QUESTION: 69

A 45-year-old male with type II diabetes, hypertension, and hyperlipidemia presents to your clinic as a new patient. He has been out of his cholesterol medications and came to your office requesting a refill. The patient brought his most recent lipid profile (done after he was off his cholesterol medication for 3 months) which revealed:

Cholesterol (total): 242 mg/dL
HDL cholesterol: 38 mg/dL
Triglycerides (TGs): 660 mg/dL
LDL cholesterol = unable to calculate due to high TGs
He also had recent liver function tests that were normal. Based on Adult Treatment Panel (ATP) III guidelines, which of the following medications should be the initial pharmacologic treatment for this patient?

atorvostatin
gemfibrozil
cholestyramine
omega-3 fatty acids
nicotinic acid

Answer(s): B

Explanation:

According to the Third Report of the National Cholesterol Education Program (NCEP) on the ATP III once the TG levels are in very high range (>500 mg/dL) the focus changes from LDL to reducing TGs, as such high levels can trigger acute pancreatitis. Once the LDL is lower than 500 mg/dL, the attention can be turned toward lowering LDL for CHD reduction. The results of various recent meta-analyses revealed that elevated TGs are also an independent risk factor for CHD. Some factors that may lead to elevated TG include obesity, physical inactivity, tobacco use, alcohol use, high carbohydrate diets, diabetes, chronic kidney disease, familial disorders, and certain drugs. ATP III adopts the following classification for serum TGs:
· Normal TGs: <150 mg/dL
· Borderline-high TGs: 150199 mg/dL
· High TGs: 200499 mg/dL
· Very high TGs: 500 mg/dL
Nicotinic acid and fibrates have the largest reduction in TG (2530% and 3550%, respectively) and are thus the first-line recommendations in addition to diet modification and exercise in cases of very high TG. Statins reduce TG by roughly 1033%, while bile acid sequestrant can have no effect or even increase TG levels. Fish oils in high doses can be used in recalcitrant cases as they may reduce TG by up to 50%; however GI side effects are common. It is also important to note that active omega-3 fatty acids make up only 3050% of many fish oil supplements, whereas Omacor has 90% omega-3 fatty acids. Although this class of agents can reduce TG effectively, they have the unwanted effect of elevating LDL-C levels.

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QUESTION: 70

A 48-year-old woman complaining of dysuria is diagnosed with a UTI by urinalysis. Urine culture and sensitivities reveal that the causative organism belongs to the genus Klebsiella and is resistant to multiple antibiotics. Based upon the results available, you decide to begin therapy with gentamicin.

Before doing so, you explain to the patient that antibiotics such as gentamicin are often associated with which of the following?

hepatotoxicity
nephrotoxicity
interstitial pulmonary fibrosis
pulmonary edema
splenomegaly

Answer(s): B

Explanation:

Aminoglycosides such as gentamicin accumulate in the proximal tubular cells of the kidney, resulting in a defect in renal concentrating ability and reduced glomerular filtration after several days. This renal impairment is almost always reversible. Of all the aminoglycosides, gentamicin and tobramycin are the most nephrotoxic. Aminoglycosides may also cause ototoxicity in the form of irreversible auditory or vestibular damage. There is a direct relationship between aminoglycoside dosage and the risk for development of ototoxicity, so doses should be adjusted according to a patient's baseline renal function. Complicated UTIs involve metabolic or hormonal abnormalities such as those seen in M or during pregnancy; the presence of foreign bodies such as calculi, tumors, or catheters; the presence of strictures causing turbulent urine flow or vesicoureteral reflux; incomplete voiding such as that seen in neurogenic bladder, prostate hyperplasia or cancer; and, the presence of unusual infecting microorganisms. A history of recurrent UTI does not in itself lead to the classification of subsequent infections as complicated. Due to anatomic differences in urethral length between males and females, any UTI in a male is considered complicated. A history of recent surgery does not correlate with development of a complicated UTI unless the surgical procedure resulted in the creation of some anatomic abnormality which increased the risk of infection; examples of such abnormalities include adhesions or strictures. Apostvoid residual volume greater than 50100 mL suggests abnormal bladder emptying, which would predispose an individual to development of UTIs.

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QUESTION: 71

A 48-year-old woman complaining of dysuria is diagnosed with a UTI by urinalysis. Urine culture and sensitivities reveal that the causative organism belongs to the genus Klebsiella and is resistant to multiple antibiotics. Based upon the results available, you decide to begin therapy with gentamicin. Which of the following irreversible complications is also associated with gentamicin use?

vestibular dysfunction
cardiomyopathy
optic nerve dysfunction
myelodysplastic disease
cerebellar degeneration

Answer(s): A

Explanation:

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QUESTION: 72

A 48-year-old woman complaining of dysuria is diagnosed with a UTI by urinalysis. Urine culture and sensitivities reveal that the causative organism belongs to the genus Klebsiella and is resistant to multiple antibiotics. Based upon the results available, you decide to begin therapy with gentamicin.

Which of the following would lead to the classification of this patient's infection as "complicated?"

a history of recurrent UTIs
a diagnosis of type II DM
the patient's gender
a history of undergoing a laparoscopic appendectomy 1 month ago
a postvoid residual volume of 25 cc

Answer(s): B

Explanation:

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