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Episode 18

The Mystery at the Seaside

Emergency Vehicles

Let’stryyourself

  1. Delayed Diagnosis and Treatment: The blood culture results, which confirmed Pseudomonas aeruginosa as the cause of her infection, were received too late. Timely identification and the use of a specific antibiotic, such as Piperacillin/tazobactam, might have altered the outcome.

  2. Delayed Blood Culture Results: The average time for blood culture results to be processed is approximately 24-48 hours. This delay in results may have prevented the initiation of targeted antibiotic therapy.

  3. Hospital Acquired Infection: Lara’s infection could have been aggravated by an ongoing hospital-acquired infection outbreak, which may have contributed to the rapid deterioration of her condition.

  4. Suicide: Considering the content of the letter found in her pocket, it's possible that Lara’s death could be attributed to suicide, despite the initial appearance of an accidental fall or other causes.

  5. Homicide or Foul Play: Investigators must also consider the possibility of external factors or foul play, especially given the initial uncertainty about whether her fall was accidental or deliberate.

DetailedAnswer

Lara was diagnosed with Pseudomonas aeruginosa after her death. This pathogen is known to be resistant to many antibiotics, making Piperacillin/tazobactam a critical treatment option.

 

Treatment Failure: If Piperacillin/tazobactam was not administered, the empirical treatment would have been inadequate to combat Pseudomonas aeruginosa, leading to a worsening of her infection.

 

Conclusion: Given that the correct treatment was not used, this choice directly explains why Lara's condition deteriorated and contributed to her death.

 

Why It Could Be True: Pseudomonas aeruginosa is resistant to many antibiotics, and Piperacillin/tazobactam is a key treatment option for infections caused by this bacterium. If this antibiotic was not used, Lara’s condition could have worsened despite the best empirical efforts. Since her blood culture results indicated this specific pathogen, the failure to use Piperacillin/tazobactam likely led to the ineffective treatment of her infection.

 

Why It Might Not Be True: There might be a possibility that the antibiotic was available but not administered due to oversight or mismanagement. However, this specific factor should be investigated to confirm if it was indeed the missed treatment.

 

Delayed Diagnosis Due to Slow Blood Culture Processing:

Why It Could Be True: Blood culture results took 24-48 hours to process, which delayed the identification of Pseudomonas aeruginosa and the initiation of targeted treatment. This delay could have contributed to the severity of Lara’s infection.

 

Why It Might Not Be True:

While delays in processing are a factor, it is the specific treatment used (or not used) that is more critical. If Piperacillin/tazobactam was not used despite the delay, it still points to treatment errors as the primary issue.

 

Hospital-Acquired Infection Complicated Her Condition:

Why It Could Be True: Lara was in a hospital with an ongoing infection outbreak, which may have contributed to the severity of her illness. This could have complicated her treatment and recovery.

 

Why It Might Not Be True:

The specific infection causing Lara’s death was Pseudomonas aeruginosa, and the main concern should be whether the correct antibiotic treatment was administered. The broader hospital infection issue might have played a role but does not directly explain the lack of appropriate treatment.

 

Suicide:

Why It Could Be True: The letter found in Lara’s pocket suggested she was distressed and potentially suicidal. This context might have influenced her initial condition and subsequent actions.

 

Why It Might Not Be True: The primary cause of death was related to the infection, not her mental state. While the letter provides background, it does not directly address the medical mismanagement that led to her death.

 

Homicide or Foul Play:

Why It Could Be True: The initial uncertainty about the circumstances of Lara’s fall might suggest foul play or external factors.

 

Why It Might Not Be True: There was no evidence of foul play, and the primary issue was related to the infection and its treatment. The focus should be on the medical management rather than potential external causes.

 

In conclusion, the key factor to investigate is whether Piperacillin/tazobactam was administered to effectively treat the identified Pseudomonas aeruginosa infection. This specific treatment issue is the most likely cause of Lara’s death if not addressed properly.

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Pharmacotherapy and Patient Care:

  1. A 45-year-old female with hypertension is prescribed hydrochlorothiazide. What potential side effect should the patient be counseled about?

    • A) Hyperkalemia

    • B) Hypokalemia

    • C) Hypercalcemia

    • D) Hypocalcemia

  2. A 60-year-old male with a history of coronary artery disease is prescribed atorvastatin. Which of the following should be monitored during therapy?

    • A) Liver function tests

    • B) Serum sodium

    • C) Thyroid function

    • D) Blood pressure

  3. A patient is prescribed a combination of lisinopril and spironolactone for heart failure. Which of the following electrolyte imbalances is most likely to occur?

    • A) Hypocalcemia

    • B) Hyperkalemia

    • C) Hyponatremia

    • D) Hypokalemia

  4. A patient with rheumatoid arthritis is started on methotrexate. Which of the following supplements should be taken to prevent side effects from this medication?

    • A) Vitamin B12

    • B) Vitamin D

    • C) Folic acid

    • D) Iron

  5. A patient with asthma is prescribed montelukast. What is the mechanism of action of montelukast?

    • A) Leukotriene receptor antagonist

    • B) Beta-2 agonist

    • C) Muscarinic antagonist

    • D) Corticosteroid

Pharmacokinetics:

  1. A drug has a half-life of 4 hours. If the initial plasma concentration is 20 mg/L, what will the concentration be after 12 hours?

    • A) 5 mg/L

    • B) 10 mg/L

    • C) 2.5 mg/L

    • D) 1 mg/L

  2. A patient is prescribed a drug with a clearance of 10 L/hour and a volume of distribution of 40 L. What is the drug’s half-life?

    • A) 0.5 hours

    • B) 2.8 hours

    • C) 4.0 hours

    • D) 8.0 hours

  3. A patient is taking a drug with first-order kinetics. If the dose is increased from 200 mg to 400 mg, how will the plasma concentration change?

    • A) It will double

    • B) It will triple

    • C) It will increase fourfold

    • D) It will not change

Biostatistics:

  1. A clinical trial for a new anticoagulant reports a relative risk reduction (RRR) of 30% for preventing stroke. If the baseline risk of stroke is 8%, what is the absolute risk reduction (ARR)?

    • A) 0.8%

    • B) 2.4%

    • C) 5.6%

    • D) 8%

  2. In a study comparing two antihypertensive medications, the p-value is reported as 0.04. What is the correct interpretation of this p-value?

    • A) The results are statistically significant

    • B) The results are not statistically significant

    • C) There is a 4% chance the results are due to random error

    • D) The results are likely not clinically significant

Medication Safety:

  1. A patient is prescribed lithium for bipolar disorder. Which of the following should be monitored regularly due to the risk of toxicity?

    • A) Thyroid function

    • B) Liver function

    • C) Serum creatinine

    • D) Serum calcium

  2. A patient is started on amoxicillin and develops a rash after 2 days. What is the most appropriate course of action?

    • A) Discontinue amoxicillin and avoid all penicillins in the future

    • B) Continue amoxicillin and treat the rash with antihistamines

    • C) Switch to azithromycin immediately

    • D) Monitor the patient for anaphylaxis

Compounding:

  1. A pharmacist needs to prepare 100 mL of a 2% lidocaine solution. How many grams of lidocaine are needed?

    • A) 0.2 g

    • B) 2 g

    • C) 20 g

    • D) 200 g

  2. When preparing a sterile compounded product, which of the following is an essential step to maintain sterility?

    • A) Using sterile gloves

    • B) Wearing a surgical mask

    • C) Working in an ISO Class 8 cleanroom

    • D) Using alcohol wipes after compounding

Immunizations:

  1. A 72-year-old patient with chronic obstructive pulmonary disease (COPD) asks about recommended vaccinations. Which of the following should be recommended?

    • A) Meningococcal vaccine

    • B) Pneumococcal conjugate vaccine (PCV13)

    • C) Human papillomavirus (HPV) vaccine

    • D) Varicella vaccine

  2. A pregnant woman is in her third trimester. Which of the following vaccines should be recommended for her?

    • A) Influenza (inactivated)

    • B) Zoster

    • C) MMR

    • D) Pneumococcal polysaccharide vaccine (PPSV23)

Infectious Diseases:

  1. A patient is diagnosed with community-acquired pneumonia caused by Streptococcus pneumoniae. Which of the following antibiotics is the most appropriate choice?

    • A) Ciprofloxacin

    • B) Azithromycin

    • C) Amoxicillin

    • D) Metronidazole

  2. A patient with a urinary tract infection (UTI) is prescribed nitrofurantoin. Which of the following conditions is a contraindication to nitrofurantoin use?

    • A) Hypothyroidism

    • B) Renal impairment

    • C) Hypertension

    • D) Diabetes

Oncology:

  1. A patient receiving cisplatin chemotherapy should be monitored for which of the following potential side effects?

    • A) Nephrotoxicity

    • B) Cardiotoxicity

    • C) Hepatotoxicity

    • D) Pulmonary toxicity

  2. Which of the following medications is a monoclonal antibody used in the treatment of HER2-positive breast cancer?

    • A) Bevacizumab

    • B) Trastuzumab

    • C) Rituximab

    • D) Pembrolizumab

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ANSWERS:

Pharmacotherapy and Patient Care:

  1. B) Hypokalemia
    Explanation: Hydrochlorothiazide is a thiazide diuretic that can cause hypokalemia (low potassium levels) due to increased potassium excretion.

  2. A) Liver function tests
    Explanation: Atorvastatin can affect liver function, so liver enzymes should be monitored regularly to detect any potential hepatotoxicity.

  3. B) Hyperkalemia
    Explanation: Combining lisinopril (an ACE inhibitor) with spironolactone (a potassium-sparing diuretic) can lead to hyperkalemia, as both can increase potassium levels.

  4. C) Folic acid
    Explanation: Methotrexate can cause folic acid deficiency, so supplementation with folic acid helps mitigate side effects such as mucositis and gastrointestinal distress.

  5. A) Leukotriene receptor antagonist
    Explanation: Montelukast works by blocking leukotriene receptors, which helps reduce inflammation and bronchoconstriction in asthma.

Pharmacokinetics:

  1. C) 2.5 mg/L
    Explanation: After 12 hours (3 half-lives), the concentration is reduced to 1/8 of the original (20 mg/L), so 20 mg/L ÷ 8 = 2.5 mg/L.

  2. B) 2.8 hours
    Explanation: Half-life (t½) can be calculated using the formula: t½ = (0.693 × Vd) / Cl. Here, t½ = (0.693 × 40 L) / 10 L/hour = 2.8 hours.

  3. A) It will double
    Explanation: In first-order kinetics, doubling the dose results in a proportional doubling of the plasma concentration.

Biostatistics:

  1. B) 2.4%
    Explanation: The absolute risk reduction (ARR) is calculated as the baseline risk (8%) multiplied by the relative risk reduction (30%), resulting in ARR = 8% × 0.30 = 2.4%.

  2. A) The results are statistically significant
    Explanation: A p-value of 0.04 indicates statistical significance since it is less than the common threshold of 0.05.

Medication Safety:

  1. C) Serum creatinine
    Explanation: Lithium can cause nephrotoxicity, so monitoring serum creatinine helps assess kidney function and prevent toxicity.

  2. A) Discontinue amoxicillin and avoid all penicillins in the future
    Explanation: If a patient develops a rash from amoxicillin, it may indicate an allergy, and it is advisable to discontinue the medication and avoid future use of penicillins.

Compounding:

  1. B) 2 g
    Explanation: A 2% lidocaine solution means 2 grams per 100 mL. For 100 mL, you need 2 grams of lidocaine.

  2. A) Using sterile gloves
    Explanation: Using sterile gloves is essential to maintain sterility when preparing compounded sterile products to prevent contamination.

Immunizations:

  1. B) Pneumococcal conjugate vaccine (PCV13)
    Explanation: The pneumococcal conjugate vaccine (PCV13) is recommended for patients with COPD to protect against pneumococcal pneumonia.

  2. A) Influenza (inactivated)
    Explanation: The inactivated influenza vaccine is recommended during pregnancy to protect both the mother and the infant from flu complications.

Infectious Diseases:

  1. C) Amoxicillin
    Explanation: Amoxicillin is effective against Streptococcus pneumoniae and is commonly used to treat community-acquired pneumonia.

  2. B) Renal impairment
    Explanation: Nitrofurantoin is contraindicated in patients with significant renal impairment because it can accumulate and cause toxicity.

Oncology:

  1. A) Nephrotoxicity
    Explanation: Cisplatin is known for causing nephrotoxicity, and patients receiving this drug should have their renal function monitored closely.

  2. B) Trastuzumab
    Explanation: Trastuzumab is a monoclonal antibody used to target HER2-positive breast

cancer cells, helping to inhibit cancer growth.

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