2nd Annual

WAHLUCASE 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

# 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. MonocytesB. BasophilesC. EosinophilesD. Lymphocytes

# 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?

A. HematocritB. HemoglobinC. White Blood Cell CountD. 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” cigaretteB. Water pipe (Hookah)C. E-cigarette D. Large cigar

# 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?

A. AlcoholismB. Chronic hepatitis BC. Nonalcoholic steatohepatitisD. 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 syndromeB. Alcohol abuseC. Iron deficiency anemiaD. 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 neutrophilesD. Nucleated red blood cells

# 7

Applicant has seasonal asthma and eczema.

Which type of white blood is MOST LIKELY to be elevated in his differential count?

A. MonocyteB. EosinophilC. BasophilD. Lymphocyte

# 8

In which of the following contexts is a positive cocaine screening test MOST LIKELY to be a

false-positive result?

A. Chewing coca leavesB. Drinking mate de coca teaC. Anesthetic for facial laceration surgeryD. Handling $20 bills in a Miami bank

# 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 CB. Hepatitis BC. Hepatitis ED. Autoimmune hepatitis

# 10

Which test is a cardiologist LEAST LIKELY to usewhen working up a 31 year old male

world champion chess player for hyperlipidemia?

A. Apolipoprotein EB. Apolipoprotein BC. Apolipoprotein A-ID. Non-HDL-C cholesterol

Please exchange score sheets

with the table nearest yours

and then circle the correct answers only

as I review them.

#1Correct 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)

# 2Correct 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

# 3Correct 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.

# 4Correct 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.

# 5Correct Answer is C

Iron deficiency anemia has a low MCV.

Alcohol abuse, pernicious anemia and myelodysplastic syndrome are often

associated with an elevated MCV.

# 6Correct 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

# 7Correct 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.

# 8Correct 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.

# 9Correct Answer is B

Hepatitis D requires HBV to replicate.

None of the others are associated with an increased risk of hepatitis D.

# 10Correct 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?

If so, now we go to the tie-breaking

(and jaw-dropping) questions!

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?

A. ColposcopyB. CystoscopyC. ColonoscopyD. EsophagogastroscopyE. BronchoscopyF. Transthoracic anoscopy

Correct answer is C

Anyone who answered F should be stripped of their FALU!

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. eGFRB. CreatinineC. Serum AlbuminD. Hepatitis C antibody testE. GGTF. 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

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?

A. BUN of 3 (normal 5-25)B. Cholesterol of 116 (normal 160-200)C. Bilirubin of 0.1 (normal 0.3-1.1)D. AST of 72 (normal 0-35)E. HDL-C of 19 (normal 45-80)F. 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

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 drugsC. Isolated alkaline phosphatase elevation in a 22 year old

male who just returned on crutches from a ski resortD. Isolated serum globulin elevation in a female NASCAR

driverE. Isolated total bilirubin 2.5 times normal in a 48 year old

washed up pro golferF. 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

Tie-Breaker # 5

Which of these medications is NOT a potentially abusable drug?

A. Pregabalin (Lyrica)B. Chlordiazepoxide (Librium)C. Aripiprazole (Abilify)D. Buprenorphine (Buprenex)E. Methylphenidate (Ritalin)

Correct answer is C

Aripiprazole (Abilify) is an antipsychotic

and no one would want to take it for fun!