MT is 47-year-old man who presents to the ER with painful, red, swollen area on his left leg. His temperature is 38.4, respiratory rate 30 and heart rate 95. He has been taking cephalexin day 4 today, as prescribed by his primary care physician. His CMP is normal a CBC shows elevated WBC of 16,000/mm3.
What would be the most appropriate antibiotic/s to initiate on MT empirically?
This patient is displaying signs of a severe case of cellulitis. Severe cellulitis is defined as having one of the following: failed oral antibiotic treatment, immunocompromised, clinical signs of deeper infection, or meeting the SIRS criteria. Based on this patient’s presentation they have failed antibiotic treatment and meet SIRS criteria. For severe cellulitis, IDSA SSTI guidelines recommend using Vancomycin along with Zosyn.
A CD4 count of 180 cells per cubic meter may be evaluated as which of these?
A CD4 count of 180 cells per cubic meter is considered very low – typically an indicator that the patient has an immunocompromised state, such as AIDS. CD4 counts are a measure of healthy T-cell levels. The lower the count, the more susceptible the patient is to opportunistic infections. A normal range is between 500 and 1,500 cells.
What is the Osmolarity of NS with KCL 40 meq/L? (MW of KCl: 74.55 g/mol) (MW of NaCl: 58.44 g/mol)
KCl: Osmoles = number of particles in solution Convert 40meq to weight in g: 40meq × 1equiv/1000 mEq × 74.5g/1 equiv = 2.98g of KCL. Calculate mOsm/L: 2.98g/L × 1mol/74.5g × 2Osm/1 mol × 1000mOsm/1 Osm = 80mOsm/L. NaCl: 0.9g/100ml × 1mol/58.5 g × 2 Osm/1mol × 1000 mOsm/ 1Osm × 1000ml/1L = 308 mOsm/L 80 mOsm/L + 308 mOsm/L = 388 mOsm/L
You need 51.3 mEq of NaCl to make 1/3 NS 1 liter bag. How many ml of 23.4% NaCl would you need? (Molecular weight of Na is 23 and Cl is 35.5)
1mEq NaCl= 58.5; Valence = 1. mg = mEq × molecular weight / valence. mg = 51.3mEq × 58.5mg / 1 = 3001.05mg = 3g. 23.4 g/100ml = 3g/Xml X = 12.825mL
An order is received to start Milrinone at 0.75mcg/kg/min, Milrinone comes as 20mg/100ml D5W. What is the infusion rate in mL/hr? Patient weighs 115kg.
Patient dose: 0.75mcg × 115kg = 86.25mcg/min (100mL/20mg) × (86.25mcg/1hr) × (60min/1hr) × (1mg/1000mcg) = 25.875mL/hr Rate of infusion of Milrinone
A 67-year-old female presents to your clinic complaining of fatigue, diarrhea, headaches and a loss of appetite. Upon examination you find that she is having some cognitive difficulty. Laboratory results reveal: MCV: 109fL; Hgb: 9g/dL; MMA and homocystine are both elevated. Shilling test is positive.
What is the next best step in the management of this patient?
Lifelong Vitamin B12 supplementation. Vitamin B12 (cyanocobalamin) deficiency generally presents in patients as fatigue, diarrhea and headaches but can also be the cause of cognitive changes (difficulty concentrating, even mild dementia). Pernicious anemia is a macrocytic anemia, therefore laboratory findings indicate an increased mean corpuscular volume (MCV), with a decreased hemoglobin. A positive Schilling test indicates that the B12 deficiency is due to a lack of intrinsic factor. Lifelong cyanocobalamin supplementation (either orally or via injections) is needed to treat pernicious anemia. A is incorrect. Folic acid deficiency anemia is another common type of macrocytic anemia. However, cognitive deficits are not typically seen with folic acid deficiency. Furthermore, a schilling test would be negative and the methylmalonic acid (MMA) would be normal, rather than elevated. C is incorrect. Iron deficiency anemia causes a microcytic anemia, characterized by a decreased MCV. D is incorrect. A Coomb’s test is used to detect autoimmune hemolysis that may be suspected in patients with normocytic anemia (anemia with an MCV in the normal range). E is incorrect. Corticosteroids and iron supplementation are indicated as treatment in hemolytic anemia.
How many millimoles of sodium are in 0.9% sodium chloride?
0.9% = 9 grams per every 1,000mL Molecular weight of NaCl = 58.5 9 / 58.5 = 0.154 moles 0.154 moles is the same as 154 millimoles There are 154 millimoles of sodium ions and 154 millimoles of chloride ions in 0.9% sodium chloride.
Select the class of Anti-diabetic medication that works in the specified organ to prevent hyperglycemia. Select all that applies. Kidney (G)
SGLT2 inhibitors Sulfonylureas work in beta cells in the pancreas that are still functioning to enhance insulin secretion. Alpha-Glucosidase Inhibitors stop α-glucosidase enzymes in the small intestine and delay digestion and absorption of starch and disaccharides which lowers the levels of glucose after meals. DPP4 blocks the degradation ofGLP-1, GIP, and a variety of other peptides, including brain natriuretic peptide. Glucagon-like peptide-1 receptor agonists work in various organs of the body. Glucagon-like peptide-1 receptor agonists enhance glucose homeostasis through: (i) stimulation of insulin secretion; (ii) inhibition of glucagon secretion;
(iii) direct and indirect suppression of endogenous glucose production; (iv) suppression of appetite; (v) enhanced insulin sensitivity secondary to weight loss; (vi) delayed gastric emptying, resulting in decreased postprandial hyperglycaemia. Thiazolidinediones are the only true insulin-sensitising agents, exerting their effects in skeletal and cardiac muscle, liver, and adipose tissue. It ameliorates insulin resistance, decreases visceral fat. Biguanides work in liver, muscle, adipose tissue via activation of AMP-activated protein kinase (AMPK) reduce hepatic glucose production. SGLT2 inhibitors work in the kidneys to inhibit sodium-glucose transport proteins to reabsorb glucose into the blood from muscle cells; overall this helps to improve insulin release from the beta cells of the pancreas.
Results from a Meta-analysis where they looked at frequency of postoperative arterial fibrillation in patients on Ascorbic acid after cardiac surgery found odds ratio, 0.44 (95% CI, 0.32 to 0.61). How can you interpret this data?
Odds ratio of 0.44 (44%) means that this group was associated with an event happening 44% of the time, compared to 1 (an event happening 100% of the time if unexposed), therefore 100 - 44 = 56%, which is the reduction caused by the exposure. Exposure is the use of ascorbic acid.
A 15-year-old presents with 6 days of nasal congestion with thin, clear rhinorrhea. She notes mild facial pain but has had no fevers. She feels her symptoms are improving.
What is the most likely cause of her symptoms?
This patient shows symptoms of acute sinusitis. The most common etiology of which is viruses. Indications that an infection is viral as opposed to bacterial included a shorter infection tie (less than 10 days) and no purulent discharge (hers is watery). She does not show any evidence of a complication developing and even notes that her symptoms are improving. If her symptoms were attributed to a bacterium, then the most common cause of acute sinusitis is Streptococcus pneumoniae followed by Haemophilus influenza, then Moraxella catarrhalis. Anaerobic species such as Bacteroides fragilis and Staphylococcus aureus are more commonly found in patients with chronic sinusitis (sinusitis lasting longer than 12 weeks). This is important to realize before indiscriminately providing antibiotics for these patients.
Which H2-receptor blocker may cause gynecomastia in men due to its antiandrogenic effects?
Cimetidine has multiple drug interactions due to its inhibitory effects on CYP1A2, 2C9, 2D6, and 3A4. Inhibition of these enzymes can cause an increase in the serum concentrations of drugs metabolized by these enzymes, leading to toxicity.
LT is a 42-year-old white female with past medical history of epilepsy, gastroesophageal reflux disease and seasonal allergies. She weighs 86 kg, height 5’6” and allergic to Aspirin (rash) and Phenobarbital (difficulty breathing).
Her medications include Omeprazole 40mg daily, Phenytoin 200mg twice daily, Valproic acid 500mg four times daily, Loratadine 10mg daily. She comes to your community pharmacy to pick up prescription for Primidone 250mg twice daily.
Pertaining to Primidone what is the most appropriate action to take?
Primidone is an anticonvulsant drug that is structurally related to phenobarbital. Primidone is metabolized to
phenobarbital and therefore shares its anticonvulsant and sedative properties. Primidone may be more effective than therapy with phenobarbital alone because primidone and both of its metabolites, phenobarbital and phenylethylmalonamide (PEMA), possess anticonvulsant activity.
Which of the following antidiabetic medication works by inhibiting carbohydrate breakdown?
Acarbose is an alpha glucosidase inhibitor that inhibits carbohydrate breakdown. Metformin is a biguanide that decreases hepatic glucose production. Dapagliflozin is a SGLT2 inhibitor to decrease glucose reabsorption in
the kidney. Pioglitazone is a TZD that increases insulin sensitivity. Sitagliptin is a DPP-4 inhibitor that works on incretins/increase insulin secretion/decrease glucagon secretion.
If you mix 30 gm 5% lidocaine cream and 90gm of 0.5% hydrocortisone cream, what percent of lidocaine and hydrocortisone do you have as the end product?
Lidocaine: 30g × 0.05 = 1.5g. Hydrocortisone: 90g × 0.005 = 0.45g. 90g + 30g = 120g. 1.5g/120g = 0.0125 × 100 = 1.25% Lidocaine. 0.45g/120g = 0.00375 × 100 = 0.375% Hydrocortisone.
Which of the following antidiabetic medication works by decreasing glucose reabsorption?
Empagliflozin is a SGLT2 inhibitor to decrease glucose reabsorption in the kidney. Linagliptin is a DPP-4 inhibitor that works on incretins/increase insulin secretion/decrease glucagon secretion. Pioglitazone is a TZD that increases insulin sensitivity. Exenatide is a GLP-1 agonist which increase insulin secretion/decrease glucagon secretion/increase satiety.
Which of these is an example of postrenal acute kidney injury (AKI)?
Benign prostatic hyperplasia (BPH) is an example of postrenal acute kidney injury (AKI). Postrenal AKI, as the name suggests, involves an effect ‘post’ or ‘beyond’ the kidney, to problems that emerge downstream from the kidney. BPH is one such example of that. Other examples include kidney stones, bladder stones and bladder cancer.
In the US Nurses’ Health Study (NHS) cohort study, where they looked at association of regular aspirin use (≥two 325 mg tablets/week) and colorectal cancer in 82,911 women found (RR, 0.77; 95% CI, 0.67–0.88) over 20 years of follow-up.
In an another analysis of the NHS, regular aspirin use, investigator also found (hazard ratio [HR]=0.72, 95% CI 0.56–0.92), what does this say about the mortality from colorectal cancer? How can this data best be interpreted?
Relative risk can be stated as 0.77 times as likely or 0.77 times the risk, but it could also be illustrated as a relative risk reduction and stated as a 23% risk reduction or 23% lower risk by taking the medication.
Which of the following beta-blocker is NOT proven to reduce mortality in patients with Systolic CHF?
Nadolol is not proven to reduce mortality in patients with systolic CHF. The efficacy of nadolol in HF has not been determined. For patients taking nadolol, it should be used with caution in those with compensated heart failure and patients should be monitored for a worsening of the condition. Bisoprolol, carvedilol, and sustained- release metoprolol succinate are the beta-blockers that have been proven to reduce mortality in patients with systolic CHF. These 3 beta-blockers have been effective in reducing the risk of death in patients with chronic HFrEF. Other beta-blockers were found to be less effective. Bucindolol did not exhibit uniform effectiveness across different populations. Metoprolol tartrate was found to be less effective in HF clinical trials.
Which of the following medication should be avoided if a patient is on lithium to avoid lithium toxicity?
ACE-inhibitors (such as lisinopril), NSAIDs (such as naproxen) and loop diuretics (furosemide) can all increase the risk of lithium toxicity.
A 20-year-old student came to the emergency department with primary complaints of palpitations, low-grade fever, and anxiety for 2 months. She reports that she is irritable and suffers severe mood swings that is interfering with her sleep and relationships (she admits to crying spells and frequent fights with friends and family). She has also lost 12 pounds in the past 2 months with no apparent alteration in her diet or physical activity (though she is happy with her weight loss). She denies any past medical problems, though her friends have always been worried that she eats too little.
Her temperature is 38.0 C (100.4 F), blood pressure is 148/62 mm Hg, pulse is 122/min and regular, and respiratory rate is 28/min. Examination reveals a bruit heard over the anterior neck, fine tremor of the hands, and warm, moist skin. Her eyes and eyelids do not move together during finger following test (with steady head). Laboratory work is sent, including a thyroid panel, but will not be available until tomorrow morning.
Which of the following is the most appropriate initial management at this time?
This patient had hyperthyroidism, though the exact cause of her condition is not currently clear. The immediate treatment should focus on controlling the patient’s symptoms for which a non-specific beta-blocker is
seemingly an ideal choice. Propranolol therapy can be initiated without any adverse effects while the patient undergoes further workup of her condition. As the treatment for hyperthyroidism varies depending upon the cause of the condition, more definitive therapy should be avoided. Diltiazem (choice A) helps control heart rate
but does not have the same antiadrenegenic properties as beta-blockers/ The initial treatment for symptomatic hyperthyroidism is propranolol. Iodine (choice B) can be used in high doses to inhibit thyroid production of T3 and T4. Until it’s clear that this patient does not have an exogenous source of thyroid hormone (and until it is clear she is not pregnant), this agent should not be considered. Propylthiouracil (PTU) and Methimazole (choice C) inhibit the organification of iodine to tyrosine residues. If this patient has Graves diseases, this would be an appropriate treatment. Until a diagnosis is made, however, initial therapy should consist of a beta- blocker. Surgical treatment (choice E) of hyperthyroidism is often a reasonable treatment for patients who cannot tolerate medical therapy of radioactive iodine ablation.
A 22-year-old woman adopted a cat. Shortly thereafter, she developed itchy eyes and persistent rhinorrhea. She was clearly allergic to the pet, but desperately wanted to keep it. She tried taking diphenhydramine, but it had intolerable side effects.
Which of the following is a common effect of this type of medication?
Diphenhydramine possesses anticholinergic properties. Xerostomia, or dry mouth, is a common side effect of anti-cholinergic medications, due to anti-muscarinic, parasympatholytic effects. Other adverse reactions may include: • Mydriasis with blurred vision, photophobia • Urinary retention • Constipation • Anhidrosis • Hyperthermia • Tachycardia • Altered mental status
A commonly referenced mnemonic for anti-cholinergic toxicity is “mad as a hatter, red as a beet, dry as a bone, hot as a hare, blind as a bat” to reflect confusion, flushing, dry mouth, hyperthermia and mydriasis, respectively.
Diabetic ketoacidosis, a potential complication of type 2 diabetes, is most associated which of the following antidiabetic drug classes?
SGLT-2 inhibitors have a black box warning for diabetic ketoacidosis, which manifests as euglycemic and makes it relatively difficult to detect without monitoring. The complex physiology by which this occurs is not clearly understood. On the other end, they have been shown to reduce major cardiovascular events (MACE) in persons with type 2 diabetes and established cardiovascular disease.
Which of the following side effects should LT be made aware of while on Divalproex Sodium?
Common GI side effects of Valproic Acid and Divalproex Sodium are Weight gain, Nausea, Vomiting, Diarrhea, abdominal pain, dyspepsia. Divalproex sodium or valproic acid affects reproductive endocrine function in women. Menstrual irregularities defined as amenorrhea, oligomenorrhea, and prolonged cycles were common. Gynecomastia is not a side effect of Divalproex Sodium. For list of drugs that causes gynecomastia refer the reference. Gingival hyperplasia is a well-known side effect of phenytoin.