Episode 19
Gold Medal Tragedy
The Mysterious
Collapse of
Elena Ivanov
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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.
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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.
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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.
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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.
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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.
Elena's autopsy revealed acute kidney damage and severe electrolyte imbalances. Protein powders, commonly used by athletes to enhance muscle mass and recovery, are generally safe when used within recommended dosages. However, excessive intake of protein can overwhelm the kidneys, leading to acute renal failure.
The kidneys are responsible for filtering metabolic waste, including byproducts of protein metabolism. When protein intake exceeds the kidneys' capacity to process it, harmful metabolites accumulate, causing stress and damage to renal tissues. This damage can disrupt electrolyte balance, resulting in conditions like hypocalcemia or hyperkalemia.
In Elena's case, the excessive dosage of protein powder led to these imbalances, contributing to her collapse during the competition. The immediate medical intervention and subsequent autopsy confirmed that while her protein powder was legal and not banned by sports authorities, the quantity she ingested was significantly higher than recommended, leading to fatal complications. The situation was exacerbated by the extreme physical exertion of the Olympic event.
2. Cardiac Event Due to Genetic Condition: Cardiac conditions such as arrhythmias or congenital heart defects can cause sudden death, especially under physical stress. However, the initial tests and autopsy findings did not indicate any primary cardiac pathology or genetic heart condition. The primary evidence pointed towards kidney damage and electrolyte imbalances rather than cardiac issues. Additionally, no family history or genetic predisposition to heart disease was documented in Elena’s case, and the symptoms were more consistent with metabolic and renal disturbances rather than acute cardiac events.
3. Acute Allergic Reaction to Medication: Allergic reactions typically present with symptoms like rash, swelling, difficulty breathing, or anaphylaxis. The investigation found no evidence of such reactions. Blood tests and autopsy results did not show elevated eosinophils or other markers typically associated with allergies. The focus was on kidney damage and metabolic imbalances from excessive protein intake rather than an allergic response. The absence of symptoms consistent with anaphylaxis or other allergic manifestations supports that an allergic reaction was not a contributing factor to her death.
4. Unusual Hotel Room Activities Leading to Dehydration: Although dehydration can impact athletic performance and health, there was no direct evidence from the hotel room investigation indicating that Elena engaged in activities that would cause severe dehydration. The available data pointed towards her supplement use rather than dehydration as the primary issue. Kidney failure is a long-term problem that usually develops gradually due to chronic stress or damage. Severe dehydration might cause acute symptoms but is less likely to lead to immediate, fatal kidney failure. The symptoms of dehydration include dry skin, extreme thirst, and decreased urine output, which were not reported or observed in Elena’s medical records. The primary issue highlighted by the investigation and autopsy was the excessive use of protein powder and its effects on her renal and electrolyte balance, not dehydration from activities in her hotel room.
5. Accidental Overdose of Prescription Medication:
Prescription medication overdoses can lead to serious health issues, but the investigation did not reveal any evidence of such an overdose. The toxicological screenings and medical reports did not show elevated levels of any prescription medications. The main findings from the autopsy and medical investigations pointed to the impact of excessive protein powder consumption rather than prescription medication. The absence of overdose indicators and the focus on metabolic and renal issues further support that prescription medication overdose was not the cause of Elena's death.
1. A patient with chronic kidney disease is prescribed digoxin. Due to renal impairment, the dose should be adjusted. If the usual dose is 0.125 mg daily, what dose should be given to this patient with a creatinine clearance of 30 mL/min?
A) 0.25 mg daily
B) 0.125 mg every other day
C) 0.5 mg daily
D) 0.0625 mg daily
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2. A pharmacist receives a prescription for warfarin 10 mg daily for an elderly patient. The typical starting dose is 5 mg. What might be the consequence of the prescribed dose?
A) Subtherapeutic INR
B) Therapeutic INR
C) Increased risk of bleeding
D) No effect
3. A patient is prescribed lithium for bipolar disorder. The normal therapeutic range for lithium is 0.6-1.2 mEq/L. The patient's blood level is 1.5 mEq/L. What is the likely outcome?
A) Therapeutic effect
B) Subtherapeutic effect
C) Lithium toxicity
D) No effect
4. A child weighing 20 kg is prescribed amoxicillin 400 mg/5 mL for an ear infection. The usual pediatric dose is 80 mg/kg/day divided into two doses. What is the correct dose per administration?
A) 4 mL
B) 5 mL
C) 10 mL
D) 8 mL
5. A patient with atrial fibrillation is prescribed dabigatran 150 mg twice daily. The patient has a creatinine clearance of 25 mL/min. What adjustment should be made?
A) Increase to 300 mg twice daily
B) Continue at 150 mg twice daily
C) Decrease to 75 mg twice daily
D) Stop the medication
6. A patient is prescribed vancomycin 1 g IV every 12 hours. After 5 doses, the trough level is 25 mcg/mL (normal 10-20 mcg/mL). What should be the next step?
A) Increase the dose
B) Decrease the dose
C) Continue current dosing
D) Discontinue vancomycin
7. A patient is prescribed levothyroxine 200 mcg daily for hypothyroidism. The patient's TSH level is 0.1 mIU/L (normal 0.4-4.0 mIU/L). What should be done?
A) Increase the dose
B) Decrease the dose
C) Continue current dose
D) Discontinue the medication
8. A patient is prescribed metformin 1000 mg twice daily. The patient’s GFR is 35 mL/min. What adjustment should be made to the metformin dose?
A) Increase to 1500 mg twice daily
B) Continue at 1000 mg twice daily
C) Decrease to 500 mg twice daily
D) Discontinue metformin
9. A patient with congestive heart failure is prescribed furosemide 20 mg daily. The patient experiences no symptom relief and gains weight. What should be done?
A) Increase the dose
B) Decrease the dose
C) Switch to spironolactone
D) Discontinue furosemide
10. A patient is prescribed phenytoin 400 mg daily. The therapeutic range is 10-20 mcg/mL. The patient’s phenytoin level is 25 mcg/mL. What is the likely outcome?
A) Therapeutic effect
B) Subtherapeutic effect
C) Phenytoin toxicity
D) No effect
11. A patient is prescribed insulin glargine 100 units daily for diabetes. The patient experiences frequent episodes of hypoglycemia. What is the most appropriate action?
A) Increase the dose
B) Decrease the dose
C) Continue current dose
D) Switch to another insulin
12. A patient is prescribed methotrexate 20 mg daily for rheumatoid arthritis. The usual dose is 20 mg weekly. What is the most likely outcome?
A) Therapeutic effect
B) Subtherapeutic effect
C) Methotrexate toxicity
D) No effect
13. A patient with hypertension is prescribed lisinopril 80 mg daily. The usual maximum dose is 40 mg daily. What might be the consequence of this dosage?
A) Therapeutic blood pressure control
B) Subtherapeutic blood pressure control
C) Hypotension
D) No effect
14. A patient with asthma is prescribed albuterol 4 puffs every hour for exacerbation. The patient reports palpitations and tremors. What is the most appropriate next step?
A) Increase the dose
B) Decrease the dose
C) Discontinue albuterol
D) Switch to another bronchodilator
15. A patient with depression is prescribed sertraline 200 mg daily. The patient reports increased anxiety and restlessness. What should be done?
A) Increase the dose
B) Decrease the dose
C) Continue current dose
D) Discontinue sertraline
16. A patient is prescribed warfarin, and their INR is consistently over 4.0. What is the most appropriate course of action?
A) Increase the dose of warfarin
B) Decrease the dose of warfarin
C) Continue current dose
D) Discontinue warfarin
17. A patient with chronic pain is prescribed morphine 30 mg every 4 hours as needed. The patient reports severe drowsiness and confusion. What is the appropriate next step?
A) Increase the dose
B) Decrease the dose
C) Continue current dose
D) Switch to another opioid
18. A patient with diabetes is prescribed glyburide 10 mg daily. The patient experiences hypoglycemia frequently. What is the best action?
A) Increase the dose
B) Decrease the dose
C) Continue current dose
D) Switch to metformin
19. A patient is prescribed amiodarone for arrhythmia. The therapeutic range is 0.5-2.5 mcg/mL. The patient's level is 4 mcg/mL. What should be done?
A) Increase the dose
B) Decrease the dose
C) Continue current dose
D) Discontinue amiodarone
20. A patient with anxiety is prescribed alprazolam 2 mg three times daily. The patient reports excessive sedation. What is the best action?
A) Increase the dose
B) Decrease the dose
C) Continue current dose
D) Discontinue alprazolam
Answers:
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D
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C
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C
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A
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C
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B
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B
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C
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A
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C
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B
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C
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C
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B
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B
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B
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B
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B
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B
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B