back 18

Alkaline phosphatase

Front 19

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?

Back 19

Wednesday at 06:00

Front 20

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.)

Back 20

AMethyldopaBQuinidineCQuinine

Front 21

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 the medical rounds is asked if any of the patient's medications could have contributed to the low folate levels. Select the best response:

Back 21

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

Front 22

A seven year old child is receiving 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 supra therapeutic dosing. Which test should be ordered?

Back 22

anti-Xa

Front 23

Which lab test is used to detect early or mild B12 deficiency?

Back 23

Methylmalonate (MMA)

Front 24

Sunni Sing is an 80 year-old Asian female being treated for S. aureus bacteremia. She is receiving Cubicin 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?

Back 24

Creatinine phosphokinase

Front 25

Leslie McMan 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 mmHgLabs:Labs:Na (mEq/L) = 146 (135 – 145) K (mEq/L) = 4.1 (3.5 – 5) Cl (mEq/L) = 100 (95 – 103) HCO3 (mEq/L) = 25 (24 – 30) BUN (mg/dL) = 16 (7 – 20) SCr (mg/dL) = 0.9 (0.6 – 1.3) Glucose (mg/dL) = 112 (100 – 125) Ca (mg/dL) = 8.2 (8.5 – 10.5) Mg (mEq/L) = 2.1 (1.3 – 2.1) PO4 (mg/dL) = 3.2 (2.3 – 4.7) WBC (cells/mm^3) = 13.6 (4 – 11x10^3) Hgb (g/dL) = 10.8 (12 – 16 female)Hct (%) = 32.1 (36 – 46 female)Plt (cells/mm^3) = 345 (150 – 450x10^3)AST (IU/L) = 142 (10 – 40) ALT (IU/L) = 130 (10 – 40) GGT (units/L) = 32 (9 – 58) T Bili (mg/dL) = 0.8 (0.1 – 1.2)TSH (mIU/L) = 0.15 (0.3 – 3)FT4 (ng/dL) = 4.2 (0.9 – 2.3)Albumin (g/dL) = 2.8 (3.5 – 5) INR = 0.8Question: Which of the following is the correct assessment of Ms. McMan's hypothyroidism and current treatment?

Back 25

She is currently hyperthyroid. Decrease levothyroxine dose.

Front 26

Elaine Kissel is beginning amiodarone therapy. She is easily stressed and worried about having "racing heart and dizziness" or what her physician said was an "arrhythmia". Elaine 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:

Back 26

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

Front 27

Tom Gallon, a 72 year-old male, is hospitalized with a pulmonary embolism. He is receiving unfractionated heparin for VTE treatment. His lab values were all within normal values when he was admitted. The lab values below were taken on day #5 of the hospitalization. Which of the following lab values are most indicative of an acute decline in renal function?WBC: 11 (3.5 - 12)HGB: 16.1(13.4 - 17.7)HCT: 48.2 (40 - 53)MCV: 93 (80 - 97)PLT: 73 (150 - 420)Glucose: 149 ( < 199 mg/dl)Chloride: 103 (96 - 108 mmol/L)HCO3: 27 (24 - 30 mmol/L)Sodium: 141 (135 - 145 mmol/L)Potassium: 5.2 (3.5 - 5 mmol/L)BUN: 26 (6 - 23 mg/dL)Creatinine: 1.9 (0.7 - 1.6 mg/dL)Calcium: 9.1 (8.5 - 10.5mg/dl)PO4: 2.9 (2.5 - 4.5 mg/dL)Uric acid: 6.6 (2.5 - 8.5 mg/dL)AST: 20 (0 - 41 U/L)ALT: 28 (0 - 41 U/L)Alkaline Phosphate: 85 (45 - 140 U/L)LDH: 228 (110 - 220 U/L)Bili, T: 0.5 (0.0 - 1.6 mg/dL)Protein, T: 7.3 (6.0 - 8.5 g/dL)Albumin: 3.2 (3.5 - 5.0 g/dL)Total Cholesterol: 212 (60 - 200 mg/dL)

Back 27

BUN, creatinine, potassium

Front 28

The CBC includes each of the following lab values except:

Back 28

Blood urea nitrogen

Front 29

Leslie McMan 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 mmHgLabs:Na (mEq/L) = 146 (135 – 145) K (mEq/L) = 4.1 (3.5 – 5) Cl (mEq/L) = 100 (95 – 103) HCO3 (mEq/L) = 25 (24 – 30) BUN (mg/dL) = 16 (7 – 20) SCr (mg/dL) = 0.9 (0.6 – 1.3) Glucose (mg/dL) = 112 (100 – 125) Ca (mg/dL) = 8.2 (8.5 – 10.5) Mg (mEq/L) = 2.1 (1.3 – 2.1) PO4 (mg/dL) = 3.2 (2.3 – 4.7) WBC (cells/mm^3) = 13.6 (4 – 11x10^3) Hgb (g/dL) = 10.8 (12 – 16 female)Hct (%) = 32.1 (36 – 46 female)Plt (cells/mm^3) = 345 (150 – 450x10^3)AST (IU/L) = 142 (10 – 40) ALT (IU/L) = 130 (10 – 40) GGT (units/L) = 32 (9 – 58) T Bili (mg/dL) = 0.8 (0.1 – 1.2)TSH (mIU/L) = 0.15 (0.3 – 3)FT4 (ng/dL) = 4.2 (0.9 – 2.3)Albumin (g/dL) = 2.8 (3.5 – 5) INR = 0.8Question: Which of Ms. McMan's lab abnormalities is a well-known adverse effect of one of her medications?

Back 29

Increased LFTs

Front 30

Markus Brooks is being seen today by his PCP. Physical/Vitals:Age: 35 Height: 6'1"Weight: 190 pounds Labs:Na (mEq/L) = 132 (135 – 145) K (mEq/L) = 4.9 (3.5 – 5) Cl (mEq/L) = 100 (95 – 103) HCO3 (mEq/L) = 25 (24 – 30) BUN (mg/dL) = 13 (7 – 20) SCr (mg/dL) = 0.5 (0.6 – 1.3) Glucose (mg/dL) = 98 (100 – 125) Ca (mg/dL) = 8.2 (8.5 – 10.5) Mg (mEq/L) = 2.1 (1.3 – 2.1) PO4 (mg/dL) = 3.2 (2.3 – 4.7) WBC (cells/mm^3) = 11.3 (4 – 11x10^3) Hgb (g/dL) = 15.5 (13.5 – 18 male)Hct (%) = 40 (38 – 46 male)Plt (cells/mm^3) = 145 (150 – 450x10^3)AST (IU/L) = 52 (10 – 40) ALT (IU/L) = 36 (10 – 40) GGT (units/L) = 32 (9 – 58) T Bili (mg/dL) = 0.8 (0.1 – 1.2)Albumin (g/dL) = 1.4 (3.5 – 5) INR = 1.8Amylase (units/L) = 28 (60 – 180)Question: Without knowing Mr. Brooks' medications or past medical history, what is most likely diagnosis based on his labs?

Back 30

Chronic liver disease

Front 31

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. Medications taken at home were aspirin, irbesartan, simvastatin, sertraline, isoniazid, atenolol and pyridoxine.Medical Conditions: Hypertension, dyslipidemia, depression, TB-test positive (annual work requirement).Which medication is most likely to have caused the hemolytic anemia?

Back 31

Isoniazid

Front 32

What lab values will be present in a patient with a metabolic acidosis?

Back 32

Low pH, low serum bicarbonate

Front 33

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

Back 33

CChloroquineDDapsoneEMethylene blue

Front 34

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

Back 34

AST and ALT

Front 35

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?

Back 35

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

Front 36

Tom Gallon, a 72 year-old male, is hospitalized with a pulmonary embolism. He is receiving unfractionated heparin for treatment of a VTE. All lab values were within normal limits prior to starting unfractionated heparin. Which of the patient's lab values indicates possible heparin-induced thrombocytopenia?WBC: 13.5 (3.5 - 12)HGB: 16.1(13.4 - 17.7)HCT: 48.2 (40 - 53)MCV: 93 (80 - 97)PLT: 73 (150 - 420)Glucose: 149 ( < 180 mg/dl)Chloride: 103 (96 - 108 mmol/L)HCO3: 27 (24 - 30 mmol/L)Sodium: 141 (135 - 145 mmol/L)Potassium: 5.2 (3.5 - 5 mmol/L)BUN: 22 (6 - 23 mg/dL)Creatinine: 1.9 (0.7 - 1.6 mg/dL)Calcium: 9.1 (8.5 - 10.5mg/dl)PO4: 2.9 (2.5 - 4.5 mg/dL)Uric acid: 6.6 (2.5 - 8.5 mg/dL)AST: 20 (0 - 41 U/L)ALT: 28 (0 - 41 U/L)Alkaline Phosphate: 85 (45 - 140 U/L)LDH: 228 (110 - 220 U/L)Bili, T: 0.5 (0.0 - 1.6 mg/dL)Protein, T: 7.3 (6.0 - 8.5 g/dL)Albumin: 3.2 (3.5 - 5.0 g/dL)Cholesterol: 212 (60 - 200 mg/dL)

Back 36

the platelets

Front 37

Tom Gallon, a 72 year-old male, is hospitalized with a pulmonary embolism. He is receiving unfractionated heparin initiated at a rate of 1000 units/hour. The control value at this hospital is 22-38 seconds. Select the correct test and an appropriate treatment level for this patient:

Back 37

aPTT, 44 seconds

Front 38

A patient presents with confusion and rapid breathing. A lab report reveals a low serum bicarb level. Which of the following antiepileptic drugs can cause metabolic acidosis?

Back 38

topamax

Front 39

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

Back 39

CBC