2nd Annual WAHLU CASE CLINIC CHALLENGE

There are 10 questions Each table will record its consensus answer to each question on its score sheet Then, tables will exchange score sheets and we will grade them as the correct answers are presented and reviewed In the event of a tie, there are additional questions to determine the winning tables

A. Monocytes B. Basophiles C. Eosinophiles D. Lymphocytes # 1 In which of these white blood cell varieties is a modestly increased % in the differential count MOST LIKELY to represent a significant underlying disorder? A. Monocytes B. Basophiles C. Eosinophiles D. Lymphocytes

Mean Corpuscular Hemoglobin Concentration (MCHC) # 2 A 3 pack-per-day smoker with a history of “smoker’s erythrocytosis” has a screening CBC. Which of these tests is LEAST LIKELY to be elevated? Hematocrit Hemoglobin White Blood Cell Count Mean Corpuscular Hemoglobin Concentration (MCHC)

# 3 Applicant does not disclose that he smokes one of the following once every day. Which is MOST LIKELY to result in a positive cotinine test? A. “Light” cigarette B. Water pipe (Hookah) C. E-cigarette D. Large cigar

Nonalcoholic steatohepatitis Sclerosing cholangitis # 4 Underweight male with longtime ulcerative colitis presents with fatigue. He has elevated alkaline phosphatase x 2, elevated GGT x 3, minimally elevated ALT, plus high normal AST and bilirubin Which diagnosis should you be MOST CONCERNED about? Alcoholism Chronic hepatitis B Nonalcoholic steatohepatitis Sclerosing cholangitis

# 5 Which of the following is the LEAST LIKELY cause of an isolated MCV of 114 fl (normal range 80 – 100)? A. Myelodysplastic syndrome B. Alcohol abuse C. Iron deficiency anemia D. Pernicious anemia

# 6 Which of the following CBC findings is LEAST LIKELY to be associated with extra mortality in an asymptomatic applicant? A. Elevated mean platelet volume (MPV) B. Elevated red blood cell distribution width (RDW) C. Banded neutrophiles D. Nucleated red blood cells

Monocyte Eosinophil Basophil Lymphocyte # 7 Applicant has seasonal asthma and eczema. Which type of white blood is MOST LIKELY to be elevated in his differential count? Monocyte Eosinophil Basophil Lymphocyte

B. Drinking mate de coca tea # 8 In which of the following contexts is a positive cocaine screening test MOST LIKELY to be a false-positive result? A. Chewing coca leaves B. Drinking mate de coca tea C. Anesthetic for facial laceration surgery D. Handling $20 bills in a Miami bank

A. Hepatitis C B. Hepatitis B C. Hepatitis E D. Autoimmune hepatitis # 9 The applicant says he has 2 types of hepatitis. One of them is hepatitis D. Which is MOST LIKELY to be the other one? A. Hepatitis C B. Hepatitis B C. Hepatitis E D. Autoimmune hepatitis

# 10 Which test is a cardiologist LEAST LIKELY to use when working up a 31 year old male world champion chess player for hyperlipidemia? A. Apolipoprotein E B. Apolipoprotein B C. Apolipoprotein A-I D. Non-HDL-C cholesterol

Please exchange score sheets with the table nearest yours and then circle the correct answers only as I review them.

#1 Correct answer is B Basophilia should be considered as potential evidence of leukemia or a related disorder until determination of the absolute count (and, if also elevated, further assessment)

# 2 Correct answer is D Mean corpuscular hemoglobin concentration has nothing to do with heavy smoking or “smoker’s erythrocytosis.” Hematocrit is always elevated, hemoglobin is sometimes minimally elevated and the white blood cell count is also sometimes elevated in heavy smoking due to inflammation

# 3 Correct Answer is B Water pipe smoking typically involves substantial exposure to nicotine even when used just on one occasion. One daily “light” cigarette, large cigar or E-cigarette is unlikely to cause elevated cotinine at prevailing industry cutoffs.

# 4 Correct Answer is D Sclerosing cholangitis is a serious complication of inflammatory bowel disease presenting with this cholestatic pattern of abnormal liver tests. None of the others are more prevalent in ulcerative colitis and, of these other three, only chronic hepatitis B is more than rarely encountered with this pattern of test results.

# 5 Correct Answer is C Iron deficiency anemia has a low MCV. Alcohol abuse, pernicious anemia and myelodysplastic syndrome are often associated with an elevated MCV.

# 6 Correct Answer is C Banded neutrophiles are common in healthy people and persons with various kinds of transient infections Elevated MPV is associated with excess mortality due to potentially significant causes Elevated RDW has increased mortality in its own right Nucleated red blood cells are an absolute RED FLAG for underlying hematological disease

# 7 Correct Answer is B Eosinophilia is common in allergy-related disorders such as asthma and eczema. The others are not significantly more prevalent in either of these disorders.

# 8 Correct Answer is D Chewing coca leaves and drinking mate de coca are often associated with true positive cocaine tests. Cocaine is sometimes used as an anesthetic for facial surgery and a positive test would have to be considered true positive pending further investigation with the surgeon. Handling money in a Miami bank makes no sense as an argument for a true-positive test! Therefore, given the low prevalence of true-positives in the general population, this scenario is most apt to represent a false-positive.

# 9 Correct Answer is B Hepatitis D requires HBV to replicate. None of the others are associated with an increased risk of hepatitis D.

# 10 Correct Answer is A Apolipoprotein E tests are mainly used for detecting genetic predisposition to Alzheimer dementia…and any form of dementia is rather rare in a 31 year old genius! Apolipoproteins B and A-1, as well as non-HDL-C cholesterol are all used in the context of hyperlipidemia.

Any table that got the first 9 questions correct but the last one wrong is clever, because someone obviously noticed that all of the first 9 correct responses were GREEN But then they got tripped up because I used BROWN for the correct answer to question # 10!

Do We Have any Tie Scores for 1ST, 2ND or 3RD Place Do We Have any Tie Scores for 1ST, 2ND or 3RD Place? If so, now we go to the tie-breaking (and jaw-dropping) questions!

Transthoracic anoscopy Tie-breaker #1 66 year old female had CBC with hemoglobin 9.1, HCT 28% and MCV 69. Her ferritin test was 20 Which of the following endoscopic examinations is she most likely to have next? Colposcopy Cystoscopy Colonoscopy Esophagogastroscopy Bronchoscopy Transthoracic anoscopy

Anyone who answered F should be stripped of their FALU! Correct answer is C Anyone who answered F should be stripped of their FALU!

D. Hepatitis C antibody test E. GGT F. Cystatin C Tie-breaker # 2 Which of the following tests is LEAST LIKELY to be elevated/positive in a Type 2 diabetic due to the diabetes or its prevalent comorbidities? A. eGFR B. Creatinine C. Serum Albumin D. Hepatitis C antibody test E. GGT F. Cystatin C

Correct Answer is C Elevated albumin is due mainly to transient dehydration and has nothing to do with diabetes or its prevalent comorbidities. Elevated eGFR often occurs due to kidney hyperfiltration prior to onset of diabetic nephropathy. All of the others are also clearly related to diabetes or its comorbidities

Cholesterol of 116 (normal 160-200) Bilirubin of 0.1 (normal 0.3-1.1) Tie-breaker # 3 In a 6’8”, 335 lb longshoreman and competitive weightlifter, which abnormal lab finding on a routine screening blood profile is LEAST LIKELY to have underwriting implications? BUN of 3 (normal 5-25) Cholesterol of 116 (normal 160-200) Bilirubin of 0.1 (normal 0.3-1.1) AST of 72 (normal 0-35) HDL-C of 19 (normal 45-80) GGT of 110 (normal 0-65)

Correct answer is D Modestly elevated AST is not uncommon in this setting and is most likely due to weightlifting as well as the heavy labor involved in his day job. GGT, unlike AST, is not elevated by exercise or muscle use Low BUN is a red flag for advanced liver disease, etc. Very low levels of cholesterol and HDL-C suggest anabolic steroid abuse in a weightlifter Very low total bilirubin is an independent marker for excess mortality in all settings

B. Isolated GGT elevation in an epileptic on 2 drugs Tie-breaker # 4 Which of these scenarios is MOST LIKELY to be associated with significant extra mortality A. Isolated ALT elevation in a slender woman with polycystic ovary syndrome B. Isolated GGT elevation in an epileptic on 2 drugs C. Isolated alkaline phosphatase elevation in a 22 year old male who just returned on crutches from a ski resort D. Isolated serum globulin elevation in a female NASCAR driver E. Isolated total bilirubin 2.5 times normal in a 48 year old washed up pro golfer F. Isolated creatinine elevation in Packer defensive lineman Johnny Jolly

Correct Answer is D NACAR driving has no correlation with elevated globulin and elevated globulin is presumed to be due to disease and must be further evaluated. All of the others can potentially be explained by the circumstances in which they have occurred and are unlikely to be associated with significant mortality in these contexts

Chlordiazepoxide (Librium) Aripiprazole (Abilify) Tie-Breaker # 5 Which of these medications is NOT a potentially abusable drug? Pregabalin (Lyrica) Chlordiazepoxide (Librium) Aripiprazole (Abilify) Buprenorphine (Buprenex) Methylphenidate (Ritalin)

Correct answer is C Aripiprazole (Abilify) is an antipsychotic and no one would want to take it for fun!