top of page

Episode 15

Silent Betrayal

Screen Shot 2024-08-24 at 13.09.26.png

Let’stryyourself

  1. Given Dr. Hart’s family history of heart disease and her own hypertension, a sudden heart attack could be a possible cause of death. Her sedentary lifestyle and high-stress levels might have contributed to this.

  2. With her prediabetes and history of hypertension, Dr. Hart was at risk for a stroke. Symptoms can include sudden falls, confusion, and loss of consciousness, which align with her collapse.

  3. Her elevated BUN and serum creatinine levels, along with electrolyte imbalances, point to acute kidney injury, likely exacerbated by her inconsistent medication use and underlying health conditions.

  4. A blood clot in the lungs could cause sudden death. Dr. Hart’s sedentary lifestyle and high-stress environment might have led to this fatal condition.

  5. The threatening emails from Mark Anderson could suggest foul play. Dr. Hart could have been poisoned, leading to her sudden and unexplained collapse and death.

DetailedAnswer

Acute Kidney Injury

Dr. Emily Hart's untimely demise was ultimately due to acute kidney injury (AKI), a condition that manifests as a sudden decline in kidney function. Let's delve into the specifics of how AKI led to her death and why the other possible causes were ruled out.

 

Understanding Acute Kidney Injury

Acute kidney injury occurs when the kidneys suddenly become unable to filter waste products from the blood. When the kidneys lose their filtering ability, dangerous levels of waste may accumulate, and the blood’s chemical makeup may get out of balance.

 

Key Indicators in Dr. Hart's Case:

  • Elevated Serum Creatinine (2.5 mg/dL): This is a significant increase from the normal range (0.6-1.2 mg/dL). Creatinine is a waste product that kidneys normally remove from the blood. When kidney function declines, creatinine levels rise.

  • Elevated Blood Urea Nitrogen (BUN) (25 mg/dL): Normal levels range from 7-20 mg/dL. BUN is another waste product that is typically filtered out by the kidneys. An elevated BUN level indicates impaired kidney function.

  • Hyponatremia (Sodium: 130 mEq/L): Normal sodium levels range from 135-145 mEq/L. Low sodium levels can cause symptoms like confusion, seizures, and even coma, which might explain Dr. Hart's initial fall and subsequent collapse.

  • Hyperkalemia (Potassium: 5.8 mEq/L): Normal potassium levels range from 3.5-5.0 mEq/L. High potassium levels can lead to cardiac arrhythmias, which can be fatal if not treated promptly.

 

Factors Leading to AKI in Dr. Hart:

  • Medication Mismanagement: Dr. Hart’s inconsistent use of medications for her chronic conditions could have contributed to kidney damage. For instance, antihypertensive medications, if not taken regularly, can lead to uncontrolled blood pressure, further straining the kidneys.

  • Prediabetes: This condition can lead to diabetic nephropathy, where high blood sugar damages the kidneys over time. Even if Dr. Hart was only in the prediabetic stage, her blood sugar levels might have contributed to kidney stress.

  • Hypertension: Chronic high blood pressure is a well-known cause of kidney damage. Dr. Hart’s history of hypertension likely placed a significant burden on her renal system.

  • Sedentary Lifestyle: Lack of physical activity can lead to poor circulation and increased risk of kidney disease. Dr. Hart’s sedentary lifestyle could have exacerbated her kidney issues.

  • Emotional and Physical Stress: The constant stress from her professional and personal life may have further impaired her bodily functions, including renal health.

 

Ruling Out Other Possible Causes

 

Heart Attack:

While Dr. Hart had risk factors for a heart attack (hypertension, stress), the lab results did not indicate myocardial infarction markers (like elevated troponins).

Her symptoms, such as electrolyte imbalances and elevated creatinine, pointed more toward kidney dysfunction rather than cardiac issues.

 

Stroke:

Stroke symptoms often include sudden numbness, confusion, and trouble walking, which could match Dr. Hart’s initial fall. However, strokes typically show specific neurological deficits that were not consistent with her presentation.

Imaging studies (like CT or MRI) would have revealed a stroke, but these were not indicated in her medical records or the autopsy.

 

Pulmonary Embolism:

A pulmonary embolism can cause sudden death, but usually presents with symptoms such as shortness of breath, chest pain, and rapid heart rate.

The lack of respiratory distress and the specific lab findings pointed away from a pulmonary embolism.

 

Poisoning:

Given the threatening emails from Mark Anderson, poisoning was a plausible suspicion. However, toxicology reports did not find any unusual substances or toxins in Dr. Hart’s system.

The primary findings in her lab results (elevated creatinine, BUN, electrolyte imbalances) were consistent with internal organ failure rather than external toxic agents.

 

Detailed Breakdown of Events Leading to AKI

 

Initial Symptoms: Dr. Hart’s fall in the classroom was likely due to a combination of hyponatremia (low sodium) and general weakness from her declining health.

 

Ignoring Symptoms: Her decision to not seek immediate medical attention allowed her condition to worsen. The ongoing stress, hypertension, and prediabetes were silently damaging her kidneys.

 

Collapse in Office: When she collapsed in her office, it was the culmination of her body’s inability to cope with the failing kidneys. By this point, her electrolyte imbalances were severe.

 

Hospital Admission: Upon hospital admission, the lab results clearly indicated severe kidney impairment. Despite medical intervention, the damage was too extensive and too advanced to reverse.

Threatening Emails: These added a layer of psychological stress but did not directly contribute to her physical health decline.

 

Conclusion

Dr. Emily Hart’s death was due to acute kidney injury, a result of multiple contributing factors including chronic hypertension, prediabetes, medication mismanagement, and a high-stress, sedentary lifestyle. This condition led to the critical imbalances in her body’s electrolytes and waste products, ultimately resulting in her untimely demise. The careful piecing together of her medical history and lab results allowed the Drug Detectives to uncover the true cause amidst the myriad of possibilities.

NAPLEXMockupTest

Pharmacotherapy and Patient Care:

  1. A 55-year-old patient with type 2 diabetes is prescribed metformin. What is a common side effect of metformin that patients should be aware of?

    • A) Hypoglycemia

    • B) Weight gain

    • C) Gastrointestinal upset

    • D) Insomnia

  2. A patient with chronic kidney disease is prescribed a medication that is predominantly eliminated by the kidneys. What is a key consideration in dosing this medication?

    • A) Increase the dose to compensate for reduced metabolism

    • B) Monitor for signs of liver toxicity

    • C) Adjust the dose based on the patient's renal function

    • D) Discontinue the medication if renal function is compromised

  3. A patient with hypertension is prescribed losartan. Which of the following is a common adverse effect associated with this medication?

    • A) Cough

    • B) Hyperkalemia

    • C) Hypoglycemia

    • D) Constipation

  4. A 70-year-old female patient is started on warfarin. Which laboratory test is essential for monitoring her therapy?

    • A) Hemoglobin A1c

    • B) Prothrombin time (PT) / International Normalized Ratio (INR)

    • C) Serum potassium

    • D) Serum creatinine

  5. A patient is prescribed prednisone for the treatment of an autoimmune disorder. What is an important counseling point regarding this medication?

    • A) Take the medication on an empty stomach

    • B) Do not abruptly stop the medication

    • C) Avoid high-protein foods

    • D) Monitor blood glucose levels closely

Pharmacokinetics:

  1. A drug has a bioavailability of 50% and an oral dose of 200 mg is administered. What is the amount of drug that reaches systemic circulation?

    • A) 50 mg

    • B) 100 mg

    • C) 150 mg

    • D) 200 mg

  2. A patient is on a medication with a clearance rate of 5 L/hour and a volume of distribution of 25 L. What is the steady-state concentration if the infusion rate is 50 mg/hour?

    • A) 1 mg/L

    • B) 2 mg/L

    • C) 5 mg/L

    • D) 10 mg/L

  3. If a drug is 90% protein-bound, what fraction of the drug is free in the plasma?

    • A) 0.1

    • B) 0.2

    • C) 0.5

    • D) 0.9

Biostatistics:

  1. In a clinical trial, the relative risk of developing a condition is 0.6. If the incidence of the condition in the control group is 10%, what is the incidence in the treatment group?

    • A) 4%

    • B) 6%

    • C) 8%

    • D) 12%

  2. A study reports a 95% confidence interval for the mean difference between two treatments as [3, 7]. What can be concluded about the difference between the treatments?

    • A) The treatments are not significantly different

    • B) The mean difference is between 3 and 7 with 95% confidence

    • C) There is no evidence to suggest a difference

    • D) The treatments are significantly different

Medication Safety:

  1. A patient on ciprofloxacin develops tendon pain. What is the most appropriate action?

    • A) Continue ciprofloxacin and use analgesics

    • B) Discontinue ciprofloxacin and consult a physician

    • C) Increase the dose of ciprofloxacin

    • D) Switch to an oral corticosteroid

  2. A patient receiving chemotherapy with doxorubicin is at risk for which of the following adverse effects?

    • A) Nephrotoxicity

    • B) Cardiotoxicity

    • C) Hepatotoxicity

    • D) Neurotoxicity

Compounding:

  1. A prescription requires a solution of 0.5% lidocaine. How many milliliters of a 2% lidocaine solution are needed to prepare 100 mL of the 0.5% solution?

    • A) 10 mL

    • B) 25 mL

    • C) 50 mL

    • D) 75 mL

  2. In preparing a sterile injectable product, which of the following practices helps ensure sterility?

    • A) Working in a laminar flow hood

    • B) Using non-sterile gloves

    • C) Cleaning surfaces with non-sterile wipes

    • D) Storing products at room temperature

Immunizations:

  1. Which vaccine should be administered annually to protect against seasonal influenza?

    • A) MMR

    • B) Tdap

    • C) Influenza (inactivated)

    • D) HPV

  2. A patient with a history of anaphylaxis to a previous vaccine should avoid which of the following types of vaccines?

    • A) Live attenuated vaccines

    • B) Inactivated vaccines

    • C) Subunit vaccines

    • D) Recombinant vaccines

Infectious Diseases:

  1. A patient with a confirmed diagnosis of HIV should be started on which class of medications as part of antiretroviral therapy (ART)?

    • A) Penicillins

    • B) Beta-blockers

    • C) Nucleoside reverse transcriptase inhibitors (NRTIs)

    • D) Proton pump inhibitors

  2. Which antibiotic is commonly used to treat Clostridium difficile infection (CDI)?

    • A) Vancomycin

    • B) Azithromycin

    • C) Ciprofloxacin

    • D) Cephalexin

Oncology:

  1. A patient undergoing chemotherapy with cyclophosphamide is at risk for which of the following adverse effects?

    • A) Hemorrhagic cystitis

    • B) Ototoxicity

    • C) Pulmonary fibrosis

    • D) Neutropenia

  2. For patients with advanced non-small cell lung cancer (NSCLC) that is positive for epidermal growth factor receptor (EGFR) mutations, which of the following drugs is commonly used?

    • A) Bevacizumab

    • B) Erlotinib

    • C) Rituximab

    • D) Doxorubicin

​

​

​

​

​

​

​

​

​

​

ANSWERS:

Pharmacotherapy and Patient Care:

  1. C) Gastrointestinal upset
    Explanation: Metformin commonly causes gastrointestinal upset, including nausea, diarrhea, and abdominal discomfort.

  2. C) Adjust the dose based on the patient's renal function
    Explanation: Medications eliminated by the kidneys often require dose adjustments in patients with chronic kidney disease to prevent accumulation and toxicity.

  3. B) Hyperkalemia
    Explanation: Losartan, an angiotensin receptor blocker (ARB), can lead to hyperkalemia, particularly when used with other medications that affect potassium levels.

  4. B) Prothrombin time (PT) / International Normalized Ratio (INR)
    Explanation: Warfarin therapy requires regular monitoring of PT/INR to ensure therapeutic anticoagulation and to avoid bleeding complications.

  5. B) Do not abruptly stop the medication
    Explanation: Prednisone should not be stopped suddenly due to the risk of adrenal insufficiency; it should be tapered gradually.

Pharmacokinetics:

  1. B) 100 mg
    Explanation: With a bioavailability of 50%, 100 mg of the drug would be absorbed into systemic circulation from an oral dose of 200 mg.

  2. B) 2 mg/L
    Explanation: Steady-state concentration (Css) is calculated by the formula Css = (Infusion rate) / (Clearance). Here, Css = 50 mg/hour / 25 L/hour = 2 mg/L.

  3. A) 0.1
    Explanation: If a drug is 90% protein-bound, 10% of the drug is free in the plasma, which is 0.1 (or 10%).

Biostatistics:

  1. A) 4%
    Explanation: The relative risk reduction is 0.6, so the incidence in the treatment group is 10% × 0.6 = 6%. Hence, the incidence is 4% less than the control group.

  2. B) The mean difference is between 3 and 7 with 95% confidence
    Explanation: A 95% confidence interval indicates that we are 95% confident that the true mean difference lies within the interval of 3 to 7.

Medication Safety:

  1. B) Discontinue ciprofloxacin and consult a physician
    Explanation: Tendon pain is a known adverse effect of ciprofloxacin. The medication should be discontinued, and a physician should be consulted to prevent further complications.

  2. B) Cardiotoxicity
    Explanation: Doxorubicin is known to cause cardiotoxicity, which can lead to heart damage, requiring close monitoring of cardiac function.

Compounding:

  1. B) 25 mL
    Explanation: To prepare 100 mL of a 0.5% lidocaine solution from a 2% solution, you need 25 mL of the 2% solution (using the dilution formula: C1V1 = C2V2).

  2. A) Working in a laminar flow hood
    Explanation: Using a laminar flow hood helps maintain sterility by providing a sterile environment and reducing the risk of contamination.

Immunizations:

  1. C) Influenza (inactivated)
    Explanation: The inactivated influenza vaccine is recommended annually to protect against the seasonal flu.

  2. A) Live attenuated vaccines
    Explanation: Patients with a history of anaphylaxis to a previous vaccine should avoid live attenuated vaccines due to the risk of severe allergic reactions.

Infectious Diseases:

  1. C) Nucleoside reverse transcriptase inhibitors (NRTIs)
    Explanation: NRTIs are a class of antiretroviral medications used in the treatment of HIV infection.

  2. A) Vancomycin
    Explanation: Vancomycin is commonly used to treat Clostridium difficile infection, especially in severe cases.

Oncology:

  1. A) Hemorrhagic cystitis
    Explanation: Cyclophosphamide can cause hemorrhagic cystitis, a condition characterized by bleeding and inflammation in the bladder.

  2. B) Erlotinib
    Explanation: Erlotinib is used for advanced non-small cell lung cancer (NSCLC) with EGFR mutations, targeting the EGFR tyrosine kinase.

bottom of page