QUESTION: 85

A 23-year-old woman presents to your acute care clinic with a complaint of fever, sore throat, and malaise of sudden onset. Her prior medical history is significant for schizophrenia. Her vitals signs are:
BP 116/80, HR 112, RR 26, Temp 100.6 degrees Fahrenheit. On physical examination, her oral cavity features painful aphthous ulcers as well as swollen gums. Initial laboratory testing includes a CBC which returns with the following results:
· Leukocyte count 800/mm3
· Hgb 12.1 g/dL
· HCT 37.0%
· Platelet count 212 × 109/L
· Differential:
· Neutrophils, segmented 52%
· Neutrophils, bands 3%
· Lymphocytes 35%
· Monocytes 7%
· Eosinophils 3%
· Basophils 0%
Use of which of the following must be considered when formulating a differential diagnosis to explain this patient's symptoms?

haloperidol
chlorpromazine
risperidone
thioridazine
clozapine

Answer(s): E

Explanation:

This patient's presentation is consistent with agranulocytosis, which is defined by an absolute neutrophil count (ANC) of fewer than 500/mm3. ANC is defined as the percentage of the WBC count that is accounted for by segmented neutrophils and bands. In the case of this patient, the ANC is 55% of the WBC count or 440/mm3. Individuals with agranulocytosis commonly experience a sudden onset of malaise, fever, chills, and pharyngitis. They may also develop painful aphthous ulcers affecting the oropharyngeal mucosa. Suppression of the bone marrow, including agranulocytosis, is associated with the use of clozapine. The incidence approaches 1% within several months of treatment, independent of dose. Patients on clozapine should be monitored closely with weekly measurement of the CBC. Mild leukocytosis and other blood dyscrasias occur much less frequently with other antipsychotic drugs.Usually, there is a prodrome of several weeks duration in which the WBC count gradually declines. Decreasing the dose or discontinuing the offending agent does not always prevent progression to full blown agranulocytosis. Patients with druginduced neutropenia recover more quickly with the assistance of granulocyte colonystimulating factor (G-CSF). Additionally, individuals suffering from agranulocytosis frequently develop infections which require the use of antibiotic therapy. In these cases, further supportive and symptomatic care may be necessary depending on the severity of infection. Delaying or withholding intervention is inappropriate. Tardive dyskinesia is an adverse effect related to use of antipsychotic medications; it is not inherently related to agranulocytosis.

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QUESTION: 86

A 23-year-old woman presents to your acute care clinic with a complaint of fever, sore throat, and malaise of sudden onset. Her prior medical history is significant for schizophrenia. Her vitals signs are:
BP 116/80, HR 112, RR 26, Temp 100.6 degrees Fahrenheit. On physical examination, her oral cavity features painful aphthous ulcers as well as swollen gums. Initial laboratory testing includes a CBC which returns with the following results:

· Leukocyte count 800/mm3
· Hgb 12.1 g/dL
· HCT 37.0%
· Platelet count 212 × 109/L
· Differential:
· Neutrophils, segmented 52%
· Neutrophils, bands 3%
· Lymphocytes 35%
· Monocytes 7%
· Eosinophils 3%
· Basophils 0%

Which of the following best describes the expected course of the patient's condition?

The condition is usually self-limiting and requires no intervention.
Use of G-CSF has been shown to speed recovery.
Dose reduction of the offending agent often leads to resolution of symptoms.
If discovered earlier, discontinuation of the offending agent would have prevented progression of the condition to its current severity.
Tardive dyskinesia usually develops as a late finding.

Answer(s): B

Explanation:

This patient's presentation is consistent with agranulocytosis, which is defined by an absolute neutrophil count (ANC) of fewer than 500/mm3. ANC is defined as the percentage of the WBC count that is accounted for by segmented neutrophils and bands. In the case of this patient, the ANC is 55% of the WBC count or 440/mm3. Individuals with agranulocytosis commonly experience a sudden onset of malaise, fever, chills, and pharyngitis. They may also develop painful aphthous ulcers affecting the oropharyngeal mucosa. Suppression of the bone marrow, including agranulocytosis, is associated with the use of clozapine. The incidence approaches 1% within several months of treatment, independent of dose. Patients on clozapine should be monitored closely with weekly measurement of the CBC. Mild leukocytosis and other blood dyscrasias occur much less frequently with other antipsychotic drugs.Usually, there is a prodrome of several weeks duration in which the WBC count gradually declines. Decreasing the dose or discontinuing the offending agent does not always prevent progression to full blown agranulocytosis. Patients with druginduced neutropenia recover more quickly with the assistance of granulocyte colonystimulating factor (G-CSF). Additionally, individuals suffering from agranulocytosis frequently develop infections which require the use of antibiotic therapy. In these cases, further supportive and symptomatic care may be necessary depending on the severity of infection. Delaying or withholding intervention is inappropriate. Tardive dyskinesia is an adverse effect related to use of antipsychotic medications; it is not inherently related to agranulocytosis.

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QUESTION: 87

A62-year-old female with a history of a recent pulmonary embolus presents to your office for follow- up on anticoagulation treatment. She takes warfarin on a daily basis. She reports that for the last week she has noticed mild rectal bleeding and multiple bruises over the extremities with minimal trauma. She is comfortable appearing with normal vital signs and is not orthostatic. You ordered a stat CBC and PT/INR which revealed a mildly decreased Hgb at 11 g/dL and an elevated INR of 7. Which of the following would be the most appropriate intervention?

subcutaneous injections of heparin
oral allopurinol
intravenous protamine sulfate
oral vitamin E
oral vitamin K

Answer(s): E

Explanation:

Warfarin acts as a vitamin K antagonist by blocking the regeneration of the reduced form of the vitamin. The result is a decrease in clotting factors II, VII, IX, and X leading to an increase in bleeding time. Warfarin toxicity can be alleviated by increasing the availability of vitamin K.

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QUESTION: 88

A 42 year old male admitted for pulmonary embolus was placed on heparin, dosed by a weight based protocol. However, later in the day, you receive a call from the floor nurse stating that the patient had spontaneous epistaxis and a very high aPTT. Use of which of the following would be best at this time?

cimetidine
heparinase
clofibrate
protamine sulfate
vitamin K

Answer(s): D

Explanation:

Protamine sulfate is a strongly basic molecule that is thought to inhibit acidic heparin electrostatically. It may not, however, affect heparin-induced platelet aggregation. Cimetidine is an H2-antagonist that increases the anticoagulant response by an as yet unknown mechanism. Clofibrate is an agent used to reduce plasma lipid levels. Vitamin K is used to reverse the effect of warfarin. Heparinase is not used clinically.

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